Nurse Family Partnership

Public Health & Prevention: Home- or Family-based
Benefit-cost methods last updated December 2023. Literature review updated March 2018.

The Nurse Family Partnership program provides intensive visitation by nurses during a woman’s pregnancy and the first two years after birth. The program is designed to serve low-income, at-risk pregnant women expecting their first child. The goal is to promote the child's development and provide support and instructive parenting skills to parents. Among programs included in the meta-analysis, participants received 25–35 home visits on average, spread over approximately two years.

ALL	BENEFIT-COST	META-ANALYSIS	CITATIONS

For an overview of WSIPP's Benefit-Cost Model, please see this guide. The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2022). 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	$5,061	Benefits minus costs	$6,570
Participants	$13,270	Benefit to cost ratio	$1.47
Others	$983	Chance the program will produce
Indirect	$1,181	benefits greater than the costs	65%
Total benefits	$20,495
Net program cost	($13,925)
Benefits minus cost	$6,570

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

^{^^}WSIPP does not include this outcome when conducting benefit-cost analysis for this program.

^***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. See Estimating Program Effects Using Effect Sizes for additional information.

**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	Treatment age	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
Crime Any criminal conviction according to court records, sometimes measured through charges, arrests, incarceration, or self-report.	19	Primary	2	229	-0.106	0.080	31	-0.106	0.080	41	-0.463	0.092
Major depressive disorder Clinical diagnosis of major depression or symptoms measured on a validated scale.	19	Primary	1	192	0.025	0.116	37	0.013	0.142	39	0.069	0.711
Employment Any employment, including part-time work.	19	Primary	3	426	0.019	0.062	27	0.000	0.000	28	0.078	0.405
Public assistance Any form of welfare assistance, such as Temporary Assistance for Needy Families (TANF) or Assistance for Families with Dependent Children (AFDC).	19	Primary	3	456	-0.036	0.060	30	-0.036	0.060	30	-0.153	0.176
Food assistance Receipt of food assistance, such as from the Supplemental Nutrition Assistance Program (SNAP).	19	Primary	3	450	-0.031	0.060	30	-0.031	0.060	30	-0.130	0.264
Anxiety disorder Clinical diagnosis of an anxiety disorder (e.g., general anxiety, panic, social anxiety, obsessive compulsive disorder) or symptoms measured on a validated scale.	19	Primary	1	192	-0.013	0.116	37	-0.007	0.142	39	-0.037	0.833
Crime Any criminal conviction according to court records, sometimes measured through charges, arrests, incarceration, or self-report.	1	Secondary	2	232	-0.032	0.080	18	-0.032	0.080	28	-0.119	0.320
K-12 grade repetition Repeating a grade. This is sometimes called "grade retention."	1	Secondary	3	367	0.051	0.094	11	0.051	0.094	11	0.127	0.317
K-12 special education Placement into special education services.	1	Secondary	3	367	0.031	0.111	11	0.031	0.111	11	0.046	0.820
Alcohol use before end of middle school Any use of alcohol by the end of middle school, typically by age 13.	1	Secondary	1	191	-0.114	0.087	13	-0.114	0.087	13	-0.317	0.001
Child abuse and neglect Substantiated or founded reports to child protective services.	1	Secondary	2	206	-0.353	0.141	6	-0.353	0.141	17	-0.620	0.010
Out-of-home placement The removal of a child from parental care, most often to foster care.	1	Secondary	1	191	0.147	0.116	13	0.147	0.116	17	0.408	0.001
Low birthweight birth^*** Infant is born with a birth weight less than 2,500 grams.	1	Secondary	3	9617	0.021	0.022	1	0.000	0.000	2	0.022	0.325
Very low birthweight birth^*** Infant is born weighing less than 1,500 grams.	1	Secondary	2	9162	-0.040	0.045	1	0.000	0.000	2	-0.040	0.373
Infant mortality Infant death within 12 months after birth.	1	Secondary	2	8815	-0.130	0.118	1	0.000	0.000	2	-0.143	0.170
High school graduation^{^^} On-time completion of high school with a diploma (excluding GED attainment).	19	Primary	2	401	0.035	0.086	23	0.035	0.086	23	0.096	0.271
Substance use disorder^{^} A non-specified alcohol or drug use disorder. Typically, a collection of different types of disorders reported by study authors.	19	Primary	1	183	0.013	0.119	37	n/a	n/a	n/a	0.035	0.831
Cannabis use^{^} Adult use of cannabis that does not rise to the level of “disordered.”	19	Primary	2	401	-0.061	0.108	23	n/a	n/a	n/a	-0.168	0.134
