Breastfeeding intentions and practice

“I was learning in the classes that it’s better milk. They have more – they have less ear infections, um, less breathing problems, you know? More healthy, more routine and stuff like that . . . I think it’s an excellent thing because the child has better qualities.” (Teen 2).

“I wanted to do it just because, like they say, it makes them not get as sick as much, infections and all that. And he’ll be smarter. Just healthier, I guess. So, I didn’t have to have my period. And because they say you lose your weight faster.” (Teen 5).

Teen 4 breastfed for a different set of reasons starting with a strong determination that stemmed from her opposition to formula: “I don’t want to go to formula. I don’t want my baby to even know what formula is…I don’t even want to be in the state’s system. The only thing I want to be in the state system for is Medicaid . . . because I can’t pay for Medicaid . . . My main reason [for breastfeeding] was less money I had to spend. Like I said, I don’t have the funds to get formula milk . . . Two, my mom did it . . . And then I’ve always heard from the TPMP, ‘breastfeed, breastfeed, breastfeed, breastfeed, breastfeed, breastfeed, breastfeed.”’ Her other reasons include financial constraints, her need for financial independence, her mother’s positive breastfeeding experience, and the encouragement of the TPMP.

All five teens who intended to breastfeed did initiate; however duration was shorter than might be expected from their prenatal intentions with only one exception (Teen 4) (see Table1). Milk expression by pumping was an integral part of their breastfeeding practices and extended the duration of human milk feeding. Four of the five breastfed for similarly short durations; these four mothers collectively fed at the breast for 9 days. The addition of pumping to breastfeeding or pumping exclusively extended the provision of human milk to 109 days. Teen 4, in contrast, continued to breastfeed at 6 months at the time we conducted her follow-up interview; she exclusively breastfed until she started offering solid food at about 5 months.

Mixed breastfeeding messages and support

All of the teens had adults in their lives who were supportive of their breastfeeding. Two (Teens 1 and 4) had mothers who had breastfed; the mother of Teen 1 was breastfeeding her own baby at the time of the study. This same teen indicated at follow up that she received support from the nurse at school, a doctor and staff of the WIC (Women, Infants and Children) program at the health department. Teen 3 was told by the school counselor (at baseline) that she would help the teen to pump at lunch and she could “leave class—my last class 5 minutes early before the buses get here, to pump”. Teens 3 and 5 indicated that “everybody” wants them to breastfeed because it is best for the baby. Teen 4’s mother had breastfed and she brought the baby to campus so the teen could breastfeed during the day: “I was away from the baby for a week [for college]. And they had programs back-to-back so I wasn’t able to go home. My mom was coming to [campus], getting the breast milk I was pumping, and taking it home. At that time I only had a hand pumpa. . . so while pumping the other one is leaking. . .So my mom would come . . . and I’d feed her . . . I give [my mom] the milk I have.”

The teens noted that their friends offered more negative views of breastfeeding. Teen 1 for example reported that she received only negative comments from her friend: “Some people told me, like my friend at school, “Why you breastfeeding, your, you know, it will get uglier.” [Interviewer: How do you feel about what they said?]. “I don’t feel bad at all. But what they say is still opinion, you know. But I don’t think that way. Teen 2 indicated at baseline that she had not told her boyfriend she planned to breastfeed and Teen 4 reported that her boyfriend told her that “breastfeeding is not for the baby – I mean breasts are not for the baby. But for. . . [pause ][Interviewer: He’s thinking sexual?] “Yes. But he says it’s cheaper too .” The latter was a key reason why Teen 4 breastfed, as previously mentioned.

Teen 4 learned a different message from the infant feeding experiences of those around her: “I don’t want to go to formula. I don’t want my baby to even know what formula is. . . Friends I’ve had – like a friend I’ve lived with she had a baby not too long ago. And her baby was going to the hospital every other week, and were like ‘What is wrong with her’. And she’s like ‘Oh, it’s her formula is breaking her out. Oh her formula is messing up her stomach’. She had to change her formula so many times.” This teen also received good support from her mother who brought her baby to campus during the day so she could breastfeed.

Poor breastfeeding knowledge and skills

Although all the teens in the study had received basic breastfeeding education as part of their childbirth class, they started their breastfeeding journey with little knowledge about the challenges of breastfeeding and without the skills needed to sustain it. While many of the teens indicated having “support” for their decision to breastfeed, this support was not accompanied by knowledge that could help them breastfeed or solve problems they encountered. Except for the two teens whose mothers had breastfed, the teens themselves and those in their social networks appeared to be uninformed about how to breastfeed. Unfortunately, these young women “don’t know what they don’t know.” When asked at follow-up interviews about information that they wished that they had known about breastfeeding, three of the four teens who had multiple problems stated they knew what they needed to know about breastfeeding. Mostly, they seemed to recall information about the different positions they could use, but they did not have the knowledge or skills needed to be clear about things that were going wrong or actions that they could do differently to solve breastfeeding problems: “I know what positions I should put him in. Well, the best position is the football position. And that’s all I needed to know. And like how to, uh, how to store my milk and stuff like that” (Teen 2). Teen 3 indicated at follow-up that she wished she had known more about the difficulties of breastfeeding and had more information about how to continue breastfeeding without stopping out of frustration. She stated that she would like for others to know “It’s not going to always work the first time. You have to keep going and keep going for it to get easier. It’s going to get harder before it gets easier I should say” .

