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Nurse-Family Partnership

Blueprints Program Rating: Model

A nurse home visiting program for first-time pregnant mothers that sends nurses to work one-on-one with the pregnant women to improve prenatal and child rearing practices through the child’s second birthday.

  • Child Maltreatment
  • Delinquency and Criminal Behavior
  • Early Cognitive Development
  • Internalizing
  • Mental Health - Other
  • Physical Health and Well-Being
  • Preschool Communication/Language Development
  • Reciprocal Parent-Child Warmth

    Program Type

    • Home Visitation
    • Parent Training

    Program Setting

    • Home

    Continuum of Intervention

    • Selective Prevention (Elevated Risk)

    A nurse home visiting program for first-time pregnant mothers that sends nurses to work one-on-one with the pregnant women to improve prenatal and child rearing practices through the child’s second birthday.

      Population Demographics

      The population consisted of women at risk of preterm delivery and low-birth-weight children, with a focus on low-income, unmarried, teenage women bearing their first child.

      Age

      • Infant (0-2)

      Gender

      • Female only

      Race/Ethnicity

      • All Race/Ethnicity

      Race/Ethnicity Specific Findings

      • White
      • African American
      • Hispanic or Latino

      Race/Ethnicity/Gender Details

      The Elmira program consisted of a largely white population from the Appalachian region of New York. The Memphis and Denver programs, however, were designed to target low-income African American and Hispanic women, children, and their families living in major urban areas, respectively.

      One Dutch study (Mejdoubi et al., 2013) included Surinamese, Turkish, and Moroccan women.

      Risk: low birth weight, prenatal exposure to drugs, alcohol, or tobacco; mother's psychological immaturity, dysfunctional caregiving, stressful conditions in the household, low household SES, household social risk factors (e.g. poor education, experience of violence or neglect).

      • Family
      • Individual
      Risk Factors
      • Individual: Stress
      • Family: Family conflict/violence*, Family history of problem behavior, Household adults involved in antisocial behavior*, Lack of prenatal care*, Low parental education, Low socioeconomic status*, Mother substance use during pregnancy*, Neglectful parenting*, Parent history of mental health difficulties, Parent stress, Parental attitudes favorable to antisocial behavior, Parental attitudes favorable to drug use, Parental unemployment*, Poor family management, Psychological aggression/discipline, Unplanned pregnancy*, Violent discipline
      Protective Factors
      • Family: Attachment to parents*, Breastfeeding*, Non-violent discipline, Opportunities for prosocial involvement with parents, Parent social support*, Rewards for prosocial involvement with parents

      *Risk/Protective Factor was significantly impacted by the program.

      See also: Nurse-Family Partnership Logic Model (PDF)

      Nurse-Family Partnership begins during pregnancy as early as is possible and continues through the child's second birthday. Nurses work with low-income pregnant mothers bearing their first child to improve the outcomes of pregnancy, improve infant health and development, and improve the mother's own personal life-course development through instruction and observation during home visits. These visits generally occur every other week and last 60-90 minutes.

      Specific objectives include improving women's diets; helping women monitor their weight gain and eliminate the use of cigarettes, alcohol, and drugs; teaching parents to identify the signs of pregnancy complication; encouraging regular rest, appropriate exercise, and good personal hygiene related to obstetrical health; and preparing parents for labor, delivery, and early care of the newborn.

      The Dutch study (Mejdoubi et al., 2013) adapted the program for Dutch women and their health care system. The most important adaptations included placing more emphasis on home delivery, instructing women to stop smoking during pregnancy, and offering more information about the advantages of breastfeeding. Similarly, a German adaptation of the program (Sierau et al., 2016) used social workers or midwives rather than nurses as home visitors. It also used a German developmental screening instrument and provided information on well-child check-ups.

      Robling et al. (2015) adapted the program for use in a publicly funded healthcare system in England. In this context, mothers have access to publicly funded health and social care, including universally offered screening, education, immunization, and support from birth to the child’s second birthday. The FNP program also provides an assigned family nurse, who makes up to 64 home visits, while other mothers receive care as needed from a specialist community public health nurse.

      Nurse-Family Partnership sends nurses to the homes of pregnant women who are predisposed to infant health and developmental problems (i.e., at risk of preterm delivery and low-birth weight children). The goal is to improve parent and child outcomes. Treatment begins during pregnancy, with 60-90 minute visits about once every other week, and continues to 24 months postpartum. Program content covered in the home visits includes (a) parent education about influences on fetal and infant development; (b) the involvement of family members and friends in the pregnancy, birth, early care of the child, and support of the mother; and (c) the linkage of family members with other formal health and human services.

      In addition to working with the mothers directly, the nurses promote the goals of the program by engaging other family members and close friends in the program and by assisting families to use other formal health and social services.

      The Dutch study (Mejdoubi et al., 2013) adapted the program for Dutch women and their health care system. The most important adaptations included placing more emphasis on home delivery, instructing women to stop smoking during pregnancy, and offering more information about the advantages of breastfeeding. Similarly, a German adaptation of the program (Sierau et al., 2016) used social workers or midwives rather than nurses as home visitors. It also used a German developmental screening instrument and provided information on well-child check-ups.

      Robling et al. (2015) adapted the program for use in a publicly-funded healthcare system in England. In this context, mothers have access to publicly funded health and social care, including universally offered screening, education, immunization, and support from birth to the child’s second birthday. The FNP program also provides by the assigned family nurse, who makes up to 64 home visits, while other mothers receive care as needed from a specialist community public health nurse.

      The home visitors were equipped with a theory-driven program design and a visit-by-visit protocol that were designed to guide their efforts to help women improve their health-related behaviors, their care of their children, their planning of subsequent pregnancies, educational achievement, and participation in the work force. These adaptive skills focus on both their own behavior and their ability to summon family and community support to improve the material and social contexts in which they live. Some of the theories that helped to inform the content of the program include human ecology theory, self-efficacy theory, and attachment theory.

      Human ecology theory played an important role in identifying which families would be enrolled in the study and when. The study focused on women who had no previous live births, and thus were undergoing a major role change known as an ecological transition. The program began during pregnancy and the early childhood years because during pregnancy, women have not yet formally assumed the parental role. In providing support to young people prior to and while they were learning about being parents, it was reasoned that the visitors would enhance their influence on parents' during orientation to their roles as parents and providers. Human ecology theory also focused the home visitors' attention on the systematic evaluation and enhancement of the material and social environment of the family; the involvement of other family members, friends, and partners; the identification of family stressors and needed health and human services; and the linkage of families with formal community services.

      Self-efficacy theory played a role in the design of the Elmira program, through an emphasis on helping women set small achievable objectives for themselves that would strengthen their confidence in their capacity for behavioral change. However, it was not emphasized explicitly as a theoretical foundation in Elmira to the same degree as it was in Memphis. Self-efficacy theory also focused home visitors' attention on promoting mothers' healthy behavior, optimal caregiving, family planning, and economic self-sufficiency by identifying family strengths and reinforcing behaviors that are close to the goals of the program and teaching the problem-solving method as a general approach to coping.

      Attachment theory affected the design of the home visitation programs in three fundamental ways: 1) emphasizing the visitors developing an empathic relationship with the mother; 2) the emphasis of the program on helping mothers and other caregivers review their own childrearing histories; and 3) the explicit promotion of sensitive, responsive, and engaged caregiving in the early years of the child's life.

      • Attachment - Bonding
      • Self Efficacy

      Three major studies done in Elmira, New York, Memphis, Tennessee, and Denver, Colorado, used similar designs. Each study recruited women who were pregnant for the first time and faced special risks such as low income, teen pregnancy, or single parenthood. Investigators randomly assigned the women to the Nurse-Family Partnership or control conditions. Follow-up assessments done after the two-year program measured a variety of outcomes for the mothers and their children.

      The Elmira study used data from 400 pregnant women who were recruited in 1978 from clinics in a rural Appalachian area of New York State with a largely white population. The study included 15-year and 19-year follow-ups, with about 310 adolescent children participating.

      The Memphis study began in 1990 and obtained data from a sample of 743 pregnant, mostly black women. A variety of measures for the mother and child were obtained at 3 years, 9 years, and 12 years after the birth. At the 12-year follow-up, 613 first-born children of the 743 randomized women were studied.

      The Denver study, which began in 1994, obtained data on a sample of 735 pregnant, mostly Hispanic and white women. Unlike the other studies, this one randomized women to two intervention conditions, one using nurses and one using paraprofessionals, and to one control condition. Posttest and two-year follow-up assessments were done for 86% of randomized mothers and 82% of the children.

      A replication study of Dutch women (Mejdoubi et al., 2013) examined intimate partner violence using a randomized controlled trial and longitudinal data through 2 years after the child’s birth. The sample had 460 women at baseline but attrition reached 42% by posttest.

      In a study completed in England (Robling et al., 2015), first time mothers aged 19 or younger were recruited from local maternity services. A total of 1,645 women were assigned randomly. The treatment group received screening, education, immunization, and support from birth to the child’s second birthday from an assigned family nurse, while control mothers received usual care from a specialist community public health nurse. The study measured the program’s effect on mother’s smoking at late pregnancy, additional pregnancies within 24 months after birth, child’s birth weight, and child’s emergency attendance or admission within 24 hours of birth.

      A study conducted in Germany (Sierau et al., 2016) included 755 low SES mothers with at least one social risk factor, such as low education or experience of violence. All recruited women were volunteers and were randomly assigned, after being stratified by site, age, and nationality, to either the treatment or control groups. The study measured the program’s effect on the family environment, maternal competencies, and child development.

      Elmira, New York: Women who received the Nurse-Family Partnership program demonstrated significant improvements in prenatal health, such as reductions in hypertensive disorders, fewer kidney infections, improved diet, and reductions in cigarette use. Children of nurse-visited women also experienced reductions in health-care visits for injuries. Nurse-visited mothers were rated as more involved with their children. At six months of age, nurse-visited infants were significantly less likely to exhibit emotional vulnerability in response to fear stimuli than were control group infants, and nurse-visited children of women with low psychological resources were significantly less likely to display low emotional vitality in response to joy and anger stimuli. At 21 months, nurse-visited children were significantly less likely to exhibit language delays than children in the control group (this effect was concentrated among children whose mothers had low psychological resources). Nurse-visited children born to women with low psychological resources also had superior average language and mental development in contrast to control-group counterparts. Fewer unintended subsequent pregnancies were reported by nurse-visited women, and increases in the interval between first and second births were also observed.

      15-year follow-up: Child abuse and neglect was significantly reduced. Children of nurse-visited women experienced significantly fewer arrests and convictions at age 15.

      19-year follow-up: Children of nurse-visited mothers were less likely to have ever been arrested or convicted and had fewer lifetime arrests and convictions than their counterparts in the comparison condition. There were no program effects on youths' self-reported criminal behavior or their use of alcohol or illegal drugs, high school graduation, economic productivity, number of sexual partners, use of birth control, teen pregnancy or childbearing, and use of welfare, food stamps, or Medicaid.

      Denver Study. Nurse-visited smokers had significantly greater reductions in the chemical markers for nicotine from intake to the end of pregnancy than did the control group at 24 months. In addition, nurse-visited women had significantly longer intervals between their next conception than did women in the control group at both 24 and 48 months. Women visited by nurses also were employed longer during the second year after giving birth than were control women. Nurse-visited mother-infant pairs interacted with one another more responsively than did control pairs, and at six months of age, nurse-visited infants were significantly less likely to exhibit emotional vulnerability in response to fear stimuli than were control group infants. Nurse-visited children of women with low psychological resources were significantly less likely to display low emotional vitality in response to joy and anger stimuli, and were less likely to exhibit language delays than children in the control group at 21 months. Nurse-visited children born to women with low psychological resources also had superior average language and mental development at 24 months. Nurse-visited women also reported less domestic violence from partners during the six-month interval before the four-year interview. Finally, nurse-visited children born to women with low psychologic resources, compared with control group counterparts, had home environments more conducive to early learning, better language development, superior executive functioning, and better behavioral adaptation during testing.

