Perceived usefulness and satisfaction of pregnant women with a WhatsApp-based education intervention aiming to improve access to pregnancy care: a mixed-methods evaluation

Abstract

Introduction

Mobile health interventions are increasingly used to improve access to antenatal care (ANC), yet evidence on end-user usefulness and satisfaction is limited. This study evaluated the perceived usefulness and satisfaction of pregnant women with a WhatsApp-based education programme implemented in Yaoundé, Cameroon.

Methods

A mixed-methods sequential explanatory design was used. Participants’ enrolment was done through a purposive sampling for the qualitative component and through exhaustive sampling for the quantitative component of the study. Qualitatively, women participated in one-on-one interviews and data were analysed thematically. Quantitative data were collected through a structured questionnaire and analysed using descriptive and inferential statistics. Integration of findings followed the Pillar Integration Process.

Results

A total of 132 women were included in the quantitative study component while 12 accepted to participate in the one-on-one interviews. The perceived usefulness and satisfaction with the intervention mean score were 30.6, SD 4.5 (Scale 5–35) and 25.1, SD 1.7 (Scale 4–28), respectively. These scores were explained by the interviews: women emphasised reassurance from direct nurse interaction, better navigation of facility/laboratory schedules and the breadth and clarity of video lessons. Participants reported delays in the care provider’s response to their questions and frequent referrals to the health facility when they requested a medication prescription. Participants requested more frequent/diverse content and faster responses from care providers. In adjusted models, usefulness score was significantly higher in primiparous women compared with multiparous ones (p<0.001) and significantly lower among women with primary versus university education (p=0.019). No significant difference in satisfaction score was observed across sociodemographic, behavioural, psychosocial and health-related characteristics.

Conclusions

The WhatsApp-based education programme was perceived as useful and satisfactory for enhancing ANC engagement and knowledge. Optimising response timeliness and pre-enrolment orientation, and tailoring content for women with lower education and multiparous ones, could further strengthen impact and equity.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Mobile health interventions using WhatsApp have shown promise in improving maternal health outcomes, but limited evidence exists on end-user perceptions of usefulness and satisfaction with such programmes.

WHAT THIS STUDY ADDS

• This mixed-methods evaluation demonstrates that pregnant women perceive WhatsApp-based educational interventions as highly useful and satisfactory, though primiparous women and those with higher education derive greater perceived usefulness.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• Findings suggest that WhatsApp-based maternal health programmes should include pre-enrolment orientation on scope limitations, optimise provider response times and tailor content specifically for multiparous women and those with lower educational attainment to maximise equity and impact.

Background

Maternal and perinatal outcomes remain a major public health priority across sub-Saharan Africa (SSA). Despite progress toward reducing maternal and neonatal deaths, SSA still accounts for about 70% of the global maternal mortality burden, with many deaths attributed to preventable causes such as late initiation of antenatal care (ANC), delayed recognition of danger signs and poor continuity of care.1,3 These causes are consequences of persistent inadequate pregnancy-related knowledge among pregnant women.⁴ Studies from multiple African countries indicate that many women initiate ANC only after the first trimester, often due to lack of awareness, misconceptions or limited access to trusted information sources.^{5 6} To improve on maternal knowledge, several interventions have been tested and implemented, including those leveraging digital health.

The rapid growth of mobile phone availability across SSA has created an unprecedented opportunity to improve access to reliable health information in pregnant women. As of 2023, the mobile ownership rate exceeded 70% in the women population, and messaging applications such as WhatsApp have gradually become one of the most used media to offer health communication and health promotion interventions during pregnancy.7,10 WhatsApp offers unique advantages for health education in low-resource settings, due to its features like low data requirements, multimedia capability, group messaging and real-time interaction.¹¹ These features facilitate continuous engagement between healthcare providers and users, enabling both health education and psychosocial support during pregnancy, a period where information needs, anxiety and uncertainty are particularly high.¹² By providing tailored, culturally appropriate messages and fostering two-way communication with providers, WhatsApp-based interventions can promote behaviour change, improve adherence to ANC schedules, pregnancy-related knowledge, psychological well-being, satisfaction with ANC and strengthen trust between women and healthcare systems.8,1013

