Infant Feeding and Contraceptive Practices Among Adolescents with a High Teen Pregnancy Rate: A 3-Year Retrospective Study

Abstract

Background:

Adolescents consistently demonstrate the lowest rates of breastfeeding among women of reproductive age despite well-documented benefits of breastfeeding. In Amarillo, Texas, a medium-sized community with a perennially high teen pregnancy rate, we sought (1) to determine breastfeedings practices among adolescent females immediately after delivery and again at 6 weeks and (2) to identify contraceptive choices among the same teen population.

Methods:

This was a retrospective chart review focused on adolescents between the ages of 13 and 18 coming to a university-based obstetrical service between January 1, 2006, and December 31, 2008. Data on breastfeeding and contraceptive practices were analyzed.

Results:

Five hundred forty-three cases were analyzed. At hospital discharge, 59.3% initiated breastfeeding, but this dropped to 22.2% at the 6-week postpartum appointment. Over 27% of all study subjects failed to appear for postpartum evaluation. Multiparity was the only outcome variable associated with failure to initiate breastfeeding. Depot-medroxyprogesterone acetate, the levonorgestrel intrauterine device (IUD), and combination oral contraceptives were the most popular contraceptive choices, but 16% elected to forego any form of contraception at the postpartum visit.

Conclusions:

Adolescent women living in an area of Texas with a high teen pregnancy rate reported relatively low breastfeeding rates immediately postpartum, with a >50% decrease in breastfeeding in any form by 6 weeks postpartum. A substantial number failed to initiate any form of contraception at the postpartum visit. These findings support the critical need for additional breastfeeding support and contraceptive education in this at-risk adolescent population.

Introduction

Human breast milk is recognized as the superior method of infant feeding and is endorsed by the American College of Obstetricians and Gynecologists (ACOG)¹ and the American Academy of Pediatrics (AAP).² The AAP recommends that women breastfeed for 1 year.² The benefits of breastfeeding for the infant and the mother are well established, with important public health implications for maternal-child health and fertility control.²

Despite the advantages of breastfeeding, adolescents consistently demonstate low levels of initiation and continuation compared with older parturients.³ In one large population survey, the breastfeeding initiation rate among adolescents was 50% compared with 68% for women aged 20–29 and 78% in women >30 years. Only 15% of adolescents continued to breastfeed at 6 months postpartum and only 5% at 1 year.³ When analyzing the regional data from the Ross Laboratory Mothers Survey, Ryan et al.⁴ reported a lower rate of breastfeeding among women in the southern region of the United States compared with other regions, especially those <20 years of age.

For many years, Amarillo, Texas, has recorded the highest teen birth rate in Texas, with an average of 157 teen births per 1000 females aged 15–17 in Potter County and 39 teen births per 1000 in Randall County in 2005.⁵ Amarillo straddles Potter and Randall counties, but Randall county has a higher socioecomic profile than Potter County. The state of Texas averaged 35.3 births per 1000 women aged 15–17 in 2005, whereas the national average was 21.4.⁵ The objective of this study was to determine the frequency of breastfeeding among teens after delivery and at 6 weeks postpartum in this at-risk community. In addition, contraceptive preferences among adolescents at discharge and at 6 weeks postpartum were determined. These data will better define the scope of the problem in the region and assist in developing specific interventions.

Materials and Methods

A retrospective review was undertaken analyzing clinic charts from adolescents between the ages of 13 and 18 who received obstetrical care at Texas Tech University Health Sciences Center Department of Obstetrics and Gynecology in Amarillo between January 1, 2006, and December 31, 2008. Historically, Texas Tech supervises care for most adolescent pregnancies in the Amarillo area. Approval was obtained from the Texas Tech University Health Sciences Center at Amarillo Institutional Review Board.

