With increasing use of mobile devices, particularly smartphones, the public now has easier access of means by which to monitor and manage their own health . Mobile health (mHealth), as defined by the WHO, is the use of mobile and wireless technologies to support the achievement of health objectives . Use of all types of mHealth technology is on the rise, with the majority of mHealth applications (apps) being general wellness related . Similar to other fields of medicine, reproductive health, in particular, family planning, has also experienced a surge in mHealth interventions. While previous research has evaluated use of mobile technology by family planning providers for patient education and counseling, in this review, we focus on the use of mobile technology by patients for their own clinical use.
MOBILE APPLICATIONS FOR CONTRACEPTION
Given the current available options of well tolerated and effective contraceptive methods, there is a need for evidence-based guidance to assist women in choosing the most appropriate method for themselves and to promote perfect use . Fertility awareness-based (FAB) contraceptive methods help women identify their fertile days within each menstrual cycle, which, in turn, allows women and their male partners to adapt sexual behavior based on this information. Effectiveness of FAB methods vary greatly in the literature, depending on the fertility indicators used, resulting in typical-use Pearl Index ranging from 1.8 to 24.0 [5,6]. The availability of fertility apps to consumers has created a market which has the potential to have a large public health impact, but providers and patients should be wary about making behavioral decisions based on information they receive from these apps . Many fertility apps may have low accuracy, and even fewer have published data in peer-reviewed journals. Thus, reliance on such apps could lead to unintended pregnancies.
In recent years, there has been an increase in interest among women to use fertility monitors as a method of contraception to avoid hormonal methods . Use of such ‘fertility apps’ has increased across all age groups. Fertility apps are also the fourth most popular health monitoring apps among adults and the second most popular among adolescents . A web-based pilot survey found that approximately one quarter of respondents reported using a fertility app or having used one in the recent past . Regardless of respondents’ knowledge level about the menstrual cycle and fertility, 63% of users reported it was ‘highly’ important to them that these apps be science-based and successfully identify fertile days. However, of the fertility apps that women reported using, most of them were not designed as a digital FAB method platform to aid in recording fertility signs and deliver ‘interpretative capability,’ with the most commonly used app amongst current users being Period Tracker (53.7%), which is not approved by the US Food and Drug Administration (FDA) as a contraceptive method . It is especially concerning that many available apps cannot be relied on for accurate, science-based pregnancy prevention methods, yet women using these apps expect and trust that they are receiving expert information.
In August 2018, the US FDA approved marketing of the first mobile medical application (app) to be used as a method of contraception – a step viewed by some groups as controversial. The app, called NaturalCycles, has been approved for use in Europe since 2017. It utilizes fertility awareness and is designed for mobile devices such as a smartphone, tablet, or laptop computer . NaturalCycles requires input of basal body temperature daily and the dates of menstruation. Input of luteinizing hormone (LH) results is optional entry points. The app then uses said information in an algorithm that calculates the days of the month a woman is likely to be fertile based and returns a red (unsafe) or green (safe) day to the user depending on calculated risk of getting pregnant . For women using the app for contraceptive purposes, the app displays ‘use protection’ on days that are calculated to be ‘unsafe,’ and thus women are advised to abstain from sex or use an alternative method of protection (such as barrier methods).
Initial studies to evaluate the application's ability to correctly identify a woman's fertile window found only 0.05% of green (safe) days were inaccurate . In 2016, Scherwitzl et al. conducted a retrospective study that evaluated the apps efficiency to prevent unwanted pregnancy by reporting the Pearl Index for typical and perfect usage . They reported a Pearl Index of 7.0 for typical use and a 0.5 for perfect use and conception probability of 7.5% over 13 cycles . This was significantly lower than the general typical-use Pearl Index of 24.0 during the first year for fertility awareness-based methods . Scherwitzl et al. later conducted a prospective study, employing a larger dataset to better calculate the perfect and typical-use efficacy, and also method failure rate. They reproduced similar results to this 2016 study with typical-use Pearl Index of 6.9 pregnancies per 100 woman-years [95% confidence interval (CI) 6.5–7.2], a perfect-use Pearl Index of 1.0 pregnancy per 100 woman-years (95% CI 0.5–1.5), and a 13-cycle typical-use failure rate of 8.3% (95% CI 7.8–8.9).
