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. Author manuscript; available in PMC: 2023 Sep 1.
Published in final edited form as: Infant Ment Health J. 2022 Jul 28;43(5):797–807. doi: 10.1002/imhj.22013

Enrollment and outcomes of home visiting for mothers with and without a history of out-of-home care

Katie Nause 1, Robert T Ammerman 1,2, Alonzo T Folger 2,3, Eric S Hall 4, Mary V Greiner 2,5, Sarah Beal 1,2
PMCID: PMC10468224  NIHMSID: NIHMS1881524  PMID: 35901191

Abstract

Women previously in out-of-home care (i.e., foster care) experience poorer health and psychosocial outcomes compared to peers, including higher pregnancy rates and child protective services involvement. Home visiting programs could mitigate risks. Studies examining home visiting enrollment for women with a history of out-of-home care are needed. Women previously in out-of-home care based on child welfare administrative data between 2012 and 2017 (n = 1375) were compared to a demographically matched sample (n = 1375) never in out-of-home care. Vital records data identified live births in the two groups. For those who had given live birth (n = 372), linked administrative data were used to determine and compare rates of referral and enrollment into home visiting, and two indicators of engagement: number of days enrolled, and number of visits received. Women previously in out-of-home care were referred for home visiting more often than their peers. There were no differences in rates of enrollment. Women previously in out-of-home care remained enrolled for shorter durations and completed fewer home visits than peers. Findings suggest barriers to home visiting enrollment and retention in home visiting programs for women previously in out-of-home care. Studies with larger samples and more complete assessments of outcomes are warranted.

Keywords: child development, foster care, home visiting, maternal depression, out of home care

1 |. INTRODUCTION

More than 400,000 children are in out-of-home care (i.e., foster care) in the United States (U.S. Department of Health and Human Services, 2017). A history of out-of-home care is associated with increased physical and behavioral health risks, while youth are in and following exits from out-of-home care (Courtney et al., 2011; Greeno, Lee, et al., 2019). Young people with a history of out-of-home care experience significant barriers in adulthood, including difficulties with education, employment, and stable housing. Disrupted healthcare access further complicates this transition, limiting access to behavioral health services (Courtney et al., 2011; Greeno, Fedina, et al., 2019; Kang-Yi & Adams, 2017). Those with a history of out-of-home care experience poorer mental health outcomes compared to the general population and, among those who become parents, face increased barriers to supporting the mental health and wellbeing of their infants (Larrieu et al., 2008; Shpiegel et al., 2017, 2020). Early childhood home visiting programs for new mothers and their children could address some of these challenges (Ribaudo et al., 2022; Sama-Miller et al., 2019). The purpose of this study was to examine differences in engagement in home visiting for mothers with and without a history of out-of-home care.

For those with a history of out-of-home care, the transition to parenting is complicated. An estimated 33%–50% of adolescent girls with child welfare involvement experience pregnancy by age 18 (Casanueva et al., 2014; Guttmacher Institute, 2010), compared to 14% in the general population (Guttmacher Institute, 2010) with variation primarily due to data source (e.g., medical records vs. self-report). Studies linking child welfare and state birth records have found that 11% experienced a first birth before age 18 (Putnam-Hornstein & King, 2014). Earlier entry into parenting, poor maternal mental health, and other contextual factors associated with a history of out-of-home care (e.g., unemployment and homelessness; Courtney et al., 2011; Greeno, Lee, et al., 2019) likely contribute to elevated risk of intergenerational involvement with child welfare compared to other adolescent girls who give birth before age 18 (Wall-Wieler et al., 2018).

