Perceptions of Social Support from Pregnant and Parenting Teens Using Community-Based Doulas

Abstract

Few studies have examined community-based doula care during the childbearing period. This descriptive study was designed to explore and describe the perceptions of disadvantaged pregnant and parenting teens (N = 24) who received support from culturally matched, community-based doulas. Their reported perceptions included enhanced knowledge about childbearing, support during childbirth, self-care, and early attachment to the newborn. Participants concurred that the community-based doula intervention had a positive impact on their supportive networks. This innovative model can supplement perinatal programs through utilization of culturally sensitive, community-based doulas that provide comprehensive relationship-based caring.

REVIEW OF LITERATURE

In the United States, adolescent girls—particularly young girls living in poverty—who continue an unintended pregnancy often encounter overwhelming medical and psychosocial challenges that encompass not only their pregnancy but also their future (Corcoran, 1998). Adequate social support during pregnancy in both disadvantaged and nondisadvantaged populations of women improves perinatal outcomes for the mother and her infant (Norbeck, DeJoseph, & Smith, 1996; Schaffer & Hoagberg, 1997). Although social support related to stress, self-esteem, and similar concepts has been studied in teen populations during pregnancy (Connelly, 1998; Lutenbacher & Hall, 1998; Renker, 1999), a discussion of perceived adequacy of support throughout all phases of childbearing is limited. Recent research investigating teen mothers' perceptions of coping following childbirth suggests that pregnancy and parenting at a young age may positively affect their personal strengths and overall coping; however, it is unclear whether supportive intervention is necessary in order to move beyond to a brighter future (Burke & Liston, 1994; Smith-Battle, 1995; Williams & Vines, 1999).

An historical model of supportive care in childbirth that emphasized “mothering the mother” (p. 13) was first described in a classic book by noted anthropologist Dana Raphael, The Tender Gift: Breastfeeding (1973):

We have adopted a word to describe the person who performs this function [supporting new mothers]—the doula. The word comes from the Greek, and in Aristotle's time meant ‘slave.’ Later it came to describe the woman who goes into the home and assists a newly delivered mother by cooking for her, helping with the other children, holding the baby, and so forth. She might be a neighbor, a relative, or a friend, and she performs her tasks voluntarily and on a temporary basis” (p. 24).

The doula's work, as described by Raphael's definition, involved interacting with and caring for the mother in early pregnancy through the transition to confident mothering. This person was essentially anyone who could assist and ease the mother through all of her childbearing and early childrearing needs. Raphael's viewpoint reflects an anthropologic perspective emphasizing the need for adequate human support during the childbearing and childrearing process. Particular emphasis on social support that improves successful breastfeeding and attachment of mothers to infants is argued.

The doula's work, as described by Raphael's definition, involved interacting with and caring for the mother in early pregnancy through the transition to confident mothering.

Through classic studies and current investigations, other researchers familiarized the public and health-care community with the role of doulas in a more circumscribed scope: labor support. Klaus, Kennell, Robertson, and Sosa (1986) described the doula as a layperson who continuously provides physical support during labor and birth and serves as an advocate for the mother/family unit. The seminal research conducted by Sosa, Kennell, Klaus, Robertson, and Urrutia (1980) occurred in Guatemala. Normal, healthy, laboring mothers (N = 20) were randomized into either a control or doula-supported group. The study's findings, published in The New England Journal of Medicine, revealed a positive effect of this supportive companion (doula) on the frequency of perinatal problems, length of maternal labor, and mother-infant interaction. The findings also included a potential number of significant perinatal benefits, including less medical intervention, fewer medical complications, shorter labor, and less use of maternal analgesia.

Today, doulas in America primarily serve mothers during labor and birth by providing advocacy, continuous presence, and physical and emotional support. Thus, the doula's role evolved from the self-directed, caring woman within the community—one who “mothered” the mother—to a more formally defined paraprofessional in the birth setting.

Other researchers have joined the growing body of evidence to suggest significance and value in the presence of a doula during labor and birth. Hodnett, Gates, Hofmeyr, and Sakala (2004) provide the most recent, comprehensive review of continuous support for women during childbirth. The primary objective of this review was to provide findings from randomized controlled trials that assessed outcomes of mothers and babies when provided continuous care from a doula as compared with usual care. To date, 15 trials involving over 12,000 women are included in the review. Findings from the meta-analysis posit that, when compared to women who do not have labor support, women with doula (labor) support are less likely to have analgesia or an operative birth or to report dissatisfaction with their experience.

