eHealth as the Next-Generation Perinatal Care: An Overview of the Literature

Be a Mom's Efficacy in Enhancing Positive Mental Health among Postpartum Women Presenting Low Risk for Postpartum Depression: Results from a Pilot Randomized Trial

In this study, we conducted a preliminary investigation of the efficacy of Be a Mom, a web-based self-guided intervention, in enhancing positive mental health among postpartum women at low risk for postpartum depression. Additionally, we examined Be a Mom's efficacy regarding secondary outcomes as well as its acceptability and adherence. A total of 367 participants were randomly assigned to the Be a Mom group (n = 191) or to the waiting-list control group (n = 176) and completed baseline (T1) and postintervention (T2) assessments. The intervention group reported significant increases in positive mental health between T1 and T2 compared to the control group. Additionally, group effects were found for depressive and anxiety symptoms. A significantly higher proportion of participants in the Be a Mom group had an improvement trajectory (from not flourishing at T1 to flourishing at T2). A total of 62 (32.5%) women completed Be a Mom, and most would use it again if needed (n = 82/113; 72.6%). This study provides preliminary evidence of Be a Mom's efficacy in increasing positive mental health among low-risk postpartum women. Our findings support mental health promotion strategies in the postpartum period and highlight the important role of web-based CBT interventions.

Patients' Perceptions of Barriers and Facilitators to the Adoption of E-Hospitals: Cross-Sectional Study in Western China

BACKGROUND

As an innovative approach to providing web-based health care services from physical hospitals to patients at a distance, e-hospitals (ie, extended care hospitals through the internet) have been extensively developed in China. This closed health care delivery chain was developed by combining e-hospitals with physical hospitals; treatment begins with web-based consultation and registration, and then, patients are diagnosed and treated in a physical hospital. This approach is promising in its ability to improve accessibility, efficiency, and quality of health care. However, there is limited research on end users' acceptance of e-hospitals and the effectiveness of strategies aimed to prompt the adoption of e-hospitals in China.

OBJECTIVE

This study aimed to provide insights regarding the adoption of e-hospitals by investigating patients' willingness to use e-hospitals and analyzing the barriers and facilitators to the adoption of this technology.

METHODS

We used a pretested self-administered questionnaire and performed a cross-sectional analysis in 1032 patients across three hierarchical hospitals in West China from June to August 2019. Patients' sociodemographic characteristics, medical history, current disease status, proficiency with electronic devices, previous experience with web-based health services, willingness to use e-hospitals, and perceived facilitators and barriers were surveyed. Multiple significance tests were employed to examine disparities across four age groups, as well as those between patients who were willing to use e-hospitals and those who were not. Multivariate logistic regression was also performed to identify the potential predictors of willingness to use e-hospitals.

RESULTS

Overall, it was found that 65.6% (677/1032) of participants were willing to use e-hospitals. The significant predictors of willingness to use e-hospitals were employment status (P=.02), living with children (P<.001), education level (P=.046), information technology skills (P<.001), and prior experience with web-based health care services (P<.001), whereas age, income, medical insurance, and familiarity with e-hospitals were not predictors. Additionally, the prominent facilitators of e-hospitals were convenience (641/677, 94.7%) and accessibility to skilled medical experts (489/677, 72.2%). The most frequently perceived barrier varied among age groups; seniors most often reported their inability to operate technological devices as a barrier (144/166, 86.7%), whereas young participants most often reported that they avoided e-hospital services because they were accustomed to face-to-face consultation (39/52, 75%).

CONCLUSIONS

We identified the variables, facilitators, and barriers that play essential roles in the adoption of e-hospitals. Based on our findings, we suggest that efforts to increase the adoption of e-hospitals should focus on making target populations accustomed to web-based health care services while maximizing ease of use and providing assistance for technological inquiries.

Using mHealth in postpartum women with pre-eclampsia: Lessons learned from a qualitative study

OBJECTIVE

To explore perceptions and attitudes of postpartum women with pre-eclampsia towards remote monitoring (mHealth) and communication with the call center.

METHODS

A non-randomized cohort study was conducted in postpartum hypertensive women, recruited from a tertiary hospital between October 2015 and February 2016. Participants were categorized into users (using mHealth) and non-users (not using mHealth) to monitor vital signs at home over a 2-week period after discharge. Non-users were informed about functionality of mHealth. Both groups participated in a 30-minute phone interview at the end of the study. Directed content analysis of interview transcripts was conducted.

RESULTS

In total, 21 users and 16 non-users participated in the interview. Both groups perceived that mHealth helped manage their condition. However, non-users were concerned about the challenge of incorporating mHealth into their routine, whereas users mentioned that they liked using mHealth on a daily basis. They also stated that communication with nurses in the call center was helpful. Barriers identified by users included size of the blood pressure cuffs, size of the equipment set, wireless connection, and stress associated with mHealth monitoring. Users stated that they would have preferred using mHealth during pregnancy.

CONCLUSION

The findings provide useful insights to inform a successful remote monitoring program among perinatal and postpartum women.

Design, development and usability testing of Essential Coaching for Every Mother: A postnatal text message educational intervention

BACKGROUND

The transition to motherhood is an exciting yet challenging period that requires physical, emotional, and social adjustment. During the postpartum period, mothers require support and information to ensure a smooth transition and adjustment to motherhood. One innovative strategy to provide mothers with this information is mobile health (mHealth), and specifically, text messaging.

OBJECTIVE

To describe the design, development and usability testing of a postnatal text message intervention called Essential Coaching for Every Mother.

METHODS

First time mothers (n=11) and postpartum healthcare providers (n=18) were involved in iterative interviewing in Halifax, Canada. Adaption of content occurred through three rounds of user testing using semi-structured interviews. The Information Assessment Method (IAM) Parents survey was also completed by mothers.

