Nurse-Family Partnership Research Articles

Right from the start: protocol for a pilot study for a randomised trial of the New Baby Programme for improving outcomes for children born to socially vulnerable mothers

BackgroundChildren born to mothers who experience social complexity (e.g. substance misuse, intimate partner violence, mental ill health, a history of maltreatment) are at increased risk for a range of adverse outcomes at birth and during development. Home visiting programmes have been advocated as a strategy for improving outcomes for disadvantaged mothers and children, such as the Nurse-Family Partnership for young, socially disadvantaged first-time mothers. However, no evidence-based programme is available for multiparous women or older first-time mothers. The New Baby Programme was developed in Northern Ireland. It augments the universal health visiting service available in the UK with a content designed to promote maternal health and well-being in pregnancy, maximise secure attachments of children and parents and enhance sensitive parenting and infant cognitive development.Methods/DesignThis pilot study is designed to investigate whether it is possible to recruit and retain socially vulnerable mothers in a randomised trial that compares the effects of the New Baby Programme with standard antenatal and postnatal care. Feasibility issues include the referral/recruitment pathway (including inclusion and exclusion criteria), the consent and randomisation, the ability to maintain researcher blinding, the acceptability of the intervention to participants, and the feasibility and acceptability of the outcome measures. The results of the study will inform a definitive phase-3 RCT.DiscussionTrials of complex social interventions often encounter challenges that lead to the trial being abandoned (e.g. because of problems in recruitment) or present considerable analytic challenges relating to dropout, attrition and bias. This pilot study aims to maximise the chances of successful implementation.Trial registrationISRCTN35456296 retrospectively registered

DNA methylome variation in a perinatal nurse-visitation program that reduces child maltreatment: a 27-year follow-up

This study reveals the influence of child maltreatment on DNA methylation across the genome and provides the first evidence that a psychosocial intervention program, the Nurse Family Partnership (NFP), which targets mothers at risk for abusive parenting, associates with variation in the DNA methylome in adult offspring. The 188 participants were born to women randomly assigned to control (n = 99) or nurse-visited intervention groups (n = 89) and provided blood samples and a diagnostic interview at age 27 years. Interindividual variation in the blood DNA methylome was described using principal components (PC) scores derived from principal component analysis and showed that the NFP program (PC10: p = 0.029) and a history of abuse/neglect (PC1: p = 0.029, PC2: p = 0.009) significantly associated with DNA methylome variation at 27 years of age independent of gender, ancestry, cellular heterogeneity, and a polygenic risk index for major psychiatric disorders. The magnitude of the association between child maltreatment and DNA methylation was reduced when accounting for lifestyle factors, including smoking. These findings reflect the sustained impact of both childhood adversity as well as intervention programs that target such adversity on the epigenome but highlight the need for prospective longitudinal studies of DNA methylome variation in the context of early intervention programs.

Healthy Foundations Study: a randomised controlled trial to evaluate biological embedding of early-life experiences

IntroductionAdverse early experiences are associated with long-lasting disruptions in physiology, development and health. These experiences may be ‘biologically embedded’ into molecular and genomic systems that determine later expressions of vulnerability....

Evaluating the effects of financial incentives to support first-time young mothers to breastfeed

Women aged less than 20 years are less likely to initiate and sustain breastfeeding until their baby is 6 weeks and older compared with older mothers, according to the Infant Feeding Survey ( McAndrew et al, 2010 ). The ‘vouchers for breastfeeding’ scheme, which was trialled in 2015–2016 with more than 10 000 women in parts of Yorkshire and Derbyshire, offered mothers shopping vouchers worth up to £200 if they provided breast milk to their baby up to the age of 6 months. Over the period of this large-scale scheme, a parallel small-scale intervention was commissioned and offered by a family nurse partnership (FNP) to first-time young mothers in an adjacent area. This article reports on the evaluation of the initiative within the local FNP service. The results indicate that the scheme was acceptable and deliverable within this setting.

