Helping Relationships in a Doula Home Visiting Program: Perspectives from Young Mothers and Home Visitors

Background:  Many programs targeting parenting, infant mental health, and early childhood development have adopted a relationship-based framework, which has been recognized as an evidence-based best practice (Raikes & Edwards, 2009; Zeanah, 2000).  A guiding principle of those programs is the parallel process:  Positive helping relationships between program staff and families promote strong parent-child relationships and positive changes within families.  Although helping relationships have been identified as central to the success of infant-mental-health and parenting programs (Elicker, Magana, & Sketchley, 2000), the nature of relationships between program staff and participants has not been well studied in existing literature.   

Objectives:  This research examines the quality of helping relationships between program participants and home visitors, and compares and contrasts both parties’ perspectives to explore their congruence. 

Methods:  The study uses data from a randomized controlled trial of a program in which community doulas offer support to young, low-income African American mothers.  Doulas are trained paraprofessionals with connections to the communities in which their clients live.  Doulas provide emotional support and comfort to the mothers during labor and delivery and weekly home visiting, beginning in the last three months of pregnancy and extending through the first three months after birth.  Home visiting focused on emotional support, health education, and promotion of mother-infant relationships.  124 mothers in the intervention group were included in the study.  Mothers were an average age of 18.2 years, began the intervention when they were an average of 26.6 weeks of pregnancy.  Most were not working (84%), and most were using Medicaid for prenatal care (95%).  

In confidential research interviews after intervention completion, both mothers and doulas reported on their relationship quality, using an adaptation of the Working Alliance Inventory (Horvath & Greenberg, 1994), a 12-item, 4-point rating scale that includes comparable service provider and client versions.   

Results:  On average, the mothers tended to rate helping relationships much more positively than the doulas (3.54 vs. 2.65).  On 75% of the scale items, there was a greater than 1 point difference between the doula and mother ratings.  The ratings of the relationship provided by mothers and doulas were correlated at a modest level (r = .37, p < .01).  At the item level, the doulas and mothers had the most congruence on whether they liked each other, had shared understanding of what to accomplish in visits, and whether the doula understood what the clients’ concerns were.  Doulas and mothers had the least agreement on whether they were appreciated by the other and in confidence in the doula’s ability to help.

Conclusion:  This study suggests that program participants and home visitors experience their relationships quite differently, with home visitors greatly underestimating the quality of the clients’ experience.  Findings hold implications for program practice, including home visitor training in areas related to listening and understanding participant perspectives and developing mutually agreed goals.  Most importantly findings suggest the need to provide supervision of paraprofessional that supports them in their difficult work and helps develop their confidence in the positive impact their work may be having.