Mobile phone applications for midwives with focus on antenatal care: A mapping and assessment of quality and suitability for low-resource settings. 

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Amalie Panman, Vanessa S. Sakalidis, Leah F. Bohle This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4815995/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Reducing maternal mortality in low-resource settings remains a priority in achieving the Sustainable Development Goal 3. The provision of antenatal care is an essential pillar in maternal health care. Digital health applications, which target midwives providing antenatal care, can assist workers in low-resource settings by providing access to quality tools and education for evidence-based care. This study aimed to identify mobile apps for midwives focusing on antenatal care and assessed their quality and suitability for use in low-resource settings. Methods A systematic mapping of mobile apps accessible on Google Play Store was performed using pre-defined search terms related to midwifery and antenatal care. Inclusion criteria based on numbers of downloads, English language, free of cost, and thematic focus, resulted in 15 apps for evaluation. The quality of apps and suitability for use in low-resource settings was assessed using two frameworks. An individual score was calculated for each app and a ranking was performed. Results Of the 15 apps identified, the focus was on educational content (n = 10), antenatal care measurement tools (n = 4), and patient documentation (n = 1). The quality of apps overall ranged between 1.77–4.80 points, with a maximum of 5 points. Suitability for low-resource settings was favourable in that the majority of the apps were available offline (n = 11), however, only some offered additional languages (n = 5), and few integrated cultural diversity and sensitivity (n = 2). All apps integrated at least one of WHO’s recommendations for a positive pregnancy, suggesting the apps were somewhat suitable for midwives delivering antenatal care; although no apps referenced WHO or referred to national clinical guidelines. Conclusions Significant gaps in the availability of apps targeting midwives represented a missed opportunity in the digital health landscape. Only two apps holistically implemented WHO antenatal care recommendations, and were rated high quality. No apps combined educational content and tools; or connected the midwife and pregnant woman. This review demonstrated that while there are several comprehensive apps targeting midwives, the minority of these are focusing on antennal care in low-resource settings and would benefit from further resources, development and regulation. Antenatal Maternal Health Midwifery Mobile Applications mHealth Prenatal Care LMIC Resource-Limited Settings SDG3 Figures Figure 1 Figure 2 Background The Sustainable Development Goal (SDG) 3.1 aims to reduce the global maternal mortality ratio to less than 70 per 100 000 live births by 2030 (1). Despite international efforts, reductions in maternal mortality are stagnating globally. Without renewed efforts, the SDG 3.1 target is unlikely to be achieved. The poorest maternal health outcomes remain in sub-Saharan Africa (2), where the leading causes of maternal death are obstetric haemorrhage, hypertensive disorder in pregnancy, non-obstetric disorders and pregnancy related infections (3). Antenatal care (ANC), intrapartum care, and postnatal care are essential pillars of pregnancy-related care. ANC includes risk identification, prevention and management of pregnancy-related or concurrent diseases, health education and health promotion (4). It allows for timely identification of direct and indirect causes influencing maternal health outcomes (4). Since 2016, the World Health Organization (WHO) has recommended eight ANC contacts during the course of a pregnancy, of which four should be provided by a skilled birth attendant in person (5). However, ANC coverage is lowest in sub-Saharan Africa, with only approximately 56% of pregnant women having received four ANC visits in 2021 (6). Midwives play a crucial role in the provision of care to pregnant women. If educated in line with international standards, midwives can avert and prevent up to 60% of all maternal deaths (7). In the majority of low-resource settings, midwives are at the forefront of providing care to pregnant women at all levels of care. Providing high-quality care plays a pivotal role in maternal health outcomes. Nonetheless, midwives in low-resource settings face wider health-system challenges and need to operate in environments with limited resources, and access to information (8). Mobile phone applications (i.e., mHealth applications or apps) have great potential to support the provision of care. These may include but are not limited to apps with educational content (e.g., information, health promotion, evidence-based healthcare provision, etc.), digital tools (e.g., calculators), supporting the communication between healthcare providers and clients, or shared information, such as electronic patient records. With increasing availability, accessibility and affordability of smartphones and internet coverage, apps can be an easy to access and cost-efficient resource, potentially contributing to the provision of high-quality maternal health care, specifically in low-resource settings. While many apps focus on education, behaviour change, pregnancy and antenatal care for the mother (9–14), it is less clear which apps are available to support health workers, and in particular midwives in the provision of ANC. Several studies have evaluated effectiveness, behaviour change, functionally, user-friendliness (15–17) and quality (9–14) of maternal health apps with either pregnant women or parents as the end-users. However, no studies have assessed midwives as the end-user. This study aimed to identify mobile phone applications for use by midwives with focus on antenatal care and assess their quality suitability for use in low-resource settings by 1. Conducting a systematic mapping of mobile phone applications accessible on Google Play Store; 2. Applying the validated MARS framework by Stoyanov et al. (18) to assess the quality of the apps identified and calculate a quality score; and 3. Utilizing an adapted MARS framework by Sharma et al. (19) to explore the suitability of the apps for use in low-resource settings. Mobile phone applications are herein defined as software applications developed for small wireless computer devices, and which can be installed and accessed on e.g., smartphones and tablets (20, 21). ANC was defined as "the care provided by skilled healthcare professionals to pregnant women (…) to ensure the best health conditions for both mother and baby during pregnancy. The components of ANC include: risk identification, prevention and management of pregnancy related or concurrent diseases and health education and health promotion", and is aligned to the WHO recommendations of ANC for a positive pregnancy experience (5). Methods Identification and mapping of mobile phone applications We conducted a systematic search of mobile phone applications between 24th of February and 3rd of April 2023.The Google Play Store was searched based on the following pre-defined search terms: "midwives", "midwife", “midwifery” and “antenatal”, resulting in a total of n = 308 apps. After removing duplicates, 278 apps were identified and a three-stage review process was applied based on pre-defined inclusion criteria (see Table 1 ). A systematic search was conducted in Google Play, as it is estimated that approximately 85% of all phone/tablet users in low- and middle- income countries use an Android phone (22). Table 1 Inclusion and exclusion criteria Inclusion Criteria Exclusion Criteria - English language - Midwives as target group (i.e., end-user) - Topic: antenatal care - Free of charge - Minimum 5000 downloads - Pregnant women, mothers, fathers, parents, obstetricians/ gynaecologists, community health workers, only as target groups - Focus on exam preparation only - Used for care, excluding antenatal care (e.g., postnatal care, pre-pregnancy apps, fertility calendars, menstrual calendars, games, photo editing apps, training apps baby equipment checklists) - Additional device required (e.g., ultrasound device, doppler device) - Dependency on an additional device to be functional (e.g., ultrasound device, doppler, etc.) Based on the above inclusion criteria, an initial first stage screening of the text-based app description was conducted. As a result, 250 apps were excluded, not fulfilling the inclusion criteria. In the second stage, 16 of the remaining 28 apps with at least 5000 downloads were retained. In the third stage, the 16 