Randomized Controlled Trial of Doula-Home-Visiting Services: Impact on Maternal and Infant Health

Randomized Controlled Trial of Doula-Home-Visiting Services: Impact on Maternal and Infant Health Introduction Although home-visiting programs typically engage families during pregnancy, few studies have examined mater- nal and child health outcomes during the antenatal and newborn period and fewer have demonstrated intervention impacts. Illinois has developed an innovative model in which programs utilizing evidence-based home-visiting models incorporate community doulas who focus on childbirth education, breastfeeding, pregnancy health, and newborn care. This randomized controlled trial (RCT) examines the impact of doula-home-visiting on birth outcomes, postpartum maternal and infant health, and newborn care practices. Methods 312 young (M = 18.4 years), pregnant women across four communities were randomly assigned to receive doula-home-visiting services or case management. Women were African American (45%), Latina (38%), white (8%), and multiracial/other (9%). They were interviewed during pregnancy and at 3-weeks and 3-months postpartum. Results Intervention-group mothers were more likely to attend childbirth-preparation classes (50 vs. 10%, OR = 9.82, p < .01), but there were no differences on Caesarean delivery, birthweight, prematurity, or postpartum depression. Intervention-group mothers were less likely to use epidural/pain medication during labor (72 vs. 83%; OR = 0.49, p < .01) and more likely to initiate breastfeeding (81 vs. 74%; OR = 1.72, p < .05), although the breastfeeding impact was not sustained over time. Intervention-group mothers were more likely to put infants on their backs to sleep (70 vs. 61%; OR = 1.64, p < .05) and utilize car-seats at three weeks (97 vs. 93%; OR = 3.16, p < .05). Conclusions for practices The doula-home-visiting intervention was associated with positive infant-care behaviors. Since few evidence-based home-visiting programs have shown health impacts in the postpartum months after birth, incorporating doula services may confer additional health benefits to families. Keywords Doula · Home visiting · Breastfeeding · Safe sleep Significance with other indicators of mother and newborn health at birth or improvements in maternal depression. What’s Known on This Subject Research has shown that home-visiting programs have positive impacts in varied domains of parent and child functioning. However, few stud- Introduction ies have examined maternal and child health at birth and during the newborn period. Home Visiting and Maternal Child Health What This Study Adds This study, evaluating a home- visiting model that incorporates community doulas into the Growing evidence shows that childhood home-visiting pro- intervention team, demonstrates improvements in childbirth grams for socially and economically vulnerable families can preparation, breastfeeding initiation, safe sleep practices, have impacts in multiple areas, including maternal and child and early car-seat use. The intervention was associated with health, parenting, child development, and family economic less use of pharmacologic pain control during labor, but not self-sufficiency (Paulsell et al. 2010). When federal sup- port for home visiting was dramatically increased in 2010 through the Maternal Infant Early Childhood Home Visit- * Sydney L. Hans ing (MIECHV) program (Thompson et al. 2011), the leg- shans@uchicago.edu islation set expectations that program should have impacts School of Social Service Administration, University across multiple domains, including “improved maternal and of Chicago, 969 E 60th Street, Chicago, IL 60637, USA Vol.:(0123456789) 1 3 S106 Maternal and Child Health Journal (2018) 22 (Suppl 1):S105–S113 newborn health” (“Patient Protection and Affordable Care a model where doulas were integrated into home-visiting Act”). Although MIECHV legislation did not prioritize programs in order to enhance the quality of health-related specific maternal and newborn health outcomes, the U.S. services during pregnancy and the postnatal period (Glink Department of Health and Human Services’ national health 1998, 1999). blueprint, Healthy People 2020 (Office of Disease Preven- In the “community doula” model that resulted, doulas are tion and Health Promotion 2014), identifies such priorities: community health workers who have training in pregnancy mother health at birth and postpartum (including attendance health, childbirth preparation, labor support, lactation coun- at childbirth preparation classes, reduction in Caesarean seling, and newborn care. They serve as specialized home deliveries, reduction in maternal postnatal medical compli- visitors, providing home-based education and support dur- cations, and reduced postpartum depression), infant morbid- ing the last half of pregnancy and for 6 weeks postpartum. ity and mortality (including reduction in infant deaths, low Doulas accompany laboring women to the hospital to pro- birthweight and preterm birth), and infant care (including vide comfort measures and emotional support and to offer increased breastfeeding and increased proportion of infants postpartum help around breastfeeding and bonding. put to sleep on their backs). The rationale for including doulas within a home-based The United States lags behind other developed nations model drew from strong meta-analytic evidence that doula with respect to infant mortality and low birthweight (Mac- labor support is associated with improved health outcomes, Dorman et al. 2014; Wardlaw 2004), and there are dispari- including fewer Caesarean deliveries, decreased use of anal- ties in newborn and pregnancy outcomes related to maternal gesia/anesthesia, shorter labors, and higher Apgar scores age, poverty and race (Bryant et al. 2010; Martin et al. 2017; (Hodnett et al. 2013). One RCT examining the impact of a Nagahawatte and Goldenberg 2008). Despite evidence that community doula model in which doulas provided home vis- breastfeeding has advantages for mother and child health its in addition to labor support found increases in breastfeed- (Stuebe 2009), breastfeeding rates remain low in the US ing initiation among young, low-income mothers (Edwards among young, low-income and African-American women et al. 2013). (McDowell et al. 2008). Additionally, although the Ameri- The goal of this RCT is to examine whether young, low- can Academy of Pediatrics (Task Force on Sudden Infant income families receiving doula-home-visiting services, Death Syndrome 2016) recommends that infants be placed compared to families receiving lower-intensity case-man- in supine sleep positions in their own beds in order to reduce agement services, have improved maternal and child health the risk of sleep-related infant deaths, infants born to young, outcomes during the period between birth and 3 months of low-income mothers have a relatively high risk for prone age. placement and for co-sleeping (Colson et al. 2009; Caraballo et al. 2016). Despite many studies on infant and early childhood home Methods visiting, few reports document impacts on maternal and newborn health or newborn care practices. Only a few home- Study Sites, Enrollment, Randomization visiting studies have examined maternal depression during and Follow‑Up Procedures the first postpartum months, and none have found program impacts reducing symptoms (e.g., Barlow et al. 2013; Carta Study recruitment took place between 2011 and 2015. Part- et al. 2013). A few studies have shown impacts on preventing ners in the RCT were four agencies offering doula-home- low birthweight and/or preterm birth (Lee et al. 2009; Wil- visiting programs to young mothers in high-poverty Illinois liams et al. 2017), but others have not (e.g., Kitzman et al. communities. Two programs were located in a large city, and 1997; Olds et al. 1986). Most studies have not examined two in smaller urban areas. One served an African-American newborn health. Some home-visiting studies have reported population, one served a Latinx population, and two served impacts on early breastfeeding (Kitzman et al. 1997; Wen mixed-ethnic populations. Programs serving Latinx popu- et al. 2011), but most have not found impacts (Green et al. lations provided services in English