Factors Associated with Breastfeeding Initiation and Exclusive Breastfeeding Rates in Turkish Adolescent Mothers

Abstract

Objective:

This study aimed to determine the early initiation time of breastfeeding and exclusive breastfeeding (EBF) rates during the first 6 months and the main factors affecting EBF practice in Turkish adolescent mothers.

Study Design and Methods:

A cross-sectional study was conducted with 200 adolescent mothers who were raising 6 to 24 month-old children. A face-to-face interview was conducted for sociodemographic characteristics, obstetric history, information about the baby, information about breastfeeding, and the factors affecting breastfeeding. We detected breastfeeding prevalence as well as its initiation time and duration.

Results:

The mean age of the patients was 17.9 ± 1.15 years. The percentage of patients who started breastfeeding within 1 hour was 45.5%. Approximately, 74% of the adolescent mothers provided breastfeeding before any type of formula as the baby's first food. Women who initiated breastfeeding earlier had planned pregnancies, educated for breastfeeding, delivered vaginally, and had boy infants. The mothers who started breastfeeding earlier fed their babies significantly more frequently at night, had longer EBF times, and had longer total breastfeeding times than the mothers who started breastfeeding later than 2 hours. Planned pregnancy, vaginal delivery, and having a boy infant were significantly associated with early breastfeeding. Age, planned pregnancy, postpartum education, frequent breastfeeding at night, and formula initiation time were predictors of EBF.

Conclusions:

Adolescent pregnants may start breastfeeding earlier when had planned pregnancy, educated and encouraged for breastfeeding from the family and medical staff. Therefore, strategies should be formed to improve breastfeeding programs.

Introduction

Adolescence is defined as the period between 10 and 19 years of age according to the World Health Organization (WHO).¹ Approximately, 15 million adolescent girls between 15 and 19 years of age give birth each year, with the majority of these in underdeveloped or developing countries, constituting roughly 10% of births worldwide.¹ Adolescent pregnancies are a major health problem that could lead to obstetric or neonatal complications. Moreover, adolescent girls account for 13% of all maternal deaths,^1,2 and neonatal mortality rates are increased in adolescent pregnancies.^1,3

Breastfeeding is one of the most important factors in reducing infant and child mortality rates. WHO recommendations suggest exclusive breastfeeding (EBF) of infants, especially during the first 6 months of life, and breastfeeding beyond this point with complementary foods for achieving optimal growth, development, and health for up to 2 years.⁴ Breastfeeding has been shown to have several benefits for both the mother and infant, including reduced postnatal mortality rates and sudden infant death syndrome; decreased infection risks for conditions such as otitis media, allergic diseases, and respiratory and gastrointestinal tract infections; lowered risk of developing infant diabetes and obesity; reduction in postpartum blood loss; lower risk of breast and ovarian cancers; and more rapid weight loss for mothers.^5–8

Since an adolescent pregnancy is considered a high-risk pregnancy, and the unique content of breast milk provides protection against numerous diseases, breastfeeding is crucial for the infants of adolescent mothers. However, breastfeeding rates among adolescents are below the recommended levels. Adolescent mothers are faced with problems in the initiation and continuation of breastfeeding during the postpartum period. Previous studies have reported lower EBF durations and higher cessation of breastfeeding before 6 months in adolescent mothers compared to adult mothers.^9,10 The lower income and educational levels, unemployment, lack of both experience and education concerning breastfeeding, and insufficient support from the spouse and family members are factors that have an impact on the lower initiation of breastfeeding and EBF among adolescent mothers.^11,12

According to the Turkey Demographic and Health Survey—2013, the adolescent age group constitutes 17.2% of the general population, and the proportion of those who have given birth in the 15- to 19-year age group is 16.2%.¹³ Thus, a further understanding of the risk factors, which reduce EBF rates, and the determinants of EBF practice among adolescent mothers is crucial for improving both the initiation and duration rates of breastfeeding in this age group.

