Do Breastfeeding Intentions of Pregnant Inner-City Teens and Adult Women Differ?

Abstract

Objective:

This study compared the breastfeeding intentions and attitudes of pregnant low-income inner-city teens (age ≤19 years) and non-teens (age ≥20) to determine if age is a significant determinant of intent to breastfeed in this population.

Patients and Methods:

We used structured interviews to examine the feeding intentions and attitudes of consecutive healthy pregnant women receiving obstetrical care at the Women's Health Center, MacDonald Women's Hospital, Cleveland, OH (June 1–July 31, 2007). The primary outcome measure was rate of intent to breastfeed among teen versus non-teen participants. Attitudes and self-assessed knowledge regarding breastfeeding were compared between teens and non-teens, and multiple logistic regression analysis was used to examine the effect of age on breastfeeding intent.

Results:

We interviewed 176 pregnant women (95% African-American, 94% single marital status, median age 22 years [range, 15–41 years], 46 [26%] teens) at a median of 27 weeks of pregnancy. There were no significant differences between teens and non-teens in race, marital status, or timing of first prenatal visit or interview. Rate of intent to breastfeed and planned duration and exclusivity of breastfeeding, as well as most measured attitudes about breastfeeding including “back to work” plans, were not significantly different between groups. Significant determinants of feeding intent included primiparity, good self-assessed knowledge about breastfeeding, and having support from the father of the baby.

Conclusions:

In a population at high risk for choosing not to breastfeed, we found no significant explanatory effect of age on breastfeeding intention, implying that an inclusive targeted breastfeeding intervention program may be effective for both teens and non-teens in a low-income inner-city population. We also found that the support of the father of the baby significantly influenced breastfeeding intent among our participants, suggesting that paternal involvement will be integral to the success of breastfeeding.

Introduction

Breastfeeding offers many benefits for infants and mothers. Breastfeeding reduces the incidence and severity of lower respiratory infections and gastrointestinal diseases in infants and may reduce the risk of sudden infant death syndrome. Health benefits extend into childhood, with probable lower risk for diabetes, obesity, and atopic dermatitis.¹ Health benefits for mothers include a decreased risk of breast cancer and type 2 diabetes.¹ The American Academy of Pediatrics and the World Health Organization recommend exclusive breastfeeding for the first 6 months of life with continuation through at least the first year of life.^2,3 Although 74% of U.S. mothers initiated breastfeeding (in 2005), national rates of exclusive breastfeeding at 3 and 6 months (32% and 12%, respectively, also in 2005) do not meet Healthy People 2010 goals of 60% exclusive breastfeeding at 3 months and 25% at 6 months.^4,5

Sociodemographic factors that have been specifically and significantly associated with lower rates of breastfeeding include African-American race, lower educational level, Special Supplemental Nutritional Program for Women, Infants, and Children (WIC) eligibility, being unmarried, and lower socioeconomic status.^6,7 An additional risk factor for choosing not to breastfeed is younger maternal age: Recently available (from 2005) data show that 51.2% of teens (<20 years of age) initiated breastfeeding, compared to 70.6% of women 20–30 years old and 78.5% of women over 30 years of age.⁵ Teen attitudes towards breastfeeding are not well described, and several studies have concluded that teen knowledge about breastfeeding is lacking.^8,9 However, the specific contribution of age to infant feeding choice in the presence of other risk factors has not been fully examined.

Subjects and Methods

Objectives

Our aims were (1) to compare the rate of intent to breastfeed between pregnant low-income inner-city teens (age ≤19 years) and non-teens (age ≥20 years), (2) to determine if age is a significant determinant of intent to breastfeed in this population after adjusting for other psychosocial characteristics, and (3) to determine if self-assessed knowledge and attitudes about breastfeeding differ between pregnant teens and non-teens. We anticipated that (1) the rate of intent to breastfeed is lower among pregnant low-income inner-city teens (age ≤19 years) than non-teens (age ≥20 years) and (2) age is a significant factor in determining feeding intention among pregnant low-income inner-city women after adjusting for other psychosocial characteristics.

