Use of and Attitudes About Telelactation Services among New Parents

Abstract

Background:

We conducted a national, cross-sectional survey among new parents to explore use and acceptability of telelactation.

Methods:

Recruitment occurred between October 2021 and January 2022 on Ovia's parenting mobile phone application. Poststratification survey weights were used, and logistic and linear regression models estimated associations between demographics and telelactation use.

Results:

Among 1,617 respondents, 33.8% had at least one telelactation visit. Odds of any telelactation visit(s) were greater for parents who gave birth in 2021 versus 2019 (odds ratio [OR]: 1.69, 95% confidence interval [CI]: 1.26–2.25), insured by Medicaid (OR: 1.43, 95% CI: 1.02–2.02), and younger parents (OR: 2.07, 95% CI: 1.32–3.34). In total, 56.0% agreed that they would be comfortable breastfeeding over video to get help, and 27.6% agreed that lactation support over video is as good as in-person support.

Conclusions:

Telelactation is increasingly common and acceptable to many parents.

Introduction

Telelactation services connect breastfeeding parents to remotely located lactation professionals through video or phone. A common model is for a breastfeeding parent to initiate a videoconferencing visit with a lactation consultant on a personal device (e.g., using a mobile phone application). Telelactation can increase access to and timeliness of professional breastfeeding support, and thereby increase breastfeeding rates.¹ However, telelactation typically requires devices, broadband, and digital literacy and as a result, may not be accessible to all parents. Further, although breastfeeding parents can use telelactation to address a variety of breastfeeding challenges (e.g., obtain advice about increasing milk supply, learn how to operate a breast pump), some parents may not be comfortable with visits that call for demonstrating breastfeeding over video.

Like other telehealth services, availability of telelactation increased during the COVID-19 pandemic due to expansions in reimbursement and recommendations from public health authorities. In 2020, the Centers for Disease Control and Prevention recommended lactation specialists offer telehealth whenever possible, given that in-person “breastfeeding consults typically require very close contact between the lactation specialist and the lactating caregiver-child dyad,” and The International Lactation Consultant Association posted numerous resources to support lactation consultants in transitioning to telehealth during the pandemic.^2,3

Little is known about the use and acceptability of telelactation, including how utilization may vary by sociodemographic characteristics. Data on experiences with telelactation are urgently needed to understand care delivery changes and identify inequities in access. While telelactation represents an innovation in health care delivery with the potential to narrow disparities in breastfeeding rates, low-income and minority parents may face unique barriers to using these services as designed.⁴ For example, certain populations may lack access to affordable broadband, and services may not be culturally appropriate. Evidence from the early pandemic period suggests that racial and ethnic minorities may be accessing telehealth services at lower rates; as a result, they may be receiving less support overall and/or receiving primarily in-person support.^5–7

To address this knowledge gap, we conducted a national, cross-sectional survey among new parents who gave birth before and at two time points during the COVID-19 pandemic.

Methods

A cross-sectional survey was fielded on Ovia's parenting application (app) between October 2021 and January 2022. Ovia's suite of apps are among the most popular pregnancy and parenting apps available in the United States for free download on iOS and Android devices. The parenting app provides information about parenting, and includes a child milestone tracker and development guide. At any given time, the app has ∼120,000 active users who engage with it at least three times per week. Ovia apps are frequently used to recruit pregnant and postpartum parents for research studies given their large user base. Multiple studies, including several on the impact of COVID-19 on obstetric care, have shown that Ovia's users mirror the population of birthing parents in the United States with respect to demographic characteristics.^8–12

To be eligible to participate, parents needed to be 18–45 years of age, and to have given birth in one of three time periods or “birth cohorts,” including prepandemic (August–December 2019), early pandemic (March–May 2020), or later pandemic (June–August 2021). The survey opportunity was advertised to ∼180,000 parents through e-mail or app advertisement, and 6,782 (4%) clicked on the link to assess eligibility. Among those who clicked the link, 4,567 (74%) were found ineligible. Recruitment ended when we obtained 1,500 participants (∼500 in each birth cohort) who completed the full survey. This goal was set a priori to provide adequate power to detect differences in the receipt of breastfeeding support across time periods.

Survey responses were anonymous. Participants were informed that their participation in the survey was voluntary, and they could end their participation at any time. Participants received a $10 Amazon e-gift card for completing the survey. RAND's Institutional Review Board approved the study.