apps were downloaded to an Android smartphone, and one app was further excluded based on the mandatory requirement for payment, which was only visible after the download and once a mandatory user profile was established. A total of 15 apps were therefore included and evaluated (23). (Fig. 1 and Additional file 1) Quality assessment The Mobile Application Rating Scale (MARS) was used to assess the quality of the apps (18). The MARS tool ensures an evidence-based approach, designed to provide an objective, reliable and multi-disciplinary quality assessment of mobile phone applications, with focus on health-related apps and an internal consistency of 90% (18). The tool consists of five broad categories entailing 23 criteria (Additional file 2), which are made up of four objective quality categories: engagement (n = 5 criteria), functionality (n = 4 criteria), aesthetics (n = 3 criteria), and information (n = 7 criteria); and a subjective quality category (n = 4 criteria). Each criteria was rated on a scale of 1–5 (1 = inadequate, 2 = poor, 3 = acceptable, 4 = good, 5 = excellent). Following the assessment, a mean score was calculated for each of the five categories, followed by a joint mean score for the four objective quality scales (n = 19 criteria), with the highest possible score of 5.00. The score of the subjective quality scale (n = 4 criteria) was calculated separately due to its subjective nature and aligned with the guidelines of the MARS tool (18); here a maximum mean score of 5.00 could be reached. The scores were rounded to two decimal places. 20% of the apps were first blindly rated by two users (AP, LFB) to check inter-rater reliability, followed by a rating of all apps by one user (AP). Suitability assessment with focus on midwives working with antenatal care in low-resource settings The assessment of suitability of apps for use in low-resource settings was based on an adaption of the framework by Sharma et al. (19). The framework utilized a modified MARS framework to focus end-users in low-resource settings, using a total of 36 criteria. We further adapted the framework by excluding criteria identical or very similar to the MARS framework, resulting in a total of nine remaining criteria. These included 1) offline availability, 2) cultural sensitivity and diversity, 3) accessibility of the app (Google Play and/or iTunes), 4) language availability, 5) payment requirements, 6) interaction possibilities to interact with the pregnant client, 7) data exportation possibilities, 8) when the app was last time updated and 9) if the information within the app was kept confidential. In a second step, additional criteria were added by the authors (n = 6), based on the WHO recommendations antenatal care for a positive pregnancy experience’s (5) five the categories: 1) nutritional interventions, 2) maternal and foetal assessments, 3) preventive measures, 4) investigation for common physiological symptoms, and 5) health systems interventions to improve the utilization and quality of antenatal care. The additional criteria therefore assessed whether the app was based on the above WHO recommendations; if national clinical guidelines were taken into account; information on the end-user target group (i.e. in-service midwives, midwifery educators and/or pre-service midwives); and the professional background of the developer/development team, utilizing a yes/no scoring check-list. The adapted check-list was tested on two randomly selected apps of the total of n = 15 apps in a blinded approach by two authors (AP, LFB). Results were compared, differences discussed and the criteria were further refined and finalized (see the adapted tool in Additional file 3–4). The adapted framework was applied on all 15 apps exploring the suitability of the apps for the provision of antenatal care with a specific focus on low-resource settings. Ranking of the mobile applications A ranking of the mobile applications was conducted, based on the MARS tool and the suitability assessment. The MARS scores of the mobile apps were first ranked from the highest to the lowest score. This was followed by the app´s performance of the suitability assessment. It is important to note that some of the suitability questions/statements had more significance than others (e.g., ability to use the mobile application offline, non-payment requirement for full use, cultural sensitivity and diversity consideration, language, content reliability (based on WHO recommendations, the developer’s profession, citation within the mobile application)). Following, the MARS scores and the results from the suitability assessment was compared and evaluated together. Consequently, the apps were finally ranked from the highest to lowest quality and suitability for midwives and the provision of antenatal care in low-resource settings. Results The majority of apps identified provided educational content (n = 10), with two of the apps designed to inform decision making at the bedside. Four out of ten apps with educational content had additional functions, including exam and/or self-learning questions (n = 3), or calculation tools (n = 1). Other apps identified (n = 4) were tools (e.g., measurement and calculation tools), and only one app was a patient documentation tool that midwives can use in their work with pregnant women. Apps covered either a range of topics related to antenatal care and maternal health in general, excluding one app which focused on a single antenatal care topic. No apps combined educational content and tools (Additional file 1). Quality assessment The mean MARS quality score of all fifteen mobile applications was 3.49, out of a possible 5.00 (range: 1.77 to 4.80). Fourteen of the 15 mobile applications assessed had a mean MARS score above 2.50. The Safe Delivery App and the Safe Abortion app reached the highest score (4.80 and 4.74 respectively) (Additional file 5). The MARS score was also assessed and calculated for each of the separate categories to provide more detail on the strengths and weaknesses of each app, and the highest rated category. Results showed that the category “functionality” scored highest (3.71), followed by “information” (3.68), “aesthetics” (3.47), “engagement” (3.08) and “subjective quality” (2.60). (Fig. 2 ) Suitability in low-resource settings Of the fifteen mobile applications evaluated, eleven were fully functional offline. Among all apps, only two mobile applications had integrated aspects of diversity and cultural sensitivity (Safe Delivery App and Safe Abortion app), and three had partially implemented it. All the fifteen assessed mobile applications provided the content in English language, one mobile app offered one additional language, and three mobile applications provided more than two language options. All fifteen mobile applications were free to download, but two of these mobile apps required additional payment to get access to the entire content. There was no mobile application that allowed communication between midwives and their colleagues and/or the client. Seven mobile applications allowed confidential information to be entered into the mobile application, but only two of the seven clearly stated that they keep the information confidential. The last update of the mobile applications varied, with nine apps indicating being updated during the last 6–12 months; one app being updated during the last 12–18 months, and five during the last 18 months or longer. Suitability for midwives providing antenatal care Among the fifteen apps assessed, six were suitable for in-service midwives only as the end-user, and the remaining nine were suitable for in-service midwives, pre-service midwives and midwifery educators. To assess the suitability of the apps with focus on antenatal care, six additional criteria were created based on the WHO’s recommendations for antenatal care for a positive pregnancy experience (5). All mobile applications assessed incorporated at least one or more of the five thematic sections highlighted by WHO, including either nutritional interventions (n = 3), maternal and foetal assessment (n = 12), preventive measures (n = 5), interventions for common physiological symptoms (n = 4), and health systems interventions to improve the utilization and quality of antenatal care (n = 6). One mobile application had at least one recommendation from all five sections for a positive birth experience (WCEA app). Two apps cited the World Health Organization (Safe Delivery App, Safe Abortion app), but none referred to the WHO recommendations for antenatal care for a positive pregnancy experience. One mobile app mentioned the recommendation of eight ANC contacts (Safe Delivery App), while no apps referenced national clinical guidelines. Information on the