      Memphis Study. Fewer nurse-visited women had Pregnancy Induced Hypertension as compared to the control group. In addition, children of nurse-visited women had fewer health care encounters and days of hospitalization for injury or ingestion at 24 months and fewer second pregnancies at 24 months. These program effects were sustained at 54 months. Four years after the end of the program at child age 2 years, nurse-visited women had fewer subsequent pregnancies and births, less use of welfare, longer relationships with their partners, and greater enrollment of their children in some form of preschool or licensed day care. Nurse-visited children demonstrated higher IQs and language scores and fewer behavioral problems in the borderline or clinical range.

      During the 9-year period after the birth of the first child, among women with at least one subsequent child, there were longer intervals between the births of first and second children and fewer cumulative subsequent births per year among nurse-visited women. Averaging across the 6- and 9-year follow-up periods, nurse-visited mothers had longer relationships with their current partners, and were associated with employed partners to a greater degree than were women in the control group. Through age 12, the program reduced children's use of substances and internalizing mental health problems.

      Netherlands Study. Significant program effects on psychological aggression, physical assault, sexual coercion, injury, and combined forms of intimate partner violence (Mejdoubi et al., 2013), and cigarette smoking (Mejdoubi et al., 2014).

      England Study (Robling et al, 2015). No significant effects were found for mother’s late pregnancy smoking, additional pregnancies within 24 months, or birth weight. The study found a possible iatrogenic effect for emergency attendance or admission.

      German Study (Sierau et al., 2016) No significant effects were found for child development and only marginally significant effects were found for maternal stress, parental self-efficacy, and feelings of attachment.

      The three studies of pregnant women and their children – Elmira, Memphis, and Denver – found intervention-group improvements relative to the control group in the following areas:

      Mother (Elmira, Memphis, Denver)

      • Unintended subsequent pregnancies, and the interval between first and second births
      • Domestic violence among married or cohabiting women
      • Maternal employment and use of welfare and food stamps

      Infants and Young Children (Elmira, Memphis, Denver)

      • Health-care visits and hospitalization for injuries and illnesses
      • Emotional vulnerability, particularly among children born to mothers with low psychological resources
      • Language and mental development, particularly among children born to mothers with low psychological resources
      • Child abuse and neglect, and behavioral problems caused by use of alcohol or drugs (seen in mothers at 15- and 19-year follow-up in Elmira)

      6-to-12-Year Follow-up (Memphis)

      • Intellectual functioning and receptive language
      • Behavioral problems at age 6
      • Relationship quality of mothers with current partners
      • Children's use of substances and internalizing mental health problems at age 12

      15-year and 19-Year Follow-up (Elmira)

      • Among children, arrests and convictions

      Significant Program Effects on Risk and Protective Factors

      • Prenatal health, such as hypertension and use of cigarettes
      • Responsive interactions with child
      • Parent social support (Elmira)

      Netherlands Study (Mejdoubi et al., 2013, 2014)

      • Significant program effects on cigarette smoking, psychological aggression, physical assault, sexual coercion, injury, and combined forms of intimate partner violence. No effects on pregnancy outcomes, such as birthweight.

      England Study (Robling et al., 2015)

      • No significant positive effects on 3 of 4 measures and one possible iatrogenic effect for emergency attendance or admission.

      German Study (Sierau et al., 2016)

      • No significant positive effects on 7 measures of child development
      • Marginally significant effects on 2 of 8 measures of maternal competencies (parental self-efficacy and feelings of attachment)
      • Marginally significant effect on 1 of 5 measures of family environment (maternal stress)

      One study presented a formal mediation analysis, though for a subset of the Elmira sample with low to moderate levels of self-reported domestic violence (N = 251). Eckenrode et al. (2017) used this subsample to examine official reports of child maltreatment through the 15-year follow-up. The mediation analysis found that the program effect on child maltreatment was significantly mediated by both months on public assistance and subsequent births.

      Most studies calculated mean differences and confidence intervals rather than standardized effect sizes. There are several exceptions, however. Olds, Kitzman et al. (2004) reported generally weak effect sizes for the Memphis 6-year follow-up. For mother outcomes, effect sizes ranged from near zero to .24; for child outcomes, effect sizes ranged from near zero to .32. Olds et al. (2007) likewise reported generally weak effect sizes for the Memphis 9-year follow-up: For child academic performance, effect sizes ranged from near zero to .33. Olds, Robinson et al. (2004) reported weak effect sizes for the Denver study. For mother outcomes, effect sizes ranged from near zero to .32; for child outcomes, effect sizes ranged from near zero to .47. Across all studies, effects sizes below .10 predominated.

      More studies report odds ratios. These are sometimes large (e.g., 3.89 for re-enrollment in or graduation from high school for women who had dropped out by the start of the Elmira study). Consistent with effect sizes for the continuous measures, however, most odds ratios for categorical or count outcomes were small. In the Dutch study (Mejdoubi et al., 2013), odds ratios ranged from small-medium (.53 to .57) to large (.10). In the England study (Robling et al, 2015), the odds ratio for the possible iatrogenic effect was very small (1.32).

      The program in New York was not representative of inner cities or extremely isolated rural communities, or nonwhites. The Elmira trial was replicated in Memphis with a sample of low-income black families and in Denver with a sample of low-income Hispanic families. Initial analyses indicate that the program remains effective across racial, ethnic, geographic, and socioeconomic groups. However, the program works best for higher risk women. One study examined the effects in the Netherlands (Mejdoubi et al, 2013), a second examined the effects in England (Robling et al., 2015), and a third examined the effects in Germany (Sierau et al., 2016).

      The studies in Elmira, Denver, and Memphis combine strong designs with positive results. The limitations are few:

      • Each study sample is narrow, but in combination represent rural and urban mothers, and white, black, and Hispanic mothers.
      • Some evidence emerged of bias in recruitment, baseline differences, and attrition. However, the potential bias was modest and moderated by appropriate controls for covariates.

      Mejdoubi et al. (2013, 2014)

      • High rate of attrition and large differences in attrition rates for intervention and control groups.

      Robling et al. (2015)

      • Some significant differences in attrition by condition
      • No significant effects on primary outcomes, but some small positive effects in secondary outcomes
      • Possible iatrogenic effect in higher rate of ER attendance or admission after birth among treatment group than control group

      Sierau et al. (2016)

      • Some child measures were reported by mothers, who participated in the program
      • Possible problem with loss of subjects for intent-to-treat analysis
      • Lower SES households (younger, lower income, and experienced foster care placement) were more likely to drop out of the study
      • No effect on main child development outcomes and only marginal effects on family environment and mother competencies

      A review of other pregnancy and infancy home visitation programs suggest that many do not work. The more successful programs focus their services on families at greater risk and use nurses who visit frequently, beginning during pregnancy (Olds and Kitzman, 1990; Olds and Kitzman, 1993). There is no convincing evidence that paraprofessionals can be used with significant success.

      References

      Olds, D. L., and Kitzman, H. (1993). Review of research on home visiting for pregnant women and parents of young children. The Future of Children: Home Visiting, 3, 53-92.

      Olds, D. L., and Kitzman, H. (1990). Can home visitation improve the health of women and children at environmental risk? Pediatrics, 86, 108-116.

      • Blueprints: Model
      • Coalition for Evidence-Based Policy: Top Tier
      • Crime Solutions: Effective
      • OJJDP Model Programs: Effective
      • SAMHSA: 3.2-3.5

      For Information on Peer Sites, Contact:
      Michelle Neal, MS, RN
      Colorado Program Director, Nurse-Family Partnership
      1775 Sherman Street, Suite 2075
      Denver, CO 80203
      303.839.1808 ext. 101
      mneal@iik.org

      Eckenrode, J., Campa, M., Luckey, D. W., Henderson, C. R., Cole, R., Kitzman, H., ... Olds, D. (2010). Long-term effects of prenatal and infancy nurse home visitation on the life course of youths: 19-year follow-up of a randomized trial. Archives of Pediatrics & Adolescent Medicine, 164, 9-15.

      Kitzman, H., Olds, D. L., Cole, R. E., Hanks, C. A., Anson, E. A., Arcoleo, K. J., ... Holmberg, J. R. (2010). Enduring effects of prenatal and infancy home visiting by nurses on children: Follow-up of a randomized trial among children at age 12 years. Archives of Pediatrics & Adolescent Medicine, 164(5), 412-418.

      Kitzman, H., Olds, D. L., Henderson, C. R., Hanks, C., Cole, R., Tatelbaum, R., ... Barnard, K. (1997). Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing. Journal of the American Medical Association, 278(8), 644-652.

      Mejdoubi, J., van den Heijkant, S. C. C. M., van Leerdam, F. K. M., Heymans, M. W., Hirasing, R. A., & Crijnen, A. A. M. (2013). Effect of nurse home visits vs. usual care on reducing intimate partner violence in young high-risk pregnant women: A randomized controlled trial. PLOS One. DOI: 10.1371/journal.pone.007818.

      Mejdoubi, J., van den Heijkant, S. C. C. M., van Leerdam, F. K. M., Crone, M., Crijnen, A., & Hirasing, R. A. (2014). Effects of nurse home visitation on cigarette smoking, pregnancy outcomes and breastfeeding: A randomized controlled trial. Midwifery 30, 688-695.

      Olds, D. L., Eckenrode, J., Henderson, C. R., Kitzman, H., Powers, J., Cole, R., ... Luckey, D. (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect: 15-year follow-up of a randomized trial. Journal of the American Medical Association, 278(8), 637-643.

      Olds, D. L., Henderson, C. R., Cole, R., Eckenrode, J., Kitzman, H., Luckey, D., ... Powers, J. (1998). Long-term effects of nurse home visitation on children's criminal and antisocial behavior: 15-year follow-up of a randomized controlled trial. Journal of the American Medical Association, 280(14),1238-1244.

      Olds, D. L., Henderson, C. R., & Kitzman, H. (1994). Does prenatal and infancy nurse home visitation have enduring effects on qualities of parental caregiving and child health at 25 to 50 months? Pediatrics, 93, 89-98.

      Olds, D. L., Henderson, C. R., Chamberlin, R., & Tatelbaum, R. (1986). Preventing child abuse and neglect: A randomized trial of nurse home visitation. Pediatrics, 78, 65-78.

      Olds, D. L., Henderson, C. R., Tatelbaum, R., & Chamberlin, R. (1986). Improving the delivery of prenatal care and outcomes of pregnancy: A randomized trial of nurse home visitation. Pediatrics, 77,16-28.

      Olds, D. L., Kitzman, H., Cole, R., Hanks, C., Arcoleo, K., Anson, E., ... Stevenson, A. (2010). Enduring effects of prenatal and infancy home visiting by nurses on maternal life course and government spending: Follow-up of a randomized trial among children at age 12 years. Archives of Pediatrics & Adolescent Medicine, 164(5), 419-424.

      Olds, D. L., Kitzman, H., Cole, R., Robinson, J., Sidora, K., Luckey, D. W., ... Holmberg, J. (2004). Effects of nurse home visiting on maternal life course and child development: Age 6 follow-up results of a randomized trial. Pediatrics, 114, 1550-1559.

      Olds, D. L., Kitzman, H., Hanks, C., Cole, R., Anson, E., Sidora-Arcoleo, K., ... Bondy, J. (2007). Effects of Nurse Home Visiting on maternal and child functioning: Age 9 follow-up of a randomized trial. Pediatrics, 120, 832-845.

