JOURNAL OF ADOLESCENT HEALTH 19!32;13:676-681
Psychosocial and Economic Factors Associated Infant Feeding Intentions of Adolescent Mothers JENNIFER L. LIZARRAGA, M.D., DEBORAH L. WINGARD,
Ph.D.,
JENNIFER AND
MARIANNE
The infant feeding intentions of 64 primiparous, adolescent females, ages 14-18 years, were studied to assess factors which differentiated those who chose breastfeeding from those who did not. The study population consisted of 43 Hispanic,9 black, 7 non-Hispanic white, and 5 Filipino or Southeast Asian subjecb interviewed after delivery. Among the Hispanics, 31 primarily spoke Spanish, and 12 primarily spoke English. A total of 72% intended to breastfeed, and 22% planned to exclusively formula feed. Those teens who intended to breastfeed were signi&ntly older, more often married,morelikely to be Hispanic and Spanish speaking, and less likely to have been in school during the pregnancy. In addition, teens were more likely to choose breastfeeding if they had been breastfed themselves or exposed to other women who breastfed. These data suggest that the younger, non-Hispanic, single teen who is enrolled in school and lacking exposure to breastfeeding is the most in need of breastfeeding-promotion programs. KBYWORDS:
Adolescentmothers Infantnutrition feeding Hispanic Americans Breast
Despite the known benefits of breastfeeding, national studies demonstrate a decreasing trend in FPWI theDepartmentof Community and Family Medicine, UnivarsityofCali@miaSanDiego SchoolofMedicineand MedicalCenter,
San Diego, Cali)kda (I.L.L., I.C.M., D.L.W.); and the Department of Me, Division ofAdolescentMedicine, Universityof Maryland MedicnlSystem, BaJtimore,Maryland (M.E.F.). Addmss reprint ~ue~b to: Deborah Wingard, Ph.D., Department of Communityand FamilyMedicine, 0607, 9500 Gilman Drive, Uni=if!I of califinnia San D&go, Ia lolia, CA 92093-0607. ManuscriptluxvptedJuly 3, 1992. 676 1654-lS9~.00
C. MABHR,
f’uHished by Else&r
M.D.,
E. FELICE,
M.D.
breastfeeding rates among new mothers under the age of 20 years: 39.3% initiated breastfeeding in 1983, 36.8% in 1984, and only 30.2% in 1989 (1,2). In addition, teen mothers initiate breastfeeding less often than older mothers: 30.2% for mothers less than 20 years of age versus 52.2% for all mothers (2). The literature is sparse in identifying factors associated with the adolescent mother’s choice to breast- or bottlefeed her infant. The purpose of this study is to assess psychosocial and economic factors which differentiate primiparous teen mothers who choose to breastfeed from those who do not.
Methods The study population consisted of 64 primiparous, adolescent females. All primiparous teens who were 14-18 years of age and who delivered infants at the University of California San Diego (UCSD) Medical Center between August and December 1989 were asked to participate. A few teen mothers with a brief postpartum hospitalization were discharged before they could be entered in the study. A total of six mothers declined interview; four of these mothers were planning for the adoption of their babies. Every study participant voluntarily consented to act as a research subject as outlined by the UCSD Comm’ittee of Investigations Involving Human Subjects. Information on maternal demographics, habits, prenatal care, support system, choice of infant feeding, exposure to breastfeeding, attitude toward breastfeeding, and plans for returning to work 3r school was obtained by interview at the bedside within 48 hr postpartum. A support system was defined as the presence of a close friend or relative who would provide assistance to the teen mother - ..
