Choice of feeding method of adolescent mothers: Does ego development play a role?

J Pediatr Adolesc Gynecol (1999) 12:83-89

Choice of Feeding Method of Adolescent Mothers: Does Ego Development Play a Role? N. Pierre, MD, MPH,‘33 S.J. Emans, MD,’ D.A. Obeidallah, PhD,’ Y. Gastelum, MA,’ R.H. DuRant, PhD,2 L. King Moy, BS,l S.T. Hauser, MD, PhD,’ J. Paradise, MD,3 and E. Goodman, MD’ ‘Division of Adolescent Medicine, Children’s Hospital, Harvard Medical School, Boston, Massachusetts; “The Brenner Center for Child and Adolescent Health, Wake Forest University School of Medicine, Winston-Salem, North Carolina; and 3Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts

Abstract: Study Objectives: The purpose of this study was to determine whether, among childbearing adolescents, ego development was associated with intention to breast-feed and with actual breast-feeding behavior at birth and at 2 weeks postpartum. In addition, we sought to determine whether positive attitudes toward breast-feeding influenced pregnant adolescents’ intentions to breast-feed and actual breast-feeding at the hospital and at 2 weeks postpartum. We hypothesized that adolescents with higher levels of ego development and positive attitudes toward breast-feeding would be more likely to intend to breast-feed and to actually breast-feed. Design: Prospective cohort study of pregnant adolescents who completed questionnaires, Loevinger’s Sentence Completion Tests, and attitudes toward breast-feeding scales before delivery and a follow-up questionnaire at 2 weeks postpartum assessing feeding practice in the hospital and at 2 weeks postpartum. Setting: Two adolescents’ clinics and two “teen-and-tot” clinics in urban teaching hospitals. Participants: Fourteen- to 22-year-old pregnant adolescents who had never given birth and who planned to carry their pregnancy to term and parent their children. Main Outcome Measures: 1) Intended feeding practice during pregnancy, 2) feeding method in the hospital, and 3) feeding method at 2 weeks postpartum. Results: Of the 125 subjects enrolled in the study, 106 were at 2 weeks postpartum or more. Of these 106 participants, 75% (n = 78) completed more than 75% of the attitudes toward breast-feeding scale and Loevinger’s Sentence Completion Test and are included in these analyses. Mean age at entry was 17.8 f 1.5 years (range, 14.3 to 21.8 years). Mean gestational

Supported in part by Project No. MCJ-MA 259195 from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, US Department of Health and Human Services. Address reprint requests to: N. Pierre, MD, MPH, c/o E. Goodman, MD, Division of Adolescent/Young Adult Medicine, Children’s Hospital, JB 335, 300 Longwood Avenue, Boston, Massachusetts 02115. 1083-3188 0 1999 Lippincott Williams & Wilkins, Inc.

age at enrollment was 21.2 r 11.6 weeks (range, 4 to 41 weeks). Of the 78 participants, 12% (n = 9) were at the preconformist, 85% (n = 66) at the conformist, and 4% (n = 3) at the postconformist level of ego development as determined by the Sentence Completion Test. Attitudes toward breastfeeding, intention to breast-feed, breast-feeding in the hospital, and breast-feeding at 2 weeks postpartum were not significantly associated with adolescents’ stages of ego development. Almost three fourths of the adolescents intended to breast-feed, and 85% tried breast-feeding in the hospital. A total of 97% (56 of 58) of those who intended to breast-feed tried breast-feeding in the hospital compared with 40% (4 of 10) of those who did not intend to breast-feed (P < .OOOl). At 2 weeks postpartum, 58% of the participants were still breast-feeding. Of those participants who intended to breast-feed, 67% (39 of 58) were breast-feeding at 2 weeks postpartum compared with 10% (1 of 10) who did not intend to breast-feed (P = .OOl). The mean breast-feeding attitude score was 53.7 f 11.6 (range, 25 to 72). The mean breast-feeding attitude score was higher for those who intended to breast-feed than for those who intended to formula-feed (P = .009), but the score was not associated with breast-feeding in the hospital or at 2 weeks postpartum. Conclusion: Adolescent mothers were predominantly in ego stages 4 and 5, the conformist level. Because ego development was not associated with outcome measures in this study, ego development may not be a crucial factor when designing interventions to facilitate breast-feeding among adolescents. Attitudes toward breast-feeding were associated with the intention to breast-feed but not behaviors; the intention to breast-feed was significantly associated with breast-feeding behaviors.

