Sample Review
Prevention

Enduring effects of prenatal and infancy home visiting by nurses on maternal life course and government spending: Follow-up of a randomized trial among children at age 12 years. David L Olds, Harriet J Kitzman, Robert E Cole et al. Arch Pediatr Adolesc Med 2010; 164(5):419-424. (from Aurora CO and Rochester NY)

Enduring effects of prenatal and infancy home visiting by nurses on children: Follow-up of a randomized trial among children at age 12 years. Harriet J Kitzman, David L Olds, Robert E Cole et al. Arch Pediatr Adolesc Med 2010; 164(5):412-418. (from Rochester NY and Aurora CO)

Review from Autumn 2010 issue

Olds and colleagues have conducted three randomized controlled trials (RCTs) of home visiting by nurses. The purpose of home visiting for at-risk children is to prevent child abuse and neglect, promote the child’s development, and improve the life course of the mother. These articles report on the results of the second study, which was conducted in Memphis, Tennessee. The study focused on the outcomes for the mothers and children when the children were 12 years of age, ten years after the completion of the home visiting in the intervention group.

The study was conducted in a public system of obstetric and pediatric care. Pregnant women were enrolled from June, 1990 to August, 1991 if they were less than 29 weeks of gestation, had no previous live births, and had two of the following sociodemographic risk factors: unmarried, less than 12 years of education, and/or unemployed. Of the 743 pregnant women who were enrolled, 228 were in the intervention group and 515 were in the control group. The women were socially high-risk: 98% were unmarried, 85% were in households below the poverty level, and 64% were younger than 19 years of age. Of the sample, 92% were African American.

When the children were 12 years of age, interviews of mothers or custodians were completed in 84% of the intervention group and 82% of the control group. Interviews of children were completed in 79% of the intervention group and 79% of the control group.

RE: Study of the Mothers
Thirteen key outcomes related to the mothers were assessed: 1) relationship of being partnered or married to the biological father, 2) reported interpersonal violence (IPV) between the child’s ninth year and the 12-year interview, 3) duration of relationship with current partner, 4) use of alcohol or drugs, 5) reported impairment in functioning due to alcohol or drugs, 6) mother’s symptoms of psychological distress, 7) mother’s sense of mastery, 8) subsequent births, 9) number of times mother reported being arrested, 10) number of times mother reported being jailed, 11) placements of children in foster care or with relatives, 12) number of months per year of using food stamps, Medicaid, and Aid to Families with Dependent Children/Temporary Assistance for Needy Families, and 13) government spending for these three welfare benefits for the family.

Results showed that there were a few differences that favored the mothers in the intervention group over mothers in the control group. Intervention mothers were less likely to report impairment due to alcohol or drug use (0% vs. 2.5%, p = .04); they had longer durations with their current partners (59.6 vs. 52.7 months, p = .02), and they reported a higher sense of mastery when their children were from 6 months to 12 years of age (p = .005). These differences resulted in effect sizes of 0.14 to 0.18, which are considered small.

An interesting finding was that mothers with higher psychological functioning had fewer subsequent births. In previous analyses in this study and in the other home visiting studies of Olds, the intervention was most powerful for women with low psychological functioning.

The major finding in the Memphis study was that the government spending was on average $1,025 (in 2006 U.S. dollars) less per year for each of the 12 years in the intervention group vs. the control group. This totaled to $12,300 over the 12 years compared to the total cost of the program was $11,511. Based on these figures, there was a net savings of $789.

Reviewed by John M. Leventhal, M.D.

Reviewer’s Note on Study of the Mother:
The authors conclude: “In general, these findings support the effectiveness of NFP [Nurse Family Partnership].” I agree, but the results are less impressive than those reported in the long-term follow-up of study #1, which took place in Elmira, NY. Of note, in the Memphis study there was no difference in the percentage of mothers who reported IPV from the child’s 9th to 12th years and there was a trend (p = .08) in the number of children who were placed in foster care or with relatives with a higher number in the intervention group. Unfortunately, the authors were not able to collect data about reports to child protective services (CPS) or about cases substantiated as maltreatment.

Comparing the Memphis to the Elmira study, there were two other important differences in outcomes; these related to maternal arrests and subsequent pregnancies. In the Elmira study when the children were 15, mothers in the intervention group reported significantly fewer arrests and fewer subsequent pregnancies.  The latter outcome seemed particularly important in terms of the mother’s child care burden and costs to the welfare system. In the Memphis trial, there were no differences between the intervention and control groups in either of these outcomes, except in a subanalysis that showed intervention mothers with higher psychological resources had fewer subsequent births than similar control mothers.

The level of poverty was higher in Memphis than in Elmira or in the third trial, which took place in Denver. This difference in the communities where the studies were conducted likely influenced the outcomes.

The take-home message is that there were long-term effects of the home visiting that occurred during pregnancy and the first two years of the child’s life. In the Memphis study, however, these effects on the mother’s life course were moderate.