Telelactation use patterns among a racially and ethnically diverse sample of US parents: secondary analysis of a randomized controlled trial

Objective:

Telelactation—synchronous video visits with lactation consultants—can reduce the disparities in access to professional breastfeeding support and improve breastfeeding experiences and rates. Previous literature on telephonic or application-based breastfeeding support has described use patterns for breastfeeding hotlines and applications that provide educational content.^1,2 Telelactation video visits are now widely available. Although as many as a third of new parents used telelactation in 2020 to 2021,³ little is known about how individuals engage with these services. We described use patterns among new parents offered telelactation as part of a randomized controlled trial designed to assess the effectiveness of telelactation across diverse populations of birthing people.

Study Design:

A total of 1052 individuals in the trial (ClinicalTrials.gov Identifier: NCT04856163) received access to on-demand telelactation visits through a smartphone application provided by Pacify Health from July 2021 to August 2023. The trial methods were previously described in the published protocol.⁴

We used participant survey data to extract demographic information, breastfeeding behaviors, and receipt of breastfeeding support and used electronic health record data to extract visit characteristics. The primary outcome was telelactation use. We examined how use varied by key sociodemographic characteristics and assessed visit characteristics among telelactation users. The study was approved by the RAND institutional review board.

To build parsimonious adjusted models, we estimated an elastic net regression. After variable selection, we estimated logistic and Poisson regressions for binary dependent variable (telelactation use; yes or no) and count models (number of telelactation visits among users), respectively, and reported adjusted odds ratios (aORs), means, and 95% confidence intervals (CIs). Stata MP 17 (StataCorp LLC, College Station TX) was used to conduct analyses.

Results:

A total of 963 (92%) participants completed the final survey at 6 months postpartum and were included in the analysis. The mean age of study participants was 29.46 years (standard deviation, 5.22), and 303 (31%) had Medicaid insurance or were uninsured (Supplemental Table 1). In total, 360 (37%) completed at least 1 telelactation visit that addressed a breastfeeding challenge.

In adjusted models, maternal age was positively associated with telelactation use (aOR, 1.06; 95% CI, 1.02–1.09) (Table 1). Parents who reported receiving breastfeeding support from family (aOR, 1.73; 95% CI, 1.29–2.33) or other sources (not including peers, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), doctors, in-person lactation consultants, or nurses) (aOR, 2.71; 95% CI, 1.56–4.71) had greater adjusted odds of using the service. The odds of use also increased as the number of reported breastfeeding problems increased (aOR, 1.31; 95% CI, 1.18–1.46). There were no significant associations between parent’s race or ethnicity, health insurance, plans to work in the first year of life, rurality, primary language spoken in the home, internet access, mode of delivery, or opinions about technology companies and the use of telelactation.

TABLE 1.

Predictors of any use of telelactation and intensity of use

	Dependent variable: any telelactation				Dependent variable: number of consultations (among users)
	Crude OR	95% CI	Adjusted OR	95% CI	Coefficient	95% CI
Characteristic	n=963a		n=921		n=350
Age (y)	1.08b	1.05–1.11	1.06b	1.02–1.09	0.03b	0.01–0.04
Race or ethnicity
Black	0.74	0.53–1.03	0.89	0.61–1.3	−0.08	−0.28 to 0.11
Latinx only	0.77	0.56–1.05	0.81	0.55–1.2	0.37b	0.19–0.55
Non-Black and non-Latinx	Ref		Ref		Ref
Medicaid or uninsured	0.46b	0.34–0.62	0.91	0.62–1.35	−0.17	−0.38 to 0.03
Lives in rural area or HPSA	0.66	0.39–1.10	0.71	0.39–1.28	−0.25	−0.58 to 0.08
Speaks language besides English at home	1.16	0.87–1.53	1.33	0.92–1.92	0.00	−0.16 to 0.17
Plans to work during first year	1.39c	1.04–1.86	1.17	0.83–1.64	−0.22d	−0.38 to 0.03
Only has internet through cell phone	0.2c	0.05–0.86	0.37	0.08–1.71	−0.8	−2.22 to 0.61
Uses video applications often	1.48d	1.14–1.94	1.35c	1–1.82	0.19	0.02–0.36
Trusts technology companies	0.67d	0.50–0.90	0.85	0.59–1.23	0.12c	−0.07 to 0.31
Believes data are kept safee	0.6d	0.43–0.83	0.70	0.47–1.04	−0.02	−0.16 to 0.12
Delivered by cesarean delivery	1.02	0.76–1.36	0.86	0.65–1.13	−0.02	−0.16 to 0.12
Breastfeeding support from (not mutually exclusive)
Doctor	1.01	0.71–1.45	0.81	0.54–1.21	−0.34d	−0.55 to —0.12
In-person LC	1.83d	1.24–2.71	1.48	0.93–2.36	−0.11	−0.36 to 0.15
Family	1.89b	1.45–2.46	1.73b	1.29–2.32	0.04	−0.22 to 0.30
WIC	0.54d	0.36–0.82	0.71	0.44–1.15	−0.07	−0.28 to 0.14
Other	3.11b	1.86–5.18	2.71b	1.56–4.71	0.03	−0.01 to 0.08
No. of breastfeeding problems related to infant through 24 wkf	1.24	0.65–2.35	1.31b	1.18–1.46	0.04	−0.01 to 0.08

All covariates listed, except maternal age, are dichotomous Indicator variables (0/1). All covariates listed, except race/ethnlclty, were Identified by the elastic net regression.

CI, confidence interval; HPSA, Health Professional Shortage Area; LC, Lactation Consultant; OR, odds ratio; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.

