Home visits by nurses to low-income first-time mothers, starting during pregnancy and extending into the second year of their children’s lives, have a positive and long-lasting impact on families. The latest findings, by Dr. David Olds and colleagues at the University of Colorado- Denver, indicate that the Nurse-Family Partnership (NFP) program improves outcomes for mothers and children 10 years after its administration and saves the government money. The benefits of the program—now documented among three groups of low-income mothers and children—have led to the expansion of government funding and technical support for states to deliver the intervention.
Help at the Start
During 1990 and 1991, Dr. Olds and colleagues recruited 743 low-income pregnant women in Memphis, Tennessee, and randomly assigned them to the NFP or a control group. All the women were about to become mothers for the first time, all but a few were African-American, about two-thirds were teens, and most were unmarried.
The women in both groups received free transportation for scheduled prenatal care, as well as developmental screenings and referrals for their children at ages 6 months, 12 months, and 24 months. Women assigned to the NFP program also received home visits from a nurse—on average, seven visits prior to giving birth and 26 visits during the child’s first 2 years.
The Nurse Connection A 17-year old first-time mother in the program says, "When I was pregnant, I felt I didn't have anybody to lean on. I was so lucky to have a nurse like her.”The visiting nurses used program guidelines designed to improve the women’s health practices relevant to birth outcomes, bolster parents’ caregiving attitudes and expand their skills, and encourage parents to enhance their own life-course development. In addition to giving practical advice on pregnancy and child care, the nurses guided the mothers toward healthy decisions—for example, completing their own educations, getting into the work force, and making good choices about their next pregnancy.
Ten Years Later
The researchers contacted and interviewed 594 of the mothers and 578 of their children when the children were 12 years old. At this assessment, the NFP mothers reported greater sense of mastery over the challenges of living and rearing their children. None of the NFP mothers reported that alcohol or other drug use impaired her functioning at work or home, compared with 2.5 percent among those in the control group. The nurse-visited mothers also reported longer relationships with current partners—averaging 60 months versus 53 months for women in the control group.
At 12 years of age, fewer NFP children than control children reported having used cigarettes, alcohol, or marijuana during the past 30 days (1.7 percent versus 5.1 percent). Although these percentages are small, the potential impact of the three-fold difference is great because children who begin using substances at such an early age have a high risk of becoming dependent on them. The NFP children also reported less clinical or near-clinical anxiety and depression than the controls (22 percent versus 31 percent). Among those children whose mothers had low “psychological resources” (such as problems with depression or anxiety or low confidence that they could manage challenges), the NFP children’s reading and math scores were higher than those of the control group throughout the first through the sixth grades.
Program Costs Offset
The cost of NFP nurse training, visits, and program administration averaged $11,511 per family (all monetary figures are in 2006 dollars and discounted at 3 percent per year). Over the years of services and followup, the government spent $12,300 less per NFP family compared with that spent per control family on food stamps, Medicaid, Aid to Families with Dependent Children, and Temporary Assistance for Needy Families. The net saving of roughly $800 per NFP family does not take into account potential reduced medical, social service, and other costs related to the children’s improved outcomes. If the NFP pattern of benefits continues, the bulk of such savings will accrue during the children’s late adolescence, when their risks for drug abuse, neuropsychiatric illness, and criminal justice involvement are greatest.
Dr. Olds and colleagues hypothesize that the NFP women reduced their need for government aid by spacing their subsequent pregnancies more widely and through the increased stability of their partner relationships. The researchers note, however, that one anticipated source of reduced welfare-related costs did not materialize: Counter to expectations, over the entire followup period, the NFP mothers did not have higher employment rates than the controls.
