Literature Search Results
The review identified available evidence on the digital health technologies used in pregnancy healthcare. The search strategy yielded an initial 3354 studies, of which 3204 remained after duplicates had been removed. Title and abstract screening based on the inclusion and exclusion criteria reduced the 3204 studies to 205 studies. Upon full-text review, an additional 144 studies were eliminated, leaving 61 studies for data extraction. The selection process and main reasons for eliminating the studies at each stage are listed in Fig. 1 (PRISMA flow diagram). Table 1 lists the summary of findings and evidence of the final included studies.
Data Charting
Characteristics of the Included Studies
All articles reported on DHI use for ANC. The number of studies examining digital technology use in ANC increased steadily over the past 5 years, as shown in Figure 2. This increase could be attributed to the increasing adoption of digital technology in the market and the effect of the recent global healthcare situation, particularly the COVID-19 pandemic. The included studies had been conducted in a total of 24 countries, where most of the studies were conducted in high-income countries (HICs, 60.65%, n=37), with the US contributing the most studies (19.67%, n=12), followed by Australia (9.83%, n=6) and the UK (8.2%, n=5). The other HICs were Belgium (n=2), the Netherlands (n=2), Sweden (n=2), Saudi Arabia (n=2), Canada, Columbia, Germany, Korea, Israel, Norway, and Italy (n=1 each). The lower- or middle-income countries (LMICs) contributed 39.3% (n=24) of the included studies, with seven studies from Africa, three each from India and Turkey, two each from Palestine and Pakistan, and one each from Kenya, Uganda, Ethiopia, Nigeria, Iraq, and Brazil.
The most frequently used methodological approach was CS (33.78%, n=20), followed by RCT (27.86%, n=17). The other methodological approaches used were quasi-experimental (14.75%, n=9), cohort (9.83%, n=6), and qualitative (8.19%, n=5), while one study each involved a content analysis, case–control, prospective observational, and ecological design, respectively.
Area of Health Focus
This review centred on pregnant women and healthcare providers who provide ANC. The clinical areas that received the most attention in digital technology studies on ANC were general maternal care, mental health, and high-risk pregnancies. Among these, the highest percentage of DHIs were designed for general maternal health care (36.06%, n=22), followed by those designed for mental health issues (11.47%, n=7) and gestational diabetes mellitus (GDM, 11.47%, n=7). Some studies focused on high-risk pregnancies, encompassing various health issues in pregnancy (8.19%, n=5), hypertensive disease of pregnancy (6.55%, n=4), education (8.19%, n=5), and gestational weight gain monitoring (4.91%, n=3). Only one study was dedicated to smoking cessation interventions for pregnant women (1.64%, n=1). Similarly, a small percentage of studies (1.64%, n=1 each) were dedicated to vaccination education and reminders, cardiovascular health, interfacility imaging, and translation applications. Three studies (4.91%) explored non-health-related purposes in the antenatal period, such as facilitating health service payments for antenatal services and addressing intimate partner violence. Digital technologies were crucial in enabling synchronised and asynchronous communication between patients and healthcare providers for health management and monitoring. The primary modalities used included remote monitoring through specific smartphone mobile apps or web-based platforms, real-time virtual care for remote consultations, phone consultations, and text messaging systems. Additionally, standalone mobile app systems, wearables, and tracking devices were frequently used for personal health monitoring.
Categorisation of Digital Interventions
Digital health encompasses a wide range of technologies, such as wearable devices, telehealth and telemedicine solutions, mHealth, HIT systems, and personalised medicine approaches [64]. In this review, the digital technologies used to support ANC were broadly categorised into mHealth (64%, n=39) and telehealth (36%, n=22). Many articles have discussed mHealth use since 2018, whereas telehealth gained popularity during the COVID-19 pandemic due to movement restrictions and social distancing measures that severely affected the accessibility of traditional healthcare services (Fig. 3). Figure 3 illustrates a gradual and consistent upward trend in telehealth use over the past 5 years. While mHealth was more commonly used in both HICs and LMICs, comprising 64% of the digital modalities used, telehealth use was less prevalent, accounting for only 36% of usage. However, it is noteworthy that telehealth was more prominent in HICs, comprising 72.72% of the total usage in these regions. Patients and HCPs used telehealth solutions to bridge the gap created by physical barriers and to maintain essential medical care, which enabled the continuation of healthcare services.
Most of the studies included in the present review used mobile apps [89, 86, 69, 55, 78, 33, 90, 52, 91, 66, 56, 67, 33, 35, 37, 76, 38, 80, 87, 39, 92, 47, 81, 70, 58, 68, 75, 85], six studies used one- or two-way text messaging systems [73, 64, 65, 83, 48, 84], two studies used web-based cloud apps (59, 60), and only one study mentioned the use of a clinical decision support system to support antenatal health care (1). Twenty-two studies used synchronised telehealth communication either through audio/telephone consultation [63, 42, 45, 46] or virtual care [71, 72, 78, 62, 54, 82, 36, 79, 57, 40, 41, 43, 44, 88, 49, 50, 51, 74]. However, it was difficult to specify the digital technologies implemented in each study, as most of the articles described the use of more than one digital platform combining a few modalities, such as wireless digital devices and mHealth apps or web-based cloud centres for remote monitoring with teleconsultation [71, 73, 87, 47, 55, 69, 44, 58, 75, 74] or a combination of virtual platforms with digital booklets/videos and text messaging systems [86, 63, 39]. Four studies involved provider-to-provider consultation to discuss treatment decision-making, including technology platforms that enable real-time ultrasound consultation and synchronous and asynchronous referral systems when indicated between community health workers and health professionals in tertiary centres [69, 34, 37, 40].
