All things to all people? A scoping review of mobile phone apps that support breastfeeding

All things to all people? 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A scoping review of mobile phone apps that support breastfeeding Benjamin Newton This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7254515/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: The widespread availability of smartphones has given rise to the development of mobile health (mHealth) interventions, including breastfeeding support interventions delivered through smartphone apps. Aims: The aim of this scoping review was to identify articles that evaluated the use of mobile phone apps to deliver breastfeeding support. Methods: A search of BNI, CINAHL, MEDLINE and PsycINFO was undertaken in December 2022 and 880 records were identified. Through a systematic approach, two reviewers, 12 articles were identified that met the inclusion criteria and were included in the review synthesis. Results: The included articles were published between 2018-2022, with half originating from the USA. Study objectives focused on usability testing, impact evaluation, or a combination of these. Outcome measures focused on breastfeeding rates, breastfeeding confidence, usability and satisfaction. Breastfeeding support apps largely featured written educational material. Some apps contained links to other resources and some featured breastfeeding trackers. Studies tended to feature women with higher levels of education which can challenge the generalisability of the results. Most articles identified positive feedback regarding usability, but only two articles featured interventions that demonstrated significantly higher breastfeeding rates. Discussion: The role of intersectionality in breastfeeding is reflected on in relation to the preponderance of more educated participants in these studies. Whilst there are clear educational benefits to breastfeeding support apps, there is a risk that apps promote an individualistic focus to the detriment of structural breastfeeding barriers being addressed. Healthcare commissioners should consider how health inequalities can be tackled when considering mHealth breastfeeding interventions. Nursing Obstetrics & Gynecology Psychology Breastfeeding Smartphone mHealth Scoping Review Intersectionality Figures Figure 1 Introduction The benefits of breastfeeding infants are well documented alongside poorer outcomes of not doing so, for both child and mother (Ip et al. 2007, Victora et al., 2016). Other researchers have highlighted financial savings to healthcare services if infants are exclusively breastfed, with Ajetunmobi et al. (2024) suggesting a saving of £100 per child breastfed up to 6 weeks. Latest annual breastfeeding data from England suggests the aggregate rate of breastfeeding six to eight weeks after birth is 52.7% (OHID, 2024) which is an improvement on the previous year of 49.2% (OHID, 2023) but well below the 70% target set by the World Health Assembly (UNICEF, 2021). Different breastfeeding interventions have been attempted globally to drive breastfeeding rates up, including peer support, health education, social media campaigns and breastfeeding counselling (Khatib et al. 2023). Given study heterogeneity, it can be challenging to compare breastfeeding studies to assess the overall effectiveness of interventions in improving breastfeeding. A review of six systematic reviews (Khatib et al. 2023) found an improvement rate ranging from 44%-93% in early initiation of breastfeeding using interventions compared to routine care. A Cochrane review by Balogun et al. (2016) reported improved rates of breastfeeding initiation among professional-led interventions, while multi-media interventions did not improve initiation rates. Meanwhile, another review of breastfeeding interventions concluded such interventions were more effective than usual care, but to such a small degree that the authors concluded that the real-word effects and were questionable (Chung et al., 2008). Given the exponential growth in mobile phone users (Ben-Zeev et al. 2015) and digital health technology, health interventions are increasingly being delivered on mobile phone platforms in a field known as mHealth (Marcolino et al. 2018). This has the potential of facilitating easier access to healthcare for citizens (Yao et al. 2022). Delivering interventions to improve the take-up and continuation of breastfeeding, via mobile health technology is a logical step forward. One report identified that during the Covid-19 pandemic, women welcomed remote and digital breastfeeding support as it supported their personal privacy (Department of Health and Social Care, 2021). Compared to traditional interventions, other advantages to digital breastfeeding apps, include offering a greater audience reach alongside providing continuous support. Aims This scoping review of the literature was initially undertaken as an adjunct to a real-world evaluation of a digital breastfeeding app (Newton et al. 2025). This review sought to systematically identify articles that have evaluated the use of mobile phone apps to support breastfeeding. Two additional aims were to synthesise the findings of identified articles and identify key learning points about the use of breastfeeding apps in a real-world context. Method Article screening A search of four indexing databases (British Nursing Index, CINAHL, MEDLINE and PsycINFO) was undertaken on 22 nd December 2022 using keyword and subject terms related to ‘breastfeeding’ and ‘smartphone apps’. These databases provide access to a range of nursing, allied health, medical and psychological articles, which are disciplines pertinent to the area of breastfeeding interventions. The search strategy used is available in supplementary file 1. The title and abstract of articles were screened by two individuals (BN and NA), one of whom is an experienced qualitative researcher (BN). Articles were included if they reported on an evaluation of the use of mobile phone apps to support breastfeeding. Specifically: The focus of the app must be on supporting mothers to breastfeed using the intervention app. The intervention under consideration must primarily be a mobile phone application. Interventions such as mobile texting or phone calls are considered out of scope. The article concerns primary research and is not a review article. The article is written in English. BN and NA read through the titles and abstracts and developed the following exclusion criteria: The article is not about breastfeeding support. There is no intervention used OR the intervention is not directly used with mothers. The article is not an evaluation of a breastfeeding support app. The article is not a journal article presenting primary research (i.e. conference abstracts, news stories and grey literature were not included). The article is not available in English language. Table 1. Number of abstracts excluded across criteria categories for each reviewer. Criteria No. articles excluded by reviewer BN NA 1. The article is not about breastfeeding support. 418 391 2. There is no intervention used OR the intervention is not directly used with mothers. 54 39 3. The article is not an evaluation of a breastfeeding support app. 121 144 4. The article is not a journal article presenting primary research. 24 40 5. The article is not available in English language. 0 5 Included 34 31 All 651 titles and abstracts were then screened by both BN and NA, applying these exclusion criteria in a step-wise process. As Table 1 shows, BN identified 34 records and NA identified 31 records for inclusion, resulting in a total of 52 unique records. The reviewers met and considered the 52 records. Through discussion and application of the exclusion criteria, they agreed on selecting 20 articles for full-text review. See Figure 1 for the flow of articles. Excluded articles from full-text screening A third reviewer (PW), an experienced manager in maternity care, worked with BN to read the 20 full-text articles and consider their suitability for inclusion. They independently read the articles and decided whether each one met the inclusion criteria. Disagreements were resolved through discussion resulting in a final list of 12 articles being selected for data charting. Discussion was held around whether to include evaluation of app prototypes; given the scoping nature of this work, the reviewers agreed to include prototype evaluations. Of the eight excluded articles, several referred to apps but an evaluation of a specific breastfeeding app did not take place: In two articles, authors produced an analytics report of a breastfeeding app (Padró‐Arocas et al., 2021a; Padró-Arocas et al., 2021b); Dienelt et al. (2020) considered women’s experiences of breastfeeding tracker apps; Akber et al. (2019) described a community-based programme of work rather than a specific breastfeeding app evaluation; whilst Musgrave et al. (2021) offered a theoretical exploration of how their app delivered change by retrospectively applying a behavioural model. The remaining studies were excluded for other reasons: two did not use a mobile phone-based app (Farr et al., 2019; Ogaji, Arthur and George, 2021); and one article focussed on psychological distress rather than breastfeeding (Koçak, Ege and İyisoy, 2021). Data charting A data charting form was developed by BN and tested by both BN and PW. Following discussion, no iterations were made after initial use of the form. The data charting form covered the following data fields: (i) authors; (ii) title of article; (iii) year of publication; (iv) primary country of research; (v) study aims; (vi) number of participants; (vii) recruitment approach & context; (viii) research design including comparator description where applicable; (ix) smartphone app name; (x) features of the app; (xi) how the app was used with participants; (xii) main outcome measures; (xiii) key findings; (xiv) key strengths; (xv) key limitations; (xvi) lessons for real-world implementation. The author drew upon the data charting results to synthesise the articles, re-reading the articles where necessary. Articles included in this scoping review were not critically appraised, following Munn et al.’s (2018) reasoning that scoping reviews are not seeking to answer a specific question. Results Overview of included studies Across the twelve articles included for final synthesis, ten unique interventions were described: articles A4, A5 and A6 refer to the same intervention. Table 2 shows the article reference number, as well as the authors, publication year, primary country, sample size, intervention name and app features. Articles were published between 2018 and 2022. with the modal year 2021. This date range suggests that breastfeeding smartphone apps have become available relatively recently and perhaps reflects the exponential growth in mHealth (Cano et al. 2020 ). Half of the studies originated in the United States (A1, A3, A4-6, A9), with two of the studies being undertaken in Australia (A7, A12). Across the articles, there was a large range in the number of participants. Usability studies tended to have smaller numbers (n < 10). Larger evaluations recruited hundreds of participants, with the largest recruiting 1266 people (A2). Study design The study objectives could be categorised into one of two types; i) usability testing and ii) impact evaluation. Slightly more studies focused on evaluating the impact of the app (A2, A4-6, A8, A10) which was focused on breastfeeding outcomes in all cases. Four articles focused on usability testing of the app (A3, A7, A9, A11) with a further two articles considering both usability and impact (A1, A12). Usability testing included looking at user acceptance, user engagement and usefulness of the app. Table 2 Articles selected for inclusion. Article Authors Year Primary country Participants Smartphone name App features A1 Bunik, Jimenez-Zambrano, Solano, Beaty, Juarez-Colunga, Zhang et al. 2022 USA n = 467 recruited Mother’s Milk Messaging™ • Daily text messages 3–4 weeks before birth of baby and up to 3 months after, 20 different messages before delivery and 40 after. • Informational and personal videos available along with external links. • Breastfeeding content available by topic. • Feeding tracker. • Bilingual, both English and Spanish. A2 Doan, Pham, Binns, Lee, Zhao, Dinh et al. 2022 Vietnam n = 1266 consented - • Tailored messages in pregnancy and after birth, with further resources in the app that could be explored. Messages connected with multi-media resources. A3 Jefferson, Zachary and Majee. 