David L. Olds

The nurse–family partnership: An evidence‐based preventive intervention

Pregnancy and the early years of the childs life offer an opportune time to prevent a host of adverse maternal, child, and family outcomes that are important in their own right, but that also reflect biological, behavioral, and social substrates in the child and family that affect family formation and future life trajectories. This article summarizes a 27-year program of research that has attempted to improve early maternal and child health and future life options with prenatal and infancy home visiting by nurses. The program is designed for low-income mothers who have had no previous live births. The home-visiting nurses have three major goals: to improve the outcomes of pregnancy by helping women improve their prenatal health, to improve the childs health and development by helping parents provide more sensitive and competent care of the child, and to improve parental life course by helping parents plan future pregnancies, complete their education, and find work. The program has been tested in three separate large-scale, randomized controlled trials with different populations living in different contexts. Results from these trials indicate that the program has been successful in achieving two of its most important goals: (a) the improvement of parental care of the child as reflected in fewer injuries and ingestions that may be associated with child abuse and neglect and better infant emotional and language development; and (b) the improvement of maternal life course, reflected in fewer subsequent pregnancies, greater work-force participation, and reduced dependence on public assistance and food stamps. The impact on pregnancy outcomes is equivocal. In the first trial, the program also produced long-term effects on the number of arrests, convictions, emergent substance use, and promiscuous sexual activity of 15-year-old children whose nurse-visited mothers were low-income and unmarried when they registered in the study during pregnancy. In general, the impact of the program was greater on those segments of the population at greater risk for the particular outcome domain under examination. Since 1996, the program has been offered for public investment outside of research contexts. Careful attention has been given to ensuring that organizational and community contexts are favorable for development of the program, to providing excellent training and guidance to the nurses in their use of the programs visit-by-visit guidelines, to monitoring the functioning of the program with a comprehensive clinical information system, and to improving the performance of the programs over time with continuous improvement strategies.

Prenatal and Infancy Home Visiting by Nurses: From Randomized Trials to Community Replication

This paper summarizes a 25-year program of research that has attempted to improve the early health and development of low-income mothers and children and their future life trajectories with prenatal and infancy home visiting by nurses. The program has been tested in two separate large-scale randomized controlled trials with different populations living in different contexts. The program has been successful in improving parental care of the child as reflected in fewer injuries and ingestions that may be associated with child abuse and neglect; and maternal life-course, reflected in fewer subsequent pregnancies, greater work force participation, and reduced use of public assistance and food stamps. In the first trial, the program also produced long-term effects on the number of arrests, convictions, emergent substance use, and promiscuous sexual activity of 15-year-old children whose nurse-visited mothers were low-income and unmarried when they registered in the study during pregnancy. Since 1996, the program has been offered for public investment outside of research contexts. Careful attention has been given to ensuring that the program is replicated with fidelity to the model tested in the scientifically controlled studies by working with community leaders to ensure that organization and community contexts are favorable for the program; by providing the nurses with excellent training and technical assistance and detailed visit-by-visit guidelines; and by providing organizations with a web-based clinical information system that creates a basis for monitoring program performance and continuous quality improvement.

Review of research on home visiting for pregnant women and parents of young children.

In this paper, David Olds and Harriet Kitzman review the results of the experimental literature concerning the effectiveness of home visiting programs in improving the lives of children and families. Their extensive review concentrates on randomized trials, that is, those most methodologically rigorous studies of all in which families are randomly assigned to two groups, typically to receive either (1) home visiting services (the experimental group) or (2) care as usual (the control group). Olds and Kitzman further focus on just those studies in which the effects of home visiting can be teased apart from the effects of other sorts of services (for example, medical care and child care). Thus, their review does not include some of the studies that are mentioned by other authors (for example, Powell and Weiss) in their articles for this journal issue or described in the Appendix (page 205). Nevertheless, the review is very comprehensive. The authors summarize results of 31 home visiting programs that have focused on preventing preterm delivery and low birth weight; improving the outcomes of infants born preterm or low birth weight; or serving low-income families or families at risk for child maltreatment. Tables 2, 3, and 4 depict the results of studies on outcomes including changes in parental behavior, home environment, child development and behavior, child abuse, rates of preterm and low birth weight births, and health care utilization. The authors conclude that home visiting is a promising approach, but all too often the promise has not been clearly demonstrated. Indeed, results suggest that home visiting programs in the past have benefited some families but not others and have improved some outcomes but not others. Olds and Kitzman suggest that these differences in effectiveness may be the result of several characteristics of the home visiting programs, including their comprehensiveness of purpose and goals, level of staffing, frequency of visits, and the populations they are designed to serve. In general, the authors suggest that programs which are comprehensive in focus, have frequent visits, are staffed by well-trained professionals, and serve families that are initially at elevated risk for poor outcomes are more likely to demonstrate success. The authors conclude that carefully designed home visiting programs should continue to receive support.

Improving the life-course development of socially disadvantaged mothers: a randomized trial of nurse home visitation.

