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Comparing Primiparous and Multiparous Mothers in a Nurse Home Visiting Prevention Program Paul Lanier, PhD, and Melissa Jonson-Reid, PhD ABSTRACT: Background: An important yet overlooked feature of prominent prevention
programs serving expectant mothers is the exclusion of women with children. This study examines mothers (n = 3,260) participating in a program without parity exclusion criteria, and compares demographic characteristics, risk status, service use, and child maltreatment outcomes. Methods: A longitudinal, prospective study comparing primiparous (n = 1,890) and multiparous (n = 1,370) mothers participating in a nurse home visiting program. Patient groups are compared using bivariate and multivariate methods. Results: Comparison by parity shows multiparous mothers had higher cumulative risk scores and individual risk factors related to maternal and child health, behavioral health, and violence exposure. Multiparous mothers were more likely to seek out services themselves and to initiate services later in the postnatal period. A significant trend exists among more children and greater caregiver stress, maternal depression, and child maltreatment. Multivariate models indicate infants of multiparous mothers have a higher risk (hazard ratio = 1.49) for later reports of child maltreatment. Conclusions: As compared with primiparous mothers, multiparous mothers were at higher risk but had similar levels of service use. Programs limited to primiparous mothers are missing a critical opportunity for prevention. Programs serving multiparous mothers should incorporate strategies to directly address caregiver stress and postpartum depression. (BIRTH 41:4 December 2014) Key words: child maltreatment, home visits, parity
All of the things that are challenging and stressful about parenting are made more so by having multiple children. Home visiting program manager (1)
Passage of the Patient Protection and Affordable Care Act (U.S. Public Law 111–148) sparked an expansion of evidence-based early childhood home visiting services in the United States. Early proposals sought to fund a single program (2), the Nurse-Family Partnership (3), which assists mothers from early pregPaul Lanier, PhD, is an Assistant Professor, UNC—Chapel Hill, Chapel Hill, NC, USA; Melissa Jonson-Reid, PhD, is a Professor and Director of the Center for Violence and Injury Prevention, Washington University in St. Louis, St. Louis, MO, USA. Funding Source: Doris Duke Fellowship for the Promotion of Child Well-Being. Financial Disclosure: The authors have no financial relationships relevant to this article to disclose.
nancy through the first 2 years of childrearing but limits program participation to high-risk first-time mothers. The Nurse-Family Partnership model was developed through a systematic program of longitudinal research and scaling-up strategies that gave rigorous attention to model fidelity (3,4). Although some aspects of the Nurse-Family Partnership have been tested empirically (5), others are justified by theory only. The NurseFamily Partnership remains the prevalent model, although the Maternal, Infant, and Early Childhood Conflict of Interest: The authors have no conflicts of interest to disclose. Address correspondence to Paul Lanier, School of Social Work, UNC—Chapel Hill, 325 Pittsboro Street, Chapel Hill, NC 275993550. Accepted April 16, 2014 © 2014 Wiley Periodicals, Inc.
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Home Visiting Program was eventually broadened to allow funding of other evidence-based models of home visiting programs both with and without criteria related to parity or previous live births. The availability of these models is critical because the Nurse-Family Partnership first-time mother criterion excludes about 62 percent of newborns (2.7 million annually) who could benefit from such services (6). Restricting the Nurse-Family Partnership to first-time mothers is based on the assumption that “first-time mothers are more receptive to home visitation services concerning pregnancy and childrearing than are women who have already given birth” (7) and the belief that these mothers will transfer the skills to subsequent pregnancies. In addition to childrearing information, the Nurse-Family Partnership offers family planning support to help mothers concentrate on building economic resources while parenting their first child (7). Notably, these justifications for the Nurse-Family Partnership practices are described as beliefs, and supported as a targeted allocation of resources with the argument that first-time mothers represent the highest potential return on investment. However, if parity excludes mothers from perinatal services that could prevent negative outcomes, then the return on the Nurse-Family Partnership investment is unlikely to offset the higher long-term costs among multi-child households. Thus, examining the extent to which preventive interventions are ideology-based versus evidence-based (8) is warranted. A primary outcome of early child home visiting is the prevention of child maltreatment. There exists ample evidence that suggests parity and the number of children in the home is related to the risk for maltreatment. A recent meta-analysis found a significant effect of family size on risk for maltreatment (9). This relationship is also supported by findings from the Fourth National Incidence Study (10), a national study that measures the incidence of maltreatment across subgroups. This study found that households with four or more children had significantly higher risk of maltreatment compared with households with one child (62.9 vs 36.6 per 1,000). The link between maltreatment and family size for infants is supported in a prospective, longitudinal analysis of the etiology of child maltreatment that found families with three or more children had twice the risk of maltreatment during a child’s first year of life (11). These findings are also consistent with epidemiologic population-based birth cohort studies (12,13). Despite the known relationship between parity and maltreatment, particularly for infants, there are few examples of research comparing primiparous and multiparous mothers involved in early childhood home visiting (1). Some studies show no difference in outcomes based on parity (1,14) whereas an Australian study
found services were less effective for multiparous mothers on certain outcomes (15). One study of Healthy Families, a paraprofessional home visiting program, found parity was related to the level of risk for the mothers but not related to participation (1). However, another Healthy Families evaluation found a prevention subgroup (teenage first-time mothers who enrolled in the program prenatally) experienced improved treatment effects measured by self-reports of physical aggression and harsh parenting but not official reports of maltreatment (16). The Nurse-Family Partnership model is focused on primiparous mothers and the trials have produced no known findings related to parity. There are no known studies in the United States comparing participants in a nurse home visiting program by parity. This research compares primiparous and multiparous mothers participating in the nurse home visiting program, Nurses for Newborns (NFN). NFN does not exclude mothers based on parity. Furthermore, this research did not attempt to compare program effectiveness based on parity because the study did not use a comparison group design. Rather, the intent of this study is to describe the service population of a nurse home visiting program that serves primiparous and multiparous mothers. Comparing demographic characteristics and risk factors helps identify differences in a diverse perinatal service population. Moreover, the study explores service engagement and retention to better understand whether differences in service use would be expected in a program serving multiparous mothers. Last, to better understand outcomes of families that receive nurse home visiting services and whether outcomes are related to parity, the study compares child maltreatment reports for families served by the NFN program.
