E v i d e n c e - b a s e d public h e a l t h 0 Harcourt Brace and Company Lid 1998

Home visits by nurses before and after birth had beneficial effects for both child and family

1. Olds D L, Eckenrode J, Henderson C R et al. Long-term effects of home visitation on maternal life course and ehiM abuse attd neglect. JAMA 1997; 278:637-643 2. Kitzman H, Olds D L, Henderson C R et al. Effect o f prenatal and iafancy home visitation by nurses on pregnancy outcomes, childhood hzjures, and repeated childbearing. JAMA 1997; 278:644--652

PAPER 1

Objective

To measure the long-term effects of prenatal and early childhood home visiting by nurses.

Setting

New York State, USA.

Method

Randomized trial, started 15 years ago. The intervention was nine home visits during pregnancy and 23 home visits from the child's birth through to their second birthday.

Literature review

No explicit strategy; 25 references.

Results

There were significant reductions in the number of subsequent pregnancies, the need for financial support from the State, child

abuse and criminal behavior among low income unmarried mothers for up to 15 years after the birth of their first child.

Authors' conclusions

The authors take into account all the confounding factors that could explain these results other than the effect of the visit from the nurse. They conclude that total cost of the program is met by reductions in other forms of health care and welfare costs before the child reached 4 years of age, but emphasize that the results cannot be assumed to other types of home visit programs.

PAPER 2

Objective

To measure the effect of prenatal and infancy home visits by nurses on problems in pregnancy and child development.

Setting

Memphis, Tennessee, USA.

Method

Randomized controlled trial. The average number of home visits were seven during pregnancy and 26 between birth and the child's second birthday.

Literature review

No explicit strategy; 41 references.

Outcome measures

I. Pregnancy-induced hypertension 2. Pre-term delivery and low birth weight 3. Children's injuries, immunizations and

reports of behavior problems 4. Mother's reports of subsequent pregnancy 5. Mother's educational achievement 6. Labor force participation of welfare

use.

Results

In the intervention there was a significant reduction in pregnancy-induced hypertension, childhood injuries and subsequent pregnancies, but no effect on pre-term delivery or birth weight.

Authors' conclusions

The authors point out that they were trying to influence the mother's 'mastery' of child- rearing, namely a general psychological attribute affecting the individual's ability to cope with a wide range of challenges. They conclude that it would be 'injudicious' to drop the pre-natal part of the program because of its absence of signifcant effects on pregnancy and birth outcomes as it may be that the beneficial postnatal effects result from pre-natal intervention. This topic should be studied more closely in future.

:OMMENTAR~I

These two studies confirm powerfully the value of nurse visiting programs. A systematic review shows that home-based social support has significant benefits. 1 Surely now there is enough evidence to set up nurse visiting programs for at-risk teen, one-parent or low socio-economic families. But is there? There are three issues to consider. Firstly, these are US studies and may not be generalizable to other countries. For instance, in the UK we have midwives and health visitors already targeting visits to at-risk mothers. Secondly, what is the magic factor that resuits in success? Other studies are suggesting that the intervention can be given more cost-

effectively and more sensitively by experienced mothers local to the community. ~ Thirdly, such interventions should be assessed as part of a range of public health measures designed to improve family functioning. For instance, behaviorally-oriented parent training programs are emerging as effective in child behavior modification. 2 So how do we use these studies to inform local policy? For a start, inter-agency and community groups looking at the needs of children and families should review the existing evidence and tailor policies for local circumstances, and purchasers and providers of health care must ensure better targeting of existing resources towards those families at highest risk. We cannot ignore this evidence.

References 1. Hodnett E D, Roberts I. Home-based social

support for socially disadvantaged mothers. In: Neilson J P, Crowther CA, Hodnett E D, Hofmeyr G J, Keirse M J N C. (Eds). Pregnancy and Childbirth Module of The Cochrane Database of Systematic Reviews [updated 4 March 1997]. The Cochrane Collaboration: Issue 2. Oxford, Update Software

2. Barlow J. Systematic review of the effectiveness of parent-training programmes in improving behaviour problems in children aged 3-10 years. Health Services Resarch Unit, Oxford, 1997

Dr Alison Hill Director of Public Health

Buckinghamshire Health Authority, UK

12 EVIDENCE-BASED HEALTH POLICY AND MANAGEMENT MARCH 1998