Abstract
Purpose:
We aimed to understand adolescents’ and young adults’ perceptions and the extent of their knowledge about breastfeeding.
Methods:
Participants (adolescents and young adults in the United States, 14–24 years of age) were texted five open-ended questions about their perceptions of various aspects of breastfeeding including their initial reaction to breastfeeding, the impact on the infant and parent, how it compares with formula, and whether they were breastfed. The responses were analyzed for themes using an inductive content analysis approach. Responses were compared using χ2 tests to assess if knowledge and education about breastfeeding differed according to gender identity and age.
Results:
Among 1,283 participants, 829 responded (response rate = 64.4%). The average age was 18.8 (standard deviation [SD] = 2.9), with 53% female and 10% Black. Most adolescents and young adults understand there are health benefits of breastfeeding for the breastfeeding dyad (n = 589; 78.8%), yet also indicate an awareness of negative aspects (n = 256; 36.1%). Participants who identified as female or gender-variant and those who were older were more likely to refer to the emotional and bonding connections breastfeeding creates (p = 0.0011 and p = 0.0002). Males were more likely to have less knowledge about breastfeeding effects on the breastfeeding person but have more negative attitudes toward formula (p = 0.0298 and p = 0.0543). Younger respondents tended to indicate that formula was better than breast milk (p = 0.0534).
Conclusion:
We found a mix of positive and negative perceptions of breastfeeding among adolescents and young adults. Understanding how youth view breastfeeding can inform targeted education for this population that includes all genders and can begin before pregnancy.
Background
International and national health organizations recognize breastfeeding as the gold standard for infant nutrition,1–3 yet breastfeeding rates across the globe remain low.4,5 Barriers to breastfeeding that can result in early cessation include a lack of knowledge about the health benefits for the parents producing breast milk and the infant, lack of partner or family support, workplace bias, and insufficient parental leave (in the United States). 6 In addition, among higher-income countries, societal norms have shifted to a culture in which breastfeeding is shunned in public or breasts have become sexualized. 7 It is important to understand and address such cultural barriers across populations to create a more accepting society toward breastfeeding. Promoting breastfeeding has significant positive public health implications due to the health impacts and social benefits.
An unassuming population to target for breastfeeding education and related outcomes includes adolescents and young adults. Previous reports have indicated that teens commonly have misconceptions of or negative attitudes toward breastfeeding, such as it being an act only done in private.8,9 Adolescence is a critical time for health behavior education, as their values, attitudes, and beliefs around health, including reproduction and breastfeeding, are being shaped and they are now of reproductive age. Thus, intentionally engaging adolescents in education and discussion about the health benefits of breastfeeding for the infant and breastfeeding parent should inherently create societal norms and be beneficial to population health.
Encouraging and supporting breastfeeding can lead to a healthier population, lower healthcare costs, and a more sustainable future. To elicit such promotion of breastfeeding, we must understand how today’s adolescents perceive breastfeeding in an engaging format accessible to this population. In this project, we aimed to understand adolescents’ perspectives on and basic understanding of breastfeeding by collecting qualitative experiences through MyVoice, a nationwide text message survey of youth.
Methods
Study population
MyVoice is a longitudinal nationwide survey cohort that utilizes a short-message system (text message) to survey adolescents’ perspectives on policy and health topics. The details of the MyVoice protocol are described elsewhere. 10 Briefly, MyVoice recruits adolescents and young adults aged 14–24 years old to participate using targeted social media advertisements, based on age, gender, race and ethnicity, and region. Individuals were eligible to enroll if they were between the ages of 14–24 years, demonstrated English literacy, and had access to a phone with text-messaging capabilities. The study was approved by the University of Michigan Institutional Review Board with a waiver of parental consent for minors.
Upon enrollment, written consent and/or assent and demographic information were obtained online. Demographic information collected during enrollment includes self-reported age, gender, race/ethnicity, education, and U.S. region. MyVoice cohort continuously enrolls twice yearly and current participants are asked to update their demographic information once a year.
Participants are provided modest incentives for participating. At enrollment, they receive US $5 incentive for completing the demographic survey. Each week they are eligible to receive US $1 for responding to the survey questions.