The combination of these risk factors stemming from a history of out-of-home care could have negative impacts on infant wellbeing, as maternal depression and history of maltreatment are believed to undermine child development (Folger et al., 2017; Noll et al., 2009). One opportunity to alleviate these risks is through home visiting programs, that promote positive parenting skills to ensure optimal child development and prevent negative outcomes, including child maltreatment (Duggan et al., 2007; Sama-Miller et al., 2019). Typically, these programs involve a home visitor, such as a social worker, educator, or nurse, who provides new parents with case management and education concerning parent–child attachment, parenting skills, maintaining a safe home environment, and maternal and infant health. Home visiting programs often begin before a mother gives birth and continue until the child is between 2 and 5 years of age, though the duration, target population, and services rendered may vary. Some home visiting models target infant mental health as a key focus (Slade et al., 2005), and research has demonstrated positive benefits of home visiting approaches that prioritize infant mental health (Weatherston et al., 2020). Most home visiting programs, however, conceptualize infant mental health as a secondary outcome, believed to be affected by maternal-focused interventions that are primary elements of their models (Sama-Miller et al., 2019).

Home visiting may be particularly beneficial for young mothers with a history of out-of-home care, as many aspects of home visiting align with known areas of vulnerability for this population (Demeusy et al., 2021). For example, a strong interpersonal support network is known to lessen the effects of maternal depression on child outcomes (Goodman & Gotlib, 1999), and social support is an identified area of need for young adults with a history of out-of-home care (Greeson et al., 2015). Although some research has demonstrated positive effects of home visiting on the mental health of infants and children whose mothers have a self-reported history of childhood maltreatment (Ribaudo et al., 2022; Shenk et al., 2017), there has been insufficient research to support the benefits of home visiting in women with a history of out-of-home care because no studies have specifically examined home visiting in this population. Separation from families of origin, experiences with child welfare system oversight, transiency in placement during childhood, and other characteristics unique to out-of-home care may also contribute to barriers to enrollment for these women compared to peers. As a result, it remains unclear what, if any, bearing a mother’s out-of-home care history has on enrollment and engagement in home visiting programs.

In addition to enrollment, young women with a history of out-of-home care may experience different levels of engagement and, as a result, differing benefits from home visiting than their peers. Findings regarding engagement with home visiting programs for young mothers of various socioeconomic backgrounds have been mixed (Adler & Newman, 2002; Ammerman et al., 2006; Cho et al., 2017). Educational achievement is a widely-used indicator of socioeconomic status (Adler & Newman, 2002) including in the present study. Findings suggest that home visiting engagement is complex and multifactorial and that women with a history of out-of-home care may have unique needs that should be considered in home visiting programs in order to optimize services. Without flexibility in services, young mothers with a history of out-of-home care could be more vulnerable to discharge from home visiting programs without receiving all program content, which may decrease positive effects of home visiting.

The potential for variation in enrollment and engagement for young mothers with a history of out-of-home care may help us to better understand variation for other groups with increased need. While the effects of home visiting programs are generally positive (Nievar et al., 2010), that is not universally observed. A systematic review of 21 randomized control trials showed mixed home visiting effects on three outcomes: child abuse and neglect reports, child developmental delay, and child physical health assessments (Michalopoulos et al., 2017; Peacock et al., 2013). One proposed reason for inconsistent findings is that most studies have not examined individual differences and other mechanisms that might contribute to differential response to these programs (Home Visiting Research Network, 2013). This is particularly relevant for young mothers with a history of out-of-home care, as there is evidence that maternal experiences in out-of-home care are associated with increased exposure to maltreatment in their children compared to other teen mothers (Wall-Wieler et al., 2018), and youth with child welfare involvement are vulnerable to both developmental delay (Zimmer & Panko, 2006) and increased physical health concerns compared to the general population (Courtney et al., 2011). As a result, one might expect to see increased health risks among infants in home visiting programs whose mothers have a history of out-of-home care. Several home visiting research organizations have prioritized attending to maternal characteristics, program characteristics, and modes of delivery that may modify the effectiveness of home visiting programs for specific sub-groups of participants, however, effectiveness for mothers with a history of out-of-home care has not yet been examined. For the reasons stated above, mothers with a history of out-of-home care may be one important subgroup.

