title: Effect of home visiting by nurses on maternal and child mortality: results of a 2-decade follow-up of a randomized clinical trial.
abstract: OBJECTIVE
  Mothers and children living in adverse contexts are at risk of premature death.
  
  
  OBJECTIVE
  To determine the effect of prenatal and infant/toddler nurse home visiting on maternal and child mortality during a 2-decade period (1990-2011).
  
  
  METHODS
  A randomized clinical trial was designed originally to assess the home visiting program's effect on pregnancy outcomes and maternal and child health through child age 2 years. The study was conducted in a public system of obstetric and pediatric care in Memphis, Tennessee. Participants included primarily African American women and their first live-born children living in highly disadvantaged urban neighborhoods, who were assigned to 1 of 4 treatment groups: treatment 1 (transportation for prenatal care [n = 166]), treatment 2 (transportation plus developmental screening for infants and toddlers [n = 514]), treatment 3 (transportation plus prenatal/postpartum home visiting [n = 230]), and treatment 4 (transportation, screening, and prenatal, postpartum, and infant/toddler home visiting [n = 228]). Treatments 1 and 3 were included originally to increase statistical power for testing pregnancy outcomes. For determining mortality, background information was available for all 1138 mothers assigned to all 4 treatments and all but 2 live-born children in treatments 2 and 4 (n = 704). Inclusion of children in treatments 1 and 3 was not possible because background information was missing on too many children.
  
  
  METHODS
  Nurses sought to improve the outcomes of pregnancy, children's health and development, and mothers' health and life-course with home visits beginning during pregnancy and continuing through child age 2 years.
  
  
  METHODS
  All-cause mortality in mothers and preventable-cause mortality in children (sudden infant death syndrome, unintentional injury, and homicide) derived from the National Death Index.
  
  
  RESULTS
  The mean (SE) 21-year maternal all-cause mortality rate was 3.7% (0.74%) in the combined control group (treatments 1 and 2), 0.4% (0.43%) in treatment 3, and 2.2% (0.97%) in treatment 4. The survival contrast of treatments 1 and 2 combined with treatment 3 was significant (P = .007); the contrast of treatments 1 and 2 combined with treatment 4 was not significant (P = .19), and the contrast of treatments 1 and 2 combined with treatments 3 and 4 combined was significant (post hoc P = .008). At child age 20 years, the preventable-cause child mortality rate was 1.6% (0.57%) in treatment 2 and 0.0% (SE not calculable) in treatment 4; the survival contrast was significant (P = .04).
  
  
  CONCLUSIONS
  Prenatal and infant/toddler home visitation by nurses is a promising means of reducing all-cause mortality among mothers and preventable-cause mortality in their first-born children living in highly disadvantaged settings.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT00708695.
authors.affiliation: Department of Pediatrics, School of Medicine, University of Colorado, Aurora.
authors.forename: David L
authors.initials: DL
authors.lastname: Olds
authors.affiliation: School of Nursing, University of Rochester, Rochester, New York.
authors.forename: Harriet
authors.initials: H
authors.lastname: Kitzman
authors.affiliation: Department of Pediatrics, School of Medicine, University of Colorado, Aurora.
authors.forename: Michael D
authors.initials: MD
authors.lastname: Knudtson
authors.affiliation: School of Nursing, University of Rochester, Rochester, New York.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Anson
authors.affiliation: School of Nursing, University of Rochester, Rochester, New York.
authors.forename: Joyce A
authors.initials: JA
authors.lastname: Smith
authors.affiliation: School of Nursing, University of Rochester, Rochester, New York.
authors.forename: Robert
authors.initials: R
authors.lastname: Cole
mesh_terms: D001741:Black or African American; D002648:Child; D002662:Child Health Services / Q000706:statistics & numerical data*; D046688:Child Mortality / Q000639:trends*; D002669:Child Welfare; D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D006792:House Calls / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D008297:Male; D008427:Maternal Health Services / Q000706:statistics & numerical data*; D008428:Maternal Mortality / Q000639:trends*; D064691:Nurses, Community Health / Q000639:trends; D011247:Pregnancy; D011256:Pregnancy Outcome; D016019:Survival Analysis; D013714:Tennessee; D014505:Urban Population