The Standards for Reporting Qualitative Research reporting guidelines were followed for this study. 11 In addition, MyVoice is a member and adheres to the guidelines for survey research of the American Association for Public Opinion Research Transparency Initiative.12,13
MyVoice methods and question development
Five open-ended questions on participants’ knowledge and opinions of breastfeeding were sent to 1,283 MyVoice participants on September 6, 2019. Data collection ended on September 13, 2019. MyVoice utilizes open-ended questions to allow adolescents and young adults to share their thoughts in an unstructured way, allowing researchers to better understand their knowledge and experiences. The questions were iteratively developed with students and experts in research and adolescent health, resulting in the final language. The first question was sent at the start of the week. Once a participant answered the question, they were texted the next question, and so on. They had 1 week to complete the questions. The following were the five questions sent to students.
Hey! This week’s questions are about breastfeeding. What is the first thing that comes to mind when you think of breastfeeding? Breastfeeding includes feeding a baby from the breast or pumping breast milk in a bottle. How do you think breastfeeding impacts babies? In what ways do you think breastfeeding impacts mothers? How do you think breastfeeding compares to formula feeding? Were you breastfed as a child? How do you feel about that?
We analyzed the data for questions 1–4. Question 5 asked participants about whether or not they had been breastfed and how that made them feel. As this question focused more on their experience with breastfeeding and not their knowledge, data are not included in this article. Before analysis all response data was stripped of identifiers and merged with demographic data.
Qualitative coding
Qualitative coding methods were utilized for the deidentified responses to questions 1–4. The messages were reviewed by three authors (A.G., M.W., and C.H) using an inductive content analysis approach to qualitative analysis to develop a codebook. Utilizing these codes, three authors (A.G., M.W., and X.A.) independently coded all responses in pairs, with discrepancies resolved through discussion between all three coders.
All coding authors at the time of coding were between 17 and 26 and identified as cis-gender females. The authors had no relationship with the participants. A.G. is a doctoral student that focuses on human milk composition research, no other authors have personal attributes or experiences that may have influenced the research.
Quantitative analysis
All statistical summaries were completed using SAS, version 9.4 (SAS Institute Inc.). Quantitative coding results were summarized using descriptive statistics. To assess if knowledge and education about breastfeeding differed according to gender identity and age, responses were compared using χ2 tests between identities and groups. We were unable to compare knowledge and education about breastfeeding according to racial/ethnic groups due to small sample sizes among minority groups for which combining cell sizes may result in masking a racial/ethnic group identity. Additionally, we were unable to compare knowledge and education about breastfeeding according to education as many participants were still completing school so we do not have detailed information if the participant were actively enrolled in school or if degree progress was terminated.
Results
Participant demographics
Eight-hundred twenty-nine participants responded to at least one of the five questions (response rate = 64.6%). On average, participants were 18.84 years old (SD = 2.91). The cohort has a wide range of gender identities, participants primarily identified as female (n = 439, 53.1%) or male (n = 306, 37.0%). Almost 10% (n = 82, 9.9%) of our population identified as gender-variant, with 38 identifying as transgender, 30 identifying as non-binary, and 14 identifying as other. Sixty-four percent (n = 528, 63.9%) of the participants identified as White, 13.2% (n = 109) identified as Asian, 9.8% (n = 81) identified as Black, 9.43% (n = 78) identified as mixed-race, and 2.7% (n = 22) identified as other and wrote in the answer. Fourteen percent (n = 114, 13.8%) of the participants identified as Hispanic. Participants who identified as Hispanic primarily identified as White (n = 65/114, 57.02%), mixed race (n = 21/114, 18.4%), and other (n = 18/114, 15.8%). Additional demographics and characteristics can be found in Table 1.
Participant Demographics and Characteristics
n = 2 participants did not complete select questions. SD, standard deviation.
