Other prenatal home visiting programs

Health Care: Maternal and Infant Health
Benefit-cost estimates updated December 2017. Literature review updated December 2016.

This grouping of "other" prenatal home visiting programs provides services to women, children, and families during the prenatal period. In these programs, nurses, social workers, or trained paraprofessional providers make regular home visits to provide one or more non-clinical services that support maternal wellness and infant health during the prenatal period. Services may include case management, health education, risk assessment, psychosocial support, or nutritional counseling.

Programs are intended for women with high-risk pregnancies based on socioeconomic status, age, race, or other pregnancy risk factors. We exclude programs that solely target adolescent women from this analysis. Women are eligible for these programs during their pregnancy. Some program services continued for up to 12 months postpartum. All women in treatment and comparison groups receive clinical prenatal care (treatment as usual).

We performed sensitivity analysis on provider type (paraprofessional versus nurses/social workers) and length of program. We found no difference in cost or effect size, so all provider types are included in this analysis. This analysis does not include "name-brand" programs that provide prenatal home visiting as part of a larger model (e.g., Nurse Family Partnership, Healthy Families America).

BENEFIT-COST	META-ANALYSIS	CITATIONS

The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2016). The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.

Benefits to:

Taxpayers	$748	Benefits minus costs	$10,932
Participants	$1,210	Benefit to cost ratio	$16.77
Others	$0	Chance the program will produce
Indirect	$9,668	benefits greater than the costs	100 %
Total benefits	$11,625
Net program cost	($693)
Benefits minus cost	$10,932

¹In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

²“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

³“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Benefits from changes to:¹	Benefits to:
Detailed Monetary Benefit Estimates Per Participant
	Taxpayers	Participants	Others²	Indirect³	Total

Health care associated with Cesarean sections	$29	$0	$0	$15	$44
Health care associated with small for gestational age births	($2)	$0	$0	($1)	($3)

Subtotals	$27	$0	$0	$14	$41
From secondary participant
Health care associated with small for gestational age births	($40)	$0	$0	($20)	($60)
Infant mortality	$549	$1,210	$0	$9,914	$11,673
Health care associated with very low birthweight births	$212	$0	$0	$107	$318

Subtotals	$721	$1,210	$0	$10,001	$11,931
Adjustment for deadweight cost of program	$0	$0	$0	($347)	($347)

Totals	$748	$1,210	$0	$9,668	$11,625

Annual cost		Year dollars	Summary
Detailed Annual Cost Estimates Per Participant
Program costs	$692	2016	Present value of net program costs (in 2016 dollars)	($693)
Comparison costs	$0	2016	Cost range (+ or -)	15 %

Treatment cost estimates for this group of programs reflect costs beyond treatment as usual. Per-participant estimates are based on average costs for all included studies. We estimate provider hours including home visiting hours, training hours, and supervisory hours; apply the mean hourly wage estimate for Washington State reported by the Bureau of Labor Statistics (September 2016) for the appropriate provider; and increase wages by a factor of 1.441 to account for the cost of employee benefits. Included studies averaged 7 home visiting hours, 0.5 training hours, and 1 supervisory hour per participant. Supervisors varied by program and included social workers or nurses.

The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.

Estimated Cumulative Net Benefits Over Time (Non-Discounted Dollars)

The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in non-discounted dollars to simplify the “break-even” point from a budgeting perspective. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

^{^}WSIPP’s benefit-cost model does not monetize this outcome.

^***We report this outcome twice: once for mothers (designated as the primary participant) and once for infants (designated as the secondary participant). We do this because the outcome is associated with costs and benefits for both mothers and infants, and the amount of the cost or benefit is different for mothers than it is for infants.

**Meta-analysis** is a statistical method to combine the results from separate studies on a program, policy, or topic in order to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The **outcomes** measured are the types of program impacts that were measured in the research literature (for example, crime or educational attainment). **Treatment N** represents the total number of individuals or units in the treatment group across the included studies.

An **effect size** (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases.

**Adjusted effect sizes** are used to calculate the benefits from our benefit cost model. WSIPP may adjust effect sizes based on methodological characteristics of the study. For example, we may adjust effect sizes when a study has a weak research design or when the program developer is involved in the research. The magnitude of these adjustments varies depending on the topic area.

