Technologies Applied to the Mental Health Care of Pregnant Women: A Systematic Literature Review

Objective:  This article aims to review the literature regarding the use of technologies to promote mental health for pregnant women. We seek to: understand the strategies that pregnant women use for mental health care. Also, we investigate the existence of scientific evidence that validates such practices. Methods:  This study follows the PRISMA guidelines for systematic reviews. We analyze 27 studies published between 2012 and 2019. We include publications in Portuguese, English, and Spanish. Results:  The results revealed several different possibilities to use technology, including the use of text messages and mobile applications on smartphones. Mobile applications are the most commonly used approaches (22.5%). Regarding the strategies used, cognitive-behavioral approaches, including mood checks, relaxation exercises, and psychoeducation comprised 44.12% of the content. Conclusion:  There is a need for further investigation and research and development efforts in this field to better understand the possibilities of intervention in mental health in the digital age.


Introduction
Pregnancy is an important period in a woman's life being characterized by substantial changes. Specifically, pregnancy leads to several changes in the women's body, affecting organs, systems, and cycles, which impact physical, hormonal, and psychosocial aspects of a woman's life. Such changes also have a direct impact on the mental health of pregnant women. [1][2][3][4] Therefore, pregnancy demands specialized care for women's health. Such care is particularly important when risk factors exist.
Health outcomes for mental health during pregnancy and postpartum are linked to numerous risk factors. Risk factors include the history of mental illness, unwanted pregnancy, use of alcohol or illicit substances, low education level, financial burden, and unemployment. In addition to that hormonal changes may also result in symptoms related to anxiety and depression, which can lead to psychological suffering. [5][6][7] Among protective factors that reduce risk, we can highlight prenatal care, education, and social support. 3,8 Among protective factors, we also remark the importance of activities that promote mental health during pregnancy. Such activities encompass multidisciplinary expertise, 9,10 aiming to reduce risk factors while augmenting protective ones. 11 More specifically, mental health interventions train women by offering support, educative information, and preparation during their pregnancy, aiding pregnant women not only to recognize and express their emotions, 12 but also to learn strategies to cope with emotions.
There are several ways to provide care and support for pregnant women, including the use of technologies, mobile devices, smartphones, as well as monitoring equipment, personal assistants, and other wireless devices. [13][14][15][16] The usage of technology to promote health, defined by the World Health Organization (WHO) as mobile health (mHealth), is innovative and seeks to promote prenatal care. 17 The definition of mobile health (mHealth) is a "public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other wireless devices" (p. 6). 18 Technology usage for healthcare in general contributes to improve information dissemination. It also facilitates healthcare delivery, and coordination among specialized services. Lastly, it also involves pregnant women more closely and actively in their own healthcare practices. 18,19 According to recent literature reviews on mHealth during pregnancy, technological interventions that support healthcare strategies result in positive outcomes, for example by accelerating the access to health services, 17 reducing patients' concerns, reducing symptoms of anxiety and depression, 20 and managing pregnancy risks when those exist (e.g., in case of gestational diabetes). 15 The type of technology used varies, ranging from webbased informative programs to remote monitoring, telehealth, mobile care, and online psychotherapy. [21][22][23][24][25] Taking into account that child-bearing age women are frequent users of technology, and the growing need to investigate evidence-based approaches around this topic, 22 this paper aims to review the literature regarding the use of mHealth technologies to promote mental health for women during pregnancy and postpartum. Our goal is to better understand what the strategies are employed in mental health care for these women, as well as to identify the scientific evidence that validate such practices.

Methods
We conducted a systematic literature review seeking to analyze research studies previously published, and to systematically understand the topic of interest. 26 We aim to synthesize previous studies, and to obtain a unified view of research findings by following a scientific and systematic process. Therefore, we structured our systematic review based on a scientific investigation that includes several decision points regarding the inclusion and exclusion of research studies according to a pre-defined set of criteria. Our approach also seeks to assess the validity of the findings obtained with the literature review. 27 Specifically, the search was carried out following conventional scientific standards as outlined in the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA). 28 The analysis of the literature included six steps: (1) identification of the topic of interest and research questions; (2) definition of the inclusion and exclusion criteria; (3) gathering and selection of related work; (4) categorization of selected work; (5) analysis and interpretation of the results; and (6) presentation of a synthesis of the topic investigated. The inclusion criteria defined by the authors are papers published in Portuguese, English, or Spanish whose document is available online; studies published and Resultados: Os resultados revelaram diferentes possibilidades de utilização da tecnologia, sendo o uso de mensagens de texto e de aplicativos em smartphones mais os utilizados (22,5%). No que se refere às ferramentas utilizadas, estratégias cognitivo-comportamentais, tais como verificação do humor, exercícios de relaxamento e psicoeducação compreenderam 44,12% do conteúdo. Conclusão: Verifica-se a necessidade de mais investimentos nessa área para que se possa compreender as possibilidades de intervenção em saúde mental na era digital.
indexed in the following bases Lilacs, Medline/PubMed, PsycINFO, Scielo, Scopus and Web of Science; work related to the topic of interest (use of mHealth technology to promote mental health for pregnant women). The papers were selected for analysis regardless of their publication dates. For analysis, we excluded papers that present results related to babies, children, or postpartum.
The advanced search resulted in 1,010 papers. Two researchers used the tool EndNote Web to organize the data and followed the protocol PRISMA to proceed with the review. 28 Also, the authors used a validated technique 28 (PRISMA) to extract data directly from the primary source and as such select relevant information from the publications gathered for further analysis. The data analysis relied on descriptive statistics, and content analysis. Content analysis encompasses a series of analysis techniques for communication. It employs systematic procedures and objectives, aiming to describe the information obtained. 29 After reading all articles, the authors grouped the information in categories by completing a categorical content analysis. The review was not registered.

