Kashyap M. Integrating mobile health technology in community based doula programs to extend childcare related support to adolescent single mothers. HPHR. 2021;34.
The effect of all aspects of maternal health before, during, and after pregnancy on prenatal and early childhood health and well-being is well documented. Early childhood outcomes have been empirically established as predictors of well-being in later life (Heckman et. al., 2013). Research on motherhood indicates that social and instrumental support from family of origin has a greater positive impact on adolescent mothers than adult mothers (Nath et. al., 1991). However, the absence of such forms of support among adolescent single mothers might have detrimental implications for maternal and child well-being outcomes.
The role of doulas in providing physical, emotional, and informational support to mothers during labor and post-partum, and fostering positive mother-infant relationships is widely recognized in maternal and child health research. (Ahlemeyer, J., & Mahon, S., 2015, & Hans et. al., 2013). Therefore, community-based doula programs can be an effective way to improve maternal and child health outcomes in populations of adolescent single mothers. This paper proposes adaptation of existing community-based doula programs to the unique features of adolescent parenting by integrating mobile health technology to build an alert virtual ecosystem that facilitates immediate provision of social and instrumental support, and childcare related services to adolescent single mothers at high risk of detrimental birth outcomes.
Community based doula programs have been empirically proven to model positive behavior change in mothers, parents, and families as it relates to enhancing outcomes of maternal and child well-being. However, majority of parent populations served by these interventions are adults. Adolescent parenthood differs from adult parenthood due to the differences in developmental needs and capacities of adolescents and adults. A quantitative study conducted in rural Maine found that on average, adolescent mothers had significantly lower empathy for their child’s needs as compared to adult mothers (Baranowski et.al., 1990). Another study supported this hypothesis suggesting that adolescent mothers were significantly less aware of child development trajectories, displayed less desirable parenting style, and held more undesirable attitude about parenting roles than adult mothers (Sommer et. al., 1993). For these reasons, adolescent parents may encompass unique needs for childcare related services and support.
A study showed that adolescent mothers have greater requirements of social and instrumental support than adult mothers (Nath et. al., 1991). For single teen mothers, the transition to parenthood can be a socially isolating process in the absence of immediate support from families and networks of adolescent parents (Lowenthal B. & Lowenthal R., 1997). Lack of socio-emotional and instrumental support to teen mothers may have deleterious public health consequences for the mother and the child. A school-based teen parents’ program found that social isolation, concerns about physical appearance, and self-efficacy to adapt to motherhood were factors that predisposed adolescent mothers to postpartum depression (Berkland et. al., 2005). Another study revealed that low levels of self-perceived social support and high levels of parenting stress were characteristic of maternal depression among adolescent mothers at baseline (Huan et. al., 2014). Huan et. al. also found that higher levels of maternal depression were associated with developmental delays in infants one-year post-baseline. This study also identified maternal depression as mediating the relationship between parenting stress and later child outcomes.
Additionally, single motherhood in adolescence may reduce parental supervision and involvement with the child as the mother may be occupied with securing a livelihood (McLanahan S. & Booth K., 1989). The pressure of securing a livelihood may also increase dropout rates from secondary and post-secondary educational institutes among adolescent mothers. Low levels of literacy among mothers has shown to increase the likelihood of negative parenting or child preventive care behaviors (Sanders et. al., 2009). Furthermore, time demands of work may discourage breastfeeding among the target population predisposing their child(ren) to nutrient deficiencies and weak immunity against infectious diseases (Wambach, K. A., & Cohen, S. M., 2009 ; Huffman, S. L., & Lamphere, B. B.,1984).
Evidence suggests that children born to adolescent mothers show higher risks of delays in intelligence, language, cognition, socioemotional adjustment, social competence, and face greater academic difficulties in early school years (Whitman et. al., 2001). The lack of adequate cognitive maturity and development during teenage motherhood may also result in unrealistic expectations of child development and failure to cultivate reciprocal parent-child relationships, increasing the likelihood of child abuse and maltreatment (Musick J. S., 1994). A study assessing adolescent parenting outcomes found that daughters raised by single teen mothers develop favorable attitudes and behavioral intentions towards early pregnancy and single motherhood in adolescence threatening to perpetuate sub-optimal maternal and child well-being outcomes across generations (McLanahan S. & Booth K., 1989). Therefore, the lack of socio-emotional support systems and necessary services to facilitate parenting and childcare among adolescent single mothers can create barriers to positive parenting and healthy development of their offspring.
