Journal of Community Health Nursing
ISSN: 0737-0016 (Print) 1532-7655 (Online) Journal homepage: http://www.tandfonline.com/loi/hchn20
Community Health Nursing Visits for At-Risk Women and Infants Jane Ryburn Starn To cite this article: Jane Ryburn Starn (1992) Community Health Nursing Visits for At-Risk Women and Infants, Journal of Community Health Nursing, 9:2, 103-110, DOI: 10.1207/ s15327655jchn0902_5 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0902_5
Published online: 07 Jun 2010.
Submit your article to this journal
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Citing articles: 13 View citing articles
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Date: 14 November 2015, At: 22:21
JOURNAL OF COMMUNITY HEALTH NURSING, 1992,9(2), 103-110 Copyright O 1992, Lawrence Erlbaum Associates, Inc.
Community Health Nursing Visits for At-Risk Women and Infants Jane R y b u r n Starn, RNC, MS, DrPH Downloaded by [Deakin University Library] at 22:21 14 November 2015
University of Hawaii
The purpose of this study was to utilize the Barnard Model of parent-infant interaction and instruments from the Barnard Newborn Nursing Models study to assess 30 pregnancy clients and to help determine appropriate interventions. Upon consent, the 30 study participants were randomly assigned to one of three groups: primiparous, unmarried, or otherwise socially at-risk. Thirty-three percent of the participants were under 19 years of age. A doctorally prepared community health nurse (CHN) completed all interventions, including a comprehensive assessment. Over 20% of participants admitted mild to moderate abuse of alcohol, cigarettes, and/or street drugs during early pregnancy. Counseling/supportive interventions established rapport and encouraged women to develop and maintain healthy life-styles. The control group of 10 were evaluated when their infant reached 6 months. A second group was followed during pregnancy, then evaluated at 6 months. A third group of 10 women were followed through pregnancy and the first 6 months of their babies' lives. Results indicated that substance abuse stopped or substantially decreased during intervention. Mothers in the intervention groups had fewer perinatal complications and better parent-infant interaction scores than the controls. This research supports previous reports that home visitor programs foster more healthy pregnancies and improve child developmental outcomes.
BACKGROUND AND SIGNIFICANCE During the past 30 years, the U.S. has dropped from 6th place to 23rd among industrialized nations in basic infant mortality statistics (Our Children At Risk, 1991). Lack of adequate early prenatal care and poor nutrition during pregnancy are associated with low birth weight, handicapping conditions, and high infant mortality (National Center for Health Statistics, 1985). Hawaii's data confirm national trends. In 1988, Hawaii's fertility rates were higher than the mean for the U.S.; 10% of all babies were born t o women less than 20, resulting in a birth rate of 34.2/1,000 for teens 16 and 17 years of age. Additionally, over 20% of all women had n o prenatal care in the first trimester and three counties had rates of over 25% (Regional Perinatal Program, 1990). Government expenditures for the sequelae of adolescent and out-of-wedlock Requests for reprints should be sent to Jane Ryburn Starn, RNC, MS, DrPH, 1532 Kamole Street, Honolulu, HI 96821.
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childbearing are enormous. The U.S. paid $19.83 billion in 1988 alone for Aid to Families with Dependent Children, Medicaid, and Food Stamps for families whose first birth occurred when the mother was a teen (Government Accounting Office [GAO], 1990). Recent federal legislation has attempted to address the problems of maternalhnfant morbidity and mortality through the Consolidated Omnibus Reconciliation Act (Moore, 1988). The State of Hawaii has enacted sweeping legislation to make early prenatal care and child health care from pregnancy through age 5 available to all families. However, the problems of unintended pregnancy and of compromised maternal and infant development continue due to inadequate supports and services for childbearing women and their infants (Miller, Fine, Adams-Taylor, & Schoor, 1986). The costs of early detection and intervention are far lower than the cost incurred for welfare funding, foster care for abused children, and medical support for infants born with birth defects, learning disabilities, pulmonary problems, or anomalies related to substance abuse. All of these are documented sequelae of failure to provide adequately for socially disadvantaged families (GAO, 1990). Health professionals working in overburdened prenatal clinics serving a low socioeconomic clientele may be frustrated by the lack of time to assess and intervene with their pregnant and child-rearing patients. The project reported here replicated the work of several investigators by determining