Question 1: First thing that comes to mind about breastfeeding
Participants’ responses when prompted about what comes to mind when they think of breastfeeding showed a wide range of perceptions about the first thing that comes to mind when they think of breastfeeding, resulting in over 20 distinct codes. Participants reported they “think of babies when they hear about breastfeeding” (n = 203/813, 25.0%), “A mother feeding her baby” (n = 177/813, 21.8%), or “my mom”/“motherhood” (n = 126/813, 15.5%). Many participants commented on public opinions of breastfeeding, mentioning they “think of the debate about whether it should be done in public” or “the formula vs breastfeeding debate” (n = 142/813, 17.5%).
Question 2: Impact of breastfeeding on babies
When participants were asked, how breastfeeding impacts babies, the majority of participants (Table 2) thought that breastfeeding “seems beneficial” or “makes them healthier” (n = 589 [216 and 371], 78.8% [28.92% and 49.67%]). More specifically, 371 participants were able to indicate knowledge of a health- or growth-promoting property of breastmilk (n = 371, 49.7%), with participants commenting that breastfeeding “can strengthen their immune system and increase a bond between mother and child with more skin to skin contact” and that “it helps with their development as breast milk contains certain nutrients that can’t be found elsewhere.” One person commented that they took a reproductive health class, which taught them about the benefits of breastfeeding including “being less likely to develop asthma and allergies.” In addition, participants were able to identify that breastfeeding “bonds them more with the mother” (n = 168, 22.5%). Some participants compared breastmilk to formula with 13.4% (n = 100) saying breastmilk is “better than formula” and 3.6% (n = 27) indicating that there was no difference, and breastfeeding “is one method out of many for feeding babies. It just depends on personal preference.”
Question 2 Responses to Breastfeeding Includes Feeding a Baby From the Breast or Pumped Breast Milk in a Bottle. How Do You Think Breastfeeding Impacts Babies?
n = 747. Percentages were calculated based on question-specific response rates. The percentages may not sum up to 100% as codes are not mutually exclusive, except “breastfeeding is good/healthy” and “breastfeeding has specific health/growth promoting property” for which answers were mutually exclusive. A p value of 0.05 was utilized to indicate a significant difference between groups from chi-square test.
A select group of participants indicated that breastfeeding health depended on the mother’s health, as “it can be beneficial as long as the mother/person providing the breast milk is eating healthy and avoiding any substance that could be harmful” (n = 24, 3.2%) and another set of participants thought that breastfeeding was unsafe or created issues (n = 11, 1.5%), these select participants commented that “most breast milk is unfortunate[ly] contaminated with trace concentrations of pesticides and other toxins” or that “babies get too addicted to breast milk and it would be bad.”
Finally, 4.7% (n = 35) of participants did not know how breastfeeding impacts babies, with some participants saying “I’m not sure, they don’t really cover women’s health in sex ed.” and “I am not a doctor. I have no opinion.” Additional representative quotes are located in Table 3.
Questions, Codes, and Sample Quotes for Questions 2–4
Impact on babies by gender identity
When we compared the responses to this question across gender identities, we found statistically significant differences in three codes, 1) breastfeeding is good/healthy (p = 0.0041), 2) breastfeeding has specific health-/growth-promoting properties (p = 0.0005), and 3) breastfeeding provides a bonding opportunity (p = 0.0143). In general, females were more likely to identify a specific health-promoting factor while gender-variant participants were more likely to just state that it was healthy. Males were least likely to remark on the bonding properties of breastfeeding.
Impact on babies by age
When evaluated based on age group, older participants were more likely to identify a breastfeeding-specific benefit (p = 0.0057) and indicate that they thought breastfeeding was better than formula (p = 0.0545).
Question 3: Impact of breastfeeding on mothers
When we asked participants, in what ways do you think breastfeeding impacts mothers, the most common response was that it promotes an emotional connection with their baby (n = 323, 45.5%), stating that breastfeeding “makes them feel closer to their baby” and “helps them feel better about raising their child” (Table 4). Some participants provided additional physical or emotional positive maternal impacts (n = 147, 20.7%), such as “it helps them lose weight after pregnancy,” “makes them feel empowered and useful,” and “you get to have more skin to skin time with the baby, and that is great for preventing postpartum depression!” However, many participants identified negative maternal impacts (n = 256, 36.1%) and commented that breastfeeding “can be tiresome and cause soreness around the nipples” and “can cause discomfort for the mother.” While only a small group of participants reported they did “not know. As I do not study the female body. I do not have an answer to this question” (n = 35, 4.9%).