Data were collected from each chart and entered into a Microsoft Excel spreadsheet. Maternal age, gestational age at delivery, gravidity and parity, mode of delivery, method of infant feeding at discharge and at the 6 week postpartum visit, and contraceptive method desired at hospital discharge and at the 6-week postpartum visit were recorded. Detailed discharge data are recorded in the patient chart on a standardized form, and postpartum data were taken from the clinic medical record. Method of infant feeding was recorded based on whether the mother was breastfeeding, formula feeding, or using a combination of the two. Subjects who were breastfeeding exclusively as well as those breastfeeding and supplementing formula were categorized as breastfeeding. Contraceptive preference at discharge from the hospital was recorded based on a stated preference, or in some cases, a patient was given an injection of depo-medroxyprogesterone acetate before discharge. At the postpartum visit, contraceptive methods were recorded based on written prescription, insertion of intrauterine device (IUD) or etonogestrel implant, administration of depot-medroxyprogesterone acetate, or stated intention to use condoms, abstinence, or no contraception. Patients were routinely counseled on contraceptive options in the hospital and at the postpartum visit, including a discussion of side effects, risks, benefits, and failure rates.

Before data analysis, teen subjects with the following conditions known to adversely impact breastfeeding in older (nonadolescent) women were excluded from further study: (1) preterm delivery before 37 weeks' gestation, (2) positive screen for drugs of abuse or admitted alcohol consumption or illicit drug use during pregnancy, (3) HIV-positive status, (4) active tuberculosis, (5) newborn galactosemia, (5) planned adoption placement, or (6) use of pharmaceutical medications^6,7 that could be considered deleterious to the breastfeeding infant.

Statistical analysis

Relative frequencies of the recorded outcomes were calculated and expressed as percentages. Pearson's chi-square was applied to test the associations between the categorical variables and breastfeeding outcomes, and odds ratios (OR) were calculated, with 95% confidence intervals (CI). To meet assumptions necessary for chi-square analysis, women between the ages of 13 and 15 were combined into a single group. Statistical significance was assumed when p < 0.05. MedCalc 10.1 Statistical Software (Mariakerke, Belgium) was used for statistical analysis.

Results

Data from 543 consecutive subjects were analyzed; 5 subjects were excluded from the final analysis: 3 because of established substance abuse, 1 who placed the baby for adoption, and 1 with an intrauterine fetal demise. No patient was excluded because of the presence of infectious diseases, neonatal galactosemia, or use of medications that would contraindicate breastfeeding. The distribution of ages represented in this study was skewed to the older patient range.

At hospital discharge, 59.3% of teen mothers reported partial or exclusive breastfeeding, and 40.7% were formula feeding only (Table 1). There was no statistically significant difference regarding breastfeeding initiation rate and maternal age, gestational age at delivery, or mode of delivery. In contrast, maternal parity was significantly associated with decreased likelihood of breastfeeding initiation. Primiparous adolescent women were more likely to initiate breastfeeding compared to their multiparous counterparts (63.0 vs. 43.0%, OR 2.25, 95% CI 1.28-3.98, p = 0.005). There was a statistically significant decrease in breastfeeding between hospital discharge and the postpartum visit (59.3% vs. 22.2%, OR 0.20, 95% CI 0.15-0.26, p < 0.001).

Table 1.

Breastfeeding Practices Based on Recorded Outcomes

Characteristic	n	Formula only (%)	Breastfeeding ^a (%)	Odds ratio (95% CI)	p
Age, years					0.94
13–15	41	39.1	60.9
16	106	38.7	61.3
17	168	42.3	57.7
18	228	40.8	59.2
Delivery method
Cesarean-section	97	33.0	67.0	1
Vaginal	446	42.4	57.6	0.67 (0.42-1.06)	0.11
Gestational age, weeks
39+	204	45.1	54.9	1
37–39	339	38.1	61.9	1.34 (0.94-1.90)	0.13
Parity
≥2	100	57.0	43.0	1
1	443	37.0	63.0	2.25 (1.28-3.98)	0.005
Feeding preference
Hospital discharge	543	40.7	59.3	1
6 weeks postpartum	400	77.7	22.3	0.20 (0.15-0.26)	<0.001

Breastfeeding includes those who partially or exclusively breastfed.

CI, confidence interval.