Key Words. Adolescent pregnancy-Breast-feedingInfant feeding method-Ego development Introduction For many years, the American Academy of Pediatrics and other groupshave encouragedmothersto breast-feed

84

Pierre et al: Choice of Feeding Method of Adolescent Mothers

their infants. In 1989, only 52% of adult mothers were initiating breast-feeding, and less than 20% were still nursing 6 months later.’ The rate of breast-feeding among adolescent mothers was even lower (11.8% to 34.0%).2,3 One of the United States Department of Health and Human Services Year 2000 Health Objectives is for 75% of infants to be breast-fed at birth and 50% at 6 months postpartum.4 In 1982, the American Academy of Pediatrics (AAP) Committee on Nutrition issued a recommendation that breast-feeding be continued for the first 6 to 12 months of life.5 The recommendation was updated in 1997, when the AAP identified breast-feeding as the ideal method of feeding and nurturing infants and recognized breast-feeding as primary in achieving optimal infant and child health, growth, and development.6 These objectives, however, were aimed primarily at adult mothers. Although many studies have examined adult mothers’ decisions about infant feeding,‘-I4 few studies have examined the factors specifically associated with adolescent mothers’ decisions. 15-19Two studies noted that high school students lack information and hold numerous misconceptions about breast-feeding.‘7.18 In another study of nonpregnant adolescents, positive attitudes toward breast-feeding were associated with a greater exposure to breast-feeding mothers, as well as a higher likelihood of considering breast-feeding.” Consistent with these results, other studies demonstrated that a positive attitude toward breast-feeding had the strongest impact on choice of method, followed by method preferred by the partner and more knowledge about breast-feeding.7 Although valuable, these studies provide little information about the correlates of breast-feeding among pregnant adolescents. In addition to attitudes toward breast-feeding, another important factor that could influence adolescents’ decisions about infant feeding method is their level or stage of cognitive or psychosocial development. An adolescent’s decision to breast-feed is hypothesized to be related to her inner experience and perceptions of people and events, behaviors involved with impulse control, anticipation, responsibility taking, social judgment, and cognitive complexity.20,21 This evolution of meanings that the adolescent imposes on herself, which may be less visible to the casual observer of the adolescent, is referred to as “ego development.“2’ Reasoning, perceiving, and ways of conceptualizing feelings and relationships are all included within the domain of ego development.20’2’ Although female adolescents may be physically able to become pregnant, their abilities to decide on breast-feeding may be hindered or potentially enhanced by their level of cognitive and psychosocial development.3 Previous studies have provided inconsistent support for the connections between level of ego development and pregnancy status among adolescents.22,23 Ego level was shown to be associated with the use of effective

contraception among adolescents in one study.24 NO studies have assessed connections between pregnant adolescents’ ego development and their decisions to breastfeed. The purpose of this study was to determine whether, among a sample of predominantly minority, pregnant adolescents who intended to parent their children, ego development was associated with their intention to breast-feed and with actual breast-feeding behavior at birth and at 2 weeks postpartum. Furthermore, we tested whether attitudes toward breast-feeding were associated with the intention to breast-feed and actual breastfeeding behavior. We hypothesized that adolescents with positive attitudes toward breast-feeding and adolescents with higher levels of ego development would be more likely to both intend to and to actually breast-feed.

