This article describes the outcomes at 1 year for a randomized clinical trial of Resources, Education and Care in the Home-Futures: a program to reduce infant mortality through home visits by a team of trained community residents led by a nurse. Low-income, inner-city pregnant women who self-identified as African American or Mexican American were recruited in two university prenatal clinics in Chicago. Because African Americans and Mexican Americans differed greatly at intake, we compared their outcomes at 12 months and then examined the effects of the intervention separately for these two groups. Participants were randomly assigned to the intervention or control group and were interviewed during the last trimester of pregnancy and at 2, 6, and 12 months after birth. The effects of the program varied by race/ethnicity. For African Americans, the program was associated with better maternal documentation of infant immunizations, more developmentally appropriate parenting expectations, and higher 12-month infant mental development scores. For Mexican Americans, the program had positive effects on maternal daily living skills and on the play materials subscale of the Home Observation for the Measurement of the Environment assessment. This study, along with previous research, suggests that home visits by a nurse-health advocate team can improve maternal and infant outcomes even for inner-city, low-income, minority families. Effective programs must be culturally sensitive, intensive, and adequately staffed and financed.

This article describes the Resources, Education and Care in the Home program (REACH-Futures), an infant mortality reduction initiative in the inner city of Chicago built on the World Health Organization (WHO) primary health care model and over a decade of experience administering programs to reduce infant mortality through home visits. The program uses a nurse-managed team, which includes community residents selected, trained, and integrated as health advocates. Service participants were predominately African American families. All participants were low-income and resided in inner-city neighborhoods with high unemployment, high teen birth rates, violent crime, and deteriorated neighborhoods. Outcomes for the first 666 participants are compared to a previous home-visiting program that used only nurses. Participant retention rates were equivalent overall and significantly higher in the first months of the REACH-Futures program. There were two infant deaths during the course of the study, a lower death rate than the previous program or the city. Infant health problems and developmental levels were equivalent to the prior program and significantly more infants were fully immunized at 12 months. The authors conclude that the use of community workers as a part of the home-visiting team is as effective as the nurse-only team in meeting the needs of families at high risk of poor infant outcomes. This approach is of national interest because of its potential to achieve the desired outcomes in a cost-effective manner.

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A review of all postpartum early discharge program outcomes in the United States published between 1960 and 1985 indicates that discharge under 48 hours after delivery has generally been safe for mothers and infants. The levels and types of morbidities did not appear to differ from those experienced with longer hospital stays. Infant readmissions and overall morbidity rates were consistently higher than the number of maternal readmissions and morbidity. The major infant morbidity was hyperbilirubinemia. Differences in identification and treatment of this single problem accounted for much of the variation in infant readmission rates among programs.Expansion of postpartum early discharge based on these favorable results must proceed with caution. Nearly all reported outcomes were for programs with extensive prenatal preparation and postpartum follow-up, serving relatively advantaged middle-class populations. It is not clear that equally good outcomes would result from less intensive programs or those serving disadvantaged populations. More research is needed on the effectiveness of early discharge procedures, cost savings, and patient satisfaction. (BIRTH 14:3, September 1987) Escalating health care costs and changing reimbursement policies have generated great pressure to discharge patients from the hospital as quickly as possible. In obstetric units, changes in high-risk antenatal and intrapartum care have greatly increased demand for beds. Today, postpartum early discharge is still relatively infrequent, usually an option available to self-selected parents. Over the next few years, this practice for low-risk mothers will become more common, perhaps even the prevailing standard of care, since health maintenance organizations (HMOs) and third-party payers will reimburse only the shortest possible stay. For low-income families and families in HMOs or dependent on third-party