Alcohol use^{^} Adult use of alcohol that does not rise to the level of “problem” or “disordered.”	19	Primary	2	9162	0.088	0.214	23	0.088	0.214	33	0.264	0.186
Low birthweight birth^*** Infant is born with a birth weight less than 2,500 grams.	19	Primary	3	9617	0.021	0.022	19	0.000	0.000	20	0.022	0.325
Preterm birth^*** Infant is born at less than 37 weeks gestation.	19	Primary	3	9162	0.021	0.027	19	0.000	0.000	20	0.001	0.990
Very low birthweight birth^*** Infant is born weighing less than 1,500 grams.	19	Primary	1	9162	0.000	0.081	19	0.000	0.000	20	0.000	0.990
Very low birthweight birth^*** Infant is born weighing less than 1,500 grams.	19	Primary	2	9162	-0.040	0.045	19	0.000	0.000	20	-0.040	0.373
Substance use^{^} Nonspecified substance use (i.e., alcohol, cannabis, or illicit drugs) that does not rise to the level of "disordered."	19	Primary	2	266	-0.049	0.094	31	n/a	n/a	n/a	-0.237	0.215
Smoking during late pregnancy^{^} Any smoking after 32 weeks gestation.	19	Primary	1	237	-0.099	0.114	19	n/a	n/a	n/a	-0.099	0.386
High school graduation On-time completion of high school with a diploma (excluding GED attainment).	1	Secondary	2	226	0.023	0.107	18	0.023	0.107	18	0.051	0.682
Test scores Standardized, validated tests of academic achievement.	1	Secondary	3	370	0.026	0.066	14	0.023	0.073	17	0.060	0.492
Smoking before end of middle school Any smoking of tobacco by the end of middle school, typically by age 13.	1	Secondary	1	191	-0.075	0.087	13	-0.075	0.087	13	-0.208	0.018
Cannabis use before end of middle school Any use of cannabis by the end of middle school, typically by age 13.	1	Secondary	1	191	-0.114	0.087	13	-0.114	0.087	13	-0.317	0.001
Substance use disorder^{^} A non-specified alcohol or drug use disorder. Typically, a collection of different types of disorders reported by study authors.	1	Secondary	1	194	0.045	0.115	19	n/a	n/a	n/a	0.126	0.274
Attention-deficit/hyperactivity disorder symptoms Clinical diagnosis of attention-deficit/hyperactivity disorder (ADHD) or symptoms measured on a validated scale.	1	Secondary	1	166	-0.094	0.142	10	0.000	0.141	11	-0.260	0.068
Externalizing behavior symptoms Symptoms of externalizing behavior (e.g., aggressive, hostile, or disruptive behavior) measured on a validated scale.	1	Secondary	2	319	0.010	0.094	15	0.005	0.049	18	-0.065	0.676
Internalizing symptoms Symptoms of internalizing behavior (e.g., sadness, anxiety, or withdrawal) measured on a validated scale.	1	Secondary	2	332	-0.048	0.092	15	-0.048	0.092	17	-0.174	0.127
Hospitalization^{^^} Hospital admission, for any reason.	1	Secondary	2	5232	0.038	0.021	4	n/a	n/a	n/a	-0.018	0.832
Alcohol use before end of high school^{^^} Any use of alcohol by the end of high school, typically between ages 14 and 18.	1	Secondary	1	38	-0.162	0.206	16	n/a	n/a	n/a	-0.450	0.031
Smoking before end of high school^{^^} Any smoking of tobacco by the end of high school, typically between ages 14 and 18.	1	Secondary	1	38	-0.122	0.206	16	n/a	n/a	n/a	-0.339	0.102
Illicit drug use before end of high school^{^^} Any use of illicit drugs by the end of high school, typically between ages 14 to 18. When possible, we exclude cannabis/marijuana use disorder from this outcome.	1	Secondary	1	38	-0.087	0.206	16	n/a	n/a	n/a	-0.242	0.242
Emergency department visits^{^} Whether someone visited the emergency department, or the number of times they visited the emergency department.	1	Secondary	1	216	-0.010	0.105	3	n/a	n/a	n/a	-0.027	0.796
Small for gestational age (SGA)^{***^} Infants with birthweight at or below the 10th percentile compared with infants of the same gestational age.	1	Secondary	1	455	0.000	0.081	1	0.000	0.000	2	0.000	1.000
Preterm birth^*** Infant is born at less than 37 weeks gestation.	1	Secondary	3	9617	0.021	0.027	1	0.000	0.000	2	0.001	0.990
Very preterm birth^{^} Infant is born at less than 32 weeks gestation.	1	Secondary	1	8598	-0.135	0.079	1	n/a	n/a	n/a	-0.135	0.087
NICU admission Infant is admitted to a neonatal intensive care unit (NICU).	1	Secondary	1	564	-0.016	0.056	1	0.000	0.000	2	-0.016	0.781
Substance use^{^} Nonspecified substance use (i.e., alcohol, cannabis, or illicit drugs) that does not rise to the level of "disordered."	1	Secondary	1	194	0.013	0.115	19	n/a	n/a	n/a	0.035	0.752
Preschool test scores^{^} Measures of cognition in young children on standardized scales.	1	Secondary	2	394	0.043	0.065	5	n/a	n/a	n/a	0.120	0.086
Click to expand													Click to collapse

