Enduring effects of nurse home visitation on maternal life course: a 3-year follow-up of a randomized trial

Effect of early childhood development interventions delivered by healthcare providers to improve cognitive outcomes in children at 0-36 months: a systematic review and meta-analysis

OBJECTIVE

To determine the effect of early childhood development interventions delivered by healthcare providers (HCP-ECD) on child cognition and maternal mental health.

DESIGN

Systematic review, meta-analysis.

SETTING

Healthcare setting or home.

PARTICIPANTS

Infants under 1 month of age.

INTERVENTIONS

HCP-ECD interventions that supported responsive caregiving, early learning and motor stimulation. MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Health Technology Assessment Database, Database of Abstracts of Reviews of Effects and Cochrane Database of Systematic Reviews were searched until 15 November 2021. Studies reporting prespecified outcomes were pooled using standard meta-analytical methods.

MAIN OUTCOME MEASURES

Cognitive development in children at 0-36 months.

RESULTS

Forty-two randomised controlled trials with 15 557 infants were included in the narrative synthesis. Twenty-seven trials were included in the meta-analyses. Pooled data from 13 trials suggest that HCP-ECD interventions may improve cognitive outcomes in children between 0 and 36 months (Bayley Scales of Infant Development version IIII (BSID-III) mean difference (MD) 2.65; 95% CI 0.61 to 4.70; 2482 participants; low certainty of evidence). Pooled data from nine trials suggest improvements in motor development (BSID-III MD 4.01; 95% CI 1.54 to 6.48; 1437 participants; low certainty of evidence). There was no evidence of improvement in maternal mental health (standardised MD -0.13; 95% CI -0.28 to 0.03; 2806 participants; 11 trials; low certainty of evidence).

CONCLUSIONS

We report promising evidence, particularly for cognitive and motor outcomes, of the effect of HCP-ECD interventions. However, effect sizes were small, and the certainty of evidence ranged from very low to moderate. Additional high-quality research is required.

PROSPERO REGISTRATION NUMBER

CRD42019122021.

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.

A scoping review of 'think-family' approaches in healthcare settings

BACKGROUND

'Think-family' child health approaches treat child and parent/carer health as inter-related. They are promoted within health policy internationally (also called 'family paediatrics' or 'whole-family', 'family-centred' approaches or 'child-centred' approaches within adult services).

METHODS

We reviewed publications of think-family interventions. We developed a typology of these interventions using thematic analysis of data extracted from the included studies.

RESULTS

We included 62 studies (60% USA and 18% UK); 45/62 (73%) treated the parent as patient, helping the child by addressing parental mental health, substance and alcohol misuse and/or domestic violence. Our typology details three common mechanisms of change in relevant interventions: screening, health promotion and developing relationships (inter-professional and parent-professional).

CONCLUSIONS

Policy-makers, practitioners and researchers can use our typology to develop and evaluate think-family approaches within healthcare. Strong relationships between parents and professionals are key in think-family approaches and should be considered in service design. Although helping the child through the parent may be a good place to start for service development, care is needed to ensure parental need does not eclipse child need. Strategies that reach out to the parent behind the child (child as patient) and which work simultaneously with parent and child warrant attention.

A Systematic Review of Programs to Promote Aspects of Teen Parents' Self-sufficiency: Supporting Educational Outcomes and Healthy Birth Spacing

Introduction

Expectant and parenting teens experience many challenges to achieving self-sufficiency and promoting their children’s healthy development. Teen parents need support to help them address these challenges, and many different types of programs aim to support them. In this systematic review, we examine the research about programs that aim to support aspects of teen parents’ self-sufficiency by promoting their educational outcomes and healthy birth spacing.

Methods

We conducted a comprehensive literature search of published and unpublished literature to identify studies of programs to support teen parents that met this review’s eligibility criteria. The quality and execution of the eligible study research designs were assessed to determine whether studies’ findings were at risk of bias. We then extracted information about study characteristics, outcomes, and program characteristics for studies considered to provide rigorous evidence.

Results

We identified 58 eligible studies. Twenty-three studies were considered to provide rigorous evidence about either education, contraceptive use, or repeat pregnancy or birth. Seventeen of these studies showed at least one favorable effect on an outcome in one of these domains, whereas the other six did not show any significant or substantial effects in these domains. These 17 studies represent 14 effective programs.

Discussion

Effective programs to support expectant and parenting teens have diverse characteristics, indicating there is no single approach for promoting teens’ education and healthy birth spacing. More rigorous studies of programs to support teen parents are needed to understand more about how to support teen fathers and the program characteristics associated with effectiveness.

Electronic supplementary material

The online version of this article (10.1007/s10995-019-02854-w) contains supplementary material, which is available to authorized users.

Components associated with the effect of home visiting programs on child maltreatment: A meta-analytic review

BACKGROUND

Home visiting programs are widely endorsed for preventing child maltreatment. Yet, knowledge is lacking on what and how individual program components are related to the effectiveness of these programs.

OBJECTIVE

The aim of this meta-analysis was to increase this knowledge by summarizing findings on effects of home visiting programs on child maltreatment and by examining potential moderators of this effect, including a range of program components and delivery techniques.

METHODS

A literature search yielded 77 studies (N=48,761) examining the effectiveness of home visiting programs, producing 174 effect sizes. In total, 35 different program components and delivery techniques were coded.

RESULTS

A small but significant overall effect was found (d=0.135, 95 % CI (0.084, 0.187), p<0.001). Programs that focused on improving parental expectations of the child or parenthood in general (d = 0.308 for programs with this component versus d = 0.112 for programs without this component), programs targeting parental responsiveness or sensitivity to a child's needs (d = 0.238 versus d = 0.064), and programs using video-based feedback (d = 0.397 versus d = 0.124) yielded relatively larger effects. Providing practical and instrumental assistance was negatively associated with program effectiveness (d=0.044 versus d = 0.168). Further, program effects were larger when percentages of non-Caucasians/non-Whites in samples and follow-up durations increased.

CONCLUSIONS

In general, home visiting programs can prevent child maltreatment only to a small extent. However, implementing specific components and techniques can improve program effectiveness.

Evidence of Effectiveness of a Home Visitation Program on Infant Weight Gain and Breastfeeding

OBJECTIVES

Adequate weight gain is important to reduce the risk of infant morbidity and mortality. Breastfeeding is also important to prevent infant morbidity. Home visitation programs have been used for many years to prevent infant and child morbidity and maltreatment. Nurses for Newborns is a home visitation model with the goals of preventing infant mortality and maltreatment. This study evaluated the impact of the Nurses for newborns program on infant weight gain and breastfeeding.

METHODS

We used a retrospective case-control propensity matched model to evaluate outcomes. We received secondary data from Vanderbilt Research Derivative Group and Tennessee Office of Health Statistics to conduct the analysis. Data were accessed for infants born in 2013, 2014 and 2015 and limited to those with at least four NFN visits and no more than 2 days in the NICU. We conducted chi square analysis and logistic regression to test our hypotheses.

RESULTS

NFN infants were two times more likely to triple their birth weight in the first year. NFN infants were also two times more likely to be breast fed at 2 weeks, but this finding was not statistically significant.

CONCLUSIONS FOR PRACTICE

Home visitation models can be effective in encouraging adequate weight gain in the first year of life. In addition, home visitors can encourage women to breastfeed. Significance Home visitation models can prevent infant morbidity and mortality. Few studies, however, have demonstrated that infant weight gain, an important factor in the health of infants, can be enhanced using this approach. In addition, home visitation can positively impact breastfeeding, another important factor in preventing infant morbidity. Findings from this study suggest that the NFN model of home visitation can improve weight gain and breastfeeding, indicating the impact of this model.

