Protocol for a randomized controlled trial evaluating the impact of the Nurse-Family Partnership's home visiting program in South Carolina on maternal and child health outcomes

Effect of an Intensive Nurse Home Visiting Program on Postpartum Contraceptive Use and Birth Spacing: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effect of an intensive nurse home visiting program on postpartum contraceptive use and birth spacing among individuals with a first pregnancy who were eligible for Medicaid insurance in South Carolina.

METHODS

We conducted a nonblinded, randomized controlled trial of the Nurse-Family Partnership (NFP), an established intensive home visiting program that provides prenatal and postpartum home visits through 2 years after childbirth. The trial included patients who were eligible for Medicaid insurance with a first pregnancy at less than 28 weeks of gestation between April 1, 2016, and March 17, 2020, who were followed up through 2 years after childbirth. Participants were randomized 2:1 to NFP compared with standard of care treatment. The primary outcome was a birth interval of less than 21 months between the index pregnancy and a subsequent birth. The secondary outcomes were birth intervals of less than 15 and 24 months, receipt of a contraceptive implant or intrauterine device (IUD) immediately postpartum, any contraceptive use and receipt of a family planning visit (at both 6 weeks and 1 year postpartum), and IUD receipt at 1 year postpartum. We assessed outcomes using linked birth certificate records and Medicaid claims data.

RESULTS

A total of 4,932 trial participants (3,295 in the intervention group and 1,637 in the control group) were included in the study analysis. Within 21 months of the study index birth, 11.0% of individuals in the NFP group and 12.2% of the usual care group had a subsequent birth. The NFP did not have a statistically significant effect on birth intervals of less than 21 months (adjusted coefficient -1.1, 95% CI, -2.9 to 0.8). There were no statistically significant differences between the NFP and control groups for any of the study's eight secondary outcomes related to birth spacing and postpartum contraceptive use.

CONCLUSION

Home visits with a registered nurse did not affect postpartum contraceptive use or birth spacing.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03360539.

Home Visits and the Use of Routine and Emergency Postpartum Care Among Low-Income People: A Secondary Analysis of a Randomized Clinical Trial

Importance

Access to appropriate postpartum care is essential for improving maternal health outcomes and promoting maternal health equity.

Objective

To analyze the impact of the Nurse-Family Partnership (NFP) home visiting program on use of routine and emergency postpartum care.

Design, Setting, and Participants

This study was a secondary analysis of a randomized clinical trial that enrolled eligible participants between 2016 and 2020 to receive NFP or usual care from a South Carolina Medicaid program. Participants were nulliparous pregnant individuals at less than 28 weeks' gestation at enrollment who were enrolled in Medicaid during pregnancy or delivery. Analysis was performed February 2, 2023, to July 16, 2024.

Intervention

Participants were enrolled in a 2:1 ratio to receive NFP, an established model of nurse home visiting, or usual care. NFP visits are conducted prenatally and for up to 2 years post partum.

Main Outcomes and Measures

This study assessed one of the trial's preregistered secondary outcomes: attendance at a routine postpartum health care visit before 12 weeks post partum. Other exploratory outcomes included outpatient care use, hospitalization, and emergent, nonemergent, and any use of emergency department (ED) health services at 12 weeks and 1 year post partum. Subgroup analyses examined individuals who underwent cesarean delivery, had chronic disease, experienced pregnancy complications, reported non-Hispanic Black race and ethnicity, were socially vulnerable, or were unaffected by COVID-19.

Results

Among 5670 participants enrolled, 4877 were analyzed (median [IQR] age, 21 [19-25] years), including 3261 who received NFP and 1616 who received usual care. By race and ethnicity, the sample included 259 Hispanic individuals (5.7%); 56 non-Hispanic Asian, Indigenous, or Native Hawaiian and Pacific Islander individuals (1.2%); 2535 non-Hispanic Black individuals (55.4%); 1587 non-Hispanic White individuals (34.7%); and 141 individuals (3.1%) with more than 1 race reported (and non-Hispanic ethnicity). There was no significant difference in attendance of routine postpartum visit at 12 weeks between NFP and usual care groups (63.8% vs 64.2%; adjusted difference [AD] -0.3 [95% CI, -3.2 to 2.5] percentage points). In exploratory analyses, the NFP group was less likely to have a visit to the ED without admission (AD, -2.5 [95% CI, -4.8 to -0.1] percentage points) in the first 12 weeks post partum. Other outcomes, including hospitalizations, outpatient visits, and emergent and nonemergent ED visits, were not different between intervention and control groups. There were also no statistically significant differences within subgroups.