Status of High Body Weight Among Nurse-Family Partnership Children

Increased prevalence of high levels of body weight in early childhood has become a public health concern, given its potential association with adult obesity and related comorbidities. Both socioeconomic status and race-ethnicity are related to increased prevalence. The purpose of this study was to identify additional risk factors common to children of low-income families; and to guide quality improvement initiatives within home visiting programs, potentially fostering more desirable physical development outcomes. A cohort of children (n = 14,318) of all mothers enrolled in Nurse-Family Partnership between 2007 and 2010 was evaluated. Measures consisted of demographics, health behaviors, and physical growth metrics collected by specially educated nurses during the course of home visits that also delivered the program model. Measures of weight (W) versus length (L) were converted to percentiles using the Centers for Disease Control and Prevention-World Health Organization norms with high W/L (≥97.7th percentile) defining a binary outcome. Multiple logistic regression modeling was then used to derive risk models for that outcome. Across each of the four time points for body measures (child's age 6, 12, 18, and 24 months), race-ethnicity, prepregnancy body mass index (BMI), maternal weight gain, and breastfeeding duration emerged as common risk factors. Moderation of weight gain during pregnancy, extending breastfeeding duration, and normalization of BMI before subsequent pregnancies may potentially serve as means of lowering the prevalence of high body weight levels in young children of low-income families served by home visitors.

Randomized controlled trial and economic evaluation of nurse-led group support for young mothers during pregnancy and the first year postpartum versus usual care

BackgroundChild maltreatment is a significant public health problem. Group Family Nurse Partnership (gFNP) is a new intervention for young, expectant mothers implemented successfully in pilot studies. This study was designed to determine the effectiveness and cost-effectiveness of gFNP in reducing risk factors for maltreatment with a potentially vulnerable population.MethodsA multi-site, randomized controlled, parallel-arm trial and prospective economic evaluation was conducted, with allocation via remote randomization (minimization by site, maternal age group) to gFNP or usual care. Participants were expectant mothers aged below 20 years with at least one live birth, or aged 20–24 years with no live births and with low educational qualifications. Data from maternal interviews at baseline and when infants were 2, 6 and 12 months, and video-recording at 12 months, were collected by researchers blind to allocation. Cost information came from weekly logs completed by gFNP family nurses and other service delivery data reported by participants. Primary outcomes measured at 12 months were parenting attitudes (Adult-Adolescent Parenting Index, AAPI-2) and maternal sensitivity (CARE Index). The economic evaluation was conducted from a UK NHS and personal social services perspective with cost-effectiveness expressed in terms of incremental cost per quality-adjusted life year (QALY) gained. The main analyses were intention-to-treat with additional complier average causal effects (CACE) analyses.ResultsBetween August 2013 and September 2014, 492 names of potential participants were received of whom 319 were eligible and 166 agreed to take part, 99 randomly assigned to receive gFNP and 67 to usual care. There were no between-arm differences in AAPI-2 total (7 · 5/10 in both, SE 0.1), difference adjusted for baseline, site and maternal age group 0 · 06 (95% CI − 0 · 15 to 0 · 28, p = 0 · 59) or CARE Index (intervention 4 · 0 (SE 0 · 3); control 4 · 7 (SE 0 · 4); difference adjusted for site and maternal age group − 0 · 68 (95% CI − 1 · 62 to 0 · 16, p = 0 · 25) scores. The probability that gFNP is cost-effective based on the QALY measure did not exceed 3%.ConclusionsThe trial did not support gFNP as a means of reducing the risk of child maltreatment in this population but slow recruitment adversely affected group size and consequently delivery of the intervention.Trial registrationISRCTN78814904. Registered on 17 May 2013.

Results of the First Steps study: a randomised controlled trial and economic evaluation of the Group Family Nurse Partnership (gFNP) programme compared with usual care in improving outcomes for high-risk mothers and their children and preventing abuse