Despite an increase in evidence-based findings relating efficacy of doula services in labor and birth to positive perinatal outcomes in the general population, no published studies have investigated benefits of doula care in teen populations. The purpose of this descriptive study was to explore and describe pregnant teens' perceptions of social support provided by ethnically similar, community-based doulas serving in an extended relationship from early pregnancy into early mothering. These findings are part of a larger study evaluating a community-based doula model.

METHODOLOGY AND BACKGROUND

Four research questions were designed to guide probing questions for participant interviews related to social support:

1. How do teen mothers describe networks and individuals that provide assistance and support?

2. What supportive characteristics from the doula are described by teens during pregnancy, labor/birth, and early mothering?

3. How is support from the doula different from other types of support?

4. How is the support from the doula valued?

The doula project study site was part of a larger grant-funded consortium in the Midwest and was one of three multicultural community centers administered by a nonprofit organization. Oversight for the community-based doulas was built upon a sound history of training peer counselors as paraprofessionals working with adult mothers. The doulas were recruited, trained, supervised, and employed as lay-community members to serve in a broadly defined doula role for economically deprived teens in urban core settings. In this study's setting, teens received care from four doulas whose comprehensive services included facilitating pregnancy and parenting education classes, providing 24-hour call availability at labor and birth, conducting pre- and postbirth home visitations, and offering additional individual guidance and counseling as needed by the participants. Primary assignment for pre- and postnatal contacts with participants were equally divided among the four doulas; however, they collectively shared 24-hour call assignments for labor and birth. These veteran doulas (with an average of two years in this role) were all adult women of the same culture as the participants—African American—and resided within the same neighborhood near the community center where services were provided. Doulas informally embraced a shared belief of using their supportive measures to redirect young families in their neighborhood toward brighter futures.

Doulas informally embraced a shared belief of using their supportive measures to redirect young families in their neighborhood toward brighter futures.

Purposive recruitment allowed implementation of cross-sectional analysis methods as the cohort of pregnant (n = 12) and parenting (n = 12) teens experienced various components of doula services over an extended time period. Both primiparous and multiparous teens were included. After receiving informed consent, the principal investigator personally interviewed all the participants. Inclusion criteria called for pregnant or parenting girls aged 14 to 18 years who were receiving state Medicaid benefits, reported normal pregnancy or birth, and were involved in the community-based doula project for a minimum of three doula-initiated encounters. All interviews were audiotaped to provide verbatim transcription and validate findings. A demographic form outlined each participant's age, marital status, pregnancy or postdelivery status, intendedness of pregnancy, educational level, attendance in school, and employment history. Predesigned semistructured interview questions guided discussion to elicit responses related to the research questions. At the conclusion of the interview, participants received a package of 48 diapers in appreciation for enrolling in the study.

RESULTS

Transcribed interviews were coded and analyzed in order to identify, name, and describe themes utilizing Krippendorff's (1980) method of content analysis (see Table 1). Validation of generated themes was established by using three methods. First, the principal investigator conducted a process of test/retest conditions by using interviews, as described by Krippendorff (1980). Secondly, researchers who were content experts in the study's setting confirmed generated themes after examining portions of the interviews. Finally, two research assistants who were experienced in qualitative study methods confirmed the themes. Both research assistants selected sections of the transcripts, which were coded twice by different individuals, and determined whether any disagreements or inconsistencies existed between researchers and the principal investigator. No inconsistencies of named or described themes were identified. An audit trail of validated findings has been maintained.

Table 1.

Krippendorff's Content Analysis Method^*

Level of Analysis	Steps in Analysis
Primary	Extrapolating units of words and sentences that characterize a set of attributes described through participant responses in order to categorize responses for each research question.
Secondary	Identifying and clustering attributes to partition co-occurrences of participant responses for each research question.
Tertiary	Counting, classifying, and naming identified units of commonality into contextual meaning that describes an underlying conceptualization of participant experiences.

^*Resource: Krippendorff, K. (1980). Content analysis: An introduction to its methodology. Beverly Hills, CA: Sage.

Demographic characteristics of most of the 24 participants included poor living conditions. Seventy-five percent described their neighborhood as dangerous and unsafe with such disadvantages as overcrowding, street violence, gang shootings, and unsound housing structures. Using the Centers for Disease Control (2004) pregnancy risk assessment monitoring system (or PRAMS) that defines intendedness of pregnancy, the researchers found that two of the participants had wanted to be pregnant sooner, 11 had wanted to be pregnant later, four wanted to be pregnant at the time of this conception, and seven did not want to be pregnant currently or at any time in the future. Only six participants identified their babies' fathers as somewhat supportive. Additional demographic information is presented in Table 2.

