title: Hawaii's healthy start home visiting program: determinants and impact of rapid repeat birth.
abstract: OBJECTIVE
  Healthy People 2010 calls for reductions in rapid repeat births (RRBs), defined as births occurring within 24 months after a previous birth for women of all ages, and prevention of repeat births during adolescence, regardless of the birth interval. Home visiting has been promoted as a mechanism to prevent child abuse and neglect and to improve pregnancy outcomes. This study aims to assess the impact of home visiting in preventing RRB and its malleable determinants and assesses the influence of RRB on the mother and the index child. We hypothesized that maternal desire to have a RRB, access to a family planning site, and use of birth control would be significant malleable determinants and that the effects of the program in preventing RRB would be mediated through its influence on these variables. We also hypothesized that the occurrence of RRB would result in increased stress and family dysfunction, resulting in adverse maternal and child outcomes such as severe maternal stress, maternal neglect of the index child, decreased maternal warmth toward the index child, and increased behavior problems of the index child.
  
  
  METHODS
  The Healthy Start Program (HSP) is a home visiting program to prevent child abuse and neglect and to promote child health and development among newborns of families identified as being at risk for child maltreatment. This study was a randomized, controlled trial of Hawaii's HSP, in which eligible families were randomly assigned to home-visited and control groups. A total of 643 families at risk for child abuse were enrolled between November 1994 and December 1995. Data to measure RRB and malleable determinants were collected through structured maternal interviews and observation of the home environment. We measured RRB through maternal self-report by asking about a subsequent birth in follow-up interviews at 1, 2, and 3 years. To measure the malleable determinants, we measured the mother's desire for a RRB at baseline and at the 1-year interview and determined whether she had access to a family planning site. The mother was also asked which contraceptive methods she had ever used in the past and which methods, if any, she used in the year following the index child's birth. We measured 3 maternal parenting outcomes at the year 3 follow-up interview, ie, parenting stress, neglectful behavior toward the index child, and warmth toward the index child. We used odds ratios with 95% confidence intervals (CIs) to measure the strength of associations. Multiple logistic regression was used to assess 1) program effects on RRB and its malleable determinants, 2) the impact of the malleable determinants on RRB, and 3) the association between RRB and adverse maternal and child outcomes.
  
  
  RESULTS
  Each year, 88% of the sample completed a follow-up interview; 81% completed all 3 follow-up interviews. There was no program impact on RRB for mothers overall (HSP: 21%; control: 20%; adjusted odds ratio [AOR]: 1.05; 95% CI: 0.69-1.58). HSP and control groups did not differ significantly in any of the malleable determinants of RRB. When we combined the 2 study groups, malleable determinants had significant effects on RRB. Mothers with a desire to have a child within 2 years after the index birth were significantly more likely to have a RRB, whether this desire was expressed at baseline (AOR: 2.48; 95% CI: 1.32-4.64) or at the year 1 interview (AOR: 2.86; 95% CI: 1.57-5.22). Lack of access to a family planning site at baseline was not associated with RRB, but there was a trend toward a greater likelihood of RRB among those lacking a site at 1 year (AOR: 1.61; 95% CI: 0.93-2.79). Women who had never used birth control before the index birth were more likely to have a RRB (AOR: 1.89; 95% CI: 1.20-2.98), and there was a trend toward a greater likelihood of RRB among women who did not use birth control in the year following the index child's birth (AOR: 1.67; 95% CI: 0.98-2.82). At the 3-year follow-up interview, mothers with a RRB were more likely to have adverse maternal and child outcomes. There was greater likelihood of severe maternal parenting stress (AOR: 2.29; 95% CI: 1.17-4.48), neglectful behavior toward the index child (AOR: 2.42; 95% CI: 1.41-4.18), and poor warmth toward the index child (AOR: 2.84; 95% CI: 1.71-4.42). In families with a RRB, the index child was more likely to exhibit internalizing behavior (AOR: 1.64; 95% CI: 1.04-2.58) and there was a trend toward higher odds of externalizing behavior (AOR: 1.56; 95% CI: 0.98-2.49).
  
  
  CONCLUSIONS
  Overall, 20% of the mothers in our sample of at-risk families had a RRB, which was far greater than the national average of 11%. RRB was associated with a greater likelihood of adverse consequences for both the mother and the index child. The lack of program effects can be traced to shortcomings in the program's design and implementation system. HSP contracts required only that family planning be introduced any time during a family's first year of enrollment. Because conception can occur very soon after the index birth, a better design would be to introduce family planning counseling early in a family's enrollment in home visiting. Another shortcoming was that, although fathers could be included in counseling, they took part in only approximately one-fifth of home visits. It is possible that program effects were attenuated in families in which the father wanted a child. In conclusion, the Hawaii HSP did not reduce RRB or alter its malleable determinants. RRB was associated with adverse outcomes for both the mother and the index child. This is particularly relevant for this population of families that are already at risk for child maltreatment, for which we have found parenting stress to be associated with abusive parenting behavior by the mother. Our findings support and broaden the rationale for the Healthy People 2010 objective to reduce RRB. We think our findings are valuable for guiding the future development of home visiting in general and this widely replicated paraprofessional model in particular.
authors.affiliation: Johns Hopkins University School of Medicine, Baltimore, Maryland 21205-1903, USA.
authors.forename: Samer S
authors.initials: SS
authors.lastname: El-Kamary
authors.forename: Susan M
authors.initials: SM
authors.lastname: Higman
authors.forename: Loretta
authors.initials: L
authors.lastname: Fuddy
authors.forename: Elizabeth
authors.initials: E
authors.lastname: McFarlane
authors.forename: Calvin
authors.initials: C
authors.lastname: Sia
authors.forename: Anne K
authors.initials: AK
authors.lastname: Duggan
mesh_terms: D001721:Birth Intervals; D002649:Child Abuse / Q000517:prevention & control*; D002669:Child Welfare; D002675:Child, Preschool; D005193:Family Planning Services; D005260:Female; D006254:Hawaii; D006266:Health Education; D040361:Healthy People Programs; D006699:Home Care Services; D006792:House Calls; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D016487:Parenting; D015397:Program Evaluation; D012736:Sex Education / Q000379:methods*