Pregnancy in the digital health era: exploring digital health usage amidst the COVID-19 pandemic

doi:10.21203/rs.3.rs-2115070/v1

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Pregnancy in the digital health era: exploring digital health usage amidst the COVID-19 pandemic

https://doi.org/10.21203/rs.3.rs-2115070/v1

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Digital health tools such as apps are being increasingly used by women to access pregnancy-related information. Conducted during the COVID-19 pandemic, this study investigated pregnant women’s usage of digital health tools and self-monitoring behaviours. In addition, views and interest in theoretical pregnancy app features: (1) a direct patient-to-healthcare-professional communication tool and (2) a novel body measurement tool was assessed. Using a mixed methods approach, 108 pregnant women were surveyed and 15 currently or recently pregnant women were interviewed online. We found that the COVID-19 pandemic had impacts on multiple dimensions of the experiences of pregnant women including their experiences with healthcare, their relationships with themselves and their social circle. Most participants said that they would use the theoretical app features we described and also identified a gap in the availability of evidence-based educational information. Other features that they would include in a pregnancy app were a “Digital Wallet” and a desire for a holistic pregnancy app that allowed for more continuous and personalised care. The main factor that influenced how likely participants were to use pregnancy apps were concerns about data privacy and security. This study highlights the gaps and needs of pregnant women and should inform all stakeholders designing pregnancy digital healthcare. This study offers a unique insight into the experiences of pregnant women during a very particular and unique period in human history.

Digital Health

Pregnancy

COVID-19 Pandemic

Maternal and neonatal disorders were among the top ten causes of global burden of disease in 2019 [1]. Better access to perinatal healthcare would help to reduce preventable morbidity associated with pregnancy [2]. The increase in access to and use of smartphones presents a unique opportunity to transform and improve how women monitor their own health during pregnancy, especially for those in remote regions. Furthermore, the COVID-19 pandemic has emphasized the need for more effective digital health interventions, better data collection, and continuity of care [3–5].

Research demonstrates that pregnant women frequently search the internet and use digital health tools such as apps to access pregnancy-related information [6–8]. The usage of pregnancy apps either persisted or increased during the COVID-19 pandemic, partly due to the decreased access to in-person healthcare services [9]. However, several recent scoping reviews and cross-sectional studies have highlighted the need for better quality apps with greater content credibility [8, 10–14]. Most pregnancy apps are primarily focused on providing educational information, and do not include self-monitoring features, which can assist with behaviour changes that lead to improved healthcare outcomes [12, 15]. Additionally, pregnant women are eager for app features to connect pregnant users to healthcare professionals [9].

Monitoring body shape changes using anthropometry (e.g., measuring weight) during pregnancy can indicate the risk of developing certain health conditions such as gestational diabetes (GDM), obesity, pre-eclampsia, and the need for a caesarean delivery [16–19]. These potential risks are not isolated to the expectant mother, as they can result in neonatal premature birth, neonatal mortality, and early childhood obesity [20–22]. Historically, the most common anthropometric measurement used for perinatal health assessment is pre-pregnancy Body Mass Index (BMI). However, this measure does not capture the distribution and the percentage of a person’s body fat nor their genetic risk of disease. As such, two people with completely different body shapes and sizes can fall into the same BMI category yet have drastically different risk profiles for developing adverse health outcomes [23–26].

Monitoring BMI as well as gestational weight gain (GWG) is now the standard approach. However, other anthropometric and health measures in addition to BMI and GWG are needed to help stratify disease risk as not all individuals are at equal risk of developing certain diseases such as GDM and preeclampsia [27, 28]. For instance, a prediction tool for the early identification of GDM in pregnant women with obesity combined anthropometric measures with other measures such as blood pressure to identify women at high-risk for GDM [29].

Furthermore, another downside of using simple anthropometric measurements such as pre-pregnancy BMI and GWG is that it is difficult to develop guidelines that encompass all ethnicities and physical differences, including those seen in people with disabilities [30, 31]. As such, other more specific anthropometric measurements should also be taken to allow for the development of more inclusive guidelines and prediction tools. Moreover, studies reporting the reliability and accuracy by which doctors take anthropometric measurements revealed that while BMI is reliably measured, measures of hip circumference, waist circumference, and waist-to-hip ratio are measured less reliably especially in patients with obesity [32, 33]. Thus, novel digital approaches to taking body measurements should be explored to allow for more consistent and convenient measurements.

The overarching aim of this study was to evaluate how willing pregnant women would be to self-monitor their bodies using digital health tools, and whether they would find these tools useful. To help gauge their attitudes more tangibly, we asked them about a hypothetical app, which extracts digital measurements of the body from photos taken by users on their smartphones and allows for direct communication with their healthcare professionals. In addition, using a combination of online surveys and interviews, this study also investigated (i) pregnant women’s experiences of pregnancy during the COVID-19 pandemic, (ii) their usage of currently available digital health tools, and (iii) their self-monitoring behaviours.

Study design

A convergent mixed method approach was used. Quantitative and qualitative data were collected concurrently and analysed separately through surveys and interviews. The participants could complete both the survey and interview, but their data were not linked. The study findings and interpretations were triangulated from the combined data. At the end of both the surveys and interviews, participants were asked about their thoughts on two theoretical app features: (1) a digital tool that would allow them to communicate with their chosen healthcare professionals, and (2) a body measurement tool, that extracts digital measurements of their body from photos taken on their smartphone. Specifically, participants were asked if they would be comfortable taking photos of their entire body or body parts regularly in an app that monitors how their body is changing and would give feedback about those changes. If participants wanted further elaboration, examples were provided of how the measurement tool could be used (such as, using the tool to monitor whether swelling in the ankle region was increasing or decreasing). Participants were then asked if they would feel comfortable communicating with and sharing health information with their chosen healthcare professionals.

Ethics Approval

Ethics approval was obtained from Nepean Blue Mountains Local Health District Human Research Ethics Committee (Ethics approval number: ETH00580). Online consent was obtained from all participants.

