Can a text message a week improve breastfeeding?

A Pilot Breastfeeding-Supportive Texting Program for African American and Black Mothers

Background: Exclusive breastfeeding is recommended through age 6 months, and 24.9% of all U.S. mothers, but only 19.8% of African American or Black (AA/B) mothers, achieved this goal (2020). Smartphone technology, specifically short message service (SMS or texting), may provide a strategy to reach and engage AA/B women who otherwise face barriers related to racism in accessing breastfeeding resources. Unfortunately, few mobile health applications are designed for AA/B women. Methods: We created a culturally sensitive breastfeeding promotion and support text message library that begins at 28 weeks prenatally and continues through 10 weeks postpartum. We tested feasibility and acceptability with a proof-of-concept (POC) trial that enrolled 20 AA/B women, and we tested content and perceived usefulness with a pilot study that enrolled 28 AA/B women. Results: In the POC trial, 95% of participants received all messages, demonstrating feasibility, and none requested fewer or to stop messages, demonstrating acceptability. In the pilot, >85% of participants responded positively regarding the number and helpfulness of the texts received, and whether the information was needed. Using a validated measure for online content for parents, >70% of POC and pilot study participants found that the information was very relevant or relevant, completely understandable, taught them something new, and "will help me improve the health or well-being of my child." Conclusion: A new breastfeeding-supportive text messaging program intended for AA/B mothers appears feasible, acceptable, informative, and relevant. This is the first breastfeeding text messaging application of which we are aware that is tailored for the AA/B population.

Text messaging interventions for breastfeeding outcomes: A systematic review and meta-analysis

BACKGROUND

Given the health benefits of breastfeeding for infants and mothers, breastfeeding has become a significant public health issue. The global growth of mobile phone usage has created new options for breastfeeding promotion, including text messaging.

OBJECTIVE

We aimed to evaluate the efficacy of text messaging interventions on breastfeeding outcomes and to identify the efficacy moderators of such interventions.

METHODS

Ten electronic databases were searched from the inception of the databases to 5 July 2023. Studies were included if they used randomized controlled trials or quasi-experimental designs to evaluate the effect of text messaging interventions on breastfeeding outcomes. Two reviewers screened the included studies, assessed the risk of bias, and extracted the data. Pooled results were obtained by the random-effects model, and subgroup analyses were conducted on intervention characteristics to identify potential moderators. The protocol of this study was registered on PROSPERO (ID: CRD42022371311).

RESULTS

Sixteen studies were included. Text messaging interventions could improve the exclusive breastfeeding rate (at <3 months: OR = 2.04; 95 % CI: 1.60-2.60, P < 0.001; at 3-6 months: OR = 1.66; 95 % CI: 1.18-2.33, P = 0.004; at ≥6 months: OR = 2.13; 95 % CI: 1.47-3.08, P < 0.001), and the breastfeeding self-efficacy (SMD = 0.30, 95 % CI: 0.14-0.45, P < 0.001). Text messaging interventions that covered antenatal and postnatal periods, delivered weekly were most effective in improving the exclusive breastfeeding rate.

CONCLUSIONS

Text messaging interventions may improve breastfeeding practice compared with no or general health information. We suggest text messaging conducted from the pre- to postnatal periods in a weekly manner can effectively increase exclusive breastfeeding rates and breastfeeding self-efficacy. Further studies should investigate the relation between new theories (such as the health action process approach and the theory of message-framing) and efficacy of breastfeeding interventions, using text components.

Effect of online intervention mode on breastfeeding results: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effect of Internet based intervention model on breastfeeding knowledge, attitude, self-confidence and breastfeeding rate.

METHODS

An electronic literature search of PubMed, Embase, Web of Science, Cochrane Library, CINAHL, CNKI, Wanfang, CBM and VIP database was performed using combinations of the keywords "Breastfeeding," "Breastfeeding, Exclusive," "Internet," "Online," and "Website". The retrieval period was from their inception to March 31, 2023. Quality appraisal was performed using the Cochrane 5.1 for randomized controlled trials (RCTs). RevMan5.3 was used for data analysis.

RESULTS

Thirty-two studies were included in the review, with a total of 9514 samples. The results of Meta-analysis showed that, compared with routine nursing, the intervention model based on the Internet can effectively improve breastfeeding knowledge and attitude of pregnant women, improve breastfeeding self-confidence (P < 0.05), and improve the rate of exclusive breastfeeding in the short term (within 6 weeks) and the long-term postpartum (3-6 months) had a positive effect on the rate of exclusive breastfeeding (P < 0.05).

CONCLUSIONS

The Internet breastfeeding intervention model may be an effective intervention to improve the effect of exclusive breastfeeding. In the future, more high-quality, large-sample randomized controlled trials can be carried out to further explore the effect of the Internet intervention model on breastfeeding.

Tailored text messages to improve breastfeeding practices in Yangon, Myanmar: the M528 individually randomized controlled trial

BACKGROUND

Text messages are a feasible delivery channel for breastfeeding promotion, but only a few articles have examined their effectiveness.

OBJECTIVE

To evaluate the impact of mobile phone text messages on breastfeeding practices.

DESIGN

We implemented a 2-arm, parallel, individually randomized controlled trial with 353 pregnant participants at the Central Women's Hospital, Yangon. The intervention group (n = 179) received breastfeeding-promotion text messages, and the control group (n = 174) received other maternal and child health care messages. The primary outcome was the exclusive breastfeeding rate at 1-6 mo postpartum. Secondary outcomes were other breastfeeding indicators, breastfeeding self-efficacy, and child morbidity. Using the intention-to-treat approach, the available outcome data were analyzed with generalized estimation equation Poisson regression models to estimate RR and 95% CIs, adjusted for within-person correlation and time, and tested for treatment group-by-time interactions.

RESULTS

Exclusive breastfeeding prevalence was significantly higher in the intervention than in the control group for the 6 follow-up visits combined (RR: 1.48; 95%CI: 1.35, 1.63; P < 0.001) and at each monthly follow-up visit. At 6 mo, exclusive breastfeeding was 43.4% in the intervention compared with 15.3% in the control group (RR: 2.74; 95%CI: 1.79, 4.19; P < 0.001). Also, at 6 mo, the intervention increased current breastfeeding (RR: 1.17; 95%CI: 1.07, 1.26; P < 0.001) and reduced bottle feeding (RR: 0.30; 95%CI: 0.17, 0.54; P < 0.001). Exclusive breastfeeding was progressively higher in the intervention group than in the control group at each follow-up (P for interaction < 0.001) and similarly for current breastfeeding. The intervention increased the mean breastfeeding self-efficacy score (adjusted mean difference 4.0; 95%CI: 1.36, 6.64; P = 0.030). Over the 6-month follow-up, the intervention significantly reduced diarrhea risk by 55% (RR: 0.45; 95%CI: 0.24, 0.82; P < 0.009).

CONCLUSIONS

Regular, targeted text messages delivered to urban pregnant women and mothers via mobile phones significantly improve breastfeeding practices and reduce infant morbidity during the first 6 mo of life.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12615000063516; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367704.

Designing and developing a mobile app (BeBo) in a randomized controlled trial study to promote breastfeeding among Vietnamese mothers

BACKGROUND

Breastfeeding should begin as soon as possible after birth and continue exclusively to 6 months of age. In Vietnam, as in many other countries, breastfeeding is decreasing because of modern lifestyles and the promotion of infant formula. It is important to provide mothers, family members, and the community with the knowledge and strategies to improve breastfeeding rates. Smartphones are almost ubiquitous in Vietnam and of the potential to provide information about breastfeeding. This study aimed to document the process of designing and developing a mobile app to increase breastfeeding rates in Vietnamese women.

METHODS

We used a four-step mixed methods approach with a literature review, formative research (22 in-depth interviews and 49 self-administered online questionnaires), and testing of prototype apps (3 focus groups discussion and external experts). Formative research and focus group discussion involved 99 participants. Finally, the revisions of the app were tested. All of the formative research was undertaken in Hanoi in 2019-2020. Target behaviors followed by key determinants, to improve breastfeeding self-efficacy were studied and this information was then applied in developing the messages and library content. Barriers and facilitators to breastfeeding were identified from literature reviews and qualitative research. The messages were targeted at not only mothers but also included fathers, mothers-in-law, or families.

RESULTS

Mothers were mostly concerned about the initiation of breastfeeding, preventing and reducing difficulties encountered during breastfeeding, and nutrition for breastfeeding mothers. Mental health and well-being in the postnatal period are also concerns. Three key features to be included in the app were identified from the formative research: (1) notifications; (2) an information library; and (3) a searching function. The research found that the app should be installed during pregnancy rather than after delivery (81% vs 17%, respectively). Notifications that convey breastfeeding messages should be sent 2-3 times per week.

CONCLUSION

The development of the app followed a best practice approach, including the involvement of stakeholders and grounding in behavior change theory. The next step is to evaluate the effectiveness of the BeBo mobile app in a well-conducted randomized controlled trial.

TRIAL REGISTRATION

ACTRN12619000531112.

Theory-based mHealth targeting fathers and mothers to improve exclusive breastfeeding: a quasi-experimental study

BACKGROUND

Exclusive breastfeeding remains sub-optimal in low-income countries contributing to infant mortality. Mobile health (mHealth) interventions, delivered through personal mobile phones, to improve exclusive breastfeeding have shown promise, but very few include fathers or have been applied in low-income countries. The aim of this study was to assess the effectiveness of a SMS-based breastfeeding intervention targeting fathers and mothers in improving exclusive breastfeeding at three months in a low-income country.

METHODS

A quasi-experimental study was carried out with couples in their last trimester of pregnancy, at health centers, Mekelle, Tigray. This study was conducted from September 2018 to March 2019. The SMS-based intervention delivered a total of 16 SMS text messages to two arms: mothers-and-fathers, and mothers-only with the third group acting as the control. The main outcome measure was exclusive breastfeeding at months one, two and three after birth.

RESULT

There were no significant differences in exclusive breastfeeding at month one between the three, mothers-and-fathers (95.1%), mother-only (90.2%), and control group (85%). At month three 85% of babies were exclusively breastfed in the mothers-and-fathers compared to 60% in the control group (p = 0.01). At month three 80% of babies were exclusively breastfed in the mothers-only compared to 60% in the control group (p = 0.04). In the multivariate analysis, babies born to mothers in the mother-and-fathers group were almost five times more likely to be exclusively breastfeed at three months than babies born to mothers who received standard care [AOR: 4.88, 95% CI (1.35,17.63)].

