Work-in-Progress CHI 2014, One of a CHInd, Toronto, ON, Canada

Babywijzer: An Application to Support

Women During their Pregnancy

Anouk Wierckx, Suleman Shahid Abstract

Department of Communication and Information sciences Mobile health (mHealth) provides a new way to bridge
Tilburg University the communication gap between patients and their
Warandelaan 2, 5037 AB Tilburg, the Netherlands primary health care providers. 1This study investigates
a.c.d.g.wierckx@tilburguniversity.edu, s.shahid@uvt.nl how a mobile application can support Dutch pregnant
women. A prototype, called Babywijzer, was designed
to support pregnant womens needs. Babywijzer is a
Abdullah Al Mahmud1 mobile intervention, which enables pregnant women to
Faculty of Health, Arts and Design search directly for an answer to their pregnancy related
School of Design questions and follow current evidence based
Swinburne University of Technology
recommendations. The early evaluation showed that
Building PA. 144 High Street
Prahran VIC Australia 3181 the Babywijzer app has a positive effect on the
pregnant womens knowledge, awareness, confidence
and satisfaction.

Author Keywords
Pregnancy; behavior change; health intervention

ACM Classification Keywords

Permission to make digital or hard copies of part or all of this work for
H.5.2 [User interfaces]: prototyping,
personal or classroom use is granted without fee provided that copies are
evaluation/methodology.
not made or distributed for profit or commercial advantage and that
copies bear this notice and the full citation on the first page. Copyrights
Introduction
for third-party components of this work must be honored. For all other
The use of mobile communication in maternal health
uses, contact the Owner/Author.
care enables pregnant women to enhance their self-
Copyright is held by the owner/author(s).
care agency. Mobile technologies are being actively
CHI 2014, Apr 26 - May 01 2014, Toronto, ON, Canada
ACM 978-1-4503-2474-8/14/04. 1
This project was proposed as a master thesis by the third
http://dx.doi.org/10.1145/2559206.2581179 author and was supervised by the second and third author.

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Work-in-Progress CHI 2014, One of a CHInd, Toronto, ON, Canada

used to
t deliver health behavior
b interventtions and A few mob bile health interveentions were desig gned for
mobilee health interventtions have alreadyy been applied pregnant women
w in the dev
veloped world. Rec cently in
to suppport the management of diabetes,, hypertension, the Unitedd States and Russiia an intervention program,
asthmma, eating disorders and HIV treatm ment [1]. called Textt4Baby (T4B), wa as developed. Afte er sending
Severral studies have innvestigated the usse of mHealth in pected birth date, pregnant women receive
childs exp
develooping countries too reduce the perin
natal mortality. three text messages a week k with evidence-based
Howev ver, a few studiess investigated the improvement informatioon [5]. The evaluation of the progra am is still in
of maternal health care e by mobile comm munication for progress bbut it is hoped thaat this service will result in
middlee-income or developed countries. A number of improved health care utiliza ation, increased biirth rate
recentt studies show thaat pregnant wome en in developed and birth weight,
w decrease in maternal and in nfant
countries are also inseccure about their pregnancies
p and mortality and
a improved com mmunication with patients.
they do
d feel the need fo or more structure
ed, customized In the casee of the Netherlan nds, most of the m mobile
and reeliable information
n for gaining conffidence and self- application
ns designed for prregnant women arre not
efficac
cy [2]. intended ffor above mention ned purposes. Mos st of the
application
ns have been desiigned from a diffe erent
This study
s extends our previous work in this area [9] perspectivve e.g. for entertainment (e.g. Baby y-Namen
and iss focused on the Dutch
D health care system. This Pro), incre
easing the sales off pregnancy-relate ed products
system m is rather unique e in handling preggnancies and (e.g. Momm2B), too general in nature and info ormation
stressses on taking overrall pregnancy (an nd delivery) as not tailore
ed to a womens in ndividual health (e e.g.
natura ally as possible. In
n a developed cou untry like the Zwanger.n nl), inform about a very specific issue (e.g.
Nethe erlands, pregnant women get obste etrician support Zwanger & Eten -inform wo omen about what they can
and on average 10 ante enatal visits, whic
ch should lead and canno ot eat during their pregnancy) or de esigned for
to hea althy babies. An innternational comp parison showed specific areas in the Netherlands (e.g.
that the perinatal mortality in the Netherlands is still ZwangerAppassistent). In this study, we inve estigate
Figure 1. Early prototype
e of
relativ
vely higher than in n Finland and Swe eden. how mHea alth can support (e e.g. increase know wledge,
the main food screen whe
ere
Furthe ermore, women are relatively less confident about improve co onfidence, bring structure
s in life, ettc.)
user can
c check the daily
their pregnancy
p and to considering that they do not pregnant women
w in the Nettherlands.
schedule and her perform
mance
alway ys have timely acc cess to the relevan nt information
on hea
alth meter.
[3]. This
T study attemptts to improve preg gnant womens User res
search
self-caare agency by des signing a mobile application
a The goal of
o user research wasw to discover diffferent
which is tailored to their needs. Research showed that a issues which Dutch women face during their pregnancy
wome ens self-care agen ncy could be enha anced by proper and to findd out the key information gaps. We e decided to
healthh education [4]. In ncreasing the hea alth knowledge focus on th he first-time pregnant women beca ause of
of preegnant women will result in improve ed health their insuffficient experience
e in handling pregnancy and
literac
cy, which will posiitively affect their health status. high insecurity. In total, thirteen women and d three
obstetricia
ans participated inn semi-structured interviews

