Using mHealth in postpartum women with pre-eclampsia: Lessons learned from a qualitative study

Abstract

Objective:

To explore perceptions and attitudes of postpartum women with pre-eclampsia towards remote monitoring (mHealth) and communication with the call center.

Methods:

A non-randomized cohort study was conducted in postpartum hypertensive women, recruited from a tertiary hospital between October 2015 and February 2016. Participants were categorized into users (using mHealth) and non-users (not using mHealth) to monitor vital signs at home over a 2-week period after discharge. Non-users were informed about functionality of mHealth. Both groups participated in a 30-minute phone interview at the end of the study. Directed content analysis of interview transcripts was conducted.

Results:

In total, 21 users and 16 non-users participated in the interview. Both groups perceived that mHealth helped manage their condition. However, non-users were concerned about the challenge of incorporating mHealth into their routine, whereas users mentioned that they liked using mHealth on a daily basis. They also stated that communication with nurses in the call center was helpful. Barriers identified by users included size of the blood pressure cuffs, size of the equipment set, wireless connection, and stress associated with mHealth monitoring. Users stated that they would have preferred using mHealth during pregnancy.

Conclusion:

The findings provide useful insights to inform a successful remote monitoring program among perinatal and postpartum women.

1. INTRODUCTION

Current evidence-based practices indicate that pregnancies complicated by pre-eclampsia can be monitored closely on an outpatient basis with frequent clinic visits before delivery or inpatient hospital monitoring until delivery [1, 2]. Such monitoring could be achieved remotely, safely, and effectively through the combination of using mobile health (mHealth) technologies and outpatient services for appropriate management [3–8]. A remote monitoring using mHealth in pregnant women during the prenatal period has shown positive results in decreasing healthcare costs and improving outcomes in newborns [6, 9]. It offers patients the ability to better manage chronic conditions, transfers real-time information with integrated devices, improves clinical decision-making, provides necessary emergency care, and delivers patient care directly at their homes, which makes healthcare more accessible [10–12]. Use of mHealth is further beneficial to those residing in rural areas with limited obstetrical healthcare services. High-risk pregnant women with pre-eclampsia residing in rural communities are often transferred to urban tertiary care centers before delivery where the travel time could be several hours from patient’s home [13]. The use of mHealth technologies has the potential to address this challenge by offering the ability to remotely monitor patients’ wellbeing, particularly the vital signs in postpartum or pregnant women with pre-eclampsia. mHealth can assist in transferring measures of vital signs in real time to a centralized location staffed by nurses for continuous monitoring. This, in addition to improving the communication between the pregnant woman and the healthcare team, also provides nurses the opportunity to triage and intervene if the vital signs deserve intervention [14]. However, studies reporting the feasibility of the use of mHealth technologies to remotely monitor postpartum or pregnant women with pre-eclampsia are limited, considering widespread availability of mHealth technologies in the U.S. market [3–5, 7, 14, 15].

To promote the uptake of mHealth technologies in obstetrical care, it is important to have a full understanding about the perceived usefulness and ease of use, perceived barriers, and attitudes of pregnant women associated with the use of mHealth technology. The present study provided in-depth information from qualitative interviews of users and non-users of the mHealth technology for future dissemination of mHealth in monitoring pre-eclamptic postpartum care. The aims of the present study were to: (1) explore perceptions and attitudes of postpartum women toward mHealth; (2) identify facilitators and barriers of using mHealth; and (3) document views toward call center communication for integrating mHealth into possible standard of care.

2. MATERIALS AND METHODS

The present study was a part of a pilot, non-randomized cohort study conducted in women with postpartum hypertension for 2 weeks after discharge from the hospital [14]. Women aged 18 years and older, who were delivering a baby at a university hospital between October 2015 and February 2016, were invited to participate if they were diagnosed with pre-eclampsia during pregnancy, intrapartum, or postpartum, and spoke English. Women were excluded if they had psychiatric disorders or did not have access to a telephone 24/7, which was needed for the call center nurses and research staff to communicate with participants. All participants provided a written consent to participate in the study. The study protocol was approved by the UAMS Institutional Review Board (IRB#203360).

Participants who met the eligibility criteria and consented to the study were offered an option to use (users) or not use (non-users) the mHealth technology for monitoring vital signs at home after hospital discharge. Vital signs included blood pressure, weight, and level of oxygen. Individuals in the user group were given mHealth devices to take home and participated in the exit interview after the 2-week study period. They received US$50 as compensation for their participation. Those who elected not to use the mHealth technology were asked to participate in a phone interview 2 weeks after discharge from the hospital and were offered US$20 to compensate their time.