whether case-managed nurse home visits to psychosocially disadvantaged pregnant women improves their health, developmental, and life circumstantial outcomes. Because prenatal stressors have been found to negatively influence birth and child-rearing outcomes, intervention with disadvantaged families seems warranted (Institute of Medicine, 1985; Norbeck & Tilden, 1983). The federal government has legislated but not funded home visiting programs in the Maternal Child Health Block Grant of the Omnibus Budget Reconciliation Act (American Public Health Association, 1991; GAO, 1990). A review of the literature supports the effectiveness of visiting nurse programs. Olds, Henderson, Eitlebaum, and Chamberlin (1988) reported that public health nurses followed 400 women through pregnancy and the first 2 years of life. Findings indicated that the intervention groups had improved pregnancy outcomes and parenting function. This group also completed more education, found more employment, and experienced fewer subsequent pregnancies than the control group. Field, Widmayer, Greenberg, and Stoler (1985) found that a nurse visitor program for teen mothers in Miami resulted in better weight and developmental scores for infants and increased school and/or job performance for their mothers. Barnard, Booth, Mitchell, and Telzrow (1988) followed women during pregnancy and for the first 3 months post-birth. The team's results suggest that public health nursing intervention programs should be included as a standard preventive child health measure. The value of home visiting has also been supported by Chapman, Seigel, and Cross (1990) who reviewed seven successful programs and concluded that increased birth weight, improved prenatal care, maternal-infant interaction and use of community resources result from home visitor programs. A GAO (1990) report indicated that successful programs, some utiliz-
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ing nurse home visitors and some paraprofessional with professional supervision, evolved only when services were based on clearly stated objectives, carefully planned service delivery, and wide-range availability/funding of services. The Department of Health and Human Services critique of the aforementioned report stated that community health nursing has had a long history of effective home visiting, but has had to struggle recently to maintain its funding base while a patchwork of community-based services have proliferated (GAO, 1990). This study evolved from my concern about the fragmented services often experienced by socially and economically at-risk pregnant women. The study was based on premises that CHNs assist families to cope with stress and expand options for education, work, and family planning. Nurses also help families improve their health, nutrition, and parenting practices leading to improved infant health and development. The goals of the project were: (a) to demonstrate a model for at-risk families which could then be applied to already existing health delivery systems, and (b) to confirm that intervention during pregnancy and early child rearing produces improved health, developmental, and life circumstantial outcomes for socially disadvantaged women and their children. Sample
Thirty women who were primiparous, unmarried, or otherwise socially at-risk participated in the study. All women were in the late second or early third trimester of their pregnancy. The majority were under 24 years old and 33% were under 19 years old. Thirty percent of the women stated that they smoked and 26% stated they drank alcohol during the first trimester of pregnancy. Twenty-six percent of the women admitted to using marijuana, cocaine, or multiple drugs. More than half (57%) were living temporarily with a relative or friends, and 73% stated that the pregnancy was a surprise. The ethnicity was varied: 27% Hawaiian or part Hawaiian, 20% White, 17% Filipino, 17% Samoan, 13 % Asian, and 6% Other. Methodology
The CHN explained the project to women during their obstetric clinic visit. Following informed consent, they were randomly assigned to one of the three groups. The Barnard Model of parent-infant interaction and selected instruments from the Newborn Nursing Models study were utilized to assess the clients and to help determine appropriate interventions (Barnard, Booth, Mitchell, & Telzrow, 1983). Group 1 consisted of a non-intervention control group of 10 women and infants who were enrolled and then not visited until their infants reached 6 months of age and the postdelivery evaluation visit was completed. Group 2 was a pregnancy intervention group of 10 women who were followed through their pregnancy with nursemanaged home visits and then evaluated when their babies reached 6 months. A pregnancy to 6 months post-birth intervention group of 10 women who received nursing home visits during the pregnancy until their babies' 6th month followed by the postdelivery evaluation comprised Group 3.