Methods This study was part of a longitudinal investigation of child maltreatment prevention among families served by NFN. During home visits, nurses used laptop computers to document case notes and to collect information on infant health, child development, and family risk factors. Data on child maltreatment reports were obtained from linked child protective services (CPS) records (linked with participants’ consent). The study was approved by the university Institutional Review Board and NFN and CPS agencies.
Sample The study sample was drawn from families receiving services from the St. Louis, Missouri, NFN program.
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346 Most NFN referrals originate from social workers or health care professionals based on a perceived risk of child maltreatment; NFN accepts referrals of mothers from the prenatal period to 18 months postnatal. NFN services are delivered by experienced registered nurses who receive specialized NFN training, including classroom instruction and mentoring. A typical caseload is 25–40 families. During the home visits, the nurse addresses issues identified through needs assessments and screening outcomes, provides information on parenting skills, and assists mothers with accessing community resources. Although NFN is designed to be flexible, fidelity to clinical guidelines is ensured via case reviews, case-management meetings, peer and supervisory reviews, and client satisfaction surveys. Inclusion/exclusion criteria The sampling frame included only NFN cases opened in 2009 and closed by July 2011. The initial sample included 7,154 families; however, cases without baseline or infant birth data were excluded. If a family had multiple children receiving services, then we selected the child with the most documented visits as the study child. The sample included only birth mothers who were eligible for Medicaid, Women, Infants, and Children supplement, or Temporary Assistance to Needy Families. These restrictions yielded a final sample of 3,260 families.
Measurement Demographic characteristics The primary grouping variable was maternal parity captured through documented obstetric and pregnancy histories. For trend analyses, parity was recoded as 0, 1, 2, or 3 or more prior births. Among multiparous women, 97.2 percent had at least one live birth. Additional variables included infant’s race, ethnicity, and gender, and the mother’s age, partner status, education, employment, and geographic urbanicity (derived from ZIP codes). Risk factors Maternal and child risk for negative outcomes was assessed using 25 dichotomous variables drawn from existing NFN documentation and from the nurses’ assessment notes. These variables were summed to create a cumulative risk score. The nurse documented the risk factors most relevant to the mother based on a clinical interview conducted during the first home visit and information provided in the referral. Infant risk fac-
tors included six characteristics: a stay in neonatal intensive care; preterm birth/low birthweight; drug exposure/withdrawal at birth; jaundice; cardio-respiratory issues; congenital disabilities/abnormalities at birth; and a CPS referral before receiving NFN services. Maternal psychosocial risks included five areas: homelessness/unstable living situation; uncertain paternity/father not involved; teenage mother (< 20 years at time of current birth); no high school education; and unemployed. Three variables captured maternal exposure to violence: partner violence; sexual abuse/rape; and childhood history of maltreatment. Maternal behavioral health risks were measured with six variables: alcohol use; drug use; smoking during pregnancy; mood or behavioral disorder/reported suicide attempt; learning disorder or developmental disability; and neurologic impairment/injuries. Maternal health factors were related to prenatal health risk: unintended pregnancy; pregnancy complications; inadequate/late prenatal care; and chronic physical health problems. Maternal screening tools Nurses used the Edinburgh Postnatal Depression Scale (17) to screen for postpartum depression. This measure has been validated for use with pregnant mothers (18). A score of less than 10 indicates possible depression. Nurses also used the Everyday Stressors Index (19) to screen for chronic daily stress. This measure was designed for use with low-income mothers with young children. Because the Everyday Stressors Index lacks a clinical cutoff, a median split (median = 6) was used to divide the sample into “low stress” and “high stress” groups. During the study period, the NFN program was beginning to integrate these screening tools as a part of routine services. However, in many cases, the nurse could not screen the mother before service termination, yielding high rates of missing data for these measures. Service use Referral response time was measured as the number of days from the program’s receipt of a referral to the first home visit by an NFN nurse. A categorical variable captured whether the referral was prenatal or postpartum, and the proximity of the referral to the birth. Three categories of referral sources were defined: maternal self-referral, health care provider, or social service/education agency. Mothers who received more than one home visit were considered initially engaged. Program retention was measured in several ways: a count of prenatal, postpartum, and total home visits; total hours of service contact; and number of days between the first and last visit.
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Child maltreatment reports
Risk factors
Child abuse and neglect reports were identified using linked CPS data from the state Children’s Division. Administrative data allow precise dating of an allegation of maltreatment, thus avoiding inaccurate retrospective recall of maltreatment or services (20). In December 2012, NFN data were linked by the state using child identifiers, with follow-up ranging from 10 to 47 months after receipt of NFN services. Mounting research suggests the CPS label of “substantiated” (indicating evidence of maltreatment exists and meets legal burden of proof) is not a useful predictor of maltreatment risk; therefore, this study made comparisons without regard for this distinction (8,21). Only maltreatment reports made after NFN services ended were counted to limit the potential for surveillance bias associated with having a nurse in the home.
Multiparous mothers had higher cumulative risk scores (M = 5.0, SD = 2.2) compared with primiparous mothers (M = 3.8, SD = 1.9) and significantly higher rates of 14 risk factors (homelessness, teenage mother, partner violence, history of rape/sexual abuse, history of physical abuse/neglect, drug use/smoking during pregnancy, mental health diagnosis, neurological impairment, pregnancy complications, unintended pregnancy, inadequate prenatal care, preterm infant/low birthweight, drug-exposed infant, and prior CPS report) (Table 2).
Data Analysis All analyses were conducted in SAS 9.3 (SAS Institute, Cary, NC, USA). Bivariate tests of association (v2, ttests) were used to examine the relationship of parity to demographic characteristics, risk factors, and service use. The Cochran-Armitage test for trend was used to assess a linear relationship with parity. Multivariate analyses were used to examine the influence of parity on initial engagement and number of NFN home visits completed controlling for family demographics and known risk factors. Additional analytic considerations were warranted given the longitudinal nature of the study and the structure of the data. Multivariate survival analysis (Cox regression) was used to account for the different periods of time at risk for maltreatment depending on when services began. Advanced modeling techniques were used to account for the fact that although a mother received home visits from the same nurse, the experience across different nurses may have impacted outcomes.