Recruitment

Participants were eligible to complete the survey only if they were women who (1) were currently pregnant, (2) were able to provide consent, and (3) were English literate. Participants were eligible for the interviews only if they met the criteria described above and if they were recently pregnant in the last 12 months. Eligibility was assessed for interview and survey participants upon completion of an online form. All participants were recruited online or in person at the Nepean Hospital Antenatal Clinic, Australia. Online recruitment was conducted via social media posts and advertisements as well as via email newsletter advertisements. All participants had the option to provide their contact details at the end of the survey if they wished to express their interest in participating in the interviews. Survey recruitment occurred during November 2020 – May 2022 and the interviews were completed between July 2021- March 2022.

Survey

The online survey questions were modified from existing validated questionnaires or were newly created for this study by the authors. Questions were selected to address the study aims. Questions were modified from questionnaires designed to: (1) assess at risk pregnant women on a national level (PRIMS – Pregnancy Risk Assessment Monitoring System)[34], (2) investigate the use of pregnancy apps [35], and (3) assess body perception attitudes [36, 37]. The survey contained 52 questions and took approximately 20–30 minutes to complete. The majority of the survey questions were closed-ended. Questions were related to respondents’ health and health experiences during pregnancy, their health monitoring behaviour, their attitudes and usage of digital health tools, and thoughts about features included in the proposed app. At the end of the survey, respondents were asked two open-ended questions related to how the COVID-19 pandemic impacted their pregnancy and their use of digital health. Refer to section 2 of the supplementary material for the survey in its entirety.

Interviews

If a participant expressed their interest to participate in an interview at the end of the survey or signed up for an interview via the advertising link, they were contacted and instructed to schedule an interview via Calendly at a suitable time for them. All interviews took place online, via Zoom video communications software, and were conducted by the same interviewer (NL) to ensure consistency. Interviews lasted between 30–60 minutes (mean = 45 min, range = 33–70 min) and were semi-structured to allow for open discussion and elaboration of particular responses. Interview questions were created by the authors or modified from questions designed to assess weight related attitudes [16]. The demographic characteristics of the interview participants were established during the interviews. Interviews were recorded on Zoom and a digital voice recorder as a backup and the audio was transcribed automatically using Otter.ai software. The transcripts were proofread and imported into NVivo 12 for coding and analysis.

The coding structure was first defined via an iterative process. Three authors (CP, CC, and NL) coded one initial interview and discussed the coding structure. Two authors (CP and NL) then coded two different interviews and finalised the coding structure. Coding between authors of these interviews was found to be highly consistent. One author coded all 15 interviews (NL) while another author coded 9 interviews (CP). Figure 1 illustrates the coding structure used. Once the interviews were coded, a coding comparison query was run in NVivo to numerically assess percentage agreement between coders (percentage of interview transcripts that should be coded to a specific node or case) and was found to be ≥93%. This confirmed that the coding was consistent. All authors then discussed and confirmed the themes and subthemes based on the coding structure and study aims. Refer to section 2 of the supplementary material for the interview guide in its entirety.

Data Analyses

Analysis of quantitative data

Survey respondents who completed 75% or more of the survey questions were included in the analysis. Multiple logistic regression was used to assess which variable predicted the use of pregnancy apps by survey participants. More specifically, the relationship between (i) BMI, (ii) age, (iii) gravidity, (iv) their usage of digital health more during pregnancy, (v) their belief that they can monitor themselves from home, (vi) any reported health condition and (vii) if they had concerns about data privacy and security issues in pregnancy apps, were the predictor variables, and the ‘use of pregnancy apps’ was the response variable. Predictor variables were selected based on their theoretical and conceptual relevance. Only full survey responses were included in the logistic regression analysis. These results are reported as 95% confidence intervals and adjusted odds ratios. All statistical analyses were completed in R Studio version 4.2.0 (see supplementary section R codes).

Analysis Of Qualitative Data

Common themes and subthemes from qualitative data in both the surveys and interviews were identified using a thematic analysis as described by Braun and Clarke [38]. The research team (CP, NL, and CC) concluded that data saturation for the interviews was met after the analysis was completed. Participants reported relevant demographic information during interviews (whether they were currently pregnant, their location and gravidity). Other demographics were recorded if participants chose to mention them during the interviews (education level and health status).

Data Availability Statement

All data available upon reasonable request to corresponding author.

Demographic data

The demographic characteristics of the 108 survey participants (101 completed and 7 partial responses) are presented in Table 1. Three quarters of the participants (76%) were in Australia. The majority of the participants were between the ages of 18 and 35 (71%), were in their second or third trimesters (84%), were experiencing their first pregnancy (55%), were in the normal and overweight BMI ranges (71%) and reported no health conditions (65%) (See Supplementary Table 1 for more demographic details).

The majority of the interview participants were recently pregnant and in their postnatal period (10/15, 67%), while the rest were pregnant at the time of the interview. Fifty-three percent (8/15) reported that it was their first pregnancy. Majority of participants were in Australia (10/15) (Supplementary Table 2).

Table 1

The demographics of the total of 108 respondents are presented.
Participant Demographics (n 108)
Continent	n	%
Australia	82	75.9
North America	8	7.4
Africa	7	6.5
Europe	7	6.5
Asia	4	3.7
Age	n	%
18–34	76	71.0
35–50	31	30.0
Trimesters	n	%
First trimester (1–13 weeks)	17	15.7
Second trimester (14–27 weeks)	48	44.4
Third trimester (28–42 weeks)	43	39.8
Gravidity	n	%
None	59	54.6
One	36	33.3
More than one	13	12.0
BMI	n	%
Underweight	7	6.5
Normal/Healthy	47	43.5
Overweight	29	26.9
Obesity	25	23.1
Reported health condition *	n	%
Yes	38	35.9
No	69	65.1
* The health conditions respondents selected from include Type 1 and 2 diabetes, hypertension, depression, Polycystic Ovarian Syndrome, non-alcoholic fatty liver disease, obstructive sleep apnoea and other. Ancestry was entered by respondents as free text and grouped into regions.

