Health Managers’ Perspectives on Utilization and Barriers of Health Apps in Indonesian Maternal Health Services: A Qualitative Descriptive Study

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M. Hitijahubessy, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7137611/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background Internet-based healthcare has raised polarizing opinions due to differing evidence of its positive and negative effects, particularly in maternal-fetal health services. The usability and sustainability of digital technology, including mobile health applications, rely on collaboration among health services leaders, policymakers, and health professionals. However, little is known about their views on the use of internet-based healthcare in maternal health services during the rapid digital transformation program in Indonesia's health sector. This study aims to explores the perspectives of health managers in using internet-based technology and mobile applications in maternal health services. Methods A qualitative approach with a descriptive design was applied to conduct focus group discussions at three research locations in Indonesia (Garut, Ambon, Kupang) at the end of 2024. The sample included 20 policymakers and health professionals with managerial roles who were purposefully chosen for the study. Data was transcribed verbatim and analyzed using a framework analysis with a general inductive approach. Results Thematic analysis resulted in the identification of three main themes: ( 1 ) Variety of health applications for maternal health records and reports; ( 2 ) Advantages of digitizing registries and applications for pregnancies; and ( 3 ) Barriers and challenges in the use of applications in maternal health services. The number of health apps utilized in maternal health services is extensive; each has a different purpose and content, and some have overlapping data. Conclusion The maternal-fetal health service in Indonesia have incorporated an internet-based system for various purposes. However, challenges are still frequently reported, including inadequate facilities, limited internet networks, low or unskilled human resources, and non-standardized monitoring and evaluation. This urges the necessity of a multisectoral collaboration in optimizing the purpose and functions of an internet-based healthcare service. Further studies on developing a comprehensive, standardized, and integrated application to improve the maternal-fetal health service in Indonesia. E-Registry Health applications Health workers Pregnancy Figures Figure 1 Background Many low- and middle-income countries, including Indonesia, have not achieved the current Sustainable Development Goal (SDG) targets, notably those for reducing maternal and fetal mortality. Globally, the maternal mortality rate dropped from 339 deaths to 223 deaths per 100,000 live births; this translates to an average annual reduction rate of 2.1% ( 1 , 2 ). The SDG targets are 70 maternal deaths per 100,000 live births and 12 fetal deaths per 1000 live births by 2030 ( 3 ). Developing countries have continued with their efforts to achieve these targets in the rapidly expanding health technology era, especially since the COVID-19 pandemic. Digital technology-based health services have become the focus of health development in Indonesia ( 4 ). Maternal and fetal mortality are interrelated. The condition of the fetus is one of the leading indicators for assessing whether the pregnancy is healthy or threatens the health of the mother and fetus. Complications in the fetus include disease and developmental disorders, which can lead to intrauterine fetal death (IUFD). Previous studies have shown that the most common cause of fetal death in low-income countries was either infection (15.8%) or hypoxic peripartum death (11.6%); the most common cause in the middle- and high-income countries was a placental condition (13.7–14.4%); and antepartum haemorrhage was a common cause of stillbirth globally (8.4–9.3%) ( 5 ). Other data have revealed that maternal factors, such as insufficient antenatal care, preterm labor, intrapartum hypoxia, prematurity, asphyxia, and infections, contribute to fetal death ( 6 ). Several studies in various regions in Indonesia have identified an increase in IUFD cases ( 7 – 9 ). Intensive fetal monitoring is essential for pregnant women with certain health conditions because both mother and fetus are at risk of developing complications, with potentially adverse effects. Health programs have been developed to improve maternal and fetal health in Indonesia. The transformation of health technology, internet use and digitization of health services have become the focus of Indonesian health development ( 4 ). The internet offers an opportunity to overcome barriers that limit access to quality maternal and fetal health; it can help women, their families, and local health workers seek timely and appropriate health services. Studies have found that information technology has the potential to significantly improve maternal and fetal health ( 10 – 13 ). Notably, in recent years the internet has become a popular source of health information for pregnant women and health professionals. It has been used as an information source regarding pregnancy, birth, and the postpartum period ( 14 ). In Indonesia, the Ministry of Health has mandated that health offices at the provincial, district, and city levels realize the digitalization roadmap for health ( 15 ). Each health office is responsible for ensuring that healthcare facilities in its area have adopted appropriate digital technology and utilized it optimally to improve health services. Various challenges, such as access to health services, patient data management, and information system integration, can be addressed through digitalization. In addition, the health office is responsible for ensuring that health service standards are met, accessibility and quality of services are maintained, and integration of information systems between health services runs optimally. Health offices have the authority to carry out a broad range of duties, from facilitating collaboration among health professionals to supervising and evaluating the health system's performance in primary care facilities. The latter include health centers, clinics and general practitioners, as well as advanced/secondary services such as general hospitals or specialty hospitals. The digital transformation efforts carried out by Indonesia are very much in line with previous studies on the potential for mHealth to enhance healthcare utilization, promote affordability, and support accountability of healthcare in low- and middle-income countries ( 10 , 13 , 16 – 18 ). Digitalization is also carried out in maternal health services, and managed from the health office in collaboration with the head of the health centre and the coordinating midwife, each of whom has specifically designated roles and activities. However, there is limited research in Indonesia exploring the experiences and perspectives of health service workers with managerial roles on digitalization in maternal health services. This study aims to evaluate maternal health service managers' perspectives on usage of the internet and mobile applications for pregnancy support. Methods 1.1 Research design Descriptive qualitative design aims to obtain an understanding of a phenomenon through assessing the experiences and points of view of research participants in their natural environment ( 19 ). This study adopted such design, involving health professionals and policy makers from different public health centres in three different cities in Indonesia in semi-structured focus groups. The aim was to gain an in-depth understanding of participants’ experiences and perspectives on the usage of internet and health applications for pregnant women. Presentation of this study adheres to the Consolidated Criteria for Reporting Qualitative Research Studies (COREQ) Checklist ( 20 ). 1.2 Setting and samples A total of 20 health professionals and policy makers who worked managerial roles in primary health centre or a public health office were recruited from three Indonesian cities representing different provinces of Indonesia: Garut (West Java), Ambon (Maluku), and Kupang (East Nusa Tenggara). They were selected through purposive sampling according to the following criteria: ( 1 ) holds a managerial position at their primary health centre/public health office and was appointed by their institution to participate; ( 2 ) worked in maternal and child health (MCH) services; ( 3 ) had access to the health data or reports of all pregnant women in their work area; and ( 4 ) was an expert in the e-Registries and/or applications for pregnant women used in their work area. Managers or equivalent who worked outside of the MCH health department were excluded. Each focus group session comprised 4–9 participants to ensure control of the discussion and equal opportunities to share insights and observations ( 21 ). The three research locations involved in the study are areas with a maternal and fetal mortality rate above the Indonesian national average; frequency in accessing internet-based services based on the Google Trend Index; and availability of network signal in the areas. Selection of the primary health centres was based on the criteria of maternal and fetal mortality rates in the area, ranging from low to high maternal mortality rate. Table 1 presents the distribution of participants. Table 1 Focus Group Discussion Participants Location Participant Garut Ambon Kupang Public Health Office G1 A1 K1 K2 K3 K4 K5 K6 K7 Primary Health Centre G2 G3 G4 G5 G6 G7 G8 G9 A2 A3 A4 - 1.3 Data collection Invitations for participation were sent out to primary health centres and public health offices after obtaining research ethics approval. The participants appointed by each institution were then screened based on the eligibility criteria. Prior to the focus group discussion (FGD) sessions, informed consent was obtained verbally from each participant after the study details had been thoroughly explained to them. The FGDs were conducted face-to-face in Garut (West Java) on 21 November 2024, in Ambon (Maluku) on 5 December 2024, and in Kupang on 18 December 2024. A semi-structured focus group guide with open-ended questions was developed based on previous studies ( 22 , 23 ). The questions revolved around the usefulness and ease of use of systems/applications employed in health services from the perspectives of those in health managerial roles who use online support services for pregnant women. An expert in the field of public health and health policies reviewed the structure and content of the questions, and corrections were pilot-tested to ensure that the discussion, note-taking, and recording process worked efficiently. The FGD sessions were conducted by different moderators and facilitators recruited by the research team. They were briefed as a group about the study details to achieve the same understanding and consistency throughout all sessions. Experts in public health and/or nursing, the moderators - many with experience in guiding FGDs - were tasked with asking the main and follow-up questions. The facilitators were research assistants with nursing backgrounds and were tasked with recording and taking field notes of the sessions. Each FGD, lasting for approximately 40–60 minutes, was audio-recorded and documented with field notes. The audio recording of the FGD was transcribed verbatim in Indonesian and then translated into English by the primary researcher and research assistants (fluent in speaking and writing English and Indonesian). Each participant received an incentive for their involvement in the study. 1.4 Data analysis All transcripts and field notes used for analysis were in English. A general inductive approach was used to code dialogue and identify basic patterns and themes with an open coding process ( 19 ). A total of 17 categories were developed among the two coders based on consensus. Then, the transcripts and coding were reviewed by two research team members to ensure consistency. Any remaining discrepancies in the coding were discussed between coders until an agreement was achieved. A total of six themes emerged from the data, following the framework analysis outlined below ( 24 ): Familiarization: Two research team members independently read each transcript from the FGD groups while listening to the recordings for a minimum of three times. Coding: The researchers independently coded the transcripts as they emerged to inductively function as the foundation for themes. Developing a framework: The researchers met to compare their coding and reach a consensus on a draft analytical framework where subthemes were grouped into higher-order themes. One researcher then repeated steps 1 to 2, applying the draft framework to the transcripts while noting any new or inconsistent subthemes. The other researcher repeated step 1. The two researchers then met again to discuss and refine the draft framework. This process was repeated until a final framework was agreed. Indexing: One researcher applied the final framework to every transcript on NVivo version 17. Any observed relationships between themes were indexed. The other researcher randomly selected transcripts to check for theme inconsistencies between the transcripts. Charting: Data were summarized into tables, using one row for each subcategory and one column for each participant, and each theme separated into different tables. Each row of the subcategory included verbatim quotes of the FGD. Interpretation and mapping: The researchers met to discuss the interpretation of the data. Each theme category was described, including any observed similarities or differences. 1.5 Trustworthiness/rigor Lincoln and Guba’s criteria for trustworthiness (credibility, transferability, dependability, and objectivity) were used to determine the reliability of the study’s qualitative approach ( 25 ). In order to establish credibility, the team discussed the details of each research phase, including confirming the codes assigned to the respondents. Transferability was achieved by verifying that the data and information pertaining to the health services were related to the services provided by the health worker in charge of pregnant women, such as the village midwife. The dependability stage ensured that specialists were consulted at every level of the study process and that the results were compared to earlier studies that followed the same methodology. An external reviewer's assessment of the procedure and findings helped preserve the objectivity of this study. 