Significance

This study clearly positions universal nurse home visiting in the early postpartum period as an important strategy for postpartum care for women and provides insights that can be utilized by other communities seeking to adopt and implement such a program.

Introduction

The postpartum period is a critical time for mothers, their infants, and families in general. Both mother and infant are in a time of transition and adaptation, with the risk of death highest for both mother and infant during this time (World Health Organization 2015). Newborns have unique needs related to sleep, body temperature and self-regulation, feeding and growth, and must reach important neurodevelopmental milestones to ensure normal development (Warren and Phillipi 2011). During this critical time, newborns are totally dependent on others in their environment, particularly their mothers, to successfully navigate these transitions and ensure their most basic needs are met.

During the early postpartum period, when infants’ needs are greatest, mothers must recover from childbirth while also adapting to their own physical, social, and psychological changes. Together with other members of her family, mothers must learn how to feed and care for their infants while getting little sleep and possibly experiencing pain. Postpartum women are also at risk of experiencing the “baby blues” or major postpartum depression (American College of Obstetricians and Gynecologists 2016). In addition, many women experience significant morbidity (e.g., diabetes, hypertension) during pregnancy, which often continues after delivery (Callaghan et al. 2012). In fact, in 2011–2013, 40% of pregnancy-related maternal deaths occurred in the early postpartum period (Creanga et al. 2017). Recent pregnancy also increases the risk of subsequent unintended pregnancy among women of reproductive age not using contraception (Fagan et al. 2009) with rates up to 44% in the first postpartum year (Chen et al. 2010). Adequate birth spacing is important for women’s and infant’s health, as pregnancies with an interpregnancy interval within 18 months of delivery have been associated with increased risk of preeclampsia, preterm birth, and low birth weight (Gemmill and Lindberg 2013).

Given the important tasks for women and infants during the postpartum period, early engagement with new mothers and their families is critical. However, while the infant health care schedule in the US begins with a visit two to 5 days after birth and continues monthly (Hagan et al. 2017) with high rates of attendance (Child and Adolescent Health Measurement Initiative 2016), mothers’ first postpartum visit is typically 4 to 6 weeks post-delivery (Stumbras et al. 2016). Estimates for postpartum visit non-attendance range from 11 to 50% (Bryant et al. 2006; Lu and Prentice 2002; Chu et al. 2007; Kabakian-Khasholian and Campbell 2005; D’Angelo et al. 2007; Weir et al. 2011; Masho et al. 2018). Among Medicaid-insured women in Illinois, fewer than 55% received a postpartum visit in 2013 (Illinois Department of Healthcare and Family Services 2016) within the specified interval as measured by HEDIS (between 21 and 56 days) (National Committee for Quality Assurance 2010). Importantly, however, in April 2018, the American College of Obstetricians and Gynecologists (ACOG) issued new guidance stating: “postpartum care should become an ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual needs. ACOG recommends that all women have contact with their obstetrician–gynecologists or other obstetric care providers within the first 3 weeks postpartum” (ACOG 2018, p. 949).

One approach to guarantee all families receive an early postpartum “touch” is a postpartum home visit. The World Health Organization (WHO) has recommended home visits for all women and infants in the first week postpartum (World Health Organization 2015), and in many Northern Western European nations, women and infants either receive a home visit shortly after birth, or can rest and receive support in maternity homes (Cheng et al. 2006). In contrast, in the US, home visiting is not routinely part of postpartum care, and home visiting programs are typically neither universal nor particularly focused on the perinatal period.

