Telehealth and Breastfeeding: An Integrative Review

Abstract

Background:

This is an integrative review of scientific articles, published from 2000 to 2018, that address strategies for breastfeeding through telehealth. Telehealth is the safe and low cost use of information and communication technologies (ICTs) in health care. The objective is to identify the scientific production on the subject of telehealth as a support strategy for breastfeeding.

Methods:

A qualitative research study was carried out with emphasis on the integrative review of the Embase, Bireme, and PubMed databases, in Portuguese, English, and Spanish. The descriptors used were “breastfeeding” and “telemedicine.”

Results:

Twenty-three articles were identified and categorized as (1) synchronous support for telephone calls and/or videoconference; (2) asynchronous support for audio and text messaging, interactive websites, and mobile application; and (3) systematic review and meta-analysis. Experiences demonstrated viability to implementation, impact on exclusive breastfeeding time, and maintenance of breastfeeding, as well as positive user satisfaction.

Conclusion:

Viable telehealth strategies exist to support breastfeeding. With the existence of telehealth hubs, structured more than 10 years in Brazil, there seems to be potential in the development of projects in the area. There is room for innovation and for the expansion of telehealth services already offered.

Introduction

The World Health Organization (WHO) states that it is not possible to reach universal health care coverage without investing in e-health.¹ For decades, the incorporation of information and communication technologies (ICTs) in the field of health has been termed as telemedicine or, in a comprehensive way, telehealth. Telehealth constitutes the e-health, which is the safe and low-cost use of ICTs in support of health, health services and health-related factors, health surveillance, health literature, and health education, knowledge, and research.²

Telehealth strategies can be developed for the interaction between professionals and/or between the professional and the person (user, client, patient) for whom it is desired to offer a health service.³ In this way it consists of removing barriers of time and distance, enabling the accomplishment of prevention, diagnosis, and treatment of diseases, research and evaluation, and continuing education in all places.⁴

The health of women and children is considered a priority for the development of a country. Countries that concentrate a large proportion of maternal and child mortality worldwide are already developing telehealth actions that are improving access to care and helping women to take control of their own health.⁵

The benefit of breastfeeding for the health of the woman and child dyad is proven. But a report released by WHO and the United Nations Children's Fund (UNICEF) at the end of the first half of 2017 showed that only 40% of the world's children are exclusively breastfed for the first 6 months of life. In Brazil, this index is 39%.⁶

This study aimed to identify the scientific production on the subject of telehealth as a support strategy for breastfeeding. It is intended to describe actions that are being developed in the promotion of breastfeeding through e-health. Hopefully, this general framework built on the literature review will bring benefits to future research and development on telehealth.

Telehealth: ICTs Allied to Health Promotion

Interaction through remote communication devices can occur among health professionals, a practice already common in developed countries, where a smaller hospital, for example, can share and discuss cases with specialists from other places, which are not available in person in the institution.³

When the interaction is direct between health professional and patient, this can be done at home, in an educational institution or anywhere else. This tool is often used for clinical visits that do not require physical presence, such as behavioral health, counseling, follow-up, test results, and patient education.³

Silva⁴ also describes the following two modalities for distance interaction: synchronous and asynchronous. The first occurs when the information is shared and received in real time. A common example occurs when the exchange is made through a conventional telephone or by videoconference. The second form, asynchronous, is information exchanged off-line, as in text messages or prerecorded voice.

These are booming practices that have gained significant support in recent years. With an acceptable care methodology, they have effective use in many clinical domains, as well as evidence of cost reduction, increased access—particularly in rural and neglected areas—and user satisfaction.^7,8

The superiority of breastfeeding over other forms of infant feeding, as well as the positive impact in underdeveloped and developing countries, already has scientific evidence of great consistency. Considered one of the most important studies of recent years, Victora et al.⁹ list the benefits of breastfeeding as essential for the achievement of the Sustainable Development Goals,¹⁰ an agenda created by the United Nations in 2015, with goals to be obtained through 2030.

McFadden et al.,¹¹ in a systematic review conducted through the Cochrane database, concluded that for healthy women who breastfeed healthy full-term infants, breastfeeding support increases their duration and the proportion of exclusive breastfeeding. To be effective, such support should be routinely provided by trained persons during pregnancy or postpartum, include prescheduled visits—so that women know when support will be available—and be tailored to local needs and to the needs of the population group.

When WHO states that there will not be universal health coverage without the use of e-health strategies, the health of women and children is pointed out as one of the axes to be explored. In the last survey conducted among the countries that participate in the Commission for Information and Accountability for Women's and Children's Health (75 countries that together have 98% of maternal and child mortality in the world), only one third reported the use of the tools for the development of their policies and strategies for women's and children's health.⁵

With the expansion of the research, it is possible to find several experiences being described and, most of them, pointing out some benefits in the development of services that support breastfeeding, either through text messages or video calls between lactating and nursing professionals, as well as projects to qualify health care professionals in care.

Methods

We performed an integrative review, with the objective to gather and synthesize research results on a delimited topic or issue, in a systematic and orderly manner, contributing to the deepening of the knowledge of the subject under investigation.¹² As a guiding question for this integrative review it was used “what the literature reports on support for breastfeeding by telehealth?”

