By Yen Duong

When Denise Ward first moved to Charlotte in the summer of 2017, she was pregnant, jobless and homeless. She found a landing spot at the Florence Crittenden residential program for homeless pregnant women. Soon after, Ward joined the Nurse-Family Partnership program offered by the community health nonprofit Care Ring.

From that point, until her son turns two this month, a nurse from the program meets with her at least monthly to guide her through physical and mental changes of pregnancy, infancy and toddlerhood, support her toward independence, and educate her on parenthood.

“I’ve never met anyone that was so caring and so full of help. I can go to her about anything, she’s like a second mother to me,” Ward said of her NFP nurse. “She was always coming around checking on me and my son, she makes you feel like you’re at home, like a mom, very nurturing.”

A mother with a "graduate" sash, toddler in a graduation gown and a nurse smiling
A Nurse-Family Partnership client poses with her two-year-old daughter and NFP nurse at their graduation ceremony. Photo credit: Care Ring.

Last fall, Care Ring, which began its NFP program in 2009, won the national “Tenacious Caregiver Award” among NFP network providers from over 633 counties across the United States for operating at full capacity with high nurse and client retention and high graduation rates. Care Ring has provided health services for uninsured and underinsured Mecklenburg residents since 1955.

‘Helping them do for themselves’

In NFP programs, low-income first-time mothers join on or before their 28th week of pregnancy and need to have income low enough to qualify for the federal WIC program: last year, that was $31,284 for a family of two. At first, their assigned nurses visit them in their homes or convenient locations once a week, then eventually every several weeks. In addition to prenatal and postnatal education and care, the nurses help women deal with “social determinants of health”—issues such as housing, transportation and access to healthy food.

“One of the big things is we don’t do everything for them, we’re helping them do for themselves and that’s a really important step in the process,” said Carolyn Mullins, Care Ring’s Chief Operating Officer who runs the NFP program. “This type of nursing care is not every nurse’s cup of tea. It can be very tough watching someone and feeling like they aren’t doing what’s best for them, but you can’t make them do anything.”

NFP began spreading from Colorado in 1996, after decades of fine-tuning by its founder, researcher David Olds, according to the program’s website. Every NFP program in the country follows exacting standards and sends newly hired nurses to Denver for a week of training to learn the curriculum. In North Carolina, 14 such programs cover 26 counties. Since 2000, NFP has served more than 7,400 families in the state.

Registered nurse Chiquita Reid, who has worked for the program for six years, agrees that the most important part of her job is teaching women to advocate for themselves and their babies. After doing research into disparities in birth outcomes for African American women while earning a master’s degree in nursing, Reid put her research into practice with her job with NFP.

For instance, Reid said that several of her clients had mentioned postpartum depression symptoms to their doctors and ended up getting turned away with “a pamphlet on how to cope with stress.” NFP nurses sit with clients [as they call their regular program participants] and give tips on how to get the care they need.

“It doesn’t matter what your socioeconomic background is, you’re still a human being,” Reid said. “You deserve to be heard and you deserve to be listened to.”

Dealing with unique issues

In Mecklenburg County, many NFP clients are victims of intimate partner violence, Mullins said. The women range from 14 to 40, with an average age of 21. Finding trusted medical translators for languages such as Vietnamese, Hmong and Sudanese adds another level of complexity to the program, which has one Spanish-speaking nurse among its staff of 11.

“Definitely this is my favorite nursing job that I’ve had in my over 10 years of nursing,” said Reid, who cares for 25 to 30 clients at a time. “I get to see you come in pregnant, and I get to see you give birth to a baby and get to see you go through the birthing process of becoming a mother.

Nurses and staff in light blue t-shirts posing for a photo
Nurse-Family Partnership nurses and staff posed for a photo at a graduation event. Photo credit: Care Ring.

“That’s in contrast to hospital-based labor and delivery nursing,” she said. “They deliver the baby, but then they go home within two days and then I never hear from you again.”

Mullins and Reid both described pregnant women who lived on air mattresses in overcrowded apartments with few ideas about what resources were available to help with their transition to motherhood. After a few months at the residential program with the support of her NFP nurse, Ward found housing and a new job which she still holds.

“I always say, you really don’t know nursing until you do community nursing because it gives you the whole picture,” Reid said. “When you go to the hospital or you work in a doctor’s office all day, all they can see is this patient hasn’t been to any of their appointments and they’re not compliant. But what’s the bigger story? Maybe they had an issue with transportation, maybe they didn’t have child care, it’s deeper than what meets the eye.”

Great expectations

In 2018, the Care Ring NFP program served over 300 Mecklenburg County families, and since its inception, it has cared for over 1,000 families. Mullins said NFP programs decrease rates of smoking and hypertension during pregnancy, rates of preterm birth and infant mortality and rates of emergency room visits for childhood injuries.

“It was astounding to think [… of] what this program has given back to the community here in Mecklenburg County,” Mullins said. “We need to do a better job getting this information out to people because it’s truly astounding when you think about it.”

Many of the program’s benefits are less tangible but no less important.

Mullins recounted one such example of a harder-to-measure impact of the program’s services: She described one of the nurses taking three books out to a young mother, and the father happened to be there.

“He took the books and he started crying,” Mullins said. “The nurse asked ‘What’s wrong?’; she was really worried she had upset him somehow.

“These were tears of joy because he was so proud of his son for already having a library,” she continued. “For others of us, it’s such a normal thing for a baby to have books, for this family it meant the world to them.”

The Mecklenburg NFP program is funded by a mixture of government funds and private grants and donations. Mullins said that the cost of the program for each family is a bit over $8,600, but that NFP saves over $20,000 per family in eventual Medicaid costs.

“You get savings from Medicaid, the criminal justice system … we have children needing less resources in special education,” said Mullins. “There’s less government assistance with our families. And of course, you get improved quality of life for the families that have been participating. If Medicaid fully funded the NFP program, each level of the government would get huge savings that would exceed the cost by the time the child was seven.”

How we reported this story:

  • Received a press release from Care Ring on receiving an award
  • Did research on NFP programs nationally and locally, including reading research
  • Phone interviews with each person quoted in the story

Note: This article has been updated to reflect that the Mecklenburg NFP program does not receive Medicaid funding, although other NFP programs in the country do so. 

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Yen Duong covers health care in Charlotte and the southern Piedmont for North Carolina Health News.