Improving Exclusive Breastfeeding Via Mobile Phone Text Messages: a Randomized Controlled Trial in Southern Jordan

World Health Organization (2001) recommended that infants should be exclusively breastfed for the first 6 months and could be continued in the second year of life or longer. Exclusive breastfeeding (no additional food, liquids or water) for the first six months helps protect children against diseases, supports healthy brain development and is associated with better educational achievement (World Health Organization, 2013). Breastfeeding is known to provide nutritional, immunologic, psychological, social, economic, and environmental benefits (World Health Organization, 2013, 2013b) and promote stronger attachment between mother and baby (Rapley, 2002). Evidence from the literature strongly indicate that this optimal method of infant feeding should be encouraged to ensure the best possible health outcomes for women and their children(Racine, Frick, Guthrie, & Strobino, 2009). However, few of the world's newborns, including in Jordan, are exclusively breastfed for the first six months of life.

In Jordan, religion and culture support breastfeeding, but still the breastfeeding practices are not optimal. The rate of exclusive breastfeeding (EBF) in Jordan is in progressive decline. In 2002 the EBF rate among babies less than 6 months old was 26.7% and unfortunately this rate dropped to 22% in 2007 and to 23% in 2012 (Department of Statistics 2013). In Jordan, 68% of babies receive breast milk within 24 hours of birth and the large majority continues to do so for 12.5 months, but EBF rates are very low(Department of Statistics 2013). While health and nutrition experts recommend that introduction of complementary foods should start only when an infant is six months old, other liquids such as water, juice, and formula milk are being introduced to most Jordanian infants in the first couple of months(World Health Organization, 2001). Thus, urgent attention is directed towards improving exclusive breastfeeding rates during the first six months of life.

Research studies to date examining breastfeeding practices in both developed and developing countries have found high rates of breastfeeding initiation and also that this high initiation rate is accompanied by a sharp fall in EBF in the first 6 months of life(Alzaheb, 2017; Jones, Kogan, Singh, Dee, & Grummer-Strawn, 2011). For example in Australia a high initiation rate of 92% was found for EBF from 2004 to 2005 , this rate then dropped to 71% of infants who exclusively breastfed at 1 month of age, 56% at 3 months, and 14% at 6 months (Akca, et al., 2017). Similarly, in Jordan, findings from a recent research study indicate that 51% of infants began EBF within 24 hours, falling to 47% at 1 month of age, and 33% at 6 months (Khasawneh & Khasawneh, 2017).

Significance of the study Despite scientific evidence concerning the benefits of breast milk, the practice of EBF is still uncommon in Jordan. Even with the consolidation of numerous strategies to promote breastfeeding and the general public health recommendation that infants should be exclusively breastfed during the first six months of life, the duration of breastfeeding in Jordan is in progressive decline and the percentage of infants exclusively breastfed for the first six months of life is still low and worrisome. A review of previous studies in Jordan, showed that most of these are descriptive studies focused on studying the factors affecting the rate of EBF and the reasons why women stop breastfeeding their children. There is no study on improving EBF for women in Jordan so far. To date there have been no interventions using mobile phones to improve breastfeeding and other feeding practices in Jordan. The aim of this research is to improve the EBF rates and duration through using a mobile phone-based EBF promotion (Text message).

METHODS Design A randomized controlled trial with follow-up from recruitment until 6 months post-delivery will be conducted to implement EBF promotion intervention using mobile phone text messages in southern Jordan, and evaluate its impact on breastfeeding practices. The intervention group will receive EBF promotional messages and the control group will receive child health care-related messages (except breastfeeding messages) from the time of discharge until 6 months post delivery.