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.
Affected outcome:	Resulting benefits:¹	Benefits accrue to:
Detailed Monetary Benefit Estimates Per Participant
		Taxpayers	Participants	Others²	Indirect³	Total

Crime	Criminal justice system	$218	$0	$359	$109	$686

Public assistance	Public assistance	$465	($170)	$0	$232	$527

Employment	Labor market earnings	$463	$1,091	$0	$0	$1,555

Major depressive disorder	Health care associated with major depression	($56)	($16)	($58)	($28)	($158)
Major depressive disorder	Mortality associated with depression	$0	$0	$0	($5)	($5)

Anxiety disorder	Health care associated with anxiety disorder	$29	$8	$29	$14	$80

Food assistance	Food assistance	$147	($130)	$0	$74	$91

	Subtotals	$1,265	$783	$331	$396	$2,775
From secondary participant

Crime	Criminal justice system	$307	$0	$650	$153	$1,111

Child abuse and neglect	Child abuse and neglect	$163	$1,807	$0	$81	$2,051
Child abuse and neglect	Labor market earnings associated with child abuse & neglect	$4,070	$9,588	$0	$0	$13,659

K-12 grade repetition	K-12 grade repetition	($84)	$0	$0	($42)	($126)

K-12 special education	K-12 special education	($969)	$0	$0	($485)	($1,454)

Out-of-home placement	Out-of-home placement	($189)	$0	$0	($95)	($284)

Alcohol use before end of middle school	Property loss associated with alcohol abuse or dependence	$0	$1	$2	$0	$3

Low birthweight birth	Health care associated with low birthweight births	($71)	$0	$0	($36)	($107)

