A Nurturing, Caring Relationship

VOLUME 21 | ISSUE 2 | SUMMER 2014

Many mothers can attest to the benefits of working with a doula, a paraprofessional who visits a family in the third trimester and assists during the birth. Before that wonderful moment when a new mother holds her baby comes the delivery, which can be difficult, particularly the first time. Having a doula at a mother's side makes the process easier.

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ABSTRACT 

Sydney Hans, SSA’s Samuel Deutsch Professor, has recently published her research on the impact of a “community doula” who, in addition to joining the mother during labor and delivery, visits new parents in the home in the weeks before and after birth to answer questions and help the mother get to know her baby. Her work shows that the low-income, young mothers who had been clients of the University of Chicago Doula Project are more likely to breastfeed and more comfortable with their roles as mothers. To add to her findings, she has launched a new randomized controlled trial examining the effectiveness of the community doula model as it is being implemented in home visiting programs statewide.

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Thanks to the work of Sydney Hans, the benefits of extending the role of a doula to working with a young mom before and after the birth are clear as well. Hans, SSA's Samuel Deutsch Professor, has recently published her research on the impact of a "community doula" who, in addition to joining the mother during labor and delivery, visits new parents in the home in the weeks before and after birth to answer questions and help the mother get to know her baby.

In two papers, Hans has reported just how effective those helpers can be for very young parents who are living in poverty. Her work shows that the mothers who were clients of the University of Chicago Doula Project, which Hans started in 2000, are more likely to breastfeed and more comfortable with their roles as mothers. "The doula can go to doctors' visits before birth, explain what is going on as a woman goes into labor and begins to feel pain, and be there afterwards to encourage a mother to breastfeed and learn about her baby," Hans says. 

Hans' work on home visits and collaborations with social service agencies in Chicago could have an important impact on how the needs of young disadvantaged mothers are addressed. The Affordable Care Act is providing $1.5 billion to states to support home visitation programs. From the start, Hans' research was designed to measure the impact of doulas in home visitation, and to add to her findings to date, she has launched a new randomized controlled trial examining the effectiveness of the community doula model as it is being implemented in home visiting programs statewide.

"In making guidelines for spending those funds, the federal government developed a list of home visiting models where there is evidence of effectiveness," Hans says. "They want the funds to go toward models that have been demonstrated to work." 

Hans' research early in her career on mother and child attachment and the challenges faced by adolescent mothers attracted the attention of the late Chicago philanthropist Irving B. Harris, who was one of the nation’s leading advocates of early intervention for children at risk. As chairman emeritus of the Ounce of Prevention Fund, a partnership between private donors and the state of Illinois that supports programs to help children who are born into poverty, Harris was an original supporter of the groundbreaking research that established the value of doula services.

“It was in the 1990s and Irving wondered if having doulas would benefit young women from disadvantaged situations,” Hans recalls. “He was firm believer in the value of rigorous research to identify successful interventions to address social problems.”

Some of the most impressive research results around interventions in early childhood development have been around home visitation, where a nurse or paraprofessional makes regular visits to the home of at-risk mothers in the first years after a child is born. First studied in the late 1970s, home visitation models have been tested dozens of times since, and in a 2003 report for the Centers for Disease Control, the Task Force on Community Preventive Services recommended home visitation for families at risk for maltreatment, including disadvantaged populations and families with low birth weight infants.

In the late 1990s, several community service organizations in Chicago funded by the Ounce of Prevention were providing a variation on home visitation that utilized a doula as part of a home visiting team for women during pregnancy and the newborn period. “[The doulas] create a fabric of support that weaves together unswerving belief in the young woman, which impacts her own belief in herself and her capacity to have a voice and to be heard in how she wants to go through pregnancy and the birthing process,” says Nick Wechsler, director for program development at the Ounce of Prevention.

With the support of the Irving Harris Foundation and federal funding, Hans established the University of Chicago Doula Project to provide an institutional platform to do a longitudinal study of the community doula’s effectiveness, particularly around health and parenting outcomes. The project hired four doulas, who received 10 weeks of extensive training from HealthConnect One, a nonprofit advocate for community-based, peer-to-peer support for pregnancy, birth, breastfeeding and early parenting. Supervised in their work by a pediatric nurse, they also received continuing education.

Over three years, the team recruited 248 African-American women under 21 years of age, most of whom were low-income, to be part of the study, starting when they were less than 34 weeks pregnant. Half received normal prenatal care and the other half received that care as well as weekly visits from doulas from before birth and for three months afterwards.

During the weekly prenatal visits, the doulas built relationships with the mother while discussing pregnancy, health, childbirth preparation and bonding with the unborn infant. After birth, at the weekly meetings, the doulas built on that relationship and trust, approaching the home visits from a family support model. The doulas attempted to guide mothers to positive behaviors in a nonjudgmental way, encouraging the women to read and talk to their children, for example, and engaging the mothers in conversations to promote a nurturing, caring relationship.