Methods A total of 125 14- to 22-year-old pregnant adolescents who had never given birth and who planned to carry their pregnancies to term and parent their children were recruited from two urban, teaching, hospital-based adolescents’ programs and “teen-and-tot” clinics. A questionnaire was administered to the study participants during clinic sessions between July 1996 and November 1997. A total of 106 participants were at 2 weeks postpartum or more at the time of this analysis. Of the 106 participants, 75% (n = 78) completed more than 75% of the attitudes toward breast-feeding scale’7325 and Loevinger’s Sentence Completion Test (SCT)20,26-27 and were included in this study. No significant differences in age, race or ethnicity, gestational age at enrollment, prior pregnancy, grades in school or dropout rate, intention to breast-feed, or breast-feeding behaviors were observed among participants who were included (n = 78) and those who were excluded (n = 28). Informed consent was obtained using the guidelines of the participating institutions. Follow-up was performed at well-child clinic visits or by phone (if a clinic visit was not kept) at 2 weeks, 2 months, 4 months, and 6 months postpartum. Data from the initial and 2-week assessments are presented in this article. All initial assessments occurred during the adolescents’ pregnancies. The questionnaire at the initial visit consisted of 100 items assessing demographic variables, social support surrounding breast-feeding, previous experiences with breast-feeding, and intended feeding method (before delivery); the attitudes toward breastfeeding scale25; and the Loevinger’s SCT.20,26-27 The attitudes toward breast-feeding scale, an l&item measure, was adapted for this sample.i7 The final version included 16 items. Items were measured on a 5-point Likert scale. Higher scores indicated more-positive atti-

Pierre

et al:

Choice

of Feeding

tudes. The attitudes scale had a possible score range of 16 to 80 points. In this sample, scores ranged between 25 and 72 points. Cronbach cx coefficient of the final scale was 0.82 in this study population. The Loevinger’s XT, a measure of ego development, is a 36-item test composed of sentence stems. The SCT, being a free-response test, is designed to measure adolescents’ frame of reference, and it requires 20 to 30 minutes to complete. The unidimensionality of the SCT was assessed in several ways by Loevinger and Wessler28 from a sample of 543 adults and adolescents of diverse ages and backgrounds, with an internal consistency estimate of 0.91 using Cronbach (Y. The Cronbach (Y estimate from this sample is 0.78. Loevinger demonstrated high inter-rater reliability (range, 0.76 to 0.92) in several studies.28*29 Ego development is operationalized by Loevinger in eight stages: impulsive, E2; selfTable

1. Loevinger’s Stage

Preconformist E2 Impulsive

E3 Self-protective

Conformist ES Conformist

E5 Self-aware

Post conformist E6 Conscientious

E7 Individualistic

E8 Autonomous

E9 Integrated

*From tFrom

patients. Loevinger.3’

Sentence Completion

Method

of Adolescent

Mothers

85

protective, E3; conformist, E4; self-aware, E5; conscientious, E6; individualistic, E7; autonomous, ES; and integrated, E9. From the eight different stages, three broad levels emerged: (1) preconformist (E2-E3), (2) conformist (E4-E5), and (3) postconformist (E6-E9). Table 1 lists the stages and their distinguishing features, with examples of responses from participants in this study and from Loevinger. 3o For example, i ndividuals in the preconformist level (E2-E3) understand causation in conCrete terms, are considered opportunistic, and have exploitative attitudes toward people (eg, a response may be, “Rules are . . . rules.“). Adolescents at the conformist level (E4-E5) are at a period characterized by cognitive simplicity and a nearly knee-jerk conformity to rules (eg, a response may be, “Rules are . . . meant to be followed.“). Individuals at the postconformist level (E6-E9) demonstrate cognitive complexity, internalization of

Test Characteristics

Response

Example

The world is oversimplified into dichotomies Causation is understood in concrete terms Egocentric self-interest First step toward control of impulses Opportunistic, controlling, manipulative and exploitative attitudes toward people Lacks long-term goals and ideas.

