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

Abstract

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

The rates and factors of perceived insufficient milk supply: A systematic review

“…Importantly, mothers should be confident that they can produce enough milk to meet the needs of their babies even in the first few days after delivery (McGuire, 2018 ). In order to reinforce mothers' breastfeeding self‐efficacy, it is necessary to provide mothers and their family members with breastfeeding knowledge in the prenatal period, including breastfeeding techniques, breastfeeding benefits, normal patterns of infant breastfeeding behaviour, physiology of breast milk production, resolution of breastfeeding problems, etc., (Demirci et al, 2020 ; Lauwers & Swisher, 2010 ; Rodrigo et al, 2018 ; Safon et al, 2017 ). If a mother is concerned that her baby is not getting sufficient breast milk, health professionals can use more reliable parameters to evaluate her baby, such as the number of wet diapers and stools (American Academy of Pediatrics, 2005 ), infant alertness, skin colour, muscle tone, and consistent weight gain and growth (Amir, 2006 ; Neifert, 2004 ; Shrago et al, 2006 ).…”

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

“…In Australia alone, an estimated 92% over the age of 18 used a mobile phone in 2012, additionally over half of those aged 25–34 were mobile-only phone users [ 7 ]. Public health and health promotion researchers have harnessed the increased dependability on mobile phones to deliver interventions via telephone and/or text messages [ 8 , 9 ]. Crucially, this mode of delivery was welcomed for its cost-effectiveness [ 10 ], ability to reach wider population [ 11 ] and its acceptability to those receiving the interventions [ 12 ].…”

Understanding the Role of Technology to Support Breastfeeding

“…less than six months is only 40%, and only 23 countries in the world have a breastfeeding rate above 60% until children reach the age of six months [53], falling behind the World Health Organisation directives [54]. Various attempts to tackle barriers to breastfeeding through technology have been made, for example, through information systems that provide breastfeeding education [1,25,31,34,36,42], communication systems to deliver ad-hoc breastfeeding support [20,21,29,59,71], and social networks to facilitate practical and peer support [6,16,19,[66][67][68].…”