Prenatal and Infancy Nurse Home Visiting Effects on Mothers: 18-Year Follow-up of a Randomized Trial

Evaluating the real-world implementation of the Family Nurse Partnership in England: a data linkage study

Background/objectives

The Family Nurse Partnership is an intensive home visiting programme for adolescent mothers. We aimed to evaluate the effectiveness of the Family Nurse Partnership on outcomes up to age 7 using national administrative data.

Design

We created a linked cohort of all mothers aged 13-19 using data from health, educational and children's social care and defined mothers enrolled in the Family Nurse Partnership or not using Family Nurse Partnership system data. Propensity scores were used to create matched groups for analysis.

Setting

One hundred and thirty-six local authorities in England with active Family Nurse Partnership sites between 2010 and 2017.

Participants

Mothers aged 13-19 at last menstrual period with live births between April 2010 and March 2019, living in a Family Nurse Partnership catchment area and their firstborn child(ren).

Interventions

The Family Nurse Partnership includes up to 64 home visits by a family nurse from early pregnancy until the child's second birthday and is combined with usual health and social care. Controls received usual health and social care.

Main outcome measures

Indicators of child maltreatment (hospital admissions for injury/maltreatment, referral to social care services); child health and development (hospital utilisation and education) outcomes and maternal hospital utilisation and educational outcomes up to 7 years following birth.

Data sources

Family Nurse Partnership Information System, Hospital Episode Statistics, National Pupil Database.

Results

Of 110,520 eligible mothers, 25,680 (23.2%) were enrolled in the Family Nurse Partnership. Enrolment rates varied across 122 sites (range: 11-68%). Areas with more eligible mothers had lower enrolment rates. Enrolment was higher among mothers aged 13-15 (52%), than 18-19 year-olds (21%). Indicators of child maltreatment: we found no evidence of an association between the Family Nurse Partnership and indicators of child maltreatment, except for an increased rate of unplanned admissions for maltreatment/injury-related diagnoses up to age 2 for children born to Family Nurse Partnership mothers (6.6% vs. 5.7%, relative risk 1.15; 95% confidence interval 1.07 to 1.24). Child health and developmental outcomes: there was weak evidence that children born to Family Nurse Partnership mothers were more likely to achieve a Good Level of Development at age 5 (57.5% vs. 55.4%, relative risk 1.05; 95% confidence interval 1.00 to 1.09). Maternal outcomes: There was some evidence that Family Nurse Partnership mothers were less likely to have a subsequent delivery within 18 months of the index birth (8.4% vs. 9.3%, relative risk 0.92; 95% confidence interval 0.88 to 0.97). Younger and more vulnerable mothers received higher numbers of visits and were more likely to achieve fidelity targets. Meeting the fidelity targets was associated with some outcomes.

Limitations

Bias by indication and variation in the intervention and usual care over time and between areas may have limited our ability to detect effects. Multiple testing may have led to spurious, significant results.

Conclusions

This study supports findings from evaluations of the Family Nurse Partnership showing no evidence of benefit for maltreatment outcomes measured in administrative data. Amongst all the outcomes measured, we found weak evidence that the Family Nurse Partnership was associated with improvements in child development at school entry, a reduction in rapid repeat pregnancies and evidence of increased healthcare-seeking in the mother and child.

Future work

Future evaluations should capture better measures of Family Nurse Partnership interventions and usual care, more information on maternal risk factors and additional outcomes relating to maternal well-being.

Study registration

The study is registered as NIHR CRN Portfolio (42900).

Funding

This award was funded by the National Institute of Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/99/19) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 11. See the NIHR Funding and Awards website for further award information.

The Elephant in the Room: A Systematic Review of the Application and Effects of Psychological Treatments for Pregnant Women with Dual Pathology (Mental Health and Substance-Related Disorders)

PURPOSE

Maternal mental health and substance use, referred to as dual pathology, represent significant concerns associated with adverse pregnancy and birth outcomes, a prevalence higher than commonly anticipated. Nonetheless, a notable dearth exists ofevidence-based treatment protocols tailored for pregnant women with dual pathology.

METHODS

A systematic review, adhering to the PRISMA methodology, was conducted.

RESULTS

Out of the 57 identified papers deemed potentially relevant, only 2were ultimately included. Given the limited number of studies assessing the efficacy of psychological interventions utilizing randomized controlled trials (RCTs) for both mental health and substance misuse, and considering the diverse objectives and measures employed, definitive conclusions regarding the effectiveness of psychological interventions in this domain prove challenging.

CONCLUSIONS

Maternal mental health appears to be the proverbial "elephant in the room". The development of specialized and integrated interventions stands as an imperative to effectively address this pressing issue. As elucidated in the present review, these interventions ought to be grounded in empirical evidence. Furthermore, it is essential that such interventions undergo rigorous evaluation through RCTs to ascertain their efficacy levels. Ultimately, the provision of these interventions by psychology/psychiatric professionals, both within clinical practice and the RCTs themselves, is recommended to facilitate the generalizability of the results to specialized settings.

Structural and relational factors for successful cross-sector collaboration in home visiting: a multiple case study

BACKGROUND

Aligning delivery and financing systems across sectors to create broader systems of care can improve the health and well-being of families experiencing adversities. We aimed to identify structural and relational factors for best practices to achieve successful cross-sector collaboration among home visiting programs in the United States.

MATERIALS AND METHODS

We used a multiple case study approach to identify best practices for successful cross-sector collaboration between home visitors and other community service providers. We selected five diverse exemplary cases with cross-sector collaboration with variation in implementing agency type and geographic location. Cases were selected using a positive deviance approach based on strong coordination and integration with different community service provider types identified from previous survey data. We conducted in-depth qualitative interviews with home visiting staff, community providers, and clients with a total of 76 interviews conducted from 2021 to 2022. We wrote memos to synthesize themes within each case through data triangulation using interview data, documents, and site visit observations. We compared themes across the five cases to create a cross-case synthesis of best practices for successful cross-sector collaboration.

RESULTS

Across the five cases, relational factors including leadership from all levels, champions across sectors, and shared goals between community providers were key factors for successful collaboration. Interpersonal relationships, coupled with the desire and capacity to engage, facilitated effective coordination to address families' needs. At the structural level, shared data systems, written agreements, and co-location enabled care coordination activities. Community Advisory Boards provided a venue for developing partnerships, relationship-building, resource-sharing, and increasing awareness of home visiting.