BackgroundFamily Nurse Partnership (FNP) is a home-based nurse home-visiting programme to support vulnerable parents. Group Family Nurse Partnership (gFNP) has similar aims and materials and was demonstrated to be feasible in implementation evaluations.ObjectivesTo determine whether or not gFNP, compared with usual care, could reduce risk factors for maltreatment in a vulnerable group and be cost-effective.DesignA multisite randomised controlled parallel-group trial and prospective economic evaluation, with eligible women allocated (minimised by site and maternal age group) to gFNP or usual care.SettingCommunity locations in the UK.ParticipantsExpectant mothers aged < 20 years with one or more previous live births, or expectant mothers aged 20–24 years with no previous live births and with low educational qualifications (defined as General Certificate of Education at grade C or higher in neither mathematics nor English language or, if they had both, no more than four General Certificates of Education at grade C or higher).InterventionForty-four sessions of gFNP (14 during pregnancy and 30 in the first 12 months after birth) were offered to groups of between 8 and 12 women with similar expected delivery dates (the difference between the earliest and latest expected delivery date ranged from 8 to 10 weeks depending on the group) by two family nurses (FNs), one of whom had notified her intention to practise as a midwife.Main outcome measuresParenting was assessed by a self-report measure of parenting opinions, the Adult Adolescent Parenting Inventory Version 2 (AAPI-2), and an objective measure of maternal sensitivity, the CARE-Index. Cost-effectiveness was primarily expressed in terms of incremental cost per quality-adjusted life-year (QALY) gained.Data sourcesInterviews with participants at baseline and when infants were aged 2, 6 and 12 months. Cost information from nurse weekly logs and other service delivery data.ResultsIn total, 166 women were enrolled (99 to the intervention group and 67 to the control group). Adjusting for site and maternal age group, the intention-to-treat analysis found no effect of gFNP on either of the primary outcomes. AAPI-2 total was 7.5/10 [standard error (SE) 0.1] in both arms [difference also adjusted for baseline 0.08, 95% confidence interval (CI) –0.15 to 0.28;p = 0.50]. CARE-Index maternal sensitivity mean: intervention 4.0 (SE 0.3); control 4.7 (SE 0.4) (difference –0.76, 95% CI –1.67 to 0.13;p = 0.21). The sensitivity analyses supported the primary analyses. The probability that the gFNP intervention was cost-effective based on the QALY measure did not exceed 3%. However, in terms ofchangein AAPI-2 score (baseline to 12 months), the probability that gFNP was cost-effective reached 25.1%. A separate discrete choice experiment highlighted the value placed by both pregnant women and members of the general population on non-health outcomes that were not included in the QALY metric.LimitationsSlow recruitment resulted in smaller than ideal group sizes. In some cases, few or no sessions took place owing to low initial group size, and small groups may have contributed to attrition from the intervention. Exposure to gFNP sessions was below maximum for most group members, with only 58 of the 97 intervention participants receiving any sessions; FNs were experienced with FNP but were mainly new to delivering gFNP.ConclusionsThe trial does not support the delivery of gFNP as a means of reducing the risk of child abuse or neglect in this population.Future workA randomised controlled trial with modified eligibility to enable first-time mothers aged < 20 years to be included, and a modified recruitment strategy to enable faster identification of potential participants from antenatal medical records.Trial registrationCurrent Controlled Trials ISRCTN78814904.FundingThis project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 5, No. 9. See the NIHR Journals Library website for further project information.

Exploring the Long-term Influence of the Family Nurse Partnership on the Lives of Young Mothers

Exploring the Long-term Influence of the Family Nurse Partnership on the Lives of Young Mothers

A Qualitative Evaluation of Engagement and Attrition in a Nurse Home Visiting Program: From the Participant and Provider Perspective.

Beginning parenting programs in the prenatal and early postnatal periods have a large potential for impact on later child and maternal outcomes. Home-based parenting programs, such as the Nurse Family Partnership (NFP), have been established to help address this need. Program reach and impact is dependent on successful engagement of expecting mothers with significant risks; however, NFP attrition rates remain high. The current study qualitatively examined engagement and attrition from the perspectives of NFP nurses and mothers in order to identify mechanisms that enhance service engagement. Semi-structured interviews were conducted in focus groups composed of either engaged (27 total mothers) or unengaged (15 total mothers) mothers from the NFP program. NFP nurses (25 total nurses) were recruited for individual semi-structured interviews. Results suggest that understanding engagement in the NFP program requires addressing both initial and sustained engagement. Themes associated with enhanced initial engagement include nurse characteristics (e.g., flexible, supportive, caring) and establishment of a solid nurse-family relationship founded on these characteristics. Factors impacting sustained engagement include nurse characteristics, provision of educational materials on child development, individualized services for families, and available family support. Identified barriers to completing services include competing demands and lack of support. Findings of this study have direct relevance for workforce planning, including hiring and training through integrating results regarding effective nurse characteristics. Additional program supports to enhance parent engagement may be implemented across home-based parenting programs in light of the current study's findings.

ANFPP (Australian Nurse Family Partnership Program): Connectedness and mindfulness

ANFPP (Australian Nurse Family Partnership Program): Connectedness and mindfulness

Visit Attendance Patterns in Nurse-Family Partnership Community Sites.

