Pregnancy Apps: Your Patients Use Them—Are You Up to Speed?

Tara Haelle

Disclosures

February 28, 2018

No Shortage of Apps for Pregnant Women

As many as 4 in 5 US women of childbearing age have a smartphone, and about one fourth of these women use health apps, according to Katherine Chen, MD, professor and vice-chair of education in the Department of Obstetrics, Gynecology and Reproductive Science at the Icahn School of Medicine at Mount Sinai in New York City. Among more than 90,000 apps in the Apple iTunes® store, 7% focus on women's health and pregnancy.[1]

These apps, which number in the thousands, aim to capture the attention of pregnant women by offering tools for everything from tracking fetal development to timing contractions. "Apps are becoming more patient-centered," said Dr Chen, who studies ob/gyn-related mobile apps. Although she focuses on apps for clinicians, Dr Chen sees growing interest in apps that help pregnant women track their health and communicate with providers.

Few data exist on how many women use pregnancy apps or which apps are most used, but their popularity is undeniable. A 2013 report by ByteMobile[2] found that pregnancy-related apps edged out fitness apps as the most-used health apps. Among smartphone owners using health apps, 47% were using one or more apps related to pregnancy, compared with 39% who were using fitness apps. More recent analytics on health apps are hard to come by, but US smartphone use has more than doubled since 2011, from 35% to 77% in 2016,[3] suggesting more widespread app use.

Providers need some sense of what apps their patients might be using. "At this point, well into the mobile age of informatics, doctors really should be asking patients whether they're using an app for their health," said Nathaniel DeNicola, MD, an assistant professor of obstetrics and gynecology at the George Washington School of Medicine and Health Sciences in Washington, DC. Doctors also need to know whether patients are using apps to drive any clinical decisions, he said.

Dr DeNicola said that well over one half of his patient population uses a health app of some kind, especially during pregnancy. "It's a time when women are very aware of everything they're consuming and are very attentive to lifestyle choices," Dr DeNicola said. "So many demands are placed on pregnant women that anything that makes it easier to manage their health and pregnancy would be appealing."

From Counting Kicks to the Kitchen Sink

The features and the quality of health apps vary dramatically. "For patients, there are about 2000 ob/gyn apps, so obviously it's impossible to vet and certify even a small percentage of them," Dr DeNicola said. Their sheer number can cause app overload for consumers and providers, who lack guidance on mobile technology.

Dozens of apps focus on a single function, such as counting fetal kicks, calculating due dates, or tracking ovulation or contractions. Other apps are more comprehensive, offering those features plus weekly fetal development information, checklists, weight and sleep tracking, baby name lists, medical articles pegged to the user's gestational week, educational videos, photo albums, diaries, social forums, and more. Other apps specialize in a particular health need, such as managing gestational diabetes, planning for twins, or preventing stillbirth.

Among the most popular comprehensive pregnancy apps, based on number of reviews and search algorithms in the iTunes App Store, are the following (Figure 1):

Figure 1. a. A sampling of available pregnancy apps. b. Apps for timing contractions.

Patient-centered pregnancy apps are offered by several medical organizations, including the American College of Obstetricians and Gynecologists (ACOG), the Society for Maternal-Fetal Medicine (SMFM), and the Association of Professors of Gynecology and Obstetrics (APGO). Even these have their specializations; for example, the ACOG app's due-date calendar uses algorithms based on clinical guidelines while accounting for indicated deliveries. APGO's app focuses exclusively on nausea and vomiting of pregnancy, and SMFM has an app aimed at preventing preterm birth. ME Preg, made by Project Alive & Kicking, focuses on stillbirth prevention.

And those are just the consumer-focused apps, separate from OB wheels, prescription drug information, or other medical reference apps designed for clinicians. Knowing which app is going to be useful, however, is another issue.

"There is a lack of credible information about apps," said Nihar Ganju, MD, director of digital health at Advantia Health in Silver Spring, Maryland. User reviews provide some insights, but they typically come from other patients, who may not be as discriminating as medical professionals, Dr Ganju said. ACOG currently has a taskforce writing best practices for all aspects of telehealth, including mobile app use, said Dr DeNicola, but this guidance is not yet available.

Helping Patients Choose

Still, providers are well poised to help women evaluate pregnancy apps, which can empower patients and facilitate patient/provider communication.

"When patients educate themselves, they provide themselves with the best healthcare, because they can identify specifically where they need help," said Christopher Robinson, MD. a partner at Charleston Maternal Fetal Medicine in South Carolina and a member of the medical advisory committee for Project Alive & Kicking.

The trick is helping consumers pick useful apps for their specific needs. For example, fertility apps that allow women to enter the length of their menstrual cycles or that calculate menstrual cycle length will be more accurate than apps that use a generic 28-day cycle.

"One thing to look for is whether the app was developed by a medical society or has physicians standing behind it," he said. Apps from such medical societies as ACOG, SMFM, the American Academy of Pediatrics, the National Institutes of Health, or the Centers for Disease Control and Prevention have the most credibility. "It's always a good idea to go to the credits," Dr Robinson said. "Where did the app come from? Who developed it and why?" Knowing who developed the app offers clues to its accuracy (particularly if it relies on peer-reviewed research or was developed with clinician input), and insight into the developers' aims—are they helping patients, or just making profits?

