Goldstein, Rachel

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Randomized	  Controlled	  Trial	  of	  a	  Universal	  
Postnatal	  Nurse	  Home	  Visiting	  Program:	  
Impact	  on	  Maternal	  Wellbeing,	  18	  months	  
after	  Childbirth	  
EXECUTIVE	  SUMMARY	   	   	   	   	   	   April  2014  
	  
  
Prepared  for  |   Ken  Dodge,  Ben  Goodman,  and  Jeannine  Sato       
Durham  Connects  
 
 
Prepared  by  |  Rachel  Goldstein  
Master  of  Public  Policy  Candidate  
The  Sanford  School  of  Public  Policy  
Duke  University  
 
 
Faculty  Adviser  |   Anna  Gassman-­‐Pines,  Ph.D.  
     
	  
	  
Randomized	  Controlled	  Trial	  of	  a	  Universal	  Postnatal	  Nurse	  Home	  Visiting	  Program:	  
Impact	  on	  Maternal	  Wellbeing,	  18	  months	  after	  Childbirth	  
	  
EXECUTIVE	  SUMMARY	  |	  ii	  
I. INTRODUCTION	  
Background	  	  
Home	  Visiting	  	  
Home visiting (HV) programs have become a popular early intervention tool to fight child 
maltreatment and to promote healthy child and family development. In the U.S. alone, there are over 
400 programs that collectively serve 450,000 families (Avellar & Paulsell, 2011; Johnson, 2009).  
 
The Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV), authorized by the 2010 
Patient Protection and Affordable Care Act (ACA), substantially increased federal funding for home-
visiting programs. Prior to this federal development, public funding for home visitation came mainly 
from state and local sources. Approximately 15 state Medicaid programs provide funding for home 
visiting programs (Witgert, Giles, & Richardson, 2012). 
 
Seventy-five percent of federal MIECHV funds are allocated to programs that meet the U.S. 
Department of Health and Human Services (HHS) criteria for evidence of effectiveness, and up to 25 
percent of the funds may be allocated to programs that exhibit “promising approaches” to HV. 
Durham	  Connects	  	  
The Durham Connects (DC) program, a universal postnatal nurse home visiting program in Durham 
County, North Carolina, is in the process of evaluating the effectiveness of its model. Evidence of 
effectiveness could lead to MIECHV funds for the program, which would secure financial stability for 
DC’s operating model for years to come.  
 
DC aims to increase child wellbeing by linking parents to a network of community resources based on 
exhibited type of service need. DC departs from most other home visiting models on a number of 
defining program characteristics. The program is universal rather than targeted, is brief in duration 
relative to other models (DC lasts only a month or two max, while other programs can last over a year), 
and focuses on the postnatal period rather than the prenatal period.  
 
DC’s main goals are to reduce child abuse, to increase appropriate medical care, and to increase 
connections to community services and agencies that will promote and foster child and family health 
and wellbeing. A DC staff member first connects with the mother and infant in the hospital upon 
delivery in order to enroll interested mothers in the program and to schedule a subsequent home visit.  
 
Registered nurses (RNs) visit the home within three weeks following delivery. During the 1-3 hour-
long visit, the RNs assess the family’s risk level, deliver “tailored teachings” to the mother, and provide 
the family with referrals for medical and community-based resources. The nurses close out most 
families’ cases within one to two weeks of the first home visit. See Figure 1 for a complete depiction of 
the program timeline.  
	  
	  
Randomized	  Controlled	  Trial	  of	  a	  Universal	  Postnatal	  Nurse	  Home	  Visiting	  Program:	  
Impact	  on	  Maternal	  Wellbeing,	  18	  months	  after	  Childbirth	  
	  
EXECUTIVE	  SUMMARY	  |	  iii	  
	  	  	  	  	  	  	  Figure	  1.	  Timeline	  of	  Durham	  Connects	  intervention	  	  
 
	  
 
The DC program design can impact maternal wellbeing in two potential ways: (1) nurse-delivered 
teachings, and (2) referrals for medical and/ or community resources. During the RCT period, nurses 
reported that of the tailored teachings they delivered, teachings on maternal wellbeing were among the 
most common. It is possible that because of either or both of these teachings and DC-initiated linkages, 
women could experience improved wellbeing.  
Research	  Objectives	  
(1) 18 months following the birth of a child, do mothers who participated in Durham Connects 
show improved wellbeing, relative to controls? 
(2) Does the program benefit a certain group of mothers more than others?  
 
II. RECOMMENDATIONS	  	  
 
Capturing the impact of DC on mothers’ wellbeing (and overall health) is a critical component of 
evaluating the complete effectiveness of the DC program. In future research and analytical strategy 
planning efforts, the impact evaluation team should consider ways to strengthen their ability to capture 
these benefits, including: 
 
(1) Mapping a logic model for how specific program mechanisms could impact specific maternal 
outcomes. 
(2) Adding and/ or revising questions that measure maternal health and wellbeing. 
	  