Development of an academic practice partnership to improve maternal child health

This manuscript describes one nursing school's innovative community-based partnership with community organizations and Nurse-Family Partnership (NFP), an established nurse home visiting program for first-time, low income mothers and infants. The aim of this academic nursing endeavor with the community and NFP is to improve the health and well-being of low-income, first time mothers and their children while also providing comprehensive, population-based nursing experiences for students and service leadership and scholarship opportunities for faculty. The academic-practice community partnership described here makes a case for utilizing the expertise and capacity of a nursing school to implement and administer an NFP program and serves as an exemplar for the recommendations described in the New Era for Academic Nursing report (AACN, 2016). The value of forming partnerships between a public health department, the philanthropic community and an academic nursing institution is highlighted. In this case, the three organizations partnering together around a common purpose of improving birth outcomes enabled the partnership to accomplish more than any individual organization could have accomplished alone.

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

BACKGROUND

Prenatal and infancy home-visiting by nurses is promoted as a means of improving maternal life-course, but evidence of long-term effects is limited. We hypothesized that nurse-visitation would lead to long-term reductions in public-benefit costs, maternal substance abuse and depression, and that cost-savings would be greater for mothers with initially higher psychological resources.

METHODS

We conducted an 18-year follow-up of 618 out of 742 low-income, primarily African-American mothers with no previous live births enrolled in an randomized clinical trial of prenatal and infancy home visiting by nurses. We compared nurse-visited and control-group women for public-benefit costs, rates of substance abuse and depression, and examined possible mediators of intervention effects.

RESULTS

Nurse-visited women, compared with controls, incurred $17 310 less in public benefit costs (P = .03), an effect more pronounced for women with higher psychological resources ($28 847, P = .01). These savings compare with program costs of $12 578. There were no program effects on substance abuseor depression. Nurse-visited women were more likely to be married from child age 2 through 18 (19.2% vs 14.8%, P = .04), and those with higher psychological resources had 4.64 fewer cumulative years rearing subsequent children after the birth of the first child (P = .03). Pregnancy planning was a significant mediator of program effects on public benefit costs.

CONCLUSIONS

Through child age 18, the program reduced public-benefit costs, an effect more pronounced for mothers with higher psychological resources and mediated by subsequent pregnancy planning. There were no effects on maternal substance abuse and depression.

Prenatal and Infancy Nurse Home Visiting and 18-Year Outcomes of a Randomized Trial

OBJECTIVES

Given earlier effects found in randomized clinical trials of the Nurse-Family Partnership, we examined whether this program would improve 18-year-old first-born youths' cognition, academic achievement, and behavior and whether effects on cognitive-related outcomes would be greater for youth born to mothers with limited psychological resources (LPR) and on arrests and convictions among females.

METHODS

We enrolled 742 pregnant, low-income women with no previous live births and randomly assigned them to receive either free transportation for prenatal care plus child development screening and referral (control; n = 514) or prenatal and infant home nurse visit (NV) plus transportation and screening (n = 228). Assessments were completed on 629 18-year-old first-born offspring to evaluate these primary outcomes: (1) cognitive-related abilities (nonverbal intelligence, receptive language, and math achievement) and (2) behavioral health (internalizing behavioral problems, substance use and abuse, sexually transmitted infections, HIV risk, arrests, convictions, and gang membership).

RESULTS

Compared with control-group counterparts, NV youth born to mothers with LPR had better receptive language (effect size = 0.24; 95% confidence interval [CI]: 0.00 to 0.47; P = .05), math achievement (effect size = 0.38; 95% CI: 0.14 to 0.61; P = .002), and a number of secondary cognitive-related outcomes. NV females, as a trend, had fewer convictions (incidence ratio = 0.47; 95% CI: 0.20 to 1.11; P = .08). There were no intervention effects on other behaviors.

CONCLUSIONS

The program improved the cognitive-related skills of 18-year-olds born to mothers with LPR and, as a trend, reduced female convictions but produced no other effects on youth behavioral health.

Costs and consequences of the Family Nurse Partnership (FNP) programme in England: evidence from the Building Blocks trial

Background: The Family Nurse Partnership (FNP) is a licensed intensive home visiting intervention programme delivered to teenage mothers which was originally introduced in England in 2006 by the Department of Health and is now provided through local commissioning of public health services and supported by a national unit led by a consortium of partners. The Building Blocks (BB) trial aimed to explore the effectiveness and cost-effectiveness of this programme. This paper reports the results of an economic evaluation of the Building Blocks randomised controlled trial (RCT) based on a cost-consequence approach.

Methods: A large sample of 1618 families was followed-up at various intervals during pregnancy and for two years after birth. A cost-consequence approach was taken to appraise the full range of costs arising from the intervention including both health and social measures of cost alongside the consequences of the trial, specifically, the primary outcomes.

Results: A large number of potential factors were identified that are likely to attract additional costs beyond the implementation costs of the intervention including both health and non-health outcomes.

Conclusion: Given the extensive costs and only small beneficial consequences observed within the two year follow-up period, the cost-consequence model suggests that the FNP intervention is unlikely to be worth the substantial costs and policy makers may wish to consider other options for investment.

Trial registration: ISRCTN23019866 (20/04/2009)

Characteristics of effective collaboration: A study of Nurse-Family Partnership and child welfare

BACKGROUND

In February 2018, President Trump signed into law the Family First Prevention Act, legislation in the United States aimed at providing prevention services for families at risk of entering the child welfare system. The effectiveness of these prevention efforts is dependent on the formation of collaborative relationships between prevention-programs and child welfare.

OBJECTIVE

To identify factors that influence the ability of the Nurse-Family Partnership (NFP) and Child Protective Services (CPS) to collaborate in serving high-risk mothers and their children.

PARTICIPANTS

123 NFP, CPS workers, and community partners.

SETTING

Seven sites in the U.S. state of Colorado selected to include an array of community sizes, geographies, apparent levels of collaboration, and variations in internal structures and practices.

METHODS

Using an adapted grounded theory approach, we conducted semi-structured interviews with frontline NFP and CPS workers and supervisors. Interviews were recorded, transcribed, validated, and coded in NVivo 10.

RESULTS

Alignment of core organizational mission and methods was key in determining collaboration levels between NFP and CPS. Only when workers perceived there to be alignment in organizational mission, did other factors such as program eligibility, communication channels, and risk and safety assessment practices influence the perceived benefits and efforts undertaken to enhance collaboration.

CONCLUSIONS

High-risk families frequently require services that go beyond the scope of any one organization. As programs that serve high-risk families refine their efforts to serve them effectively, collaborative efforts should focus on examining opportunities and challenges involved in creating greater mission alignment.

A Qualitative Evaluation of Engagement and Attrition in a Nurse Home Visiting Program: From the Participant and Provider Perspective

Beginning parenting programs in the prenatal and early postnatal periods have a large potential for impact on later child and maternal outcomes. Home-based parenting programs, such as the Nurse Family Partnership (NFP), have been established to help address this need. Program reach and impact is dependent on successful engagement of expecting mothers with significant risks; however, NFP attrition rates remain high. The current study qualitatively examined engagement and attrition from the perspectives of NFP nurses and mothers in order to identify mechanisms that enhance service engagement. Semi-structured interviews were conducted in focus groups composed of either engaged (27 total mothers) or unengaged (15 total mothers) mothers from the NFP program. NFP nurses (25 total nurses) were recruited for individual semi-structured interviews. Results suggest that understanding engagement in the NFP program requires addressing both initial and sustained engagement. Themes associated with enhanced initial engagement include nurse characteristics (e.g., flexible, supportive, caring) and establishment of a solid nurse-family relationship founded on these characteristics. Factors impacting sustained engagement include nurse characteristics, provision of educational materials on child development, individualized services for families, and available family support. Identified barriers to completing services include competing demands and lack of support. Findings of this study have direct relevance for workforce planning, including hiring and training through integrating results regarding effective nurse characteristics. Additional program supports to enhance parent engagement may be implemented across home-based parenting programs in light of the current study's findings.

The Ultimate Goal of Prevention and the Larger Context for Translation

Type II translational research tends to emphasize getting evidence-based programs implemented in real world settings. To fully realize the aspirations of prevention scientists, we need a broader strategy for translating knowledge about human wellbeing into population-wide improvements in wellbeing. Far-reaching changes must occur in policies and cultural practices that affect the quality of family, school, workplace, and community environments. This paper describes a broad cultural movement, not unlike the tobacco control movement, that can make nurturing environments a fundamental priority of public policy and daily life, thereby enhancing human wellbeing far beyond anything achieved thus far.

