Nurse-Family Partnership (Nurse home visitation program for low-income, pregnant women)

Randomized controlled trials show a major impact on life outcomes of the mothers and their children.

Description of the intervention:  The Nurse-Family Partnership program provides nurse home visits to low-income, pregnant women, most of whom are (i) unmarried, (ii) teenagers, and (iii) without previous children.  The nurses visit the women approximately once per month during their pregnancy and the first two years of their children’s lives.  The nurses teach (i) positive health related behaviors, (ii) competent care of children, and (iii) maternal personal development (family planning, educational achievement, and participation in workforce).  The program costs approximately $10,600 per woman over the three years of visits (in 2007 dollars).  Click here to go to the program's web site.

EVIDENCE OF EFFECTIVENESS

Study 1

Randomized controlled trial of 300 women (average age 19) in Elmira, N.Y., a semi-rural community.  The women, who had agreed to enroll in the study, were randomly assigned either to a group that participated in the Nurse Family Partnership, or to a control group that did not.  Approximately 90% of the women were white, 60% were low income, and 60% were unmarried.

Effects on the first-born children of the nurse-visited women at age 15, versus the control group:

• 59% fewer arrests (an average of 0.15 arrests per child in the nurse-visited group, versus 0.37 per child in the control group).
• 57% fewer convictions and probation violations (an average of 0.10 for the nurse-visited group, versus 0.23 for the control group).  This effect was statistically significant at the .10 level, but not the .05 level.
• 48% fewer officially-verified incidents of child abuse and neglect (an average of 0.26 versus 0.50). 
• No significant effects on incidence of (i) smoking or use of alcohol or drugs, (ii) running away or being stopped by police, or (iii) being sent to youth corrections; or on number of self-reported major delinquent acts.
• No significant effects on percent of children who had had sexual intercourse, become pregnant, or caused a pregnancy.  

Effects on the nurse-visited women at the age-15 follow-up (versus the control group):

• 61% fewer arrests (an average of 0.13 arrests per nurse-visited woman, versus 0.33 per woman in the control group). 
• 72% fewer convictions (an average of 0.05 for the nurse-visited women, versus 0.18 for the control group).
• 20% less time on welfare (53 months versus 66 months).  This effect was statistically significant at the .10 level, but not the .05 level.  
• 19% fewer subsequent births (an average of 1.3 versus 1.6).
• There were no significant effects on months employed, months on food stamps or medicaid, or behavior-impairing substance abuse. 

There was suggestive evidence that the above effects were largest for the subgroup of unmarried women of low socioeconomic status, and their children.

Description of study quality (click here for glossary of terms) 

• This was a relatively large study which had low attrition and a long-term follow-up:  Outcome data were obtained for 79-83% of the original sample at the age-15 follow-up.
• The study reported outcomes using an intention-to-treat analysis.
• In measuring outcomes, the study used official arrest, conviction, and child abuse/neglect records to corroborate maternal and child survey interview data.
• Research staff gathering outcome data were blind as to whether women were assigned to the nurse-visitation group or the control group.

Source (click on linked authors' names for their contact information)

Olds, David L., Charles R. Henderson Jr, Robert Cole, John Eckenrode, Harriet Kitzman, Dennis Luckey, Lisa Pettitt, Kimberly Sidora, Pamela Morris, and Jane Powers.  "Long-term Effects of Nurse Home Visitation on Children's Criminal and Antisocial Behavior:  15-Year Follow-up of a Randomized Controlled Trial."  Journal of the American Medical Association, vol. 280, no. 14, October 14, 1998, pp. 1238-1244.

Olds, David L., John Eckenrode, Charles R. Henderson Jr, Harriet Kitzman, Jane Powers, Robert Cole, Kimberly Sidora, Pamela Morris, Lisa M. Pettitt, and Dennis Luckey.  "Long-term Effects of Home Visitation on Maternal Life Course and Child Abuse and Neglect:  15-Year Follow-up of a Randomized Trial."  Journal of the American Medical Association, August 27, 1997, vol. 278, no. 8, pp. 637-643.

Luckey, Dennis W., David L. Olds, Weiming Zhang, Charles Henderson, Michael Knudtson, John Eckenrode, Harriet Kitzman, Robert Cole, and Lisa Pettitt. "Revised Analysis of 15-Year Outcomes in the Elmira Trial of the Nurse Family Partnership", Prevention Research Center for Family and Child Health, University of Colorado Department of Pediatrics, 2008. 

Study 2

Randomized controlled trial of 743 women (average age 18) in Memphis, Tennessee.  Women were randomly assigned either to a group that received nurse visits or a control group which did not.

