Mobile health applications for pregnancy in Iran: Current state investigation

Abstract

BACKGROUND:

The expansion of pregnancy-related mobile applications has led to an increase in the usage of these applications by Iranian women, which has the potential to have a long-term impact on women's pregnancy health and, as a result, community health. The goal of this research was to investigate the state of pregnancy-related mobile applications in Iran.

MATERIALS AND METHODS:

This was a descriptive-applied research approach which was conducted in 2020. One hundred and fifty-seven pregnancy apps from different Iranian mobile app markets were installed and were examined in terms of the resources used and their validity, subject distribution, participation of obstetricians in the app development, apps volume, rank acquired by users and distribution of apps according to the developers. The relationship between the number of resources used and user rankings was also tested.

RESULTS:

A total of 157 apps were categorized into 12 subject categories based on their content. Only 1.3% of the apps were developed with the participation of obstetricians. Only 5% of the apps had used reliable information resources. Furthermore, the number of resources referenced in the studied apps did not have a significant relationship with star ratings (r = 0.03, P = 0.64), according to the Pearson correlation test.

CONCLUSION:

Iranian mobile applications in the field of pregnancy have grown significantly in terms of quantity, subject diversity, and user acceptance; however, the credibility of the information in these apps cannot be validated. This serves as a reminder to users to exercise caution while using such apps.

Introduction

Mobile health apps are easily available and ubiquitous software that enable health and clinical information on smartphones and tablets. Because of the ease of use and cheap cost of these apps, women have turned to health apps for information on prenatal and maternity care.[1] The quality of such apps is critical since it may have an impact on the health of pregnant women and, as a result, the community's health. As a result, it is critical to assess the current state and quality of these apps. The state of mobile health apps has been studied in Iran and throughout the globe, including the following research: Ghazi-Saeedi on the validity of resources in mobile health applications available in the online store Cafe Bazaar.[2] Ershad Sarabi on the role of mobile phone use in health care in Iran,[3] Langarizadeh et al. and Kalhori et al., on personal health record application for gestational diabetes,[4,5] Borjalilu et al. on the mobile applications in the delivery of mental health services,[6] Connor, on evaluating of prenatal mobile health apps,[7] Biviji, In assessing the quality of applications of maternal and child health,[8] Gyselaers to review health apps along with the pregnancy assessment and monitoring,[9] Bland et al. in assessing the coverage and nutrition information content of applications accessible to pregnant women,[10] Lee and Moon to review characteristics, contents and the validity of applications of pregnant women.[11] Furthermore, there are the reviews of mobile health apps on other topics such as obesity management,[12] pain management,[13] chronic kidney disease care management,[14] iPhone pregnancy apps[15] and Google Play,[16] physical activity in people with rheumatoid arthritis,[17] postpartum care, contraception, health behavior change,[18,19,20] weight management,[21] cancer diagnosis,[22] and establishment of ranking scales for mobile health applications[23] was conducted.

Iranian women now utilize Persian pregnancy health apps from online app stores such as Cafe Bazaar, Pars Hub, Iran Apps, Kandoo, Myket and Avval Market. As a result, the purpose of this research is to establish the state of these apps in terms of star rating (user opinion), app size, and resources referenced, amount of obstetrician engagement in the creation process, and subject distribution. Then, the relationship between the number of information resources referenced and user rankings was also tested.

Materials and Methods

The current research is an applied study that was done in 2020 using the descriptive approach. First, the most well-known Android app stores in Iran were discovered via an online search. In these stores, the keywords such as “prenatal care,” “childbirth,” and “pregnancy” were used to look for mobile apps. A total of 374 pregnancy-related apps were identified in six app stores, of which 157 were chosen for the research based on inclusion criteria, which included: 139 apps from Cafe Bazaar, 11 apps from Myket Market, 3 apps from Kandoo, 2 apps from Iran Apps, one app from Avval Market and also an app from Pars Hub. The following inclusion criteria were applied:[1] App availability in the Persian language,[2] relevance to pregnancy,[3] Availability for free or in-app payments[4] Getting at least 2.5 out of 5 stars by users. The apps was installed on the Xiaomi Redmi 6 pro phone and from different aspects such as information resources used and their validity, subject distribution, participation of obstetricians in the apps development, apps volume, star rank acquired by users, distribution of apps according to the developers and also relationship between the number of resources used and user rankings were examined.

The data were entered into Microsoft Excel spreadsheet and analyzed by descriptive statistics such as frequency and percentage. Furthermore, the association between the number of resources referenced in pregnancy apps and user star ratings was measured using the Pearson correlation test in IBM SPSS-21 software (IBM SPSS Statistics for Windows, version-21).

