Changing behaviour in pregnant women: A scoping review

Harnessing Consumer Wearable Digital Biomarkers for Individualized Recognition of Postpartum Depression Using the All of Us Research Program Data Set: Cross-Sectional Study

BACKGROUND

Postpartum depression (PPD) poses a significant maternal health challenge. The current approach to detecting PPD relies on in-person postpartum visits, which contributes to underdiagnosis. Furthermore, recognizing PPD symptoms can be challenging. Therefore, we explored the potential of using digital biomarkers from consumer wearables for PPD recognition.

OBJECTIVE

The main goal of this study was to showcase the viability of using machine learning (ML) and digital biomarkers related to heart rate, physical activity, and energy expenditure derived from consumer-grade wearables for the recognition of PPD.

METHODS

Using the All of Us Research Program Registered Tier v6 data set, we performed computational phenotyping of women with and without PPD following childbirth. Intraindividual ML models were developed using digital biomarkers from Fitbit to discern between prepregnancy, pregnancy, postpartum without depression, and postpartum with depression (ie, PPD diagnosis) periods. Models were built using generalized linear models, random forest, support vector machine, and k-nearest neighbor algorithms and evaluated using the κ statistic and multiclass area under the receiver operating characteristic curve (mAUC) to determine the algorithm with the best performance. The specificity of our individualized ML approach was confirmed in a cohort of women who gave birth and did not experience PPD. Moreover, we assessed the impact of a previous history of depression on model performance. We determined the variable importance for predicting the PPD period using Shapley additive explanations and confirmed the results using a permutation approach. Finally, we compared our individualized ML methodology against a traditional cohort-based ML model for PPD recognition and compared model performance using sensitivity, specificity, precision, recall, and F1-score.

RESULTS

Patient cohorts of women with valid Fitbit data who gave birth included <20 with PPD and 39 without PPD. Our results demonstrated that intraindividual models using digital biomarkers discerned among prepregnancy, pregnancy, postpartum without depression, and postpartum with depression (ie, PPD diagnosis) periods, with random forest (mAUC=0.85; κ=0.80) models outperforming generalized linear models (mAUC=0.82; κ=0.74), support vector machine (mAUC=0.75; κ=0.72), and k-nearest neighbor (mAUC=0.74; κ=0.62). Model performance decreased in women without PPD, illustrating the method's specificity. Previous depression history did not impact the efficacy of the model for PPD recognition. Moreover, we found that the most predictive biomarker of PPD was calories burned during the basal metabolic rate. Finally, individualized models surpassed the performance of a conventional cohort-based model for PPD detection.

CONCLUSIONS

This research establishes consumer wearables as a promising tool for PPD identification and highlights personalized ML approaches, which could transform early disease detection strategies.

A systematic review of behaviour change interventions to improve maternal health outcomes in sub-Saharan Africa