Service use Health care practitioners were more likely to refer primiparous mothers (67.6% primiparous and 52.0% multiparous) to the NFN program during the early stages of the pregnancy, whereas multiparous mothers were more likely to be referred by a social service agency (18.3% primiparous and 26.9% multiparous) or to selfrefer (13.8% primiparous and 20.7% multiparous) but not until several months postpartum (Table 3). Overall, bivariate tests of engagement and retention showed almost no difference in service use by parity. Relationship between parity and maltreatment, depression, and stress The percent of mothers with a maltreatment report increased from 12.2 percent for primiparous mothers to 26.5 percent for mothers with three or more prior births. The percent of mothers with caregiver stress (as assessed by the Everyday Stressors Index) increased from 42.7 percent for primiparous mothers to 70.0 percent for mothers with three or more prior births. The percent of mothers with depression (as measured using the Edinburgh Postnatal Depression score) increased from 9.4 percent for primiparous mothers to 15.9 percent for mothers with three or more prior births. All relationships were statistically significant at the p < 0.05 level. Figure 1 illustrates this relationship.
Results Bivariate Analysis Demographic characteristics The sample was split between first-time primiparous (58%) and multiparous (42%) mothers. Parity was not related to race, ethnicity, infant’s gender, or family’s geographic region (Table 1). Compared with multiparous mothers, primiparous mothers were more likely to be students, younger, and single.
Multivariate Models When demographic variables and risk factors were controlled using logistic regression, we found no differences in initial engagement in home visiting services by parity OR 0.86 (95% CI 0.68–1.07). When we examined retention (number of visits), controlling for other factors, multiparous mothers (b = 0.07, SE = 0.03, 95% CI 0.14 to 0.01) received fewer visits overall. However, the difference could be considered
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348 small, adding up to about one visit less for multiparous mothers. In the Cox regression model, the adjusted odds of having a maltreatment report after NFN services ended were almost 50 percent higher for multiparous mothers (hazard ratio = 1.49, 95% CI 1.16–1.91).
Discussion This study examined differences in risk, service use, and child maltreatment outcomes between primiparous and multiparous mothers receiving nurse home visiting services. We found differences between primiparous and multiparous mothers in terms of risk and maltreatment outcomes, but not in service use. Multiparous mothers participated in the NFN home visiting program at a similar level as first-time mothers. The similar service use between primiparous and multiparous mothers may indicate equivalent perception of need and acceptability of home visiting services among families that are referred to the program regardless of parity. These findings suggest that although multiparous mothers
may have some experience with childrearing, those who are able to access nurse home visiting services may have a higher risk for child maltreatment than their peers who do not use home visiting services. One explanation for the relationship of parity to maltreatment might be the increased level of maternal stress associated with caring for multiple children (22,23) and the strong relationship between parenting stress and child maltreatment (9). Substantial research and theory have linked family size with maltreatment (24–31). Proponents of a sociological model of maltreatment etiology suggest additional children might “raise levels of stress beyond tolerable limits” (31), particularly among families already experiencing financial stress and material hardship. Consistent with the literature, this study found a dose–response relationship between the number of prior births and risk for a later maltreatment report. The experience of caring for multiple children, particularly with the birth of a new child, might contribute to the emergence of maternal risk factors for maltreatment, such as postpartum depression and parenting stress. In contrast, multiparous mothers in our sample
Table 1. Demographic Characteristics Comparing Primiparous and Multiparous Mothers
Infant race (black) Infant ethnicity (Hispanic) Infant gender (female) Maternal age at referral (years) Urbanicity† Urban Rural Suburban Maternal marital status Single (separated, divorced, widowed) Married/consensual union Maternal level of education No high school diploma High school or equivalent Some college 4-year college degree Maternal employment status Unemployed Disabled Homemaker Student Employed part-time Employed full time
Total sample (n = 3,260) %/mean (SD)
Primiparous (n = 1,890) %/mean (SD)
Multiparous (n = 1,370) %/mean (SD)
46.0 3.7 48.4 22.5 (5.6)
45.4 3.4 48.5 20.2 (4.3)
46.8 4.2 48.1 25.7 (5.5)*
78.1 13.9 8.0
78.3 13.0 8.7
77.8 15.0 7.2
83.2 16.8
88.5 11.5
75.9* 24.1
37.7 37.4 19.8 5.1
38.0 38.0 18.9 5.1
37.3 36.5 21.1 5.1
50.9 2.0 7.8 16.3 10.6 12.3
45.4 1.3 5.7 24.6 11.0 11.7
58.4* 3.0 10.7 4.8 10.0 13.0
*p < 0.05, †Household ZIP code was linked with Census Rural-Urban Community Area Codes.
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reported risk factors (e.g., childhood history of maltreatment, partner violence) that were or could have been issues before the first birth. Thus, rather than family size predicting risk, it might be, at least for some mothers, that preexisting risk factors predict early childbearing and repeated births. Some research has suggested relationship violence prevents women from effectively using contraception, resulting in unwanted pregnancies (32). Other studies have found that highrisk populations such as incarcerated women have high rates of prior pregnancies characterized by poor use of birth control and multiple partners (33). Because home visiting services are typically voluntary, perhaps the
individuals with these preexisting risk factors either refuse services or are not referred for services until a subsequent pregnancy. Home visiting programs serving high-risk multiparous mothers need to be aware of preexisting risks that may not have been adequately addressed previously. What remains unclear is whether programs serving multiparous mothers will be more successful than programs targeting only first-time mothers. This study found higher levels of risk among multiparous mothers using home visiting services but similar participation, which is consistent with prior research (1). There exists no comparable research comparing differences in rates
Table 2. Caregiver and Child Risk Factors for Nurses for Newborns Sample Comparing Primiparous and Multiparous Mothers
Total sample (n = 3,260) %/mean (SD) Caregiver risk factors Psychosocial Homeless Father unknown/not involved Teenage mother No high school education Unemployed Violence exposure Current partner violence History of rape/sexual abuse History of physical abuse/neglect Behavioral health Alcohol use during pregnancy Drug use during pregnancy Smoking during pregnancy/in home Mental health diagnosis Cognitive/learning disabilities Neurological impairments/injury Maternal health Unintended pregnancy Current pregnancy complication Inadequate prenatal care Chronic physical health problem Child risk factors Special/intensive care nursery Low birth weight/preterm Drug exposed Jaundice Heart/lung complications Major congenital disability Prior abuse/neglect report Cumulative risk score *p < 0.05.
