Exploring Health Providers’ Perspective Regarding the Needs of Adolescent Mothers During Breastfeeding: A Qualitative Study

INTRODUCTION

Initiation of breastfeeding, exclusive breastfeeding, and continuous breastfeeding for up to two years are less common among adolescent mothers than adult mothers. ^{1 , 2} As characterized by the World Health Organization (WHO) in an explanation, breastfeeding by adolescent mothers is called “feeding under exceptionally difficult circumstances”. ³ WHO prescribes that babies should be solely breastfed until the age of six months. Despite the suggestions of the WHO, around 44% of babies in the world receive breast milk up to six months. ^{4 , 5} Different nations have lower breastfeeding rates among adolescent mothers than the adult mothers. ^{2 , 6 , 7}

Depending on the age and social circumstances, the components influencing infant feeding methods vary in adolescent and adult mothers. Adolescent mothers need information of breastfeeding, often need support from families and healthcare workers, and have less capacity to oversee breastfeeding problems. ⁸ In addition, based on the results of various studies, most of these mothers are not in good social and economic conditions and face many physical, psychological and social challenges, including facing unknown situations, mental health problems such as depression, anxiety, lack of self-confidence, multiple responsibilities, dropping out of school, financial problems, and negative cultural reaction related to their ability to become parents, which affect their breastfeeding. ^{9 , 10}

Breast milk is the finest nourishment for babies of adolescent mothers. Since their babies frequently confront health issues caused by premature birth and low birth weight, breastfeeding can decrease the seriousness of these babies’ health issues because human milk contains antibodies and enzymes that support the development of babies. ¹¹

In spite of the importance of breastfeeding in adolescent mothers, it is not specified within the breastfeeding guidelines and studies of Iran; also, breastfeeding needs of this group of mothers is ignored within the Iranian health system. Therefore, in order to recognize and discover this phenomenon, we made an attempt to conduct a qualitative study which was required in this field. ¹² The term “need” has been defined in a variety of ways, all aiming at enhancing the population’s access to health care. Needs assessments serve as a catalyst for enhancements and modifications to healthcare offerings. ¹³ The concept of needs used in this study was according to Bradshaw’s taxonomy of social needs. Bradshaw distinguished between four different kinds of needs: comparative, normative, felt, and expressed. For this study, one category from Bradshaw’s taxonomy was used: the normative needs. Normative need is defined by experts and typically produces services meant to look after members of society. ¹⁴

To the best of the research team’s knowledge, no study was found in the field of explaining the breastfeeding needs of adolescent mothers in Iran. Therefore, the present study was carried out with the aim of exploring the normative needs of adolescent mothers during breastfeeding from healthcare providers’ perspective.

METHODS

This is a qualitative content analysis conducted in two provinces of Iran, Mashhad and Urmia. Participants were health providers, which had appropriate knowledge in the field of breast milk including pediatricians, obstetricians, lactation consultants, midwives, nurses, and senior managers in the field of breast milk. They were required to have at least two years of relevant work experience and willingness to cooperate to participate in the study. Their unwillingness to take part at each stage during the interview was the exclusion criterion.

Sampling was done purposefully and with maximum variation such as various organizational positions, age, sex, work experience, and education level. The researcher attended the workplace of the participants to do the sampling. After a brief explanation of the purpose of the study was provided and their consent to participate in the study was obtained, an appointment was made with them to conduct an interview. Before the interview, written consent was obtained from the participants who had entered the study. The interview location was selected based on the participants’ convenience, such as health centers, hospitals or their work office. Based on the admission requirements, in-depth interviews were conducted with 14 stakeholders. Sampling continued from October 2022 to June 2023.

The first author performed face-to-face, semi-structured interviews that lasted approximately one hour (ranging from 48-80 minutes). Health providers were asked to express their thoughts and experiences with adolescent mothers’ breastfeeding needs and respond to open-ended questions. The interview guide included the following questions: “What problems and obstacles do adolescent mothers face during breastfeeding?”, “What conditions do you think affect breastfeeding of adolescent mothers?”, “If we want to take measures to support the breastfeeding of adolescent mothers, what should we pay attention to?” Questions such as “Can you tell me more about that?” or “Can you give an example of this?” were used to encourage the participants to share more and probing. All interviews were recorded using a voice recorder and transcribed verbatim. Sampling continued until we obtained no additional information and had gathered sufficient data regarding the subject under study.

