Exploring satisfaction on ANC digital health among pregnant women: a qualitative study

Abstract

Background

Pregnant women, have concerns regarding the potential risk of COVID-19 and other communicable diseases during their prenatal check-ups at healthcare facilities. They need routine online consultations to reduce the risk of complications for both themselves and their unborn children. The health services should adapt by offering digital health solutions, one of those is the ‘Guide Me’ application, which is accessible to pregnant women and designed to support their antenatal care through online services. However, although the implementation of mHealth solutions in communities may encounter various challenges, offering a comprehensive range of online services has the potential to significantly improve antenatal care (ANC) satisfaction for pregnant women. This study aims to evaluate the impact of the “Guide Me” app on pregnant women’s satisfaction with antenatal care. By assessing the satisfaction levels of women using the app for ANC, the study seeks to determine the effectiveness of this digital health service in improving their overall satisfaction with the care provided.

Methods

This study employed a qualitative study at the antenatal clinics of Community Health Centers (CHCs) located in Pamulang, Banten Province, Indonesia from August 2022 to January 2023. The inclusion criterion for participants was being in the second and third trimester of pregnancy.

Results

The results of this study demonstrated that the “Guide Me” application provides substantial benefits to pregnant women utilizing online ANC services. The app highlights the flexibility and potential of technology-based healthcare services in addressing disparities in access to medical consultations and information. However, they encounter technological challenges, particularly related to signal interference, which leads to inconsistent communication during consultations.

Conclusion

This study contributes to the advancement of ANC services through its exploration of women’s experiences in using the Guide Me App.

Introduction

Pregnant women, who are considered a vulnerable group, have voiced concerns regarding the potential risk of COVID-19 exposure during their prenatal check-ups at healthcare facilities [1]. Pregnant women in Indonesia continued to face various barriers in accessing maternal healthcare services during the COVID-19 pandemic, including antenatal care (ANC). These barriers were not only structural—such as limited health service availability, transportation difficulties, and reduced healthcare personnel—but also personal, social, and economic in nature. Fear of infection, uncertainty, and financial constraints contributed to reduced ANC visits [2]. While research indicates that neonatal outcomes for mothers exposed to COVID-19 are typically safe, including those with preterm birth [3], many pregnant women, especially those without early symptoms of infection, have opted for routine online consultations to reduce the risk of complications for both themselves and their unborn children [4].

According to the World Health Organization (WHO) data in 2020, Indonesia’s Antenatal Care (ANC) coverage is significantly lower than in many other countries, with only 82% of pregnant women receiving any ANC checks compared to a benchmark of 96.1% for both the first (K1) and fourth (K4) ANC visits, while actually ANC coverage during K4 has tended to increase from 2008 to 2020, but remains below the government’s target [5–7]. ANC coverage data in Banten in 2020 was quite high, 96.6%, but did not meet the national target of 100% (Kemenkes, 2021). One of primary health centre in South Tangerang, namely Setu Primary Health Center in South Tangerang is one of the health centers impacted by the COVID-19 pandemic. According to the 2020 South Tangerang Health Office Annual Report, Setu Community Health Center had the highest maternal mortality rate in South Tangerang, with 3 deaths per 1,632 live births. The causes of death were hypertension and COVID-19 infection [8]. Therefore, this research conducted in South Tangerang. In response to this emerging need, healthcare systems must adapt by offering digital health solutions [9]. Telemedicine has emerged as a promising tool to address the healthcare requirements of pregnant women, particularly during the COVID-19 pandemic. Among these digital solutions, mobile health (mHealth) apps have become increasingly popular due to their ability to deliver healthcare services via smartphones, enhancing accessibility and convenience for users [9].

Globally, the United Nations reports 754 million illiterate or low-educated, with 63% are women [10]. The Women’s Empowerment Index (WEI) 2022 ranks Indonesia as having low women’s empowerment, with only 34.6% of women aged 25 and above completing secondary or higher education. This indicates that approximately 65.4% of women have low education achieving less than junior high school [11].

However, the implementation of mHealth solutions in communities may encounter various challenges. Therefore, the researchers initiated to create the “Guide Me” application, by offering a comprehensive range of online services, has the potential to significantly improve antenatal care (ANC) satisfaction for pregnant women. Although the Ministry of Health already provides the Maternal and Child Health Book, contains comprehensive screening and health education, the added value of this app is the feature to have direct consultation with experts.

