Abstract
Background
Breastfeeding is associated with many positive health outcomes, including lower rates of infectious diseases, lower rates of gastrointestinal infections, and improved cognition. 1,2 Longer term health benefits include lower rates of diabetes and obesity. 3 Maternal benefits have included increased postpartum weight loss and lower rates of cancers, including ovarian and breast. 3 The World Health Organization and the American Academy of Pediatrics recommends exclusive breastfeeding for the first 6 months of life because of its well-established benefits. 1,4
Breastfeeding may be beneficial for adolescent mothers and their infants because of the higher risk of low birth weight, preterm delivery, and neonatal mortality associated with young maternal age. 5 According to the National Immunization Survey conducted by the Centers for Disease Control and Prevention, 75% of women attempted to breastfeed. However, only 58% of non-Hispanic African American women initiated breastfeeding. 6 Disparities also exist by age, as 80% of mothers older than 30 years initiated breastfeeding compared with 60% of mothers younger than 20 years. The lowest breastfeeding initiation rates were reported by non-Hispanic African American mothers younger than 20 years at 30%. 7 Goals outlined by Healthy People 2020 target 81.9% of mothers to initiate breastfeeding and 60.6% breastfeeding at 6 months postpartum. 8
Despite previous research, low partial and full breastfeeding rates among adolescents heighten the need for continued inquiry and integrated community support. 9 Further descriptive data are warranted from underserved and minority adolescents because of existing health disparities. 9 The objective of this qualitative study was to explore adolescent barriers and facilitators to breastfeeding initiation and duration.
Methods
Participants
Four focus groups were conducted with adolescent mothers (females younger than 20 years; child of any age) and pregnant adolescents (female younger than 20 years), who were English speaking from a convenience sample. Focus groups took place in an urban setting at a local community resource center for underserved mothers. Informed consent was obtained from participants 18 years or older. Parental consent and minor assent was obtained from participants younger than 18 years. Participants received a $15 gift card for participating. The study was approved by the university’s institutional review board.
Data Collection
Guidelines for focus group procedures and data management were replicated from Berg. 10 Each focus group followed a semistructured interview to guide the group facilitator and explore specific breastfeeding related topics. Audio recordings were conducted, transcribed, verified, and compared with notes for accuracy similar to previously reported methodology. 11 Demographic data were collected at the beginning of each group.
Data Analysis Procedures
This was a nonrandomized study using qualitative methods. Focus group data analysis was in accordance with Stewart et al. 12 Transcripts were assessed for themes across focus group questions. Study power was obtained through the continuation of focus group sessions until saturation was achieved.
Results
Four focus groups of 4 to 10 participants were conducted (N = 29). The majority of participants were between 18 and 20 years old (55%, n = 16), resided in an urban setting (59%, n = 17), were in high school (45%, n = 13), and were unemployed (66%, n = 19). Participants were mainly non-Hispanic (76%, n = 22) and African American (50%, n = 18). Only 4 participants reported an affiliation with an after-school organization/activity (14%, n = 4; Table 1). Of those who had children, approximately one third of participants initiated breastfeeding (n = 9) and less than 7% (n = 2) breastfed longer than 1 month.
Participant Demographics (N = 29).
One participant did not report.
Some participants reported more than one race.
Qualitative Data
Data from the focus groups were organized around 4 themes, including behavioral histories of breastfeeding, community assets, social support, and barriers.
Behavioral Histories
Many participants reported a history of negative attitudes regarding breastfeeding from important social supports in their lives. Some participants reported their own mothers did not support breastfeeding and other mothers they knew commonly bottle-fed their babies and they were “fine.” A few participants described positive situations where they saw family members, friends, or other significant adults in their lives breastfeeding; however, these behavioral histories were infrequently reported by participants.
Community Assets
Participants referred to many community assets when describing features of their environment that made it more likely to for them to initiate breastfeeding. Reported facilitators for breastfeeding initiation included the availability of a free breast pump and free prenatal education classes in the community. Online schools and schools with daycare/nursing rooms were also identified as facilitators for continued breastfeeding.