While several studies have documented clinical outcomes of WhatsApp-based maternal health interventions,^{9 10 13} comprehensive evaluation of user satisfaction and perceived usefulness remains limited, particularly in sub-Saharan African contexts. A 2018 feasibility study in Kenya demonstrated high acceptability of moderated WhatsApp groups among pregnant women, with participants reporting positive experiences and informational support benefits.¹⁶ Similarly, a 2023 case study from Brazil reported high satisfaction among participants in a WhatsApp-based perinatal support initiative during COVID-19.¹⁷ However, systematic assessment of user perceptions using mixed-methods approaches combining quantitative and qualitative data remains scarce in low-resource settings.

Beyond WhatsApp, user satisfaction with various mHealth interventions during pregnancy has been documented, though findings vary by platform and context. For instance, SMS-based reminder systems have shown high satisfaction in several African settings.¹⁸ However, interactive platforms enabling direct communication with healthcare providers such as WhatsApp may offer distinct advantages in terms of social support and real-time information exchange that influence user perceptions differently than one-way communication tools. Understanding these platform-specific differences in perceived usefulness and satisfaction is critical for optimising future intervention designs.

Understanding how women perceive and engage with digital interventions is crucial for optimising content, frequency and provider engagement, while clarifying the scope of virtual counselling versus face-to-face care. Additionally, understanding users’ perspectives can reveal barriers such as digital literacy gaps, trust in online communication or unrealistic expectations; factors that may affect both satisfaction and sustainability of such programmes.

This evaluation builds on a randomised controlled trial⁸ conducted at the same facility, which demonstrated that a 12-week WhatsApp-based educational intervention significantly improved ANC visit completion, pregnancy-related knowledge scores and reduced pregnancy-related anxiety among 310 pregnant women in Yaoundé, Cameroon. The main objective of this mixed-method study was to explore women’s usefulness and satisfaction perceptions of the pregnancy-related WhatsApp-based educational programme among participants who completed the intervention.

Method

Study design

This study used a mixed-methods sequential explanatory design to evaluate women’s perceptions of the usefulness and satisfaction with a WhatsApp-based educational intervention aiming to improve access to pregnancy care. A purposive sampling strategy was used to select diverse participants for the qualitative component based on parity, WhatsApp engagement and sociodemographic characteristics, while all remaining women were invited to participate in the quantitative component of the study. Data for the quantitative component were collected through a structured KoboToolbox questionnaire shared via WhatsApp and through semi-structured interviews with selected participants for the qualitative component. Quantitative items on usefulness and satisfaction were adapted from the mHealth App Usability Questionnaire¹⁹ and analysed using descriptive and inferential statistics. Qualitative interviews were analysed thematically using Atlas.ti. Integration of findings followed the Pillar Integration Process.²⁰

WhatsApp-based education intervention

The clinical trial consisted of 12 weekly educational videos on pregnancy-related topics, delivered via 3 WhatsApp groups of averagely 51 pregnant women. Groups were moderated by nurses who responded to women’s concerns and questions. Details on the WhatsApp-based clinical trial can be found online.⁸ Summarily, the trial demonstrated that a 12-week WhatsApp-based educational intervention significantly improved early ANC initiation (adjusted OR (aOR) 2.8, 95% CI 1.9 to 4.1), ANC visit completion (aOR 2.1, 95% CI 1.4 to 3.2) and pregnancy-related knowledge scores among 310 pregnant women in Yaoundé, Cameroon.

Study setting and period

This study was conducted from January to March 2025 at the ANC unit of the Centre Médical Jean Zoa hospital, a faith-based hospital in the Centre region of Cameroon. Based on the national data reporting system (DHIS 2), the hospital receives the highest number of pregnant women for antenatal visits in the country, more than 400 new pregnant women monthly.

Qualitative component

We used the Standards for Reporting Qualitative Research (SRQR) reporting guideline²¹ to draft this manuscript, the SRQR reporting checklist²¹ and the Strengthening the Reporting of Observational studies in Epidemiology.²²

Approach and theoretical framework

The qualitative component of this study employed a descriptive qualitative approach to explore participants’ lived experiences with and perceptions of the WhatsApp-based maternal health intervention.²³ This approach was selected for its focus on understanding phenomena from participants’ perspectives without imposing predetermined theoretical frameworks, making it particularly suitable for programme evaluation and user experience research.