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A mental health model as described in Barnard's Newborn Nursing Models was used to establish rapport and encourage women to develop and maintain healthy life-styles during their pregnancies and early child rearing (Barnard et al., 1983). Role modeling, referral, active listening, and facilitation of support were utilized to establish a helping relationship during weekly phone calls and monthly home visits by the parent-child nurse visitor. Prenatal and psychosocial history was assessed during the first home visit of Groups 2 and 3 utilizing the Difficult Life Circumstances @LC) and Community Life Skills Scale (CLSS). (See Tables 1 and 2 for a description of study instruments and schedule for measurement.) Interventions were then individualized according to actual and potential problems. For instance, five women needed assistance in completing Women and Infant Children (WIC) nutrition forms. A 24-hr nutrition history was used to recommend eating practices based on culturally accepted food preferences. Support and/or referral was given for decreasing or stopping alcohol, smoking, and drugs. Eight women received referrals to high school completion or community college programs, and 10 received counseling about job opportunities. The CHN gave each woman specific childbirth preparation and infant care instruction based on her knowledge and needs. Suggestions for coping with particular pregnancy discomforts were given and support systems were determined. The CHN modeled a supportive relationship and encouraged kin and friendship networking. Because over 50% of the 20 subjects were living temporarily with friends or family, the women were assisted to apply for low-income housing, despite the 8 to 10 month waiting period. The CHN also counseled women regarding relationship problems with partners and/or family members. The pregnancy intervention for Group 2 ended with a telephone call after the women had given birth to allow the mother to report on her labor and delivery. The 10 subjects for the 6-month follow-up (Group 3) received this same intervention in a home visit within the 1st month after the baby's birth. During this visit, the nurse did a modified Brazleton Neonatal Assessment to introduce each mother to her newborn's responsive and reflexive abilities. Mothers were encouraged to elicit verbal and visual alerting responses. The nurse also assessed and taught about maternal recovery, plans for family planning, and infant feeding and care. Adapting to parenthood was assessed and counseling and support given for issues such as how to TABLE 1 Description of Instruments - -
Community Life Skills Scale: A 33-item measure which assesses client's skills in organizing daily living. Difficult Life Circumstances Scale: A 28-item scale designed to determine the extent of chronic family problems which divert energy from pregnancy and/or child rearing. NCAST Feeding Scale: This scale utilizes 76 items in six subscales measuring parent-infant interaction during a feeding. NCAST Teaching Scale: Seventy-three items are in six subscales measuring the parent-infant interaction during a structured task which requests the parent to teach the baby an age-appropriatetask. HOME Observation for the Measurement of the Environment: This is a 45-item scale which assists the nurse to determine the parent's ability to provide an enriching environment for the child. DDST (Denver Developmental Screening Test): Strengths and weaknesses of the child are identified in gross motor, fine motor, language, and personal-social areas of development.
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TABLE 2 Schedule of Measurement for Study Instruments
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Measurement Intervals
Group 1-Non-intervention/control CLSS DLC Perinatal complications HOME NCAFS NCATS DDST Group 2-Pregnancy intervention CLSS DLC Perinatal complications HOME NCAFS NCATS Home visits DDST Group 3-Pregnancy to 6 months intervention CLSS DLC Perinatal complications HOME NCAFS NCATS Home visits Brazelton modified DDTS
Second Tkimester Pregnancy
Postpartum
3-4 Months Age
X X
6 Months Age
X X X X X X
X X
X X X X X
X X
X X
X X X
X
X X
X X X X
X X X
X
X
Note. CLSS (Community Life Skills Scale), DLC (Difficult Life Circumstances), HOME (Home Observation for the Measurement of the Environment), NCAFS (Nursing Child Satellite Feeding), NCATS (Nursing Child Satellite Teaching, DDST (Denver Developmental Screening Test).
involve partners in infant care. One teen mother was helped to negotiate primary care responsibility with her mother who was dominating the care of her new grandchild. The Denver Developmental Screening Test (DDST) was introduced at the 2nd month home visit and repeated monthly through the 6th month visit. Infant stimulation and ideas for simple toys and parenting practices were taught at each visit. Each mother was given a copy of "Baby's First Year Calendar of Learning Games and Memories," which reinforced activities for daily play (Stodden, 1986). Maternal physical and emotional health and coping was also assessed as well as life-style practices including smoking, drug, and alcohol use. The continuing weekly phone calls allowed further assessment, teaching, and support. The Nursing Child Assessment Feeding Scale (NCAFS) was done during the third home visit. Immediate feedback to the mother included the positive aspects of her feeding, discussion of her baby's cues, and suggestions such as how to feed in the "en face" position to increase mother-baby interaction during feeding. The home assessment of the environment (HOME) was also completed which assessed the
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parent-infant setting and surroundings. The Nursing Child Assessment Teaching Scale (NCA'IS) was done during the fourth home visit. The assignment of a teaching task for the mother to teach her baby reinforced the importance of the mother as her infant's teacher and furthered discussion of appropriate toys and parenting techniques. Anticipatory guidance for the next month of the baby's development was given at each visit and play activities suggested per the Baby's First Year Calendar. The 5-month visit included an assessment of infant development, feeding practices and parenting, support for the mother and further counseling and guidance for parenting, relationship issues, and plans for work and school. Findings
Shortly after birth, a medical record chart review was conducted to determine perinatal problems or complications encountered by either the mother or her infant. The 6th month postdelivery evaluation visits were conducted by three graduate students reliable in using the NCAST instruments. When groups were compared, they were found to be similar demographically. Therefore, the differences found were considered to be a result of intervention. Mothers in Groups 2 and 3 who received the pregnancy intervention were found to have fewer perinatal complications. This was not true for their infants because one Group 3 infant had a low birth Apgar score, a congenital heart anomaly, flaccid tone, and pronounced developmental delay. Infants also did not show significant differences in development as measured by the DDST. However, the postbirth follow-up group (Group 3) when compared to Groups 1 and 2 by cross tabulation did have significantly better scores for parentinfant interaction on the NCAFS subscales of Infant Clarity of Cues, Maternal Sensitivity to Cues, Response to Distress, and the HOME subscales of Avoidance of Restriction and Punishment and Provision of Play Materials. When the postbirth (Group 3) Teaching scores on the NCATS at 4 months (completed by CHN) were compared to the 6 months evaluation scores, the NCATS total score and the SocialEmotional Growth Fostering subscale were significantly better than those for Groups 1 and 2. Thus, both infants and mothers in the intervention group had better parent-infant interaction scores. One mother in Group 3 became pregnant when her son was 4 months old, which negated a difference among groups. All other women were successfully using birth control at the 6-month evaluation. Statistically, more women did not return to work or school in the intervention groups. However, a strong trend occurred with only 14% of the non-intervention group working compared to 44% of the pregnancy group and 55% of the 6 months follow-up group working or in school. The DLC and CLSS scores also showed no differences at the 6 months evaluation when compared by groups. Crowded housing and additional financial burdens postbirth were persistent stressors which may have prevented an improvement in the scales for most of the women. Although funding was not available for toxicology screening, the women reported that substance abuse stopped or substantially decreased during the interven-
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tion period. Because an average of three visits were made to the pregnancy group and nine visits to the 6 months follow-up-group, it does seem probable that both groups had better outcomes secondary to the increased support.