Table 2.

Participants' Demographics (N = 24)

N = 24	Minimum	Maximum	Mean
Age (Years)	14	17	16.5
Months Pregnant at Prenatal Interview (n = 12)	4	8	6.4
Months Postpartum at Interview (n = 12)	3	11	7.8
Highest Educational Grade Level Completed	9	12	10.2

CONTEXTUAL THEMES AND PARTICIPANTS' EXPERIENCES

Themes generated from the participant's interviews are listed in Table 3. Supportive doula characteristics identified by this study's population included the following: age-appropriate and culture-specific educational enrichment; emotional and physical support throughout pregnancy, labor, and beyond; relational caring that was reciprocal in nature; attention to future orientation; and support from adult women within the community. In order to elicit a richer understanding of generated themes, portions of the responses from the interviews are provided below.

Table 3.

Contextual Themes

Research Questions	Generated Themes
1. How do teen mothers describe networks and individuals that provide assistance and support?	1. Network assistance included aid from institutions, programs, religious groups, and prenatal clinics. Primary network assistance identified as doula project.
		2. Individual assistance from family and friends, although not always reported as valued or sufficient.
2. What supportive characteristics from the doula are described by teens during pregnancy, labor/birth, and early mothering?	1. Imparting knowledge through pregnancy, childbirth, and parenting education classes.
	2. Offering encouragement and orientation to future goals.
	3. Providing emotional and physical support during pregnancy, labor, birth, and mothering.
3. How is support from the doula different from other types of support?	1. Caring women from same culture and community.
	2. Relationship-based caring.
	3. Served as positive role models.
	4. Encouraged and modeled self-care.
4. How is the support from the doula valued?	1. Distinctly appreciated.
	2. Promoted pregnancy as a positive life experience.

Supportive Characteristics of Networks and Individuals

Identified themes from the first research question (“How do teen mothers describe networks and individuals that provide assistance and support?”) included a description of assistance and aid from institutions, programs, religious groups, and prenatal clinics. All of the participants identified their primary network support as the assistance received from the community agency where the doula program resided. Supportive assistance included tangible and nontangible assistance. Family members or friends were also identified as important in supporting the teens. Supportive roles of individuals included provision of basic needs (e.g., shelter, food, clothing, and transportation) and emotional support.

For example, one participant offered the following comment about caring support from family: “They like, they all just walk in the house and, if I have a little frown on my face, they make me come talk to them because they know that I'm feeling down.” Conversely, another participant living with her pregnant aunt responded to the despair of minimal support and expressed her basic need for somewhere better to live:

Really nothin'—really the only thing I can honestly say that I got her help with, that is food. And then I got to help her buy that. It seems like once she got pregnant she just got lazy cause she don't want to cook…. It's really like I am taking care of her kids and my son and pregnant with another one. Only thing she got time for is really nothin' but her husband, and both of them sit out and sleep all day.

One participant described an example of network support, as provided by the doulas' educational components:

About my temper with her [toddler sitting in pregnant lap] when she gets out of control, what to do and how to do it. And the methods of how to not get myself so upset that I don't want to deal with her and with my child that I am carrying now…and, they show me the procedures that will be goin’ on [during labor and birth].

Supportive Characteristics of Doulas

Generated themes from the second research question (“What supportive characteristics from the doula are described by teens during pregnancy, labor/birth, and early mothering?”) included the provision of prenatal, childbirth, and parenting education; continuous emotional and physical support during labor and birth; and assistance in defining and establishing pathways to success for a brighter future.

One participant noted, “They [doulas], like I said, helped you with the breathin’ and exercises. And they talk about the different stuff in the classes that you would be experiencing and things you should do and not do with your baby.” Another teen offered this response:

I want to convey this about the doula program: If you don't have anybody, this can be your somebody here. They teach you a lot. You might not have anybody to turn to—some people don't have a mother in their lives or their father ran out—but they [doulas] give you hope and help you plan your future. No one else has done that.

Another teen mother stated, “The doulas make you a better parent, make you more confident in taking care of your baby. I don't know what I would have done without their support.” As one pregnant teen shared:

It's not as hard as everybody makes it seem, and they [doulas] say they gonna be there for us, that we be havin’ the baby and they're there to help us, be with us. Like, they won't make you feel so down about your mistake [pregnancy], but being about helping you go on, you know. Being taken care of is support and most support you can use in life is knowledge.