Our work was informed by the Technology Acceptance Model,²⁴ which posits that perceived usefulness and ease of use are key determinants of technology adoption and satisfaction. However, we adopted a largely inductive analytical approach, allowing themes to emerge from the data while remaining sensitised to concepts of usefulness, satisfaction, barriers and facilitators. This pragmatic paradigm prioritises practical understanding of participant experiences to inform programme improvement and implementation, aligning with the mixed-methods evaluation design.

The integration of qualitative and quantitative components allowed us to both measure satisfaction and usefulness quantitatively and understand the contextual factors and nuances underlying these perceptions.

Eligibility criteria

For the qualitative component, participants were eligible if they: (1) had completed the WhatsApp-based intervention, (2) were willing to participate in a 15–30 min audio-recorded interview and (3) were available for interview within 3 weeks of programme completion either in person at the facility or via telephone.

Data collection

For the qualitative component, we used purposive sampling to select 15 women who completed the clinical trial, aiming for maximum variation across key characteristics (parity, engagement level, age, education). Sample size was guided by information power principles, considering our narrow study aim, sample specificity, established theory use, high-quality dialogue and appropriate analysis strategy. Of the 15 invited, 12 (80.0%) accepted and were interviewed. Saturation of major themes was achieved by the 12th interview, with no substantially new themes emerging. Data was collected through one-on-one in-depth semistructured interviews, using a pilot tested interview guide exploring user experience, usefulness and ideas for improvement. The main questions presented in the guide were: (1) Tell me about your overall experience with the WhatsApp programme, (2) What aspects were most helpful or meaningful for you? Why? (3) What, if anything, was frustrating or unhelpful? (4) How did the programme affect your knowledge, your attitude and your confidence in giving birth? Online supplemental file 1 presents the complete interview guide used in this study.

Interviews were held either at the hospital (women coming for their postpartum visit or for their child vaccination) or via phone calls, depending on participants’ preference. Each interview lasted between 15 and 30 min and was conducted within 1–3 weeks following programme completion. All interviews were audio-recorded with women’s permission, and interviewers took notes to capture contextual details and initial impressions.

Researcher characteristics and reflexivity

Qualitative interviews were conducted by a trained qualitative female researcher, with a master’s degree and 5 years experience in maternal health research and qualitative methods. The interviewer’s prior involvement in implementing the intervention provided contextual understanding but presented potential for social desirability bias. To mitigate this, the interviewer emphasised that honest feedback, including negative experiences, was valued and would not affect participants’ healthcare.

The research team recognised potential confirmation bias given our interest in demonstrating programme effectiveness. We addressed this by actively seeking disconfirming evidence during analysis, prioritising critical comments and suggestions for improvement, and engaging in reflexive team discussions. The lead analyst maintained reflexive notes documenting initial assumptions and instances where data challenged expectations. Member checking was not feasible due to resource constraints.

Data analysis

Audio recordings were transcribed verbatim, and transcripts were uploaded into Atlas.ti for analysis. A thematic analysis approach was employed: two researchers independently coded the transcripts, compared their coding frameworks and resolved discrepancies through discussion. Codes were grouped into categories and then into overarching themes that reflected participants’ experiences and satisfaction with the programme. Reflexivity memos were maintained throughout to document researchers’ assumptions and potential biases. Final themes were validated through team discussions and by checking against raw data to ensure consistency and credibility.

Quantitative component

Eligibility criteria

For the quantitative component, participants were eligible if they: (1) had been enrolled in and completed the WhatsApp-based educational intervention clinical trial, (2) had access to a smartphone with internet connectivity and (3) were not selected for the qualitative interviews.