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CONCLUSION
These findings support previous reports by Barnard et al. (1988), Olds et al. (1988), and Field et al. (1985) that CHN home visiting programs foster healthier pregnancies and improve child developmental outcomes. At-risk families who are poor, uneducated, or headed by teenage or single parent mothers often face barriers to getting the health, education, and social services they need. Implications are that routine clinic care needs to be expanded in scope to include a long-term and comprehensive approach including psychosocial issues for socially at-risk women and their infants. Longitudinal efforts need to study the cost effectiveness of nursing home visiting programs by reduction in medical complications and governmental spending and improved social, educational, developmental, and economic outcomes for at-risk families. Strategies need to be researched for reaching at-risk populations such as substance abusing or adolescent women who do not readily seek care. This article supports the effectiveness of CHNs in improving circumstances for at-risk families. In this era of increasing infant mortality and other poor outcomes and an eroding financial base for CHN visits, this article implies political activism may be warranted by CHNs, not to preserve their function, but to ensure the health and development of those families most at-risk for illness, developmental delay, and lives of poverty and despair. REFERENCES American Public Health Association. (1991, January). Home visiting and parent support. MCH Newsletter, 1, 3. Barnard, K., Booth, C., Mitchell, S., & Telzrow, R. (1983). Newborn nursing models (Final report on Grant R01-NU-00719). Washington, DC: Department of Health and Human Services, Division of Nursing. Barnard, K., Booth, C., Mitchell., S., & Telzrow, R. (1988). Newborn nursing models: A test of early intervention to high-risk infants and families. In E. D. Hibbs (Ed.), Children and families: Studies in pnevention and intervention (pp. 63-82). Madison, WI: International Universities Press. Chapman, J., Seigel, E., &Cross, A. (1990). Home visitors and child health: Analysis of selected programs. Bdiatrics, 85, 1059-1068. Field, T., Widmayer, S., Greenberg, R., & Stoler, S. (1985). Home and center-based intervention for teenage mothers and their at-risk infants. In S. Hare1 & M. J. Anastasiow (Eds.), The at-risk infant: Psychological, sociological and medical aspects (pp. 29-40). Baltimore: Brooks. Government Accounting Office. (1990, July). Home visiting: A promising early intervention strategy for at-riskfamilies. Washington, DC: Author. Institute of Medicine, Division of Health Promotion and Disease Prevention. (1985). Preventing low birthweight. Washington, DC: National Academy Press. Miller, C. A., Fine, A., Adams-Tbylor., & Schoor, L. B. (1986). Monitoring children's health: Key indicators. Washington, DC: American Public Health Association.
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Moore, M. L. (1988). Cobrahobra: Reaching out to low-income women. Genesis, 10(4), 12-14. National Center for Health Statistics. (1985). Advance report, final natality statistics. Monthly Vital Statistics Report, 36, 4. Norbeck, J. S, & Tilden, V. P. (1983). Psychological and social factors in complications of pregnancy: A prospective, multivariate approach. Journal of Health and Social Behavior, 24, 30-46. Olds, D. L., Henderson, C. R., Tatlebaum, R., & Chamberlin, R. (1988). Improving the life-course development of socially disadvantaged mothers: A randomized trial of nurse home visitation. American Journal of Public Health, 78(1 l), 1436-1445. Our children at risk. (1991, October). Honolulu Star Bulletin, p. C-2. Regional Perinatal Program. (1990). Woman and infant numbers in Hawaii. Honolulu: Author. Stodden, N. J. (1986). Baby'sfirst year calendar of learning games and memories. Honolulu: International Education Corporation.