Purpose of Digital Health
The DHIs were categorised into two primary groups according to their intended purpose: as a supplementary or substitute to routine care. Among the 61 included studies, 32 (52.45%) incorporated DHIs as supplementary to the regular care routine [89, 86, 62, 73, 63, 78, 64, 90, 52, 91, 65, 82, 66, 67, 35, 76, 84, 38, 80, 87, 39, 48, 84, 81, 59, 60, 68, 74, 75, 85, 61, 53], whereas 29 studies (47.54%) used DHIs as substitutes for conventional care methods [77, 71, 72, 23, 69, 54, 55, 33, 34, 36, 37, 40, 92, 41, 42, 43, 44, 88, 45, 46, 47, 70, 49, 50, 51, 58, 79, 57, 56].
Substitution for usual care refers to the integration of digital intervention in routine care by replacing a few routine antenatal visits with telehealth, reducing physical visits with clinicians [47, 44, 33, 71]. In comparison, the complementary digital platform used in addition to routine care supplements the standard care provided. DHI use as an integrated service in ANC demonstrated a noticeable upward trend over the past 5 years (Fig. 4). This trend aligned with the growth of telehealth practices in ANC, as mentioned above. Telehealth or telemedicine provides synchronised real-time communication between healthcare providers and patients. Notably, it has been predominantly used in general maternal care, constituting 71.4% (n=16) of cases, where it acts as a substitute for conventional routine care. Typically, mobile apps or text messaging systems are supplementary tools to support routine care. Additionally, mobile phone apps are used as an interface to simplify data gathering, decision-making, and patient–HCP communication. A few of the included studies reported that the integration of mobile apps with telehealth services was used to augment healthcare quality [34, 37, 39, 47, 69, 71, 72].
Our review determined that digital health platforms use multiple modalities in a single clinical setting to fulfil their functions in healthcare provision. These platforms offer various healthcare services, such as virtual or phone consultations, two-way text messaging for healthcare consultation and management, remote monitoring, self-tracking through digital apps, education and training, and appointment reminders (Table 1). While there are safety and privacy concerns, no adverse perinatal outcomes were reported, and standard care of practice was maintained according to antenatal guidelines [44, 71] with the utilisation of digital health.
Table 1 Summary of Digital Health Intervention Utilized to Provide Antenatal Care
|
Author, year,
location
|
Journals
|
Study design
|
Utilization
|
Description of digital technology
|
Intervention type
|
Purposed
|
Main outcome
|
|
General maternal care
|
1
|
(Dansharif et al., 2021)
|
Procedia Computer Science
|
Qualitative
|
General maternal care
|
mHealth tools for self-management
|
Self-monitoring care during pregnancy
|
Substitute
|
Benefit:
Fewer hospital visits.
Improve healthcare service.
Challenges:
Lack of electrical supply and facility.
Language barrier of the apps.
|
2
|
(Borsari et al., 2018)
|
Journal of Immigrant and Minority Health
|
Quasi experimental
|
General maternal care
|
Pregnancy and New-born Diagnostic Assessment (PANDA) :
mHealth system to facilitate the provision of high-quality, standardized ANC in underserved settings (between community level and referral hospital)
|
Teleconsultation
: interfacility consultation and referral with health management
|
Substitute
|
91.9% of patients are satisfied with the system
Enabled the identification of a diverse range of high-risk conditions.
Increase HCPs' care provision to ANC recommendations.
Provides comprehensive and high-quality antenatal care.
Facilitates the continuity and interfacility continuation of care
|
3
|
(Barron et al., 2018)
|
BMJ Global Health
|
CS
|
General maternal care
|
MOMConnect :
One way text messaging system delivered twice weekly providing health information related to pregnancy and child care
|
Health promotion
|
Supplement
|
High acceptance with 63% registration of all women attending their first ANC appointment to the system.
High end user satisfaction,
Incomplete registration lead to missing data.
Costly with limitation of length to 160 characters.
|
4
|
Sulaman et al., 2022
|
International Journal of Medical Informatics
|
CS
|
General maternal care
|
Telemedicine
|
Teleconsultation
|
Substitute
|
Majority (54%) intend to use telemedicine in future
|
5
|
Paduano et al., 2022
|
International Journal of Environmental Research and Public Health
|
RCT
|
General maternal care
|
mHealth system PANDA (Pregnancy And New-born Diagnostic Assessment)
|
Teleconsultation
: interfacility consultation and referral with health management
|
Supplement
|
High level of acceptance and satisfaction among patients and HCPs in intervention group.
Improve quality, access and utilization of ANC visits.
Increase HCPs to ANC recommendation.
|
6
|
Arnaert et al., 2019
|
Digital Health
|
Qualitative
|
General maternal care
|
STREAMS (Strengthening Relationships and Enhancing Access to Maternal Services): mhealth supported antenatal care
|
Teleconsultation
|
Substitute
|
Potential to improve mothers' pregnancy awareness and
increase their prenatal care attendance.
Improvement in the patient–provider relationship.
Increase engagement to ANC services.
|
7
|
Musiimenta et al.,2021
|
Digital Health
|
RCT
|
General maternal care
|
MatHealth app:
Health information via multimedia videos and audios messages.
Appointment reminders.
Phone consultation
|
Teleconsultation health promotion with appointment reminders
|
supplement
|
MatHealth app is acceptable and feasible intervention among illiterate women.