To better understand how out-of-home care might impact home visiting, the current study examined referral, enrollment, and completion of a home visiting program by young mothers with a history of out-of-home care compared to a matched population never in out-of-home care. Data were gathered from four sources: 1) county child welfare administrative records; 2) electronic health records of the pediatric hospital; 3) state vital birth records; and 4) home visiting administrative records. It was hypothesized that, due to increased need, greater perceived benefit from mothers, and higher birth rates for women with a history of out-of-home care (Guttmacher Institute, 2010), these women would have higher rates of referral and enrollment into home visiting, remain enrolled in home visiting longer, and complete more home visits than their peers never in out-of-home care. It was also expected that due to their maltreatment and child welfare experiences, women with a history of out-of-home care would have higher rates of maternal depression (Folger et al., 2017; Goodman & Gotlib, 1999) and lower levels of interpersonal support (Greeson et al., 2015; Shenk et al., 2017) compared to women with no history of out-of-home care who enrolled in home visiting. Finally, we explored whether children born to mothers with a history of out-of-home care who received home visiting would have higher rates of developmental delay.

2 |. METHODS

2.1 |. Setting

The study drew from a single community-based home visiting program that serves an under-resourced area, administered by eight sites. Study participants either had a history of out-of-home care or were demographically matched to youth in out-of-home care. Approximately 1% of children in the community enter out-of-home care annually (Public Children’s Services Association of Ohio, 2019). At the time of data collection, out-of-home care ended when a young person achieved permanency or on their 18th birthday. To be eligible for home visiting, women (with and without a history of out-of-home care) had to be first-time mothers and have at least one of the following four risk factors: unmarried, low income (up to 300% of poverty level, receiving Medicaid, or self-reported financial concerns), younger than 18 years of age, or having received inadequate prenatal care. Mothers whose infants were removed from their custody were not eligible to continue home visiting. Home visiting referrals were self-initiated or occurred through prenatal clinics, birth hospitals, pediatric clinics, and other community resources. The central home visiting office assigned a service provision agency based on geographic region. Women received an assessment and comprehensive screening to determine eligibility before the first home visiting session. The home visiting program utilized the Healthy Families America (HFA) model, which emphasizes education in child health and development, parenting skills, prevention of child maltreatment, and maternal economic self-efficacy. Home visitors made weekly or bi-weekly visits during pregnancy and the first year after birth, with visits lasting 60–90 min.

2.2 |. Participants

Females of reproductive age (n = 1375, 12 years and older, M age = 16.8 years, SD = 4.0) in out-of-home care between 2012 and 2017 participated. Participants were predominantly African American or multi-racial (n = 915, 66.5%). Participants were matched to a comparison sample never in out-of-home care. While live birth and enrollment in home visiting were not inclusion criteria for this study, analyses for home visiting referral and enrollment were conducted using the subset of women who gave live birth (n = 372; 14%), and analyses for home visiting engagement and outcomes were conducted using the subset of women who gave live birth and enrolled in home visiting (n = 243; 65%).

2.3 |. Procedures

To identify women with a history of out-of-home care, child welfare administrative data provided by the local child welfare agency were linked to electronic health records data from the pediatric hospital where the study took place using previously validated and published deterministic methods (Dexheimer et al., 2019). Once the out-of-home care cohort was selected, a matching comparison sample was selected from remaining records for patients seen at the pediatric hospital where the study occurred who had never experienced out-of-home care and were enrolled in Medicaid. One-to-one rule-based matching was conducted using gender, race, ethnicity, and date of birth within 6 months. When more than one potential match was identified, a match was randomly selected. Child welfare administrative records, electronic health records, state vital records, and home visiting administrative records were linked and reviewed with established probabilistic matching processes (Hall et al., 2017) using mother and child names and dates of birth, as well as associated street addresses. After records were linked, data were de-identified and provided to the researchers for analysis. This study was approved by the institutional review boards at the pediatric hospital where the study took place, the county children’s services division, and state vital records department. Due to the sensitive nature of child welfare administrative records, data were provided following approval of required data use and transfer agreements with all agencies involved.

