Nurse Home Visiting for First-Time Adolescent Mothers Print

(Elmira NY, Memphis TN, and Denver CO)

Programs that Work to Prevent Subsequent Pregnancy among Adolescent Mothers

Components

  • Home-based, prenatal, nurse visiting and continuing nurse home visits until the child’s second birthday
  • Detailed curriculum to guide nurses in their home visits
  • Sensory and developmental screening and referral services for infants at 12 and 24 months of age
  • Optional free, round-trip transportation for scheduled prenatal care appointments and for babies’ well-care appointments

For Use With

  • Urban and rural white, first-time, adolescent mothers living in poverty
  • Urban Latina and African American, first-time, adolescent mothers living in poverty

Evaluation Methodology

Elmira NY

  • Experimental design with two treatment and two comparison conditions
  • Pregnant women at less than 30 weeks gestation, bearing their first child (n=400), randomly assigned to two treatment (n=90 and 94) and two control (n=100 and 116) conditions
  • Baseline data on women and follow-up data at the child’s sixth, 10th, 22nd, and 46th month of life
  • Data from infants’ medical records and states’ child abuse and neglect records
  • Social services data on public assistance through the child’s fourth birthday
  • Follow-up on participants (n=324) when the child reached age 15

Memphis TN

  • Experimental design with two treatment and two control conditions
  • Pregnant women at less than 29 weeks gestation, with no prior live births and either unmarried, unemployed, or lacking 12 years of education (n=1,139), randomly assigned to two treatment (n=230 and 228) and two control (n=116 and 515) conditions
  • Baseline data on women; follow-up at delivery (n=1,126), at six months postpartum (n=672), at 12 months postpartum (n=682), and at 24 months postpartum (n=675)
  • Baseline data on infants one to three days after birth (n=1,082) and at 24 months after birth (n=697)

Denver CO

  • Experimental design with two treatment and one control conditions
  • Pregnant women with no previous live births (n=735) randomly assigned to nurse visiting (n=235), paraprofessional visiting (n=245), or control (n=255) condition
  • Baseline assessment of pregnant women, using interviews, brief tests of intellectual functioning, and urine tests for tobacco, alcohol, and other drug use
  • End-of-pregnancy assessment at 36 weeks of gestation, using interviews and urine tests
  • Follow-up assessment at 12, 15, 21, and 24 months postpartum to assess subsequent pregnancies, educational achievement, and workforce participation
  • Assessment of infants’ emotional, mental, and behavioral development at six, 12, 15, 21, and 24 months of age

Evaluation Findings

  • Reduced incidence of repeat pregnancy and births (Elmira NY, Memphis TN, and Denver CO)
  • Improved emotional vitality and increased mental development in infants (Denver CO)
  • Reduced incidence of child abuse and neglect and of accidents among children up to age 15 (Elmira NY) and among children under age two (Memphis TN)
  • Reduced incidence of arrests or convictions or use of public assistance among mothers (Elmira NY)

Program Description

This program for first-time mothers living in poverty provides nurse home visiting for pregnant and parenting women, especially adolescents. Based in theories of human ecology, human attachment, and self-efficacy, the program operates through public and private health care settings. The program may also provide women with free round-trip transportation to scheduled prenatal appointments and to well-baby appointments after their infant’s birth.4,5

Each participating mother is assigned to a nurse for home visiting and receives intensive home visits during pregnancy and for 24 months after her child’s birth. Nurses promote a healthy pregnancy, including attention to diet, weight gain, substance use, hypertension, and urinary and reproductive tract infections. Visiting nurses help mothers and other caregivers to improve the physical and emotional care given the children, have positive parent-child interactions, understand infants’ and toddlers’ cognitive development, and create safe households. The nurses also help the young women to clarify their personal goals and to solve problems that could interfere with completing their education, finding work, and planning future pregnancies. As needed, young mothers are referred to vocational training, family planning and mental health clinics, and for legal aid and WIC (the nutritional supplemental program for women, infants, and children). Using a detailed curriculum to guide their activities and tailoring the activities to the individual needs of each young family, the nurses’ central focus is an emphasis on the strengths of the women and their families.4,5

