Breastfeeding and Complementary Food: RandomizedTrial of Community Doula Home Visiting

abstractOBJECTIVES: Despite recent efforts to increase breastfeeding, youngAfrican American mothers continue to breastfeed at low rates, andcommonly introduce complementary foods earlier than recommended.This study examines the effects of a community doula home visitingintervention on infant feeding practices among young mothers.

METHODS: Low-income, African American mothers (n = 248) under age22 years participated in a randomized trial of a community doulaintervention. Intervention-group mothers received services fromparaprofessional doulas: specialized home visitors trained aschildbirth educators and lactation counselors. Doulas providedhome visits from pregnancy through 3 months postpartum, andsupport during childbirth. Control-group mothers received usualprenatal care. Data were obtained from medical records andmaternal interviews at birth and 4 months postpartum.

RESULTS: Intent-to-treat analyses showed that doula-group mothersattempted breastfeeding at a higher rate than control-groupmothers (64% vs 50%; P = .02) and were more likely to breastfeedlonger than 6 weeks (29% vs 17%; P = .04), although few mothers stillbreastfed at 4 months. The intervention also impacted mothers’cereal/solid food introduction (P = .008): fewer doula-groupmothers introduced complementary foods before 6 weeks of age(6% vs 18%), while more waited until at least 4 months (21% vs13%) compared with control-group mothers.

CONCLUSIONS: Community doulas may be effective in helping youngmothers meet breastfeeding and healthy feeding guidelines. The inter-vention’s success may lie in the relationship that develops betweendoula and mother based on shared cultural background and monthsof prenatal home visiting, and the doula’s presence at the birth, whereshe supports early breastfeeding experiences. Pediatrics 2013;132:S160–S166

AUTHORS: Renee C. Edwards, PhD,a Matthew J. Thullen,PhD,b Jon Korfmacher, PhD,c John D. Lantos, MD,d,e LindaG. Henson, MA,a and Sydney L. Hans, PhDa

aSchool of Social Service Administration, The University ofChicago, Chicago, Illinois; bSchool of Health Professions,University of Missouri, Columbia, Missouri; cErikson Institute,Chicago, Illinois; dDepartment of Pediatrics, University ofMissouri – Kansas City, Kansas City, Missouri; and eChildren’sMercy Hospital, Mercy Bioethics Center, Kansas City, Missouri

KEY WORDSdoulas, home visiting, breastfeeding, complementary feeding,young mothers

Dr Edwards carried out data analyses, drafted the initialmanuscript, and reviewed and revised the manuscript;Dr Thullen assisted with data analyses and reviewed andrevised the manuscript; Dr Korfmacher designed the interviewsand reviewed and revised the manuscript; Dr Lantos served asthe medical director for the study and participated in design ofstudy methods; Ms Henson designed the interviews, coordinatedand supervised data collection, and reviewed and revised themanuscript; Dr Hans conceptualized and designed the study andinterviews and reviewed and revised the manuscript; and allauthors approved the final manuscript as submitted.

This trial has been registered at www.clinicaltrials.gov(identifier NCT01925664).

www.pediatrics.org/cgi/doi/10.1542/peds.2013-1021P

doi:10.1542/peds.2013-1021P

Accepted for publication Aug 26, 2013

Address correspondence to Renee C. Edwards, PhD, TheUniversity of Chicago, School of Social Service Administration,969 E 60th St, Chicago, IL 60637. E-mail: rcduffy@uchicago.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2013 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

FUNDING: All phases of the research study reported in thispaper were supported by the Maternal and Child Health BureauResearch Program, HRSA, DHHS, grant R40 MC 00203. Theintervention implementation was funded by grants from theIrving B. Harris Foundation, the Blowitz-Ridgeway Foundation,the Prince Charitable Trusts, the Visiting Nurses AssociationFoundation, and the Michael Reese Health Trust.

POTENTIAL CONFLICT OF INTEREST: The authors have indicatedthey have no potential conflicts of interest to disclose.

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Breastfeeding rates among young, Af-rican American, and low-incomewomen remain very low despite in-creased efforts among health careproviders to promote breastfeeding.1,2

In the 2006 National Health and Nutri-tion Study, for example, only 30% ofblack adolescent mothers had everattempted to breastfeed their infants.2

Research also indicates that youngmothers commonly introduce cereal orother solid foods to their infants muchearlier than the American Academy ofPediatrics recommended 4 to 6 monthsof age.3–6 Given the health, social, andeconomic benefits associated withbreastfeeding7–13 and potential prob-lems related to early introduction ofcomplementary foods,14–16 young, low-income mothers remain an importantgroup to target for intervention sur-rounding infant feeding practices.

