Reducing low birth weight through home visitation: a randomized controlled trial

Geographical variation, socioeconomic inequalities of low birth weight, and its relationship with maternal dietary diversity: Insights from the maternal infant and young child nutrition programme in Bangladesh

Background

Globally, every year, 20 million neonates are born with weights below 2500 g and are considered low birth weight (LBW). About 90% of these births occur in low- and middle-income countries. Information regarding the geographical variation, socioeconomic inequalities of LBW neonates, and the relationship between maternal inadequate dietary diversity and LBW is limited in rural areas of Bangladesh. We aimed to explore the geographical disparities and socioeconomic inequalities in the prevalence of LBW and its association with inadequate maternal dietary diversity.

Methods

We extracted data from a large-scale evaluation programme conducted as a part of the maternal infant and young child nutrition phase two in Bangladesh, implemented by BRAC. We used the concentration index (CIX) to measure the socioeconomic inequalities of LBW. We performed a cluster-adjusted multiple logistic regression analysis to determine the association between LBW and maternal dietary diversity.

Results

A total of 4651 children aged <5 years with their mother's information were included. The overall prevalence of LBW was 13.5%. About 16% of mothers living in the poorest wealth quintile gave birth to LBW babies, whereas 10% of mothers living in the richest households gave birth to LBW babies. The CIX exhibited LBW babies were more prevalent among the socioeconomically worst-off (poorest) group (CIX = -0.08), indicating mothers of the poorest households are vulnerable to giving birth to normal-weight babies. An adjusted multiple logistic regression model indicated that mothers with inadequate dietary diversity had higher odds (adjusted odds ratio (AOR) = 1.27; 95% confidence interval (CI) = 1.04, 1.54) of giving birth to LBW babies. Notably, in the interaction of mothers' age and dietary diversity, we found that adolescent mothers (aged ≤ 19 years) with inadequate dietary diversity had 2.56 times (AOR = 2.56; 95% CI = 1.14, 5.76) higher odds of giving birth to LBW babies compared to adult mothers (aged >19 years) who consumed diversified foods.

Conclusions

Intervention strategies for reducing LBW prevalence should target the poorest households. Also, interventions for improving the dietary diversity of adolescent pregnant mothers are expected to reduce the number of LBW babies from the rural areas of Bangladesh.

Exploring the Links Between Immigration and Birth Outcomes Among Latine Birthing Persons in the USA

BACKGROUND

Birth outcomes are worse for birthing people and infants in the USA than other high-income economies and worse still for underprivileged communities. Historically, the Latine community has experienced positive birth outcomes, despite low socioeconomic status and other socio-political disadvantages, leading to what has been termed as the Hispanic birth paradox. However, this perinatal advantage and protective effect appears to have been shattered by unfavorable policies, structural conditions, societal attitudes, and traumatic events impacting Latine immigrants, leading to negative effects on the health and well-being of birthing Latines-regardless of citizenship status and increasing rates of preterm birth and low birth weight infants.

METHODS AND RESULTS

We conducted a comprehensive literature review and identified two pathways through which birth outcomes among Latine birthing persons may be compromised regardless of citizenship status: (1) a biological pathway as toxic levels of fear and anxiety created by racialized stressors accumulate in the bodies of Latines and (2) a social pathway as Latines disconnect from formal and informal sources of support including family, friends, health care, public health programs, and social services during the course of the pregnancy.

CONCLUSION

Future research needs to examine the impact of immigration climate and policies on health and racial equity in birth outcomes among Latines regardless of citizenship status. Attaining health and racial equity necessitates increased awareness among health providers, public health practitioners, and policy makers of the impact of larger socio-political pressures on the health of Latine birthing persons.

Examining Impacts of Healthy Families America on Infant Health Care

OBJECTIVE

Healthy Families America (HFA) is an evidence-based home visiting program that provides parenting education with the overall goal of preventing child maltreatment and optimizing child development. This study compares the health care utilization and vaccination of infants enrolled in HFA with similar infants not in the program.

METHODS

From January 2014 to December 2020, 604 children served statewide by HFA in Arkansas were identified in vital statistics and administrative medical claims records. Using propensity score matching, infants in HFA were matched with nonprogram control infants based on family demographics and birth characteristics. Double propensity-score adjustment method and generalized linear models were used to estimate program effects.

RESULTS

In the first year after birth hospital discharge and compared to a propensity score matched cohort of infants not enrolled, those enrolled in HFA had significantly greater use of the emergency department overall (incidence rate ratios (IRR) = 1.24 [95% confidence interval (CI) = 1.07-1.43], P = .004) and for less complex conditions (IRR = 1.22 [95% CI = 1.04-1.44], P = .01), more outpatient medical appointments for child wellness (IRR = 1.09 [95% CI = 1.03-1.15], P = .003), illness (IRR = 1.17 [95% CI = 1.07-1.29], P = .001), and speech and language therapies (IRR = 2.86 [95% CI = 1.18-6.93], P = .02), and more medical visits during which vaccinations were provided (IRR = 1.09 [95% CI = 1.04-1.15], P = .002).

CONCLUSIONS

Findings from the current study suggest that HFA supports increased health care utilization and visits in which vaccinations occurred during the first year of life.

Maternal Mental Health and Offspring Brain Development: An Umbrella Review of Prenatal Interventions

The idea that risk for psychiatric disorders may be transmitted intergenerationally via prenatal programming places interest in the prenatal period as a critical moment during which intervention efforts may have a strong impact, yet studies testing whether prenatal interventions also protect offspring are limited. The present umbrella review of systematic reviews and meta-analyses (SRMAs) of randomized controlled trials aimed to synthesize the available evidence and highlight promising avenues for intervention. Overall, the literature provides mixed and limited evidence in support of prenatal interventions. Thirty SRMAs were included. Of the 23 SRMAs that reported on prenatal depression interventions, 16 found a significant effect (average standard mean difference = -0.45, SD = 0.25). Similarly, 13 of the 20 SRMAs that reported on anxiety outcomes documented significant reductions (average standard mean difference = -0.76, SD = 0.95 or -0.53/0.53 excluding one outlier). Only 4 SRMAs reported child outcomes, and only 2 (of 10) analyses showed significant effects of prenatal interventions (massage and telephone support on neonatal resuscitation [relative risk = 0.43] and neonatal intensive care unit admissions [relative risk = 0.91]). Notably missing, perhaps due to our strict inclusion criteria (inclusion of randomized controlled trials only), were interventions focusing on key facets of prenatal health (e.g., whole diet, sleep). Structural interventions (housing, access to health care, economic security) were not included, although initial success has been documented in non-SRMAs. Most notably, none of the SRMAs focused on offspring mental health or neurodevelopmental outcomes. Given the possibility that interventions deployed in this period will positively impact the next generation, randomized trials that focus on offspring outcomes are urgently needed.

Cost-benefit analysis of home visiting to reduce infant mortality among preterm infants

PURPOSE

The Following Baby Back Home (FBBH) visiting program, which is provided by nurse and social worker teams, supports families of low-birthweight preterm infants after discharge from a neonatal intensive care unit. Enrollment in the FBBH program has been documented to reduce the likelihood of infant death. In this study, we conducted a cost-benefit analysis of the FBBH program.

DESIGN AND METHODS

Infants enrolled in the FBBH program (N = 416) were identified through administrative records. Infants in the FBBH program were propensity score matched with comparison infants to estimate the difference in healthcare costs in the first year of life.

RESULTS

Infants enrolled in the FBBH program incurred similar medical care costs compared to a comparison group. Avoided deaths, program costs, healthcare costs resulted in net economic benefits of the FBBH program to avoid infant death estimate at $83,020, cost per life saved at $3080, and benefit-to-cost ratio at 27.95.

CONCLUSIONS

The FBBH program's net economic benefits from avoided deaths suggest a substantial return on investment of resources, yielding benefits in excess of program and healthcare costs.

PRACTICE IMPLICATIONS

It is economically beneficial to provide home visiting services to families of low-birthweight babies by a team comprised of a registered nurse and social worker.

Using probabilistic record linkage and propensity-score matching to identify a community-based comparison population

In retrospective cohort studies of interventions disseminated to communities, it is challenging to find comparison groups with high-quality data for evaluation. We present one methodological approach as part of our study of birth outcomes of second-born children in a home visiting (HV) program targeting first-time mothers. We used probabilistic record linkage to link Connecticut's Nurturing Families Network (NFN) HV program and birth-certificate data for children born from 2005 to 2015. We identified two potential comparison groups: a propensity-score-matched group from the remaining birth certificate sample and eligible-but-unenrolled families. An analysis of interpregnancy interval (IPI) is presented to exemplify the approach. We identified the birth certificates of 4822 NFN families. The propensity-score-matched group had 14,219 families (3-to-1 matching) and we identified 1101 eligible-but-unenrolled families. Covariates were well balanced for the propensity-score-matched group, but poorly balanced for the eligible-but-unenrolled group. No program effect on IPI was found. By combining propensity-score matching and probabilistic record linkage, we were able to retrospectively identify relatively large comparison groups for quasi-experimental research. Using birth certificate data, we accessed outcomes for all of these individuals from a single data source. Multiple comparison groups allow us to confirm findings when each method has some limitations. Other researchers seeking community-based comparison groups could consider a similar approach.

