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Myanmar has a high burden of mortality for children aged younger than 5 years in which undernutrition plays a major role. Despite current efforts, the exclusive breastfeeding rate for children under 6 months is only 24%. To date there have been no interventions using mobile phones to improve breastfeeding and other feeding practices in Myanmar.
This study aims to implement a breastfeeding promotion intervention using mobile phone text messages in Yangon, Myanmar, and evaluate its impact on breastfeeding practices.
M528 is a 2-group parallel-arm randomized controlled trial with 9 months follow-up from recruitment until 6 months post-delivery. A total of 353 pregnant women between 28 and 34 weeks’ gestation who had access to a mobile phone and were able to read and write have been recruited from the Central Women’s Hospital, Yangon, and allocated randomly to an intervention or control group in a 1:1 ratio. The intervention group received breastfeeding promotional SMS messages 3 times a week while the control group received maternal and child health care messages (excluding breastfeeding-related messages) once a week. The SMS messages were tailored for the women’s stage of gestation or the child’s age. A formative qualitative study was conducted prior to the trial to inform the study design and text message content. We hypothesize that the exclusive breastfeeding rate in the intervention group will be double that in the control group. The primary outcome is exclusive breastfeeding from birth to 6 months and secondary outcomes are median durations of exclusive breastfeeding and other infant feeding practices. Both primary and secondary outcomes were assessed by monthly phone calls at 1 to 6 months postdelivery in both groups. Participants’ delivery status was tracked through text messages, phone calls, and hospital records, and delivery characteristics were assessed 1 month after delivery. Child morbidity and breastfeeding self-efficacy scores were assessed at 1, 3, and 5 months postdelivery. Social desirability was measured at 5 months, and text messages expressing delivery success and user experience were assessed at the end of the study.
The targeted 353 pregnant women were recruited between January and March 2015. Baseline data have been collected; SMS messages have been developed and pretested and sent to the women from both groups. Follow-up data collection via phone calls has been completed. Data analysis is being done and results are expected soon. This is the first RCT study examining the effects of mobile text messaging for promoting exclusive breastfeeding.
This trial is timely in Myanmar following the telecommunications market opening in 2014. Our results will help determine whether text messaging is an effective and feasible method for promoting appropriate feeding practices and will inform further research to assess how this model could be replicated in the broader community.
Australian New Zealand Clinical Trial Registry ACTRN12615000063516; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367704 (Archived by WebCite at http://www.webcitation.org/ 6rGif3l81)
Globally, undernutrition is the underlying cause of an estimated 45% of deaths in young children and contributes to 35% of the disease burden in children under 5 years and 11% of total global disability-adjusted life years [
In Myanmar, regardless of race or religion, breastmilk is considered the most beneficial food for newborns, and breastfeeding is culturally and socially supported in both urban and rural areas [
Globally, with increased availability of mobile phones, the use of mobile technology for health-related interventions (mHealth) has greatly increased [
The mobile network in Myanmar used to be solely controlled by the government and, until recently, there was low access to mobile services by the general population. Consequently, there have been no interventions in Myanmar using mobile phones to promote community health and well-being. With political reform in 2011, Myanmar is on the verge of a communications revolution. Mobile phone prices have reduced considerably and the penetration of mobile services has increased from 2% in 2011 to 49% in 2014 [
The objective of this study is to implement a mobile phone–based EBF promotion in pregnant women attending the antenatal clinic at Central Women’s Hospital, Yangon, and to evaluate its impact on breastfeeding practices. The primary hypothesis is to test whether breastfeeding promotional text messages can help increase EBF practices in the intervention group. We hypothesize that EBF rates in the intervention group during the 6 months after delivery will be double (30%) that of the control group (15%). Although the Myanmar Multiple Indicator Cluster Survey 2010 reported that 24% of infants younger than 6 months were exclusively breastfed, only 15% of infants were exclusively breastfed until they were 6 months old [
A 2-group parallel arm RCT with hospital-based recruitment and 9 months of follow-up was conducted to test the effect of a text message–based intervention for EBF promotion in participants recruited from the Central Women’s Hospital, Yangon. A total of 353 women were recruited for the study. The intervention group received breastfeeding promotional messages and the control group received pregnancy- and childcare-related messages (except breastfeeding messages) from the time of recruitment until 6 months postdelivery. The study involved conducting a formative (qualitative) study to inform the trial design and to develop text messages, recruiting pregnant women, implementing the intervention, collecting data at baseline and from 1 to 6 months postdelivery by monthly phone calls, and evaluating effectiveness at the end of the study.