NaturalCycles stands out as one of the few apps to publish data in a peer-reviewed setting – an undertaking very few other app companies have accomplished. However, the studies have also been met with criticism due to limitations in study design and concerns that the data do not actually allow the app to provide reliable estimated rates of unplanned pregnancy. Reviewers have remarked on the studies’ failure to adequately assess pregnancy intentions and quoting an ‘inappropriate’ perfect-use pregnancy rate . Based on the original retrospective data, Scherwitzl et al. reported ‘perfect-use’ Pearl Index rate using all cycles in the denominator, without accounting for sexual behavior and therefore not truly calculating perfect-use cycles. This methodology significantly underestimates perfect-use rate . While Scherwitzl et al. attempted to remedy this in subsequent prospective trials , by only including cycles where they were confident users did not have unprotected intercourse on a fertile day, critics still questioned the validity of the reported pregnancy rates because 47% of cycles recorded lacked intercourse data . Furthermore, a large number of participants who became pregnant also had failed to log sexual behavior data . Nevertheless, this published research remains valuable because the results reflect real-world data or ‘typical users.’
MOBILE APPLICATIONS FOR ABORTION
While mobile phone apps for abortions exist, there is very little published research regarding the quality or patient usage of these apps. Researchers at Ibis Reproductive Health are, at present, conducting research and developing a comprehensive sexual and reproductive health smartphone app, but no published data are yet available (Gerdts, CE, personal communication). There is a lack of information regarding how women seeking or receiving abortion care prefer to receive information using mobile technology. Gill et al. recently conducted a mixed-methods study using a cross-sectional survey at three urban abortion centers to evaluate women's interest in follow-up care after induced surgical abortion in the first phase of a three-phase study. Qualitative interviews conducted with eight participants revealed that a website-based platform with secure e-mail or text notifications was preferable . Women reported they wanted information on emotional well being, contraceptive decision-making, general sexual health, and postprocedure care. In subsequent phases of this study, the authors designed an intervention and piloted it in a prospective, mixed-methods study, and data are forthcoming.
Mobile applications in underserved and minority populations
With the ongoing assailing of reproductive rights and legislation that threatens to prohibit or, at best, limit the provision of reproductive healthcare in the United States, minority and underserved women remain most at risk of losing access. Mobile health, through app-based pregnancy prevention methods, may offer the potential for a large public health impact, especially for such populations at high risk of compromised access to reproductive health care. Helping adolescents, young adults, and minority populations prevent unintended pregnancy is a public health priority due to the substantial health, social, and economic impacts [19,20].
With the rise in access to smartphone technology, specifically apps, and the rapid uptake among youth, guidelines on best practices for adolescent and young adult pregnancy prevention through mobile apps is needed. An assessment rubric, called the Mobile Criteria for Adolescent Pregnancy Prevention (mCAPP), was created to serve as a framework evaluating mobile health apps for adolescents using evidence-based practices . Experts in the field were consulted to help define best practices for in-person teen pregnancy prevention interventions that could also be expected to work via mobile technology. For example, these practices ranged from delivering persuasive communication about abstaining from sexual activity to providing clear information about the risk of pregnancy due to sexual activity. In a systematic review evaluating mCAPP, it demonstrated that the quality of apps for adolescent pregnancy prevention varies greatly, and that apps available at present may not reflect best practices for teen pregnancy prevention, which is particularly detrimental, because this population above others is relying on their technology device for information . The apps reviewed displayed a number of strengths such as the inclusion of sexual and reproductive health (SRH) education and best practices for interventions for teen pregnancy prevention. Nearly half of the apps reviewed included information around SRH communication, negotiation, or refusal skills. Weaknesses of the apps included having limited information for specific ethnic and racial groups, lack of persuasive messaging in half of the apps which translates to a lack motivation for behavior change. The finding of greatest concern is that of the 22 apps reviewed; 5 did not offer any of the best practices for teen pregnancy prevention as defined by health experts and peer-reviewed literature. This illustrates the need for more apps that contain content to reflect best practices but also have the design and interface that can be disseminated across larger audiences .
