1. Breastfeeding Support for Millennial Moms: An Evaluation of Mississippi WIC’s Use of Smartphone Technology to Improve Lactation Support
Jameshyia B. Thompson, PhD, RDN, LD, CLC
Deputy Bureau Director
Mississippi WIC Program
For this portion of the presentation, we will discuss an application of technology done by the Mississippi WIC Program.
This is an evaluation of the Mississippi WIC Program’s Use of Smartphone Technology to Improve Lactation Support.

2. Background Mississippi WIC Program Mississippi Breastfeeding Program
Average participation 84,143
Mississippi Breastfeeding Program
Average participation 2,721
FNS Operational Adjustment Grant
$204,500
First I will start by giving you a bit of an overview of the Mississippi WIC Program, so that you can have an idea of the size and scope of our program…
In Fiscal Year 2017, the Mississippi WIC Program has an average monthly participation of 84,143. This included an average 2,721 breastfeeding women, 9,250 non breastfeeding women, 8,510 pregnant women, 24,742 infants, and 38,918 children.
The average participation of breastfeeding participants is about 2,721 breastfeeding women.
In calendar year 2015, an operational adjustment grant was written and received in the amount of $204,500.

3. Mississippi At-Risk District 1 District 2 District 4 District 3
50 Miles
50 KM
District 1
District 7
District 6
District 2
District 3
District 5
District 4
District 8
District 9
Mississippi is divided into 9 public health districts and 82 counties. Currently each county has a county health department where WIC services are offered. However Mississippi faces several challenges unique to its rural design and conservative nature.
Specific challenges include the lack of IBCLCs and CLC’s to hire in hospitals, clinics, and WIC settings; lack of hospitals and providers offering lactation support to complement WIC support; lack of public and private transportation; extremely remote communities; and lack of a culture that supports and values breastfeeding.
All of these challenges culminate to create lower breastfeeding rates…

4. Mississippi At-Risk 2014 2016 Ever breastfed 61.5 52
Breastfeeding at 6 months
28.9
23.9
Breastfeeding at 12 months
10.0
11.3
Exclusively breastfeeding at 3 months
28.8
21.4
Exclusively breastfeeding at 6 months
10.1
9.3
Number of CLCs per 1,000 live births
0.57
2.21
Number of IBCLCs per 1,000 live births
1.81
1.93
Mississippi traditionally suffers low breastfeeding rates. It is well known that the decision to initiate breastfeeding and continue breastfeeding is partially based on having support.
In the 2014 CDC Breastfeeding Report, Mississippi had the 4th lowest breastfeeding initiation rates. By the 2016, we had the lowest breastfeeding initiation rates nationwide.
According to the CDC Breastfeeding Reports, Mississippi experienced a 9.5% decrease in women who have ever breastfed, a 5% decrease in women who were breastfeeding at 6 months, and a 7.4% decrease in women exclusively breastfeeding at 3 months.
On the brighter side, the number of CLC’s in the state has increased by 1.64, and the number of IBCLC’s has increased by 0.12 per 1,000 live births.

5. Mississippi At Risk Generation Age Range WIC Population Baby Boomers
(Based on MS State workforce data)
WIC Population
(Approximations based on WIC data from Oct. 2015)
Baby Boomers
(53- 71) 0%
Generation X
(38- 52)
2.4%
Generation Y, Millennials
(22- 37)
70.2%
Generation Z, iGen
(7- 21)
27.4%
Another challenge Mississippi faces is generational differences.
I have seen several different ways to divide the generations, but the generation classifications in the chart shown were based on Mississippi State workforce data.
As shown here, the vast majority of WIC mothers are Generation Y and/ or Millennials. Therefore, the decision was made to focus breastfeeding interventions on this specific group in order to reach more people.