and Spanish. Each of 2014; Kemp et al. 2013; Mitchell-Herzfeld et al. 2005). the programs already was implementing an evidence-based home visiting model (see overview of evidence in Paul- Community Doulas sell et al. 2010), either Healthy Families America (HFA) (“Healthy Families America” 2015) or Parents as Teachers Twenty years ago, early childhood advocates in Illinois (PAT) (“Parents as Teachers” 2018). Programs were from were concerned about home-visiting programs having lim- a network of state-funded home-visiting programs and not ited impact on maternal and newborn health outcomes. A demonstration programs for research purposes only. partnership between the Irving Harris Foundation, Health- Programs received information about young pregnant Connect One and the Ounce of Prevention Fund developed women from their usual referral networks—public health 1 3 Maternal and Child Health Journal (2018) 22 (Suppl 1):S105–S113 S107 departments, WIC programs, health clinics, and schools. Home visitors focused on the mother-infant relationship, Program staff contacted women to determine eligibility and child development, child safety, and educational-work plan- explain the program and research study. Women were told ning, as well as screening to make sure that family basic that the only way to participate in the doula-home-visiting needs were being met. Doulas focused on issues related to program was to participate in the study. If they were not pregnancy health, childbirth preparation, breastfeeding, interested in the research, they received contact information newborn care, postpartum health, and early bonding. Doulas for other community programs providing services for preg- sometimes accompanied mothers to prenatal and postpartum nant women, including case management, home visiting, and medical visits. Doulas attended births at the hospital where parenting programs in hospitals and health clinics. To be eli- they provided mothers with physical comfort, emotional sup- gible for the study, women needed to be under 26, less than port, and advocacy during labor and delivery and breast- 34 weeks gestation, living in the program geographic catch- feeding counseling postpartum. Doulas also offered prenatal ment area, planning to remain the area, and meeting sociode- classes at the program sites. All programs conducted regular mographic risk criteria used by the HFA or PAT models. Out depression screenings and made referrals to mental health of ethical concerns, pregnant women who were under 14, consultants. involved with the child welfare or juvenile justice systems, or had significant cognitive impairments were excluded from Case Management Control the study and offered home-visiting services. After screening, the research team scheduled a baseline After randomization to the control group, mothers were pro- session with mothers that included a written-informed- vided information about case management services in their consent procedure and a 2-h structured interview. At the communities, and case management providers were given end of this session, the interviewer opened a sealed opaque mothers’ contact information. In some communities, moth- envelope that showed whether the participant was assigned ers were referred to existing state-funded case-management to doula-home-visiting services (intervention condition) providers; in other communities, social-service provid- or case management (control condition). These envelopes ers were contracted to provide case management. It was had been prepared by the principal investigator before the expected that mothers would have at least two meetings with beginning of the study. Randomization tables were created case managers—one during pregnancy and one after birth. separately for each community. Meetings could be in families’ homes, in agency offices, or At 37-weeks of pregnancy, 3-weeks postpartum and occasionally by phone. Case managers determined whether 3-months postpartum, mothers were re-interviewed. Fami- families’ basic needs with respect to health, housing, food, lies received modest monetary compensation at each session employment, education, and childcare were being met, and if and a baby book and toy at each postpartum session. All needed, made referrals. Case managers screened to identify study procedures were approved by the Institutional Review needs for services regarding substance misuse, depression, Board at The University of Chicago, and the study is regis- and domestic violence. tered with clinicaltrials.gov [identifier NCT01947244]. Interviews Description of Group Conditions Outcomes were chosen based on Healthy People 2020 Doula-Home-Visiting Intervention maternal and newborn health priorities and outcomes that have been reported in previous studies of doula interven- After randomization to the intervention group, doula-home- tions. Interviews were available in English and Spanish and visiting programs assigned families a home visitor (also administered in the mother’s preferred language. Interview- called a Family Support Worker or Parent Educator) and ers working in Latinx communities were bilingual. Inter- a community doula. Doulas and home visitors all had deep views were usually conducted in families’ homes. roots in their communities. All home visitors and doulas At baseline, interviewers asked questions related to had completed at least the foundational training required the pregnancy, health care, mental health, education and by their national models, and doulas had completed at least employment, and relationships with family. Baseline inter- the basic training provided through the Ounce of Preven- view questions were used to check equivalence of the groups tion Fund. During pregnancy and postpartum, mothers were as randomized. visited weekly by a home visitor, doula, or both together. At all follow-up interviews, intervention-group mothers The doula worked with the mother more intensively during were asked about numbers of contacts with doulas and home pregnancy and the first weeks postpartum, while the home visitors. All mothers were asked about childbirth preparation visitor became the primary provider by 6 weeks postpartum. class attendance and any other pregnancy/parenting services. 1 3 S108 Maternal and Child Health Journal (2018) 22 (Suppl 1):S105–S113 At the 3-week postpartum interview (or 3-month inter- CONSORT chart identifying the flow of subjects through view if mother missed the earlier session), mothers reported the study. on birth outcomes, including pain medication/epidural use Participants in the baseline interview were young and during labor, vaginal versus Caesarean delivery, gestational low-income, with almost half identifying as black/Afri- age (GA) at delivery, infant birthweight, NICU admis- can American (45%, n = 140) and just over a third Latina/ sion, length of hospital stay, and mother and/or newborn Hispanic (38%, n = 117). 11% of mothers preferred to be re-hospitalizations. interviewed in Spanish. Most mothers were in their second At the 3-week and 3-month interviews, mothers reported trimester of pregnancy and expecting their first child. Over on breastfeeding. Breastfeeding initiation was defined as two-thirds were partnered (coupled, engaged, married) with breastfeeding at least through the hospital stay. Mothers were the father of the baby (71%, n = 220). Table 1 shows that asked how often they used a car-seat, the positions they used the only baseline difference between groups was that more when laying down their infant to sleep and where the infant intervention-group mothers were living with a parent figure slept. Mothers reported on depressive symptoms using the compared to control-group mothers (77 vs. 64%, p < .05). Center for Epidemiological Studies-Depression Scale (CES- Co-residence with parent figure was a control variable in D) (Radloff 1977), dichotomized to identify mothers with all analyses. clinically significant levels of depression (≥ 16). Intervention Participation Analytic Plan Virtually all mothers (99%, n = 153) assigned to the doula- home-visiting group received at least one home visit. Among First, the intervention and control groups were compared on mothers interviewed at 37 weeks, the average number of multiple baseline maternal characteristics