Enabled appropriate maternal health practices, spouse support, clinic visit reminders, and communication with healthcare provider.
Challenges; phone sharing, lack of electricity and IT illiterate.
|
8
|
Bhandari et al., 2020
|
Telemedicine and eHealth
|
CS
|
General maternal care
|
ANGELS program telehealth services
: Remote consultations for obstetric patients, clinic appointment and referrals.
|
Teleconsultation and health communication
|
Substitute
|
High levels of satisfaction were reported by both patients and providers with the telehealth services.
Better access to obstetric care for patients and improved health outcomes.
|
9
|
Galle et al., 2021
|
BMJ Global Health
|
CS
|
General maternal care
|
Telemedicine for maintaining the provision of maternal healthcare during covid
|
Teleconsultation
|
Substitute
|
More than half (58%) of health professionals use telemedicine.
Two-fifths of them claimed they had not received any telemedicine guidelines.
Challenges reported:
Inadequate infrastructure and limited technology literacy, restricted monitoring capabilities, financial and language barriers, absence of nonverbal feedback and rapport, as well as patient distrust.
|
10
|
(Duryea et al., 2021)
|
JAMA Network Open
|
Cohort
|
General maternal Care
|
Audio-only virtual visits
: integration of synchronous audio-only virtual visits into prenatal care
|
Teleconsultation
|
Substitute
|
There were no association of adverse perinatal outcomes with the use of audio-only virtual prenatal visits.
Access and attendance at prenatal visits increased in a vulnerable population during the COVID-19 pandemic.
The findings indicate that a synchronous, audio-only virtual prenatal care platform in ANC is safe, effective, and legitimate.
|
11
|
Hofmann et al., 2022
|
Maternal and Child Health Journal
|
CS
|
General maternal care
|
Telehealth
|
Teleconsultation
|
Substitute
|
Telehealth was discovered to be feasible, appropriate, and acceptable across all providers categories.
Challenges:
Patients preference for in person visits, lack of necessary tools for teleconsultation , inadequate clinic support.
|
12
|
Butler Tobah et al., 2019
|
American Journal of Obstetric gynaecology
|
RCT
|
General maternal care
|
OB Nest: prenatal care model integrated with remote home monitoring devices and nursing support.
|
Teleconsultation with remote monitoring
|
Substitute
|
Higher satisfaction with integrated care and reduce prenatal stress.
Fewer number of scheduled visits with clinicians
Maternal and fetal outcome are similar in both groups
Adherence to ACOG prenatal care service was similar in both groups: standard care is maintained
|
13
|
Wali et al., 2022
|
Women’s Health
|
CS
|
General maternal care
|
Phone-based antenatal care
|
Teleconsultation
|
Substitute
|
The use of phone-based ANC during the pandemic showed high level of satisfaction (93.9%)
|
14
|
Zulfeen & Chandrasekaran, 2022
|
Elmer Press
|
CS
|
General maternal care
|
Virtual prenatal care
phone calls and direct video conferencing.
|
Teleconsultation
|
Substitute
|
Mothers were less satisfied with virtual prenatal care telehealth services, especially vulnerable patient populations.
|
15
|
Marko et al., 2019
|
JMIR MHEALTH AND UHEALTH
|
RCT
|
General maternal care
|
Babyscripts app
: deliver educational content via a mobile app and to remotely monitor blood pressure and weight
: any blood pressure and weight triggers were identified and managed
|
Teleconsultation
Tele-education
Remote monitoring
|
Substitute
|
The use of a mobile app for prenatal care was linked to fewer in-person visits.
There’s no change in patient or provider satisfaction.
|
16
|
Coleman et al., 2020
|
Reproductive Health
|
Intervention cohort
|
General maternal care
|
Sms text messages:
One way informative and pregnancy stage-based maternal health information text messages throughout pregnancy
|
Tele-education
and behavioral counseling
|
Supplement
|
Pregnant women are more likely to consistently complete maternal and infant health care and attend ANC visits more often.
|
17
|
Futterman et al., 2021
|
American Journal of Perinatology
|
CS
|
General maternal care
|
Telehealth
|
Teleconsultation
|
Substitute
|
Telehealth allows continuation of prenatal care however showed lower overall satisfaction for telehealth use.
|
18
|
Jeganathan et al., 2020
|
AJOG MFM
|
CS
|
General maternal care
|
Telehealth in high-risk obstetrical care
|
Teleconsultation
|
Substitute
|
Approximately 87% of patients and 88% of healthcare providers were satisfied with using telehealth for managing high-risk pregnancies.
Reduced the occurrence of missed and cancelled appointments
Improve access to health care.
|
19
|
Lapadula et al., 2021
|
Frontiers in Paediatric
|
CS
|
Neonatology prenatal consultation
|
Virtual visits through Zoom Pro platform
|
Virtual consultation
|
Substitute
|
Virtual consultations met the expectations of both patients and medical practitioners, resulting in a high level of satisfaction among both parties with virtual visits
|
20
|
Pinheiro dos Santos et al. 2022
|
Frontiers in PH
|
Qualitative
|
Routine ANC and vaccination
|
HERA mobile apps
preventive maternal-child healthcare
|
Health education
Appointment reminder
|
supplement
|
High acceptance of the mobile apps use among Syrian refugee in turkey
|
21
|
(Alhaidari et al. 2018)
Iraq
[53]
|
Journal of Perinatal Medicine
|
Experimental
|
General maternal care
|
Two ways text messaging system
|
Health education
Appointment reminder
|
Supplement
|
High acceptance and feasible.