6. Using technology to improve upon evidence-based strategies
Former US Surgeon General recommends increased access to IBCLCs as an evidence-based strategy for increasing breastfeeding duration and exclusivity
Women with telephone-based IBCLC support maintained exclusive breastfeeding for three times as long as control groups
97% of women aged own smartphones
Due to the specific issues Mississippi faces, it was important for us to be creative and specific in our efforts to increase breastfeeding rates. Recent research suggests that the use of a telephone- based intervention may improve breastfeeding rates for WIC mothers in Mississippi.
The former US Surgeon General identified access to IBCLC’s as an evidence-based strategy for increasing breastfeeding duration and exclusivity.
In recent research published in the American Journal of Clinical Nutrition, telephone based IBCLC support helped mothers to maintain exclusive breastfeeding for 3 times as long the control group who received routine care.
And according to a Nielsen survey, 97% of women ages own a smartphone.
Sources:
1) U.S. Surgeon General’s Call to Action to Support Breastfeeding,
2) American journal of Clinical Nutrition,
3) “Millennials are top smartphone users.” Nielsen,

7. Intervention Dates Procedures April- May, 2016
Contract secured with Pacify
June, 2016
Developed Mississippi- specific training materials
Procedures developed
On-site training provided by Pacify
Program launched
July- August, 2016
Webinar based follow-up training
July September 2016
Monthly reports
From the issues concerning Mississippi and the recent research, out intervention was born.
After being awarded the $204,500 operational adjustment grant by FNS, a contract was secured with the company, Pacify, who offered a breastfeed and nutrition support application that linked mothers to IBCLC’s and nutritionists via video calls (similar to FaceTime).
Pacify developed Mississippi specific training materials and procedures were developed for statewide training of peer counselors and district breastfeeding coordinators.
In the course on 1 week, Pacify and the state office team visited all 9 public health districts to provide on-site training for using the app.
The program launched in June 2016, follow-up trainings were provided via webinar, and monthly reports were generated.
Encrypted monthly reports were sent to the state breastfeeding coordinator, and then disseminated to district breastfeeding coordinators and peer counselors.

8. Mobile Application
As previously stated… Pacify is an application designed to provide nutrition and breastfeeding support for mothers. Mothers have video call access to IBCLC’s and nutritionists 24/7, and phone call access to nurses 24/7. It is important to note that the app available to moms with Apple and Andriod but not Windows. Services available in English and Spanish.
When the mothers logs on using her code, she has the option on the first screen to choose who she wants to contact. Then the conversation can begin…
At the end of each conversation, the participant has the option to rate the service provided and provide qualitative feedback.
Pacify lactation consultants are IBCLCs with a minimum of five years of clinical experience. All providers average 20 years of clinical experience.

9. Evaluation Strategies
Increase participant access to breastfeeding support services
Number of accounts activated by WIC participants
Participant utilization
Improve the quality of breastfeeding promotion and support
Star quality rating
Our evaluation had specific objectives and strategies.
To measure if the intervention ‘Increased participant access to breastfeeding support services’, we reviewed the number of accounts activated and participant utilization.
To measure if the intervention ‘Improved the quality of breastfeeding promotion and support’, we reviewed the start quality ratings for all calls.

10. Evaluation Strategies
Ensure peer counselors can yield to IBCLC’s when appropriate
Peer counselor access to application
Provide a cost- saving alternative to in-clinic staffing with professional IBCLCs
Relative cost comparison (FTEs vs Pacify)
To measure if the intervention ‘Ensured peer counselors could yield to IBCLC’s when appropriate’, we measured peer counselor’s access to the application.
To measure if the intervention ‘Provided a cost saving alternative to in-clinic staffing with professional IBCLC’s’, we performed a cost comparison.

11. Key Findings – 6 month assessment
Month of Enrollment
Total Enrollment
June 18 44
July 94
August
September
132
October
136
November 98
 TOTAL
598
In 6 months, a total of 598 WIC participants had downloaded and began using the Pacify application. During these same 6 months, 493 clinical consults took place.
This showed an increase in participant access to breastfeeding support.
All peer counselors downloaded and used the application; and were able to contact an IBCLC using the application for questions, concerns, and a greater level of support for WIC moms.
This ensured the peer counselors were able to yield to an IBCLC if needed.

12. Key Findings
Of the 486 WIC participants completing the star rating, average rating was 4.5/5.0
“Sandy was very helpful. She answered my question and helped with a question I had the other day but forgot to ask!” 
“Joanne was very helpful I was on the verge of giving up bc I thought my body wasn’t making enough milk but she explained everything!”
“very knowledgeable and sweet. I enjoyed her visuals and the way she explained everything. very good at building confidence.”  
Overall, the Pacify application has a 4.5 out of 5 star rating. Qualitative feedback has also been overwhelmingly positive.
This implies that the intervention is helping to improve the quality of breastfeeding promotion and support.