Support during pregnancy for women at increased risk of low birthweight babies

BACKGROUND

Studies consistently show a relationship between social disadvantage and low birthweight. Many countries have programmes offering special assistance to women thought to be at risk for giving birth to a low birthweight infant. These programmes, collectively referred to in this review as additional social support, may include emotional support, which gives a person a feeling of being loved and cared for, tangible/instrumental support, in the form of direct assistance/home visits, and informational support, through the provision of advice, guidance and counselling. The programmes may be delivered by multidisciplinary teams of health professionals, specially trained lay workers, or a combination of lay and professional workers. This is an update of a review first published in 2003 and updated in 2010.

OBJECTIVES

The primary objective was to assess the effects of programmes offering additional social support (emotional, instrumental/tangible and informational) compared with routine care, for pregnant women believed to be at high risk for giving birth to babies that are either preterm (less than 37 weeks' gestation) or weigh less than 2500 g, or both, at birth. Secondary objectives were to determine whether the effectiveness of support was mediated by timing of onset (early versus later in pregnancy) or type of provider (healthcare professional or lay person).

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) on 5 February 2018, and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised trials of additional social support during at-risk pregnancy by either a professional (social worker, midwife, or nurse) or specially trained lay person, compared to routine care. We defined additional social support as some form of emotional support (e.g. caring, empathy, trust), tangible/instrumental support (e.g. transportation to clinic appointments, home visits complemented with phone calls, help with household responsibilities) or informational support (advice and counselling about nutrition, rest, stress management, use of alcohol/recreational drugs).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

This updated review includes a total of 25 studies, with outcome data for 11,246 mothers and babies enrolled in 21 studies. We assessed the overall risk of bias of included studies to be low or unclear, mainly because of limited reporting or uncertainty in how randomisation was generated or concealed (which led us to downgrade the quality of most outcomes to moderate), and the impracticability of blinding participants.When compared with routine care, programmes offering additional social support for at-risk pregnant women may slightly reduce the number of babies born with a birthweight less than 2500 g from 127 per 1000 to 120 per 1000 (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.86 to 1.04; 16 studies, n = 11,770; moderate-quality evidence), and the number of babies born with a gestational age less than 37 weeks at birth from 128 per 1000 to 117 per 1000 (RR 0.92, 95% CI 0.84 to 1.01, 14 studies, n = 12,282; moderate-quality evidence), though the confidence intervals for the pooled effect for both of these outcomes just crossed the line of no effect, suggesting any effect is not large. There may be little or no difference between interventions for stillbirth/neonatal death (RR 1.11, 95% CI 0.88 to 1.41; 15 studies, n = 12,091; low-quality evidence). Secondary outcomes of moderate quality suggested that there is probably a reduction in caesarean section (from 215 per 1000 to 194 per 1000; RR 0.90, 95% CI 0.83 to 0.97; 15 studies, n = 9550), a reduction in the number of antenatal hospital admissions per participant (RR 0.78, 95% CI 0.68 to 0.91; 4 studies; n = 787), and a reduction in the mean number of hospitalisation episodes (mean difference -0.05, 95% CI -0.06 to -0.04; 1 study, n = 1525) in the social support group, compared to the controls.Postnatal depression and women's satisfaction were reported in different ways in the studies that considered these outcomes and so we could not include data in a meta-analysis. In one study postnatal depression appeared to be slightly lower in the support group in women who screened positively on the Edinbugh Postnatal Depression Scale at eight to 12 weeks postnatally (RR 0.74, 95% CI 0.55 to 1.01; 1 study, n = 1008; moderate-quality evidence). In another study, again postnatal depression appeared to be slightly lower in the support group and this was a self-report measure assessed at six weeks postnatally (RR 0.85, 95% CI 0.69 to 1.05; 1 study, n = 458; low-quality evidence). A higher proportion of women in one study reported that their prenatal care was very helpful in the supported group (RR 1.17, 95% CI 1.05 to 1.30; 1 study, n = 223; moderate-quality evidence), although in another study results were similar. Another study assessed satisfaction with prenatal care as being "not good" in 51 of 945 in the additional support group, compared with 45 of 942 in the usual care group.No studies considered long-term morbidity for the infant. No single outcome was reported in all studies. Subgroup analysis demonstrated consistency of effect when the support was provided by a healthcare professional or a trained lay worker.The descriptions of the additional social support were generally consistent across all studies and included emotional support, tangible support such as home visits, and informational support.

AUTHORS' CONCLUSIONS

Pregnant women need the support of caring family members, friends, and health professionals. While programmes that offer additional social support during pregnancy are unlikely to have a large impact on the proportion of low birthweight babies or birth before 37 weeks' gestation and no impact on stillbirth or neonatal death, they may be helpful in reducing the likelihood of caesarean birth and antenatal hospital admission.

A comprehensive home-care program for health promotion of mothers with preeclampsia: protocol for a mixed method study

Background

One of the most common complications of pregnancy and the third cause of maternal death is preeclampsia. Thus this group of mothers should be supported, trained and received efficient health care services. Home-care is one strategy to improvement complications of Pregnancy. In Iran, high-risk pregnancies care provide in health care centers, hospitals and clinics by midwives and obstetricians. In this mixed method study, at first, a qualitative approach will be used to identify preeclampsia mothers’ health needs and home-care strategies for them. Then, the qualitative results will be emerged with literature review and expert ideas to develop a comprehensive home-care program which fits with the needs of these mothers in Iran.

Methods

This study is a qualitative- quantitative mixed exploratory research that consists of three sequential phases. In the first step, in qualitative study, all the women with preeclampsia, obstetricians, midwives, and maternal health policy makers will select purposefully. Health care needs and home-care strategies for mothers with preeclampsia will be determined. Sampling continues until data saturation. In the second step, an expert panel will be formed to prioritization of home-care needs and strategies extracted from result of qualitative study and review of literature. Afterwards, Primary home care program will be designed. In the third step, Delphi method will be used of minimum 10–15 experts including: obstetricians, midwives, and reproductive health professionals about validation of this home-care program by questionnaires in three rounds, then the final program is being developed.

Discussion

It is expected conducting a mixed method study to develop a home care program mothers with preeclamsia to improve their health status and wellbeing while reducing additional health care costs through preventing excessive admissions and interventions. Moreover it wants to follow up properly and timely high risk pregnant women. This study might be helpful in improvement quality of health services and promote health equity.

Conclusion

Developing a home care program for maternal health care especially for high risk pregnancy by considering Iran socio-cultural context.

A Universal Early Parenting Education Intervention in Community-Based Primary Care Settings: Development and Installation Challenges

Prevention and early intervention programmes, which aim to educate and support parents and young children in the earliest stages of the family lifecycle, have become an increasingly popular policy strategy for tackling intergenerational disadvantage and developmental inequality. Evidence-based, joined-up services are recommended as best practice for achieving optimal outcomes for parents and their children; however, there are persistent challenges to the development, adoption and installation of these kinds of initiatives in community-based primary health care settings. In this paper, we present a description of the design and installation of a multi-stakeholder early parenting education and intervention service model called the Parent and Infant (PIN) programme. This new programme is delivered collaboratively on a universal, area-wide basis through routine primary care services and combines standardised parent-training with other group-based supports designed to educate parents, strengthen parenting skills and wellbeing and enhance developmental outcomes in children aged 0–2 years. The programme design was informed by local needs analysis and piloting to establish an in-depth understanding of the local context. The findings demonstrate that a hospitable environment is central to establishing interagency parenting education and supports. Partnership, relationship-building and strategic leadership are vital to building commitment and buy-in for this kind of innovation and programme implementation. A graduated approach to implementation which provides training/education and coaching as well as organisational and administrative supports for practice change, are also important in creating an environment conducive to collaboration. Further research into the impact, implementation and cost-effectiveness of the PIN programme will help to build an understanding of what works for parents and infants, as well as identifying lessons for the development and implementation of other similar complex prevention and intervention programmes elsewhere. This kind of research coupled with the establishment of effective partnerships involving service providers, parents, researchers and policy makers, is necessary to meeting the challenge of improving family education and enhancing the capacity of family services to help promote positive outcomes for children.

