Introduction

As of 2015, ~64% of Americans have a smartphone; of these, 62% have used their smartphone to access health information.1 Smartphone applications (apps) have been shown to help distribute specific health-related information and improve disease self-management,234 and there are numerous consumer-directed apps related specifically to obstetrics and gynecology.5

Pregnancy-specific smartphone apps provide gestational age-specific information to subscribers throughout pregnancy and are in widespread use. Text4Baby (T4B) is currently available as a pregnancy-specific app that was initially developed as a free text messaging service by national agencies and has been supported by the American College of Obstetrics and Gynecology (ACOG) and March of Dimes.6 Baby Center’s ‘My Pregnancy Today’ (BC) is a pregnancy-specific app that originated as a website and is now supported by the Society of Maternal Fetal Medicine.7 Although pregnant women frequently use T4B, BC and other pregnancy-specific smartphone applications, the content delivered to patients through this technology is not well described. As digital media continues to be central resource patients turn to, it is important for providers to understand the content of the information patients receive through these sources.

The goal of this study was, therefore, to examine the content of nationally endorsed pregnancy-specific smartphone applications, identify the types and frequencies of information delivered and determine the apps’ accuracy and adherence to prenatal care guidelines.

Methods

This study was a qualitative content analysis of information delivered through T4B and BC. These apps were selected for study, as both are available as free downloads for iPhone and Android phones, and are the only two pregnancy apps that are supported by national professional organizations for physicians. Institutional Review Board approval was not required for this study, as neither information nor participation from human subjects was used.

All daily information from conception through 2 weeks postpartum were transcribed, coded and analyzed. Information available through message boards, polls, videos and links from each application was not included. The latest data available for each app through March 2015 were transcribed and reviewed, and a preliminary codebook was created by two authors (AKL and BEO) through an iterative process based in grounded theory to describe the themes of content delivered through the applications. All content was then independently according to the preliminary codebook using open-coding methodology, where themes were initially identified and defined, then content revisited and codes revised to ensure all themes were represented and clearly defined. Finally, all the content was reviewed again, to ensure the content classified according to the definitions in the revised codebook. Discrepancies in coding categories were resolved after re-examination of the content, discussion between the coders and a detailed review of the data and definitions in the codebook. Data were coded into the 12 most prevalent themes as follows: Normal Pregnancy; Fetal Development; Maternal Well-Being; Seeking Care and Abnormal Symptoms; Partner Roles; Joys of Pregnancy; Postpartum Planning; Prevention; Information about Prenatal Care, Labor and Delivery; Additional Information; Work and Motherhood; and Information about Maternal Self Care. Sub-themes were also defined for ease of coding. Content that were coded to more than one theme were identified.

Content was additionally assessed for accuracy of information provided by physician researchers. Content that was deemed to be inaccurate or incomplete was flagged and marked as such. The theme of such content was still categorized as described above. Finally, the ‘Guidelines for Perinatal Care’ from the ACOG and the American Academy of Pediatrics8 was reviewed and content that specifically outlined an aspect of the guidelines were identified.

The frequency and proportion of information each app delivered per main theme and subtheme described in the codebook was calculated. Frequency and proportion of inaccurate or ambiguous content, as well as content in accordance with the Perinatal Care Guidelines were also calculated. The χ2-test was then used to compare apps with each other, with regard to each main theme. STATA-13 statistical software (StataCorp, College Station, TX, USA) was used for all analyses.

Results

A total of 609 pieces of content from T4B and BC were transcribed and coded, and all content was captured by the themes and subthemes outlined in Table 1. A piece of content was defined as the entry that was available for each corresponding week of the pregnancy. Each app had multiple entries per each week of pregnancy: T4B had 155 entries (~4 per each of weeks 4 to 42 of pregnancy), BC had 454 entries (11 to 13 per each of weeks 4 to 42 of pregnancy and 2 postpartum weeks). Several entries contained multiple themes, resulting in 698 coded themes (T4B: 181 themes coded; BC: 517 themes coded).

Table 1 Codebook
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Table 2 outlines the distribution and frequency of thematic content delivered by each app per main theme and Table 3 does the same per subtheme. When analyzing each app’s message distribution by the main theme category, the greatest proportion of T4B’s information was about fetal development (23.8%); the greatest proportion of information delivered through Baby Center was about maternal well-being (21.1%) or normal pregnancy symptoms and management (20.1%). When stratified by subtheme, fetal development was still the most common message sub-theme in T4B, but BC’s most frequent sub-theme became information about weight, diet and nutrition (16.1%).

Table 2 Distribution of messages delivered, by main category
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Table 3 Distribution of messages delivered, by all sub-categories
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Content was then compared between apps for each main theme and subtheme. T4B had more information about fetal development compared with BC (23.8% vs 7.5%, P<0.001). BC had significantly more messages about normal pregnancy and maternal well-being compared with T4B (20.1% vs 13.3% and 21.1% vs 10.5%, respectively; P<0.05). When stratified by subtheme, T4B had significantly more information about fetal development, planning for baby’s arrival, prenatal care and prevention than BC. BC had significantly more information about management of normal pregnancy symptoms, weight, diet and nutrition, information for postpartum maternal or baby care and what to expect during labor and delivery than T4B (P<0.05 for all comparisons above).