How frequently an app is updated also offers clues to its reliability, Dr Robinson said. Users can find this by looking at the app's update history in the app store. Apple requires developers to keep pace with iOS updates and will remove apps that are not updated within 30 days after notice.[4] Google gives Android app developers 1 year to comply with updates.[5]

Dr Robinson also counsels patients about privacy and safety. Paid apps (as opposed to free apps) or those with many ads might have commercial interests that could eclipse the well-being of patients, especially if the app collects personal information, he said. "The use of an app is not always a one-way street," Dr Robinson said, referring to the fact that some apps may use personal information entered by users for other purposes.

Clinicians should also counsel patients to think twice before linking apps to their social media accounts, Dr DeNicola adds. "They may not want to share that they just had their 12-week ultrasound," he said.

Choosing apps can be collaborative. Physicians can encourage patients to download an app during a visit, Dr Robinson said. Dr Ganju recommends that his patients download two or three apps, see which ones they like, and let him know which one they end up using. This informal data collection helps him advise other patients about the apps that are most popular among his clients.

Many electronic health records also have apps for patients, or clinicians can develop their own apps, Dr Robinson said. "Some options let you build your own app from the ground up," he said. "It allows you to connect with your patients in a way that you've not been able to in the past."

Pitfalls of Pregnancy Apps

App overload and inaccuracy are the two biggest problems with health apps, said Dr Chen, whose research has found high levels of inaccuracy in some women's health apps. One study[6] found that most menstrual cycle tracking apps are inaccurate. Due-date calculator apps nearly all use the Naegele formula and are fairly reliable, Dr Robinson said, but only ACOG's app closely follows clinical guidance.

"For basic educational purposes, apps are fine because they help the patient think about her pregnancy and about how to manage her health overall," Dr Ganju said. "But there is potential for harm with some of these apps as well."

He and Dr DeNicola both mentioned concerns about apps claiming to monitor the fetal heart rate. If a pregnant woman suspects a problem and uses one of these apps, it could offer false reassurance when she actually should see her obstetric provider. Dr Chen's research[7] found that none of 19 free fetal heart rate monitoring apps that didn't require accessories could accurately detect even an adult heart rate. Furthermore, she found that "five apps were duplicates of another app, six lacked disclaimers about medical use, and five provided false information." Another danger is social forums, incorporated into some apps, where pregnant women share potentially inaccurate information.

"The key question isn't which app to use," Dr DeNicola said. "It's what clinical decision [the patient is] using the app to help [them] make." Drs DeNicola and Robinson emphasize to their patients that apps can complement, but not replace, medical care and should not drive clinical decisions. Patients should always consult their physicians before any major decisions, especially related to medication safety, Dr Robinson said.

Down the Road: Mobile Care Integration

Most apps present information that's already available elsewhere (eg, online or in a book), but a mobile platform has much more to offer, said Dr Ganju, who expects to see more mobile technology integrated into patient care in the future.

"Could we improve maternal mortality through biometric measures?" Robinson mused. It's possible, he suggested, that real-time monitoring of blood pressure and blood sugar management could eventually reduce morbidity from preeclampsia and gestational diabetes.

"We are getting much more data today, and in the age of information, big data is king," Dr DeNicola agreed. "If a pregnant woman with hypertension is monitoring her blood pressure, this could be a great way to catch a brewing event before it becomes something catastrophic or leads to a poor outcome."

The first company to successfully integrate their mobile service with patient care is BabyScripts, a "data-centric" remote monitoring tool that patients can use if their providers have signed up for the service. Along with the app, pregnant women also receive a US Food and Drug Administration (FDA)-approved WiFi- and Bluetooth-enabled blood pressure cuff and scale (for maternal weight tracking) that instantaneously send data to her obstetric provider. The clinician pays a monthly fee per patient for the service, which offers an estimated 300% return on investment, claims cofounder Juan Pablo Segura (Figure 2).

Figure 2. A pregnant woman monitors her blood pressure at home and transmits the data to her obstetrician.

After launching in 2014, the company has moved from managing only low-risk, private-pay patients to managing higher-risk patients , including women with hypertension and gestational diabetes, and patients on Medicaid, Segura said. "We've really been focused on offering a whole end-to-end risk-stratified model that allows a provider to have a virtual experience with about 90% of his or her pregnant patient population," Segura said. "We think that monitoring patients who are higher-risk is where you can really start to identify more problems and intervene to deliver better care."

BabyScripts works with more than 15 health systems across the United States and has monitored approximately 8000 pregnant women. This year's goal is to monitor 50,000 women—and to make progress on their "moonshot to eliminate preterm birth by 2027," Segura said. They will soon unveil a feature that manages postpartum patients, too, including contraception counseling, blood pressure monitoring, and quality measures. They already have a program that screens women for postpartum depression for 6 weeks after delivery.

BabyScripts, developed with input from ob/gyns, is furthest ahead with obstetric care integration, other companies are exploring similar strategies. Bloomlife's Belli uses an at-home wearable device to monitor contractions, and Airstrip is moving into the consumer market with an FDA-cleared Sense4Baby system that lets pregnant women do fetal monitoring at home. It will take years, Dr Ganju said, to see how clinically relevant all this data collection can be, but it's the early adopters who will make that possible.

"I definitely can see more integration with clinical care and patient-generated data to the point where it might become commonplace for a patient to show up at the clinic and share all the data that have been collected since the last visit," Dr DeNicola said. Communication through online portals will also increase, he predicted. "If a health system or provider practice doesn't have a digital engagement strategy, they're going to get stuck, especially with this generation that is so tech-savvy," Segura said.

Home-monitoring with mobile apps and related devices could also eventually help triage patients, Dr Ganju said. "I think that's where we're headed, but we're still in the early stages," Dr Ganju said. "As more players come in and play with how the data can be clinically relevant, I have hopes that it will even change how we deliver care."

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