Should public health nurses visit every family with a new baby?
Sara Savidant already had two children, but that didn’t make the Lethbridge, Alberta mom feel any more confident when she was caring for newborn twins in 2015. “I forgot so much in that short amount of time between the births of my kids,” she says.
But when the public health nurse walked in the door, she immediately felt at ease. “She just offered me reassurance,” recalls Savidant, who invited the nurse to visit a few more times. “It felt different from seeing a doctor, I felt more comfortable in my own home.” Plus, it was extremely difficult for Savidant to get to the clinic – she was recovering from a C-section and couldn’t carry one car seat, let alone two. So she was relieved the nurse could examine her twins at home. (Savidant ended up taking one of the twins to a doctor, because the nurse was concerned about jaundice.)
In most jurisdictions across Canada and many higher-income countries, public health nurses follow up with women after delivery through phone calls and/or home visits, to assess their needs, recommend community programs and give advice on feeding, safety, early childhood development and more.
“You really get a much more natural sense of how things are going for them in home visits,” explains Barbara Webster, a clinical nurse specialist who used to do home visits and now oversees community nurses at the First Nations Health Authority in BC. “We can talk about the safety things that are pertinent in the house (such as potential suffocation hazards in a crib), and the woman doesn’t have to get out of her pajamas.”
But depending on the province and region moms live in, they either get a lot, or very little, public health follow up. As to the best way to conduct the visits, how many should be provided, and who should be visited, that’s a question health officials are still trying to figure out. Many argue, however, that the current follow up is inadequate.
“Sometimes it seems like we provide all this prenatal support, and the baby is born, and we say, ‘Wonderful! Congratulations! Good luck!’ It’s almost like saying, ‘We don’t do returns,’” jokes Michael Geary, chief of obstetrics and gynecology at St. Michael’s Hospital. “But an adverse environment in the first year of life has been shown to affect your ability to thrive and grow well into adulthood…we really need to focus more on the first weeks, months and year of life.” Indeed, poor early nutrition, inadequate cognitive stimulation and other issues in infancy have been shown to increase the risk of poor long-term health outcomes, such as cardiovascular disease, diabetes, obesity and more.
What’s the evidence behind postpartum home visits?
Home visits have been shown to increase mother-child interactions and positive stimulation for babies. Systematic reviews have found nurse visiting led to greater uptake of other medical and educational interventions (such as pediatric visits and community support groups) as well as improved the safety of the home environment. One randomized controlled trial found nurse visits decreased smoking rates and slightly improved cognitive development among babies, among other effects.
A review of six studies in which women were provided home visits with counselors trained in postpartum depression found that four of them demonstrated that the visits helped prevent or improve postpartum depression.
But not all studies have noticed differences between families visited by public health nurses and those not visited. Generally, the effects are found when the mothers are considered high-risk, based on how they answer screening questions, or because they are young, or have low levels of education, income or family support. When home visits are provided to everyone regardless of need, benefits are often unnoticeable.
In fact, one study randomized 733 women to either receive a telephone call (and be visited if the nurse or mother felt there was a need) or to be visited at home twice, without an assessment. The study found no difference between maternal confidence nor health problems in infants in each group at four weeks. Similarly, there was no difference between the two group’s breastfeeding rates at six months. But the cost difference between the two interventions was significant, with the cost of the call group averaging about $150 per infant and the two-visit group averaging $240 per infant.
Geary points out, however, that if the public health interventions are dramatically helpful for a very small percentage of the general population, that can be hard to capture in a study. And it’s necessary to reach everyone in order to reach the few who will be helped, he argues. This is why all women receive home visits in the UK, where Geary did his medical training.
“We’re very good at identifying the high-risk mom and baby and managing them, but the real challenge is identifying the high risk baby of the low-risk mom,” he says. (In other words, sometimes, babies born to families who have high levels of resources and supports still have issues such as undernourishment. And those babies could be missed because no problems are expected.) Additionally, when it comes to postpartum depression, which can have devastating effects on moms and babies if left untreated, the benefits of the home visits are noticed among studies of the general population.
It’s important to note that not all public health programs are created equally. The effects of home visits are greatest when the visits are intensive and frequent, as well as combined with a larger program. One of the most frequently cited studies showed impressive impacts of home visits among high-risk women in Elmira, New York. There, women were visited weekly for at least eight weeks (half the women were additionally followed up to 24 months) and were provided with transportation to medical appointments.
In comparison, an Ontario study found there was no difference in breastfeeding rates between women who were called or visited by a public health nurse, and those who were not – possibly because most women only received one home visit, on average.
