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thesis entitled

CHARACTERISTICS ASSOCIATED WITH
INFANT FEEDING METHODS IN
ADOLESCENT MOTHERS RECEIVING WIC

presented by

Elizabeth A. Hesseltine

has been accepted towards fulfillment
of the requirements for

Master of SciencedegreeinNMLSLBg—

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MSU In An Affirmative Action/Equal Opportunity Institution
Willa-9.1

CHARACTERISTICS ASSOCIATED WITH
INFANT FEEDING METHODS IN
ADOLESCENT MOTHERS RECEIVING WIC

BY

Elizabeth A. Hesseltine

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1995

ABSTRACT
CHARACTERISTICS ASSOCIATED WITH
INFANT FEEDING METHODS IN
ADOLESCENT MOTHERS RECEIVING WIC
BY
Elizabeth A. Hesseltine

The purpose of this study was to describe and compare
demographic and behavioral variables in a sample of
adolescent women receiving WIC program assistance, who
breastfed or bottlefed their infants. This study reviewed
the WIC program records, and gathered data from a self
reported health history form. The sample consisted of 61
adolescent mothers, age 13-21 years. Records were selected
to represent equal numbers of breast and bottlefeeding
mothers. A higher mean maternal age and education level
were associated with adolescent mothers who breastfed
compared to adolescent mothers who bottlefed their infants.
Breastfeeding tended to be positively associated with a
higher income level, being married, and drinking more than
one alcohol containing drink per week, although these
associations were not statistically significant.
Implications for Advanced Practice Nurses include assessing,
educating, managing, and researching adolescent mothers and

their method of infant feeding.

This thesis is dedicated to Ed Hesseltine, who is my
husband, and my best friend. Thank-you for all your love
and support throughout my graduate school education, and the
writing of my thesis. You are the most wonderful man in the

world, and I am glad that you are in my life.

 

ACKNOWLEDGMENTS

Special thanks to Dr. Linda Beth Tiedje, Chairperson of
my thesis committee. I appreciated all of her support,
knowledge, and guidance, throughout my project. I would
like to thank Dr. Rachel Schiffman, and Dr. Claudia Holzman
for their input and guidance as my thesis committee members.
I would also like to thank the WIC staff at The Corner
Health Center in Ypsilanti, MI, for helping me with this

project.

TABLE OF CONTENTS

LIST OF TABLES . . . . . . . . . .
LIST OF FIGURES . . . . . . . . . .

INTRODUCTION . . . . .
Statement of the Problem . .
Study Purpose . . . . . . .
Research Question . . . . .

REVIEW OF LITERATURE . . .
Demographic Empirical Evidence
Behavioral Empirical Evidence
Summary . . . . . . . . . . .

CONCEPTUAL DEFINITION OF VARIABLES
Demographic Variables . . . .
Behavioral Variables . . . . .
Infant Feeding Method . . . .

THEORETICAL FRAMEWORK . . . . . .
Definition of Theory . . . .
Theoretical Framework . . .
Linkage of Study Variables .

METHODS . . . . . . . . . . . . . .
Research Design . . . . . . .
Sample . . . . . . .
Operational Definition . . .
Procedure . . . .
Protection of Human Rights .
Limitations to the Study . .
Data Analysis . . . . . . .

RESULTS . . . . . . . . . . . . .
Sample Description . . . . .
Interpretation of Findings . .

DISCUSSION . . . . .

o o o 0

Recommendations for. Future Research
Discussion of the Theoretical Model

Implications for Advanced Nursing Practice

V

Table of Contents (Cont.)

LIST OF REFERENCES . . .

APPENDIX A

UCRIHS Approval Letter

APPENDIX B
Data Entry Form . .
WIC Income Guidelines

0

vi

43

46

47
48

Table

Table

Table

Table

Table

1:

2:

5:

LIST OF TABLES

Means and Standard Deviations of Demographic
and Behavioral Variables . . . . . . . . . .
Frequency and Percent of Demographic and
Behavioral Variables . . . . . . . . . . . .
Means and Standard Deviations of Behavioral
and Demographic Characteristics in the
Breastfeeding and Bottlefeeding Adolescent
Mothers . . . . . . . . . . . . . . . . . . .
Cross Tabulation of the Level of Education
and Maternal Age . . . . . . . . . . . . . .
Chi-square Analysis of the Demographic and
Behavioral Variables Between Breastfeeding
and Bottlefeeding Adolescent Mothers . . .

vii

Page

LIST OF FIGURES

Figure 1: The Person as an Adaptive System

Figure 2: Linkage of Study Variables to Roy's

Adaptation Model . . . . . . .

INTRODUCTION

The purpose of this study was to describe and compare
demographic and behavioral variables in a sample of
adolescent women receiving the Women, Infants, and Children
(AC) program who breastfed or bottlefed their infants. The
AC program is a special supplemental food program for women,
infants, and children created by Public Law 92-433 and
funded by the United States Department of Agriculture
through the Michigan Department of Public Health (MI Dept.
Of Public Health, 1990). To be eligible for the AC program
participants must be residents in the state of Michigan,
must be income eligible, and/or at a nutritional health
risk. Income eligible is defined as at or below 185% of
Federal Poverty Income Guidelines, or on Medicaid or Food
Stamps. Clinic staff in local agencies may also determine
eligibility if the woman, infant, or child has a nutrition
and/or health risk (Michigan Department of Public Health,
1990).

This study reviewed AC program records, and obtained
demographic and behavioral information from a self reported
history form that is filled out approximately 2-6 weeks
post-partum. The breastfeeding adolescent mothers were
described and compared with randomly chosen adolescent
bottle-feeding mothers.

Statement of the Problem
The issue of breastfeeding versus bottlefeeding has

been a topic of discussion and research for many years. In

1

2

1990, virtually all of U.S. mothers breastfed their infants
(Saunders, Carroll, & Johnson, 1990). From the 1940's to
the 1970's, steady declines were noted in the number of
women who breastfed their infants. The decline was mainly
among the young, black, poor, and less educated women
(Saunders et al., 1990). Since the 1970's breastfeeding has
increased in popularity as the preferred infant feeding
method, but younger, African American, economically
disadvantaged, and less educated women have been the slowest
to return to breastfeeding (Joffe & Radius, 1987). The
number of newborns who were breastfed nearly doubled in the
United States between 1965 and 1982, when breastfeeding
peaked at sixty-two percent. In 1990, the breastfeeding
percentages were substantially higher among whites (65%),
than African-Americans (33%), higher among older married
women with some college education (73%), than those not
completing high school (32%), and also less prevalent among
lower income women (28%) (Jacobson, Jacobson, & Frye, 1991).
National studies have demonstrated a decreasing trend in
breastfeeding rates among new mothers under the age of 20
years with 39.3% of adolescent mothers reporting that they
breastfed their infants in 1983, 36.8% of adolescent mothers
in 1984, and only 30.2% of adolescent mothers in 1989
(Lizarrago, Maehr, Wingard, & Felice, 1992).

Since 1978, The World Health Organization and Health
and Welfare Canada have made the promotion of breastfeeding

a primary goal (Milligan, McGovern, Minelli, Edwards, &

A

3
Warrers, 1993). Healthy_2egp1e_zggg has a goal to increase
to at least 75%, the proportion of mothers who breastfeed
their babies in early postpartum and to at least 50% the
proportion who continue breastfeeding until their babies are
5 to 6 months old (Public Health Service, 1992). While the
rates of those starting to breastfeed have increased since
the recommendations were made from 38% to as high as 80% in
many areas, the goal of breastfeeding for all babies for at
least six months has still not been attained (Milligan et
al., 1993).