Birth-Related Outcomes for Second Children Following Home Visiting Program Enrollment for New Parents of First Children

INTRODUCTION

Home visiting (HV) programs aim to promote child and family health through perinatal intervention. HV may benefit second children through improving subsequent pregnancy and birth outcomes. However, HV impacts on birth outcomes of second children have not been examined in a naturalistic setting.

METHODS

Using data from Connecticut Nurturing Families Network (NFN) home visiting program of families enrolled from 2005 to 2015, we compared birth-related outcomes (birthweight, preterm birth, Cesarean section delivery, prenatal care utilization) of second children (n = 1758) to demographically similar propensity-score-matched families that were not enrolled in NFN (n = 5200). We examined whether the effects of NFN differed by maternal age, race and ethnicity, or visit attendance pattern.

RESULTS

There was no program effect for the full sample. The effect of NFN did not differ by maternal age or visit attendance pattern but did differ by maternal race and ethnicity. Black women in NFN were more likely to receive adequate prenatal care during their second pregnancy (OR 1.05; 95% CI 1.01, 1.09) and Hispanic women in NFN were less likely to deliver by Cesarean section for their second birth (OR 0.97; 95% CI 0.94, 0.99), compared to Black and Hispanic women in the comparison group respectively. There was a protective program effect on prematurity of the second child (OR 0.92; 95% CI 0.85, 0.996) for women with a preterm first birth.

DISCUSSION

These findings suggest that benefits of HV extend to subsequent birth-related outcomes for women from marginalized racial/ethnic groups. HV may help buffer some harmful social determinants of health.

Economic evaluation methods used in home-visiting interventions: A systematic search and review

Home-visiting interventions are used to improve outcomes for families experiencing disadvantage. As scarce resources must be allocated carefully, appropriate methods are required to provide accurate information on the effect of these programmes. We aimed to investigate: economic evaluation/analysis methods used in home-visiting programmes for children, young people and families, study designs and methods suitable in situations where randomised-controlled-trials are not feasible, and type of costs included in analyses, including any implementation costs stated. A systematic search and review was conducted of existing full economic evaluation/analysis methods in home-visiting programmes for children, young people and/or families. We included studies published in English between January 2000 and mid-November 2020. Of the 4,742 papers sourced, 60 were retained for full-text review, and 21 included. Economic-analysis methods found in the included studies were: within trial economic evaluation, economic evaluation using decision analytic modelling (i.e. cost-utility, cost-benefit analysis), cost comparison and cost-consequence. Studies incorporating return on investment and budget impact analysis were also found. Study designs suitable when randomisation was not feasible included parallel cluster randomised trials and using pre-post intervention data. Costs depended mainly on study context and only one study reported implementation costs. We hope this information will help guide future economic evaluations of home-visiting interventions.

Prevalence of Common Mental Disorders among pregnant women-Evidence from population-based study in rural Haryana, India

Background:

Mental disorders during pregnancy is one of the major public health problem because of its effect on both mother and child.

Objectives:

The objective of the study was to assess the burden of common mental disorders (CMDs) among pregnant women in rural Haryana, North India.

Methods:

A community-based cross-sectional study was conducted in 28 villages of rural Haryana in 2016. Pregnant women in the study area with period of gestation 25–34 weeks were enrolled and assessed for presence of CMDs in two phases. Primary Care Evaluation of Mental Disorders—Patient Health Questionnaire was used for screening and Mini International Neuropsychiatric Interview (MINI) for diagnosis of CMDs.

Results:

A total of 457 pregnant women were included in the study. Mean age of pregnant women was 23.9 years (SD- 3.9). Prevalence of CMDs was 15.3% (95% CI, 12.0–18.6). Of these, major depression was 2.8% (95% CI, 1.4– 4.4), and Generalized Anxiety Disorder was 15.1% (95% CI, 11.8–18.4) as per MINI. On multivariate analysis, no statistically significant association was found between CMDs during pregnancy with any obstetric, sociodemographic determinants, and child health outcomes.

Conclusion:

High prevalence of CMDs, especially anxiety, observed among pregnant women in rural area necessitates the need for integration of screening of CMDs during routine antenatal care in India.

Addressing maternal and child health equity through a community health worker home visiting intervention to reduce low birth weight: retrospective quasi-experimental study of the Arizona Health Start Programme

OBJECTIVE

To test if participation in the Health Start Programme, an Arizona statewide Community Health Worker (CHW) maternal and child health (MCH) home visiting programme, reduced rates of low birth weight (LBW), very LBW (VLBW), extremely LBW (ELBW) and preterm birth (PTB).

DESIGN

Quasi-experimental retrospective study using propensity score matching of Health Start Programme enrolment data to state birth certificate records for years 2006-2016.

SETTING

Arizona is uniquely racially and ethnically diverse with comparatively higher proportions of Latino and American Indian residents and a smaller proportion of African Americans.

PARTICIPANTS

7212 Health Start Programme mothers matched to non-participants based on demographic, socioeconomic and geographic characteristics, health conditions and previous birth experiences.

INTERVENTION

A statewide CHW MCH home visiting programme.

PRIMARY AND SECONDARY OUTCOME MEASURES

LBW, VLBW, ELBW and PTB.

RESULTS

Using Health Start Programme's administrative data and birth certificate data from 2006 to 2016, we identified 7212 Health Start Programme participants and 53 948 matches. Programme participation is associated with decreases in adverse birth outcomes for most subgroups. Health Start participation is associated with statistically significant lower rates of LBW among American Indian women (38%; average treatment-on-the-treated effect (ATT): 2.30; 95% CI -4.07 to -0.53) and mothers with a pre-existing health risk (25%; ATT: -3.06; 95% CI -5.82 to -0.30). Among Latina mothers, Health Start Programme participation is associated with statistically significant lower rates of VLBW (36%; ATT: 0.35; 95% CI -0.69 to -0.01) and ELBW (62%; ATT: 0.31; 95% CI (-0.52 to -0.10)). Finally, Health Start Programme participation is associated with a statistically significant lower rate of PTB for teen mothers (30%; ATT: 2.81; 95% CI -4.71 to -0.91). Other results were not statistically significant.

CONCLUSION

A state health department-operated MCH home visiting intervention that employs CHWs as the primary interventionist may contribute to the reduction of LBW, VLBW, ELBW and PTB and could improve birth outcomes statewide, especially among women and children at increased risk for MCH inequity.

Interventions to reduce preterm birth in pregnant women with psychosocial vulnerability factors-A systematic review

OBJECTIVE

Pregnant women with psychosocial vulnerability factors face a higher risk of preterm birth, a heavier burden of perinatal morbidity and mortality and less social health equity. Prevention of preterm birth in this group has proved difficult, and more knowledge is needed to ensure evidence-based care and improve prevention. This study aimed to determine the effectiveness of preventive interventions to reduce preterm birth among pregnant women with psychosocial vulnerability factors.

DESIGN

A systematic review of preventive interventions was conducted, searching the databases Cinahl, Cochrane Library, Embase, ProQuest, PsycInfo, PubMed and Scopus to identify RCT's. The search was completed on October 14, 2019. Using the Cochrane Collaboration tools, quality assessments were made, and independent single-data extraction was conducted. Due to heterogeneity in, e.g., participant characteristics, intervention content and duration, the data were synthesised qualitatively. Included studies were ranked in evidence-based hierarchical order, elucidating the risk of bias of each individual study, all of which were ranked as having a medium or low level of evidence.

FINDINGS

We identified 1,562 articles, of which five focused on prevention of preterm birth, met our predefined criteria for inclusion and quality assessment, and were therefore included. Interventions consisted of home visits in two studies, group meetings in one study, phone calls in one study, and physical massage in the last study. Four transverse themes arose: intervention intensity, initiation, continuity of care, and the healthcare professionals' educational background.

KEY CONCLUSIONS

The evidence base for interventions aiming to prevent preterm birth among pregnant women with psychosocial vulnerabilities is limited. Interventions based on ten antenatal group meetings initiated during the second trimester and facilitated by the same midwife have the greatest likelihood of being effective. Continuity in intervention delivery and healthcare professional's educational background may positively impact the efficiency of the intervention. Further research is needed to address questions about the impact of intervention initiation and intensity and its degree of continuity and mode of delivery.

Examining the Causal Impact of Prenatal Home Visiting on Birth Outcomes: A Propensity Score Analysis

OBJECTIVES

In Ohio, African American babies die at 2.5-3 times the rate of White babies. Preterm birth and low birth weight are the leading causes of infant mortality. Home visiting is an evidence-based strategy for serving low-income pregnant women; however, there are relatively few rigorous studies examining its effect on birth outcomes.

METHODS

This study uses a propensity score technique to estimate the causal effect of participation in home visiting on prematurity and low birth weight among a low-income, predominantly African American sample (N = 26,814).

RESULTS

We found that participation in home visiting significantly reduced the odds of experiencing both adverse birth events, with a larger program effect for the low birth weight outcome.

CONCLUSIONS FOR PRACTICE

Results suggest that selective prevention strategies must be accompanied by universal attempts to improve the health and life circumstances of low income and minority women.

Implementation of a telehealth-enhanced home visiting programme for families of young children

INTRODUCTION

Health systems are applying innovative solutions, such as telehealth and home visiting, to reduce unnecessary healthcare utilization, including emergency department (ED) visits. A large paediatric healthcare system implemented a telehealth-enhanced home visiting programme as an extension of primary care services. The purpose of this paper is three-fold: (1) Examine the process of implementation and the intermediate clinical outcomes; (2) Evaluate patient experiences and acceptability of the programme post-implementation; (3) Identify system, clinic and patient factors influencing implementation of the home visiting programme.