CONCLUSION

An mHealth intervention targeting fathers and mothers, and mothers increased the likelihood of babies being exclusively breastfed at three months. The risk of not exclusively breastfeeding in the control group increased over time. A low-cost SMS-based breastfeeding intervention targeting fathers and mothers showed potential to improve exclusive breastfeeding. Such mHealth interventions could be integrated into the antenatal and postnatal follow-up services provided by midwives.

TRIAL REGISTRATION

This trial was registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) 12,618,001,481,268.

Can mHealth campaigns improve CCT outcomes? Experimental evidence from sms-nudges in Indonesia

Employing a clustered RCT this paper examines the short-term impact of a 12-month mHealth BCC campaign on health practices & outcomes among CCT beneficiaries in Indonesia. Our analysis reveals that the intervention led to substantial improvements in maternal health behavior (postnatal care, child vaccinations, hygiene practices) & outcomes (anemia rates). Adopting a heterogeneous treatment effect framework, we further show that improvements in maternal hygiene practices and anemia rates are closely linked to health knowledge gained by mothers through the sms campaign. In contrast, we provide suggestive evidence that improvements in other health indicators are more likely to be related to the reminder and nudge components of the intervention.

Support for healthy breastfeeding mothers with healthy term babies

BACKGROUND

There is extensive evidence of important health risks for infants and mothers related to not breastfeeding. In 2003, the World Health Organization recommended that infants be breastfed exclusively until six months of age, with breastfeeding continuing as an important part of the infant's diet until at least two years of age. However, current breastfeeding rates in many countries do not reflect this recommendation.

OBJECTIVES

1. To describe types of breastfeeding support for healthy breastfeeding mothers with healthy term babies. 2. To examine the effectiveness of different types of breastfeeding support interventions in terms of whether they offered only breastfeeding support or breastfeeding support in combination with a wider maternal and child health intervention ('breastfeeding plus' support).  3. To examine the effectiveness of the following intervention characteristics on breastfeeding support:      a. type of support (e.g. face-to-face, telephone, digital technologies, group or individual support, proactive or reactive);      b. intensity of support (i.e. number of postnatal contacts);      c. person delivering the intervention (e.g. healthcare professional, lay person);     d. to examine whether the impact of support varied between high- and low-and middle-income countries.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (which includes results of searches of CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP)) (11 May 2021) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing extra support for healthy breastfeeding mothers of healthy term babies with usual maternity care. Support could be provided face-to-face, over the phone or via digital technologies. All studies had to meet the trustworthiness criteria.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane Pregnancy and Childbirth methods. Two review authors independently selected trials, extracted data, and assessed risk of bias and study trustworthiness.  The certainty of the evidence was assessed using the GRADE approach.

MAIN RESULTS

This updated review includes 116 trials of which 103 contribute data to the analyses. In total more than 98,816 mother-infant pairs were included.  Moderate-certainty evidence indicated that 'breastfeeding only' support probably reduced the number of women stopping breastfeeding for all primary outcomes: stopping any breastfeeding at six months (Risk Ratio (RR) 0.93, 95% Confidence Interval (CI) 0.89 to 0.97); stopping exclusive breastfeeding at six months (RR 0.90, 95% CI 0.88 to 0.93); stopping any breastfeeding at 4-6 weeks (RR 0.88, 95% CI 0.79 to 0.97); and stopping exclusive breastfeeding at 4-6 (RR 0.83 95% CI 0.76 to 0.90). Similar findings were reported for the secondary breastfeeding outcomes except for any breastfeeding at two months and 12 months when the evidence was uncertain if 'breastfeeding only' support helped reduce the number of women stopping breastfeeding.  The evidence for 'breastfeeding plus' was less consistent. For primary outcomes there was some evidence that 'breastfeeding plus' support probably reduced the number of women stopping any breastfeeding (RR 0.94, 95% CI 0.91 to 0.97, moderate-certainty evidence) or exclusive breastfeeding at six months (RR 0.79, 95% CI 0.70 to 0.90).  'Breastfeeding plus' interventions may have a beneficial effect on reducing the number of women stopping exclusive breastfeeding at 4-6 weeks, but the evidence is very uncertain (RR 0.73, 95% CI 0.57 to 0.95). The evidence suggests that 'breastfeeding plus' support probably results in little to no difference in the number of women stopping any breastfeeding at 4-6 weeks (RR 0.94, 95% CI 0.82 to 1.08, moderate-certainty evidence). For the secondary outcomes, it was uncertain if 'breastfeeding plus' support helped reduce the number of women stopping any or exclusive breastfeeding at any time points.  There were no consistent findings emerging from the narrative synthesis of the non-breastfeeding outcomes (maternal satisfaction with care, maternal satisfaction with feeding method, infant morbidity, and maternal mental health), except for a possible reduction of diarrhoea in intervention infants.  We considered the overall risk of bias of trials included in the review was mixed. Blinding of participants and personnel is not feasible in such interventions and as studies utilised self-report breastfeeding data, there is also a risk of bias in outcome assessment.   We conducted meta-regression to explore substantial heterogeneity for the primary outcomes using the following categories: person providing care; mode of delivery; intensity of support; and income status of country.  It is possible that moderate levels (defined as 4-8 visits) of 'breastfeeding only' support may be associated with a more beneficial effect on exclusive breastfeeding at 4-6 weeks and six months. 'Breastfeeding only' support may also be more effective in reducing women in low- and middle-income countries (LMICs) stopping exclusive breastfeeding at six months compared to women in high-income countries (HICs). However, no other differential effects were found and thus heterogeneity remains largely unexplained. The meta-regression suggested that there were no differential effects regarding person providing support or mode of delivery, however, power was limited.  AUTHORS' CONCLUSIONS: When 'breastfeeding only' support is offered to women, the duration and in particular, the exclusivity of breastfeeding is likely to be increased. Support may also be more effective in reducing the number of women stopping breastfeeding at three to four months compared to later time points.  For 'breastfeeding plus' interventions the evidence is less certain. Support may be offered either by professional or lay/peer supporters, or a combination of both. Support can also be offered face-to-face, via telephone or digital technologies, or a combination and may be more effective when delivered on a schedule of four to eight visits. Further work is needed to identify components of the effective interventions and to deliver interventions on a larger scale.

Online intervention to prevent postnatal depression and anxiety in Chilean new mothers: Protocol for a feasibility trial

Symptoms of postpartum depression and anxiety in new mothers are prevalent and negatively impact maternal emotional wellbeing and infant development. Barriers to accessing treatment prevent women from receiving mental health care, a situation that has worsened due to the COVID-19 pandemic. mHealth interventions hold the potential to support women during the transition to parenthood despite these barriers and to promote the use of preventive interventions. This study uses a mixed methods design to assess the feasibility and preliminary effectiveness of a psychoeducational, guided mHealth intervention to prevent postpartum mental health difficulties in women who receive care in primary health centers in Chile. The study will contribute to evidence-based research on the effectiveness of mHealth interventions for new mothers from an understudied cultural background. The findings will also enable the development of a larger randomized controlled trial to assess the effectiveness of the intervention, which, if effective, could significantly contribute to the emotional wellbeing of women and their families.

Innovations in Breastfeeding Support

Despite the numerous benefits that breastfeeding confers to those who breastfeed and their infants, the United States' exclusive breastfeeding rates and any breastfeeding rates at 12 months remain low and inequitable. This public health crisis has been prioritized in the US Healthy People 2030 goals. Current evidence-based practices to support lactation have afforded limited progress, thus, achieving national breastfeeding goals requires innovative ideas in thinking, technology, and care. This article highlights potential innovative strategies in the field of lactation to improve outcomes and work toward achieving health equity, while underscoring the critical role that perinatal caregivers play in lactation support.

Infant Feeding Tracker Applications: Cross-Sectional Analysis of Use

OBJECTIVE

Examine the extent to which postpartum patients use infant feeding tracker applications (apps), characteristics of app users, and app features most used and desired.

DESIGN

Cross-sectional survey.

SETTING

An obstetrics/gynecology practice in Northern New Jersey in 2019.

PARTICIPANTS

One hundred twenty-six patients aged ≥ 18 years recruited during their 6-week postpartum visit.

MAIN OUTCOME MEASURES

Self-reported sociodemographics, infant feeding behaviors, and health app use. Respondents were grouped by self-reported use of an infant feeding tracker app.

ANALYSIS

Frequencies were calculated for descriptive analysis, and comparisons were made between user groups. Fisher's exact tests of independence were used to analyze categorical data. Mann-Whitney U tests were employed for continuous variables (significance at P &lt; 0.002).

RESULTS

Fifty-seven percent of respondents reported using an app to track infant feeding. Compared with nonusers, users were more likely to have an infant who was ever breastfed (P = 0.001; Cramer's V = 0.30) and exclusively breastfed (P &lt; 0.001; Cramer's V = 0.44). Users also used significantly more health apps than nonusers (P &lt; 0.001). Most respondents used the app to track infant feeding, diapering, and sleep.

CONCLUSIONS AND IMPLICATIONS

Given their frequency of use-particularly among those who breastfeed-infant feeding tracker apps have the potential to support parents in meeting their infant feeding goals.

Systematic Review of the Effect of Technology-Mediated Education Intervention on Maternal Outcomes in the First Year After Birth

OBJECTIVE

To synthesize the findings on the effect of technology-mediated education intervention in the first year after birth on maternal health outcomes and to evaluate interventions for participant perspectives and health equity.

DATA SOURCES

We conducted a systematic review of the literature using the electronic databases PubMed, Embase, and CINAHL for articles published between 2010 and 2020. The search strategy was developed by a health sciences librarian.

STUDY SELECTION

We included articles if the following criteria were met: they reported studies conducted in the United States or a resource-similar nation on the evaluation of a technology-mediated education intervention within the first year after birth and they included the assessment of at least one maternal health outcome.

DATA EXTRACTION

The lead author extracted data from the full-text articles and entered them into Microsoft Excel. We assessed the quality and risk of bias using the Cochrane Collaboration's tool for examining the potential risk of bias.

DATA SYNTHESIS

We identified 21 articles that met the inclusion criteria. Videos were the most commonly reported technology-mediated education intervention, followed by text messages, phone calls, and websites. Maternal health outcomes addressed in the included articles were mental health, weight loss, breastfeeding, general postpartum education, perineal care, and substance use. Technology-mediated education interventions positively affected mental health, weight loss, and breastfeeding outcomes.

CONCLUSION

The current evidence suggests that technology-mediated education intervention is beneficial for the physical and mental health outcomes of women during the first year after birth. Future work may benefit from more attention to health equity and design in collaboration with women to gain a better understanding of the information needs and desired technology features.

