Research
Original Investigation
Effect of Short Message Service on Infant Feeding Practice Findings From a Community-Based Study in Shanghai, China Hong Jiang, PhD; Mu Li, PhD; Li Ming Wen, PhD; Qiaozhen Hu, MS; Dongling Yang, MS; Gengsheng He, PhD; Louise A. Baur, PhD; Michael J. Dibley, MPH; Xu Qian, PhD
IMPORTANCE Appropriate infant feeding practices have the potential for long-term health
effects. However, research findings on improving early infant feeding practices are limited. The wide use of mobile phone short message service (SMS) provides new opportunities for health promotion and services. OBJECTIVE To assess the effect of an SMS intervention on infant feeding practices. DESIGN AND SETTING Quasiexperimental design with follow-up measures scheduled at 4, 6, and 12 months at 4 community health centers in Shanghai, China. Two community health centers represented the intervention group, and 2 other community health centers represented the control group. PARTICIPANTS In total, 582 expectant mothers were recruited during the first trimester. Expectant mothers were eligible to participate if they owned a mobile phone, were first-time mothers, conceived a singleton fetus, were older than 20 years and less than 13 weeks’ gestation, had completed at least a compulsory junior high school education, and had no illness that limited breastfeeding after childbirth. INTERVENTION Mothers in the intervention group received weekly SMS messages about
infant feeding from the third trimester to 12 months’ post partum. MAIN OUTCOMES AND MEASURES The primary outcome was the duration of exclusive breastfeeding (EBF). Survival analysis was used to compare the duration of EBF between the intervention group and the control group. RESULTS Compared with the control group, the intervention group had a significantly longer median duration of EBF at 6 months (11.41 [95% CI, 10.25-12.57] vs 8.87 [95% CI, 7.84-9.89] weeks). The hazard ratio for stopping EBF in the intervention group was 0.80 (95% CI, 0.66-0.97). The intervention resulted in a significantly higher rate of EBF at 6 months (adjusted odds ratio, 2.67 [95% CI, 1.45-4.91]) and a significantly lower rate of the introduction of solid foods before 4 months (adjusted odds ratio, 0.27 [95% CI, 0.08-0.94]). CONCLUSIONS AND RELEVANCE An SMS intervention may be effective in promoting EBF, delaying the introduction of solid foods, increasing awareness of the World Health Organization breastfeeding guidelines, and improving knowledge of appropriate infant feeding practices for new mothers.
Author Affiliations: Author affiliations are listed at the end of this article.
JAMA Pediatr. 2014;168(5):471-478. doi:10.1001/jamapediatrics.2014.58 Published online March 17, 2014.
Corresponding Author: Xu Qian, PhD, School of Public Health, Fudan University, 138 Yixueyuan Rd, Mailbox 175, Shanghai 200032, China (xqian @fudan.edu.cn).
471
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Research Original Investigation
Short Message Service and Infant Feeding Practices
T
he low breastfeeding rate and inappropriate feeding practices in China are of concern.1,2 In 2008, the exclusive breastfeeding (EBF) rate in urban areas was only 16% for infants aged up to 5 months.3 Other national data suggest that one-third of infants are introduced to solid foods before age 4 months.4 Such factors may have contributed to the emerging childhood obesity epidemic in China.5,6 To date, no established model exists for improving early infant feeding practices. Early intervention studies7-10 have included home visits, interactive group education for new parents, and web-based services. Recent Australian studies11-13 have shown that early infant feeding interventions can be effective in prolonging breastfeeding duration and improving feeding practices, with one investigation12 also showing a reduction in body mass index at age 24 months. Mobile phone technology is increasingly used in the health sector for delivering health care services, health promotion interventions, and disease prevention programs (also known as mobile health [mHealth]). Short message service (SMS) via mobile phones is the most widely adopted and inexpensive example of mHealth.14 It presents a new channel for information delivery, allowing access at a time and place that suits the individual.15 Short message service can be effective in promoting weight management and improving health services.16-18 However, the effect of SMS on promoting breastfeeding or improving infant feeding practices has not been assessed to date. In China, the ownership of mobile phones is high, and most users are aged 18 to 40 years,19 including almost all expectant and new mothers. On average, 1200 messages are sent from each phone annually,20 which represents an opportunity to use SMS in promoting improved early infant feeding practices. This article reports the 12-month results from a communitybased SMS infant feeding promotion intervention study delivered to expectant first-time mothers in Shanghai, China. The mothers in the intervention group received weekly SMS plus routine maternal and child health care. The mothers in the control group received only routine care. The duration of EBF was the primary study outcome and was compared between the 2 groups.
