PEDIATRICS Vol. 101 No. 6 June 1998, p. e11

ELECTRONIC ARTICLE:
Racial/Ethnic Differences in the Decision to Breastfeed Among Adolescent Mothers

Constance M. Wiemann^*, Jacqueline C. DuBois, and Abbey B. Berenson^*,

From the Departments of ^* Obstetrics and Gynecology and  Pediatrics, University of Texas Medical Branch, Galveston, Texas.

	ABSTRACT

Top Abstract Introduction Methods Results Discussion Conclusion References

Objective.  To identify racial/ethnic differences in prevalence and the factors that influence decisions to breastfeed among adolescent mothers.

Methods.  A total of 696 Mexican-American, African-American, and Caucasian adolescent mothers 18 years of age were interviewed on the postpartum ward of university hospital within 48 hours of delivery. Self-reported factors associated with the decision to breastfeed were assessed.

Results.  The decision to breastfeed was reported by 55% of Mexican-American, 45% of Caucasian, and 15% of African-American adolescent mothers. With the exception of perceived benefits of breastfeeding and exposure to educational materials, most factors associated with breastfeeding differed by race/ethnicity. Among Mexican-Americans, important factors included having relied on feeding advice (adjusted odds ratio [AOR] = 7.6); the feeding preference of a partner (AOR = 7.0) or mother (AOR = 6.6); and feeding decisions made in early pregnancy (AOR = 4.7). Among African-Americans, important factors included living with a partner (AOR = 10.6); having a mother who breastfed (AOR = 5.9); the feeding preference of a partner (AOR = 5.6) or health care provider (AOR = 4.7); and low family support (AOR = 3.4). Among Caucasians, health care providers' feeding preference (AOR = 6.1); having two or more breastfeeding role models (AOR = 4.1); not being enrolled in Women, Infants, and Children's Supplemental Nutrition Program (AOR = 3.0); having relied on infant-feeding advice (AOR = 3.0); and prenatal alcohol use (AOR = 2.6) were associated with the decision to breastfeed.

Conclusions.  Prevalence and influences to breastfeed differ by patient race/ethnicity. We speculate that targeting the adolescent mother and members of her support system, educating them before and during pregnancy, and stressing benefits of this method while eliminating misinformation, especially among African-Americans, may be important intervention strategies to promote breastfeeding.

	INTRODUCTION

Top Abstract Introduction Methods Results Discussion Conclusion References

Breastfeeding has nutritional, immunologic, economic, and psychologic advantages over formula-feeding^1-4 and is the method of infant feeding recommended by the World Health Organization and the American Academy of Pediatrics.^5,6 Although rates of breastfeeding among women residing in the United States have increased in the last 2 decades, parallel trends have not been observed among women of various racial/ethnic backgrounds or in the very young.⁷ To reverse this trend, interventions that target adolescents and minority women must consider the complex set of factors that influence the mother's choice of infant-feeding method. Yet, few data are available on the predictors of breastfeeding in these special populations. Research among adolescent mothers has suffered from small sample size,^8-11 absence of racial/ethnic diversity,¹⁰ and a limited focus on attitudes^8-10 or demographic characteristics^12-14 without attempts to evaluate their relative and combined influence. The present study was undertaken to address some of these shortcomings by using a large sample of racially/ethnically diverse adolescent mothers to examine the breastfeeding decision.

Studies on adults cannot be extrapolated to adolescents because previous studies suggest differences by age.^13-21 In fact, the special circumstances of adolescent motherhood may shape decisions about infant feeding for this subgroup of mothers. For example, although partners are an important source of encouragement to breastfeed or bottle-feed among women of any age,^9,14,16,22 adolescent mothers are less likely than are adults to be married. Hence, peers may be an important influence in the adolescent mother's infant-feeding decision;²³ this relationship has not been examined systematically. Among adult populations, there is some suggestion that women who choose to breastfeed also are more likely to demonstrate positive health habits such as avoidance of tobacco^16,20 and illicit drugs.¹⁶ Despite the common co-occurrence of risk behaviors such as early sexual activity, unprotected sexual intercourse, and substance use among some adolescents,²⁴ as well as the documented passive transmission of harmful substances through breast milk,²⁵ no published study has systematically examined the role of tobacco, alcohol, or illicit drug use in the infant-feeding decision of adolescent mothers.