In this study, we aimed to determine the initiation time of breastfeeding and EBF rates during the first 6 months and the main factors affecting EBF practice in Turkish adolescent mothers.

Materials and Methods

A cross-sectional study was conducted in the outpatient clinic of a tertiary hospital from July to December 2015. A total of 200 mothers who gave birth during adolescence (15–19 years of age) and were raising 6- to 24-month-old children were studied. The participating mothers volunteered for this study when they were admitted for a check-up for either their infants or themselves. Mothers were excluded if they had multiple pregnancies, preterm births (<37 weeks), gave birth at >19 years of age, had serious complications during the ante/postpartum period, had a systemic disease (liver, kidney, and thyroid diseases; chronic infections; or leukemia and other blood disorders), or had previously diagnosed depression or using antidepressants.

Babies were excluded if they had postpartum health problems, required neonatal intensive care unit (NICU) treatment or intubation, or had a serious illness (such as systemic illness or anomaly which affects breastfeeding) during the 6 months after their birth. This study was approved by the local ethics committee, and written informed consent was obtained from each participant. A face-to-face interview was conducted to complete a questionnaire that included sociodemographic characteristics (maternal age at birth, educational level, employment status of the mother and husband, family structure, total monthly income, maternal smoking, and perceived emotional and practical support from the husband, mother/father, or their friends); obstetric history (planned pregnancy or not, delivery type, place of birth, gestational week at birth, and complications during pregnancy or birth); information about the baby (birth weight, gender, NICU or intubation after birth, and diseases during the first 6 months); information about breastfeeding (initiation time of the first breastfeed, early breastfeeding, breastfeeding duration, EBF duration, breastfeeding at night, time of starting supplementary foods, and the infant's age in months when the mother stopped breastfeeding); and information about the factors affecting breastfeeding (antenatal breastfeeding course attendance, support after birth by health professionals, bottle feeding or pacifier use, and breast problems).

We recorded breastfeeding initiation times and durations of the patients. The initiation time of the first breastfeed was defined as the time at which the mother started breastfeeding after delivery. Early breastfeeding was defined when it was started within 1 hour after birth. EBF was defined as being from the date of birth if the baby was fed only breast milk with no water, formula, or liquid supplements. Complementary feeding was defined as giving formula or other liquids in addition to breastfeeding, and bottle-feeding as the only feeding with formula and no breastfeeding. The reasons for discontinuing EBF, the age at which complementary feeding was started, and the type of food added to the diet were questioned.

Statistical analyses were performed using SPSS software (Statistical Package for the Social Sciences, version 15.0; SPSS, Inc., Chicago, IL). The results are given as mean ± SD (standard deviation) or median. The incidences are presented as a number (percent). Chi-square tests were used for categorical variables. Multivariate logistic regression analysis was used to determine which factors best predicted EBF. A p value of <0.05 was considered statistically significant.

Results

The demographic properties of 200 adolescent pregnancies are given in Table 1. The mean age of the patients was 17.9 ± 1.15 years. Approximately, 80% were educated only up through primary school or were illiterate. One-third of the participants had a low socioeconomic status. All participants were primiparous and 12.5% had previously experienced one abortion. More than two-thirds (77%) took antenatal care, however, one-third of the patients (32%) had breastfeeding education. Two-thirds of the patients delivered vaginally, and 49.5% had girl and 50.5% had boy infants. The infant birth weights were above >2,500 g in 92% of the patients.

Table 1.