RESULTS

Three cycles of iterative testing were conducted with eight participants (3 mothers, 5 healthcare providers), thirteen participants (8 mothers, 5 healthcare providers) and 8 participants (8 healthcare providers), respectively. Messages evolved from risk-focused to prevention and education focused. Mothers felt the messages addressed their needs and healthcare providers ensured the content was consistent with the messaging currently provided to postpartum mothers.

CONCLUSION

Essential Coaching for Every Mother is the first postnatal educational text message intervention developed for mothers in Halifax, Canada. We sought to involve first time mothers (end-users) and postpartum healthcare providers (experts) in the development and usability evaluation to ensure the intervention adequately met needs and was consistent with current practices related to postpartum education.

Identifying the Needs for a Web-Based Postpartum Platform Among Parents of Newborns and Health Care Professionals: Qualitative Focus Group Study

Background

During the turbulent postpartum period, there is an urgent need by parents for support and information regarding the care for their infant. In the Netherlands, professional support is provided during the first 8 days postpartum and for a maximum of 8 hours a day. This care is delivered by maternity care assistants (MCAs). Despite the availability of this extensive care, a majority of women prefer to make use of a lesser amount of postpartum care. After this period, access to care is less obvious. Where parents are automatically offered care in the first 8 days after birth, they must request care in the period thereafter. To compensate for a possible gap in information transfer, electronic health (eHealth) can be a valuable, easily accessible addition to regular care.

Objective

We explored the needs and preferred content by new parents and health care professionals of a web-based platform dedicated to the postpartum period and identified barriers and facilitators for using such a platform.

Methods

We conducted 3 semistructured focus groups among (1) parents of newborns, (2) MCAs, and (3) clinicians and administrators in maternity care. A topic list based on a framework designed for innovation processes was used. Thematic content analysis was applied.

Results

In the focus group for parents, 5 mothers and 1 male partner participated. A total of 6 MCAs participated in the second focus group. A total of 5 clinicians and 2 administrators—a member of a stakeholder party and a manager of a maternity care organization—participated in the third focus group. All user groups underlined that a platform focusing on the postpartum period was missing in current care, especially by parents experiencing a gap following the intensive care ending after the first week of childbirth. Parents indicated that they would perceive a postpartum platform as a proper source of reliable information on topics regarding breastfeeding, growth, and developmental milestones, but also as a tool to support them in seeking care with appropriate professionals. They also emphasized the need to receive personalized information and the opportunity to ask questions via the platform. MCAs acknowledged added value of providing additional information on topics that they address during the early postpartum period. MCAs as well as clinicians and administrators would guide parents to such a platform for additional support. All user groups experienced disadvantages of using an authentication procedure and filling out extra questionnaires to receive tailored information.

Conclusions

Our research shows that parents of newborns, MCAs, and clinicians and administrators foresee the additional value of a web-based postpartum platform for at least the whole postpartum period. The platform should be easily accessible and personalized. Content on the platform should contain information regarding breastfeeding, growth, and developmental milestones. A chat function with professionals could be considered as an option.

Right-Sizing Prenatal Care to Meet Patients' Needs and Improve Maternity Care Value

Prenatal care is one of the most widely used preventive care services in the United States, yet prenatal care delivery recommendations have remained largely unchanged since just before World War II. The current prenatal care model can be improved to better serve modern patients and the health care providers who care for them in three key ways: 1) focusing more on promotion of health and wellness as opposed to primarily focusing on medical complications, 2) flexibly incorporating patient preferences, and 3) individualizing care. As key policymakers and stakeholders grapple with higher maternity care costs and poorer outcomes, including lagging access, equity, and maternal and infant morbidity and mortality in the United States compared with other high-income countries, the opportunity to improve prenatal care has been given insufficient attention. In this manuscript, we present a new conceptual model for prenatal care that incorporates both patients' medical and social needs into four phenotypes, and use human-centered design methods to describe how better matching patient needs with prenatal services can increase the use of high-value services and decrease the use of low-value services. Finally, we address some of the key challenges to implementing right-sized prenatal care, including capturing outcomes through research and payment.

Telemedicine in High-Risk Obstetrics

Telemedicine involves the use of technology to provide services to patients and share medical information. Telemedicine's use has increased as technology has advanced. It allows for medicine to be practiced from a distance to reach patients in rural or underserved areas. Telemedicine has widespread uses in high-risk obstetrics, including management of diabetes, diagnosis and management of hypertensive disorders of pregnancy, screening for fetal malformations with teleultrasound, delivering care to underserved areas, and more. The use of telemedicine to provide care to patients and information to health care providers at a distance has been well accepted by the patients and providers.

The effectiveness of mHealth interventions on postpartum depression: A systematic review and meta-analysis

INTRODUCTION

Postpartum depression (PPD) is a common psychiatric condition during the postnatal period that negatively impacts the well-being of both the mother and her infant. This study describes a systematic review and preliminary meta-analysis to assess the efficacy of mobile health (mHealth) interventions, which is defined as the use of portable electronic devices to support public health and medical practice, in addressing depressive symptoms among postpartum women.

METHODS

Databases including PubMed, PsycINFO, the Cochrane Library, Embase and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) assessing the effectiveness of mHealth interventions on PPD from database inception to December 2019.

RESULTS

The initial search identified 754 studies, of which, 11 studies fulfilled the inclusion criteria. These studies evaluated four types of distinct mHealth interventions and involved 2424 participants across six countries. Pooled results demonstrated that compared to the controls, the Edinburgh Postnatal Depression Scale score decreased in the mHealth intervention group (mean difference: -1.09, 95% confidence interval: -1.39 to -0.79).