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Work-in-Progress
Figure
e 1. Screen for view
wing
local (pregnant) friends. Users
U avoid it. So I have searrched on the Interrnet what was
can co
ommunicate and make
appoin
ntments for f2f meettings.
Translation of menu from
Dutch to English:
Week: Week, Voeding = Food,
F gives them a kind of reeassurance that all are good.
Risicos = Risks, Meer = More
M mind, I ussually forget during the consultation n session.
CHI 2014, One of a CHInd, Toronto, ON, Canada
to shaare their experiences. We asked wo omen about the happen be ecause she was rid ding on her horse? (p. #7).
awareeness of their own n health, their bab
bies health, They said they would ask th heir obstetrician during
d their
their information
i needss, and their experience with consultatio
ons if they were unsure
u about anytthing, but in
mobile e applications. Each interview tookk about 40 the early stage
s of pregnanccy there are only few
f
minuttes and was record ded. A qualitativee data analysis moments forf consultation. They
T also mention
ned that it
technique was used and the recorded intterviews were would be nice
n to get help frrom experienced women
w
transccribed and finally analyzed using op pen, axial and (someone they know person nally) who have gone
g
selecttive coding [6]. A very brief summa ary of main through thhe process of givinng birth.
theme es discovered fromm the interviews are
a given
below
w: Pregnancy y ailments
Women prreferred informatio on about pregnanncy
Food, Nutrition and weiight gain ailments too recognize their symptoms, and find a
The in
nterviews showed that almost all prregnant women potential remedy
r to make the pregnancy more
are insecure about food d and nutrition. In n particular the comfortable. In case they knew
k which ailmennt they
products and ingredients that women sh hould not eat, were suffeering from, they often had no idea wwhat could
becauuse those could ha arm the developm ment of the help them. One person say ys you must do thhis, but the
unborrn baby. So then n it is still question
nable, as with other sayss you should do thhat and then I thin
nk about
shrimpp. Can you eat thhat anyway? Becau use it says you my baby a and do not want to o take medication
ns (p. #6).
cannoot (P. #7). Duringg the consultation n with their
obstettrician the weight gain of the pregn nant women is Keeping trrack of pregnancy y
stored
d. However, the women
w experience ed difficulties Women als so faced difficultie
es in keeping track of their
with the
t amount of weiight they should gain g during their pregnancie es e.g. where are they now? What happens
pregnancy. I did not want
w to gain 20 killo if I could during a particular week? Is s there a mismatc ch between
what is noormal and what is happening in their body?
the avverage weight you u gain during yourr pregnancy. They also said that before a meeting with obstetrician
And thhat was 12 kilo I have
h read. So som metimes I they have a lot questions in n mind but they us sually
askedd other pregnant women
w on forums how much forget to a
ask all questions. During
the day, I think
they gained
g weight to check
c if I was on sschedule or about a lott of things and wa ant to ask obstetrrician about
not (p. #2). They men ntioned that asking other women them but I cannot always re ecord these questtions in the
diary givenn by our obstetriccian. The ones I ha ave in
Risky behaviors Although the
t obstetrician will
w advise them ab bout all
In adddition, they had a lot of uncertainties about the their queriies, they would also like the ability to directly
risks of
o a pregnancy an nd how they shoulld behave to access thiss information. A consultation
c with their
t
avoid these. I have exxperienced that so omeone was obstetricia
an is often very shhort and the pregn nant
riding on her horse andd got a miscarriagge. Did it women ha ave difficulty to remember what has s been
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Work-in-Progress CHI 2014, One of a CHInd, Toronto, ON, Canada