2.4 |. Measures

Data from the electronic health record included gender (only women are included in these analyses) and race and ethnicity. The electronic health record captures race as White (38%), Black or African American (59%), American Indian and Alaska Native (.3%), Asian (.2%), Hispanic/Latino (.07%), Middle Eastern (0%), Native Hawaiian and Other Pacific Islander (.1%), Other (3%), or Unknown (2%). Race and ethnicity are entered when the record is created and, depending on who is present with the child at the time the record is created, may be reported by the caregiver, the child, or determined by hospital registration staff. To account for exposure to racism and marginalization for minoritized women included in this study, race, and ethnicity are recorded as non-Hispanic white (0) or persons of color (POC; 1), aligned with best practice recommendations from the American Psychological Association (American Psychological Association, 2021). The number of mental health diagnoses was derived from ICD-9 and ICD-10 codes recorded by medical providers within the electronic health record during healthcare encounters at the pediatric hospital where the study took place. To account for comorbidity in diagnoses and remove variability due to which diagnostic code a provider billed with, diagnoses were coded as the count of unique codes that aligned with DSM-5 diagnostic categories (American Psychiatric Association, 2013). Thus, participants could have a count of diagnoses ranging from 0 (no mental health diagnostic codes) to 18 (diagnostic codes across 18 diagnostic categories). History of out-of-home care was extracted from child welfare administrative records. Birth data including maternal age at the time of birth, and maternal education (1 = 8th grade or less, 8 = doctorate or professional degree) were extracted from state health department records. Home visiting data including referral (0 = not referred, 1 = referred), enrollment (0 = referred but not enrolled, 1 = enrolled), number of home visits completed, duration of participation (i.e., number of days between first and last visit), program graduation status (i.e., having completed all program requirements; 0 = enrolled and not graduated, 1 = graduated), and reason for premature discharge when discharge occurred (0 = lost to follow-up, 1 = participant declined further participation, 2 = ineligible due to change in circumstances, e.g., participant relocation, child removal, or child death) were derived from home visiting administrative records. Home visiting data also included maternal self-report measures of perinatal depression and interpersonal support, home visitor reports of the home environment, and parent proxy reports of child developmental status. More detail on how the following measures are collected can be found in Folger et al. (2017).

2.4.1 |. Edinburgh postnatal depression scale

The Edinburgh Postnatal Depression Scale (EPDS) (Cox et al., 1987), a 10-item screening tool that measures depression over the past week, was administered before birth and 3-months postpartum (e.g., “I have been anxious or worried for no good reason”) with responses from 0 (No, not at all) to 3 (Yes, very often). Seven items are reverse-coded. Items are summed to calculate a total continuous score (sample Cronbach’s α = .82).

2.4.2 |. Interpersonal support evaluation list

Interpersonal support was measured with the 12-item Interpersonal Support Evaluation List (ISEL; (Cohen & Hoberman, 1983) at enrollment in home visiting. Participants expressed agreement to statements reflecting appraisal support (4 items; α = .69), belonging support (4 items; α = .88), and tangible support (4 items; α = .51). Mothers report the availability of social supports (e.g., “There is someone I can turn to for advice about handling problems with my family”) with response options ranging from 1 (definitely false) to 4 (definitely true); six items are reverse-coded. Items are summed to create a total score, with lower scores indicating less interpersonal support (α = .78).

2.4.3 |. Home observation measurement of the environment

The Home Observation Measurement of the Environment (HOME; Caldwell & Bradley, 2016; Totsika & Sylva, 2004) is a 45-item inventory administered at 3 months postpartum and used to measure parenting behaviors observed in the home environment and derived from interviews and observations by home visitors. Home visitors rated maternal responsiveness (11 items; α = .76), acceptance (7 items; α = .54), organization (6 items; α = .56), involvement (6 items; α = .55), provision of learning materials (9 items; α = .64), and variety (6 items; α = .51). Items are summed to calculate scale scores, as well as a total score ranging from 0 to 45, with lower scores indicating less nurturing and stimulating home environments, and higher scores indicating a more nurturing and enriched environment (α = .84).