The recommendations by health care providers, health ‘
policy specialists, and the American Academy of Pediatrics
indicates that breast milk is the preferred source of
nutrients during the first 4-6 months of an infant's life
(Cronenwett, Stukel, Kearney, Barrett, Covington, Monte,
Reinhardt, & Rippe, 1992). The WIC program has adapted its
focus to encourage women to breastfeed. In 1993, the United
States Department of Agriculture (USDA) authorized an
enhanced food package for exclusively breastfeeding women on
the WIC program giving these mothers additional food items
as an incentive to breast-feed. The WIC program has chosen
to promote breastfeeding by supplying lactation instructors,
peer counselors, and pre-natal breastfeeding instruction
along with the extra food incentives for breastfeeding
mothers. The WIC staff is working with adolescent mothers
to increase the breastfeeding rates, and promote it as the

preferred source of nutrients for an infant. Although half

‘

4
or more of infants in the United States are breastfed at
birth, at least 60% are completely formula fed by the age of
2 months, and over 85% are taking formula or regular cow's
milk by the age of 1 year (Snow & Fry, 1990). Recent
studies have shown that there continues to be a rapid
decline in breastfeeding duration, with only 30% of infants
being breastfed for 6 months, and a median age of stopping
at 3 months (Milligan et al., 1993). These declining rates
are in spite of research showing that infants benefit from
breastfeeding by demonstrating decreased rates of
gastrointestinal disease, illness, and hospitalization (Dix,
1991).

Adolescent breastfeeding is best understood in the
context of adolescent pregnancy and adolescent health
behaviors. Since 1974, more than 1 million adolescents each
year have become pregnant (Morris, Warren, & Aral, 1993).

An estimated 87% of pregnancies among never-married
adolescents are unintended (Morris et al., 1993). These
adolescent women, particularly those from low income
backgrounds are among the least likely to choose
breastfeeding as their infant feeding method (Morris et al.,
1993).

Adolescence is the time for risks and health
compromising behaviors. Certain lifestyle practices may
compromise the fetus during pregnancy and affect lactation
following delivery. Of particular concern are tobacco and

alcohol consumption, both of which will be present in breast

5
milk if consumed by the mother, and may have a detrimental
effect on the nursing baby. Alcohol consumption and tobacco
use have been reported as the most common health-risk
behaviors in adolescents (Kulbok, Earls, & Montgomery,
1988).
Study Purpose

The purpose of this study was to describe and compare
demographic and behavioral characteristics in a sample of
adolescent women receiving WIC assistance who breastfed or
bottlefed their infants.

Research Question

Are there differences with respect to the demographic
variables of maternal age, family income, education, and
martial status, and the behavioral variables of alcohol and
tobacco use in adolescent mothers receiving the WIC program
who breastfeed or bottlefeed their infants?

REVIEW 0! LITERATURE

An extensive review of the literature was done and is
discussed in the following section. The literature review
of the demographic variables of maternal age, family income,
education, and marital status are looked at first and then
the literature on behavioral variables of tobacco use and
alcohol use are reviewed.

Demographic Empirical Evidence

Despite dramatic gains in breastfeeding among middle

and upper class women, most low income and less educated

adolescents continue to bottlefeed their infants. Since

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6
1985, breastfeeding incidence and duration rates have
declined in all groups (Ryan, Rush, Krieger, & Lewandowski,
1991). Studies show a variety of reasons for the decreased
rates of breastfeeding in low income, poorly educated, and
adolescent women.

In a study done by Lizarraga et al. (1992), 64
primiparous adolescents, mostly Hispanic females, ages 14-
18, were studied to assess factors which differentiated
those who chose to breastfeed for those that chose to
bottlefeed. The study found that those adolescents who
intended to breastfeed were significantly older, with a mean
age of 17.2 for the breast-feeding adolescents, and a mean
age of 16.3 for the bottlefeeding adolescents. The
adolescent mothers who breastfeed were also less likely to
have been in school during the pregnancy, and were more
often married than unmarried. However, neither living
arrangement nor presence of a postpartum support system were
associated with the intention to breastfeed (Lizarraga et
al., 1992).

Baisch, Fox, Whitten, & Pajewski (1989) studied two
groups of low income adolescents, with the adolescent sample
totaling 127. The study assessed breastfeeding attitudes
and practices of low income adolescent mothers, and one
group of low income adult women, and compared their
breastfeeding rates. The breastfeeding rates for the two
adolescent samples was 16.7% and 32.4% respectively; while

it was 35.4% for the adult sample. In a national study by

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7
Martinez and Krieger (1984) mothers under the age of 20
breastfed at a rate of 36.8% compared with the rate of 66.6%
for mothers aged 25-29.

Grossman, Larson-Alexander, Fitzsimmons, & Cordero
(1989) studied 2,124 low income, low risk, mothers and found
that the mothers who breastfed their infants were older, had
more education, and were more often married. Martinez and
Krieger (1985) found that mothers with a family income of
less than $7,000/year breastfed at a rate of 36.6%, compared
to the 71.8% rate of women with a family income of at least
$25,000. Grossman, Fitzsimmons, Larsen-Alexander, Sachs, &
Harter (1990) interviewed 220 mothers, of which 116 were
breastfeeding, and found the breastfeeding women to be
older, more educated, more affluent, and more often married.

Jacobson, Jacobson, and Frye (1991) examined two
independent lower-income samples of first time mothers over
the age of 17: 137 were black inner-city mothers and 50 were
predominantly white mothers. The low income sample found
that the majority were unmarried, however 41.9% listed the
baby's father as their major support person. Support is
important in breastfeeding decisions as Bryant, Coreil,
D'Angelo, Bailey, and Lazarov (1992), in 35 focus group
interviews found that the support person was identified as
having the greatest influence on the mothers' infant feeding
decision.

In a study by Kurinij, Shiono, and Rhoads (1988) of

1,179 healthy African American and white women 18 years or

A

8
older, the incidence of breastfeeding was most dependent on
the maternal education. The breastfeeding rate was higher
for mothers with some college education (73%) than those not
completing high school (32%) (Jacobson et al., 1991; Kurinij
et al., 1988). The odds for breastfeeding were found to be
2.6 to 5.2 times higher for women with a college an/or
graduate school education, compared with women with a high
school education or less (Kurinij et al., 1988). Rassin,
Richardson, and Baranowski (1984) compared breastfeeding
rates in 1969 and 1980 and found increases in breastfeeding
rates in both black and white women with increased levels of
education. However, white women had a higher incidence of
breastfeeding within each educational level. In a survey
study of 254 pregnant adolescents, Joffe & Radius (1987)
found that the increased education level of the adolescent
mother was beneficial in increasing breastfeeding rates.
Behavioral Empirical Evidence
Cigarette smoking has particular appeal to the
adolescent. In an interview of 2,787 adolescents age 13-18
years, Kulbok, Earls, and Montgomery (1988), report that 21%
used tobacco every day for a month or more in the past year.
The tobacco use among adolescent males has begun to plateau,
but there has been a rise in adolescent female's tobacco
use. Approximately 30% of 13-17 year old females reported
that they smoked cigarettes, with almost half reporting that
they smoked at least a pack a day (Blum, 1987; Kulbock et

al., 1988). In a recent study by the National Center for

9
Health Statistics, 10,645 youths were interviewed about
risky health behavior. The results of this study supported
the results of other surveys: a vast number of adolescents
smoke and drank. This data was taken one step further,
reporting that adolescents who smoke are between 2 and 17
times more likely than nonsmokers to have a variety of risky
health behaviors (Neergaard, 1995).