Increase ANC visits
|
22
|
Sulaman et al., 2022
|
International Journal of Medical Informatics
|
CS
|
General antenatal care
|
Telemedicine in obstetric
|
Teleconsultation
|
Substitute
|
The majority (54%) intend to use telemedicine in future
57% did not feel satisfied with telemedicine use
|
|
GDM
|
23
|
Sung et al., 2019
|
Clinical Therapeutics
|
RCT - pilot
|
Gestational Diabetes Mellitus (GDM)
|
Mobile phone application (Huraypositive Inc, Seoul, Korea)
: tailored mobile health services for blood glucose monitoring, diet and physical activity.
|
Remote monitoring with health communication and consultation
|
Substitute
|
Glycaemic control and perinatal outcomes were similar between intervention and control groups. However, the intervention group achieved better weight management and improved insulin resistance following childbirth.
|
24
|
Alqudah et al., 2019
|
BMC health services research
|
CS
|
GDM
|
mHealth: self-management and remote monitoring
|
Teleconsultation
|
Substitute
|
The majority of pregnant women are ready to taking care of their condition at home and being remotely monitored by healthcare staff.
|
25
|
Kozica-Olenski et al., 2022
Australia
[57]
|
BMC Pregnancy and childbirth
|
Qualitative
|
GDM
|
Telehealth
|
Teleconsultation
|
Substitute
|
Both women and clinicians viewed telehealth as acceptable for diabetes in pregnancy care, and were satisfied with telehealth as an alternative to F2F consultation during pandemic.
However, telehealth was perceived to reduce the quality of care.
|
26
|
Mackillop et al., 2018
|
JMIR MHEALTH AND UHEALTH
|
RCT
|
GDM
|
Mobile phone-based real-time blood glucose management system:
GDm-health App with website and short message service (SMS) text message
|
Teleconsultation and remote monitoring
|
Substitute
|
Significantly greater numbers of blood glucose measurements, higher levels of satisfaction, and fewer caesarean sections were all observed in the intervention group.
Other maternal and neonatal outcomes were similar in both groups.
|
27
|
Miremberg et al., 2018
Israel
[59]
|
American Journal of Obstetrics and Gynaecology
|
RCT
|
GDM
|
Glucosebuddy
: web-based application generating daily report on blood glucose to research database
|
Teleconsultation and remote monitoring
|
supplement
|
Increased adherence to blood glucose monitoring.
Lower means blood glucose value
Treatment with insulin were at lower rate
Increased satisfaction with their care.
|
28
|
Rasekaba et al., 2018
|
Diabetes Research and Clinical Practice
|
RCT
|
GDM
|
TeleGDM
Online Health Portfolio
: web-based patient-controlled health record linking shared data with health professionals
|
Teleconsultation and remote monitoring
|
supplement
|
Not associated with adverse clinical outcome in GDM (clinical results comparable to standard care).
There was no additional risk to clinical quality of care.
Achieved earlier optimum glycaemic control with fewer insulin dose titration.
|
29
|
(Al-Ofi et al. 2019)
Saudi Arabia
[61]
|
Journal Of International Medical Reasearch
|
RCT
|
GDM
|
TeleGDM :
Smartphone- Glucometer and a Glucomail application installed in patients’ phones. Any abnormal readings will alert healthcare team for consultation.
|
Teleconsultation with remote monitoring
|
Supplement
|
Improve perinatal outcome
TeleGDM group significantly lower blood glucose level than the control group.
Additionally, TeleGDM group showed significant lower weight gain.
|
|
Mental Health
|
30
|
Lakshminarayanan
et al., 2020)
|
Asian Journal of Psychiatry
|
Cross-sectional with
pre- and posttest
analysis
|
Mental health
|
Digital platform training program
: improve mental health training and service delivery
|
Virtual learning and training
|
Supplement
|
Improvement in the average score of participants in pre (20%) and post (75%) training with digital platform training.
|
31
|
(AKSOY DERYA et al., 2021)
|
Midwifery
|
quasi-experimental study
|
Prenatal distress and pregnancy related anxiety
|
Interactive education and consultancy provided by phone calls, text messages and a digital education booklet.
|
Health education via virtual learning and communication
|
Supplementary
|
Tele-education successfully reduced levels of prenatal distress and anxiety.
Significant different in prenatal distress and
anxiety level in intervention group
|
32
|
Bhat et al., 2018
|
HHS Public Access
|
Quasi experimental
|
Mental health
(Depression)
|
Perinatal Collaborative Care (CC) program
: 2 ways text messaging for behavioral activation, medication reminders, depression information and appointment reminder.
|
Health information, behavioral consultation, and communication
Appointment reminders
|
supplement
|
Both patients and providers found text messaging to be acceptable and useful when used as adjunct to the conventional physical meetings
No substantial correlation observed between certain types of text message content and the improvement of depression.
|
33
|
Bogale et al., 2021
|
PLOS ONE
|
RCT
|
Fears and worries about birth and parenting
|
targeted client
communication (TCC) via short message service (SMS)
: Health information in pregnancy to alleviate worries among mothers
|
Health education Appointment reminders
|
supplement
|
Worries in pregnancy:
Women in intervention group has less worries related to pregnancies, but it was not statistically significant
Satisfaction:
No difference between intervention and control groups in women's satisfaction with ANC services
|
34
|
Brusniak et al., 2020
|
JMIR MHEALTH AND UHEALTH
|
Prospective cohort studies
|
Mental health and physical well being
|
Digital health app with self-tracking
|
Tele-education and self-monitoring
|
supplement
|
User engagement
Only 25% of patients could be considered compliant.