It provides useful information on pregnancy trimesters, breast care, and exercise routines. While some medical procedures, such as ultrasounds and haemoglobin tests, require in-person visits, the “Guide Me” app supplements ANC by offering educational resources, Q&A sections, scheduled chats, and voice or video consultations, in addition to in-person appointments, all of which contribute to enhancing the overall care experience [12, 13].

Furthermore, the “Guide Me” app includes media consultation features, allowing pregnant women to expand their knowledge about pregnancy and childbirth preparation. It is widely recognized that a lack of knowledge can lead to fear and anxiety during pregnancy, which can negatively impact both maternal and foetal health [12, 13]. However, there is still limited evidence on user satisfaction and experience with digital antenatal care services in the Indonesian context. This study aims to explore the impact of the “Guide Me” app on pregnant women’s satisfaction with antenatal care. By assessing the satisfaction levels of women using the app for ANC, the study seeks to determine the effectiveness of this digital health service in improving their overall satisfaction with the care provided.

Materials and methods

Study design and participants

This study employed a qualitative study at the antenatal clinics of Community Health Centers (CHCs) located in Pamulang, Banten Province, Indonesia. The research was carried out over a period of six months, from August 2022 to January 2023. The inclusion criterion for participants was being in the second and third trimester of pregnancy. The study focused on pregnant women in their second and third trimester, as those in the first trimester were excluded due to the limited feasibility of foetal heartbeat detection using Doppler or Linex at that stage. The research framework was rooted in the Holistic Nursing Theory (HNT), chosen for its alignment with the holistic nature of pregnant women and the comprehensive approach of nursing. This theoretical foundation guided the study design in qualitative method to explore more about their needs and implementation, emphasizing a holistic perspective that encompasses the physical, emotional, and psychological aspects of antenatal care satisfaction.

The content within the applications instructs women on healthy eating, suitable exercises for pregnancy, personal hygiene practices, monitoring blood pressure and blood sugar levels, ensuring adequate sleep, managing emotions effectively, fostering spiritual well-being, and dispelling unhealthy cultural myths (e.g., avoiding fish due to its odour, consuming only white rice, and minimizing physical activity).

Sampling

Participants were selected through purposive sampling according to specific inclusion criteria: pregnant women in their second or third trimesters (gestational age between 13 and 36 weeks); singleton pregnancies devoid of medical complications; possession of a mobile phone to facilitate weekly intervention follow-ups; and a demonstrated willingness to participate and adhere to the research procedures until the program’s conclusion. The inclusion criteria began at 13 weeks of gestation, in accordance with the guidelines from the National Institute of Child Health and Human Development (NICHD), which defines the second trimester as beginning at 13 weeks and continuing through 28 weeks [14]. The exclusion criteria comprised women in their first trimester and those with high-risk or complicated pregnancies. The decision to exclude first-trimester participants stemmed from the assumption that many women at this stage may not yet be fully engaged in antenatal care practices. Finally, there are 6 pregnant women selected with age ranged from 21 to 29 years old and all of them graduated from senior high school. Based on the guidelines from Oregon State University (2023), sampling in qualitative research has different goals than in quantitative research, in order to gain an in-depth understanding of a phenomenon rather than to produce statistical generalizations. Therefore, researchers do not need to involve the entire population, but rather select a sample that is relevant and informative. A small number of participants can still be considered sufficient if the data obtained adequately addresses the research objective [15]. Thus, following this principle, the use of six participants in this study is deemed sufficient, as they have provided rich and relevant information aligned with the focus of the research.

Data collection and analysis

Data collection only began after the researcher’s received approval from the Health Research Ethics Committee at Universitas Pembangunan Nasional Veteran Jakarta in accordance with the Declaration of Helsinki with letter number: 373/VIII/2022/KEPK. Pregnant women were provided with information about the study and signed informed consent, they free to withdraw from the study at any time and their data were kept confidentially. Data were collected by the researchers from Faculty of Health Science Universitas Pembangunan Nasional Veteran Jakarta holding a doctor degree and has experience in carrying out qualitative research by using the interview guide during three specific antenatal care (ANC) visits, each corresponding to distinct pregnancy trimesters: >3 months, eight months of gestation, and nine months of gestation. During these visits, qualitative data were acquired through comprehensive in-depth interviews and observational notes. The researchers initially met each participant in the PHC and introduced themselves, informed the participants of the study aims, and shared contact information so both can be contacted for the sake of the study.