2.4.4 |. Ages and stages questionnaire third edition

The Ages and Stages Questionnaires (ASQ-3; Squires & Bricker, 2009) was administered at six months postpartum and assesses child development in five domains: communication (6 items; α = .25), gross motor (6 items; α = .38), fine motor (6 items; α = .56), problem-solving (6 items; α = .29), and personal-social interactions (6 items; α = −.03). Mothers respond to items indicating if the child performs the behavior (e.g., “Does your child stand on one foot for about 1 second without holding onto anything?”) with “Yes” (10 points), “Sometimes” (5 points), or “Not yet” (0 points). Items are summed such that lower scores indicate lower developmental functioning (α = .69). There are ten additional open-response questions regarding the child’s development (e.g., “Do you have any concerns about your child’s behavior?”) that are not used in scoring the measure.

2.5 |. Analysis plan

Bivariate Pearson’s χ2 analyses were used to examine group differences in live birth rates, referral to home visiting, and enrollment in home visiting, with sufficient power (> .8) to detect significant differences when effect sizes were w > 0.1, a small effect (Table 1). Regression was used to model program completion, maternal depression, child developmental status, and the home environment for women with and without out-of-home care who engaged in home visiting. Continuous outcomes (e.g., ASQ scores) were modeled using linear regression, categorical outcomes (e.g., referral and enrollment status) were modeled using logistic regression, and count variables (e.g., number of home visits completed) were modeled using Poisson regression because count variables were not normally distributed and there was no evidence of overdispertion. All models adjusted for maternal age at the time of birth, maternal POC status, maternal education, and number of maternal mental health diagnoses. Although the number of days enrolled in home visiting was an outcome for this study, it is an important factor to consider when examining group differences in rates of home visiting completion, as well as child and mother outcomes; these analyses controlled for the number of days enrolled in home visiting (Tables 3 and 4). Based on samples sizes represented in these data, there was power > .80 to detect significant differences in the effect of out-of-home care when R2 > .09 and six variables were included in linear models, corresponding to small to medium effects.

TABLE 1.

Descriptive statistics of women with and without a history of out- of- home care

History of Out-of-home Care Matched Peers W
Females (N) 1375 1375
Live births N (5%)** 233 (17%) 139 (10%) .10
Women who gave live birth (n = 372)
 POC females who gave live birth N (%) 165 (71%) 109 (78%)
 Age at live birth (M, SD) 18.21, 2.21 18.98, 1.84
 Maternal education (M, SD) 2.28, .78 2.64, .74
 Mental health diagnoses (M, SD) 1.34, 1.77 .48, 1.04
 Referrals to home visiting N (%)* 163 (70%) 80 (57%) .12
 Enrollment in home visiting N (%) 107 (65%) 51 (64%) .01
Women enrolled into home visiting (n = 158)
 Days from referral to enrollment (M, SD) 53.47, 59.39 41.86, 36.30
 Maternal depression (M, SD) 5.17, 3.75 5.63, 4.57
 Social support (M, SD) 27.41, 6.83 28.77, 5.68
 ASQ total score (M, SD) 14.14., 11.60 17.14, 16.01
 HOME total score (M, SD) 34.40, 6.05 36.60, 4.41
 Number of home visits (M, SD) 20.92, 22.61 24.29, 25.04
 Number of days enrolled (M, SD) 319, 379 382, 377
 Graduation from home visiting N (%) 12 (7%) 5 (6%)
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*

p < .05

**

p < .01.

TABLE 3.

Logistic regression models estimating impact on completion of home visiting for women with and without a history of out- of- home care (n = 158)

Graduation from home visiting
OR 95% CI
Group 5.76 .54–61.39
POC status 1.90 .02–161.91
Maternal age 2.25 .83–6.11
Maternal education* .07 .01–.89
Total mental health diagnoses .58 .29–1.13
Days enrolled in home visiting** 1.01 1.01–1.02
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*

p < .05

**

p < .01.

TABLE 4.