1.6 Ethical considerations To ensure that research ethics were maintained, the Helsinki Ethical Principles were implemented ( 26 ). The principles are beneficence (the right to be free from harm, discomfort, or suffering; and the right to protection from exploitation); respect for human dignity (the right to self-determination and the right to full disclosure); and fairness (the right to fair treatment and the right to privacy). Consent to participate were obtained verbally from each participant after the study details had been thoroughly explained to them, guided by an informed consent form approved by the Universitas Padjadjaran Research Ethics Committee. This study obtained ethical approval from the Universitas Padjadjaran Research Ethics Committee (No.1806/UN6.KEP/EC/2024) and BRIN Health Ethics Committee (No: 219/KE.03/SK/12/2024). Results The focus group discussions revealed different perspectives among those in the health managerial positions on the use of health applications in prenatal and fetal health services. Data analysis found three main themes: ( 1 ) Variety of health applications for maternal health records and reports; ( 2 ) Advantages of digitizing registries and applications for pregnancies; and ( 3 ) Barriers and challenges in the use of applications in maternal health services. Figure 1 summarizes the themes and is followed by detailed descriptions. Theme 1: Variety of Health apps in Maternal Health Records and Reports Participants referred to various types of health apps used in maternal health service, including more than 12 applications created by the national government, local government, nursing organizations, and private sectors. Data analysis showed that most of the health apps developed by the Indonesian government were primarily for documenting data and reporting health cases. Midwives regularly input data into different registries/apps, each of which have specific purposes. For example, participants explained that demographic data and history of pregnancy are documented in eCohort, tetanus toxoid immunisation and physical examination data are reported to Si ASIK, nutritional status in e-PPGBM, and maternal mortality in MPDN. Also mentioned were apps developed to meet the specific needs of each region, such as RME in Kupang and Rindu KIA in Ambon. One participant highlighted another regional app: Oh, there is the MELANI application as a flagship program from the Garut District Health Office to monitor and record pregnant women with health problems including high-risk pregnancies. (G4) Beyond the government apps, several regions and private organizations have developed apps purposed for health education and interactive pregnancy consultations. Odelia and Rindu KIA, for example, were developed by the Midwives Association in Ambon with support from private online services. These apps are available for pregnant women to download independently so that they can monitor their pregnancy, complete payments, and access health information. The applications that the pregnant women can download independently from the internet usually provide good service; if the pregnant women want to look at a picture of a fetus in the application, they will receive notifications like, “Hello mom, have you checked your pregnancy?”, and if they fill in the results of a pregnancy check-up, they will receive a comment, “Your examination results today are healthy, thank you, mom” after they submit their data, so it’s interactive… interesting for pregnant women. (G1) In health services, pregnancy applications are mainly used by midwives to document and report health data. The above quotes showed the variety of apps with each having different functions and content. However, due to its saturation, midwives often find the same information required to input across different apps. This negatively affects their work as they are obligated to report the same information to the apps, which increase their workload and making them less efficient. On the other hand, the participants reported that apps developed by private sectors or non-government services allow pregnant women to fill and update their data independently. Theme 2: Advantages of Digitizing Pregnancy Registries and Apps for Pregnancies The positive impacts of digitizing health reports made by health workers include increased data accuracy, data availability, and monitoring of case evaluation. Participants conveyed that they are able to do their work more quickly and precisely. For your information, the SI ASIK registry doesn’t include duplicated data, as the input is “by-name-by-address” and so it is all clear. (G5) If any data is duplicated, we can click to check; and their name becomes highlighted in red. If it does, then it’s a duplicate. Besides inputting the online system, midwives still write the manual data. So we can check the duplication with the manual report and see the data there. If we find any differences, then we discuss with midwives how this is different. It’s in the manual registry. So we keep the manual. It’s helpful, especially to help secure data. (K3) The participants also explained that tracking tetanus vaccinations for pregnant women has become more accurate, and anyone who has not yet been vaccinated can be detected online. Every month, they monitor the reports generated by midwives through the apps on all of the services they have provided to pregnant women. With the help of digital technology, those reports can be monitored in real-time, that is, as data are being entered by the midwives. Targets that were not achieved or any differences in the data - referred to as data gaps - can be identified immediately and solved before the report is submitted to the health office. By monitoring in real-time, the managers can track the progress of existing programs, such as immunization targets in Si ASIK, nutrition status of pregnant women, and consumption of blood supplement tablets, as mentioned in the following quote: Yes, in the health centres, we have a monthly report meeting. The midwives and their coordinators present their reports. Usually, the meeting is scheduled at the end of the month because the report will be sent to the health office. The monthly meeting is called a mini-workshop, a forum to evaluate the achievements of the target report. We coordinate with other programs at the health centre, such as nutrition programs, eee... if for example there are women with malnutrition, we will provide Fe tablets. We usually coordinate for the target program monthly. (A3) Simple health applications developed by health centres and online services offered by private health companies were also utilized to facilitate intensive monitoring of pregnant women by their midwives. Participants highlighted that this is useful for monitoring pregnant women who need regular observation, particularly those with high risks, as it increases the timeliness of interventions in the event of an emergency. Because of the WhatsApp group chat, there are no limitations as long as cellular data is available for us to do phone calls and send texts or images immediately. For example, if there was a report from a pregnant woman through text that she was feeling dizzy, the midwife will ask her to send a photo. From the photo, we would be able to see her condition and do a consultation session or suggest that she checks her condition with the nearest midwife or doctor. This also makes it easy for us to ask for results after a check-up, for example, if we wanted to monitor her blood pressure. Other than that, we can do health promotion or video calls to see the patient’s condition. Sometimes, there are health centres that accept data sent through WhatsApp, so the mothers don’t necessarily have to travel there. So, WhatsApp makes it easier for us… to get information from the mothers. (A3). Whether using a simple or complex technology, applications that are developed independently by the health centre can provide assistance, facilitate monitoring, and support decision-making around appropriate actions in ways that improve pregnant women’s health. Participants also explained that internet use is optimized to provide telehealth services, especially for those requiring immediate help, including referrals to hospitals. Yes, so from us, we have an online referral service. It’s called Teleponed: (Tele-consultation-PONED). We collaborated with Leimena Hospital for a trial, then... eee. .. a problem frequently appeared: lack of coordination before referral. Teleponed facilitated that issue. We have to do a consultation with the referral hospital, or a pre-referral consultation, and if there was any medical advice, we would try to solve any we can do at the health centres ourselves. (A2) Moreover, pregnant women can independently download various applications that provide multiple online services. Some of the apps are free of charge, and some must be purchased. With the apps, the women are able to see the estimated birth and fetal development, receive reminders to take the blood supplements, and obtain health information relevant to improving their health and their fetus. Eee… being a midwife nowadays… information technology and social media is very helpful for… people. It is helpful, but you need to check the content, particularly about pregnancy, is the content appropriate? One of the advantages is that explaining health information becomes easier, especially now that the information is not only limited to during pregnancy, but also the preparation since puberty… people can check if they are suitable for pregnancy or not. (G8) The data analysis showed that pregnancy information sources are widely available and not limited to health workers. Pregnant women are encouraged to seek information independently, and this has the potential to increase their knowledge and personal awareness of the need to monitor their pregnancy and their baby’s growth and development. Theme 3: Barriers and Challenges in Using Apps for Pregnancies Various obstacles and challenges in using applications were identified from the focus groups, including network issues, unstable application systems, and incompetent human resources. Participants highlighted difficulties with internet connections, resulting in delayed reporting and inaccurate data inputs due to signal delays. Moreover, sometimes pregnant women have limited internet data plans, so they cannot be monitored or contacted online by the midwives. For example, when inputting the number of deaths, the midwives do so by clicking on their monitor… say there are two maternal deaths, but the data they’ve inputted have not appeared on their monitor yet, so they will click it again and again, and at the end the inputted data was 222 deaths… so, we would have to confirm again with the midwives. Well, that’s because the signal is unstable, so the reported data is completely incorrect. (K7) The other challenge mentioned is that websites and health apps are often down, experiencing errors, or under maintenance. When this happens, the inputted data is usually lost due to the sudden system crash. Most of the obstacles are from the application itself. When we input the data, there are usually many errors. We’ve entered a lot of data, but all of a sudden nothing is there. That’s the most difficult thing. (G7) Besides connectivity issues, participants mentioned that most apps/e-Registries used in health services have limited features, leading to repetitive data input. The lack of synchronization between the apps resulted in the same data being submitted into different platforms, causing ineffective workflow. The ones whose work is affected the most are the workers at health centres… when one data is finalized into a system, another one must be completed… there were talks of making SatuSehat as a comprehensive platform for all reporting, but in reality, more and more platforms just kept coming. (G4) …there are already too many applications, too many required data are duplicated… yes, it’s burdensome. (K1) There were also difficulties registering pregnant women and babies who did not have an identification number or a family registry. Such situations occurred when the babies were born from mothers whose marriage wasn’t recognized by the government or were born out of marriage, so they were ineligible for an Indonesian ID number. Other situations include living outside of the supervised area of a primary health centre or using a forged ID number. To address this problem, the participants explained that manual registries are used, causing differences between the data being reported online and manually. There are many problems around the ID number. The mothers would say that they have one, but once we confirm it, it turns out that their ID number was forged… they used illegal agents or brokers, invalid ones. Sometimes, people who want to create ID cards face technical problems such as no transportations or what not, so they resort to using brokers to create the IDs… well, this causes problems for when they’re sick or when they’re giving birth because we can’t apply on their behalf for the national health insurance coverage, where their treatments would be covered by the Social Security Agency of Indonesia through an online system. (K4) Connection failures, web system errors, and frequent system maintenance negatively impact workflow. Appropriate measures are needed to solve any data discrepancies between the manual and online systems, and particular attention to the quality of health workers is necessary. The managers pointed out that the change from manual to online registries required health professionals to adapt quickly. Limited training on apps, irregularly scheduled monitoring and evaluation of health workers, and workplace mutations were identified as the reasons for incompetencies around using applications for recording and reporting. I was born in the 80s, where typewriters were the norm, so I’m not as tech savvy... so I