Effect of Short Message Service on Infant

Feeding Practice: Findings From a

Community-Based Study in Shanghai, China
FREE
Hong Jiang, PhD1,2; Mu Li, PhD3; Li Ming Wen, PhD3,4; Qiaozhen Hu, MS1,2,5;
Dongling Yang, MS1,2,6; Gengsheng He, PhD1,2,7; Louise A. Baur, PhD3,8; Michael
J. Dibley, MPH3; Xu Qian, PhD1,2,7
[+] Author Affiliations
JAMA Pediatr. 2014;168(5):471-478. doi:10.1001/jamapediatrics.2014.58.
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ABSTRACT
ABSTRACT | METHODS | RESULTS | DISCUSSION | CONCLUSIONS | ARTICLE
INFORMATION | REFERENCES
Importance Appropriate infant feeding practices have the potential for long-term health effects.
However, research findings on improving early infant feeding practices are limited. The wide use
of mobile phone short message service (SMS) provides new opportunities for health promotion
and services.
Objective To assess the effect of an SMS intervention on infant feeding practices.
Design and Setting Quasiexperimental design with follow-up measures scheduled at 4, 6, and
12 months at 4 community health centers in Shanghai, China. Two community health centers
represented the intervention group, and 2 other community health centers represented the control
group.
Participants In total, 582 expectant mothers were recruited during the first trimester. Expectant
mothers were eligible to participate if they owned a mobile phone, were first-time mothers,
conceived a singleton fetus, were older than 20 years and less than 13 weeks gestation, had
completed at least a compulsory junior high school education, and had no illness that limited
breastfeeding after childbirth.
Intervention Mothers in the intervention group received weekly SMS messages about infant
feeding from the third trimester to 12 months post partum.

Main Outcomes and Measures The primary outcome was the duration of exclusive
breastfeeding (EBF). Survival analysis was used to compare the duration of EBF between the
intervention group and the control group.
Results Compared with the control group, the intervention group had a significantly longer
median duration of EBF at 6 months (11.41 [95% CI, 10.25-12.57] vs 8.87 [95% CI, 7.84-9.89]
weeks). The hazard ratio for stopping EBF in the intervention group was 0.80 (95% CI, 0.660.97). The intervention resulted in a significantly higher rate of EBF at 6 months (adjusted odds
ratio, 2.67 [95% CI, 1.45-4.91]) and a significantly lower rate of the introduction of solid foods
before 4 months (adjusted odds ratio, 0.27 [95% CI, 0.08-0.94]).
Conclusions and Relevance An SMS intervention may be effective in promoting EBF, delaying
the introduction of solid foods, increasing awareness of the World Health Organization
breastfeeding guidelines, and improving knowledge of appropriate infant feeding practices for
new mothers.
The low breastfeeding rate and inappropriate feeding practices in China are of concern.1,2 In
2008, the exclusive breastfeeding (EBF) rate in urban areas was only 16% for infants aged up to
5 months.3 Other national data suggest that one-third of infants are introduced to solid foods
before age 4 months.4 Such factors may have contributed to the emerging childhood obesity
epidemic in China.5,6
To date, no established model exists for improving early infant feeding practices. Early
intervention studies7- 10 have included home visits, interactive group education for new parents,
and web-based services. Recent Australian studies11- 13 have shown that early infant feeding
interventions can be effective in prolonging breastfeeding duration and improving feeding
practices, with one investigation12 also showing a reduction in body mass index at age 24
months.
Mobile phone technology is increasingly used in the health sector for delivering health care
services, health promotion interventions, and disease prevention programs (also known as mobile
health [mHealth]). Short message service (SMS) via mobile phones is the most widely adopted
and inexpensive example of mHealth.14 It presents a new channel for information delivery,
allowing access at a time and place that suits the individual.15 Short message service can be
effective in promoting weight management and improving health services.16- 18 However, the
effect of SMS on promoting breastfeeding or improving infant feeding practices has not been
assessed to date. In China, the ownership of mobile phones is high, and most users are aged 18 to
40 years,19 including almost all expectant and new mothers. On average, 1200 messages are sent
from each phone annually,20 which represents an opportunity to use SMS in promoting improved
early infant feeding practices.
This article reports the 12-month results from a community-based SMS infant feeding promotion
intervention study delivered to expectant first-time mothers in Shanghai, China. The mothers in
the intervention group received weekly SMS plus routine maternal and child health care. The
mothers in the control group received only routine care. The duration of EBF was the primary
study outcome and was compared between the 2 groups.