intervention site and the other as the control site. Because individuals living in the same community in Shanghai attend the same CHC, a possibility exists that they could share information. Hence, we assigned CHCs rather than individual expectant mothers to avoid potential data contamination. At approximately 12 weeks’ gestation, a pregnant woman is generally required to register and receive a pregnant woman health care card at the CHC where her household registration is held. From about 20 weeks’ gestation onward, the pregnant woman receives prenatal care at the maternity hospital where she will give birth. The mother and child are followed up by the CHC staff via 1 to 3 home visits within the first month after delivery. The CHCs are also responsible for providing child health care services from birth to age 6 years.
Participants and Recruitment When expectant mothers attended the selected CHC for the first time at approximately 12 weeks’ gestation, they were approached by a maternal and child health care staff member with a letter of invitation and an information sheet. Expectant mothers were eligible to participate if they owned a mobile phone, were first-time mothers, conceived a singleton fetus, were older than 20 years and less than 13 weeks’ gestation, had completed at least compulsory junior high school education, and had no illness that limited breastfeeding after childbirth. Partic ipating mothers were inv ited to complete a selfadministered questionnaire containing sociodemographic questions (ie, age, education level, household registration, and family income) and questions related to their awareness of the World Health Organization (WHO) recommendations for breastfeeding.21 A total of 641 pregnant women consented to participate in the study and completed the baseline survey in the first trimester. They were followed up and checked for their eligibility again during the second trimester by the CHC staff. At the beginning of the intervention in the third trimester, 59 pregnant women were excluded because they did not meet the inclusion criteria (Figure 1). Therefore, 582 women were included in the study, 281 in the intervention group and 301 in the control group.
Intervention Group
Methods Study Design An intervention study with a quasiexperimental design was performed between December 1, 2010, and October 30, 2012, to investigate the effectiveness of an SMS health promotion intervention on infant feeding practices. The study was approved by the institutional review board of the School of Public Health, Fudan University, Shanghai and the Human Research Ethics Committee of The University of Sydney, Sydney, Australia. Written informed consent was obtained from each participant at recruitment.
Study Sites and Context Four community health centers (CHCs) were selected from 2 districts in Shanghai. In each district, 2 CHCs with similar population size were chosen, and one was randomly assigned as the 472
The intervention, one weekly text message, was performed from the beginning of the third trimester (28 weeks’ gestation) to 12 months’ post partum. The total duration of the intervention was 66 weeks. The text messages, approximately 180 to 210 characters, contained relevant breastfeeding or infant feeding advice. Messages were sent from a computerbased platform using Fetion (http://feixin.10086.cn) or FrontlineSMS (http://www.frontlinesms.com) software programs; both are available free of charge on the Internet. Messages sent and received by China Mobile users, representing 91.3% of the study participants, were free via Fetion. FrontlineSMS was used for sending messages to China Telecom and China Unicom subscribers, costing ¥0.1 (approximately US $0.02) per message sent, with no cost per message received. The intervention messages were developed based on the WHO breastfeeding guidelines, consultation with pediatricians, community child health workers’ input, and the infant
JAMA Pediatrics May 2014 Volume 168, Number 5
Copyright 2014 American Medical Association. All rights reserved.