WSIPP may also adjust the second ES measurement. Research shows the magnitude of some effect sizes decrease over time. For those effect sizes, we estimate outcome-based adjustments which we apply between the **first time ES is estimated** and the **second time ES is estimated**. We also report the **unadjusted effect size** to show the effect sizes before any adjustments have been made. More details about these adjustments can be found in our Technical Documentation.
Outcomes measured	Primary or secondary participant	No. of effect sizes	Treatment N	Adjusted effect sizes (ES) and standard errors (SE) used in the benefit-cost analysis						Unadjusted effect size (random effects model)
Meta-Analysis of Program Effects
				First time ES is estimated			Second time ES is estimated			Unadjusted effect size (random effects model)
				ES	SE	Age	ES	SE	Age	ES	p-value
Adequate prenatal care (Kotelchuck Index)^{^}	Primary	3	19008	0.118	0.105	25	0.000	0.000	26	0.118	0.261
Cesarean sections	Primary	1	1033	-0.030	0.180	25	0.000	0.000	26	-0.084	0.167
Low birthweight births (< 2500g)^***	Primary	8	17785	-0.058	0.026	25	0.000	0.000	26	-0.060	0.108
Preterm birth (< 37 weeks)^***	Primary	7	17670	-0.065	0.043	25	0.000	0.000	26	-0.068	0.087
Small for gestational age (SGA)^***	Primary	2	1128	0.087	0.126	25	0.000	0.000	26	0.066	0.372
Very low birthweight birth (< 1500g)^***	Primary	3	16139	-0.094	0.073	25	0.000	0.000	26	-0.094	0.198
Infant mortality	Secondary	2	63440	-0.195	0.045	1	0.000	0.000	2	-0.195	0.001
Low birthweight births (< 2500g)^***	Secondary	8	17785	-0.058	0.026	1	0.000	0.000	2	-0.060	0.108
NICU admission	Secondary	1	1033	-0.007	0.285	1	0.000	0.000	2	-0.018	0.825
Preterm birth (< 37 weeks)^***	Secondary	7	17670	-0.065	0.043	1	0.000	0.000	2	-0.068	0.087
Small for gestational age (SGA)^***	Secondary	2	1128	0.087	0.126	1	0.000	0.000	2	0.066	0.372
Very low birthweight birth (< 1500g)^***	Secondary	3	16139	-0.094	0.073	1	0.000	0.000	2	-0.094	0.198

Citations Used in the Meta-Analysis

Jewell, N.A., & Russell, K.M. (2000). Increasing access to prenatal care: an evaluation of Minority Health Coalitions' Early Pregnancy Project. Journal of Community Health Nursing, 17(2), 93-105.

Kothari, C.L., Zielinski, R., James, A., Charoth, R.M., & Sweezy, L.C. (2014). Improved birth weight for Black infants: outcomes of a Healthy Start program. American Journal of Public Health, 104(96).

Meghea, C.I., Raffo, J.E., Zhu, Q., & Roman, L. (2013). Medicaid home visitation and maternal and infant healthcare utilization. American Journal of Preventive Medicine, 45(4), 441-7.

Meghea, C.I., You, Z., Raffo, J., Leach, R.E., & Roman, L.A. (2015). Statewide Medicaid Enhanced Prenatal Care Programs and infant mortality. Pediatrics, 136(2), 334-42.

Redding, S., Conrey, E., Porter, K., Paulson, J., Hughes, K., & Redding, M. (2015). Pathways community care coordination in low birth weight prevention. Maternal and Child Health Journal, 19(3), 643-50.

Roman, L., Raffo, J.E., Zhu, Q., & Meghea, C.I. (2014). A statewide Medicaid enhanced prenatal care program: impact on birth outcomes. Jama Pediatrics, 168(3), 220-7.

Stabile, I., & Graham, M. (2000). Florida Panhandle Healthy Start: A randomized trial of prenatal home visitation. Head Start National Research Conference.

Villar, J., Farnot, U., Barros, F., Victora, C., Langer, A., & Belizan, J.M. (1992). A randomized trial of psychosocial support during high-risk pregnancies. The Latin American Network for Perinatal and Reproductive Research. The New England Journal of Medicine, 327(18), 1266-71.