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Requirement Analysis of mHealth app for Pregnancy Care and a Framework Suggestion for Evaluating Pregnancy Mobile Apps

Background & Objective: There are a lot of apps for pregnancy care using mHealth technologies. However, it has not been studied which criteria in these apps are essential for increasing the quality of these mHealth programs in pregnant women. Thus this study aimed to review the desirable features of mobile-based pregnancy care applications and provide a model to evaluate existing applications. Materials & Methods: Features of a mobile-based pregnancy app were designed using a qualitative approach. In this research, an open questionnaire was developed. Obstetricians and gynecologists filled out this questionnaire. After thematic analysis of the questionnaires, the obtained items are embedded into a general framework for evaluation mHealth. Results: Fifteen gynecology and obstetrics experts participated in this study. Eight themes were obtained from 34 items mentioned by the experts. Finally, a specialized framework for evaluating mHealth apps for pregnancy care is proposed. Conclusion: To design mobile-based pregnancy care app and evaluate the existing apps in the field of pregnancy, the provided indicators can be used. This framework and other similar specialized frameworks could be developed to improve the quality of the mHealth apps.


Introduction
Due to the high demand of patients for being visited by medical experts and place or time barriers, they cannot regularly use face-to-face consultation. Therefore, patients may face challenges in identifying priorities to address their clinical concerns. In this regard, the Internet and smartphones have received much attention for accessing health care information as a tool for managing health care. Mobile health (mHealth) technologies, as one of the healthcare approaches, could reduce the pressure on the healthcare system and improve the quality of care for patients (1-4). The World Health Organization (WHO) has defined mHealth as mobile devices, including mobile phones, patient monitoring devices, and personal digital assistants to achieve health purposes (5). mHealth, as a self-management tool, could be used to support patients via monitoring and managing health, resulting in an improved healthy life (6).
Among mHealth platforms, besides mHealth apps in women's health (7), numerous studies have been conducted worldwide to confirm the effectiveness of mHealth in promoting the health of the mother and fetus during pregnancy (8,9). For example, several studies have reported the advantages of mHealth monitoring apps for controlling diabetes during pregnancy (10). mHealth also provides a platform for obstetricians and midwives to overcome their time and place limitations and enhance the health of pregnant women during pregnancy (11).
Systematic monitoring, including examination and consultation about pregnancy issues, education and support of the pregnant woman, and preparation of a Women need information during their pregnancy. According to the literature, many pregnant women worldwide use the Internet as a source of information (14). Instead of using paper and face-to-face techniques to obtain information, they have used mHealth technology (15). Studies have shown that more than 50% of pregnant women download pregnancy-based apps, and these women have fewer pregnancy visits (16). For example, Chan et al. demonstrated that social media and mHealth apps could be widely used for improving the quality of life during pregnancy (17). In recent years, mHealth technology has grown quickly, and mobile phones are used in various aspects such as healthcare services (18). In developing countries, mHealth is highly used among women to get healthcare services, especially prenatal care (19).
Furthermore, the necessity of mHealth apps during the COVID-19 pandemic has also been observed more than ever for reducing the need for visits due to the adverse effects of COVID-19 on pregnant women (20). For example, it was reported that 21% of prenatal visits in March 2020 and 26% of prenatal visits in April 2020 were canceled, postponed, or performed remotely (21).
In addition to all of the above, exposure to incorrect information and nonevidence-based mobile apps causes problems for pregnant women due to the high sensitivity of maternal to external impacts; therefore, these issues should be carefully considered (22). Also, it requires to be considered that many medical Web sites and smartphone mHealth apps are not transparent in providing accurate health information (23). Wallwiener et al. reported that despite the great importance of mHealth apps, many smartphone applications are not reliable sources (10). Henriksson et al. evaluated the effectiveness of a smartphone app for reducing excess weight gain, dietary habits, physical activity, and glycemia during pregnancy (24).
All in all, there are a lot of apps for pregnancy care using mHealth technologies. However, it has not been studied which criteria in these apps are essential for increasing the quality of these mHealth programs in pregnant women. Thus, this study aimed to determine a model to identify the desirable features of mobilebased pregnancy care apps for improving maternal well-being.

Data Collection
In this research, a qualitative study has been conducted. A questionnaire with one general open question from experts was asked. The question was, "what features should a good mobile-based app contain?". The questionaries were designed in Google Forms. Next, a gynecology and obstetrics expert shared the link in specialized Telegram groups with her colleagues.

Data Analysis
The codes were extracted from the answers manually. In the next step, the themes were identified based on the codes and regarding items in the general framework for mHealth apps developed by Nouri et al. (25) (Figure1).

Data Collection
Fifteen experts filled out the questionnaire. The specialist and the experts were all gynecologists and obstetrics. The work history of the experts is listed in Table 1.

Data Analysis
The new codes are listed in Table 2. The themes extracted from the codes using Nouri's framework are shown in Table 3. The specialized framework for evaluating pregnancy care mHealth apps framework is represented in Table  4. New items extracted from the codes are shown in green color. Also, the items already existed in the framework and mentioned in the answers are colored blue.

Security and Privacy
Security privacy

User-Perceived Values Designing
It should not cause you not to see a doctor As a result, by integrating the general framework model for mHealth apps and the new specialized features obtained using experts' opinions, the developed model was redesigned, as shown in Figure  2.

Discussion
In this study, a mHealth evaluation framework for pregnancy care was designed based on a previous general framework for evaluating mHealth apps. The specific domain features required by obstetrician experts had been embedded into the previous general model, resulting in a mHealth pregnancy-specific evaluation framework. The main categories of the original framework were not changed; however, Journal of Obstetrics, Gynecology and Cancer Research specialized features required for pregnancy apps were added to subcategories of the original framework. The survey results showed that this mHealth evaluation framework could be used in pregnancy care.
A previous study by Hussain et al. (26) uses Jakob Nielsen's usability principle as the evaluation framework for a mHelath pregnancy app. The principles contain a subset of the usability category in the proposed framework. Some criteria such as abling to install on multiple devices and the ability to work offline are in the proposed framework that could be used in the evaluation of similar apps.
In another study by Lee et al. (27), the authors used general website confidence and satisfaction evaluation tools to evaluate mHealth pregnancy-related tools (28). This tool contains four categories and 19 items, including content components, information clarity and protection, content management, and information source. These categories could be mapped to Information/Content and security and privacy categories of the proposed framework.
In the mentioned studies, like most research in the literature, the authors used a general framework for evaluating the pregnancy apps. The authors believe that the suggested framework could be used to evaluate the mHealth apps from a general and a specific point of view, and this framework could help the experts to have a clear image of the status of their apps. Also, this framework could help authors to prevent mistakes in the development of the pregnancy-related app. For example study by Halili et al. (29), the authors derived multiple themes using two focus groups for the evaluation of a pregnancy app. The items they categorized in the "Critique of the SmartMoms app" include design and aesthetic, Interactivity, Feedback, Emphasis on weight gain, and Developmental and technical issues. Some of these shortcomings could be prevented if the developers considered the suggested framework for the app development.

Conclusion
As a qualitative study, this study investigated essential criteria for pregnancy care mHealth apps. To this end, a general framework for evaluating mHealth app was adopted, and specialized features related to pregnancy were added to the model based on expert opinions. The findings provide an innovative perspective on the evaluation of pregnancy apps that enable the maternal to monitor and manage their health and reduce complications. Future works could focus on creating a quantitative tool derived from the current framework. Future work can also incorporate the findings of this study into the design and implementation of a comprehensive mobile app for pregnancy care.