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Short Message Service and Infant Feeding Practices
Original Investigation Research
Figure 1. Participant Recruitment and Retention 4 Community Health Centers were selected (2 with similar population size in each of 2 districts in Shanghai) 641 Pregnant women receiving care at the Community Health Centers gave informed consent and had baseline data collected in the first trimester District 1 64 At Community Health Center 1 126 At Community Health Center 2 District 2 244 At Community Health Center 3 207 At Community Health Center 4 59 Women excluded at the beginning of the third trimester 23 Natural abortion 16 Twin pregnancy 3 Newly hepatitis B virus infected 17 Could not be contacted
4 Community Health Centers (2 in each of 2 districts) randomized (582 women)
2 Community Health Centers (1 and 3) randomized to receive intervention (281 women)
2 Community Health Centers (2 and 4) randomized to receive intervention (301 women)
4-month follow-up 16 Lost to follow-up 265 Included in analysis
4-month follow-up 15 Lost to follow-up 286 Included in analysis
6-month follow-up 265 Included in analysis
6-month follow-up 2 Lost to follow-up 284 Included in analysis
12-month follow-up 41 Lost to follow-up 7 Lost to telephone contact follow-up 15 Lost to infant check-up follow-up 19 Lost to 12-mo questionnaire survey follow-up 258 Included in breast feeding and solid food analysis 243 Included in growth analysis 224 Included in awareness of breast feeding, infant feeding guideline, and specific infant feeding practice
12-month follow-up 67 Lost to follow-up 23 Lost to telephone contact follow-up 31 Lost to infant check-up follow-up 13 Lost to 12-mo questionnaire survey follow-up 261 Included in breast feeding and solid food analysis 230 Included in growth analysis 217 Included in awareness of breast feeding, infant feeding guideline, and specific infant feeding practice
feeding literature. The messages are relevant to milestones in early child development and the specific needs of expectant mothers and new mothers. The focus of SMS messages at each stage is summarized in Table 1. In addition to weekly contentspecific messages, other messages were sent inquiring whether the woman had given birth, what her breastfeeding status was, if she had returned to work, and what the timing of the introduction of solid foods was to determine the relevant types and content of messages to be sent. Participating mothers were also encouraged to communicate actively with the research team via SMS.
Control Group Mothers in the control group received the usual health care services during late pregnancy and post partum, as did the intervention group. Participating infants in both groups had routine physical checkups in the CHCs during their first year. The
In total, 582 women participated in the study, 281 in the intervention group and 301 in the control group.
mean attendance rate at the routine child health checkups (at 1, 2, 4, 6, 9, and 12 months) exceeds 95%.
Outcome Measures In this study, the primary outcome measure was the duration of EBF. Secondary outcomes included the following: (1) the rate of EBF at 6 months, (2) the duration of any breastfeeding, (3) the timing of the introduction of solid foods, (4) the breastfeeding rate at 12 months, (5) other infant feeding practices (such as drinking from a cup, taking a bottle to bed, and receiving food as a reward). Because evidence exists of widespread early introduction of complementary foods in China,22 we also measured the EBF rate at 4 months. The WHO definitions of EBF and any breastfeeding were used in this study.22 Data on EBF, breastfeeding, and the timing of the introduction of solid foods were collected and recorded by CHC child health physicians via a face-to-face interview as part of their
jamapediatrics.com
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Research Original Investigation
Short Message Service and Infant Feeding Practices
The intervention improved the EBF rate at 6 months but not at 4 months. In China, it has been traditionally accepted that the right time for stopping EBF and introducing solid foods Figure 2. Rates of Exclusive Breastfeeding by Group Allocation
Exclusive Breastfeeding Rate
1.00
0.75
0.50
0.25
Intervention Control
0 0
4
8
12
16
20
24
15 44
14 33
28
Age, wk No. remaining Control 286 Intervention 265
141 157
133 150
119 135
78 101
The median duration of exclusive breastfeeding at 6 months differed significantly between the intervention group and the control group (P < .001, log-rank test).