Illinois Family Connects (IFC) is a universal early postnatal home visiting program introduced in June 2017 by the Ounce of Prevention Fund (OPF) in two pilot counties in Illinois. IFC is based on Durham Family Connects (Dodge et al. 2013, 2014) and includes: offering a home visit to all mothers who have given birth, while still in the hospital; providing a nurse home visit at approximately 3 weeks postpartum to families that agree; utilizing a brief family risk assessment based on a Family Support Matrix; and, addressing identified needs, while in the home and/or through referrals to needed services in the community including to more comprehensive home visiting programs. The model is embedded in the community and implemented by a community-based “Lead Agency” working in conjunction with hospitals and community health and social service providers. The Family Connects model was developed by researchers focused on early childhood (Dodge et al. 2013, 2014). However, as the life course approach has brought various centers of the maternal and child health community together, early postnatal home visiting can also clearly be viewed as an important strategy for women’s health.

The aim of the current study is to explore the views of key informants with respect to the potential of universal nurse home visiting as a strategy to promote women’s health in the postpartum period. Specifically, this paper discusses the importance of a universal nurse home visit as part of women’s postpartum care, the appeal of an early postpartum nurse home visit, issues associated with women’s and family’s acceptance and completion of the nurse home visit, and the importance of marketing and engagement with providers during the prenatal period to the success of this approach. These insights and lessons can be utilized by other locales interested in universal nurse home visiting as a strategy for enhancing women’s and infant’s care after delivery.

The current study emerged out of a larger evaluation commissioned by OPF (note: the evaluators were given a 6-month contract to conduct this study to align with an Illinois policy window) to understand issues in the early implementation of the IFC universal nurse home visiting program in two Illinois sites. While some of the lessons presented in the current paper about universal home visiting in the care of postpartum women overlap with some implementation issues and challenges addressed in the larger study (Handler et al. 2018), addressing implementation challenges per se is not the main purpose of this paper.

Methods

This study relies on qualitative key informant (KI) interviews and a small amount of quantitative data extracted from reports from two IFC pilot counties to explore universal early postnatal home visiting as an innovative approach to ensuring that all women are “touched” in the postpartum period, a theme that emerged from an evaluation of the early implementation of IFC (Handler et al. 2018). The main study was conducted between December 2017 and May 2018 and was approved by the University of Illinois at Chicago (UIC) Institutional Review Board. For the main study, and the analysis for the current manuscript, the authors used the COREQ criteria to guide reporting of qualitative methods and findings.

Sample Identification and Recruitment

To identify key informants, OPF staff and the UIC research team met with the IFC Lead Agency (LA) Project Coordinators (PC) in each county via telephone. Each PC provided a list of key IFC staff, staff of participating IFC partner hospitals, and community stakeholders (e.g., members of local maternal/infant health agencies) involved in early implementation of IFC. The research team reviewed these lists to select a purposive sample of KIs to ensure multiple perspectives would be captured from each county. Specifically, the research team sought perspectives from a range of organizations (e.g., IFC LAs, IFC partner hospitals, other community partners) and IFC roles (e.g., IFC director, nurse home visitor, hospital OB administrator, representative from referral agencies). KIs were recruited via email to explain the purpose of the study and invite them to participate in an interview. The LA in County A identified 19 potential KIs. Due to resource limitations, the research team selected 10 individuals to contact; one did not respond to the invitation and the remaining nine participated in interviews. The LA in County B identified 23 potential KIs. Due to resource limitations, the research team selected 13 individuals to contact. Two potential KIs did not respond to the invitation, one declined due to lack of availability within the interview timeframe, and one declined due to limited knowledge about IFC; the remaining nine participated in interviews.

Data Collection

Nine KIs from each pilot site (n = 18, Table 1) were interviewed by phone by a member of the research team (AH, KZ, BD, CG), who all had prior experience and training in conducting qualitative interviews. The interviews, which took place over 4 weeks in January–February 2018, used a qualitative interview guide developed by the research team with input from OPF and Durham Family Connects, and were designed to evaluate the early implementation of IFC. The interviews were audio recorded and transcribed verbatim. The mean length of interviews was 34.2 min (Range 19–57 min).