DISCUSSION

Our study suggested that mHealth interventions may be a promising tool to complement routine clinical care in the prevention and treatment of PPD, but the clinical effectiveness of mHealth interventions needs to be better established. While most studies focused on telephone-based interventions, recent researches have also suggested the superiority and effectiveness of short messaging service (SMS) and smartphone applications, but the exact efficacy needs further evaluation. Therefore, more high-quality RCTs on app-based and SMS-based interventions are needed before the large-scale roll-out of these interventions in clinical practice.

Exploring the Use of Telemonitoring for Patients at High Risk for Hypertensive Disorders of Pregnancy in the Antepartum and Postpartum Periods: Scoping Review

Background

High blood pressure complicates 2% to 8% of pregnancies, and its complications are present in the antepartum and postpartum periods. Blood pressure during and after pregnancy is routinely monitored during clinic visits. Some guidelines recommend using home blood pressure measurements for the management and treatment of hypertension, with increased frequency of monitoring for high-risk pregnancies. Blood pressure self-monitoring may have a role in identifying those in this high-risk group. Therefore, this high-risk pregnancy group may be well suited for telemonitoring interventions.

Objective

The aim of this study was to explore the use of telemonitoring in patients at high risk for hypertensive disorders of pregnancy (HDP) during the antepartum and postpartum periods. This paper aims to answer the following question: What is the current knowledge base related to the use of telemonitoring interventions for the management of patients at high risk for HDP?

Methods

A literature review following the methodological framework described by Arksey et al and Levac et al was conducted to analyze studies describing the telemonitoring of patients at high risk for HDP. A qualitative study, observational studies, and randomized controlled trials were included in this scoping review.

Results

Of the 3904 articles initially identified, 20 met the inclusion criteria. Most of the studies (13/20, 65%) were published between 2017 and 2018. In total, there were 16 unique interventions described in the 20 articles, all of which provide clinical decision support and 12 of which are also used to facilitate the self-management of HDP. Each intervention’s design and process of implementation varied. Overall, telemonitoring interventions for the management of HDP were found to be feasible and convenient, and they were used to facilitate access to health services. Two unique studies reported significant findings for the telemonitoring group, namely, spontaneous deliveries were more likely, and one study, reported in two papers, described inductions as being less likely to occur compared with the control group. However, the small study sample sizes, nonrandomized groups, and short study durations limit the findings from the included articles.

Conclusions

Although current evidence suggests that telemonitoring could provide benefits for managing patients at high risk for HDP, more research is needed to prove its safety and effectiveness. This review proposes four recommendations for future research: (1) the implementation of large prospective studies to establish the safety and effectiveness of telemonitoring interventions; (2) additional research to determine the context-specific requirements and patient suitability to enhance accessibility to healthcare services for remote regions and underserved populations; (3) the inclusion of privacy and security considerations for telemonitoring interventions to better comply with healthcare information regulations and guidelines; and (4) the implementation of studies to better understand the effective components of telemonitoring interventions.

Mobile Health for Perinatal Depression and Anxiety: Scoping Review

Background

The perinatal period is a vulnerable time during which depression and anxiety commonly occur. If left untreated or undertreated, there may be significant adverse effects; therefore, access to rapid, effective treatment is essential. Treatments for mild-to-moderate symptoms according to a stepped-care approach involve psychoeducation, peer support, and psychological therapy, all of which have been shown to be efficaciously delivered through digital means. Women experience significant barriers to care because of system- and individual-level factors, such as cost, accessibility, and availability of childcare. The use of mobile phones is widespread in this population, and the delivery of mental health services via mobile phones has been suggested as a means of reducing barriers.

Objective

This study aimed to understand the extent, range, and nature of mobile health (mHealth) tools for prevention, screening, and treatment of perinatal depression and anxiety in order to identify gaps and inform opportunities for future work.

Methods

Using a scoping review framework, 4 databases were searched for terms related to mobile phones, perinatal period, and either depression or anxiety. A total of 477 unique records were retrieved, 81 of which were reviewed by full text. Peer-reviewed publications were included if they described the population as women pregnant or up to 1 year postpartum and a tool explicitly delivered via a mobile phone for preventing, screening, or treating depression or anxiety. Studies published in 2007 or earlier, not in English, or as case reports were excluded.

Results

A total of 26 publications describing 22 unique studies were included (77% published after 2017). mHealth apps were slightly more common than texting-based interventions (12/22, 54% vs 10/22, 45%). Most tools were for either depression (12/22, 54%) or anxiety and depression (9/22, 41%); 1 tool was for anxiety only (1/22, 4%). Interventions starting in pregnancy and continuing into the postpartum period were rare (2/22, 9%). Tools were for prevention (10/22, 45%), screening (6/22, 27%), and treatment (6/22, 27%). Interventions delivered included psychoeducation (16/22, 73%), peer support (4/22, 18%), and psychological therapy (4/22, 18%). Cost was measured in 14% (3/22) studies.

Conclusions

Future work in this growing area should incorporate active psychological treatment, address continuity of care across the perinatal period, and consider clinical sustainability to realize the potential of mHealth.

The Effectiveness of a Guided Internet-Based Tool for the Treatment of Depression and Anxiety in Pregnancy (MamaKits Online): Randomized Controlled Trial

BACKGROUND

Pregnant women with symptoms of depression or anxiety often do not receive adequate treatment. In view of the high incidence of these symptoms in pregnancy and their impact on pregnancy outcomes, getting treatment is of the utmost importance. A guided internet self-help intervention may help to provide more women with appropriate treatment.