M528 trial flow diagram (as per Consolidated Standards for Reporting Trials guideline).
We used the Health Belief Model [
Model used in M528 trial—adapted from Health Belief Model.
The study has been approved by the Myanmar Ethical Review Committee, Department of Medical Research, Ministry of Health and Sports, Myanmar (approval number 7/ethic 2014) and the Department of Health, Ministry of Health and Sports, Myanmar (medical care-2/A-24/2014-659). The Ethical Review Committee, University of Sydney, acknowledged and approved the study based on the approval of the ethics committee in Myanmar. Furthermore, the M528 study trial is registered through Australian New Zealand Clinical Trials Registry [ACTRN12615000063516].
The Central Women’s Hospital, Yangon, was purposely selected as it is the largest tertiary public women’s hospital in Myanmar. The antenatal care clinic operates Monday through Friday and, in 2013, the hospital reported that, on average, 2000 pregnant women visited the clinic each month. The main reason for visits is to have the opportunity to deliver at the hospital free of charge because the majority of mothers attending could not afford private hospitals or clinics. In this setting, there is a higher possibility of recruiting women from a diverse range of socioeconomic backgrounds. The hospital is accredited as a baby friendly hospital initiative and follows guidelines to provide early initiation of breastfeeding. The hospital has a policy to encourage mothers to give colostrum to babies within 1 hour after birth regardless of the type of delivery.
Inclusion criteria were women from 28 to 34 weeks gestation who could access a mobile phone (Android or Java) that could display Myanmar language fonts, who had an uncomplicated singleton pregnancy, who were able to read and write in the Myanmar language, and who lived in an area with mobile network coverage. Exclusion criteria were pregnancy complications, a multiple pregnancy, and known medical conditions including mental illness that might hinder breastfeeding.
Participant eligibility was assessed via a hospital attendance registry (used by hospital staff) and antenatal care records (kept by the participant) in which information such as age, weeks of gestation, address, and phone numbers were recorded. At recruitment, researchers identified potential participants with the help of hospital nurses, explained the study, provided an information statement and consent form written in Burmese, and confirmed eligibility. If a woman agreed to participate, informed consent was obtained, and she was requested to complete the baseline survey questions. The participant’s mobile phone was checked for compatibility with text messages and, if needed, brief training on how to read and send text messages was provided. The recruitment process took 6 weeks (January to February 2015). Out of a total of 450 potentially eligible pregnant women, 353 were confirmed to be eligible and consented to participate in the trial. Each woman received 500 Myanmar kyats (US $0.50) to compensate for sending a text message to inform the research team of her delivery date.
Eligible women were randomized to the intervention or control group according to an allocation sequence generated by a computer program [
Because the intervention could not be blinded, we minimized bias by ensuring both groups received messages and by not explaining in the consent and information sheets how the text messages differed between groups. The information statement provided only general information that each participant could be allocated randomly into a group; would receive messages containing information on pregnancy, childcare, and breastfeeding practices; and that the frequency of messages could vary from 1 to 3 times per week. Research staff and interviewers (via telephone) were blinded to each participant’s group status although they might guess the group based on participants’ responses. To minimize bias, we also blinded research staff to the trial aims and hypotheses.
Stata version 13.0 (StataCorp LLC) was used for sample size estimation and data analysis. Sample size was calculated with the assumptions of 80% power, 5% 2-sided alpha, and 13% expected loss at follow-up. The EBF rate of Myanmar children at 6 months of age was 15% [
Baseline data were collected from participants during recruitment. Follow-up (outcome) data were collected by monthly phone calls at 1 to 6 months postdelivery. Process evaluation (evaluation survey and in-depth interviews) was undertaken at completion of the study. Quantitative data were collected on Android tablets using the Dimagi CommCare app [
Baseline questionnaires comprised instruments which have been validated and tested for reliability and were adapted from the 2011 Myanmar Multiple Indicator Cluster Survey [
Summary of instruments used at various times in the M528 trial.
