Retaining women in a prenatal care randomized controlled trial in Canada: implications for program planning

<p>Abstract</p> <p>Background:</p> <p>Challenges to retention in prenatal care seem to exist under both universal systems of care, as in Canada, and non-universal systems of care, as in the United States. However, among populations being served by a system of publicly funded health care, the barriers are less well understood and universal uptake of prenatal services has not been realized. Determining the characteristics of women who dropped out of a prenatal care randomized controlled trial can help identify those who may need alternate retention and service approaches.</p> <p>Methods:</p> <p>In this study, pregnant women were randomized to: a) current standard of care; b) 'a' plus nursing support; or c) 'b' plus a paraprofessional home visitor. 16% of 2,015 women did not complete all three telephone interviews (197 dropped out and 124 became unreachable). Responders were compared to non-responders on demographics, lifestyle, psychosocial factors, and life events using chi-squared tests. Logistic regression models were constructed using stepwise logistic regression to determine the probability of not completing the prenatal program.</p> <p>Results:</p> <p>Completion rates did not differ by intervention. In comparison to responders, non-responders were more likely to be younger, less educated, have lower incomes, smoke, have low social support, have a history of depression, and have separated or divorced parents (all p < 0.05). Unreachable women were more likely to be single, use drugs, report distress and adverse life events (all p < 0.05). Non-Caucasian women were more likely to drop out (p = 0.002). Logistic regression modeling indicated that independent key risk factors for dropping out were: less than high school education, separated or divorced parents, lower social support, and being non-Caucasian. Pregnant women who were single/separated/divorced, less than 25 years old, had less than high school education, earned less than $40,000 in annual household income, and/or smoked had greater odds of becoming unreachable at some point during pregnancy and not completing the study.</p> <p>Conclusion:</p> <p>Women at risk due to lifestyle and challenging circumstances were difficult to retain in a prenatal care study, regardless of the intervention. For women with complex health, lifestyle and social issues, lack of retention may reflect incongruence between their needs and the program.</p> <p>Trial registration:</p> <p>Current Controlled Trials ISRCTN64070727</p

Three pillars of sustainability: in search of conceptual origins

The three-pillar conception of (social, economic and environmental) sustainability, commonly represented by three intersecting circles with overall sustainability at the centre, has become ubiquitous. With a view of identifying the genesis and theoretical foundations of this conception, this paper reviews and discusses relevant historical sustainability literature. From this we find that there is no single point of origin of this three-pillar conception, but rather a gradual emergence from various critiques in the early academic literature of the economic status quo from both social and ecological perspectives on the one hand, and the quest to reconcile economic growth as a solution to social and ecological problems on the part of the United Nations on the other. The popular three circles diagram appears to have been first presented by Barbier (Environ Conserv 14:101, doi: 10.1017/s0376892900011449, 1987), albeit purposed towards developing nations with foci which differ from modern interpretations. The conceptualisation of three pillars seems to predate this, however. Nowhere have we found a theoretically rigorous description of the three pillars. This is thought to be in part due to the nature of the sustainability discourse arising from broadly different schools of thought historically. The absence of such a theoretically solid conception frustrates approaches towards a theoretically rigorous operationalisation of ‘sustainability’