Young, African American mothers oftenface numerous barriers to imple-menting healthy feeding practices, in-cluding a lack of information about thebenefits of breastfeeding and risksassociated with providing solid food tovery young infants, inadequate supportfrom their ownmothers or other familyand friends, lack of peer models andnetworks for breastfeeding, fear ofpain, lack of space and privacy, em-barrassment about breastfeeding, anda cultural context in which formulafeeding and supplementing with cerealis normative practice.5, 17–19 Althoughthe promotion of breastfeeding byhospital medical professionals andlactation consultants has greatly con-tributed to the increase in overallbreastfeeding rates in the past fewyears,20 professionalsmay have limitedsuccess among young, African Ameri-can mothers given the complexity ofthe obstacles that these mothers faceand the time constraints of medicaland lactation professionals.

Research has shown that supportfrom doulas, peer counselors, or other

paraprofessional or lay providers canlead to increased breastfeeding ratesamong both low- and high-risk moth-ers.21–25 The success of lay helpers,who often share socioeconomic andethnic backgrounds with clients, isthought to derive from their un-derstanding of the economic, environ-mental, and cultural context in whichmothers live, their awareness of theparticular personal challenges that themothers face and resources availableto them, and their availability to clientsin time and place.26

Doulas are childbirth support pro-viders who have training and experi-ence focused on childbirth but who arenotmedical professionals. Doulas’ coreroles include offering continuouscomfort and emotional support tomothers during labor and delivery andencouraging bonding and breastfeed-ing during the immediate postpartumperiod.27 Based on the well-documentedsuccess of hospital-based doula inter-ventions in promoting healthy childbirthoutcomes,28 some community-basedprograms serving pregnant low-incomeor young mothers have developed a newmodel of doula services in which sup-port is offered, not only in hospital set-tings, but also in the home duringpregnancy and after birth.29,30 These“community doulas,” who usually havedeep connections to their clients’ cul-tures and communities, expand the roleof the doula to include specialized homevisitation services focused on pregnancyhealth, childbirth preparation, fetal andinfant bonding, child health, and breast-feeding.

Preliminary data suggest that youngmothers who receive community doulaservices have breastfeeding rates thatexceed those typically found amongyoung mothers,29 however, no studiesto date have rigorously examined themodel’s efficacy. Therefore, a random-ized, controlled trial of a communitydoula home visiting intervention was

designed to test, in part, the hypothesisthat community doulas would enhancebreastfeeding and healthy infant feed-ing outcomes in a group of young, Af-rican American mothers.

METHODS

Design

A randomized, controlled trial of acommunity doula intervention foryoung, pregnantwomenwasconductedat a major urban university hospital.This study was approved by the In-stitutional ReviewBoardof theaffiliateduniversity. All participants providedwritten informed consent before thebaseline interview.

Inclusion and Exclusion Criteria

Pregnant women were recruited be-tween January 2001 and April 2004through a community health centerandprenatal clinic affiliated with the uni-versity hospital. Women who were lessthan34weekspregnant, under 21 yearsof age, and planning to deliver at theaffiliated hospital were eligible to par-ticipate in the study. Mothers who wereaware at the time of recruitment thatthey would require a surgical delivery,who planned to move from the area, orwho planned to give up custody of theinfant were excluded from the study. Atotal of 468 young, pregnant womenwere informed about the study andthe doula services by a doula duringa prenatal clinic appointment. Re-search interviewers then attempted tocall women who expressed interest inthe study to schedule a session for in-formed consent and the baseline in-terview. Fifty-three percent (n = 248)were enrolled in the study, 15% (n = 70)declined participation, 17% (n = 80)could not be reached, 11% (n = 51) didnot show up for their consent sessions(often rescheduled multiple times),2.4% (n = 11) had plans to move, 1.4%(n = 7) delivered or lost the infant be-fore enrollment, and 0.2% (n = 1)

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planned to give the infant up foradoption.

Randomization

At the end of the baseline interview,women were randomly assigned toreceive usual prenatal health careservices through the clinics (n = 124;control group) or a combination ofusual services and a community doulaintervention (n = 124; doula group).Randomization took place in blocks of4, 6, or 8, with equal numbers assignedto the intervention and control groupswithin each block. A biostatisticianprepared a set of opaque envelopes,each labeled with a subject ID numberand containing a group assignment.Envelopes were opened by the in-terviewer in the presence of themother at the completion of the base-line interview. Mothers in the 2 groupswere compared on a variety of de-mographic, psychological, and healthvariables measured before randomi-zation and no significant differenceswere found (Table 1).

