A flowchart of the app selection process is presented in Figure 1. 163 applications were found in the initial search (Online search= 23, Google Play store= 74, and CaféBazaar = 66. After removing the duplicates, the remaining 65 apps were initially reviewed. During the screening, applications unrelated to pregnancy and non-Persian language were removed, and 32 apps were evaluated for the inclusion criteria. In this stage, all 32 reminded apps were assessed. Finally, applying all the inclusion criteria, only 9 applications were included in the study to be critically evaluated regarding quality, content, and suitability. All included apps (n = 9) were evaluated and rated by two evaluators independently, and disagreements about each score were discussed and resolved by consensus.
Description of the Selected Apps
Two of the nine antenatal apps reviewed were accessed through Google Play, and seven were accessed through café Bazaar. All of the apps were free to download. None of the applications were funded by the national research budget or overseen by government or academic affiliates, and all were commercial. Additionally, none of the applications were evaluated during a clinical trial, and no documentation was found regarding the publication of a scientific article related to the application. Of the nine reviewed antenatal apps, Yekzan and Gahvare had the highest downloads, valued at more than 500,000. In contrast, Pregnancy Guide, MamanaPlus, and Niniban had the lowest number of downloads, with a value of more than 10,000. The average star rating for the apps was 4.6 (SD =.57), with the highest user rating of 4.7 stars belonging to Pregnancy Week by Week, Niniban, and Gahvare and the lowest user rating of 2.9 stars related to Madarsho. All nine applications (100%) were open for initial access. However, almost half of them (Yekzan, Ooma, MamanaPlus, Niniban, Gahvare) required in-app purchases to access additional, unrestricted content, functions, and extra education. According to the program developers, only one application was available in English and Persian (Niniplus). Six of nine applications could create personal profiles and exchange views with other users (Yekzan, Madarsho, Niniplus, Ooma, MamanaPlus, Gahvare). Two applications had a very simple design and only basic educational and textual information content without any pictures, video, or entertainment graphics (Pregnancy Week by Week, Pregnancy guide). Among the available applications, only two introduced the design team and scientific members of the application (Yekzan, Ooma). In contrast, the other applications did not mention or introduce their scientific members of the design team. Only two applications were available without using the Internet (Pregnancy Week by Week, Pregnancy Guide), while others could only be used if users had access to the Internet. Other details of features and services of each application shows in more detail [see Additional file 1].
Quality Assessment of Apps
Table 2 presents the results of the app quality evaluation using the MARS tool, which revealed that the overall quality of the apps was mixed. As there was no significant difference in the scoring and evaluation of the programs between the two reviewers, a third reviewer was not required to evaluate the program further.
The mean of the four MARS subscale scores across all nine apps was 3.55 (SD 0.61).
The rankings of the applications based on the MARS score were as follows: MamanaPlus (3.75), Niniplus and Gahvare (3.62), Yekzan (3.57), Ooma (3.55), Niniban (3.35), Madarsho (3.1), Pregnancy week by week (2.27), and Pregnancy guide (2.1). Examining the four subscales individually showed that aesthetics (mean= 4.00 [SD= 1.18]) and functionality subscales (mean= 4.00 [SD= 0.71]) were rated the highest, followed by engagement (mean =3.00 [SD= 0.82]) and information subscales (mean = 2.80 [SD= .48]). The highest mean subscale scores in the engagement (4.2), functionality (5), and aesthetics (4.6) domains were related to MamanaPlus, and in the information domain (3.5), it was given to Ooma. The lowest mean subscale scores in the engagement (1.6) and information domain (2) were given to the Pregnancy guide, functionality domain (2.5) related to Madarsho, and aesthetics domain (1.3) related to Pregnancy week by week.
Coverage and Depth of Information
In general, the coverage and depth of information provided by most apps were relatively poor. The majority of app evaluations had low or no completeness of subtopics. None of the applications covered all the essential training subjects during pregnancy that the Deputy Minister of Health has mentioned.
Overall, 66% of apps (6/9 evaluations) were rated poor for Coverage and Depth of Information of health information, 33% of apps (3/9 evaluations) were rated as adequate, and no app received a superior level.
Information coverage was lowest or was completely neglected in some apps related to topics like Sexual Health, Oral Health, immunization, Do not take drugs, alcohol, and cigarettes, Stress management solutions, and prenatal classes, but topics like changes during pregnancy, fetal growth, physical activity, nutrition, Common complaints, warning signs, warning signs for pregnancy-induced hypertension were acceptable covered in most of the application. None of the reviewed applications mentioned the sources used in the production of educational content, which leads to uncertainty about the accuracy of the training and is considered a weakness of these applications. More details about coverage of educational content are reported in Table3.
Suitability of Information
To assess the suitability of applications and the suitability of their health information materials for pregnant women, Overall, 44% of apps (4/9 evaluations) were rated superior for suitability of health information, 55% of apps (5/9 evaluations) were rated as adequate, and no app received a poor score to considered as not suitable. The sum of scores showed that the highest score was given to Yekzan and MamanaPlus, with scores of 40 and 39, respectively, and the lowest score was related to Pregnancy week by week and Pregnancy Guide, with a score of 20. The domains that scored the most points in SAM among all the applications were the Literacy Demand domains and Layout and Type, and the lowest points were obtained in the field of Learning Stimulation and motivation. Although most programs were considered culturally appropriate for the Iranian environment, most applications did not have original educational images and videos. In some cases, there were cultural contradictions. More detailed findings on the SAM scores are reported in Table 4.