Table 1 Illinois Family Connects early implementation key stakeholder interviews, demographics, and site and role information (n = 18)
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Data Analysis

After interviews were completed and transcribed, the research team used content analysis methods to analyze the interviews. All team members participated in developing an initial code list based on a review of transcripts by all team members, constructs of importance to OPF, and additional patterns observed in the data. Using the initial code list, two team members (KZ and CG) developed and refined code definitions using an iterative process in which transcripts were coded separately by both team members, followed by discussions of coding discrepancies. This process was repeated three times until agreement on code definitions was reached. The remaining transcripts were then double-coded by these two team members, who met to discuss and resolve discrepancies. Coding was facilitated by Dedoose Version 8.0, SocioCultural Research Consultants, LLC. Once the coding was complete, all transcribed verbiage was organized by code. All four team members then reviewed all verbiage associated with each code. The research team then reconvened to discuss patterns in the data and discern themes.

Although the delivery of postpartum care to women was not a focus of the KI interviews, the role of universal home visiting in supporting postpartum women’s health emerged. As such, the multiple themes presented below align with the following questions: (1) Why is universal nurse home visiting in the early postpartum period an important part of the health care delivery system for postpartum women? (2) Given its benefits for women’s postpartum health, why does universal nurse home visiting appeal to staff, postpartum women, and their families? (3) What factors affect acceptance and completion of the universal nurse home visit in the postpartum period? (4) What are community-based strategies to increase acceptance of and completion of the postpartum nurse home visit by women and families?

Additional Quantitative Data

In addition to the KI interviews, the authors had access to some basic quantitative data from IFC lead agency quarterly reports. These data provide some basic demographic information and early information on program reach.

Results

The results below are provided with respect to key questions that elucidate the potential for universal home visiting to be considered a postpartum strategy for women’s health and well-being, not just for infants.

Question #1: Why is Universal Nurse Home Visiting in the Early Postpartum Period an Important Part of the Health Care Delivery System for Postpartum Women?

As shown in the brief description of themes below and the associated quotes, KIs clearly noted that early postpartum universal nurse home visiting creates an opportunity for early intervention on a range of women’s health concerns.

Theme 1: Physical Health

Although KIs were not explicitly asked about the value of universal postpartum home visiting for women’s postpartum health, they expressed support for early home visiting as a strategy to reach women shortly after hospital discharge to identify medical issues requiring immediate attention or referral to an obstetrician or other medical or non-medical provider. The KIs appeared to acknowledge the importance of a postpartum home visit for women’s health in a climate in which early hospital discharge is the norm.

…we’ve caught some serious medical conditions on those home visits and made direct connections immediately for services that have helped the families avoid some very serious health complications. We had one who had postpartum preeclampsia. It was caught by the nurse, and the nurse made contact with the doctor. The woman was admitted immediately, and they were able to address it before there were anything more serious. (Lead Agency IFC Staff, County A)

Theme 2: Mental Health

Beyond serious medical issues and postpartum complications, KIs discussed the role of early postpartum home visiting in helping to identify and support women with postpartum depression, and the importance of women getting care for depression in the early postpartum period.

Because we’re seeing these women at three weeks postpartum versus six. And I sometimes think at six weeks these women are, I don’t want to say too far out, but at three weeks they’ve done a decent amount of referrals to [local counseling center]-… And at six weeks if we’re just seeing them it takes another maybe, two, three weeks to get them seen. So, they’ve not bonded with their baby for two additional weeks, where if they’re seeing somebody at three weeks and then they’re starting counseling that’s helping tremendously than waiting an additional month. (Hospital Staff, County B)

Theme 3: Breastfeeding Support

Finally, KIs identified that postpartum home visitors play an important role in assessing difficulties with breastfeeding, providing in-home support and lactation assistance, and providing referrals for additional support.