Primiparous (n = 1,890) %/mean (SD)
Multiparous (n = 1,370) %/mean (SD)
4.9 2.5 36.1 37.7 50.9
4.0 2.2 54.2 38.0 45.4
6.1* 3.0 11.1* 37.3 58.4*
5.0 3.7 4.5
3.2 3.1 3.8
7.5* 4.5* 5.3*
4.2 12.4 24.4 19.8 4.7 2.0
4.3 8.7 21.4 16.5 4.5 1.3
4.1 17.5* 28.6* 24.5* 5.0 3.0*
85.1 10.8 21.1 14.7
87.8 11.8 18.0 13.7
81.4* 9.3* 25.3* 16.1
4.5 24.6 7.0 3.0 6.4 2.1 1.9 4.3 (2.1)
4.7 20.5 4.2 3.3 6.3 2.0 1.2 3.8 (1.9)
4.1 30.3* 10.8* 2.6 6.6 2.3 3.0* 5.0 (2.2)*
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Table 3. Service Use for Nurses for Newborns Sample Comparing Primiparous and Multiparous Mothers
Total sample (n = 3,260) %/mean (SD) Referral response time (in days) 1 2–6 7–30 > 30 Infant age at referral (in days) Prenatal > 90 Prenatal < 90 Postnatal < 30 Postnatal 30–90 Postnatal > 90 Referral source Self-referral Health care agency Social service agency Initial engagement (> 1 visit) Prenatal visits Postpartum visits Total nurse visits Total hours with nurse Total days from first to last visit
Primiparous (n = 1,890) %/mean (SD)
Multiparous (n = 1,370) %/mean (SD)
9.7 38.7 41.9 9.7
9.2 38.8 41.5 10.5
10.5 38.5 42.4 8.5
14.3 13.1 60.5 5.8 6.3
16.4 12.9 61.8 4.6 4.4
11.5* 13.3 58.7 7.5 9.0
16.7 61.0 21.9 81.3 0.6 4.7 5.3 7.0 106.6
13.8 67.6 18.3 81.8 0.6 4.6 5.3 6.9 104.5
(1.4) (4.7) (5.1) (6.6) (142.0)
20.7* 52.0 26.9 80.7 0.6 (1.4) 4.9 (4.9) 5.5 (5.4) 7.2 (7.1) 109.5 (145.1)
(1.4) (4.5) (4.8) (6.3) (139.6)
*p < 0.05; Skewed continuous variables were root-transformed for significance testing.
nal populations but not specifically mothers receiving home visits. Comparison of findings is further limited by vast differences that exist not only between home visiting program models but also between the types of risk considered in the literature and the outcomes measured. What is consistent across studies is the possibility that targeting services to first-time mothers might exclude mothers most in need of preventive services.
Limitations Fig. 1. Percentage of infants with a maltreatment report and mothers with high caregiver stress or possible maternal depression by parity. Note: Caregiver stress assessed using Everyday Stressors Index; maternal depression assessed using Edinburgh Postnatal Depression score. of maltreatment in the context of a nurse home visiting program. We find that multiparous mothers were 49 percent more likely than primiparous mothers to have a maltreatment report after ending NFN services. This finding is consistent with prior research on other mater-
CPS data reflect only cases of maltreatment for which a formal report was filed, greatly underestimating actual incidents of maltreatment. Numerous studies have found important, significant differences between outcomes of maltreatment cases with official reports and those without official reports (34,35), suggesting the false-negative rate is insufficient to affect findings with practical importance. Furthermore, surveillance bias in home visiting services is often identified as a problematic limitation of relying on official reports (36,37). This study minimized this limitation by acquiring exact dates of reports, which allowed for separate consideration of reports made after services ended. Reports
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made after the end of services cannot be subject to surveillance bias from the provider agency. Comparisons of the study findings with those of prior work are difficult given the service differences across home visitation programs and population characteristics. The findings of this study are limited to families referred to the St. Louis NFN program and that received at least one home visit. More research is needed that includes multiple program platforms and diverse populations.
Conclusion If the goal of services to prevent child maltreatment is to identify mothers at highest risk, research suggests selecting single, specific risk factors (e.g., being a firsttime parent) is not the best approach to parsing families. Rather than identifying specific risk factors, scholars working with cumulative risk models have suggested a more effective approach to identifying families at greatest risk for maltreatment is to assess the total number of risks in a household (38). Nevertheless, no one would suggest taking the opportunity for primary prevention with a first-time mother is inadvisable. The experience of child abuse and neglect, especially in the early years of development, has a profound, negative effect on the health and well-being of child victims (39). As the use of home visitation programs continues to expand, it is critical that program providers and developers explore issues of participant engagement and who to target with limited resources. Voluntary services that do not have significant incentive or popular buy-in are unlikely to be widely accessed. If the goal is to prevent maltreatment and enhance child health at the population level, then it is critical to address the needs of parents who do not access services during their first pregnancy.
Acknowledgments This research was funded by the Doris Duke Fellowships for the Promotion of Child Well-Being. The authors would like to acknowledge Melinda Ohlemiller and Angie Recktenwald at Nurses for Newborns for their support of this research and Diane Wyant at UNC—Chapel Hill for her contributions to the manuscript.
