From Idea to Implementation: Development of the Smart-e-Moms App to Reduce Postpartum Depressive Symptoms

Abstract

Introduction

Postpartum depression is the most common mental health disorder associated with the birth of a child. However, postpartum depression often remains untreated because there are not enough prevention and treatment options. Barriers such as lack of knowledge and fear of stigmatization also make it more difficult for affected women to start treatment. Digital interventions could be an option which might circumvent many of these barriers. This study describes the development process of the smartphone-based intervention Smart-e-Moms which aims to reduce postpartum depressive symptoms.

Material and Methods

The app was developed using a participatory and iterative approach. The three steps used for the formative evaluation were: (1) an analysis of needs and preferences (focus groups with 9 formerly affected women and 11 midwives), (2) an analysis of the barriers and facilitating factors to use the app (online survey of 37 mothers), and (3) testing of the app (online interviews with 10 acutely affected women). Qualitative data was analyzed with MAXQDA for content analysis.

Results

Step 1 identified numerous challenges after giving birth such as stress, negative thoughts and feelings, and lack of support, all of which flowed into the contents of the app. Ensuring that the units were short and the topics “self-care” and “relationship to the child” were also considered important. In step 2, barriers and facilitating factors were identified and incorporated into the design of the app. Step 3 consisted of a positive assessment of the first version of the app in terms of content and formal design as well as usability. The final app consisted of 10 behavioral units with written psychological guidance, constantly accessible exercises on self-care and the relationship to the child and permanently available information on common challenges after giving birth.

Conclusion

We present a new and innovative approach which aims to reach out more easily to women with postpartum depressive symptoms. The most important insights from the development process, the final design, and the elements of the program are described here.

Keywords

postpartum depression - app - smartphone-based intervention - formative evaluation