Distribution of Maternal Sociodemographic and Obstetric Characteristics

Characteristics	N (%)
Maternal age
<18 (≥15,<18)	70 (35)
≥18 (18–19)	130 (65)
Mother's education level
Illiterate or primary	158 (79)
High school	42 (21)
Mother's employment
Working	175 (87.5)
Nonworking	25 (12.5)
Monthly income (TL)
<1,300	69 (34.5)
1,300–2,500	88 (44)
>2,500	43 (21.5)
Family structure
Nuclear	103 (51.5)
Extended	97 (48.5)
Smoking
Yes	39 (19.5)
No	161 (80.5)
Planned pregnancy
Yes	148 (74)
No	52 (26)
Antenatal care
Yes	154 (77)
No	46 (23)
Breastfeeding education
Yes	65 (32.5)
No	135 (67.5)
Postpartum education
Yes	125 (62.5)
No	75 (37.5)
Delivery method
NSVD	133 (66.5)
C/S	67 (33.5)
Nipple problem
Yes	83 (41.5)
No	117 (58.5)
Infant sex
Girl	99 (49.5)
Boy	101 (50.5)
Infant birth weight (kg)
<2,500	16 (8)
≥2,500	184 (92)
First food
Breastmilk	148 (74)
Formula/others	52 (26)
Feeding pattern
Exclusive breastfeeding (6 m)	74 (37)
Bottle feeding	42 (21)
Complementary feeding	84 (42)
Breastfeeding initiation time
≤1 hour	91 (45.5)
>1 hour	109 (54.5)
Number of breastfeeding at night
0	38 (19)
1–3	112 (56)
>3	50 (25)

C/S, cesarean section; NSVD, normal spontaneous vaginal delivery; TL, Turkish lira.

The percentage of patients who started breastfeeding within 1 hour was 45.5%. Approximately, 74% of the adolescent mothers provided breastfeeding before any type of formula as the baby's first food. Maternal age, mother's educational level, mother's employment status, monthly income, family structure, smoking, regular antenatal care, infant weight, and nipple problems were not significantly different in early or late breastfeeding initiation. However, women who initiated breastfeeding significantly earlier had planned pregnancies, breastfeeding education, vaginal deliveries, and boy infants (Table 2). The mothers who started breastfeeding earlier fed their babies significantly more frequently at night, had longer EBF duration, and had longer breastfeeding duration times than the mothers who started breastfeeding later than 2 hours.

Table 2.

General Characteristics of Patients According to Initiation Time of the First Breastfeeding

	Breastfeeding initiation time
Characteristics	≤1 hour	>1 hour	p
Maternal age
<18 (≥15,<18)	27 (38.6)	43 (61.4)	0.149
≥18 (18–19)	64 (49.2)	68 (50.8)
Mother's education level
Illiterate or primary	68 (43)	90 (57)	0.175
High school	23 (54.8)	19 (45.2)
Mother's employment
Working	76 (43.4)	99 (56.6)	0.120
Nonworking	15 (60)	10 (40)
Monthly income (TL)
<1,300	28 (40.6)	41 (59.4)	0.232
1,300–2,500	46 (52.3)	42 (47.7)
>2,500	17 (39.5)	26 (60.5)
Family structure
Nuclear	48 (46.6)	55 (53.4)	0.292
Extended	43 (44.3)	54 (55.7)
Smoking
Yes	13 (33.3)	26 (66.7)	0.089
No	78 (48.4)	83 (51.6)
Planned pregnancy
Yes	79 (53.4)	69 (46.6)	<0.001^*
No	12 (23.1)	40 (76.9)
Antenatal care
Yes	72 (46.8)	82 (53.2)	0.515
No	19 (41.3)	27 (58.7)
Breastfeeding education
Yes	41 (63.1)	24 (36.9)	0.001^*
No	50 (37)	85 (63)
Postpartum education
Yes	65 (52)	60 (48)	0.17
No	26 (34.7)	49 (65.3)
Delivery method
NSVD	81 (60.9)	52 (39.1)	<0.001^*
C/S	10 (14.9)	57 (85.1)
Nipple problem
Yes	34 (41)	49 (59)	0.278
No	57 (48.7)	60 (51.3)
Infant sex
Girl	23 (23.2)	76 (76.8)	<0.001^*
Boy	68 (67.3)	33 (32.7)
Infant birth weight (kg)	3,226.4 ± 371.9	3,121.8 ± 455.7	0.071
Number of breastfeeding at night
0	10 (26.3)	28 (73.7)	<0.001^*
1–3	48 (42.9)	64 (57.1)
>3	33 (66)	17 (34)
Breastfeeding duration	11.45 ± 5.71	9.29 ± 5.6	0.004^*
Exclusive breastfeeding time (months)	4.62 ± 1.58	3.7 ± 1.84	0.001^*
Family support
Yes	56 (49.1)	58 (50.9)	0.236
No	35 (40.7)	51 (50.3)
Formula
Yes	48 (38.1)	78 (61.9)	0.006
No	43 (58.1)	31 (41.9)

The results are given as mean ± SD or n (%), p: chi-square test.

