Mobile Prenatal Education and Its Impact on Reducing Adverse Pregnancy Outcomes: A Retrospective Real-World Study

Background: Pregnancy is a pivotal phase in a woman's life, demanding special attention to ensure maternal and fetal health. Prenatal education plays a vital role in promoting healthy pregnancies and reducing adverse outcomes for pregnant women. Mobile prenatal education programs have gained traction due to their accessibility and timeliness, especially in light of finite healthcare resources and the constraints imposed by the COVID-19 pandemic. Objective: This study aims to the development and evaluation of the effectiveness of a mobile-based prenatal education program in improving pregnancy outcomes. Methods: The mobile-based prenatal education curriculum was collaboratively developed with a multidisciplinary maternal care team from Peking Union Medical College Hospital (PUMCH) in Beijing, China. Data were retrospectively collected from 1,941 pregnant women who had registered for the PUMCH mobile prenatal education program and subsequently delivered at PUMCH between May 2021 and August 2022. The study compared pregnancy outcomes between the completing group, which were pregnant women who had completed at least one course, and the not completing group. We also analyzed differences among course topics within the completing group and assessed course topic popularity among pregnant women. Results: The PUMCH mobile prenatal education curriculum consists of 436 courses across nine topics. Out of the participants, 1,521 did not complete any courses, while 420 completed at least one. compared to the non-completing group, pregnant women who completed courses exhibited a significant reduction in the risk of gestational diabetes mellitus, induced abortion, postpartum infection, fetal intrauterine distress, and neonatal malformation. Among those in the completing group, a 86.0% (361/420) started course completion during the first and second trimesters. Furthermore, completing courses related to topics of pregnancy psychology and pregnancy nutrition was associated with reduced risks of preterm premature rupture of membranes and small for gestational age infants, respectively. Pregnancy psychology and postpartum recovery were the preferred topics among pregnant women. Conclusions: The study demonstrates the potential of mobile-based prenatal education programs in improving pregnancy outcomes and supporting healthcare providers in delivering effective prenatal education. The rise of mobile prenatal education presents an opportunity to improve maternal and child health outcomes. Further research and broader implementation of such programs are warranted to continually improve maternal and child health.


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Methods：
The mobile-based prenatal education curriculum was collaboratively developed with a multidisciplinary maternal care team from Peking Union Medical College Hospital (PUMCH) in Beijing, China.Data were retrospectively collected from 1,941 pregnant women who had registered for the PUMCH mobile prenatal education program and subsequently delivered at PUMCH between May 2021 and August 2022.The study compared pregnancy outcomes between the completing group, which were pregnant women who had completed at least one course, and the not completing group.We also analyzed differences among course topics within the completing group and assessed course topic popularity among pregnant women.

Results：
The PUMCH mobile prenatal education curriculum consists of 436 courses across nine topics.Out of the participants, 1,521 did not complete any courses, while 420 completed at least one.compared to the non-completing group, pregnant women who completed courses exhibited a significant reduction