Results
Initially, we obtained 1,010 references from the databases used. After refining the search to identify duplicated work, we excluded 192 studies. Then, we discarded 681 articles, because the title of the work was not relevant to the review according to our inclusion criteria. After carefully reading the abstracts, we excluded 68 articles, and 69 publications remained for analysis. Lastly, after searching for the full documents, we excluded 42 studies because after reading the full papers of the studies we noticed that those did not meet our inclusion criteria. Thus, we obtained 27 papers for in-depth analysis, as illustrated in the ►Figure 1.

Search strings
Gestantes AND Complicações da gravidez AND transtornos mentais AND Cuidado pré-natal AND Sistemas de apoio psicossocial AND Apoio social AND Fatores de risco AND Telefone celular In our analysis, we identified the journals where the articles were published, to identify those that most frequently publish articles related to the topic. We noticed that the journals Annual Review of Cybertherapy and Telemedicine, BMC Psychiatry, Journal of Medical Internet Research and PLOS ONE published each two papers related to the topic. We also noticed that, based on the research field of the first author, 29.6% of the articles were led by investigators from Health Sciences, followed by Psychology (18.5%) and Psychiatry (18.5%), as listed in ►Table 1. Among the 27 papers analyzed, 7 (25.9%) reported literature reviews, thus we advance the state-of-the-art by updating the current analysis of the literature in the domain.

Pregnant women AND Pregnancy complications AND Mental disorders AND Prenatal care AND Psychosocial support systems AND social support AND Risk factors AND Telemedicine Pregnant women AND Pregnancy complications AND Anxiety AND Prenatal care AND Psychosocial support systems AND social support AND Risk factors AND Cell phone Pregnant women AND Pregnancy complications AND Anxiety AND Prenatal care AND Psychosocial support systems AND social support AND Risk factors AND Telemedicine Pregnant women AND Pregnancy complications AND depression AND Prenatal care AND Psychosocial support systems AND social support AND Risk factors AND Cell phone Pregnant women AND Pregnancy complications AND depression AND Prenatal care AND Psychosocial support systems AND social support AND Risk factors AND Telemedicine Pregnant women AND Pregnancy complications AND Stress psychological AND Prenatal care AND Psychosocial support systems AND social support AND Risk factors AND Cell phone Pregnant women AND Pregnancy complications AND Stress psychological AND Prenatal care AND Psychosocial support systems AND social support AND Risk factors AND Telemedicine
Our search did not return results from papers published in Portuguese, reporting studies carried out in Brazil. Moreover, the United States is the country with the largest number of studies in the domaineight in total (29.6%), followed by Italywith four (14.8%). Australia, Canada, United Kingdom and The Netherlands that conducted two studies each (7.4%). Also, there was only one study reported from Norway, Spain, Sweden, Germany, and Nigeria (3.7%). Lastly, the papers analyzed were published after 2012, as ►Figure 2 shows.
Regarding the type of technology used, the use of Short Message Service (SMS) and applications for mobile phones were commonly found (9 publications each -22.5%), followed by phone calls and telehealth in general (5 publications each -12.5%). One result returned for strategies related to audio recordings, online therapy (self-paced), video usage, voice-over-PowerPoint, and website (2.5%). Two studies reported voice messages and computer-assisted therapy (5.0%). Two publications did not specify the type of technology used (5.0%). ►Chart 2 summarizes the main aspects of each analyzed text, namely: main author, year of publication, study design, sample size and characteristics of the technology presented.
Regarding the information available in the technology, we conducted Content Analysis 29 aiming to identify the strategies used to deliver information, support, or intervention provided. We noticed a prevalent use of techniques and methods based on cognitive-behavioral approaches (44.12%). Regarding the tools available in the technology, we highlight journaling, mentioned five times (7.35%), relaxation exercises, meditation, guided imagery, and psychoeducation, which were mentioned three times (7.35%), along with non-specified techniques based on cognitive-behavioral therapy. Furthermore, strategies including sleep hygiene, mindfulness, breathing exercises, feedback, encouragement messages, behavioral activation, journaling, problem-solving, planning of positive activities, and self-care strategies were also listed as techniques and methods based on cognitive-behavioral approaches. The results obtained are presented in ►Table 2.
The period to use the tools ranged from 1 to 40 weeks, depending on the characteristics of the intervention. On   13 were shorter. Specifically, these authors investigated the user experience with a mobile app for the well-being of pregnant women, during one week, aiming to bring awareness to their affective states, besides also teaching them strategies to cope with anxiety and stress. We also found studies, like the one conducted by Gureje et al. (2015), 38 which were extendedinitially beginning with eight weekly sessions but including additional sessions during pregnancy on demand as well as an intervention six weeks after the birth of the child, depending on the levels of depressive symptoms notice in the mother during postpartum. In this case, specifically, the support and the clinical supervision were delivered mainly via mobile phone by doctors and psychiatrists. Besides this, they sent patients text and voice messages automatically, through mobile phones, in order to: (a) improve the compliance of ( The women received a telephone support intervention patients with clinical appointments and (b) follow up on their recommendations. Additional studies applied telemedicine to monitor women throughout their pregnancies. 16,45 In our analysis, we investigated whether the objectives of the studies included the study of technology usage, specifically regarding certain pathologies, or co-morbidities occurring during pregnancy. As a result, we found that 59.3% (16 papers) described the usage of technology related to treat specific pathologies. Also, 40.7% (11 papers) did not mention such objective. The pathologies mentioned are listed in ►Table 3.