Multivariate regression models estimating maternal and infant wellbeing indicators among participants in home visiting with and without a history of out-of-home care (n = 158)

EPDS
 ISEL
 ASQ
 HOME
B SE B SE B SE B SE
Intercept 27.94** 9.44 25.76** 7.56 39.21 23.84 28.46 9.21
Group −1.07 1.69 −1.01 1.52 −3.56 3.98 −1.83 1.61
POC Status −2.44 3.11 −.80 1.94 −4.46 6.09 −1.74 2.32
Maternal age −1.09 .56 −.19 .51 −.62 1.56 .30 .62
Maternal education −.31 1.55 2.39 1.35 −1.89 3.76 1.31 1.50
Total mental health diagnoses – – .13 .42 −.49 1.07 .19 .50
Days enrolled in home visiting .00 .00 .00 .00 .00 .01 .00 .00
F 1.58 1.32 .62 1.10
R2 .28 .09 .07 .11
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Abbreviations: ASQ, Ages and Stages Questionnaire; EPDS, Edinburgh Postnatal Depression Scale; HOME, Home Observation Measurement of the Environment; ISEL, Interpersonal Support Evaluation List.

*

p < .05

**

p < .01.

3 |. RESULTS

Table 1 provides descriptive data reported for women with and without a history of out-of-home care. Of women identified for this study (n = 2750; 50% with a history of out-of-home care), 372 (14%) had an identified vital birth record indicating that they had given live birth in the state where the study took place. Among women with a history of out-of-home care, 17% gave live birth compared to 10% of matched peers (10%; χ2 (1) = 27.47, p < .01). Of all women who gave live birth, 243 (65%) had an identified home visiting record indicating they had been, at minimum, referred for home visiting. Women with a history of out-of-home who gave live birth were referred to the home visiting program more often than peers (70.0% vs. 57.6% in matched peers; χ2 (1) = 5.91, p < .05). Differences in referral rates did not translate to significant differences in enrollment into home visiting (65.6% of women with a history of out-of-home care, 63.8% of matched peers; χ2 (1) = .08, p = .77).

Due to the non-normal distribution of number of days enrolled and number of home visits, models for those outcomes were modeled using Poisson regression. Findings indicate that women with a history of out-of-home care completed fewer home visits and were enrolled in home visiting for significantly less time compared to peers (Table 2). Further, mothers who were older or POC completed more visits and were enrolled for a longer duration. Mental health diagnoses increased enrollment duration, while maternal education shortened enrollment. Logistic regression models further indicated that rates of completion of the home visiting program did not differ among the cohorts, nor did reasons for premature discharge from the program when discharge occurred (ps > .10; Table 3). A supplemental analysis examining reason for premature discharge found no significant effects of group membership or covariates among women discharged due to being lost to follow up versus declining further participation or for being lost to follow up versus ineligibility for further participation.

TABLE 2.

Poisson regression models estimating impact of maternal factors on total number of home visits completed and total number of days enrolled in home visiting for women with and without a history of out- of- home care (n = 158)

Total home visits completed
 Total days enrolled in home vising
B SE B SE
Intercept 2.07** .19 4.76** .05
Comparison group .10* .04 .13** .01
OHC group (Reference) .00 .00 .00 .00
POC status .44** .06 .55** .01
Maternal age .04** .01 .04** .00
Maternal education −.02 .03 −.05** .01
Total mental health diagnoses .01 .01 .01** .00
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*

p < .05

**

p < .01.

In multivariable models (Table 4), women with and without a history of out-of-home care did not significantly differ with respect to depression, interpersonal support, home environment, or developmental screenings. All models accounted for variance in outcomes (R2) between .07 and .28. The effect of out-of-home care ranged between d = .11 and .39 for all multivariable models, indicating that out-of-home care status has small to medium effects across home visiting outcomes.