Search

Three electronic databases (Embase, Bireme, and PubMed) were searched from March to June 2018. The descriptors of Medical Subject Headings (MeSH) and the operator “OR” and “AND” were used, resulting in the following combinations: “Breast Feeding”[Mesh] OR “Feeding, Breast” OR “Breastfeeding” OR “Breast Feeding, Exclusive” OR “Exclusive Breast Feeding” OR “Breastfeeding, Exclusive” OR “Exclusive Breastfeeding” and “Telemedicine”[Mesh] OR “Mobile Health” OR “Health, Mobile” OR “mHealth” OR “Telehealth” OR “eHealth.”

Articles published between 2000 and 2018 in Portuguese, English, and Spanish were included. Repeated articles were considered only once. The information was organized through a synoptic table that included the following information: database, author, year of publication, title, method, study objectives, and results found. The articles were classified according to the degree of evidence proposed by Paula, et al.¹³ The presentation of the results and the discussion on the subject were made in a descriptive way.

Results and Discussion

The initial search yielded 216 articles. After applying the inclusion criteria, a sample of 111 articles was obtained, and 36 articles were excluded because they were repeated. The abstracts of 75 articles were analyzed, and exclusion criterion was applied, documents that did not address the theme of strategies for breastfeeding through telehealth, totaling a sample of 30 articles. After the reading in full version, a sample of 23 articles was obtained.

The selected studies come from 17 different journals, with 89.5% of “general health” journals addressing the topics related to nutrition, breastfeeding, pediatrics, obstetrics, and gynecology. Only three articles (13%) were published in e-health journals from two different journals, and two studies (8.7%) were published before 2012.

The United States is the country that published most articles related to the subject of this review. Of the 23 articles, 8.7% presented evidence level N1, 43.5% used quantitative methodology presenting level of evidence N2, and 47.8% presented levels of evidence N4 or N6 (Table 1).

Table 1.

Summary Table of Included Studies

AUTHOR (YEAR)	COUNTRY	STUDY DESIGN	LEVEL OF EVIDENCE
Lau et al. (2015)	Singapore	Meta-analysis	N1
Grant et al. (2016)	United Kingdom	Systematic review and meta-analysis	N1
Hoddinott et al. (2012)	Scotland	Randomized control trial	N2
Tahir and Al-Sadat (2013)	Malaysia	Randomized control trial	N2
Carlsen et al. (2013)	Denmark	Randomized control trial	N2
Seguranyes et al. (2014)	Spain	Randomized control trial	N2
Reeder et al. (2014)	United States	Randomized control trial	N2
Fu et al. (2014)	China	Randomized control trial	N2
Efrat et al. (2015)	United States	Randomized control trial	N2
Ahmed et al. (2016)	United States	Randomized control trial	N2
Flax et al. (2017)	Nigeria	Randomized control trial	N2
Martinez-Brockman et al. (2018)	United States	Randomized control trial	N2
Guijarro et al. (2014)	Spain	Control–case pilot study	N4
Alam et al. (2017)	Bangladesh	Retrospective cross-sectional study	N4
Lindberg et al. (2007)	Sweden	Mixed method—pilot study	N6
Roberts et al. (2009)	Scotland	Mixed method	N6
Rojjanasrirat et al. (2012)	United States	Descriptive study	N6
Habibi et al. (2012)	United States	Mixed method	N6
Thomson et al. (2012)	United Kingdom	Mixed method	N6
Friesen et al. (2015)	United States	Mixed method	N6
White et al. (2016)	Australia	Mixed method	N6
Wang et al. (2018)	Thailand	Mixed method	N6
Gallegos et al. (2018)	Australia	Mixed method	N6

N, evidence level.

ICT enables a multitude of arrangements to be explored in an attempt to expand access to support for effective breastfeeding. The results of this review describe strategies already tried in several countries. Most of the studies were carried out based on recruitment performed at maternity hospitals; only two studies mention the involvement of Primary Health Care services.^14,15 No study reported on having been developed by a specific nucleus of telehealth.

The data were organized as follows: synchronous support—telephone calls (8), videoconference (4), combination of telephone calls and videoconference (2); asynchronous support—text messages through mobile phone (4), online platform and social network (1), mobile phone applications (2), and systematic review and meta-analysis (2). The synthesis of the studies is explained in tables by category.

Synchronous Support

In relation to Synchronous support (Table 2), in which the majority of the studies were concentrated (60.9%), the experiences were explored regarding the feasibility of breastfeeding support services, impact evaluation and breastfeeding efficacy after telephone and/or videoconference intervention, characterization of the demands of synchronous support services, and user satisfaction.

Table 2.