METHODS
ABSTRACT | METHODS | RESULTS | DISCUSSION | CONCLUSIONS | ARTICLE
INFORMATION | REFERENCES
Study Design

An intervention study with a quasiexperimental design was performed between December 1,

2010, and October 30, 2012, to investigate the effectiveness of an SMS health promotion
intervention on infant feeding practices. The study was approved by the institutional review
board of the School of Public Health, Fudan University, Shanghai and the Human Research
Ethics Committee of The University of Sydney, Sydney, Australia. Written informed consent was
obtained from each participant at recruitment.
Study Sites and Context

Four community health centers (CHCs) were selected from 2 districts in Shanghai. In each
district, 2 CHCs with similar population size were chosen, and one was randomly assigned as the
intervention site and the other as the control site. Because individuals living in the same
community in Shanghai attend the same CHC, a possibility exists that they could share
information. Hence, we assigned CHCs rather than individual expectant mothers to avoid
potential data contamination. At approximately 12 weeks gestation, a pregnant woman is
generally required to register and receive a pregnant woman health care card at the CHC where
her household registration is held. From about 20 weeks gestation onward, the pregnant woman
receives prenatal care at the maternity hospital where she will give birth. The mother and child
are followed up by the CHC staff via 1 to 3 home visits within the first month after delivery. The
CHCs are also responsible for providing child health care services from birth to age 6 years.
Participants and Recruitment

When expectant mothers attended the selected CHC for the first time at approximately 12 weeks
gestation, they were approached by a maternal and child health care staff member with a letter of
invitation and an information sheet. Expectant mothers were eligible to participate if they owned
a mobile phone, were first-time mothers, conceived a singleton fetus, were older than 20 years
and less than 13 weeks gestation, had completed at least compulsory junior high school
education, and had no illness that limited breastfeeding after childbirth. Participating mothers
were invited to complete a self-administered questionnaire containing sociodemographic
questions (ie, age, education level, household registration, and family income) and questions
related to their awareness of the World Health Organization (WHO) recommendations for
breastfeeding.21 A total of 641 pregnant women consented to participate in the study and
completed the baseline survey in the first trimester. They were followed up and checked for their
eligibility again during the second trimester by the CHC staff. At the beginning of the
intervention in the third trimester, 59 pregnant women were excluded because they did not meet
the inclusion criteria (Figure 1). Therefore, 582 women were included in the study, 281 in the
intervention group and 301 in the control group.
Figure 1.

Participant Recruitment and Retention

In total, 582 women participated in the study, 281 in the intervention group and 301 in the
control group.

View Large | Save Figure | Download Slide (.ppt)

Intervention Group

The intervention, one weekly text message, was performed from the beginning of the third
trimester (28 weeks gestation) to 12 months post partum. The total duration of the intervention
was 66 weeks. The text messages, approximately 180 to 210 characters, contained relevant
breastfeeding or infant feeding advice. Messages were sent from a computer-based platform
using Fetion (http://feixin.10086.cn) or FrontlineSMS (http://www.frontlinesms.com) software
programs; both are available free of charge on the Internet. Messages sent and received by China
Mobile users, representing 91.3% of the study participants, were free via Fetion. FrontlineSMS
was used for sending messages to China Telecom and China Unicom subscribers, costing 0.1
(approximately US $0.02) per message sent, with no cost per message received.
The intervention messages were developed based on the WHO breastfeeding guidelines,
consultation with pediatricians, community child health workers input, and the infant feeding
literature. The messages are relevant to milestones in early child development and the specific
needs of expectant mothers and new mothers. The focus of SMS messages at each stage is
summarized in Table 1. In addition to weekly content-specific messages, other messages were
sent inquiring whether the woman had given birth, what her breastfeeding status was, if she had
returned to work, and what the timing of the introduction of solid foods was to determine the
relevant types and content of messages to be sent. Participating mothers were also encouraged to
communicate actively with the research team via SMS.
Table 1. Focus of SMS Messages in the Intervention Group From the Third Trimester to 12
Months Post Partum

