Prenatal and Infancy Nurse Home Visiting Effects on Mothers: 18-Year Follow-up of a Randomized Trial.

BACKGROUND: Prenatal and infancy home-visiting by nurses is promoted as a means of improving maternal life-course, but evidence of long-term effects is limited. We hypothesized that nurse-visitation would lead to long-term reductions in public-benefit costs, maternal substance abuse and depression, and that cost-savings would be greater for mothers with initially higher psychological resources. METHODS: We conducted an 18-year follow-up of 618 out of 742 low-income, primarily African-American mothers with no previous live births enrolled in an randomized clinical trial of prenatal and infancy home visiting by nurses. We compared nurse-visited and control-group women for public-benefit costs, rates of substance abuse and depression, and examined possible mediators of intervention effects. RESULTS: Nurse-visited women, compared with controls, incurred $17 310 less in public benefit costs (P = .03), an effect more pronounced for women with higher psychological resources ($28 847, P = .01). These savings compare with program costs of $12 578. There were no program effects on substance abuseor depression. Nurse-visited women were more likely to be married from child age 2 through 18 (19.2% vs 14.8%, P = .04), and those with higher psychological resources had 4.64 fewer cumulative years rearing subsequent children after the birth of the first child (P = .03). Pregnancy planning was a significant mediator of program effects on public benefit costs. CONCLUSIONS: Through child age 18, the program reduced public-benefit costs, an effect more pronounced for mothers with higher psychological resources and mediated by subsequent pregnancy planning. There were no effects on maternal substance abuse and depression.

Prenatal and Infancy Nurse Home Visiting and 18-Year Outcomes of a Randomized Trial.

OBJECTIVES: Given earlier effects found in randomized clinical trials of the Nurse-Family Partnership, we examined whether this program would improve 18-year-old first-born youths' cognition, academic achievement, and behavior and whether effects on cognitive-related outcomes would be greater for youth born to mothers with limited psychological resources (LPR) and on arrests and convictions among females. METHODS: We enrolled 742 pregnant, low-income women with no previous live births and randomly assigned them to receive either free transportation for prenatal care plus child development screening and referral (control; n = 514) or prenatal and infant home nurse visit (NV) plus transportation and screening (n = 228). Assessments were completed on 629 18-year-old first-born offspring to evaluate these primary outcomes: (1) cognitive-related abilities (nonverbal intelligence, receptive language, and math achievement) and (2) behavioral health (internalizing behavioral problems, substance use and abuse, sexually transmitted infections, HIV risk, arrests, convictions, and gang membership). RESULTS: Compared with control-group counterparts, NV youth born to mothers with LPR had better receptive language (effect size = 0.24; 95% confidence interval [CI]: 0.00 to 0.47; P = .05), math achievement (effect size = 0.38; 95% CI: 0.14 to 0.61; P = .002), and a number of secondary cognitive-related outcomes. NV females, as a trend, had fewer convictions (incidence ratio = 0.47; 95% CI: 0.20 to 1.11; P = .08). There were no intervention effects on other behaviors. CONCLUSIONS: The program improved the cognitive-related skills of 18-year-olds born to mothers with LPR and, as a trend, reduced female convictions but produced no other effects on youth behavioral health.

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.

Visit Attendance Patterns in Nurse-Family Partnership Community Sites.

We examined visit attendance patterns of mothers enrolled in the Nurse-Family Partnership (NFP) home visitation program and associations between these patterns and characteristics of the families and sites, with the goal of increasing participant engagement. We utilized repeated measures latent class analysis to identify attendance patterns among 66,967 mothers in NFP sites across the USA. Mothers enrolled from 1996 to 2010. Data were collected by home visitors and aggregated by the NFP National Service Office. Five visit attendance patterns were identified. Consistent attenders (22%) remained engaged for the full program and attended 51.3 visits on average. Inconsistent attenders (9%) remained engaged but missed many visits, with an average of 36.4 visits. The remaining patterns were characterized by when participants left the program: early (28%; 6.7 visits), gradually (27%; 19.4 visits), or late (15%; 35.3 visits). Consistent and inconsistent attenders were less likely to use English as their primary language than other participants (R = 0.12; p < .001). Participants with more nurse changes per visit attended were more likely to drop out early (R = 0.11; p < .001). Sites with a higher percent of missing data had smaller portions of mothers who remained consistently engaged in the program over time (b = - 0.032; p < .01) and greater portions in the late (b = 0.007; p < .04) and gradual attrition classes (b = 0.018; p < .01). The large number of participants who dropped out early is concerning. Further exploration of this group may optimize use of resources by improving either retention or targeting of potential participants.