Study design

A prospective cross-sectional survey was done using a structured interview.

Population

The eligible population included a convenience sample of healthy pregnant women receiving care from nurses or nurse midwives at the Women's Health Center (WHC) of MacDonald Women's Hospital, University Hospital, Cleveland, OH during the study period (June 1–July 31, 2007). Sexual activity resulting in pregnancy at age 13 years or younger mandates reporting to Children's Services, and therefore the sole study exclusion criterion was maternal age ≤14 years. The WHC serves predominantly inner-city low-income WIC-eligible African-American women on the east side of Cleveland. Nurse midwives and nurses care for approximately 80% of obstetrical patients; all high-risk pregnancies are referred to on-site physicians. In 2006, 5.2% of all deliveries at MacDonald Women's Hospital were to women under age 18 years.

Study conduct

The research team collaborated with WHC health providers to identify potential study participants, and interested eligible participants were referred by their caregivers to the researcher/interviewer (A.A.). Subjects were recruited while waiting for their appointment in the obstetrical clinic. Following the informed consent procedure, women age 18 years or older completed the questionnaire interview. Pregnant minors 15, 16, and 17 years old and their parent/legal guardian were approached for consent at their first prenatal visit and interviewed at a later scheduled obstetrical visit. Informed consent for pregnant minors required the signatures of both the minor and her parent/legal guardian, and the guardian was required only to attend the first prenatal visit per WHC policy.

Interviews were not performed at initial prenatal visits for participants of any age, both in deference to provider preference and because we thought women might not have thought seriously about infant feeding methods prior to the first prenatal visit. The questionnaire interview occurred in the privacy of the patient's exam room, and each participant was given a copy of the questionnaire. The interviewer (A.A.) read each question aloud, documenting responses: the purpose of this approach was to minimize any potential confounding due to low or varied literacy levels and to promote questionnaire completion. Each interview took approximately 15 minutes to complete. This study was approved by the University Hospitals Institutional Review Board (protocol 05-07-05).

Questionnaire for structured interview

The questionnaire (available on request) included sociodemographic information regarding factors known to be associated with breastfeeding intention and duration, including age, race, marital status, and educational level. Obstetrical information including parity, prenatal body mass index, timing of first obstetrical visit, and trimester of pregnancy at interview were also noted. Women were asked how they intended to feed their baby (breast, formula, or both), how long they planned to breastfeed if any breastfeeding was selected, and when their decision had been made in relation to the start of the pregnancy. We also asked one question regarding self-assessed knowledge and several questions about breastfeeding attitudes. These questions were divided into six conceptual domains based on the Best Start breastfeeding intervention curriculum and research on teen mothers' concerns about breastfeeding.^9–11 The content areas included knowledge about breastfeeding, abstract thinking/planning, elicited maternal concerns, influence of family and friends, perceived ability to use resources, and issues regarding body image.

Statistical analysis

Categorical variables are described with percents and frequencies, and continuous variables are described with means and SDs, or medians and ranges, as appropriate. Variable distributions were evaluated prior to analysis. Comparisons were made using Student's t test for normally distributed continuous variables and the Wilcoxon rank sum for non-normally distributed continuous variables. χ² analysis was used for nominal variables when cell sizes were adequate. In these cases the value of the test statistic, the degrees of freedom, and the p value are reported. Fisher's Exact Test was used for analyses with small expected cell sizes; in this case only p values are reported. This article reports analysis of Likert-scaled and yes/no questions.

The bivariate analyses were used to compare breastfeeding intentions between pregnant teens and non-teens and to examine the research question regarding self-assessed knowledge and attitudes about breastfeeding among teens compared to non-teens. To examine the relationship between back to work/school plans and planned duration of breastfeeding, outcomes for both variables were categorized into three matching and mutually exclusive intervals (<1 month, 1–3 months, and >3 months).