is approximately 4 months.22 Exclusive breastfeeding to 6 months is a new concept for Chinese mothers, and many may be unaware of the recommendation. The SMS disseminated this information to mothers in the intervention group, which might explain the effect on EBF at 6 months. Although we actively promoted the introduction of solid foods at 6 months in the SMS messages, feedback from participating mothers (not reported herein) confirmed that some CHCs still advised them to introduce solid foods at 4 months, and our results showed that 61.6% of infants were given solid foods between 4 to 6 months. This may explain the high proportion of mothers who introduced solid foods at 4 months in this study. Given this context, the intervention seems to have had some effect on reducing the introduction of solid foods before 4 months only and not before 6 months. Encouragement of drinking from a cup and discouragement of taking a bottle to bed during infancy may help mothers and children establish an infant-led feeding model and allow them to regulate food intake by themselves.27 This in turn might be protective against the development of childhood obesity.28 Such strategies have been included in infant feeding guidelines for some countries.29 In our study, despite sig-
Table 3. Comparisons of Infant Feeding Practicesa No. (%) of Participants Variable
Total
Intervention
Control
Adjusted Odds Ratio (95% CI)
Exclusive breastfeeding At 4 mob
(n = 551)
(n = 265)
(n = 286)
Yes
237 (43.0)
123 (46.4)
114 (39.9)
1.40 (0.98-2.00)
No
314 (57.0)
142 (53.6)
172 (60.1)
1 [Reference]
(n = 549)
(n = 265)
(n = 284)
At 6 mob Yes
58 (10.6)
40 (15.1)
18 (6.3)
2.67 (1.45-4.91)
No
491 (89.4)
225 (84.9)
266 (93.7)
1 [Reference]
(n = 519)
(n = 258)
(n = 261)
Breastfeeding at 12 mob Yes
102 (19.7)
52 (20.2)
50 (19.2)
1.03 (0.65-1.63)
No
417 (80.3)
206 (79.8)
211 (80.8)
1 [Reference]
(n = 551)
(n = 265)
Introduction of solid foods Before 4 mob
(n = 286)
Yes
15 (2.7)
4 (1.5)
11 (3.8)
0.27 (0.08-0.94)
No
536 (97.3)
261 (98.5)
275 (96.2)
1 [Reference]
(n = 549)
(n = 265)
(n = 284)
Yes
353 (64.3)
179 (67.5)
174 (61.3)
1.26 (0.87-1.83)
No
196 (35.7)
86 (32.5)
110 (38.7)
1 [Reference]
(n = 441)
(n = 224)
(n = 217)
Before 6 mob
a
The number of participants varies because of loss to follow-up.
b
Multiple logistic regression controlled for baseline maternal age group (3 levels), education level, household registration, rented accommodations, family monthly income, month when returned to work, newborn sex, and baseline awareness of the World Health Organization breastfeeding guidelines.
c
Multiple logistic regression controlled for maternal age group (3 levels), education level, household registration, rented accommodations, family monthly income, month when returned to work, and newborn sex.
Other infant feeding behaviors Drinking from a cup at 12 moc Yes
221 (50.1)
120 (53.6)
101 (46.5)
1.33 (0.90-1.97)
No
220 (49.9)
104 (46.4)
116 (53.5)
1 [Reference]
(n = 441)
(n = 224)
(n = 217)
Receiving food as a rewardc Yes
175 (39.7)
102 (45.5)
73 (33.6)
1.49 (0.98-2.25)
No
266 (60.3)
122 (54.5)
144 (66.4)
1 [Reference]
(n = 441)
(n = 210)
(n = 231)
Taking a bottle to bedc
476
Yes
210 (47.6)
109 (51.9)
115 (49.8)
1.06 (0.71-1.57)
No
231 (52.4)
101 (48.1)
116 (50.2)
1 [Reference]
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Short Message Service and Infant Feeding Practices
Original Investigation Research
Table 2. Characteristics of the Study Participants From 4 Community Health Care Centers in Shanghai, Chinaa No. (%) of Participants Total (N = 582)
Intervention (n = 281)
68 (11.7)
42 (14.9)
26 (8.6)
25-29
346 (59.5)
164 (58.4)
182 (60.5)
≥30
168 (28.9)
75 (26.7)
93 (30.9)
Non-Shanghai
440 (75.6)
219 (77.9)
221 (73.4)
Shanghai
142 (24.4)
62 (22.1)
80 (26.6)
Yes
135 (23.2)
78 (27.8)
57 (18.9)
No
447 (76.8)
203 (72.2)
244 (81.1)
20 (3.4)
15 (5.3)
5 (1.7)
Characteristic
Control (n = 301)
P Value
Baseline age group, y
Original Investigation
Effect of Short Message Service on Infant Feeding Practice Findings From a Community-Based Study in Shanghai, China Hong Jiang, PhD; Mu Li, PhD; Li Ming Wen, PhD; Qiaozhen Hu, MS; Dongling Yang, MS; Gengsheng He, PhD; Louise A. Baur, PhD; Michael J. Dibley, MPH; Xu Qian, PhD
IMPORTANCE Appropriate infant feeding practices have the potential for long-term health