Data Analysis Table: Synchronous Support

AUTHOR (YEAR)	OBJECTIVE	INTERVENTION	OUTCOMES
Telephone calls
Hoddinott et al. (2012)	Evaluate the feasibility of implementing a dedicated team to support breastfeeding in a maternity hospital. To test the potential effectiveness and cost-effectiveness of telephone support of this team (proactive) and initiated by the woman (reactive) after discharge.	For telephone support, 69 women were randomized, 35 for the daily reactive proactive telephone calls and 34 for the reactive telephone calls. The intervention occurred up to 14 days after discharge from the maternity ward.	At the end of 6–8 weeks postpartum, the IG had 32 complete cases, 69% of the women were giving breast milk and of those 78% in exclusive breastfeeding. The CG had 26 complete cases, 46% of the women were giving breast milk and 67% of them were exclusively breastfed. The costs were sensitive to the organization of the institution.
Gallegos et al. (2018)	Characterize telephone calls from a 24-h breastfeeding helpline, attended by qualified nurses in maternal and child care.	In a 4-week period, 149 calls were identified with breastfeeding content and underwent self-efficacy analysis.^a	93% of the calls were made by puerperal, 5% by the baby's father, and 1% by other family members/friends, from all walks of life. The thematic analysis characterized the connections as: the medical discourse—medicalizing breastfeeding; moral discourse—moralizing breastfeeding; building high efficiency; failing to build self-efficacy; undermining self-efficacy. Demonstrated the need for specific training for telehealth care.
Efrat et al. (2015)	To evaluate whether a telephone intervention provided by breastfeeding educators influenced exclusive breastfeeding rates among low-income Hispanic women in the United States.	CG = 143 women. IG = 146 women, who received 4 phone calls during the third trimester of gestation and 17 postpartum calls (up to the sixth month) and could also contact the lactation educator more frequently if necessary. Data on the outcome were collected at 72 h, 1, 3, and 6 months postpartum.	The difference between the groups, control and intervention, was not statistically significant.
Fu et al. (2014)	To assess the effect of two postpartum professional support interventions on the duration of any breastfeeding and exclusive breastfeeding at 1, 2, and 3 months postpartum.	724 Primiparous were separated into 3 groups: 264 in standard care; 191 standard care plus 3 professional support sessions (30 min) in the first 48 h postpartum, and 269 standard care plus weekly telephone support after discharge, 20–30 min for 4 weeks or until stop completely breastfeeding. The interventions were performed by nurses trained and certified as breastfeeding consultants.	97% of participants completed follow-up. The telephone support group had superior results at all points of collection in relation to the other two groups. The difference between the telephone support group and the standard support in the first month for the continuation of breastfeeding was statistically significant 76.2% versus 67.3%, in the second month 58.6% versus 48.9%, and for exclusive breastfeeding in the first month OR 1.89; 95% CI 1.24–2.90. As well as they had a significantly lower overall risk of discontinuing breastfeeding (HR 0.79, 95% CI 0.64–0.98).
Reeder et al. (2014)	Testing whether a telephone counseling program between participants in a complementary program for women, infants, and children could increase the onset, duration, and exclusivity of breastfeeding.	1,948 Women were randomized into 3 groups: 635 without support, 625 received 4 telephone contacts, and 625 received 8 telephone contacts. The contacts were made by women who had previously participated in the program and successfully breastfed.	There was no difference between the groups that received four or eight telephone contacts; therefore, they were considered as a single category in the analysis. Counseling increased the chance of nonexclusive breastfeeding for at least 3 months by 22%. The increase in the chance of exclusive breastfeeding was greater in 20% among participants who speak Spanish between the two groups. Nonexclusive breastfeeding for at least 6 months was limited to Spanish-speaking participants, as well as a lower chance of termination of exclusive and nonexclusive breastfeeding.
Thomson et al. (2012)	Assess the overall satisfaction of users of a breastfeeding support phone line in the United Kingdom.	Telephone structured interviews were conducted with 908 participants who used the service.	74.6% of respondents reported being very satisfied, and 19.8% were satisfied with the help and support received by the helpdesk.
Tahir and Al-Sadat (2013)	To determine the effectiveness of telephone counseling in encouraging exclusive breastfeeding among mothers who have had children in a public hospital.	IG: 179 women received standard care and telephone counseling twice a month until the end of the study (12 contacts), earlier in case of interruption of breastfeeding. CG: 178 received standard care to support postnatal breastfeeding. Phone contacts were made by breastfeeding consultants.	In the first month 84.3% of the IG was in exclusive breastfeeding versus 74.7% in the CG. At 4 and 6 months, the percentages were similar in both groups (42.0% vs. 39.0%, 12.5% vs. 12.0%, respectively). At all points of collection, the CG presented higher percentages of complete interruption of breastfeeding, but the results were not statistically significant.
Carlsen et al. (2013)	To evaluate whether telephone support could increase the duration of breastfeeding in obese women, affecting the anthropometric measurements of offspring at 6 months.	IG: 108 dyads received standard support plus three telephone contacts in the first month, two in the second, and one in a month up to 6 months postpartum. Extra contacts were made for specific difficulties. All women could contact the consultant, available 7 days a week. CG: 118 dyads received standard support.	IG exclusively breastfed for an average of 120 days compared to 41 days in the CG. Any breastfeeding was maintained for an average of 184 days in the IG and 108 days for the CG. Extra calls were given in 37 cases, and only 5 people contacted the breastfeeding consultant. There was no significant effect on infant growth at 6 months of age.
Telephone calls and videoconferencing
Seguranyes et al. (2014)	To evaluate the effectiveness of a combined intervention between videoconferencing and telephone contact, compared to standard postpartum care in Primary Health Care centers in Catalonia.	IG: 683 women were able to access midwives by telephone, videoconference, or standard consultation. CG: 718 women received standard care at health centers or at home. Participants were recruited from eight health centers.	40.4% of the women in the IG accessed the midwives by videoconference or telephone. The mean number of contacts with midwives was higher in this group (2.74 vs. 1.22), and visits to the health center were lower (mean of 1 visit vs. 1.7). Prevalence of breastfeeding was similar in both groups (64.5% vs. 65.4%), as well as high satisfaction with services provided by midwives.
Videoconferencing
Rojjanasrirat et al. (2012)	To evaluate the reliability and feasibility of videoconference at home for breastfeeding support and evaluation.	10 Dyads participated in a weekly videoconference in the first 4 weeks postpartum. In the first two sessions there was the participation of a breastfeeding consultant and in the last two, only the consultant through video.	Each session lasted from 19 to 50 min. The reliability scores reached the minimum expected from the second session. The distance consultant assessed the quality, clarity of the images, and sounds as good or excellent; however, in 20% of the contacts he was not able to hear the swallowing sounds. 100% of woman reported that it was helpful to get answers and were comfortable talking about concerns about breastfeeding through videoconferencing. 70% reported that talking to the distance consultant was like talking in person. On two occasions it was necessary to reschedule the session due to device issues.
Lindberg et al. (2007)	Describe the experience of midwives who provided videoconferencing support to parents who were discharged early.	22 Midwives had the opportunity to participate in the intervention that was supported by videoconference during the first week after birth for dyads that were discharged early (72 h postpartum).	The experiences of 7 midwives were investigated (20 videoconferences) evidencing that the main reason for the contact was related to breastfeeding and the health of the child. The time to establish the connection ranged from 0.5 to 10 min, and the contacts lasted on average 13 min. Ten contacts were made by mothers, seven by midwives, two by the computer technician, and one by the father. The midwives reported some problems with the quality of the image, but considered the communication experience as positive.
Roberts et al. (2009)	To assess the feasibility and acceptability of video call postnatal support after a hospital discharge as a form of support in infant feeding and to investigate the potential use of other communication technologies (telephone, e-mail, text, and interactive digital television) in a remote rural area of Scotland.	403 Women received a questionnaire at discharge from the hospital and 91 responded. Of these, 59 were on exclusive or mixed breastfeeding. Twenty volunteers were selected for semistructured telephone interviews 6–8 weeks postpartum.	Questionnaire Group: 86% support the availability of video support. 70% opted for the service 24 h, 7 days a week. In two situations related to breastfeeding, 95–97% selected as the first option the face-to-face contact, followed by 81–88% telephone contact, 42–56% video connection, 15–17% interactive TV, 39–44% text message. Group of interviews: 75% were “pro-video” with reservations as a guarantee of access at any time, privacy and security of the information, meet in person the professionals who will answer the calls.
Friesen et al. (2015)	Explore the feasibility of videoconferencing to provide education and support to breastfeeding low-income women by a certified breastfeeding consultant.	A videoconferencing station was established at a community health center, where 35 selected women participated in scheduled sessions on the day of pre- and postpartum consultations. In 9 months, 134 sessions of 30–45 min each were performed. At the end of the project, the main participants were interviewed.	Participants reported that videoconferencing was simple to implement, allowing the breastfeeding consultant to broaden their clientele and enable women to receive specialized support that they would otherwise not receive.
Habibi et al. (2012)	To describe the maternal experience of lactation consultation through videoconference, compared to face-to-face care.	12 Women participated in a videoconference and a face-to-face consultation during a visit to the study site. Three days after the consultation, they answered a telephone interview.	All mothers reported a positive experience with videoconferencing, would indicate to other women, and scored specific situations in which it would be very convenient to have access to this resource.