METHODS

Implementation of the telehealth-enhanced home visiting programme occurred from July 2018 to March 2019. Longitudinal electronic health records (EHR) and surveys were triangulated with qualitative data to evaluate the preliminary effectiveness, feasibility, and acceptability of the programme.

RESULTS

Of the 948 eligible families, clinical care staff referred 38% of families to the home visiting programme and 49 families (5%) completed the 12-week home visiting programme. Necessary ED utilization significantly increased post-implementation compared with pre-implementation. Families were overall highly satisfied with the programme and its content. Several factors influenced implementation including outer setting (i.e. patient needs and external policy), inner setting (e.g. poor leadership engagement, fully integrated network, and high tension for change), and individual characteristics (e.g. high self-efficacy).

CONCLUSIONS

Once families were enrolled, the programme was fairly successful in addressing patient outcomes. The programme and visit process was highly regarded by families and the unlicensed healthcare professionals. Future programme recommendations, such as small programmatic changes and major improvements in the clinic, should be implemented before widespread dissemination.

Peer support for disadvantaged parents: a narrative review of strategies used in home visiting health interventions in high-income countries

BACKGROUND

Disparities in health persist even in high-income countries, and healthcare systems do not reach disadvantaged families as needed. A number of home-visiting interventions in high-income countries offering peer support for parents have been implemented to bridge the gaps in health in a cost-effective way. The lack of standard for intervention design has however resulted in a large variety of the strategies used. The objective for this article is to conduct a review of peer support home visiting interventions for parents and children in high-income countries, aiming to assess the strategies used, their outcomes and the challenges faced by peer supporters.

METHODS

Relevant articles published in English between January 2004 and August 2019 were identified using PubMed, and reference lists were reviewed to identify additional articles. Studies were included if they reported on individual peer support health interventions, delivered at home to socioeconomically disadvantaged parents in high-income countries. Nineteen studies were found that met the inclusion criteria, and data were extracted on study characteristics, intervention design and outcomes. Data on intervention design was characterized iteratively to generate overarching categories of strategies used in the programs.

RESULTS

Most studies used healthcare facilities for recruitment, even when the interventions were not delivered by the formal healthcare system. The strategies used to engage supported parents included (1) connection in the form of emotional support, relationship building and matching for background, (2) flexibility in regards to content, intensity, location and mode of contact, and (3) linking through referrals and facilitation of other contacts. A number of significant quantifiable improvements could be demonstrated. Due to large heterogeneity of outcomes, meta-analyses were not viable. Peer supporters experienced challenges with involving other family members than the supported parent as well as with finding their role in relation to other support structures.

CONCLUSIONS

Peer support delivered as home visiting interventions have been used for hard-to-reach parents in a variety of high-income contexts and for a multitude of health concerns. Overall, despite variation in intervention design, the strategies employed followed common themes and were generally well received.

Do home visiting programmes improve children's language development? A systematic review

OBJECTIVES

This review examines home visiting programmes that specifically provide home based support to vulnerable, socially disadvantaged women who are either pregnant or have recently become a new parent. Home visiting programmes often report multiple outcomes. The purpose of this review is to systematically summarise how effective home visiting programmes are at improving young children's language development.

DATA SOURCES

A comprehensive search of four online databases (Embase, Emcare, Psycinfo and Medline) between 1990 and 2020 was conducted, as well as a hand search of the references of relevant studies.

REVIEW METHOD

Studies were screened with N = 11 meeting the inclusion/exclusion criteria. The risk of bias of each study was assessed. To enable comparisons between home visiting programmes, relevant data was extracted using an adapted version of the Cochrane Public Health Group Data Extraction and Assessment Template.

RESULTS

Most of the home visiting programmes had been established in America. Six of the eleven studies reported positive language outcomes for children. Where statistical data was reported, the magnitude of the difference between the intervention and control groups represented small effect sizes. Nine different language measures were used, reporting on varying domains of language development rendering comparisons across programmes difficult. Most studies failed to report the duration of home visits, though studies which started prenatally showed the most promise in improving children's language development.

CONCLUSION

Home visiting programmes targeted at socially disadvantaged women and their children have the potential to positively influence the language development of the child. This review highlights that not all home visiting programmes measure the impact that the programme has on children's language development, and not all home visiting programmes achieve positive language outcomes. Initiating visits prenatally may help towards the improvement of children's language development. Future evaluations of home visiting programmes should explore this finding further, consider the language assessment tools selected, and improve on the reporting of their language results.

Evaluation protocol to assess maternal and child health outcomes using administrative data: a community health worker home visiting programme

INTRODUCTION

Emerging evidence suggests community health workers (CHWs) delivering preventive maternal and child health (MCH) interventions through home visiting improve several important health outcomes, including initiation of prenatal care, healthy birth weight and uptake of childhood immunisations.

METHODS AND ANALYSIS

The Arizona Health Start Program is a behavioral-based home visiting intervention, which uses CHWs to improve MCH outcomes through health education, referral support, and advocacy services for at-risk pregnant and postpartum women with children up to 2 years of age. We aim to test our central hypothesis that mothers and children exposed to this intervention will experience positive health outcomes in the areas of (1) newborn health; (2) maternal health and healthcare utilisation; and (3) child health and development. This paper outlines our protocol to retrospectively evaluate Health Start Program administrative data from 2006 to 2015, equaling 15 576 enrollees. We will use propensity score matching to generate a statistically similar control group. Our analytic sample size is sufficient to detect meaningful programme effects from low-frequency events, including preterm births, low and very low birth weights, maternal morbidity, and differences in immunisation and hospitalisation rates.

ETHICS AND DISSEMINATION

This work is supported through an inter-agency contract from the Arizona Department of Health Services and is approved by the University of Arizona Research Institutional Review Board (Protocol 1701128802, approved 25 January 2017). Evaluation of the three proposed outcome areas will be completed by June 2020.

Effects of home visits for pregnant and postpartum women on premature birth, low birth weight and rapid repeat birth: a meta-analysis and systematic review of randomized controlled trials

BACKGROUND

Home visits seem promising for improving the health of women and infants during pregnancy and postpartum. This review aimed to quantitatively analyse the effects of home visits delivered during pregnancy and postpartum on premature birth (PTB), low birth weight (LBW) and rapid repeat birth (RRB).

METHODS

Literature was retrieved from PubMed, EMBASE, Web of Science and the Cochrane Library from January 1960 to October 2018 and the references lists of related studies and reviews were also screened. Eligible papers were randomized controlled trials (RCTs) that focussed on home visits conducted with women during pregnancy or postpartum and reported at least one of the following results: PTB, LBW and RRB. Fixed- or random-effects models were used to analyse the pooled results.

RESULTS

Fourteen RCTs were included. Pooled estimates showed a beneficial effect on LBW (odds ratio (OR) = 0.83; P = 0.03; low-quality evidence) and RRB in the professional-visit subgroup (OR = 0.62; P = 0.003; moderate-quality evidence). However, there was insufficient evidence to support the favourable effects of home visits on PTB (OR = 0.96; P = 0.59, moderate-quality evidence) and RRB in the non-professional-visit subgroup (OR = 0.86; P = 0.53, moderate-quality evidence). The overall methodological quality was moderate. Egger's test suggested no publication bias for PTB and LBW.

CONCLUSION

This meta-analysis is the first to suggest that home visits can prevent and decrease LBW and RRB; however, it remains unclear whether home visits benefit PTB. Therefore, home visits can be an alternative and complementary part of primary health care for women, especially those with risk factors.

Support during pregnancy for women at increased risk of low birthweight babies

BACKGROUND

Studies consistently show a relationship between social disadvantage and low birthweight. Many countries have programmes offering special assistance to women thought to be at risk for giving birth to a low birthweight infant. These programmes, collectively referred to in this review as additional social support, may include emotional support, which gives a person a feeling of being loved and cared for, tangible/instrumental support, in the form of direct assistance/home visits, and informational support, through the provision of advice, guidance and counselling. The programmes may be delivered by multidisciplinary teams of health professionals, specially trained lay workers, or a combination of lay and professional workers. This is an update of a review first published in 2003 and updated in 2010.

OBJECTIVES

The primary objective was to assess the effects of programmes offering additional social support (emotional, instrumental/tangible and informational) compared with routine care, for pregnant women believed to be at high risk for giving birth to babies that are either preterm (less than 37 weeks' gestation) or weigh less than 2500 g, or both, at birth. Secondary objectives were to determine whether the effectiveness of support was mediated by timing of onset (early versus later in pregnancy) or type of provider (healthcare professional or lay person).