_
~~~
8 Society
for Adolescent Medicine, 1992
Sciencet’ublishing CO., Inc., 655 Avenue of the Americas, New York, NY 10010
INFANT FEEDING INTENTIONS AMONG ADOLESCENTS
December 1992
Table 1. Demographics
and Health Care Coverage Status Hispanic
Demographics and health care
677
Total (n = 64)
All Hispanic (n = 43)
Black (n = 9)
Non-I+ .- white ,n - .;
Other’ (n = 5)
16.6 f 0.9
16.2 f 1.2
17.9 f 0.4
16.8 f 1.1
0 33 67
0 67 33
0 0 100
0 20 80
Spanish speaking English speaking (n ==31) (n = 12) Mean f SD
Age (years)
16.9 f 1.0
17.0 f 1.0
17.1 a 1.0 Percent
14 15-16 17-18 During pregnancy In school Employed Married Living status w/parents w/baby’s father other Insurance None Medi-Cal Private
2 28
2 26
m
72
3 23 74
44 27 28
28 26 33
10 29 42
75 17 8
100 11 0
57 71 29
60 0 40
33 34 33
26 35 40
10 39 52
67 25 8
89 0 11
29 57 14
0 60 40
14 a0 6
19 79 2
26 71 3
0 100 0
0 89 11
0 71 29
20 80 0
“Southeast Asian or Filipino
and her infant. Maternal interview was conducted in either Spanish or English according to the patient’s preference. Information on the delivery and newborn infant was obtained by chart review. All data were recorded on a 92-item questionnaire and analyzed on a VAX 11/750 computer at the General Clinical Research Center at UCSD. The CLINFO software package (Bolt, Beranek, and Newman) was employed for data entry, storage, and management. Both the CLINFO and BMDP (University of California) software packages were used for data analysis. For analysis, the Hispanics were subdivided by primary language, into two groups: Spanish speaking and English speaking. The data were analyzed using analysis of variance and Student’s t test for normally distributed numerical data and the Kruskal-Wallis and the Mann-Whitney rank-sum tests for non-normally distributed data. When three group analyses reached statistical significance, appropriate post hoc multiple comparison tests were performed: Duncan’s Multiple Range for normally distributed data and Mann-Whitney (adjusted 0~) for non-normally distributed data. For categorical data, Pearson’s x2 test of association was used to investigate the relationship between different variables.
Results Demographic Characteristics (Table 1) Of the 64 teens studied 67% (n = 43) were Hispanic, 14% (n = 9) were black, 11% (n = 7) non-Hispanic white, and 8% (n = 5) Southeast Asian or Filipino. Of the Hispanics, 45% (n = 31) spoke Spanish and 19% (n = 12) spoke English. The proportion of married teens varied with ethnicity from 0% of the blacks to 42% of the Spanish-speaking Hispanics. NonHispanic white teens were the most likely to have private medical insurance, to have received prenatal care, and to have attended childbirth classes. Sixteen of the teens reported prescription medication use during pregnancy. Five reported tobacco use; one, drug use; and one, alcohol use during pregnancy. The mean birth weight of the infants born to this teen population was 3302 g, with a range of 2260-4370 g. Only two infants weighed less than 2500 g, and three weighed more than 4000 g.
Infant Feeding Intentions A total of 72% (n = 46) intended to breastfeed their babies, of whom 53% (n = 34) intended to do so
LIZARRAGAET AL.
678
Table 2. So&I Variables by
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 8
Infant Feeding Intentions Among Young Primiparous Mothers Intent to feed
Sociat variables
Total (n = 64)
Breast only (n = 34)
Breast and formula (n = 12)
Any breast (n = 46)
Formula only (n = 14)
Age (Years)”[R +-SD]
16.9 rt 1.0
17.0 f 1.0
17.1 -t 1.0
16.6 & 0.9
16.2 & 1.2
48
59
18 23
75 25 0
63
19 33
20 17
14 7 79
28 72
35 65
33 67
35 65
7 93
33 34
29 38 32 80
17 42 42 83
26 39 35 80
43 21 36 93
Et.hnicitylLanguagec HiSpZkIliC
spanish speaking
English speaking othc# Marital Statusb Married Unmarried Living status w/parent(s) w/baby’s father 0th
Support System
33
84
Note that there were also 4 teens who were undecided regarding mode of infant feeding. ‘Student’s Q-testanalysis performed between any breast versus formula only, p s 0.05; *p s 0.05. x2 analysis performed between any breast versus formula only. p s 0.001$ analysts performed between any breast versus formula only. Other r&rs to all black, non-Hispanic white, Filipino and Southeast Asian teens.