professional background of the app developers or the affiliated institutions was provided for seven of the fifteen apps. These included medical doctors (n = 2), a midwife (n = 1), and a nurse (n = 1), as well as institutions including University (n = 1) and non-governmental organization (NGO) (n = 2). All apps included in the review indicated the name of the person or company that had developed the app. Mobile application ranking The results from the MARS tool and the suitability assessment were compared and analysed, and ranked from the strongest to the weakest app (Additional file 5). The overall ranking showed the Safe Delivery App, followed by the Safe Abortion app, which were rated significantly higher than all other apps. Discussion Maternal mortality is particularly high in Sub-Saharan Africa and South Asia (2); midwives have the potential to significantly reduce maternal deaths if trained in line with international standards (7). A study by Nishimwe et al. showed, that the use of mobile applications by midwives has the potential to provide better care. The Safe Delivery App, the highest rated app in this study, was utilized by midwives in Rwanda, resulting in a notable reduction in postpartum haemorrhage (62–28%) and neonatal asphyxia (19–6%) within a six-month timeframe (24). While midwives’ perception of using apps for the delivery of ANC has not explicitly been assessed. However, a study could show that pregnant women in low- and middle-income countries who utilize mobile health interventions are more likely to attend ANC check-ups (25). Furthermore, though qualitative and quantitative studies midwives have emphasized the potential benefits of using mobile apps, in enabling pregnant women to make informed decisions about their pregnancy (26). Conversely, the same midwives have highlighted the risks and limitations associated with using mobile health interventions, noting the importance of the accuracy of the information conveyed and the potential for negative impacts on the patient-professional relationship (26). Future studies assessing midwives’ assessment of the apps could aid in understanding how midwives use apps, and how they perceive their strengths and limitations, and what their needs are. The availability of mobile health applications presents both opportunities and challenges in delivering pregnancy-related care. In this study, we evaluated the quality of the apps identified, aiming to contribute to the ongoing discourse surrounding the suitability, efficacy, and reliability of health and care related apps. We observed considerable diversity in app quality across various categories assessed, using the MARS tool, including engagement, information, aesthetics, and functionality. Notably, functionality emerged as the highest-scoring category overall, consistent with previous research by (12, 27, 28). Our study echoes the observation of improved app functionality over time. However, this positive trend is juxtaposed with stagnant content credibility - a concerning finding mirrored in the broader literature (28). Alarmingly, our analysis reveals a lack of prioritization of information quality among the assessed apps, with only a fraction providing citations and referencing regulatory and evidence-based sources such as the World Health Organization. This deficiency mirrors findings from related studies (28), suggesting systemic issues within app development and regulatory oversight and underscores the persistent challenge of ensuring the accuracy and reliability of health information disseminated through health apps. Notably, critical information regarding the source of content, the developer professional background, and funding sources remained obscure, contributing to the considerable variability in app reliability and quality. Additionally, only two apps explicitly mentioned measures to protect confidential information. These findings underscore the imperative for enhanced regulation in the mobile health app sector. The implications of substandard information quality are particularly grave within contexts of limited healthcare access, where mobile apps may serve as primary sources of health information and education, supporting clinical decisions. Given the documented link between incorrect health information and adverse outcomes (29)- including mortality and morbidity - it is imperative to strengthen regulatory mechanisms governing health app content and ensure adherence to evidence-based guidelines. Several methodological choices were made due to resource constraints, potentially influencing the study results. Firstly, the systematic search was confined to the Google Play app store (Android), excluding apps exclusive to the iTunes app store (Apple). This decision was informed by the widespread use of Android phones, particularly in low-resource settings, estimated at approximately 85% of all smartphone/tablet users. Secondly, the inclusion criterion of English-language applications may have excluded high-quality apps in other languages. Thirdly, apps with fewer than 5000 downloads were excluded under the assumption that low download numbers signify limited utilization. Fourth, the suitability assessment framework was developed with the objective of conducting a comprehensive evaluation of mobile apps for midwives in low-resource settings with regard to antenatal care. The framework was inspired by Sharma et al.'s framework, but adapted to align with the focus on the midwife as the end user. Based on our perception and experience, we assigned greater importance and weight to some suitability questions and statements than to others. For instance, we considered the ability to use the mobile application offline, the non-payment requirement for full use, cultural sensitivity and diversity consideration, language, and content reliability (based on WHO recommendations, the developer’s profession, and citation within the mobile application) to be of greater importance than others. These perceptions are based on the importance of diversity (cultural, ethnic and linguistic) in the app market and the lack of resources (infrastructure, money, access to knowledge, etc.) seen in low-resource settings. These factors were reflected in the final ranking of the mobile apps. We recommend that our extended framework (i.e., an adapted version of the framework by Sharma et al.), is used in the future and when assessing mobile applications for use in low-resource settings, as it is even more comprehensive. Furthermore, it is noteworthy that the app store search was conducted from Switzerland, raising the possibility of geographical bias in search results. Lastly, the dynamic nature of mobile applications, with constant updates, new releases, and removals, poses a risk of rapid obsolescence of study findings. Conclusions The increased affordability and availability of smartphones and improved internet coverage has facilitated widespread access to mobile phone applications, presenting an opportunity to enhance the quality of care, particularly in resource-constrained settings, via improved evidence-based care. In our systematic mapping of mobile phone applications, we focused on antenatal care with midwives as end-users in low-resource settings. We found a significant gap in the availability of apps targeting midwives, representing a missed opportunity within the digital health landscape. Few apps were rated of high quality or holistically implemented WHO recommendations, suggesting that apps targeting midwives and antenatal care in low-resource settings may benefit from further resources and development. Our study underscores the urgent need for enhanced quality assurance measures in designing and deploying health care-related apps. By prioritizing functionality, content credibility, and information quality, stakeholders can maximize the potential of digital interventions to improve care delivery and empower users with accurate, actionable information. Moving forward, collaborative efforts between end-users, developers, researchers, and policymakers will be essential in fostering a robust ecosystem of trustworthy digital health solutions in the field of midwifery and antenatal care that are affordable and widely available across digital platforms. This review has demonstrated that the potential of high quality mobile applications for the provision of pregnancy related care by midwives is underexplored. Abbreviations ANC Antenatal care App Application ICM International Confederation of Midwives LMIC Low- and middle-income country MARS Mobile Application Rating Scale mHealth Mobile Health NGO Non-Governmental Organization SDG Sustainable Development Goals WHO World Health Organization Declarations Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Funding No funding was received for this study. Author Contribution This manuscript was prepared for a thesis on behalf of A.P.’s Master of Advanced Studies in International Health. L.F.B. proposed the topic for the thesis, A.P. and V.S.S. contributed to the refinement of the topic. A.P. led on the concept and design of the study, with support from L.F.B. and V.S.S. A.P. conducted the research and analysis of the data; L.F.B. contributed to the reliability check. A.P. and V.S.S. prepared the graphs and tables. A.P. drafted the first version of the manuscript. L.F.B. and V.S.S. contributed to the writing and editing. All authors read and approved the final manuscript. Acknowledgement We would like to thank Dr. Karin Gross and Silvia Ammann-Fiechter to serve on the review board of the Master thesis defence. We thank all app developers, whose apps we included into the assessment, as well as Stoyanov et al. and Sharma et al. for development of the frameworks applied in this study. Availability of data and materials Not applicable. References UN. Transforming our World: The 2030 agenda for sustainable development. United Nations. 