Self-efficacy is defined as the individual assessment of the ability to successfully perform a given behavior.

CG control group; CI, confidence interval; HR, hazard ratio; IG, intervention group; OR, odds ratio.

In the subcategory “viability,” the studies demonstrated the feasibility of implementing videoconferencing services and telephone calls, with approval of users and positive results in the effectiveness of breastfeeding support and cost-effectiveness.^16

–19 They corroborate a study by Oriá et al.,²⁰ a systematic review that concluded that the evidence demonstrates telephone as a viable technology for the promotion of breastfeeding, providing units and health professionals an alternative that can contribute to the care of mother-baby.

Thomson et al.²¹ evaluated a telephone-based breastfeeding support service already established in the United Kingdom. This study reported data of overall satisfaction with 94.4% of the 908 participants being satisfied or very satisfied with the help and support received. These findings corroborate study results on similar service in Australia.²²

In the results presented by Friesen et al.,¹⁹ participants reported that videoconferencing was simple to implement and that otherwise women would not have access to a lactation consultant in that locality. This is a very interesting finding, considering that facilitating access to health services in distant localities is the main objective of telehealth.

In the subcategory “efficacy,” among the seven articles evaluating this aspect, all with a level of evidence N2, 100% presented some degree of increase in the exclusive breastfeeding time and/or maintenance of breastfeeding, as well as less probability of discontinuation of breastfeeding in the groups that underwent intervention compared to the control group (CG). Although the difference is not very expressive, it is worth mentioning that all had some type of standard support being offered to the participants in the CG, which may reflect in the efficacy results.^{14,18,23

–27}

Seguranyes et al.¹⁴ found a similar prevalence in exclusive breastfeeding among the two groups (intervention group [IG] 64.5% vs. CG 65.4%) and in the satisfaction of the users. Both had access to the support offered by midwives, and the IG could still count on the contact by videoconference and telephone call. Of the 683 women in this group, 40.4% used the telehealth service and thus had a higher average (2.74 vs. 1.22) of contact with the midwives but visited in person less the health service (1 vs. 1.7). In communities where distance is a problem, synchronous support can be an ally for increased access.