Evaluation Methodology

Elmira NY: Pregnant women were recruited if they had no previous live births, were less than age 19, were unmarried, and/or were of low socioeconomic status (SES). Other pregnant women bearing a first child were not recruited but were allowed to enroll. All enrollees were at less than 30 weeks gestation. Between April 1978 and September 1980, researchers interviewed 500 young women and enrolled 400. Researchers found no differences in age, marital status, or education between those who participated and those who declined. At registration, 47 percent of participants were under age 19, 62 percent were unmarried, and 61 percent were of low SES. Twenty-three percent of participants were ‘at risk’ according to all three indicators. The 48 non-white participants were not included in the evaluation due to their small sample size.4

The infants of all the women (both experimental and comparison groups) received sensory and developmental screening at their 12th and 24th month of life. Where indicated, children were referred for further evaluation and treatment. Participants were randomly divided into four groups:

  • Women in comparison group #1 (comparison group; n=90) received no further assistance.
  • Women in comparison group #2 (comparison group; n=94) received free transportation for regular prenatal and well-baby care.
  • Women in treatment group #3 (treatment group; n=100) received free transportation for regular prenatal and well-baby care and nurse home visiting regularly throughout pregnancy.
  • Women in treatment group #4 (treatment group; n=116) received free transportation for regular prenatal and well-baby care and nurse home visiting regularly throughout pregnancy. In addition, they received regularly scheduled nurse home visits during the first two years of their child’s life.4

Data was collected through interviews and infant assessments, carried out at registration (prior to 30th week of pregnancy) and at six, 10, 12, 22, and 24 months of the infant’s life. Medical records were abstracted for the infant’s first two years of life and child abuse and neglect registries for the states in which families lived (or the two states to which families moved) were reviewed by qualified state social services workers. For evaluation, the two comparison groups were combined when data showed that there were no differences between these two groups in their use of routine prenatal and well-baby care. Evaluators assessed outcomes related to the differences between the combined comparison group and treatment group #4—the group that received nurse visits both during pregnancy and throughout the first two years of the infants’ life.4

Memphis TN: From June 1, 1990, through August 31, 1991, researchers invited the participation of 1,290 consecutive women attending the obstetrical clinic at the Regional Medical Center in Memphis, Tennessee. All those invited were at less than 29 weeks gestation, had no previous live birth, had no specific chronic illness that might retard fetal growth or contribute to preterm delivery*, and met at least two of the following socio-demographic conditions: were unmarried, had less than 12 years of education, and/or were unemployed. Eighty-eight percent (n=1,139) elected to participate, gave informed consent, and were randomly assigned to one of four study conditions. At enrollment, participants were mostly African American (92 percent), unmarried (98 percent), 18 or younger (64 percent), and from households with incomes at or below federal poverty guidelines (85 percent of participants).5

The four study conditions included two treatment and two control groups. Women in:

  • Group one (control; n=166) received free round-trip taxicab transportation to scheduled prenatal visits. They received no other special treatment.
  • Group two (control; n=515) received: 1) free transportation to scheduled prenatal visits; and 2) developmental screening and referral services for the child at six, 12, and 24 months of age.
  • Group three (prenatal treatment; n=230) received: 1) free transportation to scheduled prenatal visits; 2) developmental screening and referral services for the child at six, 12, and 24 months of age; 3) intensive home visits by a nurse during pregnancy; 4) one postpartum visit by the nurse in the hospital; and 5) one postpartum home visit by the nurse.
  • Group four (prenatal and postnatal treatment; n=228) received: 1) free transportation to scheduled prenatal visits; 2) developmental screening and referral services for the child at six, 12, and 24 months of age; 3) intensive home visiting services from a nurse during pregnancy; 4) one postpartum visit by the nurse in the hospital; and 5) continuing home visits by the nurse until the child’s second birthday.5

Research staff interviewed participants in an office setting at the time of their enrollment (before their random assignment to one of the four treatment/control conditions). Thereafter, participant interviews, records searches, etc., were performed without researchers knowing to which conditions participants had been assigned. Participants were interviewed by phone at the 28th and 36th weeks of pregnancy.5

Participants were interviewed in the office setting at the sixth, 12th, and 24th month of their child’s life. Questions assessed: 1) whether or not they breast-fed and, if so, for how long; and 2) their attitudes associated with child abuse and neglect.* At 12- and 24-months postpartum, women also answered questions regarding the number and outcomes of subsequent pregnancies, their educational achievements, and the number of months since giving birth that they held a paid job. Medical records, including obstetrical, newborn, pediatric, and emergency room records were consulted for data on sexually transmitted infections (STIs), marijuana and cocaine use, and urinary tract infections prior to birth; well-baby care, including immunizations; and emergency room visits for illnesses and/or injuries in the child. Social services records were consulted for data related to women’s use of Aid to Families with Dependent Children (AFDC). During home visits, mothers and their children were observed and assessed on qualities related to the home environment. Finally, at the 24-month office visit, children were assessed on scales of infant development and their mothers completed a child behavior checklist.5