Effects of mHealth on the psychosocial health of pregnant women and mothers: a systematic review

OBJECTIVE

To investigate the roles of mobile health, or mHealth, in the psychosocial health of pregnant women and mothers.

METHODS

A systematic search was conducted in databases and grey literature including MEDLINE, Web of Science, CINAHL, PsycINFO, PsycARTICLES, Academic Search Complete, SocINDEX, Central Register of Controlled Trials, The Database of Abstracts of Reviews of Effects, NHS Economic Evaluation Database, Health Technology Assessment, UNICEF and WHO databases. Two searches were conducted to include original research articles published in English until 15 November 2021. Several tools were used to assess the risk of bias: revised Cochrane risk of bias tool for randomised trials, Risk of Bias in Non-randomized Studies of Interventions, National Heart, Lung, and Blood Institute quality assessment tool for cohort and cross-sectional studies, Critical Appraisal Skills Program checklist for qualitative studies and Mixed Methods Appraisal Tool for mixed-methods studies. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation approach. Due to the high heterogeneity and variability of the included studies, data synthesis was conducted narratively.

RESULTS

44 studies were included among 11 999 identified articles. Most studies reported mixed findings on the roles of mHealth interventions in the psychosocial health of pregnant women and mothers; mHealth improved self-management, acceptance of pregnancy/motherhood and social support, while mixed results were observed for anxiety and depressive symptoms, perceived stress, mental well-being, coping and self-efficacy. Furthermore, pregnant women and mothers from vulnerable populations benefited from the use of mHealth to improve their psychosocial health.

CONCLUSIONS

The findings suggest that mHealth has the potential to improve self-management, acceptance of pregnancy/motherhood and social support. mHealth can also be a useful tool to reach vulnerable pregnant women and mothers with barriers to health information and facilitate access to healthcare services. However, the high heterogeneity limited the certainty of evidence of these findings. Therefore, future studies should identify the context under which mHealth could be more effective.

Trial collaborators' perceptions of the process of delivering Healthy Beginnings advice via telephone calls or text messages

ISSUE ADDRESSED

One in four Australian children aged between the ages of two and four are affected by overweight. In New South Wales, the Communicating Healthy Beginnings Advice by Telephone (CHAT) trial delivered an intervention to pregnant women and women with infants via telephone calls and text messages. The focus of the intervention was on infant feeding and establishing healthy habits for infants by building the capacity of mothers. This study investigates trial collaborators' perspectives concerning the implementation of this intervention, to obtain insights that will support future translation and scale-up.

METHODS

This research was undertaken during the intervention phase of the trial. Twenty trial collaborators involved in the planning, implementation or delivery of the CHAT trial were invited to participate. Qualitative interviews were conducted with collaborators using open-ended questions based on Steckler and Linnan's process evaluation framework and the Consolidated Framework for Implementation Research. Inductive thematic analysis was employed to identify themes from the interview data.

RESULTS

Fourteen trial collaborators were interviewed. Collaborators included child and family health nurses (intervention providers), nurse managers with extensive child and family health nursing experience, a paediatrician, dietitians, health promotion experts, health service managers, health and nursing executives, program personnel (project coordinator, research fellow and evaluation officer) and university researchers. Following coding of qualitative data, themes were realised from the data as a result of active co-production on the part of the researcher. Five themes were identified: (a) context (organisational support, engagement and partnerships, communication and project leadership); (b) program receipt, benefit and reach; (c) program delivery (intervention providers' experience and skills, mode of intervention delivery, referral to other services, support and training for intervention providers); (d) implementation (program delivered as planned); (e) opportunities for scale-up. Collaborators perceived that the program was implemented and delivered as planned. This specific research addresses the success of the process of implementing and delivering interventions for infant feeding and establishing healthy habits for children by building the capacity of mothers. Collaborators attributed successful program implementation to contextual factors: strong support by the host organisation; good project leadership; clear communication; collaborative internal and external partnerships; intervention provision by experienced nurses. Remote delivery was convenient to program participants and participants were able to resolve other personal concerns in addition to direct immediate benefits. Because of their capacity to influence policy decisions, the absence of policymakers at project meetings was a shortcoming. Collaborative partnerships with health and research partners, understanding of contextual issues and consumer involvement could lead to program expansion. The program has the potential to be scaled up through integration with existing services and gradual expansion into other health districts prior to state-wide rollout.

CONCLUSIONS

The CHAT trial delivered the Healthy Beginnings intervention which resulted in improvements in infant feeding, active play and sedentary behaviours. This evaluation demonstrated that the involvement of key stakeholders from early planning stages through to implementation of the program and the partnerships that evolved contributed to the successful implementation of the program. An unintended benefit to participants from this program was the social support that was provided. Intervention delivery via telephone and text messages enabled easy access to the program. Most importantly, the program has the potential to be scaled up through integration into existing services and gradual expansion prior to state-wide rollout. SO WHAT?: Strong internal and external partnerships, effective communication systems and integration with existing services create the context for potential translation and scaling up of the program to other health promotion settings.

The Effect of Educational Intervention on Improvement of Breastfeeding Self-Efficacy: A Systematic Review and Meta-Analysis

Background

Self-efficacy is an important psychological and motivational factor in breastfeeding, and it is a valuable framework that predicts breastfeeding outcomes and demonstrates maternal confidence in breastfeeding. The meta-analysis evaluated the effectiveness of educational interventions on improving breastfeeding self-efficacy (BSE).

Methods

The English and Persian databases including Medline, Embase, Cochrane Database of Systematic Reviews (CDSR), PubMed, Web of Science, Scopus, CINAHL, Sid, IRANDOC, and Marg-Iran were systematically searched for studies published from January 2005 to December 2020. The quality of studies was evaluated using the Cochrane risk of bias tool and the heterogeneity by I ² statistic. The extracted data were analyzed using RevMan 5 statistical software and presented using random effects standardized mean difference (SMD). The funnel plot was used for evaluating publication bias.

Results

Results from 40 RCTs showed that educational intervention had a positive effect on the BSE compared with the usual/standard care (pooled SMD = 1.20; 95% CI = 0.75-1.64, p value <0.001). The subgroup analysis indicated that the educational intervention was based on theory, group class format, direct method education, during the first week of postpartum, doing during pregnancy, on primiparous women, and health center setting, and the Asian region has a more effect on BSE than the others.

Conclusion

Breastfeeding education is considered an influential factor in the improvement of BSE. It is recommended that breastfeeding education should be continued for several weeks after childbirth for gaining its benefit. The Asian region has a more effect on BSE than the others. Therefore, it is important to add the values in content of education in each country.

Remote Lactation Support in the COVID-19 Era

Breast milk provides optimal nourishment for all infants and has special advantages in preterm infants. Breast milk is associated with lower rates of necrotizing enterocolitis and bronchopulmonary dysplasia and improved neurodevelopmental outcomes in the preterm population. Mothers in the NICU may experience multiple psychological, physical, and social/cultural barriers that impede successful breastfeeding. Professional lactation support is of crucial importance in this population. With the social distancing requirements of the pandemic, many clinicians have adopted novel methods of education and communication to ensure continued timely support for NICU mothers.

Impact of mobile health interventions during the perinatal period on maternal psychosocial outcomes: a systematic review

OBJECTIVE

The objective of this review was to evaluate the effectiveness of mother-targeted mobile health (mHealth) education interventions during the perinatal period on maternal psychosocial outcomes in high-income countries.

INTRODUCTION

The perinatal period is an exciting yet challenging period for mothers that requires physical, emotional and social adjustment to new norms and expectations. In recent years, there has been an increase in the use of mHealth by new mothers who are seeking health information through online or mobile applications. While there have been systematic reviews on the impact of mHealth interventions on maternal and newborn health in low- and middle-income countries, the impact of these interventions on maternal psychosocial health outcomes in high-income countries remains uncertain.

INCLUSION CRITERIA

This review considered studies of mHealth education interventions targeting mothers in high-income countries (as defined by the World Bank) during the perinatal period. Interventions must have started between the antenatal period (conception through birth) through six weeks postpartum. All experimental study designs were included. Outcomes included self-efficacy, social support, postpartum anxiety and postpartum depression.

METHODS

PubMed, CINAHL, PsycINFO and Embase were searched for published studies in English on December 16, 2018. Gray literature was also searched for non-peer reviewed articles, including Google Scholar, mHealth intelligence and clinical trials databases. Critical appraisal was undertaken by two independent reviewers using standardized critical appraisal instruments from JBI. Quantitative data were extracted from included studies independently by two reviewers using the standardized data extraction tool from JBI. All conflicts were solved through consensus with a third reviewer. Quantitative data were, where possible, pooled in statistical meta-analysis using RevMan. Where statistical pooling was not possible, findings were reported narratively.

RESULTS

Of the 1,607 unique articles identified, 106 full-text papers were screened and 24 articles were critically appraised, with 21 included in the final review. Eleven were quasi-experimental and 10 were randomized controlled trials. The mHealth intervention approach varied, with text message and mobile applications being the most common. Length of intervention ranged from four weeks to six months. The topics of the mHealth intervention varied widely, with the most common topic being postpartum depression. Mothers who received an mHealth intervention targeting postpartum depression showed a decreased score on the Edinburgh Postnatal Depression Scale when measured post-intervention (odds ratio = -6.01, 95% confidence interval = -8.34 to -3.67, p < 0.00001). The outcomes related to self-efficacy, social support and anxiety showed mixed findings of effectiveness (beneficial and no change) across the studies identified.

CONCLUSIONS

This review provides insight into the effectiveness of mHealth interventions targeting mothers in high-income countries in the perinatal period to enhance four psychosocial outcomes: self-efficacy, social support, anxiety and depression. Despite a wide variety of outcome measurements used, the predominant findings suggest that there are insufficient data to conclude that mHealth interventions can improve self-efficacy and anxiety outcomes. Potential benefits on social support were related to interventions targeting postnatal behaviors. Postpartum depression was the mostly commonly reported outcome. Findings related to the comparison of pre-post outcomes and intervention versus control demonstrated that mHealth interventions targeting postpartum depression were associated with a reduction in postpartum depression.

Barriers to Breastfeeding: Supporting Initiation and Continuation of Breastfeeding: ACOG Committee Opinion, Number 821

ABSTRACT

Breastfeeding has maternal, infant, and societal benefits. However, many parents experience obstacles to achieving their breastfeeding goals, leading to reduced rates of breastfeeding initiation and continuation. Despite efforts to increase rates of breastfeeding initiation and continuation, inequities still persist. The factors that influence an individual's desire and ability to breastfeed are varied and include individual parent considerations; practitioner influences; hospital barriers; societal factors, such as workplace and parental leave policies; access to lactation support; and social support of their breastfeeding goals. A multidisciplinary approach that involves community, family, parents, and health care professionals will strengthen the support for parents and help them achieve their breastfeeding goals.

