“That was from my earlier period,” she said.
On a drizzly December afternoon, Ms. Schmidt was in the Throgs Neck section of the Bronx to visit Elizabeth De la Rosa, who is 19 years old, single and was about as pregnant as a person can be. On this day, which happened to be the date her baby was due, Ms. De la Rosa was living in her mother’s apartment, a surprise to Ms. Schmidt, 37, who had been visiting her since early in the pregnancy — sometimes at a homeless shelter, sometimes at Ms. De la Rosa’s aunt’s. Ms. De la Rosa and her mother had a history of bitter arguments, which had landed the daughter in counseling at age 14.
“I must say,” Ms. Schmidt said mildly, “I’m glad that you and your mom are getting along.”
“We don’t fight when I’m at my aunt’s,” Ms. De la Rosa said.
“Did your mother ask you to move back?” Ms. Schmidt asked.
As the two talked, Ms. De la Rosa’s mother watched television in her bedroom. There were many things to discuss:
How was Ms. De la Rosa feeling? (Impatient.) Did she have headaches or blurry vision? (Headaches.) Did she tell her doctor? (Yes.) Was she still planning to get a job and find her own place? (First she wanted to get her high school equivalency diploma.) Did she need a referral? Did she have a day care plan? Was she considering any schooling beyond the G.E.D.? How long did she plan to breast-feed?
Discussion circled back to her relationship with her mother. Ms. Schmidt, who did not get along with her own mother, nodded sympathetically and recorded Ms. De la Rosa’s answers on printed sheets that she kept in a thick folder.
Afterward, in her government-owned Prius, Ms. Schmidt confided that she was worried. “What happens when this baby’s born and her mom tells her she’s doing something wrong? Elizabeth says she doesn’t want it to get physical, but that it can get physical. She’s very strong-willed. I’m going to ride it out.”
Her face showed her further concern: In a home with physical violence, little money or resources, with a nonsupportive father, what sort of life prospects would Ms. De la Rosa’s baby have?
“I know these girls because I come from the same background as they do,” Ms. Schmidt said, adding that of the young women she visited, Ms. De la Rosa had one of the more stable home situations. “There were a few times when I found myself on the streets,” Ms. Schmidt said — “no apartment, I was cut off of welfare, living from place to place. I lived out of my car for a while. With my son.
“So my story is very much these girls’ story. And it just takes one person, one person, to just say, ‘You are worth it. You’re not a terrible person for the mistakes and the things you’ve done in the past. You may have gone through whatever, but there’s a way out.’ ”
She did not need to say that for her clients, 15 at any time, she intended to be that one person.
Joanne Schmidt is a nurse for the New York City Department of Health and Mental Hygiene, in a program called the Nurse-Family Partnership, which matches specially trained nurses with low-income first-time mothers, starting during pregnancy; they meet at the mother’s home every week or two until the child’s second birthday. She is also a daughter of the soul singer Sam Moore, of Sam and Dave — a quick-eyed woman with freckles and a Rochester accent that adds a Midwestern flavor to mild oaths like “jeez Louise” or “shut the front door.”
Raised mostly by her maternal grandmother and aunt, she was not told until age 8 who her father was, or why she looked different from her German relatives.
Her unit takes the hard cases: mothers in foster care, homeless shelters or Rikers Island.
The program, which was started in upstate New York in the 1970s and has been adopted in 42 states, is one of the rare public initiatives that have shown consistent and rigorously tested benefits for the mothers and children, as well as significant savings for taxpayers.
In different studies on different demographic groups, women in the program have had fewer premature deliveries, smoked less during pregnancy, spent less time on public assistance, waited longer to have subsequent children, had fewer arrests and convictions, and maintained longer contact with their baby’s fathers. Their children have had fewer language delays and reported less abuse and neglect, slightly higher I.Q. scores, fewer arrests and convictions by age 19, and less depression and anxiety.
A 2011 study of New York City’s Nurse-Family Partnership program, which currently has 91 nurses serving 1,940 families, projected that by the time a child in the program turns 12, the city, state and federal governments will have saved a combined $27,895, with additional savings thereafter — more than twice the program’s cost per child. The study was conducted by the Pacific Institute for Research and Evaluation using data from the Nurse-Family Partnership’s research at three locations, then extrapolated to New York.
This fall, I attended a dozen home visits, all in the Bronx, with five nurses — three from the Visiting Nurse Service of New York, which contracts with the city to provide service in the Bronx, and two, including Ms. Schmidt, with the health department’s Targeted Citywide Initiative, which tackles the most at-risk cases. The nurses’ styles and backgrounds varied; the families’ needs and challenges even more so. Each mother participated voluntarily and at no cost.
The problems were many: violence on the street, abuse in the women’s past, illness, anger, obesity, insecure housing or financial circumstances. Most of the women had the poor luck to have been born in poverty. Like their middle-class counterparts, none came into the world knowing how to raise a baby.
