Use of Electronic Communication by Physician Breastfeeding Experts for Support of the Breastfeeding Mother

Abstract

Background:

Breastfeeding initiation and duration increase because of physician encouragement. However, many physicians have not received education on breastfeeding, and some may not have a supportive attitude or commitment to breastfeeding. Patients identify dissatisfaction with their current provider as a motivating factor in seeking health information on the Internet. This survey was performed to determine how many physicians with an interest and expertise in breastfeeding are being contacted for breastfeeding information over the Internet and to examine physicians' attitudes to these requests.

Subjects and Methods:

An e-mail describing the survey, inviting participation, and containing a link to the online questionnaire was posted on the Web site of the Academy of Breastfeeding Medicine and as well as on the Listserv of the American Academy of Pediatrics—Section on Breastfeeding. Information collected included physician training, successes and challenges related to providing breastfeeding medicine support by e-mail, and current level of e-mail communication with patients regarding breastfeeding issues.

Results:

One-fourth of physicians in our survey receive e-mails with questions about breastfeeding issues from patients with whom they have no preexisting relationships. More receive e-mail from known patients. This suggests that breastfeeding mothers seek expert information on the Internet. Over half of the physicians replied to e-mails individually and without any financial reimbursement.

Conclusions:

Many breastfeeding mothers reach out to breastfeeding experts over the Internet. Our findings suggest that physicians who provide care to breastfeeding mothers need further education on breastfeeding to provide adequate support to their own patients.

Introduction

Protecting, promoting, and supporting breastfeeding, with its many known benefits for infants, children, and mothers, are key strategies toward improving the health of mothers and infants and are public health priorities. Educational, psychological, and physical support of the breastfeeding dyad is critical for a successful breastfeeding experience.^1,2 Early breastfeeding discontinuation has been associated with perceived lack of milk supply and other signs of lack of confidence. Therefore, timely encouragement, information, and reassurance may help a mother if breastfeeding poses challenges or becomes overwhelming.³ When adults look for health information, most turn to a health professional, such as a physician, for that information.⁴ Physician encouragement of breastfeeding has been shown to increase breastfeeding rates.^3,5 However, only about two-thirds of pediatricians received any education in breastfeeding management during medical school or residency, and some may not have a supportive attitude or commitment towards breastfeeding.^6,7

The Internet has increasingly become a tool for people seeking health information. A Pew Internet and American Life survey in 2011 showed that 80% of Internet users have visited a Web site for information or support for a specific health problem, 19% of whom searched for information on pregnancy and childbirth.⁸ However, very few adults receive online care or support from healthcare professionals.⁹ Concerns about privacy, malpractice liability, time, and reimbursement issues are reasons physicians cite for their reluctance to participate in online correspondence.^10,11 It is possible that online communication could eliminate some perceived and real barriers to accessing medical care.

Most Internet users start looking for health information using a search engine.¹² The key words used in that search may identify physicians who have been quoted in articles relating to breastfeeding or who have published breastfeeding-related research. Women seeking health information related to breastfeeding often identify these physicians as experts and contact them for medical advice.¹³

Electronic communication with a supportive, knowledgeable physician can be empowering and may lead people to contact physicians with whom they have no prior relationship in order to receive information. These “unsolicited e-mails” have become more common as physicians communicate electronically with their patients. The need for such communication may suggest that patients feel as if they are not receiving adequate or relevant information from their usual physician and may indicate a growing level of frustration.^13,14 Patients identify dissatisfaction with their current physician as a motivating factor in seeking health information on the Internet.¹⁵

We were unable to identify prior studies analyzing physicians' use of e-mail for breastfeeding support. This survey was done to obtain information about the use of e-mail in clinical practice by physicians with interest and expertise in breastfeeding. Knowing how often these physicians are being contacted for breastfeeding information may serve as a marker of maternal frustration with traditional means of clinical support. Our survey also assessed physicians' attitudes in responding to these requests. Knowing how breastfeeding experts handle the added burden of e-mail consultation helps inform the need for alternative resources and strategies for physicians' support of breastfeeding mothers.