2019 USA Phase 1 n = 14 Phase 2 n = 10 Mother’s Milk Connection • Breastfeeding resources for informed decision making and supporting positive attitude to breastfeeding. • Peer support – discussions with other mothers. • Feeding logs that can be exported so nurses can assess. • Video conference with breastfeeding specialist with access to feeding logs. A4 A5 A6 Primary article Lewkowitz, López, Carter, Duckham, Strickland, Macones et al. Griffin, López, Ranney, Macones, Cahill and Lewkowitz. Lewkowitz, López, Werner, Ranney, Macones, Rouse et al. 2020 2021 2021 USA n = 170 consented BreastFeeding Friend (BFF) • Educational content on breastfeeding benefits, normal infant behaviour, normal maternal postpartum physiology, diet & exercise guidance. • Material at 5th grade reading level. • Interactive advice to overcome common challenges of breastfeeding. • Breastfeeding and pumping optimisation strategies. • Links to on-demand breastfeeding and pumping videos, with the majority featuring at least one women of colour breastfeeding. • Links to local, national, and international online breastfeeding resources. • Built in tracker to inform the study team each time the app was opened. A7 Meedya, Win, Yeatman, Fahy, Walton, Burgess et al. 2021 Australia n = 7 in pilot Milky Way • Discussion forum. • Information (e.g. FAQs and Milk Supply). A8 Miremberg, Yirmiya, Rona, Gonen, Marom, Pohol et al. 2022 Israel n = 224 consented - • Information about the study. • Information on lactation and emotional challenges after birth. • Ability to communicate with the study team (including nurse, lactation consultants and clinical psychologist). A9 Patchen, Ellis, Harrington, Ma, Mohanraj, Andrews et al. 2020 USA Advisory group feedback n = 6 Focus groups n = 25 Usability testing n = 14 KULEA-NET • App delivers informational messages, which link to content in the libraries. Delivered at least three times per week. • Static and video library. • Local resources. • Feeding and nappy changing log. • Nominate a support person, who has full access to app. A10 Seyyedi, Rahmatnezhad, Mesgarzadeh, Khalkhali, Seyyedi and Rahimi. 2021 Iran n = 102 consented - • Educational programme contained seven components aligned to seven sections of Iranian Health and Education Ministry’s guide to Maternity and Child health. Specifically: o importance of breastfeeding, o behavioural methods for mothers, o complementary feeding and exclusive breastfeeding, o pumping and manual expression, o managing common breast-related and breastfeeding problems, o breastfeeding tips for special situations, o answering common queries about lactation in case of illness. A11 Wang, Chaovalit and Pongnumkul. 2018 Thailand n = 21 consented MoomMae • Feeding record. • Pumping record. • Location of public feeding places. A12 Wheaton, Lenehan and Amir. 2018 Australia n = 50 consented Breastfeeding Solutions • Provides an interactive guide to solving breastfeeding problems. • Search or browse over 100 topics. Seven articles utilised an RCT design (A1-2, A4-6, A8, A10) and all focused on demonstrating the impact of the intervention on breastfeeding (accepting that article A1 also considered user engagement). Usability studies tended to use mixed methods approaches involving interviews, focus groups or surveys, with the exception of article A12 which used a prospective cohort design to assess app usability and impact on breastfeeding outcomes. Outcome measures Listed below are the outcome measures shared across studies: All twelve studies collected some level of detail on demographics. Eight studies (A1-2, A4-6, A8, A11-12) collected data on breastfeeding rates, either exclusively breastfeeding or non-exclusive breastfeeding. There was wide variation in the time points when this was collected. One study (A2) collected it during the hospital stay as a measure of early initiation, or at Day 2 (A4-6), whilst others collected it at six months. The most common time points were three and six months postpartum (A1, A4, A8, A12). Six studies (A1, A3-6, A12) sought data on intention to breastfeed. Three studies looked at breastfeeding confidence / self-efficacy; two of these (A1, A10) used the Breastfeeding Self-Efficacy Scale (Dennis & Faux, 1999 ) with one study (A12) asking questions on breastfeeding confidence as part of understanding attitudes to feeding. Six studies explored the role of usability or acceptability (A1, A3, A7, A9, A11-12). Two studies (A3, A9) used the System Usability Scale or SUS (Bangor et al. 2008 ) and one study (A7) used a mobile application usability scale (Hoehle & Venkatesh, 2015 ). Five studies (A4-6, A11-12) measured usage of the app. Four studies (A8-9, A11-12) measured satisfaction with the app. Finally, most of the studies (A1, A3-7, A9, A11) undertook either interviews or focus groups to elicit qualitative data. App features In Table 2 the features of each intervention app are outlined. All but one of the articles (A11) featured apps that included educational written material to support breastfeeding, with five articles featuring apps that had educational videos (A1, A4-6, A9). Three articles described the apps as having a library (e.g. A2, A9) or index of topics (A12). Five articles (A2, A4-6) described the apps as having external links to other resources or support. Four articles described a feeding tracker or log (A1, A3, A9, A11), with two of these having other types of logs, such as pumping (A11) or nappy changing (A9). There were four articles (A1-2, A7, A9) where messages were sent in the form of push notifications or SMS. These could serve several purposes, such as providing content designed to influence, motivate or remind users around breastfeeding. Two articles (A3, A8) described the app featuring communication tools to connect with professionals for support. Two articles (A3, A7) facilitated peer support through connections to social media (A3) or a forum (A7). Finally, two apps (A9, A11) allowed users to identify nearby feeding spaces. App implementation There was considerable variation in how the implementation of the app was described, with some articles offering minimal information. In eight articles, women were given the app to use whilst they were pregnant (A1-2, A4-7, A9, A12); in five articles, the app was given after the baby’s birth (A3, A8, A10, A11, A12) and in one article (A12) women were recruited either before or after birth. The antenatal time period when women were given the app ranged from 24 weeks (A2) to 40 weeks (A7) gestation. Typically, when women were given the app postnatally, the article simply states “after birth”. The total length of the intervention ranged from 2 weeks (A3) to 10 months (A2). It was not always clear who installed the app. Sometimes it was a professional or a member of the study team, at other times it was the participant. In one instance, the app was pre-installed on a mobile phone that was given to participants (A4-6). With respect to instructions given to participants, in five studies, it was unclear what participants were told (A1-2, A7, A9, A11). In two studies (A3, A4-6), the study researcher supported participants with orientation to the app. Sometimes, the participant was encouraged to use the app (A3, A4-6, A8, A10, A12). In two articles, staff contacted participants during the intervention period about the app (A8, A10). Recruitment Four studies (A1, A2, A4-6, A9) recruited women who were pregnant. The pregnancy gestation when they were recruited ranged from 24 weeks up to 40 weeks. Others (A8, A9-12) recruited postpartum women, with this ranging from Day 1 postpartum to 3 months. Article A9 recruited women at antenatal and postnatal stages, as this study had multiple project phases. Researchers recruited women from local clinics or hospitals (A1-10, A12), via social media (A1, A3, A7, A11) and via local community or organisations (A7, A9, A11). With respect to the ownership of smartphones, seven articles required ownership as a condition of participation (A1, A2, A8-A12). Articles A3 & A7 did not specify whether a smartphone was required, whilst in articles A4-A6, a smartphone was given to participants by the research team. Article findings Table 3 reports on the mean age of participants and their education level indicated by the percentage of participants with an undergraduate degree or higher. The specific focus on age and education is supported by literature which shows that increased age of the mother and higher levels of education are positive determinants for breastfeeding (Standish & Parker, 2022 , Yngve & Sjöström, 2001 ). Table 3 Key demographics Article Age Under-graduate education completed A1 28.1* 58%* A2 28.7* 56.7%*^ A3 27.0 35% A4 22.7* 6%* A5, A6 A7 32.7 85.7% A8 32.5* Not measured. A9 Phase 1: 26.0 Phase 2: 26.4 Not measured. A10 26.0 37.5%*^ A11 32.7 91% A12 30.0 47.8% * Intervention group. ^ A2 described as tertiary education; A10 described as academic education. The mean age of participants ranged from 22.7 years (articles A4-6) to 32.7 years (articles A7 and A11). The mean age across all articles was 28.4 years. With respect to education, the number of participants with an undergraduate degree ranged from 6% (A4-A6) to 91% (A11). Across all articles, the mean number of participants with an undergraduate degree was 52.2%, which changes to 58.8% if one excludes articles A4-6 on the basis that the figure of 6% is an outlier. Of the ten unique studies (excluding A5-6), six measured the impact of the app on breastfeeding rates. Four studies did not measure breastfeeding rates (A7, A9-11), though article A10 measured the ‘practice’ of breastfeeding (which is not defined in the article). Only two articles found the app led to a statistically significant increase in breastfeeding; article A2 found higher breastfeeding rates during the hospital stay, whilst article A8 found significant rates at 6 weeks and 3 months. Even these two studies note breastfeeding rates were not significantly higher at other time points they both measured, with neither study finding significant increases sustained at 6 months post-birth. Meanwhile, two articles did not find any significant increase in breastfeeding (A1, A4). Turning to breastfeeding self-efficacy, three of the ten unique articles measured this (A1, A10, A12) with a further three articles (A3, A9, A11) reporting anecdotal evidence. Of the three articles that measured self-efficacy, two (A1, A10) found this significantly increased in the intervention group; one article (A12) only measured self-efficacy at baseline. With respect to usability, acceptability and satisfaction: A1 reports on how engaged participants were. This could be considered a proxy measure of usability. The authors found most mothers engaged in the app once their baby was born. Of note is the authors’ comment that the highest app users were “highly motivated, white married women” (Bunik et al, 2022 :7). They report that most mothers were satisfied with the app, according to their qualitative data. The mean SUS score in article A3 was 83 (out of 100); 90% of participants agreed that other breastfeeding mothers would frequently use the website version of the app. The second phase of testing revealed that participants thought the app was easy to use. In article A6, significantly more participants believed that an app provided the best breastfeeding support at home compared to a control group at week 6 postpartum. One might infer participants were satisfied with the app. Users in article A7 all agreed or strongly agreed that the app was easy to use, with six out of seven users stating they intended to continue using the app. Four users said the app needed further information. Participants in A8 reported high satisfaction with the ease of the app and the availability of the supporting professionals. For article A9, the mean usability score on the SUS was 73.8. The authors state that participants would be happy to recommend the app to a friend, suggesting satisfaction. In article A11, the mean usability score was 34.83 out of 40. Qualitative feedback on usability revealed 59 out of 71 comments were negative. This contrasts to qualitative feedback on the usefulness of system features which found 56 out of 66 comments were positive. The authors report that overall participants found the app acceptable, with a high intention to continue using. Finally, for article 12, most participants rated the app favourably (93.5%) with 96.8% reporting it was helpful. 