Instruments | Baseline | Postpartum month | |||||
1 | 2 | 3 | 4 | 5 | 6 | ||
Individual socioeconomic factors (participant and husband): age, sex, ethnicity, religion, education, occupation | x | ||||||
Household factors: income level, wealth index | x | ||||||
Previous pregnancy, childbirth and breastfeeding experience | x | ||||||
Breastfeeding knowledge level (high/medium/low) | x | ||||||
Intention and confidence to exclusively breastfeed | x | ||||||
Breastfeeding self-efficacy scores (high/low) | x | x | x | x | |||
Postdelivery survey: date of birth; place of birth; type of delivery; and child’s birth, weight, and sex | x | ||||||
Child morbidity characteristics: signs and symptoms of fever, cough, respiratory tract infection, diarrhea, dysentery | x | x | x | ||||
Breastfeeding and other feeding follow-up module—24-hour recall and 1-month recall | x | x | x | x | x | x | |
Social desirability scale (high/medium/low) | x | ||||||
Process evaluation on mHealth (intervention group only): frequency of text messages received, user-friendliness of the messages received, perceived relevance of messages, trust in messages, understanding of messages, and new information learned or not | x |
We will examine the relationship between breastfeeding duration and self-efficacy using self-report Likert scales (no confidence= 1, somewhat confident= 2, sometimes confident= 3, confident= 4, very confident= 5) [
Follow-up comprised a postdelivery survey, feeding follow-up assessments, morbidity, breastfeeding self-efficacy, and social desirability assessments. Questionnaires have been adopted from the Global Strategy for Infant and Young Child Feeding [
The postdelivery form was completed when the child was 10 days old and was used to assess his or her postdelivery status, including the date, place, and type of delivery and the child’s birth weight, sex, and perinatal outcomes. The feeding follow-up form was completed every month and asked if the child was breastfed and if other liquids or foods were given in the last 24 hours and over the preceding month since the last contact (or birth for the first follow-up). Each participant completed 6 assessments of their feeding practices, including detailed information about the different types of liquids and foods (
Child morbidity status and self-efficacy were assessed when the child was 1, 3, and 5 months of age using items from a validated instrument [
Liquids or fluids:
Plain water
Juice or juice drinks, honey
Oralit or any oral replacement therapy (ORS), including fruity ORS made in China
Vitamin drops or other medicines as drops including traditional Burmese medicine
Infant formula milk such as Nestle, Dumex, Chinese brandsa, and Red Cow
Milk that is tinned or powdered (PEP, Red Cow) or fresh animal milk such as cow or goat milk
Clear broth or other soup, such as chicken, beef, or fish broth
Any other water-based liquids such as sugar water, rice water, green tea, tea, coffee mix, or soda
Soya milk or yogurt
Semisolid and solid foods:
Branded baby food, such as SUN, Nestle, Dumex, Chinese brandsa)
Rice powder, cooked or blended rice, bread, noodles, porridge, or other foods made from grains such as sago
Pumpkin, carrots, squash, or sweet potatoes that are yellow or orange inside
White potatoes, yams, manioc, cassava, or any other foods made from roots
Any dark green leafy vegetables such as water cress, drum stick, lady finger, and spinach
Fruit rich in vitamin A such as ripe mango, papaya, jack fruit, oranges, and persimmons
Any other fruits or vegetables such as banana, guava, apples, green beans, and peas
Liver, kidney, heart, or other organ meats
Any meat such as beef, pork, lamb, goat, chicken, or duck
Eggs
Fresh or dried fish, dried shrimp, or other seafood
aChinese brand milk products means imported milk products from the Myanmar-China border with or without registration.
We also assessed social desirability status, which is the tendency respondents have to answer questions in a way that is viewed favorably by others (such as research team members). This can interfere with the interpretation of average tendencies as well as individual differences [
Before the start of the trial, research team members received training by the principal investigator on how to collect data by tablet, conduct recruitment, implement group allocation, conduct follow-up phone calls, and monitor times to call participants. The schedule of enrollment, interventions, and assessments is shown in
Protocol schedule of enrollment, intervention, and assessments for M528 (average length of study duration is 36-38 weeks).