The rate of decline in the global burden of avoidable maternal deaths has stagnated and remains an issue of concern in many sub-Saharan Africa countries. As per the most recent evidence, an average maternal mortality ratio (MMR) of 223 deaths per 100,000 live births has been estimated globally, with sub-Saharan Africa's average MMR at 536 per 100,000 live births-more than twice the global average. Despite the high MMR, there is variation in MMR between and within sub-Saharan Africa countries. Differences in the behaviour of those accessing and/or delivering maternal healthcare may explain variations in outcomes and provide a basis for quality improvement in health systems. There is a gap in describing the landscape of interventions aimed at modifying the behaviours of those accessing and delivering maternal healthcare for improving maternal health outcomes in sub-Saharan Africa. Our objective was to extract and synthesise the target behaviours, component behaviour change strategies and outcomes of behaviour change interventions for improving maternal health outcomes in sub-Saharan Africa. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Our protocol was published a priori on PROSPERO (registration number CRD42022315130). We searched ten electronic databases (PsycINFO, Cochrane Database of Systematic Reviews, International Bibliography of Social Sciences, EMBASE, MEDLINE, Scopus, CINAHL PLUS, African Index Medicus, African Journals Online, and Web of Science) and included randomised trials and quasi-experimental studies. We extracted target behaviours and specified the behavioural interventions using the Action, Actor, Context, Time, and Target (AACTT) framework. We categorised the behaviour change strategies using the intervention functions described in the Behaviour Change Wheel (BCW). We reviewed 52 articles (26 randomized trials and 26 quasi-experimental studies). They had a mixed risk of bias. Out of these, 41 studies (78.8%) targeted behaviour change of those accessing maternal healthcare services, while seven studies (13.5%) focused on those delivering maternal healthcare. Four studies (7.7%) targeted mixed stakeholder groups. The studies employed a range of behaviour change strategies, including education 37 (33.3%), persuasion 20 (18%), training 19 (17.1%), enablement 16 (14.4%), environmental restructuring 8 (7.2%), modelling 6 (5.4%) and incentivisation 5 (4.5%). No studies used restriction or coercion strategies. Education was the most common strategy for changing the behaviour of those accessing maternal healthcare, while training was the most common strategy in studies targeting the behaviour of those delivering maternal healthcare. Of the 52 studies, 40 reported effective interventions, 7 were ineffective, and 5 were equivocal. A meta-analysis was not feasible due to methodological and clinical heterogeneity across the studies. In conclusion, there is evidence of effective behaviour change interventions targeted at those accessing and/or delivering maternal healthcare in sub-Saharan Africa. However, more focus should be placed on behaviour change by those delivering maternal healthcare within the health facilities to fast-track the reduction of the huge burden of avoidable maternal deaths in sub-Saharan Africa.

Evidence-Based Eating Patterns and Behavior Changes to Limit Excessive Gestational Weight Gain: A Scoping Review

BACKGROUND

International prenatal care guidelines set a standard for clinicians to discuss gestational weight gain with their patients along with the complications associated with prepregnancy obesity and excessive gestational weight gain. Clinicians often lack evidence-based eating, nutrition, and activity strategies to share with patients.

METHODS

This systematic review aimed to find eating patterns and behaviors that could be used safely during pregnancy to limit excessive gestational weight gain. PubMed, MEDLINE, and Web of Science were searched for research or systematic reviews performed in the United States or Canada and published in English from 2013 to 2023. Keyword search terms included weight, manage, behavior, strategy, strategies, gestational weight gain, and nutrition. Excluded research used pediatric or adolescent populations, restrictive diets, such as no carbohydrate or no fat diets, fasting, bariatric surgery, weight loss medications, private industry or profit-earning programs using food brands, or specific diet programs.

RESULTS

A total of 844 abstracts were retrieved, with 103 full-text studies reviewed. Behaviors had to be useful for maintaining a healthy gestational weight gain and had to be safe for use during pregnancy. Behaviors useful during pregnancy included meal planning, home meal preparation, portion control, using diets such as the Mediterranean diet, the low-glycemic index diet, and the Dietary Approaches to Stop Hypertension diet (DASH), regular physical activity, sleeping 6-7 h a night, mindful eating, intuitive eating, and regular seif-weighing.

CONCLUSION

The evidence-based strategies outlined in this review are safe for use during pregnancy and can assist patients in avoiding excessive gestational weight gain while maintaining the nutrition needed for healthy fetal growth.

Perinatal Women's Perspectives of, and Engagement in, Digital Emotional Well-Being Training: Mixed Methods Study

BACKGROUND

Psychological distress in the early postpartum period can have long-lasting deleterious effects on a mother's well-being and negatively affect her infant's development. Intervention approaches based in contemplative practices such as mindfulness and loving-kindness and compassion are intended to alleviate distress and cultivate well-being and can be delivered effectively as digital mental health interventions (DMHIs).

OBJECTIVE

To understand the feasibility of engaging perinatal women in digital interventions, this study aimed to document participants' experiences in the Mums Minds Matter (MMM) study, a pilot randomized controlled trial comparing mindfulness, loving-kindness and compassion, and progressive muscle relaxation training delivered in a digital format and undertaken during pregnancy. To assess the different stages of engagement during and after the intervention, we adapted the connect, attend, participate, enact (CAPE) framework that is based on the idea that individuals go through different stages of engagement before they are able to enact change.