      Olds, D. L., Kitzman, H., Knudtson, M. D., & Anson, E. (2014). Effect of home visiting by nurses on maternal and child mortality: Results of a 2-decade follow-up of a randomized clinical trial. JAMA, 472, E1-E7. Published online July 7, 2014.

      Olds, D. L., Robinson, J., O'Brien, R., Luckey, D. W., Pettitt, L. M., Henderson, C. R., ... Talmi, A. (2002). Home visiting by paraprofessionals and by nurses: A randomized, controlled trial. Pediatrics, 110, 486-496.

      Olds, D. L., Robinson, J., Pettitt, L., Luckey, D. W., Holmberg, J., Ng, R. K., ... Henderson Jr., C. R. (2004). Effects of home visits by paraprofessionals and by nurses: Age 4 follow-up results of a randomized trial. Pediatrics, 114, 1560-1568.

      Robling, M., Bekkers, M.-J., Bell, K., Butler, C. C., Cannings-John, R., Channon, S., ... Torgerson, D. (2015). Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): A pragmatic randomized controlled trial. The Lancet, published online 14 October 2015.

      Sierau, S., Dähne, V., Brand, T., Kurtz, V., von Klitzing, K., & Jungmann, T. (2016). Effects of home visitation on maternal competencies, family environment, and child development: A randomized controlled trial. Prevention Science, 17, 40-51.

      Nurse-Family Partnership National Service Office
      1900 Grant Street, Suite 400
      Denver, Colorado 80203
      Direct phone: 303-327-4240
      Toll free: 866-864-5226
      Fax: 303-327-4260
      email: info@nursefamilypartnership.org
      www.nursefamilypartnership.org/

      Study 1 - Elmira, NY

      Eckenrode, J., Campa, M., Luckey, D. W., Henderson, C. R., Cole, R., Kitzman, H., ... Olds, D. (2010). Long-term effects of prenatal and infancy nurse home visitation on the life course of youths: 19-year follow-up of a randomized trial. Archives of Pediatrics & Adolescent Medicine, 164, 9-15.

      Olds, D. L., Eckenrode, J., Henderson, C. R., Kitzman, H., Powers, J., Cole, R., ... Luckey, D. (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect: 15-year follow-up of a randomized trial. Journal of the American Medical Association, 278(8), 637-643.

      Olds, D. L., Henderson, C. R., Chamberlin, R., & Tatelbaum, R. (1986). Preventing child abuse and neglect: A randomized trial of nurse home visitation. Pediatrics, 78, 65-78.

      Olds, D. L., Henderson, C. R., Cole, R., Eckenrode, J., Kitzman, H., Luckey, D., ... Powers, J. (1998). Long-term effects of nurse home visitation on children's criminal and antisocial behavior: 15-year follow-up of a randomized controlled trial. Journal of the American Medical Association, 280(14), 1238-1244.

      Olds, D. L., Henderson, C. R., & Kitzman, H. (1994). Does prenatal and infancy nurse home visitation have enduring effects on qualities of parental caregiving and child health at 25 to 50 months? Pediatrics, 93, 89-98.

      Olds, D. L., Henderson, C. R., Tatelbaum, R., & Chamberlin, R. (1986). Improving the delivery of prenatal care and outcomes of pregnancy: A randomized trial of nurse home visitation. Pediatrics, 77,16-28.

      Study 2 - Denver, CO

      Olds, D. L., Robinson, J., O'Brien, R., Luckey, D. W., Pettitt, L. M., Henderson, C. R., ... Talmi, A. (2002). Home visiting by paraprofessionals and by nurses: A randomized, controlled trial. Pediatrics, 110, 486–496.

      Olds, D. L., Robinson, J., Pettitt, L., Luckey, D. W., Holmberg, J., Ng, R. K., ... Henderson Jr., C. R. (2004). Effects of home visits by paraprofessionals and by nurses: Age 4 follow-up results of a randomized trial. Pediatrics, 114, 1560-1568.

      Study 3 - Memphis, TN

      Kitzman, H., Olds, D. L., Cole, R. E., Hanks, C. A., Anson, E. A., Arcoleo, K. J., ... Holmberg, J. R. (2010). Enduring effects of prenatal and infancy home visiting by nurses on children: Follow-up of a randomized trial among children at age 12 years. Archives of Pediatrics & Adolescent Medicine, 164(5), 412-418.

      Kitzman, H., Olds, D. L., Henderson, C. R., Hanks, C., Cole, R., Tatelbaum, R., ... Barnard, K. (1997). Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing. Journal of the American Medical Association, 278(8), 644-652.

      Olds, D. L., Kitzman, H., Cole, R., Hanks, C., Arcoleo, K., Anson, E., ... Stevenson, A. (2010). Enduring effects of prenatal and infancy home visiting by nurses on maternal life course and government spending: Follow-up of a randomized trial among children at age 12 years. Archives of Pediatrics & Adolescent Medicine, 164(5), 419-424.

      Olds, D. L., Kitzman, H., Cole, R., Robinson, J., Sidora, K., Luckey, D. W., ... Holmberg, J. (2004). Effects of nurse home visiting on maternal life course and child development: Age 6 follow-up results of a randomized trial. Pediatrics, 114, 1550-1559.

      Olds, D. L., Kitzman, H., Hanks, C., Cole, R., Anson, E., Sidora-Arcoleo, K., ... Bondy, J. (2007). Effects of nurse home visiting on maternal and child functioning: Age 9 follow-up of a randomized trial. Pediatrics, 120, 832-845.

      Olds, D. L., Kitzman, H., Knudtson, M. D., & Anson, E. (2014). Effect of home visiting by nurses on maternal and child mortality: Results of a 2-decade follow-up of a randomized clinical trial. JAMA, 472, E1-E7. Published online July 7, 2014.

      Elmira, New York

      Eckenrode, J., Campa, M., Luckey, D. W., Henderson, C. R., Cole, R., Kitzman, H., Anson, El. Sidora-Arcoleo, K., Powers, J., & Olds, D. (2010). Long-term effects of prenatal and infancy nurse home visitation on the life course of youths: 19-year follow-up of a randomized trial. Archives of Pediatrics & Adolescent Medicine, 164, 9-15.

      Olds, D. L., Henderson, C. R., Cole, R., Eckenrode, J., Kitzman, H., Luckey, D., Pettitt, L. Sidora, K., Morris, P., & Powers, J. (1998). Long-term effects of Nurse Home Visitation on children's criminal and antisocial behavior: 15-year follow-up of a randomized controlled trial. Journal of the American Medical Association, 280(14), 1238-1244.

      Olds, D. L., Eckenrode, J., Henderson, C. R., Kitzman, H., Powers, J., Cole, R. Sidora, K., Morris, P., Pettit, L. M., & Luckey, D. (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect: 15-year follow-up of a randomized trial. Journal of the American Medical Association, 278(8), 637-643.

      Olds, D. L., Henderson, C. R., & Kitzman, H. (1994). Does prenatal and infancy nurse home visitation have enduring effects on qualities of parental caregiving and child health at 25 to 50 months. Pediatrics, 93, 89-98.

      Olds, D. L., Henderson, C. R., Tatelbaum, R., & Chamberlin, R. (1986). Improving the delivery of prenatal care and outcomes of pregnancy: A randomized trial of nurse home visitation. Pediatrics, 77,16-28.

      Olds, D. L., Henderson, C. R., Chamberlin, R., & Tatelbaum, R. (1986). Preventing child abuse and neglect: A randomized trial of nurse home visitation. Pediatrics, 78, 65-78.

      Evaluation Methodology

      Design: A randomized, clinical trial was conducted beginning in April 1978. Pregnant women were recruited from private obstetric offices and a free antepartum clinic in the Appalachian region of New York State. Five hundred women were invited to participate in the study and 400 women (80%) were successfully recruited. The sample was stratified on the basis of marital status and race, and participants were randomly assigned to one of four treatment groups. Families in Treatment 1 (n = 94) received sensory and developmental screening for the child at 12 and 24 months of age. Based upon these screenings, children were referred for further clinical evaluation and treatment when needed. Families in Treatment 2 (n = 90) were provided with the screening services offered to those in Treatment 1, plus free transportation for prenatal and well-child care though the child's second birthday. There were no differences between Treatments 1 and 2 in their use of prenatal and well-child care; therefore these two groups were combined to form a single comparison group. Families in Treatment 3 (n = 100) received the screening and transportation services offered to Treatment 2, but in addition were provided a nurse who visited them at home during pregnancy. Families in Treatment 4 (n = 116) were provided the same services as those in Treatment 3, with continued visits until the infants were 18 to 24 months of age.

      Five registered nurses were hired though a non-profit private agency expressly for this experimental program. Each nurse had a caseload of 20-25 families and received regular clinical supervision.

      Sample: The sample consisted of 400 women, roughly 80% of those invited to participate. Of these women, 85% were either low-income, unmarried, or teenaged, and none had a previous live birth. Eighty-nine percent of the sample was White. Sample retention for the 15-year follow-up study was over 90% of the women originally assigned to treatment conditions for those cases where the mother or child had not died. The women in the four Treatment conditions were essentially equivalent on various measures after randomization.

      Measures: Interviews were carried out with participating women by project staff members at the time of registration in the project (prior to their assignment to treatments) and again at the 32nd week of pregnancy. At intake, the women were interviewed to determine their family structure, socioeconomic background, psychological characteristics, health conditions, health habits, the availability of informal support, and their child-rearing histories. At the 32nd week of pregnancy, they were interviewed regarding their use of other health and human services, the support provided to them by significant persons in their informal networks, and their health habits.

      Dietary intake was measured at both assessment periods, using 24-hour diet records and 24-hour recalls. For 74% of the sample, dietary data were gathered for two consecutive 24-hour periods at each assessment period; for an additional 14% of the sample, data were available for a single 24-hour period. These data were aggregated into a nutrient-adequacy ratio which converted the intake of 12 nutrients into a summary of percentages of Recommended Dietary Allowances.

      Serum cotinine assays were done to validate the women's reported level of smoking. Serum was derived from blood samples drawn routinely at the patients' registration in the clinic and at approximately the 36th week of pregnancy. Cotinine levels were determined by radioimmunoassay.

      Estimates of length of gestation gave priority to newborn physical and neurological examinations and to ultrasound readings taken before the 28th week of pregnancy. Reported last menstrual periods and measurements of uterine size made before 20 weeks were used when newborn examination and ultrasound data were not available. The gestational age of all low-birth-weight babies was estimated from the newborn physical examination findings.

      Analysis: For all analyses, a core statistical model was derived that consisted of a 2 X 2 X 2 X 2 factorial structure. This model was extended to include a repeated-measures structure for dependent variables measured both early and late in pregnancy. Treatments 1 and 2 were combined for purposes of analysis after it was determined that there were no differences between these two groups in their use of routine prenatal care. Treatments 3 and 4 were also combined for the prenatal analysis because they were identical during this phase of the research.

      Outcomes

      Posttest: Outcomes of Pregnancy:

      Formal and Informal Support Systems: By the end of pregnancy, nurse-visited women were aware of more community services, attended childbirth education classes more frequently, received more WIC vouchers, reported that they talked more frequently with service providers and members of their informal networks about the stresses of pregnancy and family life, indicated that their babies' fathers showed a greater interest in their pregnancies, and were accompanied by someone to the labor room more often than women in the comparison group.

      Maternal Obstetrical Conditions and Health Habits: Nurse-visited women had fewer kidney infections after enrollment than comparison women, greater improvements in the quality of their diets from registration to the 32nd week of pregnancy, and nurse-visited smokers made greater reductions in their smoking than smokers assigned to the comparison group.

      Birth Weight and Length of Gestation: No significant treatment effects were noted for birth weight or length of gestation, but the nurse-visited women gave birth to babies who were an average of 395g heavier than those in the comparison group. There was a 75% reduction in the incidence of preterm delivery among smokers; however, nurse-visited older nonsmokers gave birth to infants of shorter gestations.