ISSN: 0737-0016 (Print) 1532-7655 (Online) Journal homepage: http://www.tandfonline.com/loi/hchn20
Community Health Nursing Visits for At-Risk Women and Infants Jane Ryburn Starn To cite this article: Jane Ryburn Starn (1992) Community Health Nursing Visits for At-Risk Women and Infants, Journal of Community Health Nursing, 9:2, 103-110, DOI: 10.1207/ s15327655jchn0902_5 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0902_5
Published online: 07 Jun 2010.
Submit your article to this journal
Article views: 10
View related articles
Citing articles: 13 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=hchn20 Download by: [Deakin University Library]
Date: 14 November 2015, At: 22:21
JOURNAL OF COMMUNITY HEALTH NURSING, 1992,9(2), 103-110 Copyright O 1992, Lawrence Erlbaum Associates, Inc.
Community Health Nursing Visits for At-Risk Women and Infants Jane R y b u r n Starn, RNC, MS, DrPH Downloaded by [Deakin University Library] at 22:21 14 November 2015
University of Hawaii
The purpose of this study was to utilize the Barnard Model of parent-infant interaction and instruments from the Barnard Newborn Nursing Models study to assess 30 pregnancy clients and to help determine appropriate interventions. Upon consent, the 30 study participants were randomly assigned to one of three groups: primiparous, unmarried, or otherwise socially at-risk. Thirty-three percent of the participants were under 19 years of age. A doctorally prepared community health nurse (CHN) completed all interventions, including a comprehensive assessment. Over 20% of participants admitted mild to moderate abuse of alcohol, cigarettes, and/or street drugs during early pregnancy. Counseling/supportive interventions established rapport and encouraged women to develop and maintain healthy life-styles. The control group of 10 were evaluated when their infant reached 6 months. A second group was followed during pregnancy, then evaluated at 6 months. A third group of 10 women were followed through pregnancy and the first 6 months of their babies' lives. Results indicated that substance abuse stopped or substantially decreased during intervention. Mothers in the intervention groups had fewer perinatal complications and better parent-infant interaction scores than the controls. This research supports previous reports that home visitor programs foster more healthy pregnancies and improve child developmental outcomes.
BACKGROUND AND SIGNIFICANCE During the past 30 years, the U.S. has dropped from 6th place to 23rd among industrialized nations in basic infant mortality statistics (Our Children At Risk, 1991). Lack of adequate early prenatal care and poor nutrition during pregnancy are associated with low birth weight, handicapping conditions, and high infant mortality (National Center for Health Statistics, 1985). Hawaii's data confirm national trends. In 1988, Hawaii's fertility rates were higher than the mean for the U.S.; 10% of all babies were born t o women less than 20, resulting in a birth rate of 34.2/1,000 for teens 16 and 17 years of age. Additionally, over 20% of all women had n o prenatal care in the first trimester and three counties had rates of over 25% (Regional Perinatal Program, 1990). Government expenditures for the sequelae of adolescent and out-of-wedlock Requests for reprints should be sent to Jane Ryburn Starn, RNC, MS, DrPH, 1532 Kamole Street, Honolulu, HI 96821.
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childbearing are enormous. The U.S. paid $19.83 billion in 1988 alone for Aid to Families with Dependent Children, Medicaid, and Food Stamps for families whose first birth occurred when the mother was a teen (Government Accounting Office [GAO], 1990). Recent federal legislation has attempted to address the problems of maternalhnfant morbidity and mortality through the Consolidated Omnibus Reconciliation Act (Moore, 1988). The State of Hawaii has enacted sweeping legislation to make early prenatal care and child health care from pregnancy through age 5 available to all families. However, the problems of unintended pregnancy and of compromised maternal and infant development continue due to inadequate supports and services for childbearing women and their infants (Miller, Fine, Adams-Taylor, & Schoor, 1986). The costs of early detection and intervention are far lower than the cost incurred for welfare funding, foster care for abused children, and medical support for infants born with birth defects, learning disabilities, pulmonary problems, or anomalies related to substance abuse. All of these are documented sequelae of failure to provide adequately for socially disadvantaged families (GAO, 1990). Health professionals working in overburdened prenatal clinics serving a low socioeconomic clientele may be frustrated by the lack of time to assess and intervene with their pregnant and child-rearing patients. The project reported here replicated the work of several investigators by determining whether case-managed nurse home visits to