Understanding Factors That Influence Adolescent Mothers’ Doula Use: A Qualitative Study

ABSTRACT

In this study, we examined factors that influenced doula use among adolescent mothers in a community-based childbirth education and doula program. We used a qualitative case study approach to gather perspectives from adolescent mothers and doulas through semistructured interviews, field observations, and a focus group. These women collectively revealed multiple themes related to doula use among adolescent mothers, including relationship development and barriers to doula use at the individual and structural levels. Effective training and support for doulas that serve adolescent clients can improve these mothers’ birth experiences, and program planners in the United States and other countries can use process evaluations to improve doula programs for adolescent mothers.

Issues with health-care access, socioeconomic status, trauma, and disadvantaged environments increase the risk of complications during pregnancy and childbirth for adolescent mothers. Complications of adolescent pregnancy include such adverse birth outcomes as low birth weight, preterm birth, low Apgar scores, and infant mortality (Black, Fleming, & Rome, 2012; Chen et al., 2007; Martin, Osterman, & Sutton, 2010; Mathews & MacDorman, 2013). Given these complications, providing support at each stage of pregnancy, childbirth, and early childhood can improve health outcomes for adolescent mothers and their infants (Arat, 2013).

Previous research found that mothers that received doula support during pregnancy, childbirth, and after childbirth had favorable birth outcomes. Women who received doula support were more likely to be satisfied with their labor experience and less likely to use medication for labor pain (Hodnett, Gates, Hofmeyr, Sakala, & Weston, 2011). Furthermore, fewer babies born to mothers with doula support had low Apgar scores and lower rates of health complications and hospitalizations than those born without doula support (Hodnett et al., 2011; Kennell, Klaus, McGrath, Robertson, & Hinkley, 1991; Kozhimannil, Hardeman, Attanasio, Blauer-Peterson, & O’Brien, 2013; Scott, Klaus, & Klaus, 1999). Women who had doulas during their births also favorably described their doulas’ tailored care to the birthing partner in offering them reassurance and encouragement and providing their insight and experience of previous successful births (Koumouitzes-Douvia & Carr, 2006).

Despite the increased attention on doula use and positive findings from previous studies, studies focusing on doula support for adolescent mothers remain sparse because of the predominant focus on adult women. In the landmark Chicago Doula Project (Glink, 1998; Hans et al., 2013), adolescents who had doulas experienced more positive outcomes regarding anesthesia use, analgesia use, hospital length of stay, and positive parent–infant interactions in comparison to adolescents without doulas. Adolescents in other studies that followed this project also experienced favorable results from doula use, including helpful support during pregnancy, positive birth experiences, and healthy interactions between mothers and their infants and family members (Arat, 2013; Breedlove, 2005; Gentry, Nolte, Gonzalez, Pearson, & Ivey, 2010; Humphries & Korfmacher, 2012; Wen, Korfmacher, Hans, & Henson, 2010).

Given the scarcity of studies on doula care for adolescent mothers, we conducted a process evaluation study that examined the perspectives and experiences of both doulas and adolescent mothers to better understand doula use by program participants of a Young Women’s Christian Association (YWCA) in the Southeastern United States. To our knowledge, this study is among the first to incorporate perspectives from both doulas and adolescent clients and to specifically focus on issues of use. Conducting process evaluations with ongoing community-based programs can allow for both a better understanding of the processes behind successful programs and pinpoint areas for improvement (Patton, 2002). Furthermore, gathering perspectives of multiple program stakeholders through process evaluation studies can expose a greater complexity of salient issues to address for program improvement. Qualitative evaluation methods provide the opportunity to gather data through narrative description from program participants and to subsequently construct meanings behind individual and collective perceptions of situations (Fitzpatrick, Sanders, & Worthen, 2004). Understanding perspectives of adolescent mothers and doulas will not only provide insight for doula programs but also provide further insight for other community programs that provide pregnancy support for expectant adolescents.