At the Andrew Jackson Houses in the South Bronx, Rose Mendoza and her nurse, Susan Spadafora, were discussing Ms. Mendoza’s plans for the next week. She had a doctor’s appointment for her son, Mason, who is about 17 months old, and an appointment to get an assessment from her psychiatrist, so she could receive counseling for her longstanding temper problems. Previous attempts to get this assessment had failed, often ending with Ms. Mendoza in a tantrum.
“If she’s not there,” Ms. Mendoza said of the psychiatrist, “I’m going to be mean.”
“You don’t have to be mean,” Ms. Spadafora said. She commended Ms. Mendoza, 26, for her progress in controlling her temper since the baby’s birth.
“She’s always late,” Ms. Mendoza said. “And I get frustrated to have to wait.”
Patiently, Ms. Spadafora, 52, who works for the Visiting Nurse Service of New York, walked her client through steps they had discussed for dealing with unresponsive clinic staff members without blowing up. Several times, the nurse has gone along on appointments to demonstrate ways to ask questions and elicit better treatment. Part of her work, she said, lies in modeling good habits.
“Susan’s changed a lot for me,” said Ms. Mendoza, who dyes her hair flaming red and has a gold stud by the corner of her mouth. “A lot. Like how to deal with things, how to think before you speak. Don’t just blurt it out.”
Most of Ms. Mendoza’s friends had children as teenagers, but she did not become pregnant until she was 24, with her long-term boyfriend, David. They both left high school in their senior years.
Hers was not an easy pregnancy. Ms. Mendoza weighed as much as 380 pounds and had diabetes and dangerously high blood pressure. Early tests showed that she was pregnant with triplets. One died in the womb, then a second. The third fetus and Ms. Mendoza were both in danger of not surviving.
On a late-November morning, Mason stared alertly at the action around him and babbled. He ambled from one part of the apartment to another.
Ms. Mendoza’s goal is to move out. Two people have been killed in the building since Ms. Spadafora started visiting, including one man who was shot in the daytime; Ms. Mendoza heard him screaming on the sidewalk at the pain, waiting for an ambulance that arrived too late.
During two visits I attended, Ms. Mendoza was adamant that she was going to get her G.E.D., study to become a pastry chef, apply for housing, get an apartment with David — “he’s a great father,” she said — and begin a new life with her new family. But she has been making such plans since pregnancy, Ms. Spadafora said.
“She seems to put roadblocks in front of herself,” the nurse said. “She’s registered for six or seven G.E.D. review courses. Always the obstacles seem real, but she can exaggerate them. Success can be as scary as failure. There’ll be more expectations if she gets a degree.”
Like other nurses I talked to, Ms. Spadafora finds herself trying to counteract certain practices of the babies’ grandmothers — like putting cereal in a baby bottle, which can lead to overfeeding. “Everybody wants a fat baby,” Debra Rivera-Oquendo, who works for the Visiting Nurse Service of New York, told me.
Though childhood obesity is not high on the national Nurse-Family Partnership agenda, it is a major concern in New York and especially in the Mendoza household, where obesity and diabetes are rampant. At 295 pounds, Ms. Mendoza was greatly slimmed down but still no waif. Her mother, who is also obese and diabetic, pushed back against the nurse.
“We’re trying to make tiny breakthroughs with the baby,” Ms. Spadafora said. “I’ll ask, ‘What things did your mother do that might have contributed to your obesity?’ She knows what her mother did wrong, and doesn’t want to do that with the baby. Rose is doing better with the baby than with herself.”
The visiting nurse program, though, is not for everyone. It makes demands on both nurses and clients, not least the demand for data, which means constant reporting and paperwork.
More than half of the mothers drop out before their child turns 2 — some because they successfully move into work or school, but others because they lose interest. In the original trials, 60 percent of mothers finished the program, but the rate fell to 42 percent as the program expanded — another impetus for more data-gathering.
For Joanne Schmidt, whose team has a far lower graduation rate because of the mothers’ challenges going in, each patient who drops out becomes an unsolved mystery.
“I wonder what happens to some of them,” she said. “I wonder if they went to school. I wonder if they’re out of jail. I try hard not to take it personal. They have their own life to live, and I made it through on my own with no help. A lot of these girls are tough. They know how to use their resources.
“It sounds cold, but I have to remember that this is my role. I can’t save the world. If someone drops, you wrestle with that for a second, then it’s, ‘all right, got to pick up the next client.’ That’s part of being a nurse, knowing you’re going to have clients that die on you. You have babies that die, you have clients that die. It’s sad to see, but it’s part of why you do what you do, and part of the reason everyone can’t be a nurse.”
The Monday after Ms. Schmidt’s visit to Ms. De la Rosa, the baby had still not arrived. The nurse was hoping the birth would fall on her own birthday, Dec. 12. She needed some good news. One of her patients, a 5-month-old boy born a month early, was in the hospital with respiratory syncytial virus, or RSV, an illness that can be fatal to premature infants. Another patient, who was born two months prematurely, was sick and not receiving treatment.
