Telelactation via Mobile App: Perspectives of Rural Mothers, Their Care Providers, and Lactation Consultants

Abstract

Background: Rural–urban disparities exist in breastfeeding rates and availability of lactation support. Direct-to-consumer (DTC) telelactation that uses two-way video through personal devices has the potential to increase access to international board-certified lactation consultants (IBCLCs) in rural settings that lack them. This study describes the feasibility and acceptability of DTC telelactation for rural mothers.

Methods: We conducted semi-structured interviews among various stakeholders involved in a study exploring the impact of telelactation through mobile phone app in rural Pennsylvania. Interviewees included mother participants assigned to receive telelactation (n = 17), IBCLCs employed by the telelactation vendor (n = 7), and nurses (n = 2) and physicians (n = 1) caring for mother participants at the recruitment hospital. Thematic content analysis was used to analyze qualitative data.

Results: Interviewees reported that telelactation was convenient and efficient, provided a needed service in rural areas lacking breastfeeding support services, and increased maternal breastfeeding confidence. Telelactation was noted to have several advantages over in-person and telephone-based support. Barriers to use included maternal reluctance to conduct video calls with an unknown provider, preference for community-based breastfeeding resources, and technical issues including limited WiFi in rural areas.

Conclusions: Among rural women who experience inequitable access to qualified breastfeeding support resources, DTC telelactation appears to be an acceptable delivery model for lactation assistance.

Introduction

The 2011 Surgeon General's Call to Action to Support Breastfeeding included a directive to “ensure access to services provided by International Board-Certified Lactation Consultants” (IBCLCs).¹ This directive is supported by research demonstrating the positive impact that IBCLC-based interventions have on rates of breastfeeding duration and exclusivity in diverse populations and settings.^2,3 IBCLCs are certified healthcare professionals who undergo extensive clinical and didactic training and are considered experts in breastfeeding management.⁴

In rural communities, access to timely and qualified lactation support, including IBCLC services, is lacking^5–7 and likely contributes to rural–urban disparities in breastfeeding rates.⁸ One way to increase access to IBCLCs in rural areas is through direct-to-consumer (DTC) telelactation services.⁹ Telelactation allows breastfeeding mothers to connect to remote IBCLCs through technology, such as two-way video. Previous telelactation models have used video-conferencing equipment set-ups in mothers' homes or medical offices and prescheduled appointments.¹⁰ More recently, DTC telelactation models have proliferated; with DTC, mothers request visits on-demand through video-enabled personal devices such as tablets and smartphones, creating an experience akin to Skype. Although several companies currently offer DTC telelactation services through mobile applications, their utility in rural communities or elsewhere has not been studied. To address this gap, we assessed the feasibility, acceptability, strengths, and limitations of DTC telelactation services for rural mothers through interviews with multiple stakeholders, including rural mothers, their care providers, and telelactation IBCLCs.

Methods

A subset of mothers assigned to the intervention arm within a randomized controlled trial of telelactation were invited to participate in semi-structured telephone interviews about their experiences at 4–6 weeks postpartum. We used maximum variation sampling to select mothers who had variable patterns of telelactation use. We also recruited nurses and physicians caring for these mothers at the rural Critical Access Hospital in Pennsylvania where study enrollment occurred and IBCLCs employed and referred by the study's telelactation provider (Pacify Health).

Upon enrollment in the trial, mothers in the intervention arm were given an orientation to the telelactation application (“app”) by nurses involved in study recruitment during their postpartum hospitalization. Nurses assisted mothers in downloading the app on their personal device and conducting a test call. While smartphones were offered as a potential study incentive for study participants who needed them, most participants used their own phones for the study, including all of those included in this analysis. After download, mothers could then request unlimited, free visits on-demand with remotely-located IBCLCs. The telelactation app is Health Insurance Portability and Accountability Act-compliant and involves a network of geographically dispersed IBCLCs. IBCLCs choose to respond to calls as they are available on their mobile devices. Once an IBCLC accepts a call, they are immediately connected to the individual requesting the visit through two-way video.

Interviews followed a semi-structured script and were professionally transcribed. Recruitment of mothers and IBCLCs ceased when we observed increasing redundancy in major themes. Interviews with nurses and physicians were constrained by those available for an interview at the time of a study site visit. Thematic analysis of transcripts was conducted by the lead and senior authors according to recommendations by Miles and Huberman.¹¹ This study was approved by RAND's Institutional Review Board. Participants provided oral informed consent for study participation.

