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

Abstract

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.

Figure 1. Survival Curves for Mothers in the Nurse-Family Partnership Trial

A, All causes of death. B, External causes of death. All 1105 mothers who survived had at least 20.2 years of follow-up after randomization. The numbers at risk of dying at 20.5, 21.0, 21.5, and 22.0 years after randomization were 898, 437, 65, and 1, respectively.

Figure 2. Survival Curves for Children in the Nurse-Family Partnership Trial

A, All causes of death. B, Preventable causes of death. All 690 children who survived had at least 19.7 years of follow-up after birth. The numbers at risk of dying at 20.0, 20.5, 21.0, 21.5, and 22.0 years after randomization were 620, 369, 132, 4, and 1, respectively.