Effectiveness of a Postpartum Text Message Program (Essential Coaching for Every Mother) on Maternal Psychosocial Outcomes: Protocol for a Randomized Controlled Trial

BACKGROUND

Women experience changes both physically and psychologically during their transition to motherhood. The postnatal period is a critical time for women to develop maternal self-efficacy. Mobile health interventions may offer a way to reach women during this critical period to offer support and information. Essential Coaching for Every Mother is a text message program that seeks to educate and support women during the first 6 weeks postpartum.

OBJECTIVE

The primary effectiveness objective is to compare the effectiveness of the Essential Coaching for Every Mother program on maternal psychosocial outcomes (self-efficacy, social support, postpartum depression, and postpartum anxiety) immediately after the intervention and 6 months postpartum, collectively as well as stratified by parity. The primary implementation objective is to evaluate the implementation extent and quality of the Essential Coaching for Every Mother program.

METHODS

This will be a hybrid type 1 effectiveness-implementation randomized controlled trial. A total of 140 mothers-to-be or new mothers from Nova Scotia will be recruited and randomized to the intervention or control arm, stratified by parity. The intervention arm will receive the Essential Coaching for Every Mother program, which consists of 53 messages sent twice a day for the first 2 weeks and daily for weeks 3 through 6. The control group will receive usual care. Messages are personalized based on the infant's age and the woman's self-selected preference for breastfeeding or formula feeding and tailored with the infant's name and gender. Women can enroll in the program if they are ≥37 weeks pregnant or within 10 days postpartum, with the first message designed to be sent on the second evening after birth. The actual number of messages received will vary based on the timing of enrollment and the infant's date of birth. Participants will complete questionnaires assessing self-efficacy, social support, and postpartum depression and anxiety at baseline (enrollment after birth) and 6 weeks (postintervention) and 6 months postpartum. Implementation data will be collected throughout the trial, and evaluation feedback will be collected at 6 weeks from women who received the intervention.

RESULTS

Recruitment for this study started on January 5, 2021, and is currently ongoing, with an anticipated date of recruitment completion of January 2022.

CONCLUSIONS

This study will assess the effectiveness of a postpartum text message program to improve maternal self-efficacy and social support while decreasing postpartum depression and anxiety. It will also shed light on the implementation effectiveness of the program.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04730570; https://clinicaltrials.gov/ct2/show/NCT04730570.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/27138.

See How They Grow: Testing the feasibility of a mobile app to support parents' understanding of child growth charts

BACKGROUND

Mobile devices provide new opportunities for the prevention of overweight and obesity in children. We aimed to co-create and test an app that offered comprehensible feedback to parents on their child's growth and delivered a suite of age-specific information about nutrition and activity.

METHODS

A two-phased approach was used to co-create the digital growth tool-See How They Grow-and test its feasibility. Phase one used focus groups (parents and professionals such as paediatricians and midwives) and a national on-line survey to gather requirements and build the app. Phase two involved testing the app over 12-weeks, with parents or carers of children aged ≤ 2-years. All research activities were undertaken exclusively through the app, and participants were recruited using social media and hard copy materials given to patents at a child health visit.

FINDINGS

Four focus groups and 101 responses to the national survey informed the features and functions to include in the final app. Two hundred and twenty-five participants downloaded the app, resulting in 208 eligible participants. Non-Māori/Non-Pacific (78%) and Māori (14%) had the highest downloads. Fifty-four per cent of participants were parents of children under 6-months. These participants were more likely to regularly use the app than those with children older than 6-months (64% vs 36%, P = 0.011). Over half of the participants entered three measures (n = 101, 48%). Of those that completed the follow-up survey (n = 101, 48%), 72 reported that the app helped them better understand how to interpret growth charts.

CONCLUSION

The app was acceptable and with minor modifications, has the potential to be an effective tool to support parents understanding of growth trajectories for their children. A larger trial is needed to evaluate if the app can have a measurable impact on increasing knowledge and behaviour, and therefore on preventing childhood overweight and obesity.

Process evaluations of early childhood obesity prevention interventions delivered via telephone or text messages: a systematic review

BACKGROUND

Increasingly, public health interventions are delivered via telephone and/or text messages. Recent systematic reviews of early childhood obesity prevention interventions have not adequately reported on the way interventions are delivered and the experiences/perceptions of stakeholders. We aimed to summarise the literature in early childhood obesity prevention interventions delivered via telephone or text messages for evidence of application of process evaluation primarily to evaluate stakeholders' acceptability of interventions.

METHODS

A systematic search of major electronic databases was carried out using the Population, Intervention, Comparison, Outcomes framework. Studies were included if interventions were delivered via telephone/text messages; aimed at changing caregivers' behaviours to prevent early childhood obesity; with one or more outcomes related to early obesity risk factors such as breastfeeding, solid feeding, tummy time, sleep and settling, physical activity and screen time; published from inception to May 2020. All eligible studies were independently assessed by two reviewers using the Cochrane Collaboration tool for assessing risk of bias. Qualitative studies were assessed using the Consolidated Criteria for Reporting Qualitative Research and Standards for Reporting Qualitative Research tools.

RESULTS

Twenty-four studies were eligible, and the overall risk of bias was low. Eight studies (33%) had evidence of process evaluation that examined participants' perceptions of interventions. Participants appreciated the convenience of receiving interventions via telephone or text messages. 63% of all studies in this review showed improvement in one or more behaviours related to childhood obesity prevention. Participants were likely to modify behaviours if they received information from a credible source such as from health professionals.

CONCLUSION

There is limited reporting of stakeholders' experiences in early obesity prevention studies delivered by telephone or text messages. Only one-third of studies examined participants' acceptability and the potential for delivery of childhood obesity prevention interventions conveniently using this mode of delivery. Interventions delivered remotely via telephone or text messages have the potential to reach equal or a greater number of participants than those delivered via face-to-face methods. Future research should build in process evaluation alongside effectiveness measurements to provide important insight into intervention reach, acceptability and to inform scale up.

TRIAL REGISTRATION

PROSPERO registration: CRD42019108658.

Understanding breastfeeding behaviours: a cross-sectional analysis of associated factors in Ireland, the United Kingdom and Australia

Background

Breastfeeding is a complex behaviour relying on a combination of individual mother and infant characteristics, health systems, and family, community and professional support. Optimal breastfeeding in high-income countries is particularly low. Despite having similar sociocultural backgrounds, breastfeeding rates between Ireland, the United Kingdom (UK) and Australia vary, thus there is a need to understand whether this is due to individual, sociocultural or policy differences. This research identifies the between-country differences in infant feeding mode and examines if country differences in feeding mode persist once known individual, behavioural and structural factors are considered using socioecological and person-context models.

Methods

Participants were adult women with at least one infant less than 6 months of age, who completed an online survey (n = 2047) that was distributed by social media in June 2016. Within-country differences in infant feeding mode (‘any breastfeeding’ vs. ‘no breastfeeding’) were examined first before hierarchical multivariable logistic regression was used to determine if country differences in feeding mode persisted after adjusting for known factors associated with breastfeeding.

Results

In this sample, ‘any breastfeeding’ rates were 89, 71 and 72% in Australia, Ireland and the United Kingdom respectively. Within-country differences were evident in Australia, Ireland and the UK. Four factors showed no association with infant feeding mode in Australia while they did in the other countries (maternal age, income, skin-to-skin contact, support from friends and family). Two factors were unique to Australia: the odds of being in the ‘no breastfeeding’ group increased when the baby was delivered via caesarean and when not enough breastfeeding information was available after birth. One determinant was unique to Ireland: the odds of being in the ‘no breastfeeding’ group increased when respondents indicated they were not religious; in the UK this occurred when respondents were living in a town/village. After adjusting for sets of known factors of infant feeding mode based on socioecological and person-context models, country differences remained in hierarchical regressions: the odds of not breastfeeding were higher in both Ireland (AOR 3.3, 95%CI 1.8,6.1) and the United Kingdom (AOR 2.7, 95%CI 1.5, 4.7) compared to Australia.

Conclusions

This study indicates that different levels in the socioecological system are related to infant feeding behaviours. An adequate inter-systems level response would consider the interactions within and between behavioural and structural mechanisms which support breastfeeding behaviour. Optimising infant feeding practices will require an integrated web of interventions that go beyond the individual and focus on addressing factors that will influence families within their communities as they move between systems.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-020-00344-2.

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.

Impact of mHealth interventions during the perinatal period on maternal psychosocial outcomes: a systematic review protocol

OBJECTIVE

This review aims to evaluate the effectiveness of mother-targeted mobile health (mHealth) education interventions during the perinatal period on maternal psychosocial outcomes in high-income countries.

INTRODUCTION

Mobile health (i.e. mHealth) is defined as the use of mobile devices to transmit health content and services. The use of mHealth to provide education and support to mothers is a growing field of health innovation. Mothers seek health information online during the postpartum period to learn about health concerns and get advice and support. Despite the potential benefits of mHealth, the potential impact on maternal psychosocial outcomes requires further evaluation.

INCLUSION CRITERIA

The review will consider studies that include mHealth interventions targeting mothers in high-income countries. The mHealth education interventions must occur during the antenatal or postnatal period. This review will consider studies that compare the intervention to any comparators. Studies published in English from 2000 will be included.

METHODS

The search strategy will aim to locate both published and unpublished studies. Following the search, all identified citations will be collated and duplicates removed. Titles and abstracts will be screened and full text of selected citations will then be assessed in detail against inclusion criteria. The results of the search will be reported in full in the final systematic review. Eligible studies will be critically appraised by two independent reviewers. Data extracted will include specific details about the interventions, populations, study methods and outcomes. Studies will be pooled in statistical meta-analysis or presented in narrative form including tables and figures.

Establishing content for a digital educational support group for new adolescent mothers in the Dominican Republic: a user-centered design approach

Background As digital interventions to improve health become widespread globally, it is critical to include target end-users in their design. This can help ensure interventions are maximally beneficial among intended populations. Objectives To generate the content of a digital educational support group, administered through WhatsApp, for new adolescent mothers and establish participants' cellular access and WhatsApp use. Participants Adolescent mothers with new babies. Methods We completed a two-phase user-centered design process. In phase I design sessions, participants discussed their postpartum experiences and completed an activity to elucidate their health and wellbeing information needs. In phase II sessions, participants individually identified which health information topics were important to them, then all topics were prioritized as a group. Phase II participants also completed a brief survey on cell phone access and WhatsApp use. Results Phase I included 24 participants, 21 of whom completed phase II. Priority health and wellbeing information topics in the postpartum period were identified as: child growth and development, understanding your baby, common childhood illnesses, breastfeeding, childhood nutrition, family planning, and self-care. Of phase II participants, 45% had cellular phone access and none had a data plan. Cellular service was inconsistently obtained with data packages or Wi-Fi. 30% of participants had no experience using WhatsApp. Conclusions Participants identified numerous health information needs, which will serve as the content for our planned digital support group and provides valuable insight for health care providers globally. Less than half of participants had consistent cellular phone access, and none had reliable access to cellular service.