To consider the possibility that the formal definition of teenager (≤19 years) is not a socially or biologically valid age cutoff for comparison in this context, we used a receiver operating characteristic curve to examine the effect of age in years on intent to breastfeed. Multiple logistic regression analysis was then used to examine factors in addition to age that might explain intent to breastfeed versus not breastfeed. First, variables that described demographic, prenatal, and psychosocial characteristics postulated or known to affect breastfeeding intention were compared between women who intended to breastfeed and those who did not. For this analysis the variables were collapsed to logical dichotomous categories. Then, explanatory variables were selected for inclusion in the multivariate model if they were significant at the p = 0.2 level. In order to examine the possible effect of prior breastfeeding experience, we then performed the same multivariate analysis with the subsample of subjects who were multiparous. We report odds ratios and confidence intervals for these analyses.

No formal power analysis or sample size calculations were performed because of insufficient knowledge about the distribution of ages and rates of intent to breastfeed in the study population. However, given an age ratio as low as one teenager to every five adults, the teenage group would have 30 subjects, and results would be robust, as large-sample approximations of test statistics apply.

Results

Description of sample

During the study period, 186 eligible pregnant women were identified, 179 (96%) consented to participate, and 176 (95%) were interviewed, of whom 46 (26%) were teens. For three women age 18 years of age, consent was obtained at the first prenatal visit, but they could not subsequently be interviewed because they missed their next scheduled prenatal appointments and the study did not include the possibility of telephone call back. The population was predominantly African-American, unmarried, low-income, and WIC-eligible, with a median participant age of 22 years (range, 15–41 years). There were no significant differences between teens and non-teens in demographic or obstetrical characteristics with the exceptions of education level and parity (Table 1).

Table 1.

Population Description: Teens Versus Non-Teens

	Teens (n = 46)	Non-teens (n = 130)	p value (test statistic, degrees of freedom)
Demographic data
Non-Hispanic African-American	45 (98%)	122 (94%)	0.45
Not married	45 (98%)	122 (94%)	0.45
Education >high school	7 (15%)	61 (47%)	<0.01
Obstetrical factors
Primiparous	40 (87%)	49 (38%)	<0.01 (χ² = 32.98, df = 1)
In 3^rd trimester at interview	29 (63%)	81 (63%)	0.93 (χ² = 0.008, df = 1)
Prenatal care in 1^st trimester	36 (78%)	112 (86%)	0.21 (χ² = 1.58, df = 1)
Prenatal body mass index (mean ± SD, kg/m²)	26.4 ± 6.2	26.8 ± 5.6	0.34 (t = 0.96, df = 41.2)

Results reported are for Fisher's Exact Test, except those with a χ² statistic (χ² test) or a t statistic (t test) and degrees of freedom.

Comparison of teens versus non-teens

Breastfeeding intentions and planning

There were no significant differences in intent to breastfeed, planned duration or exclusivity of breastfeeding, or planned return to school or work between teens and non-teens (Table 2). Among the 66 women who intended to breastfeed and who had specified both a duration of breastfeeding and a back-to-work/school plan, there was no significant association between timing of back to work/school and planned duration of breastfeeding (p = 0.37, Fisher's Exact Test). The only difference between teens and non-teens was that significantly fewer teens had thought about infant feeding methods prior to becoming pregnant.

Table 2.

Feeding Intentions and Planning: Teens Versus Non-Teens

	Teens (n = 46)	Non-teens (n = 130)	p value (test statistic, degrees of freedom)
Feeding plans			0.83 (χ² = 0.37, df = 2)
Breastfeeding, any	29 (63%)	78 (60%)
Formula feeding	10 (22%)	27 (21%)
Not sure	7 (15%)	25 (19%)
If breastfeeding, planned exclusive	7/29 (24%)	33/60 (42%)	0.23
Feeding method decided before pregnancy	25 (54%)	94 (72%)	0.03 (χ² = 5.00, df = 1)
Planned breastfeeding’ duration			0.80
0–4 weeks	3 (10%)	3 (4%)
1–3 months	5 (17%)	15 (19%)
4–6 months	8 (28%)	24 (31%)
6–12 months	4 (14%)	11 (14%)
Not sure	9 (31%)	25 (32%)
Plan return to work/school			0.78
0–4 weeks	4 (9%)	14 (11%)
1–3 months	22 (48%)	70 (54%)
>3 months	3 (7%)	10 (8%)
Not sure/never	17 (38%)	36 (28%)

Results given are for Fisher's Exact Test, except as reported with a test statistic and degrees of freedom, which are for χ² test.