psychosocially disadvantaged pregnant women improves their health, developmental, and life circumstantial outcomes. Because prenatal stressors have been found to negatively influence birth and child-rearing outcomes, intervention with disadvantaged families seems warranted (Institute of Medicine, 1985; Norbeck & Tilden, 1983). The federal government has legislated but not funded home visiting programs in the Maternal Child Health Block Grant of the Omnibus Budget Reconciliation Act (American Public Health Association, 1991; GAO, 1990). A review of the literature supports the effectiveness of visiting nurse programs. Olds, Henderson, Eitlebaum, and Chamberlin (1988) reported that public health nurses followed 400 women through pregnancy and the first 2 years of life. Findings indicated that the intervention groups had improved pregnancy outcomes and parenting function. This group also completed more education, found more employment, and experienced fewer subsequent pregnancies than the control group. Field, Widmayer, Greenberg, and Stoler (1985) found that a nurse visitor program for teen mothers in Miami resulted in better weight and developmental scores for infants and increased school and/or job performance for their mothers. Barnard, Booth, Mitchell, and Telzrow (1988) followed women during pregnancy and for the first 3 months post-birth. The team's results suggest that public health nursing intervention programs should be included as a standard preventive child health measure. The value of home visiting has also been supported by Chapman, Seigel, and Cross (1990) who reviewed seven successful programs and concluded that increased birth weight, improved prenatal care, maternal-infant interaction and use of community resources result from home visitor programs. A GAO (1990) report indicated that successful programs, some utiliz-
Downloaded by [Deakin University Library] at 22:21 14 November 2015
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ing nurse home visitors and some paraprofessional with professional supervision, evolved only when services were based on clearly stated objectives, carefully planned service delivery, and wide-range availability/funding of services. The Department of Health and Human Services critique of the aforementioned report stated that community health nursing has had a long history of effective home visiting, but has had to struggle recently to maintain its funding base while a patchwork of community-based services have proliferated (GAO, 1990). This study evolved from my concern about the fragmented services often experienced by socially and economically at-risk pregnant women. The study was based on premises that CHNs assist families to cope with stress and expand options for education, work, and family planning. Nurses also help families improve their health, nutrition, and parenting practices leading to improved infant health and development. The goals of the project were: (a) to demonstrate a model for at-risk families which could then be applied to already existing health delivery systems, and (b) to confirm that intervention during pregnancy and early child rearing produces improved health, developmental, and life circumstantial outcomes for socially disadvantaged women and their children. Sample
Thirty women who were primiparous, unmarried, or otherwise socially at-risk participated in the study. All women were in the late second or early third trimester of their pregnancy. The majority were under 24 years old and 33% were under 19 years old. Thirty percent of the women stated that they smoked and 26% stated they drank alcohol during the first trimester of pregnancy. Twenty-six percent of the women admitted to using marijuana, cocaine, or multiple drugs. More than half (57%) were living temporarily with a relative or friends, and 73% stated that the pregnancy was a surprise. The ethnicity was varied: 27% Hawaiian or part Hawaiian, 20% White, 17% Filipino, 17% Samoan, 13 % Asian, and 6% Other. Methodology
The CHN explained the project to women during their obstetric clinic visit. Following informed consent, they were randomly assigned to one of the three groups. The Barnard Model of parent-infant interaction and selected instruments from the Newborn Nursing Models study were utilized to assess the clients and to help determine appropriate interventions (Barnard, Booth, Mitchell, & Telzrow, 1983). Group 1 consisted of a non-intervention control group of 10 women and infants who were enrolled and then not visited until their infants reached 6 months of age and the postdelivery evaluation visit was completed. Group 2 was a pregnancy intervention group of 10 women who were followed through their pregnancy with nursemanaged home visits and then evaluated when their babies reached 6 months. A pregnancy to 6 months post-birth intervention group of 10 women who received nursing home visits during the pregnancy until their babies' 6th month followed by the postdelivery evaluation comprised Group 3.