Engaging African American Parents to Develop a Mobile Health Technology for Breastfeeding: KULEA-NET

BACKGROUND

African Americans breastfeed less than other groups, which has implications for health throughout the life course. Little is known about mobile health technologies to support breastfeeding.

RESEARCH AIMS

This study proceeded in two phases. The aim of Phase 1 was to identify ideal technological components and content of a mobile health intervention. The aim of Phase 2 was to determine the usability of a prototype, KULEA-NET, based on the Phase 1 findings.

METHODS

For this mixed-methods study, we used community-based participatory research methods and user-centered technology design methods. We used open coding in NVivo 11 to organize data from focus groups and in-depth interviews, then we analyzed the data. We then developed a prototype and tested the prototype's usability with the System Usability Scale. Fifty pregnant and postpartum African Americans from the District of Columbia participated.

RESULTS

Participants preferred an app with text messaging technology and identified areas for intervention: self-efficacy, parent-child attachment beliefs, social support, public breastfeeding and social desirability, and returning to work. Desired features included local resources, support person access, baby care logs, identification of public breastfeeding venues, and peer discussions. The System Usability Scale score was 73.8, which indicates above average usability.

CONCLUSIONS

A mobile health technology like KULEA-NET can be used to meet the breastfeeding needs of African Americans, build social desirability, and complement traditional health care. The appeal of an African American-specific intervention is unclear. Responding to mixed feeding practices is challenging. KULEA-NET is a mobile breastfeeding intervention guided by the preferences of African American parents and offers promising usability metrics.

Targeted client communication via mobile devices for improving maternal, neonatal, and child health

BACKGROUND

The global burden of poor maternal, neonatal, and child health (MNCH) accounts for more than a quarter of healthy years of life lost worldwide. Targeted client communication (TCC) via mobile devices (MD) (TCCMD) may be a useful strategy to improve MNCH.

OBJECTIVES

To assess the effects of TCC via MD on health behaviour, service use, health, and well-being for MNCH.

SEARCH METHODS

In July/August 2017, we searched five databases including The Cochrane Central Register of Controlled Trials, MEDLINE and Embase. We also searched two trial registries. A search update was carried out in July 2019 and potentially relevant studies are awaiting classification.

SELECTION CRITERIA

We included randomised controlled trials that assessed TCC via MD to improve MNCH behaviour, service use, health, and well-being. Eligible comparators were usual care/no intervention, non-digital TCC, and digital non-targeted client communication.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane, although data extraction and risk of bias assessments were carried out by one person only and cross-checked by a second.

MAIN RESULTS

We included 27 trials (17,463 participants). Trial populations were: pregnant and postpartum women (11 trials conducted in low-, middle- or high-income countries (LMHIC); pregnant and postpartum women living with HIV (three trials carried out in one lower middle-income country); and parents of children under the age of five years (13 trials conducted in LMHIC). Most interventions (18) were delivered via text messages alone, one was delivered through voice calls only, and the rest were delivered through combinations of different communication channels, such as multimedia messages and voice calls. Pregnant and postpartum women TCCMD versus standard care For behaviours, TCCMD may increase exclusive breastfeeding in settings where rates of exclusive breastfeeding are less common (risk ratio (RR) 1.30, 95% confidence intervals (CI) 1.06 to 1.59; low-certainty evidence), but have little or no effect in settings where almost all women breastfeed (low-certainty evidence). For use of health services, TCCMD may increase antenatal appointment attendance (odds ratio (OR) 1.54, 95% CI 0.80 to 2.96; low-certainty evidence); however, the CI encompasses both benefit and harm. The intervention may increase skilled attendants at birth in settings where a lack of skilled attendants at birth is common (though this differed by urban/rural residence), but may make no difference in settings where almost all women already have a skilled attendant at birth (OR 1.00, 95% CI 0.34 to 2.94; low-certainty evidence). There were uncertain effects on maternal and neonatal mortality and morbidity because the certainty of the evidence was assessed as very low. TCCMD versus non-digital TCC (e.g. pamphlets) TCCMD may have little or no effect on exclusive breastfeeding (RR 0.92, 95% CI 0.79 to 1.07; low-certainty evidence). TCCMD may reduce 'any maternal health problem' (RR 0.19, 95% CI 0.04 to 0.79) and 'any newborn health problem' (RR 0.52, 95% CI 0.25 to 1.06) reported up to 10 days postpartum (low-certainty evidence), though the CI for the latter includes benefit and harm. The effect on health service use is unknown due to a lack of studies. TCCMD versus digital non-targeted communication No studies reported behavioural, health, or well-being outcomes for this comparison. For use of health services, there are uncertain effects for the presence of a skilled attendant at birth due to very low-certainty evidence, and the intervention may make little or no difference to attendance for antenatal influenza vaccination (RR 1.05, 95% CI 0.71 to 1.58), though the CI encompasses both benefit and harm (low-certainty evidence). Pregnant and postpartum women living with HIV TCCMD versus standard care For behaviours, TCCMD may make little or no difference to maternal and infant adherence to antiretroviral (ARV) therapy (low-certainty evidence). For health service use, TCC mobile telephone reminders may increase use of antenatal care slightly (mean difference (MD) 1.5, 95% CI -0.36 to 3.36; low-certainty evidence). The effect on the proportion of births occurring in a health facility is uncertain due to very low-certainty evidence. For health and well-being outcomes, there was an uncertain intervention effect on neonatal death or stillbirth, and infant HIV due to very low-certainty evidence. No studies reported on maternal mortality or morbidity. TCCMD versus non-digital TCC The effect is unknown due to lack of studies reporting this comparison. TCCMD versus digital non-targeted communication TCCMD may increase infant ARV/prevention of mother-to-child transmission treatment adherence (RR 1.26, 95% CI 1.07 to 1.48; low-certainty evidence). The effect on other outcomes is unknown due to lack of studies. Parents of children aged less than five years No studies reported on correct treatment, nutritional, or health outcomes. TCCMD versus standard care Based on 10 trials, TCCMD may modestly increase health service use (vaccinations and HIV care) (RR 1.21, 95% CI 1.08 to 1.34; low-certainty evidence); however, the effect estimates varied widely between studies. TCCMD versus non-digital TCC TCCMD may increase attendance for vaccinations (RR 1.13, 95% CI 1.00 to 1.28; low-certainty evidence), and may make little or no difference to oral hygiene practices (low-certainty evidence). TCCMD versus digital non-targeted communication TCCMD may reduce attendance for vaccinations, but the CI encompasses both benefit and harm (RR 0.63, 95% CI 0.33 to 1.20; low-certainty evidence). No trials in any population reported data on unintended consequences.

AUTHORS' CONCLUSIONS

The effect of TCCMD for most outcomes is uncertain. There may be improvements for some outcomes using targeted communication but these findings were of low certainty. High-quality, adequately powered trials and cost-effectiveness analyses are required to reliably ascertain the effects and relative benefits of TCCMD. Future studies should measure potential unintended consequences, such as partner violence or breaches of confidentiality.

Targeted client communication via mobile devices for improving sexual and reproductive health

BACKGROUND

The burden of poor sexual and reproductive health (SRH) worldwide is substantial, disproportionately affecting those living in low- and middle-income countries. Targeted client communication (TCC) delivered via mobile devices (MD) (TCCMD) may improve the health behaviours and service use important for sexual and reproductive health.

OBJECTIVES

To assess the effects of TCC via MD on adolescents' knowledge, and on adolescents' and adults' sexual and reproductive health behaviour, health service use, and health and well-being.

SEARCH METHODS

In July/August 2017, we searched five databases including The Cochrane Central Register of Controlled Trials, MEDLINE and Embase. We also searched two trial registries. A search update was carried out in July 2019 and potentially relevant studies are awaiting classification.

SELECTION CRITERIA

We included randomised controlled trials of TCC via MD to improve sexual and reproductive health behaviour, health service use, and health and well-being. Eligible comparators were standard care or no intervention, non-digital TCC, and digital non-targeted communication.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane, although data extraction and risk of bias assessments were carried out by one person only and cross-checked by a second. We have presented results separately for adult and adolescent populations, and for each comparison.