Conclusions and Relevance

In this secondary analysis of a randomized clinical trial of nulliparous pregnant individuals with low income, nurse home visiting did not increase use of routine postpartum care in the immediate or extended postpartum periods, even among those with greater health challenges. Nurse home visiting was associated with reduced ED use. More research is needed on how to improve continuity of perinatal care for low-income populations.

Trial Registration

ClinicalTrials.gov Identifier: NCT03360539.

Home Visits With A Registered Nurse Did Not Affect Prenatal Care In A Low-Income Pregnant Population

There is an urgent need to improve maternal and neonatal health outcomes and decrease their racial disparities in the US. Prenatal nurse home visiting programs could help achieve this by increasing the use and quality of prenatal care and facilitating healthy behaviors during pregnancy. We conducted a randomized controlled trial of 5,670 Medicaid-eligible pregnant people in South Carolina to evaluate how a nurse home visiting program affected prenatal health care and health outcomes. We compared outcomes between the treatment and control groups and found little evidence of statistically significant differences in the intensity of prenatal care use, receipt of guideline-based prenatal care services, other health care use, or gestational weight gain. Nor did we find treatment effects in subgroup analyses of socially vulnerable participants (46.9 percent of the sample) or non-Hispanic Black participants (52.0 percent of the sample). Compared with the broader Medicaid population, our trial participants had more health and social risk factors, more engagement with prenatal care, and similar pregnancy outcomes. Delivering intensive nurse home visiting programs to the general Medicaid population might not be an efficient method to improve prenatal care for those who need the most support during pregnancy.

Randomized Controlled Trial of Health Coaching for Parents of Children With Medical Complexity

BACKGROUND AND OBJECTIVE

Parents of children with medical complexity (CMCs) struggle with managing their children's care needs. Health coaching provides patients with tools to take ownership of their care. We sought to assess the impact of health coaching for parents of CMCs on activation, child's health related quality of life (HRQL), and utilization.

METHODS

Parents of CMCs receiving primary care at two academic primary care practices were randomized to receive 3-6 months of coaching from a trained health coach (n = 54) or usual care (n = 71). Parents were surveyed on activation, HRQL, and experience of care at baseline and the end of the study period. Markers of utilization (missed visit rates, ED, and admissions) were measured for 12 months prior to and after enrollment. Parametric, nonparametric, and Poisson regression were used to assess baseline differences in characteristics and average pre-post differences between the groups.

RESULTS

At baseline, activation and rating of patient experience were high in both groups, while HRQL was one standard deviation below the population-based mean. Both groups had slight increases in HRQL and P-PAM without significant differences between groups. ED visits declined significantly more in the intervention group than the usual care group (0.68 visits, (-0.03, -1.32) P = .04); there were nonsignificant differences in changes in other utilization metrics.

CONCLUSION

Health coaching was associated with a decrease in ED use but not in changes in activation, patient experience, or HRQL. More inquiry is needed to understand whether health coaching is an effective modality for improving care for children with medical complexity.

Effect of an Intensive Nurse Home Visiting Program on Adverse Birth Outcomes in a Medicaid-Eligible Population: A Randomized Clinical Trial

IMPORTANCE

Improving birth outcomes for low-income mothers is a public health priority. Intensive nurse home visiting has been proposed as an intervention to improve these outcomes.

OBJECTIVE

To determine the effect of an intensive nurse home visiting program on a composite outcome of preterm birth, low birth weight, small for gestational age, or perinatal mortality.

DESIGN, SETTING, AND PARTICIPANTS

This was a randomized clinical trial that included 5670 Medicaid-eligible, nulliparous pregnant individuals at less than 28 weeks' gestation, enrolled between April 1, 2016, and March 17, 2020, with follow-up through February 2021.

INTERVENTIONS

Participants were randomized 2:1 to Nurse Family Partnership program (n = 3806) or control (n = 1864). The program is an established model of nurse home visiting; regular visits begin prenatally and continue through 2 postnatal years. Nurses provide education, assessments, and goal-setting related to prenatal health, child health and development, and maternal life course. The control group received usual care services and a list of community resources. Neither staff nor participants were blinded to intervention group.