Effect of Gestational Weight Gain and Prepregnancy Body Mass Index in Adolescent Mothers on Weight and Body Mass Index of Adolescent Offspring.

PURPOSE: The purpose of the study was to examine the association of the gestational weight gain and prepregnancy body mass index (BMI) of low-income adolescent mothers with the risk of their children being overweight and/or obese in late adolescence. METHODS: Study subjects were low-income, primiparous adolescents (n = 360) who self-identified as black and participated in the New Mothers Study in Memphis, Tennessee, and their children. Gestational weight gain was examined as a continuous variable and also categorized into overgain, recommended gain, and undergain following the 2009 Institute of Medicine guidelines. The effects of maternal prepregnancy BMI percentiles and calculated BMI were also considered. Multivariable logistic and linear regression models were used. The main outcome measures were offspring overweight, obesity, and BMI. RESULTS: Thirty-nine percent of offspring were overweight or obese. Higher maternal gestational weight gain increased the risk for offspring overweight and obesity. There was an interaction between gestational weight gain and prepregnancy BMI: offspring of mothers with a BMI percentile ≤76 were at greater risk of obesity with higher maternal weight gain. If mothers with a BMI percentile between the 29th and 83rd percentiles overgained, offspring were at greater risk for overweight. Using calculated BMIs, if a mother's BMI was ≤26 kg/m2, offspring risk for obesity was greater with higher gestational weight gain. CONCLUSIONS: High gestational weight gain had a larger effect on offspring overweight and obesity if maternal prepregnancy BMI percentile was ≤76. The gestational weight gain of primiparous adolescents who self-identified as black had an effect on offspring weight.

The Prevention of Child Maltreatment Through the Nurse Family Partnership Program: Mediating Effects in a Long-Term Follow-Up Study.

We examine maternal life-course mediators of the impact of a nurse home visitation program on reducing child maltreatment among participants in the Elmira trial of the Nurse Family Partnership program from the first child's birth through age 15. For women having experienced low to moderate levels of domestic violence, program effects on the number of confirmed maltreatment reports were mediated by reductions in numbers of subsequent children born to mothers and their reported use of public assistance. Together, the two mediators explained nearly one half of the total effect of nurse home visiting on child maltreatment. The long-term success of this program on reducing child maltreatment can be explained, at least in part, by its positive effect on pregnancy planning and economic self-sufficiency.

A Prospective Cohort Study of Influences on Externalizing Behaviors Across Childhood: Results From a Nurse Home Visiting Randomized Controlled Trial.

OBJECTIVE: This study investigated genetic and environmental influences on behavior in a cohort of 600 children followed prenatally to 18 years. METHOD: A randomized controlled trial of prenatal/infancy nurse home visits (NHV) was conducted in 600 predominantly African American mothers and their firstborn children from Memphis, TN. Mothers were assessed in pregnancy for mental health (MH), self-efficacy, and mastery. Mothers reported longitudinally on smoking and alcohol/drug use. The functional polymorphisms SLC6A4 5-HTTLPR, FKBP5 rs1360780 and DRD2/ANKK1 rs1800497 were genotyped together with 186 ancestry informative markers. Composite externalizing disorders (ED) continuous total scores from the mother-report Achenbach Child Behavior Checklist were included as dependent variables in regression analyses for time points 2, 6, 12, and 18 years. RESULTS: Behaviors at younger ages strongly predicted later behaviors (p < .0001). Children whose mothers had high self-efficacy and had received NHV were better behaved at age 2 years. Poorer maternal MH adversely influenced ED up to 12 years, but at age 18 years, maternal mastery exerted a strong, positive effect (p = .0001). Maternal smoking was associated with worse ED at 6 and 18 years. Main and interactive effects of genetic polymorphisms varied across childhood: FKBP5 rs1360780 up to age 6, 5-HTTLPR from 6 to 12, and DRD2/ANKK1 rs1800497 from 2 to 18 years. CONCLUSION: Our study suggests that maternal MH and resilience measured in pregnancy have long-lasting effects on child behavior. Maternal smoking across childhood and genetic factors also play a role. NHV had a positive effect on early behavior. Our findings have implications for prevention of pathological behaviors in adulthood. Clinical trial registration information-Age-17 Follow-Up of Home Visiting Intervention; http://clinicaltrials.gov/; NCT00708695.