measured before doula visits prior to 37 weeks was 8.9 (SD = 6.9) and the randomization using t-tests and Chi square tests to check average number of visits from a home visitor was 5.8 whether randomization was successful. Second, intent-to- (SD = 4.8). Doulas were present in the hospital for 75% treat logistic regression analyses were conducted to examine (n = 106) of the births. By 3-months postpartum, 131 (92%) the impact of the doula-home-visiting intervention on out- mothers had received at least one postpartum visit from their comes measured at 37-weeks pregnancy, 3-week postpar- doula and 120 (84%) had received at least one postpartum tum, and 3-months postpartum. Odds ratios, 95% confidence visit from their home visitor. intervals, and one-tailed p-values were calculated for each outcome, using the control group as the reference group. Intervention Eec ff ts Program site was used as a covariate in all analyses, and any baseline maternal variables that differed between the two Mother Birth and Postpartum Health groups were used as covariates. Results from logistic regression analyses using one-tailed hypothesis tests (Table  2) show that intervention-group Results mothers were more likely to attend a childbirth education class during pregnancy (OR 9.82, 95% CI 4.84–19.89) and Sample Characteristics less likely to use epidural or other pain medication during labor compared to control-group mothers (OR 0.47, 95% Altogether 436 women were referred to the programs. 312 CI 0.25–0.88). The intervention was not associated with were enrolled in the sample and randomly assigned to the Caesarean deliveries, mother re-hospitalizations, or mother two conditions. Reasons families were not enrolled included postpartum depressive symptoms. inability to contact, women not wanting to participate in services or the study, women not meeting eligibility criteria, Infant Mortality and Morbidity and women at high risk and referred to program services without randomization. The intervention was not associated with preterm births Interviews were completed for 256 mothers (82%) at (GA < 37 weeks), low birthweight, NICU admission, length 37-weeks of pregnancy, 283 mothers (91%) at 3-weeks of newborn hospital stay, re-hospitalization of infants, hav- and 278 mothers (89%) at 3-months. Sample attrition was ing a pediatrician or pediatric clinic at 3 weeks, or having a unrelated to program site, race/ethnicity, age, education, co- well-baby check up by 3 months. Almost all families in both residence, or prenatal depressive symptoms. There were no groups reported having a pediatrician for their infants (98%), differences in sample attrition at either follow-up interview and all mothers reported taking their infant in for at least one between the intervention and control groups. Figure 1 is a well-baby check up by 3 months of age. 1 3 Maternal and Child Health Journal (2018) 22 (Suppl 1):S105–S113 S109 Health clinics, schools, and social service agencies identify young pregnant women and refer to home-visiting programs. N=436 • Couldn’t be reached: 44 • Didn’t meet eligibility criteria: 45 • Not interested: 23 • High risk and referred to program: 12 Informed consent and baseline interview N=312 Randomized to Case Management Randomized to Doula Home-Visiting n=156 n=156 37 week pregnancy followup 37 week pregnancy followup n=127 n=129 • Delivered before 37 weeks 8 • Delivered before 37 weeks 5 • Unable to contact 2 • Unable to contact 6 • Unable to schedule 12 • Unable to schedule 12 • Declined 6 • Declined 4 • Fetal death 1 • Infant death 0 3 week postpartum followup 3 week postpartum followup n=142 n=141 • Unable to contact 3 • Unable to contact 8 • Unable to schedule 2 • Unable to schedule 2 • Declined 7 • Declined 4 • Infant/fetal death 2 • Infant/fetal death 0 • Caregiver change 0 • Caregiver change 1 3 month followup 3 month followup n=139 n=139 • Unable to contact 5 • Unable to contact 11 • Unable to schedule 2 • Unable to schedule 0 • Declined 8 • Declined 5 • Infant/fetal death 2 • Infant/fetal death 0 • Caregiver change 0 • Caregiver change 1 Fig. 1 Study CONSORT diagram 1 3 S110 Maternal and Child Health Journal (2018) 22 (Suppl 1):S105–S113 Table 1 Characteristics Control group Doula/HV group of doula-home-visiting n = 156 n = 156 intervention group and control group at enrollment Mother age in years M (SD) 18.3 (1.6) 18.5 (2.0) Mother years of school completed M (SD) 10.9 (1.5) 10.9 (1.5) Mother race/ethnicity n (%)  African American 72 (46.2%) 68 (43.6%)  Latina/Hispanic 56 (35.9%) 61 (39.1%)  White 13 (8.3%) 13 (8.3%)  Multiracial/other 15 (9.6%) 14 (9.0%) Mother attends school n (%) 78 (50.0%) 86 (55.1%) Mother employed n (%) 28 (18.0%) 31 (19.9%) Mother expecting first child n (%) 154 (98.7%) 152 (97.4%) Baby gestational age in weeks M (SD) 25.7 (5.9) 25.5 (6.0) Mother has received prenatal care n (%) 154 (98.7%) 155 (99.4%) Mother receives public insurance (n = 305) n (%) 138 (90.8%) 140 (91.5%) Mother receives WIC n (%) 137 (87.8%) 131 (84.0%) Mother depressive symptoms (CES-D) M (SD) 14.2 (9.2) 13.8 (8.5) Co-residing with own mother or other parent figure n (%) 100 (64.1%) 120 (76.9%) Co-residing with baby’s father n (%) 48 (30.8%) 39 (25.0%) Partnered with baby’s father n (%) 107 (68.6%) 113 (72.4%) Chi-square test shows significant difference between intervention and control groups at p < .05 on childbirth preparation, epidural/pain medication use dur- Newborn Care Practices ing labor, breastfeeding, and safe newborn-care practices. Mothers receiving the intervention were more likely to Mothers in the intervention group were more likely to have attended a childbirth preparation class. Although vir- initiate breastfeeding in the hospital (OR 1.67, 95% CI tually all mothers in the sample had opportunities to attend 0.91–3.03). At 3 weeks, mothers in the intervention group childbirth classes through prenatal clinics and hospitals, few were more likely to always place their infants on their backs control-group women took advantage of such opportunities. for sleeping (OR 1.64, 95% CI 0.97–2.77) and to always Half of the women in the intervention group participated in put their infants in a car seat when traveling by car (OR such classes either at clinics and hospitals or through weekly 3.67, 95% CI 1.06–12.70). There was a non-statistically- classes offered by their home-visiting programs. Moreover, significant trend for infants in the intervention group to have all mothers who were visited by a doula also received indi- their own beds (OR 1.44, 95% CI 0.89–2.34, p = .07). There vidualized childbirth education at home. Perhaps as a result were no group differences on breastfeeding, sleeping or car of this preparation and the presence of the doula during seat use at 3 months. labor, mothers in the intervention group were less likely to use pharmacologic pain relief during labor, a finding similar to other studies of doula labor support (Hodnett et al. 2013). Discussion However, as with the few other home-visiting studies exam- ining birth outcomes, there were no intervention impacts Although most early-childhood home-visiting programs on Caesarean deliveries, low birthweight, or preterm birth. begin working with families during pregnancy or soon after Although other studies of labor-only doulas have found birth, relatively few evaluations have examined maternal reductions of Caesarean rates (Hodnett et al. 2013), most of and child health outcomes at birth or during the newborn these studies limited samples to obstetrically low-risk moth- period. The doula-home-visiting model, in which a com- ers whose labors began spontaneously. The present sample munity doula partners with a home visitor during preg- of young, low-income mothers was likely more medically nancy and through 6-weeks postpartum, provides greater complex. emphasis on pregnancy health, childbirth, breastfeeding, and Mothers in the intervention were more likely to initiate newborn health than most other home-visiting models, and breastfeeding, consistent with previous research on commu- additionally, offers hospital-based support during childbirth nity doulas (Edwards et al. 2013). Few other home-visiting and agency-based childbirth preparation classes. This RCT studies have found impacts on