said. The
T ability to reco
ord the conversatiion notes and testing a couple
c of design alternatives. In the e first
consult them when required was a big plus for them. round of development
d we mainly
m paid good attention
a to
Wome en mentioned thatt they try to brow wse forums but contents. Users emphasized d that the mobile application
on diffferent forums peo ople have differennt point of views should be structured and un nlike forums, all in
nformation
(too many
m I think answers). They also mentioned should be available in an ea asily searchable/browseable
many issues while brow wsing forums e.g. language format. Th he application should be customizab ble for
issuess, user account creation issue for each forum, every wom men and obstetriciian should be able e to set the
inabiliity to browse on mobile/tablets,
m tru
ust factor, and roadmap forf pregnant women. The key requiirements
too unnstructured inform mation. and featurres of the app are:1) a complete pe ersonal
health reco ord system custom mized by the userr for the
Additiional support duration ofo pregnancy and verified
v by the obstetrician,
Many women also cons sistently felt of the
e need for 2) women can monitor theirr own health records (weight
conneecting with other pregnant
p women u using social gain and b blood pressure) in different charts anda
mediaa or private groups. For example, th hey showed an compare them with average e (obstetricians prrovided a
intere
est in making an online
o group of all those women standard plan
p which can be entered in the ap pplication
who visit
v a particular healthcare center forf discussing based on thet womens cond dition e.g. current weight,
probleems and sharing updates.
u Women a also mentioned first or sec
cond pregnancy ettc.), 3) a health m meter gives
varietty of other issues. For example, the ey indicated them an in ndication of their eating
e habits e.g. enough
that they had doubts about when they should call their fruits and vegetables per da ay (obstetricians provided
p a
obstettrician, and the ob bstetricians underrpinned the list of food
ds with negative im mpact on health),, 4) a push
imporrtance of this inforrmation. So they y know now notificationn system for acco omplishing differen nt tasks
labor has begun, and th hat they should ca all. Or when (e.g. reminding about eating healthy, giving
they did
d not feel their baby
b all day. Thatt they know it is informatio on about pregnanc cy weeks, appointtment with
imporrtant to contact us s (p. #14). The o obstetricians obstetriciaans, etc.), 5) an alarm system for w warnings
mentioned that pregnant women should be informed (e.g. high blood pressure, abnormal
a weight gain,
g bad
about food intake, vitam min use, the socia al rules relating eating hab bits, etc.), 6) a jo
ournal module (en nable
Figure 3. Th
he food screen wherre to acttivities, prenatal te
esting, birth plan and get advice women to browse existing information anytim me, record
user can see
e the recommendations. when they should call. Health gain from m better their queriies for consultatioon visits and notes s after
Voeding: foo
od, Risicos: risks, Meer:
M nutritiion, healthy, varieed food, possibly a multivitamin, visits), 7) a module to send d health records to o
more. that vitamin
v D, stop sm
moking. These are e actually the obstetriciaans, 8) a section on
o social rules that prevent
most important things in terms of inform mation women fro om risky behaviorrs, and 9) a module to
provission (p. #14). connect with other pregnant women (social media m
community y - primarily enrolled with the same
Desig
gn and Develo
opment healthcare e organization). Th he initial design of the final
Based
d on above resultss, we finalized the
e list of design prototype was created using g Balsamiq Mocku ups (Figure
requirrements and decid
ded to go for a mo obile app after 1), and wa as tested with end d users. Based on the

