Pregnancy is considered a life-changing experience for women and has been perceived as one of the most gratifying experiences as a woman.1 However, pregnancy is also associated with short- and long-term changes related to various stressors that often affect the physical and emotional health of pregnant women.1,2 In particular, pregnant women must often make careful and reasonable health-related decisions about lifestyle, which can directly cause pregnancy complications, poor birth outcomes, and poorer health for themselves and their newborns.3,4 These responsibilities often exceed their ability to cope. For example, when a pregnant woman is placed in decision-making situations with little knowledge of what is good or bad, it results in maternal stress.1 A high level of maternal stress is often reported to cause negative emotional and physical complications, such as anxiety, tension, insomnia, and fatigue.1,4

Maternal stress affects not only pregnant women but also fetuses' heart rate patterns and infants' emotional development.5 A study by van de Loo et al6 found a positive correlation between prenatal maternal stress and the development of asthma and wheezing in the child. Another study by Zijlmans et al7 demonstrated that prenatal exposure to maternal anxiety and stress influenced the health of children aged 18 months to 6 years. This longitudinal study specifically noted that the children of mothers who reported having experienced maternal stress were more likely to have respiratory, general, and digestive health issues at different stages of life. These studies support the idea that maternal stress has an influence on children's health until later in childhood.

Sufficient support to help women make various health decisions during pregnancy is necessary to minimize maternal stress, which can help to prevent negative effects described previously.3 Health decisions are made throughout pregnancy. A descriptive cross-sectional study identified prenatal educational needs for information on critical complications, medication and supplements, diet, and visible changes in the body.5 Moreover, the constant physical and physiological changes as well as the fear of pain in the process of childbirth require educational support. A clinical trial of an educational intervention based on Bandura's self-efficacy theory was found to be effective in increasing coping behaviors in primipara women.8 The study aimed to support participants' knowledge so that later behavior during labor would lead to better outcomes. Educational interventions have been utilized internationally in an effort to reduce maternal stress and pain during childbirth.8,9

In light of previous studies describing the educational needs of pregnant women and demonstrating the effectiveness of education in incorporating healthy lifestyle changes,10-12 the sustainability of education during pregnancy could be considered an essential element for success in both antenatal care and maternal health. In this regard, easy access to need-based information regarding pregnancy would help toward better pregnancy-related decisions and subsequently relieve maternal stress. Among the various educational approaches, conventional face-to-face education from healthcare providers is most commonly and widely used.13 However, an increasing number of people seek health information online (ie, 80% of US Internet users search for online sources when acquiring healthcare information), and birth-related topics are some of the most common.14 More studies have explored pregnant women's online information-seeking behaviors.15,16 This change in patterns is easily understood because technology is increasingly embedded in every aspect of our daily lives, and informational resources are near-ubiquitous through the Internet and various mobile devices.17,18

Along with the change in paradigm, researchers have demonstrated the emergence of the Internet, social media, and smartphone applications ("apps") as an integral method of health information provision among expectant mothers.19,20 As O'Brien et al20 mentioned, "technology-supported lifestyle interventions are defined as dietary, exercise, or health behavioral interventions that incorporate significant contributions from telephone, video, Internet, or mobile application (app) technologies."20^(p760) Technologies are significant in that they offer ubiquitous interaction for educating and promoting behavioral changes while maximizing population reach.12

Despite the aforementioned advantages and growth in the utilization of technology-supported interventions targeting pregnant women, research regarding interventions specifically designed for pregnant women or their efficiency in achieving the targeted outcomes appears to be sparse and inconsistent. Therefore, this systematic review examined the development and delivery of technology-supported interventions for pregnant women and explored the effects of these interventions on the targeted outcomes.