OBJECTIVE

This study aimed to examine the effectiveness of a guided internet intervention (MamaKits online) for pregnant women with moderate to severe symptoms of anxiety or depression. Assessments took place before randomization (T0), post intervention (T1), at 36 weeks of pregnancy (T2), and 6 weeks postpartum (T3). We also explored effects on perinatal child outcomes 6 weeks postpartum.

METHODS

This randomized controlled trial included pregnant women (<30 weeks) with depressive symptoms above threshold (ie, Center for Epidemiological Studies Depression scale [CES-D] >16) or anxiety above threshold (ie, Hospital Anxiety and Depression Scale-Anxiety subscale [HADS-A] >8) or both of them. Participants were recruited via general media and flyers in prenatal care waiting rooms or via obstetricians and midwives. After initial assessment, women were randomized to (1) MamaKits online in addition to treatment as usual or (2) treatment as usual (control condition). MamaKits online is a 5-week guided internet intervention based on problem solving treatment. Guidance was was provided by trained students pursuing a Master's in Psychology. Outcomes were based on a Web-based self-report. Women in the control condition were allowed to receive the intervention after the last assessment (6 weeks postpartum).

RESULTS

Of the 159 included women, 79 were randomized to MamaKits online, 47% (79/37) of whom completed the intervention. Both groups showed a substantial decrease in affective symptoms on the CES-D, HADS-A, and Edinburgh Postnatal Depression Scale over time. In the intervention group, affective symptoms decreased more than that in the control group, but between-group effect sizes were small to medium (Cohen d at T3=0.45, 0.21, and 0.23 for the 3 questionnaires, respectively) and statistically not significant. Negative perinatal child outcomes did not differ between the 2 groups (χ²₁=0.1; P=.78). Completer analysis revealed no differences in outcome between the treatment completers and the control group. The trial was terminated early for reasons of futility based on the results of an interim analysis, which we performed because of inclusion problems.

CONCLUSIONS

Our study did show a significant reduction in affective symptoms in both groups, but the differences in reduction of affective symptoms between the intervention and control groups were not significant. There were also no differences in perinatal child outcomes. Future research should examine for which women these interventions might be effective or if changes in the internet intervention might make the intervention more effective.

TRIAL REGISTRATION

Netherlands Trial Register NL4162; https://tinyurl.com/sdckjek.

Mobile Health Applications for Prenatal Assessment and Monitoring

BACKGROUND

A mobile health application is an exciting, fast-paced domain that is likely to improve prenatal care.

METHODS

In this narrative review, we summarise the use of mobile health applications in this setting with a special emphasis on both the benefits of remote monitoring devices and the potential pitfalls of their use, highlighting the need for robust regulations and guidelines before their widespread introduction into prenatal care.

RESULTS

Remote monitoring devices for four areas of prenatal care are reported: (1) cardio-tocography; (2) blood glucose levels; (3) blood pressure; and (4) prenatal ultrasound. The majority of publications are pilot projects on remote consultation, education, coaching, screening, monitoring and selective booking, mostly reporting potential medical and/or economic benefits by mobile health applications over conventional care for very specific situations, indications and locations, but not always generalizable.

CONCLUSIONS

Despite the potential advantages of these devices, some caution must be taken when implementing this technology into routine daily practice. To date, the majority of published research on mobile health in the prenatal setting consists of observational studies and there is a need for high-quality randomized controlled trials to confirm the reported clinical and economic benefits as well as the safety of this technology. There is also a need for guidance and governance on the development and validation of new apps and devices and for the implementation of mobile health technology into healthcare systems in both high and low-income settings. Finally, digital communication technologies offer perspectives towards exploration and development of the very new domain of tele-pharmacology.

Home-based telemonitoring versus hospital admission in high risk pregnancies: a qualitative study on women's experiences

BACKGROUND

Hospital admission during pregnancy complications is considered to be an event of significant impact. Besides conventional in-clinic maternal and fetal monitoring, recent technologies enable home-based telemonitoring with self-measurements in high risk pregnancy. This study is part of a feasibility pilot to explore the usability and acceptability of telemonitoring and aims to gain insight in the experiences and preferences of high risk pregnant women concerning the novel strategy of telemonitoring, opposed to women who were hospitalized in pregnancy.

METHODS

Using secured Facebook Groups, we conducted four online focus groups: two focus groups with women who were admitted during pregnancy (n = 11) and two with women who received home telemonitoring in the pilot phase (n = 11). The qualitative data were analyzed thematically.

RESULTS

Four major themes emerged from both participant groups: [1] care experience, [2] emotions regarding pregnancy, [3] privacy and [4] impact on daily life. Different views were reported on all four themes, resulting in a direct comparison of experiences during hospitalization and telemonitoring. Most admitted patients reported a growing sense of boredom and anxiety during their clinical admission. Lack of privacy on ward was a great concern, as it affected their contact with hospital staff and family. This issue was not reported amongst telemonitored women. These participants still felt like a patient at times but responded that the comfort of their own home and bed was pleasant. Only a minority of telemonitored participants reported being anxious at times at home, while not having a physician or nurse nearby. Being at home resulted in less travel time for partners or family for hospital visits, which had its positive effects on family life.

CONCLUSIONS

Telemonitoring of a high-risk pregnancy provides an innovative manner to monitor fetal and maternal condition from home. Compared to the experiences of hospital admission in high risk pregnancy, it allows women to be in a comforting and private environment during an anxious time in their lives. As future studies should further investigate the safety and cost effectiveness of this novel strategy, women's views on the preference of telemonitoring need to be taken into consideration.

