Early Childhood Home Visiting Research Articles

Maintaining Family Engagement During Home Visitor Turnover: a Mixed Methods Study of Best Practices.

Evidence-based home visiting services (EBHV) are available in states and localities nationwide through the federally-funded Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program. Nevertheless, the anticipated benefits of EBHV, such as improved child developmental outcomes and increased positive parenting practices, may be undermined by the fact that most families withdraw from services earlier than the model developers planned. Prior studies have linked family attrition with staff turnover. The current study used a mixed methods design to investigate the conditions under which families remained active in the home visiting program after their assigned home visitor resigned. Coincidence Analysis revealed that giving families advance notice (at least 1month) prior to the home visitors' upcoming resignation or developing a strong positive working alliance with the inheriting home visitor appears to independently make a difference for ongoing family engagement at 3 and 6months following a staff transition. These findings suggest that emphasizing how staff turnover is managed may mitigate the risk of family withdrawal during these transitions.

Feasibility, Acceptability, and Usefulness of a Screening Tool for Caregiver Learning Differences in Early Childhood Home Visiting: Staff and Caregiver Perspectives.

Early childhood home visiting programs are well positioned to improve equity and reduce health disparities for families headed by caregivers with intellectual disabilities and other learning differences. Early identification of learning differences through screening may help home visiting staff tailor services and thus improve family engagement and outcomes. Using a mixed methods design, this study assessed potential determinants and outcomes related to implementation of a screening tool for learning differences adapted for the home visiting context. Participants were six home visiting staff and nine caregivers from multiple home visiting programs in one state. Staff completed surveys at enrollment and each time they conducted a screen with a caregiver. Staff also completed semi-structured interviews after conducting screens with at least two caregivers. Caregivers completed semi-structured interviews after taking part in a screen. At study enrollment, staff felt it was important to know if caregivers had learning differences, yet some believed caregivers would not like being asked about them. Survey and interview data aligned with theoretical determinants of implementation success, including staff competencies related to screening (e.g., knowledge, skills), perceived fit of screening with staff role and organizational context, and beliefs that the screening would improve engagement of caregivers and service delivery. Staff perceived the tool to be acceptable, feasible, and useful, although some acknowledged that caregivers might feel uncomfortable if the tool was not used carefully. Overall, caregivers found the tool to be acceptable and most believed it was helpful for the home visitor to have information about their learning experiences and needs. Findings lend initial support for the use of an adapted screening tool to identify potential learning differences.

Home visitor preparation in higher education

ABSTRACT Although home visiting is growing as a service for families with young children, the field does not adequately prepare the home visiting workforce, and higher education courses on home visiting are rare. Many home visitors are prepared through higher education as teachers, social workers, or nurses, which provides knowledge but few of the skills needed to collaborate with families to support their children’s development, revealing a need for focused pre-service preparation for home visiting. We conducted a qualitative study to (1) describe the present state of preparation in higher education and (2) propose recommendations for strengthening home visitor preparation via higher education. Focus groups (N  = 43) were conducted at conferences that included some focus on early childhood home visiting. Individual interviews (N  = 11) were conducted parallel to focus groups. Participants were faculty and administrators in higher education or home visiting related professionals. Using thematic analysis, three major themes surfaced: (1) learning, training, and awareness in higher education; (2) blending of a myriad of skills in home visiting; and (3) unification and support needs. Our findings emphasize the need for higher education to provide professional preparation for careers in home visiting. We offer recommendations to meet this need.

Promoting Coordination and Collaboration in Tribal Home Visiting Programs in the United States.

A joint statement from two federal agencies in the United States calls for coordination and collaboration between programs serving families of infants and toddlers who are at risk or developmentally delayed or disabled U.S. Department of Education and U.S. Department of Health and Human Services. Policy guidance: Joint statement on collaboration and coordination of the MIECHV and IDEA Part C programs. (2017). Individuals with Disabilities Education Act. ED/HHS Joint Guidance Document: Collaboration and Coordination of the Maternal, Infant, and Early Childhood Home Visiting Program and the Individuals with Disabilities Education Act Part C Programs. Young Native American children living on tribal lands in this country are currently eligible for two federal programs associated with these agencies which overlap in mission and implementation. This paper outlines potential strategies for creating a more seamless system of services for tribal families involving more centralized intake processes and procedures, cross training of staff to work across programs, and adopting more unifying approaches to program implementation. A streamlined system of services will result in interventions that better support family and child outcomes while reducing duplication of services, consolidating the limited number of qualified professionals available to provide services, and increasing convenience and cultural attunement of services to Native American families currently participating in both programs.