In addition, we know very little about feeding intentions of African-American women, who have been underrepresented in cross-cultural comparisons of breastfeeding mothers of any age.^18,19,26 Among adults, correlates and perceived benefits or disadvantages of breastfeeding appear to differ by patient race/ethnicity.^15,27 Despite these important differences and low rates of breastfeeding among adolescent and minority women, no study has examined systematically racial/ethnic determinants of the infant-feeding decision among adolescent mothers.

To develop racially/ethnically sensitive breastfeeding interventions to meet the unique needs of adolescent mothers, we investigated differences in the prevalence of breastfeeding and the factors that influence infant-feeding decisions in a large, triethnic sample of adolescent mothers. We hypothesized that rates of breastfeeding would be higher among Mexican-American and Caucasian than among African-American adolescent mothers. Furthermore, we expected mothers from different races/ethnicities to identify different reasons for their choice of feeding method. Finally, we wished to evaluate the relationship between tobacco, alcohol, and illicit drug use and the infant-feeding decision in this group of high-risk mothers.

	METHODS

Top Abstract Introduction Methods Results Discussion Conclusion References

All adolescents mothers through 18 years of age who delivered at our institution between June 1, 1994, and February 28, 1996, were eligible to participate if they met the following criteria: self-reported Mexican-American, African-American, or Caucasian race/ethnicity; plan to retain custody of their infant; ability to read and write at a fifth-grade level in either English or Spanish; absence of major psychiatric disorders; and delivery of a healthy infant weighing >1500 g. Adolescent mothers from other race/ethnic groups were excluded from study participation because of their numbers. There were 786 adolescent mothers who delivered an infant during the study period and were eligible to participate. Of these, 20 adolescent mothers were not approached to participate because of a large number of births on the day they delivered. Of the 766 adolescent mothers invited to participate, 70 (9%) refused. The most common reason given for declining to participate was not having enough time to complete the hour-long interview. Therefore, the study sample included 696 adolescent mothers, 274 of whom were Mexican-American, 212 African-American, and 210 Caucasian. Comparisons of demographic factors between those who refused and those who were interviewed revealed a higher refusal rate among Mexican-Americans who spoke Spanish only (P < .001).

The university's institutional review board approved all protocols. A trained research assistant interviewed each subject privately in English or Spanish within 48 hours of delivery on the postpartum ward. Because of the unpredictable nature of deliveries, matching the race/ethnicity of the interviewer with that of each subject was not possible. However, representatives from the three racial/ethnic groups under study were included in the interviewer pool. Analyses conducted to determine whether differences could be detected in the responses of study subjects when interviewers were not matched on the basis of patient race/ethnicity yielded insignificant findings. All interviewers were screened carefully and selected based on outstanding interpersonal skills. Moreover, all received extensive training in patient interviewing techniques, participated in at least four practice sessions, observed several patient interviews, and were themselves observed conducting interviews. Interviewers who spoke fluent Spanish interviewed all Spanish-speaking patients. Data were collected as part of a larger study of substance use among pregnant and parenting adolescent mothers. The larger project was presented to potential subjects as a study of the transition to adolescent parenthood. Written consent to participate was obtained from each patient. In addition, as required by the institutional review board, written consent from a parent or legal guardian was obtained for patients younger than 18 years of age who were currently living with their guardian and were not legally married.

Patients answered all questions using a face-to-face interview format with the interviewer asking questions and recording patient responses. Cards containing all possible response options were provided that enabled patients to remember their choices. The interview elicited demographic characteristics as well as factors considered important to the mother's infant-feeding decision. Questions selected were based on a review of the literature as well as discussions with lactation specialists, experts in adolescent medicine, and new adolescent mothers. All questions were pilot-tested on a group of 20 postpartum adolescent mothers, revised, and translated into Spanish using forward and backward translation. Spanish surveys underwent additional pilot testing. Delivery records were reviewed to extract information on accessing prenatal care, gravidity, parity, previous abortions, delivery type (cesarean or vaginal), and the results of urine drug screening (cannabinoids, opiates, cocaine) performed during pregnancy. Interview and delivery data were entered into an automated database and verified for accuracy. All analyses were performed using the Statistical Package for the Social Sciences (V6.1a for Windows, SPSS Inc, Chicago, IL).