Cultural and socioeconomic background factors is the most influential factors of user’s engagement.
|
35
|
Highet et al., 2021
|
Primary Health Care Research & Development
|
Descriptive Cohort
|
Mental health
|
iCOPE : perinatal mental health digital screening platform
|
Screening and diagnostic use
|
supplement
|
Screening time, scoring accuracy, and women engagement were proven efficient with iCOPE platform.
iCOPE demonstrated that the digital screening platform was widely accepted.
|
36
|
(Hantsoo et al., 2018)
|
HHS Public Access
|
RCT
|
Depression
|
Mobile mood tracking and alert (MTA) mobile application (app)
monitored activity, assessed mood, and alerted OB providers of signs of worsening mood.
|
Health communication and consultation
|
Supplement
|
The use of mobile MTA app has enhanced their self-perceived capability to handle their own health.
Well accepted and improve mental health service
|
|
Hypertension
|
37
|
Musyoka et al., 2019
|
Informative in Medicine unlock
|
Quasi
experimental
|
Preeclampsia
|
24-hour ambulatory blood pressure monitoring system
: Use of a smartwatch integrated with a mobile apps for 24 hrs ambulatory blood pressure monitoring, reporting and detection of alert symptoms
|
Teleconsultation
Remote monitoring
|
Substitute
|
The study offers practical insight into the adoption of digital health solution to support preeclampsia management.
|
38
|
(Lanssens et al., 2018)
|
European Journal of Obstetrics & Gynecology and Reproductive Biology
|
Cohort (retrospective)
|
Hypertensive disease of pregnancy
|
Obstetric surveillance via a wireless blood-pressure monitor, weight scale, and activity tracker
Predetermined alarm signals were set, if triggered will be managed accordingly.
|
Teleconsultation
Remote monitoring
|
Substitute
|
The intervention group had a lower rate of preeclampsia and a higher rate of detection of gestational hypertension.
Fewer hospitalizations and admissions to the prenatal ward.
Fewer prenatal visits.
|
39
|
Van den Heuval et al. 2020
Netherland
[71]
|
Pregnancy Hypertension
|
Case control study
|
Chronic Hypertension
Preeclampsia
|
SAFE@HOME:
digital health platform for telemonitoring blood pressure and symptoms combined with a minimal antenatal visit schedule
|
Teleconsultation
Remote monitoring
|
Substitute
|
The usage of a digital platform resulted in a significant reduction in prenatal visits, ultrasounds, and hypertension-related admissions.
Lower cost per pregnancy and societal cost
Perinatal outcomes were similar in both groups
|
40
|
van den Heuvel et al., 2019
|
European Journal of O&G and Reproductive Biology
|
Prospective observational study
|
Hypertensive disease in pregnancy
|
SAFE@HOME:
telemonitoring platform for bp monitoring and mobile apps for preeclampsia symptoms checklist and alert
telemonitoring platform, with the feature to combine repeated BP measurements monitoring with associated preeclampsia symptom alert and checklist for pregnancy
|
Teleconsultation Remote monitoring
|
Substitute
|
Blood pressure monitoring and symptom checklist compliance rates were 93% and 85%, respectively.
Most users were satisfied with the system and its usability with higher prenatal care engagement.
The telemonitoring platform is feasible for patient and HCPs
|
|
Smoking Cessation
|
41
|
King et al., 2022
|
Patient Education and Counseling
|
RCT -pilot
|
Smoking cessation
|
SKIP-IT
(SmoKing In Pregnancy – Intervening with Texts) a
Digital Storytelling interventions
narrative and picture-based smoking cessation intervention delivered via text messages.
|
Virtual learning Health communication and behavioural counselling
|
Supplement
|
The intervention group had a lower percentage of nonnon-smokers at follow-up. However, the sample size was insufficient to make conclusive judgment about effectiveness.
Recruitment was challenging, engagement was low, acceptability of the intervention was high
|
|
Gestational Weight Gain
|
42
|
Ferrara et al., 2020
|
Lancet Diabetes Endocrinology
|
RCT
|
Gestational weight gain
|
GLOW (Gestational Weight Gain and Optimal Wellness): behavioural lifestyle intervention delivered via telehealth
|
Teleconsultation and behavioural
Counseling
|
Supplement
|
GLOW intervention is deemed feasible among end users.
Significant reduction in
excess GWG , improve healthy diet and sedentary behaviours, improve markers of insulin resistance among women within the intervention group.
No difference in perinatal complications between the two groups
|
43
|
Van Horn et al., 2018
US
[75]
|
American Journal of Preventive Medicine
|
RCT
|
Gestational weight gain
|
MAMA-DASH diet programme with LOSEIT weight loss smartphone application: multimodal
intervention efforts focused on healthier diet and nutritional guideline, modest physical activity and sleep monitoring
|
Communication and behavioural counseling
Self- monitoring tracker
|
Supplement
|
Intervention group:
Exhibited a markedly reduced level of total weight gain throughout the 35-week gestational period, with no negative impact on infant health outcomes.
|
44
|
Henriksson et al., 2022
|
Scientific Report
|
RCT
|
Gestational weight gain
Diet quality
Physical activity
|
HealthyMoms app (6-month mHealth intervention)
|
Virtual learning and health promotion
Self-monitoring tracker
|
Supplement
|
The utilization of the HealthyMoms application was linked to decreased gestational weight gain, enhanced dietary quality, and modifications in levels of physical activity.