Subjects and Methods

This study is based on data gathered using an online survey of physicians with an expertise or interest in breastfeeding support. Members of the Academy of Breastfeeding Medicine (ABM), an international organization of physicians dedicated to the promotion, protection, and support of breastfeeding and human lactation, and members of the American Academy of Pediatrics—Section on Breastfeeding were invited to participate in this study. These organizations represent a large cohort of physicians with an interest in breastfeeding. Many members of the ABM are also members of the American Academy of Pediatrics—Section on Breastfeeding. Those members were asked to respond to the survey only once.

The institutional review board of Wheaton Franciscan Healthcare reviewed and approved this research. An e-mail describing the survey, inviting participation, and containing a link to the online questionnaire was posted on the Web sites and Listserv of these professional organizations in June 2007. The online survey was pilot-tested with participants of varying degrees of comfort using technology, and no technical issues were identified. In total, three invitations were sent to eligible physicians, and survey data were collected from June to September 2007.

Demographic data collected included age, sex, geographic location of practice, self-described practice setting, and number of years of experience working with breastfeeding dyads. Respondents were asked about their additional credentials with regard to breastfeeding, including certifications as an International Board Certified Lactation Consultant, Certified Lactation Educator, or Fellow of the ABM. International Board Certified Lactation Consultants are the only healthcare professionals certified in lactation care.¹⁶ Being a Fellow of the ABM indicates that the ABM member physician “has ongoing specialized professional activities related to clinical expertise, research or teaching experience, and/or significant advocacy efforts in the field of breastfeeding medicine.”¹⁷

Information collected included physicians' attitudes, successes, and challenges related to providing breastfeeding medicine support over the Internet and the physician's current level of e-mail communication with patients, established or previously unknown, regarding breastfeeding issues. We adapted questions pertaining to unsolicited e-mails, with permission, from those included in a survey conducted by Eysenbach and Diepgen.¹⁸

Results

After the overlap of memberships between the American Academy of Pediatrics—Section on Breastfeeding and ABM members was accounted for, 794 physicians were invited to participate in this study. In total, 270 responses were received, with a response rate of 34%.

Physician demographics

Characteristics of physicians who responded to the survey are described in Table 1. Most respondents were female and general pediatricians. Many physicians had additional credentials related to breastfeeding. Approximately 17% of physicians were International Board Certified Lactation Consultants, and 12% were Fellows of the ABM. Approximately half of the physicians in our study practiced in an academic setting.

Table 1.

Demographic Characteristics of Survey Respondents (n=261)

Characteristic	n (%)
Age (years) [mean (SE)]	47.8 (0.64)
Sex
Female	210 (77.8)
Practice location
Rural	41 (15.2)
Suburban	94 (34.8)
Urban, not inner-city	72 (26.7)
Urban inner-city	63 (23.3)
Practice type
Academic	199 (55.9)
Non-academic	151 (44.1)
Formal breastfeeding credentials
Fellow of the Academy of Breastfeeding Medicine	33 (12.4)
International Board Certified Lactation Consultant	45 (16.9)
Certified Lactation Educator	4 (1.5)
Primary specialty
General Pediatrics	233 (87.3)
Family Medicine	11 (4.1)
Obstetrics and Gynecology	4 (1.5)
Internal Medicine	1 (0.4)
Preventive Medicine/Public Health	4 (1.5)
Other	14 (5.2)
Subspecialty
None	212 (79.4)
Neonatology	30 (11.2)
Other	25 (9.4)

Current practices of physicians regarding online support of breastfeeding

Approximately 42% of respondents participated in e-mail communication with patients with whom they had an established physician–patient relationship. In a bivariate analysis, the use of e-mail communication for patient support was not related to age, year of graduation from medical school, sex, geographic location, or the length of time the physician had worked with breastfeeding mothers and babies. Physicians in academic practices were more likely to communicate with patients by e-mail than those in non-academic settings (p=0.009). Respondents cited lack of time, inadequate ability of patients to understand what discussions are appropriate over e-mail, lack of interest, and privacy, legal, and ethical issues as reasons for their non-participation in e-mail communication with patients. Although many physicians reported not communicating with patients by e-mail, 48% did contribute to Internet forums or Web sites related to breastfeeding. Twenty-five percent of respondents received e-mails from people with whom they had no previous physician–patient relationship. When faced with an unsolicited email, 62% of physicians reported responding to it. None of the physicians in our study reported billing or collecting any fees for e-mail support of patients.