Introduction
Pregnant brings about a multitude of psychological and social changes in a woman's life [1].Access to reliable information can aid pregnant women to make informed and healthier decisions [2].Therefore, it is important to recognize pregnant women as the primary target audience for prenatal education, aiming to mitigate potential adverse outcomes [3].To achieve desirable pregnancy outcomes, it is essential that pregnant women receive comprehensive and high-quality prenatal education.
Prenatal education has been widely acknowledged for its ability to increase prenatal examination utilization [4], enhance the psychological well-being of expectant mothers [5], and contribute to improved delivery outcomes [6], among other benefits.Recent studies have highlighted the beneficial effects of prenatal education, particularly for women experiencing their first pregnancy.A retrospective analysis demonstrated that those who participated in childbirth classes were more likely to achieve successful normal vaginal deliveries, contributing positively to overall pregnancy outcomes [7].Furthermore, the effectiveness of psychoeducational interventions has been confirmed through a randomized control trial, effectively reducing the fear of childbirth among anxious pregnant women [8].Similarly, simulation-based childbirth education programs have demonstrated their capacity to alleviate the fear of childbirth among Chinese primiparas, and in high-income countries, childbirth training workshops have effectively reduced the incidence of unnecessary caesarean sections [9].In another randomized controlled trial, a combination of two in-person and 11 telephone sessions focused on promoting healthy pregnancy behaviors led to a reduction in the weekly rate of gestational weight gain in pregnant women [10].
While traditional group prenatal education has been traditionally conducted in face-to-face settings, thereby limiting participant numbers, the evolving healthcare landscape has introduced new challenges.The increasing burden on healthcare systems has made it challenging for medical professionals to provide personalized health education to every expectant mother using conventional methods.In response to these accessibility issues and to better cater to the evolving needs of pregnant women and their partners, online prenatal education had gained significant traction [11].
Online education represents a novel and efficient teaching method, offering a more effective and timely approach compared to traditional face-to-face education [12].During the COVID-19 pandemic and amid rising healthcare costs, the popularity of online education has soared [13][14].A randomized clinical trial conducted among low-income postpartum women demonstrated that onlinebased education could reduce maternal weight gain during pregnancy [15].Additionally, researchers provided online articles on physical activity during pregnancy observed improvements in pregnant women's physical activity levels [16].Furthermore, a randomized controlled trial highlighted the benefits of online prenatal education, including a reduction in concerns about labor, fear of childbirth, and fear of COVID-19 during the pandemic [17].
Mobile-based learning has also emerged as a promising approach for supporting prenatal education [18].A smartphone-based prenatal education program aimed at parents at risk of preterm birth showcased it ability to raise awareness about preterm birth and establish a foundational knowledge base for making informed medical care choices [19].In China, mobile-based prenatal education has gained significant traction [20], with thousands of maternal health-related apps available, most of which focus on prenatal education [21].Recent statistics reveal that approximately half of pregnant women in China have utilized maternal-related apps [22], with the majority participating in at least one mobile-based prenatal course during their early and mid-pregnancy [23].Despite this, both national surveys have highlighted a shared desire among pregnant women for the development of evidence-based and well-informed mobile-based prenatal education programs, endorsed by obstetricians [22,23].The needs of pregnant women underscore the prevailing tendency of existing mobile-based prenatal education programs to narrow their focus on specific topics, often lacking the comprehensive curriculum design offered by experienced obstetrician-led teams.
In this study, we present a comprehensive mobile-based prenatal education program tailored to the needs of pregnant women.Deployed within a hospital-authorized smartphone app, our program seeks to enhance the accessibility and cost-effectiveness of prenatal education.To evaluate the program's effectiveness, we conducted a retrospective real-world analysis of app module usage records and clinical outcomes among pregnant women.Our mobile-based prenatal education module helps to address the needs for professional healthcare support and improve outcomes for expectant mothers.

Methods
Our study consists of two distinct phases.In the first phase, we developed a comprehensive curriculum for a mobile-based prenatal education program, with the invaluable support and expertise of a multidisciplinary maternal care team at the Peking Union Medical College Hospital (PUMCH) in Beijing, China.All courses were designed to be easily accessible via smartphones.The second phase involved evaluating the effectiveness of our prenatal education program by analyzing the records of class attendance.The workflow of our study is shown in Figure 1.

Development of the PUMCH Mobile Prenatal Education
The curriculum of our mobile-based prenatal education was designed and implemented by a multidisciplinary maternal care team at the PUMCH in Beijing, China.This team includes obstetricians, nutritionists, psychologists, dentists, dermatologists, and rehabilitation specialists, all possessing extensive expertise with over twenty-years in traditional prenatal education.Drawing upon evidence-based insights gathered from pregnant women [22,23], the PUMCH team developed a comprehensive curriculum comprising a total of 436 courses, organized into nine topics, which are obstetrical knowledge, gestational nutrition, daily health care, complications, obstetric examination, pregnancy psychology, painless childbirth, neonatal care, and postpartum recovery.
To optimize the learning experience, the courses were structured to span the entire duration of pregnancy.Roughly 1-2 courses were made available for each topic daily, and each course required just about five minutes to complete.This scheduling accommodated the busy routines of pregnant women, enabling them to learn effectively during shorter, fragmented periods of time.Furthermore, two external nurses conducted individual reviews of the developed courses to maintain the quality of our content.To enhance the knowledge acquisition experience, these courses were presented in a multimedia format, including articles and videos.
In addition, all courses were seamlessly integrated into the official PUMCH app, which provides a wide range of patient services, including registration, payment, and health education.Upon visiting the obstetrician and completing the registration process, pregnant women were granted authorized access to the PUMCH mobile prenatal education curriculum through this official app.This convenient platform allowed pregnant women to access comprehensive prenatal education at their convenience, free from the constraints of location and time that are often associated with traditional prenatal programs.
Recognizing that different trimesters of pregnancy require specific knowledge, we automated the course recommendations for pregnant women based on their current pregnancy trimester.Throughout the pregnancy journey, these tailored course recommendations were delivered daily, ensuring that expectant mothers received knowledge precisely suited to their specific stage of pregnancy.

Evaluation of the Effectiveness of the PUMCH Mobile Prenatal Education
To evaluate the effectiveness of the PUMCH mobile prenatal education program, we conducted multiple comparisons to assess its impacts on the pregnancy outcomes of registered pregnant women.This evaluation aimed 1) to determine whether completing courses can reduce the occurrence of adverse pregnancy outcomes in comparison to not participating in any courses; 2) to examine the impact of learning specific topics on pregnancy outcomes among pregnant women who completed the courses.