breastfeeding. Doulas, by shows that the doula-home-visiting intervention has impacts 1 3 Maternal and Child Health Journal (2018) 22 (Suppl 1):S105–S113 S111 Table 2 Intervention impacts on maternal health, newborn health, and newborn care outcomes Control group Doula/HV group OR [95% CI] p-value n (%) n (%) (1-tailed) Mother birth and postpartum health  Entered labor having attended childbirth preparation class (n = 255) 12 (9.5%) 64 (50.0%) 9.82 [4.84, 19.89] 0.00  C-section birth (n = 286) 31 (21.5%) 33 (23.2%) 1.04 [0.59, 1.84] ns  Epidural/pain medication use during labor (n = 268) 114 (83.2%) 94 (71.76%) 0.47 [0.25, 0.88] 0.01  Mother re-hospitalized within 3 weeks (n = 286) 3 (2.1%) 4 (2.8%) 1.53 [0.33, 7.21] ns  3 week high depressive symptoms (n = 282) 31 (21.8%) 31 (22.1%) 0.96 [0.53, 1.71] ns  3 month high depressive symptoms (n = 277) 21 (15.1%) 18 (13.0%) 0.95 [0.47, 1.91] 0.45 Infant morbidity and mortality  Fetal/newborn death (n = 286) 2 (1.3%) 0 (0.0%) – –  Preterm birth (GA < 37 weeks; n = 285) 12 (8.2%) 10 (6.7%) 0.57 [0.22, 1.46] 0.18  Low birthweight (n = 285) 13 (9.0%) 9 (6.4%) 0.64 [0.26, 1.59] 0.17  NICU admission (n = 286) 23 (16.0%) 21 (14.8%) 0.87 [0.45, 1.68] 0.34  Hospital stay ≥ 4 days (n = 286) 28 (19.4%) 25 (17.6%) 0.89 [0.48, 1.63] 0.35  Has pediatrician at 3 weeks (n = 282) 139 (97.9%) 138 (98.6%) 1.56 [0.25, 9.65] 0.32  Has pediatric checkup by 3 months of age (n = 278) 139 (100.0%) 139 (100.0%) – –  Infant re-hospitalized within 3 weeks (n = 284) 5 (3.6%) 3 (1.4%) 0.45 [0.08, 2.48] 0.18 Newborn care practices  Breastfeeding initiation (n = 287) 107 (74.3%) 116 (81.1%) 1.67 [0.91, 3.03] 0.05  Breastfeeding at 3 months (n = 278) 31 (21.8%) 24 (16.9%) 0.85 [0.45, 1.60] ns  Always puts infant on back to sleep at 3 weeks (n = 282) 86 (60.6%) 98 (70.0%) 1.64 [0.97, 2.77] 0.03  Always puts infant on back to sleep at 3 months (n = 277) 83 (60.1%) 92 (66.2%) 1.34 [0.80, 2.23] 0.13  Infant sleeps in own bed at 3 weeks (n = 282) 63 (44.4%) 74 (52.9%) 1.44 [0.89, 2.34] 0.07  Infant sleeps in own bed at 3 months (n = 277) 67 (48.6%) 71 (51.1%) 1.19 [0.72, 1.95] 0.25  Always uses car seat at 3 weeks (n = 281) 132 (93.0%) 135 (97.1%) 3.67 [1.06, 12.70] 0.02  Always uses car seat at 3 months (n = 277) 126 (91.3%) 130 (93.5%) 1.28 [0.51, 3.20] 0.30 Logistic regression analyses control for co-residence with parent figure at baseline and program site A third infant from the control group died before age 4 months of age Two infants were in the hospital continuously from birth through 3 weeks of age so were excluded from analyses on re-hospitalizations offering skilled lactation counseling throughout pregnancy and have been challenging to prevent (Edwards et al. 2012; in mothers’ homes and postpartum in the hospital, increase Grote et al. 2011). A systematic review found evidence that breastfeeding initiation, even among populations that have home-based services have the potential to be effective in traditionally low breastfeeding rates. However, the interven- preventing postpartum depression, but to date evidence is tion impact on breastfeeding was not sustained, and only limited to intensive interventions delivered by professionals about 20% of mothers were breastfeeding at 3 months. (Dennis and Dowswell 2013). Research is needed to understand why many mothers initi- Mothers in the intervention were more likely to always ated breastfeeding but discontinued quickly postpartum (e.g., place their newborns on their backs to sleep and always Rozga et al. 2015) and what strategies might be effective for use a car-seat. Few previous home-visiting studies have supporting young mothers during that critical time. Never- looked at early infant safety practices. Although the pre- theless, even brief periods of breastfeeding may have health sent study does not address the manner in which mothers benefits to infants by way of colostrum (e.g., Bardanzellu received these safety messages, previous research suggests et al. 2017). that low-income mothers may reject infant sleep recom- The doula-home-visiting intervention did not show mendations, for example, because of distrust of health pro- impacts on postpartum maternal depressive symptoms, con- fessionals, reliance on advice from family members, and sistent with findings from most other home-visiting evalu- concern for infant comfort (Colson et al. 2005). Doulas ations. Postpartum depression is powerfully influenced by have many opportunities during prenatal visits and through a complex set of biological factors, chronic stress, trauma their intimate care during labor to become trusted advi- history, and instability in relationships with infants’ fathers sors to young mothers. By being present in the hospital 1 3 S112 Maternal and Child Health Journal (2018) 22 (Suppl 1):S105–S113 Acknowledgements This project was funded by award D89MC23146 and the home during the earliest weeks when mothers first from the MIECHV competitive grant program from the Health establish sleep practice, doulas may have unique oppor- Resources and Services Administration (HRSA) to the State of Illinois tunities to explain to mothers and other family members Department of Human Services (IDHS). The contents of this publica- the benefits of safe sleep practices and to offer mothers tion are solely the responsibility of the authors and do not represent the official views of HRSA or IDHS. The authors would like to thank strategies for soothing babies who seem uncomfortable their partners at the Ounce of Prevention Fund, the Illinois Governor’s on their backs. Office of Early Childhood Development, and the agencies that imple- Notably, although doula-home-visiting impacts on new- mented the doula home visiting and case management interventions. born care practices were found in the first weeks postpartum, The authors thank project director, Linda Henson, data base manager, Marianne Brennan, and the research staff involved in collecting the group differences diminished by 3 months. It may be that data, including Tanya Auguste, Melissa Beckford, Ikesha Cain, Adri- over time families chose infant feeding or sleeping prac- ana Cintron, Nicole Dosie-Brown, Tytannie Harris, Morgan Johnson- tices they felt were most effective for their family circum- Doyle, Katarina Klakus, Natasha Malone, Jasmine Nash, Erika Oslako- stances or infant preferences. It may be that as home visitors vic, Jillian Otto, Amy Pinkston, Magdalena Rivota, Rosa Sida-Nanez, Luz Silva, Caroline Taromino, Ardine Tennial, Maria Torres, Yadira took over intervention work from the doulas, the focus of Vieyra, and Lauren Wilder. the work shifted from feeding and sleep practices to other important areas such as responsive parenting, child develop- Compliance with Ethical Standards ment, and mother’s personal development. Finally, although the present study has many methodo- Conflict of interest The authors declare that they have no conflict of logical strengths—a randomized design implemented within interest. programs taken to scale in real agency settings, it also has limitations. The sample drew from only four programs in a Open Access This article is distributed under the terms of the Crea- tive Commons Attribution 4.0 International License (http://creat iveco single state and excluded adolescents at the most extreme mmons.or g/licenses/b y/4.0/), which permits unrestricted use, distribu- levels of risk. Because data in this paper were provided tion, and reproduction in any medium, provided you give appropriate through mother report and not administrative records, reli- credit to the original author(s) and the source, provide a link to the able information on important medical procedures and out- Creative Commons license, and indicate if changes were made. comes during labor, such as qualifications of health pro- viders and Apgar scores, were unavailable. Because each mother in the intervention group was offered services from References a doula and home visitor team, the independent contribution of the two different providers could not be determined. 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Randomized Controlled Trial of Doula-Home-Visiting Services: Impact on Maternal and Infant Health

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Copyright © 2018 by The Author(s)