Nicotine metabolites have been found in the urine of
breastfed infants of smoking mothers, or when passive smoke
exists. Heavy smoking (more than 10 cigarettes per day) has
been associated with decreased production and ejection of ’
milk, infant irritability, and poor sucking. For these
reasons breastfeeding mothers should be encouraged to stop
or reduce smoking (Milligan et al., 1993).

Alcohol consumption has been reported as the most
common health-risk behavior in the adolescent population
with the amount of alcohol consumed steadily increasing
(Kulbok et al., 1988). Nearly all graduating high school
seniors in America report having had a drink, with most
indicating having had his/her first drink by the age of 13
years (Blum, 1987). Kulbok et al. (1988) report that 30% of
adolescents consumed alcohol at least once per month.

The negative effect of alcohol on the breastfeeding
adolescent mother are unknown, but research suggests that
the infant could be affected by exposure to alcohol in the
mother's breast milk. In a study by Little, Anderson,

Ervin, Worthington-Roberts, & Clarren (1989), 400 infants

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10
were studied, investigating the relationship of the mother's
use of alcohol during breast-feeding to the infant's
development at one year. This study found that the alcohol
that was ingested by the infant had a slight, but
significant, detrimental effect on motor development, but
not on mental development.

In summary there is a high percentage of adolescents
who use alcohol and tobacco in America, and with the high
pregnancy rate there will inevitably be adolescent mother's
who drink and/or smoke. These behavioral habits may affect
the adolescent mother's decision about whether or not to '
breastfeed her infant. The adolescent mother may want to
continue drinking and/or smoking after the infant is born,
but may not want the infant to consume the nicotine or
alcohol via breast milk. The literature is sparse in
substantiating the behavioral habits of alcohol and tobacco
use as determining factor in the decision of adolescent
mothers to breastfeed or bottlefeed their infants.

Summary

The majority of studies have characterized
breastfeeding mothers by age, education, race, and
socioeconomic status, but less information is available in
comparing demographic data and behavioral variables of
alcohol and tobacco use in adolescents that breastfeed or
bottlefeed their infants.

The literature on the adolescent mother and

breastfeeding is limited in the studies published, the

11
variety of variables studied, and the generalizability of
the studies. The majority of the studies on breastfeeding
adolescent mothers have used smaller sample sizes, making it
very difficult to generalize the studies to a broader
population based on the decreased precision of estimate.
The studies have most often been descriptive studies
attempting to describe the population of mothers that
breastfed their infant, with little information comparing
breastfeeding and bottlefeeding adolescent mothers. The
literature has also been limited in studying the WIC program
population. This is particularly relevant since 1993,
because the WIC program has placed a heavier emphasis on the]
promotion of breastfeeding as the best preferred infantw/r~'/
feeding method.

This study will help fill a gap in the literature by
comparing both demographic and behavioral characteristics in
adolescent mothers that breastfeed or bottlefeed theirw
infants. In addition, these data were gathered after new
attempts had been initiated by the WIC program to increase//
bottlefeeding in adolescent mothers. This study is~jifi
important too because it will provide health care providerS)
with valuable information on the characteristics of ’.“/
adolescent mothers who may choose to breastfeed or A
bottlefeed their infants. 1

CONCEPTUAL DEFINITION OF VARIABLES
The three variables in this study that require

conceptual definition include: 1) demographic variables; 2)

12
behavioral variables; and 3) infant feeding method. The
demographic variables are vital statistics about an
adolescent mother which included: maternal age, family
income, education, and marital status. The behavioral
variables are defined as health choices made by the
adolescent mother and included: alcohol use and tobacco use.
The infant feeding methods include breastfeeding and
bottlefeeding.
Demographic Variables

Demographic data are significant because they give
indirect information about an individual's role in society
including information about developmental stage, lifestyle,
values, problem solving ability, and social support. The
characteristics of maternal age, income, education, and
marital status are the variables that may give us that
information, and will be discussed in this section.
Age

Conceptually, age is defined for adolescents as a
critical time period of biological and cognitive changes.
Erikson's developmental stage of adolescence is defined as
being between the ages of 13 and 21. Adolescence is the
time in which the developmental crisis of identity formation
vs. Identity diffusion is apparent. Erickson's
developmental stage of adolescence consists of three age
categories: early adolescence, middle adolescence, and late

adolescence (Block & Nolan, 1986).

£

13

The early adolescent period (approximately 11-14 years)
is characterized by growing and maturing, ending, on the
average at age 14 for females. The major concerns involve
the normalcy of physical development and the pre-occupation
with body changes and function (Stewart, 1987). The early
adolescent age mother may not view her breasts as a natural
or normal means for feeding, making her less likely to
breastfeed (Maehr, Lizarraga, Wingard, & Felice, 1993).

The middle adolescent period (approximately age 15-17
years) is characterized by puberty and stabilization of body
image. At this age, experimentation of new behaviors is
apparent, with the major influences from the peer group
(Stewart, 1987). During this developmental stage, the
adolescent may not breastfeed because of the lack of peer
support, or experimentation with alcohol and/or cigarettes.

The late adolescent period (approximately age 18-21) is
characterized by the development of an individual's
intellectual and functional identity, and the establishment
of individual relationships that are based on mutual caring
and commitment (Stewart, 1987). In the process of maturing
intellectually and functionally, the older adolescent may
utilize breastfeeding more often than adolescents in the
early or middle period. The ability to establish
relationships based on caring and commitment may potentially
help the older adolescent to better focus on the needs of an

infant. The older adolescent may also better appreciate the

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benefits that breastfeeding offers to both herself and her
infant.
Income

Income is conceptually defined as the amount of money
brought into the household by all family members living in
that household. Income is considered a proxy variable
measuring the adolescent mother's lifestyle and resources.
Lifestyle is a way of living, or a way of conducting oneself
related to the amount of resources available, including the
aid or financial support that is available to the family.
Income can be measured in numbers making it easier to
quantify, thus being able to generalize the lifestyle and
financial resources available to the adolescent mother.
Education

The third demographic characteristic of education is
conceptually defined as the knowledge and skills gained from
instruction and/or training. It is also a proxy variable in
the assessment of problem solving ability. Education gives
the adolescent mother the tools necessary to evaluate
options, problem solve, and make a decision based on the
information available. It has been shown in many studies
that higher educational attainment by the mother can
positively influence her decision to breastfeed her infant.
We

Marital status is being utilized as a proxy variable
for social support. Social support for the breastfeeding

role is defined as a provision of support. Social support

15
consists of being accepted, loved, valued, and needed for
oneself and not for what one can do for others (Pender,
1987). Social support is considered to be ongoing
throughout life. Marriage is a type of social support
consisting of a man and a women living together as husband
and wife, with the ability to love, respect, and value each
other as individuals. Marriage is not the only type of
social support for the adolescent mother, as she may not be
married yet has the support of a partner, the father of the
baby, or some other support system. The adolescent mother
seeks social support in her decision to breastfeed, and
marriage may represent that important source of positive
social support to the adolescent mother in deciding and
continuing to breastfeed. However, the social support by
the partner may also be negative, because not all males view
breastfeeding as beneficial to the infant. The male partner
may not wish to share the adolescent mother's breast with
the infant or he may be embarrassed that the adolescent
mother is hearing her breast during the feeding process.
Positive and negative support were not measured for this
study so marital status will be assessed as proxy variable
for support system.
Behavioral Variables

The two behavioral characteristics that were defined
are tobacco use and alcohol use. These characteristics
constitute health behaviors and are two of the greatest

indicators of health risks in adolescents. Drinking and

l6
smoking are also activities that most adolescents will try
and may continue because adolescence tends to be a period of
risk taking and peer pressure.