87.1% would recommend the app to other breastfeeding mothers. Curiously, only 45% of participants agreed the app helped them with their breastfeeding goals, suggesting limits to the perceived usefulness of the app. Strengths & Limitations With respect to strengths, studies frequently drew on an evidence-based approach to the development of their app. For instance, studies A1, A2, A7 & A9 used theoretical models such as social cognitive theory and self-efficacy. Article A10 stated they used Ministry of Health guidelines for the app. Meanwhile, several apps (A3, A4-7, A9) drew on a panel of experts or stakeholders to inform the app’s development. Articles A11-12 used a pre-existing app, so no explicit theoretical model was drawn on. Seven articles (A1-2, A4-6, A8 and A10) used a randomised-controlled trial, all of which were registered in a clinical trials registry. Three of these studies (A1, A2 and A10) used blinding; Articles A4-6 did not appear to use research blinding, although the authors did state that a researcher not involved in the outcomes data reviewed the app contents with participants. There are limits to the generalisability of the results from this heterogenous selection of articles. Seven of the studies explicitly required women to have pre-existing access to a mobile or tablet device (A1-2, A8-12). This potentially introduces an inequality in facilitating access to those with the resource to fund smartphone usage. In contrast, one study (A4-6) focussed on low-income women and provided participants with a pre-paid smartphone. Some of the articles were focussed on specific populations. For instance, A2 focused on women who gave birth via c-section, A4-6 recruited (low-income) women from a prenatal Medicaid / no health insurance clinic; A9 focused on African-American women. Several studies were focused on recruiting women who intended to breastfeed (A4-6, A8, A10) or who had initiated breastfeeding (A3, A12). Meanwhile, article A11 comprised of women, nearly all of whom exclusively breastfed. There are limitations associated with studies where participants self-selected. Article A1 recruited participants through advertisements on Facebook, the radio and local clinics; Article A7 used the university news platform, paper flyers and social media posts, whilst A11 used recruitment posters on a breastfeeding interest Facebook group and at the National Science and Technology Development Agency. Table 3 shows the number of participants completing under-graduate education was highest among the three articles that employed self-selecting recruitment strategies (A11–91%, A7–85.7%, A1–58%). Finally, given that nine out of the twelve articles were published between 2020–2022, at the time of the COVID-19 pandemic, checks were made as to when participants were recruited. Article A2 recruited participants during 2020–2021 and describes the study adaptations made during the pandemic. A8 was conducted between October 2019 and September 2020 (according to the Clinical Trials registration). There is no description of how the pandemic impacted the study, but the authors do acknowledge how COVID-19 reveals the need for accessible lactation support. Article A10 undertook recruitment between January to June 2019, with data collection concluded by December 2019. One might expect this study to be minimally affected by the pandemic and no reference to COVID-19 was made in the article. Implementation reflections The objectives of the twelve articles largely fell into either testing the usability of the app or evaluating the impact of the app on outcomes such as breastfeeding rates and breastfeeding self-efficacy. In recognition that the manner in which an intervention is implemented can affect the success of its adoption (see, for instance, Bauer and Kirchner, 2020 ), this last section will offer some brief reflections on key learning points from the twelve articles. Earlier in this review, the timing of the intervention was outlined, with eight articles describing the app was implemented during pregnancy and five articles stating the app was implemented postpartum. Some authors argued for introducing the app at a specific time. For instance, in A4, the authors advocated introducing the app during pregnancy at 36 weeks in line with other studies. In article A3, the app was introduced to breastfeeding mothers, but the authors reflected upon a suggestion to introduce the app during pregnancy which would allow participants greater time to engage with it. In other studies, the purpose and design of the intervention likely determined how it was implemented. For instance, the participants in A8 were recruited postpartum in line with the study objective to facilitate communication after birth with staff. Whilst in A1, women were recruited from 36 weeks gestation and the app was designed to deliver targeted breastfeeding messages during pregnancy. One might conclude there is no ‘one-size-fits-all’ approach and the timing of implementation depends on several factors. With respect to the participants involved in evaluating breastfeeding support apps, there can be challenges recruiting a diverse range of participants. For instance, A1 acknowledged the highest users of the app were married women with a high motivation to breastfeed their baby. Article A7 advocates for testing the app in other demographic groups given the participants were highly educated. In A11, they only recruited women with a high intention to breastfeed, despite attempting to recruit women with a diverse range of breastfeeding intentions. Similarly, A12 states the sample was overrepresented by women with strong intentions to breastfeed. Future evaluations might benefit from acknowledging that breastfeeding interventions can attract a specific demographic of motivated and educated participants. Mitigation steps in recruitment may be needed to achieve a heterogenous sample. Finally, it is worth highlighting how some of the studies addressed inequalities or supported accessibility. The intervention in A1 was a bilingual app. Articles A4-6 focused on working with low-income women and in line with this goal, provided participants with a free smartphone for the study. In article A2, no internet was required for the app to function once downloaded, which effectively increases the accessibility of the app and allows for it be used independent of paid-for internet services. Finally, in recognition of racial disparities in health outcomes, article A9 focused on a breastfeeding app with African-American participants. Discussion This scoping review set out to identify evaluations of mobile phone-based breastfeeding support apps. It identified twelve articles published between 2018 and 2022. The articles could be categorised into two types of evaluation, usability testing and impact evaluation. Of the usability studies, the majority of articles reported positive feedback regarding usability. This contrasts with the results on breastfeeding rates, with only two out of six studies revealing a statistically significant increase in breastfeeding. Article A12 which assessed both app usability and breastfeeding outcomes identified very high user satisfaction, but only moderate agreement that the app supported breastfeeding goals. This is in line with a recently published systematic review of mobile apps (Ziebart et al. 2025 ) which found high user satisfaction with apps but no significant improvement in breastfeeding rates. Similarly, others have found antenatal breastfeeding education does not improve breastfeeding initiation or increase exclusive breastfeeding (Lumbiganon et al. 2016 ). Perhaps one explanation for the divergent results across the studies is the underpinning theory of change. Many of the studies offered a rationale for their intervention to support breastfeeding, which included diverse theoretical models, guidance and panels of experts and stakeholders. Whilst on the face of it, a comparison of breastfeeding support apps may appear to be legitimate, the context of the underlying logic is vital and in the case of this scoping review, reveals a homogenous group of breastfeeding support apps. Of particular interest is that articles in this review tended to comprise samples of women with higher levels of education; this was particularly evident where samples were self-selected. As higher education levels are associated with stronger breastfeeding outcomes (Peregrino, 2018), one might hypothesise that self-selecting recruitment strategies in this context risks attracting participants who may be more motivated to breastfeed and who have a greater degree of privilege. The study of intersectionality may offer a useful lens to reflect on this finding. Bohren et al. ( 2023 ) argue that applying the lens of intersectionality to maternal health offers insight into how multiple forms of privilege (and exclusion) can drive inequality in maternity care. In other words, differences in ethnicity, gender, class and other demographics can combine to drive (and compound) inequality. Bartkowski et al ( 2025 ) note that the experience of Black women in breastfeeding their babies is more likely to be one of exhaustion and isolation, with Black women’s self-efficacy lower. They continue by stating breastfeeding is appreciated as a valuable practice, but given the challenges, implementing breastfeeding is a struggle. Others describe the racism experienced by Black women who wanted to breastfeed. Davis et al. ( 2021 ) describe how women experienced hospital staff giving their infant formula without their consent, disregarding their intention to exclusively breastfeed. The participants narrate difficulties with employment circumstances, with some employers unsupportive or hostile to making adaptations for pumping. The authors describe how Black women’s employment circumstances reflect the legacy of historic racism. It would be fair to note that most of the articles in this review featured apps that sought to provide educational material on breastfeeding. This suggests that one possible underlying theory of change for these apps is that by increasing knowledge about breastfeeding, women should be better educated to breastfeed their infant. Such an approach places the focus on educating app users, suggesting in part, an attempt to address knowledge deficits. Whilst there is undoubtedly a place for education, could this risk placing too much responsibility for breastfeeding success on the individual woman? Given the higher prevalence of educated women sampled in the articles reviewed, one may further question whether an education-based app risks privileging already educated women and additionally, whether this risks excluding other groups of women? When one brings an intersectionality lens, it is possible to appreciate the historic and structural barriers that women racialised as Black can experience in seeking to breastfeed. The barriers to breastfeeding identified in the two studies above (which is by no means intended to be exhaustive) include isolation, exhaustion, healthcare provider attitudes and employment circumstances; issues that go beyond education deficits. The new NHS ten-year health plan (Department of Health and Social Care, 2025) states that it will be designed to tackle inequalities in both how services are accessed and in their outcomes. Whilst it would be unrealistic to expect a breastfeeding intervention app to deal with structural barriers to feeding, those commissioning feeding support services should consider how their services will deal with inequalities and what role breastfeeding apps play in this. Of course, this review identified articles that sought to overcome inaccessibility and inequality and such efforts should be acknowledged. However, it is important to question and challenge implicit (deficit-focussed) assumptions that may underlie the theory of change supporting the intervention’s intended outcome. Strengths and limitations This scoping review provides insight into the availability of published evaluations into breastfeeding support apps, following a systematic approach. It drew on two reviewers in the process of identifying suitable articles to follow a robust process. As this review was not a core piece of work, there were delays in completing it as well as much developmental learning. Other evaluations may have been published in the period between the search and the completion of the manuscript. The review process could have been strengthened by the involvement of a second reviewer during the synthesis stage. A review protocol could have been registered on a protocol registration website. Nonetheless, despite these limitations there are valuable insights that can be derived from the review of these twelve articles. Declarations Acknowledgements The author acknowledges and thanks Najeeb Ahmed and Peter Wathan for their input during the scoping review process; he also thanks the two colleagues who provided detailed feedback on the manuscript. Data availability The data charting produced during the process of this review are available from the corresponding author on reasonable request. References Ajetunmobi O, McIntosh E, Stockton D, et al. Levelling up health in the early years: a cost-analysis of infant feeding and healthcare. PLOS ONE. 2024;19(5):e0300267. https://doi.org/10.1371/journal.pone.0300267 Akber S, Mahmood H, Fatima R, et al. Effectiveness of a mobile health intervention on infant and young child feeding among children ≤ 24 months of age in rural Islamabad over six months duration. F1000Res. 2019;8:551. https://doi.org/10.12688/f1000research.17037.3 Balogun OO, O’Sullivan EJ, McFadden A, et al. Interventions for promoting the initiation of breastfeeding. Cochrane Db Syst Rev. 2016;11:CD001688. https://doi.org/10.1002/14651858.CD001688.pub3 Bangor A, Kortum PT, Miller JT. An empirical evaluation of the System Usability Scale. Int J Hum-Comput Int. 2008;24(6):574–94. https://doi.org/10.1080/10447310802205776 Bartkowski JP, Klee K, Xu X, et al. Breastfeeding and intersectionality in the Deep South: race, class, gender and community context in coastal Mississippi. Women. 2025; 5(2):21. https://doi.org/10.3390/women5020021 Bauer MS, Kirchner J. Implementation science: what is it and why should I care? Psychiatry Res. 2020;283:112376. https://doi.org/10.1016/j.psychres.2019.04.025 Ben-Zeev D, Schueller SM, Begale M, et al. Strategies for mHealth research: lessons from 3 mobile intervention studies. Adm Policy Ment Health. 