Variable Definitions

Breastfeeding was confirmed if the patient reported that she intended to breastfeed with or without supplemental formula feedings because the majority of breastfeeding mothers stated they were unsure of whether they would breastfeed exclusively. Financial resources were considered inadequate if the patient reported insufficient funds for living. Strong family support was defined as being able to rely on members of one's nuclear or extended family for financial, tangible, emotional, and informational support. Substance use before pregnancy and the use of tobacco and alcohol during pregnancy were determined by self-report, whereas illicit drug use (cocaine, opiates, cannabinoids) during pregnancy was identified both by self-report and by results of urine drug screens. For Mexican-American adolescent mothers, measures of acculturation included their birth country, primary language spoken by family members, and the language (Spanish or English) in which the patient interview took place.

To discourage response-setting, perceived benefits and disadvantages of breastfeeding were evaluated by asking each mother to indicate on a four-point Likert scale, from strongly agree to strongly disagree, which aspects of infant feeding were most important to her decision. Responses were later dichotomized into "agree" or "disagree." Patients also were asked to indicate when they made this decision (before pregnancy, in early gestation, later in pregnancy, or in the hospital after delivery), and whose advice, if any, was most important. Exposure to breastfeeding role models was assessed by identifying members of each patient's support network who breastfed.

The following variables were coded 1 (yes) or 0 (no) for purposes of analyses: living with an older female (mother, grandmother, aunt, or mother of the infant's father); living with a male partner; school enrollment during the final 3 months of pregnancy; plans to complete high school; plans to return to school within 6 weeks after delivery; inadequate financial resources; Women, Infants, and Children's Supplemental Nutrition Program (WIC) enrollment; cesarean delivery; high school education of the infant's maternal grandmother; whether the recent pregnancy was planned; use of tobacco, alcohol, marijuana, and other illicit drugs (cocaine, LSD, heroin, inhalants, etc) during pregnancy and in the 3 months before conception; attendance at feeding classes; and exposure to infant-feeding educational materials. The relative influence of educational resources was evaluated by asking whether attendance at prenatal infant-feeding classes or exposure to written or videotaped materials encouraged each patient to breastfeed (coded 1) or bottle-feed (coded 0) or had no effect on feeding choice (also coded 0 because too few respondents chose this response to make meaningful comparisons among response choices). A delayed breastfeeding decision was defined as a choice being made in middle to late pregnancy or in the hospital (coded 1) versus before conception or in early gestation (coded 0). The number of breastfeeding role models was dichotomized as two or more (coded 1) or fewer than two (coded 0). The method of infant feeding encouraged by significant others (mother, partner, etc) was coded 1 (breast only) or 0 (bottle, either method, or unknown). Family support and perceived benefits (convenience, infant health benefits, maternal-child closeness, something only a mother could provide, etc) of breastfeeding each were conceptualized as high (coded 1) or low (coded 0).

Statistical Analyses

Selected sociodemographic characteristics, the infant-feeding method encouraged by significant others, and the number of breastfeeding role models were compared among subjects grouped by race/ethnicity (Mexican-American, African-American, and Caucasian) using ² tests and analysis of variance. Adolescent mothers who reported more than one race/ethnicity were asked to choose the one with which they identified most closely. Continuous variable distributions were evaluated for assumptions of normality and homogeneity of variance. Sheffé post hoc tests were used to isolate groups that differed significantly. To identify important influences on the infant-feeding decision, breastfeeding and bottle-feeding mothers were compared within each race/ethnicity on the following variables: sociodemographic characteristics; social and informational influences; perceived benefits of breastfeeding; and the use of tobacco, alcohol, and marijuana during pregnancy and in the 3 months before conception.

Bivariate correlates of breastfeeding (P  .10) then were considered for entry in stepwise logistic regression analyses to identify factors independently associated with the outcome. A categorical variable was created, taking into account each patient's parity and previous breastfeeding experience. The resulting variable included three levels: parity = 0 (coded 0), parity 1 and no previous breastfeeding experience (coded 1), and parity 1 and previous breastfeeding experience (coded 2). To examine the influence of perceived breastfeeding benefits on the feeding decision, a composite score indicating perceived benefits of breastfeeding was created for each race/ethnicity by adding items that successfully differentiated (P < .01) breastfeeding from bottle-feeding mothers within that group. Multicolinearity was evaluated by examining correlations among independent variables. The individual contributions of highly correlated variables to the logistic regression model were examined separately by adding and removing each in subsequent analyses.

Finally, to identify racial/ethnic differences in motivations for breastfeeding or bottle-feeding, comparisons of the reasons stated for their choice of feeding method by mothers in each racial/ethnic group were performed using ² analyses.