Outcomes

Four themes arose from the analysis of the interviews: (i) self-monitoring and digital health usage, (ii) interest in the proposed digital health monitoring tools, (iii) willingness to use digital health, and (iv) impacts of the COVID-19 pandemic. The survey and interview results are described within these themes. As the study was conducted during the pandemic, ‘the impacts of the COVID-19 pandemic’ theme influenced all the other themes (Fig. 1).

Impacts Of The Covid-19 Pandemic

The pandemic impacted the pregnancy experiences of all survey and interview participants with their healthcare, with themselves, and with their social circle (a selection of participant quotes are presented in Table 2).

Most survey participants voiced concerns about their mental health. For instance: “My mental health has been shot for most of the pregnancy. I'm worried about having to give birth alone because of lockdown restrictions. I'm worried about catching COVID in hospital but home births are a mission and a half to do without lots of money” [Survey Participant (SP) 141]. Similarly, all interview participants expressed their anxiety regarding the uncertainty associated with the pandemic. Several interview participants also raised that lack of family support due to pandemic restrictions was a barrier during their pregnancy.

The majority of the survey and interview participants expressed their concerns about their partners not being able to attend healthcare appointments, and in particular the uncertainty about whether they could be present during labour. Further, 59 survey participants (out of the 67 who elaborated) reported that social distancing, self-isolation, and quarantine measures experienced during the COVID-19 pandemic impacted the course of their pregnancy negatively. “I have increased anxiety about my own health, the health of my baby, and the impact of COVID-19 on my healthcare during pregnancy” [SP 139].

Access to healthcare for the majority of the survey and interview participants was impacted due to the pandemic. Aside from digital appointment booking tools (e.g., HotDoc app in Australia), only four interview participants were recommended apps by their healthcare facilities or used digital health software to communicate with their healthcare professionals. Others shared their frustration regarding some of their experiences with their healthcare systems. One interview participant explained that their health data was not linked between facilities: “…Because I was seen at the [hospital], and I had to go to [another hospital], which was exactly next door...And both of the hospitals didn't talk to each other. And so, I had to get double the blood tests and explain all the results to each other. And it was all a very strange process.” [Interview Participant (IP) 1]

All the interview participants were anxious about contracting COVID-19 during their pregnancy and thus minimised their healthcare visits and their social interactions. Interview participants also minimised their healthcare visits for the sake of their healthcare professionals and systems and reported that their healthcare professionals also suggested to have more frequent telehealth appointments.

Table 2

The interview quotes related to the impacts of the COVID-19 pandemic theme are presented.
Impacts of the COVID-19 on…	Participant quotes
Participant experiences with healthcare	Access to healthcare “Very concerned with lack of face-to-face visits and check-ups during pregnancy” [Survey Participant 147]. Healthcare systems “We did get the DVD. But we actually don’t have a DVD player (laughter). So yeah, my husband still hasn’t seen the ultrasound of my son” [Interview Participant 8]. Telehealth “I was quite sick through both pregnancies and had to get medication every three days. So, I became very close with my GP. So, talking to him every three days…Telehealth was great. And it saved me having to go in to get my medicine because it was all done over the phone, and they’d send me a script. So that was a lot easier than if it wasn’t the pandemic. So, there’s good and bad to it” [Interview Participant 5]. Healthcare visits “…I’m a…slightly more sort of hesitant to contact my GP [General Practitioner]…So, I think maybe I have a slightly higher threshold for wanting to sort of not burden them…I need to feel like what I’m going to see a GP for is worth their time and worth going into the hospital” [Interview Participant 10]. “I think the pandemic did sort of make me and my healthcare providers only meet when it was really necessary and use digital options where possible. And I felt like they were very good at facilitating and, you know, accommodating for that” [Interview Participant 13].
Participant experiences with themselves	Mental health and anxiety “I think being pregnant in a pandemic is a very particular kind of situation…I think it’s that unpredictable nature of it. That has been quite difficult and very different from my first pregnancy” [Interview Participant 10].
Participant experiences with their social circle (i.e., family, friends, and community)	Family “So, I live in the United States with my husband, and all my family is back in India…It sort of adds in a lot of barriers with respect to the additional support system that you can get.” [Interview Participant 11] “It has meant that my partner may not be able to attend appointments with me; also means my doula may not be able to be present at the birth which is very distressing” [Survey Participant 157].

The pandemic also influenced how willing participants were to use digital health. Of the interview participants, 73% (11/15) agreed that the pandemic has influenced how willing they were to use digital health tools or access information online: “But yes, definitely having COVID as a restriction. Yeah, far more inclined to use a digital tool” [IP 1]. Whereas the remaining participants felt that the pandemic did not influence their willingness to use digital health tools, “I don't think it has changed that much. I think for me when I was accessing apps more frequently, during my first pregnancy, it was more to do with sort of being excited, and it all being new…And I don't feel like the pandemic has sort of prompted me to do more or less of that kind of activity.” [IP 10]

Another factor affecting willingness to use digital health was concerns about data security and privacy. 63% of the survey participants reported having concerns about data privacy and security in relation to using the pregnancy apps. One interview participant mentioned that they did not use pregnancy apps and only searched online while using a private browsing window (e.g., Google chrome incognito mode) “Because I didn’t want to get Ads” [IP 9].

The multiple logistic regression found that, holding all other predictor variables constant, having “no concerns about data privacy and security issues in pregnancy apps” (\(p<.0001\)) was a significant predictor for the likelihood that survey participants used pregnancy apps (95% CI 2.81,7.58: odds ratio = 127.84). BMI, age, gravidity, “feel that they can monitor themselves from home”, “use digital health more now that they are pregnant” and “reported a health condition” were non-significant predictors (Table 3).