Activating Parental Instincts
Dr. Olds says the NFP program helps children primarily through its effects on mothers’ decisionmaking and confidence. The decisions mothers make early on, and their resourcefulness in implementing them, have a long-term influence on the family environment, improving children’s ability to control their behavior and boosting academic achievement. “The nurses in the program listen to parents, support them, and help channel parents’ instinctual drives to protect and support their children,” says Dr. Olds.
| Outcome for Children | Nurse-Family Partnership Group | Control Group |
|---|---|---|
| Percent used cigarettes, alcohol, or marijuana during past 30 days | 1.70 | 5.10 |
| Number of substances used during past 30 days | 0.02 | 0.08 |
| Number of days of substance use during past 30 days | 0.03 | 0.18 |
| Self-reported anxiety and depression | 22.10 | 30.90 |
| Reading and math scores on standardized tests* | 88.78 | 85.70 |
| Reading and math grade point average (grades 1–6)* | 2.46 | 2.27 |
| Percentile on reading and math group achievement tests (grades 1–6)* | 40.52 | 34.85 |
| * Among children whose mothers were below the median for psychological resources, experiencing depression and anxiety, and with low intellectual functioning and little confidence that they could handle challenges. | ||
Dr. Olds and colleagues plan to assess the Memphis children at age 18 to determine whether NFP participation influences substance abuse, criminal justice involvement, HIV risk behaviors, educational achievement, and other outcomes at that age. To date, the researchers have examined only first-born children, but in future work, they plan to test whether younger siblings also benefit. If other children in the family gain advantages from the NFP, then the savings to the government will be greater.
– Dr. David Olds
The Memphis findings accord well with those of other NFP studies. Dr. Olds and colleagues found lower rates of criminal justice involvement, teen motherhood, and Medicaid use among the daughters of participants in the initial NFP intervention at age 19—mostly white, unmarried, and low-income pregnant women recruited in Elmira, New York, from 1978 to 1980—compared with a control group. Families from the most recent NFP cohort of women recruited in Denver, Colorado, during 1994 and 1995, about half of whom are Latina, have also benefited from the program. At age 4, NFP children born to mothers with low psychological resources showed better language skills and executive function, such as planning and behavioral control, than their counterparts in the comparison group.
Overall, findings from the NFP trials show that early interventions with low-income families can yield long-term benefits and economic advantages. Dr. Olds notes, in particular, that the NFP was effective for families who lived in Memphis neighborhoods with high levels of poverty, unemployment, single-parent homes, and racial segregation. Moreover, during the study, these communities also experienced policy and economic shifts that influenced families’ opportunities and well-being—including welfare reform and periods of economic boom and bust.
Dr. Leslie Leve of the Oregon Social Learning Center, a prevention researcher not affiliated with the study, says, “The enduring benefits of NFP to families are impressive, and the cost savings produced by the program further showcase the high value that can come from preventive services delivered at the point when a young family is first identified as possibly being at risk but isn’t yet showing signs of failure, rather than waiting to provide support until a child has dropped out of school or has started using drugs.”
The gift of Confidence The fiancé of a woman who received pre- and postnatal nursing visits says, “We're doing okay! We can actually say we’re going to make it.”Dr. Belinda Sims of NIDA’s Division of Epidemiology, Services and Prevention Research agrees that the cost information so far available on the program is promising, and she adds that followup of children into adolescence is a critical component of the research. “The NFP addresses family-level risk factors, such as low resources and high stress, and assists families by getting mothers to prenatal care visits during pregnancy and getting children to well-baby visits in the first 2 years of life, and by linking families to resources in the community,” she says. “In this way, the intervention seems to help families put children on a positive developmental path so that they have less risk for drug abuse later.”
Sources
Eckenrode, J., et al. Long-term effects of prenatal and infancy nurse home visitation on the life course of youths: 19-year follow-up of a randomized trial. Archives of Pediatric and Adolescent Medicine 164(1):9–15, 2010. Full Text Available (PDF,496KB)
Kitzman, H.J., et al. Enduring effects of prenatal and infancy home visiting by nurses on children: Followup of a randomized trial among children at age 12 years. Archives of Pediatric and Adolescent Medicine 164(5):412–418, 2010. Full Text Available (PDF,102KB)
Olds, D.L., et al. 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. Archives of Pediatric and Adolescent Medicine 164(5):419–424, 2010. Full Text Available (PDF,262KB)