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) on 5 February 2018, and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised trials of additional social support during at-risk pregnancy by either a professional (social worker, midwife, or nurse) or specially trained lay person, compared to routine care. We defined additional social support as some form of emotional support (e.g. caring, empathy, trust), tangible/instrumental support (e.g. transportation to clinic appointments, home visits complemented with phone calls, help with household responsibilities) or informational support (advice and counselling about nutrition, rest, stress management, use of alcohol/recreational drugs).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

This updated review includes a total of 25 studies, with outcome data for 11,246 mothers and babies enrolled in 21 studies. We assessed the overall risk of bias of included studies to be low or unclear, mainly because of limited reporting or uncertainty in how randomisation was generated or concealed (which led us to downgrade the quality of most outcomes to moderate), and the impracticability of blinding participants.When compared with routine care, programmes offering additional social support for at-risk pregnant women may slightly reduce the number of babies born with a birthweight less than 2500 g from 127 per 1000 to 120 per 1000 (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.86 to 1.04; 16 studies, n = 11,770; moderate-quality evidence), and the number of babies born with a gestational age less than 37 weeks at birth from 128 per 1000 to 117 per 1000 (RR 0.92, 95% CI 0.84 to 1.01, 14 studies, n = 12,282; moderate-quality evidence), though the confidence intervals for the pooled effect for both of these outcomes just crossed the line of no effect, suggesting any effect is not large. There may be little or no difference between interventions for stillbirth/neonatal death (RR 1.11, 95% CI 0.88 to 1.41; 15 studies, n = 12,091; low-quality evidence). Secondary outcomes of moderate quality suggested that there is probably a reduction in caesarean section (from 215 per 1000 to 194 per 1000; RR 0.90, 95% CI 0.83 to 0.97; 15 studies, n = 9550), a reduction in the number of antenatal hospital admissions per participant (RR 0.78, 95% CI 0.68 to 0.91; 4 studies; n = 787), and a reduction in the mean number of hospitalisation episodes (mean difference -0.05, 95% CI -0.06 to -0.04; 1 study, n = 1525) in the social support group, compared to the controls.Postnatal depression and women's satisfaction were reported in different ways in the studies that considered these outcomes and so we could not include data in a meta-analysis. In one study postnatal depression appeared to be slightly lower in the support group in women who screened positively on the Edinbugh Postnatal Depression Scale at eight to 12 weeks postnatally (RR 0.74, 95% CI 0.55 to 1.01; 1 study, n = 1008; moderate-quality evidence). In another study, again postnatal depression appeared to be slightly lower in the support group and this was a self-report measure assessed at six weeks postnatally (RR 0.85, 95% CI 0.69 to 1.05; 1 study, n = 458; low-quality evidence). A higher proportion of women in one study reported that their prenatal care was very helpful in the supported group (RR 1.17, 95% CI 1.05 to 1.30; 1 study, n = 223; moderate-quality evidence), although in another study results were similar. Another study assessed satisfaction with prenatal care as being "not good" in 51 of 945 in the additional support group, compared with 45 of 942 in the usual care group.No studies considered long-term morbidity for the infant. No single outcome was reported in all studies. Subgroup analysis demonstrated consistency of effect when the support was provided by a healthcare professional or a trained lay worker.The descriptions of the additional social support were generally consistent across all studies and included emotional support, tangible support such as home visits, and informational support.

AUTHORS' CONCLUSIONS

Pregnant women need the support of caring family members, friends, and health professionals. While programmes that offer additional social support during pregnancy are unlikely to have a large impact on the proportion of low birthweight babies or birth before 37 weeks' gestation and no impact on stillbirth or neonatal death, they may be helpful in reducing the likelihood of caesarean birth and antenatal hospital admission.

Randomized Controlled Trial of Home-Based Lifestyle Therapy on Postpartum Weight in Underserved Women with Overweight or Obesity

OBJECTIVE

This study aimed to assess the efficacy of a home-based lifestyle intervention delivered through Parents as Teachers (PAT), a national home-visiting organization, designed to minimize excessive weight gain through 12 months post partum in socioeconomically disadvantaged (SED) African American women with overweight or obesity.

METHODS

This randomized controlled trial was conducted at a single center as part of the Lifestyle Interventions for Expectant Moms (LIFE-Moms) consortium. Analysis was conducted with 185 SED African American women (BMI 25.0-45.0 kg/m² at pregnancy onset) retained from an original sample of 267 randomized to standard PAT or PAT+Lifestyle, which embedded lifestyle therapy within standard PAT delivered prenatally and for 12 months post partum.

RESULTS

Compared with standard PAT, the PAT+Lifestyle group gained less weight (2.5 kg vs. 5.7 kg; P = 0.01) and were more likely to return to their baseline weight (38.0% vs. 21.5%; P = 0.01) from baseline to 12 months post partum. There were no differences between groups in cardiometabolic outcomes, indices of glycemic control and insulin sensitivity, and plasma lipid profile. The estimated cost of PAT+Lifestyle was $81 more to deliver per family than standard PAT.

CONCLUSIONS

PAT+Lifestyle decreases weight gain during pregnancy through 12 months post partum in SED African American women with overweight or obesity at the start of pregnancy with minimal additional cost.

In-home obesity prevention in low-income infants through maternal and social transmission

BACKGROUND

Extant obesity efforts have had a limited impact among low-income underserved children, in part because existing programs are limited in terms of their short duration and low dosage, limited accessibility and sustainability; and failure to address barriers faced by diverse low-income families.

METHODS

This two-arm, parallel, randomized controlled trial (RCT) tests whether delivering obesity prevention, as part of an ongoing home visitation program (HVP), is an effective approach for primary (infants) and secondary (mothers) obesity prevention among low-income, underserved families. This RCT further examines the role of maternal and social factors as key mechanisms of transmission of infants' obesity risk, and the real-life costs of delivering obesity prevention as part of HVPs. Specifically, 300 low-income mothers/infants (6mo at baseline) participating in the Healthy Families America home visitation program in Antelope Valley (CA) will be recruited and enrolled in the study. Home visitors serving families will be randomly assigned to deliver the standard HVP curriculum with or without obesity prevention as part of their weekly home visits for two years. Anthropometric, metabolic and behavioral assessments of mothers/infants will be conducted at enrollment and after 6 and 18 months of intervention.

DISCUSSION

This study addresses the need to develop interventions targeting at-risk infants before they become obese. The proposed research is timely as the Institute of Medicine, the United States Department of Agriculture, and the Department of Health and Human Services are revising their recommendations to address key factors influencing obesity risk in children from birth to 24 months of age.

Reducing maltreatment recurrence through home visitation: A promising intervention for child welfare involved families

Maltreatment of children is a key predictor of a range of problematic health and developmental outcomes. Not only are affected children at high risk for recurrence of maltreatment, but effective interventions with known long term impact are few and limited. While home visiting is one of the most tested secondary prevention models for improving parenting, its primary focus on young primiparous mothers underemphasizes one of the most important risk groups: child welfare involved multiparous mothers. This study's focus is a randomized controlled trial of Healthy Families New York that included a subgroup of mothers (n = 104) who had at least one substantiated child protective services (CPS) report before enrolling in the program. By the child's seventh birthday, mothers in the home visited group were as half as likely as mothers in the control group to be confirmed subjects for physical abuse or neglect (AOR = .46, p = .08). The number of substantiated reports for mothers in the control group was twice as high as for those in the home visited group (1.59 vs. 79 p = .02, ES = .44). Group differences were only observed after the child's third birthday, suggesting the possible effect of surveillance in early years. Post-hoc analyses indicate that home visited mothers had fewer subsequent births that may have contributed to less parenting stress and improved life course development for mothers. In light of our findings, we suggest considering and further testing home visiting programs as a tertiary prevention strategy for child welfare-involved mothers.

Low birthweight in second children after nurse home visiting

OBJECTIVE

To examine low birthweight and preterm birth of second children born to home-visited first-time mothers.

SUBJECTS

Women were previously recruited for a randomized controlled trial of the home visiting model disseminated as Nurse-Family Partnership. 512 of these women had second children within 18 years of the first child's birth, and were included in our sample.

RESULTS

The intervention was associated with a lower likelihood of low birthweight for second children (odds ratio: 0.51, 95% CI: 0.27, 0.97), an effect apparent only if the first-born had low birthweight and mediated by close birth spacing. These moderation and mediation patterns were similar in the preterm birth outcome.

CONCLUSION

A home visiting program provided for first-born children reduced low birthweight for second-born children, if the first-born had low birthweight. This finding implies a broader impact than previously documented, because few studies have included these second children.

Randomized Controlled Trial of Doula-Home-Visiting Services: Impact on Maternal and Infant Health

Introduction Although home-visiting programs typically engage families during pregnancy, few studies have examined maternal and child health outcomes during the antenatal and newborn period and fewer have demonstrated intervention impacts. Illinois has developed an innovative model in which programs utilizing evidence-based home-visiting models incorporate community doulas who focus on childbirth education, breastfeeding, pregnancy health, and newborn care. This randomized controlled trial (RCT) examines the impact of doula-home-visiting on birth outcomes, postpartum maternal and infant health, and newborn care practices. Methods 312 young (M = 18.4 years), pregnant women across four communities were randomly assigned to receive doula-home-visiting services or case management. Women were African American (45%), Latina (38%), white (8%), and multiracial/other (9%). They were interviewed during pregnancy and at 3-weeks and 3-months postpartum. Results Intervention-group mothers were more likely to attend childbirth-preparation classes (50 vs. 10%, OR = 9.82, p < .01), but there were no differences on Caesarean delivery, birthweight, prematurity, or postpartum depression. Intervention-group mothers were less likely to use epidural/pain medication during labor (72 vs. 83%; OR = 0.49, p < .01) and more likely to initiate breastfeeding (81 vs. 74%; OR = 1.72, p < .05), although the breastfeeding impact was not sustained over time. Intervention-group mothers were more likely to put infants on their backs to sleep (70 vs. 61%; OR = 1.64, p < .05) and utilize car-seats at three weeks (97 vs. 93%; OR = 3.16, p < .05). Conclusions for practices The doula-home-visiting intervention was associated with positive infant-care behaviors. Since few evidence-based home-visiting programs have shown health impacts in the postpartum months after birth, incorporating doula services may confer additional health benefits to families.