METHODS

Study Setting: Young Women’s Christian Association Teen Parent Program

A YWCA in the Southeastern United States delivers a support program for pregnant and parenting adolescent moms as they strive to finish school, raise healthy children, and set and fulfill goals for the future. Free childbirth classes, doula services, and mentoring opportunities are offered to all adolescents as part of this comprehensive program. Their approach to service delivery includes a unique combination of empowerment, informed decision making, peer support, self-efficacy, and a commitment to inclusion and diversity.

An eight-session childbirth class, taught by a certified childbirth educator and nurse from the local hospital, is offered three times a year. In addition to standard childbirth education content, the classes cover various topics relevant for the population, such as fetal alcohol syndrome, pregnancy-related nutrition, postpregnancy contraception, newborn care, postpartum depression, and healthy birth spacing. The classes also incorporate an informed decision-making curriculum on infant feeding tailored to adolescent mothers. Adolescents who attend classes receive case management and are offered one-on-one mentorship and transportation to and from classes.

Approximately 50% of participants in the childbirth education program choose to use the doula services. To provide free doula services, the YWCA provides doula certification training and ongoing support to local volunteers, many of whom also serve as mentors to adolescent mothers. The YWCA’s program has shown sizable results in terms of positive birth outcomes, fewer complications during childbirth, and more positive parenting practices (Gruber, Cupito, & Dobson, 2013). Although the data demonstrate positive results for all participants, adolescent mothers that receive doula services have the best outcomes.

Study Design

We used a case study design to conduct the process evaluation for this YWCA program. Case study approaches are commonly used to examine multiple shared experiences within a bounded system, which makes these approaches desirable to evaluate both how programs actually work and how program components are perceived by stakeholders (Creswell, 2013; Patton, 2002). This single-case study was bounded to one program and time from December 2010 through January 2012. The study design for the evaluation consisted of prenatal and postpartum interviews and a focus group with adolescent clients, interviews with current program doulas, and participant observations of childbirth classes. The authors’ university internal review board approved this research.

Participants

Recruitment of a purposive sample of adolescent participants consisted of an open call during childbirth classes and interested adolescents signed up for the study after class. Inclusion criteria for the adolescents’ participation covered the following characteristics: English as a primary language, age 19 years or younger at the time of their infants’ birth, and participation in one or more YWCA childbirth education classes. YWCA staff members identified other participants during regularly scheduled home visits, and research team members contacted them to verify their participation. Meanwhile, we recruited doulas via e-mail and telephone; active service in the program was the only inclusion criterion for doulas. Sixteen adolescents and six doulas completed semistructured, one-on-one interviews. Seven adolescents participated in the focus group; this number included three adolescents who also completed interviews.

In total, 20 adolescent mothers and 6 doulas participated in this study (refer to Tables 1 and 2 for demographics). Theme saturation was reached with this number of interviews; no new themes were introduced in the last few doula and adolescent interviews. Most mothers were African American between the ages of 15 to 19 years old, and all but two mothers gave birth to their first child. Few mothers attended two to four sessions of the childbirth class, but most attended six or more. The six doulas ranged in experience from newly trained to several years of involvement with the YWCA.

Table 1. Background Characteristics on Adolescent Participants.

Pseudonym	Age	Race or Ethnicity	Doula Program Participation
Kalina	16	African American	Doula at birth
Abrianna	16	African American	Wanted doula, not assigned
Cyiarra	17	African American	Wanted doula, not assigned
Miranda	18	Hispanic	Did not want doula
Heather	15	White	Did not want doula
Charmaineb	17	African American	Had doula, not at birth (first child); Wanted doula, not assigned (second child)
Josephine	19	White	Had doula, not at birth
Reina	17	African American	Had doula, not at birth
Danielle	18	White	Did not want doula
Yolanda	17	African American	Wanted doula, not assigned
Stephanie	15	African American	Did not want doula
Jerib	18	African American	Did not want doula (first child)
			Doula at birth (second child)
Destiny	17	African American	Wanted doula, not assigned
Tonya	17	Biracial	Did not want doula
Christy	17	White	Did not want doula
Jamila	17	African American	Did not want doula
Daraa	—	Asian	Did not want doula
Violeta	—	African American	Doula at birth
Ra’shawna	—	African American	Did not want doula
Teneshaa	—	African American	Did not want doula

^aParticipants in focus group only; attendance in childbirth classes and mentoring prior to study observations.