Another teen recalled:

I just couldn't take the pain so she [doula] was like trying to comfort me. She brought me ice and then she snuck in the water ’cause I was thirsty. She would massage my legs, my back, comb my hair for me. She was just really there for me. She was, you know, holding my hand, talking to me, calming me down…. She was definitely there more than anybody.

Doula Support vs. Other Support

The third research question (“How is support from the doula different from other types of support?”) generated the following themes:

• Doulas were of same ethnicity and lived within the community.

• Doulas provided relationship-based caring.

• Doulas served as positive role models.

• Doulas were designated as the participants' primary support during pregnancy, labor, and birth.

One mother shared, “You know, you can talk to your boyfriend about different stuff and you can talk to the doulas about different stuff…. She knows where I'm coming from and I know where she's coming from, and she helped me in a way nobody else did.” This teen's statement illustrates the value of the common background shared by the doula and the mother.

Another mother expressed the importance of relationship-based support:

It was more like one-on-one, and it was more in-depth, because the doulas really got down to the nitty-gritty. ‘Okay, this is going to happen so you might as well deal with it.’ You know what I mean? They all tell us the sweet stories, but then again they let us know that they're there, and not everything is perfect for the pregnancy…. I probably would have been nuts without them…. They made a difference.

Another participant noted, “Well, they [doulas] talk about my education for after I have the baby.” And another pregnant teen said, “Most of your family, well, they'll make you feel down, make sure you don't do it again. But the doulas say they still be there for you…. They help pregnant teens.” These responses illustrate the power of positive role modeling.

The Perceived Value of Doula Support

The fourth research question (“How is the support from the doula valued?”) generated two emerging themes: The doula support was highly appreciated and the support received was a positive life experience. Participants' responses included an expression of increasing hope and a sense of thankfulness.

For example, one mother expressed special appreciation because she had no other assistance. She stated, “Well, if anybody try to help me, that's thankful enough, that's good hope right there because anything is better than nothin’…. So if I can just get a little help, that's enough for me.” Another mother shared, “I'm not the same, I'm not the same. I feel different from when I first came. I am a better parent. I feel mature or something, like I am doing, like I am a part of something here [community agency].”

Another mother stated:

It makes you a better parent. Makes you more confident in taking care of your baby. I don't know what I would have done without the support because, you know, there were a lot of options I went through. You know, they [doulas] were talking about the adoption and things like that. And I didn't wanna do that, so having support made me realize, even though I had her young, that I could still do the things that I planned to do.

DISCUSSION

Participants identified the doulas as the primary network of external support that assisted them in the provision of tangible and nontangible resources. Notable value was placed on the nature of the extended relational caring from the doula that began in early pregnancy and continued through early mothering. Although published studies traditionally correlate doula-associated outcomes with support during labor and birth (Hodnett, 1999; Kennell, Klaus, McGrath, Robertson, & Hinkley, 1991; Klaus & Kennell, 1997; Scott, Berkowitz, & Klaus, 1999), this descriptive study suggests that more comprehensive, longitudinal-based perinatal support has the potential for an even greater impact. This model of community-based caregivers suggests additional benefits of doula support, including sensitivity to culture, identification and response to community sociodemographic barriers, and emphasis on identification of goals with orientation toward a positive future.

In this study, the teens' perception of relational-based caring included an appreciation for the following actions from doulas: directing conversation regarding sensitive health-care topics not already addressed by the family, respecting the right and responsibility of the teen to make health-care decisions, and confronting life challenges related to poverty and turmoil within the community. Suggested differences in doula support from other types of assistance included the emotional aspects of a “sister-like,” woman-to-woman, mother-to-daughter, or friend-to-friend relationship. Despite the adversity of circuitous poverty in which all the participants resided and the teens' lower level of education in relationship to the norms for their age group, all participants expressed personal goals and hopes for the future. The doulas were identified as the only adult caregiver throughout the childbearing period who probed the teens' interests regarding future goals while also encouraging attainment of identified goals. In her phenomenological study with a comparable group of postpartum teens, Smith-Battle (1995) described this phenomenon as “inventing a future from an impoverished past” (p. 27).

Suggested differences in doula support from other types of assistance included the emotional aspects of a “sister-like,” woman-to-woman, mother-to-daughter, or friend-to-friend relationship.