Promotion of school readiness in home visiting: creating a key driver diagram for continuous quality improvement

ABSTRACT School readiness is a topic of great interest to early childhood and maternal child health initiatives, such as the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) programme. However, there is a lack of information about best practices or strategies in home visiting and their relative effectiveness in improving school readiness, making this topic appropriate for improvement through Continuous Quality Improvement (CQI) methods. In 2022, Alabama developed a Key Driver Diagram (KDD) for improving school readiness efforts within the home visiting programme using synchronous online focus groups as a method of qualitative data collection with early childhood and home visiting experts. Findings from this study include development of a KDD that includes aims, key drivers, and secondary drivers. The KDD represents the first of many steps toward a unified theory of change. Future efforts will include development of a CQI change package and testing change ideas in the field.

Co-designing a conceptual framework of home visiting implementation quality

Early childhood home visiting is a two-generation approach to promote positive health and well-being outcomes among people who are pregnant and families with infants and young children. A popular family support strategy for the past several decades, home visiting expanded exponentially in the United States when the federal Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) was authorized in 2010 through a provision within the Affordable Care Act. MIECHV currently funds evidence-based home visiting services in underserved and historically marginalized communities in all 50 states, 22 tribes, the District of Columbia, and five U.S. territories. It is widely accepted that achieving intended child and family outcomes through home visiting services requires “high-quality” program implementation, but the field lacks a standard definition or empirical evidence for what “quality” means in the context of home visiting. With the rapid expansion of home visiting that has accompanied MIECHV, there is increased interest from the field in having a shared understanding of home visiting implementation quality that is applicable across models and accounts for dimensions of quality across the entirety of the home visiting implementation system. This paper describes the process used to develop a conceptual framework to understand home visiting quality. We engaged MIECHV awardees and other experts from the fields of home visiting, early childhood, implementation science, and health equity in a co-design process that involved initial brainstorming, a series of iterative framework drafts, and finalization of the model. The resulting framework captures the multiple levels (i.e., the contexts, agencies, entities, and individuals) that are part of the home visiting system and the theorized key aspects of quality that are applicable across the levels of the systems. We discuss potential uses of the conceptual framework, as well as lessons learned from the co-design process.

Precarity and work-family balance: fathers’ workplace demands and perinatal home visiting participation

ABSTRACT Father engagement in home visiting programs is beneficial to the family and increases program retention. This qualitative evaluation explored occupational barriers to fathers’ involvement in their child’s life and engagement in Florida Maternal, Infant and Early Childhood Home Visiting (MIECHV) programs through 29 focus groups conducted with 114 Florida MIECHV staff across eight counties and 15 interviews conducted with fathers of enrolled children/infants in seven counties. Conversations were recorded, transcribed, and coded using inductive thematic analysis. Results showed that father’s work was the most referenced of logistical factors (fathers’ work, living situation, program scheduling, and transportation) impacting father engagement in the program. Specific work factors included type of occupation, work precarity, work schedule, and the family’s reliance on father’s income. The results suggest that for the majority of fathers, not engaging in the MIECHV program is due to work demands rather than a lack of interest.

Virtual home visits during COVID-19 pandemic: mothers’ and home visitors’ perspectives