We examined visit attendance patterns of mothers enrolled in the Nurse-Family Partnership (NFP) home visitation program and associations between these patterns and characteristics of the families and sites, with the goal of increasing participant engagement. We utilized repeated measures latent class analysis to identify attendance patterns among 66,967 mothers in NFP sites across the USA. Mothers enrolled from 1996 to 2010. Data were collected by home visitors and aggregated by the NFP National Service Office. Five visit attendance patterns were identified. Consistent attenders (22%) remained engaged for the full program and attended 51.3 visits on average. Inconsistent attenders (9%) remained engaged but missed many visits, with an average of 36.4 visits. The remaining patterns were characterized by when participants left the program: early (28%; 6.7 visits), gradually (27%; 19.4 visits), or late (15%; 35.3 visits). Consistent and inconsistent attenders were less likely to use English as their primary language than other participants (R=0.12; p<.001). Participants with more nurse changes per visit attended were more likely to drop out early (R=0.11; p<.001). Sites with a higher percent of missing data had smaller portions of mothers who remained consistently engaged in the program over time (b=-0.032; p<.01) and greater portions in the late (b=0.007; p<.04) and gradual attrition classes (b=0.018; p<.01). The large number of participants who dropped out early is concerning. Further exploration of this group may optimize use of resources by improving either retention or targeting of potential participants.

Cost-effectiveness of the Family Nurse Partnership (FNP) programme in England: Evidence from the building blocks trial.

The Family Nurse Partnership (FNP) is a licensed intensive home visiting intervention developed in the United States. It has been provided in England by the Department of Health since 2006. The Building Blocks trial assessed the effectiveness and cost-effectiveness of FNP in England. We performed a cost-utility analysis (National Health Service (NHS) perspective) alongside the Building Blocks trial (over 2.5y). The analysis was conducted in accordance with National Institute for Health and Clinical Excellence (NICE) reference case standards. Health-related quality of life was elicited from mothers using the EQ-5D-3L. Resource-use data were collected from self-reported questionnaires, Hospital Episode Statistics, general practitioner records and the central Department of Health FNP database. Costs and quality-adjusted life years (QALYs) were discounted at 3.5%. The base case analysis used an intention to treat approach on the imputed dataset using multiple imputation. The FNP intervention costs on average £1812 more per participant compared to usual care (95% confidence interval: -£2700; £5744). Incremental adjusted mean QALYs are marginally higher for FNP (mean difference 0.0036, 95% confidence interval: -0.017; 0.025). The probability of FNP being cost-effective is less than 20% given the current NICE willingness to pay threshold of £20000 per additional QALY. The results were robust to sensitivity analyses. Given the absence of significant benefits of FNP in terms of the primary outcomes of the trial and only marginal maternal QALY gains, FNP does not represent a cost-effective intervention when compared with existing services already offered to young pregnant women.

Parenting and child mental health.

This paper reviews parenting programmes and their effectiveness with families of young children and highlights additional resources for primary care practitioners. Typically, 30% of GP consultations concern child behaviour problems and established behaviour problems can have lasting effects on children’s life chances. These problems can be identified in infancy and toddlerhood.Parenting is a key risk factor in their development and maintenance, yet is also amenable to change. In this paper we consider six parenting programmes that are widely evaluated and/or available in the U.K. and their evidence base . These include two NICE recommended parenting programmes (Incredible Years and Triple P), which offer tiered and flexible parenting programmes; predominantly for parents of school-age children. We also review Parent–Infant Psychotherapy, which is typically for parents of younger children. Fourth is Family Nurse Partnership, an intensive programme to support young, first-time mothers. Finally we consider, video feedback programmes which use video to focus in detail on parents’ interactions with their children, including Video Feedback to Promote Positive Parenting and Video Interactive Guidance. These interventions demonstrate the range of approaches which are being used to intervene early in children’s lives to try to prevent the development of enduring behavioural problems.Why this matters to meIt is becoming increasingly clear that the origins of many mental health problems lie in childhood. Family factors, including the quality of care that parents provide for their children, can make a huge difference to children’s early life pathways, for better or for worse. Understanding how best to intervene to support parents is a key challenge. In this article, we critically review the most widely used parenting programmes for parents of young children. It is imperative that we judge these early interventions to high standards so that we are offering children the best start in life.Key messageParenting programmes offer a means to intercept behaviour problems in early childhood before they become established.

