美国麻省理工学院Katherine Baicker团队研究了强化护士家访计划对医疗补助合格人群不良出生结局的影响。相关论文于2022年7月5日发表在《美国医学会杂志》上。

改善低收入母亲的生育结局是公共卫生的优先事项。强化护士家访已被提议作为一种干预措施，以改善这些预后。

为了确定强化护士家访计划对早产、低出生体重、小于胎龄儿或围产期死亡的综合结局的影响，研究组进行了一项随机临床试验，招募5670名符合医疗补助条件、妊娠期不足28周的未产妇，于2016年4月1日至2020年3月17日登记，随访至2021年2月。将参与者以2:1的比例随机分配，其中3806名接受护士家庭伙伴计划，1864名为对照组。

该项目是一个既定的护士家访模式；定期访视从产前开始，持续到产后2年。护士提供与产前健康、儿童健康和发展以及母亲生命过程相关的教育、评估和目标设定。对照组接受常规护理服务和社区资源清单。工作人员和参与者均未对干预组双盲。共有3个主要结局。本文根据截至2021年的生命记录、医疗补助申请和出院记录，报告了一系列不良出生结局：早产、低出生体重、小于胎龄儿或围产期死亡。

婴儿出生间隔小于21个月和在头24个月内受重伤或担心虐待或忽视的其他主要结局尚未完成评估。共有54个次要结局；已完成测评的关于产妇和新生儿健康相关因素包括综合因素加出生体重、妊娠期长、大于胎龄儿、极早产、极低出生体重、新生儿夜间重症监护室住院、严重孕产妇发病率和剖宫产。

在5670名参与者中，研究组共分析了4966名（干预组中3319名；对照组中1647名）的主要孕产妇和新生儿健康结局（中位年龄为21岁[1.2%为非西班牙裔亚裔、土著或夏威夷土著和太平洋岛民；5.7%为西班牙裔；55.2%为非西班牙裔黑人；34.8%为非西班牙裔白人；3.0%为非西班牙裔混血）。干预组和对照组的综合不良出生结局发生率分别为26.9%和26.1%，校正后组间差异为0.5%。在整个样本中或在任何一个预先指定的亚组中，干预组的结果对任何孕产妇和新生儿健康的主要或次要结局都没有显著改善。

研究结果表明，在这项基于南卡罗来纳州的符合医疗补助条件的孕妇试验中，分配参加强化护士家访计划并没有显著降低不良出生结局的发生率。该计划的整体有效性评估尚不完整，有待对幼儿期和生育间隔结局进行评估。

附：英文原文

Title: Effect of an Intensive Nurse Home Visiting Program on Adverse Birth Outcomes in a Medicaid-Eligible Population: A Randomized Clinical Trial

Author: Margaret A. McConnell, Slawa Rokicki, Samuel Ayers, Farah Allouch, Nicolas Perreault, Rebecca A. Gourevitch, Michelle W. Martin, R. Annetta Zhou, Chloe Zera, Michele R. Hacker, Alyna Chien, Mary Ann Bates, Katherine Baicker

Issue&Volume: 2022/07/05

Abstract:

Importance  Improving birth outcomes for low-income mothers is a public health priority. Intensive nurse home visiting has been proposed as an intervention to improve these outcomes.

Objective  To determine the effect of an intensive nurse home visiting program on a composite outcome of preterm birth, low birth weight, small for gestational age, or perinatal mortality.

Design, Setting, and Participants  This was a randomized clinical trial that included 5670 Medicaid-eligible, nulliparous pregnant individuals at less than 28 weeks’ gestation, enrolled between April 1, 2016, and March 17, 2020, with follow-up through February 2021.

Interventions  Participants were randomized 2:1 to Nurse Family Partnership program (n=3806) or control (n=1864). The program is an established model of nurse home visiting; regular visits begin prenatally and continue through 2 postnatal years. Nurses provide education, assessments, and goal-setting related to prenatal health, child health and development, and maternal life course. The control group received usual care services and a list of community resources. Neither staff nor participants were blinded to intervention group.

Main Outcomes and Measures  There were 3 primary outcomes. This article reports on a composite of adverse birth outcomes: preterm birth, low birth weight, small for gestational age, or perinatal mortality based on vital records, Medicaid claims, and hospital discharge records through February 2021. The other primary outcomes of interbirth intervals of less than 21 months and major injury or concern for abuse or neglect in the child’s first 24 months have not yet completed measurement. There were 54 secondary outcomes; those related to maternal and newborn health that have completed measurement included all elements of the composite plus birth weight, gestational length, large for gestational age, extremely preterm, very low birth weight, overnight neonatal intensive care unit admission, severe maternal morbidity, and cesarean delivery.

Results  Among 5670 participants enrolled, 4966 (3319 intervention; 1647 control) were analyzed for the primary maternal and neonatal health outcome (median age, 21 years [1.2% non-Hispanic Asian, Indigenous, or Native Hawaiian and Pacific Islander; 5.7% Hispanic; 55.2% non-Hispanic Black; 34.8% non-Hispanic White; and 3.0% more than 1 race reported [non-Hispanic]). The incidence of the composite adverse birth outcome was 26.9% in the intervention group and 26.1% in the control group (adjusted between-group difference, 0.5% [95% CI, 2.1% to 3.1%]). Outcomes for the intervention group were not significantly better for any of the maternal and newborn health primary or secondary outcomes in the overall sample or in either of the prespecified subgroups.

Conclusions and Relevance  In this South Carolina–based trial of Medicaid-eligible pregnant individuals, assignment to participate in an intensive nurse home visiting program did not significantly reduce the incidence of a composite of adverse birth outcomes. Evaluation of the overall effectiveness of this program is incomplete, pending assessment of early childhood and birth spacing outcomes.

DOI: 10.1001/jama.2022.9703

Source: https://jamanetwork.com/journals/jama/article-abstract/2793825