An Integrative Review of Factors Influencing Breastfeeding in Adolescent Mothers

ABSTRACT

The purpose of this integrative review was to describe factors that influence breastfeeding behaviors in adolescent mothers. Twenty-two articles met inclusion criteria. Findings showed that most adolescent mothers intended to breastfeed during pregnancy. Yet, breastfeeding initiation ranged from 39% to 69%. Almost half of adolescent mothers stopped within 1 month. Less than 25% continued to breastfeeding behaviors to 6 months. Factors that influenced breastfeeding decisions in adolescent mothers included social and cultural norms. Personal beliefs about being a good mother were important to intention and initiation of breastfeeding. Promoting maternal competence was found to be essential to breastfeeding initiation and continuation for adolescent mothers. Support from partners and professionals also led to positive attitudes toward breastfeeding initiation and continuation.

Breastfeeding is well established as the optimal method for ensuring healthy infant nutrition. However, many adolescents remain unaware of the role of breastfeeding in health promotion and disease prevention. Although there is an increase in the number of adolescent mothers worldwide (World Health Organization, 2008), adolescent mothers between 13 and 19 years of age continue to have the lowest rate of breastfeeding in the United States, as well as throughout other countries (Centers for Disease Control and Prevention, 2009). There are approximately 425,000 infants born to adolescents in the United States each year (National National Center for Health Statistics, 2007); of these, only 43% will initiate breastfeeding, in contrast to 75% of mothers of adult age (Forste & Hoffman, 2008). Spear (2006) found that although 39% of adolescent mothers intended to breastfeed for at least 6 months after birth, only 6% continued breastfeeding until 6 months.

Factors that are associated with lower rates of breastfeeding among adolescent mothers have been considered. Wambach and Koehn (2004) explained that adolescent mothers have both positive and negative attitudes toward their decision making about infant feeding methods and efforts to continue breastfeeding. Some adolescent mothers make their decision to breastfeed during the prenatal period (Wambach & Cohen, 2009), a decision that is often the result of effective breastfeeding promotion and education. Others decide with the birth of their infant. Breastfeeding initiation occurs during this critical transition, and for many adolescent mothers, the new and ambiguous role of motherhood can be turbulent, making successful initiation of breastfeeding problematic. Breastfeeding performance can seem very demanding and difficult to achieve (Mossman, Heaman, Dennis, & Morris, 2008). To better understand adolescent mothers’ breastfeeding attitudes during pregnancy and behaviors in the postpartum period, it is necessary to explore all the factors that contribute to or detract from success. Once the complexities of breastfeeding in adolescence are better understood, targeted nursing intervention can be developed to facilitate initiation and continuation of breastfeeding, as well as support successful attainment of the maternal role. The purpose of this integrative review was to review and synthesize the research literature related to breastfeeding in adolescent mothers and to articulate existing knowledge about factors that may be influential in the breastfeeding situation.

Once the complexities of breastfeeding in adolescence are better understood, targeted nursing intervention can be developed to facilitate initiation and continuation of breastfeeding as well as support successful attainment of the maternal role.

METHODS

Data Sources

An integrative review of research was undertaken to better understand factors that influence breastfeeding for adolescent mothers and their infants (Table 1). Structured searches with a nursing/medical librarian were conducted within four electronic databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, PubMed, and Web of Science. Articles published between 2000 and 2012 were included in the search. The keywords used were breastfeeding, breast-feeding, infant feeding, adolescent mother, teenage mother, and young mother. The keywords were first used one by one for searching the articles and then in combination with each other. Eligible studies met the following criteria:

TABLE 1. Studies Related to Breastfeeding in Adolescent Mothers.

