Home based support for disadvantaged adult mothers

The idea makes sense: Partner indigent mothers with a mentor who offers parenting and health advice and helps find resources in the community.

Numerous, disparate programs have experimented with the concept of home-based support both in the United States and Europe. The problem is that there is no evidence the programs work, according to a new review of studies.

The inconclusive results do not necessarily mean that home-visiting programs are ineffective, said review co-author Geraldine Macdonald “The jury is still out, hence the need for more research.”

Still, it would be helpful if researchers “could spend some time deciding what sorts of problems and people might … be helped by what sorts of home-visiting programs, delivered at what ‘dose' over what period of time,” said MacDonald, director of social work education at the School of Sociology, Social Policy and Social Work at Queen's University Belfast in Northern Ireland.

The Cochrane review examined 11 studies that included 4,751 participants and found “no statistically significant difference for those receiving home visiting in relation to maternal depression, anxiety or stress associated with parenting.”

As for child outcomes, there was also a lack of evidence that the home visits made a difference in “preventative health care, psychological health, language development, behavior problems or accidental injuries.”

Evidence about child abuse and neglect was difficult to interpret, researchers wrote, “but the picture painted by the five studies that reported on this outcome is mixed.”

It surprised researchers that the results did not clearly indicate the worth of even one or two of the programs, Macdonald said. “Although by the time we had carefully unpacked each study and considered the variations described in the review … we were perhaps less surprised.”

The researchers question the effectiveness of a limited number of visits from professional or lay advisers in combating a variety of family and societal problems.

“If you think that poor parenting is the result of poor attachment, parental fecklessness or inadequate knowledge or skills, then you will focus your efforts there,” MacDonald said. “This may be right, but if in fact it is the considerable stress of living in poverty, in squalor and in neighborhoods that terrify you, then you may not only be wasting your time and taxpayers' money, but it is likely you are adding insult to injury” for the families that the programs are aimed at helping.

According to Macdonald, an American researcher, David Olds, developer of a home-visiting program, has come closest to devising a study with the specificity and focus sought by the reviewers, “and his early findings were very promising. But even his programs vary across key dimensions, and he is not good at reporting his data in ways that make comparisons or syntheses of efficacy easy.”

However, the review studies are all so different that it is difficult to compare and make cross-generalizations, said Olds, director of the Prevention Research Center for Family and Child Health at University of Colorado.

“Home-based support can vary” Olds said. “When does the intervention begin Who is delivering it What do these supports do What kind of clinical strategies are used”

Olds was lead author in a 2002 study among those reviewed in the Cochrane report. That study, published in the journal Pediatrics , found that nurses making home visits produced significant effects on a wide range of maternal and child outcomes.

“In our case, prenatal and infancy home visiting was by nurses who serve low-income mothers having first babies,” Olds said. These mothers are feeling vulnerable, he added. “They are more receptive to offers of help. They believe – and they're right – that nurses can reduce that vulnerability. That belief that nurses can help means [the mothers] will engage.”

In May, then-Prime Minister Tony Blair announced pilot programs — based on Olds' work — that would target 1,000 families in 10 areas of England, according to a London newspaper. First-time mothers are to be assigned a personal visitor when 16 to 20 weeks into their pregnancy, the Guardian story said.

Considering the results of the Cochrane review, Macdonald believes researchers might need to do some “serious thinking about what these programs are designed to do and what the necessary ingredients, quantities and recipes would need to look like.”

Bennett C, et al. Home based support for disadvantaged adult mothers (Review). Cochrane Database of Systematic Reviews 2007, Issue 3.

The Cochrane Collaboration is an international nonprofit, independent organization that produces and disseminates systematic reviews of health care interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. Visit http://www.cochrane.org for more information.