Research question broken down

- O: Accompanying mothers in the breastfeeding process | Breastfeeding outcomes

To answer the research question, the integrative review method was chosen, as it includes both empirical and theoretical publications, thus allowing the understanding of the phenomenon or topic of interest from different perspectives, so the information extracted will be synthesized in a narrative and critical way. ⁸

A search was conducted in the Pubmed, Scopus, CINAHL, ProQuest, ClinicalKey and Science Direct collections with the MeSH and DeCS descriptors: Breastfeeding, Telehealth and Telemedicine.

The search strategy incorporated the Boolean operators AND and OR, and automatic filters were used to obtain the primary articles available in full text, published between 2016-2021.

The inclusion criteria for the articles also considered that the research population included pregnant women, healthy women and infants who were recipients of care through eHealth in all or some of the stages of their breastfeeding process.

Subsequently, and once the articles had been selected by title and abstract, a critical reading was carried out using the instruments for the analysis of clinical trials, qualitative and observational studies of the Critical Reading Skills Program in Spanish (CASPe), so that all those that did not meet the established criteria of methodological rigor were eliminated from the sample, triangulating the information between authors in the event of controversy.

Professional accompaniment strategies through eHealth for breastfeeding mothers

Within the eHealth strategies in the studies analyzed, synchronous interventions such as telephone calls and video conferences were distinguished, as well as asynchronous ones such as text messages, use of social networks, telephone applications and digital platforms.

Regarding the modalities, a greater openness to receive professional support via telephone, email and text messages was reported, compared to video calls. However, when compared to face-to-face support, they tended to be less time-consuming, which emerged as a welcome feature for mothers in more urbanized areas, who also expressed gratitude for the flexible hours.^9,10

Patel et al.¹¹ on strategies used to promote breastfeeding concluded that any pre- and postnatal support strategy increased exclusive breastfeeding rates by almost 6 times compared to no intervention.

Consistent with this, other research also highlighted that eHealth support interventions enabled mothers who received them to be more likely to breastfeed exclusively and even more so when interventions were implemented with mothers in rural or hard-to-reach areas.^{9,12 -14}

Silva et al.¹⁵ in their study commented that these interventions, grouped as eHealth in this research, do not require expensive technologies or large investments in infrastructure, especially considering the large number of mobile phones worldwide, as recognized by Maslowsky et al. ¹²

In the same vein, Wu et al. ¹⁶ highlighted that smartphones have become the new channels and tools for information acquisition and exchange, to which users have enthusiastically adapted and as mentioned by other authors, the use of mobile technologies and the internet are viable, innovative, accessible and increasingly popular options among people. ^12,15,17,18

In line with the above, the research by Ahmed et al. ¹⁷ makes explicit the idea that the integration of mobile phones in the accompaniment of breastfeeding women is an innovative strategy to improve postpartum care, offering information and support through the creation of people networking, promoting breastfeeding and especially exclusive breastfeeding.

A number of studies have reported an increase and improvement in the practice of exclusive breastfeeding, which is directly related to the frequency of contacts and the number of difficulties encountered. ^12,15,17,19

Regarding the above, Patel et al. ¹¹ reported that their mobile phone text messaging intervention substantially increased exclusive breastfeeding rates from birth to 6 months of age, where 95% of infants in the intervention group were exclusively breastfed compared to 48.5% of infants in the control group.

Silva et al. ¹⁵ noted that inclusion of mothers in a social network group promoted by health professionals reduced rates of early discontinuation of exclusive breastfeeding during the first 6 months of life by 62 % compared to mothers who did not participate in this group.

Improvements in exclusive breastfeeding rates are directly related to the promotion of self-efficacy. In relation to this, Gallegos et al. ²⁰ acknowledged in their research that professional support by telephone calls has the potential to promote breastfeeding self-efficacy, which was corroborated by other studies. ^18,21

In addition to increased self-efficacy and willingness to breastfeed, the benefits of eHealth to support breastfeeding were found to include cost savings associated with seeking face-to-face support, providing greater access to care. ²²

These benefits are also recognized by other authors who argue that remote professional support is an innovation in care delivery that, in addition to lowering costs, increases comfort and responsiveness to breastfeeding.^13,14,23

