Teaching by texting to promote positive health behaviours in pregnancy: a protocol for a randomised controlled trial of SmartMom

Background and rationale

Prenatal education is designed to teach expectant parents and their support persons about the physiologic and psychological changes of pregnancy, what to expect during prenatal care (PNC), and how to prepare for labour, birth and newborn care. In this paper, we use the term ‘women’ to refer to women and gender diverse people who are capable of giving birth.1 Attendance at prenatal education classes has been associated with positive health behaviours, including optimal weight gain,2 attendance at PNC,3 acceptance of routine screening tests,4 smoking cessation, decreased alcohol consumption and increased rates of breast feeding.5 Moreover, adoption of these behaviours has been associated with reduced rates of caesarean birth,3 6 preterm birth and low birth weight.7 The pan Canadian Maternity Experiences Study (MES) reported that only one-third of Canadian women attend prenatal classes.8 Women with Indigenous identity, younger age, low socioeconomic status, less education, non-dominant ethnic identity or residing in rural locations were even less likely to attend.9 10

To navigate the complexities of pregnancy and childbirth, expectant parents are increasingly turning to the internet and smartphone apps.11 12 However, there are serious concerns about the quality and comprehensiveness of this information.13 In addition, expectant parents participating in focus groups in British Columbia (BC) have revealed that information from apps or the internet is overwhelming in its sheer volume and that they ‘don’t have time’ to scroll through windows and search for topics.14

In the absence of effective, structured prenatal education, expectant parents are experiencing concerning gaps in knowledge. For example, a Canadian population-based survey indicated that only 25% of respondents had been informed that there are risks associated with suboptimal weight gain during pregnancy.15 The MES reported that 59.4% of women surveyed gained above the recommended weight for their body mass index (BMI).

Gestational weight gain above the Institute of Medicine recommendations16 is associated with caesarean delivery, gestational diabetes, large for gestational age newborns with potential for birth injury and pre-eclampsia in the current pregnancy as well as increased risk for type 2 diabetes, cardiovascular disease and metabolic syndrome in later adult life.17 In addition, excessive weight gain, if not lost after delivery, is likely to influence future pregnancy outcomes.18 Inadequate gestational weight gain below the institute’s recommendations is associated with both preterm birth and small for gestational age (SGA) status at birth.19

As well, the MES reported 18.9% of women had inadequate attendance at PNC visits.20 Inadequate attendance at PNC is associated with low birth weight, stillbirth, SGA status and neonatal death.21–23

To address the need for easily accessible and reliable information, we created ‘SmartMom’, Canada’s first prenatal education programme delivered by short message service (SMS) text messaging. SmartMom provides relevant, timely, gestational age-tailored and evidence-based information aimed at motivating behaviour change.24 Each message contains links to online sources for additional information. Different from apps, SmartMom delivers messages to the user’s mobile phone, three times weekly, without requiring any effort on the part of the user. The overall goal of SmartMom is to motivate adoption of positive prenatal health behaviours in order to improve pregnancy and newborn health outcomes.

The use of text messaging for health promotion is based on the social cognitive theory of behaviour change.25 Our links take participants to interactive learning tools, such as videos and animated stories, which are designed to model healthy behaviours and thus enhance engagement, and promote self-efficacy, all critical elements in behaviour change.25 26 Our focus group findings27 and those of others28 have reported that parents want a ‘personalised touch’ in digital programmes. To achieve this, SmartMom provides optional supplemental streams for individuals who wish to have additional messages addressing special topics such as reducing use of substances, mental health, weight management and others.

Recent evidence, including randomised controlled trials (RCTs), indicates that text messaging can improve health behaviours. An RCT of the Text4Baby programme in the USA reported higher rates of alcohol reduction among those who received text messages.29 In South Africa, an RCT showed that SMS messaging improved PNC attendance, increased rates of vaginal birth after a previous caesarean (VBAC) and decreased the risk of delivering a low birthweight infant.30 Decreased perinatal mortality has been reported in Zanzibar,31 lowered levels of anxiety in Thailand32 and reduced rates of macrosomia in China.33 Further, meta-analytical evidence suggests that in low-income and middle-income countries text messaging is associated with higher rates of breast feeding at birth.34 There have been no trials of pregnancy outcomes related to texting programmes in high-income countries.

SmartMom was developed in BC, Canada with over 16 000 participants to date. Pilot observational data have demonstrated significant improvements in knowledge and mental health scores among programme users35 and improvements in pregnancy outcomes among programme participants compared with a random population sample.36 We now propose a Canadian RCT of the SmartMom programme.

This post was originally published on https://bmjopen.bmj.com