Pregnancy-Related Information Seeking and Sharing in the Social Media Era Among Expectant Mothers: Qualitative Study

Background

Social media has become the most popular communication tool used by Chinese citizens, including expectant mothers. An increasing number of women have adopted various forms of social media channels, such as interactive websites, instant messaging, and mobile apps, to solve problems and obtain answers to queries during pregnancy. Although the use of the internet by pregnant women has been studied extensively worldwide, limited research exists that explores the changing social media usage habits in China, where the 1 child policy ended in 2015.

Objective

This study aimed to (1) present the status quo of pregnancy-related information seeking and sharing via social media among Chinese expectant mothers, (2) reveal the impact of social media usage, and (3) shed light on pregnancy-related health services delivered via social media channels.

Methods

A qualitative approach was employed to examine social media usage and its consequences on pregnant women. A total of 20 women who had conceived and were at various stages of pregnancy were interviewed from July 20 to August 10, 2017. Thematic analysis was conducted on the collected data to identify patterns in usage.

Results

Overall, 80% (16/20) of participants were aged in their 20s (mean 28.5 years [SD 4.3]). All had used social media for pregnancy-related purposes. For the seeking behavior, 18 codes were merged into 4 themes, namely, gravida, fetus, delivery, and the postpartum period; whereas for sharing behaviors, 10 codes were merged into 4 themes, namely, gravida, fetus, delivery, and caretaker. Lurking, small group sharing, bad news avoidance, and cross-checking were identified as the preferred patterns for using social media. Overall, 95% (19/20) of participants reported a positive mental impact from using social media during their pregnancy.

Conclusions

It is indisputable that social media has played an increasingly important role in supporting expectant mothers in China. The specific seeking and sharing patterns identified in this study indicate that the general quality of pregnancy-related information on social media, as well as Chinese culture toward pregnancy, is improving. The new themes that merge in pregnancy-related social media use represent a shift toward safe pregnancy and the promotion of a more enjoyable pregnancy. Future prenatal care should provide further information on services related to being comfortable during pregnancy and reducing the inequality of social media–based services caused by the digital divide.

Nutrition information in pregnancy: Where do women seek advice and has this changed over time?

AIM

Nutrition during pregnancy is fundamental to both the health of the mother and her baby. Sources of nutrition-related information are available via many sources but their accuracy is unknown. The present study aimed to (a) identify where women source their nutrition information during pregnancy and (2) assess the accuracy of nutrition information for pregnancy that is available on the internet.

METHODS

A survey instrument that identified the main sources of nutrition information was administered to 68 pregnant women recruited online. Data from this survey were compared to previous similar surveys conducted with pregnant mothers across years 2008, 2011 and 2014. A content analysis of websites was simultaneously conducted to assess the accuracy of available information.

RESULTS

The main source of nutrition information for a variety of topics was verbal communication from health professionals (% responses affirmative for that source ranged from 6.6% to 69% across survey years). There was an increasing trend in internet sourced information for most nutrition topics, but this source remained low for iodine across all years (range: 7.3%-15.9%). The internet was the main source of information for listeria/food safety (15.3%-32.4%) and healthy eating (25%-42%). Of the n = 165 websites identified by the content analysis, 82.4% (n = 136) were rated as accurate, with government (96.9%) and business/company (100%) sites having the highest accuracy.

CONCLUSION

Verbal communication from health professionals remains the most important source of nutrition information for pregnancy. The high credibility of websites indicates this to be an additional resource. Further study into health literacy levels among women visiting these sites is needed to assess impact on dietary behaviour.

A feasibility study of activity tracking devices in pregnancy

BACKGROUND

We aimed to evaluate the feasibility of using an activity-tracking device (ATD) during pregnancy and compare self-reported to ATD-calculated energy expenditure in a 2-phase study.

METHODS

(Phase 1) Twenty-five pregnant women were asked about exercise, computer use, smartphone ownership, and ATD attitudes. Descriptive statistics were reported. (Phase 2) Women ≥18 years, smartphone owners, < 16-weeks gestation, and without exercise restrictions were approached to participate in 2016-2017. Women received instructions to wear and sync the ATD daily. We assessed protocol adherence and satisfaction via surveys at 36-weeks and used mixed models to assess the relationship between gestational age and ATD data. Energy expenditure from the Pregnancy Physical Activity Questionnaire (PPAQ) was compared to ATD-calculated energy expenditure.

RESULTS

(Phase 1) Walking was the most common exercise; 8% did not perform any activity during pregnancy. All women had internet access and owned a smartphone. Women stated they would wear the ATD all the time during a pregnancy (88%), with the intent to improve their health (80%). (Phase 2) The characteristics of the 48 women were: pre-pregnancy BMI 28, 62% non-Hispanic black, 62% multiparas. Of the 18 women who completed the 36-week survey, only 56% wore the ATD daily, 33% had a lost or broken ATD, and 17% had technical problems; however, 94% enjoyed wearing it, 94% would recommend it to a pregnant friend, and 78% thought it helped them reach activity goals. According to ATD data, the median number of active days was 41 (IQR 20-73) and the median proportion of active days out of potential days was 22% (IQR 11-40). As gestational age increased, mean log steps decreased, active minutes decreased, and sedentary hours increased in unadjusted and adjusted models (P < 0.05 all comparisons). There were no differences in mean energy expenditure (MET-h/week) estimated by PPAQ or ATD data at 28 weeks gestation [212 (22-992 range) vs. 234 (200-281 range), P = 0.66] and at 36 weeks [233 (86-907 range) vs. 218 (151-273 range), P = 0.68]).

CONCLUSIONS

Women reported high motivation to wear an ATD and high satisfaction with actually using an ATD during pregnancy; however adherence to the study protocol was lower than expected and ATD technical problems were frequent.