	RESULTS

Top Abstract Introduction Methods Results Discussion Conclusion References

Selected demographic characteristics of the total sample are presented in Table 1. In addition, 27% (75/274) of the Mexican-American participants were interviewed in Spanish, with 38% (103/274) reporting that Spanish was the primary language spoken at home. Mexico was the birth country for 36% (99/274) of these patients. Comparisons of demographic characteristics among racial/ethnic groups revealed a number of significant differences (Table 1). However, racial/ethnic groups were not observed to differ by parity >1, cesarean delivery, or access to prenatal care.

Overall, 35% (274/696) of the sample decided to breastfeed, including 55% of Mexican-Americans, 45% of Caucasians, and 15% of African-Americans (P < .001). Health care providers were the most frequently endorsed source of encouragement to breastfeed across all racial/ethnic groups, followed by the patient's own mother, partner, and peers (Fig 1). African-American adolescent mothers were the least likely to report receiving encouragement to breastfeed from any source examined (Fig 1) (P < .001), including health care providers. Moreover, an absence of breastfeeding role models was reported more often among African-Americans (37%) compared with Mexican-Americans (18%) and Caucasians (19%) (data not shown) (P < .001). In fact, whereas 50% of Mexican-American and 37% of Caucasian adolescent mothers reported that their own mother had breastfed, only 15% of African-Americans reported similarly (data not shown) (P < .001).

View larger version (57K): [in this window] [in a new window]   Fig. 1.   Sources of encouragement to breastfeed for all subjects stratified by ethnicity.

Comparing sociodemographic and reproductive characteristics between breastfeeding and bottle-feeding mothers within each racial/ethnic group (Table 2) first identified important influences on the decision to breastfeed. This group of variables (education, school enrollment, plans to finish high school, financial status, WIC enrollment, parity > 1) was most likely to differentiate breastfeeding and bottle-feeding mothers within the Mexican-American group. Having inadequate financial resources was positively related to bottle-feeding among Mexican-Americans only. Measures of acculturation (being born in Mexico, speaking primarily Spanish at home, and being interviewed in Spanish) were associated consistently with the decision to breastfeed among Mexican-Americans. Age, cesarean delivery, and previous breastfeeding experience were unrelated to the decision to breastfeed for any racial/ethnic group.

Next, social and informational factors associated with infant-feeding decisions were evaluated within each racial/ethnic group (Table 3). Across all races/ethnicities, the decision to breastfeed was associated with perceived benefits, encouragement to breastfeed by significant others, and exposure to educational materials. Whereas living with an older female was associated with bottle-feeding across all three groups, the decision to breastfeed was more common in both the Mexican-American and African-American groups if the mother lived with a partner. Timing of the mother's decision to breastfeed was different among Mexican- and African-American patients; a decision made in middle to late pregnancy or after delivery was associated with the choice of bottle-feeding among Mexican-Americans, whereas a delayed decision among African-Americans more often led to a choice of breastfeeding. Timing of the infant-feeding decision was unrelated to feeding choice among Caucasian adolescent mothers.

To evaluate the relationship of previous or current tobacco, alcohol, or other drug use and the feeding decision, breastfeeding and bottle-feeding mothers were compared on the use of harmful substances during pregnancy and in the 3 months before conception. Tobacco (5% vs 15%; P = .004) and marijuana (3% vs 9%; P = .029) use during pregnancy, and tobacco (15% vs 31%; P = .001), alcohol (28% vs 46%; P = .002), and marijuana (8% vs 17%; P = .03) use before conception were positively associated with bottle-feeding among Mexican-Americans. Substance use during pregnancy was unrelated to feeding method within the Caucasian racial/ethnic group; however, alcohol (61% vs 53%; P = .074) and marijuana (20% vs 10%; P = .048) use during the 3 months before conception were associated marginally with breastfeeding in this group. No substance use variable was related to the chosen method of infant feeding among African-Americans. The number of adolescent mothers from any racial/ethnic group reporting illicit drug use other than marijuana was too small to conduct meaningful analyses.