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Youth Serv Rev 2009;31(6):617–624. doi: 10.1016/j.childyouth. 2008.11.005. Belsky J. Three theoretical models of child abuse: A critical review. Child Abuse Negl 1978;2(1):37–49. doi: 10.1016/ 0145-2134(78)90005-4. Gazmararian JA, Petersen R, Spitz AM, et al. Violence and reproductive health: Current knowledge and future research directions. Matern Child Health J 2000;4(2):79–84. Clarke JG, Hebert MR, Rosengard C, et al. Reproductive health care and family planning needs among incarcerated women. Am J Public Health 2006;96(5):834–839. Jonson-Reid M, Drake B, Kohl PL. Is the overrepresentation of the poor in child welfare caseloads due to bias or need? Child Youth Serv Rev 2009;31(3):422–427. Lanier P, Jonson-Reid M, Stahlschmidt MJ, et al. Child maltreatment and pediatric health outcomes: A longitudinal study of lowincome children. J Pediatr Psychol 2010;35(5):511–522. doi: 10. 1093/jpepsy/jsp086. Howard KS, Brooks-Gunn J. The role of home-visiting programs in preventing child abuse and neglect. Future Child 2009;19 (2):119–146. Gomby DS. Home Visitation in 2005: Outcomes for Children and Parents. Investment in Kids Working Paper 7. Committee for Economic Development: Invest in Kids Working Group, 2005. Begle AM, Dumas JE, Hanson RF. Predicting child abuse potential: An empirical investigation of two theoretical frameworks. J Clin Child Adolesc Psychol 2010;39(2):208–219. Shonkoff JP, Boyce WT, McEwen BS. Neuroscience, molecular biology, and the childhood roots of health disparities: Building a new framework for health promotion and disease prevention. JAMA 2009;301(21):2252–2259. doi: 10.1001/jama.2009.754.
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Comparing Primiparous and Multiparous Mothers in a Nurse Home Visiting Prevention Program Paul Lanier, PhD, and Melissa Jonson-Reid, PhD ABSTRACT: Background: An important yet overlooked feature of prominent prevention
programs serving expectant mothers is the exclusion of women with children. This study examines mothers (n = 3,260) participating in a program without parity exclusion criteria, and compares demographic characteristics, risk status, service use, and child maltreatment outcomes. Methods: A longitudinal, prospective study comparing primiparous (n = 1,890) and multiparous (n = 1,370) mothers participating in a nurse home visiting program. Patient groups are compared using bivariate and multivariate methods. Results: Comparison by parity shows multiparous mothers had higher cumulative risk scores and individual risk factors related to maternal and child health, behavioral health, and violence exposure. Multiparous mothers were more likely to seek out services themselves and to initiate services later in the postnatal period. A significant trend exists among more children and greater caregiver stress, maternal depression, and child maltreatment. Multivariate models indicate infants of multiparous mothers have a higher risk (hazard ratio = 1.49) for later reports of child maltreatment. Conclusions: As compared with primiparous mothers, multiparous mothers were at higher risk but had similar levels of service use. Programs limited to primiparous mothers are missing a critical opportunity for prevention. Programs serving multiparous mothers should incorporate strategies to directly address caregiver stress and postpartum depression. (BIRTH 41:4 December 2014) Key words: child maltreatment, home visits, parity
All of the things that are challenging and stressful about parenting are made more so by having multiple children. Home visiting program manager (1)
Passage of the Patient Protection and Affordable Care Act (U.S. Public Law 111–148) sparked an expansion of evidence-based early childhood home visiting services in the United States. Early proposals sought to fund a single program (2), the Nurse-Family Partnership (3), which assists mothers from early pregPaul Lanier, PhD, is an Assistant Professor, UNC—Chapel Hill, Chapel Hill, NC, USA; Melissa Jonson-Reid, PhD, is a Professor and Director of the Center for Violence and Injury Prevention, Washington University in St. Louis, St. Louis, MO, USA. Funding Source: Doris Duke Fellowship for the Promotion of Child Well-Being. Financial Disclosure: The authors have no financial relationships relevant to this article to disclose.
nancy through the first 2 years of childrearing but limits program participation to high-risk first-time mothers. The Nurse-Family Partnership model was developed through a systematic program of longitudinal research and scaling-up strategies that gave rigorous attention to model fidelity (3,4). Although some aspects of the Nurse-Family Partnership have been tested empirically (5), others are justified by theory only. The NurseFamily Partnership remains the prevalent model, although the Maternal, Infant, and Early Childhood Conflict of Interest: The authors have no conflicts of interest to disclose. Address correspondence to Paul Lanier, School of Social Work, UNC—Chapel Hill, 325 Pittsboro Street, Chapel Hill, NC 275993550. Accepted April 16, 2014 © 2014 Wiley Periodicals, Inc.
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Home Visiting Program was eventually broadened to allow funding of other evidence-based models of home visiting programs both with and without criteria related to parity or previous live births. The availability of these models is critical because the Nurse-Family Partnership first-time mother criterion excludes about 62 percent of newborns (2.7 million annually) who could benefit from such services (6). Restricting the Nurse-Family Partnership to first-time mothers is based on the assumption that “first-time mothers are more receptive to home visitation services concerning pregnancy and childrearing than are women who have already given birth” (7) and the belief that these mothers will transfer the skills to subsequent pregnancies. In addition to childrearing information, the Nurse-Family Partnership offers family planning support to help mothers concentrate on building economic resources while parenting their first child (7). Notably, these justifications for the Nurse-Family Partnership practices are described as beliefs, and supported as a targeted allocation of resources with the argument that first-time mothers represent the highest potential return on investment. However, if parity excludes mothers from perinatal services that could prevent negative outcomes, then the return on the Nurse-Family Partnership investment is unlikely to offset the higher long-term costs among multi-child households. Thus, examining the extent to which preventive interventions are ideology-based versus evidence-based (8) is warranted. A primary outcome of early child home visiting is the prevention of child maltreatment. There exists ample evidence that suggests parity and the number of children in the home is related to the risk for maltreatment. A recent meta-analysis found a significant effect of family size on risk for maltreatment (9). This relationship is also supported by findings from the Fourth National Incidence Study (10), a national study that measures the incidence of maltreatment across subgroups. This study found that households with four or more children had significantly higher risk of maltreatment compared with households with one child (62.9 vs 36.6 per 1,000). The link between maltreatment and family size for infants is supported in a prospective, longitudinal analysis of the etiology of child maltreatment that found families with three or more children had twice the risk of maltreatment during a child’s first year of life (11). These findings are also consistent with epidemiologic population-based birth cohort studies (12,13). Despite the known relationship between parity and maltreatment, particularly for infants, there are few examples of research comparing primiparous and multiparous mothers involved in early childhood home visiting (1). Some studies show no difference in outcomes based on parity (1,14) whereas an Australian study
found services were less effective for multiparous mothers on certain outcomes (15). One study of Healthy Families, a paraprofessional home visiting program, found parity was related to the level of risk for the mothers but not related to participation (1). However, another Healthy Families evaluation found a prevention subgroup (teenage first-time mothers who enrolled in the program prenatally) experienced improved treatment effects measured by self-reports of physical aggression and harsh parenting but not official reports of maltreatment (16). The Nurse-Family Partnership model is focused on primiparous mothers and the trials have produced no known findings related to parity. There are no known studies in the United States comparing participants in a nurse home visiting program by parity. This research compares primiparous and multiparous mothers participating in the nurse home visiting program, Nurses for Newborns (NFN). NFN does not exclude mothers based on parity. Furthermore, this research did not attempt to compare program effectiveness based on parity because the study did not use a comparison group design. Rather, the intent of this study is to describe the service population of a nurse home visiting program that serves primiparous and multiparous mothers. Comparing demographic characteristics and risk factors helps identify differences in a diverse perinatal service population. Moreover, the study explores service engagement and retention to better understand whether differences in service use would be expected in a program serving multiparous mothers. Last, to better understand outcomes of families that receive nurse home visiting services and whether outcomes are related to parity, the study compares child maltreatment reports for families served by the NFN program.