MAIN RESULTS

We included 40 trials (27 among adult populations and 13 among adolescent populations) with a total of 26,854 participants. All but one of the trials among adolescent populations were conducted in high-income countries. Trials among adult populations were conducted in a range of high- to low-income countries. Among adolescents, nine interventions were delivered solely through text messages; four interventions tested text messages in combination with another communication channel, such as emails, multimedia messaging, or voice calls; and one intervention used voice calls alone. Among adults, 20 interventions were delivered through text messages; two through a combination of text messages and voice calls; and the rest were delivered through other channels such as voice calls, multimedia messaging, interactive voice response, and instant messaging services. Adolescent populations TCCMD versus standard care TCCMD may increase sexual health knowledge (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.23 to 1.71; low-certainty evidence). TCCMD may modestly increase contraception use (RR 1.19, 95% CI 1.05 to 1.35; low-certainty evidence). The effects on condom use, antiretroviral therapy (ART) adherence, and health service use are uncertain due to very low-certainty evidence. The effects on abortion and STI rates are unknown due to lack of studies. TCCMD versus non-digital TCC (e.g. pamphlets) The effects of TCCMD on behaviour (contraception use, condom use, ART adherence), service use, health and wellbeing (abortion and STI rates) are unknown due to lack of studies for this comparison. TCCMD versus digital non-targeted communication The effects on sexual health knowledge, condom and contraceptive use are uncertain due to very low-certainty evidence. Interventions may increase health service use (attendance for STI/HIV testing, RR 1.61, 95% CI 1.08 to 2.40; low-certainty evidence). The intervention may be beneficial for reducing STI rates (RR 0.61, 95% CI 0.28 to 1.33; low-certainty evidence), but the confidence interval encompasses both benefit and harm. The effects on abortion rates and on ART adherence are unknown due to lack of studies. We are uncertain whether TCCMD results in unintended consequences due to lack of evidence. Adult populations TCCMD versus standard care For health behaviours, TCCMD may modestly increase contraception use at 12 months (RR 1.17, 95% CI 0.92 to 1.48) and may reduce repeat abortion (RR 0.68 95% CI 0.28 to 1.66), though the confidence interval encompasses benefit and harm (low-certainty evidence). The effect on condom use is uncertain. No study measured the impact of this intervention on STI rates. TCCMD may modestly increase ART adherence (RR 1.13, 95% CI 0.97 to 1.32, low-certainty evidence, and standardised mean difference 0.44, 95% CI -0.14 to 1.02, low-certainty evidence). TCCMD may modestly increase health service utilisation (RR 1.17, 95% CI 1.04 to 1.31; low-certainty evidence), but there was substantial heterogeneity (I2 = 85%), with mixed results according to type of service utilisation (i.e. attendance for STI testing; HIV treatment; voluntary male medical circumcision (VMMC); VMMC post-operative visit; post-abortion care). For health and well-being outcomes, there may be little or no effect on CD4 count (mean difference 13.99, 95% CI -8.65 to 36.63; low-certainty evidence) and a slight reduction in virological failure (RR 0.86, 95% CI 0.73 to 1.01; low-certainty evidence). TCCMD versus non-digital TCC No studies reported STI rates, condom use, ART adherence, abortion rates, or contraceptive use as outcomes for this comparison. TCCMD may modestly increase in service attendance overall (RR: 1.12, 95% CI 0.92-1.35, low certainty evidence), however the confidence interval encompasses benefit and harm. TCCMD versus digital non-targeted communication No studies reported STI rates, condom use, ART adherence, abortion rates, or contraceptive use as outcomes for this comparison. TCCMD may increase service utilisation overall (RR: 1.71, 95% CI 0.67-4.38, low certainty evidence), however the confidence interval encompasses benefit and harm and there was considerable heterogeneity (I2 = 72%), with mixed results according to type of service utilisation (STI/HIV testing, and VMMC). Few studies reported on unintended consequences. One study reported that a participant withdrew from the intervention as they felt it compromised their undisclosed HIV status.

AUTHORS' CONCLUSIONS

TCCMD may improve some outcomes but the evidence is of low certainty. The effect on most outcomes is uncertain/unknown due to very low certainty evidence or lack of evidence. High quality, adequately powered trials and cost effectiveness analyses are required to reliably ascertain the effects and relative benefits of TCC delivered by mobile devices. Given the sensitivity and stigma associated with sexual and reproductive health future studies should measure unintended consequences, such as partner violence or breaches of confidentiality.

Effects of Telephone and Short Message Service Support on Infant Feeding Practices, "Tummy Time," and Screen Time at 6 and 12 Months of Child Age: A 3-Group Randomized Clinical Trial

Importance

There is limited information as to whether telephone or short message service (SMS) support is effective in improving infant feeding practices and tummy time and reducing screen time.

Objective

To determine the effectiveness of either nurse-led telephone or SMS support in improving infant feeding practices and tummy time and reducing screen time.

Design, Setting, and Participants

This study was part of a 2-year, 3-group parallel, randomized clinical trial conducted from February 23, 2017, to November 30, 2018, among 1155 women in the third trimester of pregnancy in New South Wales, Australia. It reports the main outcomes at 6 and 12 months of child age. All analyses were conducted on an intention-to-treat principle.

Interventions

The intervention consisted of staged information booklets mailed to the intervention groups, each followed by either a nurse-led telephone support session or SMS intervention, antenatally and at 1, 3, 5, 7, and 10 months after birth.

Main Outcomes and Measures

The primary outcomes were infant feeding practices at both 6 and 12 months and tummy time at 6 months. The secondary outcome was screen time at 12 months.

Results

Of 1155 mothers, 947 (82%; mean [SD] age, 32.5 [5.0] years) completed follow-up surveys at 6 months; 920 mothers (80%) completed follow-up surveys at 12 months. Compared with the control group, telephone support led to higher odds of appropriate timing of introducing solid foods (adjusted odds ratio [AOR], 1.68 [95% CI, 1.22-2.32]), cup use (AOR, 1.54 [95% CI, 1.12-2.13]), and early-start tummy time (AOR, 1.63 [95% CI, 1.18-2.25]) at 6 months and higher odds of having no screen time (AOR, 1.80 [95% CI, 1.28-2.53]) and no bottle at bedtime (AOR, 1.73 [95% CI, 1.23-2.42]) at 12 months. Use of SMS also led to higher odds than the control group of having no screen time (AOR, 1.28 [95% CI, 1.08-1.52]) and having no bottle at bedtime (AOR, 1.29 [95% CI, 1.10-1.51]) at 12 months. No significant differences were found in breastfeeding rates between the telephone support, SMS support, and control groups.

Conclusions and Relevance

Both the nurse-led telephone support and SMS interventions were effective in reducing screen time and bottle use at bedtime. Telephone support was also effective in promoting the appropriate timing of the introduction of solid foods, early-start tummy time, and cup use.

Trial Registration

http://anzctr.org.au Identifier: ACTRN12616001470482.

Telehealth Interventions to Improve Obstetric and Gynecologic Health Outcomes: A Systematic Review

Telehealth interventions were associated with improvements in obstetric outcomes, perinatal smoking cessation, breastfeeding, early access to medical abortion services, and schedule optimization for high-risk obstetrics.

OBJECTIVE:

To systematically review the effectiveness of telehealth interventions for improving obstetric and gynecologic health outcomes.

DATA SOURCES:

We conducted a comprehensive search for primary literature in ClinicalTrials.gov, Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE.

METHODS OF STUDY SELECTION:

Qualifying primary studies had a comparison group, were conducted in countries ranked very high on the United Nations Human Development Index, published in English, and evaluated obstetric and gynecologic health outcomes. Cochrane Collaboration's tool and ROBINS-I tool were used for assessing risk of bias. Summary of evidence tables were created using the United States Preventive Services Task Force Summary of Evidence Table for Evidence Reviews.

TABULATION, INTEGRATION, RESULTS:

Of the 3,926 published abstracts identified, 47 met criteria for inclusion and included 31,967 participants. Telehealth interventions overall improved obstetric outcomes related to smoking cessation and breastfeeding. Telehealth interventions decreased the need for high-risk obstetric monitoring office visits while maintaining maternal and fetal outcomes. One study found reductions in diagnosed preeclampsia among women with gestational hypertension. Telehealth interventions were effective for continuation of oral and injectable contraception; one text-based study found increased oral contraception rates at 6 months. Telehealth provision of medication abortion services had similar clinical outcomes compared with in-person care and improved access to early abortion. Few studies suggested utility for telehealth to improve notification of sexually transmitted infection test results and app-based intervention to improve urinary incontinence symptoms.

CONCLUSION:

Telehealth interventions were associated with improvements in obstetric outcomes, perinatal smoking cessation, breastfeeding, early access to medical abortion services, and schedule optimization for high-risk obstetrics. Further well-designed studies are needed to examine these interventions and others to generate evidence that can inform decisions about implementation of newer telehealth technologies into obstetrics and gynecology practice.

The Development and Evaluation of a Text Message Program to Prevent Perceived Insufficient Milk Among First-Time Mothers: Retrospective Analysis of a Randomized Controlled Trial

Background

Several recent trials have examined the feasibility and efficacy of automated SMS text messaging to provide remote breastfeeding support to mothers, but these texting systems vary in terms of design features and outcomes examined.

Objective

This study examined user engagement with and feedback on a theory-grounded SMS text messaging intervention intended to prevent perceived insufficient milk (PIM)—the single, leading modifiable cause of unintended breastfeeding reduction and cessation.

Methods

We recruited 250 nulliparous individuals intending to breastfeed between 13 and 25 weeks of pregnancy in southwestern Pennsylvania. Participants were randomly assigned with equal allocation to either an SMS intervention to prevent PIM and unintended breastfeeding reduction or cessation (MILK, a Mobile, semiautomated text message–based Intervention to prevent perceived Low or insufficient milK supply; n=126) or a control group receiving general perinatal SMS text messaging–based support via the national, free Text4Baby system (n=124). Participants in both groups received SMS text messages 3 to 7 times per week from 25 weeks of pregnancy to 8 weeks postpartum. The MILK intervention incorporated several automated interactivity and personalization features (eg, keyword texting for more detailed information on topics and branched response logic) as well as an option to receive one-on-one assistance from an on-call study lactation consultant. We examined participant interactions with the MILK system, including response rates to SMS text messaging queries. We also sought participant feedback on MILK content, delivery preferences, and overall satisfaction with the system via interviews and a remote survey at 8 weeks postpartum.

Results

Participants randomized to MILK (87/124, 70.2% white and 84/124, 67.7% college educated) reported that MILK texts increased their breastfeeding confidence and helped them persevere through breastfeeding problems. Of 124 participants, 9 (7.3%) elected to stop MILK messages, and 3 (2.4%) opted to reduce message frequency during the course of the study. There were 46 texts through the MILK system for individualized assistance from the study lactation consultant (25/46, 54% on weekends or after-hours). The most commonly texted keywords for more detailed information occurred during weeks 4 to 6 postpartum and addressed milk volume intake and breastfeeding and sleep patterns. MILK participants stated a preference for anticipatory guidance on potential breastfeeding issues and less content addressing the benefits of breastfeeding. Suggested improvements included extending messaging past 8 weeks, providing access to messaging for partners, and tailoring content based on participants’ pre-existing breastfeeding knowledge and unique breastfeeding trajectory.

Conclusions

Prenatal and postpartum evidence–based breastfeeding support delivered via semiautomated SMS text messaging is a feasible and an acceptable intervention for first-time mothers. To optimize engagement with digital breastfeeding interventions, enhanced customization features should be considered.

Trial Registration

ClinicalTrials.gov NCT02724969; https://clinicaltrials.gov/ct2/show/NCT02724969

Could mobile phone text messages be used for infant feeding education in Ethiopia? A formative qualitative study

A majority of the world's population now live in areas with a mobile telephone network. This expansion of the network enables people to use more mobile phone functionalities such as short message service, multimedia, and the Internet. Mobile phone-based health (mHealth) interventions have been considered to have benefits in low-income countries. The aim of this study was to explore the feasibility of a short message service for breastfeeding education in Ethiopia. Four focus groups-two with mothers and two with fathers-were conducted with a total of 41 participants. The focus group discussion recordings were transcribed in Tigrigna verbatim, and then translated to English. The data were analyzed using thematic analysis, underpinned by the technology acceptance model. The following four general themes emerged from the focus group discussions: (1) Mobile phones: integrated into everyday life; (2) SMS text messaging: anytime, anywhere, as long as there is a sound; (3) Marketing versus utility: a barrier to SMS; and (4) Scientific messages from credible experts are key to reading SMS-based messages. Parents in Ethiopia showed interest in receiving weekly infant feeding-related short messages. Short message service-based interventions could therefore be an option for improving knowledge and awareness of parents regarding infant feeding.