Follow-up study regarding the medium-term effectiveness of the home-visiting program "Pro Kind" at age 7 years: study protocol for a randomized controlled trial

BACKGROUND

Pro Kind is a German adaptation of the US Nurse Family Partnership program. It is an intervention based on home visits targeting first-time mothers from disadvantaged populations. Pro Kind was implemented as a randomized control trial from 2006 to 2012 with N = 755 first-time mothers (TG n = 394, CG n = 391). The 7-8-year follow-up aims to assess the mid-term effects of the program.

METHODS/DESIGN

Mid-term outcomes are being assessed by trained assessors. In a multimethod approach telephone interviews, on-site interviews, observations and developmental tests will be held in order to assess children's and mothers' life satisfaction, mental health, cognitive and social development, parenting behavior, signs of child abuse or neglect as well as the family's socio-economic status. Furthermore, administrative data will be accessed to obtain information regarding the mother's usage of pediatric health care, welfare usage and employment history.

DISCUSSION

Results regarding the mid-term effects of the intervention from the Pro Kind Follow-up will provide a scientific basis for future primary prevention programs as well as help stakeholders legitimizing early childhood investments.

TRIAL REGISTRATION

German Clinical Trial Registration DRKS-ID, ID: DRKS00007554 . Registered on 11 June 2015, updated on 6 October 2017.

Maternal substance use and child protection: a rapid evidence assessment of factors associated with loss of child care

This article reviews the literature on the factors associated with mothers who use substances losing care of their children. A rapid evidence assessment was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta Analyses. Medline and PsycINFO databases were searched to identify primary research studies published in English during January 2000-September 2016. Studies were included if they presented individual, formal support (e.g., receiving substance use treatment) or informal support (e.g., receiving social and family support) factors associated with mothers who use substances retaining or losing care of their child/ren (losing care refers to child protection services placing child/ren under the custody of a family relative, foster care, child care institution, or adoption). Evaluation studies or trials of interventions were excluded as were studies that focused on reunification or re-entering care as the outcome. Thirteen studies were included. Factors associated with mothers who use substances losing care of their children included: maternal characteristics (low socioeconomic status, younger age of first child, criminal justice involvement); psychological factors (mental health co-morbidity, adverse childhood experiences); patterns of substance use (use of cocaine prenatally, injection drug use); formal and informal support (not receiving treatment for substance use, fewer prenatal care visits, lack of social support). There is not enough evidence to determine the influence of substance use treatment in preventing mothers losing care of their children. Factors identified in this review provide the evidence to inform a prevention agenda and afford services the opportunity to design interventions that meet the needs of those mothers who are more likely to lose care of their children.

The Prevention of Child Maltreatment Through the Nurse Family Partnership Program: Mediating Effects in a Long-Term Follow-Up Study

We examine maternal life-course mediators of the impact of a nurse home visitation program on reducing child maltreatment among participants in the Elmira trial of the Nurse Family Partnership program from the first child's birth through age 15. For women having experienced low to moderate levels of domestic violence, program effects on the number of confirmed maltreatment reports were mediated by reductions in numbers of subsequent children born to mothers and their reported use of public assistance. Together, the two mediators explained nearly one half of the total effect of nurse home visiting on child maltreatment. The long-term success of this program on reducing child maltreatment can be explained, at least in part, by its positive effect on pregnancy planning and economic self-sufficiency.

Minding the Baby

Minding the Baby, an interdisciplinary, relationship based home visiting program, was initiated to help young, at-risk new mothers keep their babies (and themselves) "in mind" in a variety of ways. The intervention--delivered by a team that includes a nurse practitioner and clinical social worker--uses a mentalization based approach; that is, we work with mothers and babies in a variety of ways to develop mothers' reflective capacities. This approach--which is an adaptation of both nurse home visiting and infant-parent psychotherapy models--seems particularly well suited to highly traumatized mothers and their families, as it is aimed at addressing the particular relationship disruptions that stem from mothers' early trauma and derailed attachment history. We discuss the history of psychoanalytically oriented and attachment based mother-infant intervention, the theoretical assumptions of mentalization theory, and provide an overview of the Minding the Baby program. The treatments of two teenage mothers and their infants are described.

A population study of first and subsequent pregnancy smoking behaviors in Ohio

OBJECTIVE

The objective of this study is to identify maternal characteristics associated with non-smoking during a subsequent pregnancy after first pregnancy smoking.

STUDY DESIGN

We conducted a retrospective population-based analysis of Ohio vital birth records from 2007 to 2013. We used logistic regression to calculate adjusted odds ratios with 95% confidence intervals for detection of characteristics associated with non-smoking during a subsequent pregnancy after first pregnancy smoking.

RESULTS

Among 75 190 mothers, 75.6% were non-smokers and 13.7% were smokers during both pregnancies. During their first pregnancy, 49.7% of 15 075 smokers quit. Of them, 50.1% remained non-smokers during their subsequent pregnancy. Women who reduced, but continued smoking during their first pregnancy, were more than five times as likely to smoke during their subsequent pregnancy than women who quit (odds ratio (95% confidence interval): 2.85 (2.43 to 3.35) vs 0.55 (0.45 to 0.67)).

CONCLUSION

Interventions targeting complete cessation, rather than reduction in smoking among first-time mothers, may be the most effective at optimizing long-term health benefits.

The NSPCC UK Minding the Baby® (MTB) home-visiting programme, supporting young mothers (aged 14-25) in the first 2 years of their baby's life: study protocol for a randomised controlled trial

BACKGROUND

Young mothers living in low-income urban settings often are exposed to significant and chronic environmental difficulties including poverty, social isolation and poor education and typically also have to cope with personal histories of abuse and depression. Minding the Baby® (MTB) is an interdisciplinary home-visiting programme developed to support first-time young mothers, which integrates primary care and mental health approaches into a single intensive intervention from the last trimester of pregnancy until the child's second birthday. The primary aim of the intervention is to promote caregiver sensitivity, and, secondarily, to promote both child and maternal socioemotional outcomes.

METHODS/DESIGN

This is a multisite randomised controlled trial (RCT) with a target recruitment of 200 first-time adolescent mothers (under 26 years of age). One hundred participants will be randomised to the MTB group and they will receive the MTB programme in addition to the usual services available in their areas. Those participants not allocated to MTB will receive Treatment as Usual (TAU) only. Researchers will carry out blind assessments at baseline (before the birth of the baby), and outcome assessments around the child's first and second birthdays. The primary outcome will be the quality of maternal sensitivity and the secondary outcomes will focus on attachment security, child cognitive/language development, behavioural problems, postponed childbearing, maternal mental health and incidents of child protection interventions.

DISCUSSION

This study evaluates the Minding the Baby® programme in the UK. In particular, this RCT explores the effectiveness of this integrative approach, which focusses on maternal mental issues as well as parent-infant interaction, parental concerns and developmental outcomes.

TRIAL REGISTRATION

ISRCTN08678682 (date of registration 3 April 2014).

Waiting to be Caught: The Devolution of Health for Women Newly Released from Jail

Traditionally understood ideas about health and criminal behaviors are integrally linked within an individual's health, as well as a community's health. In a time when women are increasingly jailed, it is important to examine the life ways of women who are newly released. This study, using participatory action research and critical hermeneutic data analysis techniques, examined women's health and social experiences following their release from jail. Findings suggest that women experienced an onward and downward momentum of health indices, or devolution, with regard to economic status, physical and mental health status, intimate and family relationships, and general social functioning. It is argued that basic public health and community nursing interventions would provide a more seamless transition from jail back into community and would positively impact the individual and community health issues that are embedded within the criminal activity.