Additionally, participants received health applications that provided educational content encompassing various facets of pregnancy management, including nutrition, physical activity, hygiene, emotional regulation, spiritual well-being, and the dispelling of cultural myths (e.g., avoiding fish due to odour or restricting physical activity). This study applied thematic analysis, consisted of 6 themes as shown in Table 1 above and more than one person checks the reliability of the data and its interpretation.

Table 1.

Interview guide

Theme	Questions and prompts
Chat Feature	How do you feel about ANC services when using the chat feature via the “Guide Me” app?
Video Call Feature	How do you feel about ANC services when using the video call feature via the “Guide Me” app?
Appointment Scheduling Feature	How do you feel about ANC services when using the appointment feature via the “Guide Me” apps? And its implementation?
Reading Feature	How do you feel about ANC services when using the read feature via the “Guide Me” app?
Quality of Online Services Service Speed	How do you feel about officers providing solutions during online ANC services when using the “Guide Me” app fast and satisfying?
Strengths and Weaknesses of the Application	What are the strengths and weaknesses of this application?
Opportunities and Challenges of the application	What are the opportunities and challenges of the application?
Enhancing Pregnant Women’s Satisfaction	Does the app service increase the overall satisfaction of pregnant women?

Result

Based on interviews with six pregnant women who utilized the “Guide Me” application for antenatal care (ANC) services, several key findings were identified:

Theme 1: chat feature

The majority of respondents reported that the chat feature was highly beneficial as it allowed for flexible consultations without requiring a physical visit to healthcare facilities. As expressed by one respondent, A:

“Through chat, I can consult at flexible times, respond at my convenience, and communicate my needs as well as my baby’s.”

Similarly, B added:

“With chat, I can consult about my needs and my baby’s without having to wait for long periods.”

Theme 2: video call feature

Most respondents found the video call feature helpful in understanding their pregnancy conditions more effectively. However, technical issues such as signal disruptions occasionally led to interrupted communication. As mentioned by C:

“This video call feature helps me understand my problems and my baby’s needs, but sometimes the connection is lost because of poor signal at my home.”

On the other hand, D shared a positive experience:

“I like using video calls with this application because it allows me to understand my condition and pregnancy issues more quickly. The service is smooth and satisfactory.”

Theme 3: appointment scheduling feature

This feature was considered highly useful in managing time efficiently and reducing waiting times at healthcare facilities. All respondents stated that they received services on time according to the agreed schedule. As expressed by E:

“By using this feature, scheduling appointments is easy, reduces waiting time, and ensures I receive care as per the agreed schedule.”

Similarly, F mentioned:

“The appointment feature is very helpful as I don’t have to wait long to be served, and I can arrive exactly at my scheduled time.”

Theme 4: reading feature

The ability to access information at any time was considered highly beneficial. Respondents utilized their free time to read pregnancy-related information and find solutions to their concerns. F stated:

“The reading feature in this application allows me to access information anytime. During my free time, I can read about possible solutions to my problems and my baby’s needs.”

Likewise, C added:

“By using this chat, I can read information whenever I want. So, if I have any questions, I can look for answers first before consulting further.”

Theme 5: quality of online services

Respondents generally expressed satisfaction with the prompt responses and solutions provided through the chat and video call features. However, technical issues with video calls, such as the need to redial, were noted. As experienced by D:

“The feature faced technical issues, sometimes, my first video call is not answered, and I have to call again, but the explanations provided are very satisfactory.”

B also added:

“The video call service is fairly good, but sometimes I have to wait a while before the call is answered.”

Theme 6: service speed

All respondents stated that they were satisfied with the speed of service provided by the application. As expressed by B:

“The service provided is satisfying because responses are quick, and it meets all my needs.”

A also added:

“Through this service, I feel greatly assisted because I do not have to visit the healthcare facility in person; everything can be done from home.”

Theme 7: strengths and weaknesses of the application

Strengths of the application consisted of comprehensive features, fast services, and clear, complete information. However, there is also weaknesses of the app primarily signal disruptions during video calls. As mentioned by A:

“Its strengths include having all the necessary features and timely service, but its weakness is that video calls sometimes get disconnected due to poor signal.”

It is also approved by E as highlighted below:

“The only drawback is the signal issue. If the signal is good, everything runs smoothly.”

Theme 8: opportunities and challenges of the application

This application has opportunities and challenges. The opportunities are the application has significant potential to improve access to information and healthcare services for pregnant women, particularly those with limited access to healthcare facilities. A challenge faced by the application is the internet connection stability that remains a major obstacle and needs improvement for optimal service delivery. As noted by C:

“Even though this application is good, sometimes, video calls are disrupted due to poor signal quality.”

