A Randomized Controlled Trial of Telephone Peer Support's Influence on Breastfeeding Duration in Adolescent Mothers

Abstract

Purpose:

Adolescent mothers breastfeed less often and for a shorter duration than adult mothers. This randomized controlled trial was designed to evaluate the effect of telephone peer support on breastfeeding duration among adolescents.

Methods:

Five adolescents who had previously breastfed were trained to provide peer support. Seventy-eight breastfeeding mothers were randomly assigned to an intervention group that received telephone calls from the peer support persons (n = 38) or to a control group that did not receive support (n = 40). An independent interviewer telephoned all new mothers weekly to document feeding patterns. Peer support persons, subjects, and the interviewer were all blinded to the research hypothesis and to group assignment. The primary outcome variable was “any breastfeeding” duration, i.e., the age at complete breastfeeding cessation. A secondary outcome variable was exclusive breastfeeding, i.e., the age at first introduction of any supplement.

Results:

“Any breastfeeding” duration did not differ significantly between the groups (median 75 days in the intervention group vs. 35 days in the control group, p = 0.26). Among the 13 intervention and 11 control mothers who were exclusively breastfeeding at the time of hospital discharge, the duration of exclusive breastfeeding was increased in the intervention group (median 35 days vs. 10 days, p = 0.004).

Conclusions:

This study did not demonstrate a significant effect of peer support on “any breastfeeding” duration. In contrast, exclusive breastfeeding duration appeared to be extended by peer support. This latter finding would benefit from confirmation in future studies. However, unless better methods are developed for retaining peers, this is likely to be a labor-intensive approach to extending exclusive breastfeeding duration among adolescent mothers.

Introduction

Child health advocates recommend exclusive breastfeeding of infants to 6 months of age and encourage breastmilk as part of the diet to the first birthday or beyond.^1,2 The U.S. Department of Health and Human Services, in its plan for national health—Healthy People 2010—set an “any breastfeeding” goal of 75% at discharge, with 50% continuation at 6 months.³ National breastfeeding rates are slowly approaching this goal. The 2006 National Immunization Survey revealed that 74% of U.S. women were breastfeeding at discharge from hospital and 43% were breastfeeding 6 months later.⁴ Maternal age, race, ethnicity, educational achievement, marital status, and economic status affect breastfeeding behavior.⁵ Teen mothers tend to have several of these adverse risk factors, and as a group they are less likely to breastfeed (56%) and do so for shorter periods (24% at 6 months) than adult mothers.⁴

The importance of breastfeeding for both maternal and infant health has been clearly recognized in the pediatric literature. These benefits are likely to be as significant for adolescent mothers and their infants as for the general population, yet few programs have focused specifically on the improvement of breastfeeding initiation and duration in the adolescent. Breastfeeding promotion programs developed for adults do not exclude adolescent participants in principle, but they may be less successful with this population if they do not recognize the specific developmental and contextual needs of the adolescent parent. For example, breastfeeding support groups composed mainly of adult mothers may be intimidating to the adolescent or may focus on issues that are not particularly relevant to the adolescent mothering experience. In recognition of their specific developmental needs, many institutions have obstetrical programs specifically targeted to adolescent mothers; breastfeeding interventions probably also need to be targeted specifically to this group.

A 2007 Cochrane review of breastfeeding promotion programs indicates that lay support (trained non-professionals who may or may not share the same socioeconomic and cultural context) is effective in increasing breastfeeding duration and that the benefits accrue to “exclusive breastfeeding” more than to “any breastfeeding.”⁶ There are no published studies of the effect of lay support or peer support on adolescents' breastfeeding behavior, however. In determining support most effective for adolescent mothers, peer support would seem a successful strategy as an adolescent's developmental tasks include a shift from reliance on authority figures to reliance on peers. Peer support and leadership programs have been successful in changing other important adolescent health behaviors including smoking,⁷ drug and alcohol use,⁷ and contraceptive compliance.⁸

A recent prospective study found that adolescent mothers with high postnatal breastfeeding confidence are four times more likely to be breastfeeding at 1 month than mothers with low breastfeeding confidence.⁹ Peer support may be an effective way of increasing breastfeeding confidence in adolescent mothers, with the additional benefit of increasing breastfeeding duration and exclusivity.

We report the results of a double-blind, randomized controlled trial of the effect of peer breastfeeding support on breastfeeding duration among adolescents. Our hypothesis was that breastfeeding support by adolescents who have successfully breastfed would extend the overall and exclusive breastfeeding duration among adolescent mothers.

