A Healthy Start Begins at Home

At 20 months, Eddy Duarte is a whirlwind of energy and opposition.

His mother, 18-year-old Jessica Duarte, tries to busy him with crayons and paper during a recent afternoon in the cramped apartment Duarte shares with her child and mother on West 93rd Street. Eddy scribbles for a few seconds, then tosses the paper and crayons aside. Duarte sighs.

So when Monica Nunez walks through the door, cheerful and carrying a bulging briefcase, Duarte appears grateful and a little relieved. Nunez, a public health nurse employed by the county, has been Duarte’s friend and supporter since the unmarried teenager walked into the maternal health clinic at California Medical Center in 1998, five months pregnant, poor, alone and afraid.

On that day, Duarte was paired with Nunez in a small home-visitation program designed to help first-time pregnant teens have healthy babies and develop skills to keep their families thriving. Today, Eddy is healthy and happy in a calm and loving home while Duarte closes in on her goal of graduating from high school and getting a job.

The success of Duarte and other teens in the home-visitation pilot program, called the Esperanza Project, recently helped convince Los Angeles County to spend $18.7 million to expand the project. Over the next year, 1,000 pregnant teens will be enrolled countywide--up from 100 in the 1998 project. The expansion is being financed, in part, from funds that the county has accrued since welfare rolls began to decline.

“We know this program works,” says Dr. Jonathan E. Fielding, director of public health and health officer for the county, who has championed the expansion. “A young mother has to have hope and see herself as a productive person who can provide for herself and her child.”

Home-visitation programs in which a nurse or trained professional has regular contact with a young mother have been touted by health experts for almost two decades as a tool to improve infant health and give babies in disadvantaged homes a healthy start in life.

However, the specific program adopted by Los Angeles County has distinguished itself as the most effective among home-visitation models, some of which have not produced evidence of lasting benefits, according to several studies published over the past decade. The program, called Prenatal and Infancy Nurse Home Visitation, was developed by University of Colorado pediatrics professor David L. Olds, and was first tested in Elmira, N.Y., and Memphis, Tenn.

Based on 15 years of studies on a group of 400 white teenage girls in Elmira, Olds’ program was found to improve infant health, reduce child abuse and lessen the mothers’ dependence on welfare.

And, last month, Olds published a study in the Journal of the American Medical Assn. attesting to similar effectiveness when the program was offered to black urban teenagers.

‘She Was There When

I Needed Someone’

The experts’ opinions, however, are of little interest to Jessica Duarte. She knows only that Monica Nunez is a godsend.

“It was only me and my mom at first, and we were alone,” says Duarte, handing a picture book to Eddy. “My mom had just found out I was pregnant and I was scared about whether she would help me out. Monica helped me a lot. She was there when I needed someone to talk to. She understood me.”

Nunez provided such practical support as bringing the young mother some baby clothes and a thermometer to check Eddy’s temperature when he was sick, Duarte says. And, during the baby’s infancy, Nunez taught her techniques for dealing with Eddy’s severe colic, which resulted in hours of fussing.

“Sometimes, he throws himself on the ground crying, and it ticks me off,” says Duarte. “I ask Monica what I should do, and she tells me some things I can try.”

According to the program’s protocol, the nurse visits weekly for six weeks after the birth, biweekly through the baby’s 21st month and then monthly until the program concludes when the child is 2.

During pregnancy, the nurse encourages the teen to keep her prenatal visits, adopt a healthy diet, and stop smoking, if necessary, according to Olds’ protocol. After the birth, the visits concentrate on encouraging breast-feeding and teaching practical infant care techniques, such as diapering, bathing and swaddling the baby. A schedule is kept to ensure that all routine pediatrician visits are maintained.

The nurse and teen mom also complete program questionnaires designed to ensure a safe home for the baby (such as covering electrical outlets with safety plugs), and that effective and appropriate techniques are used for disciplining a toddler. Considerable time is also spent discussing the mother’s goals for herself.

“What made it easy with Jessica is that she was receptive,” says Nunez. “She was eager to learn.”

That is not always the case, say Nunez and other public health nurses working in the Esperanza Project.

“When this program started, I was really excited. I felt like, ‘Let me go into these homes and change their whole lives,’ ” Nunez recalls, sitting in her office at California Medical Center one recent afternoon. “Well, that was a slap in my face. It was so tough. Change isn’t easy for these teen moms.”

Nunez found teens who had no means of transportation to get to their prenatal care visits.

She found girls eating little but junk food.

She found her advice colliding with cultural values. For example, the program emphasizes breast-feeding to improve infant health and promote mother-baby bonding. But many Latina teens in the pilot program rejected breast-feeding, partly due to feelings of modesty and reluctance to uncover the breast.