CONCLUSIONS

We identified key elements of successful cross-sector collaboration across five case studies where home visitors coordinate care frequently and/or are structurally integrated with a range of providers. These learnings will inform future interventions to improve home visiting collaboration with other community providers to create a system of care to enhance family well-being.

Coordination of family's care in an evidence-based nurse home visiting program

Interprofessional care coordination within evidence-based prevention programs like Nurse-Family Partnership® (NFP) is necessary to meet family needs and maximize program impact. This study aimed to describe the coordination of families' care in the NFP home visiting context. We used an adapted grounded theory approach and purposively sampled seven NFP sites. We conducted telephone interviews with 95 participants: 51 NFP staff (54%), 39 healthcare providers (41%), and 5 social service providers (5%). All interviews were recorded, transcribed, validated, and analyzed in NVivo11. Many community providers in all sites described their knowledge of the characteristics of the NFP intervention, including the strength of its evidence to achieve outcomes. Care coordination was dynamic and changed over time based on client needs and staff willingness to work together. Effective care coordination in the NFP context from the provider perspective is driven by shared knowledge, integrated systems, mission alignment, and individual champions who value the program.

Engaging Community in Prioritizing Outcomes to Improve Family Health in Evidence-Based Nurse Home Visiting: Using a Modified e-Delphi Method

BACKGROUND

Evidence-based home visiting programs are designed to improve maternal child health. Nurse-Family Partnership (NFP) is a model evidence-based home visiting program, shown to improve pregnancy outcomes, child development, and economic self-sufficiency for first-time mothers and their families experiencing social and economic adversities, enrolling them early in pregnancy. Recently, NFP has expanded its services to multiparous women (previous live births) and enrolling women past 28 weeks gestation (late registrants) in selected agencies in Florida since 2021.

OBJECTIVE

To study the process and impacts of expanding NFP to expanded populations (multiparous and/or late registrants), we convened a diverse Advisory Committee to guide the NFP expansion evaluation in Florida.

METHODS

This study employed a modified e-Delphi method with three rounds of data collection, to engage diverse partners to identify process and impact outcomes for the NFP expansion evaluation.

RESULTS

Child maltreatment was identified as the highest priority outcome. Process outcomes included program reach, client enrollment, and client engagement, while impact outcomes included maternal physical health, maternal mental health and substance use, birth outcomes, and breastfeeding practices. The Advisory Committee further identified potential data sources to measure these outcomes.

CONCLUSIONS FOR PRACTICE

Identifying and selecting key process and impact outcomes using a community-engaged process is necessary to ensure equal buy-in from all partners and to inform rigorous program evaluation. This study showed that using methods such as e-Delphi is feasible and effective for achieving thoughtful and rigorous decision-making, even in times of uncertainty like the COVID-19 pandemic.

Changes in cross-sector collaboration between nurse home visitors and community providers in the United States: A panel survey analysis

OBJECTIVE

Assess changes in cross-sector collaboration between Nurse-Family Partnership (NFP) nurse home visitors and community providers in the United States.

DATA SOURCES AND STUDY SETTING

We collected primary data via internet-based surveys of all NFP nursing supervisors in the United States in 2018, 2020, and 2021.

STUDY DESIGN

We conducted a panel survey to measure changes in cross-sector collaboration between NFP nurses and 10 provider types in healthcare and social services. We assessed relational coordination using the validated seven item Relational Coordination Scale and structural integration using four items adapted from the Interagency Collaboration Activities Scale. Responses over time were compared using one-way analysis of variances (ANOVAs) and pairwise t-tests. We used the Kruskal-Wallis rank test to assess differences in collaboration by implementing agency type.

DATA COLLECTION

All nursing supervisors from NFP implementing agencies in the United States were eligible for the study. Survey implementation was conducted using Qualtrics and administered to all eligible participants (N = 370 [2018], 383 [2020], 414 [2021]). Email reminders were sent every 7-10 days, followed by a final telephone outreach.

PRINCIPAL FINDINGS

The response rate was 71% in 2018, 83% in 2020, and 74% in 2021. Relational coordination scores were calculated as a mean of the seven items and ranged from 1 to 5 (not at all to completely); integration scores were calculated as a sum of the four items and ranged from 4 to 20, where higher scores indicated greater sharing of resources. Coordination with women's care increased from 2018 to 2020 (M = 3.39 vs. 3.57; p < 0.01); while coordination (M = 3.23 vs. 3.01; p < 0.05) and integration (M = 6.50 vs. 5.28 vs. 5.43; p < 0.01) with parenting programs decreased.

CONCLUSIONS

Changes to cross-sector collaboration varied by provider type, likely due to the delivery of NFP and other services via telehealth during the COVID-19 pandemic. There is an opportunity to improve cross-sector collaboration in home visiting to better address family needs.

What contributes to the long-term implementation of an evidence-based early childhood intervention: a qualitative study from Germany

Background

Rigorous research trials have demonstrated that early childhood interventions can reach socially disadvantaged families and can have a lasting impact on the healthy development of their children. However, little is known about the internal and contextual factors that contribute to the long-term implementation of such interventions. In this study, we investigated the development of the home visiting program Pro Kind. The program was adapted from the evidence-based US-American Nurse-Family Partnership program and was implemented in Germany in 2006. Using an exploratory approach, we examined factors contributing to the long-term implementation of this program.

Methods

Qualitative interviews with program implementers (midwives, social workers, program managers) of the Pro Kind program and key stakeholders in two cities in Germany were conducted. Interview guides were developed to assess participants' perceptions and experiences on how the program had developed over time internally and in the interaction with its environment. Data were collected between March and September 2021. Drawing on the Consolidated Framework for Implementation Research (CFIR), data was coded according to the principles of thematic analysis.

Results

A total of 25 individuals (11 program implementers, 14 key stakeholders) were interviewed. The identified factors related to three out of five domains of the CFIR model in our analysis. First, regarding the intervention characteristics, the evidence of effectiveness and the relative advantage of the implementation of the program compared to similar interventions were viewed as contributors to long-term implementation. However, the program's adaptability was discussed as a constraining factor for reaching the target group. Second, concerning the inner setting, stakeholders and program implementers perceived the implementation climate, the leadership engagement and the program's size as relevant factors for networking strategies and program visibility. Third, as part of the outer setting, the degree of networking with external stakeholders was highlighted of great importance for the program.