BackgroundThe experiences of mothers enrolled in Maternal, Infant and Early Childhood Home Visiting (MIECHV) program with virtual home visiting (VHV) during the pandemic remain mostly unknown. This study aimed to describe in detail the experience of home visitors and mothers with VHV during COVID-19 pandemic. This is a prerequisite for guiding future efforts to optimize MIECHV services that are provided through virtual operation.MethodsFocus groups discussion were conducted with home visitors (n = 13) and mothers (n = 30) who were enrolled in BabyCare program in Virginia from January 2019 to June 2022. This included mothers who received in-person home visiting (IPHV), VHV, or both (hybrid IPHV and VHV). Inductive analysis was used to identify emergent themes from the transcripts, then coding was conducted following a codebook that was developed by the research team.ResultsBoth mothers and home visitors considered IPHV necessary for a proper assessment of developmental milestones of children, for the assessment of the growth of the child through measuring the weight and height/length of the child, for the mothers to open up and discuss sensitive issues like domestic violence, for building a relationship between home-visitor and the parents, and for other potential benefits (comprehensive assessment of the environment around the child inside and outside the house from home visitors’ perspective and detecting abnormal health conditions in children from mothers’ perspective). Both mothers and home visitors see that VHV has some role to play but not to be a replacement for IPHV. If VHV is to be used, video conference is preferred by both mothers and home visitors, as it allows for some assessment.ConclusionMothers and nurses considered IPHV critical for proper and comprehensive assessment of the child and the family and also essential to build the nurse-client relationship. Both mothers and home visitors considered VHV supplementary to IPHV that can be used from time to time particularly with busy mothers. VHV may have little room with parents with intellectual disabilities and the difficulty in dealing with technology seems to be no longer a major issue.

Service Coordination in Early Childhood Home Visiting: a Multiple-Case Study

Early childhood home visiting is a preventive service delivery strategy that aims to promote child and parent health, positive parenting, child development and school readiness, and family economic self-sufficiency. To meet families’ needs, programs provide a combination of direct services, and referrals and linkages to community-based services. Service coordination is therefore a critical component of home visiting’s role within the early childhood system of care. This multiple-case study describes facilitators and barriers to service coordination, as identified by home visiting program staff and families. We interviewed program managers, supervisors, home visitors, and families from four local home visiting programs in the eastern USA with diverse contextual characteristics that showed evidence of having strong coordination. Using multiple-case study methodology, we analyzed the data to understand key facilitators and barriers to service coordination for each case and identify and describe common themes across cases. Facilitators included interagency relationships and collaboration; a culture of teamwork; dedicated, well-connected staff; supervision; trusting relationships with families; and warm handoffs. Barriers to service coordination were limited availability and accessibility of local resources, perceived stigma among other service providers, and families’ ambivalence toward some services. Home visiting staff and families emphasized that relationships at multiple levels are fundamental to service coordination, barriers are complex, and coordination is time- and labor-intensive. Coalitions that bring together diverse stakeholder groups at the state and local levels can provide meaningful coordination support to the early childhood services.

Home Visitation Program Staff Attitudes and Intentions Towards Using Digital Technology to Educate Families About Preventing Early Childhood Obesity: A Qualitative Study.

Home visitation programs that reach families of young children offer a unique opportunity for large-scale early childhood obesity prevention efforts. The objective of this qualitative research was to determine stakeholder attitudes, subjective norms, perceived ease of use and usefulness, behavioral control, and behavioral intentions towards utilizing technology in a home visitation program targeting early childhood obesity prevention. Staff from the Florida Maternal, Infant, and Early Childhood Home Visiting Program (n = 27) were interviewed individually by a trained research assistant using a semi-structured script based on constructs from the Technology Acceptance Model and Theory of Planned Behavior. Demographic and technology use information were collected. Interviews were recorded and transcribed verbatim, with data extracted and coded by two trained researchers using a theoretical thematic analysis approach. Most of the home visiting staff (78%) were white and non-Hispanic and employed for an average of 5years with the program. Most staff (85%) indicated they were currently using videoconferencing for home visits. Themes and subthemes emerged, including positive attitudes towards technology as a flexible and time-efficient program alternative for childhood obesity prevention with recommendations to keep content short, at a low literacy level, and available in more than one language for ease of use. Participants recommended developing training tutorials to improve program implementation. Internet access and potential social disconnect were cited as concerns for using technology. Overall, home visitation staff had positive attitudes and intentions for using technology in home visiting programs with families for early childhood obesity prevention.

Improving connections to early childhood systems of care via a universal home visiting program in Massachusetts

