Keywords

Antenatal education, mobile health, newborn care, postnatal education, psychosocial outcomes

 

Authors

  1. Dol, Justine

ABSTRACT

Objective: This review aims to evaluate the effectiveness of mother-targeted mobile health (mHealth) education interventions during the perinatal period on maternal psychosocial outcomes in high-income countries.

 

Introduction: Mobile health (i.e. mHealth) is defined as the use of mobile devices to transmit health content and services. The use of mHealth to provide education and support to mothers is a growing field of health innovation. Mothers seek health information online during the postpartum period to learn about health concerns and get advice and support. Despite the potential benefits of mHealth, the potential impact on maternal psychosocial outcomes requires further evaluation.

 

Inclusion criteria: The review will consider studies that include mHealth interventions targeting mothers in high-income countries. The mHealth education interventions must occur during the antenatal or postnatal period. This review will consider studies that compare the intervention to any comparators. Studies published in English from 2000 will be included.

 

Methods: The search strategy will aim to locate both published and unpublished studies. Following the search, all identified citations will be collated and duplicates removed. Titles and abstracts will be screened and full text of selected citations will then be assessed in detail against inclusion criteria. The results of the search will be reported in full in the final systematic review. Eligible studies will be critically appraised by two independent reviewers. Data extracted will include specific details about the interventions, populations, study methods and outcomes. Studies will be pooled in statistical meta-analysis or presented in narrative form including tables and figures.

 

Article Content

Introduction

The perinatal period is an exciting but also challenging period for mothers as it requires physical, emotional and social adjustments to new norms and expectations. It is also characterized by significant learning and bodily changes for the mother. As a result, during the perinatal period, mothers increasingly seek information, both on specific health concerns as well as social support and advice.1 New and expectant mothers seek information from online sources, ranging from 44% during pregnancy2 and between 90.4% to 96.4% postpartum.3,4 This has resulted in growth in the use of mHealth (i.e. mobile health) by new mothers, as they seek health information through online or mobile applications.5 mHealth, a subset of eHealth (electronic health), is defined as the use of mobile devices, such as mobile phones or smartphones, to transmit various health content and services.6 Examples of mHealth include short message service (SMS), mobile applications and telemedicine. mHealth interventions can be tailored to demographic factors, such as gestational age of the fetus or age of the mother, and can include information, monitoring and motivational content.7

 

Mothers are using a range of online sources during the perinatal period, including forums, social media and mobile applications.8 A review on pregnant women's use of Internet sources found that use of these resources was associated with greater feelings of self-efficacy and social support, as well as reduced anxiety.5 The primary reasons for mothers seeking health information online during the postpartum period were related to the need to find out more information about newborn or infant health concerns and get advice and support on parenting issues.1 The use of online sources is not necessarily meant to replace formal sources of information, but to complement or clarify information received by formal in-person sources, such as doctors or nurses.1

 

Many factors contribute to the popularity of mHealth interventions, including the widespread availability and use of mobile phones. Combined with the opportunity for real-time communication, mHealth has rapidly been expanding to reach pregnant women and new mothers with the goal to improve access and health outcomes.9 The use of mHealth interventions to provide education and support to mothers is a growing field of health innovation. mHealth interventions targeting new mothers have been found to address a variety of perinatal health topics, including gestational weight gain,10 smoking cessation,11-13 breastfeeding,14 newborn education15 and mental health.16 Women are also eager to receive information through mHealth, as recent literature on SMS as an mHealth educational tool during pregnancy found that women are receptive to the use of SMS during pregnancy as a health promotion tool.17 This is a result of its ability to increase maternal education and utilization of health services during the continuum of care.17 Considering the growing evidence on the use of mHealth interventions during the perinatal period, it is important to explore the impact on maternal psychosocial health outcomes, including self-efficacy, social support, anxiety and depression.

 

The broad goal of health education during the postnatal period is not only to impart knowledge on the topics of the intervention, but also to increase the self-efficacy of mothers so that they are able to engage and provide best care for themselves and their newborns.18,19 Self-efficacy is thought to be a key factor in parenting behavior and has been linked to positive newborn outcomes.20 At the root of perinatal heath interventions is the desire to increase mothers' self-efficacy and their belief in their own ability to enhance positive parenting behaviors. Thus, targeting self-efficacy has been found to be an important outcome for existing mHealth interventions,14,15,21 and is an important psychosocial health outcome during the perinatal period.