Intervention Model

Doula-group participants were as-signed 1 of 4 program doulas. Thedoulas were African American womenfrom the communities surroundingthe clinics who had not previouslybeen trained as health professionals,

although1hadworkedasaclinicmedicalassistant, 1 had received breastfeedingpeer counselor training, and all hadinformal experience counseling preg-nant adolescents in their churches andcommunities. Three of the 4 doulas hadbeen adolescent mothers, and 3 hadbreastfed their children. Before begin-ning their work with study families, thedoulas participated in an intensive 20-week doula training course provided bythe Chicago Health Connection (HealthConnect One) and a 10-week breast-feeding peer counselor training pro-gram from the same organization. Afterinitial training, all doulas took con-tinuing education courses. All 4 becamecertified childbirth educators and 3became certified lactation counselors.Doulas received weekly individual andgroup supervision sessions led bya pediatric nurse, who had also beentrained as a doula. The nurse alsoprovided doulas with emergency clini-cal consultation, support, and medicalinformation.

The doulas focused onmultiple aspectsof maternal and infant well-being. Al-though the doulas did not followa specific breastfeeding curriculum,breastfeeding advocacy and supportwere primary areas of focus of theprogram services.

During weekly prenatal home visits, thedoulas focused on building relationships

with the mother while discussingpregnancy health, childbirth prepara-tion, and bonding with the unborn in-fant. They engaged mothers in ongoingconversations about infant feeding,listened tomothers’ ideas and concernsabout breastfeeding, and worked todispel any myths that the mothers held.Doulas sometimes shared their per-sonal experiences of breastfeeding orthe experiences of others in their com-munity to help normalize the idea ofbreastfeeding for women from theircultural and community backgrounds.The doulas educated mothers about thebenefits of breastfeeding, sometimesusing printed, video, or other in-formational materials. The doulasincluded fathers and mothers’ familymembers in discussions about thebenefits of breastfeeding and helpedmothers gain family acceptance fordecisions around feeding.

During labor and delivery, the doulaswere present in the hospital to providecontinuous emotional support and of-fer physical comfort techniques. Thedoulas were present in the firstmoments after the birth to encouragemothers to put the infant to breast andto help the infants latch. During thehospital stay and after discharge home,the doulas continued to provide en-couragement and guidance asmothersnegotiated the initial challenges ofbreastfeeding, including relievingbreast discomfort, getting the infant tolatch, and finding effective holdingpositions. Doulas suggested tomothersthat they put the infant to breast atfrequent intervals and that they notintroduce formula to infants whileestablishing lactation. The doulas pro-vided information on ways to assessand reassure mothers that the infantwas getting enough milk.

During home visits made during thefirst 3 months postpartum, doulashelped mothers adjust to parenthoodandget to know their infants andhow to

TABLE 1 Baseline (Pre-Randomization) Characteristics of Control Group and Doula GroupMothers

Characteristics Control Group(n = 124)

Doula Group(n = 124)

Maternal age at enrollment, mean (SD), yr 17.9 (1.7) 18.2 (1.7)Maternal years in school completed, mean (SD) 10.6 (1.5) 10.9 (1.5)Gestational age at enrollment, mean (SD), wk 23.8 (5.3) 23.3 (4.6)Vocabulary Score (PPVT), mean (SD) 85.5 (11.4) 86.4 (11.2)Expecting first child, No. (%) 109 (87.9) 110 (88.7)Mother in school, No. (%) 68 (54.8) 67 (54.0)Mother employed, No. (%) 27 (21.8) 10 (16.1)Co-residing with parent figure, No. (%) 98 (79.0) 96 (77.4)Partner with infant’s father, No. (%) 83 (66.9) 89 (71.8)Considering breastfeeding at enrollment, No. (%) 72 (58.1) 82 (66.1)Own mother breastfed, No. (%) 44 (35.5) 44 (35.5)Knew someone who had breastfed, No. (%) 72 (58.1) 79 (63.7)

PPVT, Peabody Picture Vocabulary Test.

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care for them. Doulas were available tobreastfeeding mothers by telephone 24hours a day to help with problems.Doulas provided breast pumps formotherswhowere returning towork orschool. For mothers who were feedingbreast milk from bottles or using for-mula, doulas discouraged the use ofcereal in the bottle. Doulas discouragedthe introduction of solid foodduring theearly months of life for both breastfedand formula-fed infants.