A research staff member explained and demonstrated how to use mHealth devices to each participant regardless of their use status during their hospital stay. Users were asked to demonstrate how to use mHealth devices before taking them home. They were also instructed to call the research staff or the call center if they had any trouble with the mHealth devices. The call center with information technology support is operational 24/7.

The mHealth technology set, Ideal Life Inc. (Toronto, ON, Canada), included a pod with cellular connectivity and three peripheral devices to monitor weight, pulse, oxygen saturation, and blood pressure. These devices were connected via Bluetooth to wirelessly transmit information or readings to a “caregiver Portal” (Verizon’s Converged Health Management), a secured cloud-based database. Nurses at the call center received alerts if any of the vital signs or daily question answers were outside the parameters set by the obstetrical healthcare team and would call the participant to triage the reading(s) outside of the parameters. Results on health outcomes, treatment adherence, and survey of the use of mHealth technology were previously reported [14].

A semi-structured interview guide was used for all telephone interviews in both the user and non-user groups, containing several open-ended questions about perceptions toward use of mHealth for managing pre-eclampsia, advantages and/or disadvantages of mHealth, how it was associated with stress/anxiety both positively and negatively, possible barriers of mHealth, and their experience with the call center (only for the users). All interviews were recorded and transcribed verbatim. All transcriptions were de-identified and analyzed using MaxQDA Plus 12 (VERBI Software, Berlin, Germany). Directed content analysis was conducted using a coding book developed from the interview guide. This technique has been used to systematically describe and quantify phenomena extracted from written and verbal communication [16].

To ensure the consistency of the analysis, five interviews were first coded by three coders in a 2-week run-in period using the initial codebook and an inductive approach. Few new codes emerged and were added to the final codebook. For the final analysis, each interview transcript was randomly assigned and independently analyzed by two coders. The coders met weekly and used a constant comparison approach to discuss and resolve discrepancies on codes until agreement was achieved. Descriptive statistics and excerpts from interviews were presented to provide in-depth understanding of the phenomena. Relationships among phenomena were displayed in a concept theory, similar to a concept mapping [17], which graphically shows the associations and degree of associations among analyzed topics.

3. RESULTS

Of the 48 participants, 37 (77.1% completion rate) completed the interview. Twenty-one (84% response rate) were from the user group and 16 (69.6%) were from the non-user group. Demographic and clinical characteristics of the two groups were similar in terms of age, race, marital status, education, income, geographic location, delivery complication, and history of hypertension during a prior pregnancy [14]. The results were presented elsewhere [14].

The content analysis shows that both groups perceived that the mHealth technology helped manage their pre-eclampsia and stated that mHealth was beneficial (Table 1). Half of the non-users mentioned the challenge of using mHealth on a daily basis during the postpartum period, which might be one of the reasons they decided not to use mHealth. On the other hand, participants who used mHealth said that they felt comfortable taking their blood pressure every day so they did not have to go to a clinic or hospital for blood pressure checks. The majority of users also stated that knowing their blood pressure decreased their stress and anxiety. Some users also mentioned that they would have used the mHealth device during pregnancy, which would have helped monitor their pre-eclampsia.

Table 1.

Perceptions toward mHealth that were discussed among users and non-users.^a

Topicb	Non-usersb (n=16)	Usersb (n=21)
Help with condition management	93.8	100.0
Daily use of mHealth
Daily use challenge	50.0	38.1
Daily use negative	25.0	43.1
Daily use positive	18.7	61.9
mHealth technology
Failure
Scale		33.3
Blood pressure cuff		23.8
Benefit	100.0	95.2
Ease	68.7	100.0
Barrier	31.2	52.4
Before: Perception toward mHealth
Negative	43.7
Positive	93.7
After: Perception toward mHealth
Negative		14.3
Positive		100.0
Experience with ANGELS Call Center
Useful information		76.2
Challenging communication		19.0
Easy communication		90.9
How mHealth impacts stress
Increase	25.0	23.8
Decrease	56.2	76.2
How mHealth impacts anxiety
Increase	31.2	28.6
Decrease	75.0	85.7

^aValues are given as percent.

^bPercentages presented on each subtopic were independent from each other. Therefore, the percentage of each topic will not add up to 100%. For example, 93.7% (n=15 out of 16) of non-users discussed their positive perception toward mHealth and 43.7% (n=7 out of 16) discussed about their negative perception toward mHealth.

