Nurse home visits may not improve prenatal health among low-income patients

The Big 3: Three questions, three answers

August 24, 2023 – Margaret McConnell, associate professor of global health economics in the Department of Global Health and Population at Harvard T.H. Chan School of Public Health, studies policies that aim to improve the health of vulnerable populations, with a focus on children and pregnant people. In a paper recently published in Health Affairs, she evaluated the impact of a longstanding national nurse home visiting program.

Q: Describe how the program works and what the objective of the study was.

A: The study is part of a wider evaluation of a large nationwide home visiting program called Nurse-Family Partnership (NFP). It is a program that was started in the 1970s to complement regular prenatal and postnatal care, and to support child development. It was then expanded in the 1990s with federal funding. Today it operates in 40 states, reaching at least 55,000 low-income families annually.

As part of the program, registered nurses visit first-time pregnant people at home as often as every other week during pregnancy and once a month for the first two years of their baby’s life. They perform health screenings, assess mental health, and refer to health care or social services if needed. The content discussed during each visit can vary substantially as it is designed to take into account the interests of the pregnant person or parent. It can cover things ranging from the baby’s language development skills to how to apply for the Supplemental Nutrition Assistance Program to improving nutrition during pregnancy.

The objective of our two recently published studies was to learn about whether the NFP program could impact pregnancy health, birth outcomes, and prenatal care use. This is important particularly because of the urgent need to understand how to improve our country’s maternal and infant health outcomes, which have been stagnant and, in some cases, worsening over time. There are also stark inequities across racial groups in the U.S., with Black birthing people much more likely to experience adverse birth outcomes than their white counterparts. So, there is a lot of attention on this nationally and state Medicaid programs are trying to understand what programs might be effective to address maternal and infant outcomes.

We conducted a randomized controlled trial of NFP in South Carolina that allowed us to compare outcomes between those assigned to receive NFP services and those who had access to usual care services in South Carolina.

Q: What were the main findings?

A: We saw that when the program was delivered at scale to the Medicaid-eligible population in South Carolina there were no impacts on either prenatal care or birth outcomes, such as preterm birth, low birth weight, small for gestational age, and perinatal mortality. We also didn’t see any improvements in outcomes among non-Hispanic Black study participants.

These are important findings at a moment when states are considering scaling up home visiting services. It also highlights the urgent need for a better understanding of what programs can move the needle and improve care during pregnancy and birth outcomes, and in particular what programs can be effective in reducing racial disparities and inequities.

Q: Why do you think that home nursing visits didn’t affect prenatal care?

A: I think it is likely to be a combination of complex factors. There are many structural challenges to addressing the high rates of adverse birth outcomes we see in our study, which are particularly driven by substantial racial disparities in birth outcomes. Many of the determinants of adverse pregnancy outcomes start even before someone becomes pregnant. Furthermore, while we see a high degree of utilization of pregnancy care in our study population, there are some important variations in quality of care. Specifically, we see substantial variation in the rates of receiving guideline-based procedures during pregnancy and limited access to maternal fetal medicine specialists. It’s hard to put all the weight of improving these forces on a one-on-one relationship between a nurse and a pregnant person. It’s a lot to ask.

For our study we were also able to compare people who enrolled in our study–who therefore wanted to participate in the Nurse-Family Partnership program–and people who lived in the same counties, were eligible for the program, but, for whatever reason, didn’t enroll. Maybe they didn’t know about the program or maybe they chose not to participate. One key difference we saw was that people who ended up becoming enrolled in the program were more engaged in care. They tended to have earlier prenatal visits, more frequent prenatal visits, and more use of social services. What that suggests is that people who are reached by a home nursing visiting program may tend to be people who are already more engaged with clinical care overall. It may be that nurse home visiting services struggle to reach populations who are accessing prenatal care late in pregnancy or those who have reasons to feel less comfortable inviting a nurse into their home. That’s another important finding.

However, the results we published so far only focus on what happens during pregnancy. We are currently looking into what happens during the post-partum period and to children’s health and well-being outcomes. So, we still have a lot to learn about the overall impact of the program.

– Giulia Cambieri