C/S, cesarean section; NSVD, normal spontaneous vaginal delivery.

Statistically significant.

In the logistic regression analysis, the factors affecting early breastfeeding initiation time were assessed. Planned pregnancy, vaginal delivery, and having a boy infant were significantly associated with early breastfeeding (Table 3).

Table 3.

Associated Factors of Early Breastfeeding Initiation Time, Binary Logistic Regression Analysis

		95% confidence interval
Odds ratio		Lower	Upper	Significance
Maternal age	0.967	0.655	1.428	0.867
Mother's education	1.037	0.381	2.820	0.943
Mother's occupation	3.030	0.799	11.501	0.103
Nonsmoking status	1.111	0.338	3.650	0.862
Planned pregnancy	5.373	1.673	17.255	0.005
Breastfeeding education	2.330	0.884	6.146	0.087
Vaginal delivery	48.332	13.960	167.331	<0.001
Boy baby	29.248	9.598	89.126	<0.001
Gestational week ≥37 weeks	5.984	0.944	37.927	0.058
Birth weight ≥2,500 g	0.607	0.167	2.214	0.450

The breastfeeding duration and the factors affecting the duration are assessed in Table 4. Older mothers, women who had a planned pregnancy, delivered a boy infant were educated in the postpartum period, had no nipple problems, and had family support experienced a longer duration of total breastfeeding time (p < 0.001). Moreover, when the number of breastfeeding sessions increased, when no formula was given or formula was initiated later, the breastfeeding duration times were longer.

Table 4.

Factors Associated with Breastfeeding Duration

Factors	N (%)	Breastfeeding duration	p
Maternal age
<18 (≥15,<18)	70 (35)	7.75 ± 4.6	<0.001
≥18 (18–19)	130 (65)	11.6 ± 5.8
Mother's education level
Illiterate or primary	158 (79)	10.2 ± 5.5	0.987
High school	42 (21)	10.6 ± 6.5
Mother's employment
Working	25 (12.5)	10.8 ± 5.69	0.397
Nonworking	175 (87.5)	11.3 ± 6.0
Planned pregnancy
Yes	148 (74)	11.4 ± 5.6	<0.001
No	52 (26)	7.0 ± 4.5
Postpartum education
Yes	125 (62.5)	11.8 ± 5.6	<0.001
No	75 (37.5)	7.7 ± 4.9
Delivery method
NSVD	133 (66.5)	10.3 ± 5.5	0.225
C/S	67 (33.5)	10.0 ± 6.24
Nipple problem
Yes	83 (41.5)	7.8 ± 4.4	<0.001
No	117 (58.5)	11.2 ± 5.9
Infant sex
Girl	99 (49.5)	9.4 ± 4.8	0.241
Boy	101 (50.5)	11.0 ± 6.4
Number of breastfeeding at night
0	38 (19)	5.0 ± 3.1	<0.001
1–3	112 (56)	9.4 ± 4.2
>3	50 (25)	16.0 ± 5.3
Family support
Yes	114 (57)	11.9 ± 5.4	<0.001
No	86 (43)	8.0 ± 5.4
Formula
Yes	126 (63)	7.8 ± 4.5	<0.001
No	74 (37)	14.4 ± 5.2
Formula initiation time
<3 months	64 (32)	7.3 ± 5.6	<0.001
≥3 months	136 (68)	11.6 ± 5.2

Age, planned pregnancy, postpartum education, frequent breastfeeding at night, and formula initiation time were the associated factors with EBF (Table 5).