User Engagement decreased over time.
|
|
High risk pregnancies
|
45
|
Venkateswaran et al., 2022
|
Lancet Digital health
|
Pragmatic Cluster RCT
|
Anaemia
Diabetes
Hypertension
Fetal growth monitoring
|
eRegQual : Clinical Decision support system
|
electronic decision-making support: guideline from medical management
|
Supplement
|
Improvement in anaemia, diabetes, and hypertension screening and management of the disease.
No improvement for abnormal fetal growth.
Absence of impact on adverse health outcomes during delivery.
No change in ANC attendance.
|
46
|
Palmer et al., 2021
|
The Lancet
|
Quasi experimental design
|
Maternal care
|
Telehealth integrated maternal care for low risk and high-risk care models
|
Teleconsultation Remote monitoring
|
Substitute
|
Primary outcomes within integrated care, such as detection and outcomes of fetal growth restriction, pre-eclampsia, and gestational diabetes, were not significantly different.
Significant reduction in preterm birth among high-risk model while no other significant difference in other outcome measures (stillbirth, neonatal intensive care unit admission).
Reduction of in-person consultations by 50% without compromising pregnancy outcomes.
|
47
|
Daly et al., 2019
|
Women and Birth
|
CS
|
Decreased fetal movement
|
Mobile applications
Self-monitoring of fetal movement
|
Patient self-monitoring
|
supplement
|
Lack of clinically grounded evidence-based guidance for women encountering reduced fetal movement.
|
48
|
Escobar et al., 2022
|
BMC Pregnancy and childbirth
|
Descriptive ecological study
|
Obstetric emergencies
|
Telehealth and education for the care of obstetric emergencies between two hospitals of medium and high complexity
|
Teleconsultation
|
Substitute
|
The use of telehealth and education model significantly reduces perinatal mortality.
Reduction in blood transfusions due to PPH and eclampsia events in patients
|
49
|
Gupta et al., 2021
|
Journal of Family Medicine and Primary Care
|
CS mixed method
|
High risk pregnancies
|
SEWA applications: System E-approach for Women at risk’
|
Identification and screening of high-risk pregnancies
|
supplement
|
Increase in the identification of pregnant women with high‑risk conditions (27.9% from 3.5% in the previous year)
The SEWA application represents a feasible and enduring approach to augment the capabilities of healthcare providers in promptly detecting high-risk medical conditions.
|
|
Education
|
50
|
Silva et al., 2019
|
Rev Bras Enferm
|
CS
|
Gestational health care.
|
e GestAção application
: health education on maternal and child care
|
Health education and self-monitoring
|
supplement
|
High index of satisfaction of this technology of support to the pregnancy.
|
51
|
Shahid & Johnson, 2018
|
Evidence-based midwifery
|
CS
|
Antenatal education
|
Solihull Approach online antenatal course
|
Tele-education
|
supplement
|
The online antenatal course reduced parental anxiety, increased intention to breastfeed and improved the
relationship with the unborn baby.
|
52
|
Basu et al., 2022
|
Short Communication
|
RCT
|
oral care and hygiene practices of pregnant women
|
mHealth: text messages on oral health promotion
|
Health education
|
supplement
|
mHealth intervention group showed a significant decrease in missed twice-daily brushing event
|
53
|
Masoi & Kibusi, 2019
|
Reproductive Health
|
Quasi experimental
(pre & post with control group)
|
Knowledge on obstetric and newborns danger signs
|
Interactive mobile messaging alert system
: received health education messages and two-way communication responses on a need basis
|
Health education and communication
|
Supplement
|
The interactive mobile messaging alert system improved women's birth preparedness practice and shown to be effective in enhancing awareness of danger signs in pregnancies.
|
54
|
(Mohammed&Mohammed, 2022)
|
Egyptian Journal of Health Care
|
Quasi -experimental
|
Fetal Kick Monitoring
|
Mobile-assisted education regarding fetal kick monitoring via online session, text messages and illustrative video
(Kick counter mobile application)
|
Health education
|
Supplement
|
Improvements in fetal kick monitoring knowledge and practice among high-risk pregnant women that are statistically significant (p 0.001) and correlate with favourable perinatal outcomes were observed in the study group as compared to the control group.
|
|
Vaccination
|
55
|
Kaufman et al., 2020)
|
Vaccination in maternity
|
CS
|
Influenza and pertussis vaccination
|
The P3-MumBubVax intervention
: sms text reminder , website and fact sheets on vaccinations
|
Digital learning to support and educate patients
|
Supplement
|
Increase maternal and early childhood vaccine uptake and acceptance.
The P3-MumBubVax intervention is feasible and acceptable in the Australian public antenatal setting.
|
|
Cardiovascular health
|
56
|
Zielinska et al., 2022
|
Medicine
|
CS
|
Cardiovascular Health
(bodyweight, heart rate, blood pressure, activity levels, and sleep patterns)
|
Multimodality remote monitoring:
Home monitoring devices, including a smartwatch, BP machine, and weighing scales.
Mobile Apps – HUMA to record daily measurements
|
Teleconsultation and remote monitoring
|
Supplement
|
Pregnant women may be successfully recruited for remote monitoring. Hence continuous health monitoring in pregnancy is feasible.
|
|
Imaging
|
57
|
Jemal et al.,2022
|
Journal of Telemedicine and Telecare
|
Cohort
|
Ultrasound for ANC
|
tele-ultrasound platform.