METHODS

Electronic data were collected from MEDLINE, CINAHL, and Scopus databases. To gather comprehensive and integrative studies and to identify trends in the literature, no time limit was applied. The keywords used in the search included pregnant, intervention, management, technology, Internet, mobile, Web, computer, and application. An initial search yielded 80 articles (Figure 1).21 Based on the title and abstract review, 15 articles were initially selected following the inclusion criteria: (1) primary study, (2) technology-supported intervention study, (3) focused on pregnant women, (4) published in English, and (5) accessible in full text. The selected articles were reviewed in full text for relevance and four articles were consequently excluded: three for being study protocols22-24 and one for not including an investigator-assigned intervention or exposure.25 Finally, 11 articles were selected and analyzed based on the following aspects: (1) objectives and designs, (2) participants and settings, (3) data collection, (4) intervention, (5) targeted outcomes and measures, and (6) major findings.

FIGURE 1. PRISMA 2009 flow diagram for selection of the studies.

A quality appraisal of the 11 selected studies was based on a checklist for the assessment of methodological quality for nonrandomized studies of healthcare interventions.26 The checklist consists of five sections determining studies' external and internal validity: "Reporting (10 items)," "External validity (three items)," "Internal validity-bias (seven items)," "Internal validity-confounding (selection bias) (six items)," and "Power (one item)." Each item is scored as 0 or 1, except for item 5, which is scored between 0 and 2. A modified checklist was used to simplify the scoring of item 27,27 which received a score of one when the study sample size was available for estimating the power of the study and zero when the description of sample size was absent. The total score for the checklist ranges from 0 to 28. The quality appraisal for each study was conducted by a nursing school professor and a nursing researcher with a master's degree. The final score for each article was reported by calculating the average of each item for the two evaluators. Studies were not excluded based on their quality appraisal score. By incorporating all available technology-supported intervention studies until the present, the review was able to highlight and recommend areas of focus for future studies.

RESULTS

Study Quality Appraisal

The appraisal scores ranged from 9.5 to 22.5 (mean [M] = 16.64, SD = 4.77). The subscores for evaluating the descriptions for "reporting" ranged from 4.5 to 10.0 (M = 7.45, SD = 1.89); "external validity," 1.0 to 3.0 (M = 2.05, SD = 0.76); "internal validity-bias," 2.0 to 5.0 (M = 3.77, SD = 1.01); "internal validity-confounding," 1.5 to 6.0 (M = 3.27, SD = 1.68); and "power," 0 to 1.0 (M = 0.09, SD = 0.30). Studies that were designed as randomized controlled trials (RCTs) tended to score higher on the appraisal checklist than did those with other designs, including qualitative studies and case reports. Checklist components that were missing in more than half of the reviewed studies included reporting the power of the study, identifying and adjusting a study's principal confounders, reporting any loss of participants during follow-up and disclosing how the loss was addressed in the analysis, and reporting any intervention-related adverse events.

Objectives and Designs

The summary of the selected studies is described in Table 1. The classification of study designs by Rohrig et al35 was used to categorize the reviewed studies. Two (18.2%) of the 11 studies used an RCT design with the objective of evaluating the efficacy of the intervention.28,31 Three studies (27.3%) used a pilot RCT design with a limited number of participants and power.32-34 The objective of the pilot RCT studies was mainly to test the feasibility, acceptability, or the preliminary effects of the intervention or to obtain effect size estimates for larger RCTs. One study was described as a pilot intervention study with a limited number of participants and no control group.12 Its main objective was similar to the studies designed as pilot RCT studies. Three studies (27.3%) used a mixed-method design and analyzed both quantitative and qualitative data.3,5,29 These studies aimed to examine the efficacy of the intervention program, explore participants' actual experience in depth, and gather suggestions for improving and expanding the intervention. One study (9.1%) used a qualitative study design and aimed to gain an in-depth understanding of the perception and effects of the interventions.1 Another study (9.1%) used a case report study design, which was designed to describe the intervention, its use by a participant, and its effects in a step-by-step manner.30