2016. https://sdgs.un.org/2030agenda. Accessed 25 Mar 2024. WHO. Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. World Health Organization. 2023. https://www.who.int/publications/i/item/9789240068759. Musarandega R, Nyakura M, Machekano R, Pattinson R, Munjanja SP. 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Supplementary Files Additionalfile1.docx Additional file 1: List of the assessed mobile applications (Additional file 1.docx, 263KB) Additionalfile2.docx Additional file 2: Mobile App Rating Scale (MARS) by Stoyanov et. al. (Additional file 2.docx, 22KB) Additionalfile3.docx Additional file 3: Suitability criteria for low-recourse settings inspired by Sharma et. al.’s framework (Additional file 3.docx, 15KB) Additionalfile4.docx Additional file 4: Suitability criteria for midwives with focus on antenatal care (Additional file 4.docx, 15KB) Additionalfile5.docx Additional file 5: MARS and suitability assessment results and ranking of the mobile applications (Additional file 5.docx, 20KB) Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Sakalidis","email":"","orcid":"","institution":"Menzies School of Health Research","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Vanessa","middleName":"S.","lastName":"Sakalidis","suffix":""},{"id":341933973,"identity":"d0c01e79-8c48-44f5-bdcc-808324ef3502","order_by":2,"name":"Leah F. Bohle","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYBACPgYGNgbGBoYEPgbmAwwMBiAxHgaQCE7ABtPCxsCWANbCQ4IWHrAVRGhhb372gHGHTR4be8/nzzwFdfb20r0HGH7uwKOF55i5AeOZtGI2nrPbpHkMDif2yJxLYOw9g0eLRIKZBGPb4cQ2idxtzDkGBxJ4JHIMmBnb8GiRf/4NokX+zePPOQZ19oS1SPDAbOFhkAYp7iGohSenTCLxTFpiG0+amfQfkF/unDE42ItHCz/78W0SH3fYJPazH378ccafOnv22T2GD37i0QIGCSg8CQaGAwQ0oAMJEtWPglEwCkbBsAcA6UhKDHjaEVgAAAAASUVORK5CYII=","orcid":"","institution":"Swiss Tropical and Public Health Institute","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Leah","middleName":"F.","lastName":"Bohle","suffix":""}],"badges":[],"createdAt":"2024-07-28 09:23:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4815995/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4815995/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":63833558,"identity":"d3eca21e-6e6f-4867-9890-e880ad447af0","added_by":"auto","created_at":"2024-09-02 19:33:13","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":382820,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePRISMA flowchart for identifying mobile applications\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4815995/v1/bb6a2a94428f0328e6a4df5e.jpeg"},{"id":63833560,"identity":"423d3c94-dc26-40ba-b448-eba0b5e1c0c2","added_by":"auto","created_at":"2024-09-02 19:33:13","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":480392,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eGraph of the mean score of all the MARS sections.\u003c/strong\u003e Objective Quality (total mean of the four objective MARS sections: Engagement, Functionality, Aesthetics and Information), Engagement, Functionality, Aesthetics, Information, and Subjective Quality for each of the mobile applications assessed.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4815995/v1/7242f297c3e5fbf38b55792a.jpeg"},{"id":66301220,"identity":"d5d82ce4-d4bc-4349-b919-6bacba7590ee","added_by":"auto","created_at":"2024-10-10 05:55:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1226498,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4815995/v1/6f6b9874-ff51-4e35-8724-b37cc12e7507.pdf"},{"id":63833874,"identity":"215f4bc1-7f94-458c-8bb4-99a82373f551","added_by":"auto","created_at":"2024-09-02 19:41:13","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":263651,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional file 1: List of the assessed mobile applications (Additional file 1.docx, 263KB)\u003c/p\u003e","description":"","filename":"Additionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4815995/v1/b38df50cf751599ace274e26.docx"},{"id":63833561,"identity":"8af71d0b-a268-4d50-9347-bc5ce817e413","added_by":"auto","created_at":"2024-09-02 19:33:13","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":21980,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional file 2: Mobile App Rating Scale (MARS) by Stoyanov et. al. (Additional file 2.docx, 22KB)\u003c/p\u003e","description":"","filename":"Additionalfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-4815995/v1/2b409c092a74bb0c16cab3fb.docx"},{"id":63833556,"identity":"02fce033-a228-45ef-be0a-d3134604a112","added_by":"auto","created_at":"2024-09-02 19:33:13","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":15253,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional file 3: Suitability criteria for low-recourse settings inspired by Sharma et. al.’s framework (Additional file 3.docx, 15KB)\u003c/p\u003e","description":"","filename":"Additionalfile3.docx","url":"https://assets-eu.researchsquare.com/files/rs-4815995/v1/651013919eaa46eacb87e8b9.docx"},{"id":63833562,"identity":"5a12c4c8-e785-4aac-a26e-7b74afe9d762","added_by":"auto","created_at":"2024-09-02 19:33:13","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":14922,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional file 4: Suitability criteria for midwives with focus on antenatal care (Additional file 4.docx, 15KB)\u003c/p\u003e","description":"","filename":"Additionalfile4.docx","url":"https://assets-eu.researchsquare.com/files/rs-4815995/v1/0af0c19b521bcd2b9f6c080e.docx"},{"id":63833563,"identity":"adea3c7e-8185-487e-a130-ce0a4ba6b76d","added_by":"auto","created_at":"2024-09-02 19:33:13","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":19844,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional file 5: MARS and suitability assessment results and ranking of the mobile applications (Additional file 5.docx, 20KB)\u003c/p\u003e","description":"","filename":"Additionalfile5.docx","url":"https://assets-eu.researchsquare.com/files/rs-4815995/v1/6c93279f2590a857ae67e80a.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Mobile phone applications for midwives with focus on antenatal care: A mapping and assessment of quality and suitability for low-resource settings. ","fulltext":[{"header":"Background","content":"\u003cp\u003eThe Sustainable Development Goal (SDG) 3.1 aims to reduce the global maternal mortality ratio to less than 70 per 100 000 live births by 2030 (1). Despite international efforts, reductions in maternal mortality are stagnating globally. Without renewed efforts, the SDG 3.1 target is unlikely to be achieved. The poorest maternal health outcomes remain in sub-Saharan Africa (2), where the leading causes of maternal death are obstetric haemorrhage, hypertensive disorder in pregnancy, non-obstetric disorders and pregnancy related infections (3). Antenatal care (ANC), intrapartum care, and postnatal care are essential pillars of pregnancy-related care. ANC includes risk identification, prevention and management of pregnancy-related or concurrent diseases, health education and health promotion (4). It allows for timely identification of direct and indirect causes influencing maternal health outcomes (4). Since 2016, the World Health Organization (WHO) has recommended eight ANC contacts during the course of a pregnancy, of which four should be provided by a skilled birth attendant in person (5). However, ANC coverage is lowest in sub-Saharan Africa, with only approximately 56% of pregnant women having received four ANC visits in 2021 (6).