exclusively, and 19% (n = 12) to combine breastfeeding and formula feeding. Twenty-two percent (0 = 14) of the teens planned to formula feed exclusively, and 6% (n = 4) were undecided+ Table 2 shows that teens intending to breastfeed (either exclusively or in combination with formula) were significantly older than those intending to exclusively formula feed, 17.2 years’ and 16.3 years, respectively (p < 0.05). The Hispanic mothers who spoke Spanish were most likely to intend to breastfeed, followed by the Hispanics who spoke English; the combined remaining ethnic groups were least likely to intend to breastfeed (p < 0.001) Breastfeeding was chosen more often by marriedthan unmarried teens ( p s 0.05). Neither living arrangement nor presence of a postpartum support system were associated with the intention to breastfeed. Mothers who decided to exclusively formula feed were more often in school during their pregnancy (78% versus 28%; p 5 0.001). Employment during pregnancy was not found to be significantly associated with breast- or bottlefeeding. Although not statistically significant, a greater proportion of teens intending to exclusively formula feed planned to return to work or school compared with teens intending to breastfeed, 7l% and 50%, respectively. Teens were more likely to choose breastfeeding
for their own infants if they thanselves had been breastfed (p I 0.001) see Table 3. Likewise, those teens choosing to breastfeed their babies tended to know a greater number of women who had breastfed: on average the mothers intending to breastfeed knew 7.7 women who had breastfed, and the mothers intending to formula feed exclusively knew 3.5 women who had breastfed (p < 0.05). The teens intending to breastfeed had also observed a greater number of women breastfeeding than their counterparts who intended to formula feed: those intending to breastfeed having seen on aver age 4.2 nursing women; and those intending to formula feed, 1.4 nursing women (p c 0.005). Compared with the combined other ethnic groups the Hispanic teens had observed more nursing mothers (4.4 versus 1.1 nursing women, p < 0.05) and were more often breastfed as infants (63% versus 29%, p 4 0.001). Although not statistically significant, a greater proportion of those intending to exclusively formula feed (71%) than breastfeed (48%) believed that it was acceptable to breastfeed in public. Medical insurance, Aid to Families with Dependent Children (AFDC), Women, Infants, and Children (WIC) enrollment, and use of prenatal care or birth classes were not significantly associated with the intention to breastfeed.
INFANT FEEDINGINTENTIONS AMONG ADOLESCENTS
December 1992
679
Table 3. Exposure To and Attitude About the Breastfeeding Dyad by Infant Feeding Intentions Among Young
Primiparous Mothers Intentto feed Breastfeeding
Total
Breast only
Breast and formula
Any breast
Formula only
8.0 + 7.0 5.2 & 3.5
7.7 -c 6.1 4.2 f 3.4
3.5 + 3.5 1.4 + 1.4
9 (75) 6 (50)
29 (63) 22 (48)
3 (21) 10 (71)
g f SD Number of women known that breastfed Number of women seen breastfeeding’
6.5 -c 5.7 3.3 -c 3.2
7.6 2 5.8 3.8 f 3.3 No. (%)
Mother breastfed as infant’ Approves of public breastfeeding
33 (52) 35 (55)
20 (59) 16 (47)
x2 analysis performed between any breast versus formula only; “p 5 0.05; bp 5 0.005; ‘p 5 0.001.
Actual versus Intended Infant Feeding Although 72% (n = 46) intended to breastfeed, either partially or exclusively, 58% (n = 37) were actually breastfeeding by 48 hr postpartum. Of the nine women who had intended to breastfeed but had not yet initiated breastfeeding, five had infants who required admission to the special care nursery, three were waiting until their milk came in to breastfeed, and one was using formula because she was unsure if she could breastfeed and still return to work alld school. A total of 34% (n = 22) were exclusively formula feeding; 8% (n = 5) of the infants were receiving formula and/or intravenous fluids in the special care nursery.
Discussion The percentage of teens in our population intending to breastfeed was 72%, with 58% having actually initiated breastfeeding by the time of the interview. These percentages are higher than the national breastfeeding rate of 30.2% for mothers less than 20 years of age (2). This discrepancy is somewhat surprising as this sample of teen primigravidas from Southern California possesses characteristics often associated with the lowest rates of breastfeeding in America: young age, ;ow income, low education level, and unmarried status (1,3-5). Other studies performed in Southern California have found similar rates of breastfeeding. Felice et al. (6) examined a population most similar to ours: pregnant adolescents of similar ethnic proportions attending the UCSD Teen OB Clinic. They found that 56% of 199 pregnant adolescents chose to breastfeed their infants for at least 6 weeks. In addition, Romero-Gwynn et al. (7) in their study of MexicanAmerican women in Southern California found that
77.7% of 132 low-income Hispanic mothers intended to breastfeed, and 63.8% initiated breastfeeding. There were significant differences between the primigravidas who planned to nurse and those who planned to bottlefeed. These differences include maternal age, degree of acculturation measured by primary language and ethnic&y, exposure to breastfeeding, marital status, and educational status. Studies have shown that increased maternal age is positively correlated with the choice to breastfeed (1,2). These studies, however, did not report differences among women between the ages of 14 and 18 years, but instead grouped women under the age of 20 into one category. In our study, we found that there was an age difference among teens. Those teens who chose to breastfeed had a significantly higher mean age than those who chose formula, 17.2 years versus 16.3 years (p < 0.05). In the process of maturing and developing psychologically, the adolescent mother may be better able to focus on the needs of her infant and to appreciate the benefits that breastfeeding offers to her baby. In addition, positive reinforcers of breastfeeding at school or in the community may be introduced over the course of the teen years. To assess the effects of acculturation on breastfeeding, this largely Hispanic population was divided according to language preference. The Spanish-speaking Hispanics were most likely to breastfeed, followed by the English-speaking Hispanics, and then all other English speakers (p < 0.001). Use of Spanish as the primary language may indicate a close association with a Hispanic culture and is most strongly associated with the intention to breastfeed. The Hispanics who spoke English, however, were also more likely to choose breastfeeding than the non-Hispanic ethnic groups who
680
-GA
ET AL.
