Effect of Home Visiting by Nurses on Maternal and Child Mortality

Abstract

IMPORTANCE Mothers and children living in adverse contexts are at risk of premature death. OBJECTIVE To determine the effect of prenatal and infant/toddler nurse home visiting on maternal and child mortality during a 2-decade period (1990–2011). DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial was designed originally to assess the home visiting program’s effect on pregnancy outcomes and maternal and child health through child age 2 years. The study was conducted in a public system of obstetric and pediatric care in Memphis, Tennessee. Participants included primarily African American women and their first live-born children living in highly disadvantaged urban neighborhoods, who were assigned to 1 of 4 treatment groups: treatment 1 (transportation for prenatal care [n = 166]), treatment 2 (transportation plus developmental screening for infants and toddlers [n = 514]), treatment 3 (transportation plus prenatal/postpartum home visiting [n = 230]), and treatment 4 (transportation, screening, and prenatal, postpartum, and infant/toddler home visiting [n = 228]). Treatments 1 and 3 were included originally to increase statistical power for testing pregnancy outcomes. For determining mortality, background information was available for all 1138 mothers assigned to all 4 treatments and all but 2 live-born children in treatments 2 and 4 (n = 704). Inclusion of children in treatments 1 and 3 was not possible because background information was missing on too many children. INTERVENTIONS Nurses sought to improve the outcomes of pregnancy, children’s health and development, and mothers’ health and life-course with home visits beginning during pregnancy and continuing through child age 2 years. MAIN OUTCOMES AND MEASURES All-cause mortality in mothers and preventable-cause mortality in children (sudden infant death syndrome, unintentional injury, and homicide) derived from the National Death Index. RESULTS The mean (SE) 21-year maternal all-cause mortality rate was 3.7% (0.74%) in the combined control group (treatments 1 and 2), 0.4% (0.43%) in treatment 3, and 2.2% (0.97%) in treatment 4. The survival contrast of treatments 1 and 2 combined with treatment 3 was significant (P = .007); the contrast of treatments 1 and 2 combined with treatment 4 was not significant (P = .19), and the contrast of treatments 1 and 2 combined with treatments 3 and 4 combined was significant (post hoc P = .008). At child age 20 years, the preventable-cause child mortality rate was 1.6% (0.57%) in treatment 2 and 0.0% (SE not calculable) in treatment 4; the survival contrast was significant (P = .04). CONCLUSIONS AND RELEVANCE Prenatal and infant/toddler home visitation by nurses is a promising means of reducing all-cause mortality among mothers and preventable-cause mortality in their first-born children living in highly disadvantaged settings.

A Prospective Cohort Study of Influences on Externalizing Behaviors Across Childhood: Results From a Nurse Home Visiting Randomized Controlled Trial

“…37,38 In mothers, the NHV program is linked to reduced rates of pregnancy-induced hypertension, 15 subsequent pregnancies/births, reductions in welfare use, 36,39 and all-cause mortality 20 years later. 22 …”

“…15,21,22 A total of 1,289 eligible women, living in highly disadvantaged urban neighborhoods, was consecutively recruited from a public system for obstetric and pediatric care between 1990–1991. Of these, 151 declined to participate.…”

Birth Order and Injury-Related Infant Mortality in the U.S.

“…Because the classification of sudden unexpected infant death (SUID) includes an external cause code (accidental suffocation and strangulation in bed [W75]), 16, 17 and SUID has been categorized alongside external causes of death in previous analyses of “preventable-cause” or “potential maltreatment” mortality, 18, 19 three alternative classifications of infant mortality were also considered: external causes excluding W75 (accidental suffocation and strangulation in bed; *U01, V01–W74, W76–Y84); external causes plus SUID (which, in addition to W75, includes two pathologic causes of death: sudden infant death syndrome [R95] and other ill-defined and unspecified causes of mortality [R99] 20 ; *U01, V01–Y84, R95, R99); and SUID alone (W75, R95, R99). Risks of infant mortality due to unintentional injury and homicide were also examined, separately.…”

Targeting Parenting in Early Childhood: A Public Health Approach to Improve Outcomes for Children Living in Poverty

“…It was developed to improve maternal and child health outcomes by providing instrumental and emotional support for first-time mothers, particularly those at risk due to poverty (Olds et al, 2014). The widely disseminated program has demonstrated long-lasting, significant effects for highest risk populations (i.e., low psychological resource, low-income mothers).…”

“…Examples of demonstrated maternal outcomes include reduced all-cause maternal mortality (Olds et al, 2014) and increased maternal relationship stability ( d = 0.24; Olds et al, 2004). Child outcomes of NFP include decreased preventable-cause mortality in firstborn children (Olds et al, 2014), fewer internalizing problems (OR = 0.63), improved academic achievement ( d = 0.18; Kitzman et al, 2010), higher intellectual functioning and receptive vocabulary ( d = 0.17–0.25), and fewer behavior problems (OR = 0.32; Olds et al, 2004). However, some impacts for NFP vary based on who is delivering the intervention, the gender of the child, and the outcome of interest (Kahn & Moore, 2010).…”