Raising a family is good* Rules are are rules*

Period of greatest cognitive simplicity. Dutifully obeys rules for the sake of belonging and to be accepted by parents or in group Love is defined in terms of security and being taken care of Preoccupied with appearance, material things, reputation, and social acceptance and belonging Less moral rigidity and greater tolerance for individual differences One’s world view and inner experience are still undifferentiated and oversimplified with a continued reliance on external sources for approval and authority

Raising a family is hard but can be fun* A man’s job is to support a family* The thing I like about myself is I am very friendly* A good father is one who takes care of his kid* Rules are meant to be followed*

Growth of cognitive complexity. Internalization of rules has taken place Have long-term purposes, goals, and ideas A capacity for complex conceptualization and tolerance for the contradiction and paradox in human existence There is a value on intimate relationships, personal authenticity, and moral responsibility There is a sense of individuality A highly developed vision of ambiguities and complexities of life and sensitivity to life’s paradoxes Recognition of other people’s need for autonomy Moral dichotomy is no longer typical Communications are often poetic, vivid, and touching One’s life view is characterized by a concern for social justice, self-actualization (fulfillment), identity, opposition to prejudice, and individuality in oneself

Raising a family will be a challenge with great rewards* Education is a very important part of life and a growing experience* A man’s job is the construction of personally meaningful world? Education is the development of the entire man, physical, mental, and spiritual7

Raising a family is a little hard* A man’s job is to take out the trash*

Raising a family is a challenge* A man’s job is to always be there for

me and the baby*

Raising a family involves a great deal of give and take and understanding of every member’s ideals and moralst Sex was a way to identify who she wast Raising a family is a fuljillment, including the fascination of seeing new spirits find themselves? The worst thing about being a woman is accepting your position as a woman and an individual, but once found ceases to be the worst and becomes the best7

86

Pierre et al:

Choice of Feeding Method of Adolescent Mothers

rules, and appreciation for nuances(eg, a responsemay be, “Raising a family . . . will be a challenge with great rewards.“). Form 80F of the SCT was used in this study. The scoring algorithm used for the SCT was the item-sum rating system.29,30Two trained raters scored the SCT using the prescribed methods.28X29 In the presentstudy, to analyze the SCT protocols without knowledge of the participants’ names, 50 of the sentence-completion forms, identified only by an identification number, were first typed by an assistantwho was unfamiliar with the purposesof the study. Raters had 85% agreementon the item-sum scores. Differences between the raters were resolved using the method suggestedby Loevinger and HY.~’ The resulting compromised ratings were used to calculate the item-sum scores,which were then used in the analyses. The follow-up questionnaire included the method of feeding; a forced-choice format for reasonsfor choosing or terminating breast-feeding; living arrangements;present contraceptive use; number of emergency room visits and health care visits; and infant immunization status, illnesses,and hospitalizations. Intention to breast-feed during pregnancy was measured with the question, “How do you intend to feed your baby?’ with possibleresponsesbeing “Breastand “Don’t know.” For feeding,” “Formula, ” “Both,” study purposes, respondents were then dichotomized into breast-feeders (ie, anyone indicating breast-feeding or a combination of breast- and bottle-feeding) or bottle-feeders. At the 2-week postpartum visit, breastfeeding in the hospital was assessedwith the question, “Did you try to breast-feed in the hospital?’ with possible responses being “Yes” and “No.” Feeding method at 2 weeks postpartum was assessedwith the question, “How are you feeding your baby now?’ with possibleresponsesbeing “Breast-feeding only,” “Breastfeeding and bottle with breast milk,” “Breast milk and formula,” and “Formula only.” Participants whose response included breast milk were considered to be breast-feeding. Statistical analyseswere performed using SPSS (Microsoft, Redmond, WA) for Windows statistical software (SPSS Inc., Chicago, IL).31 Descriptive statistics were usedto explore group frequencies and measuresof central tendencies. Pearson chi-square and Fisher’s exact tests were used to determine the relationship between ego development and 1) intention to breast-feed and 2) actual feeding practice in the hospital and at 2 weeks postpartum. Continuous variables were assessedusing the Spearman Rank Correlation Coefficient because these variables were not normally distributed. Grouped comparisons of ordinal variables were analyzed using Mann-Whitney U test to examine relationships between attitude scores and intention to breast-feed and breastfeeding behaviors.