\u003c/p\u003e \u003cp\u003eMidwives play a crucial role in the provision of care to pregnant women. If educated in line with international standards, midwives can avert and prevent up to 60% of all maternal deaths (7). In the majority of low-resource settings, midwives are at the forefront of providing care to pregnant women at all levels of care. Providing high-quality care plays a pivotal role in maternal health outcomes. Nonetheless, midwives in low-resource settings face wider health-system challenges and need to operate in environments with limited resources, and access to information (8).\u003c/p\u003e \u003cp\u003eMobile phone applications (i.e., mHealth applications or apps) have great potential to support the provision of care. These may include but are not limited to apps with educational content (e.g., information, health promotion, evidence-based healthcare provision, etc.), digital tools (e.g., calculators), supporting the communication between healthcare providers and clients, or shared information, such as electronic patient records. With increasing availability, accessibility and affordability of smartphones and internet coverage, apps can be an easy to access and cost-efficient resource, potentially contributing to the provision of high-quality maternal health care, specifically in low-resource settings.\u003c/p\u003e \u003cp\u003eWhile many apps focus on education, behaviour change, pregnancy and antenatal care for the mother (9–14), it is less clear which apps are available to support health workers, and in particular midwives in the provision of ANC. Several studies have evaluated effectiveness, behaviour change, functionally, user-friendliness (15–17) and quality (9–14) of maternal health apps with either pregnant women or parents as the end-users. However, no studies have assessed midwives as the end-user.\u003c/p\u003e \u003cp\u003eThis study aimed to identify mobile phone applications for use by midwives with focus on antenatal care and assess their quality suitability for use in low-resource settings by 1. Conducting a systematic mapping of mobile phone applications accessible on Google Play Store; 2. Applying the validated MARS framework by Stoyanov et al. (18) to assess the quality of the apps identified and calculate a quality score; and 3. Utilizing an adapted MARS framework by Sharma et al. (19) to explore the suitability of the apps for use in low-resource settings.\u003c/p\u003e \u003cp\u003eMobile phone applications are herein defined as software applications developed for small wireless computer devices, and which can be installed and accessed on e.g., smartphones and tablets (20, 21). ANC was defined as \"the care provided by skilled healthcare professionals to pregnant women (…) to ensure the best health conditions for both mother and baby during pregnancy. The components of ANC include: risk identification, prevention and management of pregnancy related or concurrent diseases and health education and health promotion\", and is aligned to the WHO recommendations of ANC for a positive pregnancy experience (5).\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eIdentification and mapping of mobile phone applications\u003c/p\u003e\u003cp\u003eWe conducted a systematic search of mobile phone applications between 24th of February and 3rd of April 2023.The Google Play Store was searched based on the following pre-defined search terms: \"midwives\", \"midwife\", “midwifery” and “antenatal”, resulting in a total of n = 308 apps. After removing duplicates, 278 apps were identified and a three-stage review process was applied based on pre-defined inclusion criteria (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A systematic search was conducted in Google Play, as it is estimated that approximately 85% of all phone/tablet users in low- and middle- income countries use an Android phone (22).\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\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\u003eInclusion and exclusion criteria\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInclusion Criteria\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExclusion Criteria\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- English language\u003c/p\u003e \u003cp\u003e- Midwives as target group (i.e., end-user)\u003c/p\u003e \u003cp\u003e- Topic: antenatal care\u003c/p\u003e \u003cp\u003e- Free of charge\u003c/p\u003e \u003cp\u003e- Minimum 5000 downloads\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Pregnant women, mothers, fathers, parents, obstetricians/ gynaecologists, community health workers, only as target groups\u003c/p\u003e \u003cp\u003e- Focus on exam preparation only\u003c/p\u003e \u003cp\u003e- Used for care, excluding antenatal care (e.g., postnatal care, pre-pregnancy apps, fertility calendars, menstrual calendars, games, photo editing apps, training apps baby equipment checklists)\u003c/p\u003e \u003cp\u003e- Additional device required (e.g., ultrasound device, doppler device)\u003c/p\u003e \u003cp\u003e- Dependency on an additional device to be functional (e.g., ultrasound device, doppler, etc.)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003eBased on the above inclusion criteria, an initial first stage screening of the text-based app description was conducted. As a result, 250 apps were excluded, not fulfilling the inclusion criteria. In the second stage, 16 of the remaining 28 apps with at least 5000 downloads were retained. In the third stage, the 16 apps were downloaded to an Android smartphone, and one app was further excluded based on the mandatory requirement for payment, which was only visible after the download and once a mandatory user profile was established. A total of 15 apps were therefore included and evaluated (23). (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Additional file 1)\u003c/p\u003e\u003cp\u003eQuality assessment\u003c/p\u003e\u003cp\u003eThe Mobile Application Rating Scale (MARS) was used to assess the quality of the apps (18). The MARS tool ensures an evidence-based approach, designed to provide an objective, reliable and multi-disciplinary quality assessment of mobile phone applications, with focus on health-related apps and an internal consistency of 90% (18). The tool consists of five broad categories entailing 23 criteria (Additional file 2), which are made up of four objective quality categories: engagement (n = 5 criteria), functionality (n = 4 criteria), aesthetics (n = 3 criteria), and information (n = 7 criteria); and a subjective quality category (n = 4 criteria). Each criteria was rated on a scale of 1–5 (1 = inadequate, 2 = poor, 3 = acceptable, 4 = good, 5 = excellent). Following the assessment, a mean score was calculated for each of the five categories, followed by a joint mean score for the four objective quality scales (n = 19 criteria), with the highest possible score of 5.00. The score of the subjective quality scale (n = 4 criteria) was calculated separately due to its subjective nature and aligned with the guidelines of the MARS tool (18); here a maximum mean score of 5.00 could be reached. The scores were rounded to two decimal places. 20% of the apps were first blindly rated by two users (AP, LFB) to check inter-rater reliability, followed by a rating of all apps by one user (AP).\u003c/p\u003e\u003cp\u003eSuitability assessment with focus on midwives working with antenatal care in low-resource settings\u003c/p\u003e\u003cp\u003eThe assessment of suitability of apps for use in low-resource settings was based on an adaption of the framework by Sharma et al. (19). The framework utilized a modified MARS framework to focus end-users in low-resource settings, using a total of 36 criteria. We further adapted the framework by excluding criteria identical or very similar to the MARS framework, resulting in a total of nine remaining criteria. These included 1) offline availability, 2) cultural sensitivity and diversity, 3) accessibility of the app (Google Play and/or iTunes), 4) language availability, 5) payment requirements, 6) interaction possibilities to interact with the pregnant client, 7) data exportation possibilities, 8) when the app was last time updated and 9) if the information within the app was kept confidential. In a second step, additional criteria were added by the authors (n = 6), based on the WHO recommendations antenatal care for a positive pregnancy experience’s (5) five the categories: 1) nutritional interventions, 2) maternal and foetal assessments, 3) preventive measures, 4) investigation for common physiological symptoms, and 5) health systems interventions to improve the utilization and quality of antenatal care. The additional criteria therefore assessed whether the app was based on the above WHO recommendations; if national clinical guidelines were taken into account; information on the end-user target group (i.e. in-service midwives, midwifery educators and/or pre-service midwives); and the professional background of the developer/development team, utilizing a yes/no scoring check-list. The adapted check-list was tested on two randomly selected apps of the total of n = 15 apps in a blinded approach by two authors (AP, LFB). Results were compared, differences discussed and the criteria were further refined and finalized (see the adapted tool in Additional file 3–4). The adapted framework was applied on all 15 apps exploring the suitability of the apps for the provision of antenatal care with a specific focus on low-resource settings.