A systematic review of the nature of support for breast-feeding adolescent mothers
Introduction
The Innocenti Declaration (WHO, 1990), which has been adopted by the WHO and UNICEF, recognises the need for protection, promotion and support of breast-feeding. Providing skilled breast-feeding support has been identified as an effective way of enabling women to breast feed (Sikorski et al., 2002; Renfrew et al., 2005) but few specify the nature of ‘support’ and how it affects women's experiences. Indeed the term ‘support’ is widely referred to, but its meaning is often unclear making the interpretation of studies problematic.
Sarafino (1994) refers to five components of support: emotional support (empathy, caring and concern); esteem support (positive regard and encouragement); instrumental support (practical assistance); informational support (provision of information); and network support (group/peer support). These components are useful for exploring the literature around support needs of breast-feeding women in general. Emotional support is identified by women as crucial, and includes staff showing sensitivity and care (Bowes and Domokos, 1998; Svedulf et al., 1998; Tarkka et al., 1998; Vogel and Mitchell, 1998; Whelan and Lupton, 1998; Hoddinott and Pill, 2000; Hauck et al., 2002; Dykes, 2005a). Included in this type of support is the ability of women to secure staff time and availability (Bowes and Domokos, 1998; Svedulf, 1998; Tarkka et al., 1998; Vogel and Mitchell, 1998; Whelan and Lupton, 1998; Hoddinott and Pill, 2000; Hauck et al., 2002; Hong et al., 2003; Dykes, 2005a). Women also prefer a quiet environment in which they feel rested, confident and less anxious (Ball, 1994; Tarkka et al., 1998; Vogel and Mitchell, 1998; Dykes, 2005a).
Esteem support, incorporating agreement, encouragement and positive regard, is highly valued by women (Schy et al., 1996; Humenick et al., 1998; Svedulf et al., 1998; Hoddinott and Pill, 2000; Gill, 2001; McCreath et al., 2001; Hauck et al., 2002; Ingram et al., 2002; Dykes et al., 2003; Dykes, 2005a). Women often welcome practical (or ‘instrumental’) support with breast-feeding when it is required (Hoddinott and Pill, 2000; Mozingo et al., 2000; Raisler, 2000; Hong et al., 2003; Dykes, 2005a), and a wealth of evidence suggests that women value provision of informational support in the form of consistent and accurate information given by knowledgeable staff (Bowes and Domokos, 1998; Whelan and Lupton, 1998; Svedulf, 1998; Hoddinott and Pill, 2000; Mozingo et al., 2000; Gill, 2001; Hauck et al., 2002; Ingram et al., 2002; McKeever et al., 2002; McLeod et al., 2002; Hong et al., 2003; Dykes, 2005a). Finally, assistance with maintaining existing networks of significant others, and the activation and establishment of supportive networks within the new situation has consistently been shown to be important to women (Tarkka et al., 1998; Dykes, 2003, Dykes, 2005b). The value of such network support is illustrated through positive evaluations of peer-support schemes (Dykes, 2003; Dykes, 2005b).
Sikorski et al. (2002) completed the most comprehensive review in this area, investigating the types of support used in intervention studies for the general population of breast-feeding women. They noted that studies providing some kind of face-to-face support showed a benefit for breast-feeding initiation and continuation, whereas those providing mainly telephone contact did not. They also noted that provision of support in the postnatal period seemed to confer the greatest benefit. They acknowledge the need for more research in this area, particularly qualitative research that explores the different elements of breast-feeding support strategies, and the mechanisms by which support operates.