Several interview participants mentioned that because of the pandemic they experienced unorthodox situations and sometimes their need for care surpassed their privacy concerns:

“I worked with a lactation consultant when I got home from the hospital. And we had to do virtual appointments because of the pandemic. And that meant that I literally texted her on WhatsApp, like pictures of naked pictures of my boobs, which, you know, is not something that I would have opted to do if there hadn't been a pandemic and I could have seen her in person…But because of the pandemic, I was like, “Great, I hope this doesn't get hacked and leaked somewhere”” [IP15].

Table 3

Results of statistical analyses using logistic regression to determine likelihood of pregnancy app usage. Odds ratios and Confidence Intervals are reported for each test.
Predictor variables	P value	Estimate	Odds ratio	95% Confidence Interval
Likelihood of pregnancy app usage (response variable) Pseudo R² (0.482) and \(\beta\) (-3.631)
Concerns about data privacy and security issues [No]	< 0.0001	4.85	127.84	2.81, 7.58
Concerns about data privacy and security issues [Yes]	0.143	1.58	4.86	-0.40, 3.97
Use digital health more now that they are pregnant [Yes]	0.130	1.24	3.46	-0.40, 2.89
Health condition [yes]	0.139	1.34	3.80	-0.32, 3.30
Feel that they can monitor themselves from home [Strongly Agree]	0.370	-1.55	0.21	-5.00, 2.06
Feel that they can monitor themselves from home [Agree]	0.870	-0.16	0.85	-2.16, 1.76
Feel that they can monitor themselves from home [Disagree]	0.483	0.866	2.37	-1.52, 3.40
Feel that they can monitor themselves from home [Strongly Disagree]	0.490	1.22	3.38	-2.00, 5.29
BMI [Obesity]	0.779	0.26	1.30	-1.54, 2.20
BMI [Overweight]	0.318	1.05	2.86	-0.89, 3.32
BMI [Underweight]	0.369	-1.28	0.28	-4.29, 1.42
Age [35–50]	0.251	0.97	2.64	-0.61, 2.79
Gravidity	0.549	-0.30	0.74	-1.21, 0.80

Self-monitoring And Digital Health Usage

Health information seeking behaviour

Over three quarters of the survey participants (81%) reported that they noticed they used apps and searched the internet more now they were pregnant. This was consistent with the interview participants who also reported using digital health more frequently, “…It’s funny, before I got pregnant, I was kind of on a mission to reduce my phone use and app usage…I’m like I want to do a tech detox…Then I got pregnant and I’m like I want all the information right now…So, I’ll be picking whatever hypothetical app a lot more than I would be if I wasn’t pregnant” [IP 14].

When asked if they use social networking sites at all to access pregnancy-related information, 70% of the survey participants reported that they used Facebook, Instagram, and YouTube most frequently. However, this was not one of their preferred resources, as participants accessed websites (81%) and pregnancy apps (72%) more frequently than social networking sites. When asked which digital pregnancy information they trust, participants reported to trust websites (e.g., blogs and websites with medical information) the most (81%) and social networking sites (e.g., Instagram, Facebook, and Twitter) the least (Table 4). Aside from accessing resources online or via digital health tools when seeking pregnancy-related information, survey participants felt the most comfortable asking their healthcare worker (93%), friend (57%) or family member (58%), and referring to books (61%).

However, some of the interview participants shared how overwhelmed they were by the conflicting pregnancy information found online and that they preferred having one main source for information, which was primarily their healthcare professional, “… I would talk to my GP, and I also had a team of midwives…So anytime I had issues, I just called them. Because I found every time I went online, like all the different information, all the different websites, I didn't know which one to listen to, which one not to follow…It would overwhelm me doing that” [IP 5].

Most survey participants (72%) reported that they used pregnancy apps during their pregnancy. As shown in Table 4, the apps were primarily used as a source of information (65%), for education (42%), for self-monitoring (45%), and for reassurance that the pregnancy is going well (36%). Similarly, 67% (10/15) of interview participants stated that they used pregnancy apps (See supplementary table 3 for a breakdown of which apps were used). While one of the most common features of pregnancy apps is baby development information and baby size-to-fruit-size comparison, only 4 people used it for that purpose. Of those interview participants that didn’t use pregnancy apps, three explained that they felt they did not need to use it because it wasn’t their first pregnancy, and they knew what to expect.

Most interview participants had concerns about the credibility of information included in apps. Two participants shared similar experiences about using the Pregnancy Plus app, which is currently the most popular pregnancy app on Google Play and Apple App store, “…So, everyone talks about it, and I don’t actually think this is that strongly evidence based” [IP 6]. Participants not only raised their concerns about app information quality, but the lack of personalization in apps. For instance: “…I mean, sometimes it made me less reassured…For example, when I felt so awful, and that carried on into my third trimester and all the apps were telling that I was going to start to feel better…but because it sort of contradicted what the health professionals were saying” [IP 4]. All the interview participants that used pregnancy apps emphasized that the app user experience, interface, and customisability were important factors when deciding which apps to use, “I’m very impatient when it comes to user interfaces, so if something doesn’t work easily for me. I’m gone” [IP 7].

Regarding accessing online information, all the interview participants searched Google to learn more about what they experienced during pregnancy, but most expressed how important it was to not use it as the main source of information. For instance: “The Google results are very frustrating. I think the top results are not very trustworthy.” [IP 3]. Participants expressed concerns about the spread of misinformation, especially amidst the COVID-19 pandemic, “I think you know, the digital space, social media has been particularly useful in the pandemic, but there's just always this risk of misinformation” [IP15]. As a result, participants have become more wary about the authenticity and credibility of online information.

Due to the inherent uncertainty early in the COVID-19 pandemic about vaccine recommendations and safety during pregnancy, many participants were reliant on accessing information through online communities, “…There's just something about anecdotal stuff that's very convincing, but I just have to keep in mind that it's not research based” [IP 6]. Additionally, the restrictions associated with the pandemic increased how frequently participants sourced information online.