Study	Design	Significant Breastfeeding Findings by Influencing Factor
Attitude and perception of breastfeeding
Tucker, Wilson, & Samandari (2011)	Mixed-methods	•Positive factor: support from professional and family. Professional support during pregnancy and encouragement from family were important to BF initiation. •Barriers: pain, perceptions of difficulties of BF such as difficulty latching on and insufficient breastmilk
Wambach & Koehn (2004)	Qualitative study	•Adolescent mothers’ perceived benefits of BF: infant health, increasing infant intelligence, fewer infant allergies, less costly, and increased bonding •The concept of freedom appeared to be tied to adolescent mothers’ discomfort with BF in public. •Pain was viewed as a disadvantage.
Dennis, Heaman, & Mossman (2010)	Quantitative study	•Maternal self-efficacy in BF was a predictor for decision to BF. •Earlier decision showed higher score of maternal self-efficacy in BF.
Glass, Tucker, Stewart, Baker, & Kauffman (2009)	Retrospective chart review	•At hospital discharge, 59.3% initiated BF, but this dropped to 22.2% at 6 weeks postpartum.
Mossman et al. (2008)	Prospective correlational design	•Prenatal attitude was a predictor of mothers who initiated BF. •Postpartum confidence was important to continue BF to 4 weeks.
Wambach & Cohen (2009)	Qualitative study	•Perceived benefit of infant health was related to BF decision. •BF initiation was influenced by positive or negative BF experiences during hospitalization. •Positive experiences: bond and closeness •Negative experiences: perceptions of physical changes (insufficient milk supply), perceived lack of family support
Camarotti, Nakano, Pereira, Medeiros, & Monteiro (2011)	Descriptive study	•Mother with previous BF experience was a positive predictor of longer than 6 months. •The most frequent problems: nipple trauma and poor sucking of the newborn
Park, Meier, & Song (2003)	Retrospective chart review	•Race is a significant predictor independently associated with BF initiation: White and Hispanic mothers’ higher BF rates than Black adolescent mothers •Early plan to BF in the first trimester was related to higher rate of BF initiation. •Smoking mothers had lower rates of BF than nonsmokers.
Hunter (2008)	Descriptive design	•Reasons given for switching from breast to mixed or bottle feeding: baby did not latch on, nipple soreness, feeling unable to BF, baby needed more milk
Perceived support of breastfeeding
Meglio, McDermott, & Klein (2010)	Randomized controlled trial	•Peer support was clearly significant for duration of exclusive BF in adolescent mothers.
Spear (2006)	Cross-sectional, descriptive design	•Friends, families, and health-care professionals were supportive of BF. •BF experiences and perceived benefit toward BF were positive factors.
Dykes, Moran, Burt, & Edwards (2003)	Qualitative study	•Five themes related to experiences emerged: (a) feeling watched and judged, (b) lacking confidence, (c) tiredness, (d) discomfort, and (e) sharing accountability. •Key supporters identified the mother’s mother, the partner, and the midwife employed in a teenage pregnancy coordinator role.
Alexander, O’Riordan, & Furman (2010)	Prospective cross-sectional survey using a structured interview	•BF attitudes, intention, and planned duration and exclusivity of BF are not significantly different between adolescent and nonadolescent women. •Significant determinants: primaparity, good self-assessed BF knowledge, and having support from the father of the baby
Lavender, Thompson, & Wood (2005)	Descriptive design	•Peer and professional support was important to BF behavior.
Nelson & Sethi (2005)	Qualitative study	•Deciding to BF based on perception of benefits of BF such as convenience and low cost •Learning to BF was related to support from family and health-care professionals. •Adjusting to BF is related to how adolescent mother accepts the change of becoming a mother and discovers the realities of BF. •Ending BF related to expectation of family and culture to make decision to continue or end BF; some concerns about having more freedom.
Wambach, Aaronson, Domian, Rojjanasrirat, & Yeh (2011)	Randomized controlled trial	•BF knowledge, prenatal intention, and social and professional support positively influenced BF duration. •69% of samples initial BF
Concerns related to public exposure and privacy
Hannon, Willis, Bishop-Townsend, Martinez, & Scrimshaw (2000)	Qualitative study	•Greatest barriers to BF: pain, embarrassment, and lack of interest 1.Influences: mothers’ mothers, health-care professionals, friends 2.Perceptions of benefits of BF: bonding, baby’s health, baby IQ, convenience 3.Perceptions of problems with BF: pain, public exposure, unease with act of BF, inconvenience, BF myths •Three main concepts that influence BF decision:
Nelson (2009)	Qualitative study	•BF beliefs helped a new mother lose her body weight and increased sense of infant bonding. •Pain was one major factor for discontinued BF. •BF attitudes: BF is the mother’s choice; the baby comes first as a benefit of BF. •Concerns related to BF: discomfort of BF, privacy, and infant’s dependence on mother
Dyson, Green, Renfrew, McMillan, & Woolridge (2010)	Mixed methods	•Intention of BF was predictive of behavior at all time points for adolescent mothers who intend to BF or intend to feed with breastmilk substitutes. •Moral norms were identified as the most predictive variable influencing adolescent mothers’ BF intentions. •Embarrassment was significantly important in influencing adolescent mothers in intention to BF. •Self-esteem, with concerns about BF in public
Breastfeeding knowledge
De Oliveira, Giugliani, Santo, & Nunes (2012)	Randomized controlled trial	•Knowledge about nutrition of breastmilk was important to BF behavior.
Dewan, Wood, Maxwell, Cooper, & Brabin (2002)	Descriptive design	•Adolescent mothers had less knowledge about basic BF messages, colostrum, and exclusive BF.
Volpe & Bear (2000)	Randomized controlled trial	•Education, including nutrition, child development, maternal-child issues, and preventive health care influenced BF initiation.

