Prenatal mobile applications reported in the scientific literature: a scoping reviewABSTRACT
Objective: To map the prenatal mobile applications described and/or evaluated in the scientific literature.
Method: Scoping review, based on JBI recommendations, with a time frame from 2017 to 2022. The searches were carried out in October/2023 in the following databases/portals: Lilacs via BVS, Web of Science, MEDLINE, Cochrane Database of Systematic Reviews, Scopus, CINAHL, and the Thesis and Dissertation Bank of the Coordination for the Improvement of Higher Education Personnel (CAPES).
Results: Forty-nine studies were analyzed, including 45 articles, three dissertations and one thesis, published in Portuguese and English. The applications are intended for health education/self-care (46.9%), clinical monitoring (28.5%), for use by health professionals (16.3%), research/data collection (6.1%) and professional education (2%).
Conclusion: The applications described and/or evaluated in the studies are diverse in their purposes and public and confirm the inclusion of mobile technology in the care and health monitoring of pregnant women.
DESCRIPTORS
Mobile Applications; Prenatal Care; eHealth Strategies; Review; Nursing Informatics
RESUMO
Objetivo: Mapear os aplicativos móveis de pré-natal descritos e/ou avaliados na literatura científica.
Métodos: Revisão de escopo, a partir das recomendações da JBI, com recorte temporal de 2017 a 2022. As buscas foram realizadas em outubro/2023 nas bases/portais Lilacs via BVS, Web of Science, MEDLINE, Cochrane Database of Systematic Reviews, Scopus, CINAHL e Banco de Teses e Dissertações da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES).
Resultados: Foram analisados 49 estudos, sendo 45 artigos, três dissertações e uma tese, publicados em português e inglês. Os aplicativos possuem finalidade para educação em saúde/autocuidado (46,9%), monitoramento clínico (28,5%), para uso por profissionais de saúde (16,3%), pesquisa/coleta de dados (6,1%) e ensino profissional (2%).
Conclusão: Os aplicativos descritos e/ou avaliados nos estudos são diversos em suas finalidades e público e confirmam a inserção da tecnologia móvel no cuidado e monitoramento em saúde das gestantes.
DESCRITORES
Aplicativos Móveis; Cuidado Pré-Natal; Estratégias de eSaúde; Revisão; Informática em Enfermagem
RESUMEN
Objetivo: Mapear las aplicaciones móviles de prénatal descritas y/o evaluadas en la literatura científica.
Método: Revisión de alcance, basada en recomendaciones del JBI, con un horizonte temporal de 2017 a 2022. Las búsquedas se realizaron en octubre/2023 en las bases/portales Lilacs vía BVS, Web of Science, MEDLINE, Base de datos Cochrane de revisiones sistemáticas, Scopus, CINAHL y Banco de Tesis y Disertaciones de la Coordinación para el Perfeccionamiento del Personal de Educación Superior (CAPES).
Resultados: Se analizaron 49 estudios, entre ellos 45 artículos, tres disertaciones y una tesis, publicados en portugués e inglés. Las aplicaciones están destinadas a educación sanitaria/autocuidado (46,9%), seguimiento clínico (28,5%), uso de profesionales sanitarios (16,3%), investigación/recopilación de datos (6,1%), y educación profesional (2%).
Conclusión: Las aplicaciones descritas y/o evaluadas en los estudios son diversas en sus propósitos y destinatarios y confirman la inserción de la tecnología móvil en la atención de salud y seguimiento de las mujeres embarazadas.
DESCRIPTORES
Aplicaciones Móviles; Atención Prenatal; Estrategias de eSalud; Revisión; Informática Aplicada a la Enfermería
INTRODUCTION
Brazil has an estimated population of over 200 million inhabitants, who use around 447 million mobile devices, using them for an average of 3h41min/day. Therefore, the density of mobile devices is of more than two devices per inhabitant and its time of daily use exceeds the world average of 2h22 min/day(1,2). Such data demonstrate how much mobile technology is embedded in the daily lives of Brazilians and this applies equally to health, in which information and communication technologies are increasingly integrated(1).
