Randomized controlled trial of Family Connects: Effects on child emergency medical care from birth to 24 months

Planning, Implementation, and Evaluation of a Postpartum Nurse Home Visit Service to Improve Health Equity

OBJECTIVE

To describe how a college of nursing and urban academic medical center partnered with the local health department to plan, implement, and evaluate a universal nurse home visit service to improve health equity in the postpartum period.

DESIGN

Evidence-based practice.

SETTING/LOCAL PROBLEM

Wide health disparity in rates of maternal and infant morbidity and mortality in Chicago, Illinois.

PATIENTS

All patients who gave birth at the medical center and lived in Chicago.

INTERVENTION/MEASUREMENTS

A nurse home visit was offered after birth to all eligible patients beginning in March 2020. We used data from a Web-based platform to determine key performance indicators for the program and examined patient demographics to determine equitable delivery of the service for all visits provided in 2022.

RESULTS

There were 1,488 patients eligible for a home visit and 714 who received a home visit. The average contact rate was 76%, the scheduling rate was 63%, the completion rate for scheduled visits was 76%, and the population reach was 48%. Sixty-eight percent of families visited were from high-economic-hardship zip code areas of the city. Eighty-one percent of visits resulted in at least one referral to meet a family's need, and 98% of patients surveyed rated their visit as "very helpful."

CONCLUSION

The successful implementation of this public-private partnership was due in part to an organizational culture that supports health equity initiatives, the inclusion of system-wide stakeholders, having a process in place to monitor outcomes, and hiring a diverse team of nurses who prioritize respectful patient-centered care.

Perinatal Health Profiles Associated With Removal From the Home and Subsequent Child Protective Services Report in Maltreated Infants

Infants face the highest risk of abuse and neglect nationally. There is a compelling need to understand the individual risk factors and needs of families of maltreated infants so that prevention efforts can be tailored for optimal effectiveness. Using linked birth certificate and CPS records data, we employed latent class analysis to identify distinct profiles of perinatal health factors associated with infant maltreatment. Classes were then regressed onto two key child welfare outcomes-removal from the home and re-report. Results indicated 10 latent classes primarily associated with supervisory neglect and presumed prenatal substance exposure. Rapid repeat pregnancy, smoking during pregnancy and inadequate prenatal care emerged as key risk factors. Presumed substance exposure was associated with high risk of removal from the home and low risk of re-report. The opposite was found for supervisory neglect. Substantial variation existed across classes and types of maltreatment, suggesting a need for tailored prevention strategies.

Unique Profiles of Postpartum Family Needs and Evidence of Racial and Ethnic Disparities: Insights from Community Implementation of Family Connects

OBJECTIVES

To delineate specific family needs during the postpartum period using data from Family Connects (FC), a universal home-visiting initiative, and to scrutinize potential racial and ethnic disparities in these needs.

METHOD

FC implementation data spanned from July 1, 2009, to August 31, 2021, in seven counties across the USA. Data encompassed nurse-led in-home assessments for 34,119 families. Nurses evaluated needs across four domains (healthcare, parenting/childcare, safe home, and parent support) comprising 12 risk factors.

FINDINGS

Overall, families reported high levels of need, and community connections were facilitated for 57% of visited families. Significant differences in need profiles between whites and minority groups were revealed, reflecting both disparity and uniqueness. Employing the Oaxaca decomposition approach, we found that racial/ethnic disparities in socioeconomic attributes were associated with racial/ethnic gaps in the need profiles.

CONCLUSIONS

The event of giving birth is both high risk and high opportunity for preventive intervention. Home-visiting programs, as an evidence-based approach, must address the diverse spectrum of familial needs comprehensively.

The effects of a large-scale home visiting programme for child development on use of health services in Brazil

Partnership between early childhood development interventions and primary health care services can help catalyse health care uptake by socially vulnerable families. This study aimed to assess the real-life effects of a large-scale home visiting programme [Primeira Infância Melhor (PIM)] in Brazil on the use of preventive (prenatal visits, well child visits, dentist visits and vaccination) and recovery (emergency room visits and hospitalization) health services. A quasi-experiment nested in a population-based birth cohort study was conducted. The intervention group was firstly defined as all children enrolled in PIM up to age 6 months, and afterwards stratified between those enrolled during pregnancy or after birth up to 6 months. Children receiving PIM were matched with controls on propensity scores based on 27 confounders to estimate effects on health service use from prenatal to age 2 years. Double adjustment was applied in outcome Quasi-Poisson regressions. No evidence was found for effects of PIM starting anytime up to 6 months (262 pairs), or for the children enrolled only after birth (133 pairs), on outcomes occurring after age 6 months. When the programme started during pregnancy (129 pairs), there was a 13% higher prevalence of adequate prenatal visits (prevalence ratio = 1.13; 95% confidence interval 1.01-1.27), but no effect on use of any other health service. Sensitivity analyses suggested longer participation in the programme with reduced visitor turnover might improve its impact on prenatal visits. Integration between PIM and primary health care was not adequate to affect overall patterns of contacts with health services. Nevertheless, prenatal home visits showed potential to increase health service contact during a sensitive period of development, indicating the need to start such programmes before birth, when there is more time for maternal care, and family engagement in a network of services is facilitated.

