David L. Olds

OBJECTIVE. Our goal was to test the effect of prenatal and infancy home visits by nurses on mothers' fertility and children's functioning 7 years after the program ended at child age 2. METHODS. We conducted a randomized, controlled trial in a public system of obstetric and pediatric care. A total of 743 primarily black women <29 weeks' gestation, with previous live births and at least 2 sociodemographic risk characteristics (unmarried, <12 years of education, unemployed), were randomly assigned to receive nurse home visits or comparison services. Primary outcomes consisted of intervals between births of first and second children and number of children born per year; mothers' stability of relationships with partners and relationships with the biological father of the child; mothers' use of welfare, food stamps, and Medicaid; mothers' use of substances; mothers' arrests and incarcerations; and children's academic achievement, school conduct, and mental disorders. Secondary outcomes were the sequelae of subsequent pregnancies, women's employment, experience of domestic violence, and children's mortality. RESULTS. Nurse-visited women had longer intervals between births of first and second children, fewer cumulative subsequent births per year, and longer relationships with current partners. From birth through child age 9, nurse-visited women used welfare and food stamps for fewer months. Nurse-visited children born to mothers with low psychological resources, compared with control-group counterparts, had better grade-point averages and achievement test scores in math and reading in grades 1 through 3. Nurse-visited children, as a trend, were less likely to die from birth through age 9, an effect accounted for by deaths that were attributable to potentially preventable causes. CONCLUSIONS. By child age 9, the program reduced women's rates of subsequent births, increased the intervals between the births of first and second children, increased the stability of their relationships with partners, facilitated children's academic adjustment to elementary school, and seems to have reduced childhood mortality from preventable causes.

Pregnancy and the early years of a child's life offer an opportune time to prevent a host of adverse outcomes that are important in their own right, but that also have significant implications for the development of criminal behavior. This paper summarizes a 27-year program of research that has attempted to improve early maternal and child health and future life prospects with prenatal and infancy home visiting by nurses. The program, known today as the Nurse-Family Partnership (NFP), is designed for low-income mothers who have had no previous live births. The home visiting nurses have three major goals: to improve the outcomes of pregnancy by helping women improve their prenatal health; to improve the child's health and development by helping parents provide more sensitive and competent care of the child; and to improve the parental life course by helping parents plan future pregnancies, complete their educations, and find work. Given consistent effects on prenatal health behaviors, parental care of the child, child abuse and neglect, child health and development, maternal life course, and criminal involvement of the mothers and children, the program is now being offered for public investment throughout the United States. Careful attention is being given to ensuring that the program is being conducted in accordance with the program model tested in the randomized trials.

Programs for parents of young children hold considerable promise for improving children's life‐course trajectories and for reducing health and development problems and associated costs to government and society. To date, this promise has not been achieved. Fulfilling the potential of parenting interventions will require substantial improvements in current practice for developing and testing such programs. Intervention development will be improved if clinicians and investigators ground parenting interventions in theory and epidemiology; and carefully pilot them to ascertain program feasibility, participant engagement, and behavioral change prior to testing them in randomized trials. Studies of parenting interventions will be improved if they adhere to the highest standards for randomization; if they examine objectively measured outcomes with clear public health relevance; and if they minimize selection factors known to compromise the analysis of data. Policy and practice recommendations for parenting interventions will be improved if they are based upon replicated randomized controlled trials, if the interventions are tested with different populations living in different contexts, and if they are examined in dissemination studies before public investments are made in such programs. Procedures need to be developed to ensure that the essential elements of evidence‐based parenting programs can be implemented reliably in a variety of practice settings so that they will produce their intended effects. To date, few programs have met these high programmatic and evidentiary standards, with the result that many large‐scale policy initiatives for at‐risk parents have failed. Evidence is accumulating, however, that some programs delivered by professionals, especially nurse home visiting programs for pregnant women and parents of young children, produce replicable effects on children's health and development, and that these programs can be reliably reproduced with different populations living in a variety of community settings.

Pregnancy and the early years of the child's life offer an opportune time to prevent a host of adverse maternal, child, and family outcomes that are important in their own right, but that also reflect biological, behavioral, and social substrates in the child and family that affect family formation and future life trajectories. This article summarizes a 27‐year program of research that has attempted to improve early maternal and child health and future life options with prenatal and infancy home visiting by nurses. The program is designed for low‐income mothers who have had no previous live births. The home‐visiting nurses have three major goals: to improve the outcomes of pregnancy by helping women improve their prenatal health, to improve the child's health and development by helping parents provide more sensitive and competent care of the child, and to improve parental life course by helping parents plan future pregnancies, complete their education, and find work. The program has been tested in three separate large‐scale, randomized controlled trials with different populations living in different contexts. Results from these trials indicate that the program has been successful in achieving two of its most important goals: (a) the improvement of parental care of the child as reflected in fewer injuries and ingestions that may be associated with child abuse and neglect and better infant emotional and language development; and (b) the improvement of maternal life course, reflected in fewer subsequent pregnancies, greater work‐force participation, and reduced dependence on public assistance and food stamps. The impact on pregnancy outcomes is equivocal. In the first trial, the program also produced long‐term effects on the number of arrests, convictions, emergent substance use, and promiscuous sexual activity of 15‐year‐old children whose nurse‐visited mothers were low‐income and unmarried when they registered in the study during pregnancy. In general, the impact of the program was greater on those segments of the population at greater risk for the particular outcome domain under examination. Since 1996, the program has been offered for public investment outside of research contexts. Careful attention has been given to ensuring that organizational and community contexts are favorable for development of the program, to providing excellent training and guidance to the nurses in their use of the program's visit‐by‐visit guidelines, to monitoring the functioning of the program with a comprehensive clinical information system, and to improving the performance of the programs over time with continuous improvement strategies.

