Tennessee Connections for Better Birth Outcomes
Condition: Preterm Birth
MeSH terms: Premature Birth
Study type: Interventional

Summary: 
      Women with a history of a prior preterm birth (PTB) have a high probability of a recurrent
      preterm birth. Some risk factors and health behaviors that contribute to PTB may be amenable
      to intervention. Home visitation is a promising method to deliver evidence based
      interventions. We evaluated a system of care designed to reduce preterm births and hospital
      length of stay in a sample of pregnant women with a history of a PTB. All participants (N =
      211) received standard prenatal care. Intervention participants (N = 109) also received home
      visits by certified nurse-midwives guided by protocols for specific risk factors (e.g.,
      depressive symptoms, abuse, smoking). Data was collected via multiple methods and sources
      including intervention fidelity assessments. Average age was 27.6 years. Racial breakdown
      mirrored local demographics. Most women had a partner, a high school education, and Medicaid.
      Enhanced prenatal care by nurse-midwife home visits may limit some risk factors and shorten
      intrapartum length of stay for women with a prior PTB. This study contributes to knowledge
      about evidence-based home visit interventions directed at risk factors associated with PTB.
    

Detailed description: 
      Preterm births (PTBs) are the leading cause of death in infants under the age of one.
      Tennessee (TN) is one of the lowest ranking states in the US for rates of PTBs (46th) and
      infant mortality (48th). Costs for neonatal care increase exponentially with decreasing
      gestational age, and there are lifelong consequences for families and communities. Despite
      medications and improved diagnostic tools, a 27% increase in PTBs has occurred in the past 20
      years. With a history of one PTB, the probability of another PTB is approximately 30%. The
      risk of having another PTB rises to almost 70% if the woman has a history of more than one
      PTB. Relationships between a variety of factors (e.g., African American race, smoking, short
      interval between pregnancies, socio-environmental stressors) likely contribute to TN's high
      rate of PTBs. Several interventions have been identified to reduce PTBs and improve maternal
      and infant health indicators but with varying success; administering intramuscular injections
      of progesterone between 16 and 36 weeks gestation, providing some prenatal care in the home
      of women with a high risk pregnancy, increasing the interval between pregnancies, and
      reducing social factors that negatively impact health, such as smoking, substance abuse and
      stress.

      The overall purpose of this study was to determine if a combined medical and biobehavioral
      intervention would prevent PTBs and reduce healthcare costs in a sample of women who have had
      a prior PTB. The medical intervention was conventional prenatal and postpartum clinic care.
      The biobehavioral intervention included certified nurse midwife home visitors who engaged
      women in an integrated System of Care (SOC) during their prenatal care. Care continued during
      the first 18 months of the infant's life by maternal-child nurse visitors. Home visits were
      in addition to regularly scheduled conventional prenatal and postpartum clinic care. Main
      study questions were:

      Is there a difference in: 1) the length of gestational age of infants of high-risk pregnant
      women who receive the medical intervention and high-risk pregnant women who receive the SOC?
      2) in health care costs between women who receive the medical intervention and the SOC? 3)
      intervals between the current pregnancy and a subsequent pregnancy across groups? and 4) in
      length of gestational age of current infant with gestational age of index prior preterm
      birth?
    

Intervention name(s): Targeted Nurse Home Visits; Conventional prenatal/postpartum care
Intervention type(s): Behavioral; Other
Intervention description(s): Advanced practice nurses provide targeted behavioral interventions during home visits. These visits were in addition to regularly scheduled conventional prenatal and postpartum clinic care. Specific protocols guided nurse interventions related to tobacco use, substance use and misuse, stress management, dental health, maternal infections, perinatal depressive symptoms, family violence, reproductive life plans and continuity of care. Home visits were continued in the postpartum period (through 18 months post-delivery) with a continued focus on risk factors identified during the prenatal period and internatal health care.; Women in this group received conventional prenatal care and postpartum clinic care.
Other intervention name(s): standard medical prenatal and postpartum care
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Prevention
Keywords: preterm; prematurity; home visitation; system of care