4 |. DISCUSSION

The purpose of this study was to examine the rates of referral, enrollment, and engagement in home visiting for young women with a history of out-of-home care as children and subsequently gave live birth compared to their peers never in out-of-home care. Findings of this study are consistent with those demonstrating higher rates of pregnancy and live birth in women with a history of out-of-home care compared to their demographically similar peers never in out-of-home care. Additionally, while rates of referral to home visiting were higher for women with a history of out-of-home care, rates of enrollment into the home visiting program did not differ among the groups. This suggests that additional support may be necessary following referral to promote higher rates of enrollment in home visiting for women referred for home visiting who have a history of out-of-home care. Higher rates of referral for women with a history of out-of-home care could be due to their connections to many community systems, thus increasing opportunities for referral; home visiting programs could leverage those same systems to ensure that these mothers get enrolled when appropriate. Previous research indicates that women with high levels of need, as is likely true for mothers with a history of out-of-home care (Courtney et al., 2011; Shpiegel et al., 2017, 2020), remain in home visiting longer and complete more visits (Ammerman et al., 2006). In this study, once enrolled, women with a history of out-of-home care were enrolled for significantly less time than their peers and completed fewer home visits. This may indicate inconsistency in follow-through with home visits. Studies examining the specific needs of women with a history of out-of-home care that could be addressed through home visiting, as well as challenges related to enrolling these women into home visiting programs and maintaining engagement to ensure successful completion, are warranted.

Findings that women with a history of out-of-home care are referred to home visiting at higher rates but with no statistically significant differences in enrollment rates compared to their peers and complete less home visiting programming are important to consider as federal policies such as the Family First Prevention Services Act (2017) target funding for home visiting programs, including partnerships such as with the Maternal, Infant, and Early Childhood Home Visiting program (MIECHV) that support mothers of children at high-risk of entry into out-of-home care (including mothers with a personal history of out-of-home care; Wall-Wieler et al., 2018), with the goal of preventing out-of-home care. For these prevention initiatives to be effective, funding and delivery of programming may require more involvement in recruiting high-risk families into programs and additional resources to ensure families stay engaged to complete programs and receive the full benefit of the intervention (e.g., Family First Prevention Services Act, 2017). Without enhanced resources, these high-risk families may be unsuccessful at accessing or completing prevention programs, which could result in mothers with highest need not receiving full benefits of home visiting programs and potential negative consequences to infants and young children. Importantly, no other statistically significant differences between mothers with a history of out-of-home care or their children were detected in this study. Effect sizes detected were generally small to medium, indicating that if differences do exist, out-of-home care is likely contributing a small amount to enrollment and engagement in home visiting. This contradicts other literatures describing risks to the children of mothers with a history of out-of-home care (Wall-Wieler et al., 2018). It may be that home visiting programs serve the highest need populations, and as a result there were no differences between mothers with a history of out-of-home care and comparison mothers who enrolled in home visiting. In addition, mothers of color and mothers who were older completed more home visits, and mothers of color, who were older, had more mental health diagnoses, and who completed less education remained enrolled in home visiting for longer periods of time. These findings are somewhat consistent with other studies demonstrating that women with more social complexity remain enrolled for longer (Ammerman et al., 2006), possibly because those programs are providing services that cannot be accessed elsewhere. However, mothers with more risk and social need may require additional flexibility and support in enrollment and completing home visits. Other research has suggested that mothers with higher levels of socioeconomic need are less likely to remain enrolled in home visiting, and complete fewer visits (Cho et al., 2017). Together, these findings support the need for targeted, rather than universal home visiting programming that can tailor services to the unique challenges mothers face, enhancing home visiting engagement and retention. It may be that mothers with a history of out-of-home care who also experience poorer mental health and lower educational attainment face additional barriers to enrollment and engagement in home visiting. While previous research suggests that the children of mothers who have experienced maltreatment or trauma have high rates of developmental delay (Folger et al., 2018), there are several other contextual factors (e.g., parenting practices, access to early care, and education) that could contribute to why no significant differences in screening results between groups were detected in this study, as other home visiting research has shown improvement in the mental health of infants and children of mothers with a history of maltreatment (Ribaudo et al., 2022).