Results

Seventeen of 21 invited mothers consented and completed an interview. Of these, 10 completed a test telelactation call in the hospital, and 9 completed one or more calls independently at home. We also conducted interviews with seven IBCLCs, one pediatrician, and two nurses. Maternal sample characteristics are included in Table 1.

Table 1.

Self-Reported Characteristics of Maternal Participants (n = 17)

CHARACTERISTICS	N (%)
Marital status
Married	11 (65)
Living together	3 (18)
Single	3 (18)
Education
Less than high school	4 (24)
High school diploma/GED	6 (35)
Some college or vocational program	3 (18)
Bachelors' degree or higher	4 (24)
Race
White/Caucasian	16 (94)
Black/African American	1 (6)
Hispanic ethnicity	0 (0)
WIC recipient	12 (71)
Type of health insurance
Private insurance	9 (53)
Medicaid	7 (41)
Medicare	5 (29)
Vaginal delivery	10 (59)
No. of prior births
0 (first baby)	5 (29)
1	7 (41)
2	3 (18)
3+	2 (12)
Prior breastfeeding experiencea	12 (71)
Expected baby age when mother planned to stop breastfeeding
3–5 months	1 (6)
7–11 months	1 (6)
12 months	7 (41)
13 months or older	5 (29)
Don't know	3 (18)

^aAny attempt to breastfed or provide breast milk for a previous child.

Three major themes emerged from the data: (1) feasibility: telelactation expectations and patterns of use among rural mothers; (2) acceptability: positive attributes of telelactation; (3) acceptability: barriers to telelactation and solutions. Each theme had multiple subthemes (Table 2).

Table 2.