spoke English. The findings imply that there may exist degrees of acculturation such that the more distant a teen mother becomes from the Hispanic culture, the less likely she may be to breastfeed. In San Diego, those Hispanics who primarily use Spanish may indeed be more closely associated with the Mexican culture, one in which breastfeeding is the norm (8). In support of the influence of language and culture, John and Martorell (9), who studied over 2500 Mexican-Americans in the Southwestern United States, found that the preferential use of Spanish rather than English was associated with a higher incidence of breastfeeding. In addition, a study of Hispanic mothers in Southern California showed that intention to breastfeed was greater for mothers who migrated from Mexico than for mothers born in the United States (7). In the present study, knowing women who have breastfed ( p < 0.05) or observing friends or relatives breastfeed (p < 0.005) positively influenced the choice to nurse. In addition, teens who were breastfed themselves were more likely to choose breastfeeding (p < 0.001). These observations are supported by several studies (10-14). The Hispanics in our population had observed a significantly greater number of women breastfeeding ( p < 0.05) and were more often breastfed themselves (p c 0.001) than the teens from the other ethnic groups. This finding is consistent with the association of the Spanish language and Hispanic culture to breastfeeding. In the Mexican-American family, the mother is one of the primary sources of support for breastfeeding (15). This culture appears to be one in which family members tend to live in close association with one another, leading to increased exposure to and acceptance of breastfeeding. Most of the adolescent mothers in this sample were unmarried. Nonetheless, being single was found to be associated with the choice to bottlefeed. This finding is consistent with many studies which have shown that married women are more likely to breastfeed than unmarried women (3,5,16). A stable male partner may be an important source of support in the decision to breastfeed. Several studies have looked at the correlation between level of education achieved and the choice to breastfeed (4,7,12,16). Missing from the literature is the association between school attendance during p~gnanc~ and the mode of infant feeding. In this study, fewer mothers intending to breastfeed were enrolled in Schoolwhile pregnant when compared with mothers intending to exclusively formula feed.
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 8
A possible reason for this negative correlation is that the teens who used Spanish as their primary language comprised a significant portion of the breastfeeding group and had the lowest school enrollment during pregnancy. Transit between the United States and Mexico may account for some of the absenteeism from school among these teens. Conversely, the fact that pregnant teens who were in school more often chose to formula feed may indicate that the promotion of breastfeeding is lacking in some high schools, or that school is perceived by these teens as a barrier to breastfeeding. Before the incidence of breastfeeding can increase among all adolescents, this society must support them in this venture. Schools could be an ideal place to offer teens prenatal education including breastfeeding information and, if possible, access to nursing rooms. Since younger teen mothers are least likely to breastfeed, health education should begin as early as possible. This work was supported in part by a grant from the Carnation Company and by the UCSD General Clinical Research Center NIH Grant MO1 RROO827. The authors are grateful to l%ul Shragg, M.A., for his patient assistance in data analysis.
References 1. Martinez GA, 2.
3.
4.
5.
6.
7.
8. 9.
10. 11.
Krieger FW. 1984 Milk-feeding patterns in the United States. Pediatrics 1985;76:1004-8. Ryan AS, Rush D, Krieger FW, et al. Recent declines in breastfeeding in the United States, 1984 through 1989. Pediatrics 1991;88:719-27. Grossman LK, Fitzsimmons SM, Larsen-Alexander JB, et al. The infant feeding decision in low and upper income women. Clinical Pediatrics 1990;29:30-7. Yeung DL, Pennell MD, Leung M, et al. Breastfeeding: Prevalence and influencing factors. Can J Public Health 1981; 72:323-30. Scrimshaw SCM, Engle PL, Arnold L, et al. Factors affecting breastfeeding among women of Mexican origin or descent in Los Angeles. Am J Public Health 1987;77:467-70. Felice ME, Shragg GP, James M, Hollingsworth DR. Psychosocial aspects of Mexican-American, white, and black teenage pregnancy. J Adolesc Health Care 1987;8:330-5. Romero-Gwynn E, Carias L. Breast-feeding intentions and practice among Hispanic mothers in Southern California. Pediatrics 1989;84:626-32. Lawrence RA. Toward understanding maternal choices for infant feeding. J Dev Behav Pediatr 1986;7:373-5. John AM, Martorell R. Incidence and duration of breastfeeding in Mexican-American infants, 1970-82. Am J Clin Nutr 1989;50:868-74. Brack DC. Social forces, feminism, and breastfeeding. Nurs Outlook 1975;23:556-61. Eastham E, Smith D, Poole D, et al. To breastfeed or not to breastfeed. BMJ 1976;1:305-7.
