Randomized Controlled Trial (RCT) of...

Nurse-Family Partnership in British Columbia - Home Visiting for Low-Income, First-Time Mothers

Reviewed

Early Childhood
Somewhat accurately reported

The Journal of Child Psychology and Psychiatry (2024) published an RCT of the Nurse-Family Partnership, a nurse home visiting program for low-income, first-time mothers, as implemented in British Columbia, Canada. This high-quality RCT found no impact on the primary outcome - child injuries - at the age 2 follow-up, but suggestive effects on two secondary outcomes (child language and behavior based on maternal reports).

Background: We investigated the effectiveness of Nurse-Family Partnership (NFP), a prenatal-to-age-two-years home-visiting programme, in British Columbia (BC), Canada.

Methods: For this randomised controlled trial, we recruited participants from 26 public health settings who were: <25 years, nulliparous, <28 weeks gestation and experiencing socioeconomic disadvantage. We randomly allocated participants (one-to-one; computer-generated) to intervention (NFP plus existing services) or comparison (existing services) groups. Prespecified outcomes were prenatal substance exposure (reported previously);  child injuries (primary) , language, cognition and mental health (problem behaviour) by age two years; and subsequent pregnancies by 24 months postpartum. Research interviewers were masked. We used intention-to-treat analyses. (ClinicalTrials.gov, NCT01672060.)

Results: From 2013 to 2016 we enrolled 739 participants (368 NFP, 371 comparison) who had 737 children.  Counts for child injury healthcare encounters [rate per 1,000 person-years or RPY] were similar for NFP (223 [RPY 316.17]) and comparison (223 [RPY 305.43]; rate difference 10.74, 95% CI -46.96, 68.44; rate ratio 1.03, 95% CI 0.78, 1.38).   Maternal reported language scores (mean, M [SD]) were statistically significantly higher for NFP (313.46 [195.96]) than comparison (282.77 [188.15]; mean difference [MD] 31.33, 95% CI 0.96, 61.71). Maternal-reported problem behaviour scores (M [SD]) were statistically significantly lower for NFP (52.18 [9.19]) than comparison (54.42 [9.02]; MD -2.19, 95% CI 3.62, 0.75). Subsequent pregnancy counts were similar (NFP 115 [RPY 230.69] and comparison 117 [RPY 227.29]; rate difference 3.40, 95% CI -55.54, 62.34; hazard ratio 1.01, 95% CI 0.79, 1.29).  We observed no unanticipated adverse events.

Conclusions: NFP did not reduce child injuries or subsequent maternal pregnancies but did improve maternal-reported child language and mental health (problem behaviour) at age two years. Follow-up of long-term outcomes is warranted given that further benefits may emerge across childhood and adolescence.

Keywords: Child injuries; child mental health; child problem behaviour; cognitive and language development; subsequent pregnancies; health inequities; nurse-home visiting; randomised controlled trial; public health.

Full Study Report

Background: We investigated the effectiveness of Nurse-Family Partnership (NFP), a prenatal-to-age-two-years home-visiting programme, in British Columbia (BC), Canada.

Methods: For this randomised controlled trial, we recruited participants from 26 public health settings who were: <25 years, nulliparous, <28 weeks gestation and experiencing socioeconomic disadvantage. We randomly allocated participants (one-to-one; computer-generated) to intervention (NFP plus existing services) or comparison (existing services) groups. Prespecified outcomes were prenatal substance exposure (reported previously); child injuries (primary), language, cognition and mental health (problem behaviour) by age two years; and subsequent pregnancies by 24 months postpartum. Research interviewers were masked. We used intention-to-treat analyses. (ClinicalTrials.gov, NCT01672060.)

Results: From 2013 to 2016 we enrolled 739 participants (368 NFP, 371 comparison) who had 737 children. Counts for child injury healthcare encounters [rate per 1,000 person-years or RPY] were similar for NFP (223 [RPY 316.17]) and comparison (223 [RPY 305.43]; rate difference 10.74, 95% CI -46.96, 68.44; rate ratio 1.03, 95% CI 0.78, 1.38). Maternal reported language scores (mean, M [SD]) were statistically significantly higher for NFP (313.46 [195.96]) than comparison (282.77 [188.15]; mean difference [MD] 31.33, 95% CI 0.96, 61.71). Maternal-reported problem behaviour scores (M [SD]) were statistically significantly lower for NFP (52.18 [9.19]) than comparison (54.42 [9.02]; MD -2.19, 95% CI 3.62, 0.75).  Mean observed cognitive scores [SD] were similar for NFP (90.35 [12.81]) and comparison (91.94 [11.59]; MD -1.59, 95% CI -4.05, 0.87; p = .2056). Mean observed language scores [SD] were similar for NFP (92.12 [16.11]) and comparison (91.10 [16.09]; MD 1.02, 95% CI     -2.23, 4.27;  p = .5383).  Subsequent pregnancy counts were similar (NFP 115 [RPY 230.69] and comparison 117 [RPY 227.29]; rate difference 3.40, 95% CI -55.54, 62.34; hazard ratio 1.01, 95% CI 0.79, 1.29). We observed no unanticipated adverse events.

Conclusions: NFP did not reduce child injuries or subsequent maternal pregnancies but did  may  improve maternal-reported child language and mental health (problem behaviour) at age two years. Follow-up of long-term outcomes is warranted given that further benefits may emerge across childhood and adolescence.

Keywords: Child injuries; child mental health; child problem behaviour; cognitive and language development; subsequent pregnancies; health inequities; nurse-home visiting; randomised controlled trial; public health.

No-Spin’s Study Overview

High-quality RCT of the Nurse Family Partnership (NFP) home visiting program for first-time mothers, conducted in British Columbia, Canada, finds no impact on the primary outcome - child injuries - at the age 2 follow-up, but suggestive effects on two secondary outcomes (child language and behavior based on maternal reports).

Program:

  • NFP is an established nurse home visiting program for first-time mothers – mostly low-income and single. Nurses visit the women 2 times per month during pregnancy and the first two years of their child’s life, providing education, assessments, and goal-setting related to prenatal health, child health and development, and maternal life course.

Study Design:

  • The study randomized 737 women from 26 urban-suburban health areas in British Columbia, Canada to NFP (treatment) or services as usual (control). Sample members averaged 20 years of age, 91% were single mothers, 51% had not completed high school, 27% were Indigenous, and their average income was approximately $10,000 CAD per year.
  • Based on careful review, this was a high-quality RCT (e.g., baseline balance, low attrition, mostly successful program implementation, prespecified analyses).

Findings:

  • The study found no effect on the study’s primary outcome: healthcare encounters for child injuries from age 0-2. There were 316 encounters per 1000 person-years in the treatment group vs. 305 in the control group, a difference that was not statistically significant.
  • At age 2, the study found beneficial, statistically significant impacts on two secondary outcome measures (mother-reported language and mother-reported problem behavior), but no significant impacts on three other secondary outcome measures (mother’s subsequent pregnancies, and direct researcher assessments of child language and cognition).
  • The two beneficial impacts are suggestive, but not yet reliable, under established standards (FDA, IES), as they could be chance findings resulting from the study’s measurement of multiple outcomes.

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