Development and Implementation of a Novel Online Breastfeeding Support Resource: The Maternal Virtual Infant Nutrition Support Clinic

Abstract

Exclusive breastfeeding is the optimal method of infant feeding for the first 6 months of life for both term and preterm infants. This recommendation is based on indisputable evidence that breastfeeding offers numerous infant and maternal health benefits. Several trials have shown the beneficial effect of peer and/or professional support on the duration of any breastfeeding up to 6 months. Although many well-established programs exist that provide this support in-person or via telephone, the Internet is a relatively new means to deliver breastfeeding help. Yet, mothers have a vast presence online and a clear desire to seek healthcare information on the Internet. The availability and accessibility of interactive communication technologies via the internet provide the opportunity for developing new methods of healthcare delivery. Our project uses information technology to deliver an innovative and cost-effective way to support breastfeeding mothers. Our new online breastfeeding support clinic has the potential to improve access to specialized professional breastfeeding support in combination with interactive peer support. This new online clinic can be readily implemented to all regions in Canada with reliable Internet access, with the potential to significantly impact the health of all Canadian infants and their families.

Introduction

Breastfeeding offers many advantages to the health of both mother and infant. The World Health Organization and the Canadian Pediatric Society both recommend that mothers exclusively breastfeed for the first 6 months and beyond. This message is clearly received in Canada, where over 88% of mothers initiate breastfeeding.¹ However, there is a dramatic decline in this rate by 6 months of age, with only 30% of Canadian mothers continuing to exclusively breastfeed.¹

Data from a 2007 Cochrane review showed that any form of breastfeeding support resulted in improved breastfeeding rates at 6 months.² This support could be peer or professional support alone, although combining lay and professional support to usual care was found to have the greatest impact.² The professional's role was to provide information and technical support, whereas lay individuals offered emotional support based on experiential knowledge.³ These findings suggest that mothers benefit most with both types of support to overcome difficulties and be able to continue to breastfeed exclusively. Accordingly, the call to “provide a seamless transition between the services provided by the hospital…and peer support programs” has been included in the Breastfeeding Committee for Canada's Integrated 10 Steps for Hospitals.⁴ Although many organizations have worked toward providing this seamless transition, we are not aware of any programs in Canada that currently provide integrated professional and lay support. A key challenge is in finding a cost-effective and easily accessible system of integrating peer and professional breastfeeding support.

The Internet provides unprecedented opportunities for access to health information and is increasingly becoming an integral part of healthcare services. Presently, there are over 74% of Canadian female home Internet users who have sought health information online.⁵ Of special note, however, is that many new mothers are part of the “Millennial Generation,” of whom almost all engage in online communication and nearly 72% use social networking Web sites.⁶ In addition, it has been found that 44% of new mothers find their time online increases after their baby's arrival with a high likelihood that they will search for breastfeeding information.⁷ This highlights an important opportunity to engage breastfeeding mothers via the Internet.⁸ Even the U.S. Surgeon General called for breastfeeding promoters to “adapt quickly to changing technology and develop new kinds of messages appropriate to these venues.”⁸

Current platforms such as e-mail, social media, or educational Web sites come with questions of confidentiality, credibility, ethics, and practice guidelines for the International Board Certified Lactation Consultant (IBCLC) and other healthcare providers.^8,9 Additionally, using established social networks presents the challenge of user-generated content that is likely to be in violation of the World Health Organization Code of Marketing Breast-milk Substitutes.¹⁰ The use of the search term “breastfeeding” in Google results in approximately 14.5 million Web sites (as of April 14, 2014), and a review by Shaikh and Scott¹¹ concluded that most breastfeeding Web sites available to the public have content of reasonable quality with reference to evidence-based practice. Yet, even with this prevalence of breastfeeding Web sites, a 2014 review by Giglia and Binns¹² reported a lack of studies where breastfeeding outcomes are definitively measured when online breastfeeding education has been an intervention. As well, a recent review by Skouteris et al.¹³ of breastfeeding interventions in high-income countries did not even identify online help as a source of education or support. Certainly, effectively teaching breastfeeding to students and professionals on the Internet is a well-established practice,¹⁴ but the question remains as to whether or not it is an appropriate delivery method for new parents.

