In 2007 Crystalon Rodrigue, a recent high school graduate living in St. James, LA, had an adverse reaction to an injectable contraceptive. She discontinued it and soon got pregnant. She was 19 years old and unemployed and living with her mother, and her relationship with her boyfriend was faltering. She turned to the state department of health; was referred to the Nurse–Family Partnership (NFP); and met “Miss Tina,” a nurse who visited her at home.
“In the beginning of my pregnancy, and maybe all throughout, I was a little stressed out,” the 21-year old Ms. Rodrigue said recently. “I was depressed because I was having relationship problems with my child’s father. Miss Tina helped me….” Ms. Rodrigue was interrupted by the chatter of her 19-month-old daughter, Nalayia, who was learning to read, her mother said with pride. Then she continued, “Miss Tina helped me to think about myself.”
It was a quiet, almost offhand remark, but it represents the kind of shift in attitude that the NFP has helped foster among young women for more than 30 years. Now active in 375 counties in 29 states, the NFP sends registered nurses (RNs), usually with baccalaureate degrees, into the homes of at-risk, low-income, first-time mothers for 64 planned visits over the course of a pregnancy and the child’s first two years.
Improving the lives of children is the chief aim of the NFP, yet the interventions target mothers. The nurse discusses options for the mother’s continued education and economic self-sufficiency; supports her in reducing or quitting smoking or drinking; teaches her about child development, nonviolent discipline, and breastfeeding; and helps her make decisions about family planning. The nurse does this by engaging the mother in a relationship that provides a model for interactions with others. The child’s father and other family members are encouraged to participate.
“We don’t look for the great big change,” said Luwana Marts, BSN, RN, regional nurse consultant for the NFP in Louisiana. “A part of the model is that only a small change is necessary. So if a client never quits smoking but she doesn’t smoke in the presence of her child, that’s a plus.”
In case-controlled, longitudinal trials conducted among racially and ethnically diverse populations — beginning in 1977 in Elmira, New York, and continuing in Memphis, Tennessee, and Denver, Colorado — the NFP has shown reductions in unintended second pregnancies and increases in mothers’ employment. Children of mothers visited by nurses are less likely to be abused and by age 15 to be arrested. (For links to these and other studies of the NFP, visit www.nursefamilypartnership.org/provenresults/published-research.) The per-child cost is $9,118; for the highest-risk children, a return of $5.70 per dollar spent is realized (Karoly et al., 2005).
Several models of home visitation are in use, but the NFP relies on trained RNs for its interventions. A 2002 study compared home visits by untrained “paraprofessionals” and nurses. On almost all measures, the nurses produced far stronger outcomes (Olds et al., 2002). “People trust nurses,” said Ruth A. O’Brien, Ph.D., RN, FAAN, professor of nursing at the University of Colorado in Denver and an author of the study. “Low-income, minority people who have not had a lot of trust in the health care system might be willing to let a nurse in the door.”
Barriers to implementation include the fact that states use various sources to fund the NFP, and in some the funding is limited. The Affordable Care Act mandates that $1.5 billion be spent over five years on home visitation programs for at-risk mothers and infants*—substantially less than the $8.5 billion over 10 years that President Obama requested in his 2010 budget (OMB, 2010). While the Act establishes a federal agency to oversee such home visitation programs, it does not specify that nurses provide the care. Also, some municipalities increase the nurse’s caseload beyond the recommended 25, diminishing the intensity and effectiveness of the interventions.
For her part, Ms. Rodrigue is looking ahead. She had completed a certified nursing assistant program while pregnant and will soon start nursing school, in which she had enrolled but quit shortly after high school. “I wasn’t ready for it,” she said. “But now I have a child and I know what to expect. I feel like I’m ready. I want to better myself.”