…their aim is to get in touch with these women in these instances early to provide early education, to assess these babies earlier than they may be assessed, to make sure mothers are getting postpartum depression screens earlier than they’re getting seen at their follow-up visits, to make sure that breastfeeding is going well, to make sure that they’re just doing well and that things are going in the right direction, and early intervention to things that are not going in the right direction so we can put resources in place to change the direction if we need to. (Hospital Staff, County B)

Question #2: Given its Benefits for Women’s Postpartum Health, Why Does Universal Nurse Home Visiting Appeal to Staff, Postpartum Women, and Their Families?

Theme 1: Universality Reduces Stigma

While the women served by IFC were not included in this study, KIs described their perceptions about families’ attitudes towards universal early postpartum home visiting. KIs frequently highlighted the universal aspect of this approach as one of its most appealing qualities. KIs indicated that they believed the universal nature of the program was one major reason staff support the program and women agree to participate.

So, this is the biggest benefit that we’ve seen from this program is that it’s universal, which is amazing because we obviously get, here at the health department, the higher risk, higher need population. But we’ve been able to identify and link families with services that we have and would not have come in contact with before had we not had the universal aspect of the program. (IFC Partner, County B)

Because this program is available to all postpartum women, it has the potential to reduce the stigma associated with programs for poor or other “at risk” populations. As a universal program, this approach can reach women not typically targeted by any public health and social service programs and ensure that women who are typically targeted by a variety of programs do not fall through the cracks.

I think we all recognize when they shifted home visiting to only being able to serve those below a certain income, they had very big concerns about those families that could have benefited from some additional follow-up but were eliminated from that opportunity because they made too much money. Once again, domestic violence, substance abuse, …developmental delay… they aren’t necessarily tied to income. So, I think being universal–plus, we also talked about the fact that it normalizes home visiting somewhat. Some of the stigma is not necessarily attached to it because it’s open to everybody. (Lead Agency IFC Staff, County A)

Theme 2: Services Provided by a Nurse

In addition to universality, according to the KIs, fundamental to acceptance of universal home visiting in the postpartum period is home visiting by a nurse. According to the KIs, when home visitors are nurses, they are viewed as having the skills, expertise, and authority to reassure women about their health and well-being and that of the infant. KIs perceived that postpartum home visits would be less appealing if they were not provided by qualified medical professionals.

I think just having medical personnel come in. Having a nurse. Usually medical professionals not just nurses are trusted, you know, have a good rapport with most patients so it’s nice having that peace of mind and having a medical professional come into assess your baby and answer your questions and I think it’s nice for moms and I think that makes it different from other home visiting programs. (Lead Agency IFC Staff, County A)

Question #3: What Factors Affect Acceptance and Completion of the Universal Nurse Home Visit in the Postpartum Period?

Theme 1: Acceptance of the Postpartum Home Visit: Family Factors

Acceptance—whether families agree to a postpartum home visit before discharge from the birth hospital—appears to be dependent on a variety of factors. KIs reported that in the hospital, families are generally receptive to an early nurse home visit, particularly if they have previously experienced home visiting, or once they learn more about the program. However, families may be less receptive if they already have children, have never received any services, or are confident about the postpartum/newborn experience.

We do have a lot of moms who say yes. Acceptance rate is pretty high…most moms who have already been exposed to some kind of home visiting or some kind of assistance, they always say yes. Some of the moms that are a little bit more skeptical may be that population that we have trouble reaching are you know, moms who…already had other children, or like I said they’ve never been offered any services, they’ve never heard about this their whole pregnancy so they’re kind of skeptical of who we are and what is this all about. (Lead Agency IFC Staff, County A)

Interviewees also indicated that other family members in the room may be supportive or hesitant about postpartum home visiting; KIs in both counties reported the need to adapt in-hospital recruitment and communication accordingly for the situation.