effects. However, research findings on improving early infant feeding practices are limited. The wide use of mobile phone short message service (SMS) provides new opportunities for health promotion and services. OBJECTIVE To assess the effect of an SMS intervention on infant feeding practices. DESIGN AND SETTING Quasiexperimental design with follow-up measures scheduled at 4, 6, and 12 months at 4 community health centers in Shanghai, China. Two community health centers represented the intervention group, and 2 other community health centers represented the control group. PARTICIPANTS In total, 582 expectant mothers were recruited during the first trimester. Expectant mothers were eligible to participate if they owned a mobile phone, were first-time mothers, conceived a singleton fetus, were older than 20 years and less than 13 weeks’ gestation, had completed at least a compulsory junior high school education, and had no illness that limited breastfeeding after childbirth. INTERVENTION Mothers in the intervention group received weekly SMS messages about
infant feeding from the third trimester to 12 months’ post partum. MAIN OUTCOMES AND MEASURES The primary outcome was the duration of exclusive breastfeeding (EBF). Survival analysis was used to compare the duration of EBF between the intervention group and the control group. RESULTS Compared with the control group, the intervention group had a significantly longer median duration of EBF at 6 months (11.41 [95% CI, 10.25-12.57] vs 8.87 [95% CI, 7.84-9.89] weeks). The hazard ratio for stopping EBF in the intervention group was 0.80 (95% CI, 0.66-0.97). The intervention resulted in a significantly higher rate of EBF at 6 months (adjusted odds ratio, 2.67 [95% CI, 1.45-4.91]) and a significantly lower rate of the introduction of solid foods before 4 months (adjusted odds ratio, 0.27 [95% CI, 0.08-0.94]). CONCLUSIONS AND RELEVANCE An SMS intervention may be effective in promoting EBF, delaying the introduction of solid foods, increasing awareness of the World Health Organization breastfeeding guidelines, and improving knowledge of appropriate infant feeding practices for new mothers.
Author Affiliations: Author affiliations are listed at the end of this article.
JAMA Pediatr. 2014;168(5):471-478. doi:10.1001/jamapediatrics.2014.58 Published online March 17, 2014.
Corresponding Author: Xu Qian, PhD, School of Public Health, Fudan University, 138 Yixueyuan Rd, Mailbox 175, Shanghai 200032, China (xqian @fudan.edu.cn).
471
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Research Original Investigation
Short Message Service and Infant Feeding Practices
T
he low breastfeeding rate and inappropriate feeding practices in China are of concern.1,2 In 2008, the exclusive breastfeeding (EBF) rate in urban areas was only 16% for infants aged up to 5 months.3 Other national data suggest that one-third of infants are introduced to solid foods before age 4 months.4 Such factors may have contributed to the emerging childhood obesity epidemic in China.5,6 To date, no established model exists for improving early infant feeding practices. Early intervention studies7-10 have included home visits, interactive group education for new parents, and web-based services. Recent Australian studies11-13 have shown that early infant feeding interventions can be effective in prolonging breastfeeding duration and improving feeding practices, with one investigation12 also showing a reduction in body mass index at age 24 months. Mobile phone technology is increasingly used in the health sector for delivering health care services, health promotion interventions, and disease prevention programs (also known as mobile health [mHealth]). Short message service (SMS) via mobile phones is the most widely adopted and inexpensive example of mHealth.14 It presents a new channel for information delivery, allowing access at a time and place that suits the individual.15 Short message service can be effective in promoting weight management and improving health services.16-18 However, the effect of SMS on promoting breastfeeding or improving infant feeding practices has not been assessed to date. In China, the ownership of mobile phones is high, and most users are aged 18 to 40 years,19 including almost all expectant and new mothers. On average, 1200 messages are sent from each phone annually,20 which represents an opportunity to use SMS in promoting improved early infant feeding practices. This article reports the 12-month results from a communitybased SMS infant feeding promotion intervention study delivered to expectant first-time mothers in Shanghai, China. The mothers in the intervention group received weekly SMS plus routine maternal and child health care. The mothers in the control group received only routine care. The duration of EBF was the primary study outcome and was compared between the 2 groups.