Methods This study was part of a longitudinal investigation of child maltreatment prevention among families served by NFN. During home visits, nurses used laptop computers to document case notes and to collect information on infant health, child development, and family risk factors. Data on child maltreatment reports were obtained from linked child protective services (CPS) records (linked with participants’ consent). The study was approved by the university Institutional Review Board and NFN and CPS agencies.
Sample The study sample was drawn from families receiving services from the St. Louis, Missouri, NFN program.
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346 Most NFN referrals originate from social workers or health care professionals based on a perceived risk of child maltreatment; NFN accepts referrals of mothers from the prenatal period to 18 months postnatal. NFN services are delivered by experienced registered nurses who receive specialized NFN training, including classroom instruction and mentoring. A typical caseload is 25–40 families. During the home visits, the nurse addresses issues identified through needs assessments and screening outcomes, provides information on parenting skills, and assists mothers with accessing community resources. Although NFN is designed to be flexible, fidelity to clinical guidelines is ensured via case reviews, case-management meetings, peer and supervisory reviews, and client satisfaction surveys. Inclusion/exclusion criteria The sampling frame included only NFN cases opened in 2009 and closed by July 2011. The initial sample included 7,154 families; however, cases without baseline or infant birth data were excluded. If a family had multiple children receiving services, then we selected the child with the most documented visits as the study child. The sample included only birth mothers who were eligible for Medicaid, Women, Infants, and Children supplement, or Temporary Assistance to Needy Families. These restrictions yielded a final sample of 3,260 families.
Measurement Demographic characteristics The primary grouping variable was maternal parity captured through documented obstetric and pregnancy histories. For trend analyses, parity was recoded as 0, 1, 2, or 3 or more prior births. Among multiparous women, 97.2 percent had at least one live birth. Additional variables included infant’s race, ethnicity, and gender, and the mother’s age, partner status, education, employment, and geographic urbanicity (derived from ZIP codes). Risk factors Maternal and child risk for negative outcomes was assessed using 25 dichotomous variables drawn from existing NFN documentation and from the nurses’ assessment notes. These variables were summed to create a cumulative risk score. The nurse documented the risk factors most relevant to the mother based on a clinical interview conducted during the first home visit and information provided in the referral. Infant risk fac-
tors included six characteristics: a stay in neonatal intensive care; preterm birth/low birthweight; drug exposure/withdrawal at birth; jaundice; cardio-respiratory issues; congenital disabilities/abnormalities at birth; and a CPS referral before receiving NFN services. Maternal psychosocial risks included five areas: homelessness/unstable living situation; uncertain paternity/father not involved; teenage mother (< 20 years at time of current birth); no high school education; and unemployed. Three variables captured maternal exposure to violence: partner violence; sexual abuse/rape; and childhood history of maltreatment. Maternal behavioral health risks were measured with six variables: alcohol use; drug use; smoking during pregnancy; mood or behavioral disorder/reported suicide attempt; learning disorder or developmental disability; and neurologic impairment/injuries. Maternal health factors were related to prenatal health risk: unintended pregnancy; pregnancy complications; inadequate/late prenatal care; and chronic physical health problems. Maternal screening tools Nurses used the Edinburgh Postnatal Depression Scale (17) to screen for postpartum depression. This measure has been validated for use with pregnant mothers (18). A score of less than 10 indicates possible depression. Nurses also used the Everyday Stressors Index (19) to screen for chronic daily stress. This measure was designed for use with low-income mothers with young children. Because the Everyday Stressors Index lacks a clinical cutoff, a median split (median = 6) was used to divide the sample into “low stress” and “high stress” groups. During the study period, the NFN program was beginning to integrate these screening tools as a part of routine services. However, in many cases, the nurse could not screen the mother before service termination, yielding high rates of missing data for these measures. Service use Referral response time was measured as the number of days from the program’s receipt of a referral to the first home visit by an NFN nurse. A categorical variable captured whether the referral was prenatal or postpartum, and the proximity of the referral to the birth. Three categories of referral sources were defined: maternal self-referral, health care provider, or social service/education agency. Mothers who received more than one home visit were considered initially engaged. Program retention was measured in several ways: a count of prenatal, postpartum, and total home visits; total hours of service contact; and number of days between the first and last visit.
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Child maltreatment reports
Risk factors
Child abuse and neglect reports were identified using linked CPS data from the state Children’s Division. Administrative data allow precise dating of an allegation of maltreatment, thus avoiding inaccurate retrospective recall of maltreatment or services (20). In December 2012, NFN data were linked by the state using child identifiers, with follow-up ranging from 10 to 47 months after receipt of NFN services. Mounting research suggests the CPS label of “substantiated” (indicating evidence of maltreatment exists and meets legal burden of proof) is not a useful predictor of maltreatment risk; therefore, this study made comparisons without regard for this distinction (8,21). Only maltreatment reports made after NFN services ended were counted to limit the potential for surveillance bias associated with having a nurse in the home.
Multiparous mothers had higher cumulative risk scores (M = 5.0, SD = 2.2) compared with primiparous mothers (M = 3.8, SD = 1.9) and significantly higher rates of 14 risk factors (homelessness, teenage mother, partner violence, history of rape/sexual abuse, history of physical abuse/neglect, drug use/smoking during pregnancy, mental health diagnosis, neurological impairment, pregnancy complications, unintended pregnancy, inadequate prenatal care, preterm infant/low birthweight, drug-exposed infant, and prior CPS report) (Table 2).