would ask the younger ones to help input the data, and us older midwives would help with something else, because we don’t know how to use computers. It’s a workplace problem. For someone my age to open an app, they’ll most likely refuse… they can’t even operate laptops, let alone applications. This is what often happens in health centres… and that’s the problem. (K5) …and the use of technology by health workers, midwives especially, isn’t really optimal yet, there are still those who are not skilled in doing so. (A4) Managers also stated that monitoring and evaluation carried out by the health office is more focused on report output and data similarity, rather than the capacity of midwives. Then… the utilization of [applications] by the health workers, midwives, are not yet monitored by the health office. The health office gives out reminders to the health centres only if there were any missing reports or problems related to the reports they submitted. Yes, those are followed up by phone call and direct visits to supervise, monitor, and evaluate the health centres… that is roughly the form of supervision that is carried out by the health office regarding the use of digital applications by the health centres. (A4) Discussion Types, Functions, and Content of Pregnancy Applications The analysis revealed that various apps with different purposes are used in pregnancy health services. Most of the apps functioned as platforms for recording and reporting health data, with a few others intended for health education, consultation, and other services. The apps developed by non-government organizations were more interactive and automated compared to those developed by the government. A few of the health centres also developed their own innovations based on their specific needs. The content included in the apps varies from educational content for normal to high-risk pregnancy and tracking of vaccinations, sexually transmitted diseases, and maternal mortality records. Use of a variety of application types, functions, and content, as mentioned by the managers of health centres and offices, has the potential to improve the efficiency and quality of services delivered to pregnant women. Previous research has identified 12 functions of mobile health applications (mHealth): health education and behavior change; sensors and point of care diagnostics; registries or vital events tracking; data collection and reporting; electronic health records; electronic decision support; provider-to-provider communication; provider work-planning and scheduling; provider training and education; human resource management; supply chain management; and financial transactions and incentives ( 27 ). The functions of mHealth are broad, comprehensive, and aim to strengthen the health system of a country. Based on the results of the focus group discussions however, not all applications have achieved the intended functionality of mHealth. Development in the functions of apps used in the Indonesian healthcare service remains minimal; apps are mostly used for health registries so their features are limited to the recording and reporting of data. Apps with a wider function have been developed, but are only impactful locally, limited in scope, have yet to be standardized, are still in the form of incidental development/research, and have not gone through any monitoring and evaluation. Therefore, research on the use of health applications and internet-based registries is necessary. The analysis found that e-Registries or apps in MCH services are not limited to registering normal pregnancies, but also pregnancies with high risks or complicated by certain illnesses. Participants explained that they used the Melani app specifically for recording pregnancies with pre-eclampsia and heavy bleeding, and SiHepi for hepatitis patients, including pregnant women. Utilizing apps for specific purposes is in line with research results in India, another developing country, which implemented the Tamil Nadu Pregnancy and Heart Disease Registry (TPNHDR) ( 28 ). It was developed to provide comprehensive data on the health of mothers and their babies, recording illness prognosis, predicting cardiovascular disorder risks in pregnant women, and identifying management gaps in pregnant women with heart disease (PWWHD). The results of the TNPHDR can help formulate actions for better care and generate personalized and practical guidelines for PWWHD management ( 28 ). In Indonesia, the translation of research results into policies is not optimized; data collected from registries has not been leveraged to develop thorough and measurable foundations for program development. This study discovered that pregnancies are still recorded and reported in static data forms, thus are not integrated into frameworks that can inform the foundation for health policies. Analysis of health policies formulated from data reported by midwives is the next potential research step. Benefits of Digitizing Registry and Pregnancy Apps Results showed that digitizing MCH registries provides significant benefits, such as improved data accuracy, reduced duplication of activities, monitoring of program achievements, and rapid case handling. In this study, Si ASIK was one example of an app that enables real-time vaccine monitoring, while WhatsApp-based programs support direct consultation and interaction with pregnant women. These benefits demonstrate that digital technology can help overcome administrative challenges while supporting pregnant women’s self-monitoring and awareness. The benefits of digitization of reporting and pregnancy apps have been widely felt in various areas. A study mentioned remote monitoring devices are useful for reporting prenatal care, such as cardiotocography, blood glucose levels, blood pressure and prenatal ultrasound results ( 17 ). Additionally, a study implemented Smart-e-Moms as a digitized form of MCH registry, which has proven effective and has potential in helping to treat postpartum depression ( 29 ). This intervention would be beneficial for both the mother and child, as it supports maternal well-being and improves child development. However, Indonesia has not yet experienced the benefits of diagnostic support; future research could focus on ways to improve diagnostic services and health worker interventions. Developing countries have also experienced the benefits of digitization. A systematic review stated that research findings regarding mHealth and maternal and neonatal healthcare service utilization vary widely ( 10 ). Most studies found that mobile phone technology is beneficial in improving several MCH services, especially in poor and developing countries. Nevertheless, several studies also identified challenges related to technology use and misuse, rich-poor discrimination, and disparities in phone ownership, all of which need to be addressed. The phenomenon of using mobile phones for a range of activities is increasing every year in Indonesia, with data showing an increase from 2021 to 2024 in both urban and rural areas ( 30 ). This is a positive sign, pointing to the potential of developing health programs for pregnant women using mobile phones. Electronic medical record (EMR) in maternity and paediatric clinical settings has been widely adopted and applied in developed countries. A previous study have demonstrated a significant improvement in the completeness of antenatal records recorded through the implementation of EMR-based data verification ( 31 ). A 42.9% difference in missing data (including screening for hypertension, tuberculosis, malaria, HIV status in women) was recorded before and after implementation. In line with this, another study explained that integrating data into electronic health records supports better patient-provider communication and shared decision-making, thus empowering patients to actively manage their health conditions ( 29 ). Similarly, it was also previously explained that e-Registries can offer support for most commonly used electronic and mobile health applications ( 27 ). Various countries are implementing health registries in assorted forms, and the majority, including Indonesia, are transitioning from paper-based data collection to electronic systems. However, very few have e-Registries that can act as the primary source of integrated health information. This reflects an electronic health system that needs to be improved as data gathered from e-Registries are beneficial for research as the foundation for health policies on a regional and national scale. In Indonesia, many e-Registries have been developed by service providers, although not optimally because they are limited to reporting data, i.e., not interactive (e-COHORT, Si ASIK, MPDN, SIMATNEO). Patients and other staff outside the region cannot see these data. There is criticism that a lot of data is reported but the impact on patients and service facilities is lacking. A small number of simple automated applications (WhatsApp groups) have been independently utilized by some parts of the health service because they felt the need for intensive, close, and interactive communication with patients. Moreover, many patient conditions, including pregnancy complications, require frequent monitoring. Outside of health services, there are various applications provided by the private sector (Pregnancy Tracker, Diary-Bumil), and most of them have in-application payment. Some are not a paid service, but are usually incidental, local, and have had no monitoring and evaluation done. The benefits of health applications for pregnant women were identified by the participants of this study, and they hoped that future applications would be multifunctional; that is, one application would cover not only recording health data but also health education, coordination of health centers, and health decision making. In this way, apps and registries could be optimized, especially in governmental services. With the simplified form of the registries and applications as one, its future use can be made to be more optimal, especially in governmental services. Barriers and Challenges in Application Utilization Various barriers and challenges in the use of applications in health services were identified in this study: (a) Limited facilities such as unstable internet connection, especially in areas with inadequate infrastructure, and basic computer devices; (b) Unpatented systems such as websites with frequent maintenance or errors, data loss, and poor synchronization reducing the effectiveness of application use; and (c) Incompetent or inadequately trained human resources such as midwives or health workers who do not have adequate skills in using technology, which slows down the adaptation process. This study supports the results of previous research conducted in four developing countries – Myanmar, Uganda, Tanzania, and Ethiopia – to identify barriers and facilitators in the implementation of WHO’s maternal health programs ( 32 ). It was found that, although each country’s health programs had a different focus, there were similar challenges, such as low-quality systems and devices and low-skilled health workers. A systematic review of research from 16 developing countries found similar challenges and specifically identified the issue of health workers not having mobile phones to be able to communicate with pregnant women ( 33 ). Therefore, improving health services in developing countries can be complex, as many improvements need to be made with regard to facilities, medical devices, and the performance of health workers. All FGD participants in our study complained about internet network facilities, and this challenge was among many established by a previous FGD research on video-call-based telehealth ( 34 ). The study established most reported barriers as follows: unreliable network connections; lack of hands-on experience; lack of access to technology; reduced observational accuracy and poor visual instruction conditions; lack of technology skills; and reduced client-practitioner interaction and communication ( 34 ). According to the Indonesian Ministry of Finance and Ministry of Health, efforts to overcome these barriers and challenges continue to be made, although not optimized ( 35 , 36 ). The health budget is increased annually, especially for medical equipment facilities, and maternal health is a key focus area for facility fulfilment. However, research investigating the health sector in terms of the need for better facilities and various supports to improve the performance of health workers remains limited. The results of this study offer information on the needs of maternal health services, particularly electronic service tools. As an example, internet network expansion continues to be a priority in Eastern Indonesia ( 37 ). An adequate internet network has the potential to improve maternal health by facilitating faster, more accurate reporting of health records as well as ensuring that health education and consultation are more accessible and affordable for pregnant women ( 38 ). However, in reality, network problems in Indonesia are still a major obstacle to ensuring effective health programs, thus putting such programs at risk. Inter-institutional advocacy efforts need to continue so that the need for functioning internet networks as part of supporting facilities for health development becomes a priority for all parties, including the Indonesian Ministry of Communication and Digital Affairs. The challenge of quality human resources was raised by participants in relation to the ability to use computer equipment and the turnover of trained staff. These resource issues are common in developing countries’ health services. Informed by a systematic review, identified three human resource issues: high staff turnover in private facilities and limited human resources and expertise; lack of community ability to adapt to technology and limited health staff with technology skills; as well as barriers related to young age, language, myths, fears, and misconceptions ( 39 ). Regarding our study’s research locations, in Garut, the majority of midwives are relatively young, so adapting to computer technology, the internet, and various applications is not an obstacle. However, in Kupang and Ambon, midwives tend to be older so struggle in the era