Women at 28-34 weeks gestation | 1 day after enrollment | At 36 weeks | Delivery | Age of child in months | |||||||
1 | 2 | 3 | 4 | 5 | 6 | ||||||
Eligibility assessment, consent, assignment, and allocation | x | ||||||||||
Both groups receive texts | x | x | x | x | x | x | x | x | x | ||
Baseline survey | x | ||||||||||
Delivery check by text and phone calls | x | x | |||||||||
Follow-up phone calls to assess | |||||||||||
Postdelivery status | x | ||||||||||
Feeding follow-up status | x | x | x | x | x | x | |||||
Child morbidity and self-efficacy scale | x | x | x | ||||||||
Social desirability scale | x | ||||||||||
Evaluation on mHealth (intervention group): |
x |
Implementation was organized in 2 phases, preparation and intervention service delivery.
In developing text messages, we reviewed infant feeding literature including United Nations Children’s Fund (UNICEF) and WHO breastfeeding guidelines [
Benefits to child (perceived benefits):
Breastmilk contains water and nutrients needed for your baby and is sufficient for the first six months of life.
Breastmilk is best for your child’s memory, brain development, and physical growth.
Breastmilk is readily available, convenient, clean, safe, free, and does not need any preparation.
Breastmilk will prevent your child from having diarrhea or pneumonia and help them recover quickly if ill.
People who were breastfed as babies are less likely to be overweight or obese or have type 2 diabetes than those who were not breastfed.
Colostrum (Noh-Oo-Ye), the first yellowish milk, is clean and not dirty. It contains antibodies and prevents your child from getting sick. Do not throw it away.
Colostrum (Noh-Oo-Ye) will protect your baby from allergies, infection, and yellow skin and eyes (A-Thar-Wah).
Benefits to mothers (perceived benefits):
If you breastfeed, your chances of having breast and ovarian cancer later in life will be reduced.
Breastfeeding may have a natural contraceptive effect.
Breastfeeding will help you reduce your weight after delivery and return to your original shape
Perceived barriers—grandmother’s (child’s grandmother) influences in adding water, honey and formula milk:
Please share this message with your grandmother: Breastmilk alone has everything your baby needs. It has all the nutrients and water required.
Please share this message with your grandmother: Don't use a bottle or teat. Your baby can drink up from a cup—even newborns. Cups should be wide mounted.
Don’t give in to peer pressure (from grandmothers and others) when they tell you to use formula milk after delivery.
Skilled training approach to overcome the perceived barriers for inadequate milk flow and breast problems:
It is important to bring your baby to your breast instead of leaning over to your baby. A good latch and position is important for good milk flow.
Make sure you have correct posture and your baby is attached properly. If your baby can suck well, you will have better milk flow and prevent sore and cracked nipples.
If you have sore or cracked nipples, breast engorgement, or mastitis, don't give up. Take your baby off your breast for a while and try again in a little while. Also try gently massaging your breast. Frequent breast feeding can reduce pain and produce more breastmilk. If pain persists, tell your midwife or health care practitioner.
Skilled training approach to overcome the perceived barriers (especially for women who have to return to work):
Plan to breastfeed before you return to work. Arrange with your employers/supervisors (if possible). If you go back to work, your grandmother or another carer may be able to bring your baby to work for breastfeeding.
Expressing milk by hand is using your hand to rhythmically compress your breast so that milk comes out. You need to compress the area under the areola (the pink or brown part of the breast) behind the nipple, not the nipple itself.
Please keep breastfeeding. Express breastmilk before you go to work. The best time is before and after work and at night time.
Expressed milk can be safely stored in the refrigerator for 72 hours and at room temperature for 24 hours. Make sure you put breastmilk in a clean, sealed container.
Perceived threat (perceived susceptibility and severity):
Do not give water, honey, sweet fluids, or anything else (such as rice powder or porridge) to your baby. These could make your child sick and slow your milk flow.
Formula milk may cause your baby to become constipated because it is harder to digest than breastmilk.
Formula milk may cause diarrhea if prepared in an unhygienic way.
Your breastmilk has all the essential things needed for your baby’s brain and eye growth, whereas formula milk does not.
Don’t start giving any semisolid or solid food to your baby before he or she is 6 months old. Your baby’s stomach is too small to digest food yet. It can also cause diarrhea.