Stepwise multiple logistic regression was used to identify factors independently associated with the breastfeeding decision and revealed distinct profiles within each racial/ethnic group (Table 4). Perceived benefits of breastfeeding and the positive influence of infant-feeding educational materials were associated significantly with the decision to breastfeed across all racial/ethnic groups (adjusted odds ratio [AOR] = 2.9 to 26.9). Other factors considered important to the breastfeeding decision among Mexican-Americans included having followed infant-feeding advice of significant others rather than having made the feeding decision alone (AOR = 7.6); the feeding preference of a partner (AOR = 7.0) and mother (AOR = 6.6); and a feeding decision made in early pregnancy or before conception (AOR = 4.7). However, measures of acculturation did not retain significance in the multivariate model. Additional factors associated with breastfeeding among African-Americans included living with a partner (AOR = 10.6); having a mother who breastfed (AOR = 5.9); the feeding preference of the partner (AOR = 5.6) or health care provider (AOR = 4.7); and low family support (financial, tangible, emotional, and informational) (AOR = 3.4). Among Caucasians, breastfeeding also was associated with having followed the feeding preference of a health care provider (AOR = 6.1); having two or more breastfeeding role models (AOR = 4.1); not being enrolled in WIC (AOR = 3.0); having followed infant-feeding advice of significant others (AOR = 3.0); and having used alcohol during pregnancy (AOR = 2.6). Two-way interaction terms were examined for each of the three sets of logistic regression analyses, but none improved the precision of the point estimates.

To evaluate racial/ethnic differences in rationale for having chosen a particular feeding method, Mexican-American, African-American, and Caucasian adolescent mothers were then compared on the reasons reported for breastfeeding or bottle-feeding. Reasons for choosing to breastfeed or bottle-feed differed significantly among racial/ethnic groups (Figs 2 and 3). No significant differences among racial/ethnic groups in reasons for breastfeeding were observed in the following areas: perceived infant health benefits, convenience, the closeness of breastfeeding, or feeling that breastfeeding is something only the adolescent mother can do for her infant. Each of these benefits was endorsed by >75% of the breastfeeding adolescent mothers from each group. There were no significant racial/ethnic differences in the reasons reported for bottle-feeding found for perceived health benefits (endorsed by 23% overall) or convenience (endorsed by 77%), perceived barriers of breastfeeding by going to school or work (endorsed by 66%), concerns about dietary restrictions (endorsed by 38%) or substance use restrictions (endorsed by 47%) required for breastfeeding, and anticipated feelings of embarrassment if the act of breastfeeding were observed by someone else (endorsed by 31%).

View larger version (34K): [in this window] [in a new window]   Fig. 2.   Selected reasons for breastfeeding stratified by ethnicity (breastfeeding mothers only).

View larger version (33K): [in this window] [in a new window]   Fig. 3.   Selected reasons for bottle-feeding stratified by ethnicity (bottle-feeding mothers only).

	DISCUSSION

Top Abstract Introduction Methods Results Discussion Conclusion References

This study demonstrates that race/ethnicity is a critical factor in the adolescent mother's decision to breastfeed. Overall, African-Americans were significantly less likely to select breastfeeding compared with Mexican-American and Caucasian adolescent mothers. Factors associated with breastfeeding among all adolescent mothers were found consistently at lower levels among African-Americans, including the availability of multiple breastfeeding role models, maternal encouragement to breastfeed, the positive influence of educational materials and infant-feeding classes, and not living with an older female adult. Moreover, among African-American adolescent mothers, breastfeeding was associated with living with a partner, having been encouraged to breastfeed by a partner and health care provider, and having a mother who breastfedfactors that were significantly underrepresented within this group.

For all racial/ethnic groups, the perceived benefits of breastfeeding consistently were associated with the decision to use this method. This result is not surprising, because women of all ages who breastfeed hold more positive attitudes toward breastfeeding, are more knowledgeable about the benefits of breastfeeding, and perceive greater advantages to this method than do women who choose to bottle-feed.^9,10,27 Nevertheless, in contrast to one previous investigation of adolescent mothers,⁹ we observed significant racial/ethnic differences in the reasons reported for adopting the chosen method, particularly among bottle-feeders. African-American adolescent mothers who bottle-feed reported the greatest concerns over personal inconvenience, breast disfigurement, perceptions that breastfeeding would be painful, and the perceived fact that no one else can feed the infant. Whereas previous research has documented embarrassment about breastfeeding to be common among African-American adolescent mothers,¹¹ we did not find anticipated feelings of embarrassment to be a significant barrier to breastfeeding among adolescent mothers from any racial/ethnic group.

The infant-feeding advice of significant others is an important influence in the breastfeeding decision. In fact, lack of support for breastfeeding or negative attitudes toward breastfeeding from significant others has been associated with bottle-feeding.²² In this and other previous research,^16,19,28 the choice of bottle-feeding was more often a decision made for and by the patient herself, whereas among Mexican-American and Caucasian adolescent mothers, breastfeeders were more likely to receive help in the infant-feeding decision from members of their support network. It was surprising that peers were not a significant source of infant-feeding advice for adolescent mothers in any race/ethnicity. Our finding that breastfeeding was encouraged significantly less often by the health care providers of African-American adolescent mothers is consistent with previous research on adults.²⁹ In fact, one in four African-American patients in our study choose to bottle-feed because they were so advised by their doctor or nurse.