“What is particularly rewarding in our visits after the  baby is born is to talk to the mother, and relive the birth through allowing her to tell her birth story and protect her memory of the birth,” says Tikvah Wadley, a doula in Hans’ study who now trains doulas for HealthConnect One. “These visits are a wonderful chance to see the baby, to talk about bathing the baby and facilitating bonding between mom and baby.” 

Other research has shown that doula support during labor leads to better obstetric outcomes, including shorter labors and less use of medical interventions. From the start of the project, Hans wanted to measure if a community doula could also increase rates of breastfeeding, which has been shown to be beneficial to children in a number of ways, including reducing infections and childhood obesity, but is relatively uncommon among young African-American mothers, due to factors such as a lack of information, cultural context, and limited support from family and friends.  

“Doulas are with the mother in the hours and days immediately after the birth that are the most critical time for initiating breastfeeding. Doulas can encourage the mother to put the baby to breast in the delivery room, to help the baby to latch on to the nipple, and to work with the mother should any problems arise,” Hans says. Three of the doulas working in the study became certified lactation counselors, and part of their work included encouraging the women to breastfeed during their prenatal visits and being ready with support after the baby arrived. They educated mothers about the benefits of breastfeeding using printed, video or other informational materials and included fathers and mothers’ family members in the discussions to build a supportive environment.

The results were encouraging. In “Breastfeeding and Complementary Food: Randomized Trial of Community Doula Home Visiting,” published in the November 2013 issue of the journal Pediatrics, Hans and her co-authors reported that 64 percent of mothers with community doula support choose to breastfeed, compared with 50 percent of the mothers in the control group. The mothers with community doulas also were nearly twice as likely to continue breastfeeding longer than six weeks. 

Hans and her team also wanted to measure whether a community doula can help improve the quality of the mother-infant relationship, which is often touted as a benefit of home visitation. Low-income, very young mothers living in difficult circumstances can have a hard time raising their babies. Does advice and support from a doula help promote “good parenting”.  

To find out, the mothers were interviewed about how they felt about being a mother and their relationship with their baby. Hans also turned to a tool that she’s used for nearly 30 years in her research—measuring mother-child interaction from video recordings. At points when the babies were four months, one year and two years old, the mother and her child visited a hospital playroom and the  mom was asked to do some routine activities, like dressing the baby and showing the baby a new toy, all documented on camera.

“My students, who didn’t know which mothers had received services from a community doula and which had not, would watch the videos and code mother and baby behaviors,” Hans says. “In this kind of research, observer reliability is important, so every tape was watched by two different researchers, and there had to be consensus on what was seen. To overcome personal and cultural biases, we trained our staff to focus on the actual behaviors they observed rather than to make judgments about whether a mother was a good parent.”

Hans says the team was particularly looking for sensitivity on the mother’s part, like noticing what the child was interested in, and in the mother’s encouragement of learning by talking with the child and interacting with him or her, “the whole back and forth between mother and a baby that research has shown means so much for early childhood development.” In “Promoting Positive Mother-Infant Relationships: A Randomized Trial of Community Doula Support for Young Mothers,” Hans and co-authors reported that mothers who had been visited by community doulas showed more encouragement of their infants’ learning at four months than did control group mothers, and the infants were less likely to have long periods of distress. The report was published in the September/October 2013 issue of Infant Mental Health Journal.

The paper also notes, though, that the impact of the doula’s work faded over time. That was no surprise to Hans, who says that she never expected a community doula to be a “magic bullet” whose work could inoculate parents forever. “The doula can be a tremendous help in the first days and weeks and months, and that has a huge impact,” she says. “But parents need to continue to get support after that with ongoing home-visiting services.”

The University of Chicago Doula Project is past its grant funding, but the work continues at HealthConnect One and the Ounce of Prevention Fund, which has 50 doulas in 23 locations around Illinois and recently reached a milestone of having assisted 10,000 births with doula services.

In the Ounce of Prevention program, a community doula and a home visitor often work together in the kind of manner Hans says works well. "Sometimes they take turns visiting the families during pregnancy, sometimes they make occasional home visits together, sometimes the doula works with the mother in the home during pregnancy, and after the birth there is a gradual handoff to the regular home visitor," Hans explains.

Having focused in on the impact of community doulas, Hans' latest project is a study of the Ounce of Prevention doula model as it is run in community agencies across Illinois. Funded through the Affordable Care Act, the research is using randomized controlled trial methods to see if there is evidence of the program's impact on pregnancy outcomes, breastfeeding and mother-infant relationships.

Wechsler praised Hans for her leadership in promoting the use of doulas and for her work as a sympathetic researcher. "She helps people understand the value of taking part in a randomized, controlled study," he says. "People who are subjects for these studies sometimes wonder what's in it for them, but she is able to encourage them to take part because she brings sensitivity to her scientific work."

Wechsler also points out the value of having research results when it comes to continuing and expanding the work. To access funding from the ACA's Maternal Infant Early Childhood Home Visiting Program, for example, a program needs to be using a model for which there is an evidence-base. "Those studies play a critical role in helping secure support as funders look for ways in which these programs demonstrate effectiveness," he says, "and that is why meaningful research such as Sydney's is so vital."