13. Key Findings BUDGET ITEM COST Total to fund 9 IBCLCs for one year
(During clinic hours only)
$313,200
Total for Pacify for one year
(24/7 access)
$204,500
DIFFERENCE
$108,700
Before reviewing this slide it is important to note that the Mississippi WIC faces a devastating shortage of IBCLC’s. We currently employ 3 IBCLC’s, with only 1 working in the clinics as an IBCLC. Partially due to the shortage of IBCLC’s statewide. In Mississippi, most IBCLC’s become IBCLC’s through their prospective occupations so they already have jobs when they become IBCLC’s. And partially due to the pay associated with IBCLCs in the WIC Program, because jobs at Mississippi WIC are state jobs that normally pay less than the private sector. The Mississippi WIC Program is in no way attempting to replace in-person IBCLC’s with a phone application. However, we are in a dire shortage already.
To fund 9 IBCLC’s (which would be one per public health district), it would cost the state $313,200 annually. The intervention cost $204,500. Equating to a cost savings of $108,700.

14. Key Findings
In the graph shown, the blue bar represents breastfeeding rates prior to the intervention launched in June 2016; the red bar represents breastfeeding rates after 4 months; and the green bar represents breastfeeding rates after 8 months.
The intervention has assisted with increases in all categories, including breastfeeding at 3 months, breastfeeding at 6 months, exclusively breastfeeding at 3 months, and exclusively breastfeeding at 6 months.
These were exciting findings for the Mississippi WIC Program.

15. Findings To Date June 18, 2016 – March 11, 2017 Total enrollments 866
Total clinical consultations
891
Portion of clinical consultations completed outside of MS WIC hours
43%
Average time to answer
21 seconds
Average participant star rating
4.5/5.0 stars
Fast forward to today…. As of March 11, 2017…
About 866 WIC participants have downloaded and tested the app; 891 clinical consultations have been made; 43% of these consultations happened outside of WIC working hours; average time to answer was 21 seconds, and the average star rating is 4.5 out of 5.

16. Best Practices
State Office WIC and Pacify involvement in kick-off trainings (held in-person trainings in all nine health districts)
Peer counselor- led enrollment process in clinics. Pacify app was an extension of the services provided by WIC.
Pacify providers often refer MS WIC clients back to WIC program and peer counselor for additional support (collective effort to support breastfeeding women)
Reports are always shared in HIPAA-compliant manner (encrypted with password protection)

17. Lessons Learned Adjustments to enrollment timing
Implemented to maximize impact of program
Started with offering to only breastfeeding participants (postpartum) and ended with offering to both breastfeeding and prenatal participants.
Importance of demonstration calls
Utilization was higher for women who made demonstration calls during enrollment
Demonstration calls can be completed in a couple of minutes.
Some lessons learned…
There were issues that arose that called for a need to adjust enrollment timeframes. We did not receive grant funding until April Therefore we only had about 6 months to implement and monitor the program. In the future infrastructure grants would be more feasible to allow for continued reporting and monitoring.
We initially offered the app only to breastfeeding mothers. After reviewing Pacify reports and receiving feedback from peer counselors, we decided to offer the app to prenatal and postpartum mothers in order t get mothers supported sooner. Pacify reports showed that women were calling with questions about re-lactation. This showed the need to give moms access to the app prior to delivery, if possible.
There is an "ah-ha" moment that occurs when a mom uses the app for the first time and a real, live lactation consultant picks up. There for it is very important for peer counselors to perform a demo call with the mothers.

18. Conclusions Benefit for Mississippi WIC Program 24/7 access
Positive participant feedback
Cost savings
Increased support for staff and participants
Improved breastfeeding rates – will continue to monitor impact on retention
Overall, the Mississippi WIC Program has benefited immensely from this intervention. Due to the low number of IBCLC’s in the state of Mississippi and the Mississippi WIC Program, having 24/7 access to lactation support from an IBCLC is imperative for our program. The quality of service provided by Pacify has been exceptional. Reports are timely. Trainings are professional. Services provided to participants are informative and helpful. As WIC participants become more aware of the application’s existence, Pacify enrollment numbers are expected to steadily increase.

19. Any Questions?