Validation of Newly Developed Surveys to Evaluate Patients' and Providers' Satisfaction with Telehealth Obstetric Services

Background: Patient and/or provider satisfaction and experience are among the most important indicators for quality assurance of health care services, including telehealth. Validated surveys should be used for this purpose to provide reliable information for a program evaluation. Objective: To validate the newly developed satisfaction surveys, report patient, and provider satisfaction with Antenatal and Neonatal Guidelines, Education and Learning Systems (ANGELS) telehealth services. Methods: Two self-administered paper surveys were developed by a multidisciplinary team. The surveys were validated among obstetric patients who received telehealth services in 2016 and providers in Arkansas from July to August 2017. Psychometric testing was performed to establish reliability and validity of both the surveys. Descriptive statistics was performed to describe patient and provider satisfaction. Results: A total of 89 patient- and 66 provider surveys were analyzed. Construct validity and internal consistency reliability (Cronbach's α >0.7) were confirmed on both the surveys. The majority of patients were highly satisfied with telehealth services and reported positive perceptions toward future use of services. In the past 12 months, telehealth (78.6%) was the most used ANGELS service by providers. Finally, >90% of the providers reported high satisfaction and rated telehealth services as "excellent." Conclusions: The newly developed patient and provider telehealth surveys were reliable and valid. The surveys also demonstrated that the telehealth services were well-accepted and highly valued in a sample of obstetric patients and providers. As both surveys are short, they can be used in routine evaluation of patient and provider satisfaction with similar telehealth programs in the country.

HOspital care versus TELemonitoring in high-risk pregnancy (HOTEL): study protocol for a multicentre non-inferiority randomised controlled trial

INTRODUCTION

Pregnant women faced with complications of pregnancy often require long-term hospital admission for maternal and/or fetal monitoring. Antenatal admissions cause a burden to patients as well as hospital resources and costs. A telemonitoring platform connected to wireless cardiotocography (CTG) and automated blood pressure (BP) devices can be used for telemonitoring in pregnancy. Home telemonitoring might improve autonomy and reduce admissions and thus costs. The aim of this study is to compare the effects on patient safety, satisfaction and cost-effectiveness of hospital care versus telemonitoring (HOTEL) as an obstetric care strategy in high-risk pregnancies requiring daily monitoring.

METHODS AND ANALYSIS

The HOTEL trial is an ongoing multicentre randomised controlled clinical trial with a non-inferiority design. Eligible pregnant women are >26+0 weeks of singleton gestation requiring monitoring because of pre-eclampsia (hypertension with proteinuria), fetal growth restriction, preterm rupture of membranes without contractions, recurrent reduced fetal movements or an intrauterine fetal death in a previous pregnancy.Randomisation takes place between traditional hospitalisation (planned n=208) versus telemonitoring (planned n=208) until delivery. Telemonitoring at home is facilitated with Sense4Baby CTG devices, Microlife BP monitor and daily telephone calls with an obstetric healthcare professional as well as weekly hospital visits.Primary outcome is a composite of adverse perinatal outcome, defined as perinatal mortality, 5 min Apgar <7 or arterial cord blood pH <7.05, maternal morbidity (eclampsia, HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome, thromboembolic event), neonatal intensive care admission and caesarean section rate. Patient satisfaction and preference of care will be assessed using validated questionnaires. We will perform an economic analysis. Outcomes will be analysed according to the intention to treat principle.

ETHICS AND DISSEMINATION

The study protocol was approved by the Ethics Committee of the Utrecht University Medical Center and the boards of all six participating centres. Trial results will be submitted to peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NTR6076.

Being 'A Google Mom' or securely monitored at home: Perceptions of remote monitoring in maternity care

AIMS

To understand the perspectives of both healthcare professionals in maternity care and pregnant women with higher risk pregnancies about remote monitoring in maternity care.

DESIGN

Qualitative descriptive design.

METHODS

Individual and focus group interviews were conducted in public maternity care and in a level III hospital in Finland during April-May 2018. The sample consisted of healthcare professionals working in the primary care and at the hospital and hospitalized pregnant women. Altogether, 17 healthcare professionals and 4 pregnant women participated in the study. The data were analysed using inductive thematic network analysis.

RESULTS

Many possibilities - and an equal number of concerns - were identified regarding remote monitoring in pregnancy, depending on the respondent's viewpoint from holistic to symptom-centred care. Healthcare staff had reservations about technology due to previous negative experiences and difficulties trusting technology. The pregnant women thought that monitoring would ease the staff's workload if the latter had enough technological skills. Remote monitoring could increase security in pregnancy care but create a feeling of false security if the women ignored their subjective symptoms. Face-to-face visits and the uniqueness of human contact were strongly favoured. Pregnant women wished to use monitoring as a confirmation of their subjective feelings.

CONCLUSION

Remote monitoring could be used as a supplementary system in pregnancy care, although it could replace only some healthcare visits. Pregnant women identified more possibilities for remote monitoring compared with the staff members both in primary care and the hospital.

IMPACT

A comprehensive understanding of pregnant women's and healthcare professionals' perceptions of remote monitoring in pregnancy was built to be able to develop new technologies in maternity care. In certain cases, remote monitoring would supplement traditional pregnancy follow-ups. Staff in primary and specialized care, and healthcare managers, should support teamwork to be able to understand different approaches to pregnancy care.

Effect of In-Utero Antibiotic Exposure on Childhood Outcomes: Methods and Baseline Data of the Fetal Antibiotic EXposure (FAX) Cohort Study

BACKGROUND

The widespread use of antepartum and intrapartum antibiotics has raised concerns about the possible disruption of the child's gut microbiota and effects on the maturation from the infant to the adult microbiome. The Fetal Antibiotic EXposure (FAX) study provides a cohort to examine the association between in-utero exposure to antibiotics and adverse childhood outcomes including body weight, atopic diseases, and autism spectrum disorders and to investigate the role of other potential factors mitigating or moderating the risk for adverse outcomes.