	  
Randomized	  Controlled	  Trial	  of	  a	  Universal	  Postnatal	  Nurse	  Home	  Visiting	  Program:	  
Impact	  on	  Maternal	  Wellbeing,	  18	  months	  after	  Childbirth	  
	  
EXECUTIVE	  SUMMARY	  |	  iv	  
(3) Including the same questions on maternal health and wellbeing in follow-up surveys in order to 
detect potential change over time. 
III. METHODS	  
 
This study evaluates the impact of DC based on the subsample of families that stemmed from data 
collected during the DC RCT (July 1, 2009 - December 1, 2010). The RCT treatment and control 
groups were randomly assigned by date of birth; babies born on even birth dates were assigned the 
intervention (n = 2,327), and babies born on odd birth dates were assigned to the “services as usual,” or 
control group (n = 2,450). The RCT utilized electronic discharge hospital records in Durham County to 
ensure that the population was fully identified and randomized for the 18-month period. See Figure 2 
for a detailed flow diagram of the RCT’s randomization and follow-up analyses. 
 
 
	  Figure	  2.	  Flow	  diagram	  of	  Durham	  Connects	  randomization	  and	  follow-­‐up	  analyses	  	  
 
 
	  
	  
Randomized	  Controlled	  Trial	  of	  a	  Universal	  Postnatal	  Nurse	  Home	  Visiting	  Program:	  
Impact	  on	  Maternal	  Wellbeing,	  18	  months	  after	  Childbirth	  
	  
EXECUTIVE	  SUMMARY	  |	  v	  
IV. RESULTS	  
 
The results of this study suggest that 18 months following childbirth, DC does not significantly impact 
most measures of mothers’ overall wellbeing. The study shows interesting findings in three outcome 
measures: Medicaid use, employment status, and contraceptive use. While the program aims to increase 
referrals and linkages with community and medical services, mothers rolling off of Medicaid could 
suggest increased family and parental stability. The significant difference in reported Medicaid use is a 
potentially promising finding for the DC program. 
 
The lower employment and lower contraceptive use findings (compared to the control group) present a 
curious twist to the results. A possible explanation for these findings could be that DC made mothers 
feel more secure, self-sufficient and economically stable, which could translate into feeling ready to 
have another child. Attempting to have another child, or being pregnant, could explain the lower 
contraceptive use amongst treatment mothers compared to the control group. The targeted teachings 
and medical and community linkages could have made mothers more confident in their ability to parent 
and engage in healthy personal and family functioning.  
 
 
Table	  2.	  Descriptive	  Statistics:	  Maternal	  Wellbeing	  Outcomes,	  18	  Months	  after	  Childbirth	  	  
	  
Intervention	   	   Control	   	  	   Difference	  
	  	  	  	  	  	  	  	  	  Variable	   Mean	   SD	   N	   	  	   Mean	   SD	   N	   	  	   P	  
Economic	  Self-­‐sufficiency	  
	   	   	   	   	   	   	   	   	  	  	  	  	  	  WIC	  use	   0.52	   0.50	   226	  
	  
0.57	   0.50	   254	  
	  
0.29	  
	  	  	  	  	  Medicaid	  use	   0.22	   0.41	   225	  
	  
0.34	   0.47	   254	  
	  
0.00	  
	  	  	  	  	  Total	  household	  income	   	  44,599	  	   	  43,405	  	   212	  
	  
	  40,740	  	   	  42,556	  	   223	  
	  
0.35	  
Work,	  Education,	  &	  Training	  
	   	   	   	   	   	   	   	   	  	  	  	  	  	  Employment	  status	   0.55	   0.50	   227	  
	  
0.65	   0.48	   254	  
	  
0.03	  
	  	  	  	  	  In	  school	  or	  training	  program	   0.17	   0.38	   225	  
	  
0.21	   0.41	   252	  
	  
0.31	  
Social	  Support	  
	   	   	   	   	   	   	   	   	  	  	  	  	  	  Emergency	  childcare	  available	   0.93	   0.25	   227	  
	  
0.94	   0.24	   254	  
	  
0.75	  
Family	  Planning	  	  
	   	   	   	   	   	   	   	   	  	  	  	  	  	  Contraceptive	  use	   0.55	   0.50	   226	  
	  
0.64	   0.48	   253	  
	  
0.04	  
	  	  	  	  	  Family	  planning	  services	  use	   0.10	   0.30	   225	   	   0.09	   0.29	   254	   	  	   0.90	  
Note.	  These	  mean	  outcomes	  do	  not	  include	  control	  variables.	  See	  full	  report	  for	  regression	  tables	  with	  covariates.	  	  	  
 
The results of this study also suggest that young mothers might benefit more from DC than older 
mothers. Younger mothers often have fewer resources, are less connected, and may be of a lower socio-
economic status. The DC program could have connected many of these women with referrals that led to 
stability. In future research, it would be interesting to run descriptive statistics on where these women 
were linked to, and if these referrals “stuck.”  
 
See the full report for a more detailed description of methods and results, a discussion of the study’s 
key limitations, and a reference list. 


Randomized Controlled Trial of a Universal Postnatal Nurse Home Visiting Program: Impact on Maternal Wellbeing, 18 months after Childbirth

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Randomized Controlled Trial of a Universal Postnatal Nurse Home Visiting Program: Impact on Maternal Wellbeing, 18 months after Childbirth

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