"A study published in September by the National Bureau of Economic Research challenged the conventional problem that blames the infant mortality problem on the premature births of newborn infants. The paper found that where the U.S. rate is significantly higher than European countries is in the number of children who die between the ages of 1-5... Which brings us to the work of Dr. David Olds. He's now a professor of pediatrics at the University of Colorado School of Medicine, where he also directs the Prevention Research Center for Family and Child Health. Since the 1970s, he's been looking at ways that home visits from nurses can help new parents take better care of their children. And that led to the Nurse-Family Partnership, which is now a national organization."
Lewis: Before we get to your new findings, will you take us back to the 70s and discuss where you got this idea in the first place?
Dr. Olds: First of all, I developed this idea when I started to work in inner-city daycare center in 1970 after finishing up undergraduate school in Baltimore. In many ways, I hoped that helping these preschoolers get off with a good start, but I realized that for most of the preschoolers in my classroom, it was too little, too late. A little boy had been exposed to alcohol; drugs during pregnancy; couldn't speak, only gesture. One little boy couldn't sleep at nap time, because he wet himself. And when he wet himself, his mother beat him, so he just couldn't sleep at all. I witnessed another child being slapped in the face on the steps of the center. This was prior to any national child abuse. What I did know was that I didn't know enough. But I did have some inkling that helping parents provide better care of their children would address some of the problems I was seeing in my classroom. I also realized that you have to pay attention to context. And material context, because parents aren't trying to take care of their children in vacuums. They are often buffeted by many other challenges such as crime and poverty that make it more difficult to protect themselves and their children.
Lewis: What made you think that nurses could make the difference; nurses going into the home, as opposed to social workers, doctors or any number of professional people that might be able to help?
Dr. Olds: The key thing is for me is that as I started tracing back to the sources of influence children's health and development and parent's protecting of their children, I got back to pregnancy. And I think the key for intervening during pregnancy is to have someone whom parents trust; parents need to make a difference in their lives and to address the types of concerns about: what does this back pain mean? What is labor and delivery going to be like? What is caring for that newborn going to be like? And while doctors can certainly address those conditions, they often don't have the amount of time and they don't have the time especially to work in families' home, which is what we decided we needed to do. And social workers don't have the training in health that is so salient for pregnant women and parents of the young children. It's an issue that needs to be addressed, for the women's own personal health, as well as for the care of the child.
Lewis: So, the resulting Nurse-Family Partnership is spread across the country. What services does the program provide to new mothers? Who arranges it in the communities? And who pays for it?
Dr. Olds: This is a program of prenatal and infant and toddler home visiting by nurses, for low-income mothers have their first babies. The nurses are in charge of improving the outcomes of pregnancy; improving children's subsequent health and developing; helping mothers help their own health; and becoming economically self-sufficient. The program is provided through local health departments, hospitals and community-based organizations. It's paid for through state and local dollars... And also there's a federal initiative, funded under the Affordable Care Act first, that has provided money for states to invest in evidence-based home visiting. And the Nurse-Family Partnership receives each year a share of that.
Lewis: Let's go onto you new study. You looked at the outcomes of kids, two decades after they were born into disadvantaged Memphis neighborhoods. Some of their mothers received nurse visits; others didn't. What results did you see in the children?
Dr. Olds: In earlier phases of the study, we found that nurse-visited women had fewer behavioral problems due to substance use, had reduced use of Welfare and Medicaid. And in the current phases that followed, the women that had received visits during pregnancy and in the newborn period, as well as those who received visits during pregnancy and through trial 2 had substantially fewer deaths over that two-decade period. The rates of death of the control group were about three times higher. And for the children, we found that nurse-visited children were less likely to die for preventable causes, such as sudden infant death syndrome, injuries and murder by the time they were 20. So, these findings were honestly unexpected because we didn't think that the rates of death, in what is an essentially healthy age range in the general U.S. population. What we found with the control group that the rates of death were so much higher than what you would see in the rest of the U.S. population that the results of the program started to emerge. I think that because the families in our Memphis trial were living under such challenging, adverse conditions that it became difficult for the mothers to protect themselves and their children without the help of the nurse.
Lewis: Let's talk a little bit about what the nurses were really providing. It sounds like it was more than just teaching a specific skill or simply showing the moms that someone actually cared about what they were doing. What does it really boil down to? What difference did the nurse's visit make?
Dr. Olds: That's a great question. I think it boils down this: First of all, nurses in this program visit women during their transition to parenthood. That is, they've had no previous live births. And during that period, a whole slew of hormones start kicking in and women's brains are being resculpted to take on the task of caring well for their children and protecting themselves. So, the nurses in this program are aligning with what is really a highly conserved basic drive of the part of the mammals, in the humans in particular, to protect themselves and to protect their children. And it's that alignment, we think, around these very strong drives to protect that gives this intervention the kind of impact that we see now over decades.
Lewis: The nurse-family partnership costs roughly around. That's according to this website. What returns though can society see from that 4,500 dollar invest?
Dr. Olds: The Rand Corporation has estimated that every dollar invest, when the program is focused on more disadvantaged families living in poverty, produces a $5.78 return on investment. The Washington State Institute for Public Policy has estimated, that on a per family basis, that the program produces a $20,000 net benefit. So, there is a strong case to be made, I think, for investing in the program when you look at both functional outcomes, mortality, as well as costs. We intend to follow the families for longer periods of time, for outcomes like chronic illness, chronic disease like cardiovascular disease, diabetes, the kinds of things that also weigh heavily on the national debt.
Lewis: One last question. At a time when the health care system is stretched then, it hard to find nurses to go out into the community to do this work?
Dr. Olds: We talk about a nursing shortage, but what's remarkable to me is that there are so many nurses who gone into this profession because they are passionate about serving. So, many of the nurses who go into this program, say to us, and say to me, "I feel like this job aligns so deeply with my reason for being, even." So the alignment between one's professional identify and one's personal commitments is very powerful. This is not for every nurse, but for those nurses who want to serve, we are astounded at the level of talent and passion that we are seeing in the workforce. So we think that we need to do more to create opportunities for young people who want to go into this role to be well prepared to serve in this capacity. But based on communications of thousands of nurses, I'm pretty sure the workforce will still be there.