Note. BF = breastfeeding.

• •Participants: adolescent mothers 13–19 years of age during pregnancy and the postpartum period who gave birth to full-term infants
• •Studies included adolescent mothers who breastfed their infant after birth and/or into the first year of age.
• •Mothers and infants with complications and/or labeled as high risk were excluded.
• •Outcomes: Primary outcomes of the studies were breastfeeding and/or factors influencing breastfeeding that were described or measured in the research.
• •Research methodology: Studies included in this integrative review were of quantitative, qualitative, and mixed-methods designs.
• •Articles were published in English.

Study Selection

Using our search terms, 143 articles were retrieved. The retrieved articles were screened first by reading the abstract and evaluating the research using the inclusion and exclusion criteria. During the initial selection process, the number of articles reviewed was initially decreased to 47. (Others were duplicates across the four databases.) There were 22 studies that met the inclusion criteria: 14 articles were quantitative research, 6 were qualitative research, and 2 were mixed-methods designs. Of the 25 articles that were excluded, 7 reported findings of studies including mothers older than 19 years of age, 5 were studies with infants older than 1 year of age, 5 were literature reviews, 2 were case studies, 2 were studies related to violence, 1 was related to premature infants, and 3 were not available in English. A diagram of the decision-making process for inclusion in the integrative review is provided in Figure 1.

Figure 1. Diagram of systematic search strategy.

CINAHL = Cumulative Index to Nursing and Allied Literature.

FINDINGS

The individual study sample size ranged from 16 to 389 adolescent mothers. The maternal age in the included studies was between 13 and 19 years, and the infant age was between 24 hours after birth and 12 months of age. The results from two quantitative studies illustrated that the intention to breastfeed during pregnancy ranged from 81% to 84% of the participating adolescent mothers (Dennis et al., 2010; Hunter, 2008). However, the actual initiation of breastfeeding ranged from 39% to 69% (Dennis et al., 2010; Glass et al., 2010; Lavender et al., 2005; Tucker et al., 2011; Wambach et al., 2011). The duration of breastfeeding varied from 1 month to 6 months after the infant’s birth. More than half of adolescent mothers who initiated breastfeeding stopped within the first month (Glass et al., 2010; Tucker et al., 2011). Dennis et al. (2010) found that only 46% of adolescent mothers who initiated breastfeeding continued to 4 weeks. Glass et al. (2010) found that only 22% of those who initiated breastfeeding continued to 6 weeks. In two other studies, it was reported that only 18.7%–22.6% of adolescent mothers continued breastfeeding at 6 months after the infant’s birth (de Oliveira et al., 2012; Dykes et al., 2003).

Findings from studies provided evidence of influencing factors significantly related to breastfeeding intention and continuation. We described the factors by grouping them into personal factors, social context factors, influences of social norms, and influences of infant characteristics on adolescent mothers’ breastfeeding behaviors. The next several sections provide evidence of how these factors are related to breastfeeding intention, initiation, and continuation for the adolescent mother and her infant during the first year of life.