The doulas were identified as the only adult caregiver throughout the childbearing period who probed the teens' interests regarding future goals while also encouraging attainment of identified goals.

Descriptive findings from this study support earlier findings in adult populations in which the presence of a doula enhanced the mother's feelings of emotional support and care during labor, enhanced early attachment behaviors, and increased self-confidence (Hodnett, 1999; Kennell et al., 1991; Klaus & Kennell, 1997; Scott et al., 1999). Participants in this study described how the doulas modeled infant care and parenting tasks during teaching opportunities at the birth and at home visits. Educational sessions led by the doulas in the prenatal period provided the opportunity to establish mutual trust while offering age-specific, culturally sensitive information in preparation for labor, birth, breastfeeding, and parenting. The extended care established a strong reciprocal bond between the doula and teen. This intimate, personalized relationship may foster a stronger attachment of the young mother to her newborn through modeling of caring. Past research suggests that constant human support by doulas positively affects maternal and infant outcomes and that doula-supported women report greater self-esteem and higher regard for their babies (Klaus & Kennell, 1997; Klaus et al., 1986; Raphael, 1973).

Limitations of the study are important to describe because generalizations to larger populations cannot be made at this time. Limitations included the absence of complementary interviews with doulas to elicit their perception of supportive assistance. No comparisons to usual care groups were conducted in the setting. No responses were elicited from participants regarding the comparison of supportive care from previous prenatal experiences. Only descriptive data were used qualitatively in order to extract themes and provide a better understanding of doula services in this setting and to formulate generative theories for future research. Findings that described the value of support from the community doulas as being higher than support from other individuals may be partially explained in that participants identified minimal substantive support from family. Additionally, even though social services were available at the agency—including social workers, home visitors, childcare, and assistance with tangible needs when requested—all participants described the community-based doula as their primary provider of support and assistance during the childbearing experience.

CONCLUSIONS

Generated themes from this study's population that described doula support included the teens' increased ability to cope with the stresses of pregnancy; appreciation of support from a “friend” through pregnancy, labor/birth, and early parenting; increased knowledge to become better mothers; and support by women from within the community who understand unique social conditions. Conclusions and generalizations regarding the impact of community-based doulas in teen populations can only be made for this study's participants.

However, this study suggests findings that should be further investigated. For example, is there an association with the extended care of community-based doulas and perinatal outcomes (e.g., preterm birth, infant birth weight, maternal attachment, breastfeeding, and self-esteem)? The study participants' positive perceptions and value specific to this intervention-based model also suggest the need for more in-depth investigation regarding future orientation. Specifically, does the role of community-based doulas provide hope-engendering strategies that enhance the transition from teen mother to stable parent? If so, can this unique model of community-based maternity care improve perinatal outcomes while enhancing a teen mother's desire for a brighter future?

In summary, the positive presence of doulas during labor and birth has been established. This study suggests that the adjunctive role of community-based doulas is vital and serves as a primary support to disadvantaged teens. Doulas provide comprehensive models of maternity care that include appropriate and sufficient psychosocial support, especially for those with identified inadequate support. Community-based doula models can contribute to increasing power within and among the population living in fragmented communities.

Yet, to the extent that doulas increasingly charge for their services, a significant portion of women who could benefit from this humanization of maternity care are being left behind because of their inability to pay. Publicly funded perinatal care seldom includes this type of support. Reducing America's high incidence of preterm births and low-birth weight infants in teen populations must also include recognizing how environmental, social, and behavioral patterns influence maternal stress. Daily stress and limited support experienced by women living in poverty are commonly associated with expensive negative effects on the childbearing process.

This study recommends further considerations for the development of and financial support for the community-based doula. As a woman recruited, trained, employed, and residing within the community, a doula provides unique support unmatched by other maternity, health, or social-service providers. Sustaining rights for all women to be adequately supported (to “mother the mother”), especially in vulnerable populations, may be one approach to improve the health and future of at-risk families.

IMPLICATIONS FOR CHILDBIRTH EDUCATORS

Other settings in the United States provide community-based doulas for disadvantaged or vulnerable childbearing women and adolescents. However, the number of such needy expectant mothers receiving the type of doula service described in this article is low.

One of the roles of childbirth educators is serving as an advocate. Childbirth educators often form groups that frequently meet in their community. In their advocacy role, groups of childbirth educators can organize to assess local perinatal support services for disadvantaged and vulnerable mothers. Where services are lacking, they can act as catalysts in their community to initiate highly personal support services, such as the doula program described in this article.