Self-assessed knowledge about breastfeeding

Participants were asked to rate their own knowledge about breastfeeding with Likert scale options of “very little,” “some,” “pretty much,” and “a lot.” Significantly more non-teens than teens felt they knew “pretty much” or “a lot” about breastfeeding (57 [44%] vs. 12 [26%], respectively; p = 0.03, χ² = 4.50, df = 1). There was no significant difference between teens and non-teens in other factors that might impact a participant's knowledge about breastfeeding, including knowing someone who has breastfed (34 [74%] vs. 106 [82%], respectively; p = 0.27, χ² = 1.21, df = 1), having been breastfed oneself (12 [26%] vs. 32 [25%], respectively; p = 0.84, χ² = 0.04, df = 1), and, among multiparas, having breastfed another baby (three of six [50%] vs. 42 of 81 [52%], respectively; p = 1.0, Fisher's Exact Test).

Influence of family, friends, and other resources

Obstetrical patients may receive information from many sources about the benefits of breastfeeding. There was no significant difference between teens and non-teens in advice sought or received from expectant grandmothers, and neither the number who had talked to the grandmother (their own mother) about breastfeeding (26 [57%] vs. 64 [49%]; p = 0.72, Fisher's Exact Test) or of those whose mother supported breastfeeding (20 of 26 [77%] vs. 52 of 64 [81%]; p = 0.77, Fisher's Exact Test) differed between groups. Regarding the father of the baby, there were no significant differences between teens and non-teens in advice sought (talked with dad about breastfeeding: 27 of 40 [59%] vs. 81 of 123 [62%], respectively; p = 0.67, χ² = 0.19, df = 1) or advice received (dad supported breastfeeding: 18 of 27 [67%] vs. 57 of 81 [70%], respectively; p = 0.71, χ² = 0.13, df = 1). Considering the prenatal obstetrical package promoting breastfeeding, WIC classes, and other resources “available to you,” there were no significant differences between teens and non-teens in their perception of resource availability, impact, or usefulness (data not shown). A majority of both teens and non-teens endorsed the statement, “the benefits of breastfeeding have been explained to me” (40 [87%] vs. 114 [88%], respectively; Fisher's Exact Test, p = 1.0).

Body and image issues

Teens compared with non-teens did not differ significantly in responses to whether breastfeeding would “change your body” (30 [65%] vs. 86 [66%], respectively, said “yes”; Fisher's Exact Test, p = 1.0), whether those changes would be considered “good” (23 of 30 [77%] vs. 71 of 86 [83%], respectively; p = 0.49, χ² = 0.50, df = 1), and whether “people will think of you differently if you breastfeed” (one [2%] vs. 15 [12%]; Fisher's Exact Test, p = 0.07). However, significantly more teens than non-teens did not consider it “okay” to breastfeed in public (22 [57%] vs. 33 [18%]; p = 0.005, χ² = 7.96, df = 1).

