The program produced enduring effects on important aspects of maternal life course and government spending through age 12 years of the firstborn child. Given that the program cost about $11 511 in 2006 US dollars after adjustment for the employment cost index,19,20
the $12 300 discounted savings (in 2006 US dollars) in welfare benefits recovered the cost of the program from the standpoint of government. Other benefits to government and society have not been monetized.
These life-course findings are consistent with an earlier trial of this program begun in 1977, which found long-term effects on maternal life course, including less role impairment owing to alcohol and other drug use and reduced use of welfare benefits.4
The Denver, Colorado, trial of the NFP, initiated during the economic boom of the 1990s, after welfare benefits reform, and with a less impoverished sample, found low use of welfare benefits and no program effects on these outcomes, although there were effects on the timing of subsequent pregnancies and births and on earned income for nurse-visited mothers that contributed to significant cost savings.21–23
The return on investment in Memphis needs to be interpreted in light of the extreme poverty and concentrated social disadvantage found in this trial. Overall, these findings reinforce earlier estimates of return on investment in this program.24,25
The program effects are consistent with corresponding effects observed in the Elmira trial on stability of partner relationships at age 3 years of the children26
and on marriage at age 15 years of the children among mothers who were unmarried and from low-income families at registration.27
The consistency of effects from the Elmira and Memphis trials lends validity to these partner relationship findings, despite absence of corresponding effects in the Denver trial.21,22
Some hypothesized effects did not emerge. We found no program effects on maternal involvement with the criminal justice system, child foster care or kinship care placements, or increased employment among nurse-visited mothers; in fact, the report of child foster care placements, as a trend, was higher in the nurse-visited than control families. Unlike the Elmira trial, we were unable to corroborate the child welfare benefits finding with administrative data.
We expected that the treatment-control difference in welfare benefits use and costs would be explained in part by earlier reductions in subsequent pregnancies and births and by increased maternal employment and involvement with the children’s biologic fathers.6–9
While we found an enduring program effect on cumulative subsequent births (among higher-resource mothers) in the present phase of follow-up, we observed no enduring program effect on maternal employment. In fact, in the 10-year to 12-year period, nurse-visited mothers, as a trend, had lower rates of employment. Although we have not conducted mediation analyses to determine the pathways through which the program reduced government spending, the decrease in closely spaced subsequent pregnancy and the increase in stability of partner relationships are prime candidates for explaining this pattern of results. Nurse-visited mothers had corresponding increases in their duration of relationships with employed partners (summed from age 6 years to age 12 years of the child, 42.88 vs 36.73 months; ES, 0.20; P
= .006) (data not shown).
The program effects found at this phase of the trial are encouraging but must be interpreted in light of their limitations. First, some of the outcomes were assessed by maternal report, which may be subject to treatment-related reporting bias. The presence of program effects on welfare benefits and cost outcomes derived from administrative data provides some assurance that the findings based on self-report are not simply owing to nurse-visited mothers’ providing more socially desirable responses. Second, nurse-visited mothers had higher rates of household poverty and worse attitudes toward child rearing at registration than those in the control group. Although we controlled statistically for these differences, it is possible that the analysis failed to control for all excess risk. However, we were able to retain a large portion of those mothers who had enrolled in the trial during their pregnancies, which increases our confidence in the estimate of enduring program effects.
It is reasonable to ask how the completion of 1 visit a month during pregnancy and the first 2 years of the child’s life might produce enduring effects on maternal and child outcomes 10 years after the program ended. It is important to note that nurses delivering this program develop relationships with first-time mothers during their pregnancies and their children’s early years. Nurses guide parents as they make important choices during this fundamental life transition that shape the subsequent trajectories of their lives and those of their children. The nurses’ work is designed specifically to respond to parents’ sense of vulnerability and to support their desire and efforts to protect their children. The theory is that nurses help parents gradually gain a sense of mastery in overcoming challenges and position themselves to create the kind of lives they want. Although we have not conducted mediation analyses to test the role of mastery in accounting for the long-term benefits of the program, the consistency in program effects on mastery suggests that it is likely to be centrally involved.
In general, these findings support the effectiveness of the NFP. The partnership offers a means of reducing government spending and family poverty, improving children’s health and development, and grounding policy based on the results of replicated randomized controlled trials.28–30