As the federal government pours more money into nurse home visitation programs for new mothers, a study released this week indicates two things: the new programs will need time to produce results, and the programs might be particularly strong at convincing teen moms in rural areas to delay having a second baby.
The assessment of Pennsylvania’s statewide Nurse-Family Partnership (NFP) program, a brand of home visitation that sends nurses to work with first-time mothers, found that the program made no difference on delayed second pregnancies from 2000 to 2003, the first three years of statewide implementation. But between 2004 and 2005, the study found, women in the program were less likely to give birth a second time within two years of having their first child than were women in a control group.
Delaying a second pregnancy is significant, study co-author Dr. David M. Rubin said Wednesday. “There is such a crossroad after she has that first infant,” he said, because the longer a teen mom waits until her next pregnancy, the better the health, developmental and economic outcomes for her and her children.
The first major study of NFP took place in Elmira, N.Y. during the 1980s, and later studies examined the success of partnerships in Denver and Memphis. This new study – conducted by the PolicyLab at The Children’s Hospital of Philadelphia and published in the November issue of the Archives of Pediatrics & Adolescent Medicine – is the first to gauge the effect of a statewide NFP program. The other three states that have fully implemented an NFP program are Colorado, Louisiana and Oklahoma.
PolicyLab looked at several outcomes, including smoking and child injuries, but the first results to be released focus on what are sometimes called “rapid” second births. Several studies have found that nurse visitation programs have some effect in reducing such births. (A federal summary of three such studies is here; the Coalition for Evidence-Based Policy’s summary is here. )
PolicyLab’s study includes rural NFP sites serving one of the nation’s largest rural populations. It followed 3,296 NFP clients in 17 urban and 548 clients from six rural sites, and compared them with a control group of 11,000 women who had a first child during the same period as the NFP participants and were on welfare.
The study found “no program effects” from 2000 to 2003, which researchers attribute to standard start-up issues “as interventions move from the controlled laboratory to community settings.”
After that, however, there were significantly fewer second live births among NFP participants compared with the control group. The study says 16.8 percent of the NFP clients had second births within two years, compared with 19 percent among the control group.
The difference between client and control was more than twice as high for women age 18 and younger: 17.9 percent of clients had second pregnancies within two years, compared with 23.3 percent of the control group.
But the Coalition for Evidence-Based Policy, which supports nurse visitation programs as a worthwhile, evidence-based intervention, said in an informal assessment for Youth Today that the study “provides suggestive, but not strong evidence, regarding the program’s effects.” The sample selection limits the value of the study, according to the Coalition as the NFP participants were self-selected and the comparison group’s demographics differed in some significant ways from the participant group.
The coalition also said the subgroup findings should “be interpreted with caution,” because such findings can be affected by numerous factors and usually have to be validated in a second study.
New Programs Need Time
Proponents of home visitation programs voice hope that federal officials note the lag time between implementation and success in this and other studies of NFP. The current plan is for states to start reporting to the Department of Health and Human Services (HHS) after three years on some home visitation benchmarks.
“States launching new home visiting programs with [health reform] funding are not likely to report improved outcomes in less than three years,” said Kay Johnson, a research professor at Dartmouth Medical School, in an editorial that accompanied the study.
Johnson suggests that five years is a better time to start looking at outcomes. Dr. David Olds, who created the NFP model in 1977, echoed that sentiment in an e-mail to Youth Today.
“The major lesson to be learned from this is that we need to give evidence-based programs that are moved into communities time to be bedded down and implemented with quality before they are evaluated in outcome studies,” said Olds. “Premature evaluation may lead to wrong conclusions.”
The federal health care overhaul passed this year designates $1.5 billion over the next five years for states to start and support home visitation programs such as NFP, the Parent-Child Home Program and Home Instruction for Parents of Preschool Youngsters (HIPPY). Such programs send health professionals, parenting experts or both into the homes of expectant or new mothers to help prepare them to raise children. (The funding is explained in this story.)
The first round of grants, about $92 million) were released this fall to every state and territory by the Health Resources and Services Administration, a division of HHS.
Rural Teens Helped Most
The most profound effect of NFP in Pennsylvania appears to be among young rural mothers. During the whole study period, authors calculated that the “hazard ratio” of having a second baby was 0.39 for rural NFP clients under 18, compared with .79 among young NFP clients in cities. In other words, the young rural moms were twice as likely to put off having another child for two years as were their NFP counterparts in Pennsylvania’s urban areas.
Dr. Rubin offered several possible explanations as to why the effect of NFP appears to be so much stronger in rural areas:
-The women in rural areas might have benefitted from personal and institutional relationships in their small communities, including religious organization membership and knowing the visiting nurses;
-rural women in the control group might not have had access to as many non-NFP services (such as family planning) as urban women who were in the control group
-the caseworkers at rural sites had easier access to the clients, because in more isolated communities the women were more likely to be home than were clients who lived in cities, and a lower number of total cases to handle.
The findings “suggest that urban sites may need more intensive programs, staff capacity, community linkages, and/or technical assistance to achieve the same results as rural sites,” Johnson said in her editorial.