F also added:

“If the signal is good, this application is very helpful, but if the signal is poor, it becomes less effective.”

Theme 9: enhancing pregnant women’s satisfaction

All respondents agreed that the “Guide Me” application was highly beneficial and enhanced their satisfaction with ANC services. The ease of accessing information and consulting with healthcare providers was regarded as a significant advantage of the application. As stated by informants, D and B:

“The service is highly satisfying. When I first visited the community health center (Puskesmas), I was informed about the application, and it has answered all my concerns.”

“I feel more at ease knowing that I can consult at any time using this application.”

Discussion

Antenatal care (ANC) is a vital link in the continuum of care across reproductive, maternal and child health services. ANC is a central component of maternity care provided by skilled healthcare providers to guarantee a healthy pregnancy outcome. The World Health Organization (WHO) endorses a package of essential interventions for ANC to confirm better perinatal and maternal outcomes that is adaptable to different settings for countries. It encompasses 5 types of interventions consisted of nutritional interventions, maternal and foetal assessment, preventive measures, intervention for common physiological symptoms and health systems interventions to improve the utilization and quality of antenatal care [16].

During COVID-19 pandemic, there is a shift of various health services, from direct (face to face) consultation to online consultation through several applications to overcome structural and personal barriers. This study explored the use of “Guide Me” application, developed to ease the antenatal care consultation. The results of this study demonstrated that the “Guide Me” application provides substantial benefits to pregnant women utilizing online Antenatal Care (ANC) services. Based on Scoping Review to 27 articles conducted by Endehabtu (2023), most of the reported use of digital health interventions was for client education and behavior change communication and were positively associated with antenatal care service utilization [17].

The study conducted by Fegita et al. (2022) shows that there is a statistically significant relationship between the formal education level of pregnant women and their antenatal care (ANC) status [18]. Specifically, 21.9% pregnant women with higher education had complete ANC status, while among 17 women with low education, only 4 had complete ANC and 13 had incomplete status. A study conducted in Ethiopia showed that pregnant women lacked formal education (AOR = 2.09; 95% CI = 1.66, 2.63), who were in the poorest wealth quintile (AOR = 5.56; 95% CI = 4.19, 7.37) were more likely to have low utilization of effective ANC coverage [19]. Shibeshi (2025) also found that higher education (AOR = 1.53) and knowledge of pregnancy are key predictors to adequate ANC [20].

This suggests that women with higher education are more likely to understand the importance of regular ANC visits and act accordingly. Education equips women with the ability to access, comprehend, and apply health information, which in turn influences their behavior toward maternal health care. Therefore, improving women’s access to education may play a critical role in increasing ANC service utilization and ultimately improving maternal health outcomes, particularly in low-resource settings [18].

The findings of this study can be interpreted through the lens of the Technology Acceptance Model (TAM), which posits that user acceptance of technology is primarily influenced by Perceived Usefulness (PU) and Perceived Ease of Use (PEOU) [21]. Themes such as the chat, video call, appointment scheduling, and reading features illustrate a high level of PU, as pregnant women perceived the application as beneficial in facilitating flexible consultations, reducing waiting times, and providing accessible information to support pregnancy and childbirth preparation. Furthermore, the overall increase in satisfaction reported by respondents suggests that the Guide Me application contributes meaningfully to enhancing antenatal care experiences. In terms of PEOU, participants generally reported that the application was easy to navigate and convenient to use, as reflected in themes related to service speed and online service quality. Additionally, participants acknowledged the strengths of the application, including its comprehensive features, timely responses, and clear information delivery. However, some weaknesses were also identified, particularly technical challenges such as unstable internet connections during video calls, which were noted as potential usability barriers. Despite these limitations, both PU and PEOU appeared to significantly influence user satisfaction and acceptance of the application.

Among its various features, the chat function is perceived as particularly advantageous. According to the informants, this feature facilitates easier access to consultations with healthcare professionals without necessitating physical visits to healthcare facilities. This finding highlights the flexibility and potential of technology-based healthcare services in addressing disparities in access to medical consultations and information. The respondents reported feeling at ease due to the absence of spatial and temporal constraints, allowing them to seek consultation based on their specific needs. These findings are consistent with the principles of telemedicine, which emphasize the use of digital technology to enhance healthcare access and patient-centered care. This is further confirmed by a study which found that telemedicine has contributed to more equitable healthcare delivery for pregnant women, particularly in remote and hard-to-reach areas [22]. In addition to improving access, telemedicine also enables regular monitoring of pregnancy without the need to travel long distances, which may lower the risk of complications [23]. Women who reside within 10 km radius to health facility (AOR = 0.33; 95% CI = 0.29, 0.38) and urban residents (AOR = 0.77; 95% CI = 0.64, 0.93) were less likely to have low effective coverage [19].