Publication History

Received: 08 November 2024

Accepted after revision: 01 March 2025

Article published online:
12 June 2025

• References/Literatur

• 1 Halbreich U, Karkun S. Cross-cultural and social diversity of prevalence of postpartum depression and depressive symptoms. J Affect Disord 2006; 91: 97-111
• 2 Howard LM, Megnin-Viggars O, Symington I. et al. Antenatal and postnatal mental health: summary of updated NICE guidance. BMJ 2014; 349
• 3 O’hara MW, Swain AM. Rates and risk of postpartum depression—a meta-analysis. Int Rev Psychiatry 1996; 8: 37-54
• 4 Shorey S, Chee C, Chong Y-S. et al. Evaluation of Technology-Based Peer Support Intervention Program for Preventing Postnatal Depression: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2018; 7: e81
• 5 Döring KJ. Postpartale Depression – Versorgungssituation in der hausärztlichen Praxis. Hamburg: Universitätsklinikum Hamburg-Eppendorf; 2021
• 6 Dorsch VM, Rohde A. Postpartale psychische Störungen – Update 2016. Frauenheilkunde up2date 2016; 10: 355-374
• 7 American Psychiatric Association. Diagnostic and statistical Manual of mental Disorders. 5. Washington, DC: American Psychiatric Association; 2013
• 8 Stewart DE, Vigod S. Postpartum depression. N Engl J Med 2016; 375: 2177-2186
• 9 Netsi E, Pearson RM, Murray L. et al. Association of Persistent and Severe Postnatal Depression With Child Outcomes. JAMA Psychiatry 2018; 75: 247-253
• 10 Reck C. Postpartale Depression: Mögliche Auswirkungen auf die frühe Mutter-Kind-Interaktion und Ansätze zur psychotherapeutischen Behandlung. Prax Kinderpsychol Kinderpsychiatr 2007; 56: 234-244
• 11 Brummelte S, Galea LAM. Postpartum depression: Etiology, treatment and consequences for maternal care. Horm Behav 2016; 77: 153-166
• 12 Field T. Postpartum depression effects on early interactions, parenting, and safety practices: a review. Infant Behav Dev 2010; 33: 1-6
• 13 Kingston D, Kehler H, Austin M-P. et al. Trajectories of maternal depressive symptoms during pregnancy and the first 12 months postpartum and child externalizing and internalizing behavior at three years. PLoS One 2018; 13: e0195365
• 14 Slomian J, Honvo G, Emonts P. et al. Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes. Womens Health (Lond Engl) 2019; 15: 174550651984404
• 15 Reinhart M, Patton C, Chawla A. et al. The Humanistic Burden of Postpartum Depression: A Systematic Literature Review. Value Health 2018; 21: S187
• 16 O’Hara MW, McCabe JE. Postpartum Depression: Current Status and Future Directions. Annu Rev Clin Psychol 2013; 9: 379-407
• 17 Małus A, Szyluk J, Galińska-Skok B. et al. Incidence of postpartum depression and couple relationship quality. Psychiatr Pol 2016; 50: 1135-1146
• 18 Byatt N, Levin LL, Ziedonis D. et al. Enhancing Participation in Depression Care in Outpatient Perinatal Care Settings: A Systematic Review. Obstet Gynecol 2015; 126: 1048-1058
• 19 Dennis C, Chung-Lee L. Postpartum depression help-seeking barriers and maternal treatment preferences: A qualitative systematic review. Birth 2006; 33: 323-331
• 20 Goodman JH. Women’s attitudes, preferences, and perceived barriers to treatment for perinatal depression. Birth 2009; 36: 60-69
• 21 McLoughlin J. Stigma associated with postnatal depression: A literature review. Br J Midwifery 2013; 21: 784-791
• 22 Werner E, Miller M, Osborne LM. et al. Preventing postpartum depression: review and recommendations. Arch Womens Ment Health 2015; 18: 41-60
• 23 O’Mahen HA, Flynn HA. Preferences and Perceived Barriers to Treatment for Depression during the Perinatal Period. J Womens Health (Larchmt) 2008; 17: 1301-1309
• 24 Nübling R, Jeschke K, Ochs M. et al. Zur ambulanten psychotherapeutischen Versorgung in Deutschland – Eine Befragung von Psychotherapeutinnen und Psychotherapeuten in fünf Bundesländern als ein Beitrag zur psychotherapeutischen Versorgungsforschung. Stuttgart: Landespsychotherapeutenkammer Baden-Württemberg; 2014
• 25 Pawils S, Kochen E, Weinbrenner N. et al. Postpartale Depression – wer kümmert sich? Versorgungszugänge über Hebammen, Gynäkologie, Pädiatrie und Allgemeinmedizin. Bundesgesundheitsbl 2022; 65: 658-667
• 26 Miura Y, Ogawa Y, Shibata A. et al. App-based interventions for the prevention of postpartum depression: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2023; 23: 441
• 27 Roman M, Constantin T, Bostan CM. The efficiency of online cognitive-behavioral therapy for postpartum depressive symptomatology: a systematic review and meta-analysis. Women Health 2020; 60: 99-112
• 28 Zhou C, Hu H, Wang C. et al. The effectiveness of mHealth interventions on postpartum depression: A systematic review and meta-analysis. J Telemed Telecare 2022; 28: 83-95
• 29 Schröder J, Berger T, Westermann S. et al. Internet interventions for depression: new developments. Dialogues Clin Neurosci 2016; 18: 203-212
• 30 Pugh NE, Hadjistavropoulos HD, Hampton AJD. et al. Client experiences of guided internet cognitive behavior therapy for postpartum depression: a qualitative study. Arch Womens Ment Health 2015; 18: 209-219
• 31 Fernandes DV, Monteiro F, Canavarro MC. et al. A Web-Based, Mindful, and Compassionate Parenting Training for Mothers Experiencing Parenting Stress: Results from a Pilot Randomized Controlled Trial of the Mindful Moment Program. Mindfulness (N Y) 2022; 13: 3091-3108
