Interactive web-based breastfeeding monitoring: feasibility, usability, and acceptability

Lessons for the UK on implementation and evaluation of breastfeeding support: evidence syntheses and stakeholder engagement

Background

Breastfeeding impacts positively on multiple health outcomes, but < 50% of UK women breastfeed at 8 weeks. Women with long-term conditions face additional challenges in breastfeeding.

Objectives

To synthesise global and UK evidence to co-create an implementation and evaluation toolkit for cost-effective breastfeeding support in the NHS.

Design

Evidence syntheses with stakeholder engagement.

Review methods

Systematic reviews examined effectiveness of breastfeeding support for (1) healthy women and (2) women with long-term conditions using Cochrane Pregnancy and Childbirth Group methods. Mixed-methods systematic reviews synthesised process evaluations of effective breastfeeding support interventions for healthy women and experiences of receiving/providing support for breastfeeding women with long-term conditions. Cross-study synthesis integrated qualitative and quantitative findings. Systematic reviews synthesised evidence on the incremental costs and cost-effectiveness of breastfeeding support following National Institute for Health and Care Excellence guidance. All searches were conducted from May 2021 to October 2022. Stakeholder engagement and toolkit development comprised online discussions, a modified Delphi study, focus groups and four workshops. Participants were 23 stakeholders, 16 parents in the parents' panels, 15 women in the focus groups and 87 stakeholders who attended the workshops.

Results

We found considerably more interventions designed for healthy women (review 1) than aimed at women with long-term conditions (reviews 1 and 4); approximately half of the studies were targeted at groups at higher risk of poor breastfeeding outcomes, and the impact of support may be different in these populations. Despite this, studies from review 2 found that women perceived the provision of support as positive, important and needed. Studies from review 5 echoed a range of suggestions from participants regarding potential strategies to improve breastfeeding support, with the most widely reported being the need to acknowledge the role and influence of other sources of support (e.g. partners, family, friends, peers, external professionals, web-based resources) and involving these sources in the provision of breastfeeding support for women with long-term conditions. In reviews 3 and 6, there was uncertainty about the cost-effectiveness of breastfeeding support interventions due to the limited number of studies and lack of good-quality evidence.

Limitations

There was a lack of evidence for the effectiveness and cost-effectiveness of breastfeeding interventions in the UK. There was often insufficient information reported about intervention characteristics.

Conclusions

'Breastfeeding only' support probably reduces the number of women stopping any or exclusive breastfeeding. The evidence for 'breastfeeding plus' interventions is less consistent, but these may reduce the number of women stopping exclusive breastfeeding at 4-6 weeks and at 6 months. We found no evidence of differential intervention effects regarding mode of provision or provider. Cost-effectiveness is uncertain due to the lack of good-quality evidence. Key enablers of successful implementation were responsiveness and tailoring of interventions to both women's and supporters' needs. Breastfeeding support as delivered in the included studies probably has little to no effect on breastfeeding outcomes for women with long-term conditions. The mixed-methods synthesis and stakeholder work identified that existing interventions may not address the complex needs of these women. The main study output is a co-produced toolkit to guide implementation and evaluation of breastfeeding support services in the UK.

Future work

Evaluation of breastfeeding support for all women, particularly those at risk of poor breastfeeding outcomes (e.g. long-term conditions, deprivation). This could involve tailoring the toolkit to local contexts via implementation and effectiveness studies or using quality improvement studies.

Study registration

This study is registered as PROSPERO CRD42022337239, CRD42021229769 and CRD42022374509. The reviews of economic evidence were not registered; however, the review protocol can be accessed via the repository held by Queen's University Belfast Research Portal (https://pure.qub.ac.uk/).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130995) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 20. See the NIHR Funding and Awards website for further award information.

Breastfeeding Monitoring Improves Maternal Self-Efficacy and Satisfaction

PURPOSE

The purpose of this study was to determine the effects of an interactive web-based breastfeeding monitoring system on breastfeeding self-efficacy and satisfaction among mothers of full-term infants at 1, 2, and 3 months after hospital discharge.

