1. SYDNEY MEDICAL SCHOOL Using short message service to improve infant feeding practices in Shanghai, China: feasibility, acceptability and results at 12 months Hong Jiang 1, Mu Li 2*, Liming Wen 2,3, Qiaozhen, Hu 1, DonglingYang 1, Gengsheng He 1, Louise A Baur 2,4, Michael J Dibley 2, Xu Qian 1

2. The Problem › Infant feeding practices can have long-term effects for children. › Despite efforts to promote breastfeeding in China, rates are very low. Exclusive breastfeeding in children younger than 6 months - 15% in major cities and 28% in rural areas. › Improving infant and young child feeding is needed not only to reduce mortality and morbidity, researches also show that children who were breastfed have lower levels of obesity than those who were formula fed.

3. MCH services in Shanghai 3 2&3 trimester register Home visit Antenatal care 1 st month postpartum BF promotion pregnancy Antenatal class CHC MH Dr childbirth 6wks postpartum exam Check up Up to 2 years Maternity Hop CHC MH Dr Maternity Hop CH /Paediatric Antenatal class 10 steps of successful BF BF advice 1 trimester Delivery Check up

4. The Approach › We have developed a community-based health promotion program to support new mothers to breastfeed their babies and to adopt healthy infant feeding practices. › The study was carried out in four Community Health Centers (CHCs). Two CHCs were assigned to the intervention group and two other CHCs were assigned as the control group.

5. The Approach 5 › Communications technologies such as SMS have enabled us to deliver the innovative public health program.

6. The Approach StageFocus of messages 3 rd trimesterAdvice on mother’s nutrition and physical activity, preparation for breastfeeding, instructions for breastfeeding after vaginal delivery or caesarean section, tips for avoiding baby reflux etc. First week to age 2 months. Rapid response to problems of breastfeeding initiation, specific guidance for women had caesarean section delivery Child’s age 2- 4 months Encouragement for exclusively breastfeeding and advice not starting complementary food at this period. For mothers who would return to work soon, encouragements and advice for continuing breastfeeding. Child’s age 4- 6 months 1) For mothers go back to work: how to adapt to their work environment and continue breastfeeding. 2) For mothers who still breastfed exclusively: continue to EBF until 6 months and preparation for starting solids at 6 months. Child’s age after 6 months Encouragement for continuing breastfeeding and adopting appropriate infant feeding practices 6

7. The Results › Delivering health promotion intervention by SMS appears not only feasible but is well accepted by new mothers with a high retention rate of 89% at 12 months › Compared with the control group, the intervention group had a significantly longer median duration of EBF at 6 months (11.41 weeks, 95% confidence interval [CI] 10.25 - 12.57 vs 8.87 weeks, 95% CI 7.84 - 9.89; P<0.001)

8. The Results AOR(95% CI) P Variables Total No. (%) Interventio n No. (%) Control No. (%) Exclusive breastfeeding at the 6 th month * (n=549) Yes58 (10.6)40 (15.1)18 (6.3) 2.67(1.45- 4.91) 0.002 No491(89.4)225 (84.9)266(93.7)1 Introduction of solid food regularly before the 4 th month * (n=551) Yes15 (2.7)4 (1.5)11 (3.8) 0.27(0.08- 0.94) 0.039 No536(97.3)261 (98.5)275(96.5)1 8

9. Implications › A cluster RCT is planned, we expect that the intervention can be embedded in the healthcare system to achieve sustainable long term impacts › More broadly, this could be a model for culturally- acceptable healthy infant feeding and childhood obesity prevention in other countries undergoing rapid socio-economic and nutrition transitions like China