A home-visiting program in the United States for low-income, first-time mothers is radically improving their well-being, and curbing future health and social problems for children. The Nurse-Family Partnership (NFP) sends specially trained nurses on regular visits to first-time, low-income mothers from pregnancy until their child’s second birthday. The program has thus far reached 269,000 families in 42 states and has the potential to save government billions of dollars.
Results & Impact
Results show a 48% reduction in child abuse and neglect, a 67% decrease in behavioural and intellectual problems at the age of six, and a 59% reduction in child arrests at age 15. By 2031, enrolments over 1996-2013 will prevent an estimated 500 infant deaths, 13,000 dangerously spaced second births, 90,000 violent crimes by youths, and 41,000 years of youth substance abuse. Over the same period, it is expected to reduce spending on Medicaid, TANF, and food stamps by $3 billion for the 177,517 enrolees, compared to a cost of $1.6 billion.
The US Department of Health and Human Services, The Nurse-Family Partnership, US state, city and county governments, and local implementing agencies, foundations and community groups.
Typically, nurses visit families around 25 to 30 times over 17 months, acting as trusted advisors. During pregnancy, support includes helping mothers to cut down on alcohol, tobacco and drug use, identifying potential prenatal complications, and helping plan their future. After birth, the nurses work with the mother to improve the child’s physical and emotional care, help to promote the child’s communication skills, encourage breastfeeding and support maternal health. The NFP National Service Office organises specific training for the nurses, runs a data collection system to monitor national progress, and gives support to implementing agencies around the country. The program is funded predominantly by the federal government, along with public and private support at the state and local level. The agencies hire nursing staff and run the program in their respective areas.
42 states across the US and the US Virgin Islands
Parents, infants and toddlers
Cost & Value
Estimated costs are around $4,500-6,000 per year. NFP receives around $90-100 million each year from the federal government as part of the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program.
The first study started in 1977 and it's been running since 1996.
NFP nurses are expensive compared to other home visitors, and the severe shortage of nurses in the US may make it more difficult to replicate the program. Nurses are considered the best providers, but when budgets are tight they could lose out to other cheaper initiatives. The program’s trial in the UK didn’t produce the same results as other countries, which has raised questions about its replicability. However, the British study was less strict about restricting the pilot to the most vulnerable mothers, while the control group experiencing “usual care” benefitted from universal healthcare, in contrast with the US' decentralised system.
Trials have taken place in Germany, the Netherlands and UK. The model is also being adapted for Australia, Canada and Bulgaria.
“When you’re pregnant with your first baby, it is a motivational, teachable moment where you’re scared and just looking for someone to be a friendly, trusted advisor.”
That’s the role nurses play in the Nurse-Family Partnership (NFP), a home-visiting program in the US, according to Sarah McGee, National Director of Advocacy at their National Service Office.
Through regular visits by specially-trained nurses, NFP is improving the lives of first-time, low-income mothers and their children. What’s more, the program could save the US government billions of dollars, with every dollar spent on highest-risk families saving an estimated $5.70 in future costs.
The biggest chunk of savings will come from Medicare: an estimated $2.2 billion by 2031.
Running since 1996, the NFP currently serves around 34,000 families in in 42 states and the US Virgin Islands. The nurses visit mothers from pregnancy to their child’s second birthday, and results are impressive thus far.
“It really is geared towards what the mother’s needs are at that time. Sometimes the nurse is just their support system, to sit there and talk about life”
Research has suggested, amongst many other positive effects, that the NFP program leads to a 48% reduction in child abuse and neglect, a 67% decrease in behavioural and intellectual problems by the age of six, and 59% reduction in child arrests by age 15. One study found that by 2031, enrolments during 1996-2013 will have prevented an estimated 500 infant deaths, 13,000 dangerously spaced second births, 90,000 violent crimes by youths, and 41,000 years of youth substance abuse.
“It really is geared towards what the mother’s needs are at that time. Sometimes the nurse is just their support system, to sit there and talk about life. That nurse may be one of the only trusted people they have in their life,” said McGee.
On average, the nurses visit families 25 to 30 times over 17 months. During pregnancy, they work to help mothers cut down on alcohol, tobacco and drug use, identify potential prenatal complications, and help plan their future with the child. After birth, the nurses work alongside the mother to improve the child’s physical and emotional care, promote the child’s development including communication skills, encourage breastfeeding and support maternal health.
Significantly for policymakers, the program has the potential to save a huge amount of cash in the long term. For example, the aforementioned study found that, by 2031, supporting the 177,517 enrollees from 1996-2013 is expected to reduce spending on Medicaid, TANF, and food stamps by $3 billion, compared to a cost of $1.6 billion. The estimated cost of the program per family is on average $4,500-6,000 per year.
NFP began with research by David Olds, which attracted government attention for its potential to reduce crime. “Where we got the most interest was from the longitudinal follow up study from the first randomised control trial in Elmira, New York, which showed reductions in crime for the mother and the child,” said McGee.
The NFP National Service Office organises specific training for the nurses – including a weeklong course in Denver, Colorado – runs a data collection system to monitor national progress, and gives support to implementing agencies around the country who apply to run the program in their area. The application process is rigorous.
NFP is predominantly run by the federal government, which receives around $90-100 million each year as part of the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program, as well as support through Medicaid, TANF, and Title V MCH block grant dollars. Agencies have access to some of this funding, along with public and private support at the state and local level, to cover costs including the hiring of nurses.
“Nurses are expensive, but you do have to use nurses for the kind of results that Nurse-Family Partnership produces”
Despite its successful results in the US, evidence in other countries has been more mixed. Trials in Germany and the Netherlands produced modest but positive results, the latter finding that three years after birth, children in the intervention group were 8% less likely to have filed with child protective services. Meanwhile, other countries including Canada, Australia, and Bulgaria are also beginning to adopt the model.
However, in the UK a trial evaluated by the Lancet was found to have no significant impact. This is often attributed to two reasons: they used less strict criteria in choosing highest-risk mothers, while the control group experiencing “usual care” benefitted from universal healthcare, in stark contrast to the US model. These results suggest that it’s only the most vulnerable first-time mothers that benefit significantly from extra support.
Another challenge is the high cost of nurses. “But you do have to use nurses for the kind of results that NFP produces. Budgets are tight, there are a lot of programs out there and a lot of families in need, so policymakers have to take tough decisions about what they’re going to fund,” said McGee.
The next step? NFP plans to scale up to 100,000 families per year in the next seven years in the US, a significant chunk of the 380,000 children per year who are born to first-time mothers. At that kind of scale, who knows how much public money could be saved in the long-term.
(Picture credits: Nurse-Family Partnership)