Results A demographic description of the study population is provided in Table 2. Mean age at entry was 17.8 f 1.5 years (range, 14.3 to 21.8 years). Mean gestationalage of fetuses at enrollment of adolescentswas 21.2 + 11.6 weeks (range, 4.0 to 41.0 weeks), with 11 participants being enrolied at between 36 and 41 weeks’ gestation. Although 2 1% of adolescentsreported having had a prior pregnancy, none had previously given birth. Sixty percent of the pregnancies were unintended. Participants were predominantly African-American and Latina. More than half of the adolescentswere in school. The majority of the adolescentswere single and never married (82%) and were living with their mothers only or both parents at enrollment (58%). At 2 weeks postpartum, 54% were living with their mothers only or both parents. Twentyfour percent of participants reported that their mothers had completed 12th grade or a GED program, 14% reported that their mothers had completed at least some college, and 22% stated that their mothers had college degreesor more. Reporting on their male partners, adolescentsindicated that their partners’ meanage was 20.6 f 4.1 years (range, 15 to 38 years); 71% (17 of 24) of the partners who were less than 19 years of age were in school. Of the partners who were 19 years of age or older, 47% (21 of 45) had completed high school, 24% (11 of 45) were currently in school, and 73% (33 of 45) were employed. In responseto questions about previous experience with breast-feeding, the majority (86%) of the participants had seensomeonebreast-feed. Nearly half (45%) of the 63 adolescentswho knew how they were fed as infants were breast-fed. Almost three fourths of the adolescentsintended to breast-feed, and 85% tried breastfeeding in the hospital (Table 3). Of note, the number of Table

2. Demographics

of 78 Study Participants

Variable

N

Age (Y) <19 219 Race/Ethnicity White (not Hispanic) African-American (black) Hispanic/Latina Biracial Other Missing School In grade 7-12 Graduated high school or completed In GED program In college Dropped out of school Previous pregnancy Abbreviation:

GED,

general

equivalency

a GED

degree.

Percentage

63 15

81 19

5 43 20 1 6 3

6 55 26 1 8 4

35 11 5 5 11 16

50 14 6 6 13 21

Pierre Table

3. Feeding

Practices

Tried breast-feeding Was breast-feeding

et al:

Choice

of Feeding

of 77 Adolescent

in hospital at 2 wk

The values shown are the number answer the intention-to-breast-feed

4. Relationship

Between

The values shown are the number

Mothers

87

Total (N = 77)

Intended to Breast-feed (n = 58)

Did Not Intend to Breast-feed (n = 10)

Don’t Know About Breast-feeding (n = 9)

66 (85) 45 (58)

56 (97) 39 (67)

4 (40) l(10)

5 (56) 4 (44)