Table 1 Summary of the 11 Reviewed Studies

Participants and Settings

The number of study participants ranged from 1 to 918 (mean number of participants = 132.1, median number of participants = 36). The participants' mean age was 21.1 to 33.7 years (mean age = 27.8, median age = 27.2). A total of three studies (27.3%) each targeted healthy pregnant women3,5,12 and women with preterm labor.28-30 Two other studies (18.2%) involved pregnant smokers,31,34 and there was one study each on pregnant alcohol drinkers,33 pregnant women with a sedentary lifestyle,32 and pregnant women who described themselves as stressed.1 The majority of the studies (81.8%) reported the gestational age of participants in terms of weeks, whereas two (18.2%) reported it in terms of trimesters.12,34 Two studies reported participants' experience of prior pregnancy as "yes" or "no,"3,31 two reported it as the number of prior pregnancies,1,30 and one reported it as the number of children.12 Among the 11 studies, nine specified the participants' ethnic background or race. Participants in four of the studies (36.4%) were mainly white,3,31,32,34 four (36.4%) consisted of mostly African American participants,1,5,29,33 and one consisted of mostly Hispanic participants.12

The studies were mostly conducted in the US (63.6%), while some were conducted in the UK (18.2%)31,34 and Switzerland (18.2%).28,30 Various strategies were used to recruit participants. A total of seven studies (63.6%) relied on offline-only recruitments from inpatient and outpatient settings, health departments, and community health centers, whereas only one relied on online-only recruitments.34 The other three studies (27.3%) used multiple methods, including offline (eg, magazine advertisement, study flyers, brochures, community network, and referrals from healthcare providers) and online recruitments (eg, Web site advertisement).28,30,32 The personnel who frequently collaborated with researchers for study recruitment included gynecologists, midwives, obstetricians, and nurses.5,28,30-33

Data Collection

All the selected studies collected self-reported data, with one study adding objective data transferred from a health-monitoring device (accelerometer)32 or cortisol levels from participants' saliva.28 Two used questionnaires embedded in the study programs that were generated automatically upon the participants' progress.12,29

In addition to data related to study outcomes, six studies (54.5%) also collected data related to intervention adherences. The participants' completion of the modules,28 log-in histories and time spent on the program,30,34 page views,34 daily activities for the intervention (eg, response rate to daily messages and keeping daily logs),1,32 and self-report on their use of the intervention3 were assessed.

Intervention

Development Process

While three of the studies did not clearly describe the process of developing the technology-supported interventions, most (45.5%) used an intervention developed by research team members who were described as experts in a related field3,32,33 or held a certificate related to the intervention, such as guided imagery.1,29 Three studies used a pre-established intervention that had been tested in other studies30,33 or a generic program.12,34 One study was developed based on interaction with and advice from an expert (ie, nurses and social service providers at a health department who work with low-income minority pregnant women, who were the target population of the study).5 Four studies reported the underpinning theory or concept for intervention development, including the transtheoretical model,12,31 motivational interviewing and self-determination theory,33 and the concepts of guided self-help or minimal contact.28

Contents and Constructs (Time Span)

Five studies (45.5%) focused on a single topic, while the others addressed multiple health topics in the intervention. The most frequently targeted topic for the intervention was women's mental health (54.5%). Three studies1,28,29 solely targeted stress management, while three others3,12,30 targeted stress as well as other topics, including anxiety and depression,30 breastfeeding and healthy eating/active living,3 and increasing fruit and vegetable consumption and smoking cessation.12 The next most frequently addressed topic in the interventions was smoking cessation (27.3%). Two studies solely targeted smoking cessation,31,34 and one addressed it in addition to other health topics.3 The targeted issues for the interventions in three studies were increasing physical activity,32 reducing alcohol consumption,33 and distributing general pregnancy and health-related information,5 respectively.

