Doula Home Visiting Intervention Effects on Sensitive Parenting and Infant Social-Emotional Development

Background and Purpose: Home visitation for low-income families has shown modest impacts on a variety of parent and child outcomes, but more research is needed to understand who benefits most from these programs. This longitudinal, randomized controlled trial tests the following research questions: 1) Are evidence-based home visiting programs enhanced with doula services for young mothers effective in promoting sensitive parenting and infant socioemotional development? 2) Do maternal depressive symptoms and mother risk-taking behavior moderate program effectiveness?

Methods: 312 young pregnant women (M=18.4 years; 49% Black/AA, 38% Latina, 8% White, 9% other) were randomly assigned to either a case management control group (n=156) or a doula home visiting intervention group (n=156). Intervention mothers were offered weekly home visits from a community doula and home visitor from mid-pregnancy through several years postpartum. Doulas focused on the mother-infant relationship, pregnancy, childbirth, and infant care, and home visitors focused on parenting and child development. Mothers were interviewed in their homes multiple times from pregnancy through 30 months postpartum, mother-infant interactions were video-recorded at postpartum follow-ups, and child developmental assessments were conducted at 13 and 30 months. Measures included standardized questionnaires and direct observation of parenting behaviors (NICHD ratings), attitudes (AAPI) and discipline strategies (CTSPC), and infant/toddler behavior (Bayley; ITSEA). Video-recorded interactions were rated by highly trained and reliable coders. Prenatal depressive symptoms (CES-D) and a composite score of mother risk-taking behaviors (delinquency, sexual risk, and substance use) were tested as moderators. OLS and logistic regression analyses were conducted, with interactions included to test for moderation.

Results: For the sample as a whole, intent-to-treat analyses showed small intervention effects on early sensitive parenting behavior and on use of appropriate discipline practices. Most intervention effects, however, were concentrated among mothers with higher levels of risk-taking behavior: high risk intervention mothers showed less intrusiveness, more careful handling, and greater sensitivity during mother-infant interactions, less use of psychological aggression, and more sensitive parenting attitudes, and their toddlers showed greater emotional regulation, fewer externalizing behaviors, and more social competence compared to high risk control mothers. Prenatal depression did not moderate intervention effects on parenting outcomes, however, only toddlers of mothers with low depressive symptoms benefited from the intervention in terms of problem behaviors.

Implications: Prior research has examined whether maternal depression attenuates the effects of home visiting services, but mother risk-taking behavior has largely been ignored as a potential moderator. The current findings suggest that doula home visiting may be especially effective for young mothers involved in risky activities. Since home visitors may find these mothers especially challenging to work with, programs may need to provide additional support, such as professional development and reflective supervision, specifically related to serving this high risk population.