The content of contacts made has not been addressed in efficacy studies. A study by Alves et al.²⁸ associated a higher prevalence of exclusive breastfeeding for 6 months with the guidelines on the importance of breast milk, but concluded that the guidelines on the management of difficulties in breastfeeding still needed to be improved.

In the subcategory “description of the experience,” different points of the interventions appeared in the results. Lindberg et al.²⁹ described that midwives who provided support through videoconference reported problems with image quality and control of the camera, but even so, they considered the communication experience positive.

In a timely intervention with 12 women, Habibi et al.³⁰ compared a face-to-face consultation and a videoconference consultation. All mothers reported a positive experience of synchronous consultation but continued to prefer face-to-face consultation. Few studies objectively compared presential assistance and distance care. From the point of view of increase in the access range, perhaps more important than evaluating the preference between modalities, is to carry out noninferiority studies comparing distant care with attending to face-to-face service.

The study by Gallegos et al.³¹ aimed to characterize the telephone calls of a 24-h service to support breastfeeding. In the thematic analysis of the content of the connections, a moralizing and medicalizing discourse of breastfeeding was perceived, often failing to build self-efficacy or even undermining the user's ability to successfully breastfeed.

Again, the need for improved management related to breastfeeding, suggested by Alves et al.,²⁸ seems to endorse the finding of the study by Gallegos et al.³¹ It is necessary to qualify the listening and to strengthen the practice centered on the user, whether by face-to-face or remote attendance.

Asynchronous Support

Asynchronous support experiences were also explored regarding the feasibility and acceptability of breastfeeding support services; impact on assessment and efficacy of breastfeeding after speech and text messaging interventions, interactive sites, and online platforms and described the development of mobile applications to support men and women in relation to breastfeed (Table 3).

Table 3.

Data Analysis Table: Asynchronous Support

AUTHOR (YEAR)	OBJECTIVE	INTERVENTION	OUTCOMES
Guijarro et al. (2014)	To demonstrate the impact of e-health strategies in the monitoring of healthy children in their first 6 months of life in a Primary Health Care service.	IG: 57 participants with standard follow-up, possibility of contacts through social networks or telemedicine platform, between 1–2, 2–4, and 4–6 months of the child, consultations on vaccinations, breastfeeding, and food introduction. CG: 57 participants.	IG: 72.5% accessed the service by site, 58.8% used social networks (Twitter^® and Facebook^®), 88.3% requested telemedicine sessions, and 78.4% participated in online speeches. This group had a lower mean number of face-to-face consultations with physicians and nurses (2 vs. 4), as well as a higher percentage of breastfeeding after 6 months of age (36% vs. 18.5%).
Ahmed et al. (2016)	To determine whether an interactive web-based breastfeeding monitoring system increases the duration, exclusivity, and intensity of breastfeeding as primary outcomes and decreases the symptoms of postpartum depression as a secondary outcome.	IG: 49 dyads had access to an interactive online breastfeeding monitoring system and were asked to record data on breastfeeding and physiological eliminations of the baby for 30 days. CG: 57 dyads followed standard care.	The IG presented higher rates of exclusive breastfeeding in 1 (63% vs. 40%), 2 (63% vs. 19%), and 3 months (55% vs.19%). At the end of the third month, 84% of the IG continued to breastfeed compared to 66% of the CG. There was no significant difference for the secondary outcome.
White et al. (2016)	Develop the first evidence-based breastfeeding application for men. Design an application to provide men with social support and information with the goal of increasing the support that men can offer their breastfeeding partners.	18 New and future fathers and 16 health professionals participated in focus groups to evaluate the design and information of the Milk Man application. Four parents tested an application prototype.	Fathers and health professionals contributed through focus groups for application development. Fathers who tested the application identified six areas of functionality and usability to address, including adding a tutorial, increasing the size of text and icons, and more customization. The appraisers rated the application very well, and the MARS (Mobile Application Rating Scale) average score for the application was 4.3 out of 5.
Wang et al. (2018)	Evaluate the utility and usability of a mobile application designed to support breastfeeding women.	21 Women received the MoomMae^® application to use for 4 weeks on their phone or tablet.	The average usability and utility scores of the postuse survey were 4.33 (SD 0.87, range from 1 to 5) and 4.60 (SD 0.74, range from 2 to 5). The qualitative analysis revealed a total of 137 feedbacks: 71 usability related (59 negative, 11 positive, and 1 neutral) and 66 associated with utility (56 positive, 9 negative, and 1 neutral). Twenty-six design problems and recommendations for future improvements were reported.
Flax et al. (2017)	To measure the feasibility and acceptability of the use of mobile phones in a group to promote breastfeeding in Nigeria.	195 Lactants were recruited, and a low-cost cell phone was provided for each small group of 5–7 participants. These groups participated in monthly face-to-face meetings and received 11 messages about breastfeeding, sent weekly through a mass message provider, for 4 months and then every 2 weeks for 3 months.	64% of women rated that the group's phone worked well or very well. 58% felt motivated to try best practices because they relied on information and had support from the group (35%). Approximately 44% of the women reported that the group met at least once a week, which had a greater chance of exclusive breastfeeding up to 6 months than women in groups that never met (OR 5.6, 95% CI 1.6–19.7). Interviews and group discussions indicated that women had positive feelings toward those in charge of the phone; messages were often shared outside the group as well.
Alam et al. (2017)	To assess the association between a text messaging service and delivery practices and maternal care of newborns in selected areas of Bangladesh.	IG: 210 women received text messages during pregnancy. CG: 266 mothers received no messages.	93% of women breastfeed immediately after birth, but there was no significant association between exposure to text messages during pregnancy and breastfeeding practices.
Martinez-Brockman et al. (2018)	Determine the impact of text message intervention on exclusive breastfeeding status at 2 weeks and 3 months postpartum.	IG: 114 women received standard care and automatic text messages with content related to breastfeeding. Text messages were sent with increasing frequency in the prenatal period and decreasing postpartum frequency. CG: 98 women received standard care.	The text messages had an impact on the early contact of women with the breastfeeding consultant (OR 2.93, 95% CI 1.35–6.37), but had no significant impact on exclusive breastfeeding status (OR 1.26, 95% CI 0.54–2.66).