Figure 1 presents the relationships among topics, extracted from users and non-users. Users discussed the benefits of mHealth (tech benefit) and how easy it is to use when they were asked about their perception toward mHealth. Ease of communication between users and the call center was also frequently described when users reflected their positive perception of mHealth, along with the usefulness of the information provided by the nurse. Advantages of mHealth from users’ perspectives were related to the opportunity to use daily (i.e. knowing their daily blood pressure) and to self-manage their condition. To a lesser degree, some users were overwhelmed with the frequent communication with the call center and the stress of taking and potentially retaking their blood pressure daily. Non-users also reported a positive perception toward mHealth and recognized the potential benefit of mHealth. However, they often discussed their perceived challenge of the twice daily monitoring of vital signs with the mHealth equipment that was required for them to participate in this study (i.e. measured blood pressure, weight, pulse, and oxygen saturation level twice a day). Table 2 describes each discussed topic in detail and provides sample excerpts from interviews.

Figure 1.

Relationships between perceptions of users and non-users.

Note: 1) Pre-perception was only coded for non-users and post-perception was only for users; 2) Neither the position (e.g., top, bottom, right, left) of each code nor distance between the codes is important, only the frequency (represented by the size of the dash line between the codes).

Table 2.

Summary and examples of excerpts extracted from interviews with users and non-users.

Topic	Summary	Users	Non-Users
Positive perception toward mHealth	The majority of participants viewed that using mHealth to monitor their blood pressure is beneficial because it can save their time traveling to the outpatient clinic or the emergency department and the benefit of having real-time communication with healthcare providers in the call center.	“I think it was a good decision. As far as people with pre-eclampsia, dealing with pre-eclampsia, I really think it was the best thing, because twice I had to go back to the ER. It really helped me, because if I didn’t have it, I would probably be still at home suffering.”	“I thought it was good, especially for families like us who lived in rural areas, because it allowed us instant communication with nurses and specialists who could deal and address any of my blood pressure concerns.”
Negative perception toward mHealth	Few participants perceived they may not be able to add more responsibilities to their busy schedule at home after delivery. One user mentioned that being monitored closely by the call center created stress as she had not had any symptoms or problems.	“I think it actually kind of stressed me out because they (the call center) called me like every night. I was like, ‘I’m fine’.”	“I was highly overwhelmed in the hospital, and I thought that it would be very overwhelming to add that on top of going home.”
Condition management toward mHealth	Most participants appreciate the fact that they could measure their blood pressure themselves and knowing their condition empowered them to take control of their health.	“That I knew what my blood pressure was. If it was high, it wasn’t like I was going to just get sick from it. It didn’t go that far because I knew what it was. I was checking it twice a day. I knew how much weight I was losing, and all of that. It kind of helped me keep an eye on it, so just in case it did get to a dangerous level.”	“I think it’s very helpful to help with your health.”
Daily use challenge	More than half of the participants admitted that it was difficult to add twice daily monitoring of their blood pressure, weight, and oxygen level in their daily schedule as they had to take care of the newborn baby, other children, house chores, and also themselves.	“I just had to figure out how to balance a newborn and a toddler with doing anything around the house at the same time and resting.”	“I was balancing between living 4 and a 1/2 hours away, having a 6-year-old, and then having a baby in the NICU, and just having a cesarean. It was a lot, it was a lot to try to keep up with, having to do all those little things up and record them on top of just trying to get better, and making trips down to Little Rock, and then having to still be a part of your family life. It was just, like you said, I just didn’t because of those reasons.”