Personal Factors

Adolescent mothers reported reasons influencing their breastfeeding choices related to personal factors such as breastfeeding attitudes, perceived benefit of breastfeeding, perceived previous experiences of breastfeeding, self-efficacy and/or knowledge of breastfeeding, and perceived problems with breastfeeding such as nipple pain and inconvenience (Glass et al., 2010; Hannon et al., 2000; Hunter, 2008; Nelson, 2009; Tucker et al., 2011; Wambach & Koehn, 2004). Wambach and Cohen (2009) found that adolescent mothers continued breastfeeding when they perceived that there were benefits related to it. Most commonly, mothers reported perceiving infant health benefits in providing the best possible nutrition. This belief was linked to the mothers’ motivation to persist in their breastfeeding. Hannon et al. (2000) also found that adolescent mothers’ perceptions of health benefits for the infant increased both the initiation and duration of breastfeeding. The benefit for the mother to continue to breastfeed was her belief that it made her a better mother, that is, increased self-esteem (Lavender et al., 2005). The second most commonly identified benefit was related to bonding. Most often, adolescent mothers reported that because they felt closer (more attached) to their infants, they made the decision to continue breastfeeding for a longer duration (Hannon et al., 2000; Wambach & Cohen, 2009).

Adolescent mothers’ positive experiences with breastfeeding were found to be important for the initiation of breastfeeding in the hospital or during the early postpartum period. However, posthospital experiences were found to be more significant to their continued provision of breastfeeding (Wambach & Cohen, 2009). These experiences were associated with perceptions of physical changes including insufficient milk supply, fatigue, nipple pain, and nipple soreness. In one study, nipple pain was reported most often as a physical problem by the mothers and often occurred during feeding (Camarotti et al., 2011). In a separate study, nipple pain was noted to be one of the major reasons that adolescent mothers discontinued breastfeeding (Nelson, 2009). Nipple soreness was also identified as a contributing factor not well understood by the adolescent mothers (Camarotti et al., 2011; Nelson, 2009). These mothers did not seem to have any perceptions or knowledge that nipple pain during early breastfeeding might be considered normal. These findings were further substantiated in the descriptions from other qualitative studies in which nipple pain, soreness, or bleeding contributed to early weaning (Hannon et al., 2000; Wambach & Cohen, 2009).

Prenatal attitudes toward breastfeeding were also identified as contributing to early breastfeeding decision making for adolescent mothers (Mossman et al., 2008). Adolescent mothers with significantly higher prenatal attitude scores were more likely to initiate breastfeeding than those with lower scores. Moreover, adolescent mothers with higher prenatal breastfeeding attitudes and higher early postpartum confidence were more likely to continue breastfeeding up to 4 weeks (Mossman et al., 2008). Attitudes about breastfeeding also were related to knowledge of the benefits of breastmilk. The adolescent mother viewed breastfeeding as a choice that provided the infant the best benefit (Nelson, 2009). Early introduction of breastfeeding education in the prenatal period served to increase the adolescent mother’s knowledge and increase awareness of the importance of breastfeeding. However, improving knowledge was not always found to lead to improvement in breastfeeding rates. Dewan et al. (2002) found that positive attitudes toward breastfeeding were not dependent on knowledge alone. For example, problems experienced in the first week after hospital discharge, including nipple soreness, nipple pain, and breast engorgement, negatively contributed to the continuation of breastfeeding (Wambach & Cohen, 2009). Consequently, breastfeeding was sometimes perceived as more difficult than the adolescent mothers had expected (Wambach & Cohen, 2009; Wambach & Koehn, 2004). Other findings from qualitative studies revealed that hearing from their peers or other mothers that breastfeeding might be painful prevented some adolescent mothers from wanting to initiate breastfeeding.