Providers need to be aware and stay updated with the various platforms patients use to receive contraceptive education and the quality of this information. In a systematic review of mobile phone apps for prevention of unintended pregnancy, Mangone et al. conducted a search of the Apple iTunes and Android Google Play stores and reviewed 218 unique apps advertised as pregnancy prevention or aiding in decision-making for various fertility purposes . Forty-one percentage of the apps did not mention any modern contraceptive methods and 23% mentioned only one method. The most commonly mentioned methods were fertility awareness (44%), oral birth control pills (43%), and condoms (34%) . The largest group of apps that advertised pregnancy prevention supported natural family planning or fertility awareness methods, which is defined by the Center for Disease Control as the least effective method of birth control . Further, in the apps that did mention a modern contraceptive method, less than 50% provided information on how to use it . Additionally, only 17% of the apps included information on long-acting reversible contraceptive (LARC) methods and only 17% provided information on where users could access contraception . Unfortunately, most of the apps (72%) did not target race, and only 10% were explicitly targeted to youth. Though only a few apps were designed specifically for young adults, these apps actually integrated the overall best practices in each app. The authors concluded that most apps fail to provide ‘valuable information, interactive decision aids, and evidence-based interventions for unintended pregnancy prevention’ and may increase the likelihood of unintended pregnancy . Figure 1 shows the 12 highest scoring apps from the search in Mangone's study. All listed apps had at least 50 points for overall features, and 15 points for contraceptive information and pregnancy prevention best practices. Of note, most of these apps were developed by credible public health-related groups such as Planned Parenthood, New York City (NYC) Department of Public Health, and the National Health Service (NHS) in the United Kingdom .
Minority populations are using mobile phones to access health information more frequently than those who classify themselves as white, which offers unique opportunities for those in public health and health education to reach underserved populations with the highest rates of health disparities by means of mHealth interventions . A systematic review by Anderson-Lewis et al. demonstrated that mHealth technology has the ability to increase prevention and health education in health disparate communities . Present literature has also shown that while mHealth apps, such as pregnancy apps, are multiplying, lower rates of uptake were seen among lower-income and non-English-speaking women . Researchers have identified the lack of tailored apps for minority communities as an ongoing problem for certain digital health interventions [22,27]. Development of a contraceptive counseling app called ‘miPlan’ was created to engage young African American and Latina women in a family planning clinic. Findings from a randomized controlled trial evaluating the app found that while it was highly acceptable and most expressed desire to use it in the future, users reported no change in regard to their contraceptive self-efficacy over the study period . There remains a lot of work to be done to improve the quality of apps and other mHealth technologies available to patients, which will require research to better understand of the unmet needs of underserved populations.
Given the consumer demand for fertility apps, specifically for pregnancy prevention, additional research is needed in this unique space to understand how women can be informed consumers, choosing the best contraceptive method for themselves. One of the appeals of digital and especially mobile technologies is to improve patient care for ‘unreachable populations’ by overcoming the limitations imposed by cost and access . In-depth reviews of app content reveal the frequent absence of evidence-based best practices for pregnancy prevention, and also essential information about effective methods of contraception. There is also a void in the literature with regards to mobile technology for abortion care. With increasing restrictions to abortion care in the United States and more states failing to ensure abortion access to women, we are likely to see the role of abortion mobile technology become more crucial.
Collaboration between women's health experts and mobile health developers remains essential to fully address the needs of women seeking family planning services. Further research is needed to aid in development of mobile health technology that best incorporates patients’ preferences to assist them in preventing pregnancy as well as evidence-based methods with respect to the delivery of health information, both for contraception and abortion services.
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Conflicts of interest
There are no conflicts of interest.
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