Supporting responsive parenting in real-world implementation: minimal effective dose of the Video Interaction Project

BACKGROUND

The Video Interaction Project (VIP) is a healthcare-based intervention that provides real-time video-feedback of parent-child play and reading interactions to families with children aged 0 to 36 months. Although evidence from randomized controlled trials demonstrates improved early relational health, including responsive parenting, after three to five VIP visits, the minimal effective dose in real-world implementations is unknown. This study aimed to determine the minimal effective dose of VIP during a real-world implementation for changing responsive parenting behaviors.

METHODS

We performed a longitudinal prospective study of 183 dyads at a public hospital pediatric clinic. Responsive parenting behaviors were assessed with an observational checklist utilized as part of standard VIP practice at baseline and two follow-up VIP visits.

RESULTS

Multilevel models adjusted for baseline sociodemographics (child's sex and age, and maternal education) and time between visits showed that responsive parenting behaviors during parent-child reading and play significantly increased after a single VIP visit (Cohen's d = 0.52, p < 0.05) with additional impact following completion of a second visit (cumulative for 2 visits: d = 0.76, p < 0.05).

CONCLUSIONS

A single VIP visit is associated with increased responsive parenting behaviors. Findings support offering VIP widely, regardless of capacity to ensure attendance at multiple visits.

IMPACT

This is the first study showing the minimal effective dose of the Video Interaction Project (VIP) for increasing responsive parenting behaviors. Responsive parenting behaviors increased by over 22% following a single VIP visit, with a cumulative increase of 37% following the second visit compared to baseline. Findings have important implications for implementation and scalability of pediatric-based preventive programs that support early relational health through activities such as reading and play.

Integrating equifinality and multifinality into the of prevention programs in early childhood: The conceptual case for use of tiered models

Introduced in the context of developmental psychopathology by Cicchetti and Rogosh in the Journal, the current paper incorporates the principles of equifinality and multifinality to support the use of tiered models to prevent the development of emerging child psychopathology and promote school readiness in early childhood. We use the principles of equifinality and multifinality to describe the limitations of applying one intervention model to address all children presenting with different types of risk for early problem behavior. We then describe the potential benefits of applying a tiered model for having impacts at the population level and two initial applications of this approach during early childhood. The first of these tiered models, Smart Beginnings, integrates the use of two evidenced-based preventive interventions, Video Interaction Project, a universal parenting program, and Family Check-Up, a selective parenting program. Building on the strengths of Smart Beginnings, the second trial, The Pittsburgh Study includes Video Interaction Project and Family Check-Up, and other more and less-intensive programs to address the spectrum of challenges facing parents of young children. Findings from these two projects are discussed with their implications for developing tiered models to support children's early development and mental health.

Unconditional Cash Transfers and Maternal Assessments of Children's Health, Nutrition, and Sleep: A Randomized Clinical Trial

Importance

Children experiencing poverty are more likely to experience worse health outcomes, including injury, chronic illness, worse nutrition, and poorer sleep. The extent to which poverty reduction improves these outcomes is unknown.

Objective

To evaluate the effect of a 3-year, monthly unconditional cash transfer on health, nutrition, sleep, and health care utilization among children experiencing poverty who were healthy at birth.

Design, Setting, and Participants

This longitudinal randomized clinical trial recruited 1000 mother-infant dyads between May 2018 and June 2019. Dyads were recruited from postpartum wards in 12 hospitals in 4 US cities: New York, New York; Omaha, Nebraska; New Orleans, Louisiana; and Minneapolis/St Paul, Minnesota. Eligibility criteria included an annual income less than the federal poverty line, legal age for consent, English or Spanish speaking, residing in the state of recruitment, and an infant admitted to the well-baby nursery who will be discharged to the mother's custody. Data analysis was conducted from July 2022 to August 2023.