 

Other key psychosocial health outcomes that have been found to be important during the perinatal period are social support, anxiety and depression. Social support is essential for the physical and emotional well-being of mothers during the postpartum period and has been linked to positive maternal outcomes.22,23 A literature review on the effects of peer support through mobile applications found improvements in mental health and an increase in feelings of support.24 Mothers who have support and discover that other mothers are struggling in similar ways develop an understanding that being a mother is learnt behavior, not innate, which can result in normalization, feelings of encouragement and validation.25 mHealth can also provide easy access to information and socialization in a way that minimizes stigma and embarrassment, which can easily accompany seeking health information.26

 

Anxiety and depression are common psychosocial health outcomes that mothers struggle with during the perinatal period, with prevalence estimated at 20-25% for prenatal anxiety,27 15% for postpartum anxiety,28 and 12% for postpartum depression.29,30 Even though mothers may go online to search for health information, some also report high anxiety after searching online due to being overwhelmed with the amount of information or becoming fearful of what information they found.31 Postpartum depression has also been associated with high levels of anxiety during the prenatal period.32 The use of mHealth interventions offers potential means to reach and impact mothers who are struggling or at risk of anxiety and depression during the perinatal period.

 

Despite the potential benefits of mHealth, the impact of these interventions on maternal psychosocial health outcomes remains uncertain. A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews and the JBI Database of Systematic Reviews and Implementation Reports was conducted, and no current or underway systematic reviews on the topic were identified. There have been several systematic reviews on the impact of mHealth interventions on maternal and newborn health in low- and middle-income countries,33-37 but the impact has not been synthesized for high-income countries. Similarly, systematic reviews have been conducted on the use and prevalence of mHealth interventions for maternal health behavior, such as smoking cessation, diabetes, weight management or breastfeeding,7,38,39 but no reviews have focused on perinatal psychosocial outcomes. A recent systematic review published by Daly et al. focused on the impact of mHealth,7 but only reported the use of mobile applications, excluding interventions that use other forms of mHealth, including SMS technology, to reach parents.

 

Therefore, the objective of this review is to evaluate the effectiveness of mother-targeted mHealth education interventions available during the perinatal period on maternal psychosocial outcomes in high-income countries.

 

Review questions

What is the effectiveness of mother-targeted mHealth education interventions available during the perinatal period on maternal psychosocial outcomes?

 

More specifically, what is the effectiveness of mother-targeted mHealth education interventions on maternal self-efficacy, social support, postpartum anxiety and depression?

 

Inclusion criteria

Participants

The review will consider studies that include mHealth interventions targeting mothers in high-income countries as defined by the World Bank.40 Studies will be excluded if the mHealth intervention primarily targets other caregivers (e.g. fathers, healthcare providers, community health workers) or were conducted in low- or middle-income countries. This review will also exclude studies that focus on refugee populations due to the confounding factors that influence their experience during the perinatal period, as well as the recent systematic review on the perinatal health outcomes in this population already conducted.41

 

Intervention

This review will consider studies that evaluate mother-targeted mHealth education interventions during the antenatal or postnatal period. No limitations on education topics covered in the intervention will be provided as long as it targets pregnant women or postnatal mothers. mHealth interventions can include mobile phones, smartphones or tablets and can occur through phone calls, video calls, SMS or mobile applications. The mHealth intervention must be initiated during the antenatal period or between birth and six weeks postnatally. The six-week postnatal period was selected to be consistent with the World Health Organization's recommendation of postnatal follow-ups.19 The mHealth component must be the primary aspect of the intervention, excluding interventions that only include a mHealth component as part of a multifaceted intervention (i.e. counselling calls options, text messages of upcoming appointments or content reminder). eHealth interventions not associated with mobiles will be excluded, such as websites or web cameras.

 

Comparator

This review will consider studies that compare the intervention to any comparators, including standard care, placebo or no treatment control.