Data analysis and management were carried out using the MAXQDA software version 10. Data analysis was carried out simultaneously with the data collection process using Graneheim and Lundman’s approach in four stages. ¹⁵ In stage 1, the interviews were read a few times to get an idea of their content and pick up an insight and the entire idea through investigating of both latent and manifest content. In stage 2, the texts of each interview transcript were separated into meaning units characterized as words, sentences, and paragraphs within the text, where the content of diverse texts were related to each other. In stage 3, the meaning units were condensed and labeled with codes. In stage 4, the codes were compared in terms of similarity and differences, and the similar codes were set within the initial categories. As the analysis advanced, the initial categories were developed and subcategories were shaped. The categories then emerged from the integration of similar subcategories.

Lincoln and Goba’s criteria including credibility, dependability, confirmability, and transferability were considered. ¹⁶ For trustworthiness, prolonged engagement with data comparison increased the credibility of the study. Also, in the analytical stage, both evaluation by experts in the research team and audit by experts in qualitative research outside the research team were used, and they confirmed appropriate decisions and analytic process (dependability). Furthermore, some quotations, codes, sub-categories and categories were evaluated by the research team (confirmability). Transferability of the data was provided via a purposive sampling which made maximum diversity in demographic characteristics.

This study was approved by the Ethics Committee of Mashhad University of Medical Sciences (IR.MUMS.REC.1401.110), and the participants provided informed consent to take part in the study after a comprehensive explanation of the study objectives and methodology. Participants were assured that their involvement was entirely voluntary, they had full right to withdraw from the study at any point, and any information they provided would be treated with utmost confidentiality. Written consent was obtained from the participants before conducting the interview.

RESULTS

The participants’ age ranged from 32 to 59 years. The majority of the participants (78.5%) were women. Health providers’ work experiences were between 7 and 33 years. Table 1 shows the participants’ characteristics in this study.

From the data analysis, 16 subcategories and seven themes were extracted from the perspective of health providers regarding the normative needs of adolescent mothers in breastfeeding duration. The main theme of “comprehensive support” was created from the integration of the categories, including the “need to correct wrong traditional beliefs”, “educational and counseling needs”, “providing quality services”, “need for psychological support”, “ need for protective laws”, “financial needs”, and “the need for social network support” (Table 2).

1. Need to Correct Wrong Traditional Beliefs

According to the key informant’s statements, the decision of adolescent mothers to begin and maintain breastfeeding is greatly influenced by the customs and traditions they have inherited from older generations. Even with the necessary information, adolescent mothers who lack freedom and knowledge about breastfeeding and living with their parents tend to adhere to traditional notions about feeding their infants. Convictions such as adolescent mothers’ and families’ perceptions of colostrum as low-quality milk, failure to breastfeed due to the adolescent mother’s small breasts, adolescent mothers’ concern about sagging breasts after breastfeeding, giving sugar water to the infant on the first day after birth, early start of complementary feeding to gain weight and the risk of breastfeeding for the health of adolescent mothers are incorrect traditions that the family and the young mothers still adhere to. A midwife said:

“I had a mother who didn’t let us breastfeed her baby after birth, she says that the baby should defecate first and then drink milk, or for example, adolescent mothers were not allowed to breastfeed, saying that their breasts are too small to produce milk.”(P10)

2. Educational and Counseling Needs

The consensus among the key informants was that adolescent mothers were insufficiently informed and lacked the necessary abilities for breastfeeding. The healthcare system and breastfeeding guidelines often neglect the needs of these mothers, leaving them without sufficient support for breastfeeding. Therefore, for success in breastfeeding, receiving training and acquiring the necessary skills from healthcare professionals are crucial. According to the study participants, adolescent mothers should be educated about breastfeeding during pregnancy, delivery, as well as before pregnancy.

Numerous participants stated that expectant adolescent mothers saught assistance at health centers, yet these facilities fail to provide education on breastfeeding. The healthcare providers solely educate pregnant adolescents on potential danger signs of pregnancy but neglect the acquisition of knowledge on breastfeeding skills of adolescent mothers. Meanwhile, adolescent mothers need to attend more educational and counseling sessions than adult mothers, and the time of each breastfeeding counseling session in this group of mothers should be more than that of adult mothers. A participant mentioned:

“During pregnancy, adolescent mothers do not receive any training from health centers to breastfeed. Health center workers only focus on pregnancy risk symptoms and do not provide these mothers who have no information about breastfeeding with education” (P6).