intervention site and the other as the control site. Because individuals living in the same community in Shanghai attend the same CHC, a possibility exists that they could share information. Hence, we assigned CHCs rather than individual expectant mothers to avoid potential data contamination. At approximately 12 weeks’ gestation, a pregnant woman is generally required to register and receive a pregnant woman health care card at the CHC where her household registration is held. From about 20 weeks’ gestation onward, the pregnant woman receives prenatal care at the maternity hospital where she will give birth. The mother and child are followed up by the CHC staff via 1 to 3 home visits within the first month after delivery. The CHCs are also responsible for providing child health care services from birth to age 6 years.
Participants and Recruitment When expectant mothers attended the selected CHC for the first time at approximately 12 weeks’ gestation, they were approached by a maternal and child health care staff member with a letter of invitation and an information sheet. Expectant mothers were eligible to participate if they owned a mobile phone, were first-time mothers, conceived a singleton fetus, were older than 20 years and less than 13 weeks’ gestation, had completed at least compulsory junior high school education, and had no illness that limited breastfeeding after childbirth. Partic ipating mothers were inv ited to complete a selfadministered questionnaire containing sociodemographic questions (ie, age, education level, household registration, and family income) and questions related to their awareness of the World Health Organization (WHO) recommendations for breastfeeding.21 A total of 641 pregnant women consented to participate in the study and completed the baseline survey in the first trimester. They were followed up and checked for their eligibility again during the second trimester by the CHC staff. At the beginning of the intervention in the third trimester, 59 pregnant women were excluded because they did not meet the inclusion criteria (Figure 1). Therefore, 582 women were included in the study, 281 in the intervention group and 301 in the control group.
Intervention Group
Methods Study Design An intervention study with a quasiexperimental design was performed between December 1, 2010, and October 30, 2012, to investigate the effectiveness of an SMS health promotion intervention on infant feeding practices. The study was approved by the institutional review board of the School of Public Health, Fudan University, Shanghai and the Human Research Ethics Committee of The University of Sydney, Sydney, Australia. Written informed consent was obtained from each participant at recruitment.
Study Sites and Context Four community health centers (CHCs) were selected from 2 districts in Shanghai. In each district, 2 CHCs with similar population size were chosen, and one was randomly assigned as the 472
The intervention, one weekly text message, was performed from the beginning of the third trimester (28 weeks’ gestation) to 12 months’ post partum. The total duration of the intervention was 66 weeks. The text messages, approximately 180 to 210 characters, contained relevant breastfeeding or infant feeding advice. Messages were sent from a computerbased platform using Fetion (http://feixin.10086.cn) or FrontlineSMS (http://www.frontlinesms.com) software programs; both are available free of charge on the Internet. Messages sent and received by China Mobile users, representing 91.3% of the study participants, were free via Fetion. FrontlineSMS was used for sending messages to China Telecom and China Unicom subscribers, costing ¥0.1 (approximately US $0.02) per message sent, with no cost per message received. The intervention messages were developed based on the WHO breastfeeding guidelines, consultation with pediatricians, community child health workers’ input, and the infant
JAMA Pediatrics May 2014 Volume 168, Number 5
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of North Dakota User on 05/19/2015
jamapediatrics.com
Short Message Service and Infant Feeding Practices
Original Investigation Research
