Exclusive Breastfeeding Promotion Utilizing Targeted Client Communication via Text Messaging in Roatán, Honduras

doi:10.21203/rs.3.rs-2114731/v1

Background: Exclusive breastfeeding (EBF) for 6 months provides significant benefits, including decreased incidence of respiratory and GI infections. Promoting EBF is a cost-effective method to improve infant health and survival. Roatán is a Honduran island where infant mortality is more than triple the country’s average. Data on infant feeding practices and EBF prevalence in Roatan is limited.

Objective: To determine if breastfeeding support and education through TCCMD will increase the prevalence of exclusive breastfeeding for 2-month-old infants in Roatán, Honduras.

Methods: From 08/16-05/17, a cross-sectional baseline survey assessed infant feeding practices and EBF prevalence at 2, 4, and 6 months of age. From 9/17-11/19, we recruited mothers of term infants with intention to breastfeed, access to a mobile device from Roatan Public Hospital’s postpartum ward to receive 158 text messages promoting EBF over 6 months. Surveys assessing EBF were collected at 2, 4, and 6 months of age (+/- 14 days). EBF was defined as given only breastmilk in the last 24 hours.

Results: 581 mothers were enrolled in the intervention group, 227, 171, and 89 surveys were completed at 2, 4, and 6 months of age, respectively. EBF prevalence for the intervention group at 2 months was 37.9% compared to 13.6% in the historical control group (p<0.0001). At 4 and 6 months, 28.7% and 13.5% of the intervention group reported EBF vs. 16.7% and 8.7% of the historical control group, p<0.05 and 0.73 respectively. Odds of EBF at 2 months, adjusted for mother’s age, education, occupation, and SES indicators, were 4.2 times higher in the intervention group compared to baseline group (p<0.0001, 95% CI [2.2, 8.1]). Across all ages 0-6 months, the baseline group reported shorter duration of any breastfeeding compared to intervention group p<0.0001.

Conclusion: The prevalence of EBF in Roatan is significantly below the global and Honduran national averages. EBF TCCMD resulted in a statistically significant increase in EBF for the first 2 months, as well as longer duration of any breastfeeding. As this study cannot rule-out a temporal trend, further study with a randomized trial would provide stronger evidence.

Exclusive Breastfeeding

Human Milk

Targeted Client Communication via Text Messaging (TCCMD)

Text Messaging

Global Health

Feeding Behavior

Health Promotion

Infant

Newborn

The Sustainable Development Goals aim to end preventable newborn deaths and reduce infant mortality to 12 deaths per 1,000 births by 2030. Promoting breastfeeding for the first 6 months of life in developing countries is the single most effective method to improve survival of infants and young children and reduce infections and chronic diseases. Yet only one-third or fewer infants in developing countries are exclusively breastfed.^, Universal exclusive breastfeeding (EBF) could prevent nearly 14% of deaths in children less than two years of age worldwide. There is a clear need for simple, cost-effective, and easily accessible solutions to successfully educate and encourage mothers to exclusively breastfeed, particularly in developing countries.

Targeted Client Communication using Mobile Devices (TCCMD) can improve care-seeking of pregnant women in developing countries and is beginning to be studied for the promotion of exclusive breastfeeding.^,^,9,10 A study in Shanghai, China found that SMS education was effective in increasing duration of exclusive breastfeeding and delaying introduction of solid foods.

It is unclear whether TCCMD changes behaviors surrounding EBF in developing countries with low EBF rates and high infant mortality. We sought to evaluate whether SMS messaging can be used to improve breastfeeding rates in a resource limited island in Honduras, where the national rate of exclusive breastfeeding in infants < 6 months old is 31.2% according to the Honduran national survey data. ^,

Study design

In 2016-2017, a baseline cross sectional survey was performed to assess EBF prevalence of mothers with infants aged less than 6 months old (n=227) from a convenience sample of mother-infant dyads attending 3 different clinics in Roatan for routine childcare. Breastfeeding status, infant feeding practices and diarrheal disease incidence were queried, and infant ages were classified into 2, 4 and 6 months.