Self-efficacy (coping efficacy to overcome barriers and to continue EBF):
Breastmilk has all nutrients in perfect balance for your baby and is an ideal food for newborns and infants. Do not be pressured by your husband, parents, or in-laws to stop breastfeeding.
Don't stop breastfeeding. You can overcome barriers!
Congratulations! You have successfully breastfed your child for 6 months. Please continue. Your child will thank you. (Note: Improved self-efficacy is linked with training mothers to EBF.)
We also saw the need to revise the inclusion criteria to include only women past 28 weeks’ gestation because the majority of women who visited the antenatal clinic did so only after they were past this point in their pregnancy. We also revised the required educational status to ability to read and write instead of primary school passed. We sought advice from Dr Nina Berry, a certified breastfeeding counselor from the University of Sydney who has had experience working in Myanmar, and antenatal clinic nurses from the study hospital. Developed messages were pretested with 15 pregnant women meeting the inclusion criteria and were revised before finalization. Messages were customized to pregnancy gestation and children’s age and categorized into 2 key periods: 28 weeks of pregnancy to delivery and delivery to the child at 6 months of age. We created messages that were simple, locally acceptable, and culturally appropriate. The developed messages were relevant to early child development milestones and the specific needs of expectant and new mothers in relation to EBF. The focus of the messages in relation to the Health Belief Model (described in the study design section) [
The intervention was delivered over 9 months—from recruitment to 6 months postdelivery. Text messages were sent to the intervention group 3 times per week (Tuesday, Thursday, and Saturday) in the evening using CommConnect [
Example of breastfeeding promotion text message.
In designing the control group, we followed the recommendations made in a review article on the design of control groups [
The primary outcome is the rate of EBF at 1 to 6 months of the infants’ age measured at monthly intervals after delivery. Secondary outcomes are median duration of EBF and rates of early initiation of breastfeeding (within 1 hour after birth); predominant breastfeeding; current breastfeeding; bottle feeding; and early introduction of solid, semisolid, or soft foods at 1 to 6 months of infant’s age (measured at monthly intervals) [
An evaluation of the use of mobile phones to promote breastfeeding practices was conducted with participants from the intervention group. Information on text delivery success, user experiences (user-friendliness), acceptability (trust), comprehension, new information learned, and feedback from received messages was assessed by trained callers during phone calls at 5 to 6 months after delivery. We measured acceptability (proportion of participants who trust the messages), comprehension (proportion of participants who can describe the last message received), and new information learned (proportion of participants who indicate they learned new information about breastfeeding). These instruments have been widely used in mHealth evaluations in other countries [
At completion, a qualitative study was conducted with intervention group participants. Based on information from follow-up calls, participants were split into 3 subgroups: EBF for 6 months, predominant and other types of breastfeeding (excluding EBF), and breastfed for less than 1 month only. In-depth interviews were held with approximately 25 women (7 to 9 women from each group) using semistructured guidelines. We explored user experiences in receiving SMS text messages, perceptions about the number of messages received, message delivery success, acceptance of the service delivery model, and effect of messages on breastfeeding practices. We expected that this number of participants would allow us to reach saturation point [
Quantitative data were collected via tablets and automatically submitted to the Dimagi server from which we could monitor data and generate reports. Stata software version 13 (StataCorp LLC) was used for data analyses. The intervention and control group outcomes will be compared using intention-to-treat principles [
For process evaluation, we used Stata software for survey data analysis. We conducted descriptive analyses to summarize participant baseline characteristics and their experiences and feedback about receiving text messages. Text message delivery success was measured by the frequencies of messages received, and proportions were compared with chi-square tests. For the qualitative study, we used thematic analysis. All digitally recorded interviews were transcribed verbatim in Burmese in Microsoft Word and were reviewed to check for accuracy and translated to English. A list of thematic codes was developed by MPH, which was independently reviewed and verified by AA. The data were then be manually coded by MPH for emerging themes, which were again verified by other investigators and the most relevant themes are summarized in a document.
The targeted 353 pregnant women were recruited between January and March 2015. Baseline data have been collected. SMS messages have been developed, pretested, and sent to the women from both groups. Follow-up data collection via phone calls is now complete. Data analysis is still ongoing and results are to be expected soon. This is the first RCT study examining the effects of mobile text messages in promoting EBF.
