Nurse Home-Visit Program Shows No Benefit for Prenatal Care Uptake

Sending registered nurses out on home visits throughout pregnancy failed to move the needle when it came to improving uptake of prenatal care, a randomized trial involving Medicaid patients found.

Use of prenatal care services and receipt of recommended guideline-based prenatal care were similar whether patients received the intensive program or were assigned to a control group of usual care, reported Rebecca Gourevitch, PhD, of the University of Maryland in College Park, and coauthors in Health Affairs.

The study, which enrolled 5,670 Medicaid-eligible pregnant people in South Carolina, a majority of whom were Black, also found no benefit with the Nurse Family Partnership (NFP) program on gestational weight gain or use of other healthcare services during pregnancy.

Maternal mortality in the U.S. has more than doubled over the past two decades, with Black women facing disproportionately higher rates of pregnancy-related death.

While nurse home visiting programs have long been seen as an evidence-based solution for improving maternal and child health, most of that evidence comes from studies conducted in the early 1970s and 1980s, explained Gourevitch.

"We thought it would be important to take a look and see how these programs fit in the modern context, when delivered on a larger scale and in association with the Medicaid program," she told MedPage Today.

The NFP program centers around teaching healthy behaviors -- emphasizing nutrition and exercise -- and encouraging clients to go to prenatal visits and receive recommended care. Prior findings from the trial, however, showed that NFP failed to reduce the risk of a composite of adverse birth outcomes versus usual care.

But many of the factors that shape pregnancy outcomes are present before pregnancy, said Gourevitch, including an individuals' overall health and social circumstances.

"The challenges that are facing these populations are much bigger than things that nurse home visiting programs are well-positioned to address during pregnancy," she explained. "It's assigning the responsibility for addressing these really big forces to one practitioner and one pregnant person, where I think we need larger structural changes to really move the needle on some of those things."

Study Details

From April 2016 to March 2020, the randomized trial enrolled 5,670 pregnant Medicaid-eligible patients (income below 200% of the federal poverty level) in South Carolina, assigning them 2:1 to either the NFP nursing home visits or to a control group.

The NFP program involved biweekly or monthly home visits throughout pregnancy and for 24 months postpartum, or until patients chose to leave the program. Almost all NFP participants received at least one home visit (mean 9.4 during pregnancy).

Participants were required to be under 28 weeks' gestation and have no prior live births.

The final analytical sample involved 4,587 patients, and baseline characteristics were balanced between groups, the authors noted. Overall, about three-fourths of participants were ages 15 to 24 years, a majority were non-Hispanic Black (52%), about a third were white, and 6% were Hispanic. Roughly two-thirds engaged with at least one social service program before enrollment, 17% reported housing insecurity, and 44% lived with their parents.

When it came to prenatal care quantity and intensity, rates of adequate or better prenatal care were similar whether pregnant patients received the nursing visits or were assigned to the control group (80.4% vs 81.3%, respectively) as were the average number of prenatal visits (13.2 vs 13.0) and ultrasounds (4.3 vs 4.2).

Regardless of the assigned group, participants received guideline-based prenatal care at similar rates, such as timely anatomy scan ultrasounds (75% for each group), gestational diabetes testing (58% in each group), and tetanus, diphtheria, pertussis (Tdap) vaccinations (about a third of each group).

The rate of recommended gestational weight gain was identical (25.7%) and both groups had on average two emergency department visits. Only 8.5% of treatment-group participants and 7.5% of control-group participants saw a maternal fetal medicine specialist, Gourevitch and her team observed.

While small differences were seen when it came to timely group B streptococcus testing (favored the control group) and dental visits during pregnancy (favored the intervention group), they were not significant after adjusting for multiple hypothesis testing, the study authors said.

After similar adjustments, no benefit was seen with NFP among two prespecified subgroups: socially vulnerable participants and the non-Hispanic Black participants.

When compared with the larger population of eligible people in South Carolina, but who did not participate in the trial, study participants tended to be slightly younger, more likely to identify as Black, less likely to have finished post-secondary education, and had higher rates of obesity and hypertension.

On the other hand, study participants were more likely to have initiated prenatal care services in their first trimester, had more prenatal visits overall, and had higher use of the Special Supplemental Nutrition Program for Women, Infants, and Children.

This suggests the study sample comprised people more engaged in and trusting of the healthcare system and social services system broadly, Gourevitch explained. "In terms of affecting utilization of prenatal care itself, there probably wasn't a lot of room for improvement."

But the analysis is not the "final word" on nurse home visiting programs, said Gourevitch.

"I think the weight of the evidence is pretty clear that in this kind of context, nurse home visiting programs don't affect prenatal and birth outcomes, but we still may see impacts of this program," she said, noting that future analyses of the study will explore postpartum health; mental health; contraception use; child health, development, and education; and parents' economic outcomes.

One limitation of the study is its reliance on administrative data, Gourevitch said. Conducting focus groups or surveys might have elicited self-reported outcomes such as "feelings of security, or empowerment, or knowledge or preparation for labor and for early parenting" that the program may address, she added.

Comment