School personnel also were not a significant source of breastfeeding advice for adolescent mothers from any racial/ethnic group. Despite the fact that nearly one in two adolescent mothers overall and almost three fourths of African-American adolescent mothers were enrolled in school at delivery, fewer than 10% of these patients reported that they had been encouraged to breastfeed by school personnel. Thus, school-based health clinics currently are being underutilized as a source of information about the benefits of breastfeeding to all patients and would seem to be a logical site to implement educational programs. Moreover, although plans to return to school or work within 6 weeks after delivery did not significantly differentiate breastfeeding from bottle-feeding mothers within any race/ethnicity, two of every three bottle-feeders cited return to school or work as an important reason for choosing to bottle-feed. Additional research is needed to elucidate the specific barriers to breastfeeding and working or going to school, and to evaluate the efficacy of providing school-based education to promote breastfeeding.

Having a mother who breastfed and having multiple breastfeeding role models was associated with breastfeeding among all patients, although the significance of these factors was demonstrated in the multivariate models for African-Americans and Caucasians only. As with the adult, the patient most likely to breastfeed was breastfed herself or exposed to women who breastfeed.^14,26,30 This finding suggests that positive exposure to breastfeeding women is an important factor in the development of favorable attitudes toward breastfeeding, which in turn can increase actual breastfeeding behavior. Additional research is needed to determine the conditions under which providing opportunities for adolescent mothers to view breastfeeding as a natural and normal eventfor example, through school health curricula and office-based prenatal feeding classespromotes positive attitudes toward breastfeeding.

Nearly one in two patients from each racial/ethnic group in this study stated that they chose to bottle-feed because breastfeeding would mean that they could not smoke, drink alcohol, or use illicit drugs. Nevertheless, a significant number of adolescent mothers from each race/ethnicity who used tobacco, alcohol, or marijuana during pregnancy or in the 3 months before conception chose to breastfeed. In fact, in the multivariate model, Caucasian adolescent mothers who drank alcohol during the three months before conception were more than twice as likely to choose breastfeeding over bottle-feeding. This finding was unexpected and difficult to interpret. It is possible that adolescent mothers who consumed alcohol up to the point of conception and therefore may have placed their developing fetus at risk, may have wanted to compensate by providing the best source of nutrition in the postnatal period. Because alcohol and drugs can be transmitted passively to the infant through breast milk,²⁵ it is critical that information concerning the potentially harmful transmission of these substances be disseminated as part of interventions to promote breastfeeding among women of all races/ethnicitiesparticularly among Caucasian adolescent mothers because of their higher observed rates of substance use.³¹ Additional research is needed to determine whether such strategies ultimately help to reduce or delay the onset of harmful substance use well into the postpartum period.

The timing of a mother's infant-feeding decision proved to be important to the method of feeding chosen by Mexican-Americans only. These findings suggest that interventions to promote breastfeeding for this subgroup could begin before conception and continue throughout pregnancy. Health care providers also should be aware that African-Americans, who have not yet decided on their feeding method by middle to late pregnancy, may be the most agreeable to interventions to promote breastfeeding, although this variable did not retain significance in the multivariate model.

Despite the higher frequency of breastfeeding observed in this study among Mexican-American patients who were born in Mexico, interviewed in Spanish, and spoke primarily Spanish with their family, acculturation as measured here was not associated independently with breastfeeding in the multivariate regression model. Among Mexican-American adults, the relationship between acculturation and breastfeeding is equivocal.^19,32 One possible explanation for these findings is that different sets of factors may be related to the choice of breastfeeding among acculturated and unacculturated adolescent mothers. Alternatively, the level of acculturation of significant others may have had an important influence on the choice of feeding method. Future research is needed to evaluate which of these possible explanations best fits our observed findings. It is important to note that the higher refusal rates observed among Spanish- versus English-speaking Mexican-American adolescent mothers in our study suggest that our findings may not generalize to all Spanish-speaking Mexican-Americans through 18 years of age.