Data collection

For the quantitative component, we employed exhaustive sampling of the remaining 140 women who completed the trial, of whom 132 (94.3%) completed the questionnaire, providing sufficient power to detect meaningful differences in satisfaction and usefulness scores. Baseline data (demographics, medical history, pregnancy outcome variables) were retrieved from the clinical trial database. Baseline variables were defined and collected as described in the parent trial.⁸ In the original trial, these data were collected at enrolment through interviewer-administered questionnaires completed by trained research assistants during participants’ ANC visits. Medical and obstetric history data were extracted from participants’ ANC records with their permission and verified through participant interview. Usefulness and satisfaction data were collected through a structured questionnaire, built in KoboToolbox software.²⁵ The questionnaire was shared to women through a link via study WhatsApp groups, and the research assistant, with the support of the data manager, monitored the completion of the questionnaire by women. In addition, individual follow-up was done through individual WhatsApp messages and phone calls for clients who did not complete the form, 1 week after the questionnaire link was shared in the WhatsApp group.

Usefulness and satisfaction questions were adapted from the mHealth App Usability Questionnaire.¹⁹ The usefulness was evaluated through five items ((1) The programme was useful for my health and well-being; (2) The programme improved my access to healthcare services; (3) The programme helped me manage my health effectively; (4) This programme provided all the information I expected to receive; (5) WhatsApp platform provided an acceptable way to receive healthcare education) and the satisfaction was evaluated using four items ((1) I am satisfied with the quality of the information provided during the programme; (2) I am satisfied with the frequency of sharing the educational videos; (3) I am satisfied with the quality of interactions with the healthcare providers in the WhatsApp groups; (4) I will recommend this programme to my friends). All items were scaled using a 7-point Likert scale with the following anchors: 1=‘Strongly Disagree’, 2=‘Disagree’, 3=‘Somewhat Disagree’, 4=‘Neither Agree nor Disagree’, 5=‘Somewhat Agree’, 6=‘Agree’, 7=‘Strongly Agree’.

Analysis

Data were summarised using numbers and percentages for categorical variables and mean (SD) for continuous variables. The satisfaction and usefulness scores for each participant were computed by summing the scores of each item, giving the possible range for overall usefulness of 5–35 and for satisfaction of 4–28.

Normality of the composite usefulness and satisfaction scores was assessed using both graphical methods (histograms with superimposed normal density curves, figure 1) and Shapiro-Wilk tests. Both usefulness (W=0.987, p=0.247) and satisfaction (W=0.994, p=0.816) demonstrated approximately normal distributions, supporting the use of parametric statistical methods.

Figure 1. Histograms with superimposed normal density curves for usefulness and satisfaction scores.

For bivariate comparisons, independent samples t-tests were used to compare usefulness and satisfaction scores across participant characteristics with two categories, and one-way analysis of variance was used for variables with more than two categories. Variables for inclusion in bivariate analysis were selected a priori based on theoretical frameworks and previous literature on digital health intervention acceptability. Variables showing significant associations (p<0.05) in bivariate analysis were subsequently included in multiple linear regression models to assess their independent effects on perceived usefulness and satisfaction scores. Model assumptions (linearity, homoscedasticity and normality of residuals) were verified through diagnostic plots.

Data integration of quantitative and qualitative parts

The mixed-methods sequential explanatory design was used to connect the quantitative and qualitative components of the study.²⁶ A four-stage technique of the Pillar Integration Process was used to integrate and present data from quantitative and qualitative findings.²⁰

Patient and public involvement

Pregnant women were not involved in the initial design of this evaluation study. However, the qualitative component of this mixed method study explicitly incorporated participant perspectives, experiences and suggestions for programme improvement. Results will be disseminated to study participants through a summary document shared via the WhatsApp groups and presented at the study facility’s community health forum. Participants will also receive individual summaries of key findings and how their feedback contributed to recommendations for future programme iterations.

Results

All participants in this evaluation were enrolled in the intervention arm of the parent randomised controlled trial and completed the full 12-week WhatsApp-based educational programme. Among the 155 women who completed the clinical trial, 15 were chosen to participate in the one-on-one in-depth interview, among which 12 (80.0%) accepted and were interviewed. The remaining 140 women were invited to the quantitative component, among which 132 (94.3%) accepted and completed the structured questionnaire. In total, 144 women participated in this evaluation study.

