Keywords
COVID-19 - Mobile application - Telemedicine - Prenatal care - Acceptability
Introduction
Perinatal care is a public health strategy that has been thought to be one of the
most effective means of reducing unfavorable perinatal outcomes.[1] However, the restrictions such as immobilization and lockdown to limit the spread
of COVID-19 caused the health services to the outpatient clinics to be interrupted
associated with an increased frequency of adverse maternal and perinatal outcomes.[2]
[3] Given this scenario and the need to assure the continuity of the provision of prenatal
care, we introduced a new model of mixed prenatal with in-person visits and a teleconsultation
program.[4]
[5] Telemedicine has been proven to be useful in the care of pregnant women in different
scenarios to provide health outcomes comparable to the traditional methods of care.[6]
[7]
[8]
[9] Therefore, the major role of integrating electronic health technology into prenatal
care is to provide broader healthcare in diverse manners and to create a lot of opportunities
for patients and health providers.
Studies of women's general assessments of what they perceive as important aspects
of antenatal care reported that sufficient information and explanation were so important.[10]
[11] We believe it is imperative to allow patients actively participation in their pregnancy
care. The availability of more information about her health status and that of her
baby allows the pregnant woman to be involved in the entire care process. This achieves
feedback between the pregnant woman and the doctor that will improve maternal and
perinatal outcomes. Mobile technology, a modality of telehealth, has been reported
as a useful and reliable tool for monitoring clinical factors and treatment in different
health conditions.[12] Thus, the introduction of new technology as a mobile application with data regarding
their pregnancy could help our patients with this objective.
In this study, we describe the development and structure of a novel mobile application
in mixed prenatal care in the context of the COVID-19 pandemic and tested its acceptability
in a cohort of patients.
Methods
We introduced telemedicine and mobile technology considering recommendations from
frameworks on the development of health-related interactive systems.[13]
[14] This study was part of a larger institutional study on COVID-19 (reference number:
063-2020-DG-N°20-OEAIDE/INMP) approved by the local institutional ethics board (reference
number: 019-2020-CIEI/INMP).
Insights
We grouped a multidisciplinary team including TI people, OB/GYN doctors, statisticians,
and external consultants supported by the hospital managers and the Ministry of Health
to build a new model of prenatal care adapted to the new scenery of the COVID-19 pandemic.
We followed 3 steps. First, we introduced a mixed model of prenatal care based on
international recommendations,[15]
[16]
[17] which essentially considers a reduced number of in-person visits and some virtual
phone consultations. A detailed description of this new care model was published in
a previous article.[5] Second, we developed a comprehensive clinical computer-based patient record (Integrated
Hospital Management System, SISGALEN PLUS®, INMP-MINSA, Peru), built on our standard
model of prenatal care previously established in agreement with CLAP recommendations
and other current international guidelines.[8]
[17]
[18] Third, we developed a mobile application to allow patients to actively participate
in their pregnancy care.
Design and Build of the Mobile Application and Prototype Characteristics
In this context, our institution developed a mobile application to help provide comprehensive
and personalized prenatal care. This technology was designed and developed by OB/GYN
doctors and computer engineers based on the novel mixed model of prenatal care with
continuous feedback from patients. We used Flutter Software version 2.2 to build the
mobile application for Android and iOS smartphones. It took 6 months from design and
construction to be introduced into the Google store. It will be soon introduced into
the Apple store.
Acceptability Assessment
We assessed the app's acceptability using an instrument for evaluating a telehealth
program proposed by Portz et al.[19] This survey is divided into 2 sections. The first one includes 8 questions measured
on a 5-point Likert scale ranging from “extremely disagree” to “extremely agree,”
and the second section includes 3 open-ended questions. According to the technology
acceptance model (TAM), our survey was applied to understand patients' adoption of
new mobile application.[20]
[21] The 4 TAM constructs applied were 1) perception of the app's usefulness (1 question), 2) perception of the app's ease of use (5 questions), 3) attitudes about the app (2 questions), and 4) intentions to use the app (1 open question) ([Supplemental 1]). We collected survey data in a cohort of patients with access to mixed prenatal
care who were invited to participate in the study in a non-random fashion. Patients
received comprehensive information on how to download and run the app, before the
acceptability survey. Demographic characteristics were collected directly from the
patients and electronic records. The acceptability was a paper questionnaire, carried
out during the last in-person visit. Answers could be clarified at the time of the
survey by the researchers.
