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Maternal and Newborn Health Challenges

  1. Top of page
  2. Maternal and Newborn Health Challenges
  3. Bottom Line
  4. A Multifacted Partnership
  5. Why Go Mobile?
  6. Literature Review
  7. Text4baby Target Audience
  8. Implementation of Service in Care Settings
  9. How It Works
  10. Reaching the Intended Audience
  11. Conclusion
  12. Get the Facts
  13. References

As more and more people across North America adopt new technologies and methods of communication, pregnant women and new mothers are no different. Text4baby, a free mobile information service of the National Healthy Mothers Healthy Babies Coalition, provides timely health information to women from early pregnancy throughout their baby's first year. The service sends important educational messages that are timed to the mother's stage of pregnancy or to the baby's age

The mobile phone, now one of the most widely used technologies in North America, is being used to promote maternal and child health. The Text4baby program sends targeted health messages to promote healthy pregnancies and healthy babies. The Healthy People 2010 target goal for the U.S. infant mortality rate is 4.5 infant deaths per 1,000 births. The current U.S. rate is approximately 50 percent higher than the goal (MacDorman & Matthews, 2008). In the United States, more than 500,000 babies—one in every eight—are born prematurely and an estimated 28,000 children die before their first birthday (March of Dimes, 2010a). According to March of Dimes (2010b), the rate of preterm birth is highest for black infants (18.4 percent), followed by Native Americans (14.2 percent), Hispanics (12.2 percent), whites (11.6 percent) and Asians (10.8 percent).

Bottom Line

  1. Top of page
  2. Maternal and Newborn Health Challenges
  3. Bottom Line
  4. A Multifacted Partnership
  5. Why Go Mobile?
  6. Literature Review
  7. Text4baby Target Audience
  8. Implementation of Service in Care Settings
  9. How It Works
  10. Reaching the Intended Audience
  11. Conclusion
  12. Get the Facts
  13. References
  • Text messaging is a very popular mode of communication.
  • Text4baby is a free service that provides vital health information to pregnant women and new mothers via text messages.
  • A multifacted public-private partnership was involved in the development of Text4baby.

Health care costs for infants born prematurely average about 10 times those for infants born full-term. In 2005, the annual societal economic cost (medical, educational and lost productivity) associated with preterm birth in the United States was at least $26.2 billion (March of Dimes, 2010a). The Text4baby program could become a powerful educational tool, providing pregnant women and new mothers with vital information, and could potentially change behavior, leading to improved birth outcomes.

A Multifacted Partnership

  1. Top of page
  2. Maternal and Newborn Health Challenges
  3. Bottom Line
  4. A Multifacted Partnership
  5. Why Go Mobile?
  6. Literature Review
  7. Text4baby Target Audience
  8. Implementation of Service in Care Settings
  9. How It Works
  10. Reaching the Intended Audience
  11. Conclusion
  12. Get the Facts
  13. References

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Text4baby is supported by a broad, public-private partnership that includes government, corporations, academic institutions, professional associations, tribal agencies and non-profit organizations. Founding partners are the National Healthy Mothers Health Babies Coalition, Voxiva, CTIA—The Wireless Foundation and Grey Healthcare Group. Johnson & Johnson is a founding sponsor of the program. Premier sponsors of Text4baby include Wellpoint, Pfizer and Care First Blue Cross and Blue Shield. U.S. government partners include the White House Office of Science and Technology Policy, the Department of Health and Human Services and the Department of Defense Military Health System. Voxiva provides the mobile health platform, and free messaging services are provided by participating wireless service providers. Federally qualified health centers, state government agencies, health plans, hospitals, health delivery networks, health clinics and businesses are examples of the diverse group of outreach partners. These outreach partners are instrumental in spreading the word about Text4baby and encouraging women they serve to sign up for the program.

Why Go Mobile?

  1. Top of page
  2. Maternal and Newborn Health Challenges
  3. Bottom Line
  4. A Multifacted Partnership
  5. Why Go Mobile?
  6. Literature Review
  7. Text4baby Target Audience
  8. Implementation of Service in Care Settings
  9. How It Works
  10. Reaching the Intended Audience
  11. Conclusion
  12. Get the Facts
  13. References

It's estimated that 50 percent of the global population owns a mobile phone, and that 98 percent of those phones have text messaging capabilities (Terry, 2008). Research shows that more than 90 percent of Americans have cell phones, 18 percent of households are “mobile only” and more than 1.5 trillion text messages were sent in the United States in 2009 (Blumberg & Luke, 2008; CTIA—The Wireless Association, 2010). A typical teenager sends 50 text messages per day, which adds up to 18,000 text messages in a year (Lenhart, Ling, Campbell, & Purcell, 2010). According to Fox and Vitak (2008), 73 percent of U.S. adults have Internet access but the average Internet use is less than 1 hour/day. Fox and Vitak (2008) report only 50 percent of patients with chronic disease have access. Mobile phones are popular among young people and across social classes and, therefore, may be a better way to deliver health information than other modes of communications, such as pamphlets, books and Web sites.