In addition to the advantages provided by the chat function, pregnant women can also benefit from the video calling option. Most informants believed that the direct, visual, and real-time engagement offered by this feature facilitated a quicker and more efficient understanding of pregnancy-related symptoms. The significance of video calling services in supporting mothers during the early stages of pregnancy was emphasized in a qualitative study that included the perspectives of midwives in the UK and Italy [24]. However, they encounter technological challenges, particularly related to signal interference, which leads to inconsistent communication during consultations [25] as also found in this study. This issue has emerged as a substantial barrier to the implementation of digital health services, especially in areas with unstable internet connectivity. Conversely, other informants reported positive experiences despite these challenges, emphasizing the ease and fluidity of consultations when supported by a stable internet connection.

The appointment feature of the app is recognized as an effective tool in reducing waiting times at healthcare facilities. All respondents reported that this functionality allows them to schedule their visits, ensuring timely service and minimizing long waiting periods. This highlights the successful integration of digital and in-person services in healthcare settings. Additionally, a web-based consultation with a physician or nurse practitioner is another example of interactive appointments [26]. Moreover, the “Guide Me” application’s information retrieval feature (Read) is praised for its usefulness. Pregnant women can utilize their free time to access pregnancy-related educational content, as the information is easily accessible at any time [27]. According to multiple informants, this feature enabled them to independently address pregnancy-related issues prior to seeking professional medical advice. This digital health literacy has the potential to enhance users’ ability to make more informed health decisions [28]. This finding is in line with the research of Nawabi et al. (2021), which showed that increased digital health literacy in pregnant women was positively correlated with their ability to evaluate health information and take appropriate self-directed action [29].

In terms of service quality, most respondents reported satisfaction with the timely responses provided through the video conference and chat features. This indicates that digital app-based services can offer speed, efficiency, and convenience that may not always be achievable through traditional service methods. The primary concern raised by respondents was signal interference, especially when using the video call function. This aligns with existing research indicating that the stability of internet connections significantly impacts the quality of telemedicine services, which subsequently influences user satisfaction [30]. Additionally, another study highlighted that while telemedicine facilitates the provision of remote health services, challenges such as insufficient technological infrastructure and unstable internet connectivity persist as significant barriers to its widespread adoption [31]. According to some informants, all application functions operate seamlessly when the signal is stable; however, when the internet connection is disrupted, the effectiveness of the service diminishes. Several telehealth studies have identified similar issues, underscoring the importance of strengthening digital infrastructure to support the advancement of electronic health services [32]. Connectivity issues, device access, and digital skills represent significant barriers to telemedicine adoption, particularly in resource-constrained areas [33].

Furthermore, the “Guide Me” app offers a valuable opportunity to improve the quality and accessibility of antenatal care (ANC) services for pregnant women, especially those living in rural areas or with limited access to healthcare facilities. Strengthening digital infrastructure in regions with poor internet connectivity and enhancing the app’s stability would further maximize its potential [34]. Additionally, user education on how to fully utilize the app’s features can also enhance its effectiveness [35]. Overall, it is anticipated that this app will contribute to increased satisfaction with ANC services among pregnant women.

Conclusion

The development of the Guide Me application, equipped with media consultation features, holds potential as a digital innovation to improve access to pregnancy education and childbirth preparation, particularly for women in resource-limited settings. This aligns with the findings of Gamberini et al. (2022), who emphasize that digital technologies can serve as effective solutions to address challenges in antenatal care (ANC) delivery where health workforce, infrastructure, and information access are limited [36]. Therefore, integrating digital tools like Guide Me may contribute to strengthening more inclusive and responsive maternal health systems.

Author contributions

DD contributed to conception, design of the study and data collection. LH were involved in data collection, data analysis and interpretation of the findings. DD and LH drafted the initial manuscript and both of them approved the final manuscript.

Funding

No funding.

Data availability

The data is freely available upon request to: [desmawati@upnvj.ac.id].

Declarations

Ethics approval and consent to participate

This research only began after the researcher’s received approval from the Health Research Ethics Committee at Universitas Pembangunan Nasional Veteran Jakarta and all informants consent to participate in accordance with the Declaration of Helsinki with letter number: 373/VIII/2022/KEPK.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.