Chart 1
Demographic and maternal characteristics (n = 50)
|
n
|
%
|
|
Mean maternal age, years (range)
|
30.0 (17.8–41.2)
|
|
|
Mean gestational age at first contact with the mobile app, weeks (range)
|
27.8 (12.1–37.1)
|
|
|
Human Development Index
|
|
|
|
Stratum I
|
2
|
4.0
|
|
Stratum II
|
22
|
44.0
|
|
Stratum III
|
21
|
42.0
|
|
Stratum IV
|
5
|
10.0
|
|
Insurance modality
|
|
|
|
National health insurance
|
43
|
86.0
|
|
Not national health insurance
|
7
|
14.0
|
|
Education level
|
|
|
|
Primary
|
3
|
6.0
|
|
High school
|
36
|
72.0
|
|
Technical or University
|
11
|
22.0
|
|
Nulliparous
|
15
|
30.0
|
|
Risk factors
|
|
|
|
Obesity (BMI≥30)*
|
29
|
58.0
|
|
Previous cesarean section
|
20
|
40.0
|
|
Mother Rh negative
|
11
|
22.0
|
|
Fetus with structural abnormalities
|
10
|
20.0
|
|
Diabetes
|
7
|
14.0
|
|
Hypothyroidism/Hyperthyroidism
|
6
|
12.0
|
|
History of hypertension/preeclampsia
|
6
|
12.0
|
|
Anemia
|
5
|
10.0
|
|
Multiple pregnancy
|
3
|
6.0
|
|
Placenta previa
|
2
|
4.0
|
|
Asthma
|
2
|
4.0
|
|
Short interpregnancy interval
|
1
|
2.0
|
|
Mother with HIV** infection
|
1
|
2.0
|
|
Previous perinatal death
|
1
|
2.0
|
|
Others
|
6
|
12.0
|
|
Operating system used by the patients
|
|
|
|
iOS
|
2
|
4.0
|
|
Android
|
48
|
96.0
|
*BMI: Body mass index
**HIV: Human immunodeficiency virus
We performed a descriptive analysis using MS Excel 2013. Results from the acceptability
survey were summarized for each point of the Likert scale and represented in a stacked
bar chart for the 9-item questions.[22] The open-ended responses were analyzed using magnitude coding, which quantifies
participants' answers, highlighting the most frequent comments. Statistical analysis
was performed using Stata Statistical Software 14.0 (Stata Corp. 2015, College Station,
TX, USA).
Results
Design and Build of the Mobile Application and Prototype Characteristics
We built a mobile application with the main attribute of being connected in real time
with the clinical computer-based record. The system was structured on a distributed
architecture of microservices, then they are consumed by an app that is structured
with a hybrid development through an “API Gateway”. This allows great versatility
to be able to deploy it on Android and IOS cell phones. This mobile application can
be delivered exclusively to patients with an electronic clinical record, accessed
with a username defined by the national ID, and a protected password. The built app's
main screens are shown in [Figures 1] and [2], and additional screens are provided in [Supplementals]. The first screen of visualization ([Figure 1]) shows the name, past medical history, and age of the patient, as well as the current
gestational age.
Fig. 1 Prototype's main screens and prenatal control schedule
Fig. 2 Scheduled tasks for the corresponding gestational age and notifications screen
It contains 5 options listed as follows: 1) prenatal control schedule including all the tasks for the corresponding gestational age, 2) prenatal card with the relevant clinical data and lab tests, 3) information about the alarm signs of the current pregnancy, 4) list of symptoms of COVID-19 disease, and 5) notifications about omitted tasks. By clicking on the prenatal control schedule, patients can visualize
the prenatal protocol care summarized in 6 appointments ([Figure 1]), each one corresponding to a specific period of pregnancy carried out either by
virtual or in-person consultation. In addition, the gestational age of the patient
at the time of the appointment can be visualized. Each completed visit is marked in
orange, and the subsequent appointments are displayed in white ([Figure 2]).
By clicking on each appointment, a screen is displayed with all the scheduled tasks
for the corresponding gestational age ([Figure 2]), such as clinical evaluation, obstetric ultrasound scan, lab tests, provision of
medications, Pap smear test, vaccination, family planning counseling, and psychoprophylaxis.
Tasks not carried out will be marked in red. The option of the maternity book enables
the user to download a printable version of the updated information about clinical
history and lab test results. Additionally, patients have access to information about
the alarm signs of pregnancy, COVID-19 disease ([Supplemental Figures]), and notifications about omitted activities and scheduled appointments ([Figure 2]). We built several previous versions, which were modified according to patient feedback.