Ensuring that adolescent mothers participate in classes to prepare for childbirth was deemed significant by some participants, and they advocated the comprehensive availability of these classes in all healthcare centers. The inclusion of specific breastfeeding instruction in these classes is also crucial. Some participants suggested that adolescent mothers should undergo specialized classes on breastfeeding before giving birth, enabling them to acquire the necessary skills. A participant told:

“These mothers need more breastfeeding training than adult mothers because they have no breastfeeding experience, so it is better to consider special breastfeeding classes for them.” (P3)

Participants agreed that adolescent mothers must receive practical breastfeeding training after giving birth. To ensure effective learning of breastfeeding skills, the midwife must stay near the mother and provide guidance. It was also emphasized that any issues regarding breastfeeding should be addressed and monitored following discharge from the hospital.

“Adolescent mothers should receive individualized breastfeeding instruction at the hospital. Rather than instructing them collectively in a room with seven or eight other mothers, a nurse or midwife should teach them individually. A young mother might not be as familiar with breastfeeding as an adult mother. Thus, you need to dedicate plenty of time to train them.” (P12)

Home visit was recommended as an appropriate solution to assess their breastfeeding progress and provide assistance if there are any challenges. A health provider implied:

“After the baby is born, we can conduct a home visit to educate adolescent mothers on breastfeeding and enhance their breastfeeding skills. A home visit presents a valuable chance to identify breastfeeding issues mothers may be facing and offer them suitable solutions” (P5).

Some participants believed that educating adolescent girls about the advantages of breastfeeding should take place in various settings such as high schools, pre-marital counseling sessions, and through media platforms like TV or the Internet.

“While at school, we are presented with a valuable opportunity to educate adolescent girls and boys about the significance of breastfeeding” (P4).

3. Providing Quality Services

This category explains the essential facilities and equipment that hospitals and health centers are required to have to effectively support breastfeeding among adolescent mothers. According to some participants, hospitals or health centers lack the necessary equipment for holding educational programs about breastfeeding or managing breast-related issues such as sunken nipples. Health centers required educational videos to demonstrate proper breastfeeding methods and breast pump machines for mothers. A lactation consultant said:

“In a big hospital like this we don’t have enough good breast pump machines. Every department needs at least one machine that helps with pumping breast milk. For instance, if a mother’s nipples are sunken in, I need to contact the neonatal unit, neonatal intensive care unit, or the delivery room to get a breast pump machine” (P6).

According to some participants, even though a significant number of premature deliveries and underweight babies are born to adolescent mothers, there is a shortage of adequate resting facilities for these mothers in the neonatal intensive care unit, so individuals who come to the hospital from different areas are required to reside in the hospital chapel. As a result, lack of adequate rest and sleep negatively impacts both the quantity and quality of the mother’s breast milk. A nurse implied:

“The mothers’ resting room is located in a small section, and mothers visiting from other cities have nowhere to rest” (P13).

The consensus among most people is that there is an inadequate number of breastfeeding counselors in the country, and the training workshops they receive are not of satisfactory quality.

Moreover, midwives and nurses in hospitals and health centers dedicate significant time to writing reports and maintaining files and less time to spend on educating breastfeeding to mothers. A participant said:

“A midwife dedicates a significant amount of time to inputting information into the computer system and completing various forms. As a result, they have limited time to educate mothers about breastfeeding in the hospital.” (P7)

Key informants mentioned that healthcare workers and doctors are not adequately educated in providing advice on promoting breastfeeding, while the workshops they participate in to enhance breastfeeding promotion are insufficient in both quantity and quality. They do not have enough knowledge and skills to provide breast milk counseling; thus, when an adolescent mother is faced with breastfeeding challenges, some specialist doctors or healthcare providers recommend feeding the baby with powdered milk.

“Pediatricians have limited experience in breastfeeding counseling. Most of them recommend formula to adolescent mothers who experience nipple pain or their baby has jaundice.” (P11)

4. Need for Psychological Support

This category expresses the psychological requirements of adolescent mothers as they nurture their babies through breastfeeding. Most of the key informants stated that adolescent mothers required psychological support from medical professionals and their families due to their young age, social status, and limited experience, to adapt to motherhood, get accustomed to breastfeeding, and conquer challenges faced during the breastfeeding process. Moreover, they believed that adolescents might not be accountable due to their youth, so emotional support is essential in ensuring that they can breastfeed and care for their babies. One of the participants stated:

“Adolescent mothers need counseling to deal with issues like sore nipples and waking up at night to breastfeed. If a mother doesn’t receive enough encouragement and psychological support, she may stop breastfeeding very soon, and this negative experience will always be on her mind.” (P12).