Virtually all of the women were African-American, low income, and unmarried.

Effects on the first-born children of nurse-visited women at age 2, versus the control group:

• 23% fewer health care encounters for children's injuries or ingestions (.43 encounters per child in the nurse-visited group vs. .56 encounters per child in the control group).
• 77% fewer average days hospitalized for injuries or ingestions (.04 days for children in the nurse-visited group versus .18 days for children in the control group).
• No significant effects on children's birth-weight, immunization rates, mental development, or behavioral problems.

Effects on the first-born children of nurse-visited women at age 6 (versus the control group):

• Much lower percentage of children exhibited severe behavioral problems (aggression, anxiety, depression), as reported by their mothers (1.8% vs. 5.4%).
• The subsample of children whose mothers had low psychological resources (i.e. were in the lower half of the sample in intelligence, mental health, and self-confidence) made sizeable gains in intellectual functioning, arithmetic achievement, and receptive vocabulary (effect sizes of 0.20-0.25 standard deviations) compared to their control group counterparts.  Click here for an explanation of effect sizes.
• The whole sample of children (as opposed to the above subsample) made more modest gains in intellectual functioning and receptive vocabulary, and no significant gains in arithmetic achievement.

Effects on the first-born children of nurse-visited women at age 9 (versus the control group):

• Lower mortality rate (0.5% of the children in the nurse-visited group died before age 9 vs. 2% of children in the control group).  This effect was statistically significant at the .10 level, but not the .05 level.  Importantly, 9 out of the 10 deaths in the control group were potentially preventable (i.e. due to complications of preterm delivery, sudden infant death syndrome, or injury).
• The subsample of children whose mothers had low psychological resources (i.e. were in the lower half of the sample in intelligence, mental health, and self-confidence) made sizeable gains in academic performance.  These children:
  
  
  • Scored 9 percentile points higher on Tennessee state reading and math achievement tests in grades 1-3 than their counterparts in the control group (the nurse-visited group scored in the 45th percentile, versus the 36th percentile for their control group counterparts).
  • Had 10% higher reading and math grade point averages in grades 1-3 than their control group counterparts (2.68 vs. 2.44).
  • There were no significant effects on these children's conduct and behavior.
    
    
• For the whole sample of children (as opposed to the above subsample), there were no significant effects on academic performance (e.g. test scores, grade retentions, special education placements), or conduct or behavioral outcomes.

Effects on the nurse-visited women at the age-9 follow-up (versus the control group):

• 21% longer interval between the births of their 1st and 2nd child (41 months for the nurse-visited group vs. 34 months for the control group)
• 12% less time on welfare during the nine years (5.2 months per year for the nurse-visited women vs. 5.9 months per year for control group women).
• 10% less time on food stamps during the nine years (7.0 months per year vs. 7.8 months per year).
• 18% more time with their current partner at year 9 (nurse-visited women had been with their current partner an average of 62 months vs. 52 months for the control group).
• 19% more total time with an employed partner at year 9 (55 months vs. 46 months).
• Fewer average substances used in the past three years-- i.e. marijuana, cocaine, or moderate-heavy alcohol use (nurse-visited women used an average of .10 substances vs. .17 substances used by control group women).  This effect was significant at the .10 level, but not the .05 level.
• Fewer subsequent low-birth weight newborns (nurse-visited women had an average of .18 subsequent low-birth weight newborns vs. .27 for control group women).  This effect was significant at the .10 level, but not the .05 level.
• No significant effects on mother's employment rate, Medicaid receipt, rate of marriage or partnership, depression, arrests, abortions, miscarriages, stillbirths, or domestic violence experienced.

Description of study quality (click here for glossary of terms) 

• This was a large study which had low attrition and a long-term follow-up:  Outcome data were obtained for 80-90 percent of the original sample at the 2, 6, and 9-year follow-ups.  (The only exception, among the outcomes reported above, is that school achievement test scores at the 9-year follow-up were obtained for 77% of the original sample).
• The study reported outcomes using an intention-to-treat analysis.
• In measuring outcomes, the study used official state agency and school records to supplement self-reported data from interviews with mothers and their children's teachers.
• Research staff gathering outcome data were blind as to whether women were assigned to the nurse-visited group or the control group.
• The study evaluated the program as it is typically implemented in a low-income community, by the County Health Department, thus providing evidence regarding the intervention's effectiveness in a real-world setting.

