Feb. 20, 2000

TEACHING NEW MOTHERS TO BE BETTER MOMS

One proposal for part of Colorado's tobacco-settlement money is to fund a program of carefully structured home visits by nurses to young mothers.

The program grows out of research by Dr. David Olds, professor of pediatrics, psychiatry and preventive medicine at the University of Colorado Medical School, and director of the Kempe Prevention Research Center. Over the past 20 years he has conducted three major field trials of the program, first in Elmira, N.Y., then in Memphis, Tenn., and most recently in Denver.

The research continues; Olds said they are now collecting data on the Elmira children at age 19 to see whether the salutary effects of the nurse visits persist. A follow-up study of Memphis will be published soon, and papers about the Denver trial have just started to appear.

But after 20 years, they're hoping to turn theory into large-scale practice. And Olds plans to be ready.

In October, the Robert Woods Johnson Foundation announced a three-year, $10 million grant to establish a national center at the University of Colorado that will train nurses and support the program in up to 40 communities. The National Center for Children, Families and Communities opened Dec. 16, a joint effort of CU's School of Nursing and School of Medicine and The Children's Hospital in Denver.

Olds wanted to make sure I understood that the grant is not for providing service directly, but to ensure that newly established programs replicate the success of the research trials. It's an essential point. All too often, ideas that work just fine in small pilot programs overseen by the people who designed them fall apart when others try them, because they don't really know why it works. It's the difference between relying on a photocopy of a fax of a photocopy, and printing out a fresh copy direct from the original on your laser printer.

The national center will collect information from places that use the program, and also spread the word on changes that ought to be made in the light of further research results.

The home visits begin during pregnancy and last until the child is 2 years old. Nurses teach the new mothers about the child's health and development, help them develop their skills as parents, and elevate their aspirations.

"They help parents become more economically self-sufficient by helping them develop a vision for their future and by delaying future pregnancies, staying in school, and finding work," Olds said.

Isn't that imposing middle-class values on them? Sure, but families value their nurses' visits. And the children are better off; among the improvements cited by the foundation in announcing its grant are fewer instances of child abuse and neglect, a delay in subsequent pregnancies and better social, cognitive and language skills among the children.

The mothers smoke less during pregnancy, too, so it really does have something to do with the tobacco-settlement money.

The pregnant women recruited for the Denver study were mostly young and unmarried, with less than a high school education and no health insurance other than Medicaid. The purpose of the study was to test whether the program worked as well with paraprofessional visitors as with nurses.

Olds can't talk about the results, because the research hasn't been published yet and - as he did not need to tell me - journals are finicky about accepting papers whose conclusions have been worried over by the media.

But one paper that has been published, in the December 1999 issue of the American Journal of Public Health, documents significant differences in how the nurses and paraprofessionals conducted their visits. The nurses spent more time on physical health during pregnancy, and on parenting issues during pregnancy, while the paraprofessionals spent more time on environmental health and safety (adequate food, clothing and shelter for the mother and child) and social support perhaps "because these were issues they had successfully managed in their own lives."

Mothers with paraprofessional visitors were less likely to keep the same one throughout the program; they had fewer visits on average and were more likely to drop out before the end.

If intervention by paraprofessionals works, that is great. If it doesn't, policymakers need to know, because it's exactly the kind of penny-pinching makeshift someone is likely to propose (the Denver program cost $7,700 per family for nurses, $5,200 for paraprofessionals).

A disposition to make changes when and only when the scientific evidence warrants is what sets this program aside from others.

(783 words)