According to some participants, adolescent mothers facing premature births require psychological support concerning their emotional well-being due to experiencing significant stress and anxiety. Milking and feeding babies via gavage are a stressful process for them. Therefore, these mothers should receive psychological counseling and support from counselors, healthcare providers, and their families to play motherly roles. One of the nurse said:

“An adolescent mother who has a premature baby feels overwhelmed and shocked when she meets the baby for the first time. These mothers should receive counseling to help them cope with their emotions while in the hospital.” (P13)

Many participants stated that most adolescent mothers lacked the self-assurance to breastfeed their babies and they did not believe in their physiological ability to breastfeed. To establish and continue the practice of breastfeeding, they require psychological support in enhancing their self-assurance and faith in their abilities by articulating their feelings and ideas. A midwife said:

Most of these mothers don’t have the necessary self-confidence to breastfeed. They don’t believe in their own abilities at all. In my opinion, this group of mothers should receive psychological support and the people around them should encourage them.”(P8)

5. The Need for Protective Laws

The category of this discussion revolves around the establishment of guidelines to assist adolescent mothers with breastfeeding their babies by the government. According to some key informants, fathers are allegedly denied the opportunity to take leave following the birth of their child by private companies or government entities. They acknowledged that young fathers should be granted longer duration leave from work following the birth of their baby to assist their spouses and offer more assistance to their wives. Also, if adolescent mothers work in private companies, they should be given maternity leave for nine months. A participant said:

“In my opinion, adolescent mothers’ husbands should be able to take more time off work after their child is born. They should have nine months of leave to support their wives emotionally and help them with household chores.” (P10)

Some mentioned that adolescent mothers dropped out of school due to their pregnancy and the need to care for their infants through breastfeeding. They suggested implementing regulations to prevent mothers from leaving school, offering a dedicated nursery school for their children, and providing the necessary facilities for milking and storing milk in school.

6. Financial Needs

This category discusses the financial requirements of adolescent mothers and need to access to the financial resources. According to the study participants, many adolescent mothers have a disadvantaged social and economic position with limited financial resources. Moreover, the adolescent mother is incapable of earning money due to her lack of the necessary skills, and their husbands are also young. For the same reason, they were denied the chance to access higher education or gain the necessary expertise to generate income, resulting in a lack of desirable employment prospects and financial stability. Therefore, these families have limited access to nutritious food during pregnancy and breastfeeding, powdered milk, and supplementary meals for children.

Despite the existing program requiring the distribution of food baskets to mothers, some participants stated that it was not implemented within the nation. Politicians must ensure meticulous planning to implement this program successfully within the country. The government and charitable organizations should provide financial assistance to support these mothers. A pediatrician said:

“The program says that food baskets can be given to mothers, but this doesn’t happen in the country. Many cases of intrauterine growth restriction are seen in adolescent mothers. Like other countries, the government should provide the pregnant women and mothers with food baskets for the first six months after their baby is born. This can help encourage mothers to breastfeed their babies.” (P1)

7. The Need for Social Network Support

The category describes that adolescent mothers require support from their social network including husband, family members, peers, and other members of society. Because of their lack of experience with breastfeeding and childcare, the majority of the participants stated that adolescent mothers required support from their husbands and families. Furthermore, peer support was essential in breastfeeding adolescent mothers, particularly in mothers with special conditions such as premature babies.

According to the participants, adolescent mothers in society are subject to criticism depending on their capability to breastfeed their infants. Additionally, they are sometimes held accountable for their early pregnancies, and there is no positive attitude towards pregnancy and breastfeeding of adolescent mothers in the society. As a result, society must accept this group of mothers and permit breastfeeding in public settings. One of the participants stated:

“When a pregnant adolescent mother wants to appear in public or breastfeed her baby, she receives negative reactions from those around her, causing her to either avoid society or not bring her baby to public places.” (P14)

DISCUSSION

This qualitative study attempts to investigate the normative needs of breastfeeding in adolescent mothers from the perspectives of the healthcare providers. One of the needs was correcting the wrong beliefs and traditions of the previous generation, which affect the initiation of breastfeeding and exclusive feeding of these mothers. According to Hannon et al. and Ingram et al., conventional behaviors play a significant role in the failure of exclusive breastfeeding among adolescent mothers. Behaviors that contradict the most recent research and recommended breastfeeding practices can result in breastfeeding failure in adolescent mothers. ^{17 , 18}

Studies in India and Kenya also show that people believe that giving colostrum to a baby should be avoided or give water to a baby in the first week of birth to prevent jaundice, ^{19 , 20} which is consistent with the results of the current study.