 

Outcomes

This review will consider studies that include the following outcomes:

 

i. Self-efficacy: measured using standardized questionnaires (e.g. Perceived Maternal Parenting Self-Efficacy (PMP S-E) tool,42 Infant Care Self-Efficacy43) or other measures as reported by studies.

 

ii. Social support: measured using standardized questionnaires (e.g. Multidimensional Scale of Perceived Social Support,44 Support Behaviour Inventory45) or other measures as reported by studies.

 

iii. Postpartum Anxiety: measured using standardized questionnaires (e.g. Postpartum Specific Anxiety Scale,46 State Anxiety Inventory scale47) or other measures as reported by studies.

 

iv. Postpartum Depression: measured using standardized questionnaires (e.g. Edinburgh Postnatal Depression Scale,48 Postpartum Depression Screening Scale49) or other measures as reported by studies.

 

 

Types of studies

This review will consider both experimental and quasi-experimental study designs including randomized controlled trials, non-randomized controlled trials, before and after studies and interrupted time-series studies. In addition, analytical observational studies including prospective and retrospective cohort studies, case-control studies, and analytical cross-sectional studies will be considered for inclusion. Studies published in English will be included. Studies published from 2000 to the present will be included based on the emergence of mHealth interventions after this period and to be consistent with other reviews on similar topics.36,37,50

 

Methods

The proposed quantitative systematic review will be conducted in accordance with JBI methodology for systematic reviews of effectiveness evidence.51

 

Search strategy

The search strategy will aim to locate both published and unpublished studies. An initial limited search of PubMed was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy for PubMed (see Appendix I). This search strategy was developed in consultation with a health science librarian. The search strategy, including all identified keywords and index terms, will be adapted for each included information source, in consultation with the same health science librarian. The reference lists of all studies selected for critical appraisal will be screened for additional studies.

 

Information sources

The databases to be searched include PubMed, CINAHL, PsycINFO, and Embase. Sources of unpublished studies and gray literature to be searched include Google Scholar and mHealth intelligence. Clinical trials databases (ClinicalTrials.gov, Cochrane Central Register of Controlled Trials [CENTRAL]) will also be searched for relevant studies.

 

Study selection

Following the search, all identified citations will be collated and uploaded into Covidence (Covidence, Melbourne, Australia) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against inclusion criteria for this review. The full text of selected citations will then be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the final systematic review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram.52

 

Assessment of methodological quality

Eligible studies will be critically appraised by two independent reviewers at the study level for methodological quality in the review, using standardized critical appraisal instruments from JBI for experimental and quasi-experimental studies.51 Any disagreements that arise will be resolved through discussion or with a third reviewer. The results of critical appraisal will be reported in narrative form and in a table. Following critical appraisal, studies that do not meet a certain quality threshold will be excluded. This decision will be based on a critical appraisal score less than 50%.

 

Data extraction

Data will be extracted from papers included in the review using the standardized data extraction tool available in JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; Joanna Briggs Institute, Adelaide, Australia) by two independent reviewers.51 The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and objectives. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.

 

Data synthesis

Studies will, where possible, be pooled in statistical meta-analysis. Effect sizes will be expressed as either odds ratios (for dichotomous data) or weighted (standardized) final post-intervention mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-squared and I2 tests. The choice of model (random or fixed effects) and method for meta-analysis will be based on the guidance by Tufanaru et al.53 Subgroup analyses will be conducted where there is sufficient data to investigate differences between interventions targeting the antenatal period alone, postnatal period alone or across the perinatal period. Analysis will also report on different subgroups within the population including low-income and/or vulnerable populations compared to a community sample. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation, where appropriate. A funnel plot will be generated to assess publication bias if there are 10 or more studies included in a meta-analysis. Statistical tests for funnel plot asymmetry will be performed, where appropriate.

 

Assessing certainty in the findings

The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach for grading the certainty of evidence will be followed and a Summary of Findings (SoF) will be created using GRADEpro (McMaster University, ON, Canada). The SoF will present the following information where appropriate: absolute risks for the treatment and control, estimates of relative risk, and a ranking of the quality of the evidence based on the risk of bias, directness, heterogeneity, precision and risk of publication bias of the review results. The outcomes reported in the SoF will be: self-efficacy, social support, postpartum anxiety and postpartum depression.