Intervention

Mothers were randomly assigned to receive either a high-cash gift ($333/mo, or $3996/y) or a low-cash gift ($20/mo, or $240/y) for the first several years of their child's life.

Main Outcomes and Measures

Primary preregistered outcomes reported here include an index of child health and medical care and child sleep disturbances. Secondary preregistered outcomes reported include children's consumption of healthy and unhealthy foods.

Results

A total of 1000 mother-infant dyads were enrolled, with 400 randomized to the high-cash gift group and 600 to the low-cash gift group. Participants were majority Black (42%) and Hispanic (41%); 857 mothers participated in all 3 waves of data collection. We found no statistically detectable differences between the high-cash and low-cash gift groups in maternal assessments of children's health (effect size [ES] range, 0.01-0.08; SE range, 0.02-0.07), sleep (ES range, 0.01-0.10; SE, 0.07), or health care utilization (ES range, 0.01-0.11; SE range, 0.03-0.07). However, mothers in the high-cash gift group reported higher child consumption of fresh produce at child age 2 years, the only time point it was measured (ES, 0.17; SE, 0.07; P = .03).

Conclusions and Relevance

In this study, unconditional cash transfers to mothers experiencing poverty did not improve reports of their child's health, sleep, or health care utilization. However, stable income support of this magnitude improved toddlers' consumption of fresh produce. Healthy newborns tend to grow into healthy toddlers, and the impacts of poverty reduction on children's health and sleep may not be fully borne out until later in life.

Trial Registration

ClinicalTrials.gov Identifier: NCT03593356.

Postpartum navigation decreases severe maternal morbidity most among Black women

BACKGROUND

Postpartum care is crucial for addressing conditions associated with severe maternal morbidity and mortality. Examination of programs that affect these outcomes for women at high risk, including disparate populations, is needed.

OBJECTIVE

This study aimed to examine whether a postpartum navigation program decreases all-cause 30-day postpartum hospitalizations and hospitalizations because of severe maternal morbidity identified using the US Centers for Disease Control and Prevention guidelines. The effect of this program was explored across patient demographics, including race and ethnicity.

STUDY DESIGN

This was a retrospective cohort study that used health records of women who delivered at 3 large hospitals in the New York metropolitan area (Queens and Long Island) between April 2020 and November 2021 and who were at high risk of severe maternal morbidity. The incidence rates of 30-day postpartum all-cause hospitalization and hospitalization because of severe maternal morbidity were compared between women who were and were not enrolled in a novel postpartum transitional care management program. Navigation included standardized assessments, development of care plans, clinical management, and connection to clinical and social services that would extend beyond the postpartum period. Because the program prioritized enrolling women of the greatest risk, the risk-adjusted incidence was estimated using multivariate Poisson regression and stratified across patient demographics.

RESULTS

Patient health records of 5819 women were included for analysis. Of note, 5819 of 19,258 deliveries (30.2%) during the study period were identified as having a higher risk of severe maternal morbidity. This was consistent with the incidence of high-risk pregnancies for tertiary hospitals in the New York metropolitan area. The condition most identified for risk of severe maternal morbidity at the time of delivery was hypertension (3171/5819 [54.5%]). The adjusted incidence of all-cause rehospitalization was 20% lower in enrollees than in nonenrollees (incident rate ratio, 0.80; 95% confidence interval, 0.67-0.95). Rehospitalization was decreased the most among Black women (incident rate ratio, 0.57; 95% confidence interval, 0.42-0.80). The adjusted incidence of rehospitalization because of indicators of severe maternal morbidity was 56% lower in enrollees than in nonenrollees (incident rate ratio, 0.44; 95% confidence interval, 0.24-0.77). Furthermore, it decreased most among Black women (incident rate ratio, 0.23; 95% confidence interval, 0.07-0.73).

CONCLUSION

High-risk medical conditions at the time of delivery increased the risk of postpartum hospitalization, including hospitalizations because of severe maternal morbidity. A postpartum navigation program designed to identify and resolve clinical and social needs reduced postpartum hospitalizations and racial disparities with hospitalizations. Hospitals and healthcare systems should adopt this type of care model for women at high risk of severe maternal morbidity. Cost analyses are needed to evaluate the financial effect of postpartum navigation programs for women at high risk of severe maternal morbidity or mortality, which could influence reimbursement for these types of services. Further evidence and details of novel postpartum interventional models are needed for future studies.