SURVEY INSTRUMENT

The survey consisted of questions on professional and lay breastfeeding support received, experience and attitudes about telelactation, and demographic characteristics (see Supplementary Appendix SA1 for survey instrument). Telelactation questions included the following: (1) receipt of breastfeeding help from a lactation consultant or other health care provider over the phone or by video call; (2) extent of agreement with the statement “I would be comfortable breastfeeding or pumping/expressing milk over video with a lactation consultant to get help with breastfeeding”; and (3) extent of agreement with the statement “virtual lactation support over video call is as good as in-person support.” For attitude questions, we categorized those who reported “agree” or “strongly agree” as agreeing with a given statement.

After developing the draft survey instrument, we recruited and conducted cognitive testing with 6 Ovia app users who gave birth in the spring of 2021. Interviewees were asked to explain how they interpreted each question using the think-aloud procedure. They also identified any questions or terms that were confusing, unclear, or cognitively burdensome, and commented on whether response options were complete. Findings from cognitive testing were used to revise the survey instrument to improve clarity and flow.

ANALYSIS

Poststratification survey weights were calculated using a raking procedure and used to generate nationally representative estimates. Logistic and linear regression models estimated associations between demographics and telelactation use. Models adjust for birth year, race, ethnicity, parent age, marital status, rurality, income, and payer. Education was not included due to collinearity with age. We analyzed survey data in R using two-sided hypothesis testing (α = 0.05).

Results

A total of 1,617 parents participated in the survey. After weighting, 59% of participants were between the ages of 25–34, 34% had a bachelor's degree or higher, 72% had a household income of <$80,000, 42% had Medicaid insurance, 24% identified as Hispanic, and 15% identified as Black. Five hundred nineteen (32%) participants gave birth before the pandemic, and 522 (34%) and 576 (36%) gave birth in the early and later pandemic, respectively (Table 1).

Table 1.

Respondent Characteristics

	UNWEIGHTED SAMPLE (N = 1,617)	WEIGHTED SAMPLE (EFFECTIVE SAMPLE SIZE = 785)	U.S. BIRTHS IN 2019 (CENTERS FOR DISEASE CONTROL AND PREVENTION) (N = 3,747,540)a
Age (years), n (%)
18–24	194 (12)	173 (22)	834,935 (22)
25–34	970 (60)	463 (59)	2,167,378 (58)
35–45	253 (28)	149 (19)	692,750 (18)
Education, n (%)
Less than high school	32 (2)	94 (12)	460,947 (12)
High school graduate or GED	647 (40)	424 (54)	2,031,167 (54)
Bachelor's degree or more	938 (58)	267 (34)	1,255,426 (34)
Household income, n (%)
<$80,000	889 (55)	565 (72)	Not reported
≥$80,000	728 (45)	220 (28)	Not reported
Race/ethnicity, n (%)
Hispanic	388 (24)	186 (24)	886,467 (23)
Non-Hispanic Black	129 (8)	116 (15)	548,075 (15)
Non-Hispanic Asian or Pacific Islander	49 (3)	55 (7)	248,539 (7)
Non-Hispanic otherb	113 (7)	29 (4)	149,902 (4)
Non-Hispanic White	938 (58)	399 (51)	1,915,912 (51)
Payer, n (%)
Private	1,180 (73)	396 (50)	1,873,770 (50)
Medicaid	356 (22)	335 (42)	1,573,927 (42)
Other	65 (4)	24 (3)	149,902 (4)
Uninsured	16 (1)	30 (4)	149,941 (4)
Birth year, n (%)
2019	519 (32)	251 (32)	N/A
2020	522 (34)	267 (34)	N/A
2021	576 (36)	267 (34)	N/A

Note: Percentages in each category are calculated excluding missing values. Percentages may not add up to 100 for each variable due to rounding.

^a Data from Centers for Disease Control and Prevention: National Vital Statistics Reports Volume 70, Number 2, March 23 Births: Final Data for 2019.

^b Other includes American Indian or Alaskan Native, “some other race,” and “more than one race.”

GED, General Educational Development Test; NA, Not Applicable.

An estimated 33.8% (95% confidence interval [CI]: 30.3–37.2%) of participants in all cohorts reported receiving one or more telelactation visits (including video and/or audio-only), and 16.3% (95% CI: 13.1–19.5%) reported receiving one or more video telelactation visits. Odds of any telelactation visit(s) were greater for parents who gave birth during the pandemic versus 2019 (odds ratio [OR]: 1.69, 95% CI: 1.26–2.25), insured by Medicaid (vs. private payer) (OR: 1.43, 95% CI: 1.02–2.02), and younger parents (age 18–24 vs. 35–45) (OR: 2.07, 95% CI: 1.32–3.34).