Additional limitations of this study are noteworthy. Although this sample is large, geographic restrictions for sample recruitment may limit the ability to generalize findings. Second, all patients in this study delivered healthy infants, and all but a few had access to prenatal care. Breastfeeding prevalence and factors influencing the choice to breastfeed may be quite different among adolescent mothers who fail to receive prenatal care or whose infants require extended periods of hospitalization. Finally, although important, an examination of breastfeeding duration was beyond the scope of the present study.

	CONCLUSIONS

Top Abstract Introduction Methods Results Discussion Conclusion References

Several suggestions for intervention strategies to promote breastfeeding among adolescent mothers can be made based on these results. However, all such approaches must be evaluated to substantiate their efficacy before large scale implementation can be recommended. Interventions may need to include both male and female children and to begin in grade school when attitudes toward methods of infant feeding first begin to form.^33,34 Breastfeeding mothers from multiple racial/ethnic groups and ages could be invited to participate as role models in all such interventions, thus children can learn to view breastfeeding as a healthy, normal activity. Additional interventions could target both the adolescent mother and specific members of her support system identified in this study as important to her feeding decision, focus on the benefits of breastfeeding, address concerns and refute fallacies common to young mothers and specific to each racial/ethnic group, and incorporate plenty of educational reading materials. Finally, a special effort must be made to overcome biases present in the health care system by training health care professionals to encourage breastfeeding among all adolescent mothers, including African-Americans.

	FOOTNOTES

Received for publication Nov 4, 1997; accepted Mar 17, 1998.

Reprint requests to (C.M.W.) Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, 301 University Blvd, Galveston, TX 77555-0587.

	ACKNOWLEDGMENTS

This project was supported by Grants DA09636 and DA08404 to CMW from the National Institute on Drug Abuse and by the Hogg Foundation for Mental Health.

We thank Gail B. Slap, MD; Constance D. Baldwin, PhD; and Vaughn I. Rickert, PsyD for their helpful comments on earlier drafts of this manuscript. We are indebted to the many adolescent participants who shared their experiences with us and to the interviewers who spent hundreds of hours collecting this information. We also thank the manager and staff of OB/GYN Publication, Grant & Media Support: R. G. McConnell, John Helms, Kristi Barrett, and Steve Schuenke for editorial and graphic assistance.

	ABBREVIATIONS

WIC, Women, Infants, and Children's Supplemental Nutrition Program. AOR, adjusted odds ratio. CI, confidence interval.

