Use of Telehealth to Increase Breastfeeding
Exclusivity and Duration in the Primary Care Setting.
An Integrated Literature Review
BreAnne Marcucci MSN, ARNP, FNP-C, IBCLC
Telehealth is a rapidly growing healthcare delivery modality that can be utilized in the primary care setting to deliver breastfeeding education and support in an effort to increase breastfeeding duration and exclusivity. The World Health Organization, the American Academy of Pediatrics and the United States Preventive Services Task Force each recommend breastfeeding education and support as an evidence-based means of increasing exclusive breastfeeding and extending duration of breastfeeding. The AAP recommends exclusive breastfeeding for the first 6 months of age, however, only 18.8% of newborns in the US reach this goal. This integrative review examines 11 studies from 2009 to 2016 related to breastfeeding, telehealth and breastfeeding exclusivity and duration. Results from the review suggest that telehealth is a promising modality for breastfeeding education and support in the primary care setting to increase breastfeeding exclusivity and duration. More research is needed to determine how telehealth modalities are best implemented in the primary care setting.
Keywords: breastfeeding, breastfeeding exclusivity, lactation, telehealth,
Breastmilk provides the optimal and preferred nutrition for infants and offers both infant and maternal benefits that have been well established (Bomer-Norton, 2014). Benefits to the infant include immunologic protection from infections and decreased risk of type 1 and 2 diabetes, Sudden Infant Death Syndrome (SIDS) and childhood obesity (Bartick & Reinhold, 2010). Examples of maternal benefits include more rapid uterine involution, decreased risk of breast, ovarian and endometrial cancers and postpartum weight loss (Bomer-Norton, 2014).
The American Academy of Pediatrics (AAP) (2012) recommends exclusive breastfeeding for the first 6 months of age and to continue breastfeeding with complementary foods until at least one year of age. Other national organizations including the Center for Disease Control (CDC) and the Office of Disease Prevention and Health Promotion (ODPHP) have also identified the importance of breastmilk and breastfeeding. These organizations have incorporated national goals related to breastfeeding into Healthy People 2020, a federal program that establishes 10 year science-based objectives that are science-based and aimed at improving the health of Americans (Healthy People 2020, 2014). Furthermore, the importance of breastmilk and breastfeeding is recognized on the global level by the World Health Organization (WHO). The WHO, like the AAP, recommends exclusive breastfeeding for the first 6 months of age, and further recommends breastfeeding for at least 2 years of age (World Health Organization, 2016).
Despite the well-known benefits and national and global recommendations related to breastfeeding, only 18.8% of newborns are exclusively breastfeeding at 6 months in the United States (CDC, 2014). This is well below the Healthy People 2020 (2014) target goal of 25.5%. Many strategies to increase breastfeeding exclusivity and duration have been studied, including maternal education related to breastfeeding and a combination of lay and professional support (Meedya, Fahy & Kable, 2010).
To further identify strategies with supportive evidence, a systematic evidence review and meta-analysis was completed in 2003 for the USPSTF. This comprehensive review found that educational programs and support interventions were the single most effective primary care setting interventions to increase breastfeeding exclusivity and duration up to 6 months in the primary care setting and that policy and research should focus on how to better implement these practices into diverse primary care settings (Guise, Palda, Weshoff, Chan, Felfand & Lieu, 2003). Content in the education and support interventions included benefits of breastfeeding, main principles of lactation, common problems, myths related to breastfeeding and skills training (Guise, et al., 2003). In 2008 the USPSTF updated these recommendation with new and current evidence and concluded with moderate certainty that interventions to promote and support breastfeeding in the primary care setting have a moderate net benefit.
Telehealth is a rapidly growing healthcare delivery method and is described as the use of technology to deliver a variety of services from a distant site including health information, education and health care (Health Resources and Services Administration, 2016). This technology has been applied successfully to many areas of health including primary care settings. When applied to breastfeeding education and support in the primary care setting, telehealth is a modern modality that can be used to promote the U.S. Preventive Services Task Force (USPSTF) recommendations for breastfeeding education and support that aim at increasing breastfeeding exclusivity and duration.
In 2016 the Health Resources and Services Administration (HRSA) defines telehealth as a combination of two broad healthcare delivery applications that include store-and-forward communication and real-time communication. Store-and-forward communication involves electronic transmission of medical information such as digital images, secure emails and pre-recorded medical advice (HRSA, 2016). Real-time communication includes phone conversations and videoconference communication (HRSA, 2016). However, telehealth also includes a broad variety of health information that may be delivered in many distant ways through technology (HRSA, 2016).
Telehealth is a booming industry that has grown exponentially in the last five years to include telehealth services provided in more than half of all U.S. hospitals (American Telemedicine Association, 2016). Benefits of telehealth are only limited to the technology available and include the possibility of increased contact between a patient and provider, access to expert consult and expansion of care into rural areas (HRSA, 2016). When applied to intervention strategies to increase national health recommendations, such as the recommendations for exclusivity and duration of breastfeeding, telehealth has great potential of increasing success toward measurable goals.