Social Support
Many participants described their significant other, supportive family members, and other respected adults as an important part of a successful breastfeeding environment. In-person social support groups that discussed and supported breastfeeding were also identified. However, when asked about the possibility of online support groups most participants did not respond positively and characterized them as “weird.”
Barriers
Many previously reported physical effects were described as barriers, including the following: problems with technique or latching on, pain, nipple leakage, breast engorgement and disfigurement, complications at birth, and delayed milk supply. 13 -15 Environmental barriers such as the social acceptability and lack of breastfeeding-friendly facilities were also noted by participants. The most prevalent theme was public embarrassment. Participants were not comfortable with the idea of breastfeeding in public, not even in secluded areas of public buildings. “If I was out in public, like I know I have this little card that people can breastfeed in public. But I think that is just going to be so awkward.”
The impact of breastfeeding on the adolescents’ lifestyle was frequently discussed. Many described breastfeeding as an inconvenience, taking too long to fit into a busy schedule. Although the effect on what the participants could consume was also important. Participants discussed the desire to drink soda and alcohol or smoke cigarettes, which they reported they could not do if they were breastfeeding.
Other environmental factors emerged as negatively associated with breastfeeding, including free formula from the hospital, availability of low-cost formula, cost of a breast pump, and breastfeeding clothing/supplies. Another important environmental factor that emerged was support from primary care providers. Participants identified lack of detail and support from providers as a barrier to breastfeeding. Most participants described their surprise with the lack of information they received from their primary care providers. “My doctor only asked me about it once, when she was asking me about like, if I had allergies and stuff.”
Discussion
Factors reported to increase the likelihood of partial and full breastfeeding among adolescents included: social support from the father of the baby, family, peers, and health professionals, 16 adolescent mothers who were breastfed as a child, and those exposed to breastfeeding through a close referent. 17 Despite the discussion of these reported factors among the focus groups, none of the previously identified factors were described by participants as influential enough to change behavior and support breastfeeding. Few of the mothers who participated reported breastfeeding initiation. The addition of social support through peer-counselors and other community resources may not overcome other environmental contingencies that support bottle feeding. More investigation is needed to explore which components of adolescents’ environments influence the behavior outcome of breastfeeding.
The findings from this study reinforce the continued need for expanded integration of primary care and public health. One aspect of the medical environment that was identified as inadequate was support from primary care providers. Previous research has identified low breastfeeding knowledge among health care providers as a barrier to exclusive breastfeeding, citing a need to improve encouragement among mothers. 18,19 Our findings support previous recommendations that include increased education for primary care providers to facilitate breastfeeding discussions. Training for health care providers would also include providing health literate materials to meet the informational needs of mothers. 20 -23
These findings should be interpreted with caution as this study is not without limitations. Individual case information may not generalize to dissimilar populations or to other settings. Specifically, the study setting in the community provided breastfeeding education and some social support to most participants prior to the study as part of their program. Participants may have been more likely to have high breastfeeding knowledge and higher levels of social support, dissimilar from the typical adolescent population. In addition, most of the participants were African American. Finally, quantitative predictions were not part of the analysis, and results could have been more easily influenced by researchers’ personal biases. To mitigate personal biases, 3 independent coders reviewed the data prior to analysis.
Conclusion
Further examination of local interventions targeting identified environmental factors in support of adolescent breastfeeding and related healthy behaviors is needed. Comprehensive interventions based on the integration of primary care and public health are needed to create conditions to support breastfeeding to increase the ease of breastfeeding despite its complexities. These comprehensive efforts should include a focus on hospital environments and training of primary care providers to increase breastfeeding support and knowledge. The health of future adolescent mothers and babies depends on comprehensive environmental strategies to change behavior.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article:
Partial funding provided by the Health Resources and Services Administration Grant No. D58HP20802 made this study possible.
Author Biographies