From this integration, new interdisciplinary and complementary concepts emerge, among which are electronic health (eHealth) and its branch, mobile health (mHealth), which generally summarize in their definitions the health practices carried out by electronic, wireless and/or mobile devices, such as cell phones and applications(3,4).
In recent years, the healthcare field has been profoundly influenced by the advancement of mobile technologies. The growing penetration of these devices in modern society has exponentially increased the use of mobile applications in the most diverse areas(5).
One of the most explored areas in mHealth has been maternal and child health, especially the prenatal period. Studies show the impact of mobile applications on various possibilities in this context, including health education for pregnant women(6), appointment reminders(7), communication with the professional who provides care during pregnancy(8), among others.
Prenatal care is essential in promoting maternal and fetal health, preventing complications, and ensuring healthy development during pregnancy(9). In this sense, mobile technologies present themselves as potentially valuable tools to improve the quality and access to information and prenatal care(10).
Thus, this study seeks to fill a gap in knowledge by mapping the prenatal mobile applications described in the scientific literature and/or evaluated in use. This description is relevant at a time when health technologies are gaining prominence in the global health scenario and review studies on applications have been based on searches in application stores such as the Apple Store and Google Play.
This research benefits pregnant women, healthcare professionals, and app developers by providing recommendations for improving mobile apps. It aims to provide an overview of the applications described and/or evaluated on prenatal care, contributing to informing clinical practices and guiding future technological innovations in the field of prenatal care through mobile applications.
Therefore, the objective of the study was to map the prenatal mobile applications described and/or evaluated in the scientific literature, in a temporal frame.
METHOD
Design of Study
Scoping review study conducted based on the recommendations of The Joanna Briggs Institute (JBI)(11) and in accordance with the recommendations of the guideline Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). The study protocol was published in Open Science Framework: https://doi.org/10.17605/OSF.IO/8MC96.
Development of the Research Question
The PCC mnemonic structure was used(12): P (population) – pregnant women and health professionals; C (concept) – description and/or evaluation of mobile applications; C (context) – health activities related to prenatal care. The guiding question was developed: What mobile applications are described and/or evaluated in the scientific literature on health activities related to prenatal care for pregnant women and/or health professionals?
The search was conducted in October 2023.
Eligibility Criteria
Considering the updates in health policies for pregnant women, a time frame was defined for the study. Studies published from 2017 to 2022, in English, Portuguese or Spanish, available in full and that presented a description and/or evaluation of mobile applications (for smartphone) in the context of prenatal care, for professional health users or pregnant women.
Research Strategy
The sample was selected from the Coordination for the Improvement of Higher Education Personnel (CAPES) journals website, through the VPN (Virtual Private Network) service from the Universidade Estadual de São Paulo (Unesp), unespNET network, and in the search for articles in the databases/websites Latin American and Caribbean Literature in Health Sciences (Lilacs) via the Virtual Health Library (VHL), Web of Science (WoS), National Library of Medicine (MEDLINE), Cochrane Database of Systematic Reviews (COCHRANE), Scopus and Current Nursing and Allied Health Literature (CINAHL)(Chart 1).
To organize the search strategy, controlled vocabulary terms were selected from the Health Sciences Descriptors (DeCS), Medical Subject Headings Section (MeSH) and CINAHL Headings, combined with boolean operators. A search was carried out in the CAPES Theses and Dissertations Database (Chart 1).
Evidence Source Selection
Research titles and abstracts were read and analyzed to identify those potentially eligible for the study. The next phase involved reading each of the selected surveys in full to: a) confirm the relevance to the review question and, if so, b) extract the data of interest, the final phase.