^bParticipants with prior children.

Table 2. Background Characteristics for Doula Participants.

Pseudonym	Race	Role of Doula	Experience
Essence	African American	Doula–mentor	>3 births
Jamye	African American	Doula–mentor	Newly trained
Monica	African American	Doula–mentor	Newly trained
Kari	White	Doula	>3 births
Jessica	White	Doula	>3 births
Amie	African American	Doula	>3 births

Data Collection

In order for the adolescents to participate in the study, parents or legal guardians of participants younger than age 18 years provided informed consent and adolescents provided assent. Doulas and adolescent participants age 18 years and older provided informed consent for study participation. Interviews lasted approximately 45 minutes to gather information on participants’ experiences with the program. Doulas described their experiences with the training, perceptions of experiences with their adolescent clients and YWCA staff, and needs for support in their volunteer endeavors. Interviewers asked adolescents about their knowledge and perceptions of doulas, reasons for or against receiving doula support, and descriptions of their birth experiences. All interviews were audio recorded, and interviewers completed field notes after each interview. The 1-hour focus group was conducted with adolescent participants to further explore themes emerging from the adolescents’ interviews. Each participant received a $20 gift certificate for completing the study. Interviews and the focus group were transcribed verbatim. The second author (TN) and two research assistants observed the childbirth classes and completed field observation reports for each class.

Data Analysis

We examined interview and focus group transcripts and field observations through content analysis (Patton, 2002), using Atlas.ti Version 6.2 as a software program to help with the management and retrieval of data. First, we immersed ourselves in the data through reading and rereading of transcripts and field notes and shared our initial thoughts through memos and discussion. From this immersion process, we developed a codebook that was applied to coding a handful of transcripts and field notes, refined through discussion, and then applied to coding the remaining transcripts and field observations. Intercoder reliability was established with the double coding of interview transcripts and observation notes and subsequent discussion to reach consensus on the codes. We compared and contrasted coded segments both within and across transcripts for key themes. We then developed a rich description of the program with an emphasis on the processes that led to doula use. Key factors in the use or nonuse of doula services by adolescent mothers emerged from the constant comparison of coded segments and the reconstruction of the data into a holistic account.

RESULTS

We first present a description of the case to provide the context of program implementation for doula use. Identified factors that promoted or inhibited the adolescent mothers’ use of doulas are then discussed. We used pseudonyms to protect participants’ anonymity.

Description of the Case

Once a year, the YWCA recruits doula volunteers to participate in a training certified by Doulas of North America (DONA). Volunteers then complete the DONA certification process, which includes attending a breastfeeding class and childbirth education classes, developing a local resource list, completing readings on childbirth, and documenting service in three births. As part of the YWCA’s program, volunteers receive a reduced rate on the DONA training. If they conduct their certification births with YWCA participants, they are reimbursed the remaining cost. Volunteers attend the breastfeeding class at no charge and have the option to attend free childbirth classes at either the local health department or the YWCA. Most chose to attend the YWCA classes because this opportunity allows them to interact with adolescent mothers. The YWCA encourages doula attendance at the childbirth classes to increase the likelihood that adolescents will choose to receive doula services.

Adolescent mothers learn about doulas both formally in childbirth education classes and informally through interactions with their case managers. They subsequently decide whether or not they want doula support. For each adolescent who desires a doula, case managers facilitate an initial meeting between the doula and the adolescent mother. If both parties agree to the match, the doula must complete a minimum of two prenatal visits, meet the adolescent mother at the hospital when she goes into labor, and provide continuous support through birth. After the birth, doulas must provide at least two postpartum visits. Each adolescent assumes responsibility for calling her doula when labor begins prior to going to the hospital. Case managers facilitate communication between doulas and the adolescent mothers as needed.