Integrative Literature Review
To review the application of telehealth to deliver breastfeeding education and support interventions, this integrative review includes all articles related to breastfeeding women and children and telehealth published from January 2009 to April 2016. Using the terms breastfeeding telehealth, lactation telehealth, breastfeeding telemedicine and lactation telemedicine, the CINHAL, Science Direct, Cochrane Library, PubMed and Medline electronic databases were searched. Inclusion criteria included primary levels of evidence from January 2009 to April 2016. Exclusion criteria included non-English language articles before 2009. The initial search resulted in 284 articles. After application of screening and exclusion criteria 11 articles were included in this review (Figure One).
Results are grouped in two categories: exclusivity and duration of breastfeeding with telehealth breastfeeding education and support, and reception of telehealth breastfeeding education and support.
Exclusivity and Duration of Breastfeeding with Telehealth Breastfeeding Education and Support
The results of 6 of the 11 included studies indicate breastfeeding exclusivity and duration are increased with telehealth breastfeeding education and support (Ahmed, Roumani, Szucs, Zhang & King, 2016; Guijarro, Sanchez & Fernandez, 2014; Jiang, Li, Hu, Yang, He, Baur, Dibley & Qian, 2014; Newby, Brodribb, Ware & Davies, 2015; Reeder, Joyce, Sibley, Arnold & Altindag, 2014). In these studies breastfeeding education and support were delivered through a variety of telehealth modalities including videoconference, telephone support, online information and free access websites including social networking sites. Ahmed et al. (2016) used an online interactive breastfeeding monitoring system in the Midwestern United States in order to evaluate exclusivity and duration of breastfeeding. A significant difference in breastfeeding outcomes was found between the different groups at 3 months, with 84% of the intervention group exclusively breastfeeding compared to 66% of the control group (Ahmed et al., 2016).
Guijarro, Sanchez and Fernandez (2014) evaluated the impact of breastfeeding education delivered through group videoconference and social network sites in 96 study participants in Madrid, Spain. Results identified that 36% of study participants continued exclusive breastfeeding through 6 months of age in the intervention group, compared to 18.6% in the control group (Guijarro et al., 2014). A considerable increase in percentage of exclusive breastfeeding was observed in the intervention group, however, there was no statistically significant difference (Guijarro et al., 2014).
The effect of short message services (SMS) on infant feeding practices including exclusive breastfeeding was studied by Jiang et al. (2014). Using a quasi-experimental design with 582 expectant mothers in Chin, a significantly longer median duration of exclusive breastfeeding at 6 months was found in the intervention group when compared with the control group (11.41 [95% CI, 10.25-12.57] vs 8.87 [95% CI, 7.84-9.89] weeks). The intervention group also demonstrated a significantly higher rate of exclusive breastfeeding at 6 months of age compared to the control group, (2.67 [95% CI, 1.45-4.91]) (Jiang et al., 2014).
In a convenience sample of postpartum women between ages 18 and 40 who found breastfeeding assistance on the internet helpful, Newby, Brodribb, Ware and Davies (2015) identified these women were more likely to feed their infants breastmilk, either by breastfeeding or by bottle feeding pumped breastmilk, compared with mothers who did not find internet information helpful. The mothers who did not find the assistance on the internet helpful had lower odds of breastfeeding or bottle feeding pumped breastmilk at 6 months postpartum (odds ratio [OR] = 0.3; 95% confidence interval [CI], 0.1-0.5) and higher odds of formula feeding their infant (OR = 3.3; 95% CI, 1.7-6.5)(Newby et al., 2015).
The effectiveness of telehealth breastfeeding support and education through 4-8 telephone contacts was evaluated in a study of 1,948 Women Infant and Children (WIC) clients who intended to breastfeed or were considering breastfeeding (Reeder, Joyce, Sibley, Arnold & Altindag, 2014). Results identified that exclusive breastfeeding was greater at 6 months among Spanish speaking clients (adjusted odds ratio: 0.78; 95% CI: 0.68-0.89) and non-exclusive breastfeeding duration was greater at 3 months for all postpartum women in the intervention group (adjusted relative risk: 1.22; 95% confidence interval [CI]: 1.10–1.34) (Reeder, et al., 2014).
Additionally Seguranyes et al. (2014) evaluated the efficacy of combining videoconferencing and telephone contact to deliver breastfeeding support and education to 1401 women in Catalonia, Spain. The prevalence of breastfeeding was similar in the control group and intervention groups and there was no significant differences between study participants that used the videoconferencing and telephone support compared to those that used face-to-face and in-office support (Seguranyes, Costa, Fuentelsaz-Gallego, Beneit, Carabantes, Gómez-Moreno, & Abella, 2014). It is important to note that the control group also received intervention, however it was not distance intervention, and therefore not considered telehealth intervention strategy (Seguranyes et al, 2014).