Subsequently in 2017-2018, we studied the effect of a targeted client communication via mobile devices (TCCMD) intervention (n=582) on the rate of exclusive breastfeeding (EBF) in Roatán, Honduras with 582 new mother-infant dyads, with the primary outcome defined as exclusive breastfeeding at age 2 months. Secondary outcomes were EBF at 4 months and 6 months, any breastfeeding and diarrhea incidence. Women were recruited from the post-partum ward at Roatán Public Hospital. Inclusion criteria were recent delivery of term infants ≥ 37 weeks gestational age, ≥18 years of age, an emancipated minor (or with parental consent if < 18 years of age), intent to breastfeed, own a phone that can receive and send SMS messages, literate (self-reported ability to read English or Spanish) and interested in receiving text messages regarding EBF. Exclusion criteria were inability to consent, illiteracy or incarceration. We collected outcome data at the infants’ 2-, 4-, and 6-month birthdays (within a window up to 2 weeks thereafter). The survey was administered by text message with follow-up phone calls to non-respondents. We evaluated effectiveness of the intervention by comparing EBF rates at 2 months in intervention study to historical controls. Figure 1 summarizes the intervention study design adapted from the Consolidated Standards of Reporting Trials (CONSORT) template.

Ethics Approval and Consent to Participate

Institutional Review Board approval for this study was obtained from the University of California, Davis (UC Davis), University of California, San Francisco (UCSF), and Catholic University of Honduras Committee of Research Ethic (Universidad Católica de Honduras/Comité de Ética de Investigación). Informed verbal consent was obtained for the baseline survey as it was exempt from requiring written informed consent. Written and verbal informed consent in English or Spanish (based on participant’s preference) was obtained during intervention study recruitment.

Setting

Roatan, Honduras is an island located 65 kilometers of the northern coast of Honduras in the Caribbean Sea. It has an estimated population of 110,000 (2020 Census) and unknown breastfeeding practices prior to this research. There is one government hospital, Roatan Public Hospital, which provides free maternal and child healthcare both inpatient and outpatient. There are three additional public pediatric clinics: Oak Ridge; French Harbor; and Los Fuertes; and one non-profit outpatient clinic, Clinica Esperanza.

Participants and recruitment

Baseline survey was conducted from August 2016 to May 2017. Mothers were recruited while waiting to receive routine pediatric care for their infant at all five pediatric clinics: Roatán Public Hospital, Oak Ridge, French Harbor, Los Fuertes, and Clinica Esperanza. These clinics serve the majority of the island population, thus a representative sample of island residents. Mothers were eligible to participate if (1) infant was within 2 weeks of their 2-, 4- or 6-month birthday, and (2) had not previously completed the survey.

Intervention study participants were enrolled from September 2017 to May 2019 solely from the postpartum ward at Roatán Public Hospital, providing access to most women delivering infants on the island. Post-partum mothers at Roatán Public Hospital were recruited via a research assistant based on aforementioned inclusion and exclusion criteria.

Historical Control Group

Mothers in the historical control group were consented and invited to complete an orally administered questionnaire containing sociodemographic questions (i.e., age, education level, occupation, household living conditions, area of residence, and infant gender), past and current breastfeeding practices, recent infant diarrheal incidence (last 2 weeks), reasons for breastfeeding discontinuation if applicable, and whether they had met their own breastfeeding or breastmilk feeding intentions. Economic status was assessed indirectly through questions of household living conditions, including access to electricity, piped water in the home, number of bedrooms and number of individuals living in the household (similar to Honduran DHS).

Intervention

The intervention messages were written in both English and Spanish. Upon enrollment, mothers completed a sociodemographic questionnaire and were sent a sample text survey in their preferred language to ensure text messages were received. Mothers completed the test survey to practice text response and to trouble shoot any technical issues. If mothers did not have their phones at enrollment, mothers verbally agreed to complete the test survey when possible. Mothers had the option to view three animated videos (created in collaboration with Aerial Contrivance Workshop^™) providing information regarding breastfeeding and latch techniques, recognizing infant feeding cues, and encouragement to practice self-care and ask for help.

The duration of the intervention was 26 weeks during which a total of 158 messages were sent, including links to the videos. Messages were concentrated in the first 31 days of enrollment (total 99 messages), when obstacles to establishing EBF are most common. Incentives for survey completion at 2, 4, 6 months were provided at an equivalent of $1 per poll in either cash or talktime credit. Messages were sent from a computer-based, SMS interactive platform using Telerivet (https://telerivet.com) software program. Messages were sent through both Honduran cell service providers (Tigo^™ and Claro^™), with no cost to users receiving messages.