The effects of a universal short-term home visiting program: Two-year impact on parenting behavior and parent mental health

BACKGROUND

At the time of childbirth, families face heightened levels of unmet need. These needs, if left unmet, can lead parents to engage in less positive parenting practices, which in turn, increase the risk of child maltreatment. Family Connects (FC) is a universal postnatal nurse home-visiting program designed to prevent child maltreatment by supporting all families in a community through one to three visits to improve parent mental health and parenting behaviors. A randomized controlled trial of FC demonstrated improving positive parenting and reducing postpartum depression through age 6 months.

OBJECTIVE

To determine sustained (2-year) impact of random assignment to FC on parenting behavior and parent mental health and identify heterogeneity of effects.

PARTICIPANTS AND SETTING

A representative subsample of 496 families that had been randomized to FC (255 treatment; 241 control) of infants born between July 1, 2009, and December 31, 2010, in Durham County, North Carolina.

METHODS

Demographic characteristics were collected through hospital discharge data. Treatment-blinded interviewers collected maternal reports of parenting behavior and mental health at infant age two years. Moderation and subgroup analyses were conducted to estimate heterogeneity in impact of FC.

RESULTS

Mothers assigned to FC engaged in more self-reported positive parenting relative to control mothers (B = 0.21; p < 0.05). Hispanic mothers assigned to FC reported greater sense of parenting competence (B = 1.28; p < 0.05). No significant main effect differences were identified for negative parenting, maternal depression, or father involvement.

CONCLUSIONS

Assignment to FC was associated with improvements in population-level self-reported scores of positive parenting 2 years post-intervention.

The Effect of a U.S. Poverty Reduction Intervention on Maternal Assessments of Young Children's Health, Nutrition, and Sleep: A Randomized Control Trial

Importance

Children experiencing poverty are more likely to experience worse health outcomes during the first few years of life, including injury, chronic illness, worse nutrition, and poorer sleep. The extent to which a poverty reduction intervention improves children's health, nutrition, sleep, and healthcare utilization is unknown.

Objective

To determine the effect of a 3-year, monthly unconditional cash transfer on health, nutrition, sleep, and healthcare utilization of children experiencing poverty who are healthy at birth.

Design

Longitudinal randomized control trial.

Setting

Mother-infant dyads were recruited from postpartum wards in 12 hospitals in four cities across the U.S.

Participants

1,000 mothers were enrolled in the study. Eligibility criteria included: an annual income below the federal poverty line, being of legal age for consent, speaking English or Spanish, residing in the state of recruitment, and having an infant admitted to the well-baby nursery with plans to be discharged to the custody of the mother.

Intervention

Mothers were randomly assigned to receive either a high-cash gift ($333 per month, or $3,996 per year; n=400) or a low-cash gift ($20 per month, or $240 per year; n=600) for the first several years of their child's life.

Main Outcomes and Measures

Pre-registered maternal assessments of the focal child's health, nutrition, sleep, and healthcare utilization were collected at children's ages 1, 2, and 3.

Results

Enrolled participants were majority Black (42%) and Hispanic (41%). 857 mothers participated in all three waves of data collection. We found no statistically detectable differences between the high-cash and low-cash gift groups in maternal assessments of children's overall health, sleep, or healthcare utilization. However, mothers in the high-cash gift group reported higher child consumption of fresh produce compared with mothers in the low-cash gift group at age 2, the only time point it was measured (β=0.17, SE=0.07, p=0.03).

Conclusions and Relevance

In this RCT, unconditional cash transfers to mothers experiencing poverty did not improve their reports of their child's health, sleep, or healthcare utilization. However, stable income support of this magnitude improved toddler's consumption of fresh produce. Healthy newborns tend to grow into healthy toddlers, and the impacts of poverty reduction on children's health and sleep may not be fully borne out until later in life.

Trial Registration

Baby's First Years (BFY; ID NCT03593356) https://clinicaltrials.gov/ct2/show/NCT03593356?term=NCT03593356&draw=2&rank=1.

Quasinatural Experiment of Postnatal Home Visiting: An Independent Impact Study of Family Connects

INTRODUCTION

Family Connects (FC) is a postnatal nurse home visiting program that has scale-up potential because it is brief, inexpensive, and universal. Three investigations have linked Family Connects to improved maternal and family outcomes, but no independent impact studies have been conducted to date.