Reception of Telehealth Breastfeeding Education and Support
Five of the studies focused on attitudes of receptivity to telehealth breastfeeding education and support. The majority of study participants were receptive, even appreciative of the telehealth support suggesting the telehealth modality as an acceptable means to deliver sensitive care and education related to breastfeeding (Ahmed & Quzzani, 2012; Freisen, Hormuth, Petersen & Babbit, 2015; Habibi, Nicklas, Hedberg, Magnuson & Kavanagh, 2012; Roberts, Hoddinott & Bryers, 2009; Rojjanasrirat, Nelson & Wambach, 2012). Ahmed and Quzzani (2012) used a mixed method study design to find that an internet based breastfeeding support system was user-friendly and acceptable among mothers. In this study mothers self-reported that using a telehealth support system was beneficial and improved early identification of possible breastfeeding problems (Ahmed & Quzzani, 2012).
In a qualitative study, Freisen, Hormuth, Petersen and Babbit (2015) evaluated the use of videoconference and telephone in the development of trust and rapport between lactation consultants and mothers. Results demonstrated that telehealth decreased maternal anxiety, increased maternal confidence and was considered an easily accessible delivery of breastfeeding education and support (Freisen et al.,2015).
In another qualitative study, Habibi et al. (2012) found responses to videoconferencing were received positively, however use of the technology was situational. Three major themes regarding telehealth breastfeeding education and support were identified. These themes included maternal interaction with technology, accuracy and trust determines acceptability, and conditional general acceptance of telehealth as a treatment modality (Habibi, Nicklas, Spence, Hedberg, Magnuson & Kavanagh, 2012). Conclusions indicated that overall responses to videoconferencing support were positive (Habibi et al, 2012).
Using a questionnaire, Roberts, Hoddinott and Bryers (2009) evaluated 403 study participants in rural Scotland and found that less than 25% of respondents would definitely or probably use telehealth modality for breastfeeding support, stating they preferred face-to-face support. Other major concerns held by this population included reservations about the potential impact of telehealth support on existing face-to-face services and concerns about privacy and security (Roberts, Hoddinott & Bryers, 2009). Lastly, no single telehealth modality suited all study participants (Roberts, Hoddinott & Bryers, 2009).
Rojjanasrirat, Nelson and Wambach (2012) found that videoconferencing can potentially be used to support breastfeeding mothers in a home setting. Ten mothers each received two videoconference and two face-to-face sessions focused on breastfeeding education and support. The breastfeeding support and evaluation tool titled LATCH (Jenson, Wallace & Kalsey, 1994) was used to compare the distant and face-to-face interactions. Results indicated an 80-100% agreement, suggesting that lactation exams using the LATCH breastfeeding support and evaluation tool have a high accuracy when preformed using videoconference. Additionally, all participants strongly agreed that videoconferencing was an acceptable and comfortable modality to discuss breastfeeding concerns (Rojjanasrirat, Nelson & Wambach, 2012)
The findings from this integrative literature review suggest that telehealth breastfeeding education and support can increase breastfeeding exclusivity and duration. Additionally this review highlights telehealth as an accepted modality for reception of breastfeeding education and support. These studies are important because findings further support the use of telehealth as a modality to promote national health recommendations for breastfeeding exclusivity and duration. These studies also demonstrate an alternative intervention strategy for breastfeeding education and support in the primary care setting.
Although telehealth breastfeeding education and support appears promising as an alternative way to promote national recommendations regarding breastfeeding exclusivity and duration, more research is needed to determine how telehealth modalities are best implemented specifically in the primary care setting. Studies with tightly controlled variables related to telehealth modality and breastfeeding education and support content, implemented in the primary care setting, are needed to better understand the relationship to breastfeeding exclusivity and duration. Due to inconsistency in telehealth modality methods used in these and previous studies, it is difficult to recommend which telehealth modality is most closely related to increased breastfeeding exclusivity and duration.
Postpartum women should have breastfeeding education and support in the primary care setting as it is clearly associated with increased breastfeeding exclusivity and duration (Guise, et al., 2003). The results from the studies examined in this integrative review suggest an increase in breastfeeding exclusivity with the telehealth education and support. However, these are small studies with focused samples, leaving it unclear if telehealth breastfeeding education and support has a similar relation with breastfeeding exclusivity on larger, more diverse populations. Therefore, although it is promising, it is difficult to definitively determine if its use in the primary care setting would promote the USPSTF recommendations for breastfeeding education and support in primary care. Additionally, when applied in the primary care setting, implementation strategy is an essential factor due to barriers such as limited provider time, scheduling difficulties and deficits in basic breastfeeding knowledge of both provider and patients. Additional barriers to breastfeeding education and support in the primary care setting must be clearly identified in order to address all complexities of telehealth implementation in the primary care setting.
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