Tobacco use is defined as smoking cigarettes on a daily
basis and is an indicator of health behaviors and choices of
the adolescent. The health behavior of cigarette smoking
could decrease the number of adolescents that breastfeed
their infants due to them not wanting to expose their
infants to the nicotine metabolite excretion in the breast
milk and decreased milk production. The assumption, then,
is that adolescent mothers may not breastfeed because they
smoke cigarettes and realize smoking's ill effects on the
infant.

Alcohol use was defined as the consumption of any drink
containing ethyl alcohol, consisting of any type of liquor,
per week. Alcohol use has been reported as the most common
health-risk behavior in the adolescent population, and it is
another indicator of health behaviors and choices of the
adolescent. Alcohol consumption has not been studied as a
characteristic of adolescent mothers that breastfeed or
bottlefeed their infants. It can be assumed, however, that
the need or want to consume alcoholic beverages may decrease
the number of adolescent mothers that breastfeed, due to the
alcohol excretion in the breast milk and the mothers wish to

not expose their infant to this.

17
Infant Feeding Method
The American College of Obstetrician and Gynecologists
define breastfeeding as having options. The options
include: 1) Breastfeeding with no bottles for 6 months; 2)
breastfeeding for a short time (6 weeks to three months) and
then bottlefeeding; 3) breastfeeding; and 4) combining
breastfeeding and bottlefeeding a few times a day (ACOG,
1990). This study defines breastfeeding as any amount of
breastfeeding during the first six weeks post-partum, and
bottlefeeding as being fed exclusively by bottle during the
first six weeks post-partum, without any breastfeeding.
THEORETICAL FRAMEWORK
Definition of the Theory
This study will use Roy's Adaptation Model to describe.\JLA
the characteristics of adolescent mothers who breastfeed or IE:
bottlefeed their infants. This study is based on Roy's I
theory of the person as an adaptive system consisting of
input, effectors, and output (Roy, 1984). This study used
Roy's Adaptation Model to assess the demographic and
behavioral characteristics of the adolescent mother that may (,“U
be associated with breastfeeding or bottlefeeding.~ " “w”'“ /
Theoretical Framework
Roy's adaptation model describes the environment as
being comprised of external and internal stimuli that act as
stressors. The stimuli serve as the input to the person.
The input can consist of focal, contextual, and residual

stimuli (See Figure 1). The focal stimuli are the provoking

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18

Figure 1. The Person as an Adaptive System

if“ 2 (\fl “1’?

L. 4.91% 2“ COHU'OI
Input 2mm
Stimuli m
Adaptation mechanisms /7
level Regulator fl

Cognator

Physiological functio
Self-concept

Role function
Interdependence

Adaptive
and
ineffective
responses

 

ROY. C. (1984). WW (9- 30)-

19
situations or events immediately confronting the person.
The contextual stimuli are all other stimuli present in the
situation, or surrounding the event, that can contribute to
the effect of the stimuli. The residual stimuli are vague,
general, and ambiguous factors that may be affecting a
person, but their influence cannot be ascertained or

validated (Lutjens, 1991). Only the focaILstimuli"were_useg__

 

f°rmt=hiifi§9§yJ

The input leads to the effectors. The effectors
consist of the four modes of adaptation: physiologic, self
concept, role function, and interdependence. These modes
influence the adaptive system. The physiologic mode is
achieved by the maintenance of physiologic integrity. This
mode allows individuals to respond physically to their
environment. The role function mode is a set of
expectations of individuals toward each other, consisting of
primary, secondary, and tertiary roles. The interdependence
mode is a social adaptive mode which includes the close
relationships of people involving the willingness and
ability to love, respect, and value others. The self
concept mode is related to the need for psychic integrity
including perceptions of physical and personal selves (Roy,
1987) (See Figure 1).

The effectors then lead to the output which consists of
the adaptive or maladaptive responses of the individual.
The level of adaptation represents the person's ability to

respond to the environment. People are the active

20
participants interacting with the input and the effectors to
form the output, an adaptive or maladaptive response.
Linkage of Study Variables

The input for this study consisted of the focal?
stimuli, which were defined as thefipregnancy SEVERE“ L‘s
adolescent and birth of the infant. The focal stimuli are
defined as the input that confronts the adolescent. The
contextual and residual stimuli are not utilized for this
study (See Figure 2).

The input of the pregnancy and birth of an infant led
to the effectors, which are denoted in Figure 2 by the arrow
going from the input to the effector. ThéiEffectégs for
this study included the demographic characteristics of
maternal age, family income, education, and maritalmstatus,
and the_behayioral variables of alcohol use and tobacco use.
These characteristics were placed under the physiologic,
role function, and interdependence modes. The self concept
mode was not utilized.

The physiologic effector mode consisted of the
characteristics of alcohol use and tobacco use. These were
placed within this mode because alcohol and cigarette
smoking havereen shown in the literature to be related tor
degteased physiologic integrity. Drinking alcohol and'“~\\ :5

_.-Iiw,r _ 4 at
smoking cigarettes physiologically change the amount and ‘45
composition of the adolescent mother's breast milk.,/AIEOH:1‘
and nicotine metabolites excreted in the breast milk alter

physiologic integrity.

‘

21

Figure 2. Linkage of Study Variables to Roy's Adaptation Model.

 

 

 

INEUI EEEESJDBS 91mm
WI
EHXSIQLQGIC ADAEIIIE
BIRTH OF TOBACCO USE BREAST-FEED
CIGARETTE USE /

 

 

 

 

\maflmcnon

 

 

 

 

 

 

 

MQDE
MATERN AL AGE \ W
W
INCOME LEVEL
BOTTLE-FEED
EDUCATION INFANT
WE
MQDE
MARITAL STATUS
Adapted from Roy, Sr. C. ' ' ' , 2nd ed.

englewood Cliffs, NJ: Prentice-Hall Inc. 1984.

22

The characteristics of maternal age, family income, and
education are placed in the role function effector mode.

All people in society have roles based on expected behaviors
and norms. The characteristics of maternal age, family
income, and education are all roles of an individual, with
expected behaviors and norms. These characteristics are
used as proxy variables for the societal expectation of an
individual to include: developmental stage, lifestyle,
resources, and problem solving ability.

The characteristics of marital status was placed in the
interdependence effector mode. Marital status is studied as
a proxy variable for social support, which consisted of an
involvement of a close relationship that led to social
support for the breastfeeding mother.