1336
Work-in-Progress
Task 1 - Fill in your personal data
Task 2 - Read on the progress of your
baby and compare it with avg.
Task 3 - Track your weight
Task 4 - Search for a specific
ingredient/product
Task 5 - Add products to daily
consumption
Task 6 - Search for a specific medicine
Task 7 write journal and prepare
queries for the next meeting
Task 8 - Read on risky behaviors
Task 9 - Read on pregnancy ailments
Task 10 - Search for other pregnant
women:
Task 11 - Timing contractions
Task 12 - Read the advice on when to
call
Task 13 - View the course of your
pregnancy:
Task 14 - Send progression to midwife
Figure 4. Major tasks for usability
evaluation
feedback, the design and flow was improved. The final
application was designed using HTML5 and Adobe
Photoshop (Figure 2).
Evaluation
The usability test was conducted to evaluate the
usefulness of the application. Eleven pregnant women
and one obstetrician took part in the evaluation. Five
women and one obstetrician from the user research
participated in the evaluation phase. During the
usability test participants had to perform 14 tasks
(figure 4) on the iPhone. After completing the tasks,
every participant filled a UX questionnaire (on Likert
scale 1 to 5 where 5 is very good). At the end, a semi-
better enables them to contact their obstetrician when
structured interview was conducted to know overall
experience of using the app, and how they think the
app would influence their lives. The qualitative data
such as video recording of user interaction, verbal
protocol, and critical incidents w ere gathered and
analyzed.
Results
Majority of the participants indicated that the
application was easy to use (M=3.82, SD=.98), the
functions were well integrated (M=3.91, SD=.70), the
structure was intuitive and easy to remember (M=4.36,
SD=.67) and they would like to use the application
frequently (M=4.36, SD=.81). Almost all participants
thought that the app will allow them to follow the
course of their pregnancy in a better way that
otherwise would be possible (M = 4.45 , SD = .93).
Participants were not sure if their overall lifestyle would
improve due to the app (M=2.91, SD=1.04). However,
participants thought that using the app will make them
more satisfied during their pregnancy (M=4.09,
SD=.83), and gives them more confidence about their
CHI 2014, One of a CHInd, Toronto, ON, Canada
choices during their pregnancy (M=3.91, SD=1.30).
They were happy that the app would allow them to
better inform their midwife about the course of their
pregnancy and improves overall communication (M=
4.00, SD = 1.34).
In the following sections, we present selected examples
from the interviews.
Convenience. Ten women are very willing to use the
application as it is. Seven women think it is much
easier to follow their progression with a mobile phone.
Well you can follow everything exactly, and you do not
have to write it down in a book. It is just so easy to do
it with your phone (p. #1). Besides, women think it
they are in a situation they need to. For example, one
participant said, The app is very convenient to use. All
risks are clearly indicated on one app, but also what
nutrition you should have, which week you are in. I
think the risks of certain behaviors are the finest, you
can realize those without calling your obstetrician or
you can see if that is necessary (p. #8). However,
obstetricians were a little reluctant to contact by using
the application. They were afraid that they have to do
a lot of extra work and pregnant women can associate
wrong expectations (e.g. too quick response) while
sharing their personal information. Although, they
thought that sharing information could be valuable, but
should be integrated to their existing midwifery
information system (as a policy) to make it workable.
Nine women appreciate the ease of getting an answer
in just a few minutes through the personalized
information. It's personal, because you can do more
with your own data and simply more practical to apply,
less reading (p. #4). In addition, they thought the
application would be a lot more applicable when outside
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Work-in-Progress
the home or at times when they cannot open a
computer (e.g. on bed) or read a book. "For example,
you're out to dinner and want something. To see if I
can eat it or not. You have to go searching or Googling
in advance and sometimes it takes quite some time "
(p. #3). [7] also highlighted that women are not always
pleased with existing information sources and a mobile
system can be useful in this regard.
Satisfaction & confidence. Women think they would be
more confident, because the babywijzer application can
serve as a reference point. "You have everything at
your fingertips. You can keep record of what is
happening with your body and compare with the avg.
provided by the obstetrician (p. #10). Women also
value the connection with other women. You do not
feel that you are alone. You realize that other have
gone through it and are ready to help you - someone
you also know personally. This finding is in line with
previous findings where it has been shown that new
mothers gain confidence from the fact that other
women also went through difficulties [8].
Conclusion and Future Work
We conducted a field study with pregnant women and
obstetricians to examine the information needs among
this group. Our field research findings strengthen the
existing findings where it has been shown that
pregnant women from developed countries are also
insecure and a mobile intervention solution can be
beneficial. Our first design provides a good starting
point for the introduction of a mobile application in
Dutch maternal health care. Participants indicated that
the application will increase their knowledge and
awareness about their behavior during their pregnancy,
they would feel confident and satisfied during their
pregnancy while using the app. We plan to run a
CHI 2014, One of a CHInd, Toronto, ON, Canada
longitudinal study to examine the impact of the app on
the behavior of pregnant women.
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