I’ve found that typically if like a grandma is in the room…a lot of them have commented on like, “Oh, that’s such a neat program,” or, “Oh, I wish I had that when I had you…” The fathers might be a little bit more leery about it, but I just kinda go with the flow of what mom says… (Lead Agency IFC Staff, County B)

Theme 2: Acceptance of the Postpartum Home Visit: Hospital and Lead Agency Factors

In addition to family factors, women’s acceptance of the postpartum home visit when approached before discharge from the birth hospital also depends on hospital and LA factors. While hospital processes differed, KIs in both counties discussed the need to ensure hospital staff understand the purpose and value of universal home visiting, are appropriately trained on postpartum home visiting recruitment processes to facilitate patient contacts and remain aware of these processes over time. In addition, KIs from both LAs discussed the importance of recruiting sufficient numbers of qualified staff for the agency coordinating the postpartum universal home visiting program.

…really involving the staff at [County B Hospital] to understand the programs and see the value and the benefit so that they could begin talking it to patients very early on. That—I believe—has increased patient buy-in. (Hospital Staff, County B)

Theme 3: Factors in Completion of the Postpartum Home Visit

While acceptance of the postpartum home visit in the hospital is essential, completion of the visit once women and their infants are home is critical to the success of a universal postpartum home visiting program. During the first year of implementation across both counties participating in the IFC universal home visiting program, postpartum home visits were provided to 559 families in the two counties out of 1150 postpartum women visited in the two hospitals. Importantly, women and families served by home visits for the most part appeared to reflect the diverse socioeconomic, racial/ethnic, and educational profile of their communities (with some over- and under- representation described directly below), as intended in a universal program. Among new mothers served in this pilot universal postpartum home visiting program, over half were Medicaid recipients, the majority were non-Hispanic White (56%) or non-Hispanic Black (24%), a large proportion had some post-secondary education (61%), and half were married. Few participants were adolescents (3%) (Table 2).

Table 2 Demographic characteristics of mothers served by Illinois Family Connects across two pilot counties (n = 545)
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KIs had multiple hypotheses regarding why women and families might agree to a nurse home visit in the hospital but fail to answer the door once home. These reasons included lack of time, feeling like the visit is not necessary, moving out of the area after childbirth, and having to return to work.

Families are really busy. They’ve got a lot going on. Sometimes they literally just forget about the visit and then you show up and their like, “I’m not gonna answer the door”. And then I think sometimes they even feel bad about that but instead of scheduling at a convenient time for them, they just kind of string you along for a little bit too. So, I think moms are just pressed for time. (Lead Agency IFC Staff, County A)

Theme 4: Completion of the Postpartum Home Visit: Strategies Utilized

KIs from both counties described multiple approaches used to increase postpartum home visit completion including making multiple attempts to reach women. Additional strategies included postcard or phone call reminders and showing up without a reminder in hopes of catching the mother and infant at home.

…if somebody’s not there or somebody doesn’t answer the door the first time, and yes, we might put a door hanger up or make a follow-up phone call, but we’re not gonna stop right away. I think there are so many barriers and things that can happen early on after mom comes home, and baby comes home from the hospital that it’s worth us taking a second or third attempt to connect with families. Obviously, after they tell us no, they verbally told us no, but if they’re a no-show or no answer, we continue to either follow-up with letters, drop by visits, and things like that so that we can get the visit done. (Lead Agency IFC Staff, County B)

Question #4: What are Community-Wide Strategies to Increase Acceptance of and Completion of the Postpartum Nurse Home Visit by Women and Families?

Theme 1: Community Marketing

KIs from both counties stressed the need for communication and marketing of universal postpartum home visiting both prior to the launch of such a program and during early implementation to increase awareness about the program and garner support. KIs stressed that these activities should not occur in isolation but should be built upon existing community and medical system relationships.