Data Analysis All analyses were conducted in SAS 9.3 (SAS Institute, Cary, NC, USA). Bivariate tests of association (v2, ttests) were used to examine the relationship of parity to demographic characteristics, risk factors, and service use. The Cochran-Armitage test for trend was used to assess a linear relationship with parity. Multivariate analyses were used to examine the influence of parity on initial engagement and number of NFN home visits completed controlling for family demographics and known risk factors. Additional analytic considerations were warranted given the longitudinal nature of the study and the structure of the data. Multivariate survival analysis (Cox regression) was used to account for the different periods of time at risk for maltreatment depending on when services began. Advanced modeling techniques were used to account for the fact that although a mother received home visits from the same nurse, the experience across different nurses may have impacted outcomes.
Service use Health care practitioners were more likely to refer primiparous mothers (67.6% primiparous and 52.0% multiparous) to the NFN program during the early stages of the pregnancy, whereas multiparous mothers were more likely to be referred by a social service agency (18.3% primiparous and 26.9% multiparous) or to selfrefer (13.8% primiparous and 20.7% multiparous) but not until several months postpartum (Table 3). Overall, bivariate tests of engagement and retention showed almost no difference in service use by parity. Relationship between parity and maltreatment, depression, and stress The percent of mothers with a maltreatment report increased from 12.2 percent for primiparous mothers to 26.5 percent for mothers with three or more prior births. The percent of mothers with caregiver stress (as assessed by the Everyday Stressors Index) increased from 42.7 percent for primiparous mothers to 70.0 percent for mothers with three or more prior births. The percent of mothers with depression (as measured using the Edinburgh Postnatal Depression score) increased from 9.4 percent for primiparous mothers to 15.9 percent for mothers with three or more prior births. All relationships were statistically significant at the p < 0.05 level. Figure 1 illustrates this relationship.
Results Bivariate Analysis Demographic characteristics The sample was split between first-time primiparous (58%) and multiparous (42%) mothers. Parity was not related to race, ethnicity, infant’s gender, or family’s geographic region (Table 1). Compared with multiparous mothers, primiparous mothers were more likely to be students, younger, and single.
Multivariate Models When demographic variables and risk factors were controlled using logistic regression, we found no differences in initial engagement in home visiting services by parity OR 0.86 (95% CI 0.68–1.07). When we examined retention (number of visits), controlling for other factors, multiparous mothers (b = 0.07, SE = 0.03, 95% CI 0.14 to 0.01) received fewer visits overall. However, the difference could be considered
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348 small, adding up to about one visit less for multiparous mothers. In the Cox regression model, the adjusted odds of having a maltreatment report after NFN services ended were almost 50 percent higher for multiparous mothers (hazard ratio = 1.49, 95% CI 1.16–1.91).
Discussion This study examined differences in risk, service use, and child maltreatment outcomes between primiparous and multiparous mothers receiving nurse home visiting services. We found differences between primiparous and multiparous mothers in terms of risk and maltreatment outcomes, but not in service use. Multiparous mothers participated in the NFN home visiting program at a similar level as first-time mothers. The similar service use between primiparous and multiparous mothers may indicate equivalent perception of need and acceptability of home visiting services among families that are referred to the program regardless of parity. These findings suggest that although multiparous mothers
may have some experience with childrearing, those who are able to access nurse home visiting services may have a higher risk for child maltreatment than their peers who do not use home visiting services. One explanation for the relationship of parity to maltreatment might be the increased level of maternal stress associated with caring for multiple children (22,23) and the strong relationship between parenting stress and child maltreatment (9). Substantial research and theory have linked family size with maltreatment (24–31). Proponents of a sociological model of maltreatment etiology suggest additional children might “raise levels of stress beyond tolerable limits” (31), particularly among families already experiencing financial stress and material hardship. Consistent with the literature, this study found a dose–response relationship between the number of prior births and risk for a later maltreatment report. The experience of caring for multiple children, particularly with the birth of a new child, might contribute to the emergence of maternal risk factors for maltreatment, such as postpartum depression and parenting stress. In contrast, multiparous mothers in our sample
Table 1. Demographic Characteristics Comparing Primiparous and Multiparous Mothers
Infant race (black) Infant ethnicity (Hispanic) Infant gender (female) Maternal age at referral (years) Urbanicity† Urban Rural Suburban Maternal marital status Single (separated, divorced, widowed) Married/consensual union Maternal level of education No high school diploma High school or equivalent Some college 4-year college degree Maternal employment status Unemployed Disabled Homemaker Student Employed part-time Employed full time
Total sample (n = 3,260) %/mean (SD)
Primiparous (n = 1,890) %/mean (SD)
Multiparous (n = 1,370) %/mean (SD)
46.0 3.7 48.4 22.5 (5.6)
45.4 3.4 48.5 20.2 (4.3)
46.8 4.2 48.1 25.7 (5.5)*
78.1 13.9 8.0
78.3 13.0 8.7
77.8 15.0 7.2
83.2 16.8
88.5 11.5
75.9* 24.1
37.7 37.4 19.8 5.1
38.0 38.0 18.9 5.1
37.3 36.5 21.1 5.1
50.9 2.0 7.8 16.3 10.6 12.3
45.4 1.3 5.7 24.6 11.0 11.7
58.4* 3.0 10.7 4.8 10.0 13.0
*p < 0.05, †Household ZIP code was linked with Census Rural-Urban Community Area Codes.