of technological transformation. Efforts can be made to improve the quality of human resources, especially senior health workers, some of whom are approaching retirement. A more personalized and gradual approach would be beneficial, one that involves simple and practical training programs, starting with the introduction of basic technology such as the use of smartphones and simple applications. Assistance or mentoring by younger colleagues can help seniors learn more effectively. Interactive workshops with hands-on simulations help to increase confidence, while motivation to embrace the digitization of health services can be boosted by showing the direct benefits of technology in daily work. In addition to human resource programs, policies are also needed. Organizational and regulatory barriers and challenges, in particular, hindered widespread adoption of applications ( 40 ). Policymakers need comprehensive guidance regarding the implementation of these applications, given their high investment cost. Another study implementing mobile immunization applications to improve parents’ timely vaccination of their children found barriers associated with the usability and accessibility of mobile technologies, which depend in part on a user’s innate characteristics such as technology readiness ( 41 ). In summary, digitalization in health services for pregnant women offers a range of benefits, but implementation still faces a number of challenges. Through a more integrated approach, improved infrastructure, and human resource capacity building, digital transformation has the potential to become a key foundation in improving the quality of health services for mothers and children in Indonesia. Strengths and Limitations This study provides valuable insights into the experiences and perceptions of health workers with managerial positions about the use of health applications and e-Registries that may act as essential guideline for developing a comprehensive antenatal and other supportive pregnancy programs that address MCH challenges in Indonesia. However, the limitation to this study should be acknowledged. The participants were limited to health workers with managerial positions in maternal and child health (MCH) services. While these individuals are well-positioned to provide strategic and administrative insights into the implementation of health applications, their perspectives may not fully capture the detailed operational challenges experienced by frontline health workers. Implications Health professionals in Indonesian maternal and children health services can utilize the results of this study to advocate for improving the quality of digital-based services and to ensure that direct services continue to be provided optimally. The study also emphasized the importance of multi-sector cooperation in improving maternal and children health services. Conclusion Various applications with different purposes were used in Indonesian MCH services, with participants noting this often resulted in overlapping data. Identified benefits of using the apps included increased accuracy, organization of work tasks, and ease of access to digital data and reports. Nonetheless, challenges were also experienced, such as inadequate electronic devices, limited internet network connection, incompetent human resources, and unstandardized monitoring and evaluation. To overcome these challenges, integration of reporting systems and developing applications with an automated and interoperability data system is recommended. Collaboration among academic institutions, industries, researchers, and government sectors is needed to develop automated IT devices and applications as an impactful innovation in maternal and child services. Future research should consider collecting and triangulating data from e-Registry and app developers as well. Declarations Ethics approval and consent to participate To ensure that research ethics were maintained, the Helsinki Ethical Principles were implemented. The principles are beneficence (the right to be free from harm, discomfort, or suffering; and the right to protection from exploitation); respect for human dignity (the right to self-determination and the right to full disclosure); and fairness (the right to fair treatment and the right to privacy). Consent to participate were obtained verbally from each participant after the study details had been thoroughly explained to them, guided by an informed consent form approved by the Universitas Padjadjaran Research Ethics Committee. This study obtained ethical approval from the Universitas Padjadjaran Research Ethics Committee (No.1806/UN6.KEP/EC/2024) and BRIN Health Ethics Committee (No: 219/KE.03/SK/12/2024). Consent for publication NA. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to participants requests of keeping institutional affiliations anonymous but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no known competing interests. Funding This research was funded by KONEKSI Collaborative Research Grant (Agreement Reference Number: KONEKSI/1447/CRG/2024/53-UNPAD). Authors' contributions RW, IP, HZ, DQU, and CNMH were responsible for the conceptualization and design of this study. The data collection was conducted by all authors. RW and IP drafted the initial manuscript. All authors critically reviewed, revised the manuscript, and approved the final version for publication. All authors take responsibility for the integrity of the data and the accuracy of the data analysis. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. Acknowledgments The authors extend sincere gratitude to KONEKSI Collaborative Research Grant for the generous financial support which was vital in the success of this study completion. The authors also thank the participants and all others who contributed to the data collection process of this project. References BPS. 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Dudkina A, Kujala S, Hägglund M, Kharko A, Wang B, Soone H, et al. Patient Input into the Electronic Health Record: Co-Designing Solutions with Patients and Healthcare Professionals. Stud Health Technol Inform. 2024 Aug;316:1477–81. BPS. Persentase Penduduk yang Memiliki/Menguasai Telepon Seluler Menurut Provinsi dan Klasifikasi Daerah, 2021-2023. 2024. p. https://www.bps.go.id/id/statistics-table/2/Mzk1Iz. Haskew J, Rø G, Saito K, Turner K, Odhiambo G, Wamae A, et al. Implementation of a cloud-based electronic medical record for maternal and child health in rural Kenya. Int J Med Inform. 2015 May;84(5):349–54. Vogel JP, Moore JE, Timmings C, Khan S, Khan DN, Defar A, et al. Barriers, Facilitators and Priorities for Implementation of WHO Maternal and Perinatal Health Guidelines in Four Lower-Income Countries: A GREAT Network Research Activity. PLoS One. 2016;11(11):e0160020. Venkataramanan R, Subramanian S V, Alajlani M, Arvanitis TN. Effect of Mobile Health Interventions in Increasing Utilization of Maternal and Child Health Care Services in Developing Countries: A Scoping Review. Digit Heal. 2022;8:20552076221143236. Rettinger L, Kuhn S. Barriers to Video Call-Based Telehealth in Allied Health Professions and Nursing: Scoping Review and Mapping Process. J Med Internet Res. 2023 Aug;25:e46715. Ministry of Finance Indonesia. Sampai dengan 30 November, Realisasi Anggaran Kesehatan Sebesar Rp164,3 T [Internet]. 2024 [cited 2025 Apr 11]. Available from: https://www.kemenkeu.go.id/informasi-publik/publikasi/berita-utama/Realisasi-Anggaran-Kesehatan-Sebesar-Rp164,3-T Ministry of Health Indonesia. Turunkan AKI-AKB, Kemenkes Pertajam Transformasi Sistem Kesehatan [Internet]. 2021 [cited 2025 Apr 11]. Available from: https://kemkes.go.id/id/turunkan-aki-akb-kemenkes-pertajam-transformasi-sistem-kesehatan Ministry of Communication and Digital Affairs Indonesia. Fondasi Akselerasi Inovasi dan Pertumbuhan Ekonomi [Internet]. 2024 [cited 2025 Apr 11]. Available from: https://www.komdigi.go.id/transformasi-digital/infrastruktur-digital Till S, Mkhize M, Farao J, Shandu LD, Muthelo L, Coleman TL, et al. Digital Health Technologies for Maternal and Child Health in Africa and Other Low- And Middle-Income Countries: Cross-disciplinary Scoping Review with Stakeholder Consultation. J Med Internet Res. 2023;25. Kaboré SS, Ngangue P, Soubeiga D, Barro A, Pilabré AH, Bationo N, et al. Barriers and Facilitators for the Sustainability of Digital Health Interventions in Low and Middle-income Countries: A Systematic Review. Vol. 4, Frontiers in Digital Health. 2022. p. 1–16. Sag OM, Li X, Åman B, Thor A, Brantnell A. Qualitative Exploration of 3D Printing in Swedish Healthcare: Perceived Effects and Barriers. BMC Health Serv Res. 2024 Nov;24(1):1455. Atkinson KM, Westeinde J, Ducharme R, Wilson SE, Deeks SL, Crowcroft N, et al. Can Mobile Technologies Improve On-time Vaccination? A Study Piloting Maternal Use of ImmunizeCA, A Pan-Canadian Immunization App. Hum Vaccin Immunother. 2016 Oct;12(10):2654–61. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7137611","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":504960494,"identity":"316cd614-e334-403a-afb7-0660abcd734f","order_by":0,"name":"Restuning Widiasih","email":"data:image/png;base64,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","orcid":"","institution":"Universitas Padjadjaran","correspondingAuthor":true,"prefix":"","firstName":"Restuning","middleName":"","lastName":"Widiasih","suffix":""},{"id":504960495,"identity":"c1bb6950-5d5b-4bb2-84d2-ab4416268e7e","order_by":1,"name":"Iqbal Pramukti","email":"","orcid":"","institution":"Universitas Padjadjaran","correspondingAuthor":false,"prefix":"","firstName":"Iqbal","middleName":"","lastName":"Pramukti","suffix":""},{"id":504960499,"identity":"3c05946f-8517-4103-9bf4-6aafb0fb5a67","order_by":2,"name":"Christy N. 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Globally, the maternal mortality rate dropped from 339 deaths to 223 deaths per 100,000 live births; this translates to an average annual reduction rate of 2.1% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The SDG targets are 70 maternal deaths per 100,000 live births and 12 fetal deaths per 1000 live births by 2030 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Developing countries have continued with their efforts to achieve these targets in the rapidly expanding health technology era, especially since the COVID-19 pandemic. Digital technology-based health services have become the focus of health development in Indonesia (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMaternal and fetal mortality are interrelated. The condition of the fetus is one of the leading indicators for assessing whether the pregnancy is healthy or threatens the health of the mother and fetus. Complications in the fetus include disease and developmental disorders, which can lead to intrauterine fetal death (IUFD). Previous studies have shown that the most common cause of fetal death in low-income countries was either infection (15.8%) or hypoxic peripartum death (11.6%); the most common cause in the middle- and high-income countries was a placental condition (13.7–14.4%); and antepartum haemorrhage was a common cause of stillbirth globally (8.4–9.3%) (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Other data have revealed that maternal factors, such as insufficient antenatal care, preterm labor, intrapartum hypoxia, prematurity, asphyxia, and infections, contribute to fetal death (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Several studies in various regions in Indonesia have identified an increase in IUFD cases (\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e–\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Intensive fetal monitoring is essential for pregnant women with certain health conditions because both mother and fetus are at risk of developing complications, with potentially adverse effects.\u003c/p\u003e\u003cp\u003eHealth programs have been developed to improve maternal and fetal health in Indonesia. The transformation of health technology, internet use and digitization of health services have become the focus of Indonesian health development (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The internet offers an opportunity to overcome barriers that limit access to quality maternal and fetal health; it can help women, their families, and local health workers seek timely and appropriate health services. Studies have found that information technology has the potential to significantly improve maternal and fetal health (\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e–\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Notably, in recent years the internet has become a popular source of health information for pregnant women and health professionals. It has been used as an information source regarding pregnancy, birth, and the postpartum period (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn Indonesia, the Ministry of Health has mandated that health offices at the provincial, district, and city levels realize the digitalization roadmap for health (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Each health office is responsible for ensuring that healthcare facilities in its area have adopted appropriate digital technology and utilized it optimally to improve health services. Various challenges, such as access to health services, patient data management, and information system integration, can be addressed through digitalization. In addition, the health office is responsible for ensuring that health service standards are met, accessibility and quality of services are maintained, and integration of information systems between health services runs optimally.