Patients and Methods

Peer support recruitment and training

A prestudy chart review determined that among adolescents who initiated breastfeeding, half discontinued within the first week and 75% within 5 weeks. Adolescents who breastfed for more than 4 weeks were highly likely to continue breastfeeding for extended periods of time. Adolescent mothers who had breastfed for more than 4 weeks were therefore deemed to be among the most experienced breastfeeding adolescents and were recruited to be peer support persons. The mothers gave written consent to participation in this study of breastfeeding adolescents and were aware that their role in the study was to provide peer support for new mothers. These young women attended a breastfeeding peer counselor training program consisting of 10 2-hour sessions developed and delivered by La Leche League leaders. The program was adapted for the adolescent audience by the leaders. Graduates of the program received La Leche League certificates and a $50 gift certificate. Twenty-four adolescents were approached to become peer support persons; 15 agreed, and five completed training.

Subject recruitment

Recruiters monitored daily births at two Rochester, NY hospitals from September 19, 1996 to June 20, 1997. All eligible subjects were approached between 12 and 36 hours after a vaginal delivery or between 24 and 48 hours after a Cesarean section. Written consent was obtained from all participants according to the research protocol approved by the University of Rochester Research Subjects Review Board and the Rochester General Hospital Clinical Investigations Committee. In order to blind subjects to the study hypothesis, recruiters explained that this was a study about:

How young mothers who breastfeed in the hospital feed their babies at home

How young mothers make feeding decisions

Who helps them make those decisions

Subjects were advised that in addition to an interview in the hospital, they would be contacted at home by a second interviewer for 5–10-minute interviews once a week for 4 weeks, then every 2 weeks for 4 weeks, and then once a month until they discontinued breastfeeding, to review the infant's intake. They were also informed that they might be contacted by another young mother. The study hypothesis and study design were not discussed.

Eligibility for the study depended on both the mother's and the baby's health status. Eligibility criteria for the mother included: breastfeeding a singleton infant; age under 20 years; no contraindications to breastfeeding (e.g., human immunodeficiency virus, active substance abuse); and uncomplicated postpartum course (e.g., no postpartum transfusion, no intensive care). Eligibility criteria for the infant included: gestational age greater than 36 weeks; weight more than 2,000 g; not in an intensive care or special care unit for more than 6 hours; no anomalies that interfered with nursing (e.g., cleft lip or palate); and discharged home with the mother.

Randomization

Group assignment was determined by the principal investigator (PI) for each of 100 possible subjects using computer-generated random numbers. The assignment was recorded in a sealed and numbered envelope. Envelopes were sequentially opened as subjects were recruited. The PI was the only person aware of group assignment and had no direct contact with any of the subjects.

The intervention

The intervention was based on a breastfeeding promotion effort developed and widely disseminated by Women, Infants and Children (WIC). WIC offices recruit, train, and remunerate adult experienced breastfeeding mothers to provide support to new breastfeeding mothers. Our intervention differed in recruiting teen mothers as support persons and in having a control group of mothers randomly assigned to receive no peer support from our program. Intervention subjects were assigned to one of the peer support persons based on the peer support persons' availability and caseload. Peer support persons telephoned the new mother at 2, 4, and 7 days postdischarge and then at 2, 3, 4, and 5 weeks postdischarge. No specific discussion topics were assigned. Peers introduced themselves and asked about the breastfeeding experience. They offered their telephone numbers so that the new mothers could call for support. They were advised to refer anyone with a problem to telephone resources for breastfeeding information or to their physician.

Peers were supported intensively from the moment that they began their training. The PI attended all the training sessions, getting to know peers personally and maintaining telephone contact to provide training day reminders, encouragement to attend, and transportation. The PI maintained weekly contact with peers who completed the training until recruitment of the subjects began and followed up with telephone calls at least weekly during the time that peers were following a subject, offering support and debriefing their telephone support experiences. The PI was available 24 hours a day by mobile telephone to respond to the peer counselors' concerns or questions. Monthly pizza parties were held for peer counselors and their assigned subjects to attend with their children. Transportation to and from events was provided. Subjects in the control group did not receive telephone support, although subjects in both groups had access to other support modalities, including family and friends, pediatric care providers, and hospital lactation consultants.