And, after having the baby, the mothers faced huge obstacles finding child care in order to resume school or get a job. Many of the teen moms also have low literacy skills, making it tough to find resources that they can use, says Vanessa Burgos, another nurse who has worked in the program for two years.

“There is a lack of resources in Spanish. And then to translate it into a more basic Spanish is difficult,” she says of the Latina clients in the pilot program. (The expanded program will include teen moms from various ethnic groups. The pilot program featured Latinas in the Pico-Union district.) “It’s also hard to keep them focused. Sometimes we’re [at the home] and they’re not there. And they move around a lot. That gets hard--tracking them down.”

Sometimes, the nurses encounter resistance or conflicting advice from the teenager’s mother.

“We often have to try and break through grandma’s myths and beliefs” to convince the teenager to adopt a different approach, such as putting the baby in child care to return to school, when the cultural tradition is for the mother to remain at home with her baby, Nunez says. “It’s even tough showing them things like how to play with their babies, how to touch them, how to read to them.”

Duarte agrees. She didn’t have a clue on what to do when Eddy was born.

“When they gave me him in the hospital, I was afraid to hold him,” she says, with the wry smile of a now-veteran mother. “I thought he would fall.”

Another tough task is convincing the teenagers to adopt some method of contraception to prevent a second pregnancy, which greatly reduces a single mother’s chances of becoming economically self-sufficient. But, of Nunez’s 30 clients in the pilot program, only one became pregnant again. The 40 public health nurses in L.A.’s expanded program will each have about 25 clients.

Progress Is Slow but Program Seems to Pay Off

The slow, tedious work by the nurses and the teen moms eventually pays off, Olds says.

“The progress is small and incremental,” he says. “On a week-to-week basis, you rarely see change. But when you are dealing with families under extreme stress, sometimes holding ground is progress. And without help those families would be deteriorating over time.”

But there are heartening success stories. Nurse Armida Enriquez has seen one of her original teen moms graduate, despite a very difficult delivery and postpartum recovery, and go on to college. Although the program is occasionally successful in convincing teens to finish high school, very few choose, or are able, to pursue college immediately after graduating.

“She breast-fed and pumped her breast milk and left bottles for the baby when she went to high school,” says Enriquez, because she thought breast milk was better for the baby. Olds believes the program works well because it uses registered nurses, who are viewed with respect and credibility by the teen moms. It also pairs the nurse and client during pregnancy and uses a detailed curricula to guide the nurses on what should be accomplished at each visit.

And a good start in life appears to have staying power. Although the teenagers and nurses say goodbye when the baby is 2, Olds’ studies show that adolescents who were babies in the home-visitation programs have fewer behavior problems, such as running away, arrests, multiple sex partners, smoking and the use of alcohol and drugs, compared with a similar group of youths who were not in the program.

A cost analysis shows the program also appears to save government money, primarily by reducing welfare costs.

But the best advertisement of its value may be that the teen mothers stay in the program.

“They wouldn’t stick with the program if it wasn’t working,” Nunez says. “It helps them become more self-sufficient and to believe in themselves.”

Duarte is eyeing that self-sufficiency goal. Last year, she returned to school and will soon earn her general equivalency diploma.

“I’m looking forward to the day when I can say that I have a job,” she says. “To be honest, I used to think I would never get ahead; that I was stuck with a kid and would never get ahead.”

On one of their final visits together, Nunez also tells Duarte about Early Head Start, a child-care program for children under 3. The program will benefit Eddy and give Duarte’s mother, Adilia Martinez, a break from child-care duties while Duarte is at school or work. Nunez’s feelings for the family are obvious as she hugs Duarte and Martinez and kisses Eddy on her way out the door.

“I feel sad that the visits will be ending soon because we have bonded,” Nunez says. “But I’m happy for Jessica because she’s where she wants to be.”

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

Benefits of Home Visits

Studies over 15 years show that the Prenatal and Infancy Nurse Home Visitation program results in healthier babies and more economically self-sufficient families. Although home visits by a nurse end when the baby is 2, long-term data show benefits that extend into adolescence.

When compared with similar families that did not receive services, home-visitation families had:

* 30 fewer months on welfare.

* 27 months’ greater spacing between first and second births.

* 33% fewer subsequent births.

* 81% fewer arrests and convictions (among teen mothers).

* 79% fewer verified cases of child abuse and neglect.

Among adolescents who were babies in the program, there were:

* 60% fewer instances of running away.

* 56% fewer arrests.

* 81% fewer convictions or violations of probation.

Source: Journal of the American Medical Assn.