Novel Approach To Improving Lactation Support With Mobile Health Technology

Immediately following delivery, mothers are given the task of learning to care for a newborn,
coping with rapid hormone changes, and in many cases, learning to breastfeed, all with
minimal contact with their obstetric provider. Traditionally, women are not seen by their
obstetrician until 6 weeks postpartum, increasing the likelihood that they will switch to
formula feeding despite a clear antenatal intent to breastfeed.

Data suggests that exclusive breastfeeding for the first six months of life is associated
with lower rates of respiratory and ear infections in babies with fewer required
hospitalizations, due to the protective effect of maternal antibodies in breast milk. Fewer
children go on to develop asthma and allergies [1][2]. Additionally, adolescents who were
breastfed demonstrate higher intelligence quotient (IQ) averages that their peers who were
not [3]. The benefits of breastfeeding for mothers include healthy weight loss and protection
against ovarian and breast cancer, as well as psychological wellness through maternal-infant
bonding [4][5]. The World Health Organization (WHO) has published extensive data to support
recommendations for exclusive breastfeeding in the first 6-month period [6]. Exclusive
breastfeeding is defined as the infant's only source of nutrition being human breast milk
(along with vitamins, minerals, and medications). While the WHO and the American Congress of
Obstetricians and Gynecologists (ACOG) recommend 6 months of exclusive breastfeeding, data
published by the Centers for Disease Control (CDC) in 2016 show that only 81.1% of mothers
ever try breastfeeding, only 44.4% exclusively breastfeed through 3 months, and only 22.3%
exclusively breastfeed over 6 months [7]. In Missouri, the CDC's report card data shows that
85.4% of mothers ever breastfed, and rates of exclusive breastfeeding were 49.7% and 24.7% at
3 and 6 months respectively. At the investigators' local hospital, a recent chart review as
part of the Barnes Jewish Hospital's Baby Friendly designation process demonstrated that only
45% of mothers who received prenatal care at the Center for Advanced Medicine (CAM) or the
Center for Outpatient Health (COH) were exclusively breastfeeding at 6 weeks postpartum
(unpublished data). In order to reach the Healthy People 2020 goals of 42.6% breastfeeding at
3 months and 60.6% at 6 months, it is important to identify modifiable barriers to optimal
breastfeeding practices and create innovative solutions to address them [8].

One of these barriers is access to lactation support [9]. Mothers frequently have difficulty
becoming familiar with the process of breastfeeding during the immediate postpartum period.
"Difficulty latching" or "inadequate milk production" are the most common causes of concern,
driving mothers to supplement with or switch to milk formula products. Once efforts to
breastfeed cease, mammary milk production slows and cannot be restarted. Mothers who have
started formula feeds at time of discharge from the hospital are five times more likely to
stop breastfeeding completely in the first week [10]. The ACOG strongly supports
breastfeeding, recognizing it as a public health priority, and has promoted the
implementation of clinical resources in hospital systems nationwide [11]. Many hospitals
employ dedicated professionals trained in breastfeeding (lactation consultants and obstetric
and postpartum nurses trained specifically in lactation support) to counsel and assist
mothers, and the use of lactation consultants has been shown to significantly increase
breastfeeding rates [12]. Unfortunately, trends show that after mothers and infants are
discharged from the hospital, they lose connection with these providers. The lack of support
is one of many factors that may lead to cessation of exclusive breastfeeding.

In typical postpartum practice, patients return to their obstetrics provider for a visit at 6
weeks. This is inadequate for addressing breastfeeding concerns, as it occurs too late to
promote a return to a breastfeeding [13]. Proactive outreach in busy obstetrics practices is
expensive, time-consuming and inefficient due to challenges with identifying and targeting
resources to mothers who are most in need of a help achieving their breastfeeding goals
[13][14]. Postpartum visits are, by default, included in a patient's global obstetric package
and providers are in many cases unable to bill separately for lactation support visits, which
can make it harder for mothers and providers to address issues earlier postpartum. Ideally,
an approach to improving patient/provider communication in the 2 postpartum weeks when most
breastfeeding challenges arise would provide support out of the office setting, with follow
up through 6 months. The system must ideally be low cost, low tech, and efficient enough to
be implemented widely. Short message service (SMS) texting interventions mark a novel entry
point to the healthcare field and enable targeting to patients across the socioeconomic
spectrum [15]. Every cell phone is equipped for SMS texting. This form of communication also
allows the patient to respond to prompt messages, thereby reducing the burden on patients to
initiate communication.

Breastfeeding improves maternal and infant health. Most expert bodies recommend at least 6
months of exclusive breastfeeding. Unfortunately, breastfeeding can be difficult to start and
sustain due to a variety of mostly treatable factors; many mothers are currently left to
navigate these difficulties on their own. The investigators hypothesize that close and
individualized assistance will increase the rates of exclusive breastfeeding. To achieve
this, a novel, automated, two-way text messaging platform has been developed. This system
offers encouragement and education but perhaps more importantly, it collects and categorizes
feedback from each mother to identify those that may benefit from personalized follow-up by a
trained professional. This system was developed by a team of students and healthcare
professionals. The investigators propose implementing it in obstetrics clinics at BJH, and
will study its impact through quantitative measures and feedback. If successful, this
proposal will create a scalable technological solution to improve breastfeeding adherence.

Hypothesis:

An automated bidirectional communication tool (EpxBreastfeeding) to monitor nursing status
and assess for common problems related to breastfeeding will improve provider awareness and
expedite personal follow-up with patients identified as at risk of stopping breastfeeding,
and will improve breastfeeding adherence over time compared to controls.

Specific Aims:

1. Determine if exclusive breastfeeding duration can be improved by using an automated
bidirectional communication tool compared to standard of care through six months
postpartum.

2. Compare time-to-event incidence reporting and subsequent provider response time to
duration of breastfeeding status (intervention cohort only).

3. Collect subjective data from mothers receiving the intervention, as well as ancillary
professionals who are designated for notification and follow-up to consider the
feasibility and acceptance of an automated bidirectional mHealth lactation support
intervention in the clinical setting.

Inclusion Criteria:

- Pregnant women age 18 to 40 years

- Singleton birth (e.g. no twins or triplets)

- Prenatal intention to breastfeed

- Have a mobile phone capable of receiving SMS text messages and phone calls

- Know how to send a text message

- ≥4th grade literacy level

Exclusion Criteria:

- Non-fluent in English

- Known fetal anomaly

- Infant delivery <37 weeks

- >3 days in neonatal intensive care unit (NICU)

- Medical history: pre-pregnancy BMI >50, history of thyroid disorders, failed one hour
and three hour glucola test or if they ever needed oral hypoglycemic, hypertension
(HTN) before/during pregnancy, postpartum hemorrhage

- Medically contraindicated for breastfeeding (provider's judgment)

- Women who will breastfeed but not from their own breast (e.g. buy breast milk on the
Internet/milk bank)

- Women who are hesitant about answering a series of text messages regularly

- Women who are unable to be contacted by SMS text message or are unwilling to provide
their contact number

- Women with neurologic, anatomic, or cognitive disorders that are unable to consent
and/or answer text messages