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A mental health model as described in Barnard's Newborn Nursing Models was used to establish rapport and encourage women to develop and maintain healthy life-styles during their pregnancies and early child rearing (Barnard et al., 1983). Role modeling, referral, active listening, and facilitation of support were utilized to establish a helping relationship during weekly phone calls and monthly home visits by the parent-child nurse visitor. Prenatal and psychosocial history was assessed during the first home visit of Groups 2 and 3 utilizing the Difficult Life Circumstances @LC) and Community Life Skills Scale (CLSS). (See Tables 1 and 2 for a description of study instruments and schedule for measurement.) Interventions were then individualized according to actual and potential problems. For instance, five women needed assistance in completing Women and Infant Children (WIC) nutrition forms. A 24-hr nutrition history was used to recommend eating practices based on culturally accepted food preferences. Support and/or referral was given for decreasing or stopping alcohol, smoking, and drugs. Eight women received referrals to high school completion or community college programs, and 10 received counseling about job opportunities. The CHN gave each woman specific childbirth preparation and infant care instruction based on her knowledge and needs. Suggestions for coping with particular pregnancy discomforts were given and support systems were determined. The CHN modeled a supportive relationship and encouraged kin and friendship networking. Because over 50% of the 20 subjects were living temporarily with friends or family, the women were assisted to apply for low-income housing, despite the 8 to 10 month waiting period. The CHN also counseled women regarding relationship problems with partners and/or family members. The pregnancy intervention for Group 2 ended with a telephone call after the women had given birth to allow the mother to report on her labor and delivery. The 10 subjects for the 6-month follow-up (Group 3) received this same intervention in a home visit within the 1st month after the baby's birth. During this visit, the nurse did a modified Brazleton Neonatal Assessment to introduce each mother to her newborn's responsive and reflexive abilities. Mothers were encouraged to elicit verbal and visual alerting responses. The nurse also assessed and taught about maternal recovery, plans for family planning, and infant feeding and care. Adapting to parenthood was assessed and counseling and support given for issues such as how to TABLE 1 Description of Instruments - -
Community Life Skills Scale: A 33-item measure which assesses client's skills in organizing daily living. Difficult Life Circumstances Scale: A 28-item scale designed to determine the extent of chronic family problems which divert energy from pregnancy and/or child rearing. NCAST Feeding Scale: This scale utilizes 76 items in six subscales measuring parent-infant interaction during a feeding. NCAST Teaching Scale: Seventy-three items are in six subscales measuring the parent-infant interaction during a structured task which requests the parent to teach the baby an age-appropriatetask. HOME Observation for the Measurement of the Environment: This is a 45-item scale which assists the nurse to determine the parent's ability to provide an enriching environment for the child. DDST (Denver Developmental Screening Test): Strengths and weaknesses of the child are identified in gross motor, fine motor, language, and personal-social areas of development.
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TABLE 2 Schedule of Measurement for Study Instruments
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Measurement Intervals
Group 1-Non-intervention/control CLSS DLC Perinatal complications HOME NCAFS NCATS DDST Group 2-Pregnancy intervention CLSS DLC Perinatal complications HOME NCAFS NCATS Home visits DDST Group 3-Pregnancy to 6 months intervention CLSS DLC Perinatal complications HOME NCAFS NCATS Home visits Brazelton modified DDTS
Second Tkimester Pregnancy
Postpartum
3-4 Months Age
X X
6 Months Age
X X X X X X
X X
X X X X X
X X
X X
X X X
X
X X
X X X X
X X X
X
X
Note. CLSS (Community Life Skills Scale), DLC (Difficult Life Circumstances), HOME (Home Observation for the Measurement of the Environment), NCAFS (Nursing Child Satellite Feeding), NCATS (Nursing Child Satellite Teaching, DDST (Denver Developmental Screening Test).
involve partners in infant care. One teen mother was helped to negotiate primary care responsibility with her mother who was dominating the care of her new grandchild. The Denver Developmental Screening Test (DDST) was introduced at the 2nd month home visit and repeated monthly through the 6th month visit. Infant stimulation and ideas for simple toys and parenting practices were taught at each visit. Each mother was given a copy of "Baby's First Year Calendar of Learning Games and Memories," which reinforced activities for daily play (Stodden, 1986). Maternal physical and emotional health and coping was also assessed as well as life-style practices including smoking, drug, and alcohol use. The continuing weekly phone calls allowed further assessment, teaching, and support. The Nursing Child Assessment Feeding Scale (NCAFS) was done during the third home visit. Immediate feedback to the mother included the positive aspects of her feeding, discussion of her baby's cues, and suggestions such as how to feed in the "en face" position to increase mother-baby interaction during feeding. The home assessment of the environment (HOME) was also completed which assessed the
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parent-infant setting and surroundings. The Nursing Child Assessment Teaching Scale (NCA'IS) was done during the fourth home visit. The assignment of a teaching task for the mother to teach her baby reinforced the importance of the mother as her infant's teacher and furthered discussion of appropriate toys and parenting techniques. Anticipatory guidance for the next month of the baby's development was given at each visit and play activities suggested per the Baby's First Year Calendar. The 5-month visit included an assessment of infant development, feeding practices and parenting, support for the mother and further counseling and guidance for parenting, relationship issues, and plans for work and school. Findings
Shortly after birth, a medical record chart review was conducted to determine perinatal problems or complications encountered by either the mother or her infant. The 6th month postdelivery evaluation visits were conducted by three graduate students reliable in using the NCAST instruments. When groups were compared, they were found to be similar demographically. Therefore, the differences found were considered to be a result of intervention. Mothers in Groups 2 and 3 who received the pregnancy intervention were found to have fewer perinatal complications. This was not true for their infants because one Group 3 infant had a low birth Apgar score, a congenital heart anomaly, flaccid tone, and pronounced developmental delay. Infants also did not show significant differences in development as measured by the DDST. However, the postbirth follow-up group (Group 3) when compared to Groups 1 and 2 by cross tabulation did have significantly better scores for parentinfant interaction on the NCAFS subscales of Infant Clarity of Cues, Maternal Sensitivity to Cues, Response to Distress, and the HOME subscales of Avoidance of Restriction and Punishment and Provision of Play Materials. When the postbirth (Group 3) Teaching scores on the NCATS at 4 months (completed by CHN) were compared to the 6 months evaluation scores, the NCATS total score and the SocialEmotional Growth Fostering subscale were significantly better than those for Groups 1 and 2. Thus, both infants and mothers in the intervention group had better parent-infant interaction scores. One mother in Group 3 became pregnant when her son was 4 months old, which negated a difference among groups. All other women were successfully using birth control at the 6-month evaluation. Statistically, more women did not return to work or school in the intervention groups. However, a strong trend occurred with only 14% of the non-intervention group working compared to 44% of the pregnancy group and 55% of the 6 months follow-up group working or in school. The DLC and CLSS scores also showed no differences at the 6 months evaluation when compared by groups. Crowded housing and additional financial burdens postbirth were persistent stressors which may have prevented an improvement in the scales for most of the women. Although funding was not available for toxicology screening, the women reported that substance abuse stopped or substantially decreased during the interven-
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tion period. Because an average of three visits were made to the pregnancy group and nine visits to the 6 months follow-up-group, it does seem probable that both groups had better outcomes secondary to the increased support.