Improving children's health and development in British Columbia through nurse home visiting: a randomized controlled trial protocol

Background

Nurse-Family Partnership is a nurse home visitation program that aims to improve the lives of young mothers and their children. The program focuses on women who are parenting for the first time and experiencing socioeconomic disadvantage. Nurse visits start as early in pregnancy as possible and continue until the child reaches age two years. The program has proven effective in the United States – improving children’s mental health and development and maternal wellbeing, and showing long-term cost-effectiveness. But it is not known whether the same benefits will be obtained in Canada, where public services differ. The British Columbia Healthy Connections Project therefore involves a randomized controlled trial evaluating Nurse-Family Partnership’s effectiveness compared with existing (usual) services in improving children’s mental health and early development and mother’s life circumstances. The trial’s main aims are to: reduce childhood injuries by age two years (primary outcome indicator); reduce prenatal nicotine and alcohol use; improve child cognitive and language development and behaviour at age two years; and reduce subsequent pregnancies by 24 months postpartum. Potential explanatory factors such as maternal mental health (including self-efficacy) are also being assessed, as is the program’s impact on exposure to intimate-partner violence. To inform future economic evaluation, data are also being collected on health and social service access and use.

Methods/design

Eligible and consenting participants (N = 1040) are being recruited prior to 28 weeks gestation then individually randomized to receive existing services (comparison group) or Nurse-Family Partnership plus existing services (intervention group). Nurse-Family Partnership is being delivered following fidelity guidelines. Data are being collected during in person and telephone interviews at: baseline; 34–36 weeks gestation; and two, 10, 18 and 24 months postpartum. Additional data will be obtained via linkages from provincial datasets. Recruitment commenced in October 2013 and will continue for approximately three years.

Discussion

This trial will provide important information about the generalizability of Nurse-Family Partnership to the Canadian context. Findings will be published in peer-reviewed journals and shared with policymakers and practitioners through extensive public health collaborations already underway.

Trial registration

Registered July 18, 2013 with ClinicalTrials.gov Identifier: NCT01672060.

Public Health Nurses and Mothers Challenge and Shift the Meaning of Health Outcomes

Maternal, child, and newborn health is a priority area in Canada and around the world. The work of public health nurses (PHNs) is often invisible and misunderstood. The purpose of this qualitative research project was to explore how universal and targeted home visiting programs for mothers and babies were organized, delivered, and experienced through the everyday practices of PHNs (n = 16) and mothers (n = 16) in Nova Scotia, Canada. Feminist poststructuralism and discourse analysis were used to analyze interviews. Concepts of relations of power enabled an understanding of how health outcomes had been socially and institutionally constructed through binary relations. PHNs and mothers spoke about the importance of “softer” health outcomes, including maternal self-confidence and empowerment that had been constructed as less important than health outcomes that were seen to be more tangible and physical. Findings from this research could be used to guide practice and planning of postpartum home visiting programs.

Relationships among obesity, physical activity and sedentary behavior in young adolescents with and without lifetime asthma

OBJECTIVE

To examine the inter-relationships among body mass index (BMI), physical activity, sedentary behavior and gender in urban, low-income, primarily African American young adolescents with or without lifetime asthma.

METHODS

Data were collected in 2002-2004 from 626 12-year old adolescents who were children of women who participated in the New Mother's Study in Memphis, TN (1990-1991). Adolescents with and without asthma were compared on BMI, physical activity and sedentary behavior. Multiple linear regression models were used to examine the association of asthma, gender and BMI with physical activity and sedentary behavior.

RESULTS

Complete data were available for 545 adolescents. Eleven percent of adolescents had lifetime asthma. Asthma and gender were associated with high-intensity physical activity (p < 0.001). Adolescents with asthma participated in less physical activity and girls participated less than boys. Gender was associated with sedentary behavior (p < 0.001): boys used personal computer (pc)/video after school more than girls. Girls with asthma had a higher BMI than girls without asthma (p = 0.027). Boys with asthma were less physically active than boys without asthma (p < 0.05).

CONCLUSIONS

Adolescents with asthma are less physically active than those without asthma and girls are less active than boys. Clinicians who provide care for adolescents with asthma are encouraged to assess physical activity/sedentary behavior and provide guidance that promotes active lifestyles. A longitudinal study is needed to shed light on the unique contribution of asthma separated from the effects of overweight/obesity on physical activity and sedentary behaviors.

Projected Outcomes of Nurse-Family Partnership Home Visitation During 1996-2013, USA

Nurse-Family Partnership (NFP) targets intensive prenatal and postnatal home visitation by registered nurses to low-income first-time mothers. Through 2013, 177,517 pregnant women enrolled in NFP programs. This article projects how NFP will affect their lives and the lives of their babies. NFP has been evaluated in six randomized trials and several more limited analyses of operational programs. We systematically reviewed evaluation findings on 21 outcomes and calculated effects on three more. We added outcome data from the NFP national data system and personal communications that filled outcome data gaps on some trials. We assumed effectiveness in replication declined by 21.8 %, proportionally with the decline in mean visits per family from trials to operational programs. By 2031, NFP program enrollments in 1996-2013 will prevent an estimated 500 infant deaths, 10,000 preterm births, 13,000 dangerous closely spaced second births, 4700 abortions, 42,000 child maltreatment incidents, 36,000 intimate partner violence incidents, 90,000 violent crimes by youth, 594,000 property and public order crimes (e.g., vandalism, loitering) by youth, 36,000 youth arrests, and 41,000 person-years of youth substance abuse. They will reduce smoking during pregnancy, pregnancy complications, childhood injuries, and use of subsidized child care; improve language development; increase breast-feeding; and raise compliance with immunization schedules. They will eliminate the need for 4.8 million person-months of child Medicaid spending and reduce estimated spending on Medicaid, TANF, and food stamps by $3.0 billion (present values in 2010 dollars). By comparison, NFP cost roughly $1.6 billion. Thus, NFP appears to be a sound investment. It saves money while enriching the lives of participating low-income mothers and their offspring and benefiting society more broadly by reducing crime and safety net demand.

Effectiveness of home visiting in reducing partner violence for families experiencing abuse: a systematic review

BACKGROUND

Intimate partner violence (IPV) against women is a major, global societal problem with enormous health consequences both for mother and child. Home visiting interventions in families at risk of abuse seem promising in decreasing IPV. In this systematic review, we aim to assess the effectiveness of home visiting in reducing IPV experienced by mothers.

METHODS

We conducted a systematic review using the Pubmed, PsychINFO and Embase databases from inception until March 2014, with a specific search strategy for each database.

RESULTS

Of the 1258 articles identified, 19 (six different home visiting studies) met our inclusion criteria and were examined in detail. Three different types of studies were identified: the primary focus of one study was on the abused mother and the secondary focus on the children (Australia); two studies (Hawaii, The Netherlands) with a primarily focus on reduction of child abuse and a secondary focus on IPV and finally three studies from the USA, which only aimed at reducing child abuse by providing support to the mother. The Australian study reported a significant lowering of the IPV score at 1-year follow-up (15.9 versus 21.8, adjusted difference -8.67, 95% confidence interval [CI]: -16.2 to -1.15). The Hawaii-study showed significantly lower rates of physical assault after 3 years follow-up (incidence rate ratio [IRR] 0.85; 95% CI: 0.71-1.00) and the Dutch study showed a significant decrease of mothers' physical assaults 2 years after birth (odds ratio 0.46; 95% CI 0.24-0.89). The other three studies showed no significant reduction of IPV.

CONCLUSIONS

Home visiting interventions that support abused women explicit to stop IPV seem to be effective in reducing IPV. However, it is not known whether these results are effective in the long term.

Long-term home visiting with vulnerable young mothers: an interpretive description of the impact on public health nurses

Background

The Nurse-Family Partnership (NFP) is a targeted, nurse home visitation program for young, low-income, first-time mothers. While the effectiveness of the NFP has been established in the United States, and is currently being evaluated in the Canadian public health care system, we have minimal understanding of how work of this nature impacts public health nurses (PHNs), an essential component of this program delivery model, on both professional and personal levels.

Methods

This two-phase study consisted of a qualitative secondary analysis of data from five focus groups conducted with PHNs (N = 6) who delivered the NFP intervention as part of a pilot study assessing feasibility and acceptability conducted in Hamilton, Ontario. The second phase, an interpretive description of individual interviews with the PHNs (N = 10) who have delivered the NFP in this context, further explored themes identified in the first phase. A practice, problem and needs analysis was conducted to describe and understand the phenomenon and promote sustainability of PHNs in this practice environment. Conventional content analysis was used to code and categorize data in the two datasets.