METHODS

The MMM study was nested within a longitudinal birth cohort, The ORIGINS Project. We aimed to recruit 25 participants per randomization arm. Data were collected sequentially during the intervention through regular web-based surveys over 8 weeks, with opportunities to provide regular feedback. In the postintervention phase, qualitative data were collected through purposive sampling.

RESULTS

Of 310 eligible women, 84 (27.1% [connect rate]) enrolled to participate in MMM. Of the remaining 226 women who did not proceed to randomization, 223 (98.7%) failed to complete the baseline surveys and timed out of eligibility (after 30 weeks' gestation), and 3 (1.3%) displayed high psychological distress scores. Across all program groups, 17 (20% [attend rate]) of the 84 participants actively opted out, although more may have disengaged from the intervention but did not withdraw. The main reasons for withdrawal were busy life and other priorities. In this study, we assessed active engagement and ongoing skills use (participate and enact) through postintervention interviews. We undertook 15 participant interviews, conducted 1 month to 3 months after the intervention. Our results provide insights into participant barriers and enablers as well as app changes, such as the ability to choose topics, daily reminders, case studies, and diversity in sounds. Implementing a DMHI that is brief, includes frequent prompts or nudges, and is easily accessible is a key strategy to target perinatal women.

CONCLUSIONS

Our research will enable future app designs that are sufficiently nuanced to maximize the uptake, engagement, and application of mental health skills and contemplative practices in the perinatal period. Providing convenient access to engaging and effective prevention programs is critical and should be part of prenatal self-care. Our research underscores the appeal and feasibility of digital intervention approaches based in contemplative practices for perinatal women.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) 12620000672954p; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12620000672954p.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/19803.

Harnessing consumer wearable digital biomarkers for individualized recognition of postpartum depression using the All of Us Research Program dataset

Postpartum depression (PPD), afflicting one in seven women, poses a major challenge in maternal health. Existing approaches to detect PPD heavily depend on in-person postpartum visits, leading to cases of the condition being overlooked and untreated. We explored the potential of consumer wearable-derived digital biomarkers for PPD recognition to address this gap. Our study demonstrated that intra-individual machine learning (ML) models developed using these digital biomarkers can discern between pre-pregnancy, pregnancy, postpartum without depression, and postpartum with depression time periods (i.e., PPD diagnosis). When evaluating variable importance, calories burned from the basal metabolic rate (calories BMR) emerged as the digital biomarker most predictive of PPD. To confirm the specificity of our method, we demonstrated that models developed in women without PPD could not accurately classify the PPD-equivalent phase. Prior depression history did not alter model efficacy for PPD recognition. Furthermore, the individualized models demonstrated superior performance compared to a conventional cohort-based model for the detection of PPD, underscoring the effectiveness of our individualized ML approach. This work establishes consumer wearables as a promising avenue for PPD identification. More importantly, it also emphasizes the utility of individualized ML model methodology, potentially transforming early disease detection strategies.

A Randomized Controlled Clinical Trial of Prenatal Oral Hygiene Education in Pregnancy-Associated Gingivitis

INTRODUCTION

Research shows there is a significant increase in gingival inflammation during pregnancy. This study was conducted to determine if an oral health intervention (OHI), including oral hygiene education delivered by nurse-led staff and an advanced over-the-counter (OTC) oral home care regimen, improved gingival inflammation in pregnant women with moderate-to-severe gingivitis compared with a standard oral hygiene control group.