Similar to any telelactation visits, odds of video telelactation visits were greater for parents who gave birth during the pandemic versus 2019 (OR: 2.13, 95% CI: 1.36–3.33), insured by Medicaid (vs. private payer) (OR: 1.77, 95% CI: 1.07–2.93), and younger parents (age 18–24 vs. 35–45) (OR: 2.18, 95% CI: 2.14–4.16). There were no significant differences in receipt of any telelactation or video telelactation by race, ethnicity, or income (Table 2).

Table 2.

Multivariable Logistic Regression Results Showing Adjusted Odds Ratios of Any and Video Telelactation Use

VARIABLE	ANY TELELACTATION (INCLUSIVE OF AUDIO-ONLY AND/OR VIDEO)		VIDEO TELELACTATION
	OR (95% CI)	p	OR (95% CI)	p
Birth year
2019	1 [Ref.]		1 [Ref.]
2020	1.47 (1.10–1.97)	0.01	2.13 (1.36–3.33)	<0.01
2021	1.69 (1.26–2.25)	<0.01	2.05 (1.31–3.21)	<0.01
Parent race/ethnicity
Non-Hispanic White	1 [Ref.]		1 [Ref.]
Hispanic	0.76 (0.57–1.01)	0.06	0.90 (0.59–1.37)	0.61
Non-Hispanic Black	0.93 (0.59–1.47)	0.76	0.81 (0.40–1.63)	0.56
Asian/API	1.17 (0.61–2.28)	0.63	1.42 (0.59–3.44)	0.43
Other	0.68 (0.41–1.12)	0.13	0.89 (0.45–1.79)	0.75
Parent age
35–45	1 [Ref.]		1 [Ref.]
25–34	0.92 (0.69–1.21)	0.53	0.86 (0.57–1.29)	0.47
18–24	2.07 (1.32–3.24)	<0.01	2.18 (2.14–4.16)	0.02
Marital status
Single	1 [Ref.]		1 [Ref.]
Married	1.11 (0.79–1.57)	0.54	1.28 (0.77–2.15)	0.35
Payer
Commercial/private	1 [Ref.]		1 [Ref.]
Medicaid	1.43 (1.02–2.02)	0.04	1.77 (1.07–2.93)	0.03
Uninsured	0.55 (0.15–1.96)	0.36	0.44 (0.06–3.52)	0.44
Household income
<$80,000	1 [Ref.]		1 [Ref.]
≥$80,000	1.29 (0.97–1.73)	0.08	1.44 (0.93–2.23)	0.10
Location
City	1 [Ref.]		1 [Ref.]
Rural area	1.00 (0.63–1.59)	1.00	0.85 (0.44–1.68)	0.65

Models adjust for birth year, race, ethnicity, parent age, marital status, rurality, income, and payer. Education was removed from the model due to collinearity with age.

API, Asian and Pacific Islander.

Among respondents, 56.0% (95% CI: 52.4–59.6%) agreed that they would be comfortable breastfeeding/expressing milk over video to get help with breastfeeding, and 27.6% (95% CI: 24.4–30.7%) agreed that lactation support over video is as good as in-person support.

Discussion

This study showed that roughly a third of new parents reported using telelactation, and there were no disparities in use by race, ethnicity, or income. More than half of parents agreed that they were comfortable using telelactation.

We lack prior estimates of telelactation utilization in part because breastfeeding support visits do not consistently appear in health care claims data. However, one survey of Connecticut lactation professionals showed that 85% provided telehealth in 2020.¹³ A small study of Florida parents reported that 81% were willing to use telelactation if it were offered free of charge.¹⁴ Our findings also demonstrate the acceptability of telelactation, but suggest that it may not be seen as fully equivalent to in-person care. The lack of demographic disparities we observed in telelactation use, as well as the greater use of telelactation among parents with Medicaid insurance, could be due in part to the use of telelactation within the Women, Infants, and Children Nutrition program, which serves low-income families.¹⁵ A key limitation of the study was that the sample was opt-in and not probability based.

Although the Affordable Care Act required payers to cover breastfeeding support, it did not specify telehealth services, and coverage of telelactation is inconsistent across plans.¹⁶ There is the risk the availability of telelactation will be curtailed once the public health emergency ends, as temporary expansions of telehealth reimbursement will sunset. Given many parents are comfortable and increasingly have experience with telelactation, it has the potential to increase access to professional breastfeeding support if deployed in an equitable manner.

Disclosure Statement

The authors have no conflicts to disclose.

Funding Information

This work was supported by a grant from the National Institutes of Health (R01NR018837). The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the article; and decision to submit the article for publication. L.U.-P. had full access to all the data in the study, and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Supplementary Material

Supplementary Appendix SA1