Teen 4, in contrast, received good advice from her mother who breastfed, as exemplified in this quotation: “She taught me how to cover my breast to cover up the right way. Because I used to have all this showing. . . Which is really good. Because. . .there was one time I was on a city bus, and I had to feed her. And I was trying to hold off. I was like, “Come on. Come on. We have 15 minutes.” And I knew I couldn’t wait 15 minutes, but I was trying. . . And the people started looking at me. I was like, “You know what?” And people, just some old women who were riding, “Oh, it’s so cute.” You know, other people were like, (laughing). I was like making sure I was covered, so.”

Teen 4 was the only mother in the study to breastfeed long enough to perceive any benefits of breastfeeding. At follow-up she described her belief that breast milk stimulated the baby’s development: “Right now the baby’s smart. She’s growing, too. She knows to turn to sound. Even though you’re supposed to be doing it now anyway. She was doing it a month before she was supposed to. Like most babies I know, they couldn’t push off their feet at four months. But they weren’t trying to scoot at four months, they don’t start to six months. She’s trying to stand up on her own. Her arms need to get a little stronger. . . Her legs are strong enough. And I’m like if I had done formula like the rest of them, my baby wouldn’t even walk. . . The two-year-old I was telling you about, she didn’t walk until her first [birthday]. . . And those examples, it was like, OK, yeah, I’m breastfeeding. Both of them did formula.”

Uncontrollable and unpleasant physical experience with breastfeeding

Perhaps in part because of their own and other’s lack of knowledge and skill, breastfeeding was more complicated than they either expected or could manage, and they quickly felt overwhelmed and out of control. Their stories indicated that they could not tell when they were getting into trouble with breastfeeding and did not have anyone who could help them problem-solve. In these situations they lacked the confidence and skills needed to take control over their own breastfeeding practice. Instead, they let the baby or their breasts control the feeding practice. The result was that the breastfeeding experience for four of the five young mothers was very physical and unpleasant. Unfortunately problems common to many women, such as pain and leaking, and their poor ability to manage them, created significant challenges for many of the mothers and contributed to their unpleasant experiences. Teen 1 breastfed for 1 week, but she stopped because she did not like “putting the baby to the breast. . . it feels funny, it tickles.” She did continue to exclusively pump until she went back to school, when she added formula to her pumping practice. The teen indicated that she did this because “Sometimes I have to get all wet and have to cover up so people don’t see. That’s a problem.” Teen 2 stated ‘When new milk comes it hurt, really bad. . . That’s like where they couldn’t do nothing about that. Because if I put ice or cold water, it would dry up the milk, then he won’t have no milk. So that’s why I couldn’t do it.” She decided to quit because her “breasts felt like hard rocks,” and “Breast milk is better than formula milk, but I had to stop.” After Teen 5 introduced formula (week 1) she experienced new problems with latching, which resulted in her pumping and mixing formula to feed the baby: “He wouldn’t latch on. So, I just pumped and mixed it” (continued pumping until day 28). Teen 3 experienced numerous problems during her short breastfeeding experience.

“I did breastfeed for like the first week, but she was – like I don’t know exactly what it was. She was kind of small, and like I just woke up, and I was just really big overnight. So, you know what I’m saying, I guess it kind of intimidated her. Because the day before like when I was in the hospital Thursday, which at the size where she could latch on—and be comfortable. But then when I woke up Friday and I tried. [Then my milk came in] and, it was just really big, and I was leaking, and like she would latch on. And, then, I guess it would come out too fast because she’s not used to that or something that she will pull away. And, then, she would latch on, pull away, latch on, pull away. And it got to the point where my skin was peeling off. It was just really painful . . . then I tried to give her formula during the night, and then breastfeed her during the day because with the breast milk she would wake up more often, because it’s not as heavy as the formula. So, she would get hungry faster. And I just got used to giving her formula, because it’s a lot easier. You just heat it up and give it to her. And, then, with me breastfeeding it was a lot harder anyway because I would have to pump in between . . . Because I was so full I would have to pump to relieve because they would be so hard and full. And I was leaking a lot . . . Just I couldn’t leave, like go nowhere, because I would have to feed her. . . So, I just like got in the habit of giving her formula.”

In contrast to the other teens, Teen 4 did not report an unpleasant experience and was able to exercise more control over her breastfeeding practice. She was able to sustain breastfeeding even when the baby was sick or ate poorly, and when she had sore nipples. She stated during the infant feeding tracking that although she did have sore nipples, this pain was not enough to cause her to quit breastfeeding. Her mother helped her with this by suggesting she use beeswax as a home remedy for sore nipples.