      Child Abuse and Neglect: First Two Years of Life: During the first two years of the children's lives, the nurse-visited women at highest risk (poor, unmarried teens) had abused or neglected their children less than the comparison group (4% vs. 19% respectively). Although the treatment effects were not statistically significant in other groups less at risk, these effects were in the same direction. Nurse-visited women reported that their babies had more positive moods, but more frequent episodes of resisting eating. They also reported greater concern about infants' behavioral problems than did women in the control group. Within the group at greatest risk (poor, unmarried teens), the nurse-visited women punished and restricted their children less at 10 and 22 months of age and provided a larger number of play materials than the comparison group. Developmental quotients of children of the poor, unmarried nurse-visited teens were higher at 12 and 24 months of life than were those in the comparison group. Babies of nurse-visited women were seen less in emergency rooms during the first and second years of life, and presented with fewer accidents and poisonings than their counterparts.

      Enduring Effects at 25 to 50 Months: Homes of nurse-visited families had fewer hazards for children at 34 and 46 months; however, there were no program differences on the extent to which mothers kept poisonous substances out of children's reach and children rode in cars with child safety restraints. Nurse-visited children had 40% fewer notations of injuries and ingestions and 45% fewer notations of child behavioral/parental coping problems in physicians' records, and 35% fewer visits to the emergency room. No treatment differences were noted in interviewers' ratings of mothers' warmth or control, but at the 34th month observation, nurse-visited women were rated as more involved with their children. Nurse-visited women punished their children more frequently than did comparison group women. During the first four years after delivery, nurse-visited women who had not completed high school returned to school more rapidly (although there were no treatment differences in educational attainment at 46 months postpartum); nurse-visited women who were poor and unmarried were employed 82% more of the time, had 43% fewer subsequent pregnancies, and delayed the birth of their second child an average of 12 months longer.

      Long-Term:

      15-Year Follow-up:
      Adolescents were age 15. At the 15 year follow-up of the Elmira subjects, 81% of the original 400 randomized cases had completed assessments. Sources of data and measures included women's use of welfare, number of subsequent children, and arrests derived from self report. Verified reports of child abuse and neglect were abstracted from state records. The adolescents' arrests, convictions, and delinquent behavior were based on self report. Treatment contrasts were between the combination of Treatments 1 and 2 (the comparison group) with Treatment 4 (the pregnancy and infancy nurse-visited group).

      Rates of Subsequent Births, Use of AFDC, Substance Use Impairment, and Arrests: Nurse-visited women had 0.3 fewer subsequent children.

      High-risk Sample: Among high-risk women (unmarried and low SES), nurse-visited unmarried women from low socioeconomic status households had 0.7 fewer subsequent pregnancies, 0.5 fewer subsequent children, and the spacing between first and second births was 30 months longer than did women in the comparison group. They also reported using AFDC 30 fewer months than did unmarried, low socioeconomic status women in the comparison group, and reported 43% fewer instances of their being functionally impaired by alcohol or drugs. Additionally, the nurse-visited low-income, unmarried women reported having been arrested 69% fewer times, having been convicted of crimes 74% fewer times and having spent 96% fewer days in jail than did comparison group women.

      Rates of Child Abuse and Neglect: Nurse-visited mothers reported 58% fewer substantiated reports (frequency) of child abuse or neglect than did mothers in the comparison group. Among the high-risk subsample, there was an 86% reduction in child abuse or neglect. When child abuse or neglect was expressed as a dichotomous variable, there was a treatment effect for the high-risk subsample (17% of the Treatment 4 nurse-visited children had been abused or neglected at least once vs. 37% of the comparison group children). In addition, Eckenrode et al. (2017) examined official reports of child maltreatment from Child Protective Services for a subsample of respondents that had low to moderate levels of self-reported domestic violence (N =251). For this subsample, they found that the program effect on child maltreatment at the 15-year follow-up was significantly mediated by months on public assistance and the number of subsequent births.

      Children's Rates of Arrests, Conviction, and Delinquency: There were 52% fewer arrests for the nurse-visited children born to women who were unmarried and from low SES households. Adolescents of nurse-visited mothers who were unmarried and from low SES households reported smoking cigarettes 21% fewer times during the six-month period prior to the 15 year interview.

      19-year followup:

      Assessments were completed on 310 youths (78% of the original sample). There were no differences in treatment grouping by mother's race, marital status, age, education, or SES; or child's sex at the 19-year follow-up.

      Nurse-visited girls were less likely to have ever been arrested or convicted and had fewer lifetime arrests and convictions than their counterparts in the comparison condition. Nurse-visited girls risk of age at first arrest was also smaller than their counterparts. The treatment effect for rate of arrests was concentrated in mid-adolescence (i.e., control girls rates declined in later adolescence and they caught up with the nurse-visited girls).

      There were no program effects on youths' self-reported criminal behavior or their use of alcohol or illegal drugs, high school graduation, economic productivity, number of sexual partners, use of birth control, teen pregnancy or childbearing, and use of welfare, food stamps, or Medicaid.

      Nurse-visited girls born to unmarried and low-income mothers had fewer children and less Medicaid use than their comparison group counterparts.

      Brief Bulleted Outcome s

      • Improvements in women's prenatal health, such as reductions in hypertensive disorders and use of cigarettes
      • Reductions in children's health-care visits for injuries
      • Fewer unintended subsequent pregnancies, and increases in the interval between first and second births
      • Increases in women's employment coupled with reductions in the use of welfare and food stamps
      • More responsive interaction between mother and child
      • At 6 months, infants were less likely to exhibit emotional vulnerability in response to fear stimuli
      • Nurse-visited children of women with low psychological resources were significantly less likely to display low emotional vitality in response to joy and anger stimuli
      • At 21 months, nurse-visited children were significantly less likely to exhibit language delays than children in the control group
      • During the first two years of children's lives, women at highest risk had abused or neglected their child less than the comparison group (4% vs. 19%)
      • Nurse-visited children born to women with low psychological resources also had superior average language and mental development in contrast to control-group counterparts.
      • Married or cohabiting women reported experiencing less domestic violence at 48 months.
      • Children born to women with low psychologic resources demonstrated better language development, executive functioning, and behavioral adaptation to testing at 48 months.

      15-year follow-up:

      • 79% reduction in child abuse and neglect
      • 44% reduction in maternal behavioral problems caused by the mothers' use of alcohol or drugs
      • 69% fewer arrests among the mothers
      • 54% fewer arrests and 69% fewer convictions among the 15-year-olds
      • 58% fewer sexual partners among the 15-year-olds
      • 28% fewer cigarettes smoked and 51% fewer days consuming alcohol among the 15-year-olds

      19-Year Followup:

      • Girls were less likely to have been arrested (10% vs. 30% relative risk) and convicted (4% vs. 20%) than controls
      • Girls had fewer lifetime arrests (mean 0.10 vs. 0.54) and convictions (0.04 vs. 0.37) than controls

      Limitations

      • Some evidence of baseline differences emerged between groups on sense of control among unmarried women and partner support, two variables then used as covariates in the models.
      • Some evidence of differential attrition emerged from the 4-year assessment. Dropouts in the intervention group had a higher mean sense of control and higher mean education than dropouts in the control group. However, the intervention group began with a stronger sense of control, and the sample of completers showed similarity on baseline measures.
      • Although baseline equivalence figures appear similar for the 15-year and 19-year follow-ups, the studies do not report significance tests.
      • Some (though not all) of the tests using Poisson regression in the 15-year follow-up overstated the significance of the intervention.
      • Many of the results were found only in the subgroup of women who were at the highest risk (unmarried and low SES).
      • By itself, the largely white and rural sample lacks generalizability.

      Denver

      Olds, D. L., Robinson, J., O'Brien, R., Luckey, D. W., Pettitt, L. M., Henderson, C. R., Ng, R. K., Sheff, K. L., Korfmacher, J., Hiatt, S., & Talmi, A. 2002. Home visiting by paraprofessionals and by nurses: A randomized, controlled trial. Pediatrics, 110, 486-496.

      Olds, D. L., Robinson, J., Pettitt, L., Luckey, D. W., Holmberg, J., Ng, R. K., Isacks, K., Sheff, K., & Henderson Jr., C. R. (2004). Effects of home visits by paraprofessionals and by nurses: Age 4 follow-up results of a randomized trial.Pediatrics, 114, 1560-1568.

      Evaluation Methodology

      Design: A three-armed randomized trial (control, paraprofessional home visits and nurse home visits) was conducted. 1178 consecutive women from 21 antepartum clinics serving low-income women in Denver were invited to participate in the study. Once accepted into the program, women were randomly assigned to either a nurse visitation group, a paraprofessional visitation group, or a control group. Women in the nurse group (n = 235) were provided developmental screening and referral services for their children at 6, 12, 15, 21, and 24, months of age plus nurse home visitation during pregnancy and infancy. Women assigned to the paraprofessional group (n = 245) received the screening and referral services plus paraprofessional home visitation during pregnancy and infancy. Women in the control group (n = 255) received the developmental screening and referral services. Visit-by-visit guidelines and detailed objectives provided direction for each nurse and paraprofessional visit. The visitors adapted the program to better suit the needs and interests of the participating families. No specific information was provided as to the content, frequency, or duration of visits. Nurses assisting with the study were required to have BSN degrees and experience in community or maternal and child health nursing. Paraprofessionals were required to have a high school education but were excluded from participation in the study if they had college preparation in the helping professions or a bachelor's degree in any discipline. Each visitor managed an average caseload of 25 families.

      Sample: Seven hundred thirty-five women were successfully recruited for participation in the study. Women were recruited if they had no previous live births and either qualified for Medicaid or had no private health insurance. This program specifically targeted Hispanic and African American women and their children. Women were allowed to enroll at any time prior to delivery. All participants completed informed consent procedures.

      Measures:
      Baseline Assessments: At registration, baseline interviews were conducted with all participants in order to determine their socioeconomic conditions, mental health, personality characteristics, obstetric histories, psychoactive drug use, conflict with partners, conflict with their own mothers, and experience of domestic violence. Highly sensitive questions were asked via a tape recorder with headphones to increase response accuracy. Women also completed brief tests to measure intellectual functioning and provided urine samples to be analyzed using gas chromatography/mass spectrometry for chemical markers for nicotine, marijuana, and cocaine. Women were designated as smokers if their creatinine-adjusted cotinine values were greater than or equal to 80 ng/mL at intake.

      A variable was created to index women's psychological resources measured at registration and based on the averaged z scores of their: 1) mental health, 2) sense of mastery, and 3) intelligence. The sample was thus split into low (40%) and higher (60%) functioning groups. After completion of the baseline interviews, identifying information on the participants was sent to the data operations office where individuals were randomized into treatment conditions via a computer program. Women assigned to one of the two home visitation groups were subsequently assigned at random to home visitors responsible for their geographic region.

      End-Of Pregnancy Assessments: Participants were interviewed at 36 weeks of gestation in the study office to assess their health-related behaviors, including use of psychoactive drugs and use of ancillary preventive and emergency services. Urine was again collected in order to test for the chemical markers for nicotine, marijuana, and cocaine. Change in tobacco use from intake to 36 weeks was measured by change in creatinine-adjusted cotinine among those designated as smokers at intake.

      Maternal Life Course: Participants were interviewed at 12, 15, 21, 24, and 48 months postpartum to assess their number and timing of any subsequent pregnancies; and at 24 and 48 months to assess educational achievement, participation in the workforce, and use of welfare. At the 48-month in-home assessment, mothers also were asked whether they had been married or cohabitating, and, for women who lived with a partner during the two-year period before the interview, whether they had experienced physical violence during the two-year and six-month periods preceding the interview. Variables were constructed to reflect years of education completed and number of months women were in the workforce and used welfare during the 1- to 12-month and 13- 24-month periods.