\u003c/p\u003e\u003cp\u003eHealth offices have the authority to carry out a broad range of duties, from facilitating collaboration among health professionals to supervising and evaluating the health system's performance in primary care facilities. The latter include health centers, clinics and general practitioners, as well as advanced/secondary services such as general hospitals or specialty hospitals. The digital transformation efforts carried out by Indonesia are very much in line with previous studies on the potential for mHealth to enhance healthcare utilization, promote affordability, and support accountability of healthcare in low- and middle-income countries (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e–\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Digitalization is also carried out in maternal health services, and managed from the health office in collaboration with the head of the health centre and the coordinating midwife, each of whom has specifically designated roles and activities. However, there is limited research in Indonesia exploring the experiences and perspectives of health service workers with managerial roles on digitalization in maternal health services. This study aims to evaluate maternal health service managers' perspectives on usage of the internet and mobile applications for pregnancy support.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003e1.1 Research design\u003c/em\u003e\u003c/p\u003e\u003cp\u003eDescriptive qualitative design aims to obtain an understanding of a phenomenon through assessing the experiences and points of view of research participants in their natural environment (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). This study adopted such design, involving health professionals and policy makers from different public health centres in three different cities in Indonesia in semi-structured focus groups. The aim was to gain an in-depth understanding of participants’ experiences and perspectives on the usage of internet and health applications for pregnant women. Presentation of this study adheres to the Consolidated Criteria for Reporting Qualitative Research Studies (COREQ) Checklist (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003ch2\u003e1.2 Setting and samples\u003c/h2\u003e\u003cp\u003eA total of 20 health professionals and policy makers who worked managerial roles in primary health centre or a public health office were recruited from three Indonesian cities representing different provinces of Indonesia: Garut (West Java), Ambon (Maluku), and Kupang (East Nusa Tenggara). They were selected through purposive sampling according to the following criteria: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) holds a managerial position at their primary health centre/public health office and was appointed by their institution to participate; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) worked in maternal and child health (MCH) services; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) had access to the health data or reports of all pregnant women in their work area; and (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) was an expert in the e-Registries and/or applications for pregnant women used in their work area. Managers or equivalent who worked outside of the MCH health department were excluded. Each focus group session comprised 4–9 participants to ensure control of the discussion and equal opportunities to share insights and observations (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe three research locations involved in the study are areas with a maternal and fetal mortality rate above the Indonesian national average; frequency in accessing internet-based services based on the Google Trend Index; and availability of network signal in the areas. Selection of the primary health centres was based on the criteria of maternal and fetal mortality rates in the area, ranging from low to high maternal mortality rate. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the distribution of participants.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFocus Group Discussion Participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;Location\u003c/p\u003e\u003cp\u003eParticipant\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGarut\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAmbon\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eKupang\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePublic Health Office\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eG1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eA1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eK1\u003c/p\u003e\u003cp\u003eK2\u003c/p\u003e\u003cp\u003eK3\u003c/p\u003e\u003cp\u003eK4\u003c/p\u003e\u003cp\u003eK5\u003c/p\u003e\u003cp\u003eK6\u003c/p\u003e\u003cp\u003eK7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePrimary Health Centre\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eG2\u003c/p\u003e\u003cp\u003eG3\u003c/p\u003e\u003cp\u003eG4\u003c/p\u003e\u003cp\u003eG5\u003c/p\u003e\u003cp\u003eG6\u003c/p\u003e\u003cp\u003eG7\u003c/p\u003e\u003cp\u003eG8\u003c/p\u003e\u003cp\u003eG9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eA2\u003c/p\u003e\u003cp\u003eA3\u003c/p\u003e\u003cp\u003eA4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003ch2\u003e1.3 Data collection\u003c/h2\u003e\u003cp\u003eInvitations for participation were sent out to primary health centres and public health offices after obtaining research ethics approval. The participants appointed by each institution were then screened based on the eligibility criteria. Prior to the focus group discussion (FGD) sessions, informed consent was obtained verbally from each participant after the study details had been thoroughly explained to them. The FGDs were conducted face-to-face in Garut (West Java) on 21 November 2024, in Ambon (Maluku) on 5 December 2024, and in Kupang on 18 December 2024. A semi-structured focus group guide with open-ended questions was developed based on previous studies (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The questions revolved around the usefulness and ease of use of systems/applications employed in health services from the perspectives of those in health managerial roles who use online support services for pregnant women. An expert in the field of public health and health policies reviewed the structure and content of the questions, and corrections were pilot-tested to ensure that the discussion, note-taking, and recording process worked efficiently.\u003c/p\u003e\u003cp\u003eThe FGD sessions were conducted by different moderators and facilitators recruited by the research team. They were briefed as a group about the study details to achieve the same understanding and consistency throughout all sessions. Experts in public health and/or nursing, the moderators - many with experience in guiding FGDs - were tasked with asking the main and follow-up questions. The facilitators were research assistants with nursing backgrounds and were tasked with recording and taking field notes of the sessions. Each FGD, lasting for approximately 40–60 minutes, was audio-recorded and documented with field notes. The audio recording of the FGD was transcribed verbatim in Indonesian and then translated into English by the primary researcher and research assistants (fluent in speaking and writing English and Indonesian). Each participant received an incentive for their involvement in the study.\u003c/p\u003e\u003ch2\u003e1.4 Data analysis\u003c/h2\u003e\u003cp\u003eAll transcripts and field notes used for analysis were in English. A general inductive approach was used to code dialogue and identify basic patterns and themes with an open coding process (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). A total of 17 categories were developed among the two coders based on consensus. Then, the transcripts and coding were reviewed by two research team members to ensure consistency. Any remaining discrepancies in the coding were discussed between coders until an agreement was achieved. A total of six themes emerged from the data, following the framework analysis outlined below (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e):\u003c/p\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eFamiliarization: Two research team members independently read each transcript from the FGD groups while listening to the recordings for a minimum of three times.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eCoding: The researchers independently coded the transcripts as they emerged to inductively function as the foundation for themes.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eDeveloping a framework: The researchers met to compare their coding and reach a consensus on a draft analytical framework where subthemes were grouped into higher-order themes. One researcher then repeated steps 1 to 2, applying the draft framework to the transcripts while noting any new or inconsistent subthemes. The other researcher repeated step 1. The two researchers then met again to discuss and refine the draft framework. This process was repeated until a final framework was agreed.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eIndexing: One researcher applied the final framework to every transcript on NVivo version 17. Any observed relationships between themes were indexed. The other researcher randomly selected transcripts to check for theme inconsistencies between the transcripts.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eCharting: Data were summarized into tables, using one row for each subcategory and one column for each participant, and each theme separated into different tables. Each row of the subcategory included verbatim quotes of the FGD.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eInterpretation and mapping: The researchers met to discuss the interpretation of the data. Each theme category was described, including any observed similarities or differences.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003ch2\u003e1.5 Trustworthiness/rigor\u003c/h2\u003e\u003cp\u003eLincoln and Guba’s criteria for trustworthiness (credibility, transferability, dependability, and objectivity) were used to determine the reliability of the study’s qualitative approach (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). In order to establish credibility, the team discussed the details of each research phase, including confirming the codes assigned to the respondents. Transferability was achieved by verifying that the data and information pertaining to the health services were related to the services provided by the health worker in charge of pregnant women, such as the village midwife. The dependability stage ensured that specialists were consulted at every level of the study process and that the results were compared to earlier studies that followed the same methodology. An external reviewer's assessment of the procedure and findings helped preserve the objectivity of this study.\u003c/p\u003e\u003ch2\u003e1.6 Ethical considerations\u003c/h2\u003e\u003cp\u003eTo ensure that research ethics were maintained, the Helsinki Ethical Principles were implemented (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). The principles are beneficence (the right to be free from harm, discomfort, or suffering; and the right to protection from exploitation); respect for human dignity (the right to self-determination and the right to full disclosure); and fairness (the right to fair treatment and the right to privacy). Consent to participate were obtained verbally from each participant after the study details had been thoroughly explained to them, guided by an informed consent form approved by the Universitas Padjadjaran Research Ethics Committee. This study obtained ethical approval from the Universitas Padjadjaran Research Ethics Committee (No.1806/UN6.KEP/EC/2024) and BRIN Health Ethics Committee (No: 219/KE.03/SK/12/2024).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe focus group discussions revealed different perspectives among those in the health managerial positions on the use of health applications in prenatal and fetal health services. Data analysis found three main themes: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Variety of health applications for maternal health records and reports; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Advantages of digitizing registries and applications for pregnancies; and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Barriers and challenges in the use of applications in maternal health services. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the themes and is followed by detailed descriptions.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 1: Variety of Health apps in Maternal Health Records and Reports\u003c/b\u003e\u003c/p\u003e\u003cp\u003eParticipants referred to various types of health apps used in maternal health service, including more than 12 applications created by the national government, local government, nursing organizations, and private sectors. Data analysis showed that most of the health apps developed by the Indonesian government were primarily for documenting data and reporting health cases. Midwives regularly input data into different registries/apps, each of which have specific purposes. For example, participants explained that demographic data and history of pregnancy are documented in eCohort, tetanus toxoid immunisation and physical examination data are reported to Si ASIK, nutritional status in e-PPGBM, and maternal mortality in MPDN. Also mentioned were apps developed to meet the specific needs of each region, such as RME in Kupang and Rindu KIA in Ambon. One participant highlighted another regional app:\u003c/p\u003e\u003cp\u003eOh, there is the MELANI application as a flagship program from the Garut District Health Office to monitor and record pregnant women with health problems including high-risk pregnancies. (G4)\u003c/p\u003e\u003cp\u003eBeyond the government apps, several regions and private organizations have developed apps purposed for health education and interactive pregnancy consultations. Odelia and Rindu KIA, for example, were developed by the Midwives Association in Ambon with support from private online services. These apps are available for pregnant women to download independently so that they can monitor their pregnancy, complete payments, and access health information.\u003c/p\u003e\u003cp\u003eThe applications that the pregnant women can download independently from the internet usually provide good service; if the pregnant women want to look at a picture of a fetus in the application, they will receive notifications like, \u0026ldquo;Hello mom, have you checked your pregnancy?