Text4baby is supported by a broad, public-private partnership that includes government, corporations, academic institutions, professional associations, tribal agencies and non-profit organizations

Literature Review

  1. Top of page
  2. Maternal and Newborn Health Challenges
  3. Bottom Line
  4. A Multifacted Partnership
  5. Why Go Mobile?
  6. Literature Review
  7. Text4baby Target Audience
  8. Implementation of Service in Care Settings
  9. How It Works
  10. Reaching the Intended Audience
  11. Conclusion
  12. Get the Facts
  13. References

Text messaging in health care is growing at an exponential rate due to the ubiquitous nature of mobile phones. Phones are personal, portable and relatively inexpensive. Text messaging has recently been recognized as a tool for behavior change, targeting performance modification in both promotion and management of health (Cole-Lewis & Kershaw, 2010).

There is an emerging body of evidence that supports the use of text messaging for health behavior change in the areas of smoking cessation, weight loss physical activity and diabetes management. A recent systematic review of 12 studies from one developing and eight developed countries analyzed the results of text messaging as a means for delivering behavior change interventions intended to promote weight loss, smoking cessation, diabetes management, asthma management and adherence to vitamin regimens. The combination of randomized control, randomized crossover and quasi-experimental trials targeted diverse populations with regard to age, gender, ethnicity, nationality and health status. The frequency of text messages among studies varied from two times a month to five times a day; some studies used consistent text messaging rates, while others titrated the intervention frequency over time. Three studies allowed the individual to choose the rate. Additionally, both unidirectional and bidirectional text messaging services were represented. Of the nine studies that had sufficient power to determine the efficacy of text messaging as a behavioral change tool, eight concluded significant behavioral outcomes; there were significant findings in three of the five studies targeting preventative behavior and five of seven focusing on health management (Cole-Lewis & Kershaw, 2010).

Text messaging has been used as a means to provide health care reminders, specific health promotion messages (such as diet and exercise) and therapeutic communication for emotional disorders (Gerber, Stolley, Thompson, Sharp, & Fitzgibbon, 2009; Haapala, Barengo, Biggs, Surakka, & Manninen, 2009; Hazelwood, 2008; Kharbanda, Stockwell, Fox, & Rickert, 2009; Leong et al., 2006; Prestwich, Perugini, & Hurling, 2009). Text messaging has also been used in health education for sexual health and smoking cessation, with study results consistently reporting this method to be an acceptable and effective way to provide advice and support to participants (Lim, Hocking, Hellard, & Aitken, 2008; Rodgers et al., 2005). The current literature promotes continued utilization of text messaging as a behavior change intervention tool; however, more research is necessary to determine the appropriate frequency, duration and degree of patient interaction for each targeted outcome. Very little is known about the utility of smart phones and their associated applications for health promotion. There is need for continued research in this area and development of evidence-based guidelines.

Text4baby Target Audience

  1. Top of page
  2. Maternal and Newborn Health Challenges
  3. Bottom Line
  4. A Multifacted Partnership
  5. Why Go Mobile?
  6. Literature Review
  7. Text4baby Target Audience
  8. Implementation of Service in Care Settings
  9. How It Works
  10. Reaching the Intended Audience
  11. Conclusion
  12. Get the Facts
  13. References

Text4baby represents an opportunity to expand the way phones are used, to demonstrate the potential of mobile health technology and to make a real difference in the way education can be provided for pregnant women and new mothers across the country. Ninety percent of women in the United States have a mobile phone and texting is especially prevalent among women of childbearing age and among minority populations, who face higher infant mortality rates (Pew Internet & American Life Project, 2010a). Box 1 compares Internet and cell phone use among low-income, less than high school–educated African Americans. African Americans typically text more on average than do whites, with a median of 10 texts a day for African Americans and 5 texts a day for whites (Pew Internet & American Life Project, 2010b). Text4baby seems to be an excellent way to communicate with low-income women and new mothers who have limited access to critical prenatal and newborn information.

Table BOX 1.  INTERNET VERSUS CELL PHONE USE
PopulationInternetaCell Phoneb
Women79%81%
<$30K income63%71%
<High school degree52%71%
African Americans71%87%

There is an emerging body of evidence that supports the use of text messaging for health behavior change

Implementation of Service in Care Settings

  1. Top of page
  2. Maternal and Newborn Health Challenges
  3. Bottom Line
  4. A Multifacted Partnership
  5. Why Go Mobile?
  6. Literature Review
  7. Text4baby Target Audience
  8. Implementation of Service in Care Settings
  9. How It Works
  10. Reaching the Intended Audience
  11. Conclusion
  12. Get the Facts
  13. References

The ease of registration for Text4baby makes it a usable educational tool in a variety of perinatal settings. It can be implemented as part of a new patient–nurse interview, when the patient history has been obtained and risk assessment is complete. As part of the initial obstetric visit, the nurse can include this tool as part of the education given during this appointment. In addition, assisting the patient in signing up while in the office will ensure timely registration in order to reap the full benefits of the educational messages.

In the hospital setting, Text4baby can be recommended by providers in the emergency room or obstetric triage. This is a prime opportunity to capture the attention of women who have not registered for prenatal care, who don't have a regular health care provider or health insurance or who frequent the emergency room or obstetrical evaluation areas with pregnancy-related concerns (Kjerulff, Frick, Rhoades, & Hollenbeak, 2007). Providers can encourage these women to sign up for the text messages before leaving the health care site.