      Mother-Infant Interaction and Quality of the Home Environment: Mother-infant interaction was videotaped at all postpartum assessments. Responsive Interaction was standardized at each assessment to a mean of 100 and a standard deviation of 10. Infants' home environments were rated at 12, 21, and 48 months.

      Child Emotional, Mental, and Behavioral Development: At six months of age, infants' emotional reactivity and looking at mother were videotaped in the laboratory and coded separately for their responses to stimuli designed to elicit fear, joy, and anger. Emotional vulnerability was defined as high distress reactions to fear stimuli coinciding with limited efforts by the infants to look at or seek assistance or comfort from their mothers. Emotional vitality was defined as the lively expression of joyful and angry affect that was shared with others.

      Children's language development was tested at 21 months in their homes and their mental development was tested using the Mental Development Index (MDI) at 24 months in the laboratory. Children with language scores below 85 were classified as delayed and children with MDI scores below 77 were classified as developmentally delayed. At 48 months, children were assessed in their homes using the Preschool Language Scales and with a series of cognitive tasks focusing primarily on the children's capacity for sustained attention and inhibitory control. Mothers reported on children's irritability at six months and their externalizing behavior problems at 24 and 48 months.

      Analysis: Data analyses were conducted on all cases for which outcome data were available. The primary statistical model consisted of treatments (three levels), maternal psychological resources (high vs. low), and the interaction between these two classification factors. In addition, five covariates were included to control for nonequivalence among the treatment groups at intake: maternal age, housing density, whether the mother registered in the study after 28 weeks of gestation, maternal conflict with her partner, and maternal conflict with her mother. The treatment groups were similar at baseline.

      Outcomes

      A total of 560 mothers completed the 24-month child assessments (Nurse n = 168; Paraprofessional n = 188; and Control n = 204). Nurse-visited women had lower rates of completed assessments than did women in the control group at each postpartum assessment period, although the pattern of baseline differences between nurse-visited and control group women on whom assessments were not conducted by child age two indicated that the nurse-visited women were higher functioning than their control group counterparts.

      Paraprofessional Program: Paraprofessional-visited mother-child pairs in which the mother had low psychological resources interacted with one another significantly more responsively than did their control group counterparts. No other significant effects were found for the paraprofessional group, although there were trends toward mothers in the paraprofessional group reducing subsequent pregnancies and births as well as to delay subsequent pregnancies.

      Nurse Program: Nurse-visited smokers had significantly greater reductions in the chemical markers for nicotine from intake to the end of pregnancy than did their control group counterparts. In addition, nurse visited women had significantly longer intervals between their next conception than did women in the control group. Women visited by nurses also were employed longer during the second year after giving birth than were control women.

      Nurse visited mother-infant pairs interacted with one another more responsively than did control pairs. At six months of age, nurse-visited infants were significantly less likely to exhibit emotional vulnerability in response to fear stimuli than were control group infants, and nurse-visited children of women with low psychological resources were significantly less likely to display low emotional vitality in response to joy and anger stimuli. At 21 months, nurse visited children were significantly less likely to exhibit language delays than children in the control group (this effect was concentrated among children whose mothers had low psychological resources). Nurse-visited children born to women with low psychological resources also had superior average language and mental development in contrast to control-group counterparts.

      For most of the outcomes, paraprofessional visitation effects were approximately half the size of those produced by nurse visitation, although the only significant difference between the two groups was that nurse-visited children born to mothers with low psychological resources demonstrated significantly superior language development than did their paraprofessional-visited counterparts.

      Long-term:

      At the 48-month follow-up, rates of completed assessments were high and equivalent across treatment conditions. Interviews were conducted with mothers in 86% of the cases randomized and 91% of those in which the child was alive and not adopted. Direct assessments of children were completed in 82% of the cases randomized and 87% of those in which the child was alive and not adopted.

      Paraprofessional Program: Two years after the end of the program, women visited by paraprofessionals were less likely to be married or live with the child's biological father than were women in the control group. Women visited by paraprofessionals worked significantly more between child age two and four and had a greater sense of mastery and better mental health than their control group counterparts. Although there were no significant effects on rates or timing of subsequent pregnancies and birth, when a subsequent pregnancy did occur, paraprofessional-visited women were significantly less likely than control women to have a low birth weight newborn.

      Paraprofessional-visited mother-child pairs displayed more sensitive and responsive interactions during free-play evaluations than did pairs in the control group. Families in which mothers had low psychologic resources at registration had home environments significantly more supportive of early learning, compared with control group counterparts.

      Nurse Program: Nurse-visited women, compared with control women, had significantly greater intervals between the births of their first and second children when a second birth occurred. Nurse-visited women also reported less domestic violence from partners during the six-month interval before the four-year interview. In addition, nurse-visited women also reported enrolling their children less frequently in preschool, Head Start, or licensed day care as compared with women in the control group.

      Nurse-visited children born to women with low psychologic resources, compared with control group counterparts, had home environments more conducive to early learning, better language development, superior executive functioning, and better behavioral adaptation during testing.

      Outcomes - Brief Bullets

      Paraprofessional-visited women:

      • More responsive interaction between mother and child
      • Trends toward reducing subsequent pregnancies
      • Greater participation in the work force, better sense of mastery, mental health, and mother-child interaction at 48 months.
      • Mothers with low psychologic resources provided home environments that were more supportive of early learning at 48 months.

      Nurse-visited women:

      • Reductions in maternal cigarette smoking
      • Reductions in subsequent pregnancies at 24 months
      • Longer periods of maternal employment in the year after birth
      • More responsive interaction between mother and child
      • At 6 months, infants were less likely to exhibit emotional vulnerability in response to fear stimuli
      • Nurse-visited children of women with low psychological resources were significantly less likely to display low emotional vitality in response to joy and anger stimuli
      • At 21 months, nurse-visited children were significantly less likely to exhibit language delays than children in the control group
      • Nurse-visited children born to women with low psychological resources also had superior average language and mental development in contrast to control-group counterparts.
      • Longer intervals between births at 48 months.
      • Married or cohabiting women reported experiencing less domestic violence at 48 months.
      • Children born to women with low psychologic resources demonstrated better language development, executive functioning, and behavioral adaptation to testing at 48 months.

      Generalizability

      The Denver study is an expansion of the original study in Elmira, NY which drew its sample from an almost exclusively white, rural population. The Denver study targeted inner-city Hispanic and African American women in order to explore the effectiveness of home visitation with paraprofessionals and nurses on a racially and ethnically diverse sample. The results should generalize easily to similar inner-city populations.

      Limitations

      • Some evidence emerged of bias in 1) recruitment (e.g., smokers were less likely to agree to participate), 2) baseline differences (e.g., maternal age, relationship conflict), and 3) attrition (e.g., dropouts from the intervention group tended to be higher functioning). However, appropriate controls for covariates were used to adjust for these potential sources of error.

      Memphis

      Kitzman, H., Olds, D. L., Cole, R. E. Hanks, C. A., Anson, E. A., Arcoleo, K. J., Luckey, D. W., Knudtson, M. D., Henderson Jr., C. R., & Holmberg, J. R. (2010). Enduring effects of prenatal and infancy home visiting by nurses on children: Follow-up of a randomized trial among children at age 12 years. Archives of Pediatrics & Adolescent Medicine, 164(5), 412-418.

      Kitzman, H, Olds, D. L., Henderson, C. R., Hanks, C., Cole, R. Tatelbaum, R., McConnochie, K. M., Sidora, K., Luckey, D. W., Shaver, D., Englehardt, K., James, D., & Barnard, K. (1997). Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing. Journal of the American Medical Association, 278(8), 644-652.

      Olds, D. L., Kitzman, H., Cole, R., Hanks, C., Arcoleo, K., Anson, E., Luckey, D., Knudtson, M., Henderson, C., Bondy, J., & Stevenson, A. (2010). Enduring effects of prenatal and infancy home visiting by nurses on maternal life course and government spending: Follow-up of a randomized trial among children at age 12 years. Archives of Pediatrics & Adolescent Medicine, 164(5), 419-424.

      Olds, D. L., Kitzman, H., Cole, R., Robinson, J., Sidora, K., Luckey, D. W., Henderson, Jr., C. R., Hanks, C., Bondy, J., & Holmberg, J. (2004). Effects of nurse home visiting on maternal life course and child development: Age 6 follow-up results of a randomized trial. Pediatrics, 114, 1550-1559.

      Olds, D. L., Kitzman, H., Hanks, C., Cole, R., Anson, E., Sidora-Arcoleo, K., Luckey, D. W., Henderson, C. R., Holmberg, J., Tutt, R. A., Stevenson, A. J., & Bondy, J. (2007). Effects of Nurse Home Visiting on maternal and child functioning: Age 9 follow-up of a randomized trial. Pediatrics, 120, 832-845.

      Olds, D. L., Kitzman, H., Knudtson, M. D., & Anson, E. (2014). Effect of home visiting by nurses on maternal and child mortality: Results of a 2-decade follow-up of a randomized clinical trial. JAMA, 472, E1-E7. Published online July 7, 2014.

      Evaluation Methodology

      Design: The Memphis trial was designed to determine if the effects of the Elmira program could be replicated through an existing health department with a large sample of low-income African American women, children, and their families living in a major urban area. The program was conducted through the Memphis/Shelby County Health Department. A randomized trial was conducted. 1,290 low-income women were recruited for participation in the study. Once accepted into the program, baseline interviews were performed and women were randomly assigned to one of four treatment groups. Women assigned to Treatment 1 (n = 166) were provided with free round-trip taxicab transportation for scheduled prenatal care appointments; they did not receive any postpartum services or child developmental assessments/screening. Women assigned to Treatment 2 (n = 515) received the free transportation for scheduled prenatal care plus developmental screening and referral services for the child at 6, 12, and 24 months of age. Women assigned to Treatment 3 (n = 230) received the free transportation and screening offered those in Treatment 2 plus intensive nurse home visitation services during pregnancy, one postpartum visit in the hospital before discharge, and one postpartum visit in the home. Women assigned to Treatment 4 (n = 228) received the same services as those in Treatment 3; in addition, they continued to be visited by nurses through the child's second birthday. Interviews with participating women were carried out by research staff members at the time of registration (prior to their assignment to treatments), at the 28th and 36th weeks of pregnancy, and at the 6th, 12th, 24th, and 54th months of the child's life, and again near the child's 6th and ninth birthdays. Medical and social-service records were abstracted and teachers' reports of children's classroom behavior (primarily first grade) were also obtained. Of mothers who were randomly assigned and had no fetal or child death, follow-up assessments at child age 9 were completed with 91% of the mothers, school records were abstracted for 88% of the children, teacher report forms were completed for 81% of the sample, and achievement-test scores were abstracted for 83%. For the evaluation of the prenatal phase of the program, Treatments 1 and 2 were combined to form a single comparison group which was then contrasted with Treatments 3 and 4, a group that had nurse visitors during pregnancy. For the postnatal phase of the study, Treatment 2 was contrasted with Treatment 4.

      Sample: From June 1990 through August 1991, 1,290 low-income women who were less than 29 weeks of gestation were recruited form the obstetrical clinic at the Regional Medical Center in Memphis. Approximately 1,089 women (88% of those recruited) enrolled in the study. Ninety-two percent of the women were African American, 98% were unmarried, 64% were aged 18 or younger at registration, 85% came from households with incomes at or below the federal poverty guidelines, and 22% smoked cigarettes at registration. The treatment groups were similar with respect to background characteristics for the participants for whom 6-year follow-up assessments were conducted, with the following exceptions: at intake, nurse-visited women (treatment 4) had higher scores for child-rearing attitudes associated with child maltreatment and lived in households with less discretionary income and higher housing densities than did women in the comparison group (treatment 2). These differences suggest that the nurse-visited group had a greater proportion of at-risk families at child age 6 years, although the proportions of families for whom assessments were conducted were large and nearly equivalent across treatment conditions.

