Abstract:

Introduction:
The World Health Organization (WHO) recommends exclusive breastfeeding (BF) during the first six months after birth and continued until the child is two years old or more. However, breastfeeding practices in Mexico have deteriorated in recent decades. Between 1999 and 2012, exclusive BF decreased from 20.3% to 14.4%, and continued BF went from 25.1% to 14.1%. This reflects a hostile environment for BF practices, with insufficient support, protection and promotion. Health personnel plays a critical role in influencing decisions that mothers take concerning BF, and it is essential that these professionals have the basic knowledge and skills to provide appropriate counselling to help resolve problems related to BF practices.
In this way, the National Institute of Public Health (INSP in Spanish) developed the course "Learning about lactation and breastfeeding: an automatized online course based on the principles of the World Health Organization", which overall objective is to provide health professionals with the necessary knowledge to protect, promote and support breastfeeding in their work field, following the Global strategy for infant and young child feeding.
The objective of this study is to measure the increase of the competencies on BF and evaluate the effectiveness of the course in a MOOC format.

Methodology:
The course consists of an introduction section and seven modules. The content is presented in an interactive format with a multiple-choice evaluation and ludic exercises in each module. After completing the course, participants can automatically download their participation certificate, which has curricular value and is issued by the INSP. The content of the course is based on current scientific evidence of 2014.
The sample of this study is composed by the participants who got enrolled the course from March 2015 to March 2016 from all states of Mexico and other Spanish speaking countries. Socio-demographic and professional information of all participants was obtained with the registration form (before accessing the content of the course), and a pre-test was applied to them. After completing the course, a post-test was applied (with the same pre-test's questions). Data were analysed using descriptive statistics. To compare the pre and post qualification tests, the Wilcoxon test was used for related samples.

Results:
So far, 14,428 participants have had enrolled, of which 11,892 have made the pre-test, and 7,109 also made the post-test, finding out that the course has had a completion rate of 49.2%, with a significant increase in regard of the competencies, between the pre and post-tests of 6.7 points (p <0.0001), with a median and interquartile range of grades in the pre-test of 86.7 (80-93.3) and 93.3 (86.7-100) for the post-test.
The greatest terminal efficiency was observed in participants with technical education levels (57.4%), and with professionals in the public health sectors.
The total production cost of the course was $20,000 dollars, which divided among the 7,109 participants who have accredited the course during the first year of its release, gives a cost result of $ 2.81 dollars per participant.

Conclusion:
Given the results, it was identified that the breastfeeding course with a MOOC format has been successful after the first year of its release. Evidence shows that terminal efficiency in MOOCs is less than 15% so, having 50% we can conclude this MOOC is successful.

Keywords:

MOOC, Breastfeeding, Mexico, Health education, Lifelong learning.