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To examine the effect of prenatal and postnatal home visits by nurses on maternal and child outcomes.
Randomised controlled trial with up to 24 months of follow up.
Obstetrics clinic in Memphis, Tennessee, USA.
1139 women (mean age 18 y, 92% African-American) who were <29 weeks pregnant, had no previous live births, no chronic illnesses, and ≥2 of the following sociodemographic risk factors: unmarried, <12 years of education, and unemployed.
Women received 1 of 4 treatments: free transportation for prenatal care (n=166); treatment 1 and developmental screening and referral services for their child (n=515); treatment 2 and prenatal home visits by nurses (n=230); or treatment 3 and 2 years of postpartum home visits by nurses (n=228). Treatments 2 and 4 were followed for 2 years (90% follow up); treatments 1 and 3 were followed until delivery (93% follow up).
Main outcome measures
Pregnancy induced hypertension; preterm delivery; low birth weight; subsequent pregnancies; mothers' educational achievement, employment, use of welfare, and childrearing beliefs associated with child abuse; children's injuries, ingestions, immunisations, behavioural problems, and mental development; and the home environment as measured by the Home Observation for Measurement of the Environment scale.
Women who received prenatal visits (treatments 3 and 4) had less pregnancy induced hypertension than those who did not receive prenatal visits (treatments 1 and 2) (13% v 20%, p=0.009). There were no treatment effects on birth weight and preterm delivery. Children who were visited at home (treatment 4) had fewer healthcare visits for injuries and ingestions than children who were not visited at home (treatment 2, mean 0.43 v 0.56, p≤0.05). Women who were visited at home (treatment 4) had fewer subsequent pregnancies than women who were not visited at home (treatment 2, 36% v 47%, p=0.006). Women who were visited at home held fewer beliefs associated with child abuse and neglect than women who were not visited at home (p=0.003). Homes that were visited by nurses were rated as more developmentally stimulating than those that were not visited by nurses (p=0.003). A trend towards less use of welfare during the second year of the child's life existed for mothers who were visited at home (7.8% v 8.4%, p=0.07). There were no differences in children's immunisation rates, behaviour, and mental development nor in mothers' education and employment.
Among low income women, prenatal home visits reduced pregnancy induced hypertension. Prenatal and postnatal home visits reduced child injuries and subsequent pregnancies.
In 1986, Olds et al published the results of a rigorous trial showing that nurse home visitation extending from pregnancy to the child's second birthday can produce positive effects on maternal and child health among disadvantaged families.1, 2 The study was conducted in a semirural area and involved predominantly white women. Although some were quick to embrace the findings of these earlier studies as evidence that home visitation improves outcomes for all women and children, Olds and Kitzman emphasised the need for further systematic evaluation and replication.3
Now, more than a decade later, come 2 landmark studies: (a) a replication of the nurse home visitation programme model applied to a major urban area with a minority population and (b) a 15 year follow up of the original study. The message is clear: home visitation by nurses can improve health and social outcomes for high risk families across geographical settings and over the long term. Kitzman et al report that the replicated programme in Memphis, Tennessee reduced child injuries and ingestions, subsequent pregnancies, and pregnancy induced hypertension among families visited by nurses; it also improved the home environment. The follow up study of the original Elmira, New York programme by Olds et al showed decreased reports of child abuse and neglect 15 years later among women visited by a nurse. Within the subgroup of low socioeconomic, unmarried women, the effect on reports of childmaltreatment was even stronger; there was also a reduction in subsequent pregnancies, substance abuse, criminal justice encounters, and use of welfare.
These 2 trials are impressive for their methodological rigour, including the use of a randomised controlled design, low attrition, length of follow up, and range of outcome measures. Some critics have argued that randomised controlled trials of preventive interventions for child maltreatment and related outcomes are not feasible due to problems in recruitment and retention of participants. The work of these investigators should convince sceptics that such research is not only possible but also essential in examining the effectiveness of prevention programmes.
Although these 2 studies show the effectiveness of nurse home visitation in improving child and maternal outcomes among high risk families, the findings cannot be generalised to populations without these risk factors. Eighty five percent of the sample originally recruited to the Elmira programme had at least 1 to 3 sociodemographic risk factors, and Olds et al emphasise that most of the positive findings were concentrated among women who were from low socioeconomic status households and unmarried. In the Memphis trial, women were required to have ≥2 sociodemographic risk conditions. The home visitation programme evaluated in these trials was applied as a targeted intervention for disadvantaged families. Although some advocate implementation of home visitation universally, these 2 trials did not address this question.
Moreover, although many types of home visitation programmes have been promoted, the findings from these studies cannot be extrapolated to interventions that differ substantially from this model. In both trials, home visitation was intensive, used a theoretical model, and was provided by nurses. Further research needs to address which elements of this model are crucial to its success. Investigation into the mechanism by which nurse home visitation leads to improved outcomes will help ensure programme effectiveness.
There is now good evidence to recommend dissemination of intensive home visitation by nurses to neighbourhoods with many disadvantaged families. It is high time we take action in providing this effective prenatal and early childhood programme.
Sources of funding: National Institute of Nursing Research; Bureau of Maternal and Child Health; Administration for Children and Families; Office of the Assistant Secretary for Planning and Evaluation; National Center for Child Abuse and Neglect; Robert Wood Johnson Foundation; Carnegie Corporation; Pew Charitable Trusts; William T Grant Foundation.
For article reprint: Dr D L Olds, University of Colorado Health Sciences Center, 303 E 17th Avenue, Suite 200, Denver, CO 80203, USA. Fax +1 303 861 2441.
A modified abstract appears in Evidence-Based Nursing 1998 Jul.
Abstract and commentary also published in Evidence-Based Medicine 1998 May-Jun.