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reported risk factors (e.g., childhood history of maltreatment, partner violence) that were or could have been issues before the first birth. Thus, rather than family size predicting risk, it might be, at least for some mothers, that preexisting risk factors predict early childbearing and repeated births. Some research has suggested relationship violence prevents women from effectively using contraception, resulting in unwanted pregnancies (32). Other studies have found that highrisk populations such as incarcerated women have high rates of prior pregnancies characterized by poor use of birth control and multiple partners (33). Because home visiting services are typically voluntary, perhaps the
individuals with these preexisting risk factors either refuse services or are not referred for services until a subsequent pregnancy. Home visiting programs serving high-risk multiparous mothers need to be aware of preexisting risks that may not have been adequately addressed previously. What remains unclear is whether programs serving multiparous mothers will be more successful than programs targeting only first-time mothers. This study found higher levels of risk among multiparous mothers using home visiting services but similar participation, which is consistent with prior research (1). There exists no comparable research comparing differences in rates
Table 2. Caregiver and Child Risk Factors for Nurses for Newborns Sample Comparing Primiparous and Multiparous Mothers
Total sample (n = 3,260) %/mean (SD) Caregiver risk factors Psychosocial Homeless Father unknown/not involved Teenage mother No high school education Unemployed Violence exposure Current partner violence History of rape/sexual abuse History of physical abuse/neglect Behavioral health Alcohol use during pregnancy Drug use during pregnancy Smoking during pregnancy/in home Mental health diagnosis Cognitive/learning disabilities Neurological impairments/injury Maternal health Unintended pregnancy Current pregnancy complication Inadequate prenatal care Chronic physical health problem Child risk factors Special/intensive care nursery Low birth weight/preterm Drug exposed Jaundice Heart/lung complications Major congenital disability Prior abuse/neglect report Cumulative risk score *p < 0.05.
Primiparous (n = 1,890) %/mean (SD)
Multiparous (n = 1,370) %/mean (SD)
4.9 2.5 36.1 37.7 50.9
4.0 2.2 54.2 38.0 45.4
6.1* 3.0 11.1* 37.3 58.4*
5.0 3.7 4.5
3.2 3.1 3.8
7.5* 4.5* 5.3*
4.2 12.4 24.4 19.8 4.7 2.0
4.3 8.7 21.4 16.5 4.5 1.3
4.1 17.5* 28.6* 24.5* 5.0 3.0*
85.1 10.8 21.1 14.7
87.8 11.8 18.0 13.7
81.4* 9.3* 25.3* 16.1
4.5 24.6 7.0 3.0 6.4 2.1 1.9 4.3 (2.1)
4.7 20.5 4.2 3.3 6.3 2.0 1.2 3.8 (1.9)
4.1 30.3* 10.8* 2.6 6.6 2.3 3.0* 5.0 (2.2)*
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Table 3. Service Use for Nurses for Newborns Sample Comparing Primiparous and Multiparous Mothers
Total sample (n = 3,260) %/mean (SD) Referral response time (in days) 1 2–6 7–30 > 30 Infant age at referral (in days) Prenatal > 90 Prenatal < 90 Postnatal < 30 Postnatal 30–90 Postnatal > 90 Referral source Self-referral Health care agency Social service agency Initial engagement (> 1 visit) Prenatal visits Postpartum visits Total nurse visits Total hours with nurse Total days from first to last visit
Primiparous (n = 1,890) %/mean (SD)
Multiparous (n = 1,370) %/mean (SD)
9.7 38.7 41.9 9.7
9.2 38.8 41.5 10.5
10.5 38.5 42.4 8.5
14.3 13.1 60.5 5.8 6.3
16.4 12.9 61.8 4.6 4.4
11.5* 13.3 58.7 7.5 9.0
16.7 61.0 21.9 81.3 0.6 4.7 5.3 7.0 106.6
13.8 67.6 18.3 81.8 0.6 4.6 5.3 6.9 104.5
(1.4) (4.7) (5.1) (6.6) (142.0)
20.7* 52.0 26.9 80.7 0.6 (1.4) 4.9 (4.9) 5.5 (5.4) 7.2 (7.1) 109.5 (145.1)
(1.4) (4.5) (4.8) (6.3) (139.6)
*p < 0.05; Skewed continuous variables were root-transformed for significance testing.
nal populations but not specifically mothers receiving home visits. Comparison of findings is further limited by vast differences that exist not only between home visiting program models but also between the types of risk considered in the literature and the outcomes measured. What is consistent across studies is the possibility that targeting services to first-time mothers might exclude mothers most in need of preventive services.
Limitations Fig. 1. Percentage of infants with a maltreatment report and mothers with high caregiver stress or possible maternal depression by parity. Note: Caregiver stress assessed using Everyday Stressors Index; maternal depression assessed using Edinburgh Postnatal Depression score. of maltreatment in the context of a nurse home visiting program. We find that multiparous mothers were 49 percent more likely than primiparous mothers to have a maltreatment report after ending NFN services. This finding is consistent with prior research on other mater-
CPS data reflect only cases of maltreatment for which a formal report was filed, greatly underestimating actual incidents of maltreatment. Numerous studies have found important, significant differences between outcomes of maltreatment cases with official reports and those without official reports (34,35), suggesting the false-negative rate is insufficient to affect findings with practical importance. Furthermore, surveillance bias in home visiting services is often identified as a problematic limitation of relying on official reports (36,37). This study minimized this limitation by acquiring exact dates of reports, which allowed for separate consideration of reports made after services ended. Reports
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made after the end of services cannot be subject to surveillance bias from the provider agency. Comparisons of the study findings with those of prior work are difficult given the service differences across home visitation programs and population characteristics. The findings of this study are limited to families referred to the St. Louis NFN program and that received at least one home visit. More research is needed that includes multiple program platforms and diverse populations.
Conclusion If the goal of services to prevent child maltreatment is to identify mothers at highest risk, research suggests selecting single, specific risk factors (e.g., being a firsttime parent) is not the best approach to parsing families. Rather than identifying specific risk factors, scholars working with cumulative risk models have suggested a more effective approach to identifying families at greatest risk for maltreatment is to assess the total number of risks in a household (38). Nevertheless, no one would suggest taking the opportunity for primary prevention with a first-time mother is inadvisable. The experience of child abuse and neglect, especially in the early years of development, has a profound, negative effect on the health and well-being of child victims (39). As the use of home visitation programs continues to expand, it is critical that program providers and developers explore issues of participant engagement and who to target with limited resources. Voluntary services that do not have significant incentive or popular buy-in are unlikely to be widely accessed. If the goal is to prevent maltreatment and enhance child health at the population level, then it is critical to address the needs of parents who do not access services during their first pregnancy.
Acknowledgments This research was funded by the Doris Duke Fellowships for the Promotion of Child Well-Being. The authors would like to acknowledge Melinda Ohlemiller and Angie Recktenwald at Nurses for Newborns for their support of this research and Diane Wyant at UNC—Chapel Hill for her contributions to the manuscript.
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