Demographic and psychosocial factors affecting intent to breastfeed

Examination of the effect of age on intent to breastfeed using a receiver operating characteristics revealed an area under the curve of 0.57, and thus age was not better than chance alone in predicting breastfeeding intent. The relationship of demographic and psychosocial factors to intent to breastfeed among (a) all participants and (b) among the subset who had a prior infant is presented, respectively, in Table 3A and B. Age was again not significantly related to breastfeeding plans. The result of multiple logistic regression analysis to adjust for demographic and psychosocial factors significant at the p = 0.2 level is summarized in Table 4. Among all participants, the support of the baby's father, self-assessed breastfeeding knowledge of “pretty much” or “a lot,” and being primiparous were significantly and positively associated with intent to breastfeed after adjusting for other factors. Among the subset of multiparous participants, only the support of the baby's father remained significant after adjusting for other factors. Of the 176 women interviewed, 167 (95%) described themselves as non-Hispanic African-American, and (a non-identical) 167 (95%) were not married. The numbers of both non–African-American and married participants were too small to test for the effect of these factors on feeding intentions, so we reconducted the multiple regression analysis (a) without the non–African-American women and then (b) without the married women. The direction, magnitude, and significance of the results were not different from results of the same analysis including the entire sample as presented.

Table 3.

Demographic Factors and Intent to Breastfeed: Bivariate Analysis

	All women (n = 176)			Multiparous women (n = 87)
	Intent to breastfeed (n = 107)	Intent to formula feed (n = 69)	p value (test statistic, degrees of freedom)	Intent to breastfeed (n = 48)	Intent to formula feed (n = 39)	p value (test statistic, degrees of freedom)
A. Demographic factor
Age [median (range)] (years)	22 (15-40)	23 (16–41)	0.14 (χ² = 1.47, df = 174)	23 (18–37)	25 (19–41)	0.16 (χ² = 1.40, df = 85)
African-American	100 (94%)	76 (97%)	0.49	43 (90%)	38 (97%)	0.22
Not married	102 (95%)	65 (94%)	0.74	43 (90%)	36 (92%)	0.73
Body mass index ≥25 kg/m²	58 (64%)	30 (51%)	0.12 (χ² = 2.45, df = 1)	28 (72%)	20 (61%)	0.33
>High school education	49 (46%)	19 (28%)	0.02 (χ² = 5.90, df = 1)	23 (46%)	8 (21%)	0.01 (χ² = 7.05, df = 1)
Primiparous	59 (55%)	39 (57%)	0.13 (χ² = 2.28, df = 1)	NA	NA
Prenatal care began in 1^st trimester	90 (84%)	58 (84%)	1.00	42 (88%)	30 (77%)	0.26
3^rd trimester interview	65 (61%)	45 (65%)	0.55 (χ² = 0.36, df = 1)	27 (56%)	25 (64%)	0.46 (χ² = 0.55, df = 1)
Plan to return to work or school in 2 months	46 (43%)	33 (48%)	0.54 (χ² = 0.40, df = 1)	28 (58%)	19 (49%)	0.37 (χ² = 0.80, df = 1)
B. Psychosocial factor
Know person who breastfed	87 (81%)	53 (77%)	0.47 (χ² = 0.52, df = 1)	37 (77%)	31 (79%)	1.0
Mother herself was breastfed	35 (33%)	9 (13%)	0.004	14 (29%)	4 (10%)	0.04
Mother breastfed a prior child	NA	NA		38 (79%)	7 (18%)	<0.001 (χ² = 32.29, df = 1)
Support of expectant
Maternal grandmother	54 (51%)	19 (28%)	0.03 (χ² = 9.09, df = 1)	27 (56%)	8 (21%)	<0.001 (χ² = 11.43, df = 1)
Ffather of baby	61 (57%)	14 (20%)	<0.001 (χ² = 23.13, df = 1)	30 (63%)	6 (15%)	<0.001 (χ² = 19.69, df = 1)
Good self-assessed knowledge	56 (52%)	13 (19%)	<0.001 (χ² = 19.75, df = 1)	39 (81%)	9 (23%)	<0.001 (χ² = 29.44, df = 1)
Breastfeeding benefits explained	91 (85%)	63 (91%)	0.25	44 (92%)	35 (90%)	1.0
Public breastfeeding considered OK	48 (45%)	34 (49%)	0.57 (χ² = 0.33, df = 1)	28 (58%)	22 (56%)	1.0
Expect “good” body change with breastfeeding	69 (65%)	30 (43%)	0.006 (χ² = 7.52, df = 1)	36 (75%)	21 (54%)	0.04 (χ² = 4.26, df = 1)

Data are number (%) except for age. NA, not applicable. p values are presented for Fisher's Exact Test; test statistic and degrees of freedom are also presented for χ² test.