With this in mind, we developed a novel online breastfeeding resource called the Maternal Virtual Infant Nutrition Support (MAVINS) Clinic. The development of this resource allows us to offer evidence-based breastfeeding education with integrated peer and professional support. It also lets us collect data on breastfeeding outcomes in a confidential online environment.

Materials and Methods

MAVINS was designed to have four arms: (1) text, pictorial, and video evidence-based breastfeeding educational resources; (2) an interactive discussion forum for mothers that is monitored and facilitated by an IBCLC; (3) the capacity for data collection; and (4) an online baby journal for text and photo entries. We recruited 200 healthy primiparous mothers of healthy term singletons during their postpartum hospital stay. Participants had home Internet access and had initiated breastfeeding with the intent to continue after hospital discharge. Half of the mothers in the MAVINS study were randomly assigned to a control group with access to all content except the interactive discussion forum. The 100 mothers in the intervention group received full access with peer and professional support in the discussion forum. We hypothesize that women who receive the interactive online support in addition to the educational resources will have an increased rate of exclusive breastfeeding at 6 months postpartum. Here we discuss the challenges of developing and implementing MAVINS at the midway point of the study.

MAVINS was structured using a Drupal Commons platform in consultation with a Web site developer for customized features. Mothers must log-on using a unique and self-created username and password, and the site is held behind the London Health Sciences Centre hospital firewall. The Web site is composed of a homepage with a welcome video from the study team as well as a newsfeed of weekly video and blog tips. There are also navigation tabs that lead mothers to content on common breastfeeding challenges, frequently asked questions, resources such as hospital handouts and teaching videos, and an online baby journal. The mothers receiving support in the intervention group also have a tab for their discussion group. Each mother is invited to make a MAVINS profile for herself, including a picture of herself, or she may remain anonymous. For the study, there are also links to surveys that appear at the data collection points of 2 weeks, 2 months, 4 months, and 6 months (Fig. 1). A feedback form is also available to all should there be a struggle with navigation or suggestions for Web site improvement. The entire Web site is also searchable by key word and has undergone preliminary optimization for use on mobile devices. Mothers are sent a welcome e-mail upon enrollment with further instructions on how to use the Web site, and the intervention group members are asked to read a discussion forum code of conduct.

FIG. 1.

Maternal Virtual Infant Nutrition Support (Mavins) Clinic homepage and navigation.

The discussion forum allows mothers to connect with one another through creating, “liking,” and responding to posts. All mothers in the intervention group receive e-mail notification when a new discussion thread is started, and then they may choose to receive each subsequent response-post in an e-mail thread by “following” the post or choose only to see messages upon logging-in to MAVINS. We tested MAVINS extensively with a pre-study focus group to optimize content and delivery. A key message was that there is a delicate balance to be had between notifying mothers about new content to foster participation and yet not overwhelming them with too many messages directly to their e-mail inboxes.

All posts are e-mailed to an IBCLC who facilitates and encourages discussion. The IBCLC also poses questions for further details, sources information and resources complementary to MAVINS, offers suggestions, answers questions, posts new breastfeeding-related studies, and encourages contact with a primary healthcare provider as appropriate. An IBCLC response is always given within 24 hours, and most responses are provided in under 3 hours.

Results

Recruitment

We recruited 200 participants in less than 5 months with an enrollment rate of 60% for eligible mothers approached. The principal reasons for mothers declining to participate were reporting that they already had good support, not wanting to complete study surveys, or being overwhelmed and unable able to commit to learning and using something new in the postpartum period. The first cohort of mothers has reached the study end point of 6 months, but it will be another 4 months until all mothers have reached the 6-month landmark and we are able to make a full evaluation on rates of breastfeeding exclusivity between the intervention and control groups. Of special note is that data gathered to date indicate that formula was introduced in-hospital to 40% of our MAVINS mothers.