OBJECTIVE

The aim of this paper was to describe the methods, cohort characteristics, and retention of infants included in the study cohort.

METHODS

For this retrospective cohort study, we included children born in Kaiser Permanente Southern California (KPSC) hospitals between January 1, 2007, and December 31, 2015, within 22 to 44 completed weeks of gestation with KPSC insurance coverage during the first year of life. Follow-up data collection was performed through electronic medical records.

RESULTS

The study cohort was comprised 223,431 children of which 65.7% (146,720/223,431) were exposed to antibiotics in-utero: 19.0% (42,511/223,431) were exposed during the antepartum period, 30.0% (66,896/223,431) during the intrapartum period, and 16.7% (37,313/223,431) exposed during both the antepartum and intrapartum periods. During their first year of life, children had a median of 5 weight and height measurements; the frequency of weight and height measurements declined to a median of 3 in their second year of life and 2 for 3 to 5 years of age. The 5-year retention of children in the health plan was over 80% with the highest retention for Hispanic children.

CONCLUSIONS

This cohort of children will provide a unique opportunity to address key questions regarding the long-term sequelae of in-utero exposure to antibiotics using real-world data. The high retention and multiple medical visits over time allow us to model the trajectories of body mass index over time.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/12065.

Tracker-Based Personal Advice to Support the Baby's Healthy Development in a Novel Parenting App: Data-Driven Innovation

BACKGROUND

The current generation of millennial parents prefers digital communications and makes use of apps on a daily basis to find information about child-rearing topics. Given this, an increasing amount of parenting apps have become available. These apps also allow parents to track their baby's development with increasing completeness and precision. The large amounts of data collected in this process provide ample opportunity for data-driven innovation (DDI). Subsequently, apps are increasingly personalized by offering information that is based on the data tracked in the app. In line with this, Philips Avent has developed the uGrow app, a medical-grade app dedicated to new parents for tracking their baby's development. Through so-called insights, the uGrow app seeks to provide a data-driven solution by offering parents personal advice that is sourced from user-tracked behavioral and contextual data.

OBJECTIVE

The aim of this study was twofold. First, it aimed to give a description of the development process of the insights for the uGrow app. Second, it aimed to present results from a study about parents' experiences with the insights.

METHODS

The development process comprised 3 phases: a formative phase, development phase, and summative phase. In the formative phase, 3 substudies were executed in series to understand and identify parents' and health care professionals' (HCPs) needs for insights, using qualitative and quantitative methods. After the formative phase, insights were created during the development phase. Subsequently, in the summative phase, these insights were validated against parents' experience using a quantitative approach.

RESULTS

As part of the formative phase, parents indicated having a need for smart information based on a data analysis of the data they track in an app. HCPs supported the general concept of insights for the uGrow app, although specific types of insights were considered irrelevant or even risky. After implementing a preliminary set of insights in a prototype version of the uGrow app and testing it with parents, the majority of parents (87%) reported being satisfied with the insights. From these outcomes, a total of 89 insights were implemented in a final version of the uGrow app. In the summative phase, the majority of parents reported experiencing these insights as reassuring and useful (94%), as adding enjoyment (85%), and as motivating for continuing tracking for a longer period of time (77%).

CONCLUSIONS

Parents experienced the insights in the uGrow app as useful and reassuring and as adding enjoyment to their use of the uGrow app and tracking their baby's development. The insights development process we followed showed how the quality of insights can be guaranteed by ensuring that insights are relevant, appropriate, and evidence based. In this way, insights are an example of meaningful DDI.

SAFE@HOME - Feasibility study of a telemonitoring platform combining blood pressure and preeclampsia symptoms in pregnancy care

OBJECTIVE

To study the feasibility of a telemonitoring platform for hypertensive disease in pregnancy, consisting of a wireless blood pressure monitor and an app in combination with an integrated preeclampsia symptom checklist.

STUDY DESIGN

Prospective observational study with 14 pregnant women during a 15 weekday study period. For feasibility purposes, compliance was measured by evaluating the number of entered BP and symptom checklists. Comparing all the entered values with the threshold values checked the accuracy of the automatic alerts. Usability and patient satisfaction were measured using questionnaires.

RESULTS

Compliance rates for blood pressure and symptom checklist were 93% and 85% respectively. No false positive or missing alerts were found in the alarm system. The telemonitoring system alarmed 7 times for BP thresholds (3.8% of all received values), Of 167 returned symptom checklists, 93% of symptom alarms could be handled with expectant management because of concurrent normal blood pressure. The majority of participants were satisfied with the system.

CONCLUSIONS

This is the first feasibility study of a telemonitoring platform, combining remote monitoring of BP with preeclampsia symptoms in pregnancy care. Action from health care providers during telemonitoring is only needed in case of alarming combinations of results. This system is potentially very useful in care for women at risk for hypertensive disorders during pregnancy.

Internet usage of women attempting pregnancy and pregnant women in the Netherlands

OBJECTIVES

Research focused on Internet behavior by women attempting pregnancy and pregnant women is scarce. Some research has been done in other countries, however it cannot be assumed those results also apply to Dutch women.

STUDY DESIGN

A descriptive cross-sectional study was performed using an Internet-questionnaire among women attempting pregnancy and pregnant women.

MAIN OUTCOME MEASURES

The aim of this study was to identify the Internet behavior of women attempting pregnancy and pregnant women in the Netherlands.