METHODS

This was a multicenter, randomized, controlled, single-masked, parallel group clinical trial conducted in obstetrics clinics of 2 medical centers. A total of 750 pregnant women between 8 and 24 weeks of pregnancy with at least 20 natural teeth and moderate-to-severe gingivitis (>30 intraoral bleeding sites) were enrolled. Participants were randomized to either the OHI group, which included oral hygiene instructions supplemented with an educational video and advanced OTC antibacterial/mechanical oral hygiene products, or the control group receiving oral hygiene instructions and standard products. Both groups received oral hygiene instructions from nurse-led staff. Experienced, masked examiners measured whole mouth gingival index (GI) and periodontal probing depths (PDs) at baseline and months 1, 2, and 3.

RESULTS

Participants enrolled in this study presented with moderate-to-severe gingivitis at baseline. Both the OHI and control groups exhibited significant reductions in GI (P < .001) and PD (P < .03) from baseline that persisted throughout the study period. The OHI group exhibited modest, yet statistically greater, reductions in GI (P ≤ .044) compared with the control at all time points. The reduction in PD directionally favored the OHI group, but between-group differences were small (<0.03 mm) and not statistically significant (P > .18).

DISCUSSION

Significant gingivitis was prevalent among participants in this study and identifies an opportunity to improve gingival health during pregnancy by providing oral health education during the course of prenatal care when coupled with an advanced OTC oral hygiene regimen.

It's time to increase physical activity promotion among pregnant women in France

BACKGROUND

The lockdown linked to COVID-19 was shown to have negative effects on healthy behaviors in the general population, prompting the implementation of adapted public health measures. However, more vulnerable populations, such as pregnant women, were not specifically taken into account. At the time of writing this study, we know little about how the COVID-19 pandemic impacted the physical activity (PA) behavior of pregnant women in France. Given the many reports in the literature about women's low level of PA throughout pregnancy and the negative effects of the COVID-19 lockdown on behaviors in the general population; however, we might assume that their sedentary behaviors increased. The current study aimed to analyze the French recommendations and PA promotion among pregnant women.

MATERIALS AND METHODS

A literature search was done using PubMed for the key terms "physical activity/physical activity promotion," "pregnant women/pregnancy,", and "French population/France." All the relevant studies were included to support the argument for this narrative review.

RESULTS

Efforts to promote PA for pregnant women often seem ineffective and even unrealistic, and many women become overweight or obese during pregnancy. Health professionals need evidence-based guidelines and continuous training and skills development in order to convincingly encourage women to be more active during pregnancy and the postpartum period.

CONCLUSION

Health policies should strengthen PA promotion among pregnant women with detailed evidence-based guidelines on PA during postpartum.

The application of the public health model in pregnancy coaching for preventing high-risk pregnancy

Introduction: Primary Health Care which is part of the Public Health Model can be applied through Pregnancy Coaching to prevent high-risk pregnancies. Design and Methods: This study was conducted using the literature review and Meta-Analysis (PRISMA) method. Results: A total of 152 articles were obtained from different databases consisting of Scopus 7, Pro-Quest 24, Science Direct 39, Pub Med 25, EBSCO 57 and were analyzed by excluding articles using PICOS. The data collection was restricted to pregnancy, pregnancy coaching, research-relevant interventions, outcomes, and article that are not systematic reviews, hence, the analysis obtained 20 relevant articles. Conclusion: Primary Health Care which is part of the Public Health Model aimed at reducing new cases is applicable to pregnant women in preventing high-risk pregnancy by optimizing health cadres.

Piloting a complex intervention to promote a tobacco and alcohol-free pregnancy: the Smoke and Alcohol Free with EHealth and Rewards (SAFER) pregnancy study

BACKGROUND

Tobacco smoking and alcohol consumption before and during pregnancy increase the risk of adverse health outcomes for mother and child. Interventions to address smoking and drinking before and during pregnancy have the potential to reduce early-life health inequalities. In the Smoke and Alcohol Free with EHealth and Rewards (SAFER) pilot study we aimed to evaluate the acceptability, feasibility and effectiveness of a complex intervention supporting women in smoking and alcohol cessation before and during pregnancy.