The input and effectors led the individual to the
output or the adaptation response, which is denoted in
Figure 2 by the arrows. The adaptation level represented
the adolescent mother's ability to respond to the
environment in an adaptive manner. There were two responses
for the adolescent mother: an adaptive response of
breastfeeding, or a maladaptive response of bottlefeeding.
Breastfeeding was chosen as the adaptive response because it
is cited in the literature as the best and preferred infant
feeding method.

Roy's Adaptation Model, which was re-defined for this
study, was used to describe the adolescent mother's output

of an adaptive response of breastfeeding, or a maladaptive

23
response of bottlefeeding. The adaptation response was
based on the input of pregnancy and birth of an infant, and
the effectdrs consisting of the demographic and behavioral
characteristics of the adolescent mother.
METHODS
Research Design

The design of this study was a descriptive comparative
analysis of the characteristics of maternal age, family
income, education, marital status, tobacco, and alcohol use
in adolescent mothers who breastfeed or bottlefeed their
infants.

This was a non-experimental, retrospective, and cross-
sectional study, because it described and compared
characteristics that had already occurred and used only one
time frame. The data were collected from chart records
obtained by the WIC program staff from a self reported
health history at a 2 to 6 week post-partum time frame.

Sample

The sample for this study consisted of the records of
adolescent mothers, aged 13-21 years, who were receiving the
Women, Infants, and Children (WIC) program at The Corner
Health Center in Ypsilanti, MI. This study included 61
subjects, with 31 in the breastfeeding sample, and 30 in the
bottlefeeding sample. The adolescent mothers' records were
eligible for inclusion in the sample if the mother delivered
a full-term baby (38-40 weeks gestation) without any serious

anomalies. The breastfeeding group consisted of adolescent

24

mothers who had done any amount of breastfeeding during the
first six weeks postpartum. The bottlefeeding sample were
eligible for inclusion if the adolescent mothers exclusively
bottlefed their infants for the first six weeks postpartum.
The first 30 breastfeeding adolescent mothers who met the
sample criteria were selected starting in March, 1995 and
going back one year. The bottlefeeding sample was selected
randomly over the same time frame until an equal number of
records were obtained to match the breastfeeding group.

Operational Definition

The three concepts that need an operational definition
are: infant feeding method, demographic variables and
behavioral variables. The infant feeding method is defined
as breastfeeding or bottlefeeding an infant. Breastfeeding
is defined as any amount of breastfeeding during 2 to 6
weeks post-partum. Bottlefeeding is defined as exclusively
bottlefeeding without any supplemental breastfeeding.

The self reported demographic variables including the
age of the adolescent mother, income level, education, and
marital status. The demographic variables were measured at
2-6 week post delivery of the infant and gathered from the
self reported health history as: 1) Age, rounded to the
nearest year, and in subsequent analysis placed in one of
three categories consisting of: the young adolescent (age
13-14 years), the middle adolescent (age 15-17 years), and
the older adolescent (age 18-20 years); 2) Education,

defined as the number of years of school completed, and

25

later placed in two groups: less than a high school
education, and high school education or greater; 3) Marital
status, defined as either married or unmarried, with single,
divorced, or widowed under the unmarried category; and 4)
income, defined as the family income, to the nearest dollar
amount, and later placed into one of three categories: less
than $5,000, $5,000-10,000, or greater than $10,000.

The self reported behavioral variables included alcohol
use and tobacco use. Alcohol use was categorized into two
groups, nondrinkers (no consumption of alcohol per week),
and drinkers (one or more drinks per week). Tobacco use was
categorized into non-smokers (no cigarettes smoked per day)
and smokers (one or more cigarettes per day).

Procedure

The data were collected from the self reported
demographic and health history in the chart records by the
WIC program staff at the Corner Health Center in Ypsilanti,
MI and was given to this researcher without any identifiers
attached. The data consisted of the information obtained
from a self reported health history form on the client
records at two to six weeks post-partum.

Protection of Human Rights

The records used for this study were obtained from the
self reported health history form in the chart records, so
the risk to the subjects was minimal to none. The names and
other identifiers of the subjects were excluded from the

data obtained, so there were no identifying factors for the

26
sample. A number was assigned to the subjects by the
researcher beginning at 01 and going through the number of
subjects in the study, ensuring confidentiality of the
individuals. Results of the research were made available to
the WIC program and to the Corner Health Center. The
proposal was approved by Michigan State University Committee
on Research Involving Human Subjects (UCRIHS) prior to the
analysis of data (See Appendix A).
Limitations to the Study

This research was not without limitations. First, a
non-probability convenience sample was used and therefore it
may not be generalized to all adolescent mothers. Second,
the data was completed with a small sample size which also
limits the power of the study and generalizability of the
results. Third, the WIC data set is limited in the amount
and the availability of information to be obtained. One
problem that occurred during data collection was that the
amount of breastfeeding was missing from the data making it
impossible to categorize the breastfeeding sample by the
amount of breastfeeding, which was originally planned to be
a descriptive component. There was also a decreased
variability in age and income based on the age of the
clients that receive care at The Corner Health Center and
the WIC program income criteria, which made it difficult to
show differences. Lastly, the data was self reported by the
adolescents, and the information was not validated by any

other sources. These are all recognized as limitations.

27
Data Analysis

The data analysis was done using the SPSS computer
program. The variables were described by frequencies,
percentages, means, standard deviations, and ranges. The
tests that were used to compare the demographic and
behavioral variables of the breastfeeding and bottlefeeding
mothers were a comparison of means (t-tests), and Chi-square
analysis. The means are continuous variables that are
tested by the t-test and the categorical variables are
tested by Chi-Square analyses.

RESULTS
Sample Description

Table 1 describes the total sample of adolescent
mothers. There were 31 breastfeeding adolescent mothers,
and 30 bottlefeeding adolescent mothers (total n=61). One
bottlefeeding adolescent mother was excluded because of
missing data, which decrease the bottlefeeding sample
number. The majority of the sample (67.3%) were white,
36.1% were Black, and 1.6% were Hispanic. The mean maternal
age for the total sample was 18.78 years. The mean
education level in grades of school completed was 10.72, and
the mean family income per year for the sample was $6,190.
The majority of the mothers were unmarried (90.2%), with
only 9.8% of the sample in the married category. About half
of the mothers (55.7%) had one pregnancy, while the other
half of the sample had two or more pregnancies. About three

quarters of the mothers (75.4%) had one live delivery, while

28
the rest had 2-3 live deliveries. The mean alcohol use was
less than one drink/week, and the mean cigarette use was
less than four cigarettes per day.

As shown in Table 2 there was one early adolescent
(1.6%), twenty-two middle adolescents (36.2%), and thirty-
seven late adolescents (62.2%). The majority of mothers
(67.2%) had less than a high school education, while 32.8%
of the mothers had a high school or greater education. An
interesting finding to note is that only about half of the
late adolescent mothers (age 18-21) had completed a high
school education or above. The majority of the sample
(62.3%) had a family income of less than $5,000. The
majority of the mothers (78.7%) reported that they drank one
or more drinks per week. The majority of mothers reported
that they were nonsmokers (63.9%).

The frequency, means, standard deviations, and t-values
of the breastfeeding and bottlefeeding adolescent mothers
are presented in Table 3. A t-test was done to test the
significance of a difference in means for the breastfeeding
and bottlefeeding adolescent mothers. The one-tailed t-
tests, using a P=.05, were done using the variables of
maternal age, education level, family income, alcohol use,
and tobacco use. The differences in age and education
between the breastfeeding and bottlefeeding adolescent
mother were statistically significant. No other
statistically significant differences were found between

breastfeeding and bottlefeeding mother.