Relationships among obesity, physical activity and sedentary behavior in young adolescents with and without lifetime asthma.

OBJECTIVE: To examine the inter-relationships among body mass index (BMI), physical activity, sedentary behavior and gender in urban, low-income, primarily African American young adolescents with or without lifetime asthma. METHODS: Data were collected in 2002-2004 from 626 12-year old adolescents who were children of women who participated in the New Mother's Study in Memphis, TN (1990-1991). Adolescents with and without asthma were compared on BMI, physical activity and sedentary behavior. Multiple linear regression models were used to examine the association of asthma, gender and BMI with physical activity and sedentary behavior. RESULTS: Complete data were available for 545 adolescents. Eleven percent of adolescents had lifetime asthma. Asthma and gender were associated with high-intensity physical activity (p < 0.001). Adolescents with asthma participated in less physical activity and girls participated less than boys. Gender was associated with sedentary behavior (p < 0.001): boys used personal computer (pc)/video after school more than girls. Girls with asthma had a higher BMI than girls without asthma (p = 0.027). Boys with asthma were less physically active than boys without asthma (p < 0.05). CONCLUSIONS: Adolescents with asthma are less physically active than those without asthma and girls are less active than boys. Clinicians who provide care for adolescents with asthma are encouraged to assess physical activity/sedentary behavior and provide guidance that promotes active lifestyles. A longitudinal study is needed to shed light on the unique contribution of asthma separated from the effects of overweight/obesity on physical activity and sedentary behaviors.

Gestational Weight Gain and Health Outcomes 18 Years Later in Urban Black Women.

OBJECTIVES: Excessive gestational weight gain (GWG) is associated with higher body mass index (BMI) later in life. Increased BMI is associated with health problems, but there is limited evidence linking GWG directly to later health in black women. We examined the association between GWG and health conditions 18 years after a first birth. METHODS: This study was a secondary data analysis of 467 urban black women, enrolled during pregnancy (1990-1991). GWG was the difference between self-reported pre-pregnancy weight and measured weight at delivery. Hypertension, diabetes, obesity, and self-reported health were assessed with self-report and measurements of blood pressure, height, and weight, approximately 18 years after first childbirth. RESULTS: Higher pre-pregnancy BMI was associated with increased probability of each health condition. Higher GWG was associated with hypertension for women with a pre-pregnancy BMI under 21.3 kg/m(2) (P < .05) and obesity for women with a pre-pregnancy BMI under 25.9 kg/m(2) (P < .05). Diabetes and poor health were not associated with GWG. CONCLUSIONS: GWG may impact a mother's hypertension and obesity status 18 years after childbirth for underweight and normal weight women.

African American mothers' self-described discipline strategies with young children in 1992 and 2012.

In this qualitative descriptive study, 30 young, unmarried, low-income African American mothers in Memphis, TN, were interviewed in 2011-2012 about their discipline strategies with their 12- to 19-month-old children. Using content analyses, their strategies were described and compared with those from a similar sample in 1992. Findings suggest both continuity and change during that 20-year period. More mothers in 2011-2012 described the use of distraction and time out, suggesting a wider variety of strategies than were used in 1992. These findings may help clinicians to better understand disciplinary methods in young low-income African American mothers such as these in Memphis. Approaching mothers in a respectful and culturally sensitive manner will help them focus on effective, developmentally appropriate strategies consistent with their own parenting goals.