Objectives. To determine whether infants who are fed initially and advanced at 30 mL/kg per day (intervention) take fewer days to get to full feedings than those who are fed initially and advanced at 20 mL/kg per day (control), without increasing their incidence of feeding complications and necrotizing enterocolitis (NEC). We also examined whether these infants regain birth weight earlier, have fewer days of intravenous fluids, and a have shorter hospital stay.

Objective. To examine the effects of prenatal and infancy home visiting by paraprofessionals and by nurses from child age 2 through age 4 years.Methods. We conducted, in public and private care settings in Denver, Colorado, a randomized, controlled trial with 3 arms, ie, control, paraprofessional visits, and nurse visits. Home visits were provided from pregnancy through child age 2 years. We invited 1178 consecutive, low-income, pregnant women with no previous live births to participate, and we randomized 735; 85% were unmarried, 47% Mexican American, 35% white non-Mexican American, 15% black, and 3% American Indian/Asian. Outcomes consisted of maternal reports of subsequent pregnancies, participation in education and work, use of welfare, marriage, cohabitation, experience of domestic violence, mental health, substance use, and sense of mastery; observations of mother-child interaction and the home environment; tests of children's language and executive functioning; and mothers' reports of children's externalizing behavior problems.Results. Two years after the program ended, women who were visited by paraprofessionals, compared with control subjects, were less likely to be married (32.2% vs 44.0%) and to live with the biological father of the child (32.7% vs 43.1%) but worked more (15.13 months vs 13.38 months) and reported a greater sense of mastery and better mental health (standardized scores [mean = 100, SD = 10] of 101.25 vs 99.31 and 101.21 vs 99.16, respectively). Paraprofessional-visited women had fewer subsequent miscarriages (6.6% vs 12.3%) and low birth weight newborns (2.8% vs 7.7%). Mothers and children who were visited by paraprofessionals, compared with control subjects, displayed greater sensitivity and responsiveness toward one another (standardized score [mean = 100, SD = 10] of 100.92 vs 98.66) and, in cases in which the mothers had low levels of psychologic resources at registration, had home environments that were more supportive of children's early learning (score of 24.63 vs 23.35). Nurse-visited women reported greater intervals between the births of their first and second children (24.51 months vs 20.39 months) and less domestic violence (6.9% vs 13.6%) and enrolled their children less frequently in preschool, Head Start, or licensed day care than did control subjects. Nurse-visited children whose mothers had low levels of psychologic resources at registration, compared with control group counterparts, demonstrated home environments that were more supportive of children's early learning (score of 24.61 vs 23.35), more advanced language (score of 91.39 vs 86.73), superior executive functioning (score of 100.16 vs 95.48), and better behavioral adaptation during testing (score of 100.41 vs 96.66). There were no statistically significant effects of either nurse or paraprofessional visits on the number of subsequent pregnancies, women's educational achievement, use of substances, use of welfare, or children's externalizing behavior problems.Conclusions. Paraprofessional-visited mothers began to experience benefits from the program 2 years after the program ended at child age 2 years, but their first-born children were not statistically distinguishable from their control group counterparts. Nurse-visited mothers and children continued to benefit from the program 2 years after it ended. The impact of the nurse-delivered program on children was concentrated on children born to mothers with low levels of psychologic resources.