Table 5.

Associated Factors of Exclusive Breastfeeding, Binary Logistic Regression Analysis

		95% confidence interval
Odds ratio		Lower	Upper	Significance
Maternal age	2.451	1.041	5.771	0.040
Mother's education	1.159	0.422	3.184	0.775
Mother's occupation	3.731	0.424	32.831	0.235
Planned pregnancy	2.495	1.016	6.131	0.046
Postpartum education	2.782	1.095	7.068	0.031
Vaginal delivery	1.825	0.777	4.287	0.167
Boy baby	0.615	0.260	1.454	0.268
No nipple problem	5.984	0.944	37.927	0.058
>3 breastfeeding at night	3.142	1.747	5.650	0.001
Formula initiation time ≥3 months	37.790	10.409	137.201	0.001

Discussion

This study presented the breastfeeding patterns of adolescent mothers and focused on the factors affecting the early initiation of breastfeeding. This study also reported the predicting factors on the duration of EBF. Planned pregnancy and vaginal delivery were the most important factors in the early initiation of breastfeeding. The factors affecting EBF duration were age, having a planned pregnancy, postpartum education, frequent breastfeeding, and late initiation of formula.

Adolescent pregnancy is still an important factor in women's health worldwide with regard to antenatal and postnatal complications. According to the WHO, the incidence of adolescent pregnancies is 10%,¹⁴ and in our country, it was reported as 16.2% in 2013.¹³ Since the incidence of early-age pregnancies increases yearly, greater attention should be paid to antenatal and postnatal care. Breastfeeding education and encouragement for early breastfeeding are important parts of postnatal care. The first 0.5–2 hours after birth are reported to be the most important time period for breastfeeding.^15,16 The WHO has classified the percentages of breastfeeding initiation times as poor (0–29%), fair (30–49%), good (50–89%), and very good (90–100%).¹⁷ In this study, 45.5% (fair) of the mothers were initiated in the first hour and 73.5% (good) within the first 2 hours after giving birth.

The incidence of early breastfeeding initiation within 1 hour varies in different countries, with ranges from 3.4% to 78%.^18,19 For instance, in Nepal early breastfeeding initiation was reported as 35%, in Bolivia 56%, and in Madagascar 34%.^18,19 In our study, maternal age was not important for the breastfeeding initiation time, however, older aged mothers breastfed for longer durations. In previous studies, maternal age did not affect breastfeeding initiation.^17,20 Multiparous women were reported to begin breastfeeding earlier and more exclusively than the primiparous women.^21,22 In our study, all our participants were primiparous and so we could not assess the effect of parity on breastfeeding.

The role of maternal educational levels in breastfeeding has been previously studied. Educated mothers in developed countries were reported to choose breastfeeding, however, in developing countries they switched to bottle feeding or complementary feeding.^23,24 In our study, the maternal educational level and family income had no effect on breastfeeding initiation or duration.

EBF in housewives was reported approximately two times more than in working mothers in the United Arab Emirates.²¹ However, in our study, we could not find any difference in breastfeeding initiation or duration times between working and nonworking mothers. This may be due to the fact that with the new strategies of the Health Ministry in Turkey, breastfeeding mothers can leave work earlier. This especially holds for the EBF time during the first 6 months when these break times are longer.

One of the most important factors predicting the breastfeeding initiation and continuation in our study was planned pregnancy. Compared to those with unplanned pregnancies, the incidence of women who gave birth after a planned pregnancy was higher in beginning breastfeeding within the 1-hour time frame and feeding their babies exclusively in the first 6 months. This was inconsistent with the findings by Orun who reported that planned pregnancy had no effect on breastfeeding habits. However, in their study, the participants were older than the mothers we studied. Unplanned pregnancies may also have a greater effect on younger patients.

