In this issue of Pediatrics, Goldfeld et al1  report maternal mental health outcomes after 3 years of follow-up from a randomized controlled trial of right@home, a nurse home visiting (NHV) program in Australia. The trial enrolled 722 pregnant women experiencing ≥2 risk factors for adversity, such as young age, limited social support, low income, and low educational attainment, and randomly assigned them to right@home (25 nurse home visits beginning antenatally) or usual care. After 2 years (when primary outcomes were to be collected), right@home produced benefits in parent care, parent responsivity, and home learning environment.2  In the current study, the authors followed participant families to 3 years and compared maternal mental health outcomes across 255 right@home women and 240 controls. In this analysis, right@home mothers reported better mental health according to the Depression Anxiety Stress Scales, with effect sizes of 0.25 (95% confidence interval: 0.08–0.32) for depression and 0.20 (95% confidence interval: 0.05–0.30) for anxiety.1 

Methodologically, the study has significant strengths, most notably, a rigorous multisite design. The results, however, should be interpreted with caution, the primary reason being that the maternal mental health outcomes at 3 years do not appear to be prespecified,3  and the authors report no a priori sample size calculations to discriminate a minimum effect size for clinically meaningful differences in these outcomes. This criticism may be construed as academic, but a few issues raise its salience. First, the adjusted effect sizes reported (∼0.2) are typically considered small,4  and a few of the outcomes lose their statistical significance with the use of multiple imputation, calling into question the stability of results in light of a considerable attrition rate (∼30%). Furthermore, it is unclear whether there is equivalence of groups at baseline because the authors present only comparisons among those who were retained and completed the 3-year follow-up. A more rigorous look at baseline differences could have eventuated in different statistical models. Lastly, none of the maternal mental health outcomes were significant at the 2-year time point.2  Although the authors offer a reasonable mechanism of action for “delayed” improvement in maternal mental health at 3 years, the effects of behavioral interventions typically attenuate, not amplify, with time. As a result, the findings from this study should be interpreted cautiously.

With those caveats, the current study stands on the shoulders of volumes of data that have shown significant benefits of NHV. One of the best known and widely disseminated models is the Nurse-Family Partnership, which started in Elmira, New York, in the 1970s and found benefits in multiple outcomes, including prenatal health behaviors; child abuse, neglect, and injuries; and later child and adolescent functioning.5  Over decades, the intervention expanded to further trials with similar positive results, although in one, a paraprofessional arm produced attenuated results compared to those of the more highly trained nurses.6  Since 1996, the Nurse-Family Partnership has served >300 000 US families.7 

In the current study, Goldfeld et al1  extend the previously established positive outcomes from these and other NHV studies to include maternal mental health outcomes. Heretofore, evidence for the effects of NHV programs on maternal mental health has been mixed; in a recent systematic review, authors found that of the studies that measured at least 1 maternal psychosocial outcome, a minority of the studies found positive effects, and of the studies that included depression outcomes, none found a positive effect.8 

The current study can also be viewed from the perspective of decades of research into depression as a preventable condition. In 1994, the National Academy of Medicine released a report on the prevention of mental disorders,9  offering a framework that subsequently sparked significant research. In 2014, authors of a meta-analysis found that many interventions were effective in preventing depressive disorders10 ; in 2019, the US Preventive Services Task Force released a B recommendation regarding prevention of perinatal depression.11  The systematic evidence review supporting the US Preventive Services Task Force recommendation included 50 interventions and excluded those that did not specifically address depression.12  A few of the interventions included home visiting components, but the number of visits was typically much fewer than visits in a typical NHV model.

In the current study, the authors aim to resolve a specific evidence gap in the NHV literature: whether such programs can result in maternal mental health benefits. Although the results of the current study seem optimistic, the methodologic limitations mentioned prohibit any definitive conclusions. That said, given the convincing evidence for the effectiveness of depression prevention programs, in future NHV studies that aim to solidify the evidence base on maternal mental health, researchers may be well served to look into the depression prevention literature and incorporate intervention components that appear to have the greatest impact. The bundling of effective depression prevention components with NHV into a single evidence-based intervention could result in substantial benefit to many families across the United States and beyond.

FUNDING: Dr Egan is funded under grant T32HS022242 from the Agency for Healthcare Research and Quality, US Department of Health and Human Services. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality, US Department of Health and Human Services, or any other funders. The funder/sponsor did not participate in the writing of this commentary. The other authors received no external funding.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2020-025361.

NHV

nurse home visiting

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: Dr Silverstein is a member of the US Preventive Services Task Force. All opinions expressed represent his own and not those of the US Preventive Services Task Force; and Drs Egan and Xuan have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.