Community-Academic Partnership to Investigate Low Birth Weight Deliveries and Improve Maternal and Infant Outcomes at a Baltimore City Hospital

Purpose Mercy Medical Center (MMC), a community hospital in Baltimore Maryland, has undertaken a community initiative to reduce low birth weight (LBW) deliveries by 10 % in 3 years. MMC partnered with a School of Public Health to evaluate characteristics associated with LBW deliveries and formulate collaborations with obstetricians and community services to improve birth outcomes. Description As part of the initiative, a case control study of LBW was undertaken of all newborns weighing <2500 grams during June 2010-June 2011 matched 2:1 with newborns ≥2500 grams (n = 862). Assessment Logistic regression models including maternal characteristics prior to and during pregnancy showed an increased odds of LBW among women with a previous preterm birth (aOR 2.48; 95 % CI: 1.49-4.13), chronic hypertension (aOR: 2.53; 95 % CI: 1.25-5.10), hospitalization during pregnancy (aOR: 2.27; 95 % CI:1.52-3.40), multiple gestation (aOR:12.33; 95 % CI:5.49-27.73) and gestational hypertension (aOR: 2.81; 95 % CI: 1.79-4.41). Given that both maternal pre-existing conditions and those occurring during pregnancy were found to be associated with LBW, one strategy to address pregnant women at risk of LBW infants is to improve the intake and referral system to better triage women to appropriate services in the community. Meetings were held with community organizations and feedback was operationalized into collaboration strategies which can be jointly implemented. Conclusion Education sessions with providers about the referral system are one ongoing strategy to improve birth outcomes in Baltimore City, as well as provision of timely home visits by nurses to high-risk women.

Grandmothers' Beliefs and Practices in Infant Safe Sleep

Background Sudden infant death syndrome (SIDS) and suffocation are leading causes of infant mortality. Supine sleep position and use of appropriate sleep surfaces reduce SIDS risk but are not universally practiced. Mothers' decisions about sleep position and environment may be influenced by guidance provided by infants' grandmothers and other caregivers. Methods A survey was conducted of a convenience sample of grandmothers aged 30-70 years who provide care at least weekly for an infant grandchild <6 months old. The survey was distributed through community partners of a university-based research team. Respondents received home safety items as compensation. Analyses focused on the relationship of grandmother demographic characteristics and beliefs on their reported practices related to infant sleep. Results Among the 239 grandmothers, 45 % reported placing infants to sleep supine on an appropriate sleep surface at the grandmother's house, while 58 % reported doing so when the infant was sleeping in the mother's house. After adjusting for other factors, respondents were less likely to adhere to recommended guidelines when they believed supine position increased choking risk (OR 0.34, 95 % CI 0.18-0.62) or believed infants are more comfortable or sleep longer when on their stomachs (OR 0.51, 95 % CI 0.28-0.93). Discussion Grandmothers do not universally observe evidence-based safe sleep practices, particularly if the infant is not sleeping in the home of the parent. Interventions for senior caregivers focused on perceived choking risk, infant comfort in the supine position, and other recent changes in recommended safety practices are warranted.

Let’s Talk About Breastfeeding: The Importance of Delivering a Message in a Home Visiting Program

Purpose:

To examine the potential impact of paraprofessional home visitors in promoting breastfeeding initiation and continuation among a high-risk population.

Design:

A secondary analysis of program data from a statewide home visitation program.

Setting:

Thirty-six Healthy Families New York sites across New York State.

Subjects:

A total of 3521 pregnant mothers at risk of poor child health and developmental outcomes.

Intervention:

Home visitors deliver a multifaceted intervention that includes educating high-risk mothers on benefits of breastfeeding, encouraging them to breastfeed and supporting their efforts during prenatal and postnatal periods.

Measures:

Home visitor-reported content and frequency of home visits, participant-reported breastfeeding initiation and duration, and covariates (Kempe Family Stress Index, race and ethnicity, region, nativity, marital status, age, and education).

Analysis:

Logistic regression.

Results:

Breastfeeding initiation increased by 1.5% for each 1-point increase in the percentage of prenatal home visits that included breastfeeding discussions. Breastfeeding continuation during the first 6 months also increased with the percentage of earlier home visits that included breastfeeding discussions. Additionally, if a participant receives 1 more home visit during the third month, her likelihood of breastfeeding at 6 months increases by 11%. Effect sizes varied by months postpartum.

Conclusions:

Delivering a breastfeeding message consistently during regular home visits is important for increasing breastfeeding rates. Given that home visiting programs target new mothers least likely to breastfeed, a more consistent focus on breastfeeding in this supportive context may reduce breastfeeding disparities.

Kentucky Health Access Nurturing Development Services Home Visiting Program Improves Maternal and Child Health

BACKGROUND AND OBJECTIVES

Home visitation programs are one of the numerous efforts to help reduce the rates of preterm birth and low birth weight as well as offering other improvements in maternal and child health and development. The Kentucky Health Access Nurturing Development Services (HANDS) is a voluntary, home visiting program serving first-time, high-risk mothers. This study's objective was to evaluate the impact of HANDS on maternal and child health outcomes.

METHODS

HANDS administrative data, live birth certificate records and data from the Division of Child Protection and Safety were used in these analyses. We analyzed 2253 mothers who were referred to HANDS between July 2011 and June 2012 and received a minimum of one prenatal home visit (mean number of prenatal visits = 12.9) compared to a demographically similar group of women (n = 2253) who did not receive a visit. Chi square statistics and conditional logistic regression models were used to evaluate the impact of HANDS.

RESULTS

HANDS participants had lower rates of preterm delivery (OR 0.74, 95% CI 0.61-0.88) and low birth weight infants (OR 0.54, 95% CI 0.44-0.67). HANDS participants also were significantly less likely to have a substantiated report of child maltreatment compared to controls (OR 0.53, 95% CI 0.43-0.65). HANDS participants also had an increase in adequate prenatal care and a reduction in maternal complications during pregnancy. Of particular important, outcomes improved as the number of prenatal home visits increased: among women receiving 1-3 prenatal home visits was 12.1%, the rate among women receiving 4-6 prenatal home visits was 13.2%, while the rate of PTB among those receiving 7 or more prenatal home visits was 9.4%.

CONCLUSIONS

HANDS program participation appears to result in significant improvements in maternal and child health outcomes, most specifically for those receiving seven or more prenatal home visits. As a state-wide, large scale home visiting program, this has significant implications for the continued improvement of maternal and child health outcomes in Kentucky.

Epilepsy, birth weight and academic school readiness in Canadian children: Data from the national longitudinal study of children and youth

PURPOSE

Birth weight is an important indicator of prenatal/in-utero environment. Variations in birth weight have been reportedly associated with risks for cognitive problems. The National Longitudinal Survey of Children and Youth (NLSCY) dataset was explored to examine relationships between birth weight, academic school readiness and epilepsy.

METHODS

A population based sample of 32,900 children of the NLSCY were analyzed to examine associations between birth weight, and school readiness scores in 4-5-year-old children. Logistic and Linear regression was used to examine associations between having epilepsy and these outcomes. Gestation data was available on 19,867 children, full-term children represented 89.67% (gestation >259days), while 10.33% of children were premature (gestation <258days). There were 20 children with reported epilepsy in the sample. Effects of confounding variables (diabetes in pregnancy, smoking in pregnancy, high blood pressure during pregnancy, and gender of the infant) on birth weight and epilepsy were controlled using a separate structural equation model.

RESULTS

Logistic regression analysis identified an association between epilepsy and lower birth weights, as well as an association between lower birth weight, having epilepsy and lower PPVT-R Scores. Model results show the relationship between low birth weight and epilepsy remains statistically significant even when controlling for the influence of afore mentioned confounding variables.

CONCLUSION

Low birth weight appears to be associated with both epilepsy and academic school readiness. The data suggest that an abnormal prenatal environment can influence both childhood onset of epilepsy and cognition. Additional studies with larger sample sizes are needed to verify this relationship in detail.

Home visitation programs: an untapped opportunity for the delivery of early childhood obesity prevention

BACKGROUND

Extant obesity efforts have had limited impact among low-income underserved children, in part because of limitations inherent to existing programs: (i) short duration and low intensity; (ii) late timing of implementation, when children are already overweight or obese; (iii) intervention delivery limiting their accessibility and sustainability; and (iv) failure to address barriers such as a lack of culturally competent services, poverty and housing instability, which interfere with healthy lifestyle changes.

OBJECTIVE

This concept paper proposes an innovative model of obesity prevention implemented in infancy and sustained throughout early childhood to address the limitations of current obesity prevention efforts. Specifically, we propose to integrate sustained, weekly, in-home obesity prevention as part of the services already delivered by ongoing Home Visitation Programs, which currently do not target obesity prevention.

CONCLUSION

The home visiting structure represents an ideal model for impactful obesity prevention as home visitation programs: (i) already provide comprehensive services to diverse low-income infants and families who are most at risk for obesity and poor health because of socio-economic and structural conditions; (ii) services are initiated in infancy and sustained throughout critical developmental periods for the formation of healthy/unhealthy behaviors; and (iii) have been in place for more than 40 years, with a widespread presence across the United States and nationwide, which is critical for the scalability and sustainability of obesity prevention.

