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.

The Impact of a Preventive Intervention on Persistent, Cross-Situational Early Onset Externalizing Problems.

The Nurse-Family Partnership (NFP) home visiting intervention for low-income first-time mothers was evaluated for its preventive impact on persistent, cross-situational early-onset externalizing problems (EXT). Seven hundred thirty-five women in the Denver, CO, area were randomly assigned into one of two active conditions (nurse or paraprofessional home visiting from pregnancy through child age 2) or a control group in which children were screened and referred for behavioral and developmental problems. Externalizing behavior was assessed by parent report when the children were 2, 4, 6, and 9 years old; teachers provided reports at ages 6 and 9. Latent profile analyses suggested the presence of persistent, cross-situational early onset EXT in approximately 6 to 7% of girls and boys. The intervention deflected girls away from these EXT and toward a pattern marked by a persistent moderate elevation of externalizing behavior that was evident at home and not at school. This finding should be interpreted cautiously given the small number of girls with the elevated EXT. Surprisingly, the intervention also moved girls away from stable low level externalizing behavior toward the moderately elevated pattern. Both of the significant effects on girls' externalizing behavior were modest. No statistically significant effects were found for boys' externalizing behaviors, which exhibited a somewhat different patterning across time and reporter. Effect sizes were generally similar for the nurse and paraprofessional-visited groups. The results are discussed in the context of prior efforts to prevent early EXT and emerging evidence on the normative development of externalizing behavior.

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.

Improving the nurse-family partnership in community practice.

BACKGROUND: Evidence-based preventive interventions are rarely final products. They have reached a stage of development that warrant public investment but require additional research and development to strengthen their effects. The Nurse-Family Partnership (NFP), a program of nurse home visiting, is grounded in findings from replicated randomized controlled trials. OBJECTIVE: Evidence-based programs require replication in accordance with the models tested in the original randomized controlled trials in order to achieve impacts comparable to those found in those trials, and yet they must be changed in order to improve their impacts, given that interventions require continuous improvement. This article provides a framework and illustrations of work our team members have developed to address this tension. METHODS: Because the NFP is delivered in communities outside of research contexts, we used quantitative and qualitative research to identify challenges with the NFP program model and its implementation, as well as promising approaches for addressing them. RESULTS: We describe a framework used to address these issues and illustrate its use in improving nurses' skills in retaining participants, reducing closely spaced subsequent pregnancies, responding to intimate partner violence, observing and promoting caregivers' care of their children, addressing parents' mental health problems, classifying families' risks and strengths as a guide for program implementation, and collaborating with indigenous health organizations to adapt and evaluate the program for their populations. We identify common challenges encountered in conducting research in practice settings and translating findings from these studies into ongoing program implementation. CONCLUSIONS: The conduct of research focused on quality improvement, model improvement, and implementation in NFP practice settings is challenging, but feasible, and holds promise for improving the impact of the NFP.

Maternal jail time, conviction, and arrest as predictors of children's 15-year antisocial outcomes in the context of a nurse home visiting program.

Data from the Nurse-Family Partnership intervention program were analyzed to compare the "selection" versus "unique" effects of maternal jail time on adolescent antisocial and health risk outcomes. Data from 320 women and their firstborn children were available from the prenatal, birth, and 15-year assessments. Consistent with a selection perspective, prenatal and demographic risks directly and indirectly related to many adolescent antisocial outcomes. Maternal conviction and arrest were also associated with adolescent contact with the criminal justice system and health risk behaviors. Maternal jail time predicted whether or not children had ever been stopped by police, sent to youth corrections, or run away from home. However, these associations were not significant after controlling for prenatal risk factors and maternal conviction and arrest. The results highlight the importance of maternal criminality and other risk factors in children's environments, including prenatal variables.

Home visiting for the prevention of child maltreatment: lessons learned during the past 20 years.

For nearly two decades, home visitation has been promoted as a promising strategy to prevent child maltreatment, but reviews of the literature on home visiting programs have been mixed. This article examines how home visitation for the prevention of child maltreatment has evolved during the past 20 years. It reviews several home visitation programs focused on preventing child maltreatment and highlights the Nurse-Family Partnership home visitation program. It discusses how advocacy and public policy for prevention of child maltreatment have shifted from a general call to promote universal home visitation programs to a more refined emphasis on promoting programs that are evidence-based, targeted to those most at risk for maltreatment, and with infrastructure in place to ensure implementation with fidelity to the model tested in trials. Finally, it discusses how primary care providers may advocate to ensure that their patients have access to evidence-based home visiting programs that meet their needs.

Improving patient outcomes of home health care: findings from two demonstration trials of outcome-based quality improvement.

OBJECTIVES: To evaluate effects on patient outcomes of Outcome-Based Quality Improvement (OBQI), a continuous quality improvement methodology for home health care (HHC). DESIGN: A quasi-experimental design with prospective pre/post and study/control components within two multiyear demonstration trials (occurring from 1995 to 2000) in which 73 home health agencies implemented OBQI, receiving several annual cycles of outcome reports to evaluate and enhance patient outcomes. SETTING: New York and 27 other states. PARTICIPANTS: The study involved 157,548 predominantly older adult patients admitted over 3 years to 54 OBQI agencies from 27 states in the National Demonstration Trial, 105,917 patients admitted over 4 years to 19 OBQI agencies in the New York State Trial, and 248,621 patients admitted over 3 years to non-OBQI control agencies in the 27 demonstration states. INTERVENTION: As a clinical management and administrative intervention, OBQI involves collecting, encoding, and transmitting patient-level health status data to a central source that provides each OBQI agency with a risk-adjusted outcome report comparing the agency's patient outcomes with those from a reference population and with its own outcomes from the prior period. Target outcomes are selected and focused plans of action implemented to change care behaviors. Outcome changes are evaluated through the next report cycle. MEASUREMENTS: Outcome measures include hospitalization rates and improvement and stabilization outcome rates in functional, physiological, emotional/behavioral, and cognitive health. RESULTS: For the National and New York State Demonstration Trials, the risk-adjusted relative rates of decline in hospitalization of 22% and 26%, respectively, for OBQI patients over the 3-year and 4-year demonstration periods were significant (P <.001) and unparalleled by considerably smaller rates of decline for the non-OBQI patients in the 27 states. The risk-adjusted rates of improvement in OBQI target outcome measures of health status averaged 5% to 7% per year in both demonstration trials and were significantly greater (P <.05) than analogous improvement rates for nontarget comparison outcomes, which averaged about 1% per year. CONCLUSION: It is feasible to integrate the programmatic, data collection, data transmission, and outcome enhancement components of OBQI into the day-to-day operations of home health agencies. The aggregate findings and the agency-level evidence available from site-specific communications suggest that OBQI had a pervasive effect on outcome improvement for home health patients. OBQI appears to warrant expansion and refinement in HHC and experimentation in other healthcare settings.