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Original Investigation |

Effect of Home Visiting by Nurses on Maternal and Child Mortality:  Results of a 2-Decade Follow-up of a Randomized Clinical Trial

David L. Olds, PhD1; Harriet Kitzman, RN, PhD2; Michael D. Knudtson, MS1; Elizabeth Anson, MS2; Joyce A. Smith, PhD2; Robert Cole, PhD2
[+] Author Affiliations
1Department of Pediatrics, School of Medicine, University of Colorado, Aurora
2School of Nursing, University of Rochester, Rochester, New York
JAMA Pediatr. 2014;168(9):800-806. doi:10.1001/jamapediatrics.2014.472.
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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

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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.

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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.

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