The interventions were mainly developed to deliver educational content on the study topic. Other components incorporated in the interventions included a forum for participants to share their experience and stories28,30 or daily logs to self-track their progress and adherence to the intervention.1,32 One used text-based dialogue as an intervention.5 The participants were encouraged to ask questions through text messages and received automated answers from a pool of possible questions and corresponding answers covering 205 pregnancy-related topics.5 The interventions in the selected studies used various audiovisual aids including audio files,29 video scripts,32 CD tracks,1 and voice-over PowerPoint slides.3

Participants' Use of the Interventions

The intervention period ranged from 25 minutes of use at the study site to 8 months. The interventions were delivered through diverse media, including mobile phones,3,5,32 computers at the study site,12,31 tablet devices,33 iPod Touch,29 and iPads.3 The necessary devices were often available for participants to borrow from the research team.5,29,32,33 While some of the studies encouraged self-directed and free navigation of the intervention,3,34 some designed the content to be generated on a daily basis or upon the participants' progress.29,32

The strategies used to encourage women's participation in the intervention included reminder text messages to use the intervention,5 using culturally appropriate and acceptable images based on each participant's baseline data including ethnicity,12,33 ensuring a fourth-grade reading level,12 receiving posts on feedback upon completing subsessions of the intervention,31 weekly encouraging feedback on their progress in the intervention program,28,30 and having a week or two of practice to get accustomed to the study's intervention and the device.32 In addition to the main intervention, the participants had access to and were supported by female psychologists and psychology students,28,30 midwives,30 and lactation consultants.3

Five of the selected studies (45.5%) had a control group. For the control groups, conventional care,31 content designed for online settings with different content,28,33,34 and content designed for offline settings with different content32 were provided.

Targeted Outcomes and Measures

As mentioned above, stress relief1,5,28-31 or stress coping12,29 was the most frequently measured outcome in the selected studies. The measures used in the studies were the Perceived Stress Scale and the Coping Self-efficacy Scale, and the Visual Analog Stress Scale for measuring maternal stress. Antenatal depression was measured in five studies5,28,30,32,33 using measures including the Center for Epidemiological Studies Depression Scale and Edinburgh Postnatal Depression Scale. The pregnant women's anxiety was measured in two studies,28,30 using the Spielberger's State-Trait Anxiety Inventory and Pregnancy-Related Anxiety Test. Birth outcomes were measured in two studies,28,33 which included gestational age, neonatal weight and height at birth, preterm birth rate, or the number of admissions to a neonatal ICU. Other measures used in the studies included the Mood and Physical Symptoms Scale,34 Prenatal Bonding Questionnaire,30 and Pregnancy Discomfort Checklist.32 In addition, pregnant women's physical activities were measured through the Stanford Brief Physical Activity Survey,32 alcohol use through the Mini International Neuropsychiatric Interview, and the amount of smoking through the Heaviness of Smoking Index.34 Questionnaires developed by the research teams included questions on the level of pregnancy knowledge, pregnancy-related uncertainty, patient-provider communication, information-seeking behavior, and eating and active living habits.3,5

The intervention program itself was evaluated in three studies.5,12,29 Qualitative data collection was performed using interviews on the acceptability, feasibility, and effectiveness of the program; perceived barriers to use; and suggestions for improvement.29 Categorical questions on the ease of use and system usability5 or a questionnaire from the National Council Institute's Educational Materials Review Form was adapted to determine the acceptability of the intervention.12 The feasibility of the program was assessed depending on whether the targeted participant recruitment numbers were met.12

Major Findings

Quantitative and qualitative data were used to report the efficacy of the technology-supported interventions. While some studies reported the intervention to be as effective as conventional interventions,28,31 others reported significant benefits in decreasing maternal stress,29 depression,5 enhancing pregnancy-related knowledge,5 lower perceived barriers to being active,32 alcohol abstinence,33 and smoking cessation.34 In addition, as qualitative data, women reported benefits in stress coping,29 reduction in anxiety and depression,30 and enhanced bonding with their babies.30

