Nurse home visitors follow detailed visit-by-visit program protocols that focus on five domains of functioning: personal health, maternal role development, environmental health, maternal life-course development, and family and friend support. The content of the protocols is organized developmentally to reflect those challenges that women are likely to confront at different stages of pregnancy and during the first 2 years of the child’s life. Within each of the five domains, specific assessments are made of maternal, child, and family functioning, and specific educational content and psychosocial interventions are implemented depending upon the nature and degree of vulnerability revealed in the assessment.

During home visits, nurses carry out three major activities: 1) promoting adaptive change in behavior that affects the outcomes of pregnancy, the health and development of the child, and maternal life course; 2) helping women build supportive relationships with family members and friends; and 3) linking family members with other health and human services. In carrying out these activities, emphasis is placed on the importance of building on parents’ strengths and promoting parental competence and control over life circumstances.

Memphis: (N=1135). Primarily (92%) African-American families. Participants had to have one of the following risk conditions: 1) unmarried, 2) less than 12 years of education, or 3) unemployed. Randomly assigned to Treatment groups 1, 2 ,3 or 4. Families in Treatment 1 (n=166) were provided transportation to prenatal care but no postnatal visits or screening. Families in Treatment 2 (n=515) were provided transportation to prenatal care, screening, and referral services until 24 months after birth. Families in Treatment 3 (n=230) were provided transportation, screening, and nurse home visits during pregnancy, once at the hospital, and once at home after birth. Families in Treatment 4 (n=228) were provided same services as Treatment 3 plus received home visits until child’s 2nd birthday. Program began June 1990 and ended August 1991.

Denver: (N=735). Including 331 (40%) Mexican-American families. Random assignment to Treatment groups 1, 2, or 3. Families in Treatment 1 (n=255) received screening for children at ages 1 and 2 years and referral to services if needed. Families in Treatment 2 (n=235) received developmental screening and referral plus nurse home visits through pregnancy through child’s 2nd year. Families in Treatment 3 (n=245) received screening and referral plus paraprofessional home visitation from pregnancy through child’s 2nd year.

Nurses’ infancy and early childhood behavioral objectives include: improving parents’ understanding of the infant’s temperament, promoting the physical care of the child, promoting the behavioral and emotional regulation of the child, improving the safety of the home environment, helping mothers adapt to changing roles, helping women search for a job, identifying safe and reliable child care, and employing a reliable method of contraception.

Nurses’ also enhance informal support by assessing the quality of the women’s relationships with their husbands, boyfriends, mothers, friends, and other family members by asking the mother about these individuals and by observing their interactions. The nurses determine the extent to which inadequate support is due to the mothers by simply having no one to turn to versus her inability to use the support available to her.

Finally, nurses assess the mother’s linkage with formal services. Beginning with the first visit, the nurses systematically assess the extent to which the family’s basic survival needs are being met. Areas considered are income and basic shelter; food and medical care; reliable and adequate housing; and physical, mental, or substance abuse problems that are unattended.

At child’s 15th birthday, child also given short IQ tests in the study offices.

Elmira Trial:

“We found that during pregnancy, nurse-visited women improved the quality of their diets to a greater extent, and those identified as smokers smoked 25% fewer cigarettes by the end of the pregnancy, than did their counterparts in the comparison group. By the end of pregnancy, nurse-visited women had fewer kidney infections, experienced greater informal social support, and made better use of formal community services. Among women who smoked, those who were nurse-visited had 75% fewer pre-term deliveries, and among very young adolescents (aged 14-16), those who were nurse-visited had babies who were nearly 400 grams heavier, than their counterparts assigned to the comparison group.”

“After delivery, 19% of the poor, unmarried teens in the comparison group abused or neglected their children during the first 2 years after delivery as opposed to 4% of the poor, unmarried teens visited by a nurse.”

“Overall, the children of nurse-visited women were less likely to receive emergency room treatment and to visit either a physician or emergency room for injuries and ingestions from their 12th to 48th month of life than were their comparison group counterparts.”