Conclusions

We identified several factors of particular importance for the long-term implementation and sustainability of an early childhood intervention at the practice level, particularly in the local context in Germany. These findings should inform the design of impactful, scalable, and sustainable early childhood interventions targeting disadvantaged families.

Early Home Visits and Health Outcomes in Low-Income Mothers and Offspring: 18-Year Follow-Up of a Randomized Clinical Trial

Importance

Individuals with low income may have heightened rates of obesity and hypertension.

Objective

To determine whether prenatal and infancy home visitation by nurses reduces maternal and offspring obesity and hypertension.

Design, Setting, and Participants

This randomized clinical trial of prenatal and infancy nurse home visitation in a public health care system in Memphis, Tennessee, enrolled 742 women with no previous live births and at least 2 sociodemographic risk factors (unmarried, <12 years of education, unemployed) from June 1, 1990, through August 31, 1991. At registration during pregnancy, 727 mothers (98%) were unmarried, and 631 (85%) lived below the federal poverty level. At offspring ages 12 and 18 years, maternal and offspring obesity and hypertension were assessed by staff masked to treatment. The data analysis was performed from July 1, 2021, to October 31, 2023.

Interventions

Women assigned to the control group received free transportation for prenatal care and child developmental screening and referral at child ages 6, 12, and 24 months. Women assigned to nurse visitation received transportation and screening plus prenatal and infant and toddler nurse home visits.

Main Outcomes and Measures

Obesity and hypertension among mothers and their offspring at child ages 12 and 18 years, although not hypothesized in the original trial design, were analyzed using post-double selection lasso method.

Results

Of the 742 participants randomized (mean [SD] age, 18.1 [3.2] years), interviews were completed with 594 mothers and 578 offspring at child age 12 years and 618 mothers and 629 offspring at child age 18 years. Obesity was assessed for 576 offspring at age 12 years and 605 at age 18 years and for 563 and 598 mothers at child ages 12 and 18 years, respectively. Blood pressure was assessed for 568 offspring aged 12 years and 596 aged 18 years and 507 and 592 mothers at child ages 12 and 18 years, respectively. There were no overall treatment-control differences in offspring obesity or hypertension at ages 12 and 18 years combined, although nurse-visited female offspring, compared with controls, had a lower prevalence of obesity (adjusted relative risk [ARR], 0.449; 95% CI, 0.234-0.858; P = .003) and severe obesity (ARR, 0.185; 95% CI, 0.046-0.748; P < .001). There were reductions at ages 12 and 18 years combined for stage 1 and stage 2 hypertension for nurse-visited vs control group mothers, with differences limited to mothers of females (stage 1: ARR, 0.613 [95% CI, 0.440-0.855; P = .001]; stage 2: ARR, 0.217 [95% CI, 0.081-0.582; P < .001]). For both obesity and hypertension outcomes, there was no intervention effect among male offspring or the mothers of males. Self-reported maternal health aligned with program effects on hypertension.

Conclusions and Relevance

In this clinical trial follow-up at offspring ages 12 and 18, nurse-visited female offspring had lower rates of obesity and mothers of females had lower rates of hypertension than control-group counterparts. These findings suggest that risks for chronic disease among mothers of females and their female offspring who live in extreme poverty may be prevented with prenatal and infant and toddler home visitations by nurses.

Trial Registration

ClinicalTrials.gov Identifier: NCT00708695.

A Mental Health Innovation for Nurse Home Visiting Program Shows Effectiveness in Reducing Depressive Symptoms and Anxiety

The objective of this paper is to report on the effectiveness of a mental health addition to a national nurse-delivered home visiting program. The methods are as follows: analysis of pre/post-launch of the standard Mental Health Intervention and comparison of 356 teams randomized to standard versus enhanced implementation. Stepwise regression controlled for significant client characteristics that were related to relevant outcomes. These characteristics were used in generalized mixed effect models comparing pre/post implementation and intervention and control groups. Pre/post analysis showed that only clients with no elevated mental health screening scores or mental health diagnoses at enrollment showed a significant decrease in depressive symptoms. Clients enrolled with and without mental health needs at enrollment significantly decreased on anxiety scores while referrals to mental health care increased. Teams receiving enhanced implementation enrolled more clients with mental health needs and clients completed more well-child visits and use of safe sleep practices. By integrating mental health care into maternal, infant, and early childhood home visiting programs, a new equitable model of primary mental health care can reach populations in need. This example provides a new paradigm of accessible and equitable mental health care for the future that can be implemented in a variety of home visiting programs.

10 Year Longitudinal Evaluation of the Spilstead Model of Milieu Intervention

Although international research has defined best-practice intervention for children from vulnerable families as integrated and comprehensive, limited implementation and longitudinal evaluation of this approach has been conducted. The Spilstead Model (SM) of early years milieu intervention provides a uniquely integrated one stop shop model of care incorporating a comprehensive range of best-practice programs within a trauma-informed approach. Results from an initial evaluation involving 23 families (mean child age 3.7 years) indicated large effect size improvements 12 months post entry in family functioning as well as child development and emotional wellbeing (ES 0.8 -1.46, p < 0.001). This study aimed to evaluate the sustainability of these outcomes for both children and families via follow-up of the initial study co-hort 10 years post the initial evaluation. The study targeted families who participated in the original evaluation. Clinician and parent-rated adolescent measures paralleled the original assessments of parent, child and family functioning. Qualitative evaluation was also conducted via a semi-structured interview with parents. 83% of the original sample participated. Mean youth age was 13.2 years. Results indicated sustained improvements in parent-child relationship, child-wellbeing and reduction of parent stress with large effect size (1.14 - 1.92 p < 0.001). On average 73% of the adolescents scored within the normal range on each measure of functioning. Few had repeated school grades or been suspended. None had been arrested. Emerging themes from the qualitative evaluation confirmed the value of the integrated model. The results further support the value of the one stop shop Spilstead Model and have the potential to inform international policy and practice.