• 32 Zhao L, Chen J, Lan L. et al. Effectiveness of Telehealth Interventions for Women With Postpartum Depression: Systematic Review and Meta-analysis. JMIR Mhealth Uhealth 2021; 9: e32544
• 33 Osma J, Barrera AZ, Ramphos E. Are Pregnant and Postpartum Women Interested in Health-Related Apps? Implications for the Prevention of Perinatal Depression. Cyberpsychol Behav Soc Netw 2016; 19: 412-415
• 34 Franco P, Olhaberry M, Kelders S. et al. Guided web app intervention for reducing symptoms of depression in postpartum women: Results of a feasibility randomized controlled trial. Internet Interv 2024; 36: 100744
• 35 Jannati N, Mazhari S, Ahmadian L. et al. Effectiveness of an app-based cognitive behavioral therapy program for postpartum depression in primary care: A randomized controlled trial. Int J Med Inform 2020; 141: 104145
• 36 Fonseca A, Monteiro F, Alves S. et al. Be a Mom, a Web-Based Intervention to Prevent Postpartum Depression: The Enhancement of Self-Regulatory Skills and Its Association With Postpartum Depressive Symptoms. Front Psychol 2019; 10: 265
• 37 Danaher BG, Milgrom J, Seeley JR. et al. MomMoodBooster Web-Based Intervention for Postpartum Depression: Feasibility Trial Results. J Med Internet Res 2013; 15: e242
• 38 Westerhoff B, Trösken A, Renneberg B. about:blank? Online Interventions for Postpartum Depression. Verhaltenstherapie 2022; 32: 54-63
• 39 Schmidt-Hantke J, Vollert B, Nacke B. et al. PandaMom – Feasibility and acceptability of an internet- and mobile-based intervention to enhance peripartum mental well-being and to prevent postpartum depression. Internet Interv 2024; 37: 100765
• 40 Rounsaville BJ, Carroll KM, Onken LS. A stage model of behavioral therapies research: Getting started and moving on from stage I. Clin Psychol (New York) 2001; 8: 133-142
• 41 Danaher BG, Seeley JR. Methodological Issues in Research on Web-Based Behavioral Interventions. Ann Behav Med 2009; 38: 28-39
• 42 Whittaker R, Merry S, Dorey E. et al. A Development and Evaluation Process for mHealth Interventions: Examples From New Zealand. J Health Commun 2012; 17: 11-21
• 43 Hoffmeister H, Hüttner H, Stolzenberg H. et al. Sozialer Status und Gesundheit. Unterschiede in der Verteilung von Herz-Kreislauf-Krankheiten und ihre Risikofaktoren in der Bevölkerung der Bundesrepublik Deutschland nach Schichten und Gruppen. München: MMV Medizin Verlag; 1992
• 44 VERBI Software. MAXQDA 2020 [Computersoftware]. Berlin: VERBI Software; 2019
• 45 Kuckartz U. Qualitative Inhaltsanalyse. Methoden, Praxis, Computerunterstützung. 4. Weinheim: Beltz Juventa; 2018
• 46 Rädiker S, Kuckartz U. Analyse qualitativer Daten mit MAXQDA. Heidelberg: Springer; 2019
• 47 Schulz M, Mack B, Renn O. Fokusgruppen in der empirischen Sozialwissenschaft: Von der Konzeption bis zur Auswertung. Heidelberg: Springer; 2012
• 48 Cox JL, Holden JM, Sagovsky R. Detection of Postnatal Depression: Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987; 150: 782-786
• 49 Herz E, Thoma M, Umek W. et al. Nicht-psychotische postpartale Depression. Geburtshilfe Frauenheilkd 1997; 57: 282-288
• 50 Jaspers MWM, Steen T, van den Bos C. et al. The think aloud method: a guide to user interface design. Int J Med Inform 2004; 73: 781-795
• 51 Burchert S, Alkneme MS, Bird M. et al. User-Centered App Adaptation of a Low-Intensity E-Mental Health Intervention for Syrian Refugees. Front Psychiatry 2019; 9: 663
• 52 Brown W, Yen P-Y, Rojas M. et al. Assessment of the Health IT Usability Evaluation Model (Health-ITUEM) for evaluating mobile health (mHealth) technology. J Biomed Inform 2013; 46: 1080-1087
• 53 Househ MS, Shubair MM, Yunus F. et al. The Use of an Adapted Health IT Usability Evaluation Model (Health-ITUEM) for Evaluating Consumer Reported Ratings of Diabetes mHealth Applications: Implications for Diabetes Care and Management. Acta Inform Med 2015; 23: 290-295
• 54 Stoyanov SR, Hides L, Kavanagh DJ. et al. Development and Validation of the User Version of the Mobile Application Rating Scale (uMARS). JMIR Mhealth Uhealth 2016; 4: e72
• 55 VERBI Software. MAXQDA 2024 [Computersoftware]. Berlin: VERBI Software; 2024
• 56 Hautzinger M. Kognitive Verhaltenstherapie bei Depressionen. 7. Weinheim: Beltz; 2013
• 57 Wolkenstein L. Postpartale Depression. Göttingen: Hogrefe; 2023
• 58 Zagorscak P, Heinrich M, Sommer D. et al. Benefits of Individualized Feedback in Internet-Based Interventions for Depression: A Randomized Controlled Trial. Psychother Psychosom 2018; 87: 32-45
• 59 Hofmann SG, Gómez AF. Mindfulness-Based Interventions for Anxiety and Depression. Psychiatr Clin North Am 2017; 40: 739
• 60 Karyotaki E, Efthimiou O, Miguel C. et al. Internet-Based Cognitive Behavioral Therapy for Depression: A Systematic Review and Individual Patient Data Network Meta-analysis. JAMA Psychiatry 2021; 78: 361-371
• 61 Ramphos ES, Kelman AR, Stanley ML. et al. Responding to women’s needs and preferences in an online program to prevent postpartum depression. Internet Interv 2019; 18: 100275
• 62 Wilkerson AK. Cognitive Performance as a Function of Sleep Disturbance in the postpartum Period. Denton: University of North Texas; 2015
• 63 Daehn D, Meyer C, Loew V. et al. Smartphone-based intervention for postpartum depressive symptoms (Smart-e-Moms): study protocol for a randomized controlled trial. Trials 2024; 25: 469