Short message service communication improves exclusive breastfeeding and early postpartum contraception in a low to middle-income country setting: a randomised trial
Open accessAbstract
Objective: To assess the effect of short message service (SMS) communication on facility delivery, exclusive breastfeeding (EBF), and contraceptive use. Design: Mobile WACh was a three‐arm unblinded individually randomised controlled trial. Setting: A public sector maternal child health (MCH) clinic in Nairobi, Kenya. Population: Three hundred women attending antenatal care were randomised, 100 to each arm, and followed for 24 weeks postpartum. Pregnant women, at least 14 years old with access to a mobile phone and able to read SMS were eligible for participation. Methods: Women were randomised (1:1:1) to receive one‐way SMS versus two‐way SMS with a nurse versus control. Weekly SMS content was tailored for maternal characteristics and pregnancy or postpartum timing. Main outcome measures: Facility delivery, EBF, and contraceptive use were compared separately between each intervention arm and the control arm by Kaplan–Meier analysis and chi‐square tests using intent‐to‐treat analyses. Results: The overall facility delivery rate was high (98%) and did not differ by arm. Compared with controls, probability of EBF was higher in the one‐way SMS arm at 10 and 16 weeks, and in the two‐way SMS arm at 10, 16, and 24 weeks (P < 0.005 for all). Contraceptive use was significantly higher in both intervention arms by 16 weeks (one‐way SMS: 72% and two‐way SMS: 73%; P = 0.03 and P = 0.02 versus 57% control, respectively); however, this difference was not significant when correcting for multiple comparisons. Conclusion: One‐way and two‐way SMS improved EBF practices and early contraceptive use. Two‐way SMS had an added benefit on sustained EBF, providing evidence that SMS messaging influences uptake of interventions that improve maternal and neonatal health. Source of funding: Funding was provided by the National Institutes of Health (K12 HD 001264 to JAU, R01 HD 080460, K24 HD 054314 to GJS, and K01 AI 116298 to ALD), the National Science Foundation (Graduate Research Fellowship to TP and BD), as well as the University of Washington Global Center for Integrated Health of Women Adolescents and Children (Global WAC h). Tweetable abstract: The Mobile WAC h RCT demonstrates that SMS improved practice of exclusive breastfeeding and early postpartum contraception.
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The effects of interactive SMS communication with a nurse on contraception uptake varied by timing and intervention arm.
“In the included Kenyan trials, interactive SMS communication with a nurse was associated with a higher uptake of highly effective contraception at selected postpartum time points, while the effects varied by timing and intervention arm (Harrington et al., 2019; Unger et al., 2018).”
From Extending the continuum: Mapping post-6-week nurse/midwife-led interventions for postnatal women – A scoping review (2026) · cites this paper as Unger et al., 2018
The Results report higher contraceptive use in both SMS arms than in controls at 16 weeks, but the difference was not significant after correction for multiple comparisons and was not significant at 24 weeks. The Methods define this outcome as use of any modern contraceptive method, not specifically highly effective contraception; the Discussion says interactive 2-way SMS conferred no additional contraceptive benefit over 1-way SMS. (LLM, conf=0.84)
Experimental — accuracy not yet measuredIn the included Kenyan trials, interactive SMS communication with a nurse was associated with a higher uptake of highly effective contraception at selected postpartum time points.
“In the included Kenyan trials, interactive SMS communication with a nurse was associated with a higher uptake of highly effective contraception at selected postpartum time points, while the effects varied by timing and intervention arm (Harrington et al., 2019; Unger et al., 2018).”
From Extending the continuum: Mapping post-6-week nurse/midwife-led interventions for postnatal women – A scoping review (2026) · cites this paper as Unger et al., 2018
The Methods describe a two-way SMS arm with a nurse, and the Results report higher contraceptive use at 16 weeks postpartum in that arm than in controls (73% versus 57%). But the measured outcome was use of any modern contraceptive method, not specifically highly effective contraception; the difference also lost statistical significance after correction for multiple comparisons. The Results report similar long-acting contraceptive use across arms. (LLM, conf=0.87)
Experimental — accuracy not yet measuredSMS-supported continuity was associated with greater use of highly effective contraception.
“SMS-supported continuity was associated with greater use of highly effective contraception and, in some analyses, with improved breastfeeding outcomes (Harrington et al., 2019; Unger et al., 2018).”
From Extending the continuum: Mapping post-6-week nurse/midwife-led interventions for postnatal women – A scoping review (2026) · cites this paper as Unger et al., 2018
The Results report greater contraceptive use by 16 weeks in both SMS arms than in controls, although the difference was not statistically significant after correction for multiple comparisons. The measured outcome included methods such as condoms, and the Results say long-acting contraceptive use was similar across arms. The paper therefore supports greater early contraceptive use, but not greater use specifically of highly effective contraception. (LLM, conf=0.88)
Experimental — accuracy not yet measuredSMS-supported continuity was associated with improved breastfeeding outcomes in some analyses.
“SMS-supported continuity was associated with greater use of highly effective contraception and, in some analyses, with improved breastfeeding outcomes (Harrington et al., 2019; Unger et al., 2018).”
From Extending the continuum: Mapping post-6-week nurse/midwife-led interventions for postnatal women – A scoping review (2026) · cites this paper as Unger et al., 2018
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- Authors
- Unger, J., Ronen, K., Perrier, T., DeRenzi, B., Slyker, J., Drake, A., Mogaka, D., Kinuthia, J., & John‐Stewart, G.
- Affiliations
- University of Washington (US)
- University of Cape Town (ZA)
- Kenyatta National Hospital (KE)
- University of Nairobi (KE)
- Department of Global Health University of Washington Seattle WA USA
- Corresponding author
- Unger, JA
- Venue
- BJOG: An International Journal of Obstetrics & Gynaecology
- Publisher
- Wiley
- Published
- 2018-08-28
- Volume
- 125
- Issue
- 12
- Pages
- 1620-1629
- ISSN
- 0306-5456 (ISSN-L)
- 1470-0328
- 1471-0528
- PMC
- PMC6179930
- OpenAlex
- W2889359583
- Cited by
- 103
- References
- 3
- Citations by year
- 2026: 17 · 2025: 7 · 2024: 13 · 2023: 13 · 2022: 16 · 2021: 10 · 2020: 14 · 2019: 11 · 2018: 1 · 2013: 1
- FWCI
- 13.75
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- BJOG An International Journal of Obstetrics & Gynaecology (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institutes of Health (K12HD001264, R01HD080460, K24HD054314, K01AI116298)
- National Science Foundation
- Topics
- Health Sciences › Health Professions › General Health Professions › Mobile Health and mHealth Applications
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Reproductive Health and Contraception
- Physical Sciences › Computer Science › Information Systems › ICT in Developing Communities
- Keywords
- short message service, exclusive breastfeeding, postpartum contraception, institutional delivery, mobile health, text messaging, prenatal care, maternal and child health, low- and middle-income countries, Kenya, contraceptive uptake, neonatal outcomes, postpartum depression screening, postpartum depression
- MeSH terms
- Maternal-Child Health Services, Adolescent, Adult, Breast Feeding, Contraception, Female, Humans, Infant, Newborn, Kenya, Medically Underserved Area, Middle Aged, Pregnancy, Prenatal Care, Outcome Assessment, Health Care, Cell Phone, Postpartum Period, Young Adult, Quality Improvement
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