Cross-sector Collaboration Between Public Health, Healthcare and Social Services Improves Retention: Findings from a Nurse Home Visiting Program

The study aimed to examine the association between cross-sector collaboration in Nurse-Family Partnership (NFP), a model home visiting program, and participant retention. We used the 2018 NFP Collaboration Survey that measured agency-level collaboration, operationalized as relational coordination and structural integration, among nine community provider types (including obstetrics care, substance use treatment, child welfare). This dataset was linked to 2014-2018 NFP program implementation data (n = 36,900). We used random-intercept models with nurse-level random effects to examine the associations between provider-specific collaborations and participant retention adjusting for client, nurse, and agency characteristics. The adjusted models suggest that stronger relational coordination between nurses and substance use treatment providers (OR:1.177, 95% CI: 1.09-1.26) and greater structural integration with child welfare (OR: 1.062, CI: 1.04-1.09) were positively associated with participant retention at birth. Stronger structural integration between other home visiting programs and supplemental nutrition for women, infants, and children was negatively associated with participant retention at birth (OR: 0.985, CI: 0.97-0.99). Structural integration with child welfare remained significantly associated with participant retention at 12-month postpartum (OR: 1.032, CI: 1.01-1.05). In terms of client-level characteristics, clients who were unmarried, African-American, or visited by nurses who ceased NFP employment prior to their infant's birth were more likely to drop out of the NFP program. Older clients and high school graduates were more likely to remain in NFP. Visits by a nurse with a master's degree, agency rurality, and healthcare systems that implement the program were associated with participant retention. Cross-sector collaboration in a home visiting setting that bridges healthcare and addresses social determinants of health has potential to improve participant retention. This study sets the groundwork for future research to explore the implications of collaborative activities between preventive services and community providers.

Contextual and Policy Influences on the Implementation of Prenatal Care Coordination

Prenatal Care Coordination (PNCC) is a Medicaid fee-for-service that provides reimbursement for supportive services to mothers and infants at high risk of adverse outcomes. Services include health education, care coordination, referral to needed services, and social support. Currently, the implementation of PNCC programs is highly variable. We aimed to identify and describe the contextual factors that influence implementation of PNCC. Using a qualitative descriptive approach and theoretical reflexive thematic analysis techniques, we conducted observation and semistructured interviews with all PNCC staff at two PNCC sites in Wisconsin, representing diversity in region and patient population. We thematically analyzed interview data to examine how contextual factors influenced program implementation with the Consolidated Framework for Implementation Research as a sensitizing model. Observational field notes were used to triangulate interview data. Overall, participants endorsed the goals of PNCC and believed in its potential. However, participants asserted that the external policy context limited their impact. In response, they developed local strategies to combat barriers and work toward better outcomes. Our findings support the need to study the implementation of perinatal public and community health interventions and consider "health in all policies." Several changes would maximize PNCC's impact on maternal health: increased collaboration among policy stakeholders would reduce barriers; increased reimbursement would enable PNCC providers to better meet the complex needs of clients; and expansions in postpartum Medicaid coverage would extend the PNCC eligibility period. Nurses who provide PNCC have unique insights that should be leveraged to inform maternal-child health policy.

Factors Related to Burnout Among Perinatal Home Visiting Nurses

PURPOSE

Risks for burnout among nurses have been understudied in public and community health settings. This qualitative descriptive study aimed to describe the experiences of nurses working in a perinatal community health program for high-risk families with a focus on challenges and risks for burnout.

METHODS

We conducted field observation and semistructured individual interviews in 2019 with nurses at 2 sites implementing Prenatal Care Coordination (PNCC), a Medicaid benefit for high-risk pregnant people and infants in Wisconsin. A larger parent study assessed the implementation of PNCC overall through a thematic analysis process. Initial deductive coding was guided by the Consolidated Framework for Implementation Research.

FINDINGS

Emergent themes demonstrated that PNCC nurses face several significant barriers and known risks for burnout, including role strain related to scope of practice and training, discordant racial and socioeconomic identities leading to role conflict, and low control combined with high psychological demand.

CONCLUSIONS

Given that the COVID-19 pandemic has exacerbated burnout risk among nurses in hospital settings, and that nurses addressing social determinants of health may be at increased risk for burnout, these findings represent a critical perspective on the experiences and needs of perinatal nurses in public and community health settings.

Birth Spacing and Child Maltreatment: Population-Level Estimates for North Carolina

We examine population-level associations between birth spacing and child maltreatment using birth records and child welfare records for 1,099,230 second or higher parity children born in North Carolina between 1997 and 2013. Building upon previous research, administrative data linkages were used to address out-of-state migration and family-level heterogeneity in birth spacing and child maltreatment risk factors. Findings provide the strongest evidence to date that very short birth spacing of zero through 6 months from last birth to the index child's conception is a prenatal predictor of child maltreatment (indexed as child welfare involvement) throughout early childhood. Consequently, information about optimal family planning during the postpartum period should become a standard component of universal and targeted child maltreatment prevention programs. However, challenging previous empirical evidence, this study reports inconsistent results for benefits of additional spacing delay beyond 6 months with regard to child maltreatment risk reduction, especially for children of racial and ethnic minorities. These findings call for further inquiry about the mechanisms driving the connections between birth spacing and Child Protective Services assessments.

Perinatal and early-life factors associated with stable and unstable trajectories of psychopathic traits across childhood

BACKGROUND

This study aimed to identify perinatal and early-life factors associated with trajectories of psychopathic traits across childhood.

METHODS

Participants were 1631 children (51.5% girls) from the Quebec Longitudinal Study of Child Development. A wide range of perinatal and early-life factors were assessed from pregnancy to age 2.5 years using medical files and mothers' reports. Psychopathic traits were assessed via teachers' reports at ages 6, 7, 8, 10, and 12 years. Latent class growth analyses and multinomial logistic regressions controlling for child sex were conducted. Two-way interaction effects between perinatal/early-life factors and child sex were explored.

RESULTS

Four trajectories of psychopathic traits were identified: High-stable (4.48%), Increasing (8.77%), Decreasing (11.46%), and Low-stable (75.29%). A few perinatal factors and most child-level and family-level early-life factors significantly increased the odds of following the High-stable v. the Low-stable trajectory. Higher levels of psychotropic exposures during pregnancy, socioeconomic adversity, child's physical aggression, child's opposition, mother's depressive symptoms, and hostile parenting increased the likelihood of following the Increasing instead of the Low-stable trajectory. Higher socioeconomic adversity, mother's depressive symptoms, and inconsistent parenting were associated with membership to the High-stable instead of the Decreasing trajectory. Most associations were not moderated by child sex.