\u0026rdquo;, and if they fill in the results of a pregnancy check-up, they will receive a comment, \u0026ldquo;Your examination results today are healthy, thank you, mom\u0026rdquo; after they submit their data, so it\u0026rsquo;s interactive\u0026hellip; interesting for pregnant women. (G1)\u003c/p\u003e\u003cp\u003eIn health services, pregnancy applications are mainly used by midwives to document and report health data. The above quotes showed the variety of apps with each having different functions and content. However, due to its saturation, midwives often find the same information required to input across different apps. This negatively affects their work as they are obligated to report the same information to the apps, which increase their workload and making them less efficient. On the other hand, the participants reported that apps developed by private sectors or non-government services allow pregnant women to fill and update their data independently.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 2: Advantages of Digitizing Pregnancy Registries and Apps for Pregnancies\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe positive impacts of digitizing health reports made by health workers include increased data accuracy, data availability, and monitoring of case evaluation. Participants conveyed that they are able to do their work more quickly and precisely.\u003c/p\u003e\u003cp\u003eFor your information, the SI ASIK registry doesn\u0026rsquo;t include duplicated data, as the input is \u0026ldquo;by-name-by-address\u0026rdquo; and so it is all clear. (G5)\u003c/p\u003e\u003cp\u003eIf any data is duplicated, we can click to check; and their name becomes highlighted in red. If it does, then it\u0026rsquo;s a duplicate. Besides inputting the online system, midwives still write the manual data. So we can check the duplication with the manual report and see the data there. If we find any differences, then we discuss with midwives how this is different. It\u0026rsquo;s in the manual registry. So we keep the manual. It\u0026rsquo;s helpful, especially to help secure data. (K3)\u003c/p\u003e\u003cp\u003eThe participants also explained that tracking tetanus vaccinations for pregnant women has become more accurate, and anyone who has not yet been vaccinated can be detected online. Every month, they monitor the reports generated by midwives through the apps on all of the services they have provided to pregnant women. With the help of digital technology, those reports can be monitored in real-time, that is, as data are being entered by the midwives. Targets that were not achieved or any differences in the data - referred to as data gaps - can be identified immediately and solved before the report is submitted to the health office. By monitoring in real-time, the managers can track the progress of existing programs, such as immunization targets in Si ASIK, nutrition status of pregnant women, and consumption of blood supplement tablets, as mentioned in the following quote:\u003c/p\u003e\u003cp\u003eYes, in the health centres, we have a monthly report meeting. The midwives and their coordinators present their reports. Usually, the meeting is scheduled at the end of the month because the report will be sent to the health office. The monthly meeting is called a mini-workshop, a forum to evaluate the achievements of the target report. We coordinate with other programs at the health centre, such as nutrition programs, eee... if for example there are women with malnutrition, we will provide Fe tablets. We usually coordinate for the target program monthly. (A3)\u003c/p\u003e\u003cp\u003eSimple health applications developed by health centres and online services offered by private health companies were also utilized to facilitate intensive monitoring of pregnant women by their midwives. Participants highlighted that this is useful for monitoring pregnant women who need regular observation, particularly those with high risks, as it increases the timeliness of interventions in the event of an emergency.\u003c/p\u003e\u003cp\u003eBecause of the WhatsApp group chat, there are no limitations as long as cellular data is available for us to do phone calls and send texts or images immediately. For example, if there was a report from a pregnant woman through text that she was feeling dizzy, the midwife will ask her to send a photo. From the photo, we would be able to see her condition and do a consultation session or suggest that she checks her condition with the nearest midwife or doctor. This also makes it easy for us to ask for results after a check-up, for example, if we wanted to monitor her blood pressure. Other than that, we can do health promotion or video calls to see the patient\u0026rsquo;s condition. Sometimes, there are health centres that accept data sent through WhatsApp, so the mothers don\u0026rsquo;t necessarily have to travel there. So, WhatsApp makes it easier for us\u0026hellip; to get information from the mothers. (A3).\u003c/p\u003e\u003cp\u003eWhether using a simple or complex technology, applications that are developed independently by the health centre can provide assistance, facilitate monitoring, and support decision-making around appropriate actions in ways that improve pregnant women\u0026rsquo;s health. Participants also explained that internet use is optimized to provide telehealth services, especially for those requiring immediate help, including referrals to hospitals.\u003c/p\u003e\u003cp\u003eYes, so from us, we have an online referral service. It\u0026rsquo;s called Teleponed: (Tele-consultation-PONED). We collaborated with Leimena Hospital for a trial, then... \u003cem\u003eeee.\u003c/em\u003e.. a problem frequently appeared: lack of coordination before referral. Teleponed facilitated that issue. We have to do a consultation with the referral hospital, or a pre-referral consultation, and if there was any medical advice, we would try to solve any we can do at the health centres ourselves. (A2)\u003c/p\u003e\u003cp\u003eMoreover, pregnant women can independently download various applications that provide multiple online services. Some of the apps are free of charge, and some must be purchased. With the apps, the women are able to see the estimated birth and fetal development, receive reminders to take the blood supplements, and obtain health information relevant to improving their health and their fetus.\u003c/p\u003e\u003cp\u003e\u003cem\u003eEee\u0026hellip;\u003c/em\u003e being a midwife nowadays\u0026hellip; information technology and social media is very helpful for\u0026hellip; people. It is helpful, but you need to check the content, particularly about pregnancy, is the content appropriate? One of the advantages is that explaining health information becomes easier, especially now that the information is not only limited to during pregnancy, but also the preparation since puberty\u0026hellip; people can check if they are suitable for pregnancy or not. (G8)\u003c/p\u003e\u003cp\u003eThe data analysis showed that pregnancy information sources are widely available and not limited to health workers. Pregnant women are encouraged to seek information independently, and this has the potential to increase their knowledge and personal awareness of the need to monitor their pregnancy and their baby\u0026rsquo;s growth and development.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 3: Barriers and Challenges in Using Apps for Pregnancies\u003c/b\u003e\u003c/p\u003e\u003cp\u003eVarious obstacles and challenges in using applications were identified from the focus groups, including network issues, unstable application systems, and incompetent human resources. Participants highlighted difficulties with internet connections, resulting in delayed reporting and inaccurate data inputs due to signal delays. Moreover, sometimes pregnant women have limited internet data plans, so they cannot be monitored or contacted online by the midwives.\u003c/p\u003e\u003cp\u003eFor example, when inputting the number of deaths, the midwives do so by clicking on their monitor\u0026hellip; say there are two maternal deaths, but the data they\u0026rsquo;ve inputted have not appeared on their monitor yet, so they will click it again and again, and at the end the inputted data was 222 deaths\u0026hellip; so, we would have to confirm again with the midwives. Well, that\u0026rsquo;s because the signal is unstable, so the reported data is completely incorrect. (K7)\u003c/p\u003e\u003cp\u003eThe other challenge mentioned is that websites and health apps are often down, experiencing errors, or under maintenance. When this happens, the inputted data is usually lost due to the sudden system crash.\u003c/p\u003e\u003cp\u003eMost of the obstacles are from the application itself. When we input the data, there are usually many errors. We\u0026rsquo;ve entered a lot of data, but all of a sudden nothing is there. That\u0026rsquo;s the most difficult thing. (G7)\u003c/p\u003e\u003cp\u003eBesides connectivity issues, participants mentioned that most apps/e-Registries used in health services have limited features, leading to repetitive data input. The lack of synchronization between the apps resulted in the same data being submitted into different platforms, causing ineffective workflow.\u003c/p\u003e\u003cp\u003eThe ones whose work is affected the most are the workers at health centres\u0026hellip; when one data is finalized into a system, another one must be completed\u0026hellip; there were talks of making SatuSehat as a comprehensive platform for all reporting, but in reality, more and more platforms just kept coming. (G4)\u003c/p\u003e\u003cp\u003e\u0026hellip;there are already too many applications, too many required data are duplicated\u0026hellip; yes, it\u0026rsquo;s burdensome. (K1)\u003c/p\u003e\u003cp\u003eThere were also difficulties registering pregnant women and babies who did not have an identification number or a family registry. Such situations occurred when the babies were born from mothers whose marriage wasn\u0026rsquo;t recognized by the government or were born out of marriage, so they were ineligible for an Indonesian ID number. Other situations include living outside of the supervised area of a primary health centre or using a forged ID number. To address this problem, the participants explained that manual registries are used, causing differences between the data being reported online and manually.\u003c/p\u003e\u003cp\u003eThere are many problems around the ID number. The mothers would say that they have one, but once we confirm it, it turns out that their ID number was forged\u0026hellip; they used illegal agents or brokers, invalid ones. Sometimes, people who want to create ID cards face technical problems such as no transportations or what not, so they resort to using brokers to create the IDs\u0026hellip; well, this causes problems for when they\u0026rsquo;re sick or when they\u0026rsquo;re giving birth because we can\u0026rsquo;t apply on their behalf for the national health insurance coverage, where their treatments would be covered by the Social Security Agency of Indonesia through an online system. (K4)\u003c/p\u003e\u003cp\u003eConnection failures, web system errors, and frequent system maintenance negatively impact workflow. Appropriate measures are needed to solve any data discrepancies between the manual and online systems, and particular attention to the quality of health workers is necessary. The managers pointed out that the change from manual to online registries required health professionals to adapt quickly. Limited training on apps, irregularly scheduled monitoring and evaluation of health workers, and workplace mutations were identified as the reasons for incompetencies around using applications for recording and reporting.\u003c/p\u003e\u003cp\u003eI was born in the 80s, where typewriters were the norm, so I\u0026rsquo;m not as tech savvy... so I would ask the younger ones to help input the data, and us older midwives would help with something else, because we don\u0026rsquo;t know how to use computers. It\u0026rsquo;s a workplace problem. For someone my age to open an app, they\u0026rsquo;ll most likely refuse\u0026hellip; they can\u0026rsquo;t even operate laptops, let alone applications. This is what often happens in health centres\u0026hellip; and that\u0026rsquo;s the problem. (K5)\u003c/p\u003e\u003cp\u003e\u0026hellip;and the use of technology by health workers, midwives especially, isn\u0026rsquo;t really optimal yet, there are still those who are not skilled in doing so. (A4)\u003c/p\u003e\u003cp\u003eManagers also stated that monitoring and evaluation carried out by the health office is more focused on report output and data similarity, rather than the capacity of midwives.\u003c/p\u003e\u003cp\u003eThen\u0026hellip; the utilization of [applications] by the health workers, midwives, are not yet monitored by the health office. The health office gives out reminders to the health centres only if there were any missing reports or problems related to the reports they submitted. Yes, those are followed up by phone call and direct visits to supervise, monitor, and evaluate the health centres\u0026hellip; that is roughly the form of supervision that is carried out by the health office regarding the use of digital applications by the health centres. (A4)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cb\u003eTypes, Functions, and Content of Pregnancy Applications\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe analysis revealed that various apps with different purposes are used in pregnancy health services. Most of the apps functioned as platforms for recording and reporting health data, with a few others intended for health education, consultation, and other services. The apps developed by non-government organizations were more interactive and automated compared to those developed by the government. A few of the health centres also developed their own innovations based on their specific needs. The content included in the apps varies from educational content for normal to high-risk pregnancy and tracking of vaccinations, sexually transmitted diseases, and maternal mortality records. Use of a variety of application types, functions, and content, as mentioned by the managers of health centres and offices, has the potential to improve the efficiency and quality of services delivered to pregnant women.