: consultation bet HCPs in rural clinic and obstetrician in tertiary centre
|
Teleconsultation
: interfacility consultation and referral with health management
|
Substitute
|
Antenatal Ultrasound performed supported by obstetrician via tele-ultrasound showed good concordance and was well received by participants, and gave rural Ethiopian women better access to antenatal imaging.
|
|
Translation
|
58
|
Bitar & Oscarsson, 2020
Sweden
[89]
|
midwifery
|
CS Qualitative
|
Provision of digital translator apps and health communication
|
Swedish-Arabic mobile application
|
Health promotion and translation tools
|
Supplement
|
Arab-speaking women valued the use of apps as communication aid
The content was educational, reliable, and understandable.
|
|
Non health related
|
59
|
Lacroze et al., 2023
Madagascar
Africa
[90]
|
Plos one
|
CS mixed method
|
Health service payment
|
Mobile Maternal Health Wallet (MMHW)
: money saving for health, electronic vouchers for antenatal ultrasound, and bonus payments upon reaching a savings goal.
|
Encouraging facility-based deliveries
|
supplement
|
Factors that influence the acceptance of MMHW includes community awareness and sensitization, strong women-health worker relationship, household level involvement in decision making, and iterative instruction concerning MMHW utilization.
The lack of phone ownership, low digital literacy, disinformation about the intervention's benefits, and technical issues including delayed pay-out procedures were the main impediments.
|
60
|
Walter et al., 2021
|
JMIR FORMATIVE RESEARCH
|
Qualitative
|
Intimate Partner Violence (IPV)
|
Tablet intervention containing IPV questions and a film to promote safety behaviours
|
Prevention
And communication
|
Supplement
|
The tablet intervention empowered women to talk about IPV openly.
Face-to-face communication capabilities should be incorporated into IPV technology.
|
61
|
Şat et al., 2021
|
Maternal and Child Health Journal
|
CS
|
Mobile Apps
|
Pregnancy related mobile application – not specified
|
Teleconsultation Remote monitoring
Health promoting and education
|
Substitute/supplement
|
77.9% used pregnancy-related mobile apps during the pandemic.
The prevalence of smartphones use among expectant mothers caused mobile health apps to be a viable option for prenatal follow-ups.
|
Outcomes
The included studies covered various outcomes related to the use of digital tools, including satisfaction (26.22%), acceptability (29.5%), feasibility (11.4%) and maternal outcomes. Most of the included studies reported improved maternal outcomes, which were reflected as improved perinatal outcomes (24.59%), improved process outcomes and health services (13.11%), improved access and increased engagement in ANC service utilisation (14.75%), low perinatal mortality in cases of hypertensive disease in pregnancy (1.64%), improved knowledge and positive behaviour changes (8.19%), and improved psychological outcomes (3.27%). A few studies mentioned the benefits of using DHIs as a replacement for ANC, including a reduction in in-person visits (9.83%), societal and pregnancy costs (1.64%), and efficient interfacility care and referral (3.27%). Contrastingly, 14.75% of the included studies reported no change in perinatal outcomes [77, 71, 78, 55, 65, 42, 44, 58, 60]. A total of 8.19% of the included studies highlighted the barriers to DHI implementation, particularly among patients, especially in LMICs [33, 39, 41, 43, 90]. Three studies reported poor satisfaction among users [65, 46, 49], and one study reported poor compliance [66], while another reported reduced quality of care with DHI use in ANC [57]. The different types of outcomes included clinical outcomes, user-reported outcomes (acceptability, satisfaction, and feasibility) and challenges in digital health.
Clinical Outcomes
DHIs have consistently demonstrated their efficiency in providing maternal care. By integrating technology and healthcare, DHIs offer innovative solutions to enhance access, convenience, and effectiveness in managing maternal health. The methodological approaches to examine maternal outcomes included RCTs [77, 73, 55, 76, 83, 58, 59, 60, 68, 74, 75], quasi-experimental studies [23, 63, 34, 85], and observational studies [89, 86, 82, 80, 42, 70]. All of the studies indicated no negative effects on clinical health outcomes when comparing conventional care to DHI-integrated care. Additionally, these studies reported that the use of DHI integrated care was safe and effective in providing proper care [77, 42, 60]. Most of the studies stated that digital health technology in ANC either improved healthcare service in general [33, 91, 68] or improved perinatal outcomes [89, 86, 73, 63, 82, 76, 83, 70, 59, 68, 74, 75], improved the detection and screening process for high-risk conditions [34, 67, 70, 77, 80], and increased access to and utilisation of ANC services [72, 37, 38, 40, 42, 88, 48, 50]. Furthermore, one study reported reduced perinatal mortality and blood transfusion rates in postpartum haemorrhage (PPH) and preeclampsia [79]. Contrary to the overall positive outcomes of DHIs in improving maternal care, one study highlighted concerns regarding a potential reduction in the quality of care associated with DHI use [57]. The study suggested that limitations in physical contact, which is a vital aspect of traditional healthcare delivery, could potentially compromise the quality of care provided through digital interventions, causing distress in some patients. A randomised controlled study on the effect of DHI in GDM determined that two studies reported an improvement in blood sugar control and monitoring with a lower rate of insulin treatment [59, 60], while three studies reported significantly reduced gestational weight gain and correspondingly improved diet quality and physical activity [74,75,76].