METHODS

This study investigates a FC program in Racine County, WI that was implemented by a multimunicipal health department in partnership with a local hospital. The sampling frame included all women who gave birth at the hospital from July 1, 2018 to August 31, 2019 (N=1,511). A quasinatural experiment resulted from systematically restricting FC recruitment to weekdays. All eligible women whose birth records and addresses were obtained from a vital records office were mailed a 6-month postpartum survey. Data collected from 489 respondents (32.4%) were analyzed in February 2022 to estimate the impact of FC on maternal health, infant health and development, and parenting behavior outcomes under intent-to-treat and per protocol assumptions.

RESULTS

No significant differences were observed between study groups at baseline. Despite evidence that the FC program in Racine met many model standards for implementation fidelity, null effects were observed at 6 months after delivery for most outcomes. Results suggested that parents from eligible households reported more frequent infant emergency medical episodes than parents who were not offered the program.

CONCLUSIONS

This study found few significant effects associated with FC participation. Further investigation is needed to identify the populations with and conditions under which the program produces its intended effects.

Is a universal nurse home visiting program possible? A cross-sectional survey of nurse home visitation service needs among pregnant women and mothers with young children

In 2019, the South Korean government established a plan to develop home visitation services for pregnant women and women with children below the age of 24 months and expand the services nationwide. Therefore, a national survey was needed to provide relevant information for the policy decision of whether to implement universal home visitation services by nurses for families with young children. To determine home visitation service needs in South Korea, 804 women who were pregnant or had children below the age of 24 months were selected as survey participants through stratified random sampling by region reflecting geographical distribution in numbers of births. Of them, 614 responded to survey questionnaires delivered via email. After excluding surveys with too short of a response time, extreme values, and incomplete answers, 500 participants’ responses were analyzed. Participants indicated whether they supported the provision of home visitation services and whether they were willing to utilize home visitation services. The survey also elicited responses regarding the level of needs for individual service items that could be delivered by nurses during home visits. The fieldwork was conducted by a consulting and research firm. The differences in whether respondents supported nurse home visitation services and intended to use nurse home visitation services according to mothers’ characteristics were examined using the chi-square test. In total, 88.0% of survey participants supported nurse home visitation services, and 81.2% indicated that they intended to receive the services. Most pregnant women and women with children below the age of 24 months responded positively to the various prenatal or postpartum services that nurses could provide during home visits. The percentages of support for the services and intention to use services were generally high among subgroups according to mothers’ characteristics. Therefore, universal home visitation services by nurses during pregnancy and in the postnatal period would be received well by Korean women.

Transitioning to virtual interaction during the COVID-19 pandemic: Impact on the family connects postpartum home visiting program activity

In this paper, we analyze program activity for Family Connects (FC), an evidence-based postpartum home-visiting intervention, during the COVID-19 pandemic. When the pandemic began, FC transitioned to a virtual protocol which maintains key psychosocial components of the in-person protocol and adjusts health assessments to address the lack of in-person contact. Program performance is contrasted for periods before the pandemic onset (April 2019-March 2020) and after the onset (April 2020-March 2021), involving 10,280 scheduled visits and 6696 visited families (46% non-Hispanic white; 20% non-Hispanic Black; 23% Hispanic; and 10% other race). Post-pandemic onset, FC program participation rates were at 89.8% of pre-pandemic levels. Home visitors observed post-onset increases in families' concerns about home safety but declines in families' needs related to infant care. Community connections were facilitated for 42.9% of visited families post-pandemic onset compared to 51.1% pre-pandemic onset. We conclude that post-pandemic onset virtual delivery rates of FC declined but are high enough to merit continued implementation during a period when some families will decline in-person visits. When in-person visits are deemed safe per public health guidelines, the findings suggest a hybrid approach that could maximize program outreach by prioritizing in-person contact and offering virtual delivery as a second choice.

Home Visiting Services During the COVID-19 Pandemic: Program Activity Analysis for Family Connects

PURPOSE

Early reports highlighted challenges in delivering home visiting programs virtually during the COVID-19 pandemic but the extent of the changes in program implementation and their implications remains unknown. We examine program activity and families' perceptions of virtual home visiting during the first nine months of the pandemic using implementation data for Family Connects (FC), an evidence-based and MIECHV-eligible, postpartum nurse home visiting program.

DESCRIPTION

Aggregate program implementation data for five FC sites for January-November of 2019 and 2020 are compared. The COVID-19 Modification Survey is used to analyze families' reactions to virtual program delivery.