CONCLUSIONS

These results shed light on the perinatal and early-life factors that are associated with specific pathways of psychopathic traits during childhood and suggest that different factors could be targeted to prevent the exacerbation (v. low and stable levels) or the stability at high levels (v. attenuation) of these traits.

"There's more love between us": The parental experience of attending Mellow Babies, a targeted, early intervention program for parents and their babies

It is recognized that parenthood in the context of psychosocial adversity can have negative implications for infant development. Parenting programs are the first line of intervention to improve outcomes for families; however, evidence for the effectiveness of group-based, targeted early interventions is still scarce. Preliminary findings indicate Mellow Babies (MB) as a promising group-based parenting program for families at risk for parenting difficulties. Using thematic analysis, we aimed to understand: (i) the aspects of the intervention that enabled parents to complete the program and (ii) the relational and behavioral changes perceived as valuable for parents and their babies post-intervention. In total, 68 parents residing in the United Kingdom were interviewed after completing MB (49 mothers and 19 fathers; 88% self-identified as British). Three themes and six subthemes were generated from the data. Parents identified several intervention components as beneficial, including the facilitators' interpersonal skills and multi-dimensional, group-based approach. Participant reflections highlighted three underlying mechanisms that enabled positive change: (i) the sense of community cultivated within the group, (ii) the process of formulating and re-conceptualizing one's difficulties, and (iii) the opportunity to reshape interpersonal interactions. Findings are discussed within the context of perinatal and infant mental health.

Maternal mental health and social support from online communities during pregnancy

Social determinants of public health have gained increasing attention. This paper studied whether social support from online communities related to maternal mental health. We focused on online maternity communities that group users with a similar prenatal status to facilitate their exchange of personal experiences and knowledge about maternal caring during pregnancy. Such online maternity communities are getting increasingly popular and can be found across countries and societies. We invited users-currently pregnant and gave birth within 1 year at the time of the study-from one such community in China to participate in a survey. The survey measured their perceived social support (PSS) exclusively from the peer group in the online community, their mental health and newborns' birth outcomes (N = 500). Users reported high score in PSS from the online peer group which was comparable to the ones from family, significant other and friends in other studies. We used linear regression models to examine the effects of PSS on mental health and birth outcomes. We found that a one-point increase in the PSS score was associated with a 0.19-point (p < 0.1) decrease in the prenatal depression and a 0.26-point (p < 0.01) decrease in the postnatal depression, which was equivalent to 3% and 4.5% of the average respectively. Moreover, a one-point increase in the PSS score was associated with a 14.49-gram increase in a newborn's weight (p < 0.01).

Association between maternal psychological factors and offspring executive function: analysis of African-American mother-child dyads

BACKGROUND

Executive function (EF) develops throughout childhood and adolescence; however, little is known about whether and how early life factors are associated with EF during these two stages. This secondary analysis examined the associations between maternal psychological characteristics at 2 years after childbirth and offspring EF at 6 and 18 years.

METHODS

Data were from the 18-year New Mothers' Study in Memphis, TN. Women who self-identified as African-American were included (mother-child dyads: N = 414). Maternal psychological characteristics (e.g., depressive symptoms, self-esteem) were assessed using standardized questionnaires; offspring EF at 6 (i.e., working memory, response inhibition) and 18 years (e.g., working memory, sustained attention) were assessed using age-appropriate cognitive tasks. Statistical analyses included principal component analysis (PCA) and regression models.

RESULTS

PCA reduced the correlated psychological characteristics to two factors: emotionality (depressive symptoms, emotional instability) and psychological resources (self-esteem, mastery, active coping). After controlling for maternal IQ, maternal emotionality was associated with worse working memory and response inhibition (marginally significant) at 6 years. Maternal psychological resources were marginally associated with better working memory at 6 years.

CONCLUSIONS

Maternal psychological characteristics may be associated with later EF in offspring. Future studies are needed to replicate these findings and to explore potential mediators.

IMPACT

African-American mothers' depressive symptoms and emotional instability at 2 years after childbirth were associated with offspring executive function at 6 and 18 years. African-American mothers' psychological resources at 2 years after childbirth were marginally associated with offspring working memory at 6 years. Maternal IQ attenuated all of the associations observed between maternal psychological status and offspring executive function.

Inequities in Availability of Evidence-Based Birth Supports to Improve Perinatal Health for Socially Vulnerable Rural Residents

Rural residents in the United States (US) have disproportionately high rates of maternal and infant mortality. Rural residents who are Black, Indigenous, and People of Color (BIPOC) face multiple social risk factors and have some of the worst maternal and infant health outcomes in the U.S. The purpose of this study was to determine the rural availability of evidence-based supports and services that promote maternal and infant health. We developed and conducted a national survey of a sample of rural hospitals. We determined for each responding hospital the county-level scores on the 2018 CDC Social Vulnerability Index (SVI). The sample’s (n = 93) median SVI score [IQR] was 0.55 [0.25–0.88]; for majority-BIPOC counties (n = 29) the median SVI score was 0.93 [0.88–0.98] compared with 0.38 [0.19–0.64] for majority-White counties (n = 64). Among counties where responding hospitals were located, 86.2% located in majority-BIPOC counties ranked in the most socially vulnerable quartile of counties nationally (SVI ≥ 0.75), compared with 14.1% of majority-White counties. In analyses adjusted for geography and hospital size, certified lactation support (aOR 0.36, 95% CI 0.13–0.97), midwifery care (aOR 0.35, 95% CI 0.12–0.99), doula support (aOR 0.30, 95% CI 0.11–0.84), postpartum support groups (aOR 0.25, 95% CI 0.09–0.68), and childbirth education classes (aOR 0.08, 95% CI 0.01–0.69) were significantly less available in the most vulnerable counties compared with less vulnerable counties. Residents in the most socially vulnerable rural counties, many of whom are BIPOC and thus at higher risk for poor birth outcomes, are significantly less likely to have access to evidence-based supports for maternal and infant health.

Implementation of a Novel Home Visiting Nurse Pilot Program for Victims of Violent Penetrating Injury

BACKGROUND

Survivors of violent injuries are at risk for readmission, rehospitalization, and reinjury. In 2017, a novel home visiting nurse pilot program was implemented within a hospital-based violence intervention program (HVIP) to address disparities in care and combat the limited health care literacy and access, and the general mistrust of health care institutions among much of this population.