Attitudes and beliefs of physicians regarding online support of breastfeeding

Table 2 describes the attitudes and beliefs of participating physicians regarding online support of breastfeeding. Approximately 66% of respondents to our survey thought that it was inappropriate for patients to seek medical advice by e-mail from physicians with whom they did not have an existing physician–patient relationship. Thirty-three percent felt it was inappropriate for a physician to provide medical advice by e-mail. Approximately half the respondents believed that unsolicited e-mails sent to physicians from patients seeking medical advice represent a significant unresolved problem on the Internet.

Table 2.

Attitudes and Beliefs Regarding Internet Communication for Medical Care (n=261)

Question	n (%)
How appropriate is it for patients to seek medical advice by e-mail from doctors with whom they do not have an existing doctor–patient relationship?
Very inappropriate	72 (27.6)
Somewhat inappropriate	101 (38.7)
Neither inappropriate or appropriate	42 (16.1)
Somewhat appropriate	37 (14.2)
Very appropriate	9 (3.4)
How appropriate is it for a physician to give medical advice over the Internet via e-mail?
Very inappropriate	23 (8.8)
Somewhat inappropriate	63 (24.1)
Neither inappropriate or appropriate	59 (22.6)
Somewhat appropriate	91 (34.9)
Very appropriate	25 (9.6)
Do you think that unsolicited e-mails from patients sent to doctors asking for medical advice represents a significant unresolved problem on the Internet?
Yes	130 (50.2)
No	47 (18.2)
Don't know	82 (31.7)

Discussion

One-fourth of physicians in our survey received e-mails with questions about breastfeeding issues from patients with whom they had no preexisting relationships. More receive e-mails seeking breastfeeding support from known patients. This suggests that breastfeeding mothers seek expert information on the Internet. Even though most physicians expressed concerns about the appropriateness of e-mail communication and about privacy, time, and legal issues, most replied to e-mail communications, even when there was no prior physician–patient relationship. No surveyed physician billed for the service.

Breastfeeding is an important public health issue given the multitude of benefits it provides for the health of mothers and babies, but also for its economic and environmental impact.¹⁹ Physician support improves breastfeeding initiation and duration rates; however, physician support and commitment to breastfeeding appears to be waning.^6,7 Unsolicited e-mails for medical support have been described as "cries for help" as frustrated patients search to find those with expertise in their area of health need and may serve as a marker for dissatisfaction with current level of medical support.¹³

Many physicians in our study felt that it was very or somewhat inappropriate for patients to communicate by e-mail about clinical concerns with physicians with whom they had no prior relationship and that such e-mails were a significant unresolved problem. However, despite concerns about inappropriate use of e-mail, time constraints, and privacy and legal issues, a large proportion of physicians responded to e-mails individually and without reimbursement. This may indicate that the experts themselves recognize that they are a resource of last resort, even if they do not agree with this role.

Our method of data collection using Web-based survey has limitations with respect obtaining a representative sample as well as response bias.²⁰ In order to ameliorate this issue, we posted the online survey three times to increase our response rate. Our response rates were about the same as online surveys similar to ours.^21,22 Web-based surveys of physicians have specifically been criticized as being unrepresentative of the physician population, even within a specific specialty. When this survey was administered in 2007, the ABM had 46 Fellows, 33 (72%) of whom responded, so in this case a significant portion of the most recognized experts was represented.

Despite these limitations our study contributes to the literature on breastfeeding support by providing new information how commonly mothers seek support for breastfeeding support over the Internet. Our findings also suggest that physicians who provide care to breastfeeding mothers need further education on breastfeeding to provide adequate support to their own patients.

Conclusions

Physicians are important to breastfeeding success, and when mothers are searching for information to help them breastfeed successfully, a few physician experts cannot possibly meet the potential demand for this information. The creation of more physician experts in breastfeeding is needed to meet the increasing demand for breastfeeding support. Future efforts should focus on physician education and encouragement of breastfeeding, as well as alternate resources and strategies for physicians so that breastfeeding mothers receive timely, expert, and accurate information and a continuity of support.

Footnotes

Acknowledgments

We would like to thank Dr. Jennifer Griffiths for her guidance with this study.

Disclosure Statement

No competing financial interests exist.

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