2015;42(2):157–67. https://doi.org/10.1007/s10488-014-0556-2 Bohren MA, Iyer A, Barros AJD, et al. Towards a better tomorrow: addressing intersectional gender power relations to eradicate inequities in maternal health. EClinicalMedicine. 2023;67:102180. https://doi.org/10.1016/j.eclinm.2023.102180 Bunik M, Jimenez-Zambrano A, Solano M, et al. Mother's Milk Messaging™: trial evaluation of app and texting for breastfeeding support. BMC Pregnancy Childb. 2022;22(1):660. https://doi.org/10.1186/s12884-022-04976-6 Cano AID, Margaix-Fontestad L, Esplugues A. Descriptive analysis of mobile phone applications on breastfeeding. An Pediatr. 2020; 92(5):302-5 https://doi.org/10.1016/j.anpede.2019.03.008 Chung M, Raman G, Trikalinos T, et al. Interventions in primary care to promote breastfeeding: an evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2008;149(8):565–82. https://doi.org/10.7326/0003-4819-149-8-200810210-00009 Davis C, Villalobos AVK, Turner MM, et al. Racism and resistance: a qualitative study of bias as a barrier to breastfeeding. Breastfeed Med. 2021;16(6):471-80. https://doi.org/10.1089/bfm.2020.0307 Dennis CL, Faux S. Development and psychometric testing of the Breastfeeding Self-Efficacy Scale. Res Nurs Health. 1999;22(5):399-409. https://doi.org/10.1002/(sici)1098-240x(199910)22:53.0.co;2-4 Department of Health and Social Care. The best start for life: A vision for the 1,001 critical days: The early years healthy development review report. United Kingdom: Department of Health and Social Care; 2021. CP419. https://www.gov.uk/government/publications/the-best-start-for-life-a-vision-for-the-1001-critical-days Department of Health and Social Care. Policy paper. Fit for the future: 10 year health plan for England – executive summary (accessible version). 2025 July 3. https://www.gov.uk/government/publications/10-year-health-plan-for-england-fit-for-the-future/fit-for-the-future-10-year-health-plan-for-england-executive-summary Dienelt K, Moores CJ, Miller J, et al. An investigation into the use of infant feeding tracker apps by breastfeeding mothers. Health Informatics J. 2020;26(3):1672–83. https://doi.org/10.1177/1460458219888402 Doan TTD, Pham NM, Binns C, et al. Effect of a mobile application on breastfeeding rates among mothers who have cesarean deliveries: a randomized controlled trial. Breastfeeding Med. 2022;17(10):832–40. https://doi.org/10.1089/bfm.2022.0088 Farr RS, Rahman F, O’Riordan MA, et al. Assessing the feasibility and effectiveness of two prenatal breastfeeding intervention apps in promoting postpartum in-hospital exclusive breastfeeding. Breastfeeding Med. 2019;14(10):724–30. https://doi.org/10.1089/bfm.2019.0053 Griffin LB, López JD, Ranney ML, et al. Effect of novel breastfeeding smartphone applications on breastfeeding rates. Breastfeed Med. 2021;16(8):614-23. https://doi.org/10.1089/bfm.2021.0012 Hoehle H, Venkatesh V. (2015). Mobile application usability: conceptualization and instrument development. MIS Quart. 2015;39(2):435–72. https://www.jstor.org/stable/26628361 Ip S, Chung M, Raman G, et al. Breastfeeding and maternal and infant health outcomes in developed countries. Evidence Report/Technology Assessment. 2007; No. 153, AHRQ Publication No. 07-E007. https://doi.org/10.1542/gr.18-2-15 Jefferson UT, Zachary I, Majee W. Employing a user-centered design to engage mothers in the development of a mHealth breastfeeding application. Comput Inform Nurs. 2019;37(10):522-531. https://doi.org/10.1097/CIN.0000000000000549 Khatib MN, Gaidhane A, Upadhyay S, et al. Interventions for promoting and optimizing breastfeeding practices: an overview of systematic review. Front Public Health. 2023;11:984876. https://doi.org/10.3389/fpubh.2023.984876 Koçak V, Ege E, İyisoy MS. The development of the postpartum mobile support application and the effect of the application on mothers’ anxiety and depression symptoms. Arch Psychiat Nurs. 2021;35(5):441–9. https://doi.org/10.1016/j.apnu.2021.06.009 Lewkowitz AK, López JD, Carter EB, et al. Impact of a novel smartphone application on low-income, first-time mothers' breastfeeding rates: a randomized controlled trial. Am J Obstet Gynecol MFM. 2020;2(3):100143. https://doi.org/10.1016/j.ajogmf.2020.100143 Lewkowitz AK, López JD, Werner EF, et al. Effect of a novel smartphone application on breastfeeding rates among low-income, first-time mothers intending to exclusively breastfeed: secondary analysis of a randomized controlled trial. Breastfeed Med. 2021;16(1):59-67. https://doi.org/10.1089/bfm.2020.0240 Lumbiganon P, Martis R, Laopaiboon M, et al. Antenatal breastfeeding education for increasing breastfeeding duration. Cochrane Db Syst Rev. 2016;12(12):CD006425. https://doi.org/10.1002/14651858.CD006425.pub4 Marcolino MS, Oliveira JAQ, D’Agostino M, et al. The impact of mHealth interventions: systematic review of systematic reviews. JMIR Mhealth Uhealth. 2018;6(1):e8873. https://doi.org/10.2196/mhealth.8873 Meedya S, Win K, Yeatman H, et al. Developing and testing a mobile application for breastfeeding support: the Milky Way application. Women Birth. 2021;34(2):e196-e203. https://doi.org/10.1016/j.wombi.2020.02.006 Miremberg H, Yirmiya K, Rona S, et al. Smartphone-based counseling and support platform and the effect on postpartum lactation: a randomized controlled trial. Am J Obstet Gynecol MFM. 2022;4(2):100543. https://doi.org/10.1016/j.ajogmf.2021.100543 Munn Z, Peters MDJ, Stern C, et al. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol. 2018;18(1):143. https://doi.org/10.1186/s12874-018-0611-x Musgrave LM, Baum A, Perera N, et al. Baby Buddy app for breastfeeding and behavior change: retrospective study of the app using the behavior change wheel. JMIR Mhealth Uhealth. 2021;9(4):e25668. https://doi.org/10.2196/25668 Newton B, Gatting L, Quinlan E. Report on the real-world evaluation of the Anya app. Health Innovation West of England. 2025 May 29:1-49. https://www.healthinnowest.net/wp-content/uploads/2025/05/Report-on-the-real-world-evaluation-of-the-Anya-app.pdf Ogaji DS, Arthur AO, George I. Effectiveness of mobile phone-based support on exclusive breastfeeding and infant growth in Nigeria: a randomized controlled trial. J Trop Pediatrics. 2021;67(1):fmaa076. https://doi.org/10.1093/tropej/fmaa076 OHID (Office for Health Improvement and Disparities). Breastfeeding at 6 to 8 weeks after birth: annual data April 2022 to March 2023. 2023 Nov 7. https://www.gov.uk/government/statistics/breastfeeding-at-6-to-8-weeks-after-birth-annual-data-april-2022-to-march-2023 OHID (Office for Health Improvement and Disparities). Breastfeeding at 6 to 8 weeks, 2023 to 2024 statistical commentary. 2024 Nov 5. https://www.gov.uk/government/statistics/breastfeeding-at-6-to-8-weeks-after-birth-annual-data-april-2023-to-march-2024/breastfeeding-at-6-to-8-weeks-2023-to-2024-statistical-commentary Padró‐Arocas A, Quifer‐Rada P, Aguilar‐Camprubí L, et al. Description of an mHealth tool for breastfeeding support: LactApp. Analysis of how lactating mothers seek support at critical breastfeeding points and according to their infant’s age. Res Nurs Health. 2021(a);44(1):173–86. https://doi.org/10.1002/nur.22095 Padró-Arocas A, Mena-Tudela D, Baladía E, et al. Telelactation with a mobile app: user profile and most common queries. Breastfeeding Med. 2021(b);16(4):338–45. https://doi.org/10.1089/bfm.2020.0269 Patchen L, Ellis L, Harrington CB, et al. Engaging African American parents to develop a mobile health technology for breastfeeding: KULEA-NET. J Hum Lact. 2020;36(3):448-60. https://doi.org/10.1177/0890334420930208 Peregrino AB, Watt RG, Heilmann A, et al. Breastfeeding practices in the United Kingdom: is the neighbourhood context important? Matern Child Nutr. 2018;14(4):e12626. https://doi.org/10.1111/mcn.12626 Seyyedi N, Rahmatnezhad L, Mesgarzadeh M, et al. Effectiveness of a smartphone-based educational intervention to improve breastfeeding. Int Breastfeed J. 2021;16(1):70. https://doi.org/10.1186/s13006-021-00417-w Standish KR, Parker MG. Social determinants of breastfeeding in the United States. Clin Ther. 2022;44(2):186-92. https://doi.org/10.1016/j.clinthera.2021.11.010 UNICEF. The extension of the 2025 maternal, infant and young child nutrition targets to 2030. 2021. https://data.unicef.org/wp-content/uploads/2021/05/UNICEF-WHO-discussion-paper-extension-targets-2030.pdf Victora CG, Bahl R, Barros AJD, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016; 387(10017):475–90. https://doi.org/10.1016/S0140-6736(15)01024-7 Wang CJ, Chaovalit P, Pongnumkul S. A breastfeed-promoting mobile app intervention: usability and usefulness study. JMIR Mhealth Uhealth. 2018;6(1):e27. https://doi.org/10.2196/mhealth.8337 Wheaton N, Lenehan J, Amir LH. Evaluation of a breastfeeding app in rural Australia: prospective cohort study. J Hum Lact. 2018;34(4):711-20. https://doi.org/10.1177/0890334418794181 Yao R, Zhang W, Evans R, et al. Inequities in health care services caused by the adoption of digital health technologies: scoping review. Journal Med Internet Res. 2022;24(3):e34144. https://doi.org/10.2196/34144 Yngve A, Sjöström M. Breastfeeding determinants and a suggested framework for action in Europe. Public Health Nutr. 2001;4(2B):729-39. https://doi.org/10.1079/phn2001164 Ziebart M, Kammermeier M, Koletzko B, et al. Mobile applications for promoting and supporting breastfeeding: systematic review and meta-analysis. Matern Child Nutr. 2025;21(1):e13733. https://doi.org/10.1111/mcn.13733 Additional Declarations The authors declare no competing interests. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7254515","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":493289315,"identity":"2c782d71-5621-4e98-8cdd-fab23ab8acb1","order_by":0,"name":"Benjamin Newton","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzElEQVRIiWNgGAWjYBACAwaGBCiT+QBpWiQYGNgS8CtF0sIA1cJjgFclHJgzMDxgLqg4XMcv3fP51c02Bnl+MQIOtGxgSGCeceawhOScs9usc84wGM6cTcCBBgeAWnjbbksY3MjdZpxTwZBgcJsoLf9AWnKeGecYEK2lAayF+TFRtlg2MyQc5jn2X3LmjDQz5pwzEoT9Ys7ek/iYpyaNn18i+fHn3DYbeX5pAloYmHkSDkCZbBLg+CEM2GE6GJg/EKN+FIyCUTAKRh4AAA/4PwGKdSS5AAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0003-1184-4375","institution":"Royal United Hospitals Bath NHS Foundation Trust","correspondingAuthor":true,"prefix":"","firstName":"Benjamin","middleName":"","lastName":"Newton","suffix":""}],"badges":[],"createdAt":"2025-07-30 15:35:49","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-7254515/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7254515/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90317721,"identity":"67a3724b-96da-448a-a7c6-dcc6de3c201f","added_by":"auto","created_at":"2025-09-01 10:28:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":49254,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdapted PRISMA flowchart showing flow of articles, reproduced under licence: CC BY 4.0. \u003c/strong\u003eSource: Page MJ, et al. BMJ 2021;372:n71. doi: 10.1136/bmj.n71.\u003c/p\u003e","description":"","filename":"Figure1v2.png","url":"https://assets-eu.researchsquare.com/files/rs-7254515/v1/6e564cf860f4bf193db23576.png"},{"id":90320382,"identity":"d61c0957-b1f5-49b0-bfb4-8acb38857574","added_by":"auto","created_at":"2025-09-01 10:44:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":902053,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7254515/v1/9f29cb31-6c80-40f0-92fb-3c530ba27e72.pdf"},{"id":90317726,"identity":"84d3fc11-5dca-4fdf-8f42-41d3f5c2f4b5","added_by":"auto","created_at":"2025-09-01 10:28:28","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":192814,"visible":true,"origin":"","legend":"\u003cp\u003eSearch strategy\u003c/p\u003e","description":"","filename":"SupplementaryFile1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7254515/v1/26100f201d250a35eaabb54f.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eAll things to all people? A scoping review of mobile phone apps that support breastfeeding\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe benefits of breastfeeding infants are well documented alongside poorer outcomes of not doing so, for both child and mother (Ip et al. 2007, Victora et al., 2016). Other researchers have highlighted financial savings to healthcare services if infants are exclusively breastfed, with Ajetunmobi et al. (2024) suggesting a saving of £100 per child breastfed up to 6 weeks. \u0026nbsp;Latest annual breastfeeding data from England suggests the aggregate rate of breastfeeding six to eight weeks after birth is 52.7% (OHID, 2024) which is an improvement on the previous year of 49.2% (OHID, 2023) but well below the 70% target set by the World Health Assembly (UNICEF, 2021).