Cost-Benefit Analysis of Two Child Abuse and Neglect Primary Prevention Programs for US States.

We assessed the US state-level budget and societal impact of implementing two child abuse and neglect (CAN) primary prevention programs. CAN cost estimates and data from two prevention programs (Child-Parent Centers and Nurse-Family Partnership) were combined with current population, cost, and CAN incidence data by US state. A cost-benefit mathematical model for each program by US state compared program costs with the future monetary value of benefits from reduced CAN. The models used a lifetime time horizon from government payer and societal perspectives. Both programs could potentially avert CAN among tens of thousands of children across the country. Lower costs from reduced CAN may substantially offset, but not always entirely eliminate, payers' program implementation cost. Results are sensitive to the rate of CAN in each US state. Given the considerable lifetime societal cost of CAN, including victims' lost work productivity, the programs were cost saving from the societal perspective in all US states using base case methods. This analysis represents an overall minimum return on payers' investment because averted CAN is just one of many positive health and educational outcomes associated with these programs and non-monetary benefits from reduced CAN were not included. Translating cost and effectiveness research on injury prevention programs for local conditions might increase decision makers' adoption of effective programs.

Challenges Faced by Young Mothers with a Care History and Views of Stakeholders About the Potential for Group Family Nurse Partnership to Support Their Needs

Women with experience of being ‘looked after’ are more likely than their peers to become young mothers. There has been limited research investigating support for their needs. This study, embedded in a randomised trial of Group Family Nurse Partnership (gFNP), involved interviews with young mothers with care experience, Family Nurses delivering group gFNP, and health and social care professionals. This first qualitative study to explore the views of these varied stakeholders found consensus regarding young mothers’ social isolation and lack of trusting relationships but diversity in views about the potential of gFNP to meet their needs.

Factors Associated With Availability of Nurse-Family Partnership Programs in the State of Texas [27K

INTRODUCTION: Current teen pregnancy rates generate significant social and economic costs, with highest rates in Hispanic, African American and socioeconomically disadvantaged youth. Their children are more likely to face health problems, incarcerations, unemployment, and to perpetuate teen pregnancies. Research-supported Nurse-Family Partnerships (NFPs) involving antepartum and postpartum nurse-home visits significantly improve teen pregnancy outcomes in Texas. Our objective was to evaluate socioeconomic, obstetrical, and perinatal outcomes of Texas counties currently served by NFPs. METHODS: We analyzed Texas and national population statistics, birth rates, socioeconomic factors, and obstetrical and neonatal outcomes extracted from federal and state databases. RESULTS: Currently, 21 Texas NFPs serve eligible women in 34 out of 254 Texas counties. These counties have higher average teen birth rates (44 per 1000) and higher average maternal poverty rates (33%) than the state of Texas (34 per 1000; 30%) and the United States (21 per 1000; 27%). They also have a higher proportion of absent prenatal care (4.5%), and infants with very low birth weights (1.7%). Across Texas, access to prenatal care decreases with decreasing maternal age, and teens have the highest rate of absent prenatal care (6.6-8.5%) and lowest rate of care starting the first trimester (6.6-8.5%). Absent prenatal care was also correlated with higher representation of birth defects. CONCLUSION: Texas NFPs serve counties with relatively high rates of teen pregnancies, maternal poverty, and absent prenatal care. This baseline data allows for advocacy, funding, and expansion of NFPs in Texas counties with comparably high levels of low-income, first-time mothers, including critically underserved Texas-Mexico border counties.

Modeling the Scaling Up of Early Crime Prevention

Research SummaryAlthough the amount of research evidence on the effectiveness of developmental crime prevention has grown considerably in recent decades, the translation of this scientific knowledge into policy and practice has lagged behind. In this article, we consider the challenges as well as the opportunities associated with scaling up evidence‐based programs and we offer an approach for considering the potential effects of deviations in implementation protocols during replications. We use results from the series of studies on the Nurse‐Family Partnership (NFP) to develop a computer simulation model. Based on a large number of simulations, we systematically adjusted key inputs (e.g., target population and fidelity) to mimic a range of possible implementation conditions and to observe the impacts on the estimated intervention effects. As the process progresses from the baseline condition, which reflects the initial implementation conditions specified in the NFP model, to alternative experimental scenarios reflecting problematic deviations in implementation, the number of arrests accumulated by treatment participants begins to increase. This indicates that these implementation challenges have a negative impact on program effects and that we can go some way toward predicting what might occur in implementation as they emerge and interact.Policy ImplicationsThe challenges facing program dissemination and their impact on program results have not been enumerated all that precisely in the literature, which has resulted in the assignment of arbitrary penalties when evaluating the prospects for taking programs to scale. Establishing efficacious interventions is only one part of the process of moving research to practice, and further consideration of the scaling‐up process is integral to translational criminology. Informed computer simulation may be one tool to help guide this program implementation process.

