Effects of nurse home visiting on maternal and child functioning: age-9 follow-up of a randomized trial.

Home visiting by nurses for low-income, at-risk families has been promoted as a promising strategy for preventing child abuse and neglect, children’s mental health problems,1–3 and infant mortality.4 Recent evidence suggests that the benefits hoped for from such programs do not hold for all types of home-visiting programs.5 A program of home visiting by nurses known as the Nurse-Family Partnership (NFP) has produced consistent effects on several aspects of maternal and child health through the preschool period when tested in randomized trials with various racial and ethnic groups, in various living contexts, and at different historical periods.6–8 Many of the apparent benefits of the program that have captured the attention of policy makers, however, have been derived from the adolescent follow-up of the first trial of the NFP, tested with a primarily white sample in Elmira, New York.9,10 The first replication trial of the NFP was conducted in Memphis, Tennessee, and focused on low-income black individuals. Results of the Memphis trial through child age 4 corroborated many of the early effects of the program on maternal life course observed in the first trial that focused on white individuals.11,12 A recent study of program effects in Memphis through child age 6 found that the program also produced positive effects on children’s cognition, mental health, and internal representations of relationships.8 Our study was designed to examine the enduring impact of the program on mothers’ life course, on children’s academic and behavioral functioning in early elementary school (grades 1–3), and on mothers’ reports of their children’s mental health through child age 9. For the current phase of follow-up, we hypothesized that the program would produce enduring effects consistent with those observed either earlier in this trial or in the first trial conducted in Elmira, New York, on primary maternal life-course outcomes: the intervals between births of first and second children, rates of subsequent births (operationalized at this phase of follow-up as the cumulative number of subsequent children born per year), use of welfare (Temporary Assistance for Needy Families [TANF] and food stamps), substance use, behavioral impairments as a result of substance use, arrests and number of days incarcerated, marriage, and duration of partner relations, as well as the biological father’s involvement in the family. Better pregnancy planning, maternal employment, sense of mastery, and father involvement, along with reductions in substance abuse, were expected to improve family economic self-sufficiency. To understand fully the clinical and economic impact of these hypothesized changes in maternal life course, we examined the following variables as secondary outcomes: counts of subsequent miscarriages, abortions, still births, and low birth weight newborns; maternal symptoms of depression; and mothers’ employment, use of Medicaid, being partnered with men who were unemployed, and experience of domestic violence. We hypothesized that the program would produce effects on the following primary child outcomes: grade-point averages (GPAs) in reading, math, and conduct; the counts of failures in academics (reading and math) and conduct, as well as disruptive behavior, anxiety, and depressive disorders; and teachers’ reports of antisocial behavior. We also examined as secondary outcomes children’s special education placements and grade retentions and teachers’ ratings of children’s academically focused behavior and peer affiliation. Given limited statistical power, we did not hypothesize program effects on the mortality of firstborn children. We nevertheless examined program effects on this outcome given emerging treatment differences in the rates and causes of mortality. Earlier reports on trials of this program have found consistent effects on child outcomes concentrated among children who were born to mothers who were more psychologically vulnerable.7 We therefore predicted that program benefits for children would be concentrated on those who were born to mothers with low psychological resources (limited intellectual functioning, poor mental health, and low sense of control over their life circumstances). We examined whether program effects on maternal fertility and welfare outcomes were greater for women with initially higher psychological resources, given greater program effects on fertility for this segment of the sample in earlier phases of this trial.9,12