Welcome Family is a universal, short-term nurse home visiting program designed to promote optimal maternal and infant physical and mental well-being and provide an entry point into the early childhood system of care to all families with newborns up to 8 weeks old living in defined communities in Massachusetts. The present study examines whether: 1) Welcome Family meets its goal of successfully connecting families to two early childhood programs—evidence-based home visiting (EBHV) and early intervention (EI)—relative to families with similar background experiences who do not participate in Welcome Family, and 2) whether these impacts are conditional on families’ race and ethnicity and their primary language—two characteristics that are related to structural racism and health inequities. The study used coarsened exact matching (CEM) based on birth certificate data to match Welcome Family participants who enrolled during 2013–2017 to mothers and their infants living in the home visiting catchment areas who did not receive home visiting during the study period. Primary study outcomes included enrollment in any EBHV program supported by the Massachusetts Maternal, Infant, and Early Childhood Home Visiting (MA MIECHV) program up to age 1 year, measured using MA MIECHV home visiting program data, and EI service receipt for children aged up to age 3 years, measured using EI program data. Impacts were assessed by fitting weighted regression models adjusted for preterm birth, maternal depression, and substance use. Mothers’ race, ethnicity, and language were included in the model as moderators of Welcome Family impacts on enrollment in EBHV and EI. Welcome Family participants (n = 3,866) had more than double the odds of EBHV enrollments up to age 1 and had 1.39 greater odds of receiving EI individualized family service plans (IFSPs) up to age 3 relative to the comparison group (n = 46,561). Mothers’ primary language moderated Welcome Family impacts on EBHV enrollments. Universal, short-term programs such as Welcome Family may be an effective method of ensuring families who could benefit from more intensive early childhood services are identified, engaged, and enrolled.

A Pilot Study of an Educational Intervention to Increase Postpartum Medical Visit Attendance in Home-Visited Mothers.

Socioeconomically disadvantaged women experience barriers to attending postpartum medical visits (PMV). This three-phase pilot study explored the feasibility, acceptability, and preliminary effectiveness of an educational intervention to increase PMV attendance in mothers enrolled in early childhood home visiting. Phases 1 and 2 occurred prior to the COVID-19 pandemic, and Phase 3 occurred during the pandemic. Home visitor implementation of the intervention with mothers was feasible and acceptable in all phases. All mothers who received the intervention reported PMV attendance. Overall, 81% of mothers reported they discussed all questions with healthcare providers at the PMV. These findings provide preliminary effectiveness for a brief educational intervention in increasing PMV attendance in home-visited mothers.

Barriers to and Systems Solutions for Increasing Early Childhood Home Visiting Referrals by Health Care Providers Serving Urban and Rural Communities.

Early childhood home visiting (ECHV) is an evidence-based prevention strategy that directly impacts maternal and child health by mitigating the poor outcomes associated with socioeconomic disadvantage and adverse childhood experiences that disproportionately affect marginalized populations. Despite its promise, health care providers in many communities do not routinely refer patients to these services. This qualitative study examined barriers to health care providers' referrals to ECHV services and identified systems-level strategies to overcome those barriers through semistructured interviews with 37 health care providers in New Mexico. Most participants were pediatricians or family practice physicians working in hospitals or community-based primary care settings, and the majority served rural communities. Barriers included insufficient knowledge about ECHV programs; lack of trust of program providers; time constraints; concerns about available funding; lack of a standardized referral process; and concerns about stigma and messaging. Five systems-level recommendations were developed to improve practice: (1) educating health care providers; (2) developing messaging prompts for providers to use when talking with patients about ECHV; (3) increasing engagement among providers and ECHV programs; (4) standardizing referral systems within practices; and (5) promoting universal referrals. Additional research is ongoing to determine the degree to which these health promotion strategies increase referrals and participation in ECHV.

O22 Determining Stakeholders’ Perceptions and Barriers on Using Digital Nutrition Education Modules in Home Visitation Programs

<h3>Background</h3> Home visitation programs that reach families of young children offer a unique opportunity to prevent early childhood obesity. Technology has become an integral part of continuing services as a result of COVID-19, yet no standardized digital curriculum targeting childhood obesity prevention currently exists. <h3>Objective</h3> To determine the perceptions and barriers of key stakeholders on using technology to enhance home visitation programs, as well as preferred digital learning formats related to the development of a digital nutrition education curriculum. <h3>Study Design, Setting, Participants</h3> Key stakeholders of the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program (N = 27) in Florida participated in a one-time, 30-minute qualitative interview via Zoom with a trained researcher using a semi-structured script based on the Technology Acceptance Model. <h3>Measurable Outcome/Analysis</h3> Interviews were audio-recorded, transcribed verbatim, and coded by two researchers using an inductive thematic approach. <h3>Results</h3> Since the onset of the COVID-19 pandemic and implementation of virtual home visits, participants expressed positive attitudes surrounding the use of technology, such as greater flexibility in scheduling and increased access to readily available information for both parents and home visitors. Further, they were receptive to continued virtual programming opportunities, but identified several barriers, including limited access to smartphones and internet access, privacy concerns, and lack of personal connection to parents. Recommendations included providing families with technology devices, using secure platforms, and developing brief digital nutrition education modules with interactive and personalized features. <h3>Conclusions</h3> Perceptions surrounding the use of technology for nutrition education in home visitation programs were positive. This promising formative research will be used to determine future directions for the development steps of a technology-based home visitation early childhood obesity prevention curriculum. <h3>Funding</h3> University of Florida Mowery Innovative Research Fund.