Exploring Multilevel Factors for Family Engagement in Home Visiting Across Two National Models.

The associations of family, home visitor and site characteristics with family engagement within the first 6months were examined. The variation in family engagement was also explored. Home visiting program participants were drawn from 21 Healthy Families America sites (1707 families) and 9 Nurse-Family Partnership sites (650 families) in New Jersey. Three-level nested generalized linear mixed models assessed the associations of family, home visitor and site characteristics with family receipt of a high dose of services in the first 6months of enrollment. A family was considered to have received a high dose of service in the first 6months of enrollment if they were active at 6months and had received at least 50% of their expected visits in the first 6months. In general, both home visiting programs engaged, at a relatively high level (Healthy Families America (HFA) 59%, Nurse-Family Partnership (NFP) 64%), with families demonstrating high-risk characteristics such as lower maternal education, maternal smoking, and maternal mental health need. Home visitor characteristics explained more of the variation (87%) in the receipt of services for HFA, while family characteristics explained more of the variation (75%) in the receipt of services for NFP. At the family level, NFP may improve the consistency with which they engage families by increasing retention efforts among mothers with lower education and smoking mothers. HFA sites seeking to improve engagement consistency should consider increasing the flexible in home visitor job responsibilities and examining the current expected-visit policies followed by home visitors on difficult-to-engage families.

An illustration of how program implementers can use population-specific analyses to facilitate the selection of evidence-based home visiting programs

Given that effective home visiting (HV) programs targeting at-risk families impact different outcomes and associations between risk factors and outcomes may vary across populations, program implementers should evaluate population-specific risk-outcome associations in order to select interventions that are most likely to benefit families in target communities. We used data collected in a rural community in upstate New York (i.e., Elmira) and three standard statistical methods (i.e., bivariate, multivariate, and cumulative risk analyses) to assess associations between maternal socio-demographic risk factors and outcomes typically targeted with HV interventions. With the results, we illustrated how program implementers could use population-specific analyses of data collected prior to the implementation of HV interventions to select interventions that may be most likely to benefit families in a target community. For example, our multivariate results suggested that lower socioeconomic families in Elmira were particularly at-risk for child maltreatment, poor family economic self-sufficiency, and poor child academic achievement, indicating that it may be particularly beneficial to implement HV programs that have been shown to affect these outcomes (e.g., Nurse Family Partnership and Parents as Teachers) in Elmira. We encourage program implementers to conduct similar population-specific analyses to help select evidence-based HV interventions for their target communities.

History of Maltreatment in Childhood and Subsequent Parenting Stress in At-Risk, First-Time Mothers: Identifying Points of Intervention During Home Visiting.

Home visiting is an effective preventive intervention that can improve parenting outcomes for at-risk, new mothers, thereby optimizing subsequent child development. A history of maltreatment in childhood is common in mothers participating in home visiting, yet the extent to which such a history is related to parenting outcomes during home visiting is unknown. The current study evaluated whether mothers with a history of maltreatment in childhood respond less favorably to home visiting by examining the direct and indirect pathways to subsequent parenting stress, a key parenting outcome affecting child development. First-time mothers (N = 220; age range = 16-42) participating in one of two home visiting programs, Healthy Families America or Nurse Family Partnership, were evaluated at enrollment and again at 9-and 18-month post-enrollment assessments. Researchers administered measures of maternal history of maltreatment in childhood, depressive symptoms, social support, and parenting stress. Maternal history of maltreatment in childhood predicted worsening parenting stress at the 18-month assessment. Mediation modeling identified two indirect pathways, one involving social support at enrollment and one involving persistent depressive symptoms during home visiting, that explained the relation between a history of maltreatment in childhood and parenting stress at the 18-month assessment. Ways to improve the preventive effects of home visiting for mothers with a history of maltreatment in childhood through the identification of relevant intervention targets and their ideal time of administration are discussed.