STUDY DESIGN

We conducted a secondary data analysis of our two-arm, repeated-measures randomized controlled trial that took place in three Midwestern hospitals. Participants were assigned to either control or intervention groups using random numbers. Of the 141 mother-baby dyads enrolled and randomized, 35 dropped out of the study, leaving 57 mothers in the control group and 49 in the intervention group. Mothers in both groups received care based on the hospital protocol, but mothers in the intervention group were also given access to an interactive web-based breastfeeding monitoring system prior to discharge. Participants were asked to enter breastfeeding data, receive educational messages for 30 days, and complete the Breastfeeding Self-Efficacy Scale (BFSE) at 1, 2, and 3 months and the Maternal Breastfeeding Evaluation Scale (MBFES) at 3 months. Mothers received feedback in case of breastfeeding problems.

RESULTS

A significant difference between groups in BFSE at the 2 and 3 months (p = 0.04; p = 0.04) with medium effect size (0.52, 0.53) was found. There was a significant difference between groups in the total score of MBFES (p = 0.02, effect size 0.53). Mean scores were 122.2, SD = 17.68 for intervention and 112.8, SD = 18.03 for control group. The MBFES scores were positively correlated to BFSE scores among intervention group at all time points (r = .714, n = 45, p < .00; r = .611, n = 41, p < .00; r = .637, n = 39, p < .00).

CLINICAL IMPLICATIONS

Interactive web-based breastfeeding monitoring improved maternal breastfeeding self-efficacy and satisfaction and may be a promising innovation to promote maternal breastfeeding self-efficacy and satisfaction.

Patient and Provider Use of Electronic Care Plans Generated From Patient-Reported Outcomes

OBJECTIVES

To determine if patients and providers perceived improved care processes through the delivery of personalized, electronic care plans (CPs) generated from the Carevive Care Planning System™.

SAMPLE & SETTING

121 women (51 with gynecologic cancer from Billings Clinic and 70 with breast cancer from Moffit Cancer Center) completed electronic patient-reported outcome assessments and were given electronically generated, personalized supportive CPs tailored to individual symptoms and local healthcare resources.

METHODS & VARIABLES

Quantitative instruments evaluated feasibility, usability, acceptability, and satisfaction of the CPs from patient and provider perspectives. Qualitative interviews described patient perceptions of the CPs.

RESULTS

Patients with cancer reported the CPs to be useful. Most perceived that CPs improved team communication, helped find needed resources, and helped manage symptoms. Provider satisfaction was highest with the platform's ability to customize patient recommendations. Interviews indicated that patients with cancer used their CP as a resource, preferred delivery at treatment initiation, and valued information to manage symptoms.

IMPLICATIONS FOR NURSING

Nurses play an integral role in patient education and in discussing individual care. Tailored CPs can be used as a teaching tool that patients with cancer can refer to for self-care.

Effectiveness of Internet-Based Electronic Technology Interventions on Breastfeeding Outcomes: Systematic Review

BACKGROUND

Supporting women to initiate and continue breastfeeding is a global challenge. A range of breastfeeding interventions employing electronic technologies (e-technologies) are being developed, which offer different delivery modes and features over the internet; however, the impact of internet-based e-technologies on breastfeeding outcomes remains unclear.

OBJECTIVE

This study aimed to identify the characteristics of current internet-based breastfeeding interventions employing e-technologies and investigate the effects of internet-based e-technologies on breastfeeding outcomes.

METHODS

A systematic search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in the following databases: Scopus, Web of Science, the Cochrane Database of Systematic Reviews, ScienceDirect, Google Scholar, the Association for Computing Machinery, SpringerLink, and Institute of Electrical and Electronics Engineers Xplore.

RESULTS

This systematic review included 16 studies published between 2007 and 2018, with 4018 women in 8 countries. The characteristics of the interventions were grouped based on (1) mode of delivery (web-based, mobile phone apps, and computer kiosk), (2) purpose of the interventions (education and support), and (3) key strategies (monitoring and breastfeeding tracking, personalization, online discussion forum, web-based consultation, and breastfeeding station locators). Combining educational activities with web-based personalized support through discussion forums appeared to be the most effective way to improve breastfeeding outcomes and long-term exclusive breastfeeding rates. Monitoring and breastfeeding trackers appeared to be the least effective ways.