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDifferent breastfeeding interventions have been attempted globally to drive breastfeeding rates up, including peer support, health education, social media campaigns and breastfeeding counselling (Khatib et al. 2023). Given study heterogeneity, it can be challenging to compare breastfeeding studies to assess the overall effectiveness of interventions in improving breastfeeding. A review of six systematic reviews (Khatib et al. 2023) found an improvement rate ranging from 44%-93% in early initiation of breastfeeding using interventions compared to routine care. A Cochrane review by Balogun et al. (2016) reported improved rates of breastfeeding initiation among professional-led interventions, while multi-media interventions did not improve initiation rates. Meanwhile, another review of breastfeeding interventions concluded such interventions were more effective than usual care, but to such a small degree that the authors concluded that the real-word effects and were questionable (Chung et al., 2008).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGiven the exponential growth in mobile phone users (Ben-Zeev et al. 2015) and digital health technology, health interventions are increasingly being delivered on mobile phone platforms in a field known as mHealth (Marcolino et al. 2018). This has the potential of facilitating easier access to healthcare for citizens (Yao et al. 2022). Delivering interventions to improve the take-up and continuation of breastfeeding, via mobile health technology is a logical step forward. One report identified that during the Covid-19 pandemic, women welcomed remote and digital breastfeeding support as it supported their personal privacy (Department of Health and Social Care, 2021). Compared to traditional interventions, other advantages to digital breastfeeding apps, include offering a greater audience reach alongside providing continuous support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAims\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis scoping review of the literature was initially undertaken as an adjunct to a real-world evaluation of a digital breastfeeding app (Newton et al. 2025). This review sought to systematically identify articles that have evaluated the use of mobile phone apps to support breastfeeding. Two additional aims were to synthesise the findings of identified articles and identify key learning points about the use of breastfeeding apps in a real-world context.\u0026nbsp;\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003e\u003cem\u003eArticle screening\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA search of four indexing databases (British Nursing Index, CINAHL, MEDLINE and PsycINFO) was undertaken on 22\u003csup\u003end\u003c/sup\u003e December 2022 using keyword and subject terms related to \u0026lsquo;breastfeeding\u0026rsquo; and \u0026lsquo;smartphone apps\u0026rsquo;. These databases provide access to a range of nursing, allied health, medical and psychological articles, which are disciplines pertinent to the area of breastfeeding interventions. The search strategy used is available in supplementary file 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe title and abstract of articles were screened by two individuals (BN and NA), one of whom is an experienced qualitative researcher (BN). Articles were included if they reported on an evaluation of the use of mobile phone apps to support breastfeeding. Specifically:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThe focus of the app must be on supporting mothers to breastfeed using the intervention app.\u003c/li\u003e\n \u003cli\u003eThe intervention under consideration must primarily be a mobile phone application.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eInterventions such as mobile texting or phone calls are considered out of scope.\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThe article concerns primary research and is not a review article.\u003c/li\u003e\n \u003cli\u003eThe article is written in English.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eBN and NA read through the titles and abstracts and developed the following exclusion criteria:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThe article is not about breastfeeding support.\u003c/li\u003e\n \u003cli\u003eThere is no intervention used OR the intervention is not directly used with mothers.\u003c/li\u003e\n \u003cli\u003eThe article is not an evaluation of a breastfeeding support app.\u003c/li\u003e\n \u003cli\u003eThe article is not a journal article presenting primary research (i.e. conference abstracts, news stories and grey literature were not included).\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;The article is not available in English language.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Number of abstracts excluded across criteria categories for each reviewer.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCriteria\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo. articles excluded by reviewer\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e1. The article is not about breastfeeding support.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e418\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e391\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e2. There is no intervention used OR the intervention is not directly used with mothers.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e3. The article is not an evaluation of a breastfeeding support app.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e144\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e4. The article is not a journal article presenting primary research.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e5. The article is not available in English language.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003eIncluded\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;All 651 titles and abstracts were then screened by both BN and NA, applying these exclusion criteria in a step-wise process. As Table 1 shows, BN identified 34 records and NA identified 31 records for inclusion, resulting in a total of 52 unique records. The reviewers met and considered the 52 records. Through discussion and application of the exclusion criteria, they agreed on selecting 20 articles for full-text review. See Figure 1 for the flow of articles.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eExcluded articles from full-text screening\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA third reviewer (PW), an experienced manager in maternity care, worked with BN to read the 20 full-text articles and consider their suitability for inclusion. They independently read the articles and decided whether each one met the inclusion criteria. Disagreements were resolved through discussion resulting in a final list of 12 articles being selected for data charting. Discussion was held around whether to include evaluation of app prototypes; given the scoping nature of this work, the reviewers agreed to include prototype evaluations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOf the eight excluded articles, several referred to apps but an evaluation of a specific breastfeeding app did not take place: In two articles, authors produced an analytics report of a breastfeeding app (Padr\u0026oacute;‐Arocas et al., 2021a; Padr\u0026oacute;-Arocas et al., 2021b); Dienelt et al. (2020) considered women\u0026rsquo;s experiences of breastfeeding tracker apps; Akber et al. (2019) described a community-based programme of work rather than a specific breastfeeding app evaluation; whilst Musgrave et al. (2021) offered a theoretical exploration of how their app delivered change by retrospectively applying a behavioural model. The remaining studies were excluded for other reasons: two did not use a mobile phone-based app (Farr et al., 2019; Ogaji, Arthur and George, 2021); and one article focussed on psychological distress rather than breastfeeding (Ko\u0026ccedil;ak, Ege and İyisoy, 2021).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData charting\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA data charting form was developed by BN and tested by both BN and PW. Following discussion, no iterations were made after initial use of the form. The data charting form covered the following data fields: (i) authors; (ii) title of article; (iii) year of publication; (iv) primary country of research; (v) study aims; (vi) number of participants; (vii) recruitment approach \u0026amp; context; (viii) research design including comparator description where applicable; (ix) smartphone app name; (x) features of the app; (xi) how the app was used with participants; (xii) main outcome measures; (xiii) key findings; (xiv) key strengths; (xv) key limitations; (xvi) lessons for real-world implementation. The author drew upon the data charting results to synthesise the articles, re-reading the articles where necessary. Articles included in this scoping review were not critically appraised, following Munn et al.\u0026rsquo;s (2018) reasoning that scoping reviews are not seeking to answer a specific question.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eOverview of included studies\u003c/h2\u003e\u003cp\u003eAcross the twelve articles included for final synthesis, ten unique interventions were described: articles A4, A5 and A6 refer to the same intervention. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the article reference number, as well as the authors, publication year, primary country, sample size, intervention name and app features.\u003c/p\u003e\u003cp\u003eArticles were published between 2018 and 2022. with the modal year 2021. This date range suggests that breastfeeding smartphone apps have become available relatively recently and perhaps reflects the exponential growth in mHealth (Cano et al. \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Half of the studies originated in the United States (A1, A3, A4-6, A9), with two of the studies being undertaken in Australia (A7, A12). Across the articles, there was a large range in the number of participants. Usability studies tended to have smaller numbers (n\u0026thinsp;\u0026lt;\u0026thinsp;10). Larger evaluations recruited hundreds of participants, with the largest recruiting 1266 people (A2).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy design\u003c/h3\u003e\n\u003cp\u003eThe study objectives could be categorised into one of two types; i) usability testing and ii) impact evaluation. Slightly more studies focused on evaluating the impact of the app (A2, A4-6, A8, A10) which was focused on breastfeeding outcomes in all cases. Four articles focused on usability testing of the app (A3, A7, A9, A11) with a further two articles considering both usability and impact (A1, A12). Usability testing included looking at user acceptance, user engagement and usefulness of the app.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eArticles selected for inclusion.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eArticle\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAuthors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYear\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePrimary country\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eParticipants\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSmartphone name\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eApp features\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBunik, Jimenez-Zambrano, Solano, Beaty, Juarez-Colunga, Zhang et al.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;467 recruited\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMother\u0026rsquo;s Milk Messaging\u0026trade;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026bull; Daily text messages 3\u0026ndash;4 weeks before birth of baby and up to 3 months after, 20 different messages before delivery and 40 after.\u003c/p\u003e\u003cp\u003e\u0026bull; Informational and personal videos available along with external links.\u003c/p\u003e\u003cp\u003e\u0026bull; Breastfeeding content available by topic.\u003c/p\u003e\u003cp\u003e\u0026bull; Feeding tracker.\u003c/p\u003e\u003cp\u003e\u0026bull; Bilingual, both English and Spanish.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDoan, Pham, Binns, Lee, Zhao, Dinh et al.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eVietnam\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;1266 consented\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026bull; Tailored messages in pregnancy and after birth, with further resources in the app that could be explored. Messages connected with multi-media resources.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eJefferson, Zachary and Majee.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePhase 1 n\u0026thinsp;=\u0026thinsp;14\u003c/p\u003e\u003cp\u003ePhase 2 n\u0026thinsp;=\u0026thinsp;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMother\u0026rsquo;s Milk Connection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026bull; Breastfeeding resources for informed decision making and supporting positive attitude to breastfeeding.\u003c/p\u003e\u003cp\u003e\u0026bull; Peer support \u0026ndash; discussions with other mothers.\u003c/p\u003e\u003cp\u003e\u0026bull; Feeding logs that can be exported so nurses can assess.\u003c/p\u003e\u003cp\u003e\u0026bull; Video conference with breastfeeding specialist with access to feeding logs.