Elsevier

The Lancet

Volume 361, Issue 9361, 15 March 2003, Pages 893-900
The Lancet

Articles
Postnatal home visits in teenage mothers: a randomised controlled trial

https://doi.org/10.1016/S0140-6736(03)12770-5Get rights and content

Summary

Background

Teenage pregnancies are associated with negative socioeconomic effects. Our aim was to ascertain whether a postnatal home-visiting service for teenage mothers younger than age 18 years could reduce the frequency of adverse neonatal outcomes and improve knowledge of contraception, breastfeeding, and infant vaccination schedules in this parent group.

Methods

We enrolled 139 adolescents, attending a teenage pregnancy clinic, in a randomised controlled trial. After completing an antenatal questionnaire designed to assess their knowledge of contraception, infant vaccination, and breastfeeding, we assigned participants to either receive five structured postnatal home visits by nurse-midwives (n=65) or not (n=71). Assessment interviews were done 6 months postpartum. Our primary endpoint was unadjusted difference in knowledge between groups, and incidence of predefined adverse neonatal outcomes. Analysis was by intention to treat.

Findings

Three women withdrew before randomisation because of late fetal loss, 11 mothers withdrew because of adverse neonatal outcomes (adverse neonatal outcome was a primary endpoint, but resulted in withdrawal from the study for knowledge outcomes), and one left vountarily. Follow-up data were, therefore, available for 124 teenagers. Postnatal home visits were associated with a reduction in adverse neonatal outcomes (invervention: 2; control: 9; relative risk 0·24, 95% CI 0·05–1·08), and a significant increase in contraception knowledge (mean difference 0·92, 95% CI 0·32–1·52). However, there was no significant increase in knowledge with respect to breastfeeding or infant vaccination schedules associated with the home visits.

Interpretation

Postnatal home-visiting services by nurse-midwives reduce adverse neonatal events and improve contraception outcomes, but do not affect breastfeeding or infant vaccination knowledge or compliance.

Introduction

The negative social and economic effect of teenage pregnancy on the community is large. In 1993, the annual cost associated with teenage pregnancy in the USA was estimated at US$21 billion.1 Psychiatric pathology, family violence, poor levels of education, social isolation, adverse obstetric outcome, and illicit drug use compound mothercrafting difficulties in the setting of teenage pregnancy.2, 3, 4, 5, 6 Social disadvantage and dependence on government benefits mean that teenage parents have to survive on or below the poverty line.7 Furthermore, the cycle of disadvantage continues, with children born to teenage mothers often remaining worse off throughout childhood than offspring born to older women of similar socioeconomic status.3, 8

Home-visiting services have been advocated as a way to improve outcomes for mothers and their infants.9 To date, only one randomised trial10 has specifically assessed the efficacy of postnatal home visits in reducing adverse outcomes in teenage mothers and their offspring; no significant effect was noted. However, visits were undertaken by a paraprofessional and not a nurse, which is an important factor since mothers who receive home visits from paraprofessionals are more likely to withdraw from parenting programmes than are those who are visited by nurses,11 possibly because nurses forge stronger therapeutic relationships with the families.11

Three other randomised trials12, 13, 14 have assessed the usefulness of home-visiting programmes. Two trials12, 13 involved disadvantaged women but, although just under half were adolescents, most were aged 18 or 19 years; teenage mothers at greatest risk of child abuse, neglect, and subsequent repeated teenage pregnancy, are those younger than age 18 years.2 In the trials, the combination of seven to nine prenatal and 23–26 postnatal home visits up to age 2 years reduced the frequency of pregnancy-induced hypertension, childhood injuries, hospital admissions, and second pregnancies. However, none of the subgroups in either trial12, 13 received postnatal home visits as the only intervention. The third trial,14 from which women younger than age 17 years were specifically excluded, involved postnatal home visits with paraprofessionals as a sole intervention; no significant differences in outcomes between those who were and were not visited were noted.14

The lack of data from randomised trials assessing strategies in teenage pregnancy is important, since observational studies systematically yield greater estimates of treatment effect than do randomised trials with respect to adolescent pregnancy outcomes.15 Our aim was to assess the effect of a postnatal home-visiting service, undertaken by certified nurse-midwives, in reducing adverse neonatal outcomes and in improving knowledge about contraception, vaccination schedules, and breastfeeding in teenage mothers younger than age 18 years.

Section snippets

Participants

Between July, 1998, and Dec, 2000, we did a randomised controlled trial to which we enrolled teenagers who were attending their first antenatal appointment at an Australian public-care teenage pregnancy clinic for first-time mothers. Inclusion data were age younger than 18 years, ability to speak English, and intention to continue with the pregnancy and not to relinquish their infant. Exclusion criteria were residence more than 150 km from hospital fetal abnormality.

The institutional ethics

Results

Figure 1 shows the trial profile. We enrolled 139 individuals, three of whom were withdrawn before randomisation because of late fetal loss. The table shows the demographic and social characteristics of participants. About 25% of the study population were indigenous Australian, and the mean age was 16 years. Kessner scores,17 a measure of antenatal care, were similar between the two groups. Most teenage mothers were of low socioeconomic status. Social-class scores were derived from pooled data

Discussion

Our findings indicate that five postnatal home visits undertaken by certified nurse-midwives, can result in a reduction in adverse neonatal outcomes and in an increased knowledge and use of contraception. Such intervention did not result in great improvements in knowledge of infant vaccination or in the proportion of infants with completed infant vaccination schedules. Furthermore, it did not raise knowledge of the benefits of breastfeeding, or the median duration of breastfeeding.

Child abuse

References (28)

  • JA Quinlivan et al.

    Adolescent pregnancy: psychopathology missed

    Aust N Z J Psychiatry

    (1999)
  • S Williams et al.

    Poverty and teenage pregnancy

    BMJ (Clin Res Ed)

    (1987)
  • RV Gueorguieva et al.

    Effect of teenage pregnancy on educational disabilities in kindergarten

    Am J Epidemiol

    (2001)
  • Anon Home visiting: opening doors for America's pregnant women and children

    (1989)
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