Results

The nurse-client relationship, the core elements and structure of the NFP program and support of NFP colleagues were described as rewarding factors, while workload and workplace factors were identified as significant contributors to stress. PHNs described transforming their nursing practice through redefining success and shifting to a philosophy where the client is the expert of her own life. PHNs described the personal impact of worry about clients and doubt about their effectiveness in addressing client concerns. High levels of satisfaction were described in relation to the depth and intensity of relationships with clients and seeing them succeed over time.

Conclusions

PHNs are impacted in multiple ways by their work with vulnerable, young mothers. The study findings have implications for identification of strategies to support PHNs in reducing staff turnover, PHN burnout, secondary traumatic stress and compassion fatigue, and improving program delivery.

Effect of home visiting by nurses on maternal and child mortality: results of a 2-decade follow-up of a randomized clinical trial

IMPORTANCE

Mothers and children living in adverse contexts are at risk of premature death.

OBJECTIVE

To determine the effect of prenatal and infant/toddler nurse home visiting on maternal and child mortality during a 2-decade period (1990-2011).

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical trial was designed originally to assess the home visiting program's effect on pregnancy outcomes and maternal and child health through child age 2 years. The study was conducted in a public system of obstetric and pediatric care in Memphis, Tennessee. Participants included primarily African American women and their first live-born children living in highly disadvantaged urban neighborhoods, who were assigned to 1 of 4 treatment groups: treatment 1 (transportation for prenatal care [n = 166]), treatment 2 (transportation plus developmental screening for infants and toddlers [n = 514]), treatment 3 (transportation plus prenatal/postpartum home visiting [n = 230]), and treatment 4 (transportation, screening, and prenatal, postpartum, and infant/toddler home visiting [n = 228]). Treatments 1 and 3 were included originally to increase statistical power for testing pregnancy outcomes. For determining mortality, background information was available for all 1138 mothers assigned to all 4 treatments and all but 2 live-born children in treatments 2 and 4 (n = 704). Inclusion of children in treatments 1 and 3 was not possible because background information was missing on too many children.

INTERVENTIONS

Nurses sought to improve the outcomes of pregnancy, children's health and development, and mothers' health and life-course with home visits beginning during pregnancy and continuing through child age 2 years.

MAIN OUTCOMES AND MEASURES

All-cause mortality in mothers and preventable-cause mortality in children (sudden infant death syndrome, unintentional injury, and homicide) derived from the National Death Index.

RESULTS

The mean (SE) 21-year maternal all-cause mortality rate was 3.7% (0.74%) in the combined control group (treatments 1 and 2), 0.4% (0.43%) in treatment 3, and 2.2% (0.97%) in treatment 4. The survival contrast of treatments 1 and 2 combined with treatment 3 was significant (P = .007); the contrast of treatments 1 and 2 combined with treatment 4 was not significant (P = .19), and the contrast of treatments 1 and 2 combined with treatments 3 and 4 combined was significant (post hoc P = .008). At child age 20 years, the preventable-cause child mortality rate was 1.6% (0.57%) in treatment 2 and 0.0% (SE not calculable) in treatment 4; the survival contrast was significant (P = .04).

CONCLUSIONS AND RELEVANCE

Prenatal and infant/toddler home visitation by nurses is a promising means of reducing all-cause mortality among mothers and preventable-cause mortality in their first-born children living in highly disadvantaged settings.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00708695.

Patterns of visit attendance in the nurse-family partnership program

OBJECTIVES

We examined visit attendance patterns in the Memphis trial of the Nurse-Family Partnership and associations between these patterns and family characteristics, outcomes, and treatment-control differences in outcomes.

METHODS

We employed repeated measures latent class analysis to identify attendance patterns among the 228 mothers assigned to receive home nurse visits during pregnancy and until the child was aged 2 years, associated background characteristics, outcomes, and treatment-control differences by visit class. Home visits were conducted from June 1990 to March 1994. We collected outcome data from May 1992 to April 1994 and July 2003 to December 2006.

RESULTS

We identified 3 visit attendance patterns. High attenders (48%) had the most visits and good outcomes. Low attenders (33%) had the most education and the best outcomes. Increasing attenders (18%) had the fewest completed visits during pregnancy, the poorest intake characteristics, and the poorest outcomes. Treatment-control group differences varied by class, with high and low attenders having better outcomes on some measures than did their control group counterparts.

CONCLUSIONS

Three patterns were associated with distinct groups of mothers with different long-term outcomes. Further examination and use of patterns to classify mothers and prioritize resources may improve efficiency in the Nurse-Family Partnership.

Effects of home visits by paraprofessionals and by nurses on children: follow-up of a randomized trial at ages 6 and 9 years

IMPORTANCE

The Nurse-Family Partnership delivered by nurses has been found to produce long-term effects on maternal and child health in replicated randomized trials. A persistent question is whether paraprofessional home visitors might produce comparable effects.

OBJECTIVE

To examine the impact of prenatal and infancy/toddler home visits by paraprofessionals and by nurses on child development at child ages 6 and 9 years.

DESIGN, SETTING, AND PARTICIPANTS

Randomized trial in public and private care settings in Denver, Colorado, of 735 low-income women and their first-born children (85% of the mothers were unmarried; 47% were Hispanic, 35% were non-Hispanic white, 15% were African American, and 3% were American Indian/Asian).

INTERVENTIONS

Home visits provided from pregnancy through child age 2 years delivered in one group by paraprofessionals and in the other by nurses.

MAIN OUTCOMES AND MEASURES

Reports of children's internalizing, externalizing, and total emotional/behavioral problems, and tests of children's language, intelligence, attention, attention dysfunction, visual attention/task switching, working memory, and academic achievement. We hypothesized that program effects on cognitive-related outcomes would be more pronounced among children born to mothers with low psychological resources. We report paraprofessional-control and nurse-control differences with P < .10 given similar effects in a previous trial, earlier effects in this trial, and limited statistical power.

RESULTS

There were no significant paraprofessional effects on emotional/behavioral problems, but paraprofessional-visited children born to mothers with low psychological resources compared with control group counterparts exhibited fewer errors in visual attention/task switching at age 9 years (effect size = -0.30, P = .08). There were no statistically significant paraprofessional effects on other primary outcomes. Nurse-visited children were less likely to be classified as having total emotional/behavioral problems at age 6 years (relative risk [RR] = 0.45, P = .08), internalizing problems at age 9 years (RR = 0.44, P = .08), and dysfunctional attention at age 9 years (RR = 0.34, P = .07). Nurse-visited children born to low-resource mothers compared with control-group counterparts had better receptive language averaged over ages 2, 4, and 6 years (effect size = 0.30, P = .01) and sustained attention averaged over ages 4, 6, and 9 years (effect size = 0.36, P = .006). There were no significant nurse effects on externalizing problems, intellectual functioning, and academic achievement.

CONCLUSIONS AND RELEVANCE

Children born to low-resource mothers visited by paraprofessionals exhibited improvement in visual attention/task switching. Nurse-visited children showed improved behavioral functioning, and those born to low-resource mothers benefited in language and attention but did not improve in intellectual functioning and academic achievement.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00438282 and NCT00438594.

Caregiver behavior change for child survival and development in low- and middle-income countries: an examination of the evidence

In June of 2012, representatives from more than 80 countries promulgated a Child Survival Call to Action, which called for reducing child mortality to 20 or fewer child deaths per 1,000 live births in every country by 2035. To address the problem of ending preventable child deaths, the U.S. Agency for International Development and the United Nations Children's Fund convened, on June 3-4, 2013, an Evidence Summit on Enhancing Child Survival and Development in Lower- and Middle-Income Countries by Achieving Population-Level Behavior Change. Six evidence review teams were established on different topics related to child survival and healthy development to identify the relevant evidence-based interventions and to prepare reports. This article was developed by the evidence review team responsible for identifying the research literature on caregiver change for child survival and development. This article is organized into childhood developmental periods and cross-cutting issues that affect child survival and healthy early development across all these periods. On the basis of this review, the authors present evidence-based recommendations for programs focused on caregivers to increase child survival and promote healthy development. Last, promising directions for future research to change caregivers' behaviors are given.