Results

Among 157 apps installed, 31 apps were available for in-app payment and 126 apps were available for free. These applications were obtained by 124 different developers. Among the developers, Maedeh Zamini had the most number of apps with 4 apps, followed by Taliam, Turk Droid, Abi, Ashk, and Ziba Khanum with 3 apps. The star rating was based on a predetermined criterion between 2.5 and 5 [Table 1].

Table 1.

Frequency distribution of pregnancy-related applications based on star rating by users

Star rank	App number (%)
2.5-3	9 (5.7)
3.1-3.5	11 (7)
3.6-4	20 (12.7)
4.1-4.5	69 (43.9)
4.6-5	48 (30.6)
Total	157 (100)

”Calculating Pregnancy Overweight” from the Cafe Bazaar had the lowest volume, while the app “Pregnancy Music Collection” from the Miket store had the highest volume. The majority of the applications (49%) were between 1 and 3.9 megabytes in size [Table 2].

Table 2.

Frequency distribution of volume of applications associated with pregnancy

App volume	Number of apps (%)
<1 Mb	5 (3)
1-3.9 MB	77 (49)
4-6.9	34 (21.8)
7-9.9	25 (16)
10-12.9	7 (4.5)
13-15.9 MB	5 (3.2)
>16 MB	4 (2.5)
Total	157 (100)

In addition, after evaluating the references of the studied apps [Table 3], it was discovered that the sources utilized are listed in the majority of them (125 apps, or 80%), but only 8 apps (5%) were used reliable and scientific information resources. In addition, just two apps (1.3%) were involved gynecologists and midwives to create the content (“Pregnancy and Child” app and “Delivery Date” app). The material for the majority of the apps was obtained from internal websites. From the application references list, the names of 13 separate websites were retrieved. In terms of citation rate, Beytoote site ranks top with 59 repetitions, followed by Aka-Iran site and Simorgh site in the second and third rank, respectively Table 3. A few scientific books and articles were mentioned among the materials utilized in these apps. Only 8 apps (5%) of the apps had used reliable information resources such as textbooks and scientific articles.

Table 3.

References cited in pregnancy applications

Type of reference	Reference	Frequency of citations by the apps studied (%)
Websites	https://www.beytoote.com	59 (34)
	http://www.akairan.com	19 (11)
	https://seemorgh.com	18 (10.3)
	https://namnak.com	13 (7.5)
	https://www.ninisite.com	13 (7.5)
	https://persianv.com	10 (5.7)
	https://niniban.com	6 (3.4)
	https://www.tebyan.net	6 (3.4)
	https://www.bartarinha.ir	5 (2.9)
	https://madarsho.com	5 (2.9)
	https://www.aparat.com	4 (2.3)
	https://www.hidoctor.ir	3 (1.7)
	https://setare.com	3 (1.7)
Books and articles	Persian pregnancy book	3 (1.7)
	Religious book	2 (1.3)
	English pregnancy specialized book	1 (0.6)
	Specialized book on nutrition	1 (0.6)
	English article	1 (0.6)

The 12 subject areas were used to categorize the apps that were analyzed. Naturally, each app focused on one or more issues [Table 4]. In Table 4, “Pregnancy Information” refers to apps that present information about overweight, gestational age, and related tests, and the term “miscellaneous” refers to apps that sporadically and briefly address various topics related to pregnancy, such as pregnancy music.

Table 4.

Thematic coverage of applications associated with pregnancy

Row	Topic of the app	Number of app (%)
1	Pregnancy Calendar	59 (27.8)
2	Pregnancy and childbirth care	44 (20.8)
3	Nutrition	42 (19.8)
4	Pregnancy information	15 (7.1)
5	Exercise in pregnancy	13 (6.1)
6	Religious advice	9 (4.25)
7	Traditional medicine	7 (3.3)
8	Child care	3 (1.4)
9	Medical Information	2 (0.94)
10	Introducing medical centers	2 (0.94)
11	Psychology	2 (0.94)
12	Miscellaneous	14 (6.6)

In addition, the Pearson correlation test revealed that there was no significant relationship between the number of resources cited in pregnancy apps and user star ratings (r = 0.03, P = 0.64); in other words, there was no temporal relationship between the two variables in either direction or nondirection.

Discussion

Pregnancy is a significant time in a woman's life and it is particularly essential to pay attention to her information demands and ways of gathering information at this time. Given the interest of communities, particularly young mothers, in the use of new information technologies, pregnancy-related health apps may play an essential role in providing mothers with credible and practical information provided they meet the appropriate requirements.