      Measures:
      Baseline Assessments: At registration, baseline interviews were conducted with all participants in order to determine their socioeconomic conditions, mental health, personality characteristics, obstetric histories, health related behaviors (cigarette smoking, alcohol and illegal drug use), and social support. Women also completed brief tests to estimate their levels of intellectual functioning. Women's pre-pregnancy weights and heights were also determined by self-report. The last weights recorded in the prenatal record prior to delivery were used to calculate pregnancy weight gains. Household per-annum discretionary income was calculated using subsistence standards for determining Medicaid eligibility in Tennessee, the number of individuals in the household, and reported household income. In addition, each participant was assigned a value that represented the percentage of poverty households in the census tract in which she resided.

      A variable was created to index women's psychological resources measured at registration and based on the averaged z scores of their: 1) intelligence, 2) mental health, and 3) sense of mastery/self efficacy. Self efficacy was assessed with a measure developed for the current study to determine mothers' confidence in their ability to behave in accordance with the major behavioral objectives of the program.

      Prenatal measures: Women were interviewed at the 28th week of gestation by phone to assess their health-related behaviors, social support, use of community services, and participation in school and work. Identical interviews were conducted at the 36th week. At the 36th week of gestation, women were also assessed to ascertain their mental health symptoms and their sense of mastery.

      Obstetrical and newborn records were abstracted directly and verified against an on-line perinatal database from the University of Tennessee.

      Urine screens for marijuana and cocaine were performed on 511 women who registered for prenatal care at the Regional Medical Center as part of their clinical assessment during the time that this trial was conducted.

      Urinary tract infections (UTIs) were recorded if a culture produced a colony count for a single uropathogen >100,000/ml of clean-catch voided urine. Diagnoses of pyelonephritis were recorded from the medical record. Cultures for Neisseria gonorrhea and Chlamydia trachomatis were obtained at the first prenatal visit and were coded from the prenatal record; as were additional STDs, infections, or Pregnancy-Induced Hypertension (PIH).

      Birth weight was recorded from the hospital record and gestational age was estimated from reported last menstrual period and ultrasound administered before the 26th week of gestation.

      Postpartum measures: Participants were interviewed in the study offices at 6 months postpartum to measure breast feeding practices and beliefs associated with child abuse and neglect.

      Maternal Life Course: Participants were interviewed at 12, 15, 21, 24, and 54 months postpartum and near the child's sixth and ninth birthdays to assess their number and timing of any subsequent pregnancies; and again at 24 months and near the child's sixth and ninth birthdays to assess educational achievement, participation in the workforce, and use of welfare and Medicaid. At the interview conducted at 54 months, women were asked whether their children attended Head Start, preschool programs, licensed day care, or early intervention programs. Near the child's sixth and ninth birthdays, women were also asked to report on their use of substances, any behavioral problems attributable to the use of substances, the number of times they had consumed three or more drinks of alcohol three or more times per month in the past year, use of marijuana. and use of cocaine since the last interview at child age 6, and the counts of maternal arrests and days jailed (age nine follow-up). Variables were constructed to reflect years of education completed and number of months women were in the workforce during the 1- to 12-month and 13- 24-month periods. The 54-month and six-year interviews also assessed rates of marriage and cohabitation, duration of women's current partnered relationships, current partners' education, employment and social class (based on their occupational codes), domestic violence since the birth of the first child, and whether the current male partner was the biological father of the child. The age nine follow-up assessed the counts of subsequent miscarriages, abortions, and low birth weight newborns; reported participation in the workforce; depression; whether they had experienced physical violence from any of their partners since their first child was 6; and the portion of time their current partners were employed while they were together after the birth of the first child.

      Mother-Infant Interaction and Quality of the Home Environment: Mother-infant interaction was videotaped at all postpartum assessments. Responsive Interaction was standardized at each assessment to a mean of 100 and a standard deviation of 10. Infants' home environments were rated at 12 and 24 months.

      Child Emotional, Mental, and Behavioral Development: At the 24th month office visit, the children were tested with the Bayley scales of infant development, and their mothers completed the Achenbach Child Behavior Checklist.

      The children's medical records were reviewed with a focus on hospitalizations, emergency department visits, and outpatient encounters in which injuries and ingestions were detected. In addition, the dates and types of children's immunizations were recorded.

      Data were also abstracted from Tennessee Department of Human Services records to ascertain women's and their first-born children's use of Aid to Families with Dependent Children during the period from the child's birth through second birthday.

      At the age six follow-up, assessments were conducted after children had completed at least seven months of kindergarten (through March). The children's mothers completed the Achenbach Child Behavior Checklist (CBCL) to assess the severity of internalizing, externalizing, and total behavior problems. The children's teachers completed the Hightower Teacher-Child Rating Scale (HTCRS) to assess the degree to which children were engaged with school and children's classroom socioemotional adjustment. Teacher reports and school data were derived primarily from the children's first grade teachers (n = 486), although a small number of reports came from kindergarten (n = 33), second grade (n = 42), and special education (n = 3) teachers. Children's responses to eight story beginnings (stems) from the McArthur Story Stem Battery (MSSB) were videotaped and coded for a series of content themes, observable affective expressions, and coherence in completing the stories. Children's representations of dysregulated aggressive behavior, parental warmth/empathy themes in the stories, and whether each story completion was incoherent were categorized by constructs and a coding scheme specially designed for low-income African American children. Finally, children's cognitive and language skills were assessed with the Kaufman Assessment Battery for Children (KABC) and the Peabody Picture Vocabulary Test (PPVT-III).

      At the age nine follow-up, children's school records in grades one to three were reviewed and teachers' reports of classroom behavior (primarily from third grade) were obtained. Children's GPAs in reading, math, and behavior were abstracted from school records. In addition, children's achievement-test scores (primarily the Tennessee Comprehensive Assessment Program Achievement Test) were also abstracted. Teacher report of antisocial behavior and maternal report of child disruptive behaviors and depressive and anxiety disorders for the past year were assessed using the Computerized Diagnostic Interview schedule for Children. Due to infrequently occurring rates of individual reported disorders, two broad categories were created: (1) a count of depressive and anxiety disorders reported in the past year with actual values ranging between 0 and 5 and (2) a count of disruptive behavior disorders reported in the past year, with actual values ranging between 0 and 2. The number of times children were retained in grades 1 to 3 was counted, and placement in special education was coded. Teachers' assessments of children's behavior in the classroom were assessed using items from the Social Competence Scale and Social Health Profile form the Fast Track trial and the Observation of Child Adjustment Revised. The items from these measures produced 3 scales: (1) antisocial behavior, a primary outcome, and (2) academically focused behavior, and (3) peer affiliation. Finally, children's death was assessed by sending every case in which the child was born alive and on which a maternal assessment was not completed at age 9 to the National Death Index (NDI). The age of the child at death (in days) and the cause of death were then coded.

      Mortality Records were collected for mothers and children using the National Death Index (Olds et al., 2014). Maternal deaths were categorized into natural (such as stroke) and external categories (such as drug overdose, homicide). Children's deaths were classified as preventable, such as sudden infant death syndrome, unintentional injuries, and homicide, and natural causes of death, such as chronic respiratory disease.

      Analysis: Data analyses were conducted on all cases for which outcome data were available. Dependent variables for which a normal distribution was assumed were analyzed in the general linear model, dichotomous outcomes and low-frequency count data were analyzed in the log-linear model. The primary statistical model for postnatal outcomes focused on classification effects for Treatments (2 vs. 4) and maternal psychological resources (high vs. low), plus two covariates (household income, and census-tract poverty level). Regressions of children's story coherence on their level of emotional expression were tested for homogeneity by treatments, with adjustment for the standard three covariates. Quantitative outcomes on which multiple assessments existed for each mother or each child were analyzed using mixed models that included, in addition to the variables from the core model, children (or mothers) as levels of a random factor, a fixed repeated measures classification factor for time of assessment, and all interactions of time with the other fixed classification factors. School performance outcomes were available for math and reading for each of 3 grades. For these outcomes, grade level was the repeated measure over time, and the model included a second fixed repeated measures factor for subject area. For maternal repeated outcomes in the age 9 follow-up, reported results were averaged over the entire period from which data was available as well as the interval between 6 and 9 years of the first child's life. For all maternal low-frequency count outcomes except the rates of subsequent low birth weight newborns, only the treatment factor (with no covariates) was included. Low birth weight newborns were analyzed in a model that included treatment, psychological resources, the treatment x psychological resource interaction, and the household poverty covariate. For all child low-frequency count outcomes except mortality, the model consisted of treatment, psychological resource interaction, and child gender; the child mortality dichotomous outcome was tested in a simple treatment model with no psychological resource factor or adjustments for covariates.

      Outcomes

      Prenatal Findings: By the 36th week of pregnancy, nurse-visited women were more likely to use other community services than were women in the control group. They were also more likely to be working, particularly among women who were not in school when they were randomized into treatment conditions. In contrast with women in the comparison group, nurse visited women had fewer instances of PIH. Among women with PIH, those who received a nurse home visitor had mean arterial blood pressures during labor that were 3.5 points lower than women in the comparison group.

      Dysfunctional Caregiving and Child Development: Children of nurse-visited mothers had fewer health-care encounters for injuries and ingestions, and they had fewer days of hospitalization for injuries or ingestions at 24 months, than did children of mothers in the comparison group. These trends were greater for children born to women with few psychological resources.

      Nurse-visited mothers reported that they at least attempted to breast feed more frequently than did women in the comparison group. By the 24th month of the child's life, nurse-visited women held fewer beliefs about childrearing associated with child abuse and neglect than did women in the comparison group. In addition, the homes of nurse-visited women were rated as more conducive to children's development using the HOME scale.

      Children born to nurse-visited mothers with limited psychological resources were observed to be more responsive to their mothers and to communicate their needs more clearly than did children born to low resource mothers in the comparison group.

      Maternal life course: Nurse-visited women reported 23% fewer second pregnancies at 24 months and 32% fewer subsequent live births (among nurse-visited women with high levels of psychological resources) than did women in the comparison group. Nurse-visited women and their children relied upon AFDC for fewer months during the second year of the child's life than did comparison group women and children. These results were sustained at 54 months. At 54 months, nurse-visited women had higher rates of living with a partner and living with the father of their child, and were with partners who had been employed for longer durations as compared to the control group. The program was able to help those women with fewer mental health symptoms, higher IQs, and more active coping styles in becoming less dependent upon welfare, but was unable to do so with women with fewer psychological resources. Nurse-visited women sustained significantly fewer subsequent pregnancies and births than did women in the comparison group, and significantly longer intervals between the births of the first and second children at 54 months and at child age six. Nurse-visited women also had longer relationships with their current partners. Between children's 54th and 72nd months (6 years) of life, nurse-visited women had fewer months of using welfare and food stamps as compared to women in the control group. In addition, nurse-visited children were more likely to have been enrolled in formal out-of-home care (Head Start, preschool, licensed day care, or early intervention) between 2 and 4.5 years of age as compared to children in the control group. There were no statistically significant program effects on women's mastery, mental health, education, employment, marriage, being in a partnered relationship, living with the father of the child, outcomes of subsequent pregnancies, current partner's education or socioeconomic status, use of marijuana, behavioral problems attributable to the use of alcohol or drugs, or domestic violence.