Data Extraction, Analysis, and Presentation of Results
The results were presented using summary tables and in a descriptive format, in accordance with the recommendations of the PRISMA-ScR guideline.
The selection process is presented, according to the PRISMA-ScR flowchart(13,14)(Figure 1).
PRISMA-ScR flowchart of study selection and inclusion process in scoping review – Botucatu, SP, Brazil, 2023.
The extraction was conducted by two reviewers, cases of disagreement were resolved by a third reviewer. For data extraction, an instrument adapted from the form recommended by JBI was used(11), with the information: Author/year/country/nature of study, Title/objective of work, Name of application/language/operating system/situation (under development or in use), Central theme of the application/target audience.
The data extracted were mapped using the software Atlas.ti(15), for organizing information and analytical process. These were expressed in summary charts, discussed descriptively, and compared to the findings of other related works.
According to Figure 1, 554 studies were retrieved (549 articles, 2 dissertations, and 3 theses). Titles and abstracts were read, 364 (362 articles and 2 theses) were excluded, and 190 works were downloaded (187 articles: Lilacs via VHL – 34, SCOPUS – 50, MEDLINE – 28, WoS – 6, CINAHL – 44, and COCHRANE – 25; 1 thesis and 2 dissertations), eligible for full reading. After excluding duplicates (61), 129 works were read in full (126 articles, 2 dissertations, and 1 thesis).
At this stage, 84 studies were excluded because they did not deal with applications for use in smartphones or addressed interventions using applications already described in other works analyzed/included in the review. The reference list of the included studies was also analyzed (3 articles and 1 dissertation were added).
RESULTS
Once the criteria have been applied, after reading and critically analyzing the publications, 49 studies were included, being 45 articles, 3 dissertations and 1 thesis, published between 2017 and 2022, predominantly in English (79.6%) and Portuguese (20.4%). Regarding the country of origin, they were developed by researchers from the Americas (44.8%) (Brazil 11, Canada 1, USA 10, Dominican Republic 1), Asia (24.4%) (Indonesia 1, China 1, Singapore 1, Japan 1, India 1, Iran 2, Israel 1, Malaysia 1, Oman 1, Republic of Korea 1, Taiwan 1), Europe (20.4%) (Germany 1, United Kingdom 2, Netherlands 2, Denmark 1, Ireland 1, United Kingdom 1, Italy 1, Norway 1), Africa (6.1%) (Nigeria 1, Kenya 1, Tanzania 1), and Oceania (2%) (Australia 1).
The following research designs were observed: randomized clinical trials (22.4%), methodological studies (24.4%), descriptive studies (20.4%), clinical study protocols (8.1%), cohort studies (8.1%), non-randomized clinical trials (4%), and other research designs (12.2%) (experimental, exploratory, mixed methods, applied, observational, qualitative and quantitative studies).
Conceptual categories were organized according to the purpose of the mobile application presented in the studies: health education/self-care (46.9%), clinical monitoring (28.5%), for use by professionals (16.3%), research/data collection (6.1%), and professional education (2%).
The results of the studies analyzed are presented in Charts by characteristics of mobile applications for the purposes of: literacy, self-care and health education for pregnant women and intervention (Chart 2); clinical monitoring (follow-up, registration, telemonitoring, consultation, monitoring of pathologies and clinical conditions – gestational diabetes mellitus, syphilis, prematurity, psychological aspects, etc.) and intervention (Chart 3); use by health professionals, related to the care of pregnant women (Chart 4); and research/data collection or recruitment of pregnant women for research, intervention, and professional education (Chart 5).
Characteristics of mobile applications for literacy, self-care, and health education purposes for pregnant women and intervention – Botucatu, SP, Brazil, 2023.
Characteristics of mobile applications for clinical monitoring and intervention purposes – Botucatu, SP, Brazil, 2023.
Characteristics of mobile applications for use by health professionals involved in the care of pregnant women and intervention –Botucatu, SP, Brazil, 2023.