Social isolation, cognitive immaturity, low socio-economic resources and education attainments, parenting stress, stress from work, and prevalence of maternal depression in adolescent mothers make it necessary to build robust networks of childcare related social and instrumental support for adolescent single mothers at high risk of negative maternal and child health outcomes. Mobile health technology can help install an alert, virtual ecosystem of maternal and child healthcare by providing prenatal, postnatal, and parenting services to low resource, high risk adolescent single mothers. Current literature on digital interventions provides empirical support for mobile healthbased technology as viable modalities of health behavior change in adolescents (Doswell et. al., 2013; Fedele et. al., 2017).
The mobile health enabled tools in this program shall consist of a wearable device for doulas, and a mobile application for use of doulas and participants. This intervention shall adopt a two-pronged approach namely “Digital Extension of Doula Care” and “Mobile Mediated Social Support Groups among Adolescent Single Mothers” with the aim to achieve positive maternal and child health outcomes in the target population. A completed informed consent form shall be collected from all participants in the program. The program shall also ensure services of a translator and/or recreate the consent form in the language(s) the participants are familiar with. Prior to implementation, a needs assessment survey shall be circulated among participants of the program to assimilate their preferred topics in areas of prenatal care, post-partum care, parenting, motherhood, and childcare for children up to three years of age. The program shall partner with community based maternal and child health research and advocacy organizations, secondary and post-secondary institutes of education, and other agencies in the communities of the target population, to identify, recruit, and follow up program participants. The program shall also devise strategies to maintain relationships with participants post completion.
The first level of the intervention involves digital extension of doula care to adolescent single mothers. Doulas shall be trained to use the wearable device and the mobile application for health education, management of health, data tracking, sharing, and monitoring in areas of positive parenting, nutritional requirements of mother and infant, safe sleep practices, breastfeeding initiation, continuation, and exclusivity, child immunization, initiation of family planning methods, ill-effects of maternal substance abuse and importance of healthy lifestyle choices, importance of secondary and post-secondary education, early detection of speech and motor delays, and child behavior management strategies to nurture maternal health and child development (Hartz et. al., 2016 & Pinzon, J. L., & Jones, V. F, 2012).
A successful digital doula program shall recruit adolescent doulas and doulas with different specializations such as labor doulas, postpartum doulas, antepartum doulas, and bereavement doulas among others (“All Kinds of Doulas”, 2014). However, decisions about the type and number of doulas recruited by the program shall be guided by the target population’s preferred topics of parenting, motherhood, and childcare, total number of participants, and community specific considerations. The community of target population shall be divided into groups based on their zip codes such that all adolescent mothers living in proximity will be designated one virtual group. While efforts shall be made to ensure uniform number of adolescent mothers in each group, the size of each group shall depend on density of target population in each locality and community specific considerations. One or more doula(s) shall be assigned to each group of adolescent single mothers.
The doulas will be required to collect, track, and monitor data related to the health and well-being of the target population using the mobile application. This data collection, tracking, and monitoring function shall be used by the doulas to send daily message reminders to the target community of upcoming antenatal care visits, and other maternal and childcare related appointments to assist with health management and on-going ascertainment of the health developments of the mothers and their child(ren), guiding further action as needed. The participants shall be required to send confirmation of healthcare appointment attendance to the doulas. The wearable device shall be connected to the mobile application and alert doulas of urgent physical attention as notified by the mothers through the mobile application. The doulas shall be trained to use the mobile application platform to share all the data on the target populations’ health and well-being outcomes with the lead project researchers. Doulas shall also be trained to use the mobile application component of the program to disseminate interactive pamphlets and information toolkits on the preferred topics of childcare, motherhood, and parenting as indicated by the target population. These pamphlets and toolkits shall be created by the lead project researchers in partnership with community-based agencies identified earlier.