Daily use negative	Negative perceptions in using mHealth are resonate with the challenges in adding the remote monitoring in their busy schedule. A few had newborns that were still in a hospital in which required them to travel back and forth between home and hospital. Having the task of monitoring themselves for worsening symptoms of pre-eclampsia became a hassle.	“I’m having to test double over what I was supposed to each day.”	“Even though they take just a few minutes to use, like I previously said, I’m going back and forth from the hospital, it felt like there was a lot more important things to be done with your time and then reminding yourself to do it and then going, ‘Okay, I need to sit down and do that,’ and actually sitting down and doing it.”
Daily use positive	The majority recited the perceived benefit of knowing their current vitals often and at home.	“I think it was great, because that way I could tell where it all was, in the mornings and at night, just I liked it.”	Not applicable.
Benefit of mHealth technology	Participants stated that having the mHealth device at home was beneficial as they can avoid traveling and also gave them a sense of relief as they can monitor their blood pressure at home.	“Because a lot of time we never have no blood pressure thing (access to a blood pressure device) when you’re out and about in everyday in life, including your home.” “I think having it at home and monitoring it would be a lot less stressful than having to go out and have it monitored.”	“Sometimes I could tell my blood pressure is up and I said ‘I wish I had this stuff (mHealth) right now so I could check it’.”
Barriers of mHealth technology	Even though each mHealth device had cellular connectivity, the major barrier raised by users was transmission problems due to poor cellular signal. A few were bothered by the bulkiness of the mHealth device and peripherals and had a difficult time keeping them away from their children.	“I live in a dead zone out in the middle of the woods with pretty much no cell phone signal. I had to drive up the road about a mile and plug it into my car to get any readings at all to send.”	“Oh, it was kind of bulky, finding the space to put everything.”
Ease of mHealth technology	All participants in both groups recognized how easy the mHealth device is to use in the home. Some were worried at first but the training for using the device cleared their concerns.	“The fact that you just push a couple of buttons, you didn’t have to go through a whole bunch of stuff like connecting to the Internet, or sending it yourself, or things like that.”	“At first I didn’t think I was going to be able to do it, but once they showed me how to get it down, I mean it’s pretty easy to use. It was okay, it was all right.”
Easy communication with the call center	The majority of the users had a positive experience with their communication with the call center. The call center nurse normally stays on the line with them when they re-measure their blood pressure or provide step-by-step information to help with trouble shooting with the device. They viewed that the call center nurses were responsive and professional.	“Then one time, my house has horrible service, and they left a message. I mean I was so glad they did that. Otherwise, I would have never known they called, so it just made it easier for me. I called them right back, and they were always real sweet and helpful.”	Not applicable.
Useful information from the call center	Participants viewed that the call center nurse provided useful information to help them manage their condition.	“They were really sweet, really nice. Even when my blood pressure was up, they would call. They’ll be like, ‘Well, take your (blood pressure) medicine. Calm down. Recheck it and let’s see how you’re doing in a few hours’.”	Not applicable.
Challenging communication with the call center	Some participants reported feeling pressure from getting a call from the call center as they felt fine, but they still received unnecessary calls. On some occasions, they disagreed with the advice given by the call center nurse and got irritated when they did not want to follow the advice given.	“I know it was important and if it was high, you know, and that’s their job but I just felt like they wouldn’t take no for an answer.”	Not applicable.
Stress/Anxiety related to using mHealth	A few participants anticipated some difficulty with transmitting the readings to the hub and caused them stress and anxious. Some reported that it was less stressful to monitor their blood pressure at home, but some felt stress from knowing that their blood pressure was high.	“I was a little stressed about not being able to send readings. Then whenever I did finally get a reading to send, it would be some off-the-wall high one. There wasn’t like a normal one. It was one where my kid jumped on me. That was a little bit more stressful but…”	“I think having it at home and monitoring it would be a lot less stressful than having to go out and have it monitored.”