Themes and Illustrative Quotes

THEME	SUBTHEME	DESCRIPTION	EXAMPLE QUOTES
Telelactation expectations and patterns of use among rural mothers	Expectations/motivation to participate in telelactation trial	• Maximize chance of breastfeeding success, prevent problems • Convenient access to support • Ensure availability of support in geographically-isolated area	“…being able to know there's someone always there to talk to, even if it's in the middle of the night” (Multiparous mother, 1 telelactation visit) “…there's not a whole lot around here as far as breastfeeding support, so it was nice to have something available…” (Primiparous mother, 3 telelactation visits)
	Characteristics and patterns of telelactation visits with rural mothers	• Timing of first call most often in first 2 weeks postpartum • Calls made when interruptions/distractions anticipated to be minimal • Addressed wide range of issues (e.g., latching, nipple pain, engorgement, oversupply, use of devices such as pumps) • IBCLCs perceived differences between calls received from mothers in rural vs. metropolitan areas	“[I used the app] mostly at night, because it was quiet and my son was sleeping” (Multiparous mother, 5 telelactation visits) “I did one [telelactation visit] in the car…two of them in my bedroom” (Primiparous mother, 3 telelactation visits) “… And then my rural moms tend to be just more like really basic stuff. Like, ‘How often am I supposed to be pumping, how long?’ So just really questions that I think any mom who can Google stuff would already know, but these moms, I don't think that seek out medical information like a more urban mom or like a higher socioeconomic status mom would” (IBCLC)
Positive attributes of telelactation	Telelactation fills a void	• Bridged gap between pediatric office visits, reduced need for in-person follow-ups for feeding issues • On-demand breastfeeding support in area lacking such resources • Cultivated nurse confidence to provide breastfeeding support	“We live in a rural area and there's not a whole lot around here as far as breastfeeding support, so it was nice to have something available and be able to use it and not have to leave the house and travel to get somewhere to get that support” (Primiparous mother, 3 telelactation visits) “It's amazing, because just the fact that [the app is] available 24 hours a day, 7 days a week…other professionals, you know, may or may not be available, or [mothers] feel badly about calling us, you know, in the middle of the night with a breastfeeding question” (Pediatrician) “I like sitting in on [telelactation visits] because I, as a nurse, feel like I'm getting feedback too” (RN) “This app provides that immediate assistance. You're not going to get that by calling your pediatrician and getting a call back the next day. That face-to-face ability to show mom things and help her when she's really feeling like she's in crisis is really the most powerful thing about the app” (IBCLC)
	Ease of app use	• Simple, easy to use app design • Quick connection speed	“I connected fast. It was simple. It's an easy app to use. All you've got to do is click on ‘Connect with lactation consultant’ and they automatically sent [a lactation consultant]…There's not any extra buttons. There's not any extra stuff that you have to do” (Primiparous mother, 4 telelactation visits)
	Value of video	• Facilitated efficiency, convenience (e.g., visualization of breast anatomy, technique, body language, and mother's home environment) • Seeing IBCLC cultivated trust, reassurance • Potentially increases in maternal confidence through “hands-off” nature of video support in which mothers “do the work” (e.g., position infant)	“…it does make it more personal, personable when you can actually see that person and talk to them, I'd say” (Multiparous mother, 1 telelactation visit) “It's nice to be able to just sit down for a minute and talk to a lactation consultant while you have the time, not make an appointment, go in, drive and meet with someone” (Multiparous mother, 5 telelactation visits) “A lot of times the mom is telling me something that she thinks is what's going on, and when I see it on the video camera I'm like, ‘Oh, yeah, that's so simple. Baby's totally positioned incorrectly…’ [Telelactation] gives me a lot more than when I'm on the phone…There's nothing like actually seeing it, you know?” (IBCLC) “The one thing I do love about it is I can see the mom's facial expressions. And there's a huge element to that because you can see whether or not she's stressed, you can see on their faces if they're understanding. And I hope that it makes a difference that they can see my facial expression, my care, that there's somebody out there that is understanding what they're going through…versus just over the phone being able to try to communicate with just words” (IBCLC)
	Quality and experience of IBCLCs	• IBCLCs perceived to have excellent communication and listening skills • Perceived as personable, empathetic, astute, professional	“Oh, yeah, she was a good listener. She was caring. She cared what I had to say, too. She didn't mow over what I had to say and, it was an actual conversation, two-sided” (Primiparous mother, 3 telelactation visits) “I just showed her quickly and she knew exactly what was wrong about how I had him [positioned]… [All of the IBCLCs] listened so carefully and…they just knew what I was talking about…Even with any doctor, you can say your issue and they'll name off a million different things could be wrong, and they're still wrong half the time…” (Multiparous mother, 3 telelactation visits)
	Effect of app on maternal breastfeeding confidence and breastfeeding outcomes	• Increased breastfeeding confidence • Resolved breastfeeding problems, prevented exacerbation of issues • Enabled efficient use of time at well-baby visits	“[If I didn't have the app], I would have kept my [breastfeeding] questions and waited until the pediatrician's visit…but I was able to get my questions answered before that, and then I didn't have to spend time during his visit to talk to them about that stuff. I was able to focus on other things” (Multiparous mother, 1 telelactation visit) “Obviously, there was nothing like this app [when I had my first child]. If they had this a couple years ago, I probably would have breastfed him longer, if I had someone that I could call right at home” (Multiparous mother, 3 telelactation visits)
Barriers to telelactation and solutions	No perceived need for telelactation	• Convenient access to in-person support that mother preferred to telelactation • Previous breastfeeding experience, lack of challenges • Competing demands that deprioritized breastfeeding concerns (e.g., infant's re-hospitalization)	“I tried to think of questions to ask, but I really don't have any because I've done this [breastfeeding] before” (Multiparous mother, no telelactation visits) “I used [the telelactation app], and then I also have a lactation consultant as well through a WIC program. Sometimes it's easier for me to just send a quick text to the [WIC] lactation consultant…[rather] than get on and do a video” (Multiparous mother, 1 telelactation visit)
	Apprehension about telelactation	• Discomfort with taking to a stranger over video • Mothers overcame apprehension by having initial test call with hospital clinicians, encouragement by family and friends, and/or experiencing worsening or persistent problem for which other supports had been inadequate	“I know some people feel uncomfortable with video chatting. I know for me, that was kind of a thing, too, like I wasn't too positive on video chatting somebody I didn't quite exactly know” (Primiparous mother, no telelactation visits) “I was so nervous and I felt so awkward at the same time, but I'm really glad that the people at the hospital had me [do a test] call, and my first experience [using the app] was really good and helpful. Because when I got home, I had some more issues. And looking back on my first time calling, it made me want to really push myself to call again” (Multiparous mother, 3 telelactation visits)
	Getting the app to work	• Logging in/updating app, poor reception/inadequate WiFi coverage, problems positioning phone while holding infant • Overall did not present as major barriers to app use	“I'm sure that if I could get [the app] to work, that it would be very helpful for me, but obviously, I'm not in a very good place for it…I'm in a very small town right now. Every public place [with WiFi coverage] is like half-an-hour away from me” (Multiparous mother, attempted 1 telelactation visit but could not connect)
	Recommendations to improve the app: offer text and audio/phone visits in addition to video visits	• Would address maternal reluctance to initiate video visits • Alternative to video when time or private space is lacking	“I'm the type of person who doesn't really like face-to-face…and then talking about my breasts to a stranger it makes me even more nervous. So, if there was like a phone call instead of video chat…” (Primiparous mother, 3 telelactation visits) “Yeah, if there was like a live chat option, I think it would be helpful, too. Because if I'm breastfeeding in the middle of the night and I had a question that I thought of, I probably wouldn't want to do a video chat when it's dark. You know, get lights on and stuff like that…If there was [a live chat] option, I probably wouldn't go to Google as often for the same kind of questions” (Multiparous mother, 1 telelactation visit)
	Recommendations to improve the app: Support follow-up with the same IBCLC	• To enhance continuity of care, build relationships/familiarity	“There's no guaranteed follow-up with the same lactation consultant and, as a provider, I don't get to know that they're doing okay. So I always tell them ‘Try to just let the next provider know what we talked about, and they'll be able to pick up where I left off.’ And so that's one limiting factor is there's that lack of continuity with the same provider” (IBCLC)

