Doula Home Visitors Are Effective at Promoting Sensitive Parenting during Early Infancy: A Randomized Controlled Study

Background and Purpose: Early infancy is the age when children are at greatest risk for serious harm from child abuse. Although evidence suggests home-visiting programs are effective at reducing parenting stress and increasing sensitive parenting behavior among parents of young children, few evaluation studies have reported impacts on parenting behavior during the earliest months of life. Moreover, although most home-visiting program developers believe that parenting interventions will be most effective if they begin before the birth of the child, engaging parents during pregnancy has been difficult. The current study examines a model in which home visitors partner with community doulas who begin working with mothers intensively during pregnancy with a focus on child birth preparation, sensitivity to infant cues, and parenting preparation. Doulas are at the birth with the mother to support her with labor, breastfeeding, and connecting to her newborn. This randomized controlled trial examines whether a doula enhancement to evidence-based home-visiting services has impacts on parenting behavior during the early months of life.

Methods: 312 mothers were randomly assigned to receive either doula-home-visiting services or less intensive case management. Eligibility criteria required participants to be first-time, low-income mothers. The sample was racially/ethnically diverse, and the average age of mothers was 18.4 years. Mothers assigned to the intervention were offered weekly doula-home-visiting services during pregnancy and continuing after the birth. At 3 weeks and 3 months postpartum, mothers were interviewed about their parenting behaviors and attitudes, and engaged in video-recorded interactions with their infant. Video-coders blind to group assignment coded the interactions for maternal sensitivity to distress, sensitivity to non-distress, intrusiveness, disengagement, positive regard, negative regard, and flatness using modified NICHD ratings. At 3 months, mothers also completed the Adult Adolescent Parenting Inventory (AAPI), a measure of parenting attitudes related to risk for child abuse and neglect.

Results: Intent-to-treat regression analyses showed differences in behavior and attitudes between the two groups. Mothers who received the intervention were observed to be less intrusive with their infants at 3 weeks (ß =-.13, p=.018) and 3 months (ß =-.13, p=.019) relative to mothers in the control group. Intervention group mothers were also more sensitive to their infant’s distress at 3 months (ß =.19, p=.017). They were less likely to hold parenting attitudes supporting use of physical punishment of children (ß =-.11, p=.033).

Conclusions and Implications: These findings demonstrate that a doula-home-visiting program that begins during pregnancy, when mothers are first developing relationships with their infants, can enhance early maternal behaviors and attitudes that reflect attunement to the baby’s cues and needs, and have been associated with reductions in child maltreatment in previous studies. This model may be a promising enhancement to home-visiting programs for the prevention of child maltreatment and promotion of positive parenting behavior. Specifically, this approach may be useful as a framework for home and community based practices to promote positive maternal behaviors and attitudes with economically vulnerable parents during initial mother-newborn interactions.