METHODS

From February 2019 till March 2021, we piloted the SAFER pregnancy intervention among pregnant women and women planning pregnancy in South-West Netherlands in an uncontrolled before-after study. Participants were supported in smoking and alcohol cessation via up to six group sessions and an online platform. In addition, biochemically validated cessation was rewarded with incentives (i.e. shopping vouchers) amounting up to 185 euros. We aimed to include 66 women. The primary outcome was smoking and/or alcohol cessation at 34-38 weeks of gestation (if pregnant) or after six group sessions (if not pregnant). Quantitative data were analysed using descriptive statistics. Focus group interviews among those involved in the study were conducted at the end of the study to explore their experiences. Qualitative data was analysed using thematic analysis.

RESULTS

Thirty-nine women who smoked were included; no women who consumed alcohol were referred to the study. Unemployment (51%), financial problems (36%) and a smoking partner (72%) were common. Thirteen women (33%) dropped out, often due to other problems impeding smoking cessation or 'being too busy' to participate in the group sessions. Eleven women (28%) had quit smoking at the study's endpoint. The personal and positive approach was highly valued and biochemical validation was felt to be helpful.

CONCLUSION

The SAFER pregnancy intervention seems appropriate for women in need of extra support for smoking cessation before and during pregnancy. Its impact on alcohol cessation could not be studied due to recruitment issues. Recruitment and prevention of early dropout need attention in further development of this intervention.

TRIAL REGISTRATION

Netherlands Trial Register: NL7493. Date registered: 04/02/2019.

Perception of the impact of maternal weight on pregnancy outcomes in overweight and obese women

OBJECTIVE

The purpose of this study was to assess and compare knowledge, self-awareness, and accuracy of perceived risks and weight status among overweight and obese women.

METHODS

This study was a secondary analysis of a cross-sectional questionnaire study of overweight and obese pregnant women who sought a routine first-trimester screening ultrasound. Those with a pre-pregnancy body mass index (BMI) ≥25 kg/m² (calculated using self-reported height and weight) were included. Perceived associations between estimated weight category and risk of pregnancy complications were assessed and compared in the overweight and obese groups. The perceived weight category was compared to an estimated weight category. A logistic regression identified the demographic and medical factors associated with correct identification of risk factors.

RESULTS

A total of 169 participants (88 overweight; 81 obese) were included. Most participants believed their weight did not impact the ultrasound detection of a fetal malformation (92.1% overweight vs. 55.6% obese, p < .01). Few participants associated their weight with pregnancy-related problems (6.8% overweight vs. 24.7% obese, p < .01). Most participants did not associate their weight with specific maternal complications (72.7% overweight vs. 45.7% obese, p < .01) and fetal complications (83.0% overweight vs. 71.6% obese, p = .08). More obese than overweight women underestimated their weight category (64.4% vs 41.3% overweight, p = .01). Women who correctly estimated their weight status, non-Hispanic participants, and those with a history of depression or at least one maternal co-morbidity were more likely to associate their weight with increased risk for pregnancy-related problems.

CONCLUSION

Although more obese than overweight women associated excess weight with pregnancy complications, both groups underestimated the impact on their pregnancies. Targeted educational programs are needed to improve the risk perception of these populations prior to pregnancy with the goal of improving their weight statuses and pregnancy outcomes.

Uptake, Engagement and Acceptance, Barriers and Facilitators of a Text Messaging Intervention for Postnatal Care of Mother and Child in India-A Mixed Methods Feasibility Study

This study aimed to test the feasibility and to identify barriers and facilitators towards adherence of a text messaging intervention for postnatal care in India. Mixed methods research involving both quantitative and qualitative methods were used. A survey questionnaire for feasibility and focus group interviews to identify the barriers and facilitators to the intervention were conducted. The top three reasons for activation of service were: helped the new mother to understand the changes (95%); provided continuation of care (90%) and clarified conflicting information (89%). Over 90% read the messages daily. 80% were happy with the message frequency. About 75% shared the content with others. The main reasons for non-activation were: 30% had technical issues, 15% did not think it would be useful, 17% did not have time to activate and for 5%, husbands made the decision. These findings were triangulated through the qualitative focus groups. The main themes identified via the focus groups were: (1) reliable, current information; (2) issues and themes well aligned with new mothers' needs and priorities; (3) expanded the repertoire of information sources available; and (4) high-quality accessible information. The satisfaction and trust rates were high. This technology may be useful for health information intervention in specific postnatal areas.