Although postpartum follow up was not examined as a primary outcome measure, it is of interest to note that 27.7% of teen mothers did not appear for postpartum care. When categorized by parity, 26.1% of primiparous adolescents and 34.3% of multiparous adolescents failed to return for postpartum care, but this did not achieve statistical significance (p = 0.12).

Contraceptive preferences were also analyzed (Table 2). In both groups, medroxyprogesterone acetate in depot form was the most common type of contraception in both lactating and bottle-feeding mothers. A total of 9.0% of those breastfeeding and 6.7% who chose to formula feed desired no contraception at the 6-week postpartum visit. We could not consistently ascertain the exact reason for the decision not to use any contraceptive method at retrospective chart review.

Table 2.

Contraceptive Choices for Breastfeeding and Formula-Feeding Adolescents at 6 Weeks Postpartum

Contraceptive	Breastfeeding (%)	Formula feeding (%)
Depo-medroxyprogesterone acetate injection	30.3	28.3
Levonorgestrel IUS	22.5	19.6
Oral contraceptives	20.2	27.7
Copper IUD	10.1	9.3
Abstinence	2.2	1.6
Etonogestrel implant	4.5	1.9
Condom	0	1.3
Contraceptive patch	0	2.3
Contraceptive vaginal ring	1.1	1.3
Diaphragm or contraceptive sponge	0	0
No contraception	9.0	6.7

IUD, intrauterine device.

Discussion

Among women of all ages, adolescents have the lowest rates of breastfeeding and higher rates of discontinuation of breastfeeding within the first year.⁸ Regional variations also play a considerable role in breastfeeding initiation and duration. In a study published in 2002, 48.8% of women <20 years of age living in the southern United States initiated breastfeeding while in the hospital; however, only 13.4% continued to breastfeed at 6 months.⁴ Our results were similar, albeit our subjects were followed for only 6 weeks after delivery.

The AAP recommends women breastfeed for a period of 1 year after delivery.² Breastfed infants have fewer episodes of upper respiratory infections, otitis media, urinary tract infections, bacteremia, bacterial meningitis, and necrotizing enterocolitis. Also, recent limited data suggest that breastfed infants may have a decreased incidence of diabetes mellitus, asthma, and leukemia in later life.^2,9 Maternal benefits of breastfeeding include decreased postpartum blood loss, increased caloric consumption during the puerperium, and accelerated return to prepregnancy weight.^1,9 Current literature also suggests breastfeeding may decrease the risk of premenopausal breast cancer, ovarian cancer, diabetes mellitus type 2, and cardiovascular disease.^1,9 Finally, breastfeeding affords a natural contraceptive advantage by delaying return of ovulation via the inhibitory effects of prolactin on gonadotropin-releasing hormone pulsatility.¹

Many barriers exist for teenagers who opt to breastfeed, most notably unease with the act of breastfeeding and inadequate knowledge of breastfeeding fundamentals.^10

–14 Maehr et al.¹⁵ determined that adolescents were less likely than adults to decide to breastfeed before delivery. Compared with their older counterparts, adolescent mothers are more likely to stop breastfeeding within the first month for a variety of reasons, including sore nipples, inadequate milk supply, and the perception that the newborn was not receiving enough breast milk.^15,16

Considerable evidence suggests that healthcare providers may have an impact on the number of women who initiate and continue breastfeeding.^17

–20 Greenwood and Littlejohn²¹ found a beneficial effect on breastfeeding rates in women age 25 enrolled in a structured community program offering counseling and support. In that study, 82.8% of women initiated breastfeeding after delivery compared with our study, where only 59% initiated breastfeeding. Another study demonstrated a positive effect on attitude and future preferences of high school girls after a 60-minute presentation on breastfeeding.²² Taken together, these investigations suggest that education can improve breastfeeding rates among adolescents.