of patients question,

with the percentages

Ego Development

Intended to breast-feed Tried to breast-feed in hospital Breast-feeding at 2 wk

of Adolescent

Mothers

adolescents in this study who chose to breast-feed seemed high and did not reflect the national data. Because one of the two hospitals provides breast pumps to breast-feeding women, we compared the participants by hospital with respect to intention to breast-feed and breast-feeding behavior in the hospital and at 2 weeks postpartum to determine whether differences in hospital support of breast-feeding affected these behaviors. No significant difference was observed by hospital with regard to breast-feeding behaviors. Ninety-seven percent (56 of 58) of those who intended to breast-feed tried breast-feeding in the hospital compared with 40% (4 of 10) of those who did not intend to breast-feed and 56% of those who were not sure (P < .OOOS). At 2 weeks postpartum, 58% of the participants were still breastfeeding. Of those participants who intended to breastfeed, 67% (39 of 58) were breast-feeding at 2 weeks postpartum compared with 10% (1 of 10) who did not intend to breast-feed (P = .OOl; Table 3). Sixty-eight percent (45 of 66) of those who tried breast-feeding in the hospital were still breast-feeding at 2 weeks postpartum. Of the 78 participants, 12% (n = 9) were at the preconformist (E3), 85% (n = 66) at the conformist (B4E5), and 4% (n = 3) at the postconformist (E6) level of ego development. Depending on ego stage, 80% to 100% tried breast-feeding in the hospital, and 33% to 78% were breast-feeding at 2 weeks postpartum (Table 4). The three participants with postconformist scores were excluded from subsequent analyses. Intention to breastfeed, breast-feeding in the hospital, and breast-feeding at 2 weeks postpartum were not significantly associated with adolescents’ stages of ego development. As reported by adolescents, their mothers and partners were supportive of the choice of breast-feeding during pregnancy (62% and 59%, respectively) and after delivery (58% and 50%). Of the adolescents who intended to breast-feed, 89% (41 of 46) reported that their partners Table

Method

shown in parentheses.

One subject

did not

preferred that they breast-feed, compared with 50% (4 of 8) of adolescents who intended to breast-feed but whose partners did not prefer breast-feeding (P = .020). Ninety-five percent (39 of 41) of adolescents who intended to breast-feed and whose partners preferred that they breast-feed tried breast-feeding in the hospital. Of the adolescents whose mothers preferred that they breastfeed, 91% (42 of 46) intended to breast-feed compared with 50% (3 of 6) of adolescents who intended to breastfeed but whose mothers did not prefer that they breastfeed (P = .026). Ninety-five percent (40 of 42) of those whose mothers preferred that they breast-feed tried breast-feeding in the hospital. Reasons for trying breastfeeding in the hospital provided by subjects at the 2-week postpartum visit are shown in Table 5. Support provided at home immediately postpartum by a family member or a friend was reported by 95% of the adolescents. By 2 weeks after delivery, 68% of participants had had a visit by a health care provider, eg, a nurse or a home health aid. The mean breast-feeding attitude score was 53.7 + 11.6 (range, 25 to 72). No significant differences were found in scores on the breast-feeding attitude scale among adolescents who were breast-fed as infants compared with those who were not (Table 6). Those who intended to breast-feed scored higher on the breastfeeding attitude scale than did those who intended to formula-feed (mean score, 55.7 v 45.4; Mann Whitney U mean rank, 37 v 19; P = .009); however, breast-feeding attitude scores were not significantly associated with breast-feeding behaviors.

Discussion

and Conclusions

During pregnancy, most adolescents intended to breastfeed. Reflecting this intention, the rate of breast-feeding at birth was 85%, exceeding recommendations set forth

and Breast-feeding

(N = 78)

E3 (n = 9)

E4 (n = 44)

E5 (n = 22)

E6 (n = 3)

9 (100) 9 (1W

30 (68) 38 (80) 24 (55)

18 (82) 19 (86) 13 (59)

1 (33) 3 (100) 1 (33)

7 (78)

of patients with the percentages

shown in parentheses.

88

Pierre et al: Choice of Feeding Method of Adolescent Mothers

Table 5. Reasons endorsed Breast-feed in the Hospital

by Adolescent (N = 66)

Mothers

No. Who Answered Question Better for the baby’s health Many women from my ethnic/racial group breast-feed It provides closer bond to my baby Support by WIC My boyfriend’s/husband’s wish It saves time and money I can pump my milk using a breast pump, store it, and give it to the baby at a later time It is easier because there are no bottles to wash and sterilize or formula to prepare I was breast-fed also as a baby It can help you lose weight after the baby is born

Table

6. Attitude

Whitney

Percentage

60

59

98

58

29

50

59 58 57 58

46 42 33 43

78 72 58 14

58

48

83

58 54

34 30

59 56

59

37

63

Mean

*Mann

No. Who Endorsed

Scale Scores and Feeding

Mom fed as infant Breast/breast formula Formula only Intent Breast/breast formula Formula only Tried breast-feeding in hospital Yes No Breast-feeding at 2 wk Breast/Breast formula Formula only