Table 4

Survey participant digital health usage
Survey participant self-monitoring & digital health usage	n	%
I feel that I can monitor my pregnancy easily from home.
Strongly Agree	5	4.6
Agree	47	43.5
Do not agree or disagree	23	21.3
Disagree	28	25.9
Strongly disagree	5	4.6
During your pregnancy, what other resources do you feel comfortable to use to access pregnancy-related information?
Asking a health care worker	100	92.6
Reading books	61	61.1
Asking a family member	63	58.3
Asking friends	66	56.5
Leaflets	36	33.3
What online resources do you prefer to use and trust most to access pregnancy-related information
	Prefer to use (%)	Trust most (%)
Websites (i.e., blogs, medical information websites)	80.6	80.6
Using a pregnancy app	72.2	48.2
Social networking sites (i.e., Instagram, Facebook, Twitter, etc..)	33.3	6.5
YouTube videos	25.9	16.7
e-Books	18.5	14.8
Podcasts	16.7	8.3
For what purposes do you use pregnancy apps?
As a source of information	70	64.8
For education	45	41.7
For self-monitoring	49	45.4
For reassurance that the pregnancy is going well	39	36.1
Other	8	7.4

Use of digital health to self-monitor

Interestingly, while most participants used digital health resources to access pregnancy-related information, only 32% (35/108) of survey participants and 30% (5/15) of the interview participants reported using an app to monitor their health. When survey participants were asked whether they agreed or disagreed with the statement “I feel that I can monitor my pregnancy easily from home", only 44% agreed. Four interview participants used apps that were not designed for pregnancy because they could not find pregnancy specific versions. These included Kegel exercise, diet, and calorie counting apps, “…All of the like health tracking…none of it has support for pregnancy, which is very annoying” [IP 3].

One of the more common reasons why interview participants reported not using an app to self-monitor was because they had been pregnant before and knew what to expect. Others had reported that they have their own approaches to self-monitoring, such as note taking, their personal memory, photos, and excel spreadsheets. Interview participants who also tracked a health condition during pregnancy tended to monitor their health more frequently, “…I have chronic hypertension. And I actually just wound up using a spreadsheet to track that” [IP 3].

Further, the interview participants that used apps to self-monitor tracked their weight only when prompted by a notification to record their weight. One remarked that when weight was tracked, no feedback was provided, “And I did track my weight in it. But I mean, that was really just a place to put it, it didn't really provide any feedback or anything.” [Participant 7]

Interest In The Proposed Digital Health Monitoring Tools

All survey and interview participants were asked how comfortable they would be to use two digital health monitoring tools or app features: (1) the body measurement tool described in the study design section of the methods and (2) a digital tool to communicate with their healthcare professionals (Fig. 2).

Communication with healthcare professionals

The vast majority of survey participants (83%) expressed that they would be comfortable sharing the health results generated from the theoretical app with their healthcare professional (e.g., their clinician, midwife or obstetrician) through a secure network. Complementing the survey findings, all the interview participants (100%, 15/15) shared that they would be happy to communicate via an app with their chosen healthcare professional/s: “Oh, of course, I’d love that…It would make it a lot more accessible. But as long as I know that she [their healthcare professional] is the one whom I’m going to be seeing even in my next appointment…That is valuable, you know, that sort of established care, continuous care with one person like that one point of contact.” [IP 11]

Participants also mentioned that they would communicate with their healthcare professional via an app to ask simple questions because communication via the phone or email was not possible or feasible, “…Because sometimes you just have the simple question, and, you know, having to wait for an appointment and go through everything is just harder.” [IP 2]. Alongside this, a common app feature participants mentioned they would find helpful was sending the questions they plan to ask their healthcare professional before their upcoming appointment.

The form of communication within an app that participants preferred was communicating via chat, voice message, or email. A participant shared their experiences communicating with their strength coach via voice message: “Just being able to send her a voice message or a thing on the other communication app we used and then she’d get back to me when it was convenient for her without, you know, having for me to wake up at a certain time…I guess asynchronous communication. And I found that quite helpful.” [IP 9] Participants wished not only to communicate with their healthcare professionals, but also share relevant health data.

Another point participants raised was the difficulties of communicating with multiple healthcare professionals or specialists. One participant explained how difficult it was to remember what their obstetrician wanted them to ask their endocrinologist and suggested how the communication between specialists could be bridged by digital health, “…My obstetrician is a bit old school, but he would often use a voice recorder and record his notes…Maybe something that could just capture a couple of points and then I could play that back to the endocrinologist or vice versa…I think that would be really useful.” [IP 8]

Body measurement tool - measuring the body from photos

About half of the survey participants were willing to take photos of their entire body (43%) and/or body parts (49%) so the app could automatically measure their body changes over time. The majority of people who were willing to take photos of their body parts were also willing to take photos of their entire body (43/52). In line with the survey results, 33% (5/15) of interview participants immediately agreed that they would be comfortable taking photos of themselves and using a body measurement tool, as it would help them monitor their health, quantify changes, and store a collection of pregnancy photos. Most of the interview participants (12/15) were interested in using the body measurement tool to track leg/ankle swelling: “,,,My feet, they started swelling. So, I was taking pictures of them to compare like, okay, is it swollen from last week or this week, but that was towards the end. So, I would use that feature, like to track the swelling on my feet” [IP 2].

Notably, a larger proportion of interview participants (47%, 7/15) expressed that they would use a body measurement tool to measure specific body parts only. These participants were hesitant about taking photos that would include their faces due to privacy and body image concerns: “Because you mentioned ankles, I think I would be totally okay, taking pictures of my ankles like that…But in my mind, I was thinking about bumps or my face or something that feels a bit different somehow…faces are obviously identifiable, and then bumps are not identifiable in the same way, but it feels a bit more personal than taking a photo of my ankles or fingers or something else. So yeah, I think that would definitely play into it. What I was taking the photo of for sure” [IP 10]

The privacy concerns were not isolated to the inclusion of their faces in photos, but to concerns about, “Who keeps that information?” [IP 1]. When the interviewer explained that only the digital measurements extracted from their photos would be stored and used to train the machine learning system, and that they would choose who their data was shared with (family/friends/healthcare professional), participants reported that their concerns were alleviated. Similarly, 68% of survey participants responded “yes” to being comfortable with the use of their anonymised data [digital measurements extracted from photos] to train and develop the app technology while using the app (21% = I am not sure and 11% = No). In addition, survey participants were asked how interested they were to use an app that learns from their anonymous data (i.e., machine learning) to assist in the identification, prediction, and prevention of adverse health outcomes during pregnancy and there was moderate-high interest (76%) in using such an app.

