Young Mothers' Service Duration in Doula Home Visitation: Roles of Depressive Symptoms and Risk-Taking Behavior

Background/Purpose. Families participating in early childhood home visitation often discontinue services while they are still eligible. Attrition rates average around 50% by the child’s first birthday and 60-70% by their second birthday. However, little is known about specific time periods during which families are especially likely to discontinue services. Additionally, only a few studies have examined roles of mother and family-level characteristics in attrition, and findings have been inconsistent. This study aims to examine the timing of service attrition and the association between mother emotional-behavioral health, specifically depressive symptoms and risk-taking behavior, and service duration.

Methods. Data were drawn from 156 young, low-income mothers (M=18.4 years) in the intervention group of a randomized controlled trial of doula-enhanced home visitation. Home visiting services from a community doula and home visitor were offered to mothers from pregnancy through several years postpartum. Doulas provided support around pregnancy health, labor and delivery, and mother-fetal bonding, and home visitors focused on child development, health, and mother personal development. Mother variables were collected during a prenatal baseline interview. Depressive symptoms were measured by the Center for Epidemiological Studies-Depression and categorized into high and low based on the clinical cutoff. A composite risk-taking score was created using indicators of mother smoking, alcohol use, sex partners, school suspensions/expulsions, and police involvement. Information about home-visiting service duration was retrieved from administrative systems and through follow-up mother interviews. Discrete-time survival analysis was used to explore the timing of service attrition and associations with mothers’ depressive symptoms and risk-taking.

Results. Half of the mothers remained in home visiting at one year postpartum. The second and third months postpartum witnessed the largest percentages of attrition. On average, mothers remained in services for 15 months. Risk-taking behavior (hazard ratio=1.86, 95% CI=[1.21, 2.84]), but not depressive symptoms (hazard ratio=0.94, 95% CI=[0.64, 1.37]), was associated with service duration. Additional analyses showed that mothers with higher levels of risk-taking (upper quartile) remained in services at similar levels as other mothers from pregnancy to six weeks postpartum (hazard ratio=0.55, 95% CI [0.12, 2.49]), but they discontinued services more rapidly after six weeks postpartum (hazard ratio=2.16, 95% CI=[1.39, 3.36]).

Conclusions/Implications. This study reveals that home-visiting attrition rates were highest in the early postpartum months, which suggests that service providers may need to develop specific strategies for retention as mothers adjust to caring for their infant and return to work or school. These may include more frequent check-ins, flexibility in timing of visits, and facilitation of the transition from doula to home visitor. This study also highlights the role of mother risk-taking in service involvement, which has received limited attention in home-visiting research. Home visitors may need ongoing training and supervision to understand mothers’ risk-taking behavior in relation to their social and developmental contexts, to address mother problem behavior, substance use, and family violence in a developmentally and culturally sensitive way that will not be perceived as punitive and judgmental, and to strategically engage mothers to facilitate their continued service involvement.