Resource use

Most mothers were more than 2 weeks postpartum when they initially logged-in to MAVINS, and we have been surprised by the number of mothers who entered the study but have never logged-on. Many conversations initiated by the IBCLC to create engagement on the forums were not responded to until the first cohort of mothers was more than 2 months postpartum. Several “live” help-sessions have also been offered where the IBCLC was available to respond in real-time but were not utilized. However, during the 5 weeks that there were mothers of both 5 month olds and newborns, activity on the forums peaked. Our Web site analytics show that the majority (72%) of mothers are spending time on MAVINS via mobile devices.

Mothers in the intervention group have logged-in over 2.5 times more on average than those in the control group. The most active discussion topics on the forums have been more lifestyle-based, focusing on sleeping, pumping, bottles for older babies, nursing in public, and transitioning to solid foods. Although some mothers did ask about latch, milk supply, and weaning off of supplementation initiated in hospital, these topics did not elicit the same response as more subjective topics.

All mother-to-mother correspondence has been polite and cordial with no inappropriate or unsupportive comments. One feature that does create momentum and engagement are weekly video tips posted to the homepage and provided in e-mail notifications. The play-count for these 2–10-minute videos produced by the MAVINS study team is over 600 to date. Very few mothers use the online baby journal feature, which was expected to be an incentive for mothers in the control group interacting with MAVINS content.

Feedback

Mothers who do regularly use the forum have given very positive feedback:

Your comment was very very informative, thank you! I've been looking all over Google for different information and you just summed it all up in one comment, hopefully some of this does help. (MAVINS user in response to IBCLC moderator response)

I really like this website. It is a great resource for breastfeeding FAQ [frequently asked questions] and provides a lot of information on issues I never even thought about. Most importantly for me, I feel that it is information I can trust. The videos are also very valuable and I find myself going back to some of them. Overall, great site. (MAVINS user feedback form submission)

Discussion

It will not be clear until all results are gathered why there was such a lag time from enrollment to first log-in to MAVINS. We may find this was because breastfeeding was stopped very soon after hospital discharge, or these mothers didn't need any support during this time, or perhaps that these mothers were more comfortable with other sources of support established antenatally and found using a new resource challenging.

The high rate (40%) of in-hospital supplementation may also impact Web site use in the early weeks as mothers quickly stop breastfeeding. In 2014 Chantry et al.¹⁵ found that in-hospital formula supplementation was associated with a nearly twofold greater risk of not fully breastfeeding at days 30–60 postpartum. At Day 60 this increased to a nearly threefold risk of not breastfeeding even in women whose intent was to exclusively breastfeed. The high rate of supplementation in our study mothers also calls into question whether or not the MAVINS intervention will be able to overcome the profound impact of this practice.

At the start of the study mothers were truly peers. However, when there were more experienced mothers to contribute to the questions of new mothers, conversation was very much enhanced and enriched.

The disparity in log-on rates between the control and intervention groups indicates that it is the support that is seen as the most valuable resource. The informational component may be responsible, however, for the discussion topics in the intervention group tending to be on more subjective rather than technical topics. The educational content of MAVINS informs about latch techniques, nipple pain, and supply issues, whereas the emotional support that normalizes breastfeeding experiences and new-mother transitions is gained on the forum. It may also be because of the delay in mothers using MAVINS during the first 2 weeks where technical information may be more important. The topics of interest on MAVINS are consistent with the ideas of the “trifecta approach to breastfeeding” recently proposed by Bunik et al.¹⁶ where community, lifestyle, and psychosocial support are important alongside technical breastfeeding knowledge and assessments.