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA4\u003c/p\u003e\u003cp\u003eA5\u003c/p\u003e\u003cp\u003eA6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003ePrimary article\u003c/b\u003e\u003c/p\u003e\u003cp\u003eLewkowitz, L\u0026oacute;pez, Carter, Duckham, Strickland, Macones et al.\u003c/p\u003e\u003cp\u003eGriffin, L\u0026oacute;pez, Ranney, Macones, Cahill and Lewkowitz.\u003c/p\u003e\u003cp\u003eLewkowitz, L\u0026oacute;pez, Werner, Ranney, Macones, Rouse et al.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003cp\u003e2021\u003c/p\u003e\u003cp\u003e2021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;170 consented\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eBreastFeeding Friend (BFF)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026bull; Educational content on breastfeeding benefits, normal infant behaviour, normal maternal postpartum physiology, diet \u0026amp; exercise guidance.\u003c/p\u003e\u003cp\u003e\u0026bull; Material at 5th grade reading level.\u003c/p\u003e\u003cp\u003e\u0026bull; Interactive advice to overcome common challenges of breastfeeding.\u003c/p\u003e\u003cp\u003e\u0026bull; Breastfeeding and pumping optimisation strategies.\u003c/p\u003e\u003cp\u003e\u0026bull; Links to on-demand breastfeeding and pumping videos, with the majority featuring at least one women of colour breastfeeding.\u003c/p\u003e\u003cp\u003e\u0026bull; Links to local, national, and international online breastfeeding resources.\u003c/p\u003e\u003cp\u003e\u0026bull; Built in tracker to inform the study team each time the app was opened.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMeedya, Win, Yeatman, Fahy, Walton, Burgess et al.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAustralia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;7 in pilot\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMilky Way\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026bull; Discussion forum.\u003c/p\u003e\u003cp\u003e\u0026bull; Information (e.g. FAQs and Milk Supply).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMiremberg, Yirmiya, Rona, Gonen, Marom, Pohol et al.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIsrael\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;224 consented\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026bull; Information about the study.\u003c/p\u003e\u003cp\u003e\u0026bull; Information on lactation and emotional challenges after birth.\u003c/p\u003e\u003cp\u003e\u0026bull; Ability to communicate with the study team (including nurse, lactation consultants and clinical psychologist).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePatchen, Ellis, Harrington, Ma, Mohanraj, Andrews et al.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAdvisory group feedback n\u0026thinsp;=\u0026thinsp;6\u003c/p\u003e\u003cp\u003eFocus groups n\u0026thinsp;=\u0026thinsp;25\u003c/p\u003e\u003cp\u003eUsability testing n\u0026thinsp;=\u0026thinsp;14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eKULEA-NET\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026bull; App delivers informational messages, which link to content in the libraries. Delivered at least three times per week.\u003c/p\u003e\u003cp\u003e\u0026bull; Static and video library.\u003c/p\u003e\u003cp\u003e\u0026bull; Local resources.\u003c/p\u003e\u003cp\u003e\u0026bull; Feeding and nappy changing log.\u003c/p\u003e\u003cp\u003e\u0026bull; Nominate a support person, who has full access to app.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSeyyedi, Rahmatnezhad, Mesgarzadeh, Khalkhali, Seyyedi and Rahimi.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIran\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;102 consented\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026bull; Educational programme contained seven components aligned to seven sections of Iranian Health and Education Ministry\u0026rsquo;s guide to Maternity and Child health. Specifically:\u003c/p\u003e\u003cp\u003eo importance of breastfeeding,\u003c/p\u003e\u003cp\u003eo behavioural methods for mothers,\u003c/p\u003e\u003cp\u003eo complementary feeding and exclusive breastfeeding,\u003c/p\u003e\u003cp\u003eo pumping and manual expression,\u003c/p\u003e\u003cp\u003eo managing common breast-related and breastfeeding problems,\u003c/p\u003e\u003cp\u003eo breastfeeding tips for special situations,\u003c/p\u003e\u003cp\u003eo answering common queries about lactation in case of illness.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWang, Chaovalit and Pongnumkul.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2018\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eThailand\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;21 consented\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMoomMae\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026bull; Feeding record.\u003c/p\u003e\u003cp\u003e\u0026bull; Pumping record.\u003c/p\u003e\u003cp\u003e\u0026bull; Location of public feeding places.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWheaton, Lenehan and Amir.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2018\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAustralia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;50 consented\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eBreastfeeding Solutions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026bull; Provides an interactive guide to solving breastfeeding problems.\u003c/p\u003e\u003cp\u003e\u0026bull; Search or browse over 100 topics.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSeven articles utilised an RCT design (A1-2, A4-6, A8, A10) and all focused on demonstrating the impact of the intervention on breastfeeding (accepting that article A1 also considered user engagement). Usability studies tended to use mixed methods approaches involving interviews, focus groups or surveys, with the exception of article A12 which used a prospective cohort design to assess app usability and impact on breastfeeding outcomes.\u003c/p\u003e\n\u003ch3\u003eOutcome measures\u003c/h3\u003e\n\u003cp\u003eListed below are the outcome measures shared across studies:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eAll twelve studies collected some level of detail on demographics.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eEight studies (A1-2, A4-6, A8, A11-12) collected data on breastfeeding rates, either exclusively breastfeeding or non-exclusive breastfeeding. There was wide variation in the time points when this was collected. One study (A2) collected it during the hospital stay as a measure of early initiation, or at Day 2 (A4-6), whilst others collected it at six months. The most common time points were three and six months postpartum (A1, A4, A8, A12).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSix studies (A1, A3-6, A12) sought data on intention to breastfeed.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThree studies looked at breastfeeding confidence / self-efficacy; two of these (A1, A10) used the Breastfeeding Self-Efficacy Scale (Dennis \u0026amp; Faux, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e1999\u003c/span\u003e) with one study (A12) asking questions on breastfeeding confidence as part of understanding attitudes to feeding.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSix studies explored the role of usability or acceptability (A1, A3, A7, A9, A11-12). Two studies (A3, A9) used the System Usability Scale or SUS (Bangor et al. \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2008\u003c/span\u003e) and one study (A7) used a mobile application usability scale (Hoehle \u0026amp; Venkatesh, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2015\u003c/span\u003e).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eFive studies (A4-6, A11-12) measured usage of the app.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eFour studies (A8-9, A11-12) measured satisfaction with the app.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eFinally, most of the studies (A1, A3-7, A9, A11) undertook either interviews or focus groups to elicit qualitative data.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eApp features\u003c/h2\u003e\u003cp\u003eIn Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e the features of each intervention app are outlined.\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eAll but one of the articles (A11) featured apps that included educational written material to support breastfeeding, with five articles featuring apps that had educational videos (A1, A4-6, A9). Three articles described the apps as having a library (e.g. A2, A9) or index of topics (A12).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eFive articles (A2, A4-6) described the apps as having external links to other resources or support.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eFour articles described a feeding tracker or log (A1, A3, A9, A11), with two of these having other types of logs, such as pumping (A11) or nappy changing (A9).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThere were four articles (A1-2, A7, A9) where messages were sent in the form of push notifications or SMS. These could serve several purposes, such as providing content designed to influence, motivate or remind users around breastfeeding.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eTwo articles (A3, A8) described the app featuring communication tools to connect with professionals for support.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eTwo articles (A3, A7) facilitated peer support through connections to social media (A3) or a forum (A7).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eFinally, two apps (A9, A11) allowed users to identify nearby feeding spaces.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eApp implementation\u003c/h2\u003e\u003cp\u003eThere was considerable variation in how the implementation of the app was described, with some articles offering minimal information.\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eIn eight articles, women were given the app to use whilst they were pregnant (A1-2, A4-7, A9, A12); in five articles, the app was given after the baby\u0026rsquo;s birth (A3, A8, A10, A11, A12) and in one article (A12) women were recruited either before or after birth.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe antenatal time period when women were given the app ranged from 24 weeks (A2) to 40 weeks (A7) gestation. Typically, when women were given the app postnatally, the article simply states \u0026ldquo;after birth\u0026rdquo;.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe total length of the intervention ranged from 2 weeks (A3) to 10 months (A2).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eIt was not always clear who installed the app. Sometimes it was a professional or a member of the study team, at other times it was the participant. In one instance, the app was pre-installed on a mobile phone that was given to participants (A4-6).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eWith respect to instructions given to participants, in five studies, it was unclear what participants were told (A1-2, A7, A9, A11). In two studies (A3, A4-6), the study researcher supported participants with orientation to the app. Sometimes, the participant was encouraged to use the app (A3, A4-6, A8, A10, A12). In two articles, staff contacted participants during the intervention period about the app (A8, A10).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eRecruitment\u003c/h2\u003e\u003cp\u003eFour studies (A1, A2, A4-6, A9) recruited women who were pregnant. The pregnancy gestation when they were recruited ranged from 24 weeks up to 40 weeks. Others (A8, A9-12) recruited postpartum women, with this ranging from Day 1 postpartum to 3 months. Article A9 recruited women at antenatal and postnatal stages, as this study had multiple project phases. Researchers recruited women from local clinics or hospitals (A1-10, A12), via social media (A1, A3, A7, A11) and via local community or organisations (A7, A9, A11). With respect to the ownership of smartphones, seven articles required ownership as a condition of participation (A1, A2, A8-A12). Articles A3 \u0026amp; A7 did not specify whether a smartphone was required, whilst in articles A4-A6, a smartphone was given to participants by the research team.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eArticle findings\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e reports on the mean age of participants and their education level indicated by the percentage of participants with an undergraduate degree or higher. The specific focus on age and education is supported by literature which shows that increased age of the mother and higher levels of education are positive determinants for breastfeeding (Standish \u0026amp; Parker, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2022\u003c/span\u003e, Yngve \u0026amp; Sj\u0026ouml;str\u0026ouml;m, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2001\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eKey demographics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eArticle\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUnder-graduate education completed\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28.1*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e58%*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28.7*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56.7%*^\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22.7*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6%*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA5, A6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e85.