Health & Science

In Philly, struggling new mothers get a lifeline from nurses making house calls

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This story was produced by MindSite News, an independent, nonprofit journalism site focused on mental health. Get a roundup of mental health news in your inbox by signing up for the MindSite News Daily newsletter here.

When Yarilette visited the emergency room in Fall of 2020, she couldn’t believe she might be pregnant. She was 19 years old, in her first year at community college, and living with a friend after an altercation with her mother led her to being kicked out the house. Soon, though, a doctor revealed the reality: Yarilette was nearing the end of her first trimester. 

She knew she wasn’t ready for a baby. So she did the only thing she could think of – working more hours at Burger King to save money. She also asked her mother if she could return home – without telling her why – and started collecting baby items and hiding them under her bed. 

Yarilette, who asked that her last name be withheld, put class registration for the next semester on pause and switched jobs from Burger King to Wendy’s to Five Guys, working long shifts and fighting through her depression. Six weeks after finding out she was pregnant, she felt faint and was hospitalized for three days due to dehydration. At 19 weeks, Yarilette felt that she couldn’t hide it anymore. She told her mother she was pregnant. At first, both of them were quiet. And then, into a tense silence, her mother asked the question: What are you going to do?

For Yarilette, the answer was clear: she’d do what she’d have to do. “This is my baby. I’m a mom. I have to get my stuff together,” she told herself. But really, the details of this declaration were vague, and she was asking herself: How will I get through this?

Born to a single teenage mother herself, Yarilette had moved to North Philadelphia from Puerto Rico as a child with the intent to break the cycle and achieve a larger dream for herself and her family. For as long as she could remember, Yarilette had been a first – the first-born daughter, the first in her family to graduate high school, the first to make it to college. Yet she feared the uncertainty that lay ahead, that her life would revert to some seemingly predestined and unavoidable path. 

“I wanted to take care of my baby. But I felt like, ‘I’m just a baby in a way, too – and I don’t know what I’m doing,’” said Yarilette. “I don’t want to be in the same cycle my family was.”

Yarilette booked an appointment with an OB/GYN, who agreed that she would need more help to ensure a healthy pregnancy. She recommended Philadelphia’s Nurse-Family Partnership, a program that connects low-income, first-time mothers with nurses that provide pre- and post-natal support. She joined the program at almost 28 weeks hoping to find a therapist, to learn new skills in supporting her baby’s development, and to find resources to help alleviate her stress associated with becoming a new mom.

High poverty, high stress

More than a third of Philadelphia’s kids – roughly 100,000 children, most of them Black and Latino – live in poverty in the poorest big city in the nation. That’s twice the national average. During pregnancy, their mothers are more likely to face stresses, like unstable housing, unemployment, absentee partners and high crime environments. 

They’re also more likely to endure premature birth, postpartum depression, and pregnancy complications that can lead to death. Prematurity and perinatal conditions were the leading causes of death among children in the city from 2011-2017, and homicide was the second. Black and Hispanic children are disproportionately impacted, accounting for the vast majority of all childhood deaths within the top 10 categories, including 96 percent of all homicides . Black women are also about four times more likely to die of pregnancy-related causes than white women in Philadelphia. 

Mental health challenges during pregnancy and postpartum, like depression and chronic stress, play a major adverse role in maternal health, infant development, and mother-infant bonding. 

Programs like the Nurse-Family Partnership program (NFP) are aimed at improving these outcomes for first-time, low-income mothers. Launched in the city in 2001, the free program pairs mothers with a nurse who visits them at home, starting in their second trimester of pregnancy. The nurse will continue visiting until the child turns 2, helping the mom nurture herself and her child, and building the bond between them.

Shukriyyah Mitchell Hinton is the senior director of advocacy and outreach at Philadelphia NFP. “Becoming a new parent is a daunting experience,” she told MindSite News. “Our nurses are essentially a constant in this ever-changing environment, for our clients and for their families.” 

Research conducted over time links the home-visiting program, founded in Elmira, New York in the 1970s, to a reduction in child abuse, improved school readiness for children, and increased employment for mothers. Over time, the program has even been linked to a decline in arrests of both mothers and children. 

“In a city like Philadelphia, where we’re plagued with violence and poverty, I think the benefit is pretty clear,” said Hinton. 

‘Phenomenal brain development’

The program aims to support mothers and infants at a uniquely critical moment. Catherine Monk, a Columbia University researcher who founded the school’s Perinatal Pathways Laboratory, describes pregnancy and the 12 months following a baby’s birth as “a central period of development” for babies, mothers, and their partners if they are present.