\u003c/p\u003e\u003cp\u003eRanking of the mobile applications\u003c/p\u003e\u003cp\u003eA ranking of the mobile applications was conducted, based on the MARS tool and the suitability assessment. The MARS scores of the mobile apps were first ranked from the highest to the lowest score. This was followed by the app´s performance of the suitability assessment. It is important to note that some of the suitability questions/statements had more significance than others (e.g., ability to use the mobile application offline, non-payment requirement for full use, cultural sensitivity and diversity consideration, language, content reliability (based on WHO recommendations, the developer’s profession, citation within the mobile application)). Following, the MARS scores and the results from the suitability assessment was compared and evaluated together. Consequently, the apps were finally ranked from the highest to lowest quality and suitability for midwives and the provision of antenatal care in low-resource settings.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe majority of apps identified provided educational content (n\u0026thinsp;=\u0026thinsp;10), with two of the apps designed to inform decision making at the bedside. Four out of ten apps with educational content had additional functions, including exam and/or self-learning questions (n\u0026thinsp;=\u0026thinsp;3), or calculation tools (n\u0026thinsp;=\u0026thinsp;1). Other apps identified (n\u0026thinsp;=\u0026thinsp;4) were tools (e.g., measurement and calculation tools), and only one app was a patient documentation tool that midwives can use in their work with pregnant women. Apps covered either a range of topics related to antenatal care and maternal health in general, excluding one app which focused on a single antenatal care topic. No apps combined educational content and tools (Additional file 1).\u003c/p\u003e \u003cp\u003eQuality assessment\u003c/p\u003e \u003cp\u003eThe mean MARS quality score of all fifteen mobile applications was 3.49, out of a possible 5.00 (range: 1.77 to 4.80). Fourteen of the 15 mobile applications assessed had a mean MARS score above 2.50. The Safe Delivery App and the Safe Abortion app reached the highest score (4.80 and 4.74 respectively) (Additional file 5).\u003c/p\u003e \u003cp\u003eThe MARS score was also assessed and calculated for each of the separate categories to provide more detail on the strengths and weaknesses of each app, and the highest rated category. Results showed that the category \u0026ldquo;functionality\u0026rdquo; scored highest (3.71), followed by \u0026ldquo;information\u0026rdquo; (3.68), \u0026ldquo;aesthetics\u0026rdquo; (3.47), \u0026ldquo;engagement\u0026rdquo; (3.08) and \u0026ldquo;subjective quality\u0026rdquo; (2.60). (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSuitability in low-resource settings\u003c/p\u003e \u003cp\u003eOf the fifteen mobile applications evaluated, eleven were fully functional offline. Among all apps, only two mobile applications had integrated aspects of diversity and cultural sensitivity (Safe Delivery App and Safe Abortion app), and three had partially implemented it. All the fifteen assessed mobile applications provided the content in English language, one mobile app offered one additional language, and three mobile applications provided more than two language options. All fifteen mobile applications were free to download, but two of these mobile apps required additional payment to get access to the entire content. There was no mobile application that allowed communication between midwives and their colleagues and/or the client. Seven mobile applications allowed confidential information to be entered into the mobile application, but only two of the seven clearly stated that they keep the information confidential. The last update of the mobile applications varied, with nine apps indicating being updated during the last 6\u0026ndash;12 months; one app being updated during the last 12\u0026ndash;18 months, and five during the last 18 months or longer.\u003c/p\u003e \u003cp\u003eSuitability for midwives providing antenatal care\u003c/p\u003e \u003cp\u003eAmong the fifteen apps assessed, six were suitable for in-service midwives only as the end-user, and the remaining nine were suitable for in-service midwives, pre-service midwives and midwifery educators. To assess the suitability of the apps with focus on antenatal care, six additional criteria were created based on the WHO\u0026rsquo;s recommendations for antenatal care for a positive pregnancy experience (5). All mobile applications assessed incorporated at least one or more of the five thematic sections highlighted by WHO, including either nutritional interventions (n\u0026thinsp;=\u0026thinsp;3), maternal and foetal assessment (n\u0026thinsp;=\u0026thinsp;12), preventive measures (n\u0026thinsp;=\u0026thinsp;5), interventions for common physiological symptoms (n\u0026thinsp;=\u0026thinsp;4), and health systems interventions to improve the utilization and quality of antenatal care (n\u0026thinsp;=\u0026thinsp;6). One mobile application had at least one recommendation from all five sections for a positive birth experience (WCEA app). Two apps cited the World Health Organization (Safe Delivery App, Safe Abortion app), but none referred to the WHO recommendations for antenatal care for a positive pregnancy experience. One mobile app mentioned the recommendation of eight ANC contacts (Safe Delivery App), while no apps referenced national clinical guidelines.\u003c/p\u003e \u003cp\u003eInformation on the professional background of the app developers or the affiliated institutions was provided for seven of the fifteen apps. These included medical doctors (n\u0026thinsp;=\u0026thinsp;2), a midwife (n\u0026thinsp;=\u0026thinsp;1), and a nurse (n\u0026thinsp;=\u0026thinsp;1), as well as institutions including University (n\u0026thinsp;=\u0026thinsp;1) and non-governmental organization (NGO) (n\u0026thinsp;=\u0026thinsp;2). All apps included in the review indicated the name of the person or company that had developed the app.\u003c/p\u003e \u003cp\u003eMobile application ranking\u003c/p\u003e \u003cp\u003eThe results from the MARS tool and the suitability assessment were compared and analysed, and ranked from the strongest to the weakest app (Additional file 5). The overall ranking showed the Safe Delivery App, followed by the Safe Abortion app, which were rated significantly higher than all other apps.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMaternal mortality is particularly high in Sub-Saharan Africa and South Asia (2); midwives have the potential to significantly reduce maternal deaths if trained in line with international standards (7). A study by Nishimwe et al. showed, that the use of mobile applications by midwives has the potential to provide better care. The Safe Delivery App, the highest rated app in this study, was utilized by midwives in Rwanda, resulting in a notable reduction in postpartum haemorrhage (62\u0026ndash;28%) and neonatal asphyxia (19\u0026ndash;6%) within a six-month timeframe (24).\u003c/p\u003e \u003cp\u003eWhile midwives\u0026rsquo; perception of using apps for the delivery of ANC has not explicitly been assessed. However, a study could show that pregnant women in low- and middle-income countries who utilize mobile health interventions are more likely to attend ANC check-ups (25). Furthermore, though qualitative and quantitative studies midwives have emphasized the potential benefits of using mobile apps, in enabling pregnant women to make informed decisions about their pregnancy (26). Conversely, the same midwives have highlighted the risks and limitations associated with using mobile health interventions, noting the importance of the accuracy of the information conveyed and the potential for negative impacts on the patient-professional relationship (26). Future studies assessing midwives\u0026rsquo; assessment of the apps could aid in understanding how midwives use apps, and how they perceive their strengths and limitations, and what their needs are.