29
Table 1

 

 

 

Variable Mean SD Range
Maternal Age 18.8 1.59 14-21
Education 10.7 1.47 7-15
Family Income 6,190.10 6,042 0-24,892
Pregnancies 1.59 .82 1-5
Deliveries 1.28 .52 1-3
Alcohol Use .78 2.28 0-8
Cigarette Use 3.7 6.29 1-20
Table 2

W
W

 

Variable Number Percent

 

Maternal Age

Early Adolescent 1 1.6

Middle Adolescent 13 21.3

Late Adolescent 47 62.2
Education Level

Less than high school 41 67.2

High school or above 20 32.8
Family Income

Less than $5,000 38 62.3

$5,000-$10,000 11 18.0

Above $10,000 12 19.7
Marital Status

Unmarried 55 90.2

Married 6 9.8
Pregnancies

one 34 55.8

more than one 27 44.2

Table 2 (Cont.)

30

 

Variable

 

 

Number Percent

Deliveries

one 46 75.4

more than one 15 24.6
Alcohol Use

nondrinkers 48 78.7

drinkers 13 21.3
Cigarette Use

nonsmokers 39 63.9

smokers 22 36.1
Table 3

 

 

Variable Mean SD t-value
Maternal Age
Breastfeed 19.23 1.407 2.26*
Bottlefeed 18.33 1.668
Education Level
Breastfeed 11.16 1.344 2.47*
Bottlefeed 10.27 1.484
Family Income
Breastfeed $6,434.52 $1,153.27 .32
Bottlefeed $5,937.63 $1,044.97
Alcohol Use
Breastfeed .84 1.77 .19
Bottlefeed .73 2.74
Cigarette Use
Breastfeed 3.52 6.56 -.22
Bottlefeed 3.87 6.10

 

*P<.05

31

As shown in Table 4, follow-up Chi Square Analyses were
done to measure the level of education (categories again
were less than high school education, and high school
education or greater) with the age of the adolescents to
analyze if education and age were related since the means
were both statistically significant. The outcome was
statistically significant (P=.01), showing that an increased
education level was associated with the older or late
adolescent age, which is an expected finding. Recall
however, that many older adolescents (about half) hadn't
completed high school.

As shown in Table 5, Chi Square tests were performed to
assess the effects of maternal age (only the middle and late
adolescent categories, the early adolescent age was not
analyzed because there was only one person in that
category), income, education, marital status, alcohol use,
and tobacco use, on the adolescent mothers method of infant
feeding. There were no statistically significant
differences found, however there were some interesting
trends in the data. There were more late adolescents in the
breastfeeding group than in the bottlefeeding group, with
fewer middle adolescents in the breastfeeding group. The
educational level reveals more of the breastfeeding sample
with a high school or above education. There are also more
married and nonsmoking adolescent mothers in the
breastfeeding sample. An interesting finding was that there

were slightly more adolescent mothers who drank one or more

32

0.. V9

 

< High School

Number EBZQBDI

High School or >

HHNDEI EEZQBDL
0 O

 

 

 

Early Adolescent 1 1.6
Middle Adolescent 13 21.3 0 0
Late Adolescent 27 44.3 20 32.8
X" (2, n=61)=8.86, n <.os
Table 5
WWW
. .o ‘: i‘ ."Q 2 ‘.- 'r .o .00 :0 ‘--‘o .o‘ -- 9
MW).
Breastfeeding Bottlefeeding
Number Remnant Number Ferment
Maternal Age
Middle Adolescent 5 16.1 8 26.7
Late Adolescent 26 83.9 21 70.0
x2 (2, H-6l)=1.l6, n--28
Income
< $5,000 20 64.5 18 60.0
$5,000-$10,000 4 12.9 7 23.3
> $10,000 7 22.6 5 16.7
x2 (1, N=61)=1.24, p=.53
Education
< high school 18 58.1 23 76.7
high school or > 13 41.9 7 23.3
x2 (1, n=61)=2.39, n=~12
Marital Status
Unmarried 26 83.9 29 96.7
Married 5 16.1 1 3.3
x2 (1, n=61)=2.81, 322.09
Alcohol Use
Nondrinker 23 74.2 25 83.3
Drinker 8 25.8 5 16.7
x2 (1, n=61)=.76, p=.38
Tobacco Use
Nonsmoker 21 67.7 18 60.0
Smoker 10 32.3 12 40.0
x2 (1, n=61)=.53, 38.53

 

33
drinks per week in the breastfeeding group than in the
bottlefeeding group.
Interpretation of Findings

In the sample of adolescent mothers (n=61) the mean
maternal age of the breastfeeding sample was 19.23, and the
mean maternal age of the bottlefeeding sample was 18.33.
Although these age differences were statistically
significant, from a clinical standpoint, both were from the
same late adolescent age category. These findings are
consistent with many of the studies in the literature
(Baisch et al., 1989; Bryant et al., 1992; Jacobson et al.,
1991; Kurinij et al., 1988; Lizarraga et al., 1992) which
show increased maternal age in adolescents to be associated
with breastfeeding. Follow up Chi-square analysis by
category was not statistically significant.

Increased educational level was also found to be
associated with the breastfeeding adolescent mothers. Again
follow-up Chi-square analyses were not statistically
significant. There was a difference in the mean education
level of the breastfeeding (11.2 years of school completed)
and bottlefeeding sample (10.3 years of school completed).
These findings are consistent with the literature (Grossman
et al., 1989; and Kurinij et al., 1988) which indicate that
more educated adolescent mothers are more likely to
breastfeed. No statistical differences were found when

education level was categorized into the two groups of: less

34
than high school education, and high school education or
greater. This is not surprising as both breast and
bottlefeeding groups had, on average, below a high school
education. Again, there was limited clinical significance,
because both groups (11.2 years of school completed for the
breastfeeding sample and 10.3 years of school completed for
the bottlefeeding sample) were theoretically at the same
development level.

The variables of marital status, income, tobacco use,
and alcohol use were found to have no statistical
relationship to breastfeeding or bottlefeeding in either the
t-test, or the Chi-square analyses. There were more married
adolescent mothers in the breastfeeding group, but no
statistical significance was found. There are only six
married mothers in the sample making the statistical power
very small. The income level was also higher in the
breastfeeding mothers, but again, not statistically
significant. The trend of the increased income level being
associated with breastfeeding mothers was consistent with
the literature (Baisch et al., 1989; Jacobson et al., 1991;
Joffe & Radius, 1987). There is a little variability in the
income level used for the study, with all of the mothers
having a low family income based on the WIC program income
criteria.

A surprising finding was that the mean rate of alcohol
use was higher in the breastfeeding adolescent mothers. The

number of drinkers was also slightly higher in the

35
breastfeeding sample, although neither were statistically
significant because the number of drinkers were so few. A
possible explanation was that the breastfeeding mothers were
more compelled to be honest about the self reporting of
behavioral habits. They may also be more honest because of
the potential consequences these habits could have on their
infants. Another possible explanation for these findings
was that the adolescent mother may feel that the benefits of
the breast milk for the infant outweigh the risk of the
infant obtaining alcohol via the breast milk. These
explanations are assumptions that were not analyzed in this
study.