December 1992
INFANT FEEDING INTENTIONS AMONG ADOLESCENTS
681
12. Seger MT, Gibbs CE, Young EA. Attitudes about breastfeeding in a group of Mexican-American primigravidas. Tex Med 1979;75~78-80.
15. Baranowski T, Bee DE, Eassin DK, et al. Social support, social influence, ethnicity and the breastfeeding decision. Sot Sci Med 1983;17:1599-611.
13. Baiih MJ, Fox RA, Goldberg BD. Breast-feeding attitudes and practices among adolescents. J Adolesc Health Care 1989;10:41-5.
16. Bassin DK, Richardson CJ, Baranowsld T, et al. Incidence of breast-feeding in a low socioeconomic group of mothers in the United States: Ethnic patterns. Pediatrics 1984;73:132-7.
14. Joffe A, Radius SM. Breast versus bottle: Correlates of adolescent mothers‘ infant-feeding practices. Pediatrics 1987; 79689-95.
Psychosocial and Economic Factors Associated Infant Feeding Intentions of Adolescent Mothers JENNIFER L. LIZARRAGA, M.D., DEBORAH L. WINGARD,
Ph.D.,
JENNIFER AND
MARIANNE
The infant feeding intentions of 64 primiparous, adolescent females, ages 14-18 years, were studied to assess factors which differentiated those who chose breastfeeding from those who did not. The study population consisted of 43 Hispanic,9 black, 7 non-Hispanic white, and 5 Filipino or Southeast Asian subjecb interviewed after delivery. Among the Hispanics, 31 primarily spoke Spanish, and 12 primarily spoke English. A total of 72% intended to breastfeed, and 22% planned to exclusively formula feed. Those teens who intended to breastfeed were signi&ntly older, more often married,morelikely to be Hispanic and Spanish speaking, and less likely to have been in school during the pregnancy. In addition, teens were more likely to choose breastfeeding if they had been breastfed themselves or exposed to other women who breastfed. These data suggest that the younger, non-Hispanic, single teen who is enrolled in school and lacking exposure to breastfeeding is the most in need of breastfeeding-promotion programs. KBYWORDS:
Adolescentmothers Infantnutrition feeding Hispanic Americans Breast
Despite the known benefits of breastfeeding, national studies demonstrate a decreasing trend in FPWI theDepartmentof Community and Family Medicine, UnivarsityofCali@miaSanDiego SchoolofMedicineand MedicalCenter,
San Diego, Cali)kda (I.L.L., I.C.M., D.L.W.); and the Department of Me, Division ofAdolescentMedicine, Universityof Maryland MedicnlSystem, BaJtimore,Maryland (M.E.F.). Addmss reprint ~ue~b to: Deborah Wingard, Ph.D., Department of Communityand FamilyMedicine, 0607, 9500 Gilman Drive, Uni=if!I of califinnia San D&go, Ia lolia, CA 92093-0607. ManuscriptluxvptedJuly 3, 1992. 676 1654-lS9~.00
C. MABHR,
f’uHished by Else&r
M.D.,
E. FELICE,
M.D.
breastfeeding rates among new mothers under the age of 20 years: 39.3% initiated breastfeeding in 1983, 36.8% in 1984, and only 30.2% in 1989 (1,2). In addition, teen mothers initiate breastfeeding less often than older mothers: 30.2% for mothers less than 20 years of age versus 52.2% for all mothers (2). The literature is sparse in identifying factors associated with the adolescent mother’s choice to breast- or bottlefeed her infant. The purpose of this study is to assess psychosocial and economic factors which differentiate primiparous teen mothers who choose to breastfeed from those who do not.
Methods The study population consisted of 64 primiparous, adolescent females. All primiparous teens who were 14-18 years of age and who delivered infants at the University of California San Diego (UCSD) Medical Center between August and December 1989 were asked to participate. A few teen mothers with a brief postpartum hospitalization were discharged before they could be entered in the study. A total of six mothers declined interview; four of these mothers were planning for the adoption of their babies. Every study participant voluntarily consented to act as a research subject as outlined by the UCSD Comm’ittee of Investigations Involving Human Subjects. Information on maternal demographics, habits, prenatal care, support system, choice of infant feeding, exposure to breastfeeding, attitude toward breastfeeding, and plans for returning to work 3r school was obtained by interview at the bedside within 48 hr postpartum. A support system was defined as the presence of a close friend or relative who would provide assistance to the teen mother - ..