Very low birthweight birth	Health care associated with very low birthweight births	$107	$0	$0	$54	$161

Infant mortality	Infant mortality	$463	$1,090	$0	$8,115	$9,668

	Subtotals	$3,796	$12,487	$652	$7,747	$24,682

Program cost	Adjustment for deadweight cost of program	$0	$0	$0	($6,962)	($6,962)

Totals		$5,061	$13,270	$983	$1,181	$20,495

Click here to see populations selected

Type	Selection
Populations - Primary
Crime	Low-income women Low-income women with or without prior criminal justice system involvement
Education	Low-income students Students from low-income families, typically those eligible for free or reduced-price lunch
Depression	General population All people
Anxiety	General population All people
Diabetes	General population All people
Earnings	Half dropouts, half graduates A mix of people who did not complete high school and who did complete high school
Maternal health	Medicaid population Women for whom Medicaid pays the medical costs for maternal care
Internalizing	General population All children

Type	Selection
Populations - Secondary
Crime	Low-income people All low-income people with or without prior ciminal justice system involvement
Education	Low-income students Students from low-income families, typically those eligible for free or reduced-price lunch
Child abuse & neglect	Low income Children from low-income families
OoHP	General population All children
Tobacco	General population All people
Alcohol	General population All people
Depression	General population All people
Anxiety	General population All people
ADHD	General population All people
Diabetes	General population All people
Hospitalization/Emergency Department	General population All people
Earnings	General population All people
Maternal health	Medicaid population Women for whom Medicaid pays the medical costs for maternal care

For more information on populations see the Technical Documentation

Annual cost		Year dollars	Summary
Detailed Annual Cost Estimates Per Participant
Program costs	$5,944	2015	Present value of net program costs (in 2022 dollars)	($13,925)
Comparison costs	$0	2015	Cost range (+ or -)	10%

Treatment cost estimates for this program reflect costs beyond treatment as usual. The annual per-participant cost estimate is based on average total cost per family in Washington State, provided by Siobhan Mahorter at the Nurse Family Partnership National Service Office, January 2017.

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.

Benefits Minus Costs

Benefits by Perspective

Taxpayer Benefits by Source of Value

Benefits Minus Costs Over Time (Cumulative 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 discounted dollars. 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.

Citations Used in the Meta-Analysis

Carabin, H., Cowan, L.D., Beebe, L.A., Skaggs, V.J., Thompson, D., & Agbangla, C. (2005). Does participation in a nurse visitation programme reduce the frequency of adverse perinatal outcomes in first-time mothers? Paediatric and Perinatal Epidemiology, 19(3), 194-205.

Holmes & Rutledge (2016). Evaluation of the Nurse Family Partnership in North Carolina. UNC Gillings School of Global Public Health.

Kitzman, H., Olds, D.L., Henderson Jr, C.R., Hanks, C., Cole, R., Tatelbaum, R., . . . Engelhardt, K. (1997). Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing: A randomized controlled trial. JAMA, 278(8), 644-652.

Kitzman, H.J., Olds, D.L., Cole, R.E., Hanks, C.A., Anson, E.A., Arcoleo, K.J., . . . Holmberg, J.R. (2010). Enduring effects of prenatal and infancy home visiting by nurses on children: Follow-up of a randomized trial among children at age 12 years. Archives of Pediatrics & Adolescent Medicine, 164(5), 412-418.

Matone, M., O'Reilly, A.L., Luan, X., Localio, A.R., & Rubin, D.M. (2012). Emergency department visits and hospitalizations for injuries among infants and children following statewide implementation of a home visitation model. Maternal and Child Health Journal, 16(9), 1754-61.

Mejdoubi, J., van, . H. S. C. C. M., van, L. F. J. M., Crone, M., Crijnen, A., HiraSing, R. A., & Special Sections: Focus on Infant Feeding and Postnatal Health and Well-being. (2014). Effects of nurse home visitation on cigarette smoking, pregnancy outcomes and breastfeeding: A randomized controlled trial. Midwifery, 30(6), 688-695.