Inadequate health care response

The teens’ lack of knowledge about infant development and care as well as breastfeeding, increased their reliance on others, including health care providers. Unfortunately, the health care system was less than helpful. Despite the teens’ intentions to breastfeed, health care providers made statements and acted in a manner that led two of the teens to believe that formula was better for their babies. Teen 2 returned to the hospital at four days postpartum because she had high blood pressure. At that time the nurse advised her to give the baby formula because he “wasn’t getting enough, he was crying because he was hungry”; her story indicated that she might have had difficulty breastfeeding because she was engorged.

Teen 5 was also encouraged by health care providers to introduce formula. During the weekly tracking conversations, Teen 5 stated that she did not have any major problems, although she also stated “If crying a lot, I put him to my boob and he falls asleep.” Her baby’s weight dropped from 7 lbs 7 oz [3.37 kg] to 6 lbs 1 oz [2.75 kg] before a nurse initiated formula use during a home visit (probably three days postpartum). During her follow-up interview she stated: “I didn’t know I wasn’t giving him enough milk because he wasn’t like he was getting any bigger. Like he only grew like two ounces since he left the hospital. When [the nurse] came to my house to do the little check-up she weighed him. And she was like, “Let’s just try to see if he gets any bigger just doing one bottle.” And she fed him a bottle, and he gained two ounces just like that. So, I didn’t ask nobody. I thought it was OK. But she was like, “It’s just best to put him on the bottle.”

After the nurse introduced the formula, she experienced new problems with latching, which resulted in her pumping and mixing formula to feed the baby: “He wouldn’t latch on. So, I just pumped and mixed it”.

Breastfeeding cessation

The reasons the teens offered for why they stopped breastfeeding and/or pumping followed rationally from their experience of unpleasant and/or uncontrollable breastfeeding and health care recommendations to incorporate formula (see Table1).

Hopes and expectations

Navigating multiple roles

The teens’ new maternal role was complicated by their other important roles as students, employed workers, and daughters. Teen 4 describes the challenges she faced integrating motherhood with being a college freshman and the tradeoffs she had to make trying to “juggle” her multiple roles “I’m sitting here thinking, like if I was such a bad parent [as family members often tell her] I wouldn’t come out here [back home] every day even when I wanted to do program at my school. Because my college has a lot of things you can do. They always have a program going on. Now, I say, I really want to go there. But I sacrifice not going, because I know I have a baby. So, instead of staying at school, I come home every day even though sometimes I don’t want to.”

Others also found combining motherhood with high school, employment and/or family obligations challenging:

“When I go back to school and I’m still breastfeeding it’s going to be hard also, because I’m still be producing milk, but I can’t relieve it how – like how I normally do. Because, then, I would have to pump during lunch. But I don’t think I could go for that long.” (Teen 3)

It’s been 2 months since I had my baby. Now I work at least about 50-something, 40-something hours at my job. I still hang with my friends and stuff, and I spend a lot of time with my boyfriend. He helps with the baby a very lot. I put him in daycare this week. My mom keeps him when I go to work. Together at home, we just like just sit up and watch TV. I’ll play with him. And like he’ll want a bottle or something, and I’ll feed him, and he’ll sleep like half the day, and half the day he’ll be up.” (Teen 2)

Youth and dependency

Four of the five teens in the study were living with their parents, and other family members, on whom they still depended. Their dependent status both complicates and eases their abilities to navigate their multiple roles since they have few financial or other resources and are typically dependent upon others for transportation, sustenance, and support. Such dependency increases the salience of the opinions and expectations of their extended family. For example, Teen 4’s mother banished her from the house when she was pregnant, but later provided her with extensive support, without which the teen would not have been able to breastfeed or manage college life. The others also relied heavily on their immediate and extended family members to care for their babies as well as provide economically for both mother and baby. Teen 3, whose mother had recently had a baby expressed it this way: “It’s kind of a pro and a con . . . It’s a pro because she can help me and I can help her . . . But it’s a con because it’s like two babies”. Both her grandmother and her boyfriends’ aunt helped care for the baby while she was in school. The teens also received financial support from the family networks: “And like financially, um, my boyfriend, my mother, and his mother buy stuff.” (Teen 2).

Dependency based on youth had its downside however. Teen 5 was very frustrated with not having a car and having to rely on everyone all the time:

“Everybody is supportive, spending time with us and taking us where we got to go. Because I don’t have a car. I don’t got a job. So, I rely on somebody all the time. . . It’s a struggle having to rely on everybody for everything. I want him in daycare so I can get a car and a job so I can do it on my own and not have to rely on everybody else. But I just love being a mom. Just brighten my world. It changed a lot, but it was for the better.”

“ If I want to go somewhere and I don’t want to bring him, that’s a struggle I have. . . I have a baby now. I’ve got to bring him or I’ve got to stay at home and can’t go anywhere.” (Teen 2).

Teen 4 struggled with her mother over the teen’s opposition to taking the legal steps necessary to receive child support. The teen’s mother wanted her to do this because they were struggling financially. The teen however did not want to do this because it would increase her dependency on the state, the baby’s father, and his father; this dependency would strain an already troubled and difficult relationship.