The second important factor on initiation and duration of breastfeeding in our study was the delivery type. Similar to previous reports,^17,21,25 cesarean deliveries were an important obstacle in breastfeeding initiation times with an OR:48.3 (95% CI 13.9–167.3) in our study. However, the breastfeeding duration was not affected by the type of delivery. Adverse effects of anesthesia, maternal pain or discomfort, limited mobility, and longer separation from the baby are cited for the late breastfeeding initiation. The incidence of cesarean procedures has been recommended to be 15% in the Healthy People Goal.²² However, cesarean rates have increased in many countries, including Turkey. The incidence was reported to have increased from 37% in 2008 to 48% in 2013. In our study, we found this rate (33.5%) to be much less than the rate in Turkey. The important factor with this relatively lower cesarean rate is that it may be due to the counseling provided for vaginal delivery.

An interesting factor in this study was that women who had boy infants started breastfeeding earlier; however, the breastfeeding duration was not affected by the infant's sex. This may be due to sociocultural attitudes. Different studies from various countries have revealed different results concerning the effect of infant sex on breastfeeding. Indians have reported that Indian girls were breastfed for shorter periods than boys and they consumed less milk.²⁶ However, a study from Spain reported that the lowest percentage of EBF was found in premature boys born by cesarean section.²⁷

Mothers who took breastfeeding education or postnatal education breastfed their babies earlier and longer than those who were not educated. Postpartum education increased the EBF rate by 2.7 times. Similarly, Dias de Oliveira et al. stated that counseling sessions during the first 4 months following a birth proved to be effective in increasing EBF duration among adolescent mothers.²⁸

Infant weights did not significantly affect the breastfeeding patterns in our study. Women who had no nipple problems breastfed for significantly longer periods than did the mothers who had nipple problems, similar to a study by Radwan et al.²¹ Furthermore, mothers who were supported by their family breastfed longer than mothers who had no family support.

The frequency of breastfeeding at night significantly affected the EBF rates. Likewise, beginning formula use at a later date increased the EBF duration in our study. These findings were similar to previous studies.²¹ WHO recommends beginning complementary food after 6 months. In our study, the majority of the patients (70%) started complementary food after 6 months. The reason for some of the mothers' initiation of complementary food earlier was because of the perception that there was an insufficient quantity of mother's milk. This may be due to the mothers' poor understanding of the proper techniques to increase breast milk. Daly and Hartman²⁹ reported that maternal milk production was positively correlated with the demands of the infant. Therefore, milk production is stimulated by the frequency of breastfeeding and EBF.

The importance of this study is that antenatal and postnatal breastfeeding education was the most important predictor for the EBF duration. Planned pregnancy and vaginal delivery significantly affected an earlier initiation of breastfeeding. Moreover, an increased frequency of breastfeeding at night and the late initiation of formula significantly predicted the duration of EBF.

One limitation of the present study is that the samples were taken from a tertiary hospital and the study is the representation of adolescent mothers who delivered and were breastfeeding during the research period. Therefore, the generalizability of this study is limited. However, the hospital where the study was conducted is a large women's health center and the results were compatible with the survey reports.³⁰ A second limitation of this study was that breastfeeding patterns of the mothers were dependent on their recall ability. All the mothers may not remember well. Moreover, we did not ask how they felt when they first held the baby and if their feelings affected the breastfeeding pattern. However, we were just mainly interested in the initiation time for breastfeeding and breastfeeding duration.

In conclusion, this study reported important factors that affect the initiation and duration of breastfeeding. Different from the other studies, planned pregnancy and having boy infants were predictors of the early initiation of breastfeeding. In this study, we also determined that adolescent mothers breastfeed longer when receiving support from the family and medical staff. Similar to other studies, mothers who delivered vaginally initiated breastfeeding earlier. Therefore, decrease in cesarean deliveries, appropriate antenatal care, and postnatal education given by the medical staff will contribute to early initiation of breastfeeding. Adolescents may feel encouraged and empowered for breastfeeding and do not feel isolated when educated systemically for breastfeeding. Exclusive breastfeeding duration may be increased by giving seminars on the benefits of breast milk or increasing visits to new mothers for postnatal care.

Footnotes

Disclosure Statement

No competing financial interests exist.

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