This tool can also reinforce and supplement the education provided by prenatal nurse case managers conducting home visits. One of the first messages that occurs in the “starter pack” is a reminder to make an appointment for prenatal care, with a phone number to call if needed. Messages such as “make sure you count the baby's movements for at least 1 hour per day,” which are sent at the start of the third trimester, address many of the concerns that women have as the pregnancy progresses. Women who haven't utilized the service during pregnancy can be sent information in the postpartum setting in order to receive infant-health messages for their baby's first year. Infant care messages, such as those that provide information on safe sleeping practices, may help reduce infant mortality.

How It Works

  1. Top of page
  2. Maternal and Newborn Health Challenges
  3. Bottom Line
  4. A Multifacted Partnership
  5. Why Go Mobile?
  6. Literature Review
  7. Text4baby Target Audience
  8. Implementation of Service in Care Settings
  9. How It Works
  10. Reaching the Intended Audience
  11. Conclusion
  12. Get the Facts
  13. References

Women can sign up for the program by texting BABY to 511411 (or by texting BEBE for Spanish). Once signed up for the service, women will receive three free SMS text messages each week timed to their due dates (infant's date of birth). Box 2 summarizes some of the selected topics included in the Text4baby program. The text messages may also connect women to public clinics and support services for prenatal and infant care.

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Message development was led by the National Healthy Mothers Healthy Babies Coalition in collaboration with the Centers for Disease Control and Prevention (CDC) and federal partners. CDC played a key role in assuring that the messages are evidence based. After the content was developed, the messages were reviewed by an interdisciplinary panel of experts including nurses, obstetricians, nurse-midwives, pediatricians, medical epidemiologists, mental health professionals, nutritionists, lactation consultants and a clinical geneticist.

Enrollees in the program receive the messages free of charge. There is no cost to the user—even if the woman doesn't have a text message plan with her mobile service provider. If she does have a text plan, Text4baby will not deduct from the total number of texts the enrollee pays for her regular plan. Close to the enrollee's due date, there are messages instructing her to text UPDATE to update her baby's due date and/or date of birth in the system and adjust the timeline.

Reaching the Intended Audience

  1. Top of page
  2. Maternal and Newborn Health Challenges
  3. Bottom Line
  4. A Multifacted Partnership
  5. Why Go Mobile?
  6. Literature Review
  7. Text4baby Target Audience
  8. Implementation of Service in Care Settings
  9. How It Works
  10. Reaching the Intended Audience
  11. Conclusion
  12. Get the Facts
  13. References

Evidence is emerging that this technology is reaching the intended audience. At the time of this writing, the program had reported more than 155,000 enrollees since February 2010. We do know that, of these, there are a limited number who are not pregnant or a mother, but may have registered to review the program. Five percent of the enrollees are registered for the Spanish version of the program. To date, the program has sent 6.7 million text messages, and 96.5 percent of the enrollees would recommend the Text4baby program to a friend. Results from preliminary national Zip code analysis of all Text4baby users shows that 61 percent of users are in Zip codes with household median income less than $50,000. Zip code analysis at the state and local level also confirms that enrollees in Zip code areas who are considered low-income and high-risk are enrolling in the Text4baby program.

Once signed up for the service, women will receive three free SMS text messages each week timed to their due dates

Media efforts continue to promote the program. The National Healthy Mother Healthy Babies Coalition reports that 95,000 posters and 75,000 tear-off pads have been distributed in English and Spanish. Outreach partners exist in 50 states with many state, county and city health departments promoting the free program. Medicaid plans in 18 states are implementing outreach efforts to 90,000 pregnant women. New York City is placing program inserts with an estimated 150,000 birth certificates per year.

Conclusion

  1. Top of page
  2. Maternal and Newborn Health Challenges
  3. Bottom Line
  4. A Multifacted Partnership
  5. Why Go Mobile?
  6. Literature Review
  7. Text4baby Target Audience
  8. Implementation of Service in Care Settings
  9. How It Works
  10. Reaching the Intended Audience
  11. Conclusion
  12. Get the Facts
  13. References

Text messaging is a fast, low-cost and popular mode of communication, which can provide vital health information to pregnant women and new mothers. The ease of registration for Text4baby makes it a usable education tool in a variety of perinatal settings. Early results indicate that the information is reaching the intended audience. However, program evaluation must continue to demonstrate its effectiveness. There is a need for national robust evaluations of critical quality to demonstrate if the text messages promoted health behavior changes and improved clinical outcomes for mothers and babies. NWH inline image http://nwhTalk.awhonn.org

References

  1. Top of page
  2. Maternal and Newborn Health Challenges
  3. Bottom Line
  4. A Multifacted Partnership
  5. Why Go Mobile?
  6. Literature Review
  7. Text4baby Target Audience
  8. Implementation of Service in Care Settings
  9. How It Works
  10. Reaching the Intended Audience
  11. Conclusion
  12. Get the Facts
  13. References