IBCLC, international board-certified lactation consultant.

Discussion

This is the first study to describe experiences with DTC telelactation. Interviews conducted with rural mothers, their pediatricians and nurses, and IBCLCs indicated that DTC telelactation is feasible and acceptable within the target population; however, not all rural mothers perceived a need for telelactation, and some experienced technical difficulties and apprehension about initial use.

Our research team previously highlighted hypothetical advantages and challenges of DTC telelactation in rural settings.⁹ Our findings here corroborate that telelactation offers convenient access to breastfeeding support and triage of breastfeeding issues. Furthermore, it may increase breastfeeding confidence when transportation or inadequate access to lactation support present as barriers. Research examining the impact of scheduled videoconferencing with IBCLCs, both in the home and community office setting, has documented similar findings.^10,12,13 An additional unforeseen benefit of telelactation noted by nurses in this study included the opportunity to receive breastfeeding education by participating in test calls with mothers.

Our previous work hypothesized that mothers using telelactation might receive inconsistent advice when support is delivered by multiple IBCLCs outside of the medical home. Rural mothers in particular may be less comfortable with technology and less likely to have access to broadband service.⁹ In fact, neither issue was identified as a major barrier in our analysis. IBCLCs were perceived as knowledgeable and consistent. Test calls helped to overcome initial trepidation about the technology in most cases, and the majority of mothers were able to access telelactation services from their own homes without connectivity problems.

Several mothers who did not utilize telelactation in our study noted no perceived need for the service, because they had existing breastfeeding support in the community or had breastfed before and were not having any problems. The technology acceptance model posits that for a new technology to be adopted, end users must feel that it is both useful (enhances life or solves a problem) and is easy to use.¹⁴ In this study, DTC telelactation fulfilled the latter criteria but not always the former.

Mothers recommended additional text message and phone (audio)-based support within the telelactation app. While several studies have documented a trend toward improved breastfeeding confidence and rates with automated and two-way text message breastfeeding support,^15–18 the impact of telephone-based support remains unclear.^19–21 A potential drawback of text and audio phone-based support, in comparison to video-based support, is a greater possibility for misinterpretation, though this has not been evaluated systematically.

Our findings may not generalize to urban settings. While telelactation in rural areas may facilitate uptake of previously unavailable breastfeeding support, in urban areas, increasing access and convenience may shift the location of care delivery. For example, mothers may use telelactation as a substitute for available in-person breastfeeding support and potentially even well-child care. Therefore, additional research is needed to determine whether telelactation maintains, elevates, or reduces overall quality of care in well-resourced areas.

Conclusions

DTC telelactation appears to be an acceptable delivery model for rural women with limited access to in-person breastfeeding support, and our findings can inform decisions regarding implementation and coverage of telelactation services. Further research is required to establish the value of DTC telelactation across diverse populations.

Disclosure Statement

Pacify Health did not have any role in data collection, analysis, and presentation of these results. Pacify Health has a commercial relationship with Medela and Lansinoh. No competing financial interests exist.