PEDIATRICS Vol. 101 No. 6 June 1998, p. e11
ELECTRONIC ARTICLE:
Racial/Ethnic Differences in the Decision to Breastfeed Among
Adolescent Mothers
, and
From the Departments of * Obstetrics and Gynecology and
Pediatrics, University of Texas Medical Branch, Galveston, Texas.
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ABSTRACT |
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Top
Abstract
Introduction
Methods
Results
Discussion
Conclusion
References
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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.
Key words: breastfeeding, adolescent mothers, pregnant adolescents, ethnicity.
Breastfeeding has nutritional, immunologic, economic, and
psychologic advantages over formula-feeding1-4 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
attitudes8-10 or demographic characteristics12-14 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
tobacco16,20 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.
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 Bivariate correlates of breastfeeding (P 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 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.
TABLE 1
INTRODUCTION
Top
Abstract
Introduction
Methods
Results
Discussion
Conclusion
References
METHODS
Top
Abstract
Introduction
Methods
Results
Discussion
Conclusion
References
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.
.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.
2 analyses.
RESULTS
Top
Abstract
Introduction
Methods
Results
Discussion
Conclusion
References
Significant Demographic Differences Between Racial/Ethnic Groups
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).
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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.
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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.
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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.
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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%).
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DISCUSSION |
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Abstract
Introduction
Methods
Results
Discussion
Conclusion
References
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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 breastfed
factors 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.
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CONCLUSIONS |
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Methods
Results
Discussion
Conclusion
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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.
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FOOTNOTES |
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Preliminary findings from this study were presented at the annual meetings for the Southern Society for Pediatric Research; February 6, 1997; New Orleans, LA, and the Society for Adolescent Medicine; March 6, 1997; San Francisco, CA.
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.
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ACKNOWLEDGMENTS |
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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.
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ABBREVIATIONS |
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WIC, Women, Infants, and Children's Supplemental Nutrition Program. AOR, adjusted odds ratio. CI, confidence interval.
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REFERENCES |
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Methods
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Conclusion
References
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Pediatrics (ISSN 0031 4005). Copyright ©1998 by the American Academy of Pediatrics
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