SD, standard deviation.

In the subcategory “viability,” the study described by Flax et al.³² has the peculiarity of distributing a mobile phone between a group of women, to receive information sent through text message and voice, and attend a meeting about once a week. In addition to reporting that the strategy worked well, they expressed confidence in the information received and had a greater chance of exclusive breastfeeding until 6 months in relation to those who had never had group meetings.

Considering utility subcategories, Wang et al.³³ obtained a positive result when offering an application designed to support women who breastfeed. However, there was a strong need for improvements in usability and application design.

In the efficacy subcategory Martinez-Brockman et al.³⁴ reported that text messages sent in the pre- and postnatal period stimulated early contact between mothers and lactation consultants, but did not have a significant impact on breastfeeding status (odds ratio 1.26, 95% confidence interval 0.54–2.66), level of evidence N2, as well as the study by Alam et al.,³⁵ level of evidence N4.

In contrast, Ahmed et al.,³⁶ level of evidence N2, found higher rates of exclusive breastfeeding in the group that received an intervention based on an online interactive system of breastfeeding monitoring through registries on breastfeeding and physiological eliminations of the baby in the first 30 days of life. Results were: in 1 month 63% versus 40%, 2 months 63% versus 19%, 3 months 55% versus 19%, and by the end of the third month, 84% of the IG was offering some form of breast milk compared to 66% of the CG. These results corroborate the study by Guijarro et al.,¹⁵ which used a similar strategy and obtained a higher percentage of breastfeeding (36% vs. 18.5%) after 6 months of age, level of evidence N4.

A content analysis developed by Schindler-Ruwisch et al.³⁷ identified that, just like mobile applications, text messaging is a potentially far-reaching resource in providing information about breastfeeding.³⁸ Austen et al.³⁹ present the use of video with musical parody as an additional resource to sensitize young adults about the importance of breastfeeding. These seem to be signs that health education must adhere to the trend of innovation.

In the subcategory “description of the experience,” White et al.⁴⁰ obtained approval from participants by presenting an application designed to offer men social support and information with the aim of increasing their ability to support breastfeeding. There were also contributions to improvements in functionality and usability of the application, such as larger letters and customization. It is worth pointing out that the suggestion of the possibility of personalizing an application is in line with the discussion of individualized health care.

Systematic Review and Meta-Analysis

In relation to systematic review and meta-analysis, two studies were aimed to assess whether e-health strategies had any effect on breastfeeding rates (Table 4). Both suggest that more well-designed randomized clinical trials are needed for an impact assessment of applied technologies to increase exclusive breastfeeding.^41,42

Table 4.

Data Analysis Table: Systematic Review and Meta-Analysis

AUTHOR (YEAR)	OBJECTIVE	INTERVENTION	OUTCOMES
Lau et al. (2015)	Synthesize the best available evidence to assess whether electronic technologies have had any effect on improving breastfeeding outcomes.	After applying the inclusion and exclusion criteria, 16 experimental studies were selected. Of which a total of 5,505 women in 6 countries were included.	50% of the selected studies had low risk of bias. Seven studies have shown that the overall effect of electronic technologies on initiating exclusive breastfeeding was significant. Five studies found improvement in exclusive breastfeeding at 4 weeks and 6 months. Five studies found efficacy in breastfeeding attitude and knowledge. Five studies have evidenced other positive findings of electronic technologies under the results of breastfeeding.
Grant et al. (2016)	To evaluate the effectiveness of mobile health interventions for maternal, newborn, and child health in low- and middle-income countries.	Sixteen international online databases were searched between January 1990 and May 2014. Fifteen studies and 2 conference abstracts fulfilled the inclusion criteria.	Meta-analysis of three studies on infant feeding showed that prenatal interventions using SMS/cell phone (vs. routine care) improved breastfeeding rates within 1 h after birth and exclusive breastfeeding in 3–4 months and for 6 months.

SMS, short message service.