\u003c/p\u003e\u003cp\u003ePrevious research has identified 12 functions of mobile health applications (mHealth): health education and behavior change; sensors and point of care diagnostics; registries or vital events tracking; data collection and reporting; electronic health records; electronic decision support; provider-to-provider communication; provider work-planning and scheduling; provider training and education; human resource management; supply chain management; and financial transactions and incentives (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The functions of mHealth are broad, comprehensive, and aim to strengthen the health system of a country. Based on the results of the focus group discussions however, not all applications have achieved the intended functionality of mHealth. Development in the functions of apps used in the Indonesian healthcare service remains minimal; apps are mostly used for health registries so their features are limited to the recording and reporting of data. Apps with a wider function have been developed, but are only impactful locally, limited in scope, have yet to be standardized, are still in the form of incidental development/research, and have not gone through any monitoring and evaluation. Therefore, research on the use of health applications and internet-based registries is necessary.\u003c/p\u003e\u003cp\u003eThe analysis found that e-Registries or apps in MCH services are not limited to registering normal pregnancies, but also pregnancies with high risks or complicated by certain illnesses. Participants explained that they used the Melani app specifically for recording pregnancies with pre-eclampsia and heavy bleeding, and SiHepi for hepatitis patients, including pregnant women. Utilizing apps for specific purposes is in line with research results in India, another developing country, which implemented the Tamil Nadu Pregnancy and Heart Disease Registry (TPNHDR) (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). It was developed to provide comprehensive data on the health of mothers and their babies, recording illness prognosis, predicting cardiovascular disorder risks in pregnant women, and identifying management gaps in pregnant women with heart disease (PWWHD). The results of the TNPHDR can help formulate actions for better care and generate personalized and practical guidelines for PWWHD management (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). In Indonesia, the translation of research results into policies is not optimized; data collected from registries has not been leveraged to develop thorough and measurable foundations for program development. This study discovered that pregnancies are still recorded and reported in static data forms, thus are not integrated into frameworks that can inform the foundation for health policies. Analysis of health policies formulated from data reported by midwives is the next potential research step.\u003c/p\u003e\u003cp\u003e\u003cb\u003eBenefits of Digitizing Registry and Pregnancy Apps\u003c/b\u003e\u003c/p\u003e\u003cp\u003eResults showed that digitizing MCH registries provides significant benefits, such as improved data accuracy, reduced duplication of activities, monitoring of program achievements, and rapid case handling. In this study, Si ASIK was one example of an app that enables real-time vaccine monitoring, while WhatsApp-based programs support direct consultation and interaction with pregnant women. These benefits demonstrate that digital technology can help overcome administrative challenges while supporting pregnant women\u0026rsquo;s self-monitoring and awareness.\u003c/p\u003e\u003cp\u003eThe benefits of digitization of reporting and pregnancy apps have been widely felt in various areas. A study mentioned remote monitoring devices are useful for reporting prenatal care, such as cardiotocography, blood glucose levels, blood pressure and prenatal ultrasound results (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Additionally, a study implemented Smart-e-Moms as a digitized form of MCH registry, which has proven effective and has potential in helping to treat postpartum depression (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). This intervention would be beneficial for both the mother and child, as it supports maternal well-being and improves child development. However, Indonesia has not yet experienced the benefits of diagnostic support; future research could focus on ways to improve diagnostic services and health worker interventions.\u003c/p\u003e\u003cp\u003eDeveloping countries have also experienced the benefits of digitization. A systematic review stated that research findings regarding mHealth and maternal and neonatal healthcare service utilization vary widely (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Most studies found that mobile phone technology is beneficial in improving several MCH services, especially in poor and developing countries. Nevertheless, several studies also identified challenges related to technology use and misuse, rich-poor discrimination, and disparities in phone ownership, all of which need to be addressed. The phenomenon of using mobile phones for a range of activities is increasing every year in Indonesia, with data showing an increase from 2021 to 2024 in both urban and rural areas (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). This is a positive sign, pointing to the potential of developing health programs for pregnant women using mobile phones.\u003c/p\u003e\u003cp\u003eElectronic medical record (EMR) in maternity and paediatric clinical settings has been widely adopted and applied in developed countries. A previous study have demonstrated a significant improvement in the completeness of antenatal records recorded through the implementation of EMR-based data verification (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). A 42.9% difference in missing data (including screening for hypertension, tuberculosis, malaria, HIV status in women) was recorded before and after implementation. In line with this, another study explained that integrating data into electronic health records supports better patient-provider communication and shared decision-making, thus empowering patients to actively manage their health conditions (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Similarly, it was also previously explained that e-Registries can offer support for most commonly used electronic and mobile health applications (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Various countries are implementing health registries in assorted forms, and the majority, including Indonesia, are transitioning from paper-based data collection to electronic systems. However, very few have e-Registries that can act as the primary source of integrated health information. This reflects an electronic health system that needs to be improved as data gathered from e-Registries are beneficial for research as the foundation for health policies on a regional and national scale.\u003c/p\u003e\u003cp\u003eIn Indonesia, many e-Registries have been developed by service providers, although not optimally because they are limited to reporting data, i.e., not interactive (e-COHORT, Si ASIK, MPDN, SIMATNEO). Patients and other staff outside the region cannot see these data. There is criticism that a lot of data is reported but the impact on patients and service facilities is lacking. A small number of simple automated applications (WhatsApp groups) have been independently utilized by some parts of the health service because they felt the need for intensive, close, and interactive communication with patients. Moreover, many patient conditions, including pregnancy complications, require frequent monitoring. Outside of health services, there are various applications provided by the private sector (Pregnancy Tracker, Diary-Bumil), and most of them have in-application payment. Some are not a paid service, but are usually incidental, local, and have had no monitoring and evaluation done. The benefits of health applications for pregnant women were identified by the participants of this study, and they hoped that future applications would be multifunctional; that is, one application would cover not only recording health data but also health education, coordination of health centers, and health decision making. In this way, apps and registries could be optimized, especially in governmental services. With the simplified form of the registries and applications as one, its future use can be made to be more optimal, especially in governmental services.\u003c/p\u003e\u003cp\u003e\u003cb\u003eBarriers and Challenges in Application Utilization\u003c/b\u003e\u003c/p\u003e\u003cp\u003eVarious barriers and challenges in the use of applications in health services were identified in this study: (a) Limited facilities such as unstable internet connection, especially in areas with inadequate infrastructure, and basic computer devices; (b) Unpatented systems such as websites with frequent maintenance or errors, data loss, and poor synchronization reducing the effectiveness of application use; and (c) Incompetent or inadequately trained human resources such as midwives or health workers who do not have adequate skills in using technology, which slows down the adaptation process.\u003c/p\u003e\u003cp\u003eThis study supports the results of previous research conducted in four developing countries \u0026ndash; Myanmar, Uganda, Tanzania, and Ethiopia \u0026ndash; to identify barriers and facilitators in the implementation of WHO\u0026rsquo;s maternal health programs (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). It was found that, although each country\u0026rsquo;s health programs had a different focus, there were similar challenges, such as low-quality systems and devices and low-skilled health workers. A systematic review of research from 16 developing countries found similar challenges and specifically identified the issue of health workers not having mobile phones to be able to communicate with pregnant women (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Therefore, improving health services in developing countries can be complex, as many improvements need to be made with regard to facilities, medical devices, and the performance of health workers. All FGD participants in our study complained about internet network facilities, and this challenge was among many established by a previous FGD research on video-call-based telehealth (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). The study established most reported barriers as follows: unreliable network connections; lack of hands-on experience; lack of access to technology; reduced observational accuracy and poor visual instruction conditions; lack of technology skills; and reduced client-practitioner interaction and communication (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAccording to the Indonesian Ministry of Finance and Ministry of Health, efforts to overcome these barriers and challenges continue to be made, although not optimized (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). The health budget is increased annually, especially for medical equipment facilities, and maternal health is a key focus area for facility fulfilment. However, research investigating the health sector in terms of the need for better facilities and various supports to improve the performance of health workers remains limited. The results of this study offer information on the needs of maternal health services, particularly electronic service tools. As an example, internet network expansion continues to be a priority in Eastern Indonesia (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). An adequate internet network has the potential to improve maternal health by facilitating faster, more accurate reporting of health records as well as ensuring that health education and consultation are more accessible and affordable for pregnant women (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). However, in reality, network problems in Indonesia are still a major obstacle to ensuring effective health programs, thus putting such programs at risk. Inter-institutional advocacy efforts need to continue so that the need for functioning internet networks as part of supporting facilities for health development becomes a priority for all parties, including the Indonesian Ministry of Communication and Digital Affairs.\u003c/p\u003e\u003cp\u003eThe challenge of quality human resources was raised by participants in relation to the ability to use computer equipment and the turnover of trained staff. These resource issues are common in developing countries\u0026rsquo; health services. Informed by a systematic review, identified three human resource issues: high staff turnover in private facilities and limited human resources and expertise; lack of community ability to adapt to technology and limited health staff with technology skills; as well as barriers related to young age, language, myths, fears, and misconceptions (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Regarding our study\u0026rsquo;s research locations, in Garut, the majority of midwives are relatively young, so adapting to computer technology, the internet, and various applications is not an obstacle. However, in Kupang and Ambon, midwives tend to be older so struggle in the era of technological transformation. Efforts can be made to improve the quality of human resources, especially senior health workers, some of whom are approaching retirement. A more personalized and gradual approach would be beneficial, one that involves simple and practical training programs, starting with the introduction of basic technology such as the use of smartphones and simple applications. Assistance or mentoring by younger colleagues can help seniors learn more effectively. Interactive workshops with hands-on simulations help to increase confidence, while motivation to embrace the digitization of health services can be boosted by showing the direct benefits of technology in daily work. In addition to human resource programs, policies are also needed. Organizational and regulatory barriers and challenges, in particular, hindered widespread adoption of applications (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Policymakers need comprehensive guidance regarding the implementation of these applications, given their high investment cost. Another study implementing mobile immunization applications to improve parents\u0026rsquo; timely vaccination of their children found barriers associated with the usability and accessibility of mobile technologies, which depend in part on a user\u0026rsquo;s innate characteristics such as technology readiness (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn summary, digitalization in health services for pregnant women offers a range of benefits, but implementation still faces a number of challenges. Through a more integrated approach, improved infrastructure, and human resource capacity building, digital transformation has the potential to become a key foundation in improving the quality of health services for mothers and children in Indonesia.