Study Population
Through the official PUMCH app, we retrospectively collected records from 1,941 pregnant women who had registered for the PUMCH mobile prenatal education curriculum and subsequently delivered at the PUMCH in Beijing, China, during the period from May 2021 to August 2022.The inclusion criteria included: (1) singleton pregnancy, (2) Registration in the PUMCH mobile prenatal education program before delivery.Exclusion criteria were as follows: (1) diabetes mellitus (DM), (2) hypertension, (3) a history of smoking [24].

Data Collect
Course-taking records, including details such as course titles, topics, and timings, were retrieved through the app from all eligible pregnant women participating in this study.Additionally, maternal characteristics and adverse pregnancy outcomes were extracted from electronic health records.Maternal characteristics included maternal age, pre-pregnancy body mass index (BMI), parity, gravidity, history of abortion, previous gestational diabetes mellitus (GDM) history, history of abnormal pregnancy, family history of DM, family history of hypertension, and polycystic ovary syndrome (PCOS).Adverse pregnancy outcomes included GDM, gestational hypertension, postpartum infection, preterm birth, induced abortion, premature rupture of membranes (PROM), fetal intrauterine distress, neonatal malformation.

Statistical Analyses
Data were analyzed with Python (version 3.8.8).As for the maternal characteristics and adverse pregnancy outcomes, continuous variables were reported as mean (standard deviation, SD) and categorical variables as count (%).To determine the effectiveness of the PUMCH mobile prenatal education, the t-test was performed for continuous variables and the chi-square test for categorical variables.P<.05 was considered statistically significant.In addition, multiple logistic regressions, adjusted by maternal characteristics, were performed.
courses.There is a statistically significant difference in pre-pregnancy BMI values (kg/m 2 ) between the two groups (P=.036), with participants in the completing group having higher BMI values than those in the not completing group.Additionally, parity and gravidity also exhibit significant differences between the two groups with very small P values.In completing group, participants have a higher proportion of nullipara, primigravida, or both.

Statistics on completing the PUMCH Mobile Prenatal Courses
In the PUMCH mobile prenatal education program, we have a total of 436 courses available, with 234 presented in video format and 202 in article format.These courses are categorized into one topic, and the topic with the highest number of courses is obstetrical knowledge, accounting for approximately 24.5% of the total course count.Among the 420 pregnant women who completed at least one course, we observed that 43.8% of them began completing courses during their first trimester, and a significant 86.0%started course completion during their first and second trimesters.Table 3 shows that the topics of obstetrical knowledge and daily health care were the most popular, with completion rates over 80%.Furthermore, when considering the average number of participants per course, it was obvious that the topics of pregnancy psychology and postpartum recovery had the most attention.Detailed participant counts for each topic are provided in Table 3.

Comparison of Adverse Pregnancy Outcomes between the Not Completing and Completing Groups
Table 4 displays the comparisons of adverse pregnancy outcomes between the two groups.There are statistically differences in adverse pregnancy outcomes for GDM, postpartum infection, induced abortion, fetal intrauterine distress, and neonatal malformation between the two groups.For instance, the odd ratio (OR) value for the not completing group compared to the completing group in GDM is 0.3043, which means that the odds of GDM in the completing group are approximately 30% lower than the odds in the not completing group.This significant OR value indicates that participants in the completing group has a lower risk of GDM compared to not completing courses.Except for neonatal malformation, for which there were no cases in the completing group, multiple logistic regressions were conducted for each significant adverse pregnancy outcome, adjusted by maternal age group, BMI group, parity, and gravidity.All remained statistically significant after adjustments.Detailed results are provided in Supplementary Table 1.However, there were no significant differences observed between the two groups for gestational hypertension, preterm birth, PROM, macrosomia, and small for gestational age (SGA).

Comparison of Adverse Pregnancy Outcomes among Course Topics in the completing group
We examined whether completing specific course topics reduced adverse pregnancy outcomes among participants in the completing group.For each topic, participants were categorized into two groups: those who completed the topic and those who did not complete it.Table 5 presents the significant differences in adverse pregnancy outcomes between the 'completing the topic' group and the 'not completing the topic' group.Participants who completed the pregnancy psychology topic course experienced a reduced risk of PROM compared to the 'not completing the topic' group (P=.0307 and OR=0.5027).Additional results of pairs of topics and adverse pregnancy outcomes are available in Supplementary Table 2.