In line with the above, it has been mentioned that eHealth has the potential to provide personalized support to breastfeeding mothers highlighting that face-to-face and individual breastfeeding support can be slow, costly and not always available, particularly in rural and remote areas. ⁹

The advent of the Internet and access to technology has provided an additional domain for the provision of services by health professionals, overcoming the aforementioned barriers of cost, isolation and time, which in more urbanized areas, was highlighted as an interfering factor. ^9,15,22

It is important to mention that for this form of professional support for mothers to result in a successful breastfeeding process, studies highlight the need for organization and training of professionals for online monitoring. ^15,18,20

As interfering factors for the success of exclusive breastfeeding, women's choice to supplement breast milk with other foods due to perceived insufficient milk production and the prescription of formula milk by physicians were mentioned. These reasons are amenable to counselling and support through eHealth. ^11,14

With regard to the limitations of eHealth, the following were described: the need for the mother to keep the device switched on and charged, rejected calls, unanswered or received by someone other than the mother who requires accompaniment, loss of mobile phones or change of number; also, the possibility of misinterpretation of written messages, in addition to the existence of areas that do not yet have internet connection. ^13,14

Results of eHealth as a tool for the professional accompaniment of breastfeeding mothers

When mothers feel supported during their breastfeeding process, they are more likely to breastfeed their children longer and exclusively. ²¹ This was reinforced by other studies which show that the support offered to mothers after discharge from hospital is decisive for the establishment, maintenance and exclusivity of breastfeeding. Therefore, it can be seen that the relevant use of eHealth-based support strategies can be a great contribution to professional support and thus help mothers to experience successful breastfeeding. ^15,19-21

Understanding the importance of this, it is imperative to organize and train professional teams around this new form of support, because if the support is not comprehensive and even perceived as insensitive or unhelpful, it can lead to negative and potentially long-lasting consequences for both mother and child. ^10,20

For interventions to be incorporated and bring about a change in health behaviors, evidence indicates that care must be person-centered, addressing the needs and particularities of the individual, leading to the delivery of culturally congruent care. ^24,25

Related to this, for example, a study targeting African American women highlights that this population may be less receptive to forums that do not recognize their history and culture. Particularly in relation to the impact of slavery on African American understanding of the meanings related to breastfeeding, the use of culturally tailored messages, images, and content, could increase African American women's feelings of inclusion and consequently improve their adherence to support. ²⁵

For there to be a real and positive influence on breastfeeding through eHealth, interventions must be mother-centered by responding to her beliefs, preferences, requests and concerns, contributing to the promotion of self-efficacy and thereby influencing the foundation for successful breastfeeding. ^9,20,22,26

There are studies that highlight that breastfeeding support strategies that are oriented towards transmitting only technical-scientific knowledge and do not address the subjectivities and realities of each woman are superficial. Consequently, they do not meet the comprehensive care needs of women in the breastfeeding process. ^13,15,19,21

In accordance with the above, it is also necessary to identify access to devices and internet, technological literacy and beliefs regarding the digital strategies that will be used to provide accompaniment. ^10,20,24

The mobile phone, in particular the use of SMS text messaging, may provide an opportunity not only to improve breastfeeding rates, but also to improve health behaviors.²⁴

Regarding this last point, other research also considered that monitoring through different eHealth strategies is a good method, not only to support mothers, increase their knowledge and improve their breastfeeding practice, but also to improve maternal and child health. ^11,12,18

This refers to the fact that mothers who received this support showed greater satisfaction, lower incidence of stress and depression; and children showed better weight gain at each check-up, reduced morbidity and limited further deterioration of health, which reduced infant hospitalization, contributing to the reduction of infant mortality. ^11,12,18,27

This form of interaction could help overcome emotional difficulties, and increase mothers' peace of mind, confidence in breastfeeding and sharing of knowledge and experiences, improving communication between professionals and mothers, making support more effective and humanized. ^15,17,18

For support to have positive results, the evidence recommends initiating it in the first few days after discharge and maintaining it continuously for at least 6 months. In addition, to achieve greater adherence to this form of professional support, it was described as necessary to generate intervention strategies developed in a pedagogical and participatory manner by health professionals. In this way they stimulate dialogue and interaction between the subjects, requiring that the generation of instances of support comes mostly from the professionals; notwithstanding always having the capacity to respond to the urgent needs of the mothers. ^{11,14,15,18,27}