Pedagogical innovation to promote physical activity in pregnancy: Interprofessional and real-life settings on the example of the educational program Move Your Baby

INTRODUCTION

Despite scientific evidence on health benefits of an active lifestyle during and after pregnancy, a gap still exists between current and recommended practice in physical activity counselling. Undergraduate education in midwifery is fundamental for physical activity promotion in professional practice. The aim of this article is to present pedagogical aspects, preliminary results and discuss the relevance of the educational program Move Your Baby.

METHODS

Between 2018 and 2020, 23 midwifery students (BSc) participated in the program at the School of Health Sciences (HESAV), HES-SO University of Applied Sciences and Arts Western, Lausanne, Switzerland. Theoretical and practical workshops as well as adapted physical activity sessions, in direct contact with pregnant women, were offered and supervised by professional midwives and one expert in adapted physical activity. Data analysis based on an exploratory self-administered questionnaire was performed to rate pedagogical effectiveness, perceived skill level and identify barriers and facilitators to promote physical activity in their future profession.

RESULTS

Midwifery students perceived improvement in their knowledge, skills and confidence to promote physical activity during pregnancy. They rated the program as pedagogically effective. However, several barriers were identified such as lack of time and material resources to promote physical activity in professional practice.

CONCLUSIONS

This community-oriented educational program based on interplay of theory, hands-on experience and interprofessional collaboration was rated successful. Teaching physical activity in real-life settings facilitates midwifery students to identify with their professional role in the field of health promotion. Midwifery students require more opportunities to promote physical activity in their professional practice.

Student nurses and midwives' experiences of teaching and learning about 'making every contact count' health behaviour change programme: Descriptive qualitative study

AIM/OBJECTIVE

To explore nursing/midwifery students' experiences of the teaching and learning of units one and two of a national undergraduate curriculum.

BACKGROUND

The 'National Undergraduate Curriculum for Chronic Disease Prevention and Management: Making Every Contact Count' (MECC) is part of Ireland's national policy to support the prevention of chronic disease by promoting health behaviour change. This is being implemented as a programme within the Irish Health Service and is also being delivered, for the first time in undergraduate medical, allied health and nursing/midwifery education by tertiary education institutes.

DESIGN

Qualitative descriptive research.

METHODS

Purposeful sampling was used to recruit participants (n = 17) from an undergraduate nursing/midwifery programme (n = 131) in one tertiary level Irish institution. Four focus groups were undertaken by two members of the research team, who were not part of the module teaching team. Each focus group was guided by a semi-structured interview guide, recorded and transcribed verbatim. Thematic data analysis was undertaken.

RESULTS

Three main themes were identified, namely: Building foundations and making connections; Personal responsibility and the Ah factor: now I understand.

CONCLUSION

Findings indicate that students had a positive learning experience whilst also highlighting the students' transition to lifelong learning encompassing adult learning and personal responsibility.

Challenges in using Mental Contrasting with Implementation Intentions (MCII) for preparation for natural birth: A feasibility study

OBJECTIVE

Women who plan a natural birth can benefit from strategies and/or resources that help them prepare for and cope with labour pain. This study aims to identify the feasibility of using Mental Contrasting with Implementation Intentions (MCII) for preparation of primiparous women for natural childbirth. Secondary aims are to test the acceptability of a health-focused information leaflet, and to describe how participants with high natural birth intentions cognitively prepare for birth.

METHODS

In third trimester, ten primiparous women participated in this interventional study with follow-up. A health-focused information leaflet on physiological childbirth, MCII, a mental strategy that helps people achieve a desired goal by envisioning obstacles and how to overcome them, and a researcher-developed questionnaire which contained the CBSEI-C32, was used. Survey data were analysed using a combination of descriptive statistics and deductive theoretical thematic analysis.