Principal Findings
In this study, we have collaboratively designed a mobile-based prenatal education program with the PUMCH multidisciplinary maternal care team.This mobile-based curriculum offers 436 courses across nine topics and is accessible through the official PUMCH app, providing pregnant women with valuable guidance throughout their entire pregnancy journey.A mixed-method study has indicated that online prenatal education can positively influence lifestyle choices and the ease of accessing health information during pregnancy [22].The COVID-19 pandemic has heightened the importance of easily accessible healthcare resources, especially for pregnant women at increased risk of severe illness if infected 1 .The World Health Organization (WHO) advises pregnant women to avoid crowded and poorly ventilated indoor spaces to reduce the risk of COVID-19 transmission.Therefore, there is an urgent need for cost-effective and easily accessible mobile-based prenatal education programs to support expectant mothers, especially in these challenging times.
To evaluate the effectiveness of our mobile-based program, we compared adverse pregnancy outcomes between the group that completed courses and the group that registered but did not complete any courses.Our data, derived from real-world app records, revealed an imbalance between the two groups, with approximately 21.6% of registered pregnant women completing at least one course.Significantly, pregnant women who completed courses demonstrated a reduced risk of adverse pregnancy outcomes such as GDM, postpartum infection, induced abortion, fetal intrauterine distress, and neonatal malformation, even after adjusting for maternal factors.For instance, GDM, a common pregnancy complication, is associated with the risk of hyperglycemia and adverse shortand long-term health outcomes for both mothers and infants [25].Our curriculum addresses GDM directly, offering courses on improving physical activity and nutrition, potentially lowering the risk of GDM.Taking those courses shows a potential to lower the risk of GDM by delivering the knowledge of improving physical activity, nutrition intake, etc. [26,27].
Furthermore, we analyzed the behavior of pregnant women who completed specific topic courses in the completing group.While the impact of completing the specific topic courses on reducing adverse pregnancy outcomes was generally modest, we identified two significant findings.First, completing the pregnancy psychology course was associated with a statistically significant reduction in the risk of PROM; and second, completing the pregnancy nutrition course may prevent the occurrence of SGA infants.
Pregnancy nutrition plays an important role in lifelong health [28], especially in terms of brain development and behavior [29].As many adverse birth outcomes originate during pregnancy [30], awareness of nutrition balance and healthy dietary habits can reduce the risk of outcomes like SGA.SGA, typically defined as birthweight below the tenth percentile [31], is a known risk factor for stillbirth [32].Previous research has demonstrated that nutrition interventions and adopting healthy dietary patterns can significantly lower the risk of SGA [33].Moreover, maternal creatine supplementation during pregnancy has shown the potential to reduce the risk of neonatal asphyxia, as evidenced in small animal studies [34].
We observed that 86% participants started course completion during their first and second trimesters, in line with survey results on Chinese web-based prenatal education [23].Pregnancy psychology and postpartum recovery are the most popular topics.These findings can inform the development of additional educational courses in both topics and further engage pregnant women.
Our mobile-based prenatal education program serves as a valuable source of information, enhancing pregnant women's knowledge regarding gestational nutrition, recommended practices, and anticipated challenges.Given that pregnant women increasingly seek information online [35], our program not only meets the rising demand for accessible mobile prenatal education but also bridges a significant gap in this field by offering a cost-effective and efficient source of information [23,35].By promoting this curriculum more widely, we aim to encourage healthier lifestyles and enhance pregnancy outcomes.

Limitation
This study has several limitations.Firstly, the effectiveness of our mobile-based prenatal education program was assessed among pregnant women from a single center, specifically PUMCH in Beijing, and its generalizability to other settings needs to be confirmed.Secondly, the analysis was based on one year of data, and a larger sample size with a longer duration would provide more robust estimates of the effectiveness of our mobile-based program.Thirdly, as this is a retrospective study with outcomes and information collected post-pregnancy, potential confounders and biases may have influenced the results.To establish the effectiveness of mobile-based prenatal education more conclusively, future research should consider conducting randomized controlled trials or prospective cohort studies.

Conclusion
This study outlined the development of a mobile-based prenatal education program and assessed its effectiveness by analyzing adverse pregnancy outcomes among pregnant women.The findings indicate that the mobile-based prenatal education curriculum has the potential to reduce adverse outcomes in pregnant women, offering valuable support for healthcare providers in delivering effective prenatal education services.The growing prominence of mobile prenatal education presents an opportunity to enhance pregnancy outcomes and the health of both mothers and children.

Figure 1 .
Figure 1.Workflow of developing and evaluating the PUMCH mobile prenatal education.

Table 2 .
Maternal characteristics of participants between two groups of not completing and completing courses.

Table 3 .
Statistics on the PUMCH mobile prenatal education: topics, course count (%), participant count, and average participants per course.

Table 4 .
Adverse pregnancy outcomes of participants between the not completing and completing groups.

Table 5 .
Effectiveness of adverse pregnancy outcomes among participants in the completing group for different topics.