OBJECTIVE

The purpose of this study was to review the design and implementation of the home visiting nurse component of the HVIP and to report the demographics, clinical characteristics, home care needs, and short-term health outcomes of the pilot sample.

METHODS

This retrospective study was performed using a cohort of patients presenting to the emergency department at an urban, Level I trauma center for a violent penetrating injury between 2017 and 2018. The χ2 and Wilcoxon rank sum tests were used to compare patient demographics and injury characteristics. Cox proportional hazards regression models were used to estimate health outcomes.

RESULTS

Of the 742 victims of violence included in this analysis, the 57 patients enrolled in the home visiting nurse pilot program were more likely to have severe gunshot wounds (68.4% vs. 40.3%, p < .001) requiring hospitalization (80.7% vs. 53.3%, p < .001), with 3.5% requiring rehospitalization within 90 days. The primary interventions provided by the home visiting nurse involved medical navigation and education, wound care, and consultation, underscoring the critical importance of health literacy and outreach for this vulnerable population.

CONCLUSION

The nurse-advocate partnership provides the foundation for this novel program to aid a marginalized population in overcoming health inequities.

A systematic review and qualitative meta-synthesis of the roles of home-visiting nurses working with women experiencing family violence

AIMS

To systematically review and synthesize qualitative research exploring home-visiting nurses' roles and identify the challenges for nurses working with women experiencing family violence.

DESIGN

We undertook a thematic synthesis of qualitative studies, focusing on the family violence work of nurse home visitors.

DATA SOURCES

A systematic search of four scientific databases (ProQuest Central, CINAHL, MEDLINE, EMBASE) was undertaken in August 2021. Grey literature was searched, including government and non-government research documents, theses, clinical guidelines, policy documents and practice frameworks.

REVIEW METHODS

Inclusion criteria included research from high-income countries, peer-reviewed qualitative studies in English published from 1985 to 2021, and included research on home-visiting nurse family violence practice. The first author conducted the data search and the initial screening. The first and second authors independently reviewed the full text of 115 papers, identifying 26 for inclusion in the thematic synthesis (Figure 1-PRISMA flowchart).

RESULTS

The thematic synthesis identified two themes: (1) relationship building-with the client, with services and with colleagues/self; and (2) family violence practice-ask/screen, validate/name, assess risk/safety plan and safeguard children.

CONCLUSION

The thematic synthesis confirmed the multiple roles fulfilled by home-visiting nurses and enabled insight into the challenges they face as they undertake complex and demanding work. The roles of the home-visiting nurse have evolved, with the initial focus on safeguarding children leading to broader family violence nursing practice roles, including the identification of family violence and safety planning discussions with women.

IMPACT

Our meta-synthesis has confirmed the high-level communication and rapport-building skills required by nurses undertaking complex and conflicting roles. Nurses need support and supervision to undertake emotionally demanding work. Integrated health systems, clinical practice guidelines and tools, and training programmes need to encompass the breadth and complexity of the roles of these specialist practitioners.

First 1,000 days: enough for mothers but not for children? Long-term outcomes of an early intervention on maternal depressed mood and child cognitive development: follow-up of a randomised controlled trial

BACKGROUND

Child cognitive development is often compromised in contexts of poverty and adversity, and these deficits tend to endure and affect the child across the life course. In the conditions of poverty and violence that characterise many low- and middle-income countries (LMIC), the capacity of parents to provide the kind of care that promotes good child development may be severely compromised, especially where caregivers suffer from depression. One avenue of early intervention focuses on the quality of the early mother-infant relationship. The aim of this study was to examine the long-term impact of an early intervention to improve the mother-infant relationship quality on child cognitive outcomes at 13 years of age. We also estimated the current costs to replicate the intervention.

METHOD

We re-recruited 333 children from an early childhood maternal-infant attachment intervention, 'Thula Sana', when the children were 13 years old, to assess whether there were impacts of the intervention on child cognitive outcomes, and maternal mood. We used the Kaufman Assessment Battery to assess the child cognitive development and the Patient Health Questionnaire (PHQ-9) and the Self-Reporting Questionnaire (SRQ-20) to assess maternal mental health.

RESULTS

Effect estimates indicated a pattern of null findings for the impact of the intervention on child cognitive development. However, the intervention had an effect on caregiver psychological distress (PHQ-9, ES = -0.17 [CI: -1.95, 0.05] and SRQ-20, ES = -0.30 [CI: -2.41, -0.19]), but not anxiety. The annual cost per mother-child pair to replicate the Thula Sana intervention in 2019 was estimated at ZAR13,365 ($780).

CONCLUSION

In a socio-economically deprived peri-urban settlement in South Africa, a home visiting intervention, delivered by community workers to mothers in pregnancy and the first six postpartum months, had no overall effect on child cognitive development at 13 years of age. However, those caregivers who were part of the original intervention showed lasting improvements in depressed mood. Despite the fact that there was no intervention effect on long-term child outcomes, the improvements in maternal mood are important.

COVID-19 preventive interventions for high-risk pregnant women and preschool children: a rehearsal for the baby boomers’ old-age pandemic?

A large research-based consensus was achieved over the past 30 years concerning the importance of prenatal and early childhood development: Preventive interventions are needed early in life because physical and psychological problems during pregnancy and early childhood often lead to serious physical, psychological, educational, and social problems throughout the life course. These problems are also transmitted to the next generation. The COVID-19 pandemic is likely to have increased the number of families who need these early-life preventive interventions. Without intensive support, children from high-risk families are likely to fail in school, to have serious physical and mental health problems, and to reproduce another generation of children with similar physical, cognitive, and mental health problems. We underline the need to: (1) assess the extent of the COVID-19 damage on pregnant women and on their spouses, as well as on the families with preschool children; (2) help service providers identify the state-of-the art services they should implement; (3) assess the implementation of these services; and (4) help service providers maintain highly effective interventions. For the next 20 to 30 years at least, governments will be under intense pressure to invest massively in the health and care of the baby boomers. We are thus facing abysmal health care and retirement costs for the next 3 decades. Governments should be pressured to substantially invest in the support of pregnant women and preschool children, rather than in the sustained quality of life of the aging baby boomers.