Characteristics Associated with Participant Attrition and Retention in a Perinatal Home Visiting Program.

Using data from the Florida Maternal, Infant, and Early Childhood Home Visiting (MIECHV) funded programs, we examined program- and participant-level characteristics associated with participant retention by time of enrollment. Analyses of data for 1,807 women enrolled in 11 sites across three years included descriptive statistics; Kaplan-Meier survival curve estimation and multilevel survival analyses using shared frailty model to assess participant- and program-level characteristics overall and by time of enrollment (during pregnancy or post-delivery). Median retention time for MIECHV participants was 462days. The primary reason for attrition was loss-to-follow-up (59.4%) due to change of address/telephone. We found participant age > 25years (compared to < 20years), enrollment during pregnancy, and an average of 1.5-2.0 home visit/month to be protective, while current/history of substance abuse was a risk factor for attrition. To improve participant retention, the Florida MIECHV program may need to bolster efforts to support housing stability, increase outreach and engagement to younger women, address barriers to achieving two home visits per month throughout the program, and target differential predictors of participant attrition depending on time of enrollment.

Transitions to virtual early childhood home visitation during COVID-19.

COVID‐19 has disrupted many of the preventive service sectors designed to promote infant mental health. The purpose of this study is to examine provider and supervisor transition strategies as well as maternal‐child outcomes during the transition from in‐person to virtual early childhood home visitation services in Los Angeles County. Los Angeles County is one of the largest home visitation sectors in the U.S. and disproportionately impacted by the COVID‐19 pandemic. Transitioning from in‐person to virtual home visitation was an important step in ensuring the continuity of infant mental health services. Home visitors reported relative ease in transitioning to virtual services themselves but noted that families encountered greater difficulty. The most helpful strategies to support this transition included training, ongoing reflective supervision, and provision of technology. Family level analysis revealed that positive screening rates for anxiety and depression decreased during the pandemic as did referrals for most support services. These findings likely highlight challenges in delivering virtual home visitation. Understanding how transitions in a key infant serving sector were managed serves an important role in forecasting for the future and preparing for future public heath emergencies.

The Role of Open Science Practices in Scaling Evidence-Based Prevention Programs

The goal of creating evidence-based programs is to scale them at sufficient breadth to support population-level improvements in critical outcomes. However, this promise is challenging to fulfill. One of the biggest issues for the field is the reduction in effect sizes seen when a program is taken to scale. This paper discusses an economic perspective that identifies the underlying incentives in the research process that lead to scale up problems and to deliver potential solutions to strengthen outcomes at scale. The principles of open science are well aligned with this goal. One prevention program that has begun to scale across the USA is early childhood home visiting. While there is substantial impact research on home visiting, overall average effect size is .10 and a recent national randomized trial found attenuated effect sizes in programs implemented under real-world conditions. The paper concludes with a case study of the relevance of the economic model and open science in developing and scaling evidence-based home visiting. The case study considers how the traditional approach for testing interventions has influenced home visiting’s evolution to date and how open science practices could have supported efforts to maintain impacts while scaling home visiting. It concludes by considering how open science can accelerate the refinement and scaling of home visiting interventions going forward, through accelerated translation of research into policy and practice.

Association Between Maternal Adverse Childhood Experiences and Neonatal SCG5 DNA Methylation-Effect Modification by Prenatal Home Visiting.