Factors in Doula Use

Although the adolescents made the ultimate decision on doula use, their decision making was not the only influencing factor for doula matching and doula’s attendance at childbirth. As shown in Table 1, four adolescents wanted a doula but were not assigned one, and three adolescents were assigned doulas who did not attend their births. Therefore, we identified factors that hindered or facilitated adolescents’ decision to have doula services and actual use of services. Detailed information on the adolescents’ birth experiences can be found in Nichols, Brown, Coley, Kelley, and Mauceri (2014).

Education About Doulas.

Several adolescents reported learning about doulas from their case managers, and most adolescents could describe the support that doulas provide during the labor process. Most adolescents perceived doulas as trained or experienced support who primarily help in the birthing room through coaching, comfort, and encouragement. Destiny supplied a typical understanding of the doula role:

It’s a person that has a license to come in while you are in labor, or even before you’re in labor while you are pregnant, to talk to you and give you breathing instructions and ways to breathe and to feel better.

However, adolescents appeared to lack knowledge about doula support in several other areas. Few adolescents discussed pregnancy support and only one adolescent mentioned birth plan development with her doula, a major activity stressed in doula training. Although doulas were described in childbirth classes as providing dual support to the mother-to-be and her support people, few adolescents explained this aspect of doula care. Instead, several adolescents felt that doulas provided support for adolescent mothers without personal support networks and did not fully see the benefit of doulas for mothers with support.

Adolescents requested doulas by either signing up during a childbirth class or letting a case manager know about their decision to have one. Once the adolescents expressed their decision, program staff matched the adolescents with available doulas. Six adolescents in this sample were matched with doulas (Table 1). All doulas except one (Jessica) mentioned program staff members introducing them to the adolescents for the initial meeting.

It is important to note that although doulas enter the program through annual trainings, adolescent mothers enter the program throughout the year. Field observations noted that information on doulas was presented and individual volunteer doulas were introduced during the first childbirth education class. However, the adolescents’ receipt of this information depended on when they entered the program. Because of the rolling admissions into the program, adolescents often started the childbirth classes after the first session. Among the adolescent respondents, only Josephine mentioned learning about doulas in the first class. Doula respondents felt that doula support needed more explanation during the childbirth classes, as Kari explained,

I know they introduce doulas to them, but . . . I don’t know that they really give them a whole lot of information . . . I think the most important aspect is for these young people to have a realistic view of what is about to occur. The more knowledge they have, the less fear they gonna have.

Adolescents’ Perceptions of Doulas.

Adolescent mothers’ perceptions of the doula role and the doulas’ personal characteristics were key factors in their decision to choose and ultimately use a doula. Although most adolescents had a basic understanding of the doula role and felt that a doula would be supportive during childbirth, several adolescents perceived the doula role as appropriate only for mothers without support. Most adolescents reported they had the support they needed for labor from their families, friends, baby’s fathers, and/or boyfriends. Only two adolescents reported wanting doulas specifically for the additional support. Destiny explained during her prenatal interview,

I don’t want my mother to take on all the stress of me . . . my mother has her own stress to worry about. She works 24-7, like she doesn’t need all of that, so a doula would really help us out.

Adolescent mothers’ perceptions of the doula role and the doulas’ personal characteristics were key factors in their decision to choose and ultimately use a doula.

Another two adolescents who did not request doulas (Cyiarra and Charmaine) retrospectively felt a doula would have been helpful when their support team members proved not to be as responsive as they anticipated. Two other adolescents (Tonya and Jamila) had more negative perceptions of the doula role and felt that doulas would “annoy” them in “asking too many questions during labor.” Other adolescents mentioned the doula’s training as a factor in their decisions to request or use a doula. Although some adolescents were comforted that a doula would know more than either herself or her support person, Josephine expressed a different perception. She was initially matched with a newly trained doula and felt the woman was too inexperienced and nervous. She felt it was scary to be “someone’s first time” and felt the YWCA should not match inexperienced doulas with adolescent mothers. Overall, perception of the doula role was one of the strongest factors among adolescents who decided not to pursue having or using a doula.