Mothers in the community doula in-terventiongroupreceivedanaverageof10 prenatal and 12 postpartum homevisits. A doula was present at the hos-pital for the birth for 81.5% of theintervention-group infants.

Outcome Measures

Data were collected by research staffthrough interviewswithmothersandbychart review. Data on breastfeedingattempts were collected by motherreport at the hospital the secondmorningafter thebirthand fromreviewof the nursing notes in the mother’smedical chart after the mother’s dis-charge. For reporting in this paper,mothers were considered to haveattempted breastfeeding if breastfeed-ing was indicated by either self reportor nursing notes. At 4 months post-partum, the mothers participated in aninterview on topics such as health,feeding practices, and parenting. Moth-ers reported on whether they werecurrently breastfeeding and, if not,when they had stopped breastfeeding.Mothers were also asked aboutwhether they had started feeding theirinfants cereal, either in the bottle orby spoon, or other solid foods, andreported the infant age atwhich they hadfirst introduced complementary foods.

Sample Retention

Data on 123 control groupmothers and122doulagroupmotherswereobtainedduring the postpartum period. One

infant in the control group and 1 infantin the doula group died at birth, and 1mother in the doula group declined toparticipate in the study after the base-line interview. A total of 221mothers, 113in the control group and 108 in the doulagroup, participated in the 4-month in-terview. Reasons for subject loss at 4months included inability to locatemothers and infant death (Fig 1).

Data Analysis

x2 tests of association were performedto examine group differences inattempted breastfeeding at the hospi-tal, breastfeeding duration, and timingof cereal/solid food introduction.Breastfeeding duration was classifiedas “never,” “less than 6 weeks,” “6weeks to 4 months,” and “longer than 4months.” Mothers were also catego-rized into 3 groups based on the age atwhich they had introduced cereal orother solid foods to their infants:“younger than 6 weeks,” “6 weeks to 4months,” and “older than 4months.” Allanalyses were by intent-to-treat.

RESULTS

Table 1 shows demographic charac-teristics of mothers in the controlgroup and doula group. All of themothers were African American, whichwas representative of women attend-ing the prenatal clinics. A total of 93.8%of mothers received Medicaid, and88.7% were giving birth for the firsttime. The mean age of the mothers atthe birth was 18.3 years (SD = 1.7).Seventy-eight percent lived with a par-ent figure at the time of enrollment.

Results show that the community doulaintervention was significantly associ-ated with breastfeeding rates (Table 2).In the hospital, 63.9% of mothers in thedoula group attempted breastfeeding,compared with 49.6% of mothers in thecontrol group (P = .02). The impact ofthe intervention on breastfeeding du-ration was less clear. Although mothers

who received doula services weremore likely to breastfeed longer than 6weeks compared with control groupmothers (28.7% vs 16.8%; P = .04), fewmothers in either group were stillbreastfeeding by 4 months postpartum(8.3% of doula-group mothers and 4.4%of control-group mothers).

There was a significant associationbetween timing of complementary foodintroduction and intervention status(P = .008). Although the majority ofmothers in both groups were feedingtheir infants cereal or other solid foodsbefore 4 months of age, more mothersin the intervention group (21.3%) com-pared with the control group (12.5%)had waited until at least 4 months. Ad-ditionally, only 5.6% of mothers in thedoula group compared with 17.9% ofmothers in the control group had in-troduced complementary foods duringvery early infancy (,6 weeks).

DISCUSSION

Previous research suggests that evenshort-term breastfeeding is associatedwith a variety of positive health out-comes for infants, including reducedrisk for Sudden Infant Death Syn-drome,13 lower incidence of otitis me-dia, respiratory tract infections, andgastrointestinal tract infections duringinfancy,31 and lower rates of childhoodobesity8,32,33 and type 2 diabetes.33,34

Additionally, delaying the introductionof complementary foods until infantsare at least 4 months of age can pre-vent choking14 and gastrointestinalproblems35 among young infants, andmay reduce the risk for childhoodobesity.15 Given that rates of breast-feeding and delayed solid food in-troduction have traditionally been verylow among young, African American,and low-incomemothers, interventionsare needed to enhance healthy feedingoutcomes among these groups.

This study, using a sample of young,AfricanAmericanmothers, is thefirst to

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examine the efficacy of a communitydoula home visiting intervention inpromoting positive infant feeding out-comes. The results demonstrate thatmore mothers assigned to communitydoula services attempted to breastfeedtheir infants in the hospital and con-tinued to breastfeed past 6 weekspostpartum compared with motherswho received usual prenatal care.