Because of the usage trends and user feedback, the development of MAVINS 2.0 is underway to be further mobile-optimized. This will allow it to function more like a smartphone application or “app” overall. It will also be able to include components more similar to other baby-feeding and baby-care apps where length of feeds, frequency of feeds, and infant growth can be tracked, which we believe will be more of an incentive for MAVINS visits than the free-form baby journal. We are also updating the content on MAVINS so that it will have an antenatal education component to engage mothers prior to their baby's arrival and also the potential to serve special populations such as mothers of premature babies.

Conclusions

MAVINS offers a unique opportunity to connect inpatient and community breastfeeding care where peer and professional support are integrated. The online delivery meets new mothers with a technology they are already using to seek health and parenting information. As we continue to optimize the technology and collect data about the mothers in the study, we are confident that we have developed a novel breastfeeding support tool that will positively impact exclusive breastfeeding outcomes.

Footnotes

Acknowledgments

We wish to thank Cesar Abeid and Stephen Cross for providing the technical support for building and maintaining the MAVINS Web page. This work was supported by the AHSC AFP Innovation Fund, Academic Medical Organization of Southwestern Ontario.

Disclosure Statement

No competing financial interests exist.

References

Statistics Canada. CANSIM Table 105-0501 and Catalogue No. 82-221-X. June 19, 2012. Available at www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/health92b-eng.htm (accessed July 1, 2012).

Britton

, McCormick

, Renfrew

, et al. Support for breastfeeding mothers. Cochrane Database Syst Rev, 2007;(1):CD001141.

Dennis

. Peer support within a health care context: A concept analysis. Int J Nurs Stud, 2003; 40:321–332.

Breastfeeding Committee for Canada. Integrated 10 Steps & WHO Code Practice Outcome Indicators for Hospitals and Community Health Services: Summary. May 14, 2012. Available at www.breastfeedingcanada.ca/documents/2012-05-14_BCC_BFI_Ten_Steps_Integrated_Indicators_Summary.pdf (accessed April 7, 2014).

Statistics Canada. Information and Communications Technology. September 30, 2011. Available at www.statcan.gc.ca/pub/11-402-x/2011000/chap/information/information-eng.htm (accessed May 5, 2014).

Lenhart

, Purcell

, Smith

, Zickuhr

. Social media and mobile Internet use among teens and young adults. Pew Internet and American Life Project. February 3, 2010. Available at www.pewinternet.org/files/old-media/Files/Reports/2010/PIP_Social_Media_and_Young_Adults_Report_Final_with_toplines.pdf (accessed April 7, 2014).

Bartholomew

, Schoppe-Sullivan

, Glassman

, et al. New parents' Facebook use at the transition to parenthood. Fam Relations, 2012; 61:455–469.

McCann

, McCulloch

. Establishing an online social media presence for your IBCLC practice. J Hum Lact, 2012; 28:450–454.

Thomas

, Shaikh

. Electronic communication with patients for breastfeeding support. J Hum Lact, 2007; 23:275–279.

10.

Abrahams

. Milk and social media: Online communities and the International Code of Marketing of Breast-milk Substitutes. J Hum Lact, 2012; 28:400–406.

11.

Shaikh

, Scott

. Extent, accuracy, and credibility of breastfeeding information on the Internet. J Hum Lact, 2005; 21:175–183.

12.

Giglia

, Binns

. The effectiveness of the Internet in improving breastfeeding outcomes: A systematic review. J Hum Lact, 2014; 30:156–160.

13.

Skouteris

, Nagle

, Fowler

, et al. Interventions designed to promote exclusive breastfeeding in high-income countries: A systematic review. Breastfeed Med, 2014; 9:113–127.

14.

Riordan

. Teaching breastfeeding on the Web. J Hum Lact, 2000; 16:231–234.

15.

Chantry

, Dewey

, Peerson

, et al. In-hospital formula use increases early breastfeeding cessation among first-time mothers intending to exclusively breastfeed. J Pediatr, 2014; 164:1339–1345.e5.

16.

Bunik

, Dunn

, Watkins

, et al. Trifecta approach to breastfeeding: Clinical care in the integrated mental health model. J Hum Lact, 2014; 30:143–147.