According to the data, a large number of Iranian users awarded these applications a suitable star rating, with an average score of 4.25 out of 5, suggesting user satisfaction. Consumer reviews and rankings may be obtained in a variety of areas, such as forums, blogs, and user comments on websites.[24] User star rating is one of these methods, and it is crucial to the success of an app. This is because it is taken into consideration by both users and developers when deciding whether or not to use an app, and it provides developers with vital information for enhancing the app's quality. Poschenrieder observed that 77% of users would not download an app with a rating of <3 stars, preferring to follow the instructions of higher-rated apps.[25] According to Biviji, users in the Google Play Store awarded mother and child applications higher ratings than health and fitness apps. In-app payments resulted in increased downloads, whereas low-cost apps got higher star ratings.[8]

The information resources utilized in applications were one of the credit factors investigated in this research. The findings revealed that just a tiny percentage of citations went to books and scholarly journals, with the majority of citations going to internal websites. The findings of the Ghazi-Saeedi study also revealed that 20% of health apps lacked a resource list, and 69.5% relied on questionable information resources to create their content.[2] Fougerouse et al. in their study of the best US mobile health apps, discovered that even the best-rated apps lack certain fundamental app quality requirements.[26] Only 10% of cancer-related apps identified content sources in their app descriptions, and only 3% claimed that information was vetted by health care practitioners, according to Charbonneau's research.[27] Gong, found that the quality of Chinese mobile apps for diabetes self-management is much below what is wanted, and greater attention to the quality of information in these apps should be given via cooperation with researchers and public health experts.[28] In a review of stroke apps on Google Play and iTunes, however, Dubey et al. found that more than 60% of the apps had accurate scientific content.[29] According to Haffy et al., 48% of drug withdrawal applications relied on reputable and first-hand resources in this field.[30] Bohme also possessed reputable resources for accepting cancer-related applications, which ranked well. In contrast, there was no differentiation between scientific content and advertising in low-rated content apps.[31] All of the studies' conclusions imply that the results of this research that developers pay less attention to using credible resources in the development of mobile health apps are consistent with the findings of the other studies.

Evaluation is the critical phase involved in creating, producing, and deploying any related health application. This evaluation was done in the current study using user star ratings (which are generally utilized by the general public) and citations of scientific publications (which are mostly favored by scholars and experts), as well as the link between the two. However, the findings revealed that there was no link between the user's star rating and the number of scientific references cited by the apps under study. Furthermore, Knitza found an overall correlation between Mobile Application Ratting Scale scores and low user star ratings in German mobile rheumatology applications.[32] Distinct assessment techniques used for the same purpose should provide comparable findings; however, the two ways of assessing apps used in the current research had different aims, requirements, and features, and they did not agree significantly. This finding reveals that regular users of mobile health apps have different opinions than the app's health science content specialists, suggesting that the star rating should be used with care.

Another aspect of Pregnancy Apps that was investigated in this research was the app's theme coverage. The findings revealed that the topic variety of the pregnancy-related apps has increased dramatically. The most shows were under the heading “Pregnancy Calendar.” The areas of “nutrition” and “prenatal care,” respectively, are the next two topics of interest. While important issues such as “psychology” and “drug knowledge” were mostly ignored. Because pregnancy is more than simply a physical condition, and the physiological changes that occur during pregnancy have a significant impact on a woman's mental state,[33] it is vital to give users with more in-depth psychological information. Missing a vital problem like medication information for pregnant women, on the other hand, necessitates additional care in pregnancy-related apps. One cause for this topic dispersion and the omission of particular pregnancy concerns in the apps described may be due to the absence of engagement of specialists in this field in the content preparation of the apps.

Conclusion

While some mobile health applications in the field of pregnancy have received positive user feedback and a high star rating, it remains to be seen whether this type of evaluation is conducted by experts and using standard tools, and whether health applications have the necessary compatibility and correlation. The citation status and subject distribution of these applications, on the other hand, revealed that these apps need qualitative evaluation by health professionals, particularly gynecologists and obstetricians. Some crucial topics, such as psychology and drug information during pregnancy, have gotten relatively little attention due to the topical distribution of these apps, indicating the apps' content and citation status, as well as the likely absence of expert involvement. The disparity between the citations' status and credibility of the pregnancy applications examined with past research also urges users of such apps to be cautious while using them. Given the increasing growth in the production and usage of pregnancy apps, and the fact that these apps may have a significant influence on the health of mothers and their children, assessing the quality of their content is critical.

Finally, health care practitioners and obstetricians should consider measures to analyze, manage, and monitor mobile health applications in this field, as well as actively engage in the development of these apps to enhance their quality.

Financial support and sponsorship

This study was financially supported by the Vice-Chancellor for Research of Isfahan University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.