In a recent pilot study to advance to a future randomized clinical trial, Patel and colleagues⁴³ used combined strategies in an intervention with 518 pregnant women, offering weekly counseling through telephone calls and daily text messages, since the third trimester of the gestation up to 1 week after the baby was 6 months old. Exclusive breastfeeding rates were sustained above 95% at all visits in the IG, while in the CG they fell from 81% at 6 weeks to 48.5% at 6 months.

Conclusions

This review described strategies that have proven viable to implementation through ICT, expanding access to information and care in a crucial period of the mother–baby dyad. Beyond viability, the impact on the success and maintenance of exclusive breastfeeding was demonstrated, as well as the high satisfaction of the participants exposed to the strategies. Therefore, they presented not only positive results but also subsidies for new initiatives.

Further studies are needed, with a more rigorous methodological approach, with larger samples. Thus, we consider that it would develop effective telehealth interventions focused on supporting early initiation of breastfeeding within 1 h of birth, exclusive breastfeeding for the first 6 months of life, and continued breastfeeding up to 2 years of age or beyond, for the pregnant women and their support network, thus helping to achieve WHO recommended rates.

Footnotes

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

References

World Health Organization. Global difusion of ehealth: Making universal health coverage achievable. Report of the Third Global Survey on EHealth. 2016. Available at http://apps.who.int/bookorders (last accessed March 20, 2019 ).

World Health Organization . Fifty-eighth World Health Assembly, Geneva, 16–25 May. 2005. Resolutions and decisions annex. 2005 . Available at http://apps.who.int/gb/ebwha/pdf_files/wha58-rec1/english/a58_2005_rec1-en.pdf (last accessed March 20, 2019 ).

Agnisarman

, Chalil Madathil

, Smith

, Ashok

, Welch

, McElligott

. Lessons learned from the usability assessment of home-based telemedicine systems. Appl Ergon, 2017; 58:424–434.

Silva

. Telehealth in Brazil—Concepts and Applications, 1st edition (in Portuguese). Rio de Janeiro: DOC Publisher, 2014.

World Health Organization. EHealth and innovation in women's and children's health: A baseline review: Based on the findings of the. 2013. Survey of CoIA Countries by the WHO Global Observatory for EHealth. 2014 . Available at www.who.int (last accessed March 20, 2019 ).

World Health

Organization

. Global breastfeeding scorecard, 2017. Tracking progress for breastfeeding policies and programmes. New York, 2017 . Available at www.unicef.org (last accessed March 20, 2019 ).

Kutscher

Wiring in rural patients. Modern Healthcare. 2014. Available at www.modernhealthcare.com/article/20140308/MAGAZINE/303089979/wiring-in-rural-patients (last accessed March 20, 2019 ).

Rojas

, Gagnon

M-P

. A systematic review of the key indicators for assessing telehomecare cost-effectiveness. Telemed J E Health, 2008; 14:896–904.

Victora

, Bahl

, Barros

AJD

, et al. Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. Lancet, 2016; 387:475–490.

10.

United Nations. Transforming our world: The. 2030. agenda for sustainable development. New York, 2015 . Available at https://sustainabledevelopment.un.org/post2015/transformingourworld (last accessed March 20, 2019 ).

11.

Mcfadden

, Gavine

, Renfrew

, et al. Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database Syst Rev, 2017; 2017:CD001141.

12.

Mendes

KDS

, Silveira

RCCP

, Galvão

. Integrative review: research method for incorporating evidence in health and nursing (in Portuguese). Text Context Nurs, 2009; 17:758–764.

13.

Paula

, Padoin

SMM

, Galvão

. Integrative review as a tool for decision making in health practice. In: Maria

Ribeiro L

, Regina Gema

, eds. Research Methodologies for Nursing and Health: From Theory to Practice, 1st edition (in Portuguese). Porto Alegre: Moriá, 2015:51–76.

14.

Seguranyes

, Costa

, Fuentelsaz-Gallego

, et al. Efficacy of a videoconferencing intervention compared with standard postnatal care at primary care health centres in Catalonia. Midwifery, 2014; 30:764–771.

15.

Guijarro

, Luna

, Bazán

. Use of the new technologies and telemedicine, in the healthy newborn follow up. Rev Pediatr Atención Primaria, 2014; 16:305–310.

16.

Roberts

, Hoddinott

, Heaney

, Bryers

. The use of video support for infant feeding after hospital discharge: A study in remote and rural Scotland. Matern Child Nutr, 2009; 5:347–357.

17.

Rojjanasrirat

, Nelson

, Wambach

. A pilot study of home-based videoconferencing for breastfeeding support. J Hum Lact, 2012; 28:464–467.

18.

Hoddinott

, Craig

, MacLennan

, Boyers

, Vale

. The FEeding Support Team (FEST) randomised, controlled feasibility trial of proactive and reactive telephone support for breastfeeding women living in disadvantaged areas. BMJ Open, 2012; 2:e000652.

19.

Friesen

, Hormuth

, Petersen

, Babbitt

. Using videoconferencing technology to provide breastfeeding support to low-income women. J Hum Lact, 2015; 31:595–599.

20.

Oriá

MOB

, Santos

LMDA

, Vasconcelos

CTM

, Dodou

, Ximenes

, Keys

AFL

. Effectiveness of telephone educational interventions to promote breastfeeding: Systematic literature review (in Portuguese). Rev from Esc Enferm from USP, 2018; 52:1–12.

21.