The second level requires creation of mobile mediated social support groups among the target population in the mobile application. Mobile mediated social support (MMSS) groups can help connect adolescent single mothers with other adolescent single mothers in the same and across different localities through private message exchanges, interactive teleconferencing, and a common broadcasting system to create an enabling environment for teen mothers to collectively share their parenting experiences, suggestions and advice related to childbearing, and discuss antenatal, postnatal, parenting, and other childcare related concerns with the intent to reduce perceived social isolation and loneliness in this population (Dunham et. al., 1998).
Membership in each MMSS shall replicate virtual membership in the first level of the intervention to ensure overall uniformity and efficiency of program implementation. This arm of the intervention shall allow for one-on-one and mass level communication between teen mothers. MMSS shall encompass private messaging and teleconferencing functions to facilitate individual interactions among participants within the same social support group (Dunham et. al., 1998). A common broadcasting system shall be utilized to allow mass level communications between adolescent mothers across different social support groups (Dunham et. al., 1998). The common broadcasting system shall require all the participants to create a unique user identification name and password (Dunham et. al., 1998). The common broadcasting system shall allow mass level communications on different topics related to motherhood, parenting and childcare. These topics shall reflect the preferences indicated by the participants in the needs assessment survey. Personal information of the participants shall not be made publicly accessible to the broadcasting system for safety concerns. Furthermore, any personal information voluntarily shared by the participants shall be at their discretion (Dunham et. al., 1998). Doulas shall be trained to monitor the quality of these exchanges to maintain a safe virtual community.
These virtual social support communities shall help instill a sense of belonging and interconnectedness in the target community by ensuring continuous availability of parenting and other childcare related knowledge from fellow members in the social groups. MMSS can also be useful in helping single mothers attend to urgent childcare needs in the event the designated doulas are unable to provide immediate physical attention. This arm of the intervention shall also allow participants the option to raise childcare related questions and/or concerns anonymously to respect concerns of privacy or social embarrassment (Dunham et. al., 1998). This digital medium can potentially improve the quality of communications among the target community by reducing the influence of social differences of race, ethnicity, and class that may inhibit face-to-face conversations (Dunham et. al., 1998).
The data tracking and monitoring functions of the mobile application can potentially reduce loss to follow up in a population as transient as adolescents. The pre-intervention needs assessment and integration of relevant community-based organizations can enhance external validity of this program across various settings. The digital nature of this intervention also makes it suitable for infectious disease outbreaks such as the coronavirus disease (COVID-19) and other forms of interpersonal social disruptions.
The digital and data sensitive nature of this project requires substantial funding, stable networks of mobile connectivity, training of doulas and participants, and device maintenance efforts which may be challenging to secure across different settings. This might hinder the external validity of the program. Further research and piloting is needed to assess the effectiveness of this program among hard to reach populations such as adolescent single mothers with intellectual and developmental challenges, incarcerated teen single mothers, teen single mothers in foster care, and adolescent single mothers currently homeless or in homeless shelters.
Research has shown that adolescent single motherhood differs characteristically from adult parenthood in ways that has implications for maternal and child health. However, despite this recognition, there is a lack of interventions that address challenges of parenting and childcare among adolescent single mothers. This paper proposes a model to investigate and incorporate the community context and multitude of factors governing childcare needs of adolescent single mothers.
The success of mobile health technology in community-based doula programs is contingent on certain considerations. In accordance with the sensitive nature of the program, efforts must be made to conduct extensive training of doulas to ensure no ethical violations in the process of data collection, tracking, monitoring, sharing, or any other aspect of using wearable device and mobile application components. Researchers must clearly define the emergency situations qualifying for immediate physical attention of the doulas in order to ensure enough doulas for adolescent mothers in need of urgent in-person care. The intervention must ensure that the health literacy interactive pamphlets and information toolkits are in tandem with the overall literacy of the target population. The research team must also make efforts to help sustain social support groups in the target population after completion of the program to continue the flow of socio-emotional and instrumental support. The program must hire evaluation specialists from the baseline of the project to facilitate precision of process/formative and outcome/summative evaluation efforts. Programmatic efforts must be made to build capacity of participants to engage in community based participatory outcome/summative evaluation of the intervention. More cross-cutting research and evaluation of digital community-based doula programs in enhancing maternal and child well-being is needed before engaging in policy advocacy.
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Marisha Kashyap is a recent graduate of the Master of Public Health program at Columbia University, Mailman School of Public Health. She is extremely passionate about furthering equitable outcomes in healthy childhood development.