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- What services do families receive from home visiting programs to promote prenatal health and improve birth outcomes?
- What are the effects of evidence-based early childhood home visiting on prenatal care, birth outcomes, and infant health care use?
- How do the effects of home visiting programs vary across different types of families, based on the features of local programs, and according to the dosage of home visiting services families receive?
Given the potentially negative societal, personal, medical and financial ramifications of poor birth outcomes, improving birth outcomes -— especially among socioeconomically disadvantaged women — has been a long-standing policy goal. One potential approach to improving birth outcomes is home visiting, which provides pregnant women and families who have young children with education and support, assessment, and referrals to community services. A few prior studies of evidence-based home visiting models — specifically, Healthy Families America (HFA) and Nurse-Family Partnership (NFP) — revealed some evidence of improvements in low birth weight and preterm birth. However, these results have not been found in all prior studies of the models’ examinations of birth outcomes and were conducted years ago, from the late 1970s through the early 2000s. Given that both families and local programs have changed since those studies were completed, a new test of whether home visiting programs can improve birth outcomes was warranted.
The Mother and Infant Home Visiting Program Evaluation-Strong Start (MIHOPE-Strong Start) was launched in 2012 to test whether evidence-based home visiting provided during pregnancy improves birth outcomes, prenatal health, and health care use in infancy. Specifically, the MIHOPE-Strong Start analysis includes 2,900 families across 66 local HFA and NFP home visiting programs in 17 states. The Administration for Children and Families partnered with the Centers for Medicare and Medicaid Services and the Health Resources and Services Administration to sponsor MIHOPE-Strong Start. MDRC conducted the evaluation in collaboration with James Bell Associates, Johns Hopkins University, Mathematica Policy Research, and New York University. This report presents final implementation and impact results from the study. A separately published report from the Mother and Infant Home Visiting Program Evaluation (MIHOPE), the legislatively mandated evaluation of the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program, presents program effects on a wider range of family outcomes and for two additional evidence-based models. An important distinction between MIHOPE-Strong Start and MIHOPE is that MIHOPE included only programs receiving MIECHV funding, while MIHOPE-Strong Start included both MIECHV- and non-MIECHV-funded programs.
The determinants of adverse birth outcomes are complicated, reflecting a confluence of behavioral, biological, psychosocial, and structural factors, in addition to medical risk factors. A shared understanding of these determinants has led to calls for more research to illuminate the potential for nonmedical strategies to improve newborn health in relation to mothers who are at disproportionate risk of experiencing adverse birth outcomes. Evidence-based home visiting for low-income pregnant women represents one such strategy.
To date, rigorous investigations of home visiting’s effectiveness in improving prenatal health and birth outcomes have been limited to a few trials, and the results have been inconsistent. MIHOPE-Strong Start was launched to examine the effectiveness of evidence-based home visiting on prenatal care, birth outcomes, and infant health care use, as well as how local home visiting programs were implemented.
Key Findings and Highlights
- Families who received at least one home visit (86 percent of the program group) had an average of eight visits over four months before the woman gave birth. Families received a similar amount of home visiting as found in prior studies, including those that found reductions in the percentage of infants born preterm or with low birth weights.
- Women who were more and less vulnerable to poor birth outcomes received similar levels of home visiting services. Among women who received at least one home visit, those who exhibited risks for compromised birth outcomes (such as being of a younger age or being a smoker) received the same number of visits and participated for similar lengths of time, on average, as women who didn’t demonstrate such risks.
- The home visiting programs in the study had no statistically significant effect on the evaluation’s focal outcomes, including families’ prenatal behaviors, birth outcomes, or health care use in the first year after birth. The estimated differences found in the study’s main outcomes, such as low birth weight and preterm birth, are small, and they are not statistically significant.
- Effects of the home visiting programs in the study are not greater for higher-risk or for lower-risk families or depending on how the programs were implemented. Home visiting did not have larger effects on prenatal behaviors, birth outcomes, or health care use after birth for any subgroups of families, nor do the effects vary across local programs or by evidence-based model.
One reason that the effects of home visiting in this study are small might be that there was little room for improvement on modifiable risk factors such as smoking, nutritional support, and access to prenatal health care. For example, only a small percentage of women smoked during pregnancy and most had access to health care providers during and after pregnancy. Another possible reason is that families did not receive as many home visits as the evidence-based models had intended, although they participated at levels similar to those found in prior HFA and NFP evaluations of birth outcomes. In addition, the findings are specific to the primarily urban sample of local programs and families, who would have had greater access to alternative prenatal health care services, and may not be generalizable to home visiting in areas where access to prenatal health care might be more limited.
Whether home visiting programs may have longer-term impacts, including positively affecting birth outcomes for later pregnancies, is a question for future research. Furthermore, as local programs in this study were recruited from 2012 to 2015, it is possible that they have continued to evolve over the past few years in ways that could make them effective at improving birth outcomes.
MIHOPE-Strong Start included home visiting programs that implemented either HFA or NFP, two widely used models and the only ones with some prior evidence of having effects on improving birth outcomes at the time programs were recruited into the study. Sixty-six MIECHV and non-MIECHV-funded local programs that primarily served Medicaid beneficiaries contributed to the MIHOPE-Strong Start analysis. A total of 2,900 women who were no more than 32 weeks pregnant and were eligible and interested in receiving home visiting were included in the analysis. Families were randomly assigned either to a local home visiting group or to a control group whose members were given information on other appropriate services in the community.
Information on program implementation comes from family surveys at baseline, descriptions home visitors provided about the services they delivered to families, surveys of home visitors and local program managers, interviews and surveys with evidence-based model developers, and management information system data. For the impact analysis, family outcomes were obtained from state vital records and Medicaid data.
Lee, Helen, Sarah Shea Crowne, Melanie Estarziau, Keith Kranker, Charles Michalopoulos, Anne Warren, Tod Mijanovich, Jill H. Filene, Anne Duggan, and Virginia Knox (2019). The Effects of Home Visiting on Prenatal Health, Birth Outcomes, and Health Care Use in the First Year of Life: Final Implementation and Impact Findings from the Mother and Infant Home Visiting Program Evaluation-Strong Start, OPRE Report # 2019-08, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services.
- MIHOPE-Strong Start:
- Mother and Infant Home Visiting Program Evaluation – Strong Start
- Mother and Infant Home Visiting Program Evaluation
- Healthy Families America
- Nurse Family Partnership