The protocol for the study specified the use of peer telephone logs to document the occurrence and extent of the intervention. However, early in the study it became clear that submission of logs was inconsistent, despite the fact that it was tied to participation incentives. Because of this, two additional lines of evidence were developed to document occurrence of the peer support telephone calls: investigator documentation of conversations with the peers about their support experiences and a semistructured interview of mothers in the intervention group regarding their experience of the peer support, conducted at the conclusion of the study.

Data collection

A single research assistant conducted all the telephone interviews, using standardized, closed-ended questionnaires. The interviewer had no knowledge of the study hypothesis or design. Subjects in both groups were contacted at 1, 2, 3, 4, 6, and 8 weeks postpartum and then at monthly intervals until breastfeeding was discontinued. If a subject had weaned since the last interview, a termination interview was performed. All subjects were contacted at 8 weeks regardless of whether they had weaned. Completing this interview was the condition required for receiving the participation incentive of a $25 mall certificate. This minimized the possibility that subjects would alter feeding decisions to obtain the monetary incentive.

Outcome variables

The primary outcome variable in this trial was “any breastfeeding” duration, as measured by the age in days at complete breastfeeding cessation. A secondary outcome variable was exclusive breastfeeding duration, as measured by the time to the first introduction of any other supplement (water, juice, vitamins, or formula). These measures are consistent with the standardized definitions proposed by the Interagency Group for Action on Breastfeeding.¹⁰

Data analysis

All analyses were performed using the SAS software package (SAS version 6.12; Research Triangle Group, Research Triangle Park, NC). Comparisons between eligible subjects who agreed to participate and those who declined, and between hospital sites, were performed using unpaired t tests or Fisher's exact tests, as appropriate.

Comparisons between the intervention and control groups with respect to the primary and secondary outcome variables were performed using the log-rank test. Kaplan-Meier curves were used to describe the cumulative probability of maintaining breastfeeding over time. Relative risks of breastfeeding cessation were quantified by hazard ratios and associated 95% confidence intervals obtained from Cox proportional hazards models. The time until cessation of breastfeeding was censored at the date of last contact for subjects who withdrew or were lost to follow-up. Analyses of duration of exclusive breastfeeding included only subjects who were exclusively breastfeeding at the time of randomization.

Results

The peers

The peers who completed training and participated in supporting the subjects were all between the ages of 17 and 19 years. The youngest child of the peers was 10 months, and the oldest was 39 months. All of the mothers were between 15 and 16 years old at the birth of their first child. Two of the mothers had two children. The shortest breastfeeding experience was 7 weeks. The other children were breastfed for 6, 8, 10, 11, 32, and 36 months, with one of the mothers tandem feeding an 11-month-old and a 32-month-old.

Subjects

Subject flow through the study is described in Figure 1. Seventy-eight subjects were randomized: 38 to the intervention group and 40 to the control group. There were no important group differences in the baseline characteristics of participants (Table 1). Also, no differences were noted between those who chose to participate and those who declined, except that non-participants were more likely to be Hispanic (50% of the 12 non-participants vs. 10% of the 78 participants).

FIG. 1.

Flow diagram.

Table 1.

Demographic Characteristics in the Intervention and Control Groups

	Percentage
	Intervention (n = 38)	Control (n = 40)
Age (years)	18.4 ± 1.3	18.2 ± 1.4
Place of birth
Mainland United States	33 (87)	36 (90)
Puerto Rico	3 (8)	1 (3)
Other	2 (5)	2 (5)
Missing data	0 (0)	1 (2)
Race
Caucasian, non-Hispanic	12 (32)	17 (42)
Caucasian, Hispanic	6 (15)	2 (5)
African American	20 (53)	19 (48)
Biracial (African American/Hispanic)	0 (0)	2 (5)
Insurance
Private or HMO	11 (29)	14 (35)
Medicaid or Medicaid HMO	27 (71)	26 (65)
Number of pregnancies
One	25 (66)	30 (75)
Two	8 (21)	8 (20)
More than two	5 (13)	2 (5)
Number of living children
One	34 (89)	34 (85)
More than one	4 (11)	6 (15)
Breastfed previous child (n = 10)
Yes	4 (100)	3 (50)
No	0 (0)	3 (50)
Trimester began prenatal care
First (<13 weeks)	20 (53)	21(53)
Second (13–24 weeks)	9 (24)	8 (20)
Third (>24 weeks)	1 (3)	4 (10)
Missing data	8 (21)	7(18)
Type of delivery
NSVD^a	31 (82)	31 (78)
Cesarean section	3 (8)	6 (15)
Forceps or vacuum	4 (10)	3 (7)

Normal spontaneous vaginal delivery.