“They are developing psychologically, and anything changing psychologically is also happening biologically,” Monk told MindSite News. “We’re having phenomenal brain development happening in utero, as well as in the first three to five years of life. This is such a key point to optimize exposures and experiences for brain development, to get families on the right track, and potentially prevent adverse outcomes in the adjustment of the parent to the child, which then affects the child in the future.”

Monk says that new research shows it’s not just babies’ brains that are developing rapidly – the brains of mothers are also changing. “The new data is very exciting, about the plasticity of the parent’s brains, as they’re becoming a parent.” she said.

In providing this assistance at such a critical time – and having friendly, reliable people offering help and balancing the often intense stress of new mothers – the Nurse-Family Partnership program can change the trajectory of a child’s life, Monk said.

“When people have a lot of stress in their lives during pregnancy and are feeling depressed, if they have a counterweight of some social support, not only does that seem to help them, but it seems like it may be protective for the future child,” she added.

In addition to in-house therapists, the program’s nurses use mental health screenings to assess their needs. Since the pandemic, the program has launched an emergency fund for families, and also works with other partners to connect families to legal assistance and other services. 

The ongoing connection between nurse and client is one of the single most important aspects of the program. 

“The nurse remains a constant for the family, and they’re consistent,” Hinton told Mindsite News. “We keep showing up. Even when other things in their lives are changing, and bad things are happening, we continue to show up.”

‘I’m here to hear you, and to serve you’

On a busy Thursday afternoon last fall, Olivia Nowinski gathered supplies, paperwork and notes for her first home visit of the day. She has been a nurse in the program for five years and each week, she conducts dozens of home visits across the city’s neighborhoods. Since Yarilette joined the program, Nowinski has met with her at least twice a month, starting with telehealth visits during the pandemic and transitioning to home visits after her child’s birth in December 2021. 

As I ride with her for the half-hour drive through the city, Nowinski shares her home-visiting philosophy: Every home will be different, and she needs to treat each one as a blank slate.

“These mothers are opening their homes up to us and trusting us with their stories and needs,” she said. “I go in with knowledge, of course – but the ability to listen to their specific desires. We want our clients to feel I’m here to hear you, and I’m here to serve you.” 

Nowinski says mothers in the program are more interested in talking about their mental health needs than they were in years past. “I’m finding that parents are more aware of postpartum depression and more aware of baby blues, and not afraid to talk about it before the baby gets there, or even after – and that is a really great thing,” she says. “It’s making it okay for people to talk about it.”

Nowinski utilizes a range of strategies and tools that can help moms and their babies. She conducts mental health screenings for mothers, and connects them with other resources if needed. She assesses the home’s safety, providing tips for child-proofing and tools that promote better sleep, feeding, and play. Periodic developmental screenings make sure that babies are on the right track. 

Sessions typically begin with a check-in to see if mothers are progressing in their goals, and if any resources might be helpful. The rest of the visit focuses on parenting skills and child development education. “We prioritize a connection with people, putting the whole person’s needs and desires first,” Nowinski said.

A mother’s journey

Three years after she first joined the program, Yarilette welcomed Nowinski and me into the two-bedroom apartment she recently moved into in the Fairhill section of North Philadelphia. It’s a sunlit afternoon and the neighborhood is bustling as she greets us at her front door, her toddler, Avery, in her arms. 

Now 22, Yarilette works as a cashier at a nearby burger joint while 20-month-old Avery transitions to full-time daycare. She wants to be a nurse and hopes to resume classes soon.

We sit down next to baby toys and moving boxes in the living room and Nowinski greets Avery with a high-five and a smile. The two women discuss Yarilette’s goals, her current routine, and her upcoming health appointments, along with Avery’s development and milestones. Avery takes small steps towards Olivia, who pulls a toddler book out of her bag to read with her. 

“I’ve had a lot of personal growth because having her made me want to be a better person,” Yarilette tells me later. She felt that without a mental shift, she “would end up traumatizing Avery like how my mom traumatized me. I see that my relationship with my mom is the same as my mom’s relationship with her mom, my grandma. I wanted Avery to not have that. So it pushed me – pushed me to help myself, pushed me to try to better myself.”

Nowinski’s visits have helped her gain self-confidence and become a better parent, she says. “I learned to trust my gut more, especially when it comes to parenting.” 