Sources (click on linked authors' names for their contact information)

Olds, David L., Harriet Kitzman, Carole Hanks, Robert Cole, Elizabeth Anson, Kimberly Sidora-Arcoleo, Dennis W. Luckey, Charles R. Henderson Jr, John Holmberg, Robin A. Tutt, Amanda J. Stevenson and Jessica Bondy.  “Effects of Nurse Home Visiting on Maternal and Child Functioning:  Age-9 Follow-up of a Randomized Trial.”  Pediatrics, vol. 120, October 2007, pp. e832-e845.  Click here for a link to this study.

Olds, David L., Harriet Kitzman, Robert Cole, JoAnn Robinson, Kimberly Sidora, Dennis W. Luckey, Charles R. Henderson Jr, Carole Hanks, Jessica Bondy and John Holmberg.  “Effects of Nurse Home-Visiting on Maternal Life Course and Child Development: Age 6 Follow-Up Results of a Randomized Trial,” Pediatrics, vol. 114, no 6, December 2004, pp. 1550-1559.  Click here for a link to this study.

Kitzman, Harriet, David L. Olds, Kimberly Sidora, Charles R. Henderson Jr, Carole Hanks, Robert Cole, Dennis W. Luckey, Jessica Bondy, Kimberly Cole, and Judith Glazner.  "Enduring Effects of Nurse Home Visitation on Maternal Life Course." Journal of the American Medical Association, vol. 283, no. 15, April 19, 2000, pp. 1983-1989.

Kitzman, Harriet, David L. Olds, Charles R. Henderson Jr, Carole Hanks, Robert Cole, Robert Tatelbaum, Ken M. McConnochie, Kimberly Sidora, Dennis W. Luckey, D Shaver, Kay Engelhardt, D James and K. Bernard.  "Effect of Prenatal and Infancy Home Visitation by Nurses on Pregnancy Outcomes, Childhood Injuries, and Repeated Childbearing." Journal of the American Medical Association, vol. 278, no. 8, August 27, 1997, pp. 644-652.

Study 3

Randomized controlled trial of 490 women (average age 20) in Denver, Colorado.  The women were randomly assigned to a group that received nurse visits or a control group which did not.  This study measured outcomes when the children reached age 4.

These women were almost all low-income, 47% were Mexican American, 35% were white, 15% were African American, and 85% were unmarried.

Effects on the first-born children of nurse-visited women at age 4, versus the control group:

• For the subsample of nurse-visited women with low psychological resources (i.e. those in the lower 40th percentile of the sample in intelligence, mental health, and self-confidence) their children made sizeable gains in language skills, behavioral adaptation (e.g., attention, impulse control, sociability), and executive functioning (e.g., capacity for sustained attention, fine and gross motor skills), compared to their control group counterparts. The effect sizes for these measures were 0.31, 0.38, 0.47 standard deviations, respectively.  Click here for an explanation of effect sizes.
• For the full sample of nurse-visited women (as opposed to the above subgroup), there were no significant effects on these child outcome measures.
• For the full sample of nurse-visited women (as well as each major subsample) there were no significant effects on children's behavior. 

Effects on the nurse-visited women at the age-4 follow-up (versus the control group):

• 20 percent longer interval between the births of their 1st and 2nd children (24.5 months for the nurse-visited women vs. 20.4 months for the control group); however, there was no significant effect on the number of subsequent births.
• Much lower percentage of women reported being victims of domestic violence in the past 6 months (7% versus 14%).
• No significant effect on the women's welfare receipt or employment; educational achievement; mental health; substance use; likelihood of being married or living with a partner; or subsequent abortions, miscarriages, or low birth weight newborns.

Description of study quality (click here for glossary of terms)

• This was a large study which had low attrition and a long-term follow-up:  Outcome data were obtained for 80-90 percent of the original sample at the 4-year follow-up.
• The study reported outcomes using an intention-to-treat analysis.
• Children's mental development and language skills were measured using well-established, objective tests.
• Research staff gathering outcome data were blind as to whether women were assigned to the nurse-visited group or the control group.
• The study evaluated the program as it is typically implemented in a low-income community, thus providing evidence regarding the intervention's effectiveness in a real-world setting.
• Study Limitation: Whereas child outcomes were measured using objective tests, maternal outcomes were measured through self-reports (survey interviews).

Source (click on linked authors' names for their contact information)

Olds, David L., JoAnn Robinson, Ruth O'brien, Dennis W. Luckey, Lisa M. Pettitt, Charles R. Henderson Jr, Rossanna K Ng, Karen L Sheff, Jon Korfmacher, Susan Hiatt, and Ayelet Talmi.  "Home Visiting By Paraprofessionals and By Nurses:  A Randomized, Controlled Trial." Pediatrics, vol. 110, no. 3, September 2002, pp. 486-496.  Click here for a link to this study.