Doula–Adolescent Interactions.

In addition to the minimum number of prenatal and postpartum meetings, doulas were expected to interact with adolescents on a regular basis through phone calls and text messages. Most doulas described their interactions with adolescents as limited to the expected minimal communication for carrying out their doula roles. In turn, few adolescents talked about interactions with doulas apart from the childbirth class and phone communication.

In contrast, multiple interactions between doulas and adolescents appeared to build the trust that adolescents had toward their doulas. “Matched” pairs that attended childbirth education classes together appeared to bond well as Jessica described her interaction with her adolescent and the adolescent’s boyfriend:

We got along really well, you know, giggled and laughed . . . then her boyfriend was enjoyable too, we all got along well. And she would call—you know I think we all felt comfortable, she would call me and ask questions . . . we had a pretty good relationship.

Some doulas that served dual roles as mentors transported the adolescents to other activities, such as doctors’ appointments. For example, Charmaine thought that her doula was “very nice” in taking her to appointments during her first pregnancy. Overall, interactions beyond the minimum appeared to increase adolescents’ reliance on doula support during pregnancy.

Relationships.

The doulas varied in their perceptions of their adolescent clients. Two doulas (Amie and Jessica) explained how adolescents dealt with various life complications such as family disturbances and required interactions with social services. Potential “mismatch[es]” between doulas and adolescents was noted by Essence as a factor for doula–adolescent interaction breakdowns. She felt the adolescents’ difficult living situations interfered with some doulas’ ability to relate to adolescents; however, she enjoyed serving as a doula-mentor to her clients. She “loves” the “old soul” adolescent (Kalina) whom she recently supported in childbirth and mentored:

She has become a part of my life. She was just a gift to me . . . we talk at least three or four times a week, we’re texting . . . three or four times a week, and it’s not like a duty . . . she’s just mine [laughter] . . . and her baby is mine, you know what I’m saying . . . she’s just an extension to my family.

Her love for the adolescent and the trust she felt from family members seemed to facilitate their continued friendship. However, this close relationship also infringed on her ability to serve as a doula and mentor other clients. She reported feeling “uncomfortable” when two of her clients were in the room together. She was concerned with balancing her attention to clients, not wanting to encourage the idea “that one is jealous of the other.” She wanted to serve as a doula to additional adolescents but struggled with learning “how to let go.” Altogether, the doulas described several factors that are important for establishing good relationships with adolescents but appear challenging to achieve: maintaining boundaries between doula and adolescents, allowing for flexibility in scheduling, and preparing for unexpected circumstances of adolescents.

Contrary to the doulas, the adolescents’ commitment appeared minimal and focused on the program requirements. Only two adolescents (Kalina and Reina) described a “friendship” that developed with their doulas. Descriptions of reciprocal benefits exchanged between doulas and adolescents were very few but noteworthy. Violet suggested a reciprocal nature that developed with her doula during her pregnancy when she stated, “She was helping me and I was helping her.” Violet acknowledged that they were “close” in describing how she helped her doula get her hours in for a massage license in exchange for a massage. Reina constantly went to her doula’s home when she needed to get away from her family. Kalina had the most interaction with her doula (Essence) because she also served as her mentor; Kalina met Essence’s family and Essence met Kalina’s family at social events.

Communication.

Although some doulas interacted with their adolescents during childbirth classes, most doula–adolescent communication occurred outside of childbirth classes which included talking or texting by phone. This communication increased to an almost constant checking in with the mothers as they got close to their due date. Kari asserted strongly that the doula’s role involves keeping open communication with their adolescent:

When . . . I have somebody that’s close to a due date, I’m calling them every day . . . If I’m within the 2-week range, for sure I’m calling them . . . you can’t just talk to them one time and 6 weeks later expect them to call you.