4. DISCUSSION

The present study sheds light on facilitators and barriers related to mHealth technology that was used to remotely monitor postpartum women with pre-eclampsia. The majority of participants had a positive perception toward self-monitoring using mHealth devices and the call center. The findings show that several factors should be considered and overcome before implementing a mHealth-related program. These can be categorized into four major factors: (1) features of mHealth technology; (2) size of a mHealth device set; (3) frequency of self-monitoring; and (4) threshold of an alert system that prompts healthcare providers to contact patients. While the mHealth devices used in this study were simple and easy to use, demonstration and training before sending them home with patients were crucial. Allowing patients to have a hand-on experience on how the mHealth device works gave them confidence and should lead to an increase in the uptake of mHealth technologies. The size of a mHealth device set may also impact the uptake as some participants had to travel with the devices between home and a hospital. This concern is valid and needs to be vetted when choosing or designing a mHealth device. Even though the devices had cellular connectivity, some participants reported problems about cellular connections to transmit results from mHealth devices. Some patients had to find a location to set up the device at home, be sent a cellular connection antenna, or had to drive to a location that allowed the readings to transmit from mHealth devices. This cellular connection issue created a concern and was perceived as a barrier to mHealth technology. Availability of information technology support became essential to help participants as needed.

Factors that inhibit mHealth pilots from reaching scale are multifaceted [18]. However, there is still limited evidence about the likely uptake or best strategies to implement these mHealth initiatives in real-world settings. A foundation of high-quality evidence on the efficacy and effectiveness of mHealth intervention would permit evidence-based scale-up [19, 20]. The literature shows that some patients appreciate the benefits of mHealth, while others may feel burdensome and refrain from using such technologies because of costs, ignorance, technophobia, and/or preference for in-person healthcare visits over being remotely monitored [21]. Costs were not an issue for patients participating in the present pilot study since the mHealth devices were lent to them and cellular connectivity was included with the device. Only a few participants in the non-user group expressed concern about using the mHealth technology. However, after being shown how to use the devices, they thought that they could use them. Additionally, it was not observed that participants in the present pilot study preferred in-person visits with their provider over monitoring their vital signs from home. This may be specific to what mHealth technology is used for and the health condition being monitored.

Both inpatient and outpatient management and treatment for pre-eclampsia in pregnancy, and also postpartum, can place a financial and social burden on affected women and families [22, 23]. A pregnant woman with pre-eclampsia who is a monitored inpatient must remain away from her family, sometimes in a hospital that is far from her home, for weeks until her delivery. Sometimes the woman has to be hospitalized because she is far from a hospital or clinic that can provide emergency triage and care, whereas a woman who lives close to a hospital can be managed on an outpatient basis. The hospitalization causes separation of the pregnant woman from her family and support system, which may include her other children, significant other, extended family, friends, and her community, and can prove to be a difficult situation. This is also a problem for postpartum women with a history of pre-eclampsia. Particularly in a state such as Arkansas with a large rural population, if the woman lives in a rural area, this can be an additional financial strain. While there is a skepticism whether self-monitoring blood pressure in pregnancy is safe and effective, self-monitoring blood pressure at home has the potential to free up the time of healthcare providers or reduce clinic visits [10, 24].

There is currently limited literature supporting the outpatient management of elevated blood pressure during pregnancy using a mHealth device. In Tucker’s study [25], 201 pregnant women received self-monitored blood pressure kits to use at home and were advised to note readings in a diary. They found that 84% of participants completed the study but persistence with self-monitoring was lower (66%). Lanssens et al. [4] recruited 48 pregnant women to the remote monitoring group to compare with 95 pregnant women in the conventional care group. The remote monitoring group received a wireless blood pressure monitor, wireless weight scale, and wearable pulse oximeter. They found that the remote monitoring group had a reduced appearance of pre-eclampsia compared to the conventional care group. The remote monitoring group also had a lower number of prenatal hospitalizations and their neonates were less likely to be admitted to intensive care. The findings were confirmed in their follow-up study [5]. The literature demonstrated the potential of mHealth to timely initiate and monitor blood pressure for gestational diabetes and pre-eclampsia. The findings from the present study reveal useful insights to inform a successful remote monitoring program for managing conditions for pregnant and postpartum women.

The first lesson learned from the present study is that it was critical to review and test a mHealth device before launching a research study. Although evaluated multiple types of mHealth equipment were evaluated, issues related to the device were still discovered, which might have contributed to the increased stress and anxiety among the participants. Most of the issues surrounded the size of the blood pressure cuff and the size of the mHealth device set. Women who had a large upper arm or were very small struggled to get accurate blood pressure readings. Second, it was also found that training participants helped minimize difficulty and anxiety related to technology. Timing of the initiation of mHealth was also voiced by some of the participants. Many wished they would have been monitored during pregnancy and continued the monitoring postpartum.

There are some limitations that need to be acknowledged. The present study was an exploratory study with a limited sample size from a single delivery hospital. Therefore, generalizability may be limited. Additionally, perceptions of participants toward mHealth intervention might be biased due to the incentive. Even though the incentive was small, it could have created a positive bias toward mHealth tested in the present study. Therefore, the findings on perceptions toward mHealth should be interpreted with caution. Lastly, the present study was a pilot study with a limited sample size in a single state and it was not a randomized trial. A full-scale randomized controlled study with a large sample size or multicenter study is warranted.

Future research should first confirm the findings from the present exploratory study and then explore the feasibility of integrating mHealth in standard care and its efficiency of using mHealth in monitoring elevated blood pressure in pregnant women, not just limited to the postpartum period. The costs of mHealth should also be assessed to demonstrate its “value” in order to facilitate adoption and dissemination of mHealth into a standard care for women with pre-eclampsia. It is believed that mHealth technology is a possible solution to expand care to women with pre-eclampsia in clinical practice, especially in a rural area (low-resource settings). It has the potential to save out-of-pocket spending for the patient and use of healthcare resources.

Synopsis.

This qualitative study reported a positive perception and attitudes toward mHealth self-monitoring of vital signs among postpartum women who had a history of pre-eclampsia.