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CONCLUSION
These findings support previous reports by Barnard et al. (1988), Olds et al. (1988), and Field et al. (1985) that CHN home visiting programs foster healthier pregnancies and improve child developmental outcomes. At-risk families who are poor, uneducated, or headed by teenage or single parent mothers often face barriers to getting the health, education, and social services they need. Implications are that routine clinic care needs to be expanded in scope to include a long-term and comprehensive approach including psychosocial issues for socially at-risk women and their infants. Longitudinal efforts need to study the cost effectiveness of nursing home visiting programs by reduction in medical complications and governmental spending and improved social, educational, developmental, and economic outcomes for at-risk families. Strategies need to be researched for reaching at-risk populations such as substance abusing or adolescent women who do not readily seek care. This article supports the effectiveness of CHNs in improving circumstances for at-risk families. In this era of increasing infant mortality and other poor outcomes and an eroding financial base for CHN visits, this article implies political activism may be warranted by CHNs, not to preserve their function, but to ensure the health and development of those families most at-risk for illness, developmental delay, and lives of poverty and despair. REFERENCES American Public Health Association. (1991, January). Home visiting and parent support. MCH Newsletter, 1, 3. Barnard, K., Booth, C., Mitchell, S., & Telzrow, R. (1983). Newborn nursing models (Final report on Grant R01-NU-00719). Washington, DC: Department of Health and Human Services, Division of Nursing. Barnard, K., Booth, C., Mitchell., S., & Telzrow, R. (1988). Newborn nursing models: A test of early intervention to high-risk infants and families. In E. D. Hibbs (Ed.), Children and families: Studies in pnevention and intervention (pp. 63-82). Madison, WI: International Universities Press. Chapman, J., Seigel, E., &Cross, A. (1990). Home visitors and child health: Analysis of selected programs. Bdiatrics, 85, 1059-1068. Field, T., Widmayer, S., Greenberg, R., & Stoler, S. (1985). Home and center-based intervention for teenage mothers and their at-risk infants. In S. Hare1 & M. J. Anastasiow (Eds.), The at-risk infant: Psychological, sociological and medical aspects (pp. 29-40). Baltimore: Brooks. Government Accounting Office. (1990, July). Home visiting: A promising early intervention strategy for at-riskfamilies. Washington, DC: Author. Institute of Medicine, Division of Health Promotion and Disease Prevention. (1985). Preventing low birthweight. Washington, DC: National Academy Press. Miller, C. A., Fine, A., Adams-Tbylor., & Schoor, L. B. (1986). Monitoring children's health: Key indicators. Washington, DC: American Public Health Association.
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Moore, M. L. (1988). Cobrahobra: Reaching out to low-income women. Genesis, 10(4), 12-14. National Center for Health Statistics. (1985). Advance report, final natality statistics. Monthly Vital Statistics Report, 36, 4. Norbeck, J. S, & Tilden, V. P. (1983). Psychological and social factors in complications of pregnancy: A prospective, multivariate approach. Journal of Health and Social Behavior, 24, 30-46. Olds, D. L., Henderson, C. R., Tatlebaum, R., & Chamberlin, R. (1988). Improving the life-course development of socially disadvantaged mothers: A randomized trial of nurse home visitation. American Journal of Public Health, 78(1 l), 1436-1445. Our children at risk. (1991, October). Honolulu Star Bulletin, p. C-2. Regional Perinatal Program. (1990). Woman and infant numbers in Hawaii. Honolulu: Author. Stodden, N. J. (1986). Baby'sfirst year calendar of learning games and memories. Honolulu: International Education Corporation.