However, communication between doulas and adolescents did not always go smoothly as Amie talked about complications in communicating with her adolescent. So much time elapsed between the childbirth classes and the first birth plan meeting that Amie thought the adolescent had changed her mind. They ended up developing the plan only a week before the adolescent’s due date. Both Jamye and Monica pointed out that communication mishaps, such as changes in phone numbers, and/or adolescents’ unwillingness could eliminate a doula’s presence at childbirth. These mishaps were exemplified by Yolanda’s experience when she did not have any phone contact with her doula until labor:

Whenever they called me, I wasn’t available and whenever I called them, they were not available . . . she reached me right when I was pushing, finally . . . She called my mom and [mom] was like “She havin’ a baby right now.” I never met her or anything.

Policy.

Confusion over hospital policy was another deciding factor for several adolescents. Some adolescents felt that the doula would take up one of the three “slots” that the hospital allowed for support people in the birthing room, as Danielle explained,

I already got my three spots taken up so I can’t [have a doula] . . . it’s very important that my mom and my boyfriend and my best friend all be in the room when the baby comes.

For adolescents like Danielle who wanted multiple family members and/or friends at their birth, this policy meant there was no room for doula attendance. However, another adolescent (Destiny) mentioned a nurse stating that the doula “doesn’t count” toward adolescents’ three-person limit.

Timing.

Issues of timing also arose in the adolescent mothers’ interviews. Adolescents’ late program entry and/or late decisions for choosing doulas resulted in adolescents not getting matched for doula support; for example, Abrianna went into labor “unexpected” and gave birth before her due date. Timing was also a factor for Reina, who was matched with a doula and used her services during both pregnancy and the postpartum period. However, she felt her labor came too quick with no time to call her doula before she gave birth.

DISCUSSION

This process evaluation study examined factors that both impeded and promoted doula use among adolescent participants in a community-based parenting support program. The adolescents in this study varied in their perceptions of doulas and the logistical challenges they faced in acquiring doula services. Major individual and structural factors influenced teens’ decisions and ability to use doula services. Taking all findings into account, adolescents’ perceptions of having enough support and misperceptions of the doula role (individual level) appeared to be major reasons why adolescents opted out of the doula program rather than negative perceptions of doulas. This reason also seemed to outweigh the potential benefits of having doulas that these adolescents described during their interviews and focus group. Likewise, logistical difficulties (structural level), particularly spotty communication with doulas, greatly impeded the likelihood that doulas would attend the adolescent mothers’ labor.

Buy-in from adolescents and doulas, when it was achieved, appeared to enhance doula use among participants. Adolescent mothers’ buy-in for doula services in this study occurred mostly through discussions with case managers. Information given during childbirth education classes was not evenly distributed across the participants due to the challenge of having to operate a rolling admissions policy. In addition, the information most adolescents received seemed to be incomplete or inaccurate because many participants were left with the impression that doula services were for adolescents who did not have any support. Adolescent mothers should receive clear education on the role of the doula, specifically on the support they provide prenatally and to the adolescents’ personal support system, and they should receive this information multiple times through multiple venues in addition to the initial childbirth class. By more effectively “selling” the full spectrum of doula support, agencies may help overcome adolescent mothers’ initial feelings that they have enough support.

A critical aspect of a doula’s ability to provide care to adolescent mothers is the relationship established between the doula and client (Humphries & Korfmacher, 2012). Buy-in also occurs after a match has been made and adolescents who are not comfortable with their assigned doula may either directly opt out of using her services or may do so indirectly by not returning phone calls or not notifying her doula when she is in labor. Doulas who maintained clear communication and built more intimate relationships with adolescent clients appeared to enhance the adolescents’ satisfaction with doula services.

Doulas who maintained clear communication and built more intimate relationships with adolescent clients appeared to enhance the adolescents’ satisfaction with doula services.