Figure 1. Participant Recruitment and Retention 4 Community Health Centers were selected (2 with similar population size in each of 2 districts in Shanghai) 641 Pregnant women receiving care at the Community Health Centers gave informed consent and had baseline data collected in the first trimester District 1 64 At Community Health Center 1 126 At Community Health Center 2 District 2 244 At Community Health Center 3 207 At Community Health Center 4 59 Women excluded at the beginning of the third trimester 23 Natural abortion 16 Twin pregnancy 3 Newly hepatitis B virus infected 17 Could not be contacted
4 Community Health Centers (2 in each of 2 districts) randomized (582 women)
2 Community Health Centers (1 and 3) randomized to receive intervention (281 women)
2 Community Health Centers (2 and 4) randomized to receive intervention (301 women)
4-month follow-up 16 Lost to follow-up 265 Included in analysis
4-month follow-up 15 Lost to follow-up 286 Included in analysis
6-month follow-up 265 Included in analysis
6-month follow-up 2 Lost to follow-up 284 Included in analysis
12-month follow-up 41 Lost to follow-up 7 Lost to telephone contact follow-up 15 Lost to infant check-up follow-up 19 Lost to 12-mo questionnaire survey follow-up 258 Included in breast feeding and solid food analysis 243 Included in growth analysis 224 Included in awareness of breast feeding, infant feeding guideline, and specific infant feeding practice
12-month follow-up 67 Lost to follow-up 23 Lost to telephone contact follow-up 31 Lost to infant check-up follow-up 13 Lost to 12-mo questionnaire survey follow-up 261 Included in breast feeding and solid food analysis 230 Included in growth analysis 217 Included in awareness of breast feeding, infant feeding guideline, and specific infant feeding practice
feeding literature. The messages are relevant to milestones in early child development and the specific needs of expectant mothers and new mothers. The focus of SMS messages at each stage is summarized in Table 1. In addition to weekly contentspecific messages, other messages were sent inquiring whether the woman had given birth, what her breastfeeding status was, if she had returned to work, and what the timing of the introduction of solid foods was to determine the relevant types and content of messages to be sent. Participating mothers were also encouraged to communicate actively with the research team via SMS.
Control Group Mothers in the control group received the usual health care services during late pregnancy and post partum, as did the intervention group. Participating infants in both groups had routine physical checkups in the CHCs during their first year. The
In total, 582 women participated in the study, 281 in the intervention group and 301 in the control group.
mean attendance rate at the routine child health checkups (at 1, 2, 4, 6, 9, and 12 months) exceeds 95%.
Outcome Measures In this study, the primary outcome measure was the duration of EBF. Secondary outcomes included the following: (1) the rate of EBF at 6 months, (2) the duration of any breastfeeding, (3) the timing of the introduction of solid foods, (4) the breastfeeding rate at 12 months, (5) other infant feeding practices (such as drinking from a cup, taking a bottle to bed, and receiving food as a reward). Because evidence exists of widespread early introduction of complementary foods in China,22 we also measured the EBF rate at 4 months. The WHO definitions of EBF and any breastfeeding were used in this study.22 Data on EBF, breastfeeding, and the timing of the introduction of solid foods were collected and recorded by CHC child health physicians via a face-to-face interview as part of their
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Copyright 2014 American Medical Association. All rights reserved.
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473
Research Original Investigation
Short Message Service and Infant Feeding Practices
The intervention improved the EBF rate at 6 months but not at 4 months. In China, it has been traditionally accepted that the right time for stopping EBF and introducing solid foods Figure 2. Rates of Exclusive Breastfeeding by Group Allocation
Exclusive Breastfeeding Rate
1.00
0.75
0.50
0.25
Intervention Control
0 0
4
8
12
16
20
24
15 44
14 33
28
Age, wk No. remaining Control 286 Intervention 265
141 157
133 150
119 135
78 101
The median duration of exclusive breastfeeding at 6 months differed significantly between the intervention group and the control group (P < .001, log-rank test).