Intervention Messages

The intervention group received promotional and educational breastfeeding messages from the time of enrollment to 6 months post-delivery. Intervention messages were developed based on standard breastfeeding guidelines from WHO,¹²the American Academy of Pediatrics¹³and the Academy of Breastfeeding Medicine; ^{14,15,16,17,18,19,20,21,22} barriers found in focus groups we performed locally²³, the California Baby Behavior Campaign^24,25 and consultation with breastfeeding medicine experts and local Honduran pediatricians. Local physicians cited lack of education, cosmetic concerns, and difficulty with technique as common barriers to breastfeeding. The messages sent included recognizing newborn hunger cues, methods and positions to obtain a comfortable latch, normal infant sleep patterns, appropriate number/frequency of feeds, maternal milk production, and other education regarding infant sleep, breastfeeding techniques, complications, specific needs and encouragement for new mothers.

Primary and Secondary Outcomes

Our primary outcome was the proportion of 2-month-old infants who were exclusively breastfed during the last 24 hours before completing the response survey. Secondary outcomes were: (1) proportion of infants exclusively breastfed at 4 and 6 months; (2) diarrheal incidence at age 2, 4 and 6 months; and (3) proportion of infants receiving any breastfeeding at 2, 4 and 6 months

Definitions

Exclusive Breastfeeding

Exclusive breastfeeding was defined as giving mother’s breastmilk in the 24 hours preceding the baseline or intervention follow up survey and not giving any other foods or fluids as defined by the WHO.¹²

Subjects’ data were included in analyses for both historical control and intervention groups if they were in the age range of 2-, 4- or 6-months of age to 2-, 4- and 6-months plus 2 weeks of age; thus, 61-75 days, 122-136 days, and 183-197 days, respectively.

Diarrhea

Diarrhea was defined as “stool more watery than usual” (baseline) or “any watery stool” (intervention) with unspecified frequency.

Interventional Study

Data collection

SMS surveys

Mothers were sent follow-up surveys regarding their breastfeeding status at 2, 4, and 6 months postpartum through Telerivet. All replies from mothers were stored on a password protected, secure survey in Telerivet, and consolidated to a password protected, secured excel database.

The multiple-choice survey questions asked: (1) Did you give breast milk (any amount) to your baby in the last 24 hours? (yes/no), (2) How old was your baby when you last gave him breastmilk? (multiple choice age-ranges) (3) In the last two weeks, has your baby had any diarrhea (any watery stool)? (yes/no), (4) Did you give your baby anything other than breast milk in the last 24 hours? (yes/no), and (5) What did baby receive in the last 24 hours? Choose all that apply: water, tea, anise, infant formula, fruit juice, cereal, breastmilk, other, and/or none.

Telephone and messaging follow-up

Per protocol revision due to loss to follow-up, from October 2018 through June 2019, if participants did not respond to the automated SMS surveys, mothers were contacted via local phone calls within two weeks and performed survey verbally. If no response was received, participants were further contacted via Whatsapp secured-messenger application by messaging and/or calls. A maximum of four attempts were made to elicit a response within the two-week window.

Lost to Follow up/Messaging failures

Responses were categorized as one of the following: (1) completed response to primary outcome, and (2) incomplete response to primary outcome, which included unresponsive/lost to follow- up efforts, withdrawn from study, missing/changed phone numbers, and network error. Please see Figure [1], flow chart of study subjects.

SMS messaging was disrupted for a period of three months due to the loss of cellular service to the Telerivet-linked primary phone, and another period of one week due to delayed Telerivet subscription renewal. Survey responses during this time were lost to follow-up. The disruption affected roughly 60 two-month survey outcomes, and thus the enrollment sample size was increased accordingly. We analyzed by ‘intention to treat’ (including these mothers with network errors) as well as ‘treatment received’ (excluding the dyads who did not receive those messages).

Data Collection:

Quantitative data were coded and collected via (1) text message responses automatically submitted to Telerivet server from which we could monitor data and generate reports, and (2) manual input via phone call or Whatsapp messaging to a password protected, secured excel database.

Data Analysis:

Primary and secondary outcomes from the historical control and intervention groups were compared by difference in proportions, with Chi-square and Fisher’s Exact tests performed to detect statistical significance.

A multivariable logistic regression that adjusted for demographic and socioeconomic factors was used to calculate the odds ratio for EBF between intervention and historical control groups at 2, 4 and 6 month infants. The Kaplan-Meier survival curve and Log-Rank test was used to portray and compare the length of time that mothers continued any breastfeeding. All statistical analyses were performed with SAS version 9.4 (SAS Institute Inc). Hypothesis tests were 2-sided and evaluated at a significance level of 0.05.