In the beginning, it was the media kickoff. After that, because we’re a small community that’s not a direct media market, a lot of things are word of mouth, and being connected at the hospitals, working with the nurses and the medical professionals throughout both medical communities to make sure that they understand that we’re there, and available, and educating them, and working with them, and sort of being seamlessly a part of their system. (Lead Agency IFC Staff, County B)

Theme 2: Prenatal Provider Outreach

While KIs were generally pleased with family acceptance of the home visit while in the hospital, several recommended expanding outreach to increase awareness about postpartum home visiting prior to delivery. KIs recommended engagement of health providers and other agencies that interact with families during the prenatal period to increase families’ awareness about postpartum home visiting and therefore acceptance of the program before discharge from the hospital.

…to me success would be having better relationships with the OB providers…because that’s who they go to when the need something, a lot of these moms and if they start finding out about us before and it becomes like, “oh this is something normal, we do this with all of our patients,” it’s gonna be more accepted within the community, more welcomed. And I feel like if we can get to that point where we get those moms their like, “Oh yeah, my doctor talked about this in the office…they said this was great. We definitely want to do this.” Getting recommendations, because I think that’s gonna help with more acceptance rate… (Lead Agency IFC Staff, County A)

Discussion

The postpartum period is a critical part of the reproductive and perinatal health continuum, and postpartum care provides the crucial link between prenatal care/labor and delivery, and well-woman and interconception care (for women who become pregnant again). With increasing understanding of the importance of postpartum care, there has been a concerted effort to explore and adopt new approaches to its delivery. While in the US, early postpartum home visiting has often been primarily perceived as a strategy to ensure infant or early childhood health and well-being, beginning with programs in the late 1800s (Abbott and Elliott 2016) to current programs such as The Welcome Home Baby Program (Kent County, MI) and Welcome Babies Program (LA County, CA) (Finello et al. 2016), early home visiting has also clearly been viewed as playing a role in supporting the health and well-being of postpartum women. However, this aspect of early home visiting has not been as prominent in home visiting discourse. As such, this study provides information about the early implementation of a pilot universal early postpartum nurse home visiting program, which can be utilized by other communities and states interested in adding a universal home visit as part of their approach to improving postpartum women’s health.

This study only includes evidence gleaned from two universal postpartum home visiting pilot communities in one state; however, by including 18 KIs offering a range of stakeholder views, important perspectives and lessons are revealed. The data presented, although not based on interviews with women served, suggest that the success of a universal postpartum nurse home visiting program likely depends on: the value women, families, and community stakeholders attach to the program; the appeal of its universality and the support for home visiting by nurses in particular; the processes adopted by the hospitals and agencies implementing the program; strategies for engaging women after leaving the hospital; and, the initial and ongoing marketing of the program, all of which ultimately may affect women’s willingness to participate.

Based on the two pilot counties participating in the particular universal home visiting program on which this paper is based, the Illinois Family Connects program, it appears that a universal nurse home visit program has appeal across race/ethnicity and class. Because attendance at the women’s postpartum visit is not consistently as high as attendance at newborn well-child visits (Illinois Department of Healthcare and Family Services 2016; Child and Adolescent Health Measurement Initiative 2016), by reducing stigma, a universal postpartum approach has great potential for reaching both women who do not think of themselves as particularly vulnerable and women typically targeted by programs but often considered “hard-to-reach.” As such, the potential for reducing disparities in maternal and infant outcomes is significant. On the other hand, if uptake is greater in “low-risk” women given the need for more extensive efforts to “touch” hard-to-reach women, disparities in postpartum outcomes will possibly increase, a potential downside to a program with a universal approach that fails to achieve universal uptake (Rowley and Hogan 2012).