RESULTS

In total, 365 women completed the questionnaire. Of these, 95.6% used the Internet as an information source before or during their pregnancy. Most searched topics were fetal development, lifestyle and pregnancy as well as birth complications. Over 90% of the women thought the information found was reliable and based pregnancy related decisions on this information. However, only 50.1% of the women discussed the information found with their caregiver. Of the respondents, 76.2% thought a reliable website is needed provided by the caregivers.

CONCLUSIONS

A vast majority of Dutch women attempting pregnancy and Dutch pregnant women use the Internet to search for information and to make decisions about their pregnancy, however they were not satisfied with the information available online. A reliable, informative, interactive and up-to-date website is deemed necessary.

Development and pilot evaluation of a pregnancy-specific mobile health tool: a qualitative investigation of SmartMoms Canada

Background

Mobile technology is ubiquitous. Women of childbearing age have embraced health information technology for pregnancy-related counsel as prenatal care provider communication is increasingly scarce and brief. Pregnant women and new mothers place high value in the use of online sources to support their pregnancy information needs. In Canada, over 300,000 women are pregnant annually, with approximately 60% exceeding evidence-based weight gain recommendations. Mobile health (mHealth) tools, such as mobile applications (app), have the potential to reduce excessive gestational weight gain, offering pregnant women trustworthy guidance, ultimately improving the health outcomes of mothers and infants. Therefore, the primary aim of this study was to implement a qualitative, descriptive research design to assess the receptiveness, functionality, and future prospective of the SmartMoms Canada mHealth app.

Methods

Two focus groups (n = 13) involving both currently pregnant and recently postpartum women were organized on the same day. Focus groups were transcribed verbatim and thematic analysis was undertaken using manual coding and NVivo software. Participants who took part in the focus groups (n = 13) and those who could not attend (n = 4) were asked to complete a Likert-scale survey. All survey responses (n = 17) were analyzed using simple tabulation and percentage analysis.

Results

Participants were technologically proficient and interacted with several mHealth tools prior to testing the SmartMoms Canada app. Six major themes emerged from thematic analysis: knowledge of pregnancy-specific mHealth services, knowledge and attitudes of weight gain guidelines, weight tracking, strengths of the app, critique and lastly, future suggestions for the app.

Conclusions

Our thematic analysis found that women positively viewed the future potential of our app and offered constructive feedback to improve the next version. Participants sought more personalization and enhanced app interactivity, along with promotion of overall maternal health including nutrition and mental health, in addition to weight tracking.

Home sperm testing device versus laboratory sperm quality analyzer: comparison of motile sperm concentration

OBJECTIVE

To test the ability of the smartphone-based YO Home Sperm Test to accurately and precisely measure motile sperm concentration (MSC) versus the SQA-Vision, an automated laboratory semen analyzer.

DESIGN

MSC compared for the YO device on Galaxy and iPhone smartphones versus the SQA-Vision in a double-blind manner.

SETTING

Academic medical center.

PATIENT(S)

Donor semen samples from 24 men in 144 aliquots.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Accuracy, precision, and agreement assessed between the YO device and the SQA-Vision for MSC results.

RESULT(S)

The YO device demonstrated good correlation and good to moderate agreement with the SQA-Vision for MSC results up to a range of 94 × 10⁶/mL with Pearson and concordance correlation coefficient above 0.92. The YO also showed a very high level of accuracy (97.8%) with positive and negative percent agreement above 94%. The difference in coefficient of variation between the YO and the SQA-Vision was low (between 9.4% and 11.2%) and not statistically significant. The precision among the YO phone devices was lower (16.0%) than the manufacturer's claim of ≤20%.

CONCLUSION(S)

The smartphone-based device has a high level of accuracy and precision when compared with the SQA-Vision. It can detect samples with abnormally "low" MSC (below 6 × 10⁶/mL cutoff), which supports its use as an effective home sperm test for screening "low" and "moderate/normal" MSC cases. In addition, the device effectively identifies varying levels of normal MSC in a precise manner over a wide range of normal MSC. Thus, the YO Score can improve patient satisfaction and empowerment.

Validation of the iHealth Track and Omron HEM-9210T automated blood pressure devices for use in pregnancy

OBJECTIVE

Self monitoring of blood pressure in pregnancy is increasingly popular with both health care professionals and patients. We assessed the validity of the iHealth Track and Omron HEM-9210T automated blood pressure devices (with Bluetooth connectivity) for the use in telemonitoring of blood pressure in pregnancy.

METHODS

In this prospective observational study, the revised 2010 International Protocol of the European Hypertension Society (EHS) was used for the validation of the two devices against auscultatory sphygmomanometry by two independent observers who took 13 same arm measurements in 33 pregnant women, of which 10 were diagnosed with preeclampsia. The measurements were alternated between the test device and a calibrated aneroid sphygmomanometer following the protocol. Both automated devices were assessed sequentially in the same women.

RESULTS

In the group of 33 women, the iHealth Track passed the EHS 2010 validation criteria with 86/98/99 of 99 device-observer systolic measurement comparisons and 88/96/98 of 99 device-observer diastolic measurement comparisons within the 5/10/15 mmHg boundaries respectively. The Omron HEM-9210T passed the same criteria with 85/94/99 of 99 device-observer systolic measurement comparisons and 82/95/99 of 99 device-observer diastolic measurement comparisons.

CONCLUSIONS

The iHealth Track and Omron HEM-9210T automated blood pressure monitors are validated for use in pregnancy. These two devices can now be added to the short list of validated devices in pregnancy and can be used for self-measurement of blood pressure in a telemonitoring setting of pregnant patients with (a high risk of) hypertensive disease.