Home visiting for first-time mothers and subsequent pregnancy spacing

OBJECTIVE

The objective of the study was to determine the association of home visiting with subsequent pregnancy outcomes.

STUDY DESIGN

Retrospective study of Ohio mothers delivering their first infant from 2007 to 2009. First, we compared mothers enrolled in home visiting with a matched eligible group. Second, we compared outcomes within home visiting based on program participation (low <25% of recommended home visits, moderate 25 to 75%, high 75 to 100% and very high >100%). Time to subsequent pregnancy within 18 months was evaluated using Cox proportional hazards regression; logistic regression tested the likelihood of subsequent preterm birth.

RESULTS

Of 1516 participants, 1460 were matched 1:1 to a comparison mother (n=2920). After multivariable adjustment, enrollment was associated with no difference in pregnancy spacing or subsequent preterm birth. Among those enrolled, moderate vs low participants had reduced risk of repeat pregnancy over 18 months (hazard ratio 0.68, P=0.003).

CONCLUSION

Increased pregnancy spacing is observed among women with at least moderate home visiting participation.

Multilevel assessment of prenatal engagement in home visiting

BACKGROUND

Low engagement in prenatal home visiting may limit programme effectiveness to improve birth outcomes. Multiple factors may influence engagement.

METHODS

A retrospective cohort study of first-time mothers enrolled in home visiting prenatally in southwest Ohio from 2007 to 2010. The primary outcome was enrolment by 20weeks' gestation; a secondary outcome included home visit frequency. Two multilevel assessments were conducted using random intercept multilevel modelling; maternal covariates were nested first within the home visiting agency and then within the ZIP code. In the first model, variations attributable to individual agency and agency volume were assessed. In the second model nested within the ZIP code, violence rates by ZIP code and interaction terms between violence rates and maternal factors were evaluated.

RESULTS

Of 837 women, 25.3% enrolled ≤20 weeks and 7.4% enrolled early and received ≥75% of expected visits. The first model demonstrated a significant variation in early enrolment based on clustering by agency (p<0.001), however, agency volume was not a significant predictor. In the second model, violence rate was not associated with early enrolment (AOR 0.92, p=0.08), but an interaction term with maternal race was significant (p=0.02). The effect of increasing community violence disproportionately affected early enrolment among white women (AOR 0.80, p=0.005) compared with black women (AOR 0.95, p=0.30). In both the random intercept multilevel models, teenagers demonstrated a decreased likelihood of enrolling early (AOR 0.58, p=0.046 and AOR 0.49, p=0.004).

CONCLUSIONS

Prenatal home visiting engagement is related to maternal, agency and community factors, presenting multiple opportunities to optimise programme implementation.

Born early and born poor: An eco-bio-developmental model for poverty and preterm birth

Poverty is associated with adverse long-term cognitive outcomes in children. Poverty is also linked with preterm delivery which, in turn, is associated with adverse cognitive outcomes. However, the extent of the effect of poverty on preterm delivery, as well as proposed mechanisms by which they occur, have not been well described. Further, the impact of poverty on preterm school readiness has not been reviewed. As the childhood poverty level continues to increase in the U.S., we examine the evidence around physiological, neurological, cognitive and learning outcomes associated with prematurity in the context of poverty. We use the evidence gathered to suggest an Eco-Bio-Developmental model, emphasizing poverty as a toxic stress which predisposes preterm birth and which, via epigenetic forces, can continue into the next generation. Continued postnatal social disadvantage for these developmentally high-risk preterm infants is strongly linked with poor neurodevelopmental outcomes, decreased school readiness, and decreased educational attainment which can perpetuate the poverty cycle. We suggest social remedies aimed at decreasing the impact of poverty on mothers, fathers, and children which may be effective in reducing the burden of preterm birth.

Home-based neonatal care by community health workers for preventing mortality in neonates in low- and middle-income countries: a systematic review

The objective of this review is to assess the effect of home-based neonatal care provided by community health workers (CHWs) for preventing neonatal, infant and perinatal mortality in resource-limited settings with poor access to health facility-based care. The authors conducted a systematic review, including meta-analysis and meta-regression of controlled trials. The data sources included electronic databases, with a hand search of reviews, abstracts and proceedings of conferences to search for randomized, or cluster randomized, controlled trials evaluating the effect of home-based neonatal care provided by CHWs for preventing neonatal, infant and perinatal mortality. Among the included trials, all from South Asian countries, information on neonatal, infant and perinatal mortality was available in five, one and three trials, respectively. The intervention package comprised three components, namely, home visits during pregnancy (four trials), home-based preventive and/or curative neonatal care (all trials) and community mobilization efforts (four trials). Intervention was associated with a reduced risk of mortality during the neonatal (random effects model relative risk (RR) 0.75; 95% confidence intervals (CIs) 0.61 to 0.92, P=0.005; I(2)=82.2%, P<0.001 for heterogeneity; high-quality evidence) and perinatal periods (random effects model RR 0.78; 95% CI 0.64 to 0.94, P=0.009; I(2)=79.6%, P=0.007 for heterogeneity; high-quality evidence). In one trial, a significant decline in infant mortality (RR 0.85; 95% CI 0.77 to 0.94) was documented. Subgroup and meta-regression analyses suggested a greater effect with a higher baseline neonatal mortality rate. The authors concluded that home-based neonatal care is associated with a reduction in neonatal and perinatal mortality in South Asian settings with high neonatal-mortality rates and poor access to health facility-based care. Adoption of a policy of home-based neonatal care provided by CHWs is justified in such settings.

Pathways community care coordination in low birth weight prevention

The evidence is limited on the effectiveness of home visiting care coordination in addressing poor birth outcome, including low birth weight (LBW). The Community Health Access Project (CHAP) utilizes community health workers (CHWs) to identify women at risk of having poor birth outcomes, connect them to health and social services, and track each identified health or social issue to a measurable completion. CHWs are trained individuals from the same highest risk communities. The CHAP Pathways Model is used to track each maternal health and social service need to resolution and CHWs are paid based upon outcomes. We evaluated the impact of the CHAP Pathways program on LBW in an urban Ohio community. Women participating in CHAP and having a live birth in 2001 through 2004 constituted the intervention group. Using birth certificate records, each CHAP birth was matched through propensity score to a control birth from the same census tract and year. Logistic regression was used to examine the association of CHAP participation with LBW while controlling for risk factors for LBW. We identified 115 CHAP clients and 115 control births. Among the intervention group there were seven LBW births (6.1 %) compared with 15 (13.0 %) among non-CHAP clients. The adjusted odds ratio for LBW was 0.35 (95 % confidence interval, 0.12–0.96) among CHAP clients. This study provides evidence that structured community care coordination coupled with tracking and payment for outcomes may reduce LBW birth among high-risk women.

Implementation of evidence-based home visiting programs aimed at reducing child maltreatment: A meta-analytic review

In recent years there has been an increase in the popularity of home visitation programs as a means of addressing risk factors for child maltreatment. The evidence supporting the effectiveness of these programs from several meta-analyses, however, is mixed. One potential explanation for this inconsistency explored in the current study involves the manner in which these programs were implemented. In the current study we reviewed 156 studies associated with 9 different home visitation program models targeted to caregivers of children between the ages of 0 and 5. Meta-analytic techniques were used to determine the impact of 18 implementation factors (e.g., staff selection, training, supervision, fidelity monitoring, etc.) and four study characteristics (publication type, target population, study design, comparison group) in predicting program outcomes. Results from analyses revealed that several implementation factors, including training, supervision, and fidelity monitoring, had a significant effect on program outcomes, particularly child maltreatment outcomes. Study characteristics, including the program's target population and the comparison group employed, also had a significant effect on program outcomes. Implications of the study's results for those interested in implementing home visitation programs are discussed. A careful consideration and monitoring of program implementation is advised as a means of achieving optimal study results.

A Community-Based Home Visitation Program's Impact on Birth Outcomes

BACKGROUND

MOMS Orange County is a coordinated home visitation program in which trained paraprofessional home visitors work under the close supervision of registered nurses. This model was developed to address health disparities in birth outcomes in a Hispanic community in Orange County, CA.

PURPOSE

The primary objective was to test the impact of MOMS Orange County on birth outcomes. The second objective was to examine the breadth of prenatal health education topics as a mediator of the relationship between home visits and birth outcomes.

METHODS

A retrospective cohort design was used. Paraprofessional home visitors collected prenatal and postnatal data during home visits. Only those whose birth outcomes were obtained were included in the analysis (N = 2,027 participants). Regression models were conducted to test the associations between prenatal home visits and birth outcomes, adjusting for 10 covariates.

RESULTS

Number of prenatal home visits predicted higher birthweight and greater gestational age at birth. Breadth of health education topics partially mediated the associations between home visits and birthweight. The same mediation was revealed with gestational age at birth.

CLINICAL IMPLICATIONS

The MOMS Orange County prenatal home visitation program may be a promising approach to decrease adverse birth outcomes in disadvantaged communities. Rigorously designed studies are needed to further test this model.

Effectiveness of Home Visits in Pregnancy as a Public Health Measure to Improve Birth Outcomes

BACKGROUND

Birth outcomes, such as preterm birth, low birth weight (LBW), and small for gestational age (SGA), are crucial indicators of child development and health.

PURPOSE

To evaluate whether home visits from public health nurses for high-risk pregnant women prevent adverse birth outcomes.