The interview participants that were not comfortable using a digital body measurement tool (20%, 3/15) had privacy and body image concerns, “I think that would make me very uncomfortable…And I'd be worried about my privacy too” [IP 4]. One participant with a nutritionist background voiced their concerns about the lack of diversity of current anthropometric standards/guidelines, “What is typical? How do you come up with references or standards, when there's this level of heterogeneity in body shapes and body types? And just in general, who stores fat where, you know, so for all you know its fluid accumulation, it's fat, or they have goiter?” [IP 11]. Similarly, when survey participants who responded “no” (28/106) to the question of being comfortable taking photos of their body parts regularly to extract digital measurements were asked to elaborate why, their explanations included discomfort/uneasiness, privacy/security concerns, body image/mental health issues, and credibility. Other survey participants also noted that how the digital measurement results are presented to app users should not elicit anxiety or cause unnecessary concern.

Additional app or digital health tool features

Interview participants were given the opportunity to make additional comments regarding the use of digital health tools to monitor pregnancy. In response, participants shared which educational information (Table 5) and additional features (Table 6) they would include in an app or digital health tool. The following are a selection of the issues they experienced during pregnancy and some of their ideas for potential solutions.

All the 15 interview participants mentioned that the educational information provided in apps or digital health tools could be improved. Some participants noted that more support and information should be provided about the initial stages of pregnancy, before their first pregnancy confirmation appointment at 8–9 weeks, and before their 20-week morphology scan. One participant explained the anxiety that they felt before their first pregnancy confirmation appointment, and how others in a pregnancy app they used (Peanut app) felt the same need of support and reassurance. Four participants added how challenging it was to access guidelines that were pregnancy specific and that there is a need for credible information to help interpret health results. Aside from access to more pregnancy specific guidelines, there was a desire to learn more about how their bodies change during pregnancy outside of how their baby is developing. Additionally, many participants felt that the support and information they received during pregnancy was satisfactory, but that postpartum support was inadequate - such as access to more diverse breast-feeding resources - and that better communication about potential postpartum complications should be encouraged.

Table 5

**Educational information for a pregnancy app or other digital health solution.** The table summarises the points interview participants raised regarding the educational information that they would like to be included in a pregnancy app or other digital health solution. The figure includes selected interview participant quotes related to some of the points raised.
What types of educational information do interview participants want?	Participant quotes
Support and information about initial pregnancy stages before the first doctor’s appointment (at 8–9 weeks) and before the 20-week morphology scan	: “A lot of us on the app, were very worried, like, you know, who had confirmed pregnancies only based on the home kit, but who had to wait till the eighth or the ninth week… And it was just such a real experience for me because, you know, you don't know what it is like till the time you actually go for your first ultrasound…So I think some sort of support in the very initial phases that will be useful to incorporate in a pregnancy app. (nervous tone throughout)” [IP 11].
Not only information about fetal development (and fruit comparison), but information about how the female body changes during pregnancy	“…And I think what would have been great was to understand how my body's changing, how my hips are spreading apart, the strains putting on my muscles, and then things I can do to help with that, to help manage that pain…Even then having like a digital tool to help you understand like, you know, there's loads of things that help you visualize how your baby's developing, but there's less about how your body's changing, and then what you can do to help you understand and help you manage that would be super helpful” [IP 13].
Pregnancy specific guidelines within the app to help interpret tests such as blood tests and risk factors (related to pre-pregnancy BMI)	“I think there's still a space for a really good pregnancy tracking app that shows, you know, all of the common things that they're looking for you. You take millions of blood tests, and they give you back like all of these, like, random numbers that you spend a bajillion years trying to figure out what they mean…My chart [the app] is the thing that most people use. They're all calibrated for non-pregnant people. And so, the app will come back and tell you that you have, you know, you have an elevated white cell blood count. And it's like, who cares all pregnant women have an elevated white blood cell count, which is only after a bunch of googling…And so there's this situation where the medical system is giving you this data, but there's nothing useful to interpret it at all (frustrated tone). And the tools that they give you for interpretation often aren't geared towards pregnancy. And so having an app that would show me how things were progressing on all of these things that they were tracking…It would have been really, really nice” [IP 3].
Breast feeding - information about diverse experiences and the top 10 common complaints or problems postpartum	“…honestly, for me, the biggest information gap came with breastfeeding. Um, and I definitely, I felt like a complete absence of support, especially from health care providers in that regard. And so, if there had been resources related to breastfeeding, that were a little bit beyond just sort of, like, you know, your baby should latch. I don't know, it was just terrible” [Participant IP 15].

With regard to possible app features, many participants stated that they would find a “Digital Wallet” that stores copies of their medical data (such as resources provided by hospitals, pregnancy antenatal cards, receipts, scripts, and referrals) extremely helpful. One of the major factors that annoyed participants was that they had to carry physical scripts or referrals to appointments. Another additional feature many participants mentioned was a tool to track their symptoms during pregnancy. A participant who experienced severe morning sickness or hyperemesis gravidarum during pregnancy mentioned how difficult it was to track the number of times they vomited. Two participants expressed that there is a current lack of support for pregnant women who are diagnosed with gestational diabetes and suggested that a gestational diabetes tracking tool should be developed.

Several participants suggested that they would find a personalised list of appointments and appointment reminders useful because their busy schedule (due to their work and childcare responsibilities) makes it difficult to track their health appointments, as well as information about what to expect during those appointments. Aside from reminders, participants indicated that they would not only like to share their data with their healthcare professionals, but with their family and friends using an export or share tool.

