The study team published analysis of the impact of NFP on outcomes related to maternal and neonatal health on July 5th 2022.
Summary of Results
In the randomized controlled trial, NFP services did not have an impact on birth outcomes. There was no statistically significant effect of receiving NFP services on the primary composite outcome of adverse birth events, which included preterm birth, low birthweight, small-for-gestational-age birthweight, or perinatal mortality. 26.9 percent of participants who were randomized to receive NFP experienced an adverse birth outcome, compared to 26.1 percent of individuals who received usual care—a difference that was not statistically significant. There was also no detectable effect on any individual component of the composite, nor on nine other secondary outcomes (including the individual elements of the composite outcome, birthweight, gestational length, large-for-gestational-age, extremely preterm, very low birthweight, overnight NICU admission, severe maternal morbidity, and cesarean delivery). These results are consistent with other recent evaluations that have suggested home visiting does not reduce adverse birth outcomes.
The study also did not find evidence of different effects for pre-specified subgroups of participants. Black individuals who received usual care experienced adverse birth events at a higher rate (31.6 percent) than the average for the usual care group overall (26.1 percent), but NFP services caused no statistically significant impacts on any adverse birth outcomes for Black individuals. There was also no difference between the intervention and usual care groups in any outcome for individuals identified as being particularly vulnerable to challenges during pregnancy and early childhood based on characteristics identified in prior home visiting trials (those who were younger than 19 years old, had not finished high school, or had challenges with mental health), who are prioritized by many current home visiting programs.
Intensive nurse home visiting programs are driven by patients’ needs, interests, and concerns and aim to change patients’ knowledge, behaviors, and access to other health resources via referral. Interventions aimed at affecting these elements during and soon after pregnancy may not be enough to address the complex factors that influence adverse birth events, including pre-pregnancy health and interrelated structural and environmental factors. Furthermore, interventions staffed by clinicians that require intensive visits to participants’ homes may struggle to engage those who are not already engaged with these services. More evidence is needed to understand which interventions are effective at reducing adverse birth outcomes and addressing racial inequities in these outcomes.
What was the impact of the expansion of the Nurse-Family Partnership in South Carolina on the primary outcome related to maternal and newborn health?
There was no statistically significant effect of receiving NFP services on the likelihood of experiencing an adverse birth outcome (perinatal death, preterm birth, low birth-weight birth or a birth that is small for gestational age).
Did the study find that participation in NFP impacted other maternal and newborn health outcomes?
We did not detect an effect on any secondary outcome related to maternal and newborn health including perinatal death, preterm birth, extremely preterm birth, birthweight, low birthweight, very low birthweight, a birth that is small for gestational age, a birth that is large for gestational age, gestational length, overnight NICU admission, severe maternal morbidity, and cesarean delivery.
Did the study find that participation in NFP impacted maternal and newborn health outcomes for specific populations?
We did not detect an effect on any outcome related to maternal and newborn health in two sub-groups of study participants defined in advance by the research team: non-Hispanic Black study participants and study participants identified as being particularly vulnerable to challenges during pregnancy and early childhood based on characteristics identified in prior home visiting trials (those who were younger than 19 years old, had not finished high school, or had challenges with mental health).
How did the Covid-19 pandemic impact the study and results?
Nearly all study participants enrolled in the study prior to the start of the Covid-19 pandemic. Study enrollment started April 1, 2016 and ended on March 17, 2020. For 87% of study participants, their due date preceded the start of the pandemic; their birth outcomes would not have been affected by the pandemic.
Does this mean that NFP did not have an impact on families in South Carolina during the study?
No. It means that NFP did not have an impact on maternal and newborn outcomes measured in this study. Our study used outcomes from administrative data sources and was not able to measure how study participants felt about participating in the program. Not enough time has elapsed to observe data and report on the program’s impact on other primary outcomes including the spacing of subsequent births and outcomes related to child-well being.
How do these results differ from the existing evidence on the impact of intensive home visiting on birth outcomes?
NFP has been evaluated in observational studies and modestly sized randomized trials in Elmira, New York in the 1970s; Memphis, Tennessee in the early 1990s; and Denver, Colorado in the mid-1990s. These early trials suggested some positive impacts on maternal and infant health: NFP participants in the Memphis trial had lower rates of pregnancy-induced hypertension and some subgroups within the Elmira trial had higher birthweights and fewer preterm deliveries. While follow-up observational studies have documented better birth outcomes for NFP participants, a recent randomized trial of the Family-Nurse Partnership in the United Kingdom saw no impact on birth outcomes. Furthermore, an evaluation of Maternal, Infant and Early Childhood Home Visiting programs commissioned by federal agencies found no impact of intensive home visiting on maternal and neonatal health outcomes.
Was the population served by NFP different during the study period?
Eligibility for the study mirrored eligibility for NFP’s programs, which target first-time low-income mothers enrolled no later than their 28th week of pregnancy. While NFP enrolls individuals of any age, the study limited enrollment to those who were at least 15 years old. Future analyses will compare characteristics of the study sample to the potential population of first-time, Medicaid paid births in counties served by NFP during the study.
Was the implementation of NFP different during the study?
The 9 agencies that implemented NFP during the study had all been working in the state of South Carolina prior to the study. New nurses were hired to scale-up the program to serve substantially more families during the study period. According to the NFP program model, visits should last 60-90 minutes and occur every week during the first four weeks after enrollment and then every other week until delivery. In the study, the median length of a home visit was 65 minutes. During the study, the median number of NFP nurse visits during pregnancy was 9, which mirrored the implementation of NFP in other recent studies.
What other services did moms in the study receive?
Less than 2% of individuals in the study participated in other federally funded nurse home visiting services during their pregnancy, with similar rates in the control group and those assigned to receive NFP services. Less than 10% of individuals in the study participated in Medicaid-funded group prenatal care (including Centering Pregnancy); this was not statistically different between the control group and those assigned to receive NFP services. Study participants in both groups may have been affected by efforts to improve clinical quality of care that were part of the South Carolina Birth Outcomes Initiative or by other local programs taking place during the years of the study.
What other outcomes will the evaluation consider?
Over the coming decades, the evaluation will continue to assess program impacts on a range of outcomes related to families’ health and well-being, such as other maternal and child health outcomes; child school-readiness and performance; maternal educational attainment; criminal justice involvement; and the use of government programs and social services such as Medicaid, WIC and SNAP.
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