Who Chose to

Intent Score

and Practices SD

P* .065

55.8 50.0

11.4 12.2

55.7 45.4

11.0 11.0

54.4 49.6

11.4 12.5

52.8 55.0

12.2 10.7

,009

,185

,356

U test for significance.

by the Year 2000 Health Objectives. The number of adolescents who chose to breast-feed in this study is extremely high and does not reflect the national data. Provision of breast-feeding pumps by one hospital did not affect breast-feeding behaviors. Hence, these data illustrated that, in this population, many adolescents intended to breast-feed and initiated breast-feeding in the hospital; however, fewer adolescents were breast-feeding at 2 weeks postpartum. In general, most adolescents held positive attitudes toward breast-feeding. These data illustrated that many adolescent mothers intended to breast-feed and initiated breast-feeding in the hospital. As expected, the intention to breast-feed was associated with breast-feeding in the hospital and at 2 weeks postpartum. In this sample, ego development stage was not associated with breast-feeding. This lack of association may reflect the fact that most participants were tightly grouped in the conformist stage. Another explanation is that ego development may not be directly associated with

specific behavioral outcomes. Rather, ego development may be a better predictor of more subtle aspects of adolescents’ intrapsychic experiences. We did not find that attitudes toward breast-feeding were correlated with ego development. Although not found in this study, positive attitudes toward breast-feeding have been associated with breastfeeding behavior in other studies. 17325332 The attitudes toward breast-feeding scale was associated with the intention to breast-feed in this sample, and the intention to breast-feed was associated with breast-feeding behaviors. These data provide insight into possible interventions to increase breast-feeding initiation and duration. Fostering positive attitudes and intention toward breastfeeding among pregnant adolescents may increase the prevalence and duration of breast-feeding. Health care professionals have an opportunity to foster positive attitudes toward breast-feeding and thereby increase the likelihood of this feeding method and duration of breastfeeding. Providers can underscore the need to have informed personnel available for adolescent mothers during pregnancy and, particularly, the critical first hours, days, and weeks immediately after delivery to aid and support those who choose to breast-feed. The availability of multiple supports following delivery may help to ensure a positive experience and promote continued breastfeeding. Furthermore, inviting adolescents’ partners and mothers to prenatal care visits may be useful, given the potential impact of these individuals on adolescents’ breast-feeding intentions during pregnancy, as shown in this study and others.8 In addition, if other studies of pregnant adolescents confirm this clustering (E4-E.5) of ego stage, education could be targeted at this level to design interventions to promote breast-feeding among adolescents. Because measures of ego development, attitudes, and feeding behaviors were all self-reported, these findings may reflect reporter bias or shared method variance. Thus, the interpretation of these patterns should be approached with caution. Further limitations include the predominance of minority youth in this survey and the small sample size, which limits statistical power. Given these limitations, these findings may not be generalizable to a larger, more ethnically diverse population of adolescents. Larger studies are required to fully address these issues. Future research is needed to determine whether other individual or sociocultural environmental factors predict choice of infant feeding method. In this study, ego development did not seem to be associated with breastfeeding and, therefore, does not seem to hamper the choice of feeding method. Future work may focus on analyzing the content of the answers to the SCT to provide further insight into the thought processes of adolescents. Additional studies, however, are needed to explore whether this instrument is sufficiently sensitive to mea-

Pierre et al: sure the level of ego development lations.

Choice of Feeding Method of Adolescent Mothers

in multiethnic

popu14.

Acknowledgments: We are thankful to Michael Becker for data entry, Amanda Tibbetts for her much-appreciated administrative assistance, and Laurie Foster, MS., for her assistance in the scoring of the ego-development Sentence Completion Test. We also thank the staff of the Young Parenting Program at Children’s Hospital, Boston, and the Teen and Tot Clinic at Boston Medical Center for their help and cooperation during the course of this study.

15.

16.

17.

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