To summarize, all interview participants besides one felt that there was room for a more holistic pregnancy app with personalised support and that tracks pregnancy at all stages (from antenatal to postpartum).

Table 6

**Additional features for a pregnancy app or other digital health solution.** The table summarises the points interview participants raised regarding the app features that they would like to be included in a pregnancy app or other digital health solution. The figure includes selected interview participant quotes related to some of the features raised.
What types of features did participants want an app or digital tool to include?	Participant quotes
Export/share tool of app data and educational information	“Yes, but the user interface would have to be very sensitive. So, the app that I have doesn't allow screenshots at all for privacy reasons. And that was frustrating because sometimes I was talking to my mom or my friend who had preeclampsia. And I was like, here are the numbers they got for me today on my protein test. And it would be really weird to have a button under my urine protein test that says share with a friend. And yet, that's exactly the feature I wanted. So, you know, something that said, like export might have been a little more appropriate” [IP 3].
Connect users to research publication database	“I found the app that I used, like they had a bit of information, but it was super basic and general, which of course, that's what you would expect in the app. But if they actually had links to solid research, and a database where you could go and look at that stuff. I think that would be really good” [IP7].
Shared user interface with healthcare professionals	“So particularly with the preeclampsia, I had to report the data back to my doctor. And so, it was a little kludgie, the medical apps, they just have like this text box for you to fill stuff in…And I would come in, and I would have my own graphs…And so, I would have my own graphs. And I would, like, bring them printed out so that we could talk about them. And it would have been so nice if there was some sort of like shared interface that we could go over the data together with and be like, here's, you know, here's what we're seeing” [IP 3].
'Digital Wallet' that includes digital copies of resources provided by hospitals, pregnancy antenatal cards, receipts, scripts etc.	“I would much prefer to have gotten everything digitally…Even scripts…I just never really understood why I had to keep it with me, why couldn't they just email it to each other, it's just like, on my file. So that kind of thing I felt was really weird. And, you know, obviously very old systems” [IP 13]. “I do think that having a digital wallet would have been literally life changing. That would be amazing, something secure, that you could store all of that documentation in” [IP 7].
Symptom tracker - could work like a contraction/ kick counter	“I just really would have loved to have something to monitor how much I was being sick… I don't know even if you just like you know, push a button every time you were sick, and then it could calculate over a period of time how often it would be happening…Well, the app, I had actually had a kick count. So, like, you could press it every time you felt kicks and then it would track that…So yeah, like something similar to that for the vomiting would have probably really helped me because I'd go into the hospital, and they would be like, "How many times have you been sick in the last 24 hours?" I'd be like, "I don't know. 1000? Like, I fill buckets? I don't know" [IP 5].
Gestational diabetes monitoring	“Maybe something about the gestational diabetes, because I think that's quite common. You know, a lot of women, you know, particularly older women sort of have that issue…I think would have been really useful” [IP 8].
A holistic app (from antenatal to postpartum)	“…There's just so many different apps for so many different things, it would be good to have something that kind of combines everything into one, especially now that I'm looking towards, like downloading apps for sleep for the baby to track their sleep, there's breastfeeding apps to track how much milk they're drinking…So, like I'm just finding that my phone is getting filled with all these different apps. And you have to keep inputting your information into every app, you know, if it's about me, it's my age, my height, my weight, how far along I'm in my pregnancy and things like that. And if it's about the baby, you have to input all that information. So, if there was some sort of app that could follow you from pre pregnancy right through to baby being born, I think that would be quite beneficial” [IP 12].

This study sought to investigate (i) pregnant women’s experiences of pregnancy during the COVID-19 pandemic; (ii) their usage of currently available digital health tools; (iii) their self-monitoring behaviours; and (iv) their interest in two theoretical app features. Using our mixed methods study design, we demonstrated that the COVID-19 pandemic had a tremendous influence on all aspects of the participants’ pregnancy journey, including their experiences with healthcare, their relationships with themselves and their social circle, and their willingness to use digital health. The majority of participants already used pregnancy apps and other digital health tools, but this was not correlated with the degree of self-monitoring behaviour. The majority of participants were also interested in a theoretical app that included a direct patient-healthcare provider communication tool as well the body measurement tool we described. Additionally, participants consistently raised the need for additional educational information and app/digital tool features that allow for more personalised and holistic care. These findings contribute to the growing literature on the experiences of pregnancy women during this tumultuous period. Our data invite two important questions: (1) what factors influence digital health usage and self-monitoring? (2) what features would pregnant women want to include in an app/digital tool?

What Factors Influence Digital Health Usage And Self-monitoring?

The use of digital health such as pregnancy apps, websites, social media, and online communities continue to be highly prevalent during pregnancy [35, 39–41], and our findings suggest that the reliance on these digital media has increased due to the pandemic. While our participants primarily used pregnancy apps to access pregnancy-related information and receive updates about their baby’s development - which is consistent with previous cross-sectional studies [35, 42] - many also expressed their desire for apps to also provide information about the changes occurring to their own bodies. Based on the survey responses and interviews, the largest barrier for using digital health and self-monitoring tools is that the currently available tools do not meet the consumer demands. This is illustrated by our finding that only 40% of survey participants felt that they could monitor themselves from home.

In contrast to previous findings [9, 35, 43], a significant barrier to using digital health found in this study was security and privacy concerns and concerns about information credibility and quality. This shift in concerns is likely due to the spread of misinformation online, which participants mentioned as being the driver for their preference for their healthcare professional to be their main point of contact. The spread of misinformation regarding the COVID-19 vaccine during pregnancy online, especially on social media, and the vague or inconsistent communication by credible health authorities contributed to participants concern about the credibility of online sources. Further, poor data privacy, sharing, and security standards in pregnancy apps is widespread [44]. Thus, the quality of information and data privacy of pregnancy apps should be more formally assessed. Perhaps apps could be reviewed by a panel of experts and scored for information quality and privacy before they are uploaded to app stores, or a central app rating platform could be created [45].