Social Context Factors

Strong evidence exists that receiving effective support significantly influences the duration of breastfeeding in adolescent mothers (Dykes et al., 2003; Hannon et al., 2000; Nelson & Sethi, 2005; Spear, 2006; Wambach & Cohen, 2009). For the adolescent mother to be continuously committed to breastfeeding, she requires social support that includes sharing information, facilitating proper breastfeeding techniques, and providing emotional support related to breastfeeding (Dykes et al., 2003). Adolescent mothers were found to gain support from their informal networks, including their partner, friends, mothers, other family members, and people in their communities. Support from formal networks, including health professionals and parenting programs, was also reported to be important (Nelson & Sethi, 2005). Most of adolescent mothers reported receiving overall positive emotional support for breastfeeding in the first weeks and months, and this informal support contributed to and enhanced their abilities to learn to breastfeed and persist with it (Nelson & Sethi, 2005). A randomized controlled trial examining the effects of peer and professional support for the initiation and continuation of breastfeeding in adolescent mothers showed that support beginning in the second trimester and extending through 4 weeks postpartum positively influenced breastfeeding duration (Wambach et al., 2011). However, adolescent mothers perceived breastfeeding as contributing to a loss of their personal freedom and to negatively changing their relationships with their partners. Some adolescents reported that their worlds were reconstructed because of motherhood and breastfeeding (Nelson, 2009; Nelson & Sethi, 2005).

Influences of Cultural Norms

Studies found that some of the mothers felt pressure about their choice of feeding methods (Dyson et al., 2010; Wambach & Cohen, 2009; Wambach & Koehn, 2004). Adolescents reported that their partners and families sometimes told them that breastfeeding was the best feeding method and other methods were not acceptable choices (Wambach & Koehn, 2004). Qualitative reports also found that adolescent mothers often perceived negative moral judgments related to their decision not to breastfeed (Nelson, 2009). However, breastfeeding was considered an acceptable infant feeding method among other adolescent mothers because it symbolized to others that they were “good mothers.” Thus, choosing to breastfeed her infant was positively perceived and reinforced by peers and cultural groups as evidence of the adolescent’s successful transition to motherhood (Dykes et al., 2003). Cultural influences related to breastfeeding were identified as predictive factors influencing adolescent mothers’ intentions and choices about infant feeding methods (Wambach & Cohen, 2009). Nonetheless, embarrassment about exposure during breastfeeding in public was viewed as a barrier for many adolescent mothers (Nelson & Sethi, 2005; Wambach & Cohen, 2009). These young mothers were aware of the potential sexual interest that this behavior might attract from others. In one study, the potential embarrassment of breastfeeding in public was often rated as important in influencing many of adolescent mothers’ intention to breastfeed (Dykes et al., 2003).

Infant Characteristics

Although a common reason to initiate breastfeeding was the perceived benefit of enhanced infant health, two studies reported how infant responses influenced the continuation of breastfeeding in adolescent mothers. Infant responses related to latching and sucking problems influenced adolescent mothers to switch from breastfeeding to mixed or bottle feeding (Hunter, 2008). On the other hand, breastfeeding experiences of adolescent mothers were perceived as more positive when their infants responded well, grew, and developed (Nelson & Sethi, 2005).

DISCUSSION

Personal factors appear to be the most important in influencing adolescent mothers’ decision to initiate and maintain breastfeeding. The perceived benefits of breastmilk motivate the mother to plan her infant feeding choices and also provide motivation for her to continue feeding for a longer duration because of the value to her infant’s health. In-hospital experience and posthospital experience are considered both positive and negative factors that influence the adolescent mother in her decision to continue breastfeeding. Because some mild-to-moderate nipple pain is normal during the initiation of breastfeeding, this finding has important implications for nursing practice and research. For example, how this information is provided to adolescents might be important to both the initiation and continuation of breastfeeding. Thus, hospital nursing intervention that helps mothers to better manage physical discomfort and encourages breastfeeding skill is required to facilitate a positive experience for adolescent mothers. Both prenatal and early postpartum breastfeeding attitudes are important to early decision making about infant feeding methods. The adolescent mother’s ability to differentiate these attitudes and perceptions and make good choices may be limited because of their personal immaturity and cognitive processing. On one hand, an adolescent mother whose cognitive processing is not as well developed may not cultivate these positive perceptions. On the other hand, breastfeeding experience may contribute to an adolescent mother’s evolution as a mother and to her overall maturation. With adjustment to breastfeeding and motherhood, the adolescent mother has the potential to accept the change and responsibility of being a mother as well as that of breastfeeding (Hannon et al., 2000; Nelson & Sethi, 2005).