Efficacy of a Breastfeeding Pain Self-Management Intervention: A Pilot Randomized Controlled Trial

BACKGROUND

Over 90% of women experience pain during breastfeeding initiation and lack strategies to self-manage breast and nipple pain. Guided by the Individual and Family Self-Management Theory, a breastfeeding self-management (BSM) intervention targeted women's knowledge, beliefs, and social facilitation to manage their breast and nipple pain and achieve their breastfeeding goals.

OBJECTIVES

The purpose of this longitudinal pilot randomized control trial (RCT) was to test the preliminary efficacy of the BSM intervention on general and specific pain related to breastfeeding.

METHODS

Sixty women intending to breastfeed were approached within 48 hours of delivery to participate in this pilot RCT (30 randomized to the BSM intervention and 30 randomized to the control group). All participants provided baseline data before discharge and pain and breastfeeding measures at 1, 2, and 6 weeks. Participants in the BSM intervention group received educational modules addressing breast and nipple pain and biweekly, text-based nurse coaching and completed a daily breastfeeding journal.

RESULTS

Women in the BSM intervention group reported significantly less breast and nipple pain at 1 and 2 weeks using a visual analog scale (p < .014 and p < .006) and at 2 weeks using the Brief Pain Inventory intensity scale (p < .029), but no difference in breastfeeding duration.

DISCUSSION

The BSM intervention pilot demonstrates a positive effect on breastfeeding specific and overall generalized pain. Future investigation is needed to identify at-risk women of ongoing breastfeeding pain and develop precision interventions to sustain this beneficial health behavior for mothers and infants.

Information and Communication Systems to Tackle Barriers to Breastfeeding: Systematic Search and Review

Background

Breastfeeding has many benefits for newborns, mothers, and the wider society. The World Health Organization recommends mothers to feed newborns exclusively with breastmilk for the first 6 months after birth, but breastfeeding rates in many countries fail to align with the recommendations because of various barriers. Breastfeeding success is associated with a number of determinants, such as self-efficacy, intention to breastfeed, and attitudes toward breastfeeding. Information and communication technology (ICT) has been leveraged to support breastfeeding by means of improving knowledge or providing practical supports in different maternal stages. Previous reviews have examined and summarized the effectiveness and credibility of interventions; however, no review has been done from a human-computer interaction perspective that is concerned with novel interaction techniques and the perspective of end users.

Objective

The objective of this review was to provide a comprehensive overview of existing digital interventions that support breastfeeding by investigating systems’ objective, technology design, validation process, and quality attributes, both in terms of clinical parameters as well as usability and user experience.

Methods

A systematic search was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in the following libraries: PubMed, Science Direct, Association for Computing Machinery Digital Library (ACM Digital Library), and Institute of Electrical and Electronics Engineers Xplore (IEEE Xplore).

Results

A total of 35 papers discussing 30 interventions were included. The main goals of these interventions were organized into 4 categories: breastfeeding education (n=12), breastfeeding promotion (n=8), communication support (n=6), and daily practical support (n=4). Of the interventions, 13 target mothers in the postnatal period. Most interventions come in forms of client communication systems (n=18), which frequently leverage Web technologies, text message, and mobile apps to provide breastfeeding support. Systems predominantly focus on mothers; validation strategies were rather heterogeneous, with 12 user studies concerning usability and user experience and 18 clinical validation studies focusing on the effects of the interventions on breastfeeding determinants; 5 papers did not report results. Generally, straightforward systems (eg, communication tools or Web-based solutions) seem to be more effective than complex interventions (eg, games).

Conclusions

Existing information and communication systems offer effective means of improving breastfeeding outcomes, but they do not address all relevant periods in parenthood (eg, the antenatal period) and often do not involve important stakeholders, such as partners. There is an opportunity to leverage more complex technical systems to open up avenues for the broader design of ICT to support breastfeeding; however, considering evaluation outcomes of existing support systems of higher complexity, such systems need to be designed with care.

Acceptability of a text message-based intervention for obesity prevention in infants from Hawai'i and Puerto Rico WIC

Background

Low-income and minority children are at increased risk for obesity. Text messaging offers advantages for delivering education, but few studies have assessed the acceptability of text messaging in interventions aimed at preventing excessive weight gain in infants. This study investigated the acceptability of a text message-based intervention for prevention of excessive weight gain in infants from Hawai‘i and Puerto Rico WIC clinics.

Methods

The four-month text message based intervention designed to improve infant feeding practices and reduce excessive weight gain was a randomized controlled trial that included mothers with infants ages 0–2 months at baseline. Participants in the intervention arm received 18 text messages (1/week) promoting breastfeeding and appropriate complementary feeding. Acceptability of the intervention was assessed from participant retention, satisfaction, and evidence of behavior change in a sequential multimethod approach, quantitatively from questions sent via text and qualitatively during the in-person exit interview. The final analysis included 80 mother-infant pairs from the intervention arm.

Results

When asked about messages liked and disliked the most, the majority of responses via text indicated that they liked all messages. From the qualitative analyses, most participants reported that all messages were useful and that the messages led them to make changes in the way they fed their infants. Participant retention was good at 78.4%.

Conclusions

The intervention was acceptable to participants based upon participant retention, measures of satisfaction, and reports of behavior change. Results may inform development of mobile health programs for minority childhood obesity prevention.

Trial registration

ClinicalTrials.gov Identifier; NCT02903186; September 16, 2016.

The effect of educational text message based on health belief model on osteoporosis preventive behaviors in women: a randomized controlled clinical trial

The purpose of this study was to investigate the effect of educational text messages, based on the health belief model, on osteoporosis preventive behaviors among women aged 30-45 years. This trial was conducted on 121 women from November until September 2017 in Shabestar, Iran. The intervention group received a daily educational text message about osteoporosis for one month, and the control group received educational text messages on frequently occurring cancers in women. Two months after the training, data were collected using the osteoporosis health belief scale, a food frequency questionnaire and the International Physical Activity Questionnaire. No significant differences were observed at baseline between the two groups, except for the perceived benefits construct. After the intervention, controlling for baseline score and adjusting for educational level, a statistically significant difference was observed between the two groups in HBM structures and nutrition performance, while no significant difference was observed in physical activity between the two groups. This study showed that educational text messages can be effective in increasing awareness, perceived susceptibility and severity, and nutritional behavior change related to risk of osteoporosis.

Promoting self-management of breast and nipple pain in breastfeeding women: Protocol of a pilot randomized controlled trial

The majority of women experience pain during breastfeeding initiation with few strategies to manage breast and nipple pain. In fact, women cite breast and nipple pain as among the most common reasons for breastfeeding cessation. To address this important issue, we developed a breastfeeding self-management (BSM) intervention, based on the Individual and Family Self-Management Theory Framework. In this framework, self-management is conceptualized as a process in which women use knowledge, beliefs, and social facilitation to achieve breastfeeding goals. The purpose of this longitudinal pilot randomized controlled trial was to test the feasibility, acceptability, and preliminary efficacy of the BSM intervention with women initiating breastfeeding. Recruitment of 60 women intending to breastfeed occurred within 48 hr of delivery and women were randomized to either the intervention or usual care group. The BSM intervention group received BSM education modules that included information of how to manage breast and nipple pain and self-management support through biweekly texting from the study nurse, and were asked to complete a daily breastfeeding journal. Primary outcomes measured at baseline, 1, 2, and 6 weeks will be used to (a) evaluate feasibility, acceptability, and preliminary efficacy of the BSM intervention, and (b) assess the influence of protective and risk factors of breastfeeding pain (including individual genetic polymorphisms related to pain sensitivity) on process variables for self-management of breastfeeding and breastfeeding pain, and on proximal (breastfeeding pain severity and interference, breastfeeding frequency) and distal outcomes (breastfeeding exclusivity and duration and general well-being).

Impact of mobile health interventions during the perinatal period for mothers in low- and middle-income countries: a systematic review protocol

REVIEW QUESTION

The objective of this review is to determine the impact of mother-targeted mobile health (mHealth) education interventions available during the perinatal period in low- and middle-income countries on maternal and newborn outcomes. Thus, the review questions are: what is the impact of mother-targeted mHealth education interventions on.

Telelactation via Mobile App: Perspectives of Rural Mothers, Their Care Providers, and Lactation Consultants

Background: Rural-urban disparities exist in breastfeeding rates and availability of lactation support. Direct-to-consumer (DTC) telelactation that uses two-way video through personal devices has the potential to increase access to international board-certified lactation consultants (IBCLCs) in rural settings that lack them. This study describes the feasibility and acceptability of DTC telelactation for rural mothers. Methods: We conducted semi-structured interviews among various stakeholders involved in a study exploring the impact of telelactation through mobile phone app in rural Pennsylvania. Interviewees included mother participants assigned to receive telelactation (n = 17), IBCLCs employed by the telelactation vendor (n = 7), and nurses (n = 2) and physicians (n = 1) caring for mother participants at the recruitment hospital. Thematic content analysis was used to analyze qualitative data. Results: Interviewees reported that telelactation was convenient and efficient, provided a needed service in rural areas lacking breastfeeding support services, and increased maternal breastfeeding confidence. Telelactation was noted to have several advantages over in-person and telephone-based support. Barriers to use included maternal reluctance to conduct video calls with an unknown provider, preference for community-based breastfeeding resources, and technical issues including limited WiFi in rural areas. Conclusions: Among rural women who experience inequitable access to qualified breastfeeding support resources, DTC telelactation appears to be an acceptable delivery model for lactation assistance.

Social Support for Breastfeeding in the Era of mHealth: A Content Analysis

BACKGROUND

Several barriers to successful breastfeeding exist, including a lack of support from peers or professionals. With the emergence of mobile health (mHealth) tools to provide additional breastfeeding support, a more thorough review of social support resources was needed. Research Aim: The aim of this study was to determine mHealth breastfeeding support resources and characterize the type of social support they provide.

METHODS

A content analysis of mHealth programs ( n = 65), including text messaging ( n = 12) and mobile applications ( n = 53), was conducted on the basis of searches of the iTunes and Google Play stores ( n = 50) and PubMed, the Cumulative Index of Nursing and Allied Health, and American Business Information/INFORM Complete Plus ( n = 15). Results were then dual-coded for key characteristics and types of support provided.