Discussion
By providing an overview of the literature, this study aimed to evaluate the applicability, the benefits, and limitation related to technology usage in prenatal care, specifically regarding mental health. This review shows that the interventions have a wide range of applications in what regards prenatal care. The categorical analysis indicates that general aspects beyond psychological factors are also covered, including clinical factors, obstetrics, and socioeconomic aspects. Thus, we noticed that the multidisciplinary approaches are emphasized in the studies analyzed.
For example, Oliveira-Ciabati et al. (2017) 46 identified that a short text message service is potentially useful for improving coverage of antenatal health practices, including syphilis and HIV testing. However, only a fifth of eligible women showed interest in and applied to join this project. Thus, the authors recognize the importance of further encouraging participants to use such tools, realizing that there are still several obstacles that need to be overcome in order to be successful in expanding the proposed interventions.
Our results show that most studies were carried out in developed countries. Hence, it is crucial to further discuss the possibilities to implement healthcare strategies driven by  In what regards the information available through technology considering the usage of cognitive-behavioral strategies, the literature provides evidence that support the efficacy of cognitive-behavioral therapies, especially from the third-wave cognitive behavioral therapy, to improve the patients' health outcomes as well as symptoms of depression, anxiety, and overall quality of life after treatment. Furthermore, the results indicate a significant efficacy obtained when such treatments are compared to control treatments for active management of depression and anxiety. 48 Because we selected publications based on a set of predefined descriptors, this review is not comprehensive. Despite the limitations of this study, the results obtained contribute to augment the discussion around the usage of technology for healthcare, and specifically for Psychology. In this context, it is relevant to consider technology use for mental health along with quality of care, data security, opportunities involved, efficacy, efficiency, and patient focus. To facilitate the implementation and usage of technology strategies, policy makers must consider the international legislation to implement and validate this new format in the delivery of health services. 41

Conclusion
Technology usage has been vastly explored for health interventions. Regarding their usage for mental health during pregnancy, this analysis of the literature suggests a growth in its development, as well as the need to further develop and study it in Brazil and Latin America, since we could not find any articles published in such countries. Still, these practices have a vast array of applications, for multiple purposes, even when focusing on prenatal care. Overall, we noticed a large adoption of apps and smartphones, as well as SMS. Also, technology has shown to be relevant in promoting and facilitating psychological interventions, in special using techniques and methods that adopt cognitive behavioral approaches. The duration of the interventions varied substantially, indicating diverse possibilities of use for tools and interventions in what regards screening, treating, or monitoring mental health. We highlight thus, that the use of technology for mental health among pregnant women is still being investigated as a potential mechanism for healthcare delivery. In this context, despite the limitations involved in this scientific study, we notice the need to further investigate, research and develop this domain, to explore interven-tions that could improve the quality of prenatal care, contributing to protect women's and children's health.

Conflicts to Interest
None to declare.