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The Chicago Doula Project: Application of a Community-based Model

Despite recent declines in the number of births to teen mothers in the United States (Curtin & Martin, 2000), adolescent childbearing continues to be a significant social welfare and public health issue. Between 1991 and 2000, the birth rate for teens (15-19 years of age) fell 22%, from 62.1 to 48.5 per 1000. However, rates of teen childbearing are higher in the United States than in any other industrialized nation and adolescent motherhood has long been associated with a wide variety of negative social, economic and health outcomes for both parents and children (Ventura & Bachrach, 2000 (Moore, Morrison & Greene, 1997; Goerge & Lee, 1997; Wolfe & Perozek, 1997).

The Chicago Doula Project began with collaboration between partners interested in finding ways to better support teen parents and their children. The purpose of the Chicago Doula Project was to integrate intensive prenatal, intrapartum and postpartum support into existing teen parent services through training and employing community women as doulas. The project was motivated by the growing body of research indicating the benefits of the doula's involvement in the birth experience.

In August 1995, representatives from the Harris Foundation, Chicago Health Connection and the Ounce of Prevention Fund first met to discuss the possibility of working together to provide doula services to teen mothers and their infants in the Chicago area. Each partner came with different, but complementary, interests and resources. The Harris Foundation had supported earlier academic hospital-based projects on doula support and saw the potential of the doula to affect the mother-infant relationship. This involvement was based on the commitment and interest of Mr. Irving Harris, a Chicago businessman and philanthropist who had a long history of funding early childhood and teen parenting programs. Chicago Health Connection had years of experience in maternal and child health promotion and considerable expertise in training community health workers. The Ounce of Prevention Fund had been working since 1982 to develop and administer teen parenting programs throughout Illinois, assisting these community-based programs in delivering home visiting and group services in order to promote healthy child and parent development. Thus, the Ounce of Prevention Fund brought existing relationships with a number of potential pilot sites for a new doula intervention. The Doula Project offered the Ounce of Prevention Fund an opportunity both to provide earlier and more intensive intervention focused on this critical period in the life of a young family and to nest it in established programs of long-term support. The Harris Foundation, the Chicago Health Connection and the Ounce of Prevention Fund were joined by three of these teen parenting program sites who elected to serve as pilot sites for the new doula intervention in their existing programs.

The community-based doula model was an extension of Chicago Health Connection's years of work based on Paulo Freire's Empowerment Education approach. Doulas are carefully selected laywomen whose racial, ethnic and socio-economic background reflect the population they serve. They are chosen for their capacity to serve as nurturers, role models and teachers. The training approach emphasizes active learning through role play, discussion, and supervised experience in labor and delivery, as well as didactic sessions on pregnancy, childbirth, adolescence and breastfeeding.

With funding from the Harris Foundation and the Robert Wood Johnson Foundation, the Doula Project officially began in July 1996. Our project differed from Klaus and Kennell's work and other studies in the literature in that it was not restricted to first-time births or to participants with full-term, uncomplicated singleton pregnancies. Any pregnant participant at the three sites was eligible for doula program services. Because our project would demonstrate the benefits of doula services to teen mothers in actual rather than ideal controlled conditions, we did not expect to achieve the same level of benefit from the doula intervention as did the studies cited previously.

The intervention was designed to start in the beginning of the last trimester of pregnancy and end at twelve weeks post-partum. Prenatal classes with the doula as teacher were scheduled to begin in the last trimester. During the last trimester, the program plan called for weekly contacts, including home visits, between the participant and the doula. The doula would support the teen during labor and delivery and assist with breastfeeding in the early post-partum period. In the following weeks, doulas would provide services in the home to help with infant care, breastfeeding and to facilitate the development of maternal attachment.

Both the Ounce of Prevention Fund and Chicago Health Connection felt strongly that the Doula Project should be nested in a program of ongoing support for teen parents. Within this context, Chicago Health Connection committed itself to "a partnership in which all participants had as much freedom as possible to make decisions affecting their own agencies" (Chicago Health Connection Doula Project, Annual Report to the Robert Wood Johnson Foundation, August, 1997). The flexibility of this approach helped agencies incorporate new services and allowed them to adapt the program in the way that worked best for the personnel and the site.

While this flexibility was a strength of the model, it also was a limitation in evaluating the effectiveness of the intervention. For a number of reasons, it was not possible to institute a randomized controlled trial for this project. Program outcomes showed that Doula Project mothers were significantly more likely than a comparable group of teen mothers to breastfeed and less likely to have a Cesarean section or epidural anesthesia. Younger mothers were also less likely to have a rapid subsequent birth. These findings have inspired a wide range of programs from around the U.S. to consider adding a doula component to their services. In addition to teen pregnancy programs, agencies serving Vietnamese and Hispanic immigrants, women in substance abuse treatment and women with chronic psychiatric illness are utilizing the community-based doula model to provide support to vulnerable populations.
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