However, it must be noted that a larger proportion of both survey and interview participants were highly educated (tertiary education: 71% and 53%), which could also explain their hyperawareness about privacy and information quality issues. In addition, due to the random sampling method used for recruitment, representation across all demographics could not be achieved (such as for country location, ethnicity, and socioeconomic status). This highlights the importance of designing accessible and culturally appropriate digital health solutions, which are reliant on the involvement of more diverse groups or several co-design iterations with different subgroups. Innovators should consider abiding by frameworks that promote digital health equity during development to prevent disparities in access to these tools [46, 40].

What Features Would Pregnant Women Want To Include In An App/digital Tool?

When we asked about the theoretical app features of a patient-healthcare provider communication tool and a digital body measurement tool, interview participants were enthusiastic to share their views and even shared their thoughts about what an ideal pregnancy app should include. All the participants emphasized their preference for a tool that enables communication with their chosen healthcare professionals. This is consistent with other studies that have demonstrated patients desire for more continuous care from their healthcare professionals during pregnancy [9, 35]. For such interventions to be successful, the involvement of healthcare professionals is a must. A mixed methods study of healthcare providers during COVID-19 revealed that when telehealth consults replaced in-person care, the quality of care was impacted [47]. Other challenges mentioned in this study were the lack of digital literacy, patient monitoring, and disruption of patient-healthcare professional bonding. Thus, digital communication should not disrupt any in-person care and should be used in conjunction [48]. The type of communication, feedback, and time commitment provided to patients by healthcare professionals should also be carefully considered and accounted for in staffing profiles.

Participants were interested in using the body measurement tool we described, in which digital body measurements are extracted from photos taken by the user on their smartphones.

This tool could allow for consistent and convenient monitoring of body shape changes over time and allow for the collection of more diverse and complete data about body changes during pregnancy. With sufficient data, machine learning could help mitigate and stratify risk (i.e., your ankle swelling has not decreased for x days, please contact your healthcare provider). It is also promising that most participants were open to their anonymised data being used to train the machine learning system of a theoretical app. And that patient image-based assessment is becoming more widely accepted, especially for wound-care management [49].

However, with the introduction of any new health assessment measures or digital screening tools, there are concerns regarding overinterpretation of results and inappropriate linkage to disease risk. Results and feedback presented to users could also induce anxiety or lead to unnecessary clinical consults. As described by [50], digital screening tools can lead to overdiagnosis and potential harm to patients, and for this reason should be validated. Another factor to consider is the privacy of machine learning models and how that can be minimised by using anonymisation and data minimization tools [51]. However, the need to tailor body measures for ethnicity and cultural appropriateness is a challenge, which is evident as there are still no concrete and accepted BMI guidelines for different ethnicities. Thus, the clinical utility of an image-based body monitoring tool should be assessed by healthcare professionals and its accuracy should be validated in an iterative process.

For digital support apps to be implemented, they require integration within current healthcare systems and workflows, which is notoriously challenging. However, studies have suggested that the restructuring of healthcare workflows is even more challenging and that embedding technologies within existing systems is the preference [52, 53]. Integration of such tools has the potential to allow for asynchronous communication, remote monitoring, and continuous care. For instance, a mobile-based telehealth service in rural Bangladesh that allowed for remote consultation for maternal, neonatal, and infant health or emergencies was able to provide users with advice, preliminary diagnosis, reassurance, referrals, and scripts and promote healthy behaviours, such as regular healthcare consults [54]. Such digital health interventions could enhance care in rural settings and/or support the flexibility of healthcare delivery during pandemics, where face-to-face contact needs to be minimised.

Overall, our findings demonstrate that pregnant women feel that there is a gap for a better pregnancy app or tool that allows for more holistic care from the prenatal to postnatal period and that could be integrated within healthcare systems. Their enthusiasm about a patient-healthcare provider tool and body measurement tool illustrates their willingness to use digital health tools to monitor their health. The additional pregnancy app/tool features outlined by pregnant women are relevant to all stakeholders developing pregnancy digital health solutions. We examined digital health usage during a very particular and unique period in human history. The question remains whether attitudes expressed here will continue in post-pandemic times. However, it is clear that such digital strategies are likely to improve the flexibility of healthcare systems to respond to such unpredictable events into the future.

Conflicts of Interest

Authors report no conflicts of interest

Acknowledgements

The authors acknowledge the technical assistance of Alex Shaw of the Sydney Informatics Hub, a Core Research Facility of the University of Sydney.

Author contributions

Natasa L: Conceptualization; Methodology; Software; Validation; Investigation; Data curation; Formal analysis; Data Curation; Writing – Original Draft; Writing – Review & Editing; Visualization; Project Administration.

Carol P: Methodology; Validation; Formal analysis; Data Curation; Writing – Review & Editing

Gillian R: Conceptualization; Methodology; Resources; Supervision; Project Administration; Writing – Review & Editing

Celine B: Conceptualization; Methodology; Resources; Supervision; Project Administration; Writing – Review & Editing

Kathryn W: Conceptualization; Methodology; Resources; Supervision; Project Administration; Writing – Review & Editing

Corinne C: Conceptualization; Methodology; Resources; Supervision; Project Administration; Writing – Review & Editing

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You are reading this latest preprint version

Pregnancy in the digital health era: exploring digital health usage amidst the COVID-19 pandemic

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Abstract

Introduction

Methods

Study design

Ethics Approval

Recruitment

Survey

Interviews

Data Analyses

Analysis of quantitative data

Analysis Of Qualitative Data

Data Availability Statement

Results

Demographic data

Outcomes

Impacts Of The Covid-19 Pandemic

Self-monitoring And Digital Health Usage

Health information seeking behaviour

Use of digital health to self-monitor

Interest In The Proposed Digital Health Monitoring Tools

Communication with healthcare professionals

Body measurement tool - measuring the body from photos

Additional app or digital health tool features

Discussion

What Factors Influence Digital Health Usage And Self-monitoring?

What Features Would Pregnant Women Want To Include In An App/digital Tool?

Conclusions

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1