Study Population

A total of 199 mothers were enrolled in the historical control group (103 at 2 months, 72 at 4 months, and 23 at 6 months; 1 at 2 months of age was excluded for incomplete survey). There were 581 mothers enrolled in the intervention group and 227, 171, and 89 surveys were completed at 2, 4, and 6 months of age, respectively, with exclusion of 51, 23 and 20 incomplete surveys respectively. We found there were more mothers employed outside the home in the intervention group than the historical control group. Both groups had similar average maternal ages, completion of high school, piped water inside home, electricity in the home, and infant gender (Table 1).

Table 1: Demographics and Socioeconomic Status

	Intervention Group (n=487)		Historical Control (n=198)
	Mean	SD	Mean	SD
Age of infant (months)	3.4 mos.	1.5	3.2 mos.	1.4
Number of Dyads	487		198
Age of mothers (years)	26.3	5.6	24.4 (n=197)	5.9 (n=197)
Number of bedrooms in home	2.1	1.0	2.3 (n=196)	1.1 (n=196)
# persons in house	4.7	2.1	4.9 (n=195)	2.3 (n=195)
*Persons: room Ratio of # rooms to persons in house )	2.5 (n=481)	1.1 (n=481)	2.4 (n=195)	1.2 (n=195)
	N	%	N	%
Completed High School	351	72.1%	133	67.2%
Work Outside Home	213	43.7%	37	18.8%
Piped Water Inside Home	249	51.1%	111	56.1%
Electricity in the Home	449	92.2%	178	92.2%
Sex of Baby - Female	266	54.6%	99	50.5%

Legend: *Person: room ratio = # people in house ÷ # rooms in house

Incomplete Surveys:

Demographics of mothers enrolled but did not respond to the intervention survey were similar to mothers who did answer the survey except for infant gender. We found that a larger proportion of mothers of males than females did not respond to the 2 month survey (62.8% vs. 37.3% respectively). In addition, a higher percentage of female infants were found to be EBF than male infants (60.5% vs. 39.5%).

Exclusive Breastfeeding:

Intention to Treat Analysis:

EBF prevalence for the intervention group at 2 months was 37.9% compared to 13.6% in the historical control group (p<0.0001). At 4 and 6 months, 28.7% and 13.5% of the intervention group reported EBF vs. 16.7% and 8.7% of the historical control group, p= 0.049 and 0.73 respectively (Table 2). There were no statistically significant differences in EBF at 2, 4 or 6 months of age between the intervention and historical control groups for male vs. female infants or by maternal ethnicity.

Table 2: Exclusive Breastfeeding by Infant Age

	2 months		4 months		6 months
	EBF	p-value	EBF	p-value	EBF	p-value
Control	14 (13.6%)	<0.0001	12 (16.7%)	0.049	2 (8.7)	0.73
Intervention	86 (37.9%)	<0.0001	49 (28.7%)	0.049	12 (13.5)	0.73

*Values based on Intention to Treat analysis

In the multivariable logistic regression analysis, the odds of EBF, after adjusting for mother’s age, education, occupation, and indicators for SES, were 4.2 times higher at 2 months and 2.3 times higher at 4 months in the intervention group compared to the historical control group (p<0.0001, 95% CI [2.2, 8.1]; and p=0.03, 95% CI [1.1, 4.9] respectively). There was no statistical difference in EBF vs. non-EBF at 6 months of age by maternal age, education (completed high school or not), employment, or SES as measured by number of people per room in household, or water or electricity inside the home (Table 3).

Table 3: Multivariate analysis

Odds of EBF vs. Not EBF at 2 Months
Variable	OR	95% Confidence Interval		p-value
Grouping: Intervention vs Historical Control	4.24	2.22	8.10	<.0001
Mother's Age	1.00	0.96	1.04	0.94
Education: Completed HS vs Did Not Complete HS	0.82	0.46	1.48	0.52
Occupation: Yes vs No	0.77	0.45	1.34	0.36
People to Room Ratio	1.10	0.87	1.38	0.44
Water Source Inside House Yes vs No	1.00	0.60	1.67	0.10
Electricity Inside House Yes vs No	1.83	0.63	5.33	0.27

As Treated Analysis:

When excluding 2 mothers who received partial messages (1 6-month and 1 4-month mother), prevalence of EBF at 2 months remained statistically significant (37.9% vs. 13.6% (p<0.0001) , but EBF at 4 months was no longer statistically significant (28.1% vs. 16.7%, p=0.06).