RESULTS

The health-focused leaflet was exclusively judged positively. Nine women did not use MCII as instructed, they did not find it helpful for childbirth preparation and wished to have a more positive, health-focused approach towards childbirth. Two themes emerged from the participants' responses: 'the ability to give birth' which was supported through childbirth preparedness, coping strategies, confidence and external supports and 'the uncertainty of giving birth' which included fears and worries about possible adverse events and the baby's health.

CONCLUSION

MCII was not a promising tool for natural childbirth preparation among primiparous women in Germany. Our findings show that women prefer a positive, health-focused approach, rather than thinking about overcoming obstacles, when they prepare for childbirth.

Challenges in applying the short Childbirth Self-Efficacy Inventory (CBSEI-C32) in German

INTRODUCTION

This study aimed to review and pilot-test feedback from childbearing women who completed the German short version of the Childbirth Self-Efficacy Inventory (CBSEI-C32), which is widely used and validated in different languages.

METHODS

Ten pregnant nulliparas, who planned a natural childbirth, completed the German CBSEI-C32 and provided comments about the comprehensibility of the tool.

RESULTS

When applying the standardized translated German CBSEI-C32, we discovered that women generally gave positive feedback, and reported that the items made them think about coping strategies for labor and birth. Some pregnant woman had problems in understanding two items: ‘Mich beherrschen’ (original English item: ‘Keep myself in control’), and ‘Mich ruhig halten’ (original English item: ‘Keep myself calm’). Some of the items were not comprehensible for pregnant women and might not represent contemporary concepts of childbirth self-efficacy.

CONCLUSIONS

Two items of the German CBSEI-C32 were interpreted ambiguously by the pilot testers. The CBSEI should be checked to identify which items could serve as the basis for a new questionnaire because there are clear and appropriate coping strategies when dealing with labour pain such as item 3 on breathing. These could be complemented with other coping behaviours that are positively worded and serve to empower rather than restrain women. For measuring self-efficacy beliefs in childbirth nowadays, it appears that health-oriented aspects, such as concentrating on the pauses between contractions or mentally staying in the present moment, are more important for women than focusing on control during childbirth.

Quality, Features, and Presence of Behavior Change Techniques in Mobile Apps Designed to Improve Physical Activity in Pregnant Women: Systematic Search and Content Analysis

Background

Physical activity during pregnancy is associated with several health benefits for the mother and child. However, very few women participate in regular physical activity during pregnancy. eHealth platforms (internet and mobile apps) have become an important information source for pregnant women. Although the use of pregnancy-related apps has significantly increased among pregnant women, very little is known about their theoretical underpinnings, including their utilization of behavior change techniques (BCTs). This is despite research suggesting that inclusion of BCTs in eHealth interventions are important for promoting healthy behaviors, including physical activity.

Objective

The aim of this study was to conduct a systematic search and content analysis of app quality, features, and the presence of BCTs in apps designed to promote physical activity among pregnant women.

Methods

A systematic search in the Australian App Store and Google Play store using search terms relating to exercise and pregnancy was performed. App quality and features were assessed using the 19-item Mobile App Rating Scale (MARS), and a taxonomy of BCTs was used to determine the presence of BCTs (26 items). BCTs previously demonstrating efficacy in behavior changes during pregnancy were also identified from a literature review. Spearman correlations were used to investigate the relationships between app quality, app features, and number of BCTs identified.

Results

Nineteen exercise apps were deemed eligible for this review and they were accessed via Google Play (n=13) or App Store (n=6). The MARS overall quality scores indicated moderate app quality (mean 3.5 [SD 0.52]). Functionality was the highest scoring MARS domain (mean 4.2 [SD 0.5]), followed by aesthetics (mean 3.7 [SD 0.6]) and information quality (mean 3.16 [SD 0.42]). Subjective app quality (mean 2.54 [SD 0.64]) and likelihood for behavioral impact (mean 2.5 [SD 0.6]) were the lowest scoring MARS domains. All 19 apps were found to incorporate at least two BCTs (mean 4.74, SD 2.51; range 2-10). However, only 11 apps included BCTs that previously demonstrated efficacy for behavior change during pregnancy, the most common being provide opportunities for social comparison (n=8) and prompt self-monitoring of behavior (n=7). There was a significant positive correlation between the number of BCTs with engagement and aesthetics scores, but the number of BCTs was not significantly correlated with functionality, information quality, total MARS quality, or subjective quality.