There were very few differences that might help to
explain the infant feeding method choice in adolescent
mothers. The only statistically significant findings
included a higher mean maternal age, which may not be
clinically significant, and a higher mean educational level,
which again may not be clinically significant, in the
breastfeeding sample. These findings may lead to a very
limited conclusion that the older and more educated
adolescents may choose the adaptive response of
breastfeeding their infant.

DISCUSSION
Recommendations for Future Research

The findings of this study have filled a small gap in

the literature by describing and comparing both the

demographic and behavioral variables of adolescent mothers

36
that are breastfeeding and bottlefeeding their infants. The
finding that older and better educated adolescents are more
apt to breastfeed confirms findings from prior studies,
however, further research with larger sample sizes, on this
topic is needed. Additional research needs to occur in the
following areas: 1) Assessing the decision making factors of
the adolescent mothers in their choice to breastfeed or
bottlefeed, especially factors that concern behavioral
habits like alcohol use, tobacco use and nutritional factors
in the decision to breastfeed; 2) Assessing if the
adolescent mothers are making their infant feeding method
based on their behavioral habits, i.e., are adolescent
mothers not breastfeeding if they drink alcohol or smoke
cigarettes; 3) Assessment of the actual and potential
barriers to breastfeeding; 4) Exploration of duration rates
in breastfeeding adolescent mothers, analyzing the reasons
why they continue, decrease, or stop breastfeeding their
infants; 5) Utilizing the Health Belief Model to explore
decisions about breastfeeding; 6) Assessing sources of
social support for the adolescent mother with regard to her
infant feeding method choice; 7) Assessing who was the major
influence on the adolescent mother's choice to breastfeed;
8) Conducting studies assessing the knowledge base of health
care providers (MD, Nurse Practitioner, Clinical Nurse
Specialist, Certified Nurse Midwife, Registered Nurse) about
breastfeeding in adolescents; 9) Assessing the health care

providers ability to provide information and education to

37
the adolescent mother on the best infant feeding method
choice; and 10) Examining different educational approaches
to breastfeeding to identify developmentally appropriate
methods that succeed in encouraging adolescent mothers to
breastfeed their infants.

There are many areas of research needed on the topic of
adolescent mothers and breastfeeding. This study suggests
focus on the assessment and identification of reasons why
adolescent mothers choose to breastfeed or bottlefeed their
infants. The research needs to focus on the identification
of factors that are associated with the breastfeeding
mothers' decision making processes, the actual and potential
barriers to breastfeeding, and the identification of the
social support network for breastfeeding. The focus of
further research needs to include the identification of
educational needs of both health care providers and
adolescent mothers.

Discussion of the Theoretical Model

This study used Roy's Adaptation Model to describe how
the input (pregnancy of the adolescent and birth of an
infant) and the effectors (characteristics of the adolescent
mother) led to the adaptive response of breastfeeding, or
the maladaptive response of bottlefeeding. The study found
that the characteristics (effectors), had a scant amount of
statistical significance. The reason for this could have
been the small sample size and restriction in some of the

variables, or it may be because the variables studied

38
actually played little to no role in determining the
adolescent mother's method of infant feeding.

Roy's model was an effective model for this study, even
though scant statistical significance was found. The
theoretical model was helpful in defining the
characteristics that could lead to the adaptive process of
breastfeeding or the maladaptive process of bottlefeeding.
However, based on the finding of this study and this
theoretical model, the only conclusion that may be drawn is
that older and more educated adolescent mothers may be more
likely to breastfeed an infant. The Health Belief Model may
have been a more helpful model to utilize for future
research studies, because it may be able to identify the
reason why adolescent mothers are choosing to breastfeed
versus bottlefeed their infants.

Implications for Advanced Nursing Practice

The goal for primary care is health promotion and
health prevention. Increasing the rate of breastfeeding
mothers is a Healtny_2ggplg_zngg goal, as well as a general
health promotion goal. To obtain the breastfeeding goal of
at least 75% of all mothers breastfeeding their infants in
the early postpartum period, information needs to be
acquired from the adolescent mothers. The knowledge and
skills of the Advanced Practice Nurse can be utilized to
gather this information by assessing, educating, managing,
and researching breastfeeding adolescent mothers. The

Advanced Practice Nurse can utilize the findings of this

39
study and incorporate them into their practice. The APN
utilizes many different roles into their practice making
them uniquely suited to utilize research results to help
assess, educate, and manage adolescent mothers and their
method of infant feeding.

The Advanced Practice Nurse needs to utilize keen
assessment skills to implement a more focused and detailed
assessment of the adolescent mother. The APN needs to
gather a full health assessment, to include demographic and
behavioral data, as well as the main social support systems
for the mother. The APN can utilize these results by
assessing for extended social support people on an
individualized basis, to include maternal support, peer
support, family support, and support of a significant other.
Assessment of the role of the support person in the decision
to breastfeed or bottlefeed, may give the APN important
information on the reasons adolescent mothers choose to
breast or bottlefeed their infants.

The APN must also assess for perceptions and barriers
of the adolescent mother and their decision to breast or
bottlefeed their infant. The assessment must also include
the support person's attitudes and feeling about
breastfeeding. The support, or lack of support, by a
partner, family member, or peer, may influence the mother's
decision to breast or bottlefeed. Identification of this
information can help the APN implement an individualized

education and management plan based on what was found in the

40
assessment of the adolescent mother. Negative support about
breastfeeding from a support person is also something to
assess for. Strategies for giving support to the adolescent
who does not have a positively supportive person in their
life, include the utilization of peer groups, health care
provider support, and community support.

The incorporation of an education and management plan
for each individual needs to be a focus for the Advanced
Practice Nurse. Based on the findings from this study the
APN needs to get beyond the idea of identifying high risk
adolescents based on demographic and behavioral variables.
Instead the APN should encourage and educate each adolescent
on an individual level.

The APN can develop an education and management plan on
what is known about the developmental levels in adolescents,
since the results of this study show that age and education
were important in decisions to breastfeed. The education of
the early adolescent will need to focus on the maintenance
of normalcy in physical development. Incorporating
information that breastfeeding may make your body regain its
shape quicker would be important. The middle adolescent
time period is a time when peer support is vital. The APN
could develop a peer counseling educational program, by
identifying adolescent mothers who have successfully
breastfed. These mothers could then counsel and educate
other adolescents about the benefits of breastfeeding. This

peer counseling and education can be effective with all

41
adolescent age groups, but especially the middle adolescent
group. The education of the late adolescent needs to be
more focused on the positive benefits of breastfeeding to
the mother. This age group, theoretically, is interested in
forming individual relationships and bonding, which needs to
be emphasized as a benefit in breastfeeding their infant.
The education and management plan as a whole needs to focus
on the potential benefits of breastfeeding.

A multifaceted educational approach to the promotion of
breastfeeding should be utilized to include the new mother,
social support persons, health care professionals, and the
broader community. The multifaceted breastfeeding education
of the adolescent mother needs to start early in the
prenatal care, and continue into the post-partum period to
ensure continuous education and encouragement of the
positive effects of breastfeeding to the mother and the
infant. The education also needs to include the potential
dangers of alcohol, tobacco, and drugs.