Health professionals have frequently been identified as providers of inadequate breast-feeding support through, for example, contradictory or misleading information (Ellis and Hewat, 1993; Garcia et al., 1998; Tarkka et al., 1998; Garforth and Garcia, 1989; Dykes and Williams, 1999; Dykes, 2003; Dykes, 2005a, Dykes, 2005c). Bernaix (2000) identifies the lack of appropriate support as a contributory factor to shorter duration of breast-feeding. This issue is particularly pertinent for adolescents who aim to breast feed (Furey, 2004; Spear, 2004), as they are less likely to initiate or to sustain breast-feeding. The most recent UK 5-yearly review of baby-feeding practices (Hamlyn et al., 2002) confirms that rates for both incidence and continuation of breast-feeding are lowest in young mothers, and especially in those who left full-time education at 16 years of age. Overall, only 46% of adolescents in the survey (aged 13–19 years) started breast-feeding, compared with 69% of all mothers. The live birth rate for adolescents in England and Wales is 58,620 per annum (ONS, 2001), the highest in Europe (UNICEF, 2001). Although there is some evidence to suggest that these rates have fallen in recent years (conception rates for women under 18 and 16 years in England have decreased by 9.8% and 9.9%, respectively, since 1998 [ONS, 2005]), teenage birth rates remain high. A strategic Department of Health document (2002) requires all Primary Care Trusts in England to increase their breast-feeding initiation rates by 2 percentage points per year, above their baseline rate before this period. The Department of Health places particular emphasis upon improving breast-feeding rates in disadvantaged groups. A number of adolescent mothers fall into this category (Botting et al., 1998).
On the basis of these factors, it is imperative that the nature of acceptable and effective support systems for adolescent mothers who are intending to breast feed are identified. In order to inform this ongoing debate, and to inform the design of further studies in this area, this systematic review of the literature sets out to describe the concept of support offered by the current breast-feeding research literature in the context of adolescent mothers.
Section snippets
Method
The research question applied to the systematic review was ‘What is the nature of support offered in or emerging from research studies undertaken in the context of breastfeeding adolescent mothers?’ The systematic review protocol broadly followed the NHS Centre for Reviews and Dissemination guidelines (2001). The main stages of the review are shown in Fig. 1.
Stage 1 of the review involved searching for publications using electronic databases, websites, citations, hand-searching relevant
Findings
The search terms identified 721 papers, of which 212 were potentially relevant. The abstracts of these papers were screened by two of the authors independently of each other and 199 were rejected. Most of these focused either on educational input to non-pregnant adolescents to assess changing attitude or supportive interventions to older women or to groups containing both younger and older women. After abstract review, full papers were obtained for 13 studies. Agreement was reached for the
Nature of included studies
Three studies were carried out in the USA, two in Australia and two in the UK. In four studies, ‘breast-feeding support’ was the primary outcome of interest. The studies encompassed the issue of support at various stages of breast-feeding. Three studies addressed pregnant adolescents’ intention to breast feed (Joffe and Radius, 1987; Benson, 1996; Lavender et al., 2005), and six addressed breast-feeding initiation (all except Joffe and Radius, 1987). Five studies also addressed continuation of
Themes relating to support
Opinions differ about the type of support that may be helpful to adolescent mothers and which are most successful in encouraging and sustaining breast-feeding. The types of support identified in this review align with the five-category support schema described by Sarafino (1994) (as described earlier). These categories can therefore be used as a framework to facilitate discussion of the findings of the systematic review.
Discussion
The papers included in this review varied in design, quality and focus, which limits the value of combining the data arising from them. However, they do represent the total population of papers we were able to locate using our search strategy. In this context, the insights from the review are useful because they describe the current state of knowledge in this area. A limitation of the review is that certain papers may have been misrepresented somewhat owing to lack of sufficient detail on the
Conclusion
The studies from the review have diverse methodologies and findings and the evidence regarding the nature of support needed to maximize breast-feeding initiation and continuation in adolescent mothers is lacking. Consequently, it is impossible to draw generalisable conclusions on a support strategy for breast-feeding in the population of adolescent mothers. Given the public health emphasis on breast-feeding combined with a low uptake of breast-feeding in this group, there is an urgent need for
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