Because four of the selected studies were designed as pilot studies12,32-34 and one30 as a case study, the efficacy of the intervention program was not the primary focus; rather, the evaluation of the intervention program was their main emphasis. The overall interventions were reported to be feasible, acceptable, and beneficial in all five studies. However, some studies suggested that the intervention might be more helpful for pregnant women who are motivated to change or actively seeking help.32,34 Several suggestions for improvements to the intervention programs included embedding a tracking component for users' progress over time, not limiting the intervention content to that generated by a schedule and allowing for self-directed use, expanding the intervention to pregnant women's significant others, and resolving users' equipment difficulty or difficulty with maintaining the participants' concentration in the program.1,29

DISCUSSION

As more people use technologies and the Internet when seeking medical information, technology-supported interventions have great potential.36 With conventional in-person education sessions, only a limited number of women who can travel to the site at the fixed time could receive the education.20 Moreover, adequate patient education is often impossible in busy clinical settings.37 Technology-supported interventions can address these limitations and inconveniences while delivering reliable educational materials to many pregnant women at their convenient time and place.37,38 Women can receive consistent and the same education regardless of healthcare providers' level of expertise.38 Considering the high information needs of pregnant women and significance of adequate education, well-developed technology-supported interventions can benefit many pregnant women.10-12

This systematic review of 11 selected studies revealed to what extent and how technology-supported interventions were developed and delivered to pregnant women. In addition, the evaluation of the intervention program itself and its effect on the targeted study outcomes in the selected studies were analyzed. Based on this review, several suggestions were made for future studies.

First, it is necessary to carefully select a topic that can be efficiently delivered through technology-supported interventions. Among multiple important health behaviors during pregnancy, it is challenging for researchers to select and focus on a limited number of topics.3 More than half of the reviewed studies' interventions were on pregnant women's mental health. Studies prioritized this topic over other pregnancy-related topics because of its relation to pregnancy complications and negative outcomes, such as preterm labor,1,28 or because of its suitability to physically limited pregnant women who are prescribed absolute bed rest and suffer from numerous stressors.29 With careful consideration of the topics chosen for the study intervention, one reviewed study divided the study into two phases; the potential target of the intervention topic was explored in terms of whether pregnant women were, in fact, interested in it before conducting feasibility testing in Phase 2.3 Because the development of technology-supported interventions is costly and resource-consuming, careful selection of the intervention topic is necessary (ie, topics that are better delivered through technological supports than through conventional methods).39

Second, special attention is necessary for targeting women who can benefit more from a technology-supported intervention. As the findings of the review showed, not all pregnant women benefit from this type of intervention. Pregnant women actively seeking help or motivated for the intervention32,34 benefited more from technology-supported interventions. These findings are consistent with previous findings that regardless of whether technology is included in the intervention delivery, participants' motivation for and adherence to the intervention were crucial factors.40 More studies are needed to explore whom technology-supported interventions should target.

Third, the inclusion of women from diverse ethnic backgrounds in both intervention studies and clinical practice is necessary. More than half of the reviewed studies were conducted in the US, while the others were conducted in Western countries (ie, the UK and Switzerland). Moreover, while two of the studies did not specify the participants' ethnicity, most of the studies included white and African American pregnant women. This skewed inclusion may represent the chronic health disparity that exists in medical fields. Pregnancy and cultural aspects are inseparable concepts, as women's experience with pregnancy is shaped based on their specific sociocultural context.41 Therefore, the experience of women from certain cultural backgrounds would not represent that of women from other backgrounds.42 Moreover, some interventions would be culturally irrelevant and unacceptable. One of the reviewed studies reported efforts to deliver a culturally appropriate and tailored intervention, in terms of the content, design, and images used in the intervention.12 For a balanced and comprehensive understanding of pregnant women's experience with technology-supported interventions, the inclusion of women from diverse cultures is crucial.43