A final version was tested for connectivity with the clinical computer-based record.
Assessment of the Acceptability
Fifty patients were surveyed in the study period in our outpatient clinic. All gave
written consent to participate in the survey. [Chart 1] details the characteristics of the study population. The mean maternal age was 30
years, and the mean gestational age at first contact with the mobile application was
27.8 weeks. Forty-three (86%) patients had national health insurance, and 11 patients
(22%) reported having access to education beyond high school. All pregnant women had
at least one risk factor, including overweight and obesity (n = 29, 58%) and previous
cesarean sections (n = 20, 40%).
Regarding the type of mobile phone, 48 (96%) reported using the Android operating
system. [Figure 3] shows the patients' acceptance of the mobile application. The 4 constructs of acceptability
yielded the following results: 1) perception of usefulness: 96% (n = 48) agree that the mobile app is essential and will help with their prenatal
care; 2) perception of ease of use: more than 94% of patients were able to enter, read, and navigate through the mobile
app, but 46% (n = 23) still needed some orientation and help to use the application;
3) attitudes about the app: all patients were pleased with how the application works and looks; and 4) intention to use: 94% (n = 47) of patients reported the intention to use the app again. Regarding
the open question asking “What do you like the most about the application?” 62% of
patients like the information about their pregnancy, visibility of lab test results,
and subsequent appointment, and 22% of women like it because it is easy to use. Only
20% of patients gave some suggestions to improve the application. Six patients recommended
that the app be available to all pregnant women, 2 of them suggested including notifications
a day before the appointment, and 1 patient suggested the possibility to contact doctors
online anytime.
Fig. 3 Acceptability survey of the mobile app among pregnant women (n = 50)
Discussion
This study details the development and structure of a novel mobile application in
a mixed model of prenatal care in the context of the COVID-19 pandemic. The assessment
of the app's acceptability was mostly positive.
There are several mobile applications commercially available dedicated to some aspect
of pregnancy care,[23] however, not all have an impact on improving maternal health. Cawley et al.[24] reported using a mobile application based on information tips to enhance healthy
behaviors among pregnant women but with no impact on clinical health outcomes. Innovative
solutions are recommended to closely manage, monitor, and empower pregnant women to
actively participate in the management of their pregnancy.[25]
[26] A mobile health app that targets pregnant women may facilitate the integration of
prenatal care into other aspects of their family and professional life. Thus, women
who are highly engaged with their healthcare decisions during pregnancy might be more
receptive to educational programs and recommendations.[27] Our new mobile application allows patients to access some aspects of the clinical
record, enhancing personalized care. In our scenario, patients have a prenatal card
as proof of compliance with the traditional prenatal care protocol summarizing the
main achieved activities. Therefore, the new app described here still allows patients
to view an updated printable card anytime and anywhere. Thus, if the app can communicate
prenatal care information and basic alarm signs of pregnancy, the in-person visits
may allow for more individualized discussion. Ultimately, health managers and providers
must ensure the privacy and security of patients' information when using telemedicine.[28] Therefore, we adhered to a strict security protocol when developing this app, allowing
access exclusively to patients with a valid ID card and an encrypted password.
This mobile application was tested with a considerable number of high-risk pregnant
women and showed an acceptable perception regarding the characteristics of the application
in 3 of the 4 constructs evaluated: perception of usefulness, attitudes toward the
app, and intention to use. However, some aspects of the ease of using the app among
the patients could dampen the usability of this new technology. These difficulties
probably occur due to the inexperience of patients with mobile applications that provide
health care information despite 94% of them having an educational level higher than
high school. Several improvements to the app should be incorporated for future use,
and instructions for use should be provided to future users. Because the inexperience
was associated with a need for assistance to use the app, instructions, and support
from health providers will be important to engage pregnant patients with the app.
Final changes to our app should also include improvements in mobile platform capability
to support the number of patients in prenatal care.
Conclusion
To our knowledge, this is the first study to introduce a mobile application among
pregnant patients during the COVID-19 pandemic scenery as a tool to increase the information
available about their pregnancies in a mixed prenatal care program in a low-resource
country. Our results provide evidence of the high acceptability of this mobile application
among users, which is an essential step to massifying this tool in routine prenatal
care. However, further studies are needed to test the impact of this novel application
among perinatal outcomes.
