Abstract
Home visiting may be a promising strategy to improve pregnancy outcomes, and home visiting by lay workers may be more accepted by pregnant women. Lay workers may impact on social and environmental risk factors as well as on health care utilization. As with any primary prevention strategy, these programs may be more successful if implemented with responsibility shared between the health care system and the community. This article reviews the state of the science related to lay home visiting during pregnancy in the United States. Using a variety of search terms, an exhaustive review of the literature was conducted using several large electronic databases. Studies of lay home visiting during pregnancy have documented mixed results. Many weaknesses exist in the studies available, including use of descriptive or quasi-experimental designs in most of the studies, absence of a clearly specified set of interventions, and lack of cost analysis. Gaps in our knowledge of the impact of lay home visitors on pregnancy outcomes persist.
Maternal child health policy in the United States broadly focuses on improving pregnancy outcomes and on reducing infant mortality through prenatal care. Despite efforts to increase early entry into prenatal care, minimal progress in reducing infant mortality rates has been reported since the early 1980s. 1 Seven out of every 1000 babies born in the United States die before their first birthday. 2 More than 250,000 infants each year are born at low birthweight, and as many as 64% of these infants do not survive. 2 Recent trends in infant mortality continue to show a 2:1 disparity between black and white infants and a national infant mortality rate higher than that of 19 other nations. 1 Infants that survive may suffer permanent impairments. Prenatal care and immunization rates in the United States lag far behind those in other industrialized countries. Children at highest risk often are born to teen mothers, women with a low income, women who smoke, unmarried women, older women, those who have not completed high school, or those who do not receive timely prenatal care. 2
Infants with low birthweight and those born preterm have a higher risk of dying in the first year of life. 2 Birthweight is one of the most important predictors of an infant's subsequent health and survival. Low birthweight can result from preterm birth, intrauterine growth retardation, or a combination of these factors. Although interacting social, physiological, psychological, and environmental factors have been causally associated with low birthweight, its etiology remains unknown. Identified risk factors for low birthweight include being young or unmarried, receiving inadequate prenatal care, and having low socioeconomic status. Rural women are also more likely to deliver babies with low birthweight, possibly due to lack of access to prenatal care services in combination with other risk factors. A variety of social conditions have been linked with low birthweight, including stress and lack of social support. Other behaviors causally linked with low birthweight include smoking, substance abuse, and poor nutritional intake. 3 Prenatal and preventive care may reduce risk. For many families, however, social, cultural, and economic conditions pose insurmountable barriers. Without some intervention designed to build self-care effectiveness, women may not seek prenatal or preventive care services during pregnancy.
Recommendations for improving pregnancy outcomes include broadening the definition of health to include socioeconomic and environmental factors, fostering teamwork and coordination among health care providers and communities, and providing pregnancy care in a more holistic manner. 1,4 As stress and psychological issues have emerged as risk factors for low birthweight, interventions providing home visiting and support services to populations considered to be at risk have emerged. Care in the home facilitates assessment of the environmental and social context in which self-care occurs, allowing the provider and family to partner in planning and implementing holistic strategies to improve health. Providers of support in these programs have ranged from professionals to lay persons. Despite the programs' promise, evaluations have shown mixed results.