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStrengths and Limitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003e This study provides valuable insights into the experiences and perceptions of health workers with managerial positions about the use of health applications and e-Registries that may act as essential guideline for developing a comprehensive antenatal and other supportive pregnancy programs that address MCH challenges in Indonesia. However, the limitation to this study should be acknowledged. The participants were limited to health workers with managerial positions in maternal and child health (MCH) services. While these individuals are well-positioned to provide strategic and administrative insights into the implementation of health applications, their perspectives may not fully capture the detailed operational challenges experienced by frontline health workers.\u003c/p\u003e\u003cp\u003e\u003cb\u003eImplications\u003c/b\u003e\u003c/p\u003e\u003cp\u003eHealth professionals in Indonesian maternal and children health services can utilize the results of this study to advocate for improving the quality of digital-based services and to ensure that direct services continue to be provided optimally. The study also emphasized the importance of multi-sector cooperation in improving maternal and children health services.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eVarious applications with different purposes were used in Indonesian MCH services, with participants noting this often resulted in overlapping data. Identified benefits of using the apps included increased accuracy, organization of work tasks, and ease of access to digital data and reports. Nonetheless, challenges were also experienced, such as inadequate electronic devices, limited internet network connection, incompetent human resources, and unstandardized monitoring and evaluation. To overcome these challenges, integration of reporting systems and developing applications with an automated and interoperability data system is recommended. Collaboration among academic institutions, industries, researchers, and government sectors is needed to develop automated IT devices and applications as an impactful innovation in maternal and child services. Future research should consider collecting and triangulating data from e-Registry and app developers as well.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo ensure that research ethics were maintained, the Helsinki Ethical Principles were implemented. The principles are beneficence (the right to be free from harm, discomfort, or suffering; and the right to protection from exploitation); respect for human dignity (the right to self-determination and the right to full disclosure); and fairness (the right to fair treatment and the right to privacy). Consent to participate were obtained verbally from each participant after the study details had been thoroughly explained to them, guided by an informed consent\u0026nbsp;form approved by the Universitas Padjadjaran Research Ethics Committee.\u0026nbsp;This study obtained ethical approval from the Universitas Padjadjaran Research Ethics Committee (No.1806/UN6.KEP/EC/2024) and BRIN Health Ethics Committee (No: 219/KE.03/SK/12/2024).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to participants requests of keeping institutional affiliations anonymous but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by KONEKSI Collaborative Research Grant (Agreement Reference Number: KONEKSI/1447/CRG/2024/53-UNPAD).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRW, IP, HZ, DQU, and CNMH were responsible for the conceptualization and design of this study. The data collection was conducted by all authors. RW and IP drafted the initial manuscript. All authors critically reviewed, revised the manuscript, and approved the final version for publication. All authors take responsibility for the integrity of the data and the accuracy of the data analysis. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors extend sincere gratitude to KONEKSI Collaborative Research Grant for the generous financial support which was vital in the success of this study completion. The authors also thank the participants and all others who contributed to the data collection process of this project.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBPS. 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Expanding Approaches for Research: Understanding and Using Trustworthiness in Qualitative Research. J Dev Educ. 2020;44(1):26\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003ePolit DF, Beck CT. Essentials of Nursing Research: Appraising Evidence for Nursing Practice. 2018. \u003c/li\u003e\n\u003cli\u003eFr\u0026oslash;en JF, Myhre SL, Frost MJ, Chou D, Mehl G, Say L, et al. eRegistries: Electronic registries for maternal and child health. BMC Pregnancy Childbirth. 2016 Jan;16:11. \u003c/li\u003e\n\u003cli\u003eGnanaraj JP, Princy SA, Sliwa-Hahnle K, Sathyendra S, Jeyabalan N, Sethumadhavan R, et al. Tamil Nadu Pregnancy and Heart Disease Registry (TNPHDR): Design and Methodology. BMC Pregnancy Childbirth. 2022 Jan;22(1):80. \u003c/li\u003e\n\u003cli\u003eDudkina A, Kujala S, H\u0026auml;gglund M, Kharko A, Wang B, Soone H, et al. Patient Input into the Electronic Health Record: Co-Designing Solutions with Patients and Healthcare Professionals. Stud Health Technol Inform. 2024 Aug;316:1477\u0026ndash;81. \u003c/li\u003e\n\u003cli\u003eBPS. Persentase Penduduk yang Memiliki/Menguasai Telepon Seluler Menurut Provinsi dan Klasifikasi Daerah, 2021-2023. 2024. p. https://www.bps.go.id/id/statistics-table/2/Mzk1Iz. \u003c/li\u003e\n\u003cli\u003eHaskew J, R\u0026oslash; G, Saito K, Turner K, Odhiambo G, Wamae A, et al. Implementation of a cloud-based electronic medical record for maternal and child health in rural Kenya. Int J Med Inform. 2015 May;84(5):349\u0026ndash;54. \u003c/li\u003e\n\u003cli\u003eVogel JP, Moore JE, Timmings C, Khan S, Khan DN, Defar A, et al. Barriers, Facilitators and Priorities for Implementation of WHO Maternal and Perinatal Health Guidelines in Four Lower-Income Countries: A GREAT Network Research Activity. PLoS One. 2016;11(11):e0160020. \u003c/li\u003e\n\u003cli\u003eVenkataramanan R, Subramanian S V, Alajlani M, Arvanitis TN. Effect of Mobile Health Interventions in Increasing Utilization of Maternal and Child Health Care Services in Developing Countries: A Scoping Review. Digit Heal. 2022;8:20552076221143236. \u003c/li\u003e\n\u003cli\u003eRettinger L, Kuhn S. Barriers to Video Call-Based Telehealth in Allied Health Professions and Nursing: Scoping Review and Mapping Process. J Med Internet Res. 2023 Aug;25:e46715. \u003c/li\u003e\n\u003cli\u003eMinistry of Finance Indonesia. Sampai dengan 30 November, Realisasi Anggaran Kesehatan Sebesar Rp164,3 T [Internet]. 2024 [cited 2025 Apr 11]. Available from: https://www.kemenkeu.go.id/informasi-publik/publikasi/berita-utama/Realisasi-Anggaran-Kesehatan-Sebesar-Rp164,3-T\u003c/li\u003e\n\u003cli\u003eMinistry of Health Indonesia. Turunkan AKI-AKB, Kemenkes Pertajam Transformasi Sistem Kesehatan [Internet]. 2021 [cited 2025 Apr 11]. Available from: https://kemkes.go.id/id/turunkan-aki-akb-kemenkes-pertajam-transformasi-sistem-kesehatan\u003c/li\u003e\n\u003cli\u003eMinistry of Communication and Digital Affairs Indonesia. Fondasi Akselerasi Inovasi dan Pertumbuhan Ekonomi [Internet]. 2024 [cited 2025 Apr 11]. Available from: https://www.komdigi.go.id/transformasi-digital/infrastruktur-digital\u003c/li\u003e\n\u003cli\u003eTill S, Mkhize M, Farao J, Shandu LD, Muthelo L, Coleman TL, et al. Digital Health Technologies for Maternal and Child Health in Africa and Other Low- And Middle-Income Countries: Cross-disciplinary Scoping Review with Stakeholder Consultation. J Med Internet Res. 2023;25. \u003c/li\u003e\n\u003cli\u003eKabor\u0026eacute; SS, Ngangue P, Soubeiga D, Barro A, Pilabr\u0026eacute; AH, Bationo N, et al. Barriers and Facilitators for the Sustainability of Digital Health Interventions in Low and Middle-income Countries: A Systematic Review. Vol. 4, Frontiers in Digital Health. 2022. p. 1\u0026ndash;16. \u003c/li\u003e\n\u003cli\u003eSag OM, Li X, \u0026Aring;man B, Thor A, Brantnell A. Qualitative Exploration of 3D Printing in Swedish Healthcare: Perceived Effects and Barriers. BMC Health Serv Res. 2024 Nov;24(1):1455. \u003c/li\u003e\n\u003cli\u003eAtkinson KM, Westeinde J, Ducharme R, Wilson SE, Deeks SL, Crowcroft N, et al. Can Mobile Technologies Improve On-time Vaccination? A Study Piloting Maternal Use of ImmunizeCA, A Pan-Canadian Immunization App. Hum Vaccin Immunother. 2016 Oct;12(10):2654\u0026ndash;61. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"E-Registry, Health applications, Health workers, Pregnancy","lastPublishedDoi":"10.21203/rs.3.rs-7137611/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7137611/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eInternet-based healthcare has raised polarizing opinions due to differing evidence of its positive and negative effects, particularly in maternal-fetal health services. The usability and sustainability of digital technology, including mobile health applications, rely on collaboration among health services leaders, policymakers, and health professionals. However, little is known about their views on the use of internet-based healthcare in maternal health services during the rapid digital transformation program in Indonesia's health sector. This study aims to explores the perspectives of health managers in using internet-based technology and mobile applications in maternal health services.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA qualitative approach with a descriptive design was applied to conduct focus group discussions at three research locations in Indonesia (Garut, Ambon, Kupang) at the end of 2024. The sample included 20 policymakers and health professionals with managerial roles who were purposefully chosen for the study. Data was transcribed verbatim and analyzed using a framework analysis with a general inductive approach.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThematic analysis resulted in the identification of three main themes: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Variety of health applications for maternal health records and reports; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Advantages of digitizing registries and applications for pregnancies; and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Barriers and challenges in the use of applications in maternal health services. The number of health apps utilized in maternal health services is extensive; each has a different purpose and content, and some have overlapping data.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe maternal-fetal health service in Indonesia have incorporated an internet-based system for various purposes. However, challenges are still frequently reported, including inadequate facilities, limited internet networks, low or unskilled human resources, and non-standardized monitoring and evaluation. This urges the necessity of a multisectoral collaboration in optimizing the purpose and functions of an internet-based healthcare service. Further studies on developing a comprehensive, standardized, and integrated application to improve the maternal-fetal health service in Indonesia.\u003c/p\u003e","manuscriptTitle":"Health Managers’ Perspectives on Utilization and Barriers of Health Apps in Indonesian Maternal Health Services: A Qualitative Descriptive Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-27 10:56:32","doi":"10.21203/rs.3.rs-7137611/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"73709925495468051204634937039220166605","date":"2026-05-23T00:56:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"62004271016936768505688696668649327224","date":"2026-05-21T13:25:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"161239526436519268631335369466575565648","date":"2025-09-02T06:21:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-01T15:41:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"338699920334254633846985265892807544804","date":"2025-08-28T08:59:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"73569803235534160186535792455508865350","date":"2025-08-24T10:06:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"276671471839521846815229305998571182386","date":"2025-08-20T04:20:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-19T08:43:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-13T06:51:11+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-23T11:19:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-23T08:04:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-07-23T08:01:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5ea2a8dd-aa36-4120-8fc2-ed6364b8c55a","owner":[],"postedDate":"August 27th, 2025","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"73709925495468051204634937039220166605","date":"2026-05-23T00:56:58+00:00","index":95,"fulltext":""},{"type":"reviewerAgreed","content":"62004271016936768505688696668649327224","date":"2026-05-21T13:25:08+00:00","index":92,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-27T10:56:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-27 10:56:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7137611","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7137611","identity":"rs-7137611","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}