METHODS

In this quasi-experimental cohort study in Kyoto city, Japan, high-risk pregnant women were defined as teenage girls (range 14-19 years old), women with a twin pregnancy, women who registered their pregnancy late, had a physical or mental illness, were of single marital status, non-Japanese women who were not fluent in Japanese, or elderly primiparas. We collected data from all high-risk pregnant women at pregnancy registration interviews held at a public health centers between 1 July 2011 and 30 June 2012, as well as birth outcomes when delivered from the Maternal and Child Health Handbook (N = 964), which is a record of prenatal check-ups, delivery, child development and vaccinations. Of these women, 622 women were selected based on the home-visit program propensity score-matched sample (pair of N = 311) and included in the analysis. Data were analyzed between January and June 2014.

RESULTS

In the propensity score-matched sample, women who received the home-visit program had lower odds of preterm birth (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.39 to 0.98) and showed a 0.55-week difference in gestational age (95% CI: 0.18 to 0.92) compared to the matched controlled sample. Although the program did not prevent LBW and SGA, children born to mothers who received the program showed an increase in birth weight by 107.8 g (95% CI: 27.0 to 188.5).

CONCLUSION

Home visits by public health nurses for high-risk pregnant women in Japan might be effective in preventing preterm birth, but not SGA.

The Early Childhood Obesity Prevention Program (ECHO): an ecologically-based intervention delivered by home visitors for newborns and their mothers

BACKGROUND

Obesity is a major problem in the United States, particularly among socio-economically disadvantaged Latino and Black children. Effective interventions that can be disseminated to large numbers of at-risk children and their families are needed. The goals of the Early Childhood Obesity Prevention Program (ECHO) are to examine the 12-month efficacy of a primary obesity prevention program targeting the first year of life that is delivered by home visitors and that engages mothers as agents of change to modify their own behavior and their infant's behavior through education and skill-building around nutrition, physical activity, and wellness, and then "echoes" her training with linkages to neighborhood programs and resources.

METHODS/DESIGN

Six family centers located in low-income neighborhoods in Hartford, CT were randomized into control and intervention neighborhoods. Fifty-seven mothers were recruited either prenatally or shortly after delivery into the Nurturing Families Network home visitation program; 27 lived in a control neighborhood and received the standard home visitation program and 30 lived in an intervention neighborhood and received both the standard home visitation program and the ECHO intervention. The intervention increases maternal skills in goal-setting, stimulus control and problem-solving, engages family members to support changes, links mothers to neighborhood resources and is embedded in the standard home visitation program. ECHO targets include breastfeeding, solids, juice and sugar-sweetened beverages, routines for sleep and responding to infant cues, television/screen time, and maternal diet and physical activity. We hypothesize that infants in ECHO will have been breastfed longer and exclusively, will have delayed introduction of solids and juice, have longer sleep duration, decreased television/screen time and a lower weight for length z-score at 12 months, and their mothers will have greater fruit and vegetable consumption and higher levels of physical activity.

DISCUSSION

ECHO will provide important information about whether an enhanced behavior change curriculum integrated into an existing home visitation program, focused on the mother as the agent of change and linked to neighborhood resources is effective in changing energy balance behaviors in the infant and in the mother. If effective, the intervention could be widely disseminated to prevent obesity in young children.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02052518 January 30, 2014.

Risk Prediction for Adverse Pregnancy Outcomes in a Medicaid Population

BACKGROUND

Despite prior efforts to develop pregnancy risk prediction models, there remains a lack of evidence to guide implementation in clinical practice. The current aim was to develop and validate a risk tool grounded in social determinants theory for use among at-risk Medicaid patients.

METHODS

This was a retrospective cohort study of 409 women across 17 Cincinnati health centers between September 2013 and April 2014. The primary outcomes included preterm birth, low birth weight, intrauterine fetal demise, and neonatal death. After random allocation into derivation and validation samples, a multivariable model was developed, and a risk scoring system was assessed and validated using area under the receiver operating characteristic curve (AUROC) values.

RESULTS

The derived multivariable model (n=263) included: prior preterm birth, interpregnancy interval, late prenatal care, comorbid conditions, history of childhood abuse, substance use, tobacco use, body mass index, race, twin gestation, and short cervical length. Using a weighted risk score, each additional point was associated with an odds ratio of 1.57 for adverse outcomes, p<0.001, AUROC=0.79. In the validation sample (n=146), each additional point conferred an odds ratio of 1.20, p=0.03, AUROC=0.63. Using a cutoff of 20% probability for the outcome, sensitivity was 29%, with specificity 82%. Positive and negative predictive values were 22% and 85%, respectively.

CONCLUSIONS

Risk scoring based on social determinants can discriminate pregnancy risk within a Medicaid population; however, performance is modest and consistent with prior prediction models. Future research is needed to evaluate whether implementation of risk scoring in Medicaid prenatal care programs improves clinical outcomes.

Strong Start for Mothers and Newborns: implications for prenatal care delivery

PURPOSE OF REVIEW

In February 2012, the Centers for Medicare and Medicaid Services announced a 4-year initiative to test new approaches to prenatal care delivery to improve rates of preterm birth for women enrolled in Medicaid. The Strong Start for Mothers and Newborns initiative was designed to achieve this goal through two strategies: first, a public awareness campaign designed to reduce the rate of elective deliveries prior to 39-week gestation, and second, a funding opportunity to test the effectiveness of enhanced prenatal care models designed to reduce the incidence of low-birth-weight infants among pregnant Medicaid beneficiaries. This article reviews previous prenatal care expansion efforts and provides insights into the alternative prenatal care delivery models currently being tested for low-income patient populations at high risk for adverse birth outcomes.

RECENT FINDINGS

Alternative prenatal care models, such as prenatal home visitation and group prenatal care for patients at high risk for adverse birth outcomes, may provide more efficient and effective care than the traditional, predominantly medical model of prenatal care delivery.

SUMMARY

The authors discuss the relationship between prenatal care utilization and adverse birth outcomes, such as low birth weight, and current efforts to reinvent prenatal care content, structure and delivery.

Is a randomised controlled trial of a maternity care intervention for pregnant adolescents possible? An Australian feasibility study

Background

The way in which maternity care is provided affects perinatal outcomes for pregnant adolescents; including the likelihood of preterm birth. The study purpose was to assess the feasibility of recruiting pregnant adolescents into a randomised controlled trial, in order to inform the design of an adequately powered trial which could test the effect of caseload midwifery on preterm birth for pregnant adolescents.

Methods

We recruited pregnant adolescents into a feasibility study of a prospective, un-blinded, two-arm, randomised controlled trial of caseload midwifery compared to standard care. We recorded and analysed recruitment data in order to provide estimates to be used in the design of a larger study.

Results

The proportion of women aged 15–17 years who were eligible for the study was 34% (n=10), however the proportion who agreed to be randomised was only 11% (n = 1). Barriers to recruitment were restrictive eligibility criteria, unwillingness of hospital staff to assist with recruitment, and unwillingness of pregnant adolescents to have their choice of maternity carer removed through randomisation.

Conclusions

A randomised controlled trial of caseload midwifery care for pregnant adolescents would not be feasible in this setting without modifications to the research protocol. The recruitment plan should maximise opportunities for participation by increasing the upper age limit and enabling women to be recruited at a later gestation. Strategies to engage the support of hospital-employed staff are essential and would require substantial, and ongoing, work. A Zelen method of post-randomisation consent, monetary incentives and ‘peer recruiters’ could also be considered.

Dosage effect of prenatal home visiting on pregnancy outcomes in at-risk, first-time mothers

BACKGROUND AND OBJECTIVE

Home visiting programs seek to improve care management for women at high risk for preterm birth (<37 weeks). Our objective was to evaluate the effect of home visiting dosage on preterm birth and small for gestational age (SGA) infants.

METHODS

Retrospective cohort study of women in southwest Ohio with a singleton pregnancy enrolled in home visiting before 26 weeks' gestation. Vital statistics and hospital discharge data were linked with home visiting data from 2007 to 2010 to ascertain birth outcomes. Eligibility for home visiting required ≥1 of 4 risk factors: unmarried, low income, <18 years of age, or suboptimal prenatal care. Logistic regression tested the association of gestational age at enrollment and number of home visits before 26 weeks with preterm birth. Proportional hazards analysis tested the association of total number of home visits with SGA status.

RESULTS

Among 441 participants enrolled by 26 weeks, 10.9% delivered preterm; 17.9% of infants were born SGA. Mean gestational age at enrollment was 18.9 weeks; mean number of prenatal home visits was 8.2. In multivariable regression, ≥8 completed visits by 26 weeks compared with ≤3 visits was associated with an odds ratio 0.38 for preterm birth (95% confidence interval: 0.16-0.87), while having ≥12 total home visits compared with ≤3 visits was significantly associated with a hazards ratio 0.32 for SGA (95% confidence interval: 0.15-0.68).

CONCLUSIONS

Among at-risk, first time mothers enrolled prenatally in home visiting, higher dosage of intervention is associated with reduced likelihood of adverse pregnancy outcomes.

Effectiveness of home visiting in improving child health and reducing child maltreatment

BACKGROUND AND OBJECTIVE

The Patient Protection and Affordable Care Act established the Maternal, Infant, and Early Childhood Home Visiting Program, which provides $1.5 billion to states over 5 years for home visiting program models serving at-risk pregnant women and children from birth to age 5. The act stipulates that 75% of the funds must be used for programs with evidence of effectiveness based on rigorous evaluation research. Home Visiting Evidence of Effectiveness reviewed the home visiting research literature and provided an assessment of the evidence of effectiveness for program models that serve families with pregnant women and children from birth to age 5.