	REFERENCES

Top Abstract Introduction Methods Results Discussion Conclusion References

1. Duncan D, Ey J, Holberg CJ, Wright AL, Martinez FD, Taussig LM Exclusive breastfeeding for at least 4 months protects against otitis media. Pediatrics. 1993; 91:867-872[Abstract/Free Full Text]
2. Howie PW, Forsyth JS, Ogston SA, Clark A, du V Florey C Protective effect of breastfeeding against infection. Br Med J. 1990; 300:11-16
3. Merritt TG, Burr ML, Butland BK Infant feeding and allergy: 12-month prospective study of 500 babies born into allergic families. Ann Allergy. 1988; 61:13-20[Medline]
4. Wright AL, Holberg CJ, Taussig LM, Martinez FD Relationship of infant feeding to recurrent wheezing at age 6 years. Arch Pediatr Adolesc Med. 1995; 149:758-763[Abstract]
5. World Health Organization. Innocenti Declaration: on the Protection, Promotion, and Support of Breastfeeding. Geneva, Switzerland: WHO; 1990
6. Task Force Report The promotion of breastfeeding. Pediatrics. 1982; 69:654-661[Abstract/Free Full Text]
7. Smith JC, Mhango CG, Warren CW, Rochat RW, Huffman SL Trends in the incidence of breastfeeding for Hispanics of Mexican origin and Anglos on the US-Mexico border. Am J Public Health. 1982; 72:59-61[Abstract/Free Full Text]
8. Yoos L. Developmental issues and the choice of feeding method of adolescent mothers. J Obstet Gynecol Neonatal Nurs. 1985;68-72
9. Baisch MJ, Fox RA, Goldberg BD Breastfeeding attitudes and practices among adolescents. J Adolesc Health Care. 1989; 10:41-45[CrossRef][Medline]
10. Radius SM, Joffe A Understanding adolescent mothers' feelings about breastfeeding. J Adolesc Health Care. 1988; 9:156-160[CrossRef][Medline]
11. Robinson JB, Hunt AE, Pope J, Garner B Attitudes toward infant feeding among adolescent mothers from a WIC population in northern Louisiana. J Am Diet Assoc. 1993; 93:1311-1313[CrossRef][Medline]
12. Neifert M, Gray J, Gary N, Camp B Factors influencing breastfeeding among adolescents. J Adolesc Health Care. 1988; 9:470-473[Medline]
13. Peterson CE, DaVanzo J Why are teenagers in the United States less likely to breastfeed than older women? Demography. 1992; 29:431-450[Medline]
14. Lizarraga JL, Maehr JC, Wingard DL, Felice ME Psychosocial and economic factors associated with infant feeding intentions of adolescent mothers. J Adolesc Health. 1992; 13:676-681[CrossRef][Medline]
15. Rassin DK, Richardson J, Baranowski T, Incidence of breastfeeding in a low socioeconomic group of mothers in the United States: racial/ethnic patterns. Pediatrics. 1984; 2:132-137
16. Grossman LK, Fitzsimmons SM, Larsen-Alexander JB, Sachs L, Harter C The infant feeding decision in low and upper income women. Clin Pediatr. 1990; 29:30-37
17. Schwartz JB, Popkin BM, Tognetti J, Zohoori N Does WIC participation improve breastfeeding practices? Am J Public Health. 1995; 85:729-731[Abstract/Free Full Text]
18. Labbok M, Krasovec K Toward consistency in breastfeeding definitions. Stud Fam Plann. 1990; 21:226-230[CrossRef][Medline]
19. Scrimshaw SC, Engle PL, Arnold L, Haynes K Factors affecting breastfeeding among women of Mexican origin or descent in Los Angeles. Am J Public Health. 1987; 77:467-470[Abstract/Free Full Text]
20. Grossman LK, Larsen-Alexander JB, Fitzsimmons SM, Cordero L Breastfeeding among low-income, high-risk women. Clin Pediatr. 1989; 28:38-42
21. Maehr JC, Lizarraga JL, Wingard DL, Felice ME A comparative study of adolescent and adult mothers who intend to breastfeed. J Adolesc Health. 1993; 14:453-457[CrossRef][Medline]
22. Freed GL, Jones TM, Schanler RJ Prenatal determination of demographic and attitudinal factors regarding feeding practice in an indigent population. Am J Perinatol. 1992; 9:420-424[Medline]
23. Matich JR, Sims LS A comparison of social support variables between women who intend to breast or bottlefeed. Soc Sci Med. 1992; 34:919-927
24. Jessor R, Jessor SL. Problem Behavior and Psychosocial Development: A Longitudinal Study of Youth. New York, NY: Academic Press; 1977
25. Baily B, Ito S Breastfeeding and maternal drug use. Pediatr Clin North Am. 1997; 44:41-54[CrossRef][Medline]
26. Seger MT, Gibbs CE, Young EA Attitudes about breastfeeding in a group of Mexican-American primigravidas. Tex Med. 1979; 75:78-80[Medline]
27. Baranowski T, Rassin DK, Richardson CJ, Brown JP, Bee DE Attitudes toward breastfeeding. J Dev Behav Pediatr. 1986; 7:367-372[Medline]
28. Bevan ML, Mosley D, Lobach KS, Solimano GR Factors influencing breastfeeding in an urban WIC program. J Am Diet Assoc. 1984; 84:563-567[Medline]
29. Kogan MD, Kotelchuck M, Alexander GR, Johnson WE Racial disparities in reported prenatal care advice from health care providers. Am J Public Health. 1994; 84:82-88[Abstract/Free Full Text]
30. Neifert M, Gray J, Gary N, Camp B Effect of two types of hospital feeding gift packs on duration of breastfeeding among adolescent mothers. J Adolesc Health Care. 1988; 9:411-413[CrossRef][Medline]
31. Bachman JG, Wallace JM, O'Malley PM, Johnstone LD, Kurth CL, Neighbors HW Racial/racial/ethnic differences in smoking, drinking, and illicit drug use among American high school seniors, 1976-89. Am J Public Health. 1991; 81:372-377[Abstract/Free Full Text]
32. Shapiro J, Saltzer EB Attitudes toward breastfeeding among Mexican-American women. J Trop Pediatr. 1985; 31:13-16[Free Full Text]
33. Purtell M Teenage girls' attitudes to breastfeeding. Health Visit. 1994; 67:156-157[Medline]
34. Pascoe JM, Berger A Attitudes of high school girls in Israel and the United States toward breastfeeding. J Adolesc Health Care. 1985; 6:28-30[CrossRef][Medline]