Patterns of visit attendance in the nurse-family partnership program.

OBJECTIVES: We examined visit attendance patterns in the Memphis trial of the Nurse-Family Partnership and associations between these patterns and family characteristics, outcomes, and treatment-control differences in outcomes. METHODS: We employed repeated measures latent class analysis to identify attendance patterns among the 228 mothers assigned to receive home nurse visits during pregnancy and until the child was aged 2 years, associated background characteristics, outcomes, and treatment-control differences by visit class. Home visits were conducted from June 1990 to March 1994. We collected outcome data from May 1992 to April 1994 and July 2003 to December 2006. RESULTS: We identified 3 visit attendance patterns. High attenders (48%) had the most visits and good outcomes. Low attenders (33%) had the most education and the best outcomes. Increasing attenders (18%) had the fewest completed visits during pregnancy, the poorest intake characteristics, and the poorest outcomes. Treatment-control group differences varied by class, with high and low attenders having better outcomes on some measures than did their control group counterparts. CONCLUSIONS: Three patterns were associated with distinct groups of mothers with different long-term outcomes. Further examination and use of patterns to classify mothers and prioritize resources may improve efficiency in the Nurse-Family Partnership.

Effect of home visiting by nurses on maternal and child mortality: results of a 2-decade follow-up of a randomized clinical trial.

IMPORTANCE: Mothers and children living in adverse contexts are at risk of premature death. OBJECTIVE: To determine the effect of prenatal and infant/toddler nurse home visiting on maternal and child mortality during a 2-decade period (1990-2011). DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical trial was designed originally to assess the home visiting program's effect on pregnancy outcomes and maternal and child health through child age 2 years. The study was conducted in a public system of obstetric and pediatric care in Memphis, Tennessee. Participants included primarily African American women and their first live-born children living in highly disadvantaged urban neighborhoods, who were assigned to 1 of 4 treatment groups: treatment 1 (transportation for prenatal care [n = 166]), treatment 2 (transportation plus developmental screening for infants and toddlers [n = 514]), treatment 3 (transportation plus prenatal/postpartum home visiting [n = 230]), and treatment 4 (transportation, screening, and prenatal, postpartum, and infant/toddler home visiting [n = 228]). Treatments 1 and 3 were included originally to increase statistical power for testing pregnancy outcomes. For determining mortality, background information was available for all 1138 mothers assigned to all 4 treatments and all but 2 live-born children in treatments 2 and 4 (n = 704). Inclusion of children in treatments 1 and 3 was not possible because background information was missing on too many children. INTERVENTIONS: Nurses sought to improve the outcomes of pregnancy, children's health and development, and mothers' health and life-course with home visits beginning during pregnancy and continuing through child age 2 years. MAIN OUTCOMES AND MEASURES: All-cause mortality in mothers and preventable-cause mortality in children (sudden infant death syndrome, unintentional injury, and homicide) derived from the National Death Index. RESULTS: The mean (SE) 21-year maternal all-cause mortality rate was 3.7% (0.74%) in the combined control group (treatments 1 and 2), 0.4% (0.43%) in treatment 3, and 2.2% (0.97%) in treatment 4. The survival contrast of treatments 1 and 2 combined with treatment 3 was significant (P = .007); the contrast of treatments 1 and 2 combined with treatment 4 was not significant (P = .19), and the contrast of treatments 1 and 2 combined with treatments 3 and 4 combined was significant (post hoc P = .008). At child age 20 years, the preventable-cause child mortality rate was 1.6% (0.57%) in treatment 2 and 0.0% (SE not calculable) in treatment 4; the survival contrast was significant (P = .04). CONCLUSIONS AND RELEVANCE: Prenatal and infant/toddler home visitation by nurses is a promising means of reducing all-cause mortality among mothers and preventable-cause mortality in their first-born children living in highly disadvantaged settings. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00708695.

Cusp catastrophe model: a nonlinear model for health outcomes in nursing research.