Extensive reviews of home visiting programs have demonstrated positive support for several models focused on outcomes such as children’s cognitive and socio-emotional development, child maltreatment, children’s health status, parenting behaviors, and mother’s employment and receipt of public benefits (Avellar and Supplee 2013; Peacock et al. 2013; Sweet and Appelbaum 2004), and for children’s early and long-term academic success (Olds et al. 2004, 2007; Kitzman et al. 2010). While many home visiting programs provide home visits over an extended period of an infant or young child’s life, a smaller subset of home visiting programs concentrate on home visiting in the early postpartum period, typically with a primary focus on the health and well-being of infants. Durham Connects, a universal nurse home visiting program, is the most well-known of the latter, and has been extensively evaluated (Dodge et al. 2013, 2014), demonstrating multiple positive effects. Based on both Durham Connects and an earlier universal home visiting program in Massachusetts (MA), a newer program, Welcome Family, has been piloted in several MA communities including Boston (Stetler et al. 2017). Although further along in implementation than IFC, Stetler et al. recently described similar issues and lessons as provided here. However, while labeled as a universal postpartum nurse home visiting program by Stetler et al. the authors do not explicitly articulate the role of Welcome Family as a women’s postpartum health strategy. Rather in the one published article on Welcome Family, this home visit is seen a way to “enhance… early childhood systems of care” (Stetler et al. 2017, p. 12).

Importantly, universal early postpartum home visiting is not a substitute for a woman’s visit with a medical provider. Rather, a home visit assures that all postpartum women will have their needs assessed by a nurse who can provide immediate care and support, and appropriately triage and refer to both medical and social services. For a universal home visiting program to have a significant impact on women’s health outcomes in particular, the home visit must be part of the reproductive and perinatal continuum of care (Handler and Johnson 2016) in which prenatal, postpartum, and well-woman care are linked, providers are aware and support women’s receipt of home visits, and women have an identified medical home which ensures continuity of care. In data not presented, one of the two pilot IFC sites provided more medical referrals, while the other more frequently referred women to social services. The reasons for this difference are not clear and may be a function of population differences between the two counties, staff familiarity with non-medical resources available to families in the two communities, and women’s lack of connectedness to a medical care home in one county versus the other. For a universal postpartum home visiting program to be successful, endorsement by and support for the program from all community sectors, particularly the health care sector, is vital to encourage all families to participate.

This study has several limitations including the issue of external validity mentioned above. In addition, this exploration was conducted during the very early implementation of one universal postpartum home visiting program in two Illinois counties, when program processes where still being developed. The brief timeframe for completion of the study did not allow us to conduct simultaneous interviews and analyses. Thus, we were unable to explore themes emergent from early interviews in greater depth. Also, neither of the pilot sites is located in a large metropolitan area and as such, the challenges of implementation of universal early postpartum home visiting in a multiple hospital, large urban setting are not considered. Most importantly, this study does not include the voices of women and families who experienced universal postpartum home visiting. Despite these limitations, this study examines serendipitous findings that emerged from the early implementation of a model universal postpartum home visiting program that has been previously tested in a randomized controlled trial and is now implemented in 10 states with 28 sites.

Finally, this study was implemented by an evaluation team with a maternal/women’s health public health orientation at the request of a major not-for-profit organization focused on early childhood. While the ultimate goals of the early childhood and maternal and child health communities are the same, the two operate utilizing different paradigms, target outcomes, and separate funding streams. Given the importance of the postpartum period for both maternal and infant outcomes, universal early nurse home visiting should be viewed not only as an early childhood program but an important strategy for improving the delivery of postpartum care for women.

Conclusion

Universal nurse home visiting in the early postpartum period is an important strategy not only as the first touch in the early childhood delivery system but as an essential component of healthcare for women in the postpartum period. For many postpartum women, the need to take their newborn to well-baby visits often supersedes the need to return for their own care and thus their own care is often neglected. Universal nurse home visiting can provide the essential link to the health care delivery system in the postpartum period for the woman while simultaneously linking the woman, her infant, and her family to a variety of additional services and programs including more long-term home visiting. As new approaches to the delivery of women’s postpartum care have been championed by both WHO and ACOG, adding the universal home visit in the early postpartum period to the variety of strategies that states and localities might consider is timely and relevant.