Our commitment to scientific rigour
The Family Nurse Partnership (FNP) National Unit is committed to understanding how FNP can improve the lives of vulnerable mothers, families and children in the UK.
The Department of Health commissioned the ‘Building Blocks’ randomised controlled trial (RCT) from Cardiff University to provide independent evidence on the effectiveness of the FNP programme in improving short term outcomes for young parents and their babies. Based on a study protocol, the trial began in 2009 and the findings which cover the period from pregnancy to the child’s second birthday' were published in October 2015. These are important early findings and add to the evidence we have from the US, Netherlands and other early evaluation in England to help improve FNP in England.
A follow up study, funded by National Institute of Health Research, is underway examining child outcomes to age six is due to report in 2018.
The FNP programme appeared to improve early child development, particularly early language development at 24 months and may also help protect children from serious injury, abuse and neglect through early identification of safeguarding risks. There were also some small improvements in mothers’ social support, relationship quality and self-efficacy. Young mothers were positive about the FNP programme, engaged very well with it and feel it helped to them to be good parents. They especially valued the close and trusting relationship with their family nurse. The study also found that the FNP programme was implemented well on the whole, in line with the US licensed model.
However, FNP did not have an impact across the study’s four main short term outcomes – pre-natal tobacco use, birth weight, subsequent pregnancy by 24 months and A&E attendances and hospital admissions in first two years of life. Neither was there any impact on these outcomes by key sub-groups (age, NEET, problems with basic life skills, area deprivation) or by variation in programme implementation. A wide range of secondary outcomes assessed also didn’t show significant benefits for FNP at this stage.
The study did help to highlight the high levels of vulnerability amongst first time teen mothers and their children suggesting the case for additional support for this group remains strong. Of trial participants 48% were Not in Education, Employment or Training (NEET) at recruitment, 35% had previously been arrested, 46% had been suspended, expelled or excluded from school, 56% were smoking in late pregnancy and 40% had experienced domestic violence in the 12 months preceding their child’s second birthday.
The research was not able to explain why FNP appears not to be making a difference on key outcomes at this stage, although some suggestions were put forward. These include that the target group, all first time young mothers-to-be, may not be as disadvantaged as those in US NFP trials, and that the control groups received relatively high levels of both universal and specialist services. Engagement with ante-natal care is high for both the intervention and control groups.
This was a rigorous study and the findings provide valuable learning. They show that first time teen mothers and their children are a vulnerable group with high risk of poor outcomes who clearly need additional support in the critical pregnancy and early years period. The FNP National Unit will work with FNP sites, local authorities, wider services and experts, to quickly adapt FNP so that impacts are improved across all key areas, including cost effectiveness.
The findings on improved child development and early identification of safeguarding risk are promising – these are important outcomes that we know may become clearer as the child gets older. Early language development is strongly associated with improved school readiness, academic achievement and improved social and emotional development. A follow up study to age six is underway looking at child safeguarding, health and educational attainment outcomes using administrative data.
The findings were disappointing in that they showed FNP did not have an impact in some key areas – in particular smoking cessation during pregnancy and subsequent pregnancy by 24 months. Smoking during pregnancy is a significant risk to a child’s health and development, and stopping smoking is a challenge amongst first time teen mothers-to-be. The cost consequences of smoking during pregnancy are high and addressing this will significantly improve cost effectiveness to the NHS. These are critical areas that need to be addressed and we will adapt and improve FNP so these and other key outcomes are improved.
Birth weight has not been shown to be effected by the Nurse-Family Partnership (NFP) programme in any of the US RCTs. Other than pre-natal tobacco use, the lack of impact on other pregnancy and birth outcomes is in line with NFP trials in the US and the Netherlands.
Family nurses are a dedicated and highly skilled workforce and are well placed to work with this group. The high level of engagement they have with first time teen mothers is very promising and provides a firm basis for moving forward.
We will investigate how we can target the programme further to ensure that we are focusing on the most vulnerable groups who are likely to benefit most.
The RCT evaluated the effectiveness of FNP in three areas between early pregnancy and the child’s second birthday in the three programme goals:
- Pregnancy and birth
- Child health and development
- Maternal life course.
- Evaluated what factors might vary the impact of FNP to improve its future delivery
- Evaluated the cost effectiveness of FNP in England to the NHS within the timeframe of this current trial and in the longer term.
Following the findings up to the child’s second birthday, a longer term follow up to age six is being funded by National Institute of Health Research and is due to report in 2018.
Between June 2009 and June 2010, 1,618 young mums were recruited from 18 sites across England. Of these, 50% were allocated to receive FNP support and 50% to receive usual care.
Data was collected at seven time points; intake, 36 weeks of pregnancy, birth, and then when the child was six, 12, 18 and 24 months old. This data was collected through face-to-face and telephone interviews, administrative records and urine samples. The data collection and analysis was completed in September 2014, and the full results were published in October 2015.
The trial focused on four primary outcome measures relating to:
- Pre-natal tobacco use
- Birth weight
- A&E attendances and emergency hospital admissions within 24 months of birth of the mother’s first child
- Subsequent pregnancies within 24 months of birth of mother’s first child.
A range of secondary outcomes were also assessed, including:
- Child language development
- Maternal education and employment
- Care-giving quality
- Maternal mental health
- Domestic abuse
- Child immunisations
- Child injuries.