ASSESSMENT

Post-pandemic onset, FC's program completion rates amounted to 86% of the pre-pandemic activity level. Activity in key components of the intervention-home-visitor education and referrals to community agencies-was maintained at 98% and 87% of the pre-pandemic level respectively. However, education and referrals rates declined among families of color and low-income families. Finally, families reported a positive response to the program, with declines in feelings of isolation and increases in positive attitudes toward in-person medical care-seeking due to FC visits.

CONCLUSIONS

During the first nine months of the COVID-19 pandemic, families' interest in home visiting remained strong, performance metrics were maintained at high levels, and families responded positively to the virtual delivery of home visiting. Home visiting programs should continue implementation with virtual modifications during the remainder of the pandemic but attention is needed to address growing disparities in access to home visiting benefits among marginalized communities.

Reducing Poverty-Related Disparities in Child Development and School Readiness: The Smart Beginnings Tiered Prevention Strategy that Combines Pediatric Primary Care with Home Visiting

This paper describes the Smart Beginnings Integrated Model, an innovative, tiered approach for addressing school readiness disparities in low-income children from birth to age 3 in the United States through universal engagement of low-income families and primary prevention in pediatric primary care integrated with secondary/tertiary prevention in the home. We build on both public health considerations, in which engagement, cost and scalability are paramount, and a developmental psychopathology framework (Cicchetti & Toth, Journal of Child Psychology and Psychiatry, and Allied Disciplines 50:16–25, 2009), in which the child is considered within the context of the proximal caregiving environment. Whereas existing early preventive models have shown promise in promoting children’s school readiness, the Smart Beginnings model addresses three important barriers that have limited impacts at the individual and/or population level: (1) identification and engagement of vulnerable families; (2) the challenges of scalability at low cost within existing service systems; and (3) tailoring interventions to address the heterogeneity of risk among low-income families. Smart Beginnings takes advantage of the existing platform of pediatric primary care to provide a universal primary prevention strategy for all families (Video Interaction Project) and a targeted secondary/tertiary prevention strategy (Family Check-Up) for families with additional contextual factors. We describe the theory underlying the Smart Beginnings model, some initial findings from its recent application in two cities, and implications for changing social policy to promote school readiness beginning during very early childhood.

Schedules for home visits in the early postpartum period

BACKGROUND

Maternal complications, including psychological/mental health problems and neonatal morbidity, have commonly been observed in the postpartum period. Home visits by health professionals or lay supporters in the weeks following birth may prevent health problems from becoming chronic, with long-term effects. This is an update of a review last published in 2017.

OBJECTIVES

The primary objective of this review is to assess the effects of different home-visiting schedules on maternal and newborn mortality during the early postpartum period. The review focuses on the frequency of home visits (how many home visits in total), the timing (when visits started, e.g. within 48 hours of the birth), duration (when visits ended), intensity (how many visits per week), and different types of home-visiting interventions.

