Relationship As a Mechanism of Change: Community Doula-Mother Relationship and Parenting Behavior in Home Visiting Servicess

Background/Purpose: Home visiting programs are often described as “relationship-based” interventions, with the parent-home visitor relationship theorized as an active ingredient in achieving programs goals, including positive parenting behavior. Specifically, mothers are nurtured by the emotional availability of and trust with home visitors and model their parenting after this relationship. However, studying the impact of the parent-home visitor relationship on parenting is challenging since the quality of the relationship cannot be randomized, thus its effect could be confounded by other variables. This study uses a propensity score-based method to account for confounding variables and to test the “relationship as an active ingredient” hypothesis.

Methods: Data came from a sample of 124 young (M=18.6 yrs), low-income mothers (48% African American, 42% Latina, 10% European American) who were offered weekly home visiting services from community doulas prenatally until 6-weeks postpartum. Doulas also provided support and comfort to mothers during childbirth. Mothers rated the quality of their relationship with their doula at 3-weeks postpartum on the 4-point Working Alliance Inventory-Short Form, which includes questions about mothers’ bond with their doula and agreement on tasks and goals. “Treatment” of a very positive relationship and “control” of a less positive relationship were defined by a cutoff of an average score of 3.5 (1=>3.5; 0=<3.5). Mothers’ parenting behaviors were coded from video-recorded mother-infant interactions at 3-months postpartum. Baseline (prenatal) covariates that were conceptually related to parenting outcomes and/or the mother-doula relationship were chosen. The propensity score (i.e., the probability of having a very positive mother-doula relationship) was estimated by regressing the “treatment” on the baseline covariates in a logistic regression. An inverse probability of treatment weight (IPTW) was calculated for each mother. After balance was achieved, treatment effects were estimated.

Results: Twelve baseline variables were selected for the propensity score model including mothers’ demographic and psychosocial characteristics and parenting attitudes. After weighting, the group with a very positive mother-doula relationship and the group with a less positive relationship were balanced on baseline characteristics and the propensity score. A very positive mother-doula relationship was associated with greater observed maternal sensitivity and careful handling of the infant, but not associated with intrusiveness, detachment or stimulation.

Conclusions/Implications: This study lends preliminary causal evidence to the “relationship as an active ingredient” hypothesis within home visitation, at least for certain parenting outcomes. The acceptance and understanding in a positive mother-doula relationship may make mothers feel valued and nurtured, and mothers may be more likely to perceive her infant’s behavior acceptable, respond to her infant’s cues effectively, and practice the sensitive and gentle parenting strategies promoted by her doula. Doulas used a strength-based approach in their work, identifying positive parenting while not singling out problematic parenting, and a very positive doula-mother relationship may be less effective in preventing negative parenting behaviors such as intrusiveness and detachment. Social workers in parenting programs may be most effective at promoting positive parenting when they develop a trusting relationship and partner with parents to achieve shared goals.