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Digital Education as Effective as Face-to-Face Counseling in Promoting Exclusive Breastfeeding

Explore findings from our randomized controlled trial with Philani with over 1,500 new mothers in the Western Cape of South Africa.

Exclusive breastfeeding, meaning an infant receives only breast milk for the first six months after birth, continues to be one of the most effective ways to protect child health because breast milk contains antibodies that deter common childhood illnesses.

The Western Cape province in South Africa has one of the lowest exclusive breastfeeding rates in the world. This is not an isolated case: around the world, nearly two-thirds of infants are not exclusively breastfed for the recommended first six months of life. 

While the global rate of exclusive breastfeeding has remained unchanged for nearly two decades, new research indicates that regular home visits by community health workers could aid in promoting exclusive breastfeeding, particularly in under-resourced settings. 

Philani MOVIE study

Combining digital education with community-based interactions, Stanford Digital Medic researchers along with researchers at the Heidelberg Institute of Global Health partnered with the Philani Maternal, Child Health and Nutrition Trust to measure the impact of a mobile video series called the Philani MObile Video Intervention for Exclusive breastfeeding (Philani MOVIE study). 

The randomized controlled trial, conducted in the Western Cape, followed 1,502 new mothers through five months post-delivery. In the treatment group, the videos were presented to new mothers on tablets by community health workers, known as “mentor mothers.” In the control group, no videos were presented and mentor mothers provided standard face-to-face counseling.

Philani’s mentor mother program aims to improve maternal and child morbidity and mortality in South Africa through community-based initiatives designed to bring preventative primary health care into family homes. Since 2002, Philani has recruited and trained mentor mothers — women who succeeded in rearing healthy children despite living in poverty.

After the trial was conducted, similar breastfeeding rates were observed between the treatment and control groups, suggesting that the video-based intervention was as effective as in-person counseling in promoting exclusive breastfeeding. An analysis of the mentor mothers’ time use revealed that the videos replaced nearly two-fifths of direct human interaction between the trial participants and mentor mothers, freeing up time for the community health workers to conduct other health-related tasks. 

This study suggests that video interventions can be leveraged to amplify the health promotion efforts of CHWs, and in areas where CHWs are limited or not present, digital education can be a potential bridge to quality preventative health models.

The findings of the 19-month study were published in PLOS Medicine on September 28, 2021.

Video intervention educates through narrative storytelling

The Philani mentor mothers showed the new mothers in the treatment group 14 animated videos, spanning two to five minutes in length, over the course of the trial period. The videos, narrated in English, Afrikaans, and isiXhosa, were developed by the Digital Medic team in South Africa along with local artists, narrators, and public health authorities. 

One of the videos portrays a mother describing to her child why she breastfed, even against the well-intentioned suggestion of her own mother. “Breastfeeding was the best possible way to help you grow strong and smart and to stay healthy,” the mother tells her daughter in the video. “We knew that giving small babies anything other than breast milk, even water, can make them very sick.”

A series of qualitative interviews with mentor mothers suggest that the video intervention lowered the workload of the 84 mentor mothers who participated in the study, according to Nophiwe Job, a Digital Medic researcher and one of the study investigators overseeing field implementation of the study.

“The mentor mothers reported to us that while their patients were watching the videos, they could catch up on filling out forms and other administrative responsibilities,” Job said. The tablets that CHWs carried with them also had the effect of increasing credibility with patients.

She added that the narrative-style videos spurred new mothers’ engagement with the topic: “With in-person counseling, CHWs told us that it was difficult to hold patient interest, so they would only share the bare minimum. But now with the short videos, the patients were so engaged and it actually made them ask questions.”

Though the rates of exclusive breastfeeding did not differ between the intervention and control groups of the trial, new mothers who watched the videos had a significant increase in maternal knowledge at one month. The comparable rates of breastfeeding suggest that the video intervention was as effective as typical face-to-face counseling. 

Social determinants of health still play a role

Encouraging exclusive breastfeeding is more difficult than simply providing education to mothers, according to Job. The ingrained cultural and societal stigmatizations  — specifically HIV and poverty — continue to pose challenges to efforts to increase the rate of exclusive breastfeeding.

Job referenced “confusing and scary” messages about whether HIV-positive mothers can breastfeed, for instance. With this in mind, the Digital Medic team incorporated HIV-specific information in the curriculum for the new mothers — and these videos were among the most viewed.

Though public health organizations in the past recommended against breastfeeding for HIV-positive women out of fear of HIV transmission, there is growing evidence that shows antiviral medicines to the mother or infant can significantly lower the risk of HIV transmission through breastfeeding. In addition, the increased risk of death if infants are not exclusively breastfed could outweigh the risk of HIV infection through breastfeeding.

The medical field “has not done an effective job of communicating key, life-saving messages,” Job said. “Breastfeeding is such a basic action, but the stigmatization and marketing from infant formula companies make it all the more difficult to encourage exclusive breastfeeding.” 

For Job, the study “validated the importance of understanding the social determinants of health.”  

The study also lays the groundwork for future work exploring the use of video-based education interventions among CHWs without the level of support and training available to Philani mentor mothers. 

“All of the mentor mothers with Philani receive exceptional training, and all of the mentor mothers in our study were experienced. The unfortunate reality is that many CHWs worldwide do not have access to this level of training,” said Jamie Johnston, Digital Medic research director and investigator on the study. “An important next step is to understand the impact of video training among novice and under-trained CHWs.”


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