There are several strengths to this study. First, the sample size of potentially eligible women is large. Second, this is the first study to leverage multiple administrative data sources to answer important questions regarding this understudied subgroup served by home visiting (Supplee & Duggan, 2019). There are several limitations to this study. First, the established cohort linking child welfare data to electronic health records was designed for a study of health in adolescence (Beal et al., 2021), examining home visiting is a secondary purpose. As a result, not all potential confounders (e.g., relationship to supportive partners, history of maltreatment) or mechanisms supporting successful outcomes (e.g., rapport building and persistence of home visitors) could be accounted for. For example, it is possible that women in the comparison sample experienced maltreatment that did not result in their removal from their family of origin, or that women with a history of out-of-home care were placed with supportive caregivers, which was not accounted for in these analyses. Additionally, limitations with probabilistic matching to home visiting records (e.g., limited access to information about name changes, potential errors in data entry for birth dates or other key information) may have contributed to some missed linked records among the 35% of participants in this study who gave live birth but did not have a matched home visiting record. Third, the use of administrative data provides an overview of the process and where differences might exist but fails to provide rich details that would be captured by prospective longitudinal study where information from parents, home visiting programs, and observations of children are collected. Such studies are important but are also resource intensive. Leveraging administrative data to detect where differences might be observed is a beneficial first step. Fourth, several of the measures are screening instruments (e.g., ASQ, EPDS), and as a result do not provide the more extensive information that would be generated from longer and more comprehensive measures. Some of these measures also had lower psychometric properties in this sample due to negative correlations among items, and findings may therefore not generalize to studies using other validated measures. Finally, effect sizes suggest small to medium but meaningful effects of out-of-home care on home visiting, which may indicate that this study is under-powered; with a larger sample size of women engaging in home visiting, these effects may be statistically significant. Future research should examine whether these findings can be generalized to other home visiting programs and populations. The lack of long-term follow-up to examine the impact of off-schedule home visiting completion is a limitation of this study. Research with larger sample sizes and more robust measures would be beneficial.

5 |. CONCLUSIONS

Women with a history of being placed in out-of-home care experience higher rates of live birth compared to their demographically similar peers never in out-of-home care. Women with a history of out-of-home care are more likely to be referred to home visiting, but no statistically significant differences in enrollment into home visiting between groups were observed. Women with a history of out-of-home care are enrolled home visiting for significantly less time than their peers and complete fewer home visits, which suggests these women may need more support to remain engaged and complete home visiting requirements. Future study of mechanisms explaining gaps between referral and enrollment into home visiting, and the barriers to completing home visiting requirements for women with a history of out-of-home care is needed. Women with a history of out-of-home care are an important subgroup who will likely benefit from targeted home visiting to improve their own mental health and the mental health and wellbeing of their children.

Statement of relevance to infant and early childhood mental health.

Preventing maltreatment and enhancing child development are primary outcomes for home visiting programs. This study used child welfare administrative and vital records data to compare home visiting engagement among mothers with a history of out-of-home care to their peers. Women with a history of out-of-home care are more likely to have child welfare involvement as parents; understanding engagement in home visiting for this population is integral to supporting infant mental health.

Key findings and implications.

  1. Women with a history of out-of-home care who have given live birth are more likely to be referred to home visiting than women without a history of out-of-home care.

  2. Despite differences in the rate of referrals, the rate of enrollment into home visiting did not differ significantly among women with and without a history of out-of-home care.

  3. Women with a history of out-of-home care remain enrolled in home visiting programs for less time and complete fewer home visits, on average, than women with no history of out-of-home care.

ACKNOWLEDGMENTS

The project described was supported in part by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number 5UL1TR001425 and by the National Institute of Drug Abuse under Award Number 1K01DA041620. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. This study was approved by the Institutional Review Board at Cincinnati Children’s Hospital Medical Center under IRB # 2017–4747, the Ohio Department of Health, and the Hamilton County Job and Family Services Prosecutor’s Office.

Funding information

the National Center for Advancing Translational Sciences of the National Institutes of Health, Grant/Award Number: 5UL1TR001425; the National Institute of Drug Abuse, Grant/Award Number: 1K01DA041620

Footnotes

CONFLICT OF INTEREST

The authors report no conflicts of interest relevant to this study.

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