Enhancing Home Visiting Programs With Doula Services

Background and Purpose:  The purpose of this study was to evaluate the benefits and challenges of incorporating doula services into existing home visiting programs for pregnant and parenting teenagers.  Meta-analyses of home visiting programs have found small but positive effects in a variety of child and maternal health and developmental outcomes.  Because of small effect sizes, attention is shifting toward identifying ways of enhancing home visiting program models to increase their effectiveness.  One promising enhancement is doula services, an evidence-based intervention offering childbirth preparation, prenatal health education, labor support, breastfeeding education, and support around newborn care, topics not thoroughly addressed in most home visiting models.  Doula services may attract clients earlier in pregnancy because of the doula’s focus on pregnancy health.  However, little is known about challenges that may arise when enhancing well-established home visiting programs with additional services.

Methods:  Focus groups were conducted at three programs serving low-income communitiesthat followed nationally-recognized home-visiting models and that were selected to receive state funding for doula services.  Focus groups were conducted with program staff immediately before and 8-9 months after implementation of the doula enhancement.  Separate focus groups were conducted with program administrators, home visitors, and doulas at each time point.  Questions focused on staff perceptions of the doula model, benefits of doula services for clients, challenges associated with implementation, and challenges to maintaining fidelity to program models. Transcripts were content coded by two raters for themes in an effort to identify themes that changed over time and themes that differed between types of respondents.  

Results:  Prior to implementation, administrators and home visitors had little experience with doulas but were enthusiastic about the new services they would be providing clients.  After implementation, doulas and home visitors reported feelings of mutual respect for each other’s work, felt they effectively negotiated sharing clients, and believed that clients were benefiting from the additional services.  Program administrators and doulas, however, were experiencing challenges in working with each other.  Administrators reported that doulas struggled to understand that their role included doing “social work” and addressing client needs in addition to providing traditional doula services.  Doulas felt that there were no clear guidelines regarding their role, or a curriculum or guide in place that they could follow when providing services.  These discrepant understandings contributed towards feelings of ineffective supervision on both the part of administrators and doulas.  Program administrators and home visitors believed that fidelity to the home visiting models was maintained throughout the implementation process.

Conclusions and Implications:  Overall, program staff believed that enhancing home visiting with doula services was beneficial for clients, and home visiting model fidelity was maintained.  However, there was ambiguity over the role of the doula within these home visiting programs.  Home visiting programs looking to incorporate doula services should lay out clear guidelines as to the role and content of services doulas should provide prior to hiring and training.  Supervisors should be trained to understand the unique work doulas provide and support needs they have in order to provide effective supervision.