In the present study, participants highlighted the need for education and counseling, which healthcare professionals should address as one of the needs of adolescent mothers for breastfeeding. Numerous sources have highlighted the significance of education for adolescent mothers. According to Jamiea et al. and Pentecost et al., adolescent mothers require information and breastfeeding training from nurses. Adolescent mothers should be permitted to breastfeed while under the supervision of nurses, and nurses should respond to their inquiries. ^{21 , 22} Due to their age and lack of college education, adolescent mothers may not have had sufficient time to acquire knowledge about breastfeeding. Additionally, these mothers have no prior experience with breastfeeding; thus, they lack the essential skills required for successful breastfeeding. Breastfeeding education is not offered to adolescent mothers in Iran before childbirth, such as during pregnancy or in the classroom, while prenatal care visit is a significant opportunity for adolescent mothers to obtain breastfeeding information. ²³

The provision of high-quality services, including proper equipment, enough staff, training, and supportive attitudes of healthcare toward breastfeeding were the other needs of adolescent mothers. One of the crucial factors in the success of breastfeeding among these mothers is raising awareness and encouraging attitudes of healthcare professionals toward breast milk. ²⁴ In a study, one of the factors that hindered breastfeeding for adolescent mothers was revealed to be the insufficient knowledge among doctors regarding breast milk. ²⁵

Psychological assistance from their families and healthcare professionals was a need to successfully adjust to their responsibilities as mothers and enhance their self-assurance and self-esteem to breastfeed successfully. Some studies showed that adolescent mothers lacked confidence in their abilities and required support, and increased self-confidence and motivation to initiate breastfeeding. ^{24 , 26}

From the perspective of healthcare providers, establishing laws that provide protection and educational opportunities is crucial for the benefit of adolescent mothers. The adolescent mothers required school support to successfully resume their education and preserve their breast milk while attending school. This achievement needs unified rules for returning to school after the birth of a child. ^{27 , 28}

Financial support was an important need for breastfeeding among adolescent mothers which was also mentioned in other studies. ^{29 , 30} It can be argued that the insufficient academic credentials of adolescent mothers for specific job positions, resulting from their dearth of education, and the lack of financial support from their impoverished parents are the primary factors contributing of their impoverishment and their financial requirements. Therefore, the philanthropic and non-governmental organization support, establishment of protective programs such as the government’s donation of food baskets and support for insurance for breastfeeding services, as well as the training of earning skills in farming and handicrafts, can be an alternative to improve the economic status of these mothers.

One of the needs of adolescent mothers during breastfeeding is the need for social network support from husbands, family members, peers, and other community members. A study revealed that adolescent mothers required psychological and informational support from their family and spouse to face the challenging practical problems associated with breastfeeding. ³¹ Adolescent mothers have more positive and productive interactions with their peers. They might find peer support and information exchange more acceptable. ²² Some studies have indicated that breastfeeding requires the support of the spouse or sexual partner and that this support is an essential factor in enabling adolescent mothers to continue breastfeeding. The support and involvement of the desired partners in breastfeeding activities can impact a mother’s ability, confidence, and self-esteem. ^{32 , 33} One could argue that adolescent mothers’ dependence on others develops due to their ignorance of child development, care, and breastfeeding and the challenges and psychological and physical changes associated with puberty. ^{34 , 35}

Findings showed that adolescent mothers faced criticism and were subject to blame while going through pregnancy and breastfeeding. This indicates that society should approach them respectfully and without condemnation, acknowledging and including them as adolescent mothers. Furthermore, adolescent mothers who breastfeed in public are subject to judgment when they are out in the community. ²⁶ A systematic review study found that breastfeeding issues related to being judged and feeling ashamed are constant obstacles to breastfeeding for adolescent mothers, resulting in low self-confidence when feeding in public. ³⁶

The current study focused on breastfeeding of adolescent mothers in Iran, and the findings can be highly valuable in recognizing the needs of the mothers and revealing them to health system policymakers. In addition, the researchers attempted to achieve the necessary diversity in participants so that they can supply rich and diverse data, which is one of the strengths of the current research. One of the limitations of the current research is that adolescent mothers and their families were not interviewed.

CONCLUSION

According to the findings of the current study, adolescent mothers in Iran have various needs during breastfeeding, and they require the assistance of their families, healthcare providers, and the government to fulfill them. Therefore, it is also recommended that policymakers in the health system should design policies to accommodate the requirements of this group of mothers. In addition to policy development in the health system, the infrastructure required for policy and law execution should be considered.

Conflict of Interest:

None declared.

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