Characteristics of mobile applications for research/data collection or recruitment of pregnant women for research, intervention and teaching in obstetric nursing – Botucatu, SP, Brazil, 2023.
As to applications for purposes of literacy, self-care and health education for pregnant women (Chart 2), it was identified that four of these were developed to promote prenatal care or even for specific conditions such as COVID-19 and syphilis. Eight (16.3%) applications were used for intervention, either in the evaluation of use in relation to monitoring of clinical conditions (weight gain, COVID-19), adherence to consultations, and encouragement of self-care with information on a healthy lifestyle.
Six (12.2%) applications were evaluated, either globally or in a specific function, regarding the acceptability of their use for telemonitoring and regarding the collection of feedback to improve the application functionality and accessibility. Three (6.1%) were evaluated for effectiveness in promoting treatments, adherence to vaccines, best practices in prenatal care and scheduling of appointments. One (2%) application for fighting mortality was in the process of cross-cultural adaptation for Brazil and one (2%) was evaluated for content quality.
Chart 3 presents studies on clinical monitoring applications. Three (6.1%) studies were identified regarding the development of applications aimed at monitoring and controlling syphilis, and one identified requirements for the ideal application. Six (12.2%) studies carried out intervention using applications and evaluated several aspects: patient-professional communication, potential for monitoring (gestational diabetes mellitus, postpartum oral glucose tolerance, psychological aspects, blood pressure combined with smartwatch) and the effect of using mobile technology in monitoring combined with reinforcement of Community Health Agents (ACSs).
Three (6.1%) studies evaluated the effectiveness of scheduling and delivering brief cognitive-behavioral therapies to treat maternal depression. Two other studies (4%) evaluated the cost-benefit of applications when compared to traditional monitoring and clinical effectiveness, and finally one aimed to evaluate the acceptability of an application for telemonitoring blood pressure.
In Chart 4, regarding applications for use by professionals, two (4%) studies indicated the development of an application to capture health information, access exams, and to assist care during the COVID-19 pandemic. Three (6.1%) evaluated the functionality and viability of the applications when they were used to provide prenatal care or to assist the work of community health workers. One (2%) study evaluated the impact of implementing the application on birth outcomes, through its use for communication between ACSs and the health team, which directed care. Two other studies (4%) standardized assistance, both through guidance provided by the application and through standardization of the language used among professionals.
Chart 5 presents three (6.1%) studies addressing applications developed or in use as an accessible means to support data collection for scientific research involving pregnant women, and one (2%) study demonstrated the development and use of an application for professional education.
DISCUSSION
Mobile applications have supported several health activities, in the context of prenatal care, assisting in health literacy, self-care, clinical monitoring by the user and health professionals, as well as for nursing education purposes.
Health literacy is potentially facilitated by the support of applications, whose use has been shown to be positive for parental education in prenatal care for pregnant women at risk of premature birth(16), identification of the need to address psychosocial aspects of high-risk pregnancy and preparation for possible hospitalization, preterm birth and neonatal hospitalization(37), promotion of self-care during the COVID-19 pandemic, as well as provision of information, and guidance on medications and complications of COVID-19 during pregnancy(27,36).
Intervention studies have shown that the use of applications was effective for monitoring clinical conditions, promoting communication between the healthcare team and pregnant women(8), in the adherence of pregnant women to prenatal consultations, improvement of healthy practices, self-care during prenatal care(8,18,25)), health literacy of pregnant women in the context of the pandemic(34), and personalized vaccine information(33).
Regarding the applications already developed that were being evaluated globally or in any of its functions, the studies showed positive usability and acceptability. They showed positive use for telemonitoring and provision of information on glycemic index, via technology, in rural areas and in developing countries(22), facilitating maternal and child care in an interactive and educational way(35), with high clinical efficacy in maternal mental health, promoting psychological support for fathers and mothers, through reliable sources of information(24,30) and good evaluation perceived even when only the interface for the birth plan was evaluated(26).