Women's reasons for attrition from a nurse home visiting program

OBJECTIVE

To describe mothers' reasons for leaving a home visiting program early.

DESIGN

Qualitative descriptive study using semistructured interviews of mothers who dropped out of the Nurse-Family Partnership (NFP) and two focus groups with nurses and nurse supervisors at an NFP site.

SETTING

A New York State site of a NFP home visitation program for low-income new mothers designed to improve the physical and emotional care of children.

PARTICIPANTS

Participants included 21 mothers, 8 nurses, and 3 nurse-supervisors.

METHODS

Semistructured interviews and focus groups were used to collect data, which were analyzed using content analysis.

RESULTS

The program was not perceived to fit a mother's needs when she was overwhelmed with other responsibilities, the nurse did not meet her expectations, the content was not of interest, or the mother did not desire visits after the infant was born. Nurses and mothers described the need for mothers to have organizational and communication skills, such as keeping track of appointments, calling to reschedule, articulating needs, and asking for assistance. Disruptive external influences included nurse turnover and unstable living situations, including frequent moves and crowded housing. Each of these types of barriers had potential to interact with the others, creating complex combinations of challenges to retention.

CONCLUSION

NFP retention might be improved by reframing program relevance to individual mothers and increasing maternal organizational and communication skill development.

Outreach and integration programs to promote family planning in the extended postpartum period

BACKGROUND

WHO recommends birth spacing to improve the health of the mother and child. One strategy to facilitate birth spacing is to improve the use of family planning during the first year postpartum.

OBJECTIVES

To determine from the literature the effectiveness of postpartum family-planning programs and to identify research gaps.

SEARCH STRATEGY

PubMed and the Cochrane Central Register of Controlled Trials were systematically searched for articles published between database inception and March 2013. Abstracts of conference presentations, dissertations, and unpublished studies were also considered.

SELECTION CRITERIA

Published studies with birth spacing or contraceptive use outcomes were included.

DATA COLLECTION AND ANALYSIS

Standard abstract forms and the US Preventive Services Task Force grading system were used to summarize and assess the quality of the evidence.

MAIN RESULTS

Thirty-four studies were included. Prenatal care, home visitation programs, and educational interventions were associated with improved family-planning outcomes, but should be further studied in low-resource settings. Mother-infant care integration, multidisciplinary interventions, and cash transfer/microfinance interventions need further investigation.

CONCLUSIONS

Programmatic interventions may improve birth spacing and contraceptive uptake. Larger well-designed studies in international settings are needed to determine the most effective ways to deliver family-planning interventions.

Effectiveness of home visiting in improving child health and reducing child maltreatment

BACKGROUND AND OBJECTIVE

The Patient Protection and Affordable Care Act established the Maternal, Infant, and Early Childhood Home Visiting Program, which provides $1.5 billion to states over 5 years for home visiting program models serving at-risk pregnant women and children from birth to age 5. The act stipulates that 75% of the funds must be used for programs with evidence of effectiveness based on rigorous evaluation research. Home Visiting Evidence of Effectiveness reviewed the home visiting research literature and provided an assessment of the evidence of effectiveness for program models that serve families with pregnant women and children from birth to age 5.

METHODS

Home Visiting Evidence of Effectiveness included a systematic search and screening process, a review of the research quality, and an assessment of program effectiveness. Reviewers rated studies' capacity to provide unbiased estimates of program impacts and determined whether a program met the Department of Health and Human Services' criteria for an evidence-based model.

RESULTS

As of July 2012, 32 models were reviewed, of which 12 met the Department of Health and Human Services criteria. Most of these models were shown to have favorable effects on child development. Other common favorable effects included health care usage and reductions in child maltreatment. Less common were favorable effects on birth outcomes.

CONCLUSIONS

Home visiting is a promising way to serve families who may be difficult to engage in supportive services. Existing rigorous research indicates that home visiting has the potential for positive results among high-risk families, particularly on health care usage and child development.

Gestational weight gain of pregnant African American adolescents affects body mass index 18 years later

OBJECTIVE

To determine if gestational weight gain (GWG) in adolescents is associated with long-term weight increases 12 years and 18 years after delivery of a first child and the differential effects of weight gain during pregnancy that is inadequate, the appropriate amount, and excessive based on the 2009 Institute of Medicine (IOM) recommendations.

DESIGN

Secondary data analysis of data from a randomized controlled trial.

SETTING

Memphis, Tennessee.

PARTICIPANTS

Two hundred ninety-eight (298) primiparous low-income Black women who were adolescents at the time of their first pregnancies.

METHOD

Linear regression was used to examine the relationship between body mass index (BMI) at 12 and 18 years postdelivery and GWG, parity, prepregnancy BMI, and smoking.

RESULTS

The total sample experienced a significant BMI increase from prepregnancy to 12 years and 18 years postdelivery. More than 50% of the women had a BMI increase greater than 10 kg/m(2) . By 18 years postdelivery, 85% were overweight or obese. Prepregnancy BMI and GWG had a positive significant effect on BMI 12 and 18 years later, whereas smoking had a negative effect. Those who gained excessive weight based on the IOM recommendations had a significantly higher BMI compared with those who gained appropriately.

CONCLUSION

Gestational weight gain had long-term effects on BMI in a minority adolescent population. Excessive pregnancy weight gain is likely to contribute to long-term weight retention, especially if adolescents are overweight or obese when they become pregnant with their first children. Intervention during pregnancy to limit GWG has the potential of limiting long-term negative health consequences that result from overweight and obesity in minority women.

Emergency department visits and hospitalizations for injuries among infants and children following statewide implementation of a home visitation model

To compare hospital-based utilization for early childhood injuries between program recipients and local-area comparison families following statewide implementation of an evidence-based home visitation program, and to describe site-level program variation. Propensity score matching on baseline characteristics was used to create a retrospective cohort of Nurse-Family Partnership (NFP) clients and local area matched comparison women. The main outcome, a count of injury visit episodes, was enumerated from Medicaid claims for injuries examined in an emergency department or hospital setting during the first 2 years of life of children born to included subjects. Generalized linear models with a Poisson distribution examined the association between injury episode counts and NFP participation, controlling for other non-injury utilization and stratifying by individual agency catchment area in a fixed effects analysis. The children of NFP clients were more likely in aggregate to have higher rates of injury visits in the first 2 years of life than the children of comparison women (415.2/1,000 vs. 364.2/1,000, P < 0.0001). Significantly higher rates of visits among children of NFP clients for superficial injuries (156.6/1,000 vs. 132.6/1,000, P < 0.0001) principally accounted for the attributable difference in injury visit rates between groups. Among more serious injuries, no significant difference in injury visit rates was found between NFP clients and comparison women. The proportion of children with at least one injury visit varied from 14.5 to 42.5% among individual sites. Contrary to prior randomized trial data, no reductions in utilization for serious early childhood injuries were demonstrated following statewide implementation of an evidence-based home visitation program. Significant program variation on outcomes underscores the challenges to successful implementation.

Design and implementation of an integrated, continuous evaluation, and quality improvement system for a state-based home-visiting program

To describe the design and implementation of an evaluation system to facilitate continuous quality improvement (CQI) and scientific evaluation in a statewide home visiting program, and to provide a summary of the system's progress in meeting intended outputs and short-term outcomes. Help Us Grow Successfully (HUGS) is a statewide home visiting program that provides services to at-risk pregnant/post-partum women, children (0-5 years), and their families. The program goals are to improve parenting skills and connect families to needed services and thus improve the health of the service population. The evaluation system is designed to: (1) integrate evaluation into daily workflow; (2) utilize standardized screening and evaluation tools; (3) facilitate a culture of CQI in program management; and, (4) facilitate scientifically rigorous evaluations. The review of the system's design and implementation occurred through a formative evaluation process (reach, dose, and fidelity). Data was collected through electronic and paper surveys, administrative data, and notes from management meetings, and medical chart review. In the design phase, four process and forty outcome measures were selected and are tracked using standardized screening and monitoring tools. During implementation, the reach and dose of training were adequate to successfully launch the evaluation/CQI system. All staff (n = 165) use the system for management of families; the supervisors (n = 18) use the system to track routine program activities. Data quality and availability is sufficient to support periodic program reviews at the region and state level. In the first 7 months, the HUGS evaluation system tracked 3,794 families (7,937 individuals). System use and acceptance is high. A successful implementation of a structured evaluation system with a strong CQI component is feasible in an existing, large statewide program. The evaluation/CQI system is an effective mechanism to drive modest change in management of the program.