_
~~~
8 Society
for Adolescent Medicine, 1992
Sciencet’ublishing CO., Inc., 655 Avenue of the Americas, New York, NY 10010
INFANT FEEDING INTENTIONS AMONG ADOLESCENTS
December 1992
Table 1. Demographics
and Health Care Coverage Status Hispanic
Demographics and health care
677
Total (n = 64)
All Hispanic (n = 43)
Black (n = 9)
Non-I+ .- white ,n - .;
Other’ (n = 5)
16.6 f 0.9
16.2 f 1.2
17.9 f 0.4
16.8 f 1.1
0 33 67
0 67 33
0 0 100
0 20 80
Spanish speaking English speaking (n ==31) (n = 12) Mean f SD
Age (years)
16.9 f 1.0
17.0 f 1.0
17.1 a 1.0 Percent
14 15-16 17-18 During pregnancy In school Employed Married Living status w/parents w/baby’s father other Insurance None Medi-Cal Private
2 28
2 26
m
72
3 23 74
44 27 28
28 26 33
10 29 42
75 17 8
100 11 0
57 71 29
60 0 40
33 34 33
26 35 40
10 39 52
67 25 8
89 0 11
29 57 14
0 60 40
14 a0 6
19 79 2
26 71 3
0 100 0
0 89 11
0 71 29
20 80 0
“Southeast Asian or Filipino
and her infant. Maternal interview was conducted in either Spanish or English according to the patient’s preference. Information on the delivery and newborn infant was obtained by chart review. All data were recorded on a 92-item questionnaire and analyzed on a VAX 11/750 computer at the General Clinical Research Center at UCSD. The CLINFO software package (Bolt, Beranek, and Newman) was employed for data entry, storage, and management. Both the CLINFO and BMDP (University of California) software packages were used for data analysis. For analysis, the Hispanics were subdivided by primary language, into two groups: Spanish speaking and English speaking. The data were analyzed using analysis of variance and Student’s t test for normally distributed numerical data and the Kruskal-Wallis and the Mann-Whitney rank-sum tests for non-normally distributed data. When three group analyses reached statistical significance, appropriate post hoc multiple comparison tests were performed: Duncan’s Multiple Range for normally distributed data and Mann-Whitney (adjusted 0~) for non-normally distributed data. For categorical data, Pearson’s x2 test of association was used to investigate the relationship between different variables.
Results Demographic Characteristics (Table 1) Of the 64 teens studied 67% (n = 43) were Hispanic, 14% (n = 9) were black, 11% (n = 7) non-Hispanic white, and 8% (n = 5) Southeast Asian or Filipino. Of the Hispanics, 45% (n = 31) spoke Spanish and 19% (n = 12) spoke English. The proportion of married teens varied with ethnicity from 0% of the blacks to 42% of the Spanish-speaking Hispanics. NonHispanic white teens were the most likely to have private medical insurance, to have received prenatal care, and to have attended childbirth classes. Sixteen of the teens reported prescription medication use during pregnancy. Five reported tobacco use; one, drug use; and one, alcohol use during pregnancy. The mean birth weight of the infants born to this teen population was 3302 g, with a range of 2260-4370 g. Only two infants weighed less than 2500 g, and three weighed more than 4000 g.
Infant Feeding Intentions A total of 72% (n = 46) intended to breastfeed their babies, of whom 53% (n = 34) intended to do so
LIZARRAGAET AL.
678
Table 2. So&I Variables by
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 8
Infant Feeding Intentions Among Young Primiparous Mothers Intent to feed
Sociat variables
Total (n = 64)
Breast only (n = 34)
Breast and formula (n = 12)
Any breast (n = 46)
Formula only (n = 14)
Age (Years)”[R +-SD]
16.9 rt 1.0
17.0 f 1.0
17.1 -t 1.0
16.6 & 0.9
16.2 & 1.2
48
59
18 23
75 25 0
63
19 33
20 17
14 7 79
28 72
35 65
33 67
35 65
7 93
33 34
29 38 32 80
17 42 42 83
26 39 35 80
43 21 36 93
Et.hnicitylLanguagec HiSpZkIliC
spanish speaking
English speaking othc# Marital Statusb Married Unmarried Living status w/parent(s) w/baby’s father 0th
Support System
33
84
Note that there were also 4 teens who were undecided regarding mode of infant feeding. ‘Student’s Q-testanalysis performed between any breast versus formula only, p s 0.05; *p s 0.05. x2 analysis performed between any breast versus formula only. p s 0.001$ analysts performed between any breast versus formula only. Other r&rs to all black, non-Hispanic white, Filipino and Southeast Asian teens.