We hope to achieve our outcomes as SMS text messaging is increasingly being applied to improve reproductive, maternal, neonatal, and child health with growing evidence of its effectiveness [
A key strength of our study is the use of an RCT design to assess the impact of text messages on improving breastfeeding practices. Although the trial cannot be fully blinded, research team members who recruit participants and conduct follow-up phone calls are blinded to group allocation. By sending messages with different content to both control and intervention groups, we reduce the possibility of indirect effects of participants receiving health messages on the targeted behaviors. Both groups receive pregnancy and child healthcare-related text messages, but only the intervention group receives messages about breastfeeding. The intervention is feasible to implement because of the significantly reduced prices of subscriber identity module (SIM) cards, increased availability of cheap smart phones, and improved coverage of a 3G network. In addition, female literacy is high with 94% of urban women and 84% of rural women able to read text messages [
Limitations include recruitment from only 1 hospital, which will reduce the generalizability of results. To date, only major cities in Myanmar have reliable access to the mobile network but this is changing rapidly as the network is expanded, offering opportunities to adapt the intervention for rural populations. The hospital selected for recruitment, which has a patient population of women from diverse ethnic and socioeconomic backgrounds, is the largest public hospital providing free quality delivery care service. Women come from all over the country, including from rural and urban slum areas. It is likely that the participants have similar feeding practices to women from other areas as feeding practices only differ slightly between states and regions [
Another limitation is that there may be technological challenges when participants are not familiar with the use of mobile phones. However, we have compensated for this by providing training. As with other mobile phone programs, we anticipate a possible low response rate because participants may not answer calls, may switch off their phone, or may change their phone number. Solutions to these problems include recording alternate contact numbers during recruitment, calling repeatedly if the phone is powered off, or trying to reach the participant based on the suggested time to call.
This is the first Myanmar RCT to test the effectiveness of mobile text messaging (mHealth) in promoting EBF practices. Our results will help determine whether text messaging is an effective and feasible method for promoting appropriate feeding practices and will inform further research to assess how this model could be replicated in the broader community.
Presentation of the study at World Conference in Public Health, Melbourne.
adjusted odds ratio
Consolidated Standards of Reporting Trials
exclusive breastfeeding
randomized controlled trial
subscriber identity module
short message service
United Nations Children’s Fund
World Health Organization
MPH is supported by an Australian Leadership Award of the Government of Australia for her PhD studies. The Sydney Medical School Foundation and Post Graduate Research Support Scheme, Sydney Medical School, University of Sydney, both provided grants for the development of the intervention and conduct of the trial.
The authors wish to acknowledge respondents (pregnant women, family members, and institutional staff from the Department of Health in the Ministry of Health and Sports, Myanmar, the private mobile company, and the international and national nongovernmental organizations) who participated in the formative study and women who participated in the intervention for their valuable time. We also acknowledge the support from the Ministry of Health and Sports, Myanmar, and authorities from the Central Women’s Hospital, Yangon, and Ethical Review Committee, Department of Medical Research, Ministry of Health and Sports, Myanmar, for approving the study and ethical clearance. Special thanks to Dr Thein Thein Htay, Deputy Minister (retired), Ministry of Health and Sports, Myanmar, for supporting the approval of the study. We also acknowledge Dr Nina Berry, a breastfeeding promotion expert, University of Sydney, Australia, for providing input into the development of breastfeeding promotional text messages. We would like to thank Dimagi for allowing the use of their pro-bono scheme for data collection. We would also like to thank Saijai Liangpunsakul from Dimagi and Jessica Hall from The University of Sydney for technical support in developing the CommCare applications.
Overall MPH conceived the study design, led the development and conduct of the trial. All authors (MPH, ML, and MD) contributed to the design of the trial and development of the behavior change SMS message contents. MPH developed and translated SMS contents and questionnaires into Burmese. MJD informed the sample size calculation, analysis methods, and the method for allocation of treatments. MPH coordinated and conducted the study, including preparing ethics applications, recruiting participants, conducting baseline study, building questionnaires in CommCare, supervising SMS sending and follow-ups, conducting the evaluation, and drafting the manuscript. AA contributed in the qualitative analysis section. All authors edited, read, and approved the final manuscript.
None declared.