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Medicine & Public Health; Public Health; Sociology, general; Population Economics; Pediatrics; Gynecology; Maternal and Child Health
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Abstract

Introduction Although home-visiting programs typically engage families during pregnancy, few studies have examined mater- nal and child health outcomes during the antenatal and newborn period and fewer have demonstrated intervention impacts. Illinois has developed an innovative model in which programs utilizing evidence-based home-visiting models incorporate community doulas who focus on childbirth education, breastfeeding, pregnancy health, and newborn care. This randomized controlled trial (RCT) examines the impact of doula-home-visiting on birth outcomes, postpartum maternal and infant health, and newborn care practices. Methods 312 young (M = 18.4 years), pregnant women across four communities were randomly assigned to receive doula-home-visiting services or case management. Women were African American (45%), Latina (38%), white (8%), and multiracial/other (9%). They were interviewed during pregnancy and at 3-weeks and 3-months postpartum. Results Intervention-group mothers were more likely to attend childbirth-preparation classes (50 vs. 10%, OR = 9.82, p < .01), but there were no differences on Caesarean delivery, birthweight, prematurity, or postpartum depression. Intervention-group mothers were less likely to use epidural/pain medication during labor (72 vs. 83%; OR = 0.49, p < .01) and more likely to initiate breastfeeding (81 vs. 74%; OR = 1.72, p < .05), although the breastfeeding impact was not sustained over time. Intervention-group mothers were more likely to put infants on their backs to sleep (70 vs. 61%; OR = 1.64, p < .05) and utilize car-seats at three weeks (97 vs. 93%; OR = 3.16, p < .05). Conclusions for practices The doula-home-visiting intervention was associated with positive infant-care behaviors. Since few evidence-based home-visiting programs have shown health impacts in the postpartum months after birth, incorporating doula services may confer additional health benefits to families. Keywords Doula · Home visiting · Breastfeeding · Safe sleep Significance with other indicators of mother and newborn health at birth or improvements in maternal depression. What’s Known on This Subject Research has shown that home-visiting programs have positive impacts in varied domains of parent and child functioning. However, few stud- Introduction ies have examined maternal and child health at birth and during the newborn period. Home Visiting and Maternal Child Health What This Study Adds This study, evaluating a home- visiting model that incorporates community doulas into the Growing evidence shows that childhood home-visiting pro- intervention team, demonstrates improvements in childbirth grams for socially and economically vulnerable families can preparation, breastfeeding initiation, safe sleep practices, have impacts in multiple areas, including maternal and child and early car-seat use. The intervention was associated with health, parenting, child development, and family economic less use of pharmacologic pain control during labor, but not self-sufficiency (Paulsell et al. 2010). When federal sup- port for home visiting was dramatically increased in 2010 through the Maternal Infant Early Childhood Home Visit- * Sydney L. Hans ing (MIECHV) program (Thompson et al. 2011), the leg- shans@uchicago.edu islation set expectations that program should have impacts School of Social Service Administration, University across multiple domains, including “improved maternal and of Chicago, 969 E 60th Street, Chicago, IL 60637, USA Vol.:(0123456789) 1 3 S106 Maternal and Child Health Journal (2018) 22 (Suppl 1):S105–S113 newborn health” (“Patient Protection and Affordable Care a model where doulas were integrated into home-visiting Act”). Although MIECHV legislation did not prioritize programs in order to enhance the quality of health-related specific maternal and newborn health outcomes, the U.S. services during pregnancy and the postnatal period (Glink Department of Health and Human Services’ national health 1998, 1999). blueprint, Healthy People 2020 (Office of Disease Preven- In the “community doula” model that resulted, doulas are tion and Health Promotion 2014), identifies such priorities: community health workers who have training in pregnancy mother health at birth and postpartum (including attendance health, childbirth preparation, labor support, lactation coun- at childbirth preparation classes, reduction in Caesarean seling, and newborn care. They serve as specialized home deliveries, reduction in maternal postnatal medical compli- visitors, providing home-based education and support dur- cations, and reduced postpartum depression), infant morbid- ing the last half of pregnancy and for 6 weeks postpartum. ity and mortality (including reduction in infant deaths, low Doulas accompany laboring women to the hospital to pro- birthweight and preterm birth), and infant care (including vide comfort measures and emotional support and to offer increased breastfeeding and increased proportion of infants postpartum help around breastfeeding and bonding. put to sleep on their backs). The rationale for including doulas within a home-based The United States lags behind other developed nations model drew from strong meta-analytic evidence that doula with respect to infant mortality and low birthweight (Mac- labor support is associated with improved health outcomes, Dorman et al. 2014; Wardlaw 2004), and there are dispari- including fewer Caesarean deliveries, decreased use of anal- ties in newborn and pregnancy outcomes related to maternal gesia/anesthesia, shorter labors, and higher Apgar scores age, poverty and race (Bryant et al. 2010; Martin et al. 2017; (Hodnett et al. 2013). One RCT examining the impact of a Nagahawatte and Goldenberg 2008). Despite evidence that community doula model in which doulas provided home vis- breastfeeding has advantages for mother and child health its in addition to labor support found increases in breastfeed- (Stuebe 2009), breastfeeding rates remain low in the US ing initiation among young, low-income mothers (Edwards among young, low-income and African-American women et al. 2013). (McDowell et al. 2008). Additionally, although the Ameri- The goal of this RCT is to examine whether young, low- can Academy of Pediatrics (Task Force on Sudden Infant income families receiving doula-home-visiting services, Death Syndrome 2016) recommends that infants be placed compared to families receiving lower-intensity case-man- in supine sleep positions in their own beds in order to reduce agement services, have improved maternal and child health the risk of sleep-related infant deaths, infants born to young, outcomes during the period between birth and 3 months of low-income mothers have a relatively high risk for prone age. placement and for co-sleeping (Colson et al. 2009; Caraballo et al. 2016). Despite many studies on infant and early childhood home Methods visiting, few reports document impacts on maternal and newborn health or newborn care practices. Only a few home- Study Sites, Enrollment, Randomization visiting studies have examined maternal depression during and Follow‑Up Procedures the first postpartum months, and none have found program impacts reducing symptoms (e.g., Barlow et al. 2013; Carta Study recruitment took place between 2011 and 2015. Part- et al. 2013). A few studies have shown impacts on preventing ners in the RCT were four agencies offering doula-home- low birthweight and/or preterm birth (Lee et al. 2009; Wil- visiting programs to young mothers in high-poverty Illinois liams et al. 2017), but others have not (e.g., Kitzman et al. communities. Two programs were located in a large city, and 1997; Olds et al. 1986). Most studies have not examined two in smaller urban areas. One served an African-American newborn health. Some home-visiting studies have reported population, one served a Latinx population, and two served impacts on early breastfeeding (Kitzman et al. 1997; Wen mixed-ethnic populations. Programs serving Latinx popu- et al. 2011), but most have not found impacts (Green et al. lations provided services in English and Spanish. Each of 2014; Kemp et al. 2013; Mitchell-Herzfeld et al. 2005). the programs already was implementing an evidence-based home visiting model (see overview of evidence in Paul- Community Doulas sell et al. 2010), either Healthy Families America (HFA) (“Healthy Families America” 2015) or Parents as Teachers Twenty years ago, early childhood advocates in Illinois (PAT) (“Parents as Teachers” 2018). Programs were from were concerned about home-visiting programs having lim- a network of state-funded home-visiting programs and not ited impact on maternal and newborn health outcomes. A demonstration programs for research purposes only. partnership between the Irving Harris Foundation, Health- Programs received information about young pregnant Connect One and the Ounce of Prevention Fund developed women from their usual referral networks—public health 1 3 Maternal and Child Health Journal (2018) 22 (Suppl 1):S105–S113 S107 departments, WIC programs, health clinics, and schools. Home visitors focused on the mother-infant relationship, Program staff contacted women to determine eligibility and child development, child safety, and educational-work plan- explain the program and research study. Women were told ning, as well as screening to make sure that family basic that the only way to participate in the doula-home-visiting needs were being met. Doulas focused on issues related to program was to participate in the study. If they were not pregnancy health, childbirth preparation, breastfeeding, interested in the research, they received contact information newborn care, postpartum health, and early bonding. Doulas for other community programs providing services for preg- sometimes accompanied mothers to prenatal and postpartum nant women, including case management, home visiting, and medical visits. Doulas attended births at the hospital where parenting programs in hospitals and health clinics. To be eli- they provided mothers with physical comfort, emotional sup- gible for the study, women needed to be under 26, less than port, and advocacy during labor and delivery and breast- 34 weeks gestation, living in the program geographic catch- feeding counseling postpartum. Doulas also offered prenatal ment area, planning to remain the area, and meeting sociode- classes at the program sites. All programs conducted regular mographic risk criteria used by the HFA or PAT models. Out depression screenings and made referrals to mental health of ethical concerns, pregnant women who were under 14, consultants. involved with the child welfare or juvenile justice systems, or had significant cognitive impairments were excluded from Case Management Control the study and offered home-visiting services. After screening, the research team scheduled a baseline After randomization to the control group, mothers were pro- session with mothers that included a written-informed- vided information about case management services in their consent procedure and a 2-h structured interview. At the communities, and case management providers were given end of this session, the interviewer opened a sealed opaque mothers’ contact information. In some communities, moth- envelope that showed whether the participant was assigned ers were referred to existing state-funded case-management to doula-home-visiting services (intervention condition) providers; in other communities, social-service provid- or case management (control condition). These envelopes ers were contracted to provide case management. It was had been prepared by the principal investigator before the expected that mothers would have at least two meetings with beginning of the study. Randomization tables were created case managers—one during pregnancy and one after birth. separately for each community. Meetings could be in families’ homes, in agency offices, or At 37-weeks of pregnancy, 3-weeks postpartum and occasionally by phone. Case managers determined whether 3-months postpartum, mothers were re-interviewed. Fami- families’ basic needs with respect to health, housing, food, lies received modest monetary compensation at each session employment, education, and childcare were being met, and if and a baby book and toy at each postpartum session. All needed, made referrals. Case managers screened to identify study procedures were approved by the Institutional Review needs for services regarding substance misuse, depression, Board at The University of Chicago, and the study is regis- and domestic violence. tered with clinicaltrials.gov [identifier NCT01947244]. Interviews Description of Group Conditions Outcomes were chosen based on Healthy People 2020 Doula-Home-Visiting Intervention maternal and newborn health priorities and outcomes that have been reported in previous studies of doula interven- After randomization to the intervention group, doula-home- tions. Interviews were available in English and Spanish and visiting programs assigned families a home visitor (also administered in the mother’s preferred language. Interview- called a Family Support Worker or Parent Educator) and ers working in Latinx communities were bilingual. Inter- a community doula. Doulas and home visitors all had deep views were usually conducted in families’ homes. roots in their communities. All home visitors and doulas At baseline, interviewers asked questions related to had completed at least the foundational training required the pregnancy, health care, mental health, education and by their national models, and doulas had completed at least employment, and relationships with family. Baseline inter- the basic training provided through the Ounce of Preven- view questions were used to check equivalence of the groups tion Fund. During pregnancy and postpartum, mothers were as randomized. visited weekly by a home visitor, doula, or both together. At all follow-up interviews, intervention-group mothers The doula worked with the mother more intensively during were asked about numbers of contacts with doulas and home pregnancy and the first weeks postpartum, while the home visitors. All mothers were asked about childbirth preparation visitor became the primary provider by 6 weeks postpartum. class attendance and any other pregnancy/parenting services. 1 3 S108 Maternal and Child Health Journal (2018) 22 (Suppl 1):S105–S113 At the 3-week postpartum interview (or 3-month inter- CONSORT chart identifying the flow of subjects through view if mother missed the earlier session), mothers reported the study. on birth outcomes, including pain medication/epidural use Participants in the baseline interview were young and during labor, vaginal versus Caesarean delivery, gestational low-income, with almost half identifying as black/Afri- age (GA) at delivery, infant birthweight, NICU admis- can American (45%, n = 140) and just over a third Latina/ sion, length of hospital stay, and mother and/or newborn Hispanic (38%, n = 117). 11% of mothers preferred to be re-hospitalizations. interviewed in Spanish. Most mothers were in their second At the 3-week and 3-month interviews, mothers reported trimester of pregnancy and expecting their first child. Over on breastfeeding. Breastfeeding initiation was defined as two-thirds were partnered (coupled, engaged, married) with breastfeeding at least through the hospital stay. Mothers were the father of the baby (71%, n = 220). Table 1 shows that asked how often they used a car-seat, the positions they used the only baseline difference between groups was that more when laying down their infant to sleep and where the infant intervention-group mothers were living with a parent figure slept. Mothers reported on depressive symptoms using the compared to control-group mothers (77 vs. 64%, p < .05). Center for Epidemiological Studies-Depression Scale (CES- Co-residence with parent figure was a control variable in D) (Radloff 1977), dichotomized to identify mothers with all analyses. clinically significant levels of depression (≥ 16). Intervention Participation Analytic Plan Virtually all mothers (99%, n = 153) assigned to the doula- home-visiting group received at least one home visit. Among First, the intervention and control groups were compared on mothers interviewed at 37 weeks, the