View Large | Save Table | Download Slide (.ppt)

Control Group

Mothers in the control group received the usual health care services during late pregnancy and
post partum, as did the intervention group. Participating infants in both groups had routine
physical checkups in the CHCs during their first year. The mean attendance rate at the routine
child health checkups (at 1, 2, 4, 6, 9, and 12 months) exceeds 95%.
Outcome Measures

In this study, the primary outcome measure was the duration of EBF. Secondary outcomes
included the following: (1) the rate of EBF at 6 months, (2) the duration of any breastfeeding, (3)
the timing of the introduction of solid foods, (4) the breastfeeding rate at 12 months, (5) other
infant feeding practices (such as drinking from a cup, taking a bottle to bed, and receiving food
as a reward). Because evidence exists of widespread early introduction of complementary foods
in China,22 we also measured the EBF rate at 4 months. The WHO definitions of EBF and any
breastfeeding were used in this study.22
Data on EBF, breastfeeding, and the timing of the introduction of solid foods were collected and
recorded by CHC child health physicians via a face-to-face interview as part of their routine
work. They were unaware of the intervention allocation and at a training session were instructed
to follow the standard data collection procedure. Researchers subsequently extracted data from
the infants health checkup records at 4, 6, and 12 months. All physicians received training on
how to collect information about EBF, breastfeeding, and the timing of the introduction of solid
foods. For example, the mother or caregiver was asked, Was the baby breastfed exclusively in
the past 24 hours? If the answer was no, she was further asked whether the infant had ever been
exclusively breastfed and the duration of EBF. The mother was also asked, Was the baby
breastfed in the past 24 hours? If the answer was no, she was further asked, What was the
duration of breastfeeding, including weaning? In addition, the mother was asked, At what age
was the baby first given solids regularly?
Data on appropriate infant feeding practices (drinking from a cup, taking a bottle to bed, and
receiving food as a reward) and on the timing of the mothers return to work were collected via a
face-to-face interview at 12 months by a staff member at each CHC using a questionnaire
adapted from the Healthy Beginnings Trial.11,23 For this study, we first translated the
questionnaire into Chinese and adapted the questions to the Chinese context. Then, we pilot

tested the questionnaire with 10 mothers in the CHCs. Based on the feedback from the pilot
testing, further revisions were made before the questionnaire was used in the study.
Statistical Analysis

Statistical analyses were performed using available software (SPSS for Windows, version 17.0;
SPSS Inc). Proportions were compared using Pearson product moment correlation 2 test, and
Mantel-Haenszel 2 test was used for comparing trends in proportions.
Survival analysis was used to compare the duration of EBF or any breastfeeding. Kaplan-Meier
curves were used to estimate the median EBF and breastfeeding times, and differences were
tested using the log-rank test. The estimated hazard ratios for stopping EBF or breastfeeding
were calculated using a Cox proportional hazards regression model, in which proportional
hazards assumptions were checked by plotting the cumulative hazards functions for the
covariates. For each of the covariates being plotted, the lines did not cross; hence, the hazard
assumptions were met. Multiple logistic regression was also applied to determine differences in
infant feeding practices. Both the Cox proportional hazards regression model and multiple
logistic regression controlled for awareness of the WHO breastfeeding guidelines at baseline and
demographic characteristics, including age, household registration, education level, and family
income, as well as when the mother returned to work after childbirth and whether she lived in
rented accommodations at baseline.

RESULTS
ABSTRACT | METHODS | RESULTS | DISCUSSION | CONCLUSIONS | ARTICLE
INFORMATION | REFERENCES
In total, 582 women participated in the study, 281 in the intervention group and 301 in the
control group (Figure 1). Compared with those in the control group, mothers in the intervention
group were younger, were more likely to live in rental accommodations at baseline, and had a
lower education level, lower family income, lower rate of return to work at 6 months, and lower
awareness at baseline of the WHO breastfeeding guidelines (Table 2). At 12 months, 519
mothers (258 in the intervention group and 261 in the control group) remained in the study, for
an overall retention rate of 89.2%.
Table 2. Characteristics of the Study Participants From 4 Community Health Care Centers in
Shanghai, Chinaa

View Large | Save Table | Download Slide (.ppt)

The median durations of EBF at 6 months were 11.41 (95% CI, 10.25-12.57) weeks for the
intervention group and 8.87 (95% CI, 7.84-9.89) weeks for the control group (P<.001, log-rank
test) (Figure 2). Compared with that in the control group, the hazard ratio for stopping EBF in
the intervention group was 0.80 (95% CI, 0.66-0.97).
Figure 2.
Rates of Exclusive Breastfeeding by Group Allocation

The median duration of exclusive breastfeeding at 6 months differed significantly between the
intervention group and the control group (P<.001, log-rank test).