Home visitation program effectiveness and the influence of community behavioral norms: a propensity score matched analysis of prenatal smoking cessation

Background

The influence of community context on the effectiveness of evidence-based maternal and child home visitation programs following implementation is poorly understood. This study compared prenatal smoking cessation between home visitation program recipients and local-area comparison women across 24 implementation sites within one state, while also estimating the independent effect of community smoking norms on smoking cessation behavior.

Methods

Retrospective cohort design using propensity score matching of Nurse-Family Partnership (NFP) clients and local-area matched comparison women who smoked cigarettes in the first trimester of pregnancy. Birth certificate data were used to classify smoking status. The main outcome measure was smoking cessation in the third trimester of pregnancy. Multivariable logistic regression analysis examined, over two time periods, the association of NFP exposure and the association of baseline county prenatal smoking rate on prenatal smoking cessation.

Results

The association of NFP participation and prenatal smoking cessation was stronger in a later implementation period (35.5% for NFP clients vs. 27.5% for comparison women, p < 0.001) than in an earlier implementation period (28.4% vs. 25.8%, p = 0.114). Cessation was also negatively associated with county prenatal smoking rate, controlling for NFP program effect, (OR = 0.84 per 5 percentage point change in county smoking rate, p = 0.002).

Conclusions

Following a statewide implementation, program recipients of NFP demonstrated increased smoking cessation compared to comparison women, with a stronger program effect in later years. The significant association of county smoking rate with cessation suggests that community behavioral norms may present a challenge for evidence-based programs as models are translated into diverse communities.

The social paediatrics initiative: a RICHER model of primary health care for at risk children and their families

Background

The Responsive Interdisciplinary Child-Community Health Education and Research (RICHER) initiative is an intersectoral and interdisciplinary community outreach primary health care (PHC) model. It is being undertaken in partnership with community based organizations in order to address identified gaps in the continuum of health services delivery for ‘at risk’ children and their families. As part of a larger study, this paper reports on whether the RICHER initiative is associated with increased: 1) access to health care for children and families with multiple forms of disadvantage and 2) patient-reported empowerment. This study provides the first examination of a model of delivering PHC, using a Social Paediatrics approach.

Methods

This was a mixed-methods study, using quantitative and qualitative approaches; it was undertaken in partnership with the community, both organizations and individual providers. Descriptive statistics, including logistic regression of patient survey data (n=86) and thematic analyses of patient interview data (n=7) were analyzed to examine the association between patient experiences with the RICHER initiative and parent-reported empowerment.

Results

Respondents found communication with the provider clear, that the provider explained any test results in a way they could understand, and that the provider was compassionate and respectful. Analysis of the survey and in-depth interview data provide evidence that interpersonal communication, particularly the provider’s interpersonal style (e.g., being treated as an equal), was very important. Even after controlling for parents’ education and ethnicity, the provider’s interpersonal style remained positively associated with parent-reported empowerment (p<0.01).

Conclusions

This model of PHC delivery is unique in its purposeful and required partnerships between health care providers and community members. This study provides beginning evidence that RICHER can better meet the health and health care needs of people, especially those who are vulnerable due to multiple intersecting social determinants of health. Positive interpersonal communication from providers can play a key role in facilitating situations where individuals have an opportunity to experience success in managing their and their family’s health.

Mothers' experiences in the Nurse-Family Partnership program: a qualitative case study

Background

Few studies have explored the experiences of low income mothers participating in nurse home visiting programs. Our study explores and describes mothers' experiences participating in the Nurse-Family Partnership (NFP) Program, an intensive home visiting program with demonstrated effectiveness, from the time of program entry before 29 weeks gestation until their infant's first birthday.

Methods

A qualitative case study approach was implemented. A purposeful sample of 18 low income, young first time mothers participating in a pilot study of the NFP program in Hamilton, Ontario, Canada partook in one to two face to face in-depth interviews exploring their experiences in the program. All interviews were digitally recorded and transcribed verbatim. Conventional content analysis procedures were used to analyze all interviews. Data collection and initial analysis were implemented concurrently.

Results

The mothers participating in the NFP program were very positive about their experiences in the program. Three overarching themes emerged from the data: 1. Getting into the NFP program; 2. The NFP nurse is an expert, but also like a friend providing support; and 3. Participating in the NFP program is making me a better parent.

Conclusions

Our findings provide vital information to home visiting nurses and to planners of home visiting programs about mothers' perspectives on what is important to them in their relationships with their nurses, how nurses and women are able to develop positive therapeutic relationships, and how nurses respond to mothers' unique life situations while home visiting within the NFP Program. In addition our findings offer insights into why and under what circumstances low income mothers will engage in nurse home visiting and how they expect to benefit from their participation.

Home visits during pregnancy and after birth for women with an alcohol or drug problem

BACKGROUND

One potential method of improving outcome for pregnant or postpartum women with a drug or alcohol problem is with home visits.

OBJECTIVES

To determine the effects of home visits during pregnancy and/or after birth for women with a drug or alcohol problem.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2011), CENTRAL (The Cochrane Library 2011, Issue 4 of 4), MEDLINE (1966 to 30 November 2011), EMBASE (1980 to 30 November 2011), CINAHL (1982 to 30 November 2011) and PsycINFO (1974 to 30 November 2011) supplemented by searches of citations from previous reviews and trials and contact with experts.

SELECTION CRITERIA

Studies using random or quasi-random allocation of pregnant or postpartum women with a drug or alcohol problem to home visits. Trials enrolling high-risk women of whom more than 50% were reported to use drugs or alcohol were also eligible.

DATA COLLECTION AND ANALYSIS

Review authors performed assessments of trials independently. We performed statistical analyses using fixed-effect and random-effects models where appropriate.

MAIN RESULTS

Seven studies (reporting 803 mother-infant pairs) compared home visits mostly after birth with no home visits. Visitors included community health nurses, paediatric nurses, trained counsellors, paraprofessional advocates, midwives and lay African-American women. Several studies had significant methodological limitations. There was no significant difference in continued illicit drug use (three studies, 384 women; risk ratio (RR) 1.05, 95% confidence interval (CI) 0.89 to 1.24), continued alcohol use (three studies, 379 women; RR 1.18, 95% CI 0.96 to 1.46), failure to enrol in a drug treatment program (two studies, 211 women; RR 0.45, 95% CI 0.10 to 1.94), not breastfeeding at six months (two studies, 260 infants; RR 0.95, 95% CI 0.83 to 1.10), incomplete six-month infant vaccination schedule (two studies, 260 infants; RR 1.09, 95% CI 0.91 to 1.32), the Bayley Mental Development Index (three studies, 199 infants; mean difference 2.89, 95% CI -1.17 to 6.95) or Psychomotor Index (MD 3.14, 95% CI -0.03 to 6.32), child behavioural problems (RR 0.46, 95% CI 0.21 to 1.01), infants not in care of biological mother (two studies, 254 infants; RR 0.83, 95% CI 0.50 to 1.39), non-accidental injury and non-voluntary foster care (two studies, 254 infants; RR 0.16, 95% CI 0.02 to 1.23) or infant death (three studies, 288 infants; RR 0.70, 95% CI 0.12 to 4.16). Individual studies reported a significant reduction in involvement with child protective services (RR 0.38, 95% CI 0.20 to 0.74) and failure to use postpartum contraception (RR 0.41, 95% CI 0.20 to 0.82).

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend the routine use of home visits for pregnant or postpartum women with a drug or alcohol problem. Further large, high-quality trials are needed.