Table 4.

Psychosocial and Demographic Factors and Intent to Breastfeed: Multiple Regression Analysis

	All women (n = 176)		Multiparous women only (n = 87)
Factor	OR, 95% CI	p value	OR, 95% CI	p value
Demographic
Age (years)	1.00, 0.91–1.11	0.95	0.99, 0.84–1.17	0.91
Body mass index ≥25 kg/m²	0.69, 0.31–1.56	0.37
>High school education	0.78, 0.33–1.82	0.56	1.35, 0.27–6.65	0.72
Primiparous	3.54, 1.29–9.70	0.01
Psychosocial
Mother was breastfed	0.66, 0.25–1.76	0.40	1.10, 0.18–6.62	0.92
Mother breastfed a prior child			0.19, 0.03–1.12	0.07
Support of expectant
Maternal grandmother	1.31, 0.55–3.13	0.55	0.89, 0.18–4.23	0.86
Father	4.00, 1.67–9.61	<0.01	13.75, 2.33–81.0	<0.01
Good knowledge	4.85, 1.83–12.83	<0.01	4.42, 0.62–31.33	0.14
Good body change	0.59, 0.26–1.36	0.21	0.59, 0.15–2.43	0.47

CI, confidence interval; OR, odds ratio.

Discussion

This study contributes a unique perspective on the health disparities issue of low breastfeeding rates among inner-city women. We interviewed pregnant inner-city low-income mainly African-American women ranging in age from 15 to 41 years, and in this homogeneous population at high risk for choosing not to breastfeed, we found no significant difference in intent to breastfeed or in planned duration or exclusivity of breastfeeding between pregnant teens and non-teens. We found that age was not a significant explanatory variable determining feeding intent. There were few significant differences in breastfeeding attitudes between teens and non-teens in this sample. Significant determinants of feeding intent included primiparity, good self-assessed knowledge about breastfeeding, and having support from the father of the baby; among multiparous women the only factor that significantly influenced feeding intent was support from the father of the baby. Studies such as this that focus specifically on low-income inner-city mothers' feeding intentions will be critical to achieving Healthy People 2010 breastfeeding goals nationally.

Most data on breastfeeding intent, initiation, and duration show an association of younger maternal with lower breastfeeding rates.^5,12–16 However, our finding that age is not a significant predictor of intent to breastfeed in a low-income, urban, predominantly African-American population confirms the findings of others.^17–21 In these studies, as in ours, multiple regression was used to identify predictors of breastfeeding intent in populations with multiple other risk factors for low breastfeeding rates, including non–Hispanic African-American ethnicity, lower educational attainment, WIC eligibility, and unmarried status. A limited number of studies with similar populations contradict this finding.^22–24 Traditionally, adolescent mothers have been considered a unique population requiring separate study and a different approach to infant feeding choice interventions.^10,25,26 However, among non–Hispanic African-American women, whose mean childbearing age is significantly younger (22.7 years) than the U.S. national mean (25.0 years), distinguishing between “adolescent” and “adult” may be less useful in public health domains related to childbearing and rearing.²⁷ In populations that are relatively homogeneous with respect to multiple risk factors for low breastfeeding rates, specifically inner-city low-income WIC-eligible African-American women, it does not appear that age is an additional predictor of feeding intent. Thus a paradigm that dichotomizes adolescents and adults does not appear to be useful for breastfeeding promotion efforts.

