Fresh out of college in 1970, David Olds went to work for an inner-city daycare center in Baltimore. “I was a product of the 1960s, and I saw early intervention programs as a way to help the world.” But for many of the children he worked with, it was too little intervention, too late.
Olds saw parents abuse their children right on the steps of the center, and it was plain that in many of the children’s homes abuse was the norm, not the exception. He remembers a boy who wouldn’t take his naps because at home he was beaten if he wet the bed. If a program were to be effective helping at-risk youth like these, Olds realized, it would have to reach them much earlier.
Over the next several years, Olds and several colleagues began developing a program to ensure the children would be reached in time by working with their mothers before the children were born. By the late 1970s Dr. Olds, now a professor of psychology at the University of Colorado, and his colleagues had a program model in hand. They proposed a nurse home-visitation program for low-income, first-time mothers, which assumed that simple measures–like improving pregnant women’s nutrition, reducing their alcohol and cigarette use, and teaching basic parenting skills–would have substantial payoffs in well-being for both mother and child. Today, Olds’ idea has become the Nurse-Family Partnership (NFP), which operates out of 170 sites in 22 states and has served some 13,000 families.
Avah Redd, who oversees the Nurse-Family Partnership site in Kansas City, Missouri, has seen firsthand the impact the program has on families’ lives. Her favorite story involves Helen (not her real name), a 32-year-old developmentally delayed woman who found herself pregnant at the hands of a man, also developmentally delayed, who was only somewhat involved with her. She had no job, no job-training, and no real means of caring for the baby. A nurse in one of Kansas City’s clinics referred Helen, then three months pregnant, to Redd.
As NFP nurses do with every patient, Redd began visiting the woman weekly. The Department of Family Services had also become involved. “The department was worried the woman couldn’t care for the baby because she was slow to respond to questions,” Redd tells Philanthropy. The department wanted to know if Redd thought the baby should be removed from the mother’s care after birth.
As Redd worked with Helen on pre-natal care, she came to understand the mother was very capable of caring for a child. “People took the mother’s slow response to mean she didn’t know” what was happening, Redd says. “It took me a while to get folks to understand that she was internalizing the information before deciding what to do.”
Helen kept the child—and Redd. In NFP, nurses don’t leave the mother after the child’s birth. They follow up pre-natal care with infant care, a catch-all phrase that can include anything from the ins-and-outs of caring for the newborn, to dealing with relationships and finding jobs. Parents “graduate” when the child turns two.
As most parents in Redd’s NFP program do, Helen landed a job. “Seventy percent of our parents move into the work force,” Redd tells Philanthropy. “Ten percent go into technical training, and about 6 percent go on to college.”
Today, mother and baby are doing well. Helen received training and now cleans offices part-time while living with her mother. And the baby is showing every sign of being a healthy, happy, intelligent child.
Good stories alone, however, don’t win grants—at least, grants large enough to sustain a nationwide program. Olds understood this early on. “If we were going to make a difference, we would need evidence that would withstand serious scientific scrutiny,” he says.
Today there are many early-intervention programs, but few have as much empirical data as NFP to prove their effectiveness. The first clinical trial of the program model was conducted in 1978 in a semi-rural upstate New York town named Elmira. In that trial, specially trained registered nurses made regular visits to the homes of low-income women (median age 19) who were in the early stages of pregnancy, and they continued their visits up through the babies’ second birthdays. The program had three goals: first, to improve fetal health by reducing the mother’s smoking and drinking, improving her diet, and identifying medical problems with mother or baby early on; second, to improve the child’s health by helping parents provide responsible and competent care; and third, to assist families in becoming economically self-sufficient by helping them plan future pregnancies, continue their own education, and find jobs.
That initial clinical trial and the 15-year follow-up study offered solid evidence that the program worked. (See nearby chart.) Additional studies have been conducted in a poor, urban, mostly African-American area of Memphis, and in a similar, largely Hispanic neighborhood in Denver. These studies show that the program’s benefits can be replicated in communities of differing class and ethnic composition—a feature Olds wanted to establish before trying to expand the program further.
The studies have also caught the attention of several foundations. In 2003, the Edna McConnell Clark Foundation gave $1.8 million to support a national roll-out of the Nurse-Family Partnership program.
We are first and foremost an outcomes funder. We’re looking for programs that can demonstrate before they replicate,” says Woodrow “Woody” McCutchen, a portfolio manager for the Edna McConnell Clark Foundation, which focuses its philanthropic efforts on helping youth-serving nonprofit organizations strengthen and expand their programs.
At first, the Edna McConnell Clark Foundation was concerned with the age of the women Olds’ program served. Edna McConnell Clark funds groups serving young people ages 9 to 24, but a number of women in the program were older than that. These concerns dissipated, however, when it became clear the majority of mothers served by the program are teenagers. In Redd’s Kansas City program, for example, the mean age of women served is 19, while their ages range from 12 to 44.
Additionally, the 15-year follow up on the Elmira study, which showed the program’s benefits to children were sustained into adolescence, made the program an easy sell. “For us, it was a program that provides multigenerational outcomes,” says McCutchen.
Nurse-Family Partnership used the foundation’s $1.8 million to launch a national office in Denver, including an expanded board of directors and a new president and CEO who helps sustain the quality of current sites and expand NFP to new locations.
Programs offered in new locations must have an “implementing agency,” either private or public, which ensures it is staged correctly and guarantees three year’s funding. In Missouri, the Missouri Department of Health sponsors that state’s sites. Redd’s program, whose budget is a relatively modest $320,000 a year, excluding salaries, also receives significant in-kind assistance from Truman Medical Centers, a nonprofit hospital in Kansas City. That budget supports four nurses, each carrying a caseload of 25 mothers and mothers-to-be. “The national office helps us as far as finding funding and offers support” for programs and back-office work, says Redd.
Our goal is to double the number of sites in the next five years or so,” says Clay Yeager, recently brought on as president and CEO of the Nurse-Family Partnership. Government is one possible source for replicating this program in other cities. But Yeager, who in 1997 was appointed to head the Governor’s Community Partnership for Safe Children in Pennsylvania, is aware of government’s poor record of funding effective programs. As a government official seeking to determine the costs and benefits of early intervention programs, Yeager found that criteria for evaluating programs were “akin to the fashion industry,” with money thrown at program models backed up by little more than educated guesses about their effectiveness. “There’s never been an agency equivalent to the FDA to approve and evaluate prevention programs,” says Yeager.
Recent independent studies, however, have shown that NFP is not only effective, but cost-effective as well. A 1997 RAND corporation study showed that for every dollar spent on the program, there was a four-dollar savings for the government–in increased revenues from greater employment and in reduced expenditures on public assistance programs and the criminal justice system. A cost-benefit study conducted last year by the Washington State Institute for Public Policy determined that Nurse-Family Partnership produced benefits of $28,298—against a cost of $9,118 per youth served—the highest cost-benefit ratio of any of the child welfare and home visitation programs they examined.
But government can’t be the only player involved. Private philanthropy also will be critical in perpetuating and replicating NFP. As noted, the budget needed to run a local NFP program is relatively modest. Foundations already supporting local hospitals, for example, may find NFP a cost-effective and natural fit in their grantmaking.
At a minimum, grantors who have grown disillusioned at the expense and uncertain effectiveness of many such programs can see that, done well, early intervention can dramatically improve the prospects of struggling parents and children, as well as their communities.
Daniel T. Kennelly is senior editor of The American Enterprise magazine.