The two families were lined up back-to-back on her Monday morning schedule, along with a mother and her 3-month-old son who were living at Inwood House, transitional housing for homeless youths who are pregnant or have children. The mother, Nicola Brown, 19, said she had been physically and emotionally abused as a child, and verbally abused by the baby’s father.
Ms. Brown was the day’s first appointment, and she had good news: in part thanks to Ms. Schmidt, she had finished her training to become a home health aide. This after getting her G.E.D. in August.
Ms. Schmidt beamed at her. “Do you feel proud of yourself?” she said. “You should.”
Ms. Brown said she wanted to work for a while, then go to nursing school. She was seeing a mental health clinician because of lingering effects of her past abuse, she said.
Ms. Schmidt was her second nurse in the program. She had not gotten along with the first, whom she described as loud and obnoxious. “Joanne has an upbeat personality, and it’s easy to trust her,” she said, adding that she did not easily trust people.
The meeting was the easiest part of Ms. Schmidt’s day. At the next appointment, in the Eastchester neighborhood, Natasha Pennant and her boyfriend, Aaron Pelzer, had a sick child, a new apartment, problems with Medicaid and stress from Ms. Pennant’s mother, who recently had shoulder surgery, and who relied on her daughter for help raising four foster children. Their daughter, Azalea, was born at 30 weeks, weighing one pound, 14 ounces.
“I feel everything is on me,” Ms. Pennant said. “With my mom and Azalea, and trying to find a steady job.” She was too busy with her mother to reapply for Medicaid, she said. Without the coverage, she did not have money to take her daughter to the pediatrician.
Ms. Schmidt asked how she was coping with the stress.
“Honestly, I’m going back to smoking,” Ms. Pennant said. Mr. Pelzer, who is trying to start a mobile app business, sat nervously by her side.
“When you smoke, where do you smoke?” Ms. Schmidt asked.
Ms. Pennant told a story about Ms. Schmidt’s visiting her in the hospital just after Azalea was born. For two days, Ms. Pennant was unable to go to her daughter in the neonatal intensive care unit because of a pounding headache, which the floor doctors were not treating. Ms. Schmidt pushed the nurses on the floor to have a doctor look into it. Finally, a doctor said that the pain was a side effect of spinal anesthesia and prescribed treatment. Ms. Pennant was able to see and hold her child.
“It was all because of Joanne,” she said.
Now Ms. Schmidt urged the couple to take Azalea to the pediatrician or the emergency room ASAP. “They cannot refuse to see you based on your inability to pay.” Because Azalea had been premature, Ms. Schmidt feared RSV, and was especially worried about delaying treatment. “I just went through this with someone, and the outcome is not going well,” she said.
The last visit of the day was the hardest: At Montefiore Medical Center’s Wakefield campus, a weary Stephanie Velez-Rivera, 23, lay with her son, Elisha, on her chest, trying to ease his weak cough. After eight days in the hospital and a week of illness before, he had lost half a pound and wasn’t eating or sleeping. The night before, he had rolled off his mother while she slept and onto the floor; in the morning, she said, the medical staff had interrogated her as if she had dropped her baby.
Now she worried that when her husband learned of the baby’s fall, he would be upset with her. During Ms. Schmidt’s last visit, Ms. Velez-Rivera’s husband had rejected a suggestion of couples counseling.
Ms. Schmidt did not criticize the husband. “His personality isn’t able to handle some of the things you can,” she said.
“He gets stressed out,” Ms. Velez-Rivera said.
Ms. Velez-Rivera, who has sickle-cell anemia, said that she had been raised in an abusive home, “physically, emotionally, verbally,” and that she was determined to make a better home for Elisha; the boy’s needs, she said, came before hers or her husband’s.
Ms. Schmidt had no easy answers. The child was very sick, the marriage was fraught, the mother was pushed beyond exhaustion — and still it was not too early to discuss birth control, so Ms. Velez-Rivera would not become pregnant again right away. The nurse promised to bring information at their next visit, and to check back in a few days.
Ms. Schmidt’s birthday came and went without Ms. De la Rosa delivering her baby. Instead of celebrating, the nurse went to a holiday party for the mothers and babies in the program. She asked her clients not to mention her birthday, saying the party was for them, not her.
By week’s end everything was still up in the air. Ms. De la Rosa’s doctor said he would wait until Dec. 18 before inducing labor. Ms. Velez-Rivera was fighting to keep Elisha in the hospital, saying he was still not eating well enough to be safely discharged.
Ms. Schmidt put away her work cellphone for the weekend, then picked up a message anyway.
“All my girls have a lot going on,” she said. “That’s their everyday life. I know that they’ll be O.K., and that the decisions they make will become the road they have to take.”
She took a deep breath. “I have to hang up my cape at some point,” she said. “You let it go, then you pick it back up.”
“One reason this particular manuscript was a good fit for Nursing Economic$ is because it addresses the measures, methods and metrics. If we are going to make a business case for caring we have to make sure that we have the data that supports nursing’s work. This article showed in black and white how what they were doing helped the bottom line,” remarked Donna M. Nickitas, PhD, RN, NEA-BC, CNE, editor of Nursing Economic$.