Public health follow up across Canada
While some jurisdictions have moved to reduce the number of moms who get public health follow-up home visit(s), others have been expanding the number. This year, for example, Toronto Public Health (TPH) changed its policy from only following up with women who screened as at-risk based on their answers to an in-hospital questionnaire. Now, they’ll be calling all women who fill out the questionnaire and consent to have their information shared with public health, regardless of their risk level. They’ll then visit those who indicate in the phone call that they could benefit from a home visit.
Lynn Walker, manager of Child Health & Development, Reproductive and Infant Health at TPH, says the change was made based on “anecdotal feedback” from families saying they appreciated the call, and it helped them get connected to local services such as breastfeeding clinics.
In 2012, the province of BC moved in the opposite direction, but ended up with the same intervention as TPH now employs. Previously, all BC women were visited in their homes; now all women are called and those who ask for are deemed to need a visit are visited.
Tama Cross, a midwife with Diversity Midwives in Scarborough, Ontario, agrees with the phone call-first approach. “We have quite a few clients who say ‘I’m fine, I don’t need the extra [public health support],’” she says. Still, she thinks it would be better if women are called a second time, perhaps after a couple of weeks, as postpartum depression and other issues may not set in immediately.
In Alberta, meanwhile, all women have a comprehensive assessment with a public health nurse to cover everything from domestic violence screening, postpartum depression screening, breastfeeding support, and general health assessments of the mother and baby. In the Calgary and Edmonton zones, these assessments often take place in clinics, while outside of these zones, most women are seen in their homes.
Because the public health nurses combine the mental and psychosocial assessment of the mother with the examination of the child, this universal approach doesn’t end up costing significantly more than a more selective approach, explains Shannon Evans, a spokesperson for Alberta Health Services. “The psychosocial health of the parent is as important to the child as it is to the parent,” she adds.
How many visits a woman receives, and what programs she’s referred to, also varies. In Alberta, a woman who is determined as needing more support may be visited weekly for up to two months; in Ontario, in very high-risk cases, families can be visited until a child is six years. Usually, however, a family that isn’t facing significant challenges will only get one visit.
Ways to improve home visits of families with newborns
Moira Sherman, a mother of two in Toronto, suffered from postpartum depression after both of her births and was visited by public health nurses both times. When her second was born, she asked specifically about postpartum depression programs, but the two programs in her area weren’t focused on depression in particular, but overall mother-child interaction. Meanwhile, the nurse didn’t offer counseling herself, but “extremely basic” advice about tummy time and feeding. “I’m a second-time mom; it felt like amateur hour,” says Sherman.
Toronto Public Health does offer free programs specific to postpartum depression, but the programs are only available in certain neighbourhoods. “Since all Healthy Baby Healthy Child programs are funded by the province, there should be more consistency in what is offered,” says a Greater Toronto Area public health nurse who wishes to remain anonymous.
Peter Spadoni, a media spokesperson for Ontario’s Ministry of Children and Youth Services says the current program is under review — in large part to address the inconsistencies with some jurisdictions (like TPH’s) choosing to call all women, while others only call at-risk families.
As to what can be done about the wide variability in community programs that nurses refer women to, each public health unit decides individually what programs it will fund. However, Patients First legislation, expected to be reintroduced this fall, may address the potential inequities by providing Local Health Integrated Network (LHIN) oversight of public health planning and programming.
There’s also concern that nurses aren’t targeting socioeconomically disadvantaged women enough. In one Ontario study, despite being 2.5 times more likely to request a public health nurse home visit, socioeconomically disadvantaged women only received one half visit more, on average, than socioeconomically advantaged women over the first four weeks post birth.
Part of the issue may be a communication failure. A 2013 evaluation of the Healthy Babies, Healthy Children program found that 18% of postpartum women weren’t reached for a phone assessment, despite having screened as having risk and consenting to having their information shared. The anonymous GTA nurse says many high-risk moms don’t have voicemail or money for minutes to call a nurse. “If you need to change the visit or you want to reconnect with someone, there’s that inability to connect,” she says.
One way to address the problem is to allow nurses to text clients, the nurse suggests. Additionally, more community workers can be engaged at the local level. In many jurisdictions, trained home visitors who are not nurses conduct follow-up visits in consultation with a nurse, and these visitors could be utilized to locate women who may be in need. For women who may not be comfortable having someone visit in their home, jurisdictions in several provinces also offer assessments at local community centres.
For First Nations people in BC, having home visitors from the local communities has helped tremendously in ensuring all women are visited, says Lucy Barney, a perinatal specialist with the First Nations Health Authority. “They often already have a relationship with the family, so they know when they’re coming home with the baby,” she says.
Cross agrees that more community supports and more visits in general are needed for the largely socioeconomically disadvantaged population she sees. “I see a lot of isolation, a lot of postpartum depression,” says Cross. “They’re asking for more help in the home, more contact, more resources.”