The Advanced Practice Nurse must also utilize the
research role so that additional information can be gathered
about the adolescent population and their decision to breast
or bottle feed their infants. The APN can utilize the
research role in three different ways. First, new research
studies can be initiated and implemented. Second, the APN
can participate in larger, national studies. Third, the APN
can informally gather information that is based on the

geographic area of practice and factors that may affect the

42
adolescent mothers infant feeding method. The research role
is very important for the APN to utilize at any level,
because studies are limited in analyzing adolescent mothers
and their choice of infant feeding method.

In summary, the information gained from this study
found statistical significance in mean age and education
level, revealing that the older and more educated adolescent
mother was more likely to breastfeed. The characteristics
of income, marital status, cigarette use, and alcohol use
were found to have no statistical significance, revealing
that these characteristics were not significant factors in
breastfeeding or bottlefeeding for adolescent mothers in
this sample. The need for future research to find factors
that affect the adolescent mother's choice of an infant
feeding method is crucial. With a growing number of
Advanced Practice Nurses in a variety of settings, and with
the utilization of the roles of assessor, educator, and
researcher, we will hopefully see a significant increase in

the breastfeeding rates of adolescent mothers in the future.

LI ST OF REFERENCES

LIST OF REFERENCES

American College of Obstetrician and Gynecologists
(1990).

Beyond. Washington, D.C. 219-221.

Baisch, M.J., Fox, R.A., Whitten, E., 8 Pajewski, N.
(1989). Comparison of Breastfeeding Attitudes and b//
Practices: Low Income Adolescent and Adult Women. Maternal; '
Child_Nursins_Journa11_18(1). 61-70-

Block. G-. & Nolan. J. (1986). Health_Assessment_fnr
Erofessinnal_Nursing, 26-30.

Blum, R. (1987). Contemporary threats to adolescent
health in the United States. JAMA‘_251(24), 3390-3395.

Bryant, C.A., Coreil, J., D'Angelo, S.L., Bailey, F.C.,
8 Lazarov, M. (1992). A strategy for promoting
breastfeeding among economically disadvantaged women and
adolescents. NAACQG_a_C1inical_Issues_in_2erinatal_and
Eomen_s_Health_Nursins1_1(4I. 723-730-

Cronenwett, L., Stukel,, T., Kearney, M., Barrett, J.,
Covington, C., DelMonte, R., Reinhardt, R., 8 Rippe, L.
(1992). Single daily bottle use in the early weeks

postpartum and breastfeeding outcomes. Eediatrigs+_20(5),
760-766.

Dix, D.N. (1991). Why women decide not to breastfeed.
Birth1_18(4). 222-229-

Grossman, L.K., Larsen-Alexander, J. B., Fitzsimmons,
S.M., 8 Cordero, L. (1989). Breastfeeding among low income, L/
high risk women. Clinical_2ediatricsi_28. 38- 42.

Grossman, L.K., Fitzsimmons, S.M., Larsen-Alexander,
J. B., Sach, L., 8 Harter, C. (1990). The infant feeding l«”
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Jacobson, S.W., Jacobson, J.L., 8 Frye, K.F. (1991).
Incidence and Correlates of Breastfeeding in

Socioeconomically Disadvantaged Women. Pediatzig+_fifi(4),
728-735.

Joffe, A., 8 Radius, S.M. (1987). Breast versus
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practices. 2ediatzigs+_12(5), 689-695.

43

44

Kurinij, N., Shiono, P.H., 8 Rhoadsm, 6.6. (1988).
Breastfeeding incidence and duration in black and white
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Kulbok, P.P., Earls, F.J., 8 Montgomery, A.C. (1988).
Life style and patterns of health and social behavior in

high-risk adolescents . W“) .
22-35.

Little, R.E., Anderson, K.W., Ervin, C.H., Worthington-
Roberts, B., 8 Clarren, S.K. (1989). Maternal alcohol use
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at one Year. Naw_Ensland_Journal_of_nedicine1_321(7I. 425-
430.

Lizarraga, J.L., Maehr, J.C., Wingard, D.L., 8 Felice,
M.E. (199). Psychosocial and economic factors associated
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Lutjens, L-R- (1991). Callista_Ro¥_An_Adantation
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Breastfeedins_§uidelines_for_flealth
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45

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.’~

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Washington, DC: Author.

APPENDIX A

 

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MICHIGANSTATE
UNIVERSITY

April 20. 1995

so: lllsabath layer
2843 Ioundtraa
Ypsilanti. MI. 48191

RE: I'll: 85-188
TITLE: CHARACTERISTICS ASSOCIATED WITH THE INFANT
5:501-0 METHODS OF ADOLESCENT MOTHERS RECEIVING

a:VIIIOI'IIOUICTID: :1:
APPROVAL DATE! 00/20/95

The University Committee on Rasaarch Involving Human Sub ects'(UCRIH8)

review of this project is complete. I am pleased to adv so that the

rights and welfare of the human subjects appear to be adequately
rotectad and methods to obtain informed consent are appropriate.

1harafore, the UCRIHS approved this project including any revision
stad above.

IIIIIIL: UCIIHS approval is valid for one calendar year, beginning with
the approval date shown above. Investigators planning to
continue a project beyond one year must use the green renewal
form (enclosed with t orlglnal :sproval letter or when a
pro act is renewed) to seek u at certification. There is a
max of four such aspadlt renewals possible. Investigators
wishing to continue a {Eajact beyond tha tlma need to submit it
again or complete rev .

IIVIIIOII: UCRIMS must review any changes in rocadurss involving human
subjects, rlor to in tlatlon of t a change. If this is done at
tha time o renewal, please use the green renewal form. o
revise an approved protocol at an 0 her time during the year
send your wr tten request to the CRIBS Chair, requesting revised
approval and rafaranci the project's IRE I and title. Include
in your request a dascr ptlon of the change and any revised
ins rummnts, consent forms or advertisements that are applicable.

ml

Ola-088: should either of the followl arlsa during the course of the
work, lnvestl ators must notl UCRIHS promptly: ll) lama
(unexpected s da affects comp alnts, a c.) lnvolv ng uman
subjects or 2% changes in the research environment or new
information n lcatlng greater risk to the human sub acts than
existed when the protocol was previously reviewed approved.

If we can be of any future help please do not hesitate to contact us
at (517)355-2130 or :ax.¢s:7)3 8- :71.

 

DIW:pjm
cc: Linda lath Tlsdjs

46

APPENDIX B

WIC POLICY Chopin/Section: 1.83A

 

 

 

AND PROCEDURE media om: was
MANUAL Imue Date: was
I“. Duper-d of MI: lid.
2. ELIGIBILITY
2.03 WIC INCOME GUIDELINES STATUS: FINAL
MICHIGAN
WIC PROGRAM
INCOME GUIDELINES

Effective date: February 9, I995
(Replace: previous guideline: effective February 10, 1994)

SIZE OF ECONOMIC UNIT‘ WEEKLY BIWEEKLY MONTHLY ANNUALLY

1 5266 S 532 $1,152 $13,820
2 357 714 1,547 18,556
3 448 896 1,941 23,292
4 539 1,078 2,336 28,028
5 631 1,261 2,731 32,764
6 722 1,443 3,125 37,500
7 813 1,625 3,520 42,236
8 904 1,807 3,915 46,972

FOR EACH ADDITIONAL MEMBER

or THE ECONOMIC UNIT +92 +183 +395 “.736

Federal Register Vol. 60, No. 27. Thursday, February 9, 1995. Notice: page 7772.

Economic unit counts a pregnant woman a: one (I).

47

 

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48

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