Mejdoubi, J., van, . H. S. C. C. M., van, L. F. J. M., Heymans, M. W., Crijnen, A., Hirasing, R. A., & Carlo, W. A. (2015). The Effect of VoorZorg, the Dutch Nurse-Family Partnership, on Child Maltreatment and Development: A Randomized Controlled Trial. Plos One, 10(4).

Olds, D., Henderson, C.R., Cole, R., Eckenrode, J., Kitzman, H., Luckey, D. (1998). Long-term effects of nurse home visitation on children's criminal and antisocial behavior: 15-year follow-up of a randomized controlled trial. JAMA, 280(14), 1238-1244.

Olds, D.L., Eckenrode, J., Henderson, C.R., Jr., Kitzman, H., Powers, J., Cole, R., . . . Luckey, D. (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect: Fifteen-year follow-up of a randomized trial. JAMA, 278(8), 637-643.

Olds, D.L., Holmberg, J.R., Donelan-McCall, N., Luckey, D.W., Knudtson, M.D., & Robinson, J. (2014). Effects of home visits by paraprofessionals and by nurses on children: follow-up of a randomized trial at ages 6 and 9 years. JAMA Pediatrics, 168(2), 114-21.

Olds, D.L., Kitzman, H., Cole, R., Robinson, J., Sidora, K., Luckey, D.W., . . . Holmberg, J. (2004). Effects of nurse home- visiting on maternal life course and child development: Age 6 follow-up results of a randomized trial. Pediatrics, 114(6), 1550-1559.

Olds, D.L., Kitzman, H., Hanks, C., Cole, R., Anson, E., Sidora-Arcoleo, K., . . . Bondy, J. (2007). Effects of nurse home visiting on maternal and child functioning: Age-9 follow-up of a randomized trial. Pediatrics, 120(4), 832-845.

Olds, D.L., Kitzman, H., Knudtson, M., Cole, R., Miller, T., Fishbein, D., . . . Collins, E. (2016). Age-18 follow-up of home visiting intervention (Grant #R01DA021624).

Olds, D.L., Kitzman, H., Knudtson, M.D., Anson, E., Smith, J.A., & Cole, R. (2014). Effect of home visiting by nurses on maternal and child mortality: results of a 2-decade follow-up of a randomized clinical trial. JAMA Pediatrics, 168(9), 800-806.

Olds, D L., Kitzman, H.J., Cole, R.E., Hanks, C.A., Arcoleo, K.J., Anson, E.A., . . . Stevenson, A. (2010). Enduring effects of prenatal and infancy home visiting by nurses on maternal life course and government spending: Follow-up of a randomized trial among children at age 12 years. Archives of Pediatrics & Adolescent Medicine, 164(5), 419-424.

Olds, D.L., Robinson, J., O'Brien, R., Luckey, D.W., Pettitt, L.M., Henderson, C.R., Jr., . . . Talmi, A. (2002). Home visiting by paraprofessionals and by nurses: A randomized, controlled trial. Pediatrics, 110(3), 486-496.

Olds, D.L., Robinson, J., Pettitt, L., Luckey, D. W., Holmberg, J., Ng, R.K., . . . Henderson, C.R., Jr. (2004). Effects of home visits by paraprofessionals and by nurses: Age 4 follow-up results of a randomized trial. Pediatrics, 114(6), 1560-1568.

Rubin, D.M., O'Reilly, A.L., Luan, X., Dai, D., Localio, A.R., & Christian, C.W. (2011). Variation in pregnancy outcomes following statewide implementation of a prenatal home visitation program. Archives of Pediatrics & Adolescent Medicine, 165,(3), 198-204.

Nurse Family Partnership

Citations Used in the Meta-Analysis

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