SEARCH METHODS

For this update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (19 May 2021), and checked reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) (including cluster-, quasi-RCTs and studies available only as abstracts) comparing different home-visiting interventions that enrolled participants in the early postpartum period (up to 42 days after birth) were eligible for inclusion. We excluded studies in which women were enrolled and received an intervention during the antenatal period (even if the intervention continued into the postnatal period), and studies recruiting only women from specific high-risk groups (e.g. women with alcohol or drug problems).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 16 randomised trials with data for 12,080 women. The trials were carried out in countries across the world, in both high- and low-resource settings. In low-resource settings, women receiving usual care may have received no additional postnatal care after early hospital discharge. The interventions and controls varied considerably across studies. Trials focused on three broad types of comparisons, as detailed below. In all but four of the included studies, postnatal care at home was delivered by healthcare professionals. The aim of all interventions was broadly to assess the well-being of mothers and babies, and to provide education and support. However, some interventions had more specific aims, such as to encourage breastfeeding, or to provide practical support. For most of our outcomes, only one or two studies provided data, and results were inconsistent overall. All studies had several domains with high or unclear risk of bias. More versus fewer home visits (five studies, 2102 women) The evidence is very uncertain about whether home visits have any effect on maternal and neonatal mortality (very low-certainty evidence). Mean postnatal depression scores as measured with the Edinburgh Postnatal Depression Scale (EPDS) may be slightly higher (worse) with more home visits, though the difference in scores was not clinically meaningful (mean difference (MD) 1.02, 95% confidence interval (CI) 0.25 to 1.79; two studies, 767 women; low-certainty evidence). Two separate analyses indicated conflicting results for maternal satisfaction (both low-certainty evidence); one indicated that there may be benefit with fewer visits, though the 95% CI just crossed the line of no effect (risk ratio (RR) 0.96, 95% CI 0.90 to 1.02; two studies, 862 women). However, in another study, the additional support provided by health visitors was associated with increased mean satisfaction scores (MD 14.70, 95% CI 8.43 to 20.97; one study, 280 women; low-certainty evidence). Infant healthcare utilisation may be decreased with more home visits (RR 0.48, 95% CI 0.36 to 0.64; four studies, 1365 infants) and exclusive breastfeeding at six weeks may be increased (RR 1.17, 95% CI 1.01 to 1.36; three studies, 960 women; low-certainty evidence). Serious neonatal morbidity up to six months was not reported in any trial. Different models of postnatal care (three studies, 4394 women) In a cluster-RCT comparing usual care with individualised care by midwives, extended up to three months after the birth, there may be little or no difference in neonatal mortality (RR 0.97, 95% CI 0.85 to 1.12; one study, 696 infants). The proportion of women with EPDS scores ≥ 13 at four months is probably reduced with individualised care (RR 0.68, 95% CI 0.53 to 0.86; one study, 1295 women). One study suggests there may be little to no difference between home visits and telephone screening in neonatal morbidity up to 28 days (RR 0.97, 95% CI 0.85 to 1.12; one study, 696 women). In a different study, there was no difference between breastfeeding promotion and routine visits in exclusive breastfeeding rates at six months (RR 1.47, 95% CI 0.81 to 2.69; one study, 656 women). Home versus facility-based postnatal care (eight studies, 5179 women) The evidence suggests there may be little to no difference in postnatal depression rates at 42 days postpartum and also as measured on an EPDS scale at 60 days. Maternal satisfaction with postnatal care may be better with home visits (RR 1.36, 95% CI 1.14 to 1.62; three studies, 2368 women). There may be little to no difference in infant emergency health care visits or infant hospital readmissions (RR 1.15, 95% CI 0.95 to 1.38; three studies, 3257 women) or in exclusive breastfeeding at two weeks (RR 1.05, 95% CI 0.93 to 1.18; 1 study, 513 women).

AUTHORS' CONCLUSIONS

The evidence is very uncertain about the effect of home visits on maternal and neonatal mortality. Individualised care as part of a package of home visits probably improves depression scores at four months and increasing the frequency of home visits may improve exclusive breastfeeding rates and infant healthcare utilisation. Maternal satisfaction may also be better with home visits compared to hospital check-ups. Overall, the certainty of evidence was found to be low and findings were not consistent among studies and comparisons. Further well designed RCTs evaluating this complex intervention will be required to formulate the optimal package.

Effect of a Universal Postpartum Nurse Home Visiting Program on Child Maltreatment and Emergency Medical Care at 5 Years of Age: A Randomized Clinical Trial

Importance

The Family Connects (FC) program, a community-wide nurse home visiting program for newborns, has been shown to provide benefits for children and families through the first 2 years of life. Potential longer-term outcomes for child well-being remain unknown.

Objective

To determine the effect of randomization to FC on child maltreatment investigations and emergency medical care through 5 years of age.

Design, Setting, and Participants

In this randomized clinical trial, families of all 4777 resident births in Durham County, North Carolina, from July 1, 2009, to December 31, 2010, were randomly assigned to receive the FC program or treatment as usual. Impact evaluation was on an intent-to-treat basis and focused on a subsample of 549 families randomly selected from the full population and included review of hospital and Child Protective Services (CPS) administrative records. Statistical analysis was conducted from November 6, 2020, to April 25, 2021.

Interventions

The FC programs includes 1 to 3 nurse home visits beginning at the infant age of 3 weeks designed to identify family-specific needs, deliver education and intervention, and connect families with community resources matched to their needs. Ongoing program engagement with service professionals and an electronic resource directory facilitate effective family connections to the community.

Main Outcomes and Measures

Two primary trial outcomes were CPS-recorded child maltreatment investigations and emergency medical care use based on hospital records.