Fourth, more studies are needed on strategies to better engage participants in intervention programs. Previous studies have reported that participants' adherence to and engagement with the intervention increase in an interactive environment (eg, personalized feedback and text messages), rather than a one-way information-receiving platform.20,44 Moreover, the activity tracking component was one of the participants' most favored functions.44 The reviewed studies used various components in the intervention program (eg, forum and daily logs) and reported participants' preference for these interactive components. In addition to these factors, several intervention barriers identified in the review were consistent with previous studies on technology-supported interventions, including difficulties with new technology, the complexity of the program, and a lack of motivation.45 Researchers need to continuously identify barriers to technology-supported interventions and consider strategic constructs to improve participation, which can lead to a better outcome.45

Fifth, more studies are necessary to clearly describe the developmental process of intervention programs as well as to test their efficacy. Nearly half of the reviewed studies used a researcher-developed technology-supported intervention. However, few successfully described the intervention programs, resulting in wide variation in quality evaluation scores; lower scores weaken study validity.46 Considering the fact that technology-supported interventions are relatively innovative compared to conventional interventions, readers may better understand an intervention and study by knowing the developmental process of the intervention.47,48 Moreover, disclosing the developmental process enhances the reproducibility of the intervention, increases the validity of the study findings, and serves as a guide to other researchers who plan to develop interventions in similar fields.47 As many of the current studies were limited to pilot studies, the effects of the technology-supported intervention programs were not evaluated. After augmenting intervention programs based on suggestions from pilot studies, studies with larger sample sizes and sufficient power are necessary to test intervention effects.33

Strengths and Limitations of the Review

This systematic review has several strengths. The selected studies were evaluated for their quality based on a quality evaluation tool specifically developed for intervention studies. Moreover, a comprehensive and detailed review of the studies was conducted following the study process, and it provides guidance for future studies. The limitations of this review are including journal articles published only in English and a wide range of quality among the selected studies.

CONCLUSION

Rapidly growing technology has enabled ubiquitous access to and the utilization of informational resources through the Internet and various mobile devices that are embedded in our daily lives.17,18 Its widespread availability and informative aspects provide a platform that can be used for educational purposes. As the importance of pregnant women's supportive care needs is gaining more clinical attention,1,3,5 this review demonstrates that the educational needs of pregnant women may be enhanced in conjunction with the use of technologies.

The studies included in this systematic review reported a variety of outcomes, including stress relief, stress coping, and birth outcomes. Moreover, the benefits of stress coping, reduction in anxiety and depression, and enhanced bonding with babies were revealed through qualitative inquiry. Technology-related interventions were reported overall to be feasible, acceptable, and beneficial, whereas some studies voiced concerns that the beneficiaries were limited to those who were actively motivated to change. Furthermore, suggestions for improvement included extending the degree of continuity and sustainability of the intervention-in particular, implementing a tracking component for users' progress and adopting an interface that is user-friendly and flexible in order to make it more approachable both for pregnant women and their significant others.

Although technology-related interventions offer a promising and pragmatic solution for guiding and educating pregnant women regarding antenatal care during a critical period, current studies have methodological limitations that affect the specificity of outcomes and generalizability of the findings. Further comprehensive studies with research topics that could better interpret the benefits of technology utilization, comprehensive outcome measures, and larger sample sizes with a broad array of participants are required. In addition, the review indicates that an acute need for a well-structured intervention with a precisely articulated development process is required to test the effects and increase the future adoption of technology-related interventions.

Given the educational needs of pregnant women, technology-related interventions appear to be beneficial in reducing maternal stress and enhancing pregnancy-related knowledge, thereby encouraging them to make better lifestyle changes for themselves and their babies. However, it is imperative that more rigorous studies be conducted and reviewed in order to increase their effectiveness and consider them in practice. Overall, further research is required before the widespread implementation of technology-related interventions.

References