We evaluated a comprehensive program of prenatal and postpartum nurse home visitation for socially disadvantaged women bearing first children. Eighty-five per cent of the participating women were either teenagers (less than 19 years at registration), unmarried, or of low socioeconomic status. Women were randomly assigned to either nurse home visitation or comparison services (free transportation for prenatal and well-child care and/or sensory and developmental screening for the child). During the first four years after delivery of their first child, in contrast to their counterparts in the comparison group, nurse-visited White women who had not graduated from high school when they registered in the study returned to school more rapidly; nurse-visited, poor, unmarried White women showed an 82 per cent increase in the number of months they were employed, had 43 per cent fewer subsequent pregnancies, and postponed the birth of second children an average of 12 months longer.

Long-term Effects of Prenatal and Infancy Nurse Home Visitation on the Life Course of Youths: 19-Year Follow-up of a Randomized Trial

OBJECTIVE To examine the effect of prenatal and infancy nurse home visitation on the life course development of 19-year-old youths whose mothers participated in the program. DESIGN Randomized trial. SETTING Semirural community in New York. PARTICIPANTS Three hundred ten youths from the 400 families enrolled in the Elmira Nurse-Family Partnership program. Intervention Families received a mean of 9 home visits (range, 0-16) during pregnancy and 23 (range, 0-59) from birth through the childs second birthday. MAIN OUTCOME MEASURES Youth self-reports of educational achievement, reproductive behaviors, welfare use, and criminal involvement. RESULTS Relative to the comparison group, girls in the pregnancy and infancy nurse-visited group were less likely to have been arrested (10% vs 30%; relative risk [RR], 0.33; 95% confidence interval [CI], 0.13-0.82) and convicted (4% vs 20%; 0.20; 0.05-0.85) and had fewer lifetime arrests (mean: 0.10 vs 0.54; incidence RR [IRR], 0.18; 95% CI, 0.06-0.54) and convictions (0.04 vs 0.37; 0.11; 0.02-0.51). Nurse-visited girls born to unmarried and low-income mothers had fewer children (11% vs 30%; RR, 0.35; 95% CI, 0.12-1.02) and less Medicaid use (18% vs 45%; 0.40; 0.18-0.87) than their comparison group counterparts. CONCLUSIONS Prenatal and infancy home visitation reduced the proportion of girls entering the criminal justice system. For girls born to high-risk mothers, there were additional positive program effects consistent with results from earlier phases of this trial. There were few program effects for boys.

Enduring effects of prenatal and infancy home visiting by nurses on children: follow-up of a randomized trial among children at age 12 years.

OBJECTIVE To test the effect of prenatal and infancy home visits by nurses on 12-year-old, firstborn childrens use of substances, behavioral adjustment, and academic achievement. DESIGN Randomized controlled trial. SETTING Public system of obstetric and pediatric care in Memphis, Tennessee. PARTICIPANTS We studied 12-year-old, firstborn children (n = 613) of primarily African American, economically disadvantaged women (743 randomized during pregnancy). INTERVENTION Program of prenatal and infancy home visits by nurses. OUTCOME MEASURES Use of cigarettes, alcohol, and marijuana; internalizing, externalizing, and total behavioral problems; and academic achievement. RESULTS By the time the firstborn child was 12 years of age, those visited by nurses, compared with those in the control group, reported fewer days of having used cigarettes, alcohol, and marijuana during the 30-day period before the 12-year interview (0.03 vs 0.18, P = .02) and were less likely to report having internalizing disorders that met the borderline or clinical threshold (22.1% vs 30.9%, P = .04). Nurse-visited children born to mothers with low psychological resources, compared with their control group counterparts, scored higher on the Peabody Individual Achievement Tests in reading and math (88.78 vs 85.70, P = .009) and, during their first 6 years of education, scored higher on group-administered standardized tests of math and reading achievement (40.52 vs 34.85, P = .02). No statistically significant program effects were found on childrens externalizing or total behavioral problems. CONCLUSIONS Through age 12, the program reduced childrens use of substances and internalizing mental health problems and improved the academic achievement of children born to mothers with low psychological resources.

Effect of prenatal and infancy nurse home visitation on government spending.

A completed series of reports on a randomized trial (N=400) indicated that, in contrast to comparison services, prenatal and infancy nurse home visitation improved a wide range of maternal and child health outcomes among poor, unmarried, and teenaged women bearing first children in a semirural county in upstate New York. Eighty-nine percent of the sample was white, and all analyses focused on this group. In this article, an analysis of the net cost of the home-visitation program from the perspective of government spending is presented. The average per-family cost of the program in 1980 dollars was

Differences in program implementation between nurses and paraprofessionals providing home visits during pregnancy and infancy: a randomized trial.

3,246 for the sample as a whole, and

The promise of home visitation: Results of two randomized trials

3,133 for low-income families. Treatment differences in government expenditures for Aid to Families with Dependent Children, Food Stamps, Medicaid, and Child Protective Services, minus tax revenues due to maternal employment (also expressed in 1980 dollars), were conceived as government savings. By the time the children were 4 years of age, government savings were

Taking preventive intervention to scale: The nurse-family partnership *

1,772 (95% confidence interval [CI]: -