Question 3 Responses to in What Ways Do You Think Breastfeeding Impacts Mothers?
n = 710. Percentages were calculated based on question-specific response rates. The percentages may not sum up to 100% as codes are not mutually exclusive. A p value of 0.05 was utilized to indicate a significant difference between groups from chi-square test.
Participants also commented on the social structure that mothers must navigate to breastfeed (n = 143, 20.1%). These individuals mentioned a lack of “adequate spots for mothers to breastfeed and there is some weird stigma around doing it in public” and that breastfeeding “is stressful to working mothers because they can’t be near their baby and they have to pump, [], it may make mothers who cannot breastfeed feel bad about themselves.”
Finally, participants commented that breastfeeding was natural, free (n = 29, 4.08%), and convenient (n = 9, 1.3%), making it “financially beneficial because you won’t have to buy formula.”
Impact on mothers by gender identity
Results compared by gender identity showed that females were more likely to highlight the emotional connection (p = 0.0011), whereas males were more likely to not know if there was an impact on mothers (p = 0.0298), and gender-variant individuals were more likely to comment on its convenience (p = 0.0289).
Impact on mothers by age
Results compared by age showed that older participants were more likely to comment on the emotional connection between mom and infant (p = 0.0002).
Question 4: Breastfeeding versus formula feeding
When we asked participants how breastfeeding compares to formula feeding, the majority of participants said that breastfeeding is better (n = 529, 74.8%) (Table 5) as it is “healthier” and “natural” while “formula is what the name says it is, meaning things put together that stimulate the milk babies need, I think breastfeeding is a more natural and safer way to ensure your baby is getting nutrients from the right things.” Although the majority of participants indicated that breastfeeding was better, many agreed that formula is an adequate substitute and that “breastfeeding is the way to go if possible but there should be no stigma on moms that choose with formula” (n = 104, 14.7%). Few participants thought that formula was unsafe or not ok (n = 38, 5.37%), stating that “formula is fake and untrustworthy.” Some participants thought formula was better (n = 14, 2.0%), as “formula feeding might be better because it has nutrients and it also has things to help babies improve their cognitive behavior.”
Question 4 Responses to How Do You Think Breastfeeding Compares to Formula Feeding?
n = 707. Percentages were calculated based on question-specific response rates. The percentages may not sum up to 100% as codes are not mutually exclusive. A p value of 0.05 was utilized to indicate a significant difference between groups from chi-square test.
Thirteen percent (n = 94, 13.3%) of participants thought “they’re pretty interchangeable” and “should be decided by the parents,” or that their decision was dependent on maternal health, “breastfeeding is better, as long as the mother is in good health and not smoking or using drugs.” About seven percent of participants (n = 46, 6.5%) were unsure as “I’m not a mom or a doctor” and “I never heard of formula feeding before.”
Finally, some participants commented on the requirements of breastfeeding and formula both in terms of physical demands on the mother (n = 48, 6.8%) and financial benefits (n = 29, 4.1%), stating that “I think they’re more or less equivalent in nutritional value, but breastfeeding puts more of a strain on the mother” and “it can be time consuming but is cheaper than formula.”
Breastfeeding versus formula feeding by gender identity
When results were compared by gender identity, participants who identified as gender-variant were more likely to comment that the formula should not be stigmatized (p < 0.0001), and males were more likely to say that the formula is not ok (p = 0.0543).
Breastfeeding versus formula feeding by age
Participants who were younger were more likely to say that the formula is better compared to participants 18 years or older (p = 0.0534).
Discussion
Through data collected via text messaging, we found a mix of perceptions on breastfeeding among adolescents. Generally, adolescents and young adults understood that there are health benefits of breastfeeding for the baby and parent, yet there was also an indication of adolescents’ awareness of stigmatization around breastfeeding. Participants who identified as female or gender-variant and those who were older were more likely to refer to emotional or bonding connections that breastfeeding creates whereas males were more likely to report less knowledge about breastfeeding effects on the breastfeeding person. Interestingly, participants who identified as male had more negative attitudes toward formula and younger respondents tended to indicate that formula was better than breast milk.