Baseline characteristics of participants

The baseline characteristics of participants presented in online supplemental table 1 show that in the quantitative components, 62 (47.0%) women were aged 25 years or below, 82 (62.1%) were single and 32 (24.2%) women were primiparous. Regarding education, 13 (9.8%) women had primary education level, 56 (42.4%) had secondary education and 63 (47.7%) women had university-level education. In the qualitative component, six participants were 25 years or below (50.0%). Most were single, with 8 (66.7%) participants compared with 4 (33.3%) who were married. In terms of education, 3 (25.0%) had primary education, 4 (33.3%) had secondary education and 5 (41.7%) had university education.

Usefulness of the intervention

On a scale from 5 to 35, the overall perceived usefulness mean score was 30.6 (SD 4.5). Participants perceived the WhatsApp-based programme as highly useful for their health and well-being (mean: 6.2; SD 0.7) (table 1). This finding was supported by qualitative narratives in which women described the intervention as enhancing their confidence and reassurance during pregnancy. They emphasised the value of being able to quickly ask questions in the WhatsApp group and receive answers from nurses, which offered psychological support and reduced anxiety.

Table 1. Pillar integration joint display of quantitative and qualitative findings on the women perceived usefulness of a WhatsApp-based education intervention for pregnancy care in Yaoundé, Cameroon.

Quantitative data (n=132)	Quantitative category	Pillar building themes	Qualitative category	Qualitative codes (n=12)
The programme was useful for my health and well-being. Mean 6.2 (SD 0.7)	Perceived usefulness for maternal health and well-being	Improved maternal confidence, reassurance and psychological well-being	Enhanced sense of support and emotional security	“I appreciated this initiative a lot. I was able to receive information on how to eat well and what to eat during pregnancy.” #2 “I was able to quickly ask questions to the nurse in the group when I was feeling some malaise, and their responses was reassuring me and reduced my anxiety” #4
The programme improved my access to healthcare services. Mean 5.8 (SD 1.1)	Access to healthcare	Facilitated navigation and engagement with health services	Improved service access and continuity of care	“In the WhatsApp group, I had information on the closing time of the service, and I was able to come to the facility after my work and was sure to meet nurses” #1 “During one of my visits to the hospital, I missed some laboratory exams, and I had time only on Saturday. I ask in the group if the lab was opened on Saturday and I got the information and I went to the facility and got my exams done” #11 “During one of the videos, the nurse explained the importance of doing at least 8 visits during the pregnancy. That help me to complete all my 8 visits during this pregnancy whereas, during my previous pregnancies, I was doing maximum 4 visits” #3
This programme provided all the information I expected to receive. Mean 6.5 (SD 0.5)	Satisfaction with comprehensiveness of information	Exceeding expectations through comprehensive and high-quality content	Information richness and breadth	“Yes, I received more information than I was expecting” #7 “The videos touched all the aspects of the pregnancy. I was really impressed by the quality of the information and there were many things that they said that I wasn’t aware of” #10
WhatsApp platform provides an acceptable way to receive healthcare education. Mean 5.3 (SD 1.0)	Acceptability of WhatsApp as a delivery platform	Culturally appropriate and socially supportive medium for health education	Normalisation of digital health education & peer support	“This initiative was wonderful! It used an app that we are using every day to help us during our pregnancy” #12 “The app helps us to share our experiences and to encourage each other. Some time, when you are alone, it is difficult. But been able to discuss with other pregnant women do a lot of good” #3

SD, Standard Deviation.

The programme was also considered to improve access to healthcare services, with a mean score of 5.8 (SD 1.1). Women shared examples of how the platform facilitated navigation through health services, such as receiving information about facility and laboratory opening days and hours. This allowed them to complete their ANC visits and laboratory tests. Others noted that the educational videos highlighted the importance of completing at least eight antenatal visits, motivating them to attend more regularly compared with previous pregnancies.

The perceived comprehensiveness of information shared in the intervention was particularly strong, with a mean score of 6.5 (SD 0.5). Participants explained that they had received more information than expected, and the videos touched on all aspects of pregnancy, from nutrition to routine check-ups. Many expressed surprise at the breadth and quality of the content, noting that they learnt new and important things they had not been aware of before.

