Mother's Milk Messaging: Evaluation of a Bilingual APP to Support Initiation and Exclusive Breastfeeding in New Mothers

Women of child-bearing age are in the generation most likely to use texting to communicate,
and most own a cellular phone, and that cell phones have been demonstrated to be efficacious
in increasing Human Immunodeficiency Virus (HIV) medication compliance and smoking cessation,
and in improving diabetes management, the investigators consider this may be a promising
strategy to increase breastfeeding. The investigators developed theoretically-based text
message content along with breast feeding informational and video content designed for
delivery via closed private groups on social media based on formative work and then conducted
a pilot study to text the effects of interactive messaging sent over a 12 week period (i.e. 6
weeks prior and after birth) that targeted barriers (e.g. insufficient milk, pain/sore
nipples, breastfeeding in public, among others) on exclusivity and continuation of
breastfeeding. The investigators innovative approach, called Mother's Milk Messaging (MMM)
specifically targets low-income and minority mothers and has the potential to reach
unprecedented numbers of mothers, to be standardized for later scalability, and to be
cost-effective.

While Text4Baby uses a similar approach, the text messages are not interactive and they do
not address specific issues with breastfeeding. The device's social media content facilitates
private, peer and expert support for breastfeeding in real time on a channel preferred by
first time mothers.

Applying a theoretically-based framework, the investigators developed content stemming from
Dr. Maya Bunik's previous published Breastfeeding Telephone Triage and Advice. Content was
adapted for delivery via a mobile application (App) with attention to an Integrated Theory of
mHealth using best practices for app design for health promotion using social and mobile
technology. The content was modified to facilitate engagement with content using technology,
utilizing communication theories such as Gain and Loss Framing and Elaboration theory, and
theories to support social networking and social support, along with behavioral health
theories such as the Theory of Planned Behavior and Social Cognitive Theory.

The MMM app has three main elements: text messages via push notification are stored and
searchable on the app, access to a breastfeeding social support group on Facebook, and access
to videos and written material to facilitate knowledge acquisition and skills building. The
text messages are targeted at specific theoretical constructs such as outcome
expectations/attitudes, barrier self-efficacy, reinforcing a message using peripheral
(expert) opinion, eliciting a sense of social currency or providing a cue-to-action. The
breastfeeding social support group on Facebook will be moderated to facilitate posting of
shared experiences. Short videos, photographs, and written blurbs on related topics are
posted on the Facebook page to reinforce the messaging and content of the texts. After a
successful pilot study of MMM the investigators are ready to test the benefits of supporting
new mothers with breastfeeding using the investigators bilingual mobile phone application
(app) and online support program.

Inclusion Criteria:

- Women who are first time mothers

- Women ages 18-40

- Who can converse and write in English and/or Spanish

- Who reside in the U.S.

- Who are expecting a normal singleton birth

- Who are pregnant

- Have access to a computer connected to the Internet

- Have access to a mobile device that can receive text messages and access the Internet
(smart phone)

Exclusion Criteria:

- Decisionally challenged