Between the two apps, there were a total of four messages with content that contained incomplete or ambiguous information—one in T4B (0.65%) and three in BC (0.66%). Excerpts are listed in Table 4. None of the information in either app was overtly medically incorrect. App content was compared with Perinatal Care Guidelines outlined by ACOG and American Academy of Pediatrics (see Table 5). T4B and BC had no statistically significant difference in the number of messages that specifically emphasized components of the Perinatal Care Guidelines (29 (18.7%) versus 87 (19.2%), respectively; P=0.90).

Table 4 Inaccurate or incomplete information by App
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Table 5 Outline of ACOG and AAP guidelines for perinatal care
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Neither app delivered any messages or information about contraception. In addition, none of the applications addressed specific prenatal care issues for women who may have pre-existing medical diseases, such as hypertension or diabetes. BC had one message (0.22%) with information specific to a twin pregnancy.

Discussion

Smartphone applications and mobile media have emerged as widely used sources of patient information potential patient intervention.2, 3, 4 Because of the widespread use of mobile phone applications in multiple disciplines of medicine, in September 2013 the Federal Drug Administration released guidelines on mobile medical applications.9 Specifically, the Federal Drug Administration notes that ‘mobile apps that provide periodic educational information, reminders, or motivational guidance to… pregnant women’ are examples of mobile apps for which Federal Drug Administration intends to exercise enforcement discretion. However, there is very limited data on the content that is delivered to pregnant women through pregnancy-specific applications.5, 10, 11

Our study found that the thematic content delivered through T4B and BC, two pregnancy-specific apps endorsed by national societies of obstetricians and perinatologists (ACOG and Society of Maternal Fetal Medicine), varies widely. BC provided a wider breadth of content, specifically including information on alternative medications and exercises, limitations to physical activity, labor and delivery, and information for postpartum care, whereas T4B did not deliver any information on these topics. Our study also demonstrates that although information is available daily through these mobile media sources, <20% of the messages delivered by either app contained information that explicitly addressed recommended prenatal care content. In addition, although generally few in number, we did find examples of what could be perceived as incomplete or confusing information. As reproductive-aged women increasingly turn to the Internet and pregnancy-specific apps for information during pregnancy,12, 13 it is particularly important that the content of digital health media be closely evaluated to avoid patient misinformation or incomplete education.

Finally, our study noted a significant gap in educational content, as there was a complete absence of information about postpartum contraception planning, despite it being an aspect of prenatal care addressed in the Guidelines of Perinatal Care.8 This gap was particularly striking for these ACOG- and Society of Maternal Fetal Medicine-supported resources, given the association of short interpregnancy interval with adverse pregnancy outcomes. Patients should be advised that these apps do not provide comprehensive prenatal care counseling, and that these apps currently do not include content specific to women with high-risk pregnancies or pre-existing medical diseases.

Our findings should be considered in the context for which these apps were created. T4B originated as a free text messaging service that could deliver messages to a cell phone that receives text messages, with the aim of reaching underserved populations.6 BC is a member of the Johnson & Johnson company and does not specify a target population.7 Although the differences in thematic content could be due to the different objectives T4B and BC originated from, the public is probably not aware of these differences and may view and reference these apps in a similar manner.

A strength of our study is that we compared the content of two similarly structured apps, which are both free and available on iPhone and Android smartphone interfaces, the two most popular smartphone systems in the United States.14 Information is delivered in a similar manner between the apps, with a subscriber entering her estimated due date and the app listing information of interest daily, according to the woman’s given gestational age.

The continuous updating and revisions that take place with smartphone technology poses a significant limitation to our study. The content of the apps is accurate as of the preparation of this manuscript, but it is understood that the content will probably change and evolve as a response to consumer feedback. In addition, our analysis was limited to the information available through each app’s daily information feed; it did not include all information that each app could exhaustively provide, as there are endless links, websites, chatrooms and videos that a women can access. Although our study could not possibly capture all possible information available through these apps, we captured all passively delivered information through each app.

In our study, we have described the thematic content and distribution of messages that are delivered through two popular smartphone applications and have highlighted areas where information is incomplete. Although this is a first step toward understanding patient-directed education through smartphone applications in the perinatal setting, the efficacy of such mobile media-based education on perinatal outcomes is not known. T4B’s original short-messaging text program is the only pregnancy-specific mobile messaging platform that has been studied to date.6, 15, 16, 17 Although the findings of these studies suggest healthier attitudes and behaviors among women enrolled in T4B text messaging, it is still unknown whether smartphone apps provide sufficient information to improve prenatal care and improve obstetric outcomes. Therefore, a future direction should be to evaluate patient understanding of prenatal care guidelines and improvement in perinatal outcomes with the use of pregnancy-specific apps and to determine patient acceptability of and reception to pregnancy-specific smartphone applications as a means of patient education. Ultimately, development of a comprehensive, more medically tailored app that conveys more prenatal care guidelines and function as a companion to prenatal care is needed to deliver more complete health-related messages and patient education during pregnancy.