CONCLUSIONS

This study demonstrated a variety of internet-based e-technologies that professionals can use to promote, educate, and support breastfeeding women. Future internet-based breastfeeding interventions employing e-technologies might consider improving interaction with mothers and personalizing the content of the proposed interventions.

Use of Telehealth to Increase Breastfeeding Exclusivity and Duration

Telehealth is a rapidly growing healthcare modality that can be utilized to deliver breastfeeding education and support to increase breastfeeding outcomes including exclusivity and duration. The purpose of this integrative review is to explore and evaluate the strength of the current research evidence supporting the effectiveness of telehealth to deliver breastfeeding education and support. The review was conducted using five electronic databases to search English language articles related to telehealth and breastfeeding from 2009 to 2016. Eleven studies were identified as meeting the inclusion criteria, and included a total of 4,896 participants in five countries. Results from the review suggest that telehealth is a promising modality for breastfeeding education and support and is perceived as an acceptable and beneficial delivery method. More research is needed to determine which specific modalities are most effective and how they are best implemented.

Pilot Testing a Web-Based System for the Assessment and Management of Chemotherapy-Induced Peripheral Neuropathy

Because numerous barriers hinder the assessment and management of chemotherapy-induced peripheral neuropathy in clinical practice, the Carevive Care Planning System, a novel Web-based platform, was developed to address these barriers. It provides patients an opportunity to report their symptoms before their clinic visit and generates customizable care plans composed of evidence-based management strategies. The purpose of this study was to evaluate patient and provider perspectives of feasibility, usability, acceptability, and satisfaction with the Carevive platform. We used a single-arm, pretest/posttest, prospective design and recruited 25 women with breast cancer who were receiving neurotoxic chemotherapy and six advanced practice providers from an academic hospital. At three consecutive clinical visits, patients reported their neuropathy symptoms on a tablet via the Carevive system. The Diffusion of Innovations Theory served as an overarching evaluation framework. The Carevive platform was feasible to use. However, patients had higher ratings of usability, acceptability, and satisfaction with the platform than did the providers, who disliked the amount of time required to use the platform and had difficulty logging into Carevive. If issues regarding provider dissatisfaction can be addressed, the Carevive platform may aid in the screening of neuropathy symptoms and facilitate the use of evidence-based management strategies.

The Effect of Interactive Web-Based Monitoring on Breastfeeding Exclusivity, Intensity, and Duration in Healthy, Term Infants After Hospital Discharge

OBJECTIVE

To determine whether a Web-based interactive breastfeeding monitoring system increased breastfeeding duration, exclusivity, and intensity as primary outcomes and decreased symptoms of postpartum depression as a secondary outcome.

DESIGN

Two-arm, randomized controlled trial.

SETTING

Three hospitals in the Midwestern United States.

PARTICIPANTS

One hundred forty one (141) mother-newborn dyads were recruited before discharge.

METHODS

Postpartum women were randomly assigned to the control or intervention groups. Women in the control group (n = 57) followed the standard hospital protocol, whereas women in the intervention group (n = 49) were given access to an online interactive breastfeeding monitoring system and were prompted to record breastfeeding and infant output data for 30 days. A follow-up online survey was sent to both groups at 1, 2, and 3 months to assess breastfeeding outcomes and postpartum depression.

RESULTS

For mothers and infants, there were no significant differences in demographics between groups. No significant differences in breastfeeding outcomes were found between groups at discharge (p = .707). A significant difference in breastfeeding outcomes was found between groups at 1, 2, and 3 months (p = .027, p < .001, and p = .002, respectively). Members of the intervention group had greater exclusive breastfeeding rates at 1, 2, and 3 months. By the end of the third month, 84% of the intervention group was breastfeeding compared with 66% of the control group. Postpartum depression symptom scores decreased for both groups at 1, 2, and 3 months (control group: 4.9 ± 3.9, 4.3 ± 4.9, and 3.2 ± 3.9, respectively; intervention group: 4.7 ± 4.5, 3.0 ± 3.4, and 2.8 ± 3.6, respectively). However, there was no significant difference between groups at 1, 2, and 3 months (p = .389, .170, and .920, respectively) for depression.

CONCLUSION

The Web-based interactive breastfeeding monitoring system may be a promising intervention to improve breastfeeding duration, exclusivity, and intensity.