For evaluation of the prenatal phase of the program, groups one and two (controls; n=681) were combined to form a single control group; groups three and four (prenatal treatment; n=458) were combined to form a single treatment group; and these two larger groups were compared. For evaluation of the postnatal phase of the program, group two (control; n=515) was contrasted to group four (postnatal treatment group; n=228). The four groups were equivalent on background characteristics with few exceptions—namely that women in treatment group four lived in households in which the head was more likely to be unemployed and in which there was less discretionary income than did women in control group two.5

Evaluation of prenatal groups found no treatment effects for birth weight, length of gestation, low birth weight, spontaneous preterm delivery, indicated preterm delivery, or Apgar scores. However by the 36th week, women in the combined treatment group were more likely than comparison women to use other community services (29 versus 20 percent; odds ratio [OR] 1.8) and more likely to be working (six versus three percent; OR 0.6).5

Denver CO: From March 29, 1994 through June 15, 1995, 1,178 consecutive women were invited to participate in the study while attending prenatal clinics (n=21) in Denver that served low-income women. Women were recruited if they had no previous live births and either qualified for Medicaid or had no private health insurance. They could enroll at any time prior to delivery. Compared to those who refused to participate, participants were more likely to be Hispanic and less likely to smoke cigarettes. Otherwise, the groups were similar on other socio-demographic measures, such as maternal age, language preference, and marital status.6

Participants were randomly assigned to:

  • Control group (n=255), receiving developmental screening and referral services for their children when the infants were six, 12, 15, 21, and 24 months of age;
  • Nurse visiting treatment group #1 (n=235), receiving infant screening and referral (as above) as well as home visiting by a registered nurse during pregnancy and the first two years of the child’s life; and
  • Paraprofessional treatment group #2 (n=245), receiving infant screening and referral (as above) as well as home visiting by a paraprofessional during pregnancy and the first two years of the child’s life.6

Participants were mostly unmarried (85 percent of controls compared to 86 percent of treatment group #1 and 87 percent of treatment group #2). The three groups were similar by race/ethnicity (46, 44, and 45 percent Hispanic, respectively; 16, 16, and 17 percent African American, respectively; and 35, 37, and 35 percent white, respectively). Similar proportions smoked cigarettes (25, 21, and 24 percent, respectively) or suffered domestic violence in the previous six months (16, 16, and 18 percent, respectively). Among those with few psychological resources, proportions were similar between the groups as a whole, except that women in both treatment groups were more likely to have suffered domestic violence (18, 27, and 30 percent, respectively).6

Findings showed statistically insignificant results for the visits of paraprofessionals, even though they were well suited for the work and shared many of the social characteristics of the families they served. Overall compared to nurse visitors, paraprofessionals had a higher average number of scheduled visits in which the family was not at home or did not answer the door (P=≤ .001). By the end of the program, 48 percent of the paraprofessional-visited families had dropped out of the program, compared to 38 percent of those visited by nurses (P=.04). As a result, the findings pertain only to the nurse-visited women and their infants.6

Outcomes:

  • Reduced incidence of emergency room visits—
    Elmira NY: During the first year of life, infants of nurse-visited women (treatment group #4) were taken to the emergency room significantly less often than infants of comparison women (0.74 versus 1.02 visits per woman) and the effect was even greater among poor, unmarried teens (0.95 versus 1.66 visits per woman, respectively).4,7
  • Reduced incidence of smoking during pregnancy—
    Denver CO: In contrast to control group women, nurse-visited smokers had significantly reduced levels of cotinine (a form of nicotine) from baseline to birth (reduction of 259.00 versus 12.32 ng/ml, P=.03).6

Long-Term Findings

  • Reduced incidence of repeat pregnancy and birth—
    Elmira NY: By 24 months postpartum, nurse-visited, poor, unmarried women had one-third as many subsequent pregnancies as poor unmarried comparisons. Between birth and 46 months postpartum, this reduction was present for all nurse-visited participants, but was strongest among poor, unmarried participants (23 versus 43 percent reduction, respectively). Nurse-visited unmarried women from low-SES households had fewer subsequent pregnancies (1.5 versus 2.2, respectively; P=.03) and live births (1.1 versus 1.6, respectively; P=.02) and greater birth spacing (64.8 versus 37.3 months, respectively; P=.001) than did comparison women. The differences were statistically significant.4,7