exclusively, and 19% (n = 12) to combine breastfeeding and formula feeding. Twenty-two percent (0 = 14) of the teens planned to formula feed exclusively, and 6% (n = 4) were undecided+ Table 2 shows that teens intending to breastfeed (either exclusively or in combination with formula) were significantly older than those intending to exclusively formula feed, 17.2 years’ and 16.3 years, respectively (p < 0.05). The Hispanic mothers who spoke Spanish were most likely to intend to breastfeed, followed by the Hispanics who spoke English; the combined remaining ethnic groups were least likely to intend to breastfeed (p < 0.001) Breastfeeding was chosen more often by marriedthan unmarried teens ( p s 0.05). Neither living arrangement nor presence of a postpartum support system were associated with the intention to breastfeed. Mothers who decided to exclusively formula feed were more often in school during their pregnancy (78% versus 28%; p 5 0.001). Employment during pregnancy was not found to be significantly associated with breast- or bottlefeeding. Although not statistically significant, a greater proportion of teens intending to exclusively formula feed planned to return to work or school compared with teens intending to breastfeed, 7l% and 50%, respectively. Teens were more likely to choose breastfeeding
for their own infants if they thanselves had been breastfed (p I 0.001) see Table 3. Likewise, those teens choosing to breastfeed their babies tended to know a greater number of women who had breastfed: on average the mothers intending to breastfeed knew 7.7 women who had breastfed, and the mothers intending to formula feed exclusively knew 3.5 women who had breastfed (p < 0.05). The teens intending to breastfeed had also observed a greater number of women breastfeeding than their counterparts who intended to formula feed: those intending to breastfeed having seen on aver age 4.2 nursing women; and those intending to formula feed, 1.4 nursing women (p c 0.005). Compared with the combined other ethnic groups the Hispanic teens had observed more nursing mothers (4.4 versus 1.1 nursing women, p < 0.05) and were more often breastfed as infants (63% versus 29%, p 4 0.001). Although not statistically significant, a greater proportion of those intending to exclusively formula feed (71%) than breastfeed (48%) believed that it was acceptable to breastfeed in public. Medical insurance, Aid to Families with Dependent Children (AFDC), Women, Infants, and Children (WIC) enrollment, and use of prenatal care or birth classes were not significantly associated with the intention to breastfeed.
INFANT FEEDINGINTENTIONS AMONG ADOLESCENTS
December 1992
679
Table 3. Exposure To and Attitude About the Breastfeeding Dyad by Infant Feeding Intentions Among Young
Primiparous Mothers Intentto feed Breastfeeding
Total
Breast only
Breast and formula
Any breast
Formula only
8.0 + 7.0 5.2 & 3.5
7.7 -c 6.1 4.2 f 3.4
3.5 + 3.5 1.4 + 1.4
9 (75) 6 (50)
29 (63) 22 (48)
3 (21) 10 (71)
g f SD Number of women known that breastfed Number of women seen breastfeeding’
6.5 -c 5.7 3.3 -c 3.2
7.6 2 5.8 3.8 f 3.3 No. (%)
Mother breastfed as infant’ Approves of public breastfeeding
33 (52) 35 (55)
20 (59) 16 (47)
x2 analysis performed between any breast versus formula only; “p 5 0.05; bp 5 0.005; ‘p 5 0.001.
Actual versus Intended Infant Feeding Although 72% (n = 46) intended to breastfeed, either partially or exclusively, 58% (n = 37) were actually breastfeeding by 48 hr postpartum. Of the nine women who had intended to breastfeed but had not yet initiated breastfeeding, five had infants who required admission to the special care nursery, three were waiting until their milk came in to breastfeed, and one was using formula because she was unsure if she could breastfeed and still return to work alld school. A total of 34% (n = 22) were exclusively formula feeding; 8% (n = 5) of the infants were receiving formula and/or intravenous fluids in the special care nursery.