average number of multiple baseline maternal characteristics measured before doula visits prior to 37 weeks was 8.9 (SD = 6.9) and the randomization using t-tests and Chi square tests to check average number of visits from a home visitor was 5.8 whether randomization was successful. Second, intent-to- (SD = 4.8). Doulas were present in the hospital for 75% treat logistic regression analyses were conducted to examine (n = 106) of the births. By 3-months postpartum, 131 (92%) the impact of the doula-home-visiting intervention on out- mothers had received at least one postpartum visit from their comes measured at 37-weeks pregnancy, 3-week postpar- doula and 120 (84%) had received at least one postpartum tum, and 3-months postpartum. Odds ratios, 95% confidence visit from their home visitor. intervals, and one-tailed p-values were calculated for each outcome, using the control group as the reference group. Intervention Eec ff ts Program site was used as a covariate in all analyses, and any baseline maternal variables that differed between the two Mother Birth and Postpartum Health groups were used as covariates. Results from logistic regression analyses using one-tailed hypothesis tests (Table  2) show that intervention-group Results mothers were more likely to attend a childbirth education class during pregnancy (OR 9.82, 95% CI 4.84–19.89) and Sample Characteristics less likely to use epidural or other pain medication during labor compared to control-group mothers (OR 0.47, 95% Altogether 436 women were referred to the programs. 312 CI 0.25–0.88). The intervention was not associated with were enrolled in the sample and randomly assigned to the Caesarean deliveries, mother re-hospitalizations, or mother two conditions. Reasons families were not enrolled included postpartum depressive symptoms. inability to contact, women not wanting to participate in services or the study, women not meeting eligibility criteria, Infant Mortality and Morbidity and women at high risk and referred to program services without randomization. The intervention was not associated with preterm births Interviews were completed for 256 mothers (82%) at (GA < 37 weeks), low birthweight, NICU admission, length 37-weeks of pregnancy, 283 mothers (91%) at 3-weeks of newborn hospital stay, re-hospitalization of infants, hav- and 278 mothers (89%) at 3-months. Sample attrition was ing a pediatrician or pediatric clinic at 3 weeks, or having a unrelated to program site, race/ethnicity, age, education, co- well-baby check up by 3 months. Almost all families in both residence, or prenatal depressive symptoms. There were no groups reported having a pediatrician for their infants (98%), differences in sample attrition at either follow-up interview and all mothers reported taking their infant in for at least one between the intervention and control groups. Figure 1 is a well-baby check up by 3 months of age. 1 3 Maternal and Child Health Journal (2018) 22 (Suppl 1):S105–S113 S109 Health clinics, schools, and social service agencies identify young pregnant women and refer to home-visiting programs. N=436 • Couldn’t be reached: 44 • Didn’t meet eligibility criteria: 45 • Not interested: 23 • High risk and referred to program: 12 Informed consent and baseline interview N=312 Randomized to Case Management Randomized to Doula Home-Visiting n=156 n=156 37 week pregnancy followup 37 week pregnancy followup n=127 n=129 • Delivered before 37 weeks 8 • Delivered before 37 weeks 5 • Unable to contact 2 • Unable to contact 6 • Unable to schedule 12 • Unable to schedule 12 • Declined 6 • Declined 4 • Fetal death 1 • Infant death 0 3 week postpartum followup 3 week postpartum followup n=142 n=141 • Unable to contact 3 • Unable to contact 8 • Unable to schedule 2 • Unable to schedule 2 • Declined 7 • Declined 4 • Infant/fetal death 2 • Infant/fetal death 0 • Caregiver change 0 • Caregiver change 1 3 month followup 3 month followup n=139 n=139 • Unable to contact 5 • Unable to contact 11 • Unable to schedule 2 • Unable to schedule 0 • Declined 8 • Declined 5 • Infant/fetal death 2 • Infant/fetal death 0 • Caregiver change 0 • Caregiver change 1 Fig. 1 Study CONSORT diagram 1 3 S110 Maternal and Child Health Journal (2018) 22 (Suppl 1):S105–S113 Table 1 Characteristics Control group Doula/HV group of doula-home-visiting n = 156 n = 156 intervention group and control group at enrollment Mother age in years M (SD) 18.3 (1.6) 18.5 (2.0) Mother years of school completed M (SD) 10.9 (1.5) 10.9 (1.5) Mother race/ethnicity n (%)  African American 72 (46.2%) 68 (43.6%)  Latina/Hispanic 56 (35.9%) 61 (39.1%)  White 13 (8.3%) 13 (8.3%)  Multiracial/other 15 (9.6%) 14 (9.0%) Mother attends school n (%) 78 (50.0%) 86 (55.1%) Mother employed n (%) 28 (18.0%) 31 (19.9%) Mother expecting first child n (%) 154 (98.7%) 152 (97.4%) Baby gestational age in weeks M (SD) 25.7 (5.9) 25.5 (6.0) Mother has received prenatal care n (%) 154 (98.7%) 155 (99.4%) Mother receives public insurance (n = 305) n (%) 138 (90.8%) 140 (91.5%) Mother receives WIC n (%) 137 (87.8%) 131 (84.0%) Mother depressive symptoms (CES-D) M (SD) 14.2 (9.2) 13.8 (8.5) Co-residing with own mother or other parent figure n (%) 100 (64.1%) 120 (76.9%) Co-residing with baby’s father n (%) 48 (30.8%) 39 (25.0%) Partnered with baby’s father n (%) 107 (68.6%) 113 (72.4%) Chi-square test shows significant difference between intervention and control groups at p < .05 on childbirth preparation, epidural/pain medication use dur- Newborn Care Practices ing labor, breastfeeding, and safe newborn-care practices. Mothers receiving the intervention were more likely to Mothers in the intervention group were more likely to have attended a childbirth preparation class. Although vir- initiate breastfeeding in the hospital (OR 1.67, 95% CI tually all mothers in the sample had opportunities to attend 0.91–3.03). At 3 weeks, mothers in the intervention group childbirth classes through prenatal clinics and hospitals, few were more likely to always place their infants on their backs control-group women took advantage of such opportunities. for sleeping (OR 1.64, 95% CI 0.97–2.77) and to always Half of the women in the intervention group participated in put their infants in a car seat when traveling by car (OR such classes either at clinics and hospitals or through weekly 3.67, 95% CI 1.06–12.70). There was a non-statistically- classes offered by their home-visiting programs. Moreover, significant trend for infants in the intervention group to have all mothers who were visited by a doula also received indi- their own beds (OR 1.44, 95% CI 0.89–2.34, p = .07). There vidualized childbirth education at home. Perhaps as a result were no group differences on breastfeeding, sleeping or car of this preparation and the presence of the doula during seat use at 3 months. labor, mothers in the intervention group were less likely to use pharmacologic pain relief during labor, a finding similar to other studies of doula labor support (Hodnett et al. 2013). Discussion However, as with the few other home-visiting studies exam- ining birth outcomes, there were no intervention impacts Although most early-childhood home-visiting programs on Caesarean deliveries, low birthweight, or preterm birth. begin working with families during pregnancy or soon after Although other studies of labor-only doulas have found birth, relatively few evaluations have examined maternal reductions of Caesarean rates (Hodnett et al. 2013), most of and child health outcomes at birth or during the newborn these studies limited samples to obstetrically low-risk moth- period. The doula-home-visiting model, in which a com- ers whose labors began spontaneously. The present sample munity doula partners with a home visitor during preg- of young, low-income mothers was likely more medically nancy and through 6-weeks postpartum, provides greater complex. emphasis on pregnancy health, childbirth, breastfeeding, and Mothers in the intervention were more likely to initiate newborn health than most other home-visiting models, and breastfeeding, consistent with previous research on commu- additionally, offers hospital-based support during childbirth nity doulas (Edwards et al. 2013). Few other home-visiting and agency-based childbirth preparation