BACKGROUND: Although health outcomes may have fundamentally nonlinear relationships with relevant behavioral, psychological, cognitively, or biological predictors, most analytical models assume a linear relationship. Furthermore, some health outcomes may have multimodal distributions, but most statistical models in common use assume a unimodal, normal distribution. Suitable nonlinear models should be developed to explain health outcomes. OBJECTIVE: The aim of this study is to provide an overview of a cusp catastrophe model for examining health outcomes and to present an example using grip strength as an indicator of a physical functioning outcome to illustrate how the technique may be used. Results using linear regression, nonlinear logistic model, and the cusp catastrophe model were compared. METHODS: Data from 935 participants from the Survey of Midlife Development in the United States (MIDUS) were analyzed. The outcome was grip strength; executive function and the inflammatory cytokine interleukin-6 were predictor variables. RESULTS: Grip strength was bimodally distributed. On the basis of fit and model selection criteria, the cusp model was superior to the linear model and the nonlinear logistic regression model. The cusp catastrophe model identified interleukin-6 as a significant asymmetry factor and executive function as a significant bifurcation factor. CONCLUSION: The cusp catastrophe model is a useful alternative for explaining the nonlinear relationships commonly seen between health outcome and its predictors. Considerations for the use of cusp catastrophe model in nursing research are discussed and recommended.

Women's reasons for attrition from a nurse home visiting program.

OBJECTIVE: To describe mothers' reasons for leaving a home visiting program early. DESIGN: Qualitative descriptive study using semistructured interviews of mothers who dropped out of the Nurse-Family Partnership (NFP) and two focus groups with nurses and nurse supervisors at an NFP site. SETTING: A New York State site of a NFP home visitation program for low-income new mothers designed to improve the physical and emotional care of children. PARTICIPANTS: Participants included 21 mothers, 8 nurses, and 3 nurse-supervisors. METHODS: Semistructured interviews and focus groups were used to collect data, which were analyzed using content analysis. RESULTS: The program was not perceived to fit a mother's needs when she was overwhelmed with other responsibilities, the nurse did not meet her expectations, the content was not of interest, or the mother did not desire visits after the infant was born. Nurses and mothers described the need for mothers to have organizational and communication skills, such as keeping track of appointments, calling to reschedule, articulating needs, and asking for assistance. Disruptive external influences included nurse turnover and unstable living situations, including frequent moves and crowded housing. Each of these types of barriers had potential to interact with the others, creating complex combinations of challenges to retention. CONCLUSION: NFP retention might be improved by reframing program relevance to individual mothers and increasing maternal organizational and communication skill development.

Gestational weight gain of pregnant African American adolescents affects body mass index 18 years later.

OBJECTIVE: To determine if gestational weight gain (GWG) in adolescents is associated with long-term weight increases 12 years and 18 years after delivery of a first child and the differential effects of weight gain during pregnancy that is inadequate, the appropriate amount, and excessive based on the 2009 Institute of Medicine (IOM) recommendations. DESIGN: Secondary data analysis of data from a randomized controlled trial. SETTING: Memphis, Tennessee. PARTICIPANTS: Two hundred ninety-eight (298) primiparous low-income Black women who were adolescents at the time of their first pregnancies. METHOD: Linear regression was used to examine the relationship between body mass index (BMI) at 12 and 18 years postdelivery and GWG, parity, prepregnancy BMI, and smoking. RESULTS: The total sample experienced a significant BMI increase from prepregnancy to 12 years and 18 years postdelivery. More than 50% of the women had a BMI increase greater than 10 kg/m(2) . By 18 years postdelivery, 85% were overweight or obese. Prepregnancy BMI and GWG had a positive significant effect on BMI 12 and 18 years later, whereas smoking had a negative effect. Those who gained excessive weight based on the IOM recommendations had a significantly higher BMI compared with those who gained appropriately. CONCLUSION: Gestational weight gain had long-term effects on BMI in a minority adolescent population. Excessive pregnancy weight gain is likely to contribute to long-term weight retention, especially if adolescents are overweight or obese when they become pregnant with their first children. Intervention during pregnancy to limit GWG has the potential of limiting long-term negative health consequences that result from overweight and obesity in minority women.