Some studies reported mixed findings regarding the clinical outcomes. One study reported higher compliance with blood glucose monitoring with a lower incidence of caesarean section deliveries [58], while other maternal and neonatal outcomes were similar. Another study reported a significant reduction in blood sugar control together with a reduction in gestational weight gain [61]. Contrastingly, another study stated that there was no difference in glycaemic control during pregnancy; however, effective weight control and improved insulin resistance were demonstrated after delivery with DHI use [55]. A quasi-experimental study on the effect of telehealth-integrated maternal care reported that it significantly reduced preterm birth among high-risk pregnancies, while other outcome measures, such as stillbirth, intrauterine growth retardation (IUGR), GDM, and preeclampsia, were similar [23]. Several studies, however, did not report a significant difference in perinatal outcome [42, 44, 65, 71, 72] between patients who received conventional prenatal care and those who used DHI-integrated care.
DHI implementation for educational purposes significantly improved knowledge and positive behaviour [82, 83, 84, 85]. By leveraging technology to deliver targeted and timely information, DHIs have the capacity to revolutionise healthcare education and contribute to better overall public health. Only two studies conducted by the same authors in consecutive years [71, 72] provided insights into the cost-effectiveness of using digital interventions in managing hypertension during pregnancy. These studies specifically examined the societal costs and cost per pregnancy associated with digital intervention implementation. The cost of sending text messages can also be a concern, particularly when large-scale dissemination is required. One study mentioned the high cost of disseminating text messages, which are subject to character limits, to patients in providing health information [35]. Traditional SMS messages are typically limited to 160 characters, although some systems support longer messages by splitting them into multiple parts. However, this nevertheless presents challenges when attempting to convey comprehensive health information. Generally, DHI integrated care did not yield unfavourable effects on maternal outcomes, nor did it result in an escalated risk for both the maternal and fetal aspects when compared to conventional care methods. Furthermore, the use of DHI supported and complemented traditional maternal care.
User-reported Outcomes
Sixteen studies [72, 34, 35, 57, 37, 40, 44, 45, 81, 50, 51, 58, 59, 46, 49, 65] assessed user satisfaction with DHI, of which 81.25% (n=13) reported a high rate of satisfaction, where one article reported that 86.9% of patients and 87.8% of providers were satisfied with the use of telehealth for the care of high-risk obstetrical patients [50]. Three studies (18.75%) reported dissatisfaction with the use of DHI-integrated care, mainly telehealth [46, 49, 65], especially among patients with a previous poor obstetric history in vulnerable populations and the feeling of reassurance and gratification with conventional visits [46]. Studies that examined the acceptance of DHI-integrated ANC consistently demonstrated that most users exhibited a positive inclination toward DHI use. The findings of these studies indicated a high level of acceptance and satisfaction among pregnant individuals who engaged with DHI in their ANC [89, 86, 69, 64, 52, 56, 67, 35, 36, 57, 37, 80, 87, 39, 41, 43, 68].
Several studies explored the feasibility and impact of DHI-integrated care in high-risk pregnancies and reported encouraging findings. These studies demonstrated that implementing digital interventions led to positive outcomes without adverse perinatal effects [69, 80, 87]. The use of multimodal digital interventions can be important in screening and identifying women at risk for adverse maternal outcomes, specifically concerning hypertensive disorders of pregnancy [77, 34, 80, 70] and mental health [67]. These interventions leverage various digital tools and technologies to assess and monitor women’s health, enabling early detection and intervention. Some studies reported reduced clinic visits by integrating DHI as a substitute for physical meetings [71, 73, 33, 44, 47, 70], which were more convenient for considering travelling time and work absence. Missed and cancelled appointments were also reduced [50], as there was flexibility in time adjustment. Antenatal attendance was increased [42, 48, 53] with higher user engagement in ANC services [72, 38, 48].
DHI use also enhanced women’s empowerment and confidence in their willingness to use technology for self-care and management [33, 56, 57, 68]. However, one study reported poor utilisation of telehealth by HCPs with no proper guidelines [41], and another study [66] described noncompliant DHI use for mental health among pregnant women, where only 25% of the pregnant women were compliant with using mobile/smartphone apps. This DHI use was related to the exclusive substitution of regular healthcare services with telehealth. It is worth noting that while multimodal digital interventions have shown promise, they should not replace in-person clinical assessments and care. Instead, they can complement traditional care models by enhancing screening processes and promoting timely interventions. An integrated telehealth model combining digital interventions and face-to-face consultations is often considered favourable and acceptable to users. This blended approach allows for the benefits of digital interventions while maintaining the essential human connection and personalised care provided through in-person consultations. Generally, our review determined that digital intervention was usable, feasible, and acceptable to users.
Challenges and Barriers
Only five studies explored the challenges and barriers of DHI [90, 33, 39, 41, 43]. Of these, three were conducted in Africa [32, 90, 39], and one in Belgium [41] and the US [43]. Challenges associated with infrastructure and IT support, such as insufficient electricity supply and necessary facilities, are significant obstacles to digital technology adoption. The lack of adequate clinic support, low smartphone ownership, and low digital literacy are also among the barriers hampering such technologies’ use. The issue is compounded by the limitations of remote monitoring, where physical examinations are unfeasible, and a lack of nonverbal feedback and bonding can foster distrust between the patient and provider. Language barriers present yet another hurdle, either in the context of app usage or during telehealth communication. This issue is particularly challenging to address in a virtual care setting. This phenomenon is particularly prominent within LMICs, wherein prevalent infrastructure and digital literacy deficiencies present significant barriers, thereby imposing substantial constraints on the implementation of digital technology within the healthcare domain. This underscores the fact that an individual’s tech-savviness and their socioeconomic status are decisive in determining their utilisation and engagement with digital healthcare services.