Diarrhea Incidence:

Infants in the intervention group were more likely to have maternal reported diarrhea within the last 2 weeks at 2 months when compared to historical controls (34.8% vs. 17.2% p=0.001). The 4- and 6- month infants had a similar trend although not statistically significant (4 months intervention vs. historical control: 26.9% vs 20.0% respectively, p=0.30; 6 months: 29.2% vs. 22.7%; p=0.61).

Any Breastfeeding:

Across all ages 0-6 months, the historical control group stopped breastfeeding sooner than the intervention group(p<0.0001) (Fig. 1).

EBF:
The main finding in this study is that mothers in Roatan, Honduras who received TCCMD based on standard breastfeeding recommendations, baby behaviors, and encouraging breastfeeding and self-care had significantly greater rates of EBF at 2 months postpartum than mothers in the historical control. There is a trend toward increased EBF at 4 months postpartum, although not statistically significant. These findings are consistent with the results of the Baby Behavior Campaign in California, in which mothers receiving messages regarding infant feeding cues and behaviors from WIC nutrition counselors breastfed longer²⁴. In our study there were no statistically significant differences between the intervention and historical control groups in EBF at 2, 4 and 6 months by infant gender, economic status, or race-ethnicity, suggesting the intervention was similarly effective in all demographic groups.

Any Breastfeeding:
Our findings suggest that the intervention group had longer duration of breastfeeding. We found that mothers in the intervention group reported giving ‘any’ breastmilk longer than the historical control group. This finding is important as many maternal and infant benefits of breastfeeding are dose-dependent. While non-exclusive breastfeeding is not as protective for the infant as exclusive breastfeeding, benefits can still be measured for both mother and infant for ‘any’ breastfeeding that is not minimal.²⁴ Maternal benefits include a linear dose-response reduction in maternal type 2 diabetes and breast and ovarian cancer.²³ If this intervention were scaled up to reach larger populations, detectable public health benefits would likely result.

Diarrhea Incidence:

We found that infants in the intervention group were more likely to have had increased maternal reported diarrheal incidence as compared to the historical control group at 2 months, but not at 4 or 6 months. This finding is surprising given the wealth of information that EBF typically decreases diarrheal incidence⁷. As there was a greater prevalence of EBF at 2 months, this difference in reported diarrhea could potentially have been due to lack of knowledge of typical breastfed infant stool consistency. As noted previously, the frequency of ‘more watery stools’ defining diarrhea for the historical control was not specified. The Honduran national survey allows that even one stool ‘more watery than usual’ would qualify as diarrhea and we used the same definition to be consistent with local standards. This was further abbreviated for the interventional trial’s text survey as ‘any watery stool’, possibly contributing to the greater likelihood of mothers’ reporting diarrhea in the intervention study. There also could have been an outbreak of diarrheal illness on the island during the intervention; there are no health surveys during that period to support or refute this. This, however, seems unlikely as there was no significant difference in maternal reports of diarrhea at 4 or 6 months in the intervention vs. historical control group, nor an indication of even a trend towards increased diarrhea in the intervention group, as would be expected (intervention group vs. baseline: (4 months: 26.3% vs 20.0% respectively, p=0.30; 6 months: 28.1% vs. 22.7%; p=0.61).

Analysis by Intent to Treat vs. Treatment Received:

Our primary analysis was completed using intent to treat. When analyzed by treatment received, our intervention continued to find statistically increased EBF at 2 months. One mother-infant dyad was excluded in the 4-month group due to some missed messages from network error; after this change in sample size the difference in EBF at 4 months was no longer statistically significant(p=0.06). Another mother-infant dyad was excluded in the 6-month group due to missed message; EBF at 6 months remained not statistically significant.

Demographics:

Of note, SES and demographics were similar between historical control and intervention groups except for a higher percentage of the intervention group reporting employment outside of the home. Given the similarity in maternal education and SES, we suspect the difference in employment answers may be related to survey timing. Mothers in the historical control group were surveyed at 2, 4 and 6 mos. (+ 2 weeks), whereas the intervention mothers were at enrollment immediately post-partum, when they may have been working up until the time of delivery. We expect, but cannot confirm, that many mothers in the historical control may have answered the question similarly if asked in the immediate postpartum period. The historical control group was not asked if they had been employed prior to delivering their infant, or whether mothers would return to work in the future. We also suspect the difference in response by gender did not have a significant impact on overall results as the EBF did not statistically differ based on gender.