Thomson

, Crossland

, Dykes

, Sutton

. UK Breastfeeding Helpline support: An investigation of influences upon satisfaction. BMC Pregnancy Childbirth, 2012; 12:150.

22.

Thorpe

, Jansen

, Cromack

, Gallegos

. Can a call make a difference? Measured change in women's breastfeeding self-efficacy across call interactions on a telephone helpline. Matern Child Health J, 2018; 22:1761–1770.

23.

Tahir

, Al-Sadat

. Does telephone lactation counselling improve breastfeeding practices?: A randomised controlled trial. Int J Nurs Stud, 2013; 50:16–25.

24.

Carlsen

, Kyhnaeb

, Renault

, Cortes

, Michaelsen

, Pryds

. Telephone-based support prolongs breastfeeding duration in obese women: A randomized trial. Am J Clin Nutr, 2013; 98:1226–1232.

25.

Reeder

, Joyce

, Sibley

, Arnold

, Altindag

. Telephone peer counseling of breastfeeding among WIC participants: A randomized controlled trial. Pediatrics, 2014; 134:e700–e709.

26.

, Fong

, Heys

, Lee

, Sham

, Tarrant

. Professional breastfeeding support for first-time mothers: A multicentre cluster randomised controlled trial. BJOG, 2014; 121:1673–1683.

27.

Efrat

, Esparza

, Mendelson

, Lane

. The effect of lactation educators implementing a telephone-based intervention among low-income Hispanics: A randomised trial. Health Educ J, 2015; 74:424–441.

28.

Alves

, Oliveira

MIC

, Rito

RVVF

. Guidelines on breastfeeding in primary health care and association with exclusive breastfeeding (in Portuguese). Cien Saude Colet, 2018; 23:1077–1088.

29.

Lindberg

, Öhrling

, Christensson

. Midwives' experience of using videoconferencing to support parents who were discharged early after childbirth. J Telemed Telecare, 2007; 13:202–205.

30.

Habibi

, Nicklas

, Spence

, Hedberg

, Magnuson

, Kavanagh

. Remote lactation consultation: A qualitative study of maternal response to experience and recommendations for survey development. J Hum Lact, 2012; 28:211–217.

31.

Gallegos

, Cromack

, Thorpe

. Can a phone call make a difference? Breastfeeding self-efficacy and nurse responses to mother's calls for help. J Child Heal Care, 2018; 22:433–446.

32.

Flax

, Ibrahim

, Negerie

, Yakubu

, Leatherman

, Bentley

. Group cell phones are feasible and acceptable for promoting optimal breastfeeding practices in a women's microcredit program in Nigeria. Matern Child Nutr, 2017; 13:DOI:10.1111/mcn.12261.

33.

Wang

C-J

, Chaovalit

, Pongnumkul

. A breastfeed-promoting mobile app intervention: Usability and usefulness study. JMIR MHealth UHealth, 2018; 6:e27.

34.

Martinez-Brockman

, Harari

, Segura-Pérez

, Goeschel

, Bozzi

, Pérez-Escamilla

. Impact of the lactation advice through texting can help (LATCH) trial on time to first contact and exclusive breastfeeding among WIC participants. J Nutr Educ Behav, 2018; 50:33.e1–42.e1.

35.

Alam

, D'Este

, Banwell

, Lokuge

. The impact of mobile phone based messages on maternal and child healthcare behaviour: A retrospective cross-sectional survey in Bangladesh. BMC Health Serv Res, 2017; 17:434.

36.

Ahmed

, Roumani

, Szucs

, Zhang

, King

. The effect of interactive web-based monitoring on breastfeeding exclusivity, intensity, and duration in healthy, term infants after hospital discharge. J Obstet Gynecol Neonatal Nurs, 2016; 45:143–154.

37.

Schindler-Ruwisch

, Roess

, Robert

, Napolitano

, Chiang

. Social support for breastfeeding in the era of mhealth: A content analysis. J Hum Lact, 2018; 34:543–555.

38.

Demirci

, Bogen

, Ray

, Uscher-Pines

, Kotzias

. Telelactation via mobile app: Perspectives of rural mothers, their care providers, and lactation consultants. Telemed J E Health, 2018; 25:853–858.

39.

Austen

, Beadle

, Lukeman

, Aquino

. Using a music video parody to promote breastfeeding and increase comfort levels among young adults. J Hum Lact, 2017; 33:560–569.

40.

White

, Martin

, White

, et al. Theory-based design and development of a socially connected, gamified mobile app for men about breastfeeding (milk man). JMIR MHealth UHealth, 2016; 4:e81.

41.

Grant

, Lee

, Pagliari

, Mukherjee

, Nwaru

, Nurmatov

. Effectiveness of mHealth interventions for maternal, newborn and child health in low- and middle-income countries: Systematic review and meta-analysis. J Glob Health, 2016; 6:010401.

42.

Lau

, Htun

, Tam

WSW

, Klainin-Yobas

. Efficacy of e-technologies in improving breastfeeding outcomes among perinatal women: A meta-analysis. Matern Child Nutr, 2015; 12:381–401.

43.

Kuhite

, Puranik

, Borkar

, Khan

, Dhande

, Patel

. Effectiveness of weekly cell phone counselling calls and daily text messages to improve breastfeeding indicators. BMC Pediatr, 2018; 18:337.