View Large | Save Figure | Download Slide (.ppt)

The EBF rates at 6 months were 15.1% in the intervention group and 6.3% in the control group
(Table 3). Using multiple logistic regression, the intervention group had a statistically higher rate
of EBF at 6 months than the control group, with an adjusted odds ratio of 2.67 (95% CI, 1.454.91).
Table 3. Comparisons of Infant Feeding Practicesa

View Large | Save Table | Download Slide (.ppt)

However, the median durations of any breastfeeding at 12 months were almost identical: 7.72
(95% CI, 7.26-8.19) months for the intervention group and 7.73 (95% CI, 7.28-8.18) months for
the control group (P= .94, log-rank test). Furthermore, Cox proportional hazards regression
analysis detected no significant difference in stopping breastfeeding between the intervention
group and the control groups (hazard ratio, 1.00 [95% CI, 0.82-1.19]).
The rates of the introduction of solid foods were 1.5% before 4 months and 67.5% before 6
months for the intervention group compared with 3.8% before 4 months and 61.3% before 6
months for the control group (Table 3). Mothers in the intervention group were less likely to give
solid foods to their children before 4 months than mothers in the control group (odds ratio, 0.27
[95% CI, 0.08-0.94]), but no significant difference was found between the groups for the
introduction of solid foods before 6 months. No significant differences were observed at 12
months in drinking from a cup, taking a bottle to bed, and receiving food as a reward (Table 3).

DISCUSSION
ABSTRACT | METHODS | RESULTS | DISCUSSION | CONCLUSIONS | ARTICLE
INFORMATION | REFERENCES
In this study, the SMS intervention led to significant improvement in the duration of EBF and the
rate of EBF at 6 months, as well as a significant reduction in the introduction of solid foods
before 4 months. Although the effect size was small, we believe that at a population level in the
Chinese context and internationally, where the rates of breastfeeding (including EBF) are still
low,24 SMS use would be of public health significance. However, caution should be exercised in
interpreting the findings because of the limitations of this study, especially the weak
quasiexperimental study design.
The EBF rate at 6 months in the control group in our study was 6.3%, which may only partially
reflect the true current EBF situation in Shanghai. This finding is similar to the reported 5.3% in
Chongqing, a large city in Southwest China.25 The Chinese state council female workers
protection regulation stipulates 120 to 135 days of maternity leave.26 In our study, about half of
the participants (47.9%) had returned to work by 4 months and almost three-quarters (74.3%) by
6 months. This might have contributed to the dramatic decrease in the EBF rate from 4 months
to 6 months post partum. The SMS intervention improved the EBF rate, which is consistent with
the findings from a web-based breastfeeding education intervention that demonstrated improved
EBF rate and frequency.7 However, unlike an Australian home visit intervention,11 we found no
effect of SMS use on prolonging the duration of any breastfeeding. There could be several
explanations, including different intervention methods and various study contexts (eg, mothers
return to work and peer pressure).
The intervention improved the EBF rate at 6 months but not at 4 months. In China, it has been
traditionally accepted that the right time for stopping EBF and introducing solid foods is
approximately 4 months.22 Exclusive breastfeeding to 6 months is a new concept for Chinese
mothers, and many may be unaware of the recommendation. The SMS disseminated this