It has been previously shown that education about health topics such as nutrition, tobacco use, or physical activity has become successful in shaping adolescents’ attitudes toward and practices of such health behaviors in a positive way.14,15 The adolescent and young adult participants in our study portrayed general knowledge about breastfeeding such as the nutritional value of breast milk, protection against viral infections in babies, and health benefits of breastfeeding parents. However, there was apprehension in participants’ responses about breastfeeding regarding timeliness or effort, negative societal views, such as feeling unsafe in public, and physical tolls on the breastfeeding parent. To help promote breastfeeding as a societal norm and as being the most healthy nutritional option for infants, it is significant to shape values toward and knowledge about breastfeeding among those in the preconception life stage, as it has been established that the decision to breast or formula feed is made before pregnancy occurs.16,17 Developing interventions that cater to adolescents, such as apps or using social media across virtual platforms, could prioritize the delivery of breastfeeding education and make a greater impact on their perceptions toward breastfeeding. 18
Established literature has described the significant role that the male partners’ influence has on whether their partner initiates breastfeeding. 19 A recent scoping review found that overwhelmingly male partners’ of a breastfeeding parent felt excluded from bonding or other aspects of parenting such as general decision-making concerning the infant, whereas other outcomes suggested male partners’ perceived discomfort in public settings when their partner breastfed.20,21 Our study found that the male adolescent respondents were less likely to comment about bonding and were more likely to be unsure about the health benefits for the breastfeeding parent. Tailored education for non-breastfeeding partners related to the benefits and how they can support a breastfeeding partner such as helping with latching could potentially foster perceptions of more equal engagement and bonding experiences with the infant. 22
Breastfeeding an infant and expressing breast milk are frequently gendered from a woman’s or mother’s perspective, yet we know that those who identify as gender-variant are also capable of breastfeeding.23,24 Healthcare inequities continue to exist across transgender and gender-variant individuals. Without understanding their perspectives on, often, gendered health topics such as breastfeeding, discrimination can continue and potentially prevent numerous people from breastfeeding because they may lack appropriate support.25,26 For example, a higher proportion of our participants who identified as gender-variant compared to those who identified as male or female, indicated that breastfeeding was physically tolling, the breastfeeding parent experienced scrutiny, and that breastfeeding was time-consuming.
Limitations
In this study, we used language that encompassed only one gender, “mother,” as one participant pointed out, “I might suggest being trans-inclusive in phrasing of the questions,” for one of the text message questions, although we understand that multiple genders can breastfeed. This could have influenced responses from those respondents who identified as gender-variant. Further, follow-up questions could not be collected to clarify unclear responses, given the nature of this text-message survey. Additionally, MyVoice is a large nationwide sample, but it is not nationally representative, which may limit the generalizability of our findings.
Finally, selection bias may have played a role in the selection of participants into the MyVoice sample. MyVoice utilizes text messaging which requires participants to have access to a cellular device. 10 However, due to the ease of participation and wide variety of respondents to participate who might otherwise be left out of research, we believe this selection bias to be minimal.
Conclusion
Understanding how adolescents and young adults view breastfeeding is important in order to develop appropriate and targeted education for this population dependent on age or life stage and gender identity. Youth who understand and value breastfeeding can lead to a healthier population, lower healthcare costs, and create a more sustainable future.
Footnotes
Acknowledgments
The authors would like to acknowledge the MyVoice participants for their continued participation and candor in sharing their knowledge and perspectives.
Authors’ Contributions
A.G., M.W., X.A., and C.H. contributed to the data analysis. A.G., M.W., and O.S. contributed to the article drafting. A.G., M.W., T.C., and O.S. contributed to the study’s conception and design. All authors reviewed and approved the final article for submission.
Disclosure Statement
The authors of this study have no conflicts of interest to report.
Funding Information
This research was funded by the Michigan Institute for Clinical & Health Research and the University of Michigan Department of Family Medicine. Funders had no part in the study design, data collection, analyses, interpretation of findings, or the decision to submit the article for publication.