The acceptability of WhatsApp as a platform for health education was well rated, with a mean score of 5.3 (SD 1.0). Women described the initiative as ‘wonderful’, highlighting that it leveraged a familiar and widely used app to deliver education. Beyond receiving information, they valued the opportunity to share experiences and encourage one another, underscoring the role of WhatsApp as a socially supportive and culturally appropriate medium that fostered peer connection during pregnancy.

User’s satisfaction with the intervention

The overall mean of women’s satisfaction was 25.1 (SD 1.7) on a scale ranging from 4 to 28. Women expressed strong satisfaction with the quality of educational content (mean 6.4, SD 0.6). This was reinforced by qualitative interviews (table 2), where participants valued the clarity and credibility of the video, noting that the materials were well-designed and delivered by trusted nurses (nurses they encounter during their ANC visits at the facility), which facilitated comprehension and assimilation of health information.

Table 2. Pillar integration joint display of quantitative and qualitative findings on women’s satisfaction with a WhatsApp-based education intervention for pregnancy care in Yaoundé, Cameroon.

Quantitative data (n=132)	Quantitative category	Pillar building themes	Qualitative category	Qualitative codes (n=12, interviews)
I am satisfied with the quality of the information provided during the programme. Mean 6.4 (SD 0.6)	Satisfaction with quality of educational content	Clear, credible and engaging delivery of health information	Positive perception of video-based education	“The fact that the education was done through videos was very good. It helps to assimilate the information easily” #6 “The videos were very clear and well designed. The fact that the videos was done by the nurses we are seeing every day we go the hospital was something good” #11
I am satisfied with the frequency of sharing the educational videos. Mean 4.3 (SD 0.8)	Satisfaction with frequency of content delivery	Desire for increased frequency and diversified educational formats	Mixed views on adequacy of video frequency	“The frequency was acceptable, but we wanted to have educational videos more frequently like two videos per week instead of one each week” #8 “Having videos once a week was good. But it would have been good if withing the week, additional information could be share by other means like flyers, text messages, photo, …” #3
I am satisfied with the quality of interactions with the healthcare providers in the WhatsApp groups. Mean 5.5 (SD 0.8)	Satisfaction with provider engagement	Trustworthy but sometimes delayed provider interactions	Reliability versus timeliness of responses	“It was a great idea to have nurses in the group. We were able to have information from the trusted source” #12 “The health care providers were responding to our questions. But they liked to refer us to the hospital when we were asking them to prescribe some medications to us” #2 “Nurses were taking too much time to respond to our questions” #6
I will recommend this programme to my friends. Mean 6.8 (SD 0.1)	Programme recommendation and endorsement	Endorsement of intervention and desire for continuity beyond pregnancy	Willingness to recommend and sustain programme	“Of course, I will recommend it to my friends” #11 “During my next pregnancy, I would like to benefit from the same program” #6 “It is possible to keep the WhatsApp group opens so that we can continue to interact with nurses and women? We still have challenges around taking care of our babies” #1

SD, Standard Deviation.

Satisfaction with the frequency of content delivery was mixed. While the overall score was above average (mean 4.3, SD 0.8), interviews revealed that participants appreciated receiving weekly videos but often desired more frequent and diversified educational formats. Several suggested two videos per week or complementary materials such as flyers, text messages and photos, indicating that while the programme met baseline expectations, there was interest in greater intensity and variety of content delivery.

Regarding the provider’s engagement, satisfaction was moderate (mean 5.5, SD 0.8). Qualitative findings highlighted that participants valued having nurses in the groups as a trusted source of health information. However, concerns were raised about the timeliness and depth of responses, with some participants noting delays or being redirected to health facilities when bringing specific requests such as medication prescriptions. This points to a tension between the reliability of provider engagement and the responsiveness expected by participants.

The programme generated strong endorsement among participants, with the highest satisfaction score observed for willingness to recommend the intervention to others (mean 6.8, SD 0.1). Qualitative narratives underscored this enthusiasm, as women not only expressed willingness to recommend the programme to friends but also expressed a desire for continuity of the WhatsApp groups beyond pregnancy. Participants emphasised the value of sustained peer support and ongoing interaction with healthcare providers to address challenges in newborn care and postpartum health.