information to mothers in the intervention group, which might explain the effect on EBF at 6
months. Although we actively promoted the introduction of solid foods at 6 months in the SMS
messages, feedback from participating mothers (not reported herein) confirmed that some CHCs
still advised them to introduce solid foods at 4 months, and our results showed that 61.6% of
infants were given solid foods between 4 to 6 months. This may explain the high proportion of
mothers who introduced solid foods at 4 months in this study. Given this context, the
intervention seems to have had some effect on reducing the introduction of solid foods before 4
months only and not before 6 months.
Encouragement of drinking from a cup and discouragement of taking a bottle to bed during
infancy may help mothers and children establish an infant-led feeding model and allow them to
regulate food intake by themselves.27 This in turn might be protective against the development of
childhood obesity.28 Such strategies have been included in infant feeding guidelines for some
countries.29 In our study, despite significant improvement in knowledge of appropriate infant
feeding practices (data not shown), we found no significant improvement in appropriate infant
feeding practices (not drinking from a cup, avoiding a bottle at bedtime, and not giving food as a
reward), as observed in other studies.11,30 One reason could be that these are new concepts in
China, and it may take some time for them to be adopted. Furthermore, the SMS promotion of
appropriate infant feeding practices (regarding cup, bottle, and reward) started late in the study,
commencing when the child reached age 6 months, which may explain the limited effect on
behavioral changes.
To our knowledge, this is the first community-based intervention study to assess the
effectiveness of promoting early infant feeding via SMS. The intervention strategy aligns with
social applications of modern telecommunication technology. The message bank was established
based on the WHO infant feeding guidelines, needs assessments of pregnant women and new
mothers, and consultations with child health workers. Therefore, the messages were evidence
based, relevant, and practical. Different messages were sent to mothers according to their childs
feeding status, which allowed the intervention to be responsive. Furthermore, we adapted the
questions for most key measures at baseline and 12 months from those used in the Healthy
Beginnings Trial,11,23 which will enable comparisons of different intervention approaches in
various settings in the future.
Our study has several limitations. First, the study findings are limited by its quasiexperimental
design. Mothers in the intervention group and the control group were not from the same CHC,
which means that the care provided to participants in addition to the intervention might not be
completely identical. Therefore, a potential bias could result from the design. However, we tried
to minimize any bias by choosing one intervention group and one control group from each
district because the counseling materials and service delivery are likely similar across the district.
In addition, a disparity in some socioeconomic variables between the 2 groups might be partly
due to the nonrandomized design. To overcome this, we used multiple regression analysis.
Second, we did not explore the cost-effectiveness of the intervention. Third, a large proportion of
the mothers were well educated, which might limit the generalizability of the findings.31 Fourth,
the effect of the SMS intervention on early introduction of solid foods before 4 months needs
further confirmation because the rate among the study population was low.

CONCLUSIONS
ABSTRACT | METHODS | RESULTS | DISCUSSION | CONCLUSIONS | ARTICLE
INFORMATION | REFERENCES
A mobile phone SMS intervention seems to be effective in promoting EBF and delaying the
introduction of solid foods. The short median duration of EBF at 6 months in this study suggests
an urgent need for breastfeeding advocacy and promotion to increase public awareness and
government support and to create supportive environments (eg, by prolonging maternal leave to
align with the WHO breastfeeding guidelines). Further exploration of the effectiveness of SMS
interventions through large-scale cluster randomized clinical trials is needed.

ARTICLE INFORMATION
ABSTRACT | METHODS | RESULTS | DISCUSSION | CONCLUSIONS | ARTICLE
INFORMATION | REFERENCES
Accepted for Publication: January 8, 2014.
Corresponding Author: Xu Qian, PhD, School of Public Health, Fudan University, 138
Yixueyuan Rd, Mailbox 175, Shanghai 200032, China (xqian@fudan.edu.cn).
Published Online: March 17, 2014. doi:10.1001/jamapediatrics.2014.58.
Author Contributions: Dr Jiang had full access to all the data in the study and takes
responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Jiang, Li, Wen, He, Dibley, Qian.
Acquisition, analysis, or interpretation of data: Jiang, Li, Wen, Hu, Yang, Baur, Qian.
Drafting of the manuscript: Jiang, Li, Wen, Baur, Qian.
Critical revision of the manuscript for important intellectual content: All authors.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was funded by a Small Research Grant from the Nestle
Foundation and by grant 12GWZX0301 from the Shanghai Municipal Health Bureau.
Role of the Sponsor: The funding source had no role in the design and conduct of the study;
collection, management, analysis, and interpretation of the data; preparation, review, or approval
of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank the Longhua, Caohejing, Meilong, and Xinzhuang

community health centers in Shanghai, China, for their support, and we thank all the participants
for their collaboration.

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