“Children born to women who smoked a moderate to heavy amount when they registered in the program during pregnancy and who received prenatal home visitation had significantly higher IQ scores at 3 and 4 years of age than their counterparts in the comparison group.”

“During the 4 year period after delivery of the first child, among low income, unmarried women, the rate of subsequent pregnancy was reduced by 42%, and the number of months that nurse-visited women participated in the work force was increased by 83%. By the first-born’s 2nd year of life, the rate of subsequent pregnancy was reduced by 33%. Much of the impact of the program on work force participation among the adolescent portion of the sample did not occur until the 2-year period after the program ended, when the teens were old enough to obtain jobs.”

“The 15-year follow-up study provides even more compelling results. During the 15-year period after delivery of their first child, unmarried women from low socioeconomic (SES) households at enrollment who were visited by nurses during pregnancy and infancy, in contrast to those in the comparison group, had 1.1 versus 1.6 subsequent births (p=.02), 65 versus 37 months between the birth of their first and 2nd children (p=.001), 60 versus 90 months on welfare (p=.005), 0.41 versus 0.73 behavioral impairments due to substance abuse (p=.03), and 0.18 versus 0.58 arrests by self-report (p=.0009). New York State records revealed that they had 0.16 versus 0.90 arrests (p=.00002).”

Memphis Trial:

“There were no treatment main effects on birthweight, low birthweight, length of gestation, spontaneous pre-term delivery, indicated pre-term delivery, or Apgar scores. Nevertheless, by the 36th week of pregnancy, nurse-visited women were more likely to use other community services than women in the control group (p= .01). They also were more likely to be working (p=.06), an effect that was particularly strong among women who were not in school when they were randomized (14% vs. 8%, p=.045, and 8% vs. 2% (p=.01), at the 28th and 36th weeks, respectively).”

“In contrast to women in the comparison group, nurse-visited women had fewer yeast infections after randomization and fewer instances of Pregnancy-Induced Hypertension (PIH) (p = .05 and p= .02, respectively). In contrast to those in the comparison group, women with PIH who received a nurse home visitor had mean arterial blood pressures during labor that were 3.5 points lower (p = .05), although there were no treatment differences in birthweight, length of gestation, or Apgar scores for women with PIH.”

“During their first 2 years, nurse-visited children had fewer health-care encounters in which injuries and ingestions were detected than children in the comparison condition (p=.05), an effect that was accounted for primarily by a reduction in outpatient encounters (p=.02). Nurse-visited children also were hospitalized for fewer days with injuries and/or ingestions than children in the comparison condition (p=.0002).”

“By the 24th month of the child’s life, in contrast to their comparison-group counterparts, nurse-visited women held fewer beliefs about child-rearing associated with child abuse and neglect—lack of empathy, belief in physical punishment, unrealistic expectations for infants (p=.003). Moreover, the homes of nurse-visited women were rated on the HOME scale as more conducive to children's development (p=.003).”

“There were no program effects on the children’s rates of immunization, mental development, or reported behavioral problems. The failure to affect immunization rates calls for a closer examination of the clinical protocols employed in promoting well-child care as the program is tested in new settings. Immunization rates approaching 100% could easily be realized simply by including immunization among the nurses’ responsibilities.”

“At the 24th month of the first child’s life, nurse-visited women reported 23% fewer second pregnancies and 32% fewer subsequent live births than women in the comparison group. The program-control difference in subsequent live births was limited to women with high levels of psychological resources, for whom the rates were 14% versus 31%, respectively. Nurse-visited women and their first-born children relied upon AFDC for fewer months during the 2nd year of the child’s life than comparison-group women and their children. There were no program effects on reported educational achievement or length of employment. The program was able to help those women with fewer mental health symptoms, higher IQs, and more active coping styles become less dependent upon welfare, but it was unable to help women with fewer psychological resources.”