is approximately 4 months.22 Exclusive breastfeeding to 6 months is a new concept for Chinese mothers, and many may be unaware of the recommendation. The SMS disseminated this information to mothers in the intervention group, which might explain the effect on EBF at 6 months. Although we actively promoted the introduction of solid foods at 6 months in the SMS messages, feedback from participating mothers (not reported herein) confirmed that some CHCs still advised them to introduce solid foods at 4 months, and our results showed that 61.6% of infants were given solid foods between 4 to 6 months. This may explain the high proportion of mothers who introduced solid foods at 4 months in this study. Given this context, the intervention seems to have had some effect on reducing the introduction of solid foods before 4 months only and not before 6 months. Encouragement of drinking from a cup and discouragement of taking a bottle to bed during infancy may help mothers and children establish an infant-led feeding model and allow them to regulate food intake by themselves.27 This in turn might be protective against the development of childhood obesity.28 Such strategies have been included in infant feeding guidelines for some countries.29 In our study, despite sig-
Table 3. Comparisons of Infant Feeding Practicesa No. (%) of Participants Variable
Total
Intervention
Control
Adjusted Odds Ratio (95% CI)
Exclusive breastfeeding At 4 mob
(n = 551)
(n = 265)
(n = 286)
Yes
237 (43.0)
123 (46.4)
114 (39.9)
1.40 (0.98-2.00)
No
314 (57.0)
142 (53.6)
172 (60.1)
1 [Reference]
(n = 549)
(n = 265)
(n = 284)
At 6 mob Yes
58 (10.6)
40 (15.1)
18 (6.3)
2.67 (1.45-4.91)
No
491 (89.4)
225 (84.9)
266 (93.7)
1 [Reference]
(n = 519)
(n = 258)
(n = 261)
Breastfeeding at 12 mob Yes
102 (19.7)
52 (20.2)
50 (19.2)
1.03 (0.65-1.63)
No
417 (80.3)
206 (79.8)
211 (80.8)
1 [Reference]
(n = 551)
(n = 265)
Introduction of solid foods Before 4 mob
(n = 286)
Yes
15 (2.7)
4 (1.5)
11 (3.8)
0.27 (0.08-0.94)
No
536 (97.3)
261 (98.5)
275 (96.2)
1 [Reference]
(n = 549)
(n = 265)
(n = 284)
Yes
353 (64.3)
179 (67.5)
174 (61.3)
1.26 (0.87-1.83)
No
196 (35.7)
86 (32.5)
110 (38.7)
1 [Reference]
(n = 441)
(n = 224)
(n = 217)
Before 6 mob
a
The number of participants varies because of loss to follow-up.
b
Multiple logistic regression controlled for baseline maternal age group (3 levels), education level, household registration, rented accommodations, family monthly income, month when returned to work, newborn sex, and baseline awareness of the World Health Organization breastfeeding guidelines.
c
Multiple logistic regression controlled for maternal age group (3 levels), education level, household registration, rented accommodations, family monthly income, month when returned to work, and newborn sex.
Other infant feeding behaviors Drinking from a cup at 12 moc Yes
221 (50.1)
120 (53.6)
101 (46.5)
1.33 (0.90-1.97)
No
220 (49.9)
104 (46.4)
116 (53.5)
1 [Reference]
(n = 441)
(n = 224)
(n = 217)
Receiving food as a rewardc Yes
175 (39.7)
102 (45.5)
73 (33.6)
1.49 (0.98-2.25)
No
266 (60.3)
122 (54.5)
144 (66.4)
1 [Reference]
(n = 441)
(n = 210)
(n = 231)
Taking a bottle to bedc
476
Yes
210 (47.6)
109 (51.9)
115 (49.8)
1.06 (0.71-1.57)
No
231 (52.4)
101 (48.1)
116 (50.2)
1 [Reference]
JAMA Pediatrics May 2014 Volume 168, Number 5
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of North Dakota User on 05/19/2015
jamapediatrics.com
Short Message Service and Infant Feeding Practices
Original Investigation Research
Table 2. Characteristics of the Study Participants From 4 Community Health Care Centers in Shanghai, Chinaa No. (%) of Participants Total (N = 582)
Intervention (n = 281)
68 (11.7)
42 (14.9)
26 (8.6)
25-29
346 (59.5)
164 (58.4)
182 (60.5)
≥30
168 (28.9)
75 (26.7)
93 (30.9)
Non-Shanghai
440 (75.6)
219 (77.9)
221 (73.4)
Shanghai
142 (24.4)
62 (22.1)
80 (26.6)
Yes
135 (23.2)
78 (27.8)
57 (18.9)
No
447 (76.8)
203 (72.2)
244 (81.1)
20 (3.4)
15 (5.3)
5 (1.7)
Characteristic
Control (n = 301)
P Value
Baseline age group, y