A continuum seemed to exist in the level of doula support and communication with adolescents for this community program, ranging from doulas who provided the minimum requirements to doula-mentors who provided additional support beyond pregnancy and childbirth. This continuum stemmed from the mentoring aspects of the YWCA and the varied nature of adolescents’ desires for support and communication. As a result, doula–adolescent relationships seemed to range from formal, less personal relationships to family-like intimacy. This continuum may exist more prominently among adolescent mothers than mothers within older populations. Adolescent mothers constitute a very transient population that can present challenges with communication, and logistical issues, such as having phones disconnected, can occur frequently. To reduce these complications, program staff should emphasize the expectations of clear communication between doulas and adolescent clients to both parties during doula training, education to adolescents, and throughout the interactions between doulas and their adolescent clients.

This study had several limitations. Readers should recognize that adolescent mothers in this sample probably represent mothers who were more motivated to get and use support; other adolescents attended childbirth class once or twice, dropped out of the program, and became unavailable for interviews. Also, we gathered a limited number of actual doula experiences because most adolescent participants in the case study chose not to have doulas. Despite these limitations, this study contributes to the limited research that provides perspectives from both doulas and adolescent mothers.

IMPLICATIONS FOR PRACTICE

Community-based doulas can serve as potential resources to increase adolescent mothers’ satisfaction and confidence with their labor experiences. Nevertheless, doulas and adolescent clients’ differing perspectives can result in various complications when doulas provide support to adolescents. Given that childbirth educators can provide valuable support for pregnant adolescents, educators can clarify any misperceptions about doulas by providing clear information multiple times during childbirth classes. In addition, better communication between program staff, volunteer doulas, and adolescent mothers could increase the number of adolescent mothers who actually receive doula care when they request it. Additional doula training, specifically in the area of relationship building with adolescent mothers, may be one venue for improving communication. Likewise, addressing logistical challenges, such as providing adolescent mothers with “loaner” cellphones on an “as needed” basis, may increase the likelihood that adolescent mothers will receive the doula support they desire. These examples are current initiatives that the program administrators are adapting based on the study’s findings.

Moreover, planning pregnancy support programs tailored for adolescent clients requires the careful incorporation of designs that meet the social and educational needs of these mothers (Broussard & Broussard, 2009). From a program planning standpoint, qualitative process evaluations can be used to identify critical areas for improving doula programs and subsequently increase doula use among adolescent mothers. To enhance training for doulas to work with adolescent clients, process evaluation studies can provide valuable information to understand how programs actually work and how stakeholders perceive the program. Once program administrators gather and review the information from process evaluations, they can use the information to alter and improve program components accordingly.

Qualitative process evaluations can be used to identify critical areas for improving doula programs and subsequently increase doula use among adolescent mothers.

Doulas provide substantial support to women during pregnancy, childbirth, and the postpartum period in many ways. Success in doula programs stems from creating mutual relationships, open communication, and mutual trust between program staff and doulas, which subsequently enhances relationships between doulas and adolescent clients. Matching adolescent mothers with comprehensive services can improve immediate and long-term health outcomes for these mothers and their infants (Ruedinger & Cox, 2012); therefore, future examinations are warranted to improve these services for the well-being of these mothers and their infants.

ACKNOWLEDGMENTS

The authors wish to thank Christina Dobson for her assistance with the study coordination and her insightful comments for this manuscript. The design and implementation of this study was funded, in part, by a community-based research grant from the Office of Leadership and Service Learning at the University of North Carolina Greensboro. Authorship for the first author was partially funded by Award No. T32HD049302 from the National Institute of Child Health and Human Development. The content is solely the authors’ responsibility and does not necessarily represent the official views of the National Institute of Child Health and Human Development or the National Institutes of Health. No conflict of interest exists in the study design, data analyses, data interpretation, or in the writing or submission of this manuscript.

Biographies

SHERYL L. COLEY is currently a postdoctoral research fellow at the Center for Women’s Health and Health Disparities Research at the University of Wisconsin Madison. Her research focuses on evaluation of community-based perinatal health programs and disparities in maternal and infant health and healthcare among underserved populations.

TRACY R. NICHOLS is a professor and chair of the Department of Public Health Education at the University of North Carolina Greensboro. Her research interests include reproductive justice, marginalized motherhoods, and the development and evaluation of gender-appropriate and transformative health promotion interventions.