Doula services also impacted the age atwhich mothers first introduced com-plementary foods to their infants:doula-groupmotherswere less likely tofeed cereal or other solids to newbornsand more likely to wait until infantswere at least 4 months old.

Qualitative interviews from mothers inthis study, reported elsewhere,36 sug-gest that the success of this community

doula intervention for breastfeedingpromotion and healthy feeding may liein the close relationship that developsbetween the community doulas and themothers during pregnancy and theongoing conversations and supportthat doulas provide around healthyfeeding practices. Trust is facilitated bythe community doulas’ respectful, non-judgmental approach, their credibility

FIGURE 1Participant flowchart.

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as women who share a cultural back-ground, their presence in mothers’homes, their presence at the birth, andtheir availability by phone when mostneeded. Although doctors, nurses, andlactation professionals are knowledge-able and may be well-intentioned, clinicappointments and brief hospital inter-ventions allow only limited windows ofopportunity to counsel young mothers.These interactions may not coincidewith times when questions arise for theyoung mothers or allow for the kind ofrelationship that the mothers may needto share very personal concerns andlisten to advice. Because doulas are ableto provide services in the home andthus facilitate a sense of comfort,mothers may be more receptive to theguidance doulas give regarding infantfeeding and allow the doulas to physi-cally support their breastfeedingattempts after the birth and in the earlypostpartum weeks.

Although the impact of the communitydoula interventionon feedingoutcomeswas statistically and clinically signifi-cant, the breastfeeding rate of 64%

found among the doula group mothersis lower than the Healthy People 2010target rate of 75%and the 2020 target of81.9%.37 Additionally, the impact of theintervention was only modestly sus-tained over time. Even in the doulagroup, there was substantial drop-offin the number of mothers still breast-feeding at 6 weeks, and only 8% ofmothers continued to breastfeed at 4months. Many mothers (79%) who re-ceived the intervention also introducedcomplementary foods to their infantsbefore 4 months of age. Given thatcurrent recommendations are formothers to breastfeed exclusively forthe first 6 months and introduce com-plementary foods after 4 to 6 months ofage,7 these results highlight the ongo-ing challenges in promoting breast-feeding and healthy feeding practicesin this population, even in the context ofa close and supportive helping re-lationship. Other assistance is likelyneeded to further enhance healthyfeeding practices, such as breastfeed-ing policies in schools and workplacesthat are applicable to this population,

supplementing the doula interventionwith longer term home visiting ser-vices, and peer support efforts.38

There are many strengths of this study,including the randomized design, datacollection from mother report andmedical records, high levels of re-tention, intent-to-treatanalyses, and thefocus on a high-risk population. Thereare also several limitations. First, theintervention was limited to 1 site andparticipants were all young, AfricanAmerican mothers, which limits thegeneralizability of the findings to othergeographic locations and other groupsof mothers. Second, doulas receivedhigh levels of support around imple-menting the intervention. Further re-search is needed to assess outcomeswhenthe intervention isusedwithotherpopulations and when model fidelitymay not be as high.

CONCLUSIONS

Community doula home visiting isa promising intervention to promotehealthy infant feeding practices amongyoung, African American mothers. Be-cause this model is currently beingused with mothers of various ethnicgroups, ages, andgeographic locations,further study is warranted to examinethe effects of the model when imple-mented more broadly. Future researchshould also focus on understanding thecomponents of the intervention mostimportant to promotinghealthy feedingpractices, and examining whether in-tervention effects can be sustainedwhen community doula services areimplemented in the context of longer-term home visiting programs.

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TABLE 2 Doula Intervention Effects on Breastfeeding and Infant Feeding Practices

Doula Group %(95% CI) No.

Control Group %(95% CI) No.

P

Birth outcomes (n = 245)Attempted breastfeeding 63.9 (55.3–72.5) n = 78/122 49.6 (40.7–58.5) n = 61/123 P = .02

4-month outcomes (n = 221)Breastfeeding duration P = .10Never 34.3 (25.2–43.3) n = 37/108 48.7 (39.4–58.0) n = 55/113,6 wk 37.0 (27.8–46.2) n = 40/108 34.5 (25.7–43.4) n = 39/1136 wk to 4 mo 20.4 (12.7–28.0) n = 22/108 12.4 (6.3–18.5) n = 14/113.4 mo 8.3 (3.1–13.6) n = 9/108 4.4 (0.5–8.3) n = 5/113

Timing of cereal/solidfood introduction

P = .008

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CI, confidence interval.

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