SDOH, Structural Barriers Quell Maternity Outcomes for Home-Based Care

Even with home-based care interventions, social determinants of health and structural barriers get in the way of good maternal health outcomes, a new Health Affairs study has found.

The report, received under embargo, showed that a home-based nursing care program had a negligible impact on the health outcomes of pregnant, Medicaid-eligible people. That’s likely because structural barriers and other social determinants of health are likely more than nurses can mitigate.

These findings call into question the efficacy of home-based nursing care among pregnant populations and how such programs can be reshaped in the future.

The researchers zeroed in on the Nurse-Family Partnership (NFP) program, which offers home visits from a registered nurse to Medicaid-eligible pregnant people throughout their pregnancy and up to 24 months after delivery. NFP operates in 40 states and, as of 2020, has served more than 50,000 families. It also received additional funding as part of the American Rescue Plan Act of 2021.

As part of their home visits, NFP nurses use different patient-provider communication strategies to uncover targeted needs and to tailor healthcare and social services solutions. In addition, NFP nurses conduct mental health screenings, monitor pregnancy, and provide guidance on healthy behaviors related to exercise and nutrition.

Finally, NFP nurses can help coordinate patient care across the healthcare and social services sector, including specialist and social determinants of health referral.

But although the model sounds promising, the researchers found that it could be an inefficient way to boost maternal health outcomes and equity.

The researchers compared outcomes for 5,670 Medicaid-eligible pregnant people in South Carolina, some of whom were enrolled in the NFP program and some of whom were not.

Overall, the researchers found little difference between the two groups. Specifically, they found no statistical difference in the intensity of prenatal care use, receipt of guideline-based prenatal services, other healthcare use, or gestational weight gain.

This is likely due to the structural forces that affect healthcare and social services access, the team said. Although the NFP nurses act as one way to support care access and provide guidance, there are structural forces too large for the nurses to assuage. In some cases, nurses may not have referred patients to social services or other types of healthcare because they knew there were structural barriers to care.

For example, the researchers noted low rates of dental referrals in the NFP group; that’s likely because many dental providers don’t accept Medicaid insurance. Factors like provider shortages may also explain low referral to maternal-fetal specialists or high emergency department visit rates.

Structural inequity may have also influenced patients’ ability to adopt healthy behaviors that NFP nurses recommended. For example, the NFP program focuses heavily on prenatal exercise and nutrition. However, food deserts and swamps may make it impossible for some patients to adopt those best practices, the researchers said.

Moreover, the assessment showed that NFP does little to impact health equity or improve outcomes among populations of focus, specifically socially complex people and non-Hispanic Black people.

Of note, NFP participants tended to be in poorer health than non-participants, with the researchers noting higher rates of obesity and pre-pregnancy hypertension. However, they also had higher rates of patient activation. NFP participants were more engaged in prenatal care and pregnancy services, clocking in greater first-trimester prenatal care initiation, more prenatal visits, and higher WIC use.

NFP may be able to move the needle more if it enrolled populations who were less engaged in their care at baseline, but the researchers said that’s currently hard to do. For one thing, patients need to enroll in NFP by 28 weeks’ gestation, meaning patients need to establish a care plan before the third trimester.

For another, enrollment in NFP requires a baseline level of patient trust, the research team said.

“Participants who are open to receiving regular home visits with a nurse may be more likely to be comfortable with, familiar with, and trusting of health and social services than those who are not interested in home visits,” the researchers explained.

“More evidence is needed to understand what interventions would be effective to reach pregnant people who are less engaged with clinical care,” they suggested.

There is still more to understand about NFP, the researchers said. Future studies should look at how NFP impacts use of social services, contraception and birth spacing, and child health and development.

These findings are amidst a backdrop of a maternal health crisis in the United States. Prior to the Health Affairs report’s publication, researchers from March of Dimes offered a bleak outlook on maternity care deserts. As of 2023, 5.6 million people live in a maternal care desert, meaning there is no or limited access to maternity care services.

A separate assessment from the Milken Institute highlighted a concerning finding about maternal health outcomes, race, and age. Overall, maternal mortality rates grow with age. However, the rate at which they grow is not the same between Black and White populations.

For Black people, there’s a sharper increase in maternal mortality rates with age compared to White people.