Youth, poverty, and preexisting disability among factors used to identify new moms for home visits

For new mothers experiencing adversity, a nurse home visit program can provide long-term mental health benefits, with positive effects measurable even three years after the actual intervention is completed, according to a recent study from researchers in Australia, who published their results in Pediatrics.

“Nurse home visiting (NHV) is an established model of health care delivery with the potential to address inequities in maternal mental health and, subsequently, children’s development. NHV prioritizes women experiencing social adversity and overcomes barriers to health service access through outreach to women’s homes. It shows promise for improving early parent care and home learning environments, with some studies revealing greater benefits of NHV for women with poorer mental health. However, few NHV studies have reported on these benefits beyond the first year postpartum,” explained Australian researchers led by Sharon Goldfeld, FRACP, FAFPHM, PhD, of the Royal Children’s Hospital, Parkville, Victoria, Australia.

They conducted a randomized controlled trial of the effects of the Australian Nurse Home Visiting (NHV) program (right@home) on 722 pregnant women who were enrolled at ten antenatal clinics in two states and who had two or more of the following ten risk factors considered indicative of adversity:

  • Young pregnancy.
  • Not living with another adult.
  • No support during pregnancy.
  • Poor health.
  • A long-term illness, health problem, or disability that hampers daily activities.
  • Current smoker.
  • Stress, anxiety, or difficulty coping.
  • Low education.
  • No household member earning an income.
  • Never having been employed.

Women were randomized to receive either the NHV intervention or usual care (control group). The NHV intervention consisted of 25 nurse home visits from pregnancy until children reached two years of age.

Participants then completed the Depression Anxiety Stress Scales (DASS) at a 1-year postintervention to report on their mental health; they also reported on their personal well-being and self-efficacy. Personal well-being was assessed via the Personal Wellbeing Index, which was comprised of eight items that rated participants’ satisfaction with specific life domains using a ten-point scale. The higher the score, the greater the well-being. Goldfeld and colleagues then assessed participants’ self-efficacy using three items designed to determine how women felt about their lives in general, whether they were getting what they wanted out of life, whether they felt in control, and whether they could run their own lives.

In all, 495 women completed the extended three-year follow-up. At baseline, mean gestational age was 28.2 weeks. Compared with women lost to follow-up, these participants were more likely to have better baseline mental health and to have completed high school, and they were less likely to report a drug problem or history of family violence.

Women who underwent the NHV intervention consistently showed benefits for mental health, as seen in DASS total scores and subscales (ES: 0.25; 95% CI: 0.12-0.38), compared with women in the control group who received usual care. They also had a higher likelihood of better mental health scores for depression (OR: 1.68; 95% CI: 1.08-2.60), anxiety (OR: 1.38; 95% CI: 0.92-2.08), and stress (OR: 2.09; 95% CI: 1.28-3.42), as well as better personal well-being (ES: 0.16; 95% CI: 0.04-0.29) and no lack of self-efficacy (OR: 1.60; 95% CI: 1.19-2.16).

These results add to increasing data that have shown significant benefits from NHVs specifically for children, including reduced child abuse, neglect, and injuries, as well as better functioning later in children and adolescents. But unlike previous studies, results from the study from Goldfeld and colleagues documented beneficial effects of NHVs on mothers.

“In the current study, Goldfeld et al extend the previously established positive outcomes from these and other NHV studies to include maternal mental health outcomes. Heretofore, evidence for the effects of NHV programs on maternal mental health has been mixed; in a recent systematic review, authors found that of the studies that measured at least 1 maternal psychosocial outcome, a minority of the studies found positive effects, and of the studies that included depression outcomes, none found a positive effect,” wrote Kelsey A. Egan, MD, of Boston Medical Center and Boston University School of Medicine, Boston, and colleagues in an accompanying editorial.

One strength of this study was its rigorous, multisite design, they noted, but some caveats are in order in light of its limitations.

“The results, however, should be interpreted with caution, the primary reason being that the maternal mental health outcomes at 3 years do not appear to be prespecified, and the authors report no a priori sample size calculations to discriminate a minimum effect size for clinically meaningful differences in these outcomes,” noted Egan et al.

Other limitations of the study, as noted by Goldfeld and colleagues themselves, include overlap in the many self-reported mental health measures, response bias in patients’ self-reports, and the non-generalizability of these results to women who were non-English speaking or those with severe intellectual disabilities.

“Although the results of the current study seem optimistic, the methodologic limitations mentioned prohibit any definitive conclusions. That said, given the convincing evidence for the effectiveness of depression prevention programs, in future NHV studies that aim to solidify the evidence base on maternal mental health, researchers may be well-served to look into the depression prevention literature and incorporate intervention components that appear to have the greatest impact. The bundling of effective depression prevention components with NHV into a single evidence-based intervention could result in substantial benefit to many families across the United States and beyond,” Egan and fellow editorialists concluded.

  1. In this randomized controlled trial, mothers enrolled in a nurse home visiting program reported better mental health, according to the Depression Anxiety Stress Scales, with effect sizes of 0.25 (95% confidence interval: 0.08–0.32) for depression and 0.20 (95% confidence interval: 0.05–0.30) for anxiety.

  2. These benefits and others were evident for maternal mental health and well-being outcomes at one-year post intervention completion.

E.C. Meszaros, Contributing Writer, BreakingMED™

This study was supported by the state governments of Victoria and Tasmania, the Ian Potter Foundation, Sabemo Trust, Sidney Myer fund, the Vincent Fairfax Family Foundation, and the National Health and Medical Research Council (NHMRC).

Goldfeld has received support from an NHMRC Practitioner Fellowship.

Egan has received funding from the Agency for Healthcare Research and Quality, US Department of Health and Human Services.

Cat ID: 138

Topic ID: 85,138,730,138,192,146,55,925