Social factors exercised both positive and negative influences on the breastfeeding experience of adolescent mothers. An adolescent may perceive breastfeeding as supporting her ability or inability to continue to interact within her social environment. Positive sources of support included partners, family members, peers, and professionals. However, some adolescent mothers perceive breastfeeding as tying their infants to them, thus limiting their social activities (Nelson, 2009). Negative perceptions related to breastfeeding included that it was a barrier to continuing social activities with peers and partners. Adolescent mothers not only need to access a variety and high level of breastfeeding supports during pregnancy and into the postpartum period but also need to connect with their social network, partners, and peers. Thus, intervention should include partner and peers to allow for a balance between being an adolescent and being a breastfeeding mother.

Concern about embarrassment from breastfeeding exposure in public is a critical issue to the adolescent mother. The breast is often perceived as sexual symbol (Dyson et al., 2010). Embarrassment about breastfeeding in public is one of the major cultural barriers that adolescent mothers are often not developmentally ready to handle. Helping adolescent mothers to find strategies to breastfeed in public without gathering attention or risking exposure would be important to facilitating their breastfeeding success. Perceptions of cultural expectations influenced breastfeeding decisions and behaviors for adolescent mothers. However, an adolescent mother may be more concerned about establishing breastfeeding when she is considered a “young” mother by others and is trying to prove she can also be a “good” mother. Adding breastfeeding to the required role transition of becoming a new mother can make this transition more challenging. Thus, the intervention should not only support breastfeeding skill and attitude but also encourage maternal competence and confidence.

Lastly, even though there is no strong evidence, infant factors seem to be considerations in adolescent mothers’ breastfeeding duration. Infant difficulties (e.g., latching and sucking problems) are often cited by younger mothers as the reason for cessation of breastfeeding within the first weeks and months. Differences in infant characteristics suggest that the initiation of breastfeeding could be stressful for some mothers and infants. It is possible that a continuing difficult temperament in some breastfeeding infants may contribute to the steady decline in breastfeeding rates. The relationship between infant characteristics and breastfeeding initiation and duration in adolescent mothers should be further explored to help these young mothers continue breastfeeding and achieve success in their new role.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Future research that focuses not only on breastfeeding issues but also on the personal factors of the young mother will be helpful in expanding recommendations for practice and in designing interventions to support adolescent mothers to successfully breastfeed their newborn infants. Although there are some common factors related to continuation of breastfeeding that have been documented both in adolescent and older mothers, the breastfeeding rate is still lower among younger mothers. Thus, the component of decision making related to breastfeeding may be associated with adolescent mothers’ level of maturity. Future research might better explore perceptions and satisfaction with parenting and breastfeeding behaviors in adolescent mothers. In addition, research related to infant responses is limited in adolescent mothers, and much understanding might be gained from studies examining the influence of infant factors on breastfeeding duration and the linkage to maternal competence in adolescent mothers.

CONCLUSIONS

This review confirms that breastfeeding knowledge, maternal attitudes, social support, and social and cultural factors play an important role in the intention to breastfeed and the initiation of breastfeeding in adolescent mothers. Interventions must be provided that encourage adolescent mothers and focus on maternal factors such as positive attitudes regarding breastfeeding based on knowledge while at the same time providing personal growth support focused on the developmental needs of a young mother making choices for herself and her infant. Although many intervention studies have been based on the provision of social support, such as peer and professional support, the breastfeeding rates in adolescent mothers have not increased. It seems that intervention strategies need to focus on not only breastfeeding techniques and various kinds of support, but also on the developmental needs of the adolescent mother as she adapts to this new role.

• •During prenatal care, promoting positive maternal perceptions about breastfeeding and perceptions of mothering is essential to supporting the intention to breastfeed.
• •In the early postpartum period, positive support from partners and health-care professionals is also essential to sustaining positive maternal attitudes toward the initiation and continuation of breastfeeding.
• •To maintain breastfeeding behavior, learning to balance her new role as a mother with concerns about personal freedom as an adolescent woman may help an adolescent mother to develop her personal growth and continue breastfeeding as a part of her maternal role.

Breastfeeding knowledge, maternal attitudes, social support, and social and cultural factors play an important role in the intention to breastfeed and the initiation of breastfeeding in adolescent mothers.

Biographies

SUPANNEE KANHADILOK is a member of the faculty at Boromrajonani College of Nursing in Phaputtabath, Saraburi, Thailand.

JACQUELINE M. McGRATH is a professor at the University of Connecticut School of Nursing.