Conclusions

Our findings showed that apps designed to promote physical activity among pregnant women were functional and aesthetically pleasing, with overall moderate quality. However, the incorporation of BCTs was low, with limited prevalence of BCTs previously demonstrating efficacy in behavior change during pregnancy. Future app development should identify and adopt factors that enhance and encourage user engagement, including the use of BCTs, especially those that have demonstrated efficacy for promoting physical activity behavior change among pregnant women.

Birth choices after caesarean in Taiwan: A mixed methods pilot study of a decision aid for shared decision making

BACKGROUND

Taiwan has a high national caesarean rate coupled with a low vaginal birth after caesarean (VBAC) rate. Studies suggest that women do not receive sufficient information about birth choices after caesarean in Taiwan and shared decision making (SDM) is not an expectation. This pilot study aimed to test the feasibility of using a birth choices decision aid to improve women's opportunity for engagement in SDM about birth after cesarean.

METHODS

A two-phase sequential mixed methods pilot study was conducted in a regional hospital in northern Taiwan. Phase I involved a randomized pre-test and post-test experimental design. Participants with one previous caesarean section (CS) were recruited at 14-24 weeks. A total of 65 women completed a baseline survey and were randomly allocated to either the intervention (birth choice decision aid booklet) or usual care (general maternal health booklet) group. A follow up survey at 37-38 weeks measured change in decisional conflict, knowledge, and birth mode preference. Birth outcomes and satisfaction were assessed one month after birth. Phase II consisted of postnatal interviews with women at one month after birth, to explore women's decision making experiences, using a constant comparative analytic technique and thematic analysis.

RESULTS

Decisional conflict was relatively low at baseline for all women. Although there were reductions in decisional conflict at follow up, differences between groups were not statistically significant. Women's early preferences regarding mode of birth influenced their knowledge-seeking behaviors and expectations or intention for engaging in SDM during pregnancy. Improvements in knowledge for the decision aid group were larger than for the usual care group, although differences between groups were not statistically significant. Four themes related to key factors in decision making were clarity, safety and risk, consistency, and support.

CONCLUSION

A cultural shift is needed to align expectations and relationships towards SDM for birth in Taiwan. Simulation-based strategies and tailored communication skills should be explored to enhance skills in decision coaching for providers. Use of interactive multimedia technology may provide opportunities to increase engagement with tools and support women during decision consultations. Midwife-led continuity of care models may also be beneficial in empowering women to actively share decisions and achieve the birth that is best for them.

Smoke and Alcohol Free with EHealth and Rewards (SAFER) pregnancy study: a before-after study protocol

Despite existing interventions, tobacco smoking and alcohol consumption during pregnancy are common. The Smoke and Alcohol Free with EHealth and Rewards (SAFER) pregnancy intervention combines monthly group sessions, access to a web-based platform and incentives upon biochemically validated cessation for a maximum duration of 6 months to promote cessation of smoking and alcohol use before and during pregnancy. To inform development of the SAFER pregnancy intervention, two focus groups with the target population were held beforehand, with results reported here alongside the final SAFER pregnancy study protocol. In a before−after study we aim to include 66 women who are pregnant or have a wish to become pregnant and who smoke and/or consume alcohol (i.e. target population of the SAFER pregnancy intervention). The primary outcome measure is cessation of smoking and/or alcohol use at 34−38 weeks of gestation, or after six group sessions if women did not become pregnant during the study period. Secondary outcomes focus on the barriers and facilitators for implementation of the SAFER pregnancy intervention.