Objective. To examine the effectiveness of home visiting by paraprofessionals and by nurses as separate means of improving maternal and child health when both types of visitors are trained in a program model that has demonstrated effectiveness when delivered by nurses. Methods. A randomized, controlled trial was conducted in public- and private-care settings in Denver, Colorado. One thousand one hundred seventy-eight consecutive pregnant women with no previous live births who were eligible for Medicaid or who had no private health insurance were invited to participate. Seven hundred thirty-five women were randomized to control, paraprofessional, or nurse conditions. Nurses completed an average of 6.5 home visits during pregnancy and 21 visits from birth to the children’s second birthdays. Paraprofessionals completed an average of 6.3 home visits during pregnancy and 16 visits from birth to the children’s second birthdays. The main outcomes consisted of changes in women’s urine cotinine over the course of pregnancy; women’s use of ancillary services during pregnancy; subsequent pregnancies and births, educational achievement, workforce participation, and use of welfare; mother-infant responsive interaction; families’ home environments; infants’ emotional vulnerability in response to fear stimuli and low emotional vitality in response to joy and anger stimuli; and children’s language and mental development, temperament, and behavioral problems. Results. Paraprofessional-visited mother-child pairs in which the mother had low psychological resources interacted with one another more responsively than their control-group counterparts (99.45 vs 97.54 standard score points). There were no other statistically significant paraprofessional effects. In contrast to their control-group counterparts, nurse-visited smokers had greater reductions in cotinine levels from intake to the end of pregnancy (259.0 vs 12.32 ng/mL); by the study child’s second birthday, women visited by nurses had fewer subsequent pregnancies (29% vs 41%) and births (12% vs 19%); they delayed subsequent pregnancies for longer intervals; and during the second year after the birth of their first child, they worked more than women in the control group (6.83 vs 5.65 months). Nurse-visited mother-child pairs interacted with one another more responsively than those in the control group (100.31 vs 98.99 standard score points). At 6 months of age, nurse-visited infants, in contrast to their control-group counterparts, were less likely to exhibit emotional vulnerability in response to fear stimuli (16% vs 25%) and nurse-visited infants born to women with low psychological resources were less likely to exhibit low emotional vitality in response to joy and anger stimuli (24% vs 40% and 13% vs 33%). At 21 months, nurse-visited children born to women with low psychological resources were less likely to exhibit language delays (7% vs 18%); and at 24 months, they exhibited superior mental development (90.18 vs 86.20 Mental Development Index scores) than their control-group counterparts. There were no statistically significant program effects for the nurses on women’s use of ancillary prenatal services, educational achievement, use of welfare, or their children’s temperament or behavior problems. For most outcomes on which either visitor produced significant effects, the paraprofessionals typically had effects that were about half the size of those produced by nurses. Conclusions. When trained in a model program of prenatal and infancy home visiting, paraprofessionals produced small effects that rarely achieved statistical or clinical significance; the absence of statistical significance for some outcomes is probably attributable to limited statistical power to detect small effects. Nurses produced significant effects on a wide range of maternal and child outcomes.

This paper summarizes a 25-year program of research that has attempted to improve the early health and development of low-income mothers and children and their future life trajectories with prenatal...

Research from JAMA — Long-term Effects of Nurse Home Visitation on Children's Criminal and Antisocial Behavior — 15-Year Follow-up of a Randomized Controlled Trial — Context.—A program of home visitation by nurses has been shown to affect the rates of maternal welfare dependence, criminality, problems due to use of substances, and child abuse and neglect. However, the long-term effects of this program on children's antisocial behavior have not been examined.Objective.—To examine the long-term effects of a program of prenatal and early childhood home visitation by nurses on children's antisocial behavior.Design.—Fifteen-year follow-up of a randomized trial. Interviews were conducted with the adolescents and their biological mothers or custodial parents.Setting.—Semirural community in New York.Participants.—Between April 1978 and September 1980, 500 consecutive pregnant women with no previous live births were recruited, and 400 were enrolled. A total of 315 adolescent offspring participated in a follow-up study when they were 15 years old; 280 (89%) were born to white mothers, 195 (62%) to unmarried mothers, 151 (48%) to mothers younger than 19 years, and 186 (59%) to mothers from households of low socioeconomic status at the time of registration during pregnancy.Intervention.—Families in the groups that received home visits had an average of 9 (range, 0-16) home visits during pregnancy and 23 (range, 0-59) home visits from birth through the child's second birthday. The control groups received standard prenatal and well-child care in a clinic.Main Outcome Measures.—Children's self-reports of running away, arrests, convictions, being sentenced to youth corrections, initiation of sexual intercourse, number of sex partners, and use of illegal substances; school records of suspensions; teachers' reports of children's disruptive behavior in school; and parents' reports of the children's arrests and behavioral problems related to the children's use of alcohol and other drugs.Results.—Adolescents born to women who received nurse visits during pregnancy and postnatally and who were unmarried and from households of low socioeconomic status (risk factors for antisocial behavior), in contrast with those in the comparison groups, reported fewer instances (incidence) of running away (0.24 vs 0.60; P=.003), fewer arrests (0.20 vs 0.45; P=.03), fewer convictions and violations of probation (0.09 vs 0.47; P<.001), fewer lifetime sex partners (0.92 vs 2.48; P=.003), fewer cigarettes smoked per day (1.50 vs 2.50; P=.10), and fewer days having consumed alcohol in the last 6 months (1.09 vs 2.49; P=.03). Parents of nurse-visited children reported that their children had fewer behavioral problems related to use of alcohol and other drugs (0.15 vs 0.34; P=.08). There were no program effects on other behavioral problems.Conclusions.—This program of prenatal and early childhood home visitation by nurses can reduce reported serious antisocial behavior and emergent use of substances on the part of adolescents born into high-risk families.