Discussion The percentage of teens in our population intending to breastfeed was 72%, with 58% having actually initiated breastfeeding by the time of the interview. These percentages are higher than the national breastfeeding rate of 30.2% for mothers less than 20 years of age (2). This discrepancy is somewhat surprising as this sample of teen primigravidas from Southern California possesses characteristics often associated with the lowest rates of breastfeeding in America: young age, ;ow income, low education level, and unmarried status (1,3-5). Other studies performed in Southern California have found similar rates of breastfeeding. Felice et al. (6) examined a population most similar to ours: pregnant adolescents of similar ethnic proportions attending the UCSD Teen OB Clinic. They found that 56% of 199 pregnant adolescents chose to breastfeed their infants for at least 6 weeks. In addition, Romero-Gwynn et al. (7) in their study of MexicanAmerican women in Southern California found that
77.7% of 132 low-income Hispanic mothers intended to breastfeed, and 63.8% initiated breastfeeding. There were significant differences between the primigravidas who planned to nurse and those who planned to bottlefeed. These differences include maternal age, degree of acculturation measured by primary language and ethnic&y, exposure to breastfeeding, marital status, and educational status. Studies have shown that increased maternal age is positively correlated with the choice to breastfeed (1,2). These studies, however, did not report differences among women between the ages of 14 and 18 years, but instead grouped women under the age of 20 into one category. In our study, we found that there was an age difference among teens. Those teens who chose to breastfeed had a significantly higher mean age than those who chose formula, 17.2 years versus 16.3 years (p < 0.05). In the process of maturing and developing psychologically, the adolescent mother may be better able to focus on the needs of her infant and to appreciate the benefits that breastfeeding offers to her baby. In addition, positive reinforcers of breastfeeding at school or in the community may be introduced over the course of the teen years. To assess the effects of acculturation on breastfeeding, this largely Hispanic population was divided according to language preference. The Spanish-speaking Hispanics were most likely to breastfeed, followed by the English-speaking Hispanics, and then all other English speakers (p < 0.001). Use of Spanish as the primary language may indicate a close association with a Hispanic culture and is most strongly associated with the intention to breastfeed. The Hispanics who spoke English, however, were also more likely to choose breastfeeding than the non-Hispanic ethnic groups who
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spoke English. The findings imply that there may exist degrees of acculturation such that the more distant a teen mother becomes from the Hispanic culture, the less likely she may be to breastfeed. In San Diego, those Hispanics who primarily use Spanish may indeed be more closely associated with the Mexican culture, one in which breastfeeding is the norm (8). In support of the influence of language and culture, John and Martorell (9), who studied over 2500 Mexican-Americans in the Southwestern United States, found that the preferential use of Spanish rather than English was associated with a higher incidence of breastfeeding. In addition, a study of Hispanic mothers in Southern California showed that intention to breastfeed was greater for mothers who migrated from Mexico than for mothers born in the United States (7). In the present study, knowing women who have breastfed ( p < 0.05) or observing friends or relatives breastfeed (p < 0.005) positively influenced the choice to nurse. In addition, teens who were breastfed themselves were more likely to choose breastfeeding (p < 0.001). These observations are supported by several studies (10-14). The Hispanics in our population had observed a significantly greater number of women breastfeeding ( p < 0.05) and were more often breastfed themselves (p c 0.001) than the teens from the other ethnic groups. This finding is consistent with the association of the Spanish language and Hispanic culture to breastfeeding. In the Mexican-American family, the mother is one of the primary sources of support for breastfeeding (15). This culture appears to be one in which family members tend to live in close association with one another, leading to increased exposure to and acceptance of breastfeeding. Most of the adolescent mothers in this sample were unmarried. Nonetheless, being single was found to be associated with the choice to bottlefeed. This finding is consistent with many studies which have shown that married women are more likely to breastfeed than unmarried women (3,5,16). A stable male partner may be an important source of support in the decision to breastfeed. Several studies have looked at the correlation between level of education achieved and the choice to breastfeed (4,7,12,16). Missing from the literature is the association between school attendance during p~gnanc~ and the mode of infant feeding. In this study, fewer mothers intending to breastfeed were enrolled in Schoolwhile pregnant when compared with mothers intending to exclusively formula feed.
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 8
A possible reason for this negative correlation is that the teens who used Spanish as their primary language comprised a significant portion of the breastfeeding group and had the lowest school enrollment during pregnancy. Transit between the United States and Mexico may account for some of the absenteeism from school among these teens. Conversely, the fact that pregnant teens who were in school more often chose to formula feed may indicate that the promotion of breastfeeding is lacking in some high schools, or that school is perceived by these teens as a barrier to breastfeeding. Before the incidence of breastfeeding can increase among all adolescents, this society must support them in this venture. Schools could be an ideal place to offer teens prenatal education including breastfeeding information and, if possible, access to nursing rooms. Since younger teen mothers are least likely to breastfeed, health education should begin as early as possible. This work was supported in part by a grant from the Carnation Company and by the UCSD General Clinical Research Center NIH Grant MO1 RROO827. The authors are grateful to l%ul Shragg, M.A., for his patient assistance in data analysis.
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