Strengths:

This study provided educational text messages that were based, in part, on California’s Baby Behavior Campaign, which was found to be associated with an increase in EBF²⁴. Our messaging intervention was relatively high-intensity with a total of 158 text messages sent over 180 days. This is over twice the mean frequency of the informative Text4Baby messages for pregnant and post-partum mothers in the US (provided by the US Department of Health and Human Services).^25,26 Messages were also offered in both English and Spanish, increasing availability and reach. This intervention could be implemented as a relatively inexpensive large scale public health initiative in the future.

Limitations:

This study has several limitations. It was a single site study conducted on the island of Roatan, Honduras and therefore may have limited generalizability. The use of a historical control is also limiting in that the difference in EBF rates could theoretically have been related to a factor other than the intervention, e.g., education of healthcare professionals or public health initiatives distinct from our intervention, which could have confounded our results. We made a good faith effort to ascertain that there were no other public health interventions that may have affected breastfeeding rates after the baseline survey and during the intervention. However, since our intervention occurred after the historical control measurement, we cannot rule out a temporal trend. Samples sizes at 4 and 6 months were less robust due to loss to follow-up and thus increases the probability of attrition bias as mothers practicing EBF may have been more likely to answer the surveys.

We found that while most mothers had cellular devices to receive text-based messages, not all mothers had access to the internet to watch the videos. This was discovered early during the study and the protocol was revised to offer mothers the opportunity to watch the videos at enrollment, with links additionally sent to all mothers during the intervention. Therefore, we were not able to determine which mothers did not watch the videos.

There was a possibility of reporter bias, wherein the mothers reported a greater rate of EBF than was the case, perhaps from a ‘social desirability’ standpoint, having received messages about greater health benefits. We believe this may have been minimized as the vast majority of data was entered into phones, rather than by personal interview. EBF was defined as only breast milk given within the last 24 hours for both the historical control and intervention group; however, EBF in the intervention was additionally operationalized as infants not given any other supplements within the last 24 hours, asking specific common foods to improve recall. Not having this information for the historical control may mean the proportion of mothers practicing EBF in that group may have been overestimated, biasing against our finding of a significant difference.

Future Studies:

This study found that TCCMD can improve EBF in Roatan, Honduras. The broader implication is that a similar text messaging program could be informative and improve EBF rates in communities with low prevalence of exclusive breastfeeding practices. Future studies randomizing a population into routine care and routine care plus TCCMD could provide stronger evidence. In addition, this intervention could be tested in a larger study population in multiple communities.

The prevalence of EBF in Roatan is significantly below the global and Honduran national averages. Encouraging and educational EBF TCCMD resulted in a statistically significant increase in EBF for the first 2 months, as well as longer duration of any breastfeeding. As this study cannot rule-out a temporal trend, further study with a randomized trial would provide stronger evidence.

EBF: Exclusive breastfeeding

TCCMD: Targeted Client Communication using Mobile Devices

CONSORT: Consolidated Standards of Reporting Trials

Ethics Approval: Institutional Review Board approval for this study was obtained from the University of California, Davis, University of California, San Francisco, and Catholic University of Honduras Committee of Research Ethic (Universidad Católica de Honduras/Comité de Ética de Investigación)

Consent for publication: Not applicable

Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request

Competing interests:
The authors declare that they have no competing interests

Funding:

-The project described was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through grant number UL1 TR001860. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

-University of California, Davis Edward D. Dickson Emeriti Professorship

-University of California, Davis Department of Pediatrics

-Izumi Foundation Grant

-UCSF School of Medicine Technology Transfer Grant

-Global Healing

Author’s contributions:

LR, AY and CC wrote and edited the manuscript with input from all authors. JY assisted with drafting manuscript. LR, CC, JH, KC and JY developed the study design. AY, LR and JY collected data. JF analyzed and interpreted results. JD, JH,KC and SF edited manuscript. CC supervised the study.

Acknowledgements:

-Aerial Contrivance Workshop

-Arup Roy-Burman

-Daniela Brissett

-Francisco Javier Panchamé Rosa
-Noely Larios Arguero

-Ana G. Murillo Flores

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No competing interests reported.

Exclusive Breastfeeding Promotion Utilizing Targeted Client Communication via Text Messaging in Roatán, Honduras

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