      During the 9-year period after the birth of the first child, among women with at least 1 subsequent child, nurse-visited women had longer intervals between the births of first and second children and had fewer cumulative subsequent births per year than did their control group counterparts. The treatment main effect on number of cumulative subsequent births was limited to women with initially high psychological resources averaging across the entire period after birth of the first child. Averaging across the 6- and 9-year follow-up periods, nurse-visited mothers had longer relationships with their current partners than did mothers in the control group. The program effect was particularly pronounced at child age 9. In correspondence with their longer partnered relationships, nurse-visited women were associated with employed partners to a greater degree than were women in the control group. From birth through child age 9, nurse-visited women used welfare (AFDC/TANF) and food stamps for fewer months per year than did women in the control group. For the 6- to 9- year interval, the program effect on food stamps was significant, but the effect on AFDC/TANF was non-significant. When examined over the entire 9-year period, nurse-visited women expressed greater mastery over the challenges in their lives than did women in the control group, but by age 9 the treatment-control group difference was no longer significant. There were no statistically significant program effects on women's subsequent miscarriages, abortions, or stillbirths; arrests or being jailed; use of Medicaid; depression; employment; or marriage or being in a partnered relationship.

      Child outcomes: At six years of age, nurse-visited children had higher scores on tests of intellectual functioning and receptive language and were reported by their mothers to have fewer problems in the borderline or clinical range of the Achenbach Child Behavior Checklist (CBCL) Total Problems scale, compared to children in the control group. In addition, nurse-visited children born to mothers with low psychologic resources had higher arithmetic achievement tests scores than their control group counterparts, and expressed less dysregulated aggression and told fewer incoherent stories than control group children. For both the entire sample and children born to mothers with low psychologic resources, fitted regressions were significantly different by treatment, favoring the nurse-visited children. Children's story coherence disintegrated in the presence of high levels of emotional expression to a greater degree in the control group, compared with children visited by nurses. There were no other significant program effects.

      At the age 9 follow-up, nurse-visited children who were born to mothers with low psychological resources, compared to their control group counterparts, had better GPAs averaged across reading and math and had better math and reading achievement-test scores in grades 1 to 3. There were no statistically significant program effects on placements in special education or mothers' reports of their children's disruptive behavior disorders or third grade teachers' reports of children's behavioral or academic adaptation to the classroom.

      Infant and childhood death: Control group children were 4.46 times more likely to die in the age range of birth through child age 9 than were nurse-visited children.

      At 21 years following randomization, women in the two nurse-visited groups were less likely to have died than women assigned to the two control groups. The comparison of control groups 1 and 2 with treatment group 3 was significant, but a similar comparison with treatment group 4 was not significant. By age 20 years, children whose mothers received home visits during pregnancy and through child age 2 years were significantly less likely to have died from preventable causes (but not all causes) compared with their counterparts in the control group (Olds et al., 2014). For the study of child mortality, inclusion of children in treatments 1 and 3 was not possible, so only the full NFP treatment was compared to one of the control conditions. For women, data was available for all 4 treatments.

      Followup at 12 years Old:

      (Kitzman, Olds, et al., 2010): Maternal interviews at 12 years were completed by 82% of the nurse-visited mothers and 79% of the control group mothers. Child interviews were completed by 79% of nurse-visited children and 77% of control children. Completion rates for other records (teacher reports, school records, social service records) vary by the record. Nurse-visited children at 12 years of age, compared to controls, reported fewer days of having used cigarettes, alcohol, and marijuana during the 30-day period before the 12-year interview and were less likely to report having internalizing disorders that met the borderline or clinical threshold. The nurse-visited children born to women with low psychological resources, compared with their control group counterparts, scored higher on the Peabody test in reading and math and during the first six years of school scored higher on group-administered standardized tests of math and reading achievement. There were no significant effects for externalizing or total behavioral problems.

      (Olds, Kitzman, Cole, Hanks, et al., 2010): The program also improved maternal life course by the time the child was age 12. Nurse-visited mothers compared with control mothers reported less role impairment owing to alcohol and other drug use, longer partner relationships, and greater sense of mastery. Government spending on food stamps, Medicaid, and AFDC/TANF was reduced. There were no differences on mothers' marriage, partnership with the child's biological father, intimate partner violence, alcohol and other drug use, arrests, incarceration, psychological distress, or reports of child foster care placements.

      Outcomes - Brief Bullets

      • Fewer nurse-visited women had Pregnancy Induced Hypertension (13% versus 20%).
      • Children of nurse-visited women had fewer health care encounters and days of hospitalization for injury or ingestion at 24 months.
      • Nurse-visited women had fewer second pregnancies at 24 months and had significantly fewer subsequent pregnancies and births and significantly longer intervals between the births of the first and second children at child age nine.
      • Nurse-visited women were more likely to be working during the second year of their child's life.
      • Decreased dependency upon AFDC during the second year of the child's life, fewer months of using welfare and food stamps between children's 54th and 72nd months (6 years) of life, fewer months of using welfare and food stamps per year, and fewer months of using food stamps for the 6- to 9- year interval.
      • Nurse-visited children were more likely to have been enrolled in formal out-of-home care between 2 and 4.5 years of age.
      • At age six, nurse-visited children had higher scores on tests of intellectual functioning and receptive language and were reported by their mothers to have fewer problems in the borderline or clinical range of the Achenbach Child Behavior Checklist (CBCL) Total Problems scale.
      • At age 6, higher arithmetic achievement tests scores, less dysregulated aggression, and fewer incoherent stories among nurse-visited children born to mothers with low psychologic resources.
      • During the 9-year period after the birth of the first child, among women with at least one subsequent child, there were longer intervals between the births of first and second children and fewer cumulative subsequent births per year among nurse-visited women.
      • Averaging across the 6- and 9-year follow-up periods, nurse-visited mothers had longer relationships with their current partners, and were associated with employed partners to a greater degree than were women in the control group.
      • Over the entire 9-year period, nurse-visited women expressed greater mastery over the challenges in their lives than did women in the control group, but by age 9 the treatment-control group difference was no longer significant.
      • At age 9, better GPAs averaged across reading and math and better math and reading achievement-test scores in grades 1 to 3 among nurse-visited children who were born to mothers with low psychological resources.
      • At age 12, the program reduced children's use of substances and internalizing mental health problems.
      • At age 12, the program improved the academic achievement of children born to mothers with low psychological resources.
      • At age 12, the program improved maternal life course and reduced government spending.

      Generalizability

      The Memphis trial was designed to determine if the effects of the Elmira program could be replicated through an existing health department with a large sample of low-income African American women, children, and their families living in a major urban area. The combined results from the Elmira and Memphis trials indicate that the program is successful with a diverse range of participants, including racially, ethnically, socioeconomically, and regionally diverse populations.

      Limitations

      • Some evidence of baseline differences emerged between groups on employment and income, but the studies presented no formal statistical tests of group differences.
      • Additional evidence of new baseline differences emerged from group comparisons at the 6-year, 9-year, and 12-year follow-ups, suggesting some differential attrition. Again, no formal statistical tests were presented.
      • The age nine follow-up did not include direct assessments of the children, instead relying of maternal report and children's school records for information on child functioning.

      Netherlands

      Mejdoubi, J., van den Heijkant, S. C. C. M., van Leerdam, F. K. M., Heymans, M. W., Hirasing, R. A., & Crijnen, A. A. M. (2013). Effect of nurse home visits vs. usual care on reducing intimate partner violence in young high-risk pregnant women: A randomized controlled trial. PLOS One. DOI: 10.1371/journal.pone.007818.

      Mejdoubi, J., van den Heijkant, S. C. C. M., van Leerdam, F. K. M., Crone, M, Crijnen, A., & Hirasing, R. A. (2014). Effects of nurse home visitation on cigarette smoking, pregnancy outcomes and breastfeeding: A randomized controlled trial. Midwifery 30, 688-695.

      This version culturally adapts the program for the special needs of pregnant women living in the Netherlands and using the Dutch health care system.

      Design:

      Recruitment /Sample size: First, midwives, general practitioners, gynecologists, and others actively recruited women in 20 municipalities in the Netherlands who met several inclusion criteria: (1) maximum age of 25 years, (2) low educational level (pre-vocational secondary education), (3) maximum 28 weeks of gestation, (4) no previous live birth, and (5) some understanding of the Dutch language. Second, nurses interviewed women to ensure they had at least one additional risk factor (being single, a history or present situation of domestic violence, psychosocial symptoms, unwanted pregnancy, financial problems, housing difficulties, no employment and/or education, alcohol and/or drug use). In some cases, potential participants not meeting all of the inclusion criteria but with multiple risk factors were still included (N = 77, 16.7%). The total number of recruited participants was 460.

      Study type/Randomization/Intervention: All 460 eligible women were randomized into the control or intervention group after stratification by region and ethnicity. The 223 women in the control group received usual health care during pregnancy, while the 237 women in the intervention group were also offered 10 nurse home visits during pregnancy, 20 during the first year of the child’s life, and 20 during the second year of the child’s life.

      Assessment/Attrition: Subjects were interviewed three times in their homes: pretest (16-28 weeks of pregnancy), interim (32 weeks of pregnancy), and posttest (2 years after birth of child). Of the 460 subjects at baseline, 111 (24.1%) were lost to follow-up, declined, moved outside of region, or could not be interviewed because of study start up problems at 32 weeks, and 194 (42.2%) were not interviewed at follow-up for the same reasons. However, the study also states that the Conflict Tactics Scale was completed by still fewer numbers: 1) in the control group by 110 (49%) at 32 weeks and 74 (33%) at 24 months (33%), and 2) in the intervention group by 156 (66%) at 32 weeks and 110 (46%) at 24 months.

      Sample characteristics:

      The female subjects averaged about 19 years of age and were primarily Dutch (49%), with representation of Surinamese/Antillean (26%), Turkish/Moroccan (6%), and other (19%) ethnicities. The subjects had low education, and few were married or living together (18%). About 18% had been a victim of physical abuse during the last year.

      Measures:

      The key outcome measure, annual prevalence of intimate partner violence, comes from the revised Conflict Tactics Scale. The scale includes four components – physical assault, psychological aggression, injury, and sexual coercion – plus a combined measure. It also takes into account the severity of violence by measuring less severe (level 1) and more severe (level 2) incidents over the past year, and both perpetration and victimization in the conflict. With the four components and a combined measure, two levels of violence, and measures of perpetration and victimization, the analysis examines a total of 20 outcomes.

      Interviewers did not administer the Conflict Tactics Scale at baseline because the scale “measures IPV [intimate partner violence] during a current or most recent relationship rather than relationships in the past.” Instead, they used the Abuse Assessment Screen to measure physical and sexual violence in the past.

      The study presents no information on the validity and reliability of the measures. The Conflict Tactics Scale has been used extensively but also has been subject to debate over its validity. Interviews were conducted in private given the sensitive nature of the measures.

      Analysis:

      Multivariable logistic regression analyses were performed to compare differences in dichotomous outcomes between the control and intervention groups. Multivariable linear regression analyses were used to compare continuous outcomes. The analyses used multilevel models for the longitudinal relationship between the intervention and the outcomes. The intervention effects over time were modeled using interaction terms between the condition and the time variables.

      The study used complete case analysis at 32 weeks, but imputed the less complete data at 24 months after birth. Although also checked with the last observation carried forward, the results reported in the tables at 24 months came from multiple imputation.

      With the use of multiple imputation at 24 months, the analysis complied with the intent-to-treat principle.

      Outcomes

      Implementation fidelity: Women in the program were offered 10 visits during pregnancy, and the majority of the subjects received 6-13 home visits.

      Baseline Equivalence: The study states “no significant differences in demographic characteristics or in the number of risk factors between the control and intervention groups were found at baseline.”

      Differential attrition: The study states that participants who were lost to follow-up did not differ significantly from participants who remained in the study with regard to demographic characteristics and risk factors. However, attrition reached 42% at the 2-year posttest, and completion of the Conflict Tactics Scale was greater in the control group (67%) than the intervention group (54%).