Maternal childhood adversity and trauma may elicit biological changes that impact the next generation through epigenetic responses measured in DNA methylation (DNAm). These epigenetic associations could be modified by the early postnatal environment through protective factors, such as early childhood home visiting (HV) programs that aim to mitigate deleterious intergenerational effects of adversity. In a cohort of 53 mother-child pairs recruited in 2015-2016 for the Pregnancy and Infant Development Study (Cincinnati, Ohio), we examined the association between maternal adverse childhood experiences (ACEs) and neonatal DNAm in the secretogranin V gene (SCG5), which is important in neuroendocrine function. We examined prenatal HV as an effect modifier. Mothers completed a questionnaire on ACEs during pregnancy, and infant buccal samples were collected 1 month postpartum. Multivariable linear regression was used to examine the association between maternal ACEs and neonatal DNAm expressed as M-values averaged across 4 cytosine-phosphate-guanine dinucleotide sites. A higher number of maternal ACEs (>3) was associated with a 5.79-percentage-point lower offspring DNAm (95% confidence interval: -10.44, -1.14), and the association was modified by the number of home visits received during pregnancy. In a population of at-risk mother-child dyads, preliminary evidence suggests that maternal ACEs have a relationship with offspring SCG5 DNAm that differs by the amount of prenatal HV.

Perinatal Mental Health Support and Early Childhood Home Visitation During COVID-19.

COVID-19 has disrupted many of the preventive service sectors designed to serve mothers at-risk for developing postpartum depression, forcing a rapid transition to telehealth-based modes of delivery. The purpose of this study was to explore differences in early childhood home visitation service provision (enrollment and depression screening) among mothers receiving home visitation services prior to and after the onset of the COVID-19 pandemic. Additional factors related to receipt of virtual home visitation services, family risk factors, and the maternal depressive symptoms were examined. Linear and logistic regression were utilized to examine whether there were differences in family risk factors, the percentage of mothers being screened for depression and maternal depressive symptoms, and associations between risk factors and positive depression screenings, while accounting for clustering by site. Samples compared outcomes for families enrolled during the pre-pandemic period (defined as March 16th to July 27th, 2019, n = 4,743) and the post-pandemic period (defined as March 16th to July 27th, 2020, n = 2,049). Families enrolled after the onset of the pandemic were significantly less likely to be impacted by housing instability, have a child with a disability, or be involved with the military, but more likely to have a history of child abuse or neglect. Fewer mothers were screened for depression during the pandemic and maternal report of depressive symptoms decreased. Virtual home visitation is currently attracting some groups of mothers who are experiencing fewer stressors, which may place them at decreased risk for exhibiting depressive symptoms. There may be aspects of the virtual depression screening experience that make detection more difficult. As a result, many mothers at risk for maternal depression may not receive adequate prevention services.

Maximizing the return on investment in Early Childhood Home Visiting through enhanced eligibility screening

BackgroundThe MIECHV (Maternal, Infant, and Early Childhood Home Visiting) program invests substantial federal resources to prevent child maltreatment and emergency medical costs. Eligibility is based on screening of demographic or clinical risk factors, but because screening accuracy in predicting poor outcomes is unknown, assignment to home-visiting might miss high-risk families or waste resources on low-risk families. ObjectivesTo guide eligibility decisions, this study tested accuracy of demographic and clinical screening in predicting child maltreatment and emergency medical care. Participants and settingA population-representative sample of 201 birthing mothers (39.8% Black, 33.8% Latina) in Durham, NC, was enrolled between July 2009, and December 2010, and followed through December 2015. MethodsParticipants were screened demographically (i.e., Medicaid, first-born, teenage, no high school diploma) and clinically (i.e., health/health care, parenting readiness, home safety, and parent mental health) at birth and followed through age 60 months, when Child Protective Services and hospital records were reviewed. Cox hazard models tested accuracy of prediction from screening variables. ResultsDemographic factors did not significantly predict outcomes, except having Medicaid/uninsured predicted more emergency medical care and being first-born was a (surprising) protective factor against a child maltreatment investigation. In contrast, clinical factors strongly predicted both maltreatment investigations (Hazard Ratio = 4.01 [95% CI = 1.97, 8.15], sensitivity = 0.70, specificity = 0.64, accuracy = 0.65) and emergency medical care (Hazard Ratio = 2.14 [95% CI = 1.03, 2.14], sensitivity = 0.50, specificity = 0.69, accuracy = 0.58). ConclusionsEven with added costs for clinical screening, selecting families for home visiting based on assessed clinical risk will improve accuracy and may yield a higher return on investment. The authors recommend a universal system of screening and care to support birthing families.