^aData on maternal age, language spoken at home, and use of video applications were available for 954 parents. Data on cell phone use were available for 921 parents. The fully adjusted model included only 921 parents due to the missing values, however overall results using the full sample without adjusting for these variables are similar to those reported here

^bP<.001

^cP<.05

^dP<.01

^eBy technology companies

^fReported trouble with latch; infant choking when breastfeeding; not waking up for, not interested in, or distracted during breastfeeding; infant wanted to breastfeed too often; not gaining enough weight; or other infant-related problem.

Users of telelactation completed an average of 2.31 consultations (95% CI, 2.02–2.60), and the median number of consultations was 1. Among users, Latinx parents completed 0.37 (95% CI, 0.19–0.55) more visits than non-Black and non-Latinx parents (Table 2). Of those included, 49 (14%) telelactation users completed consultations before birth, 259 (74%) completed consultations between birth and 4 weeks postpartum, 106 (39%) between 1 and 3 months postpartum, and 77 (22%) after 3 postpartum months (Figure). Consultations that occurred between 0 and 4 weeks postpartum were the longest in duration (average of 11.92 minutes; 95% CI, 10.81–13.04), and the most common topics discussed in these visits included latching (33%), breast issues (28%), and feeding schedule or patterns (27%) (Figure). In contrast, the most common topics in visits after 3 months postpartum included breastmilk supply (29%), feeding schedule or patterns (21%), and breast issues (21%).

TABLE 2.

Characteristics of visits and parents using telelaction during perinatal period

Characteristics	Before birth		Birth to 4 wk		1–3 mo		>3 mo
Visit details	Mean or no.	95% CI or %	Mean or no.	95% CI or %	Mean or no.	95% CI or%	Mean or no.	95% CI or %	P value
Number of visits	50		439		268		135
Length of call	10.63	8.21–13.05	11.92	10.81–13.04	10.49	9.09–11.89	8.57	7.37–9.77	.00
During business hours	35	70%	318	71%	139	80%	103	65%	.11
Visit content (not mutually exclusive)
Breastmilk supply	4	8%		8719%	59	22%	39	29%	.01
Breastmilk storge	1	2%		12 3%	22	7%	10	8%	.01
Feeding schedule or patterns	7	14%		121 27%	70	26%	28	21%	.16
Latch	4	8%		147 33%	40	15%	13	10%	.00
Pumping	6	12%		5011%	38	14%	18	14%	.71
Pump device	6	12%		12 3%	13	5%	4	3%	.01
Breast issues	4	8%		125 28%	56	21%	28	21%	.01
Maternal health and substances	3	6%		13 3%	13	5%	17	13%	.00
Baby issues	1	2%		6615%	43	16%	20	15%	.08
Return to work	0	0%		2 0%	35	13%	18	14%	.00
Miscellaneous (including preparing to breastfeed)	27	54%		40 9%	13	5%	4	3%	.00
Parent characteristics	n=49		n=259		n=106		n=77
Age	30.45	29.01–31.89	31.15	30.68–31.62	31.99	31.26–32.73	31.40	30.68–32.11	.15
Medicaid or uninsured	16	33%	52	20%	21	20%	15	19%	.06
Lives in rural community	1	2%	12	5%	4	4%	6	8%	.28

P values were determined using chi-square tests by comparing the proportions across periods or using F tests by comparing means across periods. For a visit content category to be included in the table, the category had to represent at last 5% of visits in 1 or more period.

To identify the reasons for visits, 2 members of the study team reviewed the chart notes. We applied up to 3 categories (codes) to each visit. Categories were determined after a review of a random sample of 100 chart notes. Categories included breastmilk supply, breastmilk storage, feeding schedule or patterns, weaning, latching, supplemental feeding, pumping, pump device, breast issues (medical concerns), maternal health including medications and substances with the potential to impact breastfeeding, infant issues (eg, illnesses or conditions with the potential to impact breastfeeding), and miscellaneous content (including preparing for breastfeeding) (Supplemental Table 1 contains additional detail). Visits with ambiguous content or with more than 3 content areas were reviewed and resolved by the team. We only present categories that were discussed in 5% or more of visits in 1 or more of the perinatal periods (prenatal, 0–4 weeks post-partum, 1–3 months postpartum, or >3 months postpartum). Consequently, weaning and supplemental feeding were excluded.

CI, confidence interval.

FIGURE. Patterns of telelactation use relative to birth.

A total of 350 parents with 811 total visits. The plot shows the average number of telelactation visits per parent each week and the 95% confidence intervals. The figure includes parents with at least 1 visit.

Conclusion:

Our findings demonstrate broad acceptability and use of telelactation. Furthermore, a sizable minority of parents demanded breastfeeding support before birth, suggesting interest in support across the perinatal period. This study documented the somewhat paradoxical finding that receipt of various sources of breastfeeding support is positively associated with the use of telelactation. It is likely that telelactation is most often used by individuals who seek multiple sources of support after experiencing more severe or a greater number of breastfeeding problems. Users may also represent a population with the most motivation to breastfeed.

The lack of differences in telelactation use by race and ethnicity is promising because some studies have documented lower rates of (video) telehealth use by minoritized individuals because of factors such as the digital divide.⁵ A limitation of this study is that the sample was recruited from a population of parents that used pregnancy applications. These parents may be more digitally savvy, potentially contributing to greater telelactation use. Future research should address how patterns of use and effectiveness of telelactation vary by the model of support.

Supplementary Material

SUPPLEMENTARY MATERIALS: Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.ajogmf.2024.101483.