Interim Cost-Benefit Findings:

Elmira Trial:

In 1980 dollars, the program cost $3,173 for 2½ years of intervention. We conceived of government savings as the difference in government spending for these other services between the group that received postnatal home visitation and the comparison group. Savings also were expressed in 1980 dollars and were adjusted using a 3% discount rate. By the time the children were 4 years of age, low-income families who were visited by a nurse during pregnancy and through the 2nd year of life cost the government $3,313 less than their counterparts in the comparison group. Thus, when focused on low-income families, the investment in the service was recovered with a dividend of about $180 within 2 years after the program ended. This $3,300 cost savings to government for low-income families was largely due to reductions in expenditure for AFDC and for food stamps.

Memphis Trial:

In contrast to counterparts assigned to the comparison condition, fewer women visited by nurses during pregnancy had pregnancy-induced hypertension (13% VS 20%; p=.009). during the first 2 years after delivery, women visited by nurses during pregnancy and during the first 2 years of the child’s life had fewer health care encounters for children in which injuries or ingestions were detected (0.43 vs. 0.55; P=.05); days that children were hospitalized with injuries or ingestions (0.03 vs. 0.16; P<.001); and second pregnancies (36% vs. 47%; P=.006). There were no program effects on pre-term delivery or low birth weight; children’s immunization rates, mental development, or behavioral problems; or mothers’ education and employment.

Elmira Trial:

Adolescents born to women who received nurse visits during pregnancy and postnatally and who were unmarried and from households of low socioeconomic status (risk factors for antisocial behavior), in contrast with those in the comparison groups, reported fewer instances of running away (0.24 vs. 0.60; P=.003), fewer arrests (0.20 vs. 0.45; P=.03), fewer convictions and violations of probation (0.09 vs. 0.47; P<.001), fewer lifetime sex partners (0.92 vs. 2.48; P=.003), fewer cigarettes smoked per day (1.50 vs. 2.50; P=.10), and fewer days having consumed alcohol in the last 6 months (1.09 vs. 2.49; P=.03). Parents of nurse-visited children reported that their children had fewer behavioral problems related to the use of alcohol and other drugs (0.15 vs. 0.34; P=.08). There were no program effects on other behavioral problems.

Compared with the control group, women who received home visits by nurses had fewer subsequent pregnancies (1.15 vs. 1.34; P=.03), fewer closely spaced subsequent pregnancies (0.22 vs. 0.32; P=.03), longer intervals between the birth of the first and second child (30.25 vs. 26.60 months; P=.004), and fewer months of using Aid to Families with Dependent Children (32.55 vs. 36.19; P=.01) and food stamps (41.57 vs. 45.04; P=.005). Compared with the effect of the program while the program was in operation, the effect after it ended was essentially equal for Aid to Families with Dependent Children, greater for food stamps, greater for rates of closely spaced subsequent pregnancies, and smaller for rates of subsequent pregnancy overall.

Enduring effects of a home visitation program were found on the lives of black women living in an urban setting. While these results were smaller in magnitude than those achieved in a previous trial with white women living in a semi-rural setting, the direction of the effects was consistent across the 2 studies.

“Moreover, we know little about how differences in the levels of community services affect program process and outcome. To what extent are the effects of the program dependent upon the existing system of health and human services? To what extent might the program effects be enhanced in locales where a greater portion of the families' basic needs are assured? And to what extent would the effects of the program be diminished if the existing system were depleted further? Visitors depend upon linking families with other needed services but often find that those services are in scant supply, leading some experts to take the position that home visits are necessary but not sufficient for child health and development (Chamberlin, 1980; Weiss, 1993).”

“Finally, we acknowledge that the current model of preventive intervention is limited with respect to addressing certain individual characteristics of parents as well. The visitors in each of the programs have encountered parents with major mental illness, such as depression and schizophrenia. The problems posed with this population can be considerable. The model calls for linking mentally ill parents with treatment services in the community, of course, but such services often not readily available. Moreover, barriers frequently exist to individuals' use of those services that are available. Administrators of home visitation programs may choose to hire their own mental health professionals to ensure treatment of these parents, may intensify the search for effective mental-health services through better linkages with primary care providers, or may try to directly improve the availability of mental health services in their community.”