METHODS

Home Visiting Evidence of Effectiveness included a systematic search and screening process, a review of the research quality, and an assessment of program effectiveness. Reviewers rated studies' capacity to provide unbiased estimates of program impacts and determined whether a program met the Department of Health and Human Services' criteria for an evidence-based model.

RESULTS

As of July 2012, 32 models were reviewed, of which 12 met the Department of Health and Human Services criteria. Most of these models were shown to have favorable effects on child development. Other common favorable effects included health care usage and reductions in child maltreatment. Less common were favorable effects on birth outcomes.

CONCLUSIONS

Home visiting is a promising way to serve families who may be difficult to engage in supportive services. Existing rigorous research indicates that home visiting has the potential for positive results among high-risk families, particularly on health care usage and child development.

Home visiting and outcomes of preterm infants: a systematic review

BACKGROUND AND OBJECTIVES

Home visiting is 1 strategy to improve child health and parenting. Since implementation of home visiting trials 2 decades ago, US preterm births (<37 weeks) have risen by 20%. The objective of this study was to review evidence regarding home visiting and outcomes of preterm infants

METHODS

Searches of Medline, Cumulative Index to Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, Cochrane Controlled Trial Register, PsycINFO, and Embase were conducted. Criteria for inclusion were (1) cohort or controlled trial designs; (2) home-based, preventive services for infants at medical or social risk; and (3) outcomes reported for infants born preterm or low birth weight (<2500 g). Data from eligible reports were abstracted by 2 reviewers. Random effects meta-analysis was used to synthesize data for developmental and parent interaction measures.

RESULTS

Seventeen studies (15 controlled trials, 2 cohort studies) were reviewed. Five outcome domains were identified: infant development, parent-infant interaction, morbidity, abuse/neglect, and growth/nutrition. Six studies (n = 336) demonstrated a pooled standardized mean difference of 0.79 (95% confidence interval 0.57 to 1.02) in Home Observation for Measurement of the Environment Inventory scores at 1 year in the home-visited groups versus control. Evidence for other outcomes was limited. Methodological limitations were common.

CONCLUSIONS

Reviewed studies suggest that home visiting for preterm infants promotes improved parent-infant interaction. Further study of interventions targeting preterm infants within existing programs may strengthen the impact and cost benefits of home visiting in at-risk populations.

Infant birth weight and maltreatment of adolescent mothers

BACKGROUND

Emerging literature suggests that maternal exposure to stress and adversity throughout the life course may have health consequences for offspring.

PURPOSE

To examine the maltreatment history of adolescent mothers as an independent predictor of infant birth weight.

METHODS

Birth records for all infants born between 2007 and 2009 to mothers aged 12-19 years were extracted from California's vital statistics files. Maternal information from the birth record was linked to child protection data (1999-2009) to identify young mothers with substantiated maltreatment. Generalized linear models run in 2012 were used to estimate the relationship between maternal maltreatment and infant birth weight, after adjusting for maternal sociodemographic risk factors and health behaviors.

RESULTS

Among the 153,762 singleton infants born to adolescent mothers, 7.1% (n=10,886) weighed <2500 g at birth. Of all adolescent mothers, 13.6% had been substantiated as victims of maltreatment after age 10 years and before giving birth. After adjusting for known factors predictive of negative birth outcomes, maltreatment history was associated with a slight yet significantly increased risk of low birth weight among infants (risk ratio=1.06, 95% CI=1.01, 1.12).

CONCLUSIONS

Findings from this study suggest that maltreatment history of adolescent mothers is associated with infant low birth weight (<2500 g). Although the increased risk was small and the mechanism unclear, these data indicate that maternal maltreatment not only may have consequences for the victim but also may contribute to intergenerational health disparities.

Japanese Americans' health concerns and depressive symptoms: implications for disaster counseling

This study examined factors contributing to depressive symptoms among Japanese Americans. Data were collected in Houston, Texas, in 2008, before the March 2011 Japan earthquake, through a community survey including demographic and mental health questions and the Hopkins Symptoms Checklist. Among 43 Japanese American respondents in this convenience sample, the depression prevalence was 11.6 percent. Chi-square results found that having anxiety symptoms and holding a master's degree had statistically significant relationships with depressive symptoms. An independent sample t test found that those having depressive symptoms experienced significantly more health issues than those without depressive symptoms. When these statistically significant variables were entered into a logistic regression model, the overall effect of having health issues, anxiety symptoms, and a master's degree collectively predicted depressive symptoms. It was also found that Japanese Americans rarely consult mental health professionals; in particular, female Japanese American respondents tend to seek help from religious leaders. As implied by these findings, the reluctance of Japanese Americans to seek formal help can be explained by social stigma, a health-oriented approach to treatment, and other cultural considerations. Practice implications focus on disaster counseling with a connection between mental health needs and health care support.

Effectiveness of home visiting programs on child outcomes: a systematic review

BACKGROUND

The effectiveness of paraprofessional home-visitations on improving the circumstances of disadvantaged families is unclear. The purpose of this paper is to systematically review the effectiveness of paraprofessional home-visiting programs on developmental and health outcomes of young children from disadvantaged families.

METHODS

A comprehensive search of electronic databases (e.g., CINAHL PLUS, Cochrane, EMBASE, MEDLINE) from 1990 through May 2012 was supplemented by reference lists to search for relevant studies. Through the use of reliable tools, studies were assessed in duplicate. English language studies of paraprofessional home-visiting programs assessing specific outcomes for children (0-6 years) from disadvantaged families were eligible for inclusion in the review. Data extraction included the characteristics of the participants, intervention, outcomes and quality of the studies.

RESULTS

Studies that scored 13 or greater out of a total of 15 on the validity tool (n = 21) are the focus of this review. All studies are randomized controlled trials and most were conducted in the United States. Significant improvements to the development and health of young children as a result of a home-visiting program are noted for particular groups. These include: (a) prevention of child abuse in some cases, particularly when the intervention is initiated prenatally; (b) developmental benefits in relation to cognition and problem behaviours, and less consistently with language skills; and (c) reduced incidence of low birth weights and health problems in older children, and increased incidence of appropriate weight gain in early childhood. However, overall home-visiting programs are limited in improving the lives of socially high-risk children who live in disadvantaged families.

CONCLUSIONS

Home visitation by paraprofessionals is an intervention that holds promise for socially high-risk families with young children. Initiating the intervention prenatally and increasing the number of visits improves development and health outcomes for particular groups of children. Future studies should consider what dose of the intervention is most beneficial and address retention issues.

The effect of maternal stress and health-related quality of life on birth outcomes among Macao Chinese pregnant women

This study investigated the prevalence of preterm birth and low-birth-weight in Macao. It also evaluated the effects of maternal perceived stress and health-related quality of life on these 2 birth outcomes. A quantitative study using a prospective longitudinal design was undertaken in an antenatal clinic in Macao. A community-based sample (N = 581) of pregnant women in their second trimester was recruited; birth outcome data were collected from medical records. Perceived stress was measured using the Perceived Stress Scale, whereas health-related quality of life was measured using the standard SF-12 Health Survey. The prevalence rates of preterm birth and low-birth-weight were found to be 6.4% and 7.1%, respectively. Two multiple logistic regression analyses revealed that participants with past adverse obstetric complications and higher perceived stress levels were more likely to have premature infants. Also, those participants with higher perceived stress levels and poorer health-related quality of life in the physical health domain were more likely to have low-birth-weight infants. Preliminary information was provided on risk factors associated with adverse birth outcomes; this could help nurses to design appropriate risk-specific interventions for preventing preterm birth and low-birth-weight.

Design and implementation of an integrated, continuous evaluation, and quality improvement system for a state-based home-visiting program

To describe the design and implementation of an evaluation system to facilitate continuous quality improvement (CQI) and scientific evaluation in a statewide home visiting program, and to provide a summary of the system's progress in meeting intended outputs and short-term outcomes. Help Us Grow Successfully (HUGS) is a statewide home visiting program that provides services to at-risk pregnant/post-partum women, children (0-5 years), and their families. The program goals are to improve parenting skills and connect families to needed services and thus improve the health of the service population. The evaluation system is designed to: (1) integrate evaluation into daily workflow; (2) utilize standardized screening and evaluation tools; (3) facilitate a culture of CQI in program management; and, (4) facilitate scientifically rigorous evaluations. The review of the system's design and implementation occurred through a formative evaluation process (reach, dose, and fidelity). Data was collected through electronic and paper surveys, administrative data, and notes from management meetings, and medical chart review. In the design phase, four process and forty outcome measures were selected and are tracked using standardized screening and monitoring tools. During implementation, the reach and dose of training were adequate to successfully launch the evaluation/CQI system. All staff (n = 165) use the system for management of families; the supervisors (n = 18) use the system to track routine program activities. Data quality and availability is sufficient to support periodic program reviews at the region and state level. In the first 7 months, the HUGS evaluation system tracked 3,794 families (7,937 individuals). System use and acceptance is high. A successful implementation of a structured evaluation system with a strong CQI component is feasible in an existing, large statewide program. The evaluation/CQI system is an effective mechanism to drive modest change in management of the program.