Of the 78 subjects, 11 dropped out immediately after recruitment. These subjects had follow-up times censored at 1 day of breastfeeding. Fifty-four subjects were successfully contacted for the week 8 interview, which marked the end point for receipt of a participation incentive. Of the remaining 13 who could not be contacted, eight had already reported breastfeeding discontinuation on an interim survey, and five subjects were lost to follow-up and therefore had follow-up times censored. A further 16 dropped out at varying intervals between 8 weeks and 37 weeks. In all, the follow-up times of 32 subject records were censored. Forty-six subjects were successfully followed to complete breastfeeding cessation (22 intervention and 24 control).

The intervention

Of the five adolescents who completed peer support training, three were unreliable at making the prescribed telephone contacts and were excluded after the first few peer assignments, one dropped out after 4 months, and one remained involved for the entire duration of the study.

Table 2 summarizes the lines of evidence provided for the 19 interventions that were likely to have occurred and the 19 that were likely not to have occurred.

Table 2.

Execution of the Intervention

	Number
Intervention documented
Peer logs submitted
Subject recalls contact	2
Subject does not recall contact	1
Subject could not be contacted	11
No peer logs submitted
Subject recalls contact	3
Subject could not be contacted but investigator has record of contact	2
Intervention not documented
No peer logs submitted
Subject does not recall contact and investigator has no record of contact	2
Subject could not be contacted
Weaned at discharge	3
Dropout before study phase	3
In study but no investigator record of contact	11

Breastfeeding and breastfeeding cessation

Upon recruitment, 55 mothers intended to breastfeed exclusively, but by discharge only 23 infants had received no supplements. In 28 cases, mothers reported breastfeeding exclusively in the hospital, but the infant discharge records reported at least one supplement. In our analyses, infants were considered exclusively breastfed only when both the mother and the infant hospital chart reported no supplementation.

Figure 2 shows the Kaplan-Meier curves for “any breastfeeding” duration using an intention-to-treat analysis. “Any breastfeeding” duration did not differ significantly between the intervention group and the control group (median, 75 vs. 35 days; hazard ratio 0.71, 95% confidence interval 0.39–1.30, p = 0.26).

FIG. 2.

Cumulative probability of breastfeeding continuation.

In a secondary efficacy analysis—one that considered only the control subjects who participated in at least one outpatient feeding survey (n = 30) and intervention subjects who likely received the intervention (n = 19) (see Table 2)—the median breastfeeding duration in the intervention group was 110 days compared to 41 days in the control group (p = 0.18).

Exclusive breastfeeding in teens was uncommon: infants of 68% of the intervention group and 75% of the control group received supplements prior to discharge. Among the 13 intervention and 11 control subjects who were still exclusively breastfeeding at the time of enrollment, the duration of exclusive breastfeeding was significantly increased in the intervention group (median, 35 days vs. 10 days; hazard ratio 0.26, 95% confidence interval 0.10–0.70, p = 0.004). Figure 3 presents the Kaplan-Meier curves for time to cessation of exclusive breastfeeding.

FIG. 3.

Cumulative probability of exclusive breastfeeding.

Discussion

This is a double-blind, randomized, controlled study of an intervention designed to support adolescent mothers who have chosen to breastfeed.

Contrary to our expectations, we did not demonstrate an effect of peer support on “any breastfeeding” duration. In a secondary analysis, peer support appeared to increase the duration of exclusive breastfeeding. Interestingly, the Cochrane meta-analysis of lay support programs on breastfeeding duration also found that there was a much more substantial effect of peer support on exclusive breastfeeding than there was on “any breastfeeding.”⁶ This is a perplexing outcome if one predicates exclusive breastfeeding as one extreme on a continuum of breastfeeding from 100% breastfed to 0% breastfed, with “any breastfeeding” duration being any amount of breastfeeding in between. It is possible that once supplements are introduced, a more intensive intervention is required to stem the tendency toward breastfeeding cessation. In the case of our study, it is possible that the sample size was too small to detect an effect of peer support on “any breastfeeding” duration. This latter explanation is supported by the very wide confidence around the hazard ratio for the intervention group (0.39–1.30). Our results concerning the effect of “any breastfeeding” duration, therefore, are best interpreted as inconclusive.

The Cochrane meta-analysis concluded that intervention by telephone is not effective.⁶ These data were not available at the time of our study, however. In addition, the logistics and costs of providing support for our peers to perform home visits or even postpartum hospital visits were too great. We also presumed that adolescents would feel comfortable interacting by phone. On the contrary, our peers' expressed discomfort at making “cold calls.” Our program did include a structured peer-initiated telephone contact, which the Cochrane review supports as a better strategy than having the new mother call for help.

