The PRISMA flowchart of the search process can be seen in Figure 1.
Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart of search process for educational mHealth apps with postpartum maternal morbidity and mortality risk content
Maternal Health Content
Of the 25 applications coded, only one, “What to Expect” addressed each of the 30 medical topics included in the Maternal Health coding scheme. The median number of elements addressed by each app was 19.5 (65%), with a range from 4 (13.3%) to 30 (100%). Apps affiliated with a medical organization (i.e. “Circle by Joseph Health” and “Circle by Swedish”) addressed greater than 90% of the peripartum health topics, whereas the remaining, commercially developed, apps almost universally fell below this threshold. The exceptions to this were the commercially developed “WebMD Pregnancy” and “The Bump,” which addressed 29 (96.7%) and 28 (93.3%) of the topics, respectively. A significant (r(23)=0.643, p=0.001) positive correlation was found between the percent of elements addressed in an app and the app’s MARS quality score (Figure 2). Ten of the 25 apps reviewed (40%) met the threshold for clinical authority. Examples of information addressing a maternal health topic without clinical authority include offering guidance on postpartum depression by explaining that mothers who are “feeling down” are likely feeling so because of dissatisfaction with their bodies, suggesting they should “wear flats,” and “join an online mom group to beat the postpartum blues.”
Figure 2. MARS overall quality score vs percent of maternal health information addressed by app.
Peripartum behaviors were the most frequently addressed by apps, with 5/9 (56%) addressed by more than 75% of apps in contrast to 4/12 (33%) of peripartum outpatient care topics and 0/9 (0%) of peripartum acute health risks. On average, peripartum behaviors were addressed by 70% of apps, peripartum outpatient care by 59%, and peripartum health risks by 45%. The most widely addressed were breastfeeding/breast health and depression, which were each discussed in 23 apps (92%) (Figure 3).
Figure 3. Percent of mobile applications addressing elements of peripartum behaviors, peripartum outpatient care, and peripartum acute health risks.
Inclusivity
Only 32% (8/24 apps; one app did not contain images) of applications portrayed greater than 24% of people of color in their imagery. Positive associations were found between the percent of images including people of color and both the MARS quality score (r(22)=0.535, p=0.007) and the percent of medical topics addressed (r(23)=0.756, p<0.001). No significant correlation was found between the number of ratings and percent of people of color (r(23)=0.271, p=0.20). Of the top-10 most-rated apps, only four (“Pregnancy Tracker-BabyCenter,” “What to Expect,” “The Bump,” and “Ovia Pregnancy Tracker”) reached the 24% diversity threshold. No race-biased language was noted in any of the apps, but 5 apps (20%) were noted to have race-biased imagery in the form of depicting women of color exclusively as patients while white individuals were depicted in diverse roles or in majority healthcare worker roles.
Accessibility
The average overall MARS score (quality mean score) for the 25 apps ranged from 1.9 to 4.7, with a mean quality score of 3.7, representing an “Acceptable” rating. Overall, apps scored high on functionality (mean=4.3, SD=0.5) and lower in engagement (mean=3.4, SD=1.1), aesthetics (mean=3.4, SD=1.1), information (mean=3.5, SD=0.9), and overall quality (mean=3.7, SD=0.7). The lowest-scoring MARS subscale was the optional “Subjective Quality,” which is not included in the overall quality score but takes into account how frequently a user might access the app if relevant to them, whether they would pay for the app, and whether they would recommend it to other users. Subjective quality ratings ranged widely from 1.0-5.0, (mean=3.0, SD=1.1). “Circle by Swedish” received the highest overall quality score, 4.7 (“Good”), followed by “What to Expect,” “Pregnancy Tracker-BabyCenter,” “WebMD Pregnancy,” and “Track Pregnancy&Baby:Preglife,” each with a rating of 4.5 (“Good”). None of the apps received a quality score of “Excellent.”
No significant correlation was found between the applications’ number of store ratings (a proxy for prevalence and popularity) and the quality of the application, as measured by both the proportion of the medical topics the app addressed (r(23)=0.252, p=0.224) and by the MARS quality score (r(23)=0.255,p=0.219). While the most-rated app, “Pregnancy Tracker-BabyCenter” (993,267 total ratings), addressed 90.3% of medical topics and received a MARS quality score of 4.5 (“Good”), the next-most rated application, “Pregnancy +” (685,310 ratings) addressed only 48.39% and received a MARS quality score of only 3.5 (“Acceptable”). “Circle by Swedish,” which addressed 96.7% of medical topics and received the highest MARS quality score of the apps in this review at 4.7 (“Good”) only received 1,216 ratings.
Apps with clinical authority showed a significantly greater mean percent of maternal health information addressed in the app (t(20)= 4.02, p=0.001). These apps also had higher overall MARS quality scores, (t(23)=4.74, p<0.001), with higher ratings on the engagement (t(23)=4.06, p<0.001), aesthetics (t(17)=3.10, p=0.007), and information sub-scores (t(23)=5.09, p<0.001). A significant difference was not observed in the MARS functionality score between the two groups of apps (t(21)=1.15, p=0.265). There was also no significant difference in the number of store ratings between the apps with and without clinical authority.
Highest-Quality Apps
Four apps met or exceeded all of the following criteria for an acceptable peripartum mHealth application: 1) Authored with clinical authority; 2) addressed greater than or equal to 90% of maternal health information; 3) imagery portrayed at least 24% people of color; 4) received a MARS score of at least 4 (“Good”) in each subcategory of engagement, functionality, aesthetics, and information; 5) did not depict race-biased imagery or language. These apps were “What to Expect,” “Pregnancy Tracker - BabyCenter,” “Circle by Swedish,” and “Circle by Joseph Health.”