Group comparison of usefulness and user’s satisfaction

The comparison of overall usefulness scores across baseline characteristics (see online supplemental table 2) showed that, in crude analyses, younger women (≤25 years) reported significantly higher usefulness compared with those older than 25 years (mean 32.7 vs 28.8; p<0.001). Similarly, primiparous women rated the programme as more useful than multiparous women (mean 34.9 vs 25.3; p<0.001), and those with a history of abortion (mean 31.8 vs 28.3; p=0.001), premature birth (mean 31.4 vs 28.3; p<0.001) or early neonatal loss (mean 30.9 vs 27.9; p=0.045) also reported greater perceived usefulness. Education level was associated as well, with women who had primary or secondary education reporting lower usefulness scores compared with those with university education (p=0.002 and p=0.007, respectively). After adjustment, only parity and educational level remained significantly associated with overall usefulness. Primiparous women continued to report higher usefulness scores than multiparous women (coefficient 9.5, 95% CI 8.5 to 10.5; p<0.001), and women with primary education had lower usefulness scores compared with those with university education (coefficient −1.1, 95% CI −2.2 to −0.1; p=0.019).

The comparison of satisfaction scores across baseline characteristics is presented in online supplemental table 3. It shows that younger women (≤25 years) reported slightly higher satisfaction scores compared with those older than 25 years (mean 25.9 vs 25.4; p=0.035), and women identifying with ‘other’ religions reported lower satisfaction compared with Catholics (mean 23.8 vs 25.6; p=0.034). After adjustment by parity, age and religion were no longer correlated with the satisfaction rate.

Discussion

This mixed-methods evaluation provides empirical evidence on user perspectives of WhatsApp-based maternal health education, addressing a critical gap in the digital health literature. While previous studies have demonstrated the effectiveness of such interventions on clinical outcomes,^{9 10 13} this study is among the first to systematically examine both perceived usefulness and satisfaction using validated instruments combined with in-depth qualitative exploration in a sub-Saharan African context.

The programme was perceived as highly useful for enhancing health and well-being, improving access to care and providing comprehensive pregnancy-related information. Participants reported that the ability to interact directly with nurses via WhatsApp groups offered reassurance, reduced anxiety and encouraged adherence to recommended antenatal visits. These findings are in accordance with evidence from previous mHealth interventions, which have shown improvements in care-seeking behaviour, maternal confidence and ANC attendance when digital tools are used to deliver health education and reminders.^{27 28} The comprehensiveness of the video-based education was praised, suggesting that visual and interactive content may play a critical role in bridging knowledge gaps among pregnant women, particularly in low-resource settings where routine counselling is often limited.

Satisfaction levels were also high, particularly with respect to the quality of the educational content and willingness to recommend the programme. The strong endorsement underscores the intervention’s perceived credibility and relevance, which has been documented as aligning with findings from prior studies where trust in the source of health information and involvement of health professionals in mHealth interventions was a determinant of programme success.^{29 30} Nonetheless, areas for improvement were identified. Some women desired more frequent and varied educational content, reflecting the evolving needs of pregnant women for continuous and diverse health information.

While the presence of healthcare providers in the groups was highly valued, some women expressed concerns about delays in responses or being referred to health facilities when they sought medication prescriptions in the WhatsApp groups. This suggests that provider engagement strategies may require strengthening, such as through dedicated staff or clearer protocols for addressing participants’ concerns. However, referrals to the hospital should not be interpreted as a weakness of the intervention but rather as an essential safeguard, since prescribing medications during pregnancy requires a complete clinical evaluation, including physical and laboratory examinations, to ensure maternal and fetal safety.³¹ The decision to direct women to health facilities for prescriptions not only reflects adherence to safe clinical practice but also highlights the complementary role of digital interventions alongside face-to-face care.³² However, this finding underscores the importance of preparing women prior to their enrolment into the programme by informing them on the fact that the digital intervention is intended for health education, counselling and guidance, but not for clinical diagnosis or prescribing.³³ Setting this expectation before the intervention could reduce frustration and reinforce appropriate care-seeking behaviours, while still allowing women to benefit from timely reassurance and information delivered digitally.