Studies(23,26) analyzed feedback from users and identified that the design used influences their interaction with the application. Positive results were found in the use of interactive interfaces that offer content with information to the user.
Studies have evaluated the effectiveness of applications in terms of reminding pregnant women about influenza vaccination and improving their knowledge about the vaccine, promoting positive attitudes towards vaccination(32). Furthermore, Sidik(31) proposed the development of an application according to an intervention mapping, evaluated for effectiveness in providing guidance for the treatment of urinary incontinence in pregnant women.
The application SweetMama was implemented as a mobile health intervention for low-income pregnant women with gestational diabetes, and has been shown to be easy to use, efficient, and potentially impactful, designed to meet the unique needs of this population(28).
In addition to the development and evaluation of applications, a study(34) proposed the cultural adaptation of an application to combat maternal mortality, from English to Brazilian Portuguese. Zero Mothers Die is an application with information about the prenatal routine of health facilities with teaching activities, which can provide channels for dialogue with pregnant women and updating of professionals in training(17).
The concern with the clinical monitoring of certain conditions that may emerge during pregnancy or that affect the pregnant woman directly or indirectly was highlighted in studies, both in development proposals and/or clinical trial protocols, and in interventions using such tools(46,49).
A study should be highlighted(43) in which the authors developed the application SELP with information in text and video about the signs, symptoms, causes, risks, and treatment for syphilis. The technology applies mapping resources to locate health centers, creates alerts for pregnant women and their partners about treatment dates, and maps the contact network of syphilis carriers anonymously(43).
Mobile applications are an important tool for optimizing time and shortening distances. Because they are easy-to-access and quick-to-consult tools, they have proven to be effective in reducing in-person visits, favoring virtual care for pregnant and postpartum women, and reducing waiting times for emergency services and professionals, given their communication resources(39,42). In addition to the possibility of communicating with a professional for care, several studies demonstrate the effectiveness of applications in telemonitoring blood pressure (BP) in pregnant women(45,48,51).
It was possible to promote BP monitoring in pregnant women using a smartwatch in conjunction with a mobile application; there was a reduction in the number of antenatal outpatient visits for BP-related reasons compared to management according to local guidelines and cost savings with the use of the application(45,51). The solution has demonstrated potential for adoption in healthcare systems in developing countries, given the application simplicity and accessibility(51).
Another feature, of sending alerts to start repeated BP measurements, combined with alerts for self-reported symptoms of pre-eclampsia, also demonstrated clinical relevance(48).
Daily feedback and communication intervention between patients and healthcare team improved patient adherence and glycemic control, and reduced the rate of insulin treatment(38).
In contrast, when analyzing the effect of using an application for pregnant women (Pregnant+) in women with diabetes mellitus in Norway, the results showed that the use of the application had no effect on the main outcome of glucose monitoring and reduction of rates(44). This finding may be related to the fact that the technology was not developed specifically for this purpose, which may compromise the effectiveness of the telemonitoring strategy.
In terms of impact on perinatal mental health, a tool for self-reporting psychological well-being has shown potential in allowing greater understanding of well-being in pregnancy(40). Another study(41) presented the need to promote cognitive-behavioral therapy using mobile technology, and demonstrated the effectiveness of the application in improving mental health services in obstetric practice. Interventions like this can help in early identification, monitoring, and treatment of women at high risk of developing psychiatric symptoms during pregnancy, besides having the potential to provide information based on scientific evidence, helping them to identify anxieties and insecurities during this period and seek support.
Mobile applications have a development and maintenance cost on digital platforms. Therefore, cost-effectiveness assessment studies are also described.