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32.5*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot measured.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePhase 1: 26.0\u003c/p\u003e\u003cp\u003ePhase 2: 26.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot measured.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37.5%*^\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e91%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47.8%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e* Intervention group.\u003c/p\u003e\u003cp\u003e^ A2 described as tertiary education; A10 described as academic education.\u003c/p\u003e\u003cp\u003eThe mean age of participants ranged from 22.7 years (articles A4-6) to 32.7 years (articles A7 and A11). The mean age across all articles was 28.4 years. With respect to education, the number of participants with an undergraduate degree ranged from 6% (A4-A6) to 91% (A11). Across all articles, the mean number of participants with an undergraduate degree was 52.2%, which changes to 58.8% if one excludes articles A4-6 on the basis that the figure of 6% is an outlier.\u003c/p\u003e\u003cp\u003eOf the ten unique studies (excluding A5-6), six measured the impact of the app on breastfeeding rates. Four studies did not measure breastfeeding rates (A7, A9-11), though article A10 measured the \u0026lsquo;practice\u0026rsquo; of breastfeeding (which is not defined in the article). Only two articles found the app led to a statistically significant increase in breastfeeding; article A2 found higher breastfeeding rates during the hospital stay, whilst article A8 found significant rates at 6 weeks and 3 months. Even these two studies note breastfeeding rates were not significantly higher at other time points they both measured, with neither study finding significant increases sustained at 6 months post-birth. Meanwhile, two articles did not find any significant increase in breastfeeding (A1, A4).\u003c/p\u003e\u003cp\u003eTurning to breastfeeding self-efficacy, three of the ten unique articles measured this (A1, A10, A12) with a further three articles (A3, A9, A11) reporting anecdotal evidence. Of the three articles that measured self-efficacy, two (A1, A10) found this significantly increased in the intervention group; one article (A12) only measured self-efficacy at baseline.\u003c/p\u003e\u003cp\u003eWith respect to usability, acceptability and satisfaction:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eA1 reports on how engaged participants were. This could be considered a proxy measure of usability. The authors found most mothers engaged in the app once their baby was born. Of note is the authors\u0026rsquo; comment that the highest app users were \u0026ldquo;highly motivated, white married women\u0026rdquo; (Bunik et al, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e:7). They report that most mothers were satisfied with the app, according to their qualitative data.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe mean SUS score in article A3 was 83 (out of 100); 90% of participants agreed that other breastfeeding mothers would frequently use the website version of the app. The second phase of testing revealed that participants thought the app was easy to use.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eIn article A6, significantly more participants believed that an app provided the best breastfeeding support at home compared to a control group at week 6 postpartum. One might infer participants were satisfied with the app.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eUsers in article A7 all agreed or strongly agreed that the app was easy to use, with six out of seven users stating they intended to continue using the app. Four users said the app needed further information.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eParticipants in A8 reported high satisfaction with the ease of the app and the availability of the supporting professionals.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eFor article A9, the mean usability score on the SUS was 73.8. The authors state that participants would be happy to recommend the app to a friend, suggesting satisfaction.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eIn article A11, the mean usability score was 34.83 out of 40. Qualitative feedback on usability revealed 59 out of 71 comments were negative. This contrasts to qualitative feedback on the usefulness of system features which found 56 out of 66 comments were positive. The authors report that overall participants found the app acceptable, with a high intention to continue using.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eFinally, for article 12, most participants rated the app favourably (93.5%) with 96.8% reporting it was helpful. 87.1% would recommend the app to other breastfeeding mothers. Curiously, only 45% of participants agreed the app helped them with their breastfeeding goals, suggesting limits to the perceived usefulness of the app.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eStrengths \u0026amp; Limitations\u003c/h2\u003e\u003cp\u003eWith respect to strengths, studies frequently drew on an evidence-based approach to the development of their app. For instance, studies A1, A2, A7 \u0026amp; A9 used theoretical models such as social cognitive theory and self-efficacy. Article A10 stated they used Ministry of Health guidelines for the app. Meanwhile, several apps (A3, A4-7, A9) drew on a panel of experts or stakeholders to inform the app\u0026rsquo;s development. Articles A11-12 used a pre-existing app, so no explicit theoretical model was drawn on.\u003c/p\u003e\u003cp\u003eSeven articles (A1-2, A4-6, A8 and A10) used a randomised-controlled trial, all of which were registered in a clinical trials registry. Three of these studies (A1, A2 and A10) used blinding; Articles A4-6 did not appear to use research blinding, although the authors did state that a researcher not involved in the outcomes data reviewed the app contents with participants.\u003c/p\u003e\u003cp\u003eThere are limits to the generalisability of the results from this heterogenous selection of articles.\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eSeven of the studies explicitly required women to have pre-existing access to a mobile or tablet device (A1-2, A8-12). This potentially introduces an inequality in facilitating access to those with the resource to fund smartphone usage. In contrast, one study (A4-6) focussed on low-income women and provided participants with a pre-paid smartphone.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSome of the articles were focussed on specific populations. For instance, A2 focused on women who gave birth via c-section, A4-6 recruited (low-income) women from a prenatal Medicaid / no health insurance clinic; A9 focused on African-American women.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSeveral studies were focused on recruiting women who intended to breastfeed (A4-6, A8, A10) or who had initiated breastfeeding (A3, A12). Meanwhile, article A11 comprised of women, nearly all of whom exclusively breastfed.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThere are limitations associated with studies where participants self-selected. Article A1 recruited participants through advertisements on Facebook, the radio and local clinics; Article A7 used the university news platform, paper flyers and social media posts, whilst A11 used recruitment posters on a breastfeeding interest Facebook group and at the National Science and Technology Development Agency. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the number of participants completing under-graduate education was highest among the three articles that employed self-selecting recruitment strategies (A11\u0026ndash;91%, A7\u0026ndash;85.7%, A1\u0026ndash;58%).\u003c/p\u003e\u003cp\u003eFinally, given that nine out of the twelve articles were published between 2020\u0026ndash;2022, at the time of the COVID-19 pandemic, checks were made as to when participants were recruited. Article A2 recruited participants during 2020\u0026ndash;2021 and describes the study adaptations made during the pandemic. A8 was conducted between October 2019 and September 2020 (according to the Clinical Trials registration). There is no description of how the pandemic impacted the study, but the authors do acknowledge how COVID-19 reveals the need for accessible lactation support. Article A10 undertook recruitment between January to June 2019, with data collection concluded by December 2019. One might expect this study to be minimally affected by the pandemic and no reference to COVID-19 was made in the article.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eImplementation reflections\u003c/h2\u003e\u003cp\u003eThe objectives of the twelve articles largely fell into either testing the usability of the app or evaluating the impact of the app on outcomes such as breastfeeding rates and breastfeeding self-efficacy. In recognition that the manner in which an intervention is implemented can affect the success of its adoption (see, for instance, Bauer and Kirchner, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), this last section will offer some brief reflections on key learning points from the twelve articles.\u003c/p\u003e\u003cp\u003eEarlier in this review, the timing of the intervention was outlined, with eight articles describing the app was implemented during pregnancy and five articles stating the app was implemented postpartum. Some authors argued for introducing the app at a specific time. For instance, in A4, the authors advocated introducing the app during pregnancy at 36 weeks in line with other studies. In article A3, the app was introduced to breastfeeding mothers, but the authors reflected upon a suggestion to introduce the app during pregnancy which would allow participants greater time to engage with it.\u003c/p\u003e\u003cp\u003eIn other studies, the purpose and design of the intervention likely determined how it was implemented. For instance, the participants in A8 were recruited postpartum in line with the study objective to facilitate communication after birth with staff. Whilst in A1, women were recruited from 36 weeks gestation and the app was designed to deliver targeted breastfeeding messages during pregnancy. One might conclude there is no \u0026lsquo;one-size-fits-all\u0026rsquo; approach and the timing of implementation depends on several factors.\u003c/p\u003e\u003cp\u003eWith respect to the participants involved in evaluating breastfeeding support apps, there can be challenges recruiting a diverse range of participants. For instance, A1 acknowledged the highest users of the app were married women with a high motivation to breastfeed their baby. Article A7 advocates for testing the app in other demographic groups given the participants were highly educated. In A11, they only recruited women with a high intention to breastfeed, despite attempting to recruit women with a diverse range of breastfeeding intentions. Similarly, A12 states the sample was overrepresented by women with strong intentions to breastfeed. Future evaluations might benefit from acknowledging that breastfeeding interventions can attract a specific demographic of motivated and educated participants. Mitigation steps in recruitment may be needed to achieve a heterogenous sample.\u003c/p\u003e\u003cp\u003eFinally, it is worth highlighting how some of the studies addressed inequalities or supported accessibility. The intervention in A1 was a bilingual app. Articles A4-6 focused on working with low-income women and in line with this goal, provided participants with a free smartphone for the study. In article A2, no internet was required for the app to function once downloaded, which effectively increases the accessibility of the app and allows for it be used independent of paid-for internet services. Finally, in recognition of racial disparities in health outcomes, article A9 focused on a breastfeeding app with African-American participants.