Results

Of the 4777 randomized families, 2327 were allocated to the intervention, and 2440 were allocated to services as usual. Among the children in the full study population, 2380 (49.8%) were female, 2397 (50.2%) were male, and 3359 (70.3%) were from racial/ethnic minority groups; of the 531 children included in the impact evaluation follow-up, 284 (53.5%) were female, 247 (46.5%) were male, and 390 (73.4%) were from racial/ethnic minority groups. Negative binomial models indicated that families assigned to FC had 39% fewer CPS investigations for suspected child maltreatment through 5 years of age (95% CI, -0.80 to 0.06; 90% CI, -0.73 to -0.01; control = 44 total investigations per 100 children and intervention = 27 total investigations per 100 children); intervention effects did not differ across subgroups. Families assigned to FC also had 33% less total child emergency medical care use (95% CI, -0.59 to -0.14; 90% CI, -0.55 to -0.18; control = 338 visits and overnight hospital stays per 100 children and intervention = 227 visits and overnight hospital stays per 100 children). Positive effects held across birth risk, child health insurance, child sex, single-parent status, and racial/ethnic groups. Effects were larger for nonminority families compared with minority families.

Conclusions and Relevance

The findings of this randomized clinical trial suggest that, when implemented with high quality and broad reach, a brief postpartum nurse home visiting program can reduce population rates of child maltreatment and emergency medical care use in early childhood.

Trial Registration

ClinicalTrials.gov Identifier: NCT01406184.

Annual Research Review: Universal and targeted strategies for assigning interventions to achieve population impact

This article proposes that universal and targeted preventive interventions should be compared and evaluated in terms of their benefit-cost ratio in achieving population-wide impact on mental disorders and related outcomes. Universal approaches attempt to affect every individual in a population, whereas targeted approaches select candidates for intervention based on screening of demographic or behavioral characteristics. Unique assets and challenges of each approach in achieving population impact in a cost-efficient way are discussed, along with spillover effects, sensitivity and specificity, developmental processes, timing of intervention, and the relation between severity of risk and plasticity. A general targeted-efficiency framework is proposed as a heuristic to evaluate the collective merits of universal and targeted approaches in specific cases. A tiered approach that combines universal and targeted identification strategies is proposed, and examples are described. Issues for high-priority research are identified.

Effect of a Community Agency-Administered Nurse Home Visitation Program on Program Use and Maternal and Infant Health Outcomes: A Randomized Clinical Trial

IMPORTANCE

Postnatal home visitation to support parenting and infant healthy development is becoming increasingly common based on university efficacy studies, but effectiveness when disseminated by communities is not clear.

OBJECTIVE

To test implementation and impact of the Family Connects (FC) program when administered by a community agency.

DESIGN, SETTING, AND PARTICIPANTS

In this randomized clinical trial, births were randomly assigned to receive FC or treatment as usual. Independent evaluation was conducted through parent interviews and review of health and child protective services records. Interviewers were blind to the experimental condition of participants, and participants were blind about the purpose of the interview as an intervention evaluation. A total of 936 consecutive residential births at Duke University Hospital from January 1, 2014, through June 30, 2014, were included. Data were analyzed preliminarily for reporting to funders in early 2015 before all birth-record covariates were scored and were analyzed more comprehensively in mid-2019 after administrative birth and child protective service records became available.

INTERVENTIONS

The goals of the FC brief universal program were to assess family-specific needs, complete brief interventions, and connect families with community resources. Community agencies and families were aligned through an electronic data system.

MAIN OUTCOMES AND MEASURES

Case records documented program penetration and quality. The primary outcome was child protective services investigations for maltreatment. Secondary outcomes were the number of sustained community connections, maternal mental health, parenting behavior, infant well-child care visits and maternal postpartum care compliance, and emergency health care utilization.

RESULTS

Of 936 births, 451 infants (48.2%) were female and 433 (46.3%) were from racial/ethnic minority groups. In all, 456 births (46.5%) were randomized to the intervention and 480 (53.5%) were randomized to the control. All analyses were based on intention to treat. The impact analysis included 158 intervention families and 158 control families. Intervention penetration was 76%, adherence to the protocol was 90%, and independent agreement in scoring (κ) was 0.75. Nurses identified and addressed minor problems for 52% of families and connected an additional 42% to community resources. Analysis of the primary outcome of child abuse investigations revealed a mean (SD) of 0.10 (0.30) investigations for the intervention group vs 0.18 (0.56) investigations for the control group (b = -0.09; 90% CI, -0.01 to -0.12; 95% CI, -0.18 to 0.01; P = .07). The intervention group's rate of possible maternal anxiety or depression was 18.2% vs 25.9% for the control group (b = -7.70; 90% CI, -15.2 to -0.1; 95% CI, -16.6 to 1.3; P = .09).

CONCLUSIONS AND RELEVANCE

This study indicates that a nurse home visitation program for families of newborns can be implemented by a community agency with high penetration and quality. Other communities could benefit from wider dissemination of the program provided that quality remains strong and evaluation continues.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01843036.