Use of Virtual Breastfeeding Support Among Underserved, Rural Mothers

Direct-to-consumer telelactation is an innovative telemedicine service that connects women with remotely-located lactation consultants for breastfeeding support via personal devices. Telelactation may offer certain advantages relative to in-person support, including improved convenience and timeliness and reduced costs. Given documented unmet need for lactation support in the US, these services also have the potential to increase access to professional breastfeeding support in underserved communities; however, to date, there is no published research on use of direct-to-consumer telelactation among underserved mothers. In 2016, we began recruitment for a randomized controlled trial of telelactation in a rural community (Tele-MILC trial). Those randomized to the intervention arm were given access to unlimited, on-demand telelactation via a mobile phone application at the time of their postpartum hospitalization. The mobile phone application supported two-way video visits 24 hours a day, over a three-month period. To assess predictors of utilization and telelactation visit characteristics, we merged and analyzed data from two sources: visit-level data supplied by the telelactation vendor and longitudinal surveys of women in the intervention group at four timepoints. Visit data included visit timing, reason, and duration. Survey data included demographic information, documented predictors of telemedicine use, breastfeeding intentions, and experience with telelactation. To assess predictors of utilization, we used a backward stepwise regression approach. Of the 72 women in the intervention arm, 32 (44%) used the app to obtain breastfeeding advice. Among users, 14 (44%) used the app once, 5 (16%) used it twice, and 13 (40%) used it 3+ times. The most common topics discussed included supply/milk production (8; 25% of calls), latching (6; 19%), and breast pump use/operation (4; 13%). Significant predictors of utilization were household income and comfort with mobile phone apps, while maternal age and access to Wifi at home were not significantly associated with utilization. Specifically, women with household incomes of less than $25,000 and women who reported comfort with apps were both 15% more likely to use telelactation as compared to those with higher family incomes (p<0.001) and lack of comfort (p<0.001). Among non-users in the intervention arm (n=40), reasons for lack of use aligned with Technology Acceptance Model domains. Non-users reported low perceived usefulness (no perceived problems/need for support) [20; 50%]; no longer breastfeeding [8; 20%]; low perceived ease of use (privacy concerns) [10; 21%]; and/or access challenges [9; 19%]. In conclusion, rural, underserved mothers had high demand for telelactation that exceeded rates observed for other telemedicine services, and used it for a variety of questions and concerns. Interestingly, there were few "high intensity" users even though mothers had unrestricted, free access. Understanding demand for, satisfaction with, and predictors of use of these services among target populations can inform the design, marketing, and implementation of telemedicine offerings.