Contraceptive decisions by adolescents are an important aspect of postpartum education and care as well. Lemay et al.²³ showed 20% of women aged 15–19 had a repeat pregnancy within 12 months. In our study, 18% of the subjects were multiparous. In addition, 27% of adolescents failed to appear at their assigned 6-week postpartum appointment. Of those who did return in 6 weeks, 16% chose no contraception. Postpartum teens represent a unique population that differs from all other teens in their contraceptive preference.

In 2007, the National Campaign to Prevent Teen and Unplanned Pregnancy reported that 35% of high school teens were sexually active (engaging in sexual activity within the past 3 months), and 15% reported having had four or more sexual partners.²⁴ The most common form of contraceptive used by teens was condoms, followed by oral contraceptives.²⁴ Less commonly reported contraceptive methods included withdrawal, depot-medroxyprogesterone acetate, rhythm method, and emergency contraception.²⁴ In our study of postpartum teens, about 30% chose depo-medroxyprogesterone acetate, and another 30% chose IUDs. Only a minority of the teens chose condoms. These findings suggests that contraceptive choices differ between postpartum teens and a general population of adolescent women.

In a study conducted by Lemay et al.²³ at the University of Massachusetts, adolescent girls who were at least 1 year postpartum were questioned about contraception choices before and after pregnancy. Reasons for not using contraception before pregnancy included a stated intention to remain abstinent, denial about the possibility of becoming pregnant, and a desire to become pregnant. Barriers to obtaining contraception included lack of parental or partner support, fear about confidentiality or discussing contraception with healthcare providers, and lack of knowledge about contraceptive options. Adolescents stated facility of use, minimal side effects, knowledge about method, and effectiveness as the reasons to begin and continue a particular form of contraception.²³

According to the findings of our study, postpartum teens appear to choose longer-acting and more reliable contraception compared with adolescents in general.²⁴ Perhaps by improving postpartum follow-up and encouraging increased use of longer-acting contraceptive options, such as injectible contraception, the IUD, or the etonogestrel implant, the rate of recurrent teen pregnancy can be reduced. Emphasizing the risk of pregnancy with unprotected intercourse and the consequences of teen pregnancy is a critical need. Providing a relaxing, confidential atmosphere to discuss contraceptive issues is important. Also, parental and partner support has been shown to increase compliance with the chosen contraceptive method.²⁵

Breastfeeding, as previously mentioned, has a multitude of benefits for both the mother and infant. One of the benefits is delay in the return of ovulation.¹ Women who breastfeed experience longer interpregnancy intervals than do women who formula feed.²⁶ Encouraging breastfeeding among adolescents through improved education and support both before and after delivery could decrease the rate of recurrent teen pregnancy in addition to the many other benefits.

A limitation of this study is the high rate of adolescents (nearly 28%) who failed to follow up at the 6-week postpartum visit, and this may have skewed the reported percentage of breastfeeding mothers at 6 weeks postpartum. By encouraging adolescents to follow up at the postpartum visit, emphasizing the risk of recurrent pregnancy, and the need for adequate contraception, it is likely that the rate of recurrent teen pregnancy could be reduced. Only 3 subjects (0.5%) were excluded from the analysis because of substance abuse, a lower rate than predicted by studies on substance abuse in adolescents. Substance use or abuse among adolescents varied from 1% to 6% for methamphetamines, cocaine, heroin, and hallucinogens to 25% for marijuana; 63% admit alcohol use.²⁷ The low number of subjects excluded for substance abuse in this study likely represents patient denial. That Texas Tech University cares for the overwhelming majority of teen pregnancies in the local community we consider a strength of the investigation.

The goal of the Healthy People 2010 ³ is to increase the number of mothers initiating breastfeeding while in the hospital to 75% and the number who continue breastfeeding at 6 months to 50%. Increasing the breastfeeding rate in adolescents has numerous benefits, yet many barriers remain to effective implementation. Encouraging clinic follow-up after delivery and counseling patients on the need for contraception postpartum is likely to decrease the rate of recurrent adolescent pregnancies. Finally, healthcare providers must address sexual education and reproductive health specifically designed for adolescent patients.

Footnotes

Disclosure Statement

The authors have no conflicts of interest to report.

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