classes. This RCT studies have found impacts on breastfeeding. Doulas, by shows that the doula-home-visiting intervention has impacts 1 3 Maternal and Child Health Journal (2018) 22 (Suppl 1):S105–S113 S111 Table 2 Intervention impacts on maternal health, newborn health, and newborn care outcomes Control group Doula/HV group OR [95% CI] p-value n (%) n (%) (1-tailed) Mother birth and postpartum health  Entered labor having attended childbirth preparation class (n = 255) 12 (9.5%) 64 (50.0%) 9.82 [4.84, 19.89] 0.00  C-section birth (n = 286) 31 (21.5%) 33 (23.2%) 1.04 [0.59, 1.84] ns  Epidural/pain medication use during labor (n = 268) 114 (83.2%) 94 (71.76%) 0.47 [0.25, 0.88] 0.01  Mother re-hospitalized within 3 weeks (n = 286) 3 (2.1%) 4 (2.8%) 1.53 [0.33, 7.21] ns  3 week high depressive symptoms (n = 282) 31 (21.8%) 31 (22.1%) 0.96 [0.53, 1.71] ns  3 month high depressive symptoms (n = 277) 21 (15.1%) 18 (13.0%) 0.95 [0.47, 1.91] 0.45 Infant morbidity and mortality  Fetal/newborn death (n = 286) 2 (1.3%) 0 (0.0%) – –  Preterm birth (GA < 37 weeks; n = 285) 12 (8.2%) 10 (6.7%) 0.57 [0.22, 1.46] 0.18  Low birthweight (n = 285) 13 (9.0%) 9 (6.4%) 0.64 [0.26, 1.59] 0.17  NICU admission (n = 286) 23 (16.0%) 21 (14.8%) 0.87 [0.45, 1.68] 0.34  Hospital stay ≥ 4 days (n = 286) 28 (19.4%) 25 (17.6%) 0.89 [0.48, 1.63] 0.35  Has pediatrician at 3 weeks (n = 282) 139 (97.9%) 138 (98.6%) 1.56 [0.25, 9.65] 0.32  Has pediatric checkup by 3 months of age (n = 278) 139 (100.0%) 139 (100.0%) – –  Infant re-hospitalized within 3 weeks (n = 284) 5 (3.6%) 3 (1.4%) 0.45 [0.08, 2.48] 0.18 Newborn care practices  Breastfeeding initiation (n = 287) 107 (74.3%) 116 (81.1%) 1.67 [0.91, 3.03] 0.05  Breastfeeding at 3 months (n = 278) 31 (21.8%) 24 (16.9%) 0.85 [0.45, 1.60] ns  Always puts infant on back to sleep at 3 weeks (n = 282) 86 (60.6%) 98 (70.0%) 1.64 [0.97, 2.77] 0.03  Always puts infant on back to sleep at 3 months (n = 277) 83 (60.1%) 92 (66.2%) 1.34 [0.80, 2.23] 0.13  Infant sleeps in own bed at 3 weeks (n = 282) 63 (44.4%) 74 (52.9%) 1.44 [0.89, 2.34] 0.07  Infant sleeps in own bed at 3 months (n = 277) 67 (48.6%) 71 (51.1%) 1.19 [0.72, 1.95] 0.25  Always uses car seat at 3 weeks (n = 281) 132 (93.0%) 135 (97.1%) 3.67 [1.06, 12.70] 0.02  Always uses car seat at 3 months (n = 277) 126 (91.3%) 130 (93.5%) 1.28 [0.51, 3.20] 0.30 Logistic regression analyses control for co-residence with parent figure at baseline and program site A third infant from the control group died before age 4 months of age Two infants were in the hospital continuously from birth through 3 weeks of age so were excluded from analyses on re-hospitalizations offering skilled lactation counseling throughout pregnancy and have been challenging to prevent (Edwards et al. 2012; in mothers’ homes and postpartum in the hospital, increase Grote et al. 2011). A systematic review found evidence that breastfeeding initiation, even among populations that have home-based services have the potential to be effective in traditionally low breastfeeding rates. However, the interven- preventing postpartum depression, but to date evidence is tion impact on breastfeeding was not sustained, and only limited to intensive interventions delivered by professionals about 20% of mothers were breastfeeding at 3 months. (Dennis and Dowswell 2013). Research is needed to understand why many mothers initi- Mothers in the intervention were more likely to always ated breastfeeding but discontinued quickly postpartum (e.g., place their newborns on their backs to sleep and always Rozga et al. 2015) and what strategies might be effective for use a car-seat. Few previous home-visiting studies have supporting young mothers during that critical time. Never- looked at early infant safety practices. Although the pre- theless, even brief periods of breastfeeding may have health sent study does not address the manner in which mothers benefits to infants by way of colostrum (e.g., Bardanzellu received these safety messages, previous research suggests et al. 2017). that low-income mothers may reject infant sleep recom- The doula-home-visiting intervention did not show mendations, for example, because of distrust of health pro- impacts on postpartum maternal depressive symptoms, con- fessionals, reliance on advice from family members, and sistent with findings from most other home-visiting evalu- concern for infant comfort (Colson et al. 2005). Doulas ations. Postpartum depression is powerfully influenced by have many opportunities during prenatal visits and through a complex set of biological factors, chronic stress, trauma their intimate care during labor to become trusted advi- history, and instability in relationships with infants’ fathers sors to young mothers. By being present in the hospital 1 3 S112 Maternal and Child Health Journal (2018) 22 (Suppl 1):S105–S113 Acknowledgements This project was funded by award D89MC23146 and the home during the earliest weeks when mothers first from the MIECHV competitive grant program from the Health establish sleep practice, doulas may have unique oppor- Resources and Services Administration (HRSA) to the State of Illinois tunities to explain to mothers and other family members Department of Human Services (IDHS). The contents of this publica- the benefits of safe sleep practices and to offer mothers tion are solely the responsibility of the authors and do not represent the official views of HRSA or IDHS. The authors would like to thank strategies for soothing babies who seem uncomfortable their partners at the Ounce of Prevention Fund, the Illinois Governor’s on their backs. Office of Early Childhood Development, and the agencies that imple- Notably, although doula-home-visiting impacts on new- mented the doula home visiting and case management interventions. born care practices were found in the first weeks postpartum, The authors thank project director, Linda Henson, data base manager, Marianne Brennan, and the research staff involved in collecting the group differences diminished by 3 months. It may be that data, including Tanya Auguste, Melissa Beckford, Ikesha Cain, Adri- over time families chose infant feeding or sleeping prac- ana Cintron, Nicole Dosie-Brown, Tytannie Harris, Morgan Johnson- tices they felt were most effective for their family circum- Doyle, Katarina Klakus, Natasha Malone, Jasmine Nash, Erika Oslako- stances or infant preferences. It may be that as home visitors vic, Jillian Otto, Amy Pinkston, Magdalena Rivota, Rosa Sida-Nanez, Luz Silva, Caroline Taromino, Ardine Tennial, Maria Torres, Yadira took over intervention work from the doulas, the focus of Vieyra, and Lauren Wilder. the work shifted from feeding and sleep practices to other important areas such as responsive parenting, child develop- Compliance with Ethical Standards ment, and mother’s personal development. Finally, although the present study has many methodo- Conflict of interest The authors declare that they have no conflict of logical strengths—a randomized design implemented within interest. programs taken to scale in real agency settings, it also has limitations. The sample drew from only four programs in a Open Access This article is distributed under the terms of the Crea- tive Commons Attribution 4.0 International License (http://creat iveco single state and excluded adolescents at the most extreme mmons.or g/licenses/b y/4.0/), which permits unrestricted use, distribu- levels of risk. Because data in this paper were provided tion, and reproduction in any medium, provided you give appropriate through mother report and not administrative records, reli- credit to the original author(s) and the source, provide a link to the able information on important medical procedures and out- Creative Commons license, and indicate if changes were made. comes during labor, such as qualifications of health pro- viders and Apgar scores, were unavailable. Because each mother in the intervention group was offered services from References a doula and home visitor team, the independent contribution of the two different providers could not be determined. 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Maternal and Child Health JournalSpringer Journals

Published: May 31, 2018

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