A study(47) carried out a financial analysis (return on investment) in which a group of pregnant women (intervention group) received a smartphone with internet and access to a personalized prenatal platform (evaluated in the study) with automated text messages, chat function and hyperlinks, and weekly contact from the ACS. The control group received usual prenatal care and printed educational materials. The intervention received positive evaluations from users and gained ground in adherence to prenatal care and improvement of birth outcomes in rural communities. The financial impact analysis showed positive cost-effectiveness results for the intervention, producing reduced healthcare costs for the intervention group, compared to the control group, with an overall average savings difference of US$1,079 for intervention participants.
Given the versatility and accessibility of the applications, they were also used as resources, for easy and quick access to recruit participants for scientific research involving pregnant women(59). Using applications for participant recruitment allows for real-time data and instant access to data, as well as having the ability to contact people from multiple locations(61), a promising strategy for recruiting large and diverse samples(60).
The versatility of applications has allowed their use to be integrated with other health tools or platforms, to implement prenatal care and access information about pregnant women, even in places with low internet availability(61) or during the COVID-19 pandemic(57), optimizing the quality and effectiveness of services and promoting health.
In addition to helping to assist pregnant women, applications have been used by health professionals to provide prenatal care recommendations, based on structured guidelines and recommendations. Some results are observed, such as improved communication between patients and caregivers(52), systematization of home visits and qualification of prenatal and postnatal care, together with the care of more complex cases, facilitated by the possibility of contact between the ACS and the health team(53,54).
The use of smartphones as a component of intervention packages aimed at safe motherhood can improve the support and effectiveness of ACSs(58) and other health professionals’ work, improving patient adherence rates to prenatal exams and follow-up, by providing information during pregnancy and the perinatal period(56).
Besides the applications developed to offer care via mobile phones, a study(56) proposed the construction of an application for mobile devices, to make the Terminological Subset of Women’s Health, Prenatal and Postpartum care available from the Portuguese translated version of the International Classification for Nursing Practice (ICNP®). Another study(62) proposed the development of an application for teaching obstetric nursing.
These proposals demonstrate a new profile of mobile applications aimed at supporting the assistance provided by professionals and helping students in the teaching-learning process of specific skills for obstetric nursing.
Study Limitations
Limitations of the study should be considered. A time frame from 2017 to 2022 was considered, limiting the analysis of scientific production to a specific period. The methodological quality of the studies was not assessed. Some included studies did not present complete information on the applications and, sometimes, characterization information, such as operating system, language, and status (under development or in use), was missing. It was not possible to assess the scientific basis of the content of the applications with criteria; however, it is worth noting that dissemination in scientific publications makes them more reliable for recommendation/use in prenatal care.
Contributions to Health-Related Research
This review provides a comprehensive overview of the mobile applications described/evaluated in the scientific literature, in the context of monitoring pregnant women in different clinical situations during the prenatal period. They promote access to information in the context of prenatal care using mobile technology, both for pregnant women and their partners, health professionals and students. Considering the publication of application review studies that start from the analysis of application stores, this review starts from applications published in scientific productions, which allows greater confidence in the recommendations indicated. Furthermore, this study provides recommendations for the development and evaluation of mobile health technologies.
CONCLUSION
Health technologies are increasingly gaining prominence on the global stage. Therefore, characterizing the mobile applications used or designed to monitor pregnant women based on scientific literature provided a broader view of these technologies and their forms of use.
The studies analyzed brought versatile and varied mobile applications, whose use confirms the potential for the insertion of mobile technology in different care scenarios and in monitoring pregnant women’s health. Furthermore, whether used by professionals, health students or pregnant women themselves, the applications above-mentioned have been widely used in the areas of literacy, self-care, health education for pregnant women, clinical monitoring and intervention, teaching in obstetric nursing, and for data collection or recruitment of pregnant women for research.
Future developments may be necessary so that applications can be evaluated using instruments that consider technical aspects, safety, quality of these solutions or even explore the potential of applications in other interfaces, monitoring pregnant women throughout prenatal care, expanding the results presented in this study.
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