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To determine the long term effects of prenatal and early childhood visits on maternal life course and child abuse and neglect.
Randomised controlled trial with 15 years of follow up.
A clinic and private offices in a small city in a semirural area in the USA.
400 women (48% <19 y, 62% unmarried, 59% low socioeconomic status [SES]) who had no previous live births and were <25 weeks pregnant. Follow up was 81%.
Women were allocated to 1 of 4 treatments: developmental screening services for children at 12 and 24 months (n=94); treatment 1 plus free transportation to prenatal and well child care until the child's second birthday (n=90); treatment 2 plus prenatal home visits by a nurse (n=100); and treatment 3 plus home visits for 24 months after delivery (n=116).
Main outcome measures
Mothers' self reports of subsequent births, substance abuse, and use of welfare; records of mothers' arrests and convictions; and verified reports of child abuse or neglect.
Women who received home visits until 24 months after delivery (treatment 4) were compared with women who did not (treatments 1 and 2). The results were adjusted for sociodemographic variables. Home visits reduced the number of verified reports of child abuse and neglect involving the mother as perpetrator (incidence 0.29 v 0.54, p<0.001). There were no differences in the number of subsequent births, months that women received welfare, reports of behavioural impairment due to substance abuse, arrests, or convictions. A subgroup analysis of high risk women who were unmarried and from low SES households (40%) showed that home visits reduced the number of subsequent births (mean difference [MD] 0.5, p=0.02), months that women received welfare (MD 29.9, p=0.005), reports of behavioural impairment due to substance abuse (incidence 0.41 v 0.73, p=0.005), records of arrests (incidence 0.16 v 0.90, p<0.001), convictions (incidence 0.13 v 0.69, p<0.001), and verified reports of child abuse and neglect involving the mother as perpetrator (incidence 0.11 v 0.53, p<0.01).
Home visits during pregnancy and continuing until 24 months after delivery reduced child abuse and neglect over 15 years. Positive effects on other psychosocial domains were shown for women with low socioeconomic status who were unmarried.
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: A Senior Research Scientist Award; National Institute of Mental Health; US Department of Health and Human Services; Bureau of Community Health Services; Carnegie Corporation; Commonwealth Fund; Ford Foundation; Pew Charitable Trusts; Robert Wood Johnson Foundation; 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.