      Interim and Post-test: For victimization at 32 weeks, intervention subjects showed significantly lower outcomes on 5 of 10 measures: level 2 psychological aggression, level 1 physical assault, level 2 physical assault, level 1 sexual coercion, and 2 or more forms of intimate partner violence. For victimization at posttest (24 months post-birth), intervention subjects showed significantly lower odds ratios on 1 of 10 measures: level 1 physical assault. Odds ratios for significant effects ranged from .38 (medium-large) to .57 (small-medium). Averaged over all time points, the multilevel logistic regressions revealed significantly greater reductions in the intervention group for two outcomes: level 2 psychological aggression and level 1 physical assault.

      For perpetration at 32 weeks, intervention subjects showed significantly lower outcomes on 5 of 10 measures: level 2 psychological aggression, level 1 physical assault, level 1 injury, combined forms of intimate partner violence, and 2 or more forms of intimate partner violence. Odds ratios for significant effects fell in the small-medium range (.53 to .57). For perpetration at posttest (24 months post-birth), intervention subjects showed significantly lower odds ratios on 2 of 10 measures: level 1 sexual coercion (OR = .10) and combined forms of intimate partner violence. Multilevel logistic regression analyses showed that only one outcome, level 1 physical assault, declined significantly more over all time points among the intervention group than the control group.

      For women reporting both victimization and perpetration at 32 weeks, intervention subjects showed significantly lower level 2 psychological aggression and level 1 physical assault. At 24 months after birth, intervention subjects showed significantly lower level 1 physical assault.

      Mejdoubi et al., 2014
      Fewer women in the intervention smoked during and after the birth, and they smoked fewer cigarettes per day after the birth and fewer cigarettes in the presence of the baby. More intervention women breast fed their child at six months. There were no effects on pregnancy outcomes, such as birth weight, weeks of gestation, adverse pregnancy outcomes (low birth weight, prematurity, and small for gestational age).

      Long-term effects:

      The study did not collect long-term follow-up data and therefore was not able to demonstrate sustained effects.

      Limitations

      • No outcome measure at baseline (although related measures of risk for intimate partner violence were used).
      • Debate exists over the validity of the Conflict Tactics Scale.
      • High rate of attrition and large differences in attrition rates for intervention and control groups.

      England

      Robling, M., Bekkers, M.-J., Bell, K., Butler, C. C., Cannings-John, R., Channon, S., Martin, B. C., Gregory, J. W., Hood, K., Kemp, A., Kenkre, J., Montgomery A. A., Moody, G., Owen-Jones E., Pickett, K., Richardson, G., Roberts Z. E. S., Ronaldson, S., Sanders, J., Stamuli, E., & Torgerson, D. (2015). Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomized controlled trial. The Lancet, published online 14 October 2015.

      Evaluation Methodology

      Design:

      Recruitment: The study recruited young, first-time mothers from 18 primary and secondary local National Health Service organizations and local authorities. Women were identified and approached via local maternity services and recruited usually at their home by locally based researchers. A total of 3,251 women were screened for eligibility to obtain 1645 subjects. The appendix noted that the intervention women were broadly representative of the population of women who receive the local maternity services.

      Assignment: The study assigned women randomly to FNP or usual care with randomization stratified by site and minimized by gestation (<16 weeks vs >16 weeks), smoking, and preferred language of data collection. Of the 1,645 women randomized, 823 were assigned to the treatment and 822 were assigned to the control treatment. The treatment group received screening, education, immunization, and support from birth to the child’s second birthday from an assigned family nurse, while control mothers received usual care from a specialist community public health nurse.

      Attrition: Assessments of primary outcomes occurred at baseline (<25 weeks gestation), shortly before birth (35-36 weeks gestation), after birth of the child, and 24 months after the birth of the child. Of the 1645 randomized women, 66% completed smoking measures before birth of the child, 92% had data on child birth weight, 90% had data on emergency room visits after birth of the child, and 78% had data on another pregnancy 24 months after the birth of the child. Reasons for exclusion included missing assessments or withdrawal of consent.

      Sample: The mean age of mothers in the sample was 17.3 years. The sample was comprised of 82.9% White, 4.9% Black, 1.4% Asian, 5% mixed, and 1.2% other mothers (4.6% of mothers were missing data on race/ethnicity). The study did not provide information on SES of mothers, but the sample was intended to be nationally representative of teenage mothers.

      Measures: The study used a combination of mother reports, medical records, and urinalysis. Smoking late in pregnancy was assessed with a combination of urinalysis and mother reports. Birth weight, second pregnancy less than 24 weeks after birth, and emergency room visits and admissions were assessed using mother reports and medical records. Mother reports were obtained by researchers unaware of condition.

      The study also used mother reports for 63 secondary outcomes, including child language and cognitive development.

      Analysis: The study used mixed-effects three-level regression models to adjust for site as a stratification variable and to allow for clustering by a family nurse in the intervention group. In addition, the other pretest minimization variables (gestation, smoking, and preferred language) were used as covariates. Where appropriate, baseline measures were included as covariates, and repeated measures models with group-by-time terms were used for those assessments that were taken multiple times.

      Intent-to-Treat: Analyses included all available data without imputation. The study attempted to follow all subjects (page 3, “Women who wanted to discontinue the intervention were offered the opportunity to still provide follow-up data”).

      Outcomes

      Implementation Fidelity: The appendix contains detailed information on attainment of the fidelity goals of the program and suggests that the “intervention has been delivered as intended.” The mean number of visits by community midwives was 10.4 for the treatment group and 10.68 for the control group, and for health visitors was 16.25 for the treatment group and 8.6 for the control group. The treatment group received 39.28 visits on average from their family nurse of a possible 64 maximum visits (the control group received on average .45 visits due to enrolment in error).

      Baseline Equivalence: The study stated that sociodemographic and outcome measures were well balanced between groups (Table 1), but it did not report significance tests.

      Differential Attrition: The appendix compared differential attrition between the two conditions. It summarized the findings by stating that “Overall this may suggest that women who are in a significant relationship and who are more vulnerable are more likely to disengage from the trial if they are allocated to FNP.”

      Posttest: The study found no significant effect of the program on late pregnancy smoking, second pregnancy within 24 months, or birth weight. Control group participants were significantly less likely to report ER visits or admissions (OR 1.32, p=.03).

      The study reported a small positive effect on 7 of 63 secondary outcomes: intention to breastfeed, maternally reported child cognitive development (only at 24 months), maternal reported language development (only at 24 months), using a standardized assessment (Early Language Milestone at 24 months), levels of social support, partner-relationship quality, and general self-efficacy.

      Long-Term: The measures of emergency room visits and subsequent pregnancy may be considered long-term outcomes, but they did not improve significantly more for the intervention group.

      Limitations:

      • Some significant differences in attrition by condition
      • No significant effects on primary outcomes, but some small positive effects in secondary outcomes
      • Possible iatrogenic effect in higher rate of ER attendance or admission after birth among treatment group than control group

      Germany

      Sierau, S., Dähne, V., Brand, T., Kurtz, V., von Klitzing, K., & Jungmann, T. (2016). Effects of home visitation on maternal competencies, family environment, and child development: A randomized controlled trial. Prevention Science, 17, 40-51.

      Evaluation Methodology

      Design:

      Recruitment: The study recruited low-income, first-time mothers between their 12th and 28th week of pregnancy who reported at least one economic risk factor and at least one social risk factor. Participants were recruited from gynecologists, job centers, and youth welfare offices, in addition to self-referrals. A total of 755 women volunteered to participate.

      Assignment: The study randomly assigned women to either the treatment or control groups after stratifying the sample by implementation site, age group, and maternal nationality. A total of 394 women were assigned to the treatment group and 361 to the control group. Both groups received information about existing health or social services, repayment for travel expenses to preventive medical check-ups, reimbursement for regular research attendance, and feedback about the children’s developmental status. Only the treatment group received home visits from a social worker or midwife.

      Attrition: Assessments of primary outcomes occurred at baseline (<28 weeks gestation), shortly before birth (35-36 weeks gestation), 6 months after birth of the child, 12 months after birth of the child, and 24 months after the birth of the child (at the end of the program). Of the 755 randomized women, approximately 70% completed the 36-week assessment, 67% completed the 6-month assessment, 57% completed the 12-month assessment, and 54% completed the 24-month assessment. Reasons for leaving the program included relocation, refusing services, or loss of contact.

      Sample: The mean age of mothers in the sample was 21 years and a majority was unmarried (85-89%), and born in Germany (84-89%). Approximately half had less than a high school diploma (49-54%) and a majority of the mothers were considered low income (80-82%).

      Measures: The study included three main outcomes: family environment, maternal competencies, and child development. Child development was measured with 7 outcomes. Mental development, psychomotor development, and child behavior were measured with the Bayley Scales of Infant Development-II (ICC=.62-.88), which appears to be measured with a researcher-administered scale. Language development was rated by mothers using parent questionnaire ELFRA1 and 2 (alpha=.91-.99) and by a standardized language development test for 2-year-old children, SETK-2 (alpha=.95). Internal and external socio-emotional development were measured with the child behavior checklist CBCL (alpha>.86). Most measures were taken at all time periods after birth, but language and socio-emotional development were only measured at 24 months.

      The 5 family environment measures included maternal stress (alpha=.70-.71), partnership satisfaction (alpha=.88-.89), social support (alpha=.91-.93), birth of additional children, and educational achievement. Measures for maternal stress, partnership satisfaction, and social support were externally developed Likert scales, while additional children and educational achievement were dichotomous reports.

      The 8 measures of maternal competencies were parental self-efficacy (alpha=.90-.84), knowledge on children rearing (alpha=.77-.74), feelings of attachment (alpha=.73-.79), parenting style (.69-.71), mother-child affectivity (ICC=.69-.71), mother-child responsiveness (ICC=.62-.67), maternal empathy (alpha=.69-.71), and belief of control (alpha=.66-.72). Only social support, parental self-efficacy, knowledge on child reading, and feelings of attachment were measured at baseline. Other measures were started after birth or later in the study. Most of the measures included are mother-reports. Mother-child affectivity and responsiveness, in addition to child behavior, were coded by blind reviewers using videotapes.

      Analysis: The study used generalized estimating equation models, which cluster data within persons for repeated measures. Whenever possible, the models accounted for baseline values of the outcome variables. The study reported within condition changes, but the results reported here focus on group-by-time interactions.

      Intent-to-Treat: All available data were included in the analysis. The study stated that generalized estimating equations allowed for the use of subjects with partial data. However, the high attrition substantially reduced the size of the original sample.

      Outcomes

      Implementation Fidelity: The study detailed efforts to train for fidelity. The average number of visits per household was 32.7 and ranged from 0 to 94, of an expected 59 visits.

      Baseline Equivalence: The study reported only one significant differences between conditions at baseline in either demographic or outcome measures. Control group mothers were significantly more likely to have a psychiatric disorder, which was controlled in the analysis.

      Differential Attrition: Program dropouts were younger, on average, had lower income, and experienced foster care placement. The study did not analyze completion status with condition by outcome measures.

      Posttest: The study found no significant effects on any of the 7 child development outcomes. Of 5 measures of the family environment, only maternal stress was marginally significant (p=.074). Of 8 measures of maternal competencies, only parental self-efficacy (p=.063) and feelings of attachment (p=.062) were marginally significant.

      Long-Term: The study did not conduct long-term follow-up.

      Limitations:

      • Some child measures are reported by mothers, who participated in the program
      • Possible problem with loss of subjects for intent-to-treat analysis
      • Lower SES households (younger, lower income, and experienced foster care placement) were more likely to drop out of the study
      • No effect on main child development outcomes and only marginal effects on family environment and mother competencies

      Video

      http://www.youtube.com/user/NFPNurseFamily