\u003c/p\u003e \u003cp\u003eThe availability of mobile health applications presents both opportunities and challenges in delivering pregnancy-related care. In this study, we evaluated the quality of the apps identified, aiming to contribute to the ongoing discourse surrounding the suitability, efficacy, and reliability of health and care related apps. We observed considerable diversity in app quality across various categories assessed, using the MARS tool, including engagement, information, aesthetics, and functionality. Notably, functionality emerged as the highest-scoring category overall, consistent with previous research by (12, 27, 28).\u003c/p\u003e \u003cp\u003eOur study echoes the observation of improved app functionality over time. However, this positive trend is juxtaposed with stagnant content credibility - a concerning finding mirrored in the broader literature (28).\u003c/p\u003e \u003cp\u003eAlarmingly, our analysis reveals a lack of prioritization of information quality among the assessed apps, with only a fraction providing citations and referencing regulatory and evidence-based sources such as the World Health Organization. This deficiency mirrors findings from related studies (28), suggesting systemic issues within app development and regulatory oversight and underscores the persistent challenge of ensuring the accuracy and reliability of health information disseminated through health apps. Notably, critical information regarding the source of content, the developer professional background, and funding sources remained obscure, contributing to the considerable variability in app reliability and quality. Additionally, only two apps explicitly mentioned measures to protect confidential information. These findings underscore the imperative for enhanced regulation in the mobile health app sector.\u003c/p\u003e \u003cp\u003eThe implications of substandard information quality are particularly grave within contexts of limited healthcare access, where mobile apps may serve as primary sources of health information and education, supporting clinical decisions. Given the documented link between incorrect health information and adverse outcomes (29)- including mortality and morbidity - it is imperative to strengthen regulatory mechanisms governing health app content and ensure adherence to evidence-based guidelines.\u003c/p\u003e \u003cp\u003eSeveral methodological choices were made due to resource constraints, potentially influencing the study results. Firstly, the systematic search was confined to the Google Play app store (Android), excluding apps exclusive to the iTunes app store (Apple). This decision was informed by the widespread use of Android phones, particularly in low-resource settings, estimated at approximately 85% of all smartphone/tablet users. Secondly, the inclusion criterion of English-language applications may have excluded high-quality apps in other languages. Thirdly, apps with fewer than 5000 downloads were excluded under the assumption that low download numbers signify limited utilization. Fourth, the suitability assessment framework was developed with the objective of conducting a comprehensive evaluation of mobile apps for midwives in low-resource settings with regard to antenatal care. The framework was inspired by Sharma et al.'s framework, but adapted to align with the focus on the midwife as the end user. Based on our perception and experience, we assigned greater importance and weight to some suitability questions and statements than to others. For instance, we considered the ability to use the mobile application offline, the non-payment requirement for full use, cultural sensitivity and diversity consideration, language, and content reliability (based on WHO recommendations, the developer\u0026rsquo;s profession, and citation within the mobile application) to be of greater importance than others. These perceptions are based on the importance of diversity (cultural, ethnic and linguistic) in the app market and the lack of resources (infrastructure, money, access to knowledge, etc.) seen in low-resource settings. These factors were reflected in the final ranking of the mobile apps. We recommend that our extended framework (i.e., an adapted version of the framework by Sharma et al.), is used in the future and when assessing mobile applications for use in low-resource settings, as it is even more comprehensive. Furthermore, it is noteworthy that the app store search was conducted from Switzerland, raising the possibility of geographical bias in search results. Lastly, the dynamic nature of mobile applications, with constant updates, new releases, and removals, poses a risk of rapid obsolescence of study findings.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe increased affordability and availability of smartphones and improved internet coverage has facilitated widespread access to mobile phone applications, presenting an opportunity to enhance the quality of care, particularly in resource-constrained settings, via improved evidence-based care. In our systematic mapping of mobile phone applications, we focused on antenatal care with midwives as end-users in low-resource settings. We found a significant gap in the availability of apps targeting midwives, representing a missed opportunity within the digital health landscape. Few apps were rated of high quality or holistically implemented WHO recommendations, suggesting that apps targeting midwives and antenatal care in low-resource settings may benefit from further resources and development.\u003c/p\u003e \u003cp\u003eOur study underscores the urgent need for enhanced quality assurance measures in designing and deploying health care-related apps. By prioritizing functionality, content credibility, and information quality, stakeholders can maximize the potential of digital interventions to improve care delivery and empower users with accurate, actionable information. Moving forward, collaborative efforts between end-users, developers, researchers, and policymakers will be essential in fostering a robust ecosystem of trustworthy digital health solutions in the field of midwifery and antenatal care that are affordable and widely available across digital platforms. This review has demonstrated that the potential of high quality mobile applications for the provision of pregnancy related care by midwives is underexplored.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eANC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Antenatal care\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eApp\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Application\u003c/p\u003e\n\u003cp\u003eICM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;International Confederation of Midwives\u003c/p\u003e\n\u003cp\u003eLMIC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Low- and middle-income country\u003c/p\u003e\n\u003cp\u003eMARS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Mobile Application Rating Scale\u0026nbsp;\u003c/p\u003e\n\u003cp\u003emHealth\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Mobile Health\u003c/p\u003e\n\u003cp\u003eNGO\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Non-Governmental Organization\u003c/p\u003e\n\u003cp\u003eSDG\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Sustainable Development Goals\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWHO \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; World Health Organization\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003ch2\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNo funding was received for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eThis manuscript was prepared for a thesis on behalf of A.P.\u0026rsquo;s Master of Advanced Studies in International Health. L.F.B. proposed the topic for the thesis, A.P. and V.S.S. contributed to the refinement of the topic. A.P. led on the concept and design of the study, with support from L.F.B. and V.S.S. A.P. conducted the research and analysis of the data; L.F.B. contributed to the reliability check. A.P. and V.S.S. prepared the graphs and tables. A.P. drafted the first version of the manuscript. L.F.B. and V.S.S. contributed to the writing and editing. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003e We would like to thank Dr. Karin Gross and Silvia Ammann-Fiechter to serve on the review board of the Master thesis defence. We thank all app developers, whose apps we included into the assessment, as well as Stoyanov et al. and Sharma et al. for development of the frameworks applied in this study.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eUN. Transforming our World: The 2030 agenda for sustainable development. United Nations. 2016. https://sdgs.un.org/2030agenda. Accessed 25 Mar 2024.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eWHO. Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. World Health Organization. 2023. https://www.who.int/publications/i/item/9789240068759.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMusarandega R, Nyakura M, Machekano R, Pattinson R, Munjanja SP. 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J Med Internet Res. 2022; doi:10.2196/37552.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBrunelli L, De Vita C, Cenedese F, Cinello M, Paris M, Samogizio F, Starec A, Bava M, Dal Cin M, Zanchiello S, Stampalija T. Gaps and Future Challenges of Italian Apps for Pregnancy and Postnatal Care: Systematic Search on App Stores. J Med Internet Res. 2021; doi:10.2196/29151.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eCho H, Yi F, Ahn S. Quality evaluation of pregnancy-related mobile applications in South Korea: a descriptive study. Korean J Women Health Nurs. 2023; 29(3):190\u0026ndash;199\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMusgrave L, Kizirian N, Homer C, Gordon A. Mobile Phone Apps in Australia for Improving Pregnancy Outcomes: Systematic Search on App Stores. JMIR Mhealth Uhealth. 2020; doi:10.2196/22340\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eTsai Z, Kiss A, Nadeem S, Sidhom K, Owais S, Faltyn M, Lieshout RJV. Evaluating the effectiveness and quality of mobile applications for perinatal depression and anxiety: A systematic review and meta-analysis. J Affect Disord. 2022; 296:443\u0026ndash;453\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eYu H, He J, Li K, Qi W, Lin J, Szumilewicz A. Quality assessment of pre- and postnatal nutrition and exercise mobile applications in the United States and China. Front Nutr. 2022; 9:942331.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBiviji R, Williams K, Vest J, Dixon B, Cullen T, Harle C. Consumer Perspectives on Maternal and Infant Health Apps. Qualitative Content Analysis J Med Internet Res. 2021; doi:10.2196/27403.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eChan K, Chen M. Effects of Social Media and Mobile Health Apps on Pregnancy Care: Meta-Analysis. JMIR Mhealth Uhealth. 2019; doi:10.2196/11836\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSardi L, Idri A, Redman LM, Alami H, Bezad R, Fern\u0026aacute;ndez-Alem\u0026aacute;n JL. Mobile health applications for postnatal care: Review and analysis of functionalities and technical features. Elsevier. 2020; 184:105114.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eStoyanov SR, Hides L, Kavanagh DJ, Zelenko O, Tjondronegoro D, Mani M. Mobile app rating scale: a new tool for assessing the quality of health mobile apps. JMIR Mhealth Uhealth. 2015; doi:10.2196/mhealth.2422.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSharma S, Gergen Barnett K, Maypole J, Grochow Mishuris R. Evaluation of mHealth Apps for Diverse, Low-Income Patient Populations: Framework Development and Application Study. JMIR Formative Research. 2022; doi:10.2196/29922\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eRouse M. What Does Mobile Application Mean? Tecopedia. 2020. 28.03.2023. https://www.techopedia.com/definition/2953/mobile-application-mobile-app. Accessed 28 Mar 2023\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHanna KT, Wigmore I. 2023. Mobile App. Techtarget. https://www.techtarget.com/whatis/definition/mobile-app. Accessed 28 Mar 2023\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eStatcounterGlobal. Mobile Operating System Market Share. 2023. https://gs.statcounter.com/os- market-share/mobile/worldwide. Accessed 22 Feb 2023\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLiberati A, Altman DG, Tetzlaff J, Mulrow C, G\u0026oslash;tzsche PC, Ioannidis JPA, Clarke M, Devereaux, PJ, Kleijnen J, Moher D. The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies That Evaluate Health Care Interventions: Explanation and Elaboration. PLoS Med. 2009; doi:10.1136/bmj.b2700.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eNishimwe A, Ibisomi L, Nyssen M, Conco DN. The effect of a decision-support mHealth application on maternal and neonatal outcomes in two district hospitals in Rwanda: pre - post intervention study. BMC Pregnancy Childbirth. 2022; 22:52.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMishra M, Parida D, Murmu J, Singh D, Rehman T, Kshatri JS, Pati S. Effectiveness of mHealth Interventions for Monitoring Antenatal Care among Pregnant Women in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis. Healthcare (Basel). 2023; doi: 10.3390/healthcare11192635.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eVickery M, van Teijlingen E, Hundley V, Smith GB, Way S, Westwood G. Midwives\u0026apos; views towards women using mHealth and eHealth to self-monitor their pregnancy: A systematic review of the literature. Eur J Midwifery. 2020; doi: 10.18332/ejm/126625.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eWright A. Evaluation of two mobile health apps for patients with breast cancer using the Mobile Application Rating Scale. Mhealth. 2021; doi: 10.21037/mhealth-20-161.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAltmannshofer S, Flaucher M, Beierlein M, Eskofier BM, Beckmann MW, Fasching PA, Huebner H. A content-based review of mobile health applications for breast cancer prevention and education: Characteristics, quality and functionality analysis. Digit Health. 2024; doi: 10.1177/20552076241234627.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eFridman I, Johnson S, Elston Lafata J. Health Information and Misinformation: A Framework to Guide Research and Practice. JMIR Med Educ. 2023; doi: 10.2196/38687.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Antenatal, Maternal Health, Midwifery, Mobile Applications, mHealth, Prenatal Care, LMIC, Resource-Limited Settings, SDG3","lastPublishedDoi":"10.21203/rs.3.rs-4815995/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4815995/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eReducing maternal mortality in low-resource settings remains a priority in achieving the Sustainable Development Goal 3. The provision of antenatal care is an essential pillar in maternal health care. Digital health applications, which target midwives providing antenatal care, can assist workers in low-resource settings by providing access to quality tools and education for evidence-based care. This study aimed to identify mobile apps for midwives focusing on antenatal care and assessed their quality and suitability for use in low-resource settings.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA systematic mapping of mobile apps accessible on Google Play Store was performed using pre-defined search terms related to midwifery and antenatal care. Inclusion criteria based on numbers of downloads, English language, free of cost, and thematic focus, resulted in 15 apps for evaluation. The quality of apps and suitability for use in low-resource settings was assessed using two frameworks. An individual score was calculated for each app and a ranking was performed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf the 15 apps identified, the focus was on educational content (n\u0026thinsp;=\u0026thinsp;10), antenatal care measurement tools (n\u0026thinsp;=\u0026thinsp;4), and patient documentation (n\u0026thinsp;=\u0026thinsp;1). The quality of apps overall ranged between 1.77\u0026ndash;4.80 points, with a maximum of 5 points. Suitability for low-resource settings was favourable in that the majority of the apps were available offline (n\u0026thinsp;=\u0026thinsp;11), however, only some offered additional languages (n\u0026thinsp;=\u0026thinsp;5), and few integrated cultural diversity and sensitivity (n\u0026thinsp;=\u0026thinsp;2). All apps integrated at least one of WHO\u0026rsquo;s recommendations for a positive pregnancy, suggesting the apps were somewhat suitable for midwives delivering antenatal care; although no apps referenced WHO or referred to national clinical guidelines.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eSignificant gaps in the availability of apps targeting midwives represented a missed opportunity in the digital health landscape. Only two apps holistically implemented WHO antenatal care recommendations, and were rated high quality. No apps combined educational content and tools; or connected the midwife and pregnant woman. This review demonstrated that while there are several comprehensive apps targeting midwives, the minority of these are focusing on antennal care in low-resource settings and would benefit from further resources, development and regulation.\u003c/p\u003e","manuscriptTitle":"Mobile phone applications for midwives with focus on antenatal care: A mapping and assessment of quality and suitability for low-resource settings. 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