RESULTS

Thirty-eight apps (76%) were free to users, 14 (28%) were offered in a variety of languages, and 47 (94%) provided informational support. The mobile applications were targeted largely to postpartum women, focused on breastfeeding duration, and included troubleshooting information. Mobile applications often included media components ( n = 12 [24%]); few were tailored or personalized ( n = 5 [10%]) and interactive ( n = 15 [30%]). Text-messaging programs were available in a variety of countries ( n = 7 [58%]) and provided mostly informational support ( n = 5 [42%]), were pro-breastfeeding ( n = 12 [100%]), were targeted to both pregnant and postpartum women ( n = 6 [50%]), focused on both breastfeeding initiation and duration ( n = 9 [75%]), and had two-way interactivity ( n = 6 [50%]) and personalization ( n = 5 [42%]).

CONCLUSIONS

Although freely available mobile applications and text-messaging programs exist, with potential for wide reach, the majority provide only informational support. These programs would benefit from additional study of their usefulness.

Effect of a Multi-Site Trial using Short Message Service (SMS) on Infant Feeding Practices and Weight Gain in Low-Income Minorities

OBJECTIVE

To test the effects of weekly SMS for improving infant feeding practices and infant weight.

METHODS

This was a multi-site randomized clinical trial in a convenience sample of 202 caregivers of healthy term infants 0-2 months participating in the WIC program in Puerto Rico and Hawaii. Participants were randomized to receive SMS about infant's general health issues (control) or SMS for improving feeding practices (intervention) for four months. Weight, length and infant feeding practices were assessed at baseline and four months later.

RESULTS

A total of 170 participants completed the study (n = 86 control and n = 84 intervention). Baseline characteristics were similar between groups. At the end, exclusive breastfeeding rates were similar between groups (67.4% control and 59.1% intervention). Introduction of other foods and beverages, addition of foods to the bottle, placing infants to sleep with milk bottles, caregiver's method and response to feeding infants and distractions while feeding infants were similar between groups. Also, weight status or rate of weight gain was similar between groups.

CONCLUSION

There were no significant improvements in feeding practices or in weight with the intervention. The timeline of the messages in relation to the targeted behavior may have affected the effectiveness of the intervention. Earlier dissemination of messages, higher level of intensity, longer intervention, additional contacts and inclusion of other caregivers may be needed to achieve the desired effects.

Impact of the Lactation Advice Through Texting Can Help (LATCH) Trial on Time to First Contact and Exclusive Breastfeeding among WIC Participants

OBJECTIVE

Determine the impact of a 2-way text messaging intervention on time to contact between participants and their breastfeeding peer counselors (BFPCs) and on exclusive breastfeeding (EBF) status at 2 weeks and 3 months postpartum.

DESIGN

Multisite, single-blind, randomized, controlled trial.

SETTING

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) BFPC program.

PARTICIPANTS

Low-income women (n = 174) participating in the WIC BFPC program.

INTERVENTION

The control group received the standard of care WIC Loving Support BFPC program. The intervention group received standard of care plus the text messaging intervention.

MAIN OUTCOME MEASURES

Time to contact with BFPC and EBF status.

ANALYSIS

The 2-sample t test or χ² test assessed whether an association existed between study variables and each outcome. Multivariable ordinal and binary logistic regression assessed the impact of the intervention on time to contact and EBF status.

RESULTS

Lactation Advice Through Texting Can Help had a significant impact on early contact between participants and BFPCs (odds ratio = 2.93; 95% confidence interval, 1.35-6.37) but did not have a significant impact on EBF (odds ratio = 1.26; 95% confidence interval, 0.54-2.66).

CONCLUSIONS AND IMPLICATIONS

Lactation Advice Through Texting Can Help has the potential to facilitate the work of BFPCs by shortening the time-to-first-contact with clients after giving birth. Research is needed to identify the level of breastfeeding support staff coverage that WIC clinics must have to meet the demand for services created by Lactation Advice Through Texting Can Help.

Breastfeeding, Infant Formula, and Introduction to Complementary Foods-Comparing Data Obtained by Questionnaires and Health Visitors' Reports to Weekly Short Message Service Text Messages

BACKGROUND

Studies on prevalence and effects of breastfeeding call for reliable and precise data collection to optimize infant nutrition, growth, and health. Data on breastfeeding and infant nutrition are at risk of, for example, recall bias or social desirability bias.

OBJECTIVE

The aim of the present analysis was to compare data on infant nutrition, that is, breastfeeding, use of infant formula, and introduction to complementary foods, obtained by four different methods. We assumed that weekly short message service (SMS) questions were the most reliable method, to which the other methods were compared.

DESIGN

The study population was part of the Odense Child Cohort. The four methods used were: (a) self-administered questionnaire 3 months postpartum, (b) self-administered questionnaire 18 months postpartum, (c) registrations from health visitors visiting the families several times within the first year of life, and (d) weekly SMS questions introduced shortly after birth.

RESULTS

In total, 639 singleton mothers with data from all four methods were included. The proportion of mothers initiating breastfeeding varied from 86% to 97%, the mean duration of exclusive breastfeeding from 12 to 19 weeks, and the mean age when introduced to complementary foods from 19 to 21 weeks. The mean duration of any breastfeeding was 33 weeks across methods.

CONCLUSIONS

Compared with the weekly SMS questions, the self-administered questionnaires and the health visitors' reports resulted in a greater proportion of mothers with an unknown breastfeeding status, a longer duration of exclusive breastfeeding and later introduction to complementary foods, while the duration of any breastfeeding did not differ.

The Effectiveness of eHealth Technologies on Weight Management in Pregnant and Postpartum Women: Systematic Review and Meta-Analysis

BACKGROUND

The emergence and utilization of electronic health (eHealth) technologies has increased in a variety of health interventions. Exploiting the real-time advantages offered by mobile technologies during and after pregnancy has the potential to empower women and encourage behaviors that may improve maternal and child health.

OBJECTIVE

The objective of this study was to assess the effectiveness of eHealth technologies for weight management during pregnancy and the postpartum period and to review the efficacy of eHealth technologies on health behaviors, specifically nutrition and physical activity.

METHODS

A systematic search was conducted of the following databases: MEDLINE, EMBASE, Cochrane database of systematic reviews (CDSR), Cochrane central register of controlled trials (CENTRAL), CINAHL (Cumulative Index to Nursing and Allied Health Literature), and PsycINFO. The search included studies published from 1990 to July 5, 2016. All relevant primary studies that involved randomized controlled trials (RCTs), non-RCTs, before-and-after studies, historically controlled studies, and pilot studies were included. The study population was adult women of childbearing age either during pregnancy or the postpartum period. eHealth weight management intervention studies targeting physical activity, nutrition, or both, over a minimum 3-month period were included. Titles and abstracts, as well as full-text screening were conducted. Study quality was assessed using Cochrane's risk of bias tool. Data extraction was completed by a single reviewer, which was then verified by a second independent reviewer. Results were meta-analyzed to calculate pooled estimates of the effect, wherever possible.

RESULTS

Overall, 1787 and 176 citations were reviewed at the abstract and full-text screening stages, respectively. A total of 10 studies met the inclusion criteria ranging from high to low risk of bias. Pooled estimates from studies of the effect for postpartum women resulted in a significant reduction in weight (-2.55 kg, 95% CI -3.81 to -1.28) after 3 to 12 months and six studies found a nonsignificant reduction in weight gain for pregnant women (-1.62 kg, 95% CI -3.57 to 0.33) at approximately 40 weeks.

CONCLUSIONS

This review found evidence for benefits of eHealth technologies on weight management in postpartum women only. Further research is still needed regarding the use of these technologies during and after pregnancy.

Male partner involvement on initiation and sustainment of exclusive breastfeeding among HIV-infected post-partum women: Study protocol for a randomized controlled trial

Exclusive Breastfeeding (EBF) among human immunodeficiency virus (HIV)-infected mothers is known to be associated with a sustained and significant reduction in HIV transmission and has the potential to reduce infant and under-five mortality. Research shows that EBF is not common in many HIV-endemic, resource-limited settings despite recommendations by the World Health Organization. Although evidence abounds that male partner involvement increases HIV testing and uptake and retention of prevention of mother-to-child transmission interventions, few studies have evaluated the impact of male partners' involvement and decision-making on initiation, maintenance, and sustainment of EBF. We propose a comparative effectiveness trial of Men's Club as intervention group compared to the control group on initiation and sustainment of EBF. Men's Club will provide male partners of HIV-infected pregnant women one 5-hr interactive educational intervention to increase knowledge on EBF and explore barriers and facilitators of EBF and support. Additionally, participating male partners in the Men's Club as intervention group will receive weekly text message reminders during the first 6-week post-natal period to improve initiation and sustainment of EBF. Participants in the Men's Club as control group will receive only educational pamphlets. Primary outcomes are the differences in the rates of initiation and sustainment of EBF at 6 months between the two groups. Secondary outcomes are differences in male partner knowledge of infant feeding options and the intent to support EBF in the two groups. Understanding the role and impact of male partners on the EBF decision-making process will inform the development of effective and sustainable evidence-based interventions to support the initiation and sustainment of EBF.

Feasibility and acceptability of a text message intervention used as an adjunct tool by WIC breastfeeding peer counsellors: The LATCH pilot

Breastfeeding rates among mothers in the Supplemental Nutrition Program for Women, Infants, and Children (WIC) are lower than for other mothers in the United States. The objective of this study was to test the acceptability and feasibility of the Lactation Advice thru Texting Can Help intervention. Mothers were enrolled at 18-30 weeks gestation from two WIC breastfeeding peer counselling (PC) programmes if they intended to breastfeed and had unlimited text messaging, more than fifth-grade literacy level, and fluency in English or Spanish. Participants were randomized to the control arm (PC support without texting) or the intervention arm (PC support with texting). The two-way texting intervention provided breastfeeding education and support from peer counsellors. Primary outcomes included early post-partum (PP) contact and exclusive breastfeeding (EBF) rates at 2 weeks PP. Feasibility outcomes included text messaging engagement and mother's satisfaction with texting platform. Fifty-eight women were enrolled, 52 of whom were available for intention-to-treat analysis (n = 30 texting, n = 22 control). Contact between mothers and PCs within 48 hr of delivery was greater in the texting group (86.6% vs. 27.3%, p < .001). EBF rates at 2 weeks PP among participants in the texting intervention was 50% versus 31.8% in the control arm (p = .197). Intervention group mothers tended to be more likely to meet their breastfeeding goals (p = .06). Participants were highly satisfied with the Lactation Advice thru Texting Can Help intervention, and findings suggest that it may improve early post-delivery contact and increase EBF rates among mothers enrolled in WIC who receive PC. A large, multicentre trial is feasible and warranted.