Can a text message a week improve breastfeeding?

BACKGROUND

Breastfeeding is recognised as the optimal method for feeding infants with health gains made by reducing infectious diseases in infancy; and chronic diseases, including obesity, in childhood, adolescence and adulthood. Despite this, exclusivity and duration in developed countries remains resistant to improvement. The objectives of this research were to test if an automated mobile phone text messaging intervention, delivering one text message a week, could increase "any" breastfeeding rates and improve breastfeeding self-efficacy and coping.

METHODS

Women were eligible to participate if they were: over eighteen years; had an infant less than three months old; were currently breastfeeding; no diagnosed mental illness; and used a mobile phone. Women in the intervention group received MumBubConnect, a text messaging service with automated responses delivered once a week for 8 weeks. Women in the comparison group received their usual care and were sampled two years after the intervention group. Data collection included online surveys at two time points, week zero and week nine, to measure breastfeeding exclusivity and duration, coping, emotions, accountability and self-efficacy. A range of statistical analyses were used to test for differences between groups. Hierarchical regression was used to investigate change in breastfeeding outcome, between groups, adjusting for co-variates.

RESULTS

The intervention group had 120 participants at commencement and 114 at completion, the comparison group had 114 participants at commencement and 86 at completion. MumBubConnect had a positive impact on the primary outcome of breastfeeding behaviors with women receiving the intervention more likely to continue exclusive breastfeeding; with a 6% decrease in exclusive breastfeeding in the intervention group, compared to a 14% decrease in the comparison group (p < 0.001). This remained significant after controlling for infant age, mother's income, education and delivery type (p = 0.04). Women in the intervention group demonstrated active coping and were less likely to display emotions-focussed coping (p < .001). There was no discernible statistical effect on self-efficacy or accountability.

CONCLUSIONS

A fully automated text messaging services appears to improve exclusive breastfeeding duration. The service provides a well-accepted, personalised support service that empowers women to actively resolve breastfeeding issues.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12614001091695.

Development and assessment of an interactive web-based breastfeeding monitoring system (LACTOR)

The purpose of this study is to describe an interactive web-based breastfeeding monitoring system (LACTOR), illustrate its components, explain the theoretical framework, and discuss its assessment as a model for an innovative breastfeeding support intervention. Based on the self-regulation model from Bandura Social Cognitive Theory, we have developed an interactive web-based breastfeeding monitoring system using a breastfeeding diary. The system has two main components: the Mothers' Portal, where mothers can enter their breastfeeding data and receive notifications, and the Lactation Consultants' Portal, where mothers' data can be monitored. The system is designed to send notifications to mothers in case of breastfeeding problems using triggers such as inability to latch, sleepy infant, jaundice, and maternal sore nipples. A prospective, descriptive, mixed methods study was conducted to examine the feasibility, usability, and acceptability of LACTOR among breastfeeding mothers. Eligible mothers were asked to enter their breastfeeding data into the system daily for 30 days and then submit an online system evaluation survey. Twenty-six mother/infant dyads completed the study. Feasibility of the system was established by the mothers' compliance in entering breastfeeding data. The system proved to be user-friendly. The mothers said that the monitoring was beneficial and gave them an opportunity to track their children's feeding patterns and detect any problems early. Mothers also appreciated the notifications and interventions received through the system. We concluded that the system is feasible and acceptable among breastfeeding mothers and a promising tool for maintaining communication between mothers and lactation consultants.

Establishing an online and social media presence for your IBCLC practice

Women of childbearing age, especially in industrialized nations, are using social media in record numbers and are seeking information about pregnancy, birth, and breastfeeding online. Social media is a form of communication that enables online communities to share ideas, information, and personal messages. Those providing support to breastfeeding mothers are uniquely equipped to share information, guidance, and encouragement with new mothers. Lactation professionals, advocates, and volunteers should be aware that mothers are using Web-based communication to gain information about breastfeeding. Those who support breastfeeding mothers can also learn to use these methods to engage with the breastfeeding community online. Regardless of the chosen platform, social media is most successful when it promotes engagement with a target audience. Facebook, Twitter, blogs, and Pinterest are identified as useful platforms for connecting with breastfeeding mothers.