Maternal and Child Mortality: Analysis of Nurse Home Visiting in 3 RCTs

INTRODUCTION

The impact of intensive prenatal and infant/toddler nurse home visiting on low-income mothers' and children's survival was examined in 3 RCTs following participants over 2-decade periods after trial registration during pregnancy (data gathered between 1978 and 2015 and analyzed between 2016 and 2020).

METHODS

All-cause and external-cause maternal mortality and preventable-cause child mortality were examined using National Death Index data. Survival rates were calculated for all the 1,138 mothers randomized and 1,076 live-born children in the second RCT (conducted in Memphis, TN) and for all the 1,135 mothers randomized and 1,087 live-born children in the first and third RCTs combined (conducted in Elmira, NY and Denver, CO).

RESULTS

There were no significant nurse home visiting-control differences in maternal mortality in Memphis or Elmira and Denver. Posthoc analysis, combining all 3 trials, suggested a reduction in external-cause maternal mortality among nurse-visited mothers (p=0.054). There was a marginally significant nurse home visiting-control difference in preventable-cause child mortality (p=0.09) in Memphis.

CONCLUSIONS

These results support examining maternal and child mortality in additional nurse home visiting trials with larger samples living in disadvantaged contexts. Intensive prenatal and infant/toddler home visiting by nurses for mothers and children living in poverty may decrease premature death.

Prenatal and Infancy Home Visiting in Germany: 7-Year Outcomes of a Randomized Trial

OBJECTIVES

Given the lasting positive effects of prenatal and infancy home visiting in the United States on disadvantaged mothers and children at school age, we analyzed the follow-up effects of a German home visiting program (ProKind). We hypothesized improvements in 3 domains at child age 7 years: (1) child development and life satisfaction, (2) maternal mental health and life satisfaction, and (3) adverse parenting, abusive parenting, and neglectful parenting.

METHODS

We conducted a randomized controlled trial of home visiting, enrolling 755 pregnant, low-income women with no previous live births. The intervention comprised 32.7 home visits by family midwives and/or social pedagogues until child age 2 years. Assessments were completed on 533 7-year-old firstborn offspring to evaluate 8 primary hypotheses.

RESULTS

We found significant positive effects for 4 of the 8 primary hypotheses. Mothers in the intervention group reported fewer behavioral problems among their children in the Child Behavior Checklist (effect size [ES] = 0.21; 95% confidence interval [CI]: 0.03 to 0.38), less child abusive parenting (ES = 0.19; 95% CI: 0.00 to 0.37), fewer maternal mental health problems (ES = 0.25; 95% CI: 0.07 to 0.43), and higher maternal life satisfaction (ES = 0.25; 95% CI: 0.07 to 0.43). Additional preregistered subgroup analyses regarding child sex revealed larger effects for boys and mothers of boys.

CONCLUSIONS

The results suggest that in a western European welfare state, home visiting targeting disadvantaged mothers has lasting effects in important outcome domains. Therefore, home visits also appear to be an effective and efficient public health intervention in European settings.

A randomized controlled trial testing the efficacy of a Nurse Home Visiting Program for Pregnant Adolescents

To test the efficacy of a nurse home visiting program (HVP) on child development, maternal and environmental outcomes in the first years of life. We conducted a randomized controlled trial to test the efficacy of Primeiros Laços, a nurse HVP for adolescent mothers living in a poor urban area of São Paulo, Brazil. Eighty adolescent mothers were included and randomized to receive either Primeiros Laços (intervention group, n = 40) or healthcare as usual (control group, n = 40). Primeiros Laços is a home visiting intervention delivered by trained nurses that starts during the first 16 weeks of pregnancy and continues to the child's age of 24 months. Participants were assessed by blind interviewers at 8-16 weeks of pregnancy (baseline), 30 weeks of pregnancy, and 3, 6, 12, and 24 months of child's age. We assessed oscillatory power in the mid-range alpha frequency via electroencephalography when the children were aged 6 months. Child development was measured by the Bayley Scales of Infant Development Third Edition (BSID-III). Weight and length were measured by trained professionals and anthropometric indexes were calculated. The home environment and maternal interaction with the child was measured by the Home Observation and Measurement of the Environment. Generalized estimating equation models were used to examine intervention effects on the trajectories of outcomes. Standardized effect sizes (Cohen's d) were calculated using marginal means from endpoint assessments of all outcomes. The trial was registered at clinicaltrial.gov: NCT02807818. Our analyses showed significant positive effects of the intervention on child expressive language development (coefficient = 0.89, 95% CI [0.18, 1.61], p = 0.014), maternal emotional/verbal responsivity (coefficient = 0.97, 95% CI [0.37, 1.58], p = 0.002), and opportunities for variety in daily stimulation (coefficient = 0.37, 95% CI [0.09, 0.66], p = 0.009). Standardized effect sizes of the intervention were small to moderate. Primeiros Laços is a promising intervention to promote child development and to improve the home environment of low-income adolescent mothers. However, considering the limitations of our study, future studies should be conducted to assess Primeiros Laços potential to benefit this population.Clinical Trial Registration: The study was registered at clinicaltrial.gov (Registration date: 21/06/2016 and Registration number: NCT02807818).

Does Increasing Access to Prenatal Care Reduce Racial Disparities in Birth Outcomes?

PURPOSE

To examine the effectiveness of early and adequate prenatal care (PNC) in reducing racial disparities in pre-term birth (PTB) among low-income women.

DESIGN AND METHODS

This retrospective study examined birth records for 14,950 low-income Black and White women. The primary outcome of interest was racial disparities in PTB. Exposures of interest were first trimester entry into, and adequacy of, PNC. Maternal residential proximity to nearest PNC provider was calculated. Bivariate analyses were performed for PTB by race. Binary logistic regression was performed, controlling for maternal age, smoking status and racial segregation. Attributable risk of PTB for no or late entry into PNC, and percent difference by race was calculated.

RESULTS

We find that early and adequate PNC significantly decreases the risk of preterm birth, however, we find no evidence that this reduces racial disparities. Low income black females in a large metropolitan county have greater geographic access to and utilization of PNC than low-income white females, yet racial disparities in preterm birth remain. Attributable risk of PTB for no or late entry into PNC was lower for Black women (32.2%) than White women (39.4%).

CONCLUSIONS

Our findings suggest that adequate PNC alone does not reduce the marked racial disparities in preterm birth.

