Department of Pediatrics, School of Medicine, University of Colorado, Aurora.
School of Nursing, University of Rochester, Rochester, New York.
JAMA Pediatr. 2014 Sep;168(9):800-6. doi: 10.1001/jamapediatrics.2014.472.
Mothers and children living in adverse contexts are at risk of premature death.
To determine the effect of prenatal and infant/toddler nurse home visiting on maternal and child mortality during a 2-decade period (1990-2011).
DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical trial was designed originally to assess the home visiting program's effect on pregnancy outcomes and maternal and child health through child age 2 years. The study was conducted in a public system of obstetric and pediatric care in Memphis, Tennessee. Participants included primarily African American women and their first live-born children living in highly disadvantaged urban neighborhoods, who were assigned to 1 of 4 treatment groups: treatment 1 (transportation for prenatal care [n = 166]), treatment 2 (transportation plus developmental screening for infants and toddlers [n = 514]), treatment 3 (transportation plus prenatal/postpartum home visiting [n = 230]), and treatment 4 (transportation, screening, and prenatal, postpartum, and infant/toddler home visiting [n = 228]). Treatments 1 and 3 were included originally to increase statistical power for testing pregnancy outcomes. For determining mortality, background information was available for all 1138 mothers assigned to all 4 treatments and all but 2 live-born children in treatments 2 and 4 (n = 704). Inclusion of children in treatments 1 and 3 was not possible because background information was missing on too many children.
Nurses sought to improve the outcomes of pregnancy, children's health and development, and mothers' health and life-course with home visits beginning during pregnancy and continuing through child age 2 years.
All-cause mortality in mothers and preventable-cause mortality in children (sudden infant death syndrome, unintentional injury, and homicide) derived from the National Death Index.
The mean (SE) 21-year maternal all-cause mortality rate was 3.7% (0.74%) in the combined control group (treatments 1 and 2), 0.4% (0.43%) in treatment 3, and 2.2% (0.97%) in treatment 4. The survival contrast of treatments 1 and 2 combined with treatment 3 was significant (P = .007); the contrast of treatments 1 and 2 combined with treatment 4 was not significant (P = .19), and the contrast of treatments 1 and 2 combined with treatments 3 and 4 combined was significant (post hoc P = .008). At child age 20 years, the preventable-cause child mortality rate was 1.6% (0.57%) in treatment 2 and 0.0% (SE not calculable) in treatment 4; the survival contrast was significant (P = .04).
Prenatal and infant/toddler home visitation by nurses is a promising means of reducing all-cause mortality among mothers and preventable-cause mortality in their first-born children living in highly disadvantaged settings.
clinicaltrials.gov Identifier: NCT00708695.
生活在不利环境中的母亲和儿童面临过早死亡的风险。
确定产前和婴儿/学步儿护士家访在 20 年期间（1990-2011 年）对母婴死亡率的影响。
设计、地点和参与者：最初设计了一项随机临床试验，以评估家庭访视方案对妊娠结局以及儿童 2 岁前母婴健康的影响。该研究在田纳西州孟菲斯市的公共产科和儿科护理系统中进行。参与者主要是生活在高度贫困城市社区的非裔美国妇女及其第一胎活产儿，他们被分配到 4 个治疗组之一：治疗 1（产前护理交通[ n = 166]），治疗 2（婴儿和学步儿的发育筛查交通[ n = 514]），治疗 3（产前/产后家访交通[ n = 230]）和治疗 4（交通、筛查以及产前、产后和婴儿/学步儿家访[ n = 228]）。治疗 1 和 3 的纳入最初是为了提高测试妊娠结局的统计能力。为了确定死亡率，所有 4 种治疗方法中所有 1138 名母亲的背景信息以及治疗方法 2 和 4 中除 2 名活产儿以外的所有活产儿（ n = 704）的背景信息均可用。由于许多儿童的背景信息缺失，无法纳入治疗方法 1 和 3 中的儿童。
护士试图通过从妊娠开始并持续到儿童 2 岁的家访来改善妊娠结局、儿童健康和发育以及母亲的健康和人生历程。
来自国家死亡指数的母亲的全因死亡率和儿童的可预防死因死亡率（婴儿猝死综合征、意外伤害和杀人）。
在联合对照组（治疗方法 1 和 2）中，21 年的平均（SE）母婴全因死亡率为 3.7%（0.74%），治疗方法 3 为 0.4%（0.43%），治疗方法 4 为 2.2%（0.97%）。治疗方法 1 和 2 联合治疗方法 3 的生存对比具有统计学意义（ P =.007）；治疗方法 1 和 2 联合治疗方法 4 的对比无统计学意义（ P =.19），治疗方法 1 和 2 联合治疗方法 3 和 4 的对比具有统计学意义（事后检验 P =.008）。在儿童 20 岁时，治疗方法 2 的可预防死因儿童死亡率为 1.6%（0.57%），治疗方法 4 为 0.0%（SE 不可计算）；生存对比具有统计学意义（ P =.04）。
护士的产前和婴儿/学步儿家访是一种很有前途的方法，可以降低生活在高度不利环境中的母亲及其第一胎儿童的全因死亡率和可预防死因死亡率。
clinicaltrials.gov 标识符：NCT00708695。