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis scoping review set out to identify evaluations of mobile phone-based breastfeeding support apps. It identified twelve articles published between 2018 and 2022. The articles could be categorised into two types of evaluation, usability testing and impact evaluation. Of the usability studies, the majority of articles reported positive feedback regarding usability. This contrasts with the results on breastfeeding rates, with only two out of six studies revealing a statistically significant increase in breastfeeding. Article A12 which assessed both app usability and breastfeeding outcomes identified very high user satisfaction, but only moderate agreement that the app supported breastfeeding goals. This is in line with a recently published systematic review of mobile apps (Ziebart et al. \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) which found high user satisfaction with apps but no significant improvement in breastfeeding rates. Similarly, others have found antenatal breastfeeding education does not improve breastfeeding initiation or increase exclusive breastfeeding (Lumbiganon et al. \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePerhaps one explanation for the divergent results across the studies is the underpinning theory of change. Many of the studies offered a rationale for their intervention to support breastfeeding, which included diverse theoretical models, guidance and panels of experts and stakeholders. Whilst on the face of it, a comparison of breastfeeding support apps may appear to be legitimate, the context of the underlying logic is vital and in the case of this scoping review, reveals a homogenous group of breastfeeding support apps.\u003c/p\u003e\u003cp\u003e Of particular interest is that articles in this review tended to comprise samples of women with higher levels of education; this was particularly evident where samples were self-selected. As higher education levels are associated with stronger breastfeeding outcomes (Peregrino, 2018), one might hypothesise that self-selecting recruitment strategies in this context risks attracting participants who may be more motivated to breastfeed and who have a greater degree of privilege.\u003c/p\u003e\u003cp\u003eThe study of intersectionality may offer a useful lens to reflect on this finding. Bohren et al. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) argue that applying the lens of intersectionality to maternal health offers insight into how multiple forms of privilege (and exclusion) can drive inequality in maternity care. In other words, differences in ethnicity, gender, class and other demographics can combine to drive (and compound) inequality. Bartkowski et al (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) note that the experience of Black women in breastfeeding their babies is more likely to be one of exhaustion and isolation, with Black women\u0026rsquo;s self-efficacy lower. They continue by stating breastfeeding is appreciated as a valuable practice, but given the challenges, implementing breastfeeding is a struggle. Others describe the racism experienced by Black women who wanted to breastfeed. Davis et al. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) describe how women experienced hospital staff giving their infant formula without their consent, disregarding their intention to exclusively breastfeed. The participants narrate difficulties with employment circumstances, with some employers unsupportive or hostile to making adaptations for pumping. The authors describe how Black women\u0026rsquo;s employment circumstances reflect the legacy of historic racism.\u003c/p\u003e\u003cp\u003eIt would be fair to note that most of the articles in this review featured apps that sought to provide educational material on breastfeeding. This suggests that one possible underlying theory of change for these apps is that by increasing knowledge about breastfeeding, women should be better educated to breastfeed their infant. Such an approach places the focus on educating app users, suggesting in part, an attempt to address knowledge deficits.\u003c/p\u003e\u003cp\u003eWhilst there is undoubtedly a place for education, could this risk placing too much responsibility for breastfeeding success on the individual woman? Given the higher prevalence of educated women sampled in the articles reviewed, one may further question whether an education-based app risks privileging already educated women and additionally, whether this risks excluding other groups of women?\u003c/p\u003e\u003cp\u003eWhen one brings an intersectionality lens, it is possible to appreciate the historic and structural barriers that women racialised as Black can experience in seeking to breastfeed. The barriers to breastfeeding identified in the two studies above (which is by no means intended to be exhaustive) include isolation, exhaustion, healthcare provider attitudes and employment circumstances; issues that go beyond education deficits. The new NHS ten-year health plan (Department of Health and Social Care, 2025) states that it will be designed to tackle inequalities in both how services are accessed and in their outcomes. Whilst it would be unrealistic to expect a breastfeeding intervention app to deal with structural barriers to feeding, those commissioning feeding support services should consider how their services will deal with inequalities and what role breastfeeding apps play in this.\u003c/p\u003e\u003cp\u003eOf course, this review identified articles that sought to overcome inaccessibility and inequality and such efforts should be acknowledged. However, it is important to question and challenge implicit (deficit-focussed) assumptions that may underlie the theory of change supporting the intervention\u0026rsquo;s intended outcome.\u003c/p\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and limitations\u003c/h2\u003e\u003cp\u003eThis scoping review provides insight into the availability of published evaluations into breastfeeding support apps, following a systematic approach. It drew on two reviewers in the process of identifying suitable articles to follow a robust process. As this review was not a core piece of work, there were delays in completing it as well as much developmental learning. Other evaluations may have been published in the period between the search and the completion of the manuscript. The review process could have been strengthened by the involvement of a second reviewer during the synthesis stage. A review protocol could have been registered on a protocol registration website. Nonetheless, despite these limitations there are valuable insights that can be derived from the review of these twelve articles.\u003c/p\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eThe author acknowledges and thanks Najeeb Ahmed and Peter Wathan for their input during the scoping review process; he also thanks the two colleagues who provided detailed feedback on the manuscript.\u003c/p\u003e\u003ch2\u003eData availability\u003c/h2\u003e\u003cp\u003eThe data charting produced during the process of this review are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAjetunmobi O, McIntosh E, Stockton D, et al. Levelling up health in the early years: a cost-analysis of infant feeding and healthcare. 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Description of an mHealth tool for breastfeeding support: LactApp. Analysis of how lactating mothers seek support at critical breastfeeding points and according to their infant\u0026rsquo;s age. Res Nurs Health. 2021(a);44(1):173\u0026ndash;86. https://doi.org/10.1002/nur.22095 \u003c/li\u003e\n\u003cli\u003ePadr\u0026oacute;-Arocas A, Mena-Tudela D, Balad\u0026iacute;a E, et al. Telelactation with a mobile app: user profile and most common queries. Breastfeeding Med. 2021(b);16(4):338\u0026ndash;45. https://doi.org/10.1089/bfm.2020.0269 \u003c/li\u003e\n\u003cli\u003ePatchen L, Ellis L, Harrington CB, et al. Engaging African American parents to develop a mobile health technology for breastfeeding: KULEA-NET. J Hum Lact. 2020;36(3):448-60. https://doi.org/10.1177/0890334420930208 \u003c/li\u003e\n\u003cli\u003ePeregrino AB, Watt RG, Heilmann A, et al. Breastfeeding practices in the United Kingdom: is the neighbourhood context important? Matern Child Nutr. 2018;14(4):e12626. https://doi.org/10.1111/mcn.12626 \u003c/li\u003e\n\u003cli\u003eSeyyedi N, Rahmatnezhad L, Mesgarzadeh M, et al. Effectiveness of a smartphone-based educational intervention to improve breastfeeding. Int Breastfeed J. 2021;16(1):70. https://doi.org/10.1186/s13006-021-00417-w \u003c/li\u003e\n\u003cli\u003eStandish KR, Parker MG. Social determinants of breastfeeding in the United States. Clin Ther. 2022;44(2):186-92. https://doi.org/10.1016/j.clinthera.2021.11.010 \u003c/li\u003e\n\u003cli\u003eUNICEF. The extension of the 2025 maternal, infant and young child nutrition targets to 2030. 2021. https://data.unicef.org/wp-content/uploads/2021/05/UNICEF-WHO-discussion-paper-extension-targets-2030.pdf \u003c/li\u003e\n\u003cli\u003eVictora CG, Bahl R, Barros AJD, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016; 387(10017):475\u0026ndash;90. https://doi.org/10.1016/S0140-6736(15)01024-7\u003c/li\u003e\n\u003cli\u003eWang CJ, Chaovalit P, Pongnumkul S. A breastfeed-promoting mobile app intervention: usability and usefulness study. JMIR Mhealth Uhealth. 2018;6(1):e27. https://doi.org/10.2196/mhealth.8337 \u003c/li\u003e\n\u003cli\u003eWheaton N, Lenehan J, Amir LH. Evaluation of a breastfeeding app in rural Australia: prospective cohort study. J Hum Lact. 2018;34(4):711-20. https://doi.org/10.1177/0890334418794181 \u003c/li\u003e\n\u003cli\u003eYao R, Zhang W, Evans R, et al. Inequities in health care services caused by the adoption of digital health technologies: scoping review. Journal Med Internet Res. 2022;24(3):e34144. https://doi.org/10.2196/34144 \u003c/li\u003e\n\u003cli\u003eYngve A, Sj\u0026ouml;str\u0026ouml;m M. Breastfeeding determinants and a suggested framework for action in Europe. Public Health Nutr. 2001;4(2B):729-39. https://doi.org/10.1079/phn2001164 \u003c/li\u003e\n\u003cli\u003eZiebart M, Kammermeier M, Koletzko B, et al. Mobile applications for promoting and supporting breastfeeding: systematic review and meta-analysis. Matern Child Nutr. 2025;21(1):e13733. https://doi.org/10.1111/mcn.13733 \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Royal United Hospital Bath NHS Trust","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Breastfeeding, Smartphone, mHealth, Scoping Review, Intersectionality","lastPublishedDoi":"10.21203/rs.3.rs-7254515/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7254515/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThe widespread availability of smartphones has given rise to the development of mobile health (mHealth) interventions, including breastfeeding support interventions delivered through smartphone apps.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAims: \u003c/strong\u003eThe aim of this scoping review was to identify articles that evaluated the use of mobile phone apps to deliver breastfeeding support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA search of BNI, CINAHL, MEDLINE and PsycINFO was undertaken in December 2022 and 880 records were identified. Through a systematic approach, two reviewers, 12 articles were identified that met the inclusion criteria and were included in the review synthesis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe included articles were published between 2018-2022, with half originating from the USA. Study objectives focused on usability testing, impact evaluation, or a combination of these. Outcome measures focused on breastfeeding rates, breastfeeding confidence, usability and satisfaction. Breastfeeding support apps largely featured written educational material. Some apps contained links to other resources and some featured breastfeeding trackers. Studies tended to feature women with higher levels of education which can challenge the generalisability of the results. Most articles identified positive feedback regarding usability, but only two articles featured interventions that demonstrated significantly higher breastfeeding rates.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion: \u003c/strong\u003eThe role of intersectionality in breastfeeding is reflected on in relation to the preponderance of more educated participants in these studies. Whilst there are clear educational benefits to breastfeeding support apps, there is a risk that apps promote an individualistic focus to the detriment of structural breastfeeding barriers being addressed. Healthcare commissioners should consider how health inequalities can be tackled when considering mHealth breastfeeding interventions.\u003c/p\u003e","manuscriptTitle":"All things to all people? A scoping review of mobile phone apps that support breastfeeding","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-01 10:28:23","doi":"10.21203/rs.3.rs-7254515/v1","editorialEvents":[{"type":"communityComments","content":1}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b09a4679-d8ae-4d7c-bc67-bba31e826fb6","owner":[],"postedDate":"September 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":53816440,"name":"Nursing"},{"id":53816441,"name":"Obstetrics \u0026 Gynecology"},{"id":53816442,"name":"Psychology"}],"tags":[],"updatedAt":"2025-09-01T10:28:23+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-01 10:28:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7254515","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7254515","identity":"rs-7254515","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}