Home visits become a way for new moms like Yarilette to build stronger connections with their babies and for home visitors to assess the strengths and needs of a young mother embarking on her parenting journey. 

It’s also helpful on a practical level. The program has helped Yarilette get food, a car seat, and a diaper bag, as well as a laptop so she can resume school and apply for jobs. Also helpful: connections to legal services and the program’s two in-house therapists.

“I have more financial stability because they have helped give me the things I needed,” she tells me. And her work with Nowinski and the therapists have helped her better navigate dynamics with her family. “I’m learning how to communicate my feelings,” she adds.

A permanent work in progress

Home-visiting programs date back to the 1800s but have expanded over the last 15 years. They exist in some form in all 50 states. Decades of research has shown that well-resourced home visiting programs better equip mothers with developmental tools, help prevent child abuse and maltreatment, reduce preterm births and increase educational development and school preparedness. 

In 1977, David Olds, a researcher in pediatrics and developmental psychology, tested the first-ever version of the NFP program in Elmira, New York. Over a span of 35 years, the program expanded to dozens of states and conducted randomized controlled trials in Elmira, Memphis, Tenn., and Denver, finding the most success in communities where mothers had the highest level of economic need.

Olds, a professor at the University of Colorado School of Medicine, says the program’s evidence-based focus makes the program a permanent “work in progress,” with constant adjustments to ensure mothers and families benefit. 

“We knew from the beginning that we didn’t want to have just ‘another good idea’ put out there,” Olds told MindSite News. “We needed to hold ourselves accountable to determine whether this program could really make a difference.”

The program has gone through a process of continuous iterations based on studying local needs, assessing how to meet them, piloting adjustments, and then rigorously testing the results. Olds and his team refer to this process as “innovation development.” In the Denver trial, the NFP team tested the impacts of using paraprofessionals or community health workers, instead of nurses, as home visitors and found that families were more likely to open their doors to nurses – a hallmark of the program that stuck.

Other changes aimed to upgrade nurses’ ability to offer mental health resources to mothers struggling with maternal depression and anxiety, boost retention of mothers in the program, and increase nurses’ ability to support mothers in day-to-day care of their children. The NFP also has a system for receiving feedback from participating mothers and staff, and an advisory committee of NFP staff members that provides suggestions on topics such as substance use disorder and maternal mortality. 

At the root of all this success is perhaps the biggest contribution that home-visiting programs can make – to help strengthen attachment and bonding between moms and their kids. 

”The program is built around improving the conditions for gestational development and the mother’s connection with baby,” said Olds. “The program’s nurses are trusted resources who help mothers read baby’s cues, learn how to respond to those cues in a way that promotes growth and caring, and build a sense of trust on the part of the baby. That has been at the heart of the program from day one.”

Research compiled by the national Nurse-Family Partnership since 1978 shows multiple positive outcomes associated with the program, including a 48% reduction of child abuse and neglect, a 50% drop in the language delays experienced by 21-month-old children, and an 82% increase in employment for mothers. 

An affiliate of the nonprofit Public Health Management Corporation and National Nurse-led Care Consortium, the Philadelphia NFP has served thousands of families over the past two decades, more than 500 in 2023 alone. 

The home visits with these mothers allow nurses to assess clients’ needs and offer them resources that can help. 

“Meeting clients and telling them about even tiny changes or tiny opportunities, can make way for larger health changes for people who are saddled with obstacles,” Nowinski said. “It is a lot about equity – creating some sort of equity in our communities.” 

Yarilette wants to take these skills to model a healthier family environment for Avery. Noting the challenges she has faced in her family, Yarilette tears up as she shares her hopes for her daughter. “I don’t want Avery to feel that kind of pressure. I want her to feel like a kid. I want her to be just Avery.” 

Turning a new page 

Each year, the NFP program hosts graduations for the mothers and their children. Gathered together, they receive certificates and connect with their nurses, who celebrate their participation and success. For parents completing the program, this can be a time of excitement, yet anxiety.

“Transitions can be hard. So at 18 months, we’re talking about graduation, we’re preparing our families for what’s going to be next, we’re talking about those goals, and what they would like to see happen,” said Hinton. “They set the goals, and we are there to help them reach their goals, and to just sort of cheer them on.”

Yarilette completed the program at the end of last year, and says she feels more hopeful about her future – and Avery’s. “I want her to see that even though her mom was struggling, she pushed on, she got her degree and she pulled us forward. I want her to feel like, ‘My mom could do it. Who says I can’t?’”