Community Perinatal Care (CPC) Study

1. A Randomized Controlled Trial of Supplementary Prenatal Care:Implications for Service DeliverySuzanne Tough, PhD11th Annual Maternal and Child Health Epidemiology ConferenceMiami, FloridaDecember 2005

2. Community Perinatal Care (CPC) Study • Background • Key Question • Methods • Results • Conclusions • Public Health Implications

3. How we started • Working Group on Post Partum Services of the Maternal-Newborn Committee, Calgary Health Region (1997) had identified that women lacked awareness of existing prenatal community resources • A Working Group of the Calgary Children’s Initiative (United Way) (1999/2000) identified role of prenatal care in improving pregnancy experiences and birth outcomes

4. Significance • Prenatal care is an opportunity for health promotion • Most women in Canada have 10-14 visits • A holistic view of health includes addressing psychosocial as well as medical needs • Low medical risk maternity clinics are at capacity

5. Key Question Does additional prenatal support from nurses and home visitors improve referral and access to appropriate resources for pregnant women living under a system of universal health care, particularly those with complex or special needs?

6. CPC Methods 68% response rate All Groups Groups # of womenat CPC 1 1737 # of womenat CPC 3 1352 Completionrate

7. CPC Program • Nurse • Humanist Perspective on Learning (Boyd et al, 1997) • Competency-based Approach to Comprehensive Pregnancy (Johnson et al, 2000) • Solution Focused Approach (De Jong and Berg, 1994) • Community as Partner Model (Anderson & McFarlane, 1996) • Home Visitor • “Invest in Kids” model with components from “Wisconsin” and “Within our Reach” models

8. Results • CPC Women • Average 29 yrs • 54% no previous children • 98% had a partner • 75% Caucasian • 75% earned 40K+/yr • 73% post-secondary education • CPC Babies • Average 3,400 grams • 7.1% pre-term • 4.8% low birth weight Study Group • Control • Nurse • Nurse + Home Visitor

9. Intervention Intensity • 49% of women with Nurse support had 4 or more visits • Range 0 – 11 visits • Duration approximately 60 minutes on 1st visit • 54% of women with Home Visitor support had 2 or more visits • Range 0 – 14 visits • Duration approximately 75 minutes • There was increased resource uptake with increased use of support

10. What Happened Women with extra support received more information on: prenatal vitamins and prenatal classes …but… rates of use were similar early prenatal classes …and… rates of attendance were higher parenting classes …but… rates of attendance by 3 months were similar nutrition …and… were more likely to use nutrition counseling breastfeeding …but… rates of use were similar

11. Interesting Findings Some resources included: Over 50% of women used 3 or more resources

12. What Didn’t Happen? Although women received more information on the following, there were no OVERALL differences in: • Abuse and neglect • Use of food bank, housing supports • Smoking rates and alcohol consumption • Post natal depression • Partner support post delivery • Satisfaction with services

13. Subtle Findings Need and Benefit: • 81% of women reported benefit from the Nurse and 43% indicated need of this service • 43% of women benefited from the Home Visitor and 22% indicated need of this service Characteristics of women more likely to report need of additional support: • first birth • young maternal age • low income • non-Caucasian ethnicity • abuse • negative network orientation • low-self esteem

14. Who Needs the Extra Help? • Aged 18-24 • Born outside Canada • Lived in Canada <2 years • Annual income < 40K year • No previous children • Under-employed • History of sexual abuse, neglect or alcohol problems • Never taken prenatal or parenting classes • Lower self esteem • Lower social support • Women waiting longer for specialized care provider Women attending the prenatal clinic situated in a multi-cultural, low income quadrant of the city had more of these characteristics.

15. Associated Costs • Standard care • $1,487 / mother • Mean cost of additional Nursing care • $90.90 / mother • Mean cost of additional Nurse + Home Visitor • $170.90 / mother

16. Conclusions • Support increased information received and utilization for some resources • A key opportunity exists to identify and support those who would most need additional support • Those with risk characteristics reported greatest benefit • Economic analysis suggests acceptable cost burden, particularly if allocated to high-risk women • Normalization of help seeking behavior through improved visibility and universal screening

17. Public Health Implications • Current efforts in the Calgary Health Region underway to re-design service delivery to better meet the needs of our community

18. Who We Worked With • Calgary Children’s • Initiative • Calgary Immigrant Women’s Association • University of Calgary • Pediatrics • Community Health Sciences • Centre for Health and Policy Studies Low Risk Prenatal Clinics (NE/NW) Calgary Home Visitation Collaborative Calgary Health Region Decision Support Research Team Healthy Communities Health Survey and Evaluation Unit Physician Partnership Steering Committee

19. The CPC Study Team