 

Acknowledgments

The authors would like to acknowledge Robin Parker, a health science librarian at Dalhousie University, for assistance with the search strategy.

 

This review will contribute toward a PhD in Health for the primary author, JD.

 

Funding

JD is funded through a Canadian Institute of Health Research Doctoral Award to Honour Nelson Mandela (FRN154341) as a PhD in Health trainee at Dalhousie University. MCY is funded through the Canadian Child Health Clinician Scientist Program Career Development and Canadian Institute of Health Research New Investigator. Funders had no role in the development or completion of this review.

 

Appendix I: Search strategy for PubMed

(Self Efficacy[MeSH Terms] OR Self Concept[MeSH Terms] OR Anxiety[MeSH Terms] OR Depression[MeSH Terms] OR Depression, Postpartum[MeSH Terms] OR Social Support[MeSH Terms] OR Maternal Health[MeSH Terms] OR Maternal Behavior[MeSH Terms] OR Self Care[MeSH Terms] OR Psychosocial Deprivation[MeSH Terms] OR self-efficacy[Title/Abstract] OR "social support"[Title/Abstract] OR depression[Title/Abstract] OR depressed[Title/Abstract] OR depressive[Title/Abstract] OR anxiety[Title/Abstract] OR anxious*[Title/Abstract] OR confidence[Title/Abstract] OR "maternal health"[Title/Abstract] OR "self care"[Title/Abstract] OR "self concept"[Title/Abstract] OR psychosocial[Title/Abstract] OR psycho-social[Title/Abstract])

 

AND (family[Title/Abstract] OR familial[Title/Abstract] OR maternal[Title/Abstract] OR paternal[Title/Abstract] OR caregiver*[Title/Abstract] OR mother*[Title/Abstract] OR father*[Title/Abstract] OR parent[Title/Abstract] OR parents[Title/Abstract] OR parental[Title/Abstract] OR parenting[Title/Abstract] OR women[Title/Abstract] OR woman[Title/Abstract] OR parents[MeSH Terms] OR caregiver[MeSH Terms] OR caregiver, family[MeSH Terms]) AND (neonatal[Title/Abstract] OR postnatal[Title/Abstract] OR post-natal[Title/Abstract] OR postpartum[Title/Abstract] OR post-partum[Title/Abstract] OR newborn*[Title/Abstract] OR baby[Title/Abstract] OR babies[Title/Abstract] OR infant[Title/Abstract] OR infants[Title/Abstract] OR infancy[Title/Abstract] OR neonat*[Title/Abstract] OR antenatal[Title/Abstract] OR prenatal[Title/Abstract] OR pre-natal[Title/Abstract] OR ante-natal[Title/Abstract] OR perinatal[Title/Abstract] OR peri-natal[Title/Abstract] OR pregnant[Title/Abstract] OR pregnancy[Title/Abstract] OR postpartum[MeSH Terms] OR postnatal care[MeSH Terms] OR Infant, Newborn[MeSH Terms] OR care, prenatal[MeSH Terms] OR prenatal education[MeSH Terms] OR Perinatal Care[MeSH Terms]) AND (eHealth[Title/Abstract] OR e-Health[Title/Abstract] OR mHealth[Title/Abstract] OR m-Health[Title/Abstract] OR mobile health[Title/Abstract] OR cellphone*[Title/Abstract] OR cell-phone*[Title/Abstract] OR information technology[Title/Abstract] OR FaceTime[Title/Abstract] OR smartphone*[Title/Abstract] OR smart phone*[Title/Abstract] OR mobile phone*[Title/Abstract] OR iPhone*[Title/Abstract] OR iPad*[Title/Abstract] OR handheld[Title/Abstract] OR text messag*[Title/Abstract] OR tele-medicine[Title/Abstract] OR telemedicine[Title/Abstract] OR tele-health[Title/Abstract] OR telehealth[Title/Abstract] OR SMS[Title/Abstract] OR MMS[Title/Abstract] OR cell phone[MeSH Terms] OR text messaging[MeSH Terms] OR telemedicine[MeSH Terms] OR mobile health[MeSH Terms] OR mobile phone[MeSH Terms] OR medical informatics[MeSH Terms] OR computer, handheld[MeSH Terms])

 

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