The influence of social-developmental context and nurse visitation intervention on self-agency change in unmarried adolescent mothers.

Pregnancy among unmarried adolescents has been linked to negative personal control beliefs. In contrast, self-agency beliefs about control over future possibilities have been linked to delay in subsequent childbearing. In this secondary analysis, we examined factors associated with self-agency change in 429 unmarried adolescent mothers from intervention and control groups of a nurse home visitation study. Adolescent mothers who participated in a sustained relationship with a nurse made greater gains in self-agency than did control group mothers (p = .034). Adolescents with lower cognitive ability who were behind their age-appropriate grade level in school made the greatest self-agency gains.

Mother-child interactions and the associations with child healthcare utilization in low-income urban families.

Studies have demonstrated that low-income families often have disproportionately high utilization of emergency department (ED) and hospital services, and low utilization of preventive visits. A possible contributing factor is that some mothers may not respond optimally to their infants' health needs, either due to their own responsiveness or due to the child's ability to send cues. These mother-child interactions are measurable and amenable to change. We examined the associations between mother-child interactions and child healthcare utilization among low-income families. We analyzed data from the Nurse-Family Partnership trial in Memphis, TN control group (n = 432). Data were collected from child medical records (birth to 24 months), mother interviews (12 and 24 months postpartum), and observations of mother-child interactions (12 months postpartum). We used logistic and ordered logistic regression to assess independent associations between mother-child interactions and child healthcare utilization measures: hospitalizations, ED visits, sick-child visits to primary care, and well-child visits. Better mother-child interactions, as measured by mother's responsiveness to her child, were associated with decreased hospitalizations (OR: 0.51; 95% CI: 0.32, 0.81), decreased ambulatory-care-sensitive ED visits (OR: 0.65, 95% CI: 0.44, 0.96), and increased well-child visits (OR: 1.55, 95% CI: 1.06, 2.28). Mother's responsiveness to her child was associated with child healthcare utilization. Interventions to improve mother-child interactions may be appropriate for mother-child dyads in which child healthcare utilization appears unbalanced with inadequate primary care and excess urgent care. Recognition of these interactions may also improve the care clinicians provide for families.

Effect of African- and European-American maternal attitudes and limit-setting strategies on children's self-regulation.

The effect of maternal attitudes and limit-setting strategies on children's self-regulation (measured as committed compliance) was compared in 151 African-American (AA) and 108 European-American (EA) mothers and their 3-year-old children. There were no ethnic differences in children's compliance, however ethnicity moderated the relationship between maternal authoritarian attitudes and children's compliance. Higher authoritarian attitudes predicted less children's compliance in the EA sample, but greater compliance in the AA sample. Observational limit-setting data revealed that in both ethnic groups, maternal authoritarian attitudes influenced children's self-regulation through maternal use of lower-power (gentle) verbal strategies, fewer physical strategies, and judicious use of higher-power verbal strategies. The findings indicate that the meaning and purpose of authoritarian attitudes varies across these mothers' socio-cultural contexts.

African american mothers' self-described discipline strategies with young children.

AIMS AND OBJECTIVES: African American families have been described as using higher levels of non-abusive physical discipline with their children than European American families. Few if any studies have documented AA families' use of disciplinary strategies in their own words, however, or their reasons for their use. METHODS: In this qualitative study, 51 African American mothers from a 1992 Memphis sample described their disciplinary strategies with their 12 to 19 month old children. RESULTS: Seventy-seven percent of mothers described using verbal teaching along with non-abusive physical discipline, such as tapping their children's hands. Mothers also expressed concern about being too strict, described awareness of their children's developmental limits, and used non-physical disciplinary methods, consistent with positive accepting parent-child relationships. CONCLUSIONS: These findings are important because the low-income girls who experienced such parenting in the 1990s are now young mothers themselves. Current practice guidelines encourage new mothers to think about how they themselves were parented; the knowledge from this study may assist practitioners to engage present-day African American mothers in supportive discussions about physical and non-physical discipline methods with young children.