Socioeconomically disadvantaged women in Memphis reaped several long-term benefits from a program in which they received home visits by a nurse during their first pregnancy and for two years after delivering. In the 54 months after giving birth, they had fewer additional pregnancies and were less likely to have closely spaced pregnancies than were women who received a less-intensive intervention. They also spent 3-4 fewer months receiving public assistance than mothers who had not had nurse visits. The home visit program, which reproduced a successful intervention conducted in central New York, was the first such program to demonstrate enduring benefits for low-income women.1
In 1990-1991, researchers enrolled participants in a trial of the program, which was designed to help women improve their health-related behaviors, parental caregiving skills and life-course outcomes (pregnancy planning, educational achievement and employment). Low-income women obtaining prenatal care from an obstetric clinic in Memphis were recruited for the trial if they were less than 29 weeks pregnant, they had had no previous live births and they had no chronic illnesses that increase the risk of fetal growth retardation or preterm delivery. In addition, participants had to meet at least two of the following criteria: being unmarried, having fewer than 12 years of schooling and being unemployed. Participants were randomly assigned to one of four groups, each of which received a different combination of interventions.
To assess the program's long-term effects, analysts examined outcomes for two of the study groups: One (consisting of 228 women) had received free transportation for scheduled prenatal visits; developmental screening services for their children at ages six, 12 and 24 months; and home visits by a nurse during pregnancy, a postpartum visit in the hospital and a series of home visits through the child's second birthday. The comparison group (with 515 women) had received the transportation subsidy and screening for their children, but no nurse visits. Data come from interviews conducted with the women at scheduled intervals up to 54 months after delivery and from state public assistance records.
Overall, the two groups of women had similar profiles when they entered the study. About nine in 10 women in each group were black, virtually all were unmarried and fewer than one in 10 lived with the child's father or another partner. On average, the women were about 18 years old and had had 10 years of schooling; roughly one-third lived in a census tract that was below the poverty line. Women in the home visit group were less likely than others to live in a household whose head was employed, and they had less discretionary income. The two groups had comparable levels of psychosocial resources and support.
During the 54 months after their first child was born, women in the home visit group had significantly fewer pregnancies (1.15) than those who had received the less-intensive intervention (1.34). The average interval between the first and second births was longer among women who had received nurse visits (30.3 months) than among those in the comparison group (26.6), and the likelihood of having conceived within six months after a birth was lower (22% vs. 32%). Other measures related to reproductive history did not differ between the groups. In some cases, however, the lack of statistical significance probably reflects the infrequency of an outcome, and the findings suggest clinically important results: The incidence of abortion and of newborns' admission to neonatal intensive care was marginally lower among women who had had nurse visits than among others, and these differences are consistent with the reduction in subsequent pregnancies.
While the program had no long-term effects on women's educational achievement, employment history or overall socioeconomic status, it was associated with reduced reliance on public assistance. Women in the home visit group had spent fewer months receiving Aid to Families with Dependent Children (AFDC) and food stamps (32.6 and 41.6, respectively) than had those in the comparison group (36.2 and 45.0, respectively).
At the end of the study period, the two groups still were equally likely to be unmarried, but those who had had nurse visits were significantly more likely than others to be living with a partner (43% vs. 32%) and to be living with their child's father (19% vs. 13%). Furthermore, the partners of women in the home visit group had been employed significantly more of the time (35.2 months, on average) than had men whose partners had not received this intervention (26.5).
To determine the extent to which the program effects endured after the program ended, the analysts compared data on pregnancies and public assistance during the first 24 months after women delivered (when home visits were still occurring) with data from the next three years (after the visits had ended). These comparisons revealed that women in the program had significantly fewer pregnancies than those in the comparison group while the nurses were visiting but not once the intervention ended; however, they had fewer closely spaced pregnancies only after the visits ceased. The program's effects on receipt of AFDC were the same in both periods, but its beneficial impact on receipt of food stamps was confined to the three years after the visits ended.
According to the investigators, social interventions aimed at improving low-income parents' economic situation and caregiving skills generally "have failed or produced only minimal effects." A home visit program involving a mostly white, semirural sample of women in central New York was the exception, yielding long-term benefits for both the women and their children. Although the effects were smaller when the same intervention was initiated in Memphis, where participants were urban and predominantly black, they were generally consistent with the results in New York. Programs based on home visits by nurses thus may be a promising means to improve low-income families' economic self-sufficiency and their children's health.--D. Hollander
1. Kitzman H et al., Enduring effects of nurse home visitation on maternal life course: a 3-year follow-up of a randomized trial, Journal of the American Medical Association, 2000, 283(15):1983-1989.