PRACTICE IMPLICATIONS

Public health agencies and health care providers need to look beyond access to care, to achieve racial equity in birth outcomes. Expansion of evidence-based, comprehensive nursing interventions shown to reduce preterm birth, such as the Nurse Family Partnership home visiting program, could contribute to these efforts.

Effectiveness of psychosocial support provided by midwives and family on preventing postpartum depression among first-time adolescent mothers at 3-month follow-up: A randomised controlled trial

AIMS AND OBJECTIVES

To evaluate the effectiveness of a midwife-family provided social support programme (MFPSS programme) for first-time adolescent mothers on preventing postpartum depression (PPD) at 3-month postpartum.

BACKGROUND

Adolescent mothers with lack of social support are a high-risk group for increasing the development of PPD. Interventions designed to promote social support and provided to mothers following childbirth have a more effective role in preventing PPD.

DESIGN

The Consolidated Standards of Reporting Trials (CONSORT) guidelines for a single-blinded randomised controlled trial were conducted.

METHODS

Forty-two adolescent mothers were randomly assigned to 4-week MFPSS programme plus routine care (n = 21) and routine care only (n = 21). PPD was measured using the Edinburgh Postnatal Depression Scale (EPDS), rates and severity at baseline, post-test, 6-week and 3-month postpartum follow-ups. Repeated measures ANOVA and Cohen's d were used to analyse the data.

RESULTS

At the last follow-up, 20 (95.24%) participants remained in each group. Data were analysed based on 40 adolescent mothers. After the intervention, the mean EPDS scores in the intervention group were significantly lower than the same scores in the control group at post-test, 6-week and 3-month postpartum follow-ups. Similarly, the rates and severity of PPD in the intervention group were also lower than the control group at post-test, 6-week and 3-month postpartum follow-ups.

CONCLUSION

Psychosocial support interventions designed to incorporate support from midwives and family members is an effective intervention for preventing PPD in first-time adolescent mothers and the preventive effect is sustained for up to 3-month postpartum.

RELEVANCE TO CLINICAL PRACTICE

Midwives or nurses could apply the MFPSS programme to nursing care for adolescent mothers and family members by adding health information about PPD and promoting social support.

CLINICAL TRIAL REGISTRATION

The trial was registered with Thai Clinical Trials Registry (TCTR). The trial registration number is TCTR 20190206004.

National survey of nurse home visitor collaboration with health care and social services

OBJECTIVE

To assess the degree to which nurses in a national public health home visiting program collaborate with interprofessional providers to serve families experiencing adversity.

DESIGN

A descriptive, cross-sectional survey measured collaborative practices between nurse home visitors, health care, and social service providers. A census of 263 nursing supervisors completed a web-based survey.

MEASUREMENTS

The survey included the validated 7-item Relational Coordination Scale, adapted items from the Interagency Collaboration Activities Scale on shared resources, and items related to collaboration attitudes and beliefs. Data were analyzed with descriptive statistics.

RESULTS

Relational coordination scores, which are relative measures, ranged from 1 to 5; highest with supplemental nutrition for Women, Infants & Children (M = 3.77) and early intervention (M = 3.44); and lowest with housing (M = 2.55). The greatest sharing of resources was with supplemental nutrition (sum = 12.95) and mental health providers (sum = 11.81), and least with housing (sum = 7.26); with a range of 1-30 where higher scores indicated greater resource-sharing.

CONCLUSION

Home visiting nurses collaborate with interprofessional providers with variation in the degree of collaboration between agencies and by provider type within an agency. Collaboration was a function of two interrelated domains: interpersonal relationships supported by organizational and contextual factors at the systems-level.

Long-term Cognitive, Psychological, and Health Outcomes Associated With Child Abuse and Neglect

Potential long-lasting adverse effects of child maltreatment have been widely reported, although little is known about the distinctive long-term impact of differing types of maltreatment. Our objective for this special article is to integrate findings from the Mater-University of Queensland Study of Pregnancy, a longitudinal prenatal cohort study spanning 2 decades. We compare and contrast the associations of specific types of maltreatment with long-term cognitive, psychological, addiction, sexual health, and physical health outcomes assessed in up to 5200 offspring at 14 and/or 21 years of age. Overall, psychological maltreatment (emotional abuse and/or neglect) was associated with the greatest number of adverse outcomes in almost all areas of assessment. Sexual abuse was associated with early sexual debut and youth pregnancy, attention problems, posttraumatic stress disorder symptoms, and depression, although associations were not specific for sexual abuse. Physical abuse was associated with externalizing behavior problems, delinquency, and drug abuse. Neglect, but not emotional abuse, was associated with having multiple sexual partners, cannabis abuse and/or dependence, and experiencing visual hallucinations. Emotional abuse, but not neglect, revealed increased odds for psychosis, injecting-drug use, experiencing harassment later in life, pregnancy miscarriage, and reporting asthma symptoms. Significant cognitive delays and educational failure were seen for both abuse and neglect during adolescence and adulthood. In conclusion, child maltreatment, particularly emotional abuse and neglect, is associated with a wide range of long-term adverse health and developmental outcomes. A renewed focus on prevention and early intervention strategies, especially related to psychological maltreatment, will be required to address these challenges in the future.

Reflective parenting home visiting program: A longitudinal study on the effects upon depression, anxiety and parenting stress in first-time mothers

Objective

Our study aimed to investigate the effects of a reflective parenting home visiting program in first time-mothers at risk for depression, anxiety, and parenting stress, from three to 12 months after their child's birth.

Study design

The sample was composed by 77 first-time mothers and their healthy babies (53% boys and 47% girls). Mothers filled out the Edinburgh Postnatal Depression Scale, the State-Trait Anxiety Inventory, and the Parenting Stress Index-SF at 3, 6 and 12 months of the child. Thirty-six mothers were assigned to the experimental group and received the reflective parenting home-visiting program, the other 36 constituted the control group.

Results

Analyses showed a significant higher reduction in the level of depression, anxiety and parenting stress among mothers belonging to the experimental group, compared to the control group.

Conclusion

Our findings confirm the benefits of reflective parenting home visiting programs and underline the need to constantly evaluate the levels of depression, anxiety and parenting stress throughout the perinatal period to target effective prevention programs to foster early mother-child attachment bond.