The use of WhatsApp was highlighted as both culturally appropriate and socially supportive. Beyond information delivery, participants valued the peer interaction fostered within the groups, which created a sense of community and reduced isolation. This social dimension has been emphasised in other studies of digital health interventions, where peer support is seen as a key mechanism for sustaining engagement, improving well-being and satisfaction with an mHealth intervention.^{34 35}

The analysis showed that parity and educational level were correlated to women’s perceptions of the usefulness of the WhatsApp-based intervention. Primiparous women consistently rated the programme as more useful compared with multiparous women, suggesting that women experiencing pregnancy for the first time may have a greater need for information, reassurance and continuous support.³⁶ This aligns with existing literature showing that first-time mothers often face heightened anxiety, information gaps and a stronger demand for educational interventions to guide them through pregnancy and childbirth.^{37 38} Digital health programmes delivered via widely accessible platforms such as WhatsApp may therefore provide timely and reliable information, fill critical knowledge gaps and reinforce health-seeking behaviours in this group.

Women with only primary education reported lower intervention’s usefulness compared with those with university education. This finding is consistent with evidence that educational attainment shapes health literacy, influencing individuals’ ability to interpret and apply health information delivered through digital tools.³⁹ Women with higher education may find it easier to navigate digital interventions, extract relevant health messages and engage actively with the content, while those with lower educational attainment can face barriers, leading to poor digital health literacy and reduced ability to benefit from emerging digital health tools. These findings highlight the need to tailor digital maternal health interventions to be inclusive and accessible for women across different literacy levels, ensuring that simplified language, visual aids and repeated reinforcement of key messages are integrated into programme design.

The overall high satisfaction rate observed across all sociodemographic and obstetric groups suggests that the WhatsApp-based intervention addressed a cross-cutting need for knowledge, reassurance and support during pregnancy. This finding indicates that regardless of age, education, parity or previous pregnancy experiences, women in our study setting valued the accessibility and responsiveness of the programme. Similar studies have shown that pregnant women, irrespective of background, often face uncertainties, information gaps and psychological stress that can be mitigated by structured health education and supportive communication.⁴⁰ Digital platforms such as WhatsApp offer a scalable, familiar and low-cost means to bridge these gaps by providing tailored information, direct interaction with healthcare providers and peer support networks, thereby meeting needs that cut across demographic categories. These findings reinforce the idea that digital maternal health interventions can be broadly acceptable and impactful, while still requiring careful design to ensure inclusivity for women with varying literacy and digital skills.

Study limitations

This study has several methodological limitations. Statements measuring usefulness and satisfaction were positively framed, which may introduce acquiescence bias. Participants may have been inclined to agree with favourable statements about the intervention. Social desirability bias cannot be excluded, particularly given that the intervention was delivered within a healthcare setting and moderated by nurses known to participants. Although interviews were conducted by researchers who were not direct care providers, participants may still have perceived a connection to the intervention team. Finally, the study was conducted in a single high-volume faith-based hospital, which may limit generalisability to other contexts.

Conclusion

This mixed-methods study evaluated the perceived usefulness and user satisfaction of a WhatsApp-based education intervention designed to improve access to pregnancy care among women. The findings revealed that the programme was perceived as highly beneficial for enhancing access to maternal health information, facilitating communication with healthcare providers and fostering emotional and social support during pregnancy. Participants valued the quality, clarity and relevance of the educational content and recognised WhatsApp as a convenient and acceptable platform for learning and engagement. However, some participants expressed the need for more frequent updates and quicker responses from healthcare providers. Together, the quantitative and qualitative findings underscore the potential of mobile messaging platforms to complement traditional antenatal education and strengthen continuity of care, particularly in low-resource settings. Future research should examine the long-term effects, scalability and integration of such digital tools within routine maternal health programmes. Overall, this study provides evidence that leveraging widely used social media applications like WhatsApp can be a practical, low-cost and user-centred approach to improving maternal health outcomes.

Data availability statement

Data are available upon reasonable request.