Happy fall! 🍂 Being back in Boston and close to my childhood home in New Hampshire means I can — as I did as a kid — truly enjoy this season’s foliage. 

I also know that for many of our readers, fall means heading back to school, whether as professors or students.

Did you know that Tradeoffs content has been used in over 50 college and university classes? If you’re looking to liven up your syllabus, our episodes and Research Corner archives are a great place to start.

And if you do use our content in your classroom, we’d love to hear about it! Drop my colleague Shannon Crane a line at scrane@tradeoffs.org.

South Carolina’s Bold Maternal Health Experiment Disappoints

America is in the throes of a maternal and infant health crisis — the death rate for mothers from childbirth and pregnancy complications is more than three times higher than in other high-income countries. And infant mortality in the U.S. is significantly higher than in Europe.

One big reason for this crisis, experts say: More than 5.6 million women in the U.S. have little or no access to maternity care.

Seeking to fill those gaps in care, state and federal officials have invested heavily in programs that send nurses to the homes of low-income pregnant and postpartum women for regular visits.

But a major randomized trial shows those home visits do not benefit pregnant mothers and their babies as much as policymakers had hoped.

A decades-old home visiting program delivers disappointing results for moms and babies

The trial was made possible when the state of South Carolina took an unorthodox route to expanding its home visit benefit, raising $29 million from federal and philanthropic sources — with one big string attached. To get that upfront investment, which enabled nearly 4,000 more moms to receive home visits, the state had to agree to run a rigorous randomized trial of its program.

That program is run by the Nurse-Family Partnership (NFP), a decades-old initiative that organizes regular home visits by registered nurses to the homes of first-time moms. From early in pregnancy through two years postpartum, these nurses serve as educators, coaches, care coordinators and sometimes confidants.

But does their program actually improve health outcomes for these mothers and their babies?

That’s the question a team of researchers spent the last five years trying to answer. They tracked an extensive list of variables for NFP participants, including whether their babies were born early and at a healthy weight and whether the mothers received the recommended prenatal care like office visits, ultrasounds and vaccinations. The researchers then compared the participants’ outcomes to those from a group of mothers with very similar characteristics who did not receive home visits.

The initial wave of results are in. According to one paper in the summer of 2022 in JAMA and another published last month in Health Affairs, home visits had no significant impact on the health of mothers or their babies during pregnancy and delivery. That held true even when the authors looked for effects in particular vulnerable groups of participants like Black women.

The researchers are continuing to collect data on longer term outcomes like child well-being, and they caution that it’s possible the program had positive effects their study could not capture — but they also admit the early numbers are disheartening.

“We were disappointed,” said Rebecca Gourevitch, one of the study authors. “It’s not what you want to see.” South Carolina has one of the highest rates of premature birth — the leading cause of infant death and a major risk factor for medical complications — in the country.

Broader policy issues may have led to lackluster results

While this randomized trial was rigorous, it was not designed to explain why this home visit program did or did not succeed.

In their journal articles, the researchers posit a few guesses, though. One was that many of the societal resources needed to make the most of NFP’s services are often out of reach. For example, teaching mothers about nutrition and fitness may improve health only if there are more supermarkets or places to exercise nearby.

Another potential reason: The intervention may have failed to reach the moms who could benefit the most. To qualify for services, women had to be first-time mothers and enroll with NFP before the 28th week of their pregnancy.

But having prior pregnancies and enrolling late into NFP’s services may signal an even more pressing need for home nursing visits. 

“These results, along with what we’ve heard from community stakeholders, have really accelerated us to look at wider eligibility criteria,” said Sarah McGee, chief policy officer at NFP. She added the organization is currently piloting those broader criteria at 31 sites across the U.S.

States look to other solutions, including expanding Medicaid benefits

South Carolina is still searching for other ways to improve outcomes for pregnant women and their babies. Although the state remains one of just 10 who have not yet expanded their Medicaid programs, they did recently extend benefits for postpartum women from 60 days to a full year.

Thirty-seven other states and Washington, D.C. have made similar expansions to Medicaid eligibility for new mothers.

The question remains, though: What services do these state Medicaid programs need to cover if the U.S. is going to make more progress on its maternal and infant health crisis?

There are some other evidence-based options on the menu, according to Lisa Dubay, a senior fellow at the Urban Institute. She highlighted a few promising strategies, including serving more women with low-risk pregnancies through birth centers staffed by midwives, cash transfer programs and housing vouchers.

With Medicaid covering the births of more than 1 million women each year, states have some high-stakes policy choices to make.