Repetition of this study today might have very different possibilities in terms of design. The advent of new social networking technologies (e.g., Facebook, MySpace, and texting) with very high penetration even in disenfranchised populations may make these more viable media for both providing the intervention and tracking it.

A strength of this study is its randomized double-blind design. Randomization addressed the issue of self-selection bias present in other peer support studies. Blinding of the research subjects, the peers, the recruiters, and the interviewers to the study hypothesis reduced the likelihood of extending breastfeeding in response to experimenter expectation. This was especially important in view of the finding that the median breastfeeding duration was substantially longer in this study's control group than had been predicted based on a chart review of infants of adolescent mothers from the same population (5 weeks vs. 1 week). While this might have been due to a secular trend toward longer breastfeeding in adolescents, teens also seemed to welcome and anticipate the research assistant's calls, suggesting that subjects may have experienced these calls as a source of support. While this effect was expected to be equal in the control and intervention groups because of the study design, it may have made it more difficult to detect the impact of peer support in our trial.

Another strength of this study is the use of an intention-to-treat analysis. This conservative analysis allows for a clear interpretation of the results despite three major challenges encountered in the study. The first challenge was a high peer dropout rate. Of the 15 peers recruited, five completed the training. Only one peer participated for more than 4 months. Second, the intervention was delivered inconsistently. Of the 38 intervention subjects, half may not have received any peer support for breastfeeding. Interestingly, this was reported as a challenge even in working with adult peer counselors.^11,12 Nonetheless, these challenges reflect the reality of using adolescent mothers to provide peer support for breastfeeding. Teen mothers experience multiple competing priorities, sparse social supports, and responsibilities out of proportion to their developmental stage. These obstacles make it difficult to sustain long-term commitment to a project only tangentially meaningful to their lives. The results of the trial thus reflect the effects of the strategy of using peer support rather than the effects of peer support per se.

This study is also limited by the fact that it was conducted in a medium-sized city in the Northeastern United States. Externally constructed peer support may not be equally embraced in larger metropolitan areas, rural areas, or in non-Northeastern states, and therefore it is not clear how widely generalizable the results are. Second, we noted a participation bias, with Hispanic teens being more likely to refuse participation than either Caucasian or African American teens. Thus, there is no way to ascertain whether certain cultures or subcultures may be less receptive to external interventions such as this one. Finally, our results are limited in that the data presented herein were collected more than a decade ago. Since then, well-controlled studies have shown that the strategy of face-to-face peer support is effective in extending breastfeeding duration among adults. However, we believe that our data are still a relevant addition to the body of knowledge about breastfeeding promotion in adolescents.

Conclusions

This study indicates that peer support may increase exclusive breastfeeding duration. “Any breastfeeding” duration was not shown to be improved by this strategy. A larger-scale study may show this type of peer intervention to be effective, but the difficulty experienced in retaining peers suggests that this may be a labor-intensive approach to extending breastfeeding duration in adolescents.

Footnotes

Acknowledgments

This project was funded by a Special Projects Grant from the Ambulatory Pediatric Association. Salary support for G.D.M. was provided through fellowship training grants by the National Research Service Award and the Health Research Service Award. We wish to acknowledge the valuable contributions to this project and its manuscript from the following: Dr. Barry Pless, for critical review of the manuscript; Peggy Auinger, M.S., for database development and technical support; Lisa DeBlieck for recruitment at the Rochester General Hospital; Dr. Daniel Cobaugh for developing the Emergency Department Enrollers Program at Strong Memorial Hospital and for donating its services to this project; Neal Leahy, program coordinator, and his extraordinary Enroller Program staff; Phil Yawman and the staff of Threshold Center for Alternative Youth Services, Inc. for providing a warm and hospitable site for the peer training program; the staff at the Rochester Adolescent Maternity Program, especially Jody Stevens, Sherri Seppala, Sharon Cowan, Helene Thompson-Scott, and Jane Brayley, for their assistance in understanding this population, developing and executing the needs assessment, identifying peer support persons, and facilitating data collection; and Tamara Sullivan for the hundreds of hours spent conducting telephone interviews with the subjects. Finally, we must thank the incredible adolescent mothers who participated in this project as peer counselors and as subjects.

Disclosure Statement

No competing financial interests exist.

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