    A later statistical analysis found that the differences were also statistically significant at 24 months, 36 months, and 45 months.8

    Memphis TN: By 24 months postpartum, 47 percent of women in control group two reported a subsequent pregnancy, compared to 36 percent of nurse-visited women in treatment group four (OR=0.6). This finding was statistically significant.5 By 54 months postpartum, women in treatment group four (n=203) had experienced significantly fewer subsequent pregnancies (1.15 versus 1.34, respectively; P=0.3) compared to women in control group two (n=443). Moreover, the average length of time between the birth of the first and second child was significantly longer in women in treatment group four compared to women in control group two (30.25 months versus 26.6 months, respectively; P=.004).5,9

    A later statistical analysis also found that the differences were statistically significant overall and at 24 months, 36 months, and 45 months.8

    Denver CO: By 24 months postpartum, nurse-visited women were significantly less likely to have had a subsequent pregnancy (29 versus 41 percent; P=.02). At 24 months postpartum, nurse-visited women were significantly less likely to have had a subsequent birth (12 versus 19 percent; P=.05).6

  • Improved emotional and mental outcomes among infants—
    Denver CO: At 24 months of age, children of nurse-visited women with few resources were significantly less likely than control children to respond inappropriately to joyful stimuli (24 versus 40 percent, respectively; P=.04) or to anger stimuli (13 versus 32 percent, respectively; P=.04). At 21 months, children of nurse-visited women were significantly less likely than controls to exhibit language delay (six versus 12 percent, respectively; P=0.5) and the finding was even stronger among children of nurse-visited women who had few resources (seven versus 18 percent, respectively; P=.04).6

  • Reduced incidence of child abuse and neglect and childhood injuries—
    Elmira NY:     During the first two years of the children’s lives and among those at greatest risk (unmarried, poor teens), 19 percent of comparisons and four percent of the nurse-visited women abused or neglected their children (P=.07).4,7

    At 15-year follow-up, there were significantly fewer verified reports of nurse-visited women abusing or neglecting their child (P≤.001). This effect was even greater for women who were unmarried and of low SES at baseline (P≤.001) and the effect was especially strong for the four- to 15-year period after the birth of the child. Among women who were victims of domestic violence, those who received nurse visits through their child’s second birthday were reported significantly less often for child maltreatment (P=.04) than women who did not receive nurse home visits. This effect decreased as the incidence of domestic violence increased.10,11,12

    Memphis TN: By age 24 months, children in the home-visiting group (treatment group four) had statistically fewer outpatient visits associated with injuries or accidental ingestion of injurious material compared to children in control group two (0.11 versus 0.20, respectively; P≤.05).  By age 24 months, children in the home-visiting group also had statistically fewer days of hospitalization associated with injuries or ingestion of injurious material, compared to control children (0.04 versus 0.18, respectively; P≤.01). These program effects were greater for children born to women with few psychological resources than for children born to women with more psychological resources (0.41 versus 0.67; P=.003 for total health care encounters related to injuries or ingestion of poisonous substances and 0.02 versus 0.26; P≤.001 for hospitalizations related to injuries or ingestions).5

  • Decreased incidence of drug impairment; arrest, conviction, or jail time; or use of food stamps and other public assistance—
    Elmira NY:     At 15-year follow-up, nurse-visited women who were of low SES and unmarried at baseline were also significantly less likely, versus unmarried, low-SES comparisons, to have been impaired by alcohol or other drugs or to have been arrested or convicted for drug-related offenses (P=.005; P≤.001, P=.008, respectively); they had also spent fewer days in jail (P≤.001). Finally, at 15-year follow-up, nurse-visited women who were of low SES and unmarried at baseline reported using AFDC and food stamps for fewer months than did unmarried, low-SES comparisons (P=.005 and P=.001, respectively).12

For More Information, Contact

  • The Prenatal and Early Childhood Nurse Home Visitation Program—Contact Ruth O’Brien, Kempe Prevention Research Center for Family & Child Health, 1825 Marion Street, Denver CO 80218; Phone 303.864.5210; fax 202.864.5236; or This e-mail address is being protected from spambots. You need JavaScript enabled to view it

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