Using multiple logistic regression, we found that support from the father of the baby was a significant positive predictor of intent to breastfeed among primiparous women and the only significant positive predictor among multiparous women. This finding contradicts conventional wisdom, given that our sample included >95% unmarried low-income African-American women. However, previous studies with demographically similar populations have also reported that a favorable attitude of the father, his support of breastfeeding choice and greater knowledge about breastfeeding, and encouragement from the father (or grandmother) are each positively associated with maternal breastfeeding choice.^14,28–30 Studies including both heterogeneous and predominantly middle class married populations confirm that support of the father for breastfeeding is significantly and positively associated with maternal choice of breastfeeding versus formula feeding.^31–37 Factors that appear to impact the influence of the father include (1) his relationship with the mother, in that a positive relationship, being present at delivery, and living with the partner are positively associated with breastfeeding choice, and (2) his knowledge of breastfeeding, in that both a higher educational level and better knowledge predict breastfeeding choice.^{14,18,28,30,36,38,39} Limited research in the United States, Italy, and Brazil shows that prenatal breastfeeding education for fathers can significantly increase rates both of breastfeeding initiation and of exclusive breastfeeding at 6 months.^40–43 The most effective format and content for breastfeeding education for fathers in a low-income inner-city population have not yet been examined.

The few significant differences in attitudes and self-assessed knowledge between pregnant teens and non-teens identified in this study may be useful for design of breastfeeding intervention strategies. We found that teens were significantly less likely to have decided on a feeding method prior to pregnancy. Donath et al.⁴⁴ reported that maternal intention is a stronger predictor of breastfeeding initiation and duration than sociodemographic variables, which suggests that breastfeeding promotion interventions during pregnancy may be particularly relevant for the subgroup of pregnant women undecided about feeding method. Teens compared to non-teens in our study were significantly more likely to feel it is “not okay” to breastfeed in public. Other research has previously identified embarrassment related to breastfeeding in public as a specific concern of both teen and adult women, and addressing this issue is one of the “main communications strategies” of the WIC “Loving Support”™ campaign to promote breastfeeding among WIC-eligible women.^10,23,45 Good self-assessed knowledge about breastfeeding was an important predictor of feeding choice among primiparous women in this study and in demographically similar populations.^6,17,18,20 These data support inclusion of an evidence-based education component in breastfeeding promotion strategies. In this study, teens' self-assessed knowledge about breastfeeding was significantly less than that of non-teens. However, we did not directly assess the accuracy of the participants' breastfeeding knowledge, and more information is needed about the actual breastfeeding knowledge of teens and non-teens. It is also possible that self-assessed knowledge serves as a partial proxy for breastfeeding self-efficacy, which has been shown to be an important determinant of breastfeeding initiation and continuation.^46,47

Strengths of this study include a high consent and participation rate and use of a single researcher for face-to-face interviews, which ensured consistency in questionnaire administration and data collection. Our study sample was homogeneous with respect to most sociodemographic risk factors for not breastfeeding, yet included a wide age range of participants, facilitating evaluation of the effect of age on breastfeeding intent. The study also explored some less well-understood attitudes about breastfeeding, such as expectant mothers' perception of body changes associated with breastfeeding, which illuminates the similarity of many attitudes between teens and non-teens. Potential limitations of the study include social desirability bias, because questions were framed in the context of breastfeeding rather than infant feeding in general, and, finally, although we compared teens to non-teens, the population as a whole was young, with a median age of 22 years, which could limit the generalizability of the conclusions.

Conclusions

Factors that influence breastfeeding intent are important considerations in development of breastfeeding interventions, because intent is strongly related to breastfeeding initiation.⁴⁴ We found no significant difference in prenatal breastfeeding plans between pregnant low-income inner-city teens and non-teens and no significant explanatory effect of age on breastfeeding intention. It is thus possible that a unified breastfeeding intervention program for teens and non-teens could be an effective tool in efforts to increase breastfeeding rates in this high-risk population, and further study is indicated. We also found that the support of the father of the baby significantly influenced breastfeeding intent among pregnant women with sociodemographic risk factors for low rates of breastfeeding. This suggests that paternal involvement will be integral to the success of future breastfeeding interventions.

Footnotes

Acknowledgments

A.A. was supported by a Crile Fellowship from Case Western Reserve University School of Medicine.

Disclosure Statement

No competing financial interests exist.

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