MAIN OUTCOMES AND MEASURES

There were 3 primary outcomes. This article reports on a composite of adverse birth outcomes: preterm birth, low birth weight, small for gestational age, or perinatal mortality based on vital records, Medicaid claims, and hospital discharge records through February 2021. The other primary outcomes of interbirth intervals of less than 21 months and major injury or concern for abuse or neglect in the child's first 24 months have not yet completed measurement. There were 54 secondary outcomes; those related to maternal and newborn health that have completed measurement included all elements of the composite plus birth weight, gestational length, large for gestational age, extremely preterm, very low birth weight, overnight neonatal intensive care unit admission, severe maternal morbidity, and cesarean delivery.

RESULTS

Among 5670 participants enrolled, 4966 (3319 intervention; 1647 control) were analyzed for the primary maternal and neonatal health outcome (median age, 21 years [1.2% non-Hispanic Asian, Indigenous, or Native Hawaiian and Pacific Islander; 5.7% Hispanic; 55.2% non-Hispanic Black; 34.8% non-Hispanic White; and 3.0% more than 1 race reported [non-Hispanic]). The incidence of the composite adverse birth outcome was 26.9% in the intervention group and 26.1% in the control group (adjusted between-group difference, 0.5% [95% CI, -2.1% to 3.1%]). Outcomes for the intervention group were not significantly better for any of the maternal and newborn health primary or secondary outcomes in the overall sample or in either of the prespecified subgroups.

CONCLUSIONS AND RELEVANCE

In this South Carolina-based trial of Medicaid-eligible pregnant individuals, assignment to participate in an intensive nurse home visiting program did not significantly reduce the incidence of a composite of adverse birth outcomes. Evaluation of the overall effectiveness of this program is incomplete, pending assessment of early childhood and birth spacing outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03360539.

Transitioning to telehealth due to COVID-19: Maintaining model fidelity in a home visiting program for parents of vulnerable infants

Maintaining treatment fidelity when implementing evidence‐based interventions is a significant challenge. The inability to deliver in‐person services due to the COVID‐19 pandemic critically challenged the foundation of implementation fidelity for home visiting programs across the globe. The Attachment and Biobehavioral Catch‐Up (ABC) program is an evidence‐based home visiting intervention designed to increase sensitivity in parents of infants who have experienced early adversity. ABC's community effectiveness is due to rigorous fidelity monitoring and supervision. Fidelity is measured by microanalytic coding of parenting opportunities and “in‐the‐moment” commenting, the active ingredient of ABC. In this study, we examined intervention fidelity among parent coaches implementing ABC through telehealth. Random 5‐min clips from 510 telehealth ABC session videos conducted by 91 parent coaches at 48 agencies were coded for their frequency and quality of in‐the‐moment comments. On average, parent coaches were able to exceed in‐person commenting fidelity standards when implementing ABC through the telehealth format. The active fidelity monitoring and supervision inherent to ABC's dissemination afforded a smooth transition to implementing ABC through telehealth while adhering to fidelity standards. Procedural and clinical challenges to telehealth implementation are discussed, along with future directions for telehealth program effectiveness.

Maternal and Child Mortality: Analysis of Nurse Home Visiting in 3 RCTs

INTRODUCTION

The impact of intensive prenatal and infant/toddler nurse home visiting on low-income mothers' and children's survival was examined in 3 RCTs following participants over 2-decade periods after trial registration during pregnancy (data gathered between 1978 and 2015 and analyzed between 2016 and 2020).

METHODS

All-cause and external-cause maternal mortality and preventable-cause child mortality were examined using National Death Index data. Survival rates were calculated for all the 1,138 mothers randomized and 1,076 live-born children in the second RCT (conducted in Memphis, TN) and for all the 1,135 mothers randomized and 1,087 live-born children in the first and third RCTs combined (conducted in Elmira, NY and Denver, CO).

RESULTS

There were no significant nurse home visiting-control differences in maternal mortality in Memphis or Elmira and Denver. Posthoc analysis, combining all 3 trials, suggested a reduction in external-cause maternal mortality among nurse-visited mothers (p=0.054). There was a marginally significant nurse home visiting-control difference in preventable-cause child mortality (p=0.09) in Memphis.

CONCLUSIONS

These results support examining maternal and child mortality in additional nurse home visiting trials with larger samples living in disadvantaged contexts. Intensive prenatal and infant/toddler home visiting by nurses for mothers and children living in poverty may decrease premature death.