Neighborhood Deprivation and the Effectiveness of Mobile Health Coaching to Improve Periconceptional Nutrition and Lifestyle in Women: Survey in a Large Urban Municipality in the Netherlands.

BACKGROUND: In 2011, we launched the Smarter Pregnancy mobile health (mHealth) coaching program, which has shown to effectively improve inadequate nutrition and lifestyle behaviors in women before and during pregnancy. It is known that in deprived neighborhoods, risk factors for adverse pregnancy outcomes like inadequate nutrition and lifestyle behaviors accumulate. However, it has not yet been investigated whether the Smarter Pregnancy program is equally effective in women living in deprived neighborhoods. OBJECTIVE: This paper aimed to study the associations between neighborhood deprivation and improvement of inadequate nutrition and lifestyle behaviors of women who were either contemplating pregnancy or already pregnant and subscribed to the Smarter Pregnancy program. METHODS: We performed an additional analysis on data from women who used the Smarter Pregnancy program from 2011 to 2016. The program comprised 24 weeks of coaching on 5 nutrition and lifestyle behaviors, of which adequate intakes or lifestyle behaviors were defined as an intake of 200 grams or above of vegetables, 2 pieces of fruit, daily folic acid supplement use of 400 µg per day, and no smoking or alcohol consumption. Neighborhood deprivation was determined according to the status scores of the Netherlands Institute for Social Research. Logistic regression analyses and generalized estimating equation models were used to assess the associations between the neighborhood status score (NSS) and the improvement of inadequate nutrition and lifestyle behaviors, taking into account the behaviors at baseline. We adjusted the analyses for maternal age, body mass index, geographic origin, pregnancy status, and participation as a couple. RESULTS: Of the 2554 women included, 521 participated with their male partner. Overall, daily vegetable intake was most frequently inadequate at the start of the program (77.72, 1985/2554). Women with a higher NSS (ie, nondeprived neighborhood) smoked less often (adjusted odds ratio [OR] 0.85; 95% CI 0.77-0.93), consumed alcohol more often (adjusted OR 1.14, 95% CI 1.04-1.24), and were less likely to complete the 24 weeks of coaching (OR 0.91, 95% CI 0.88-0.95) compared with women who lived in a neighborhood with a low NSS (ie, deprived). In the total group, the relative improvement of inadequate nutrition and lifestyle behaviors after 24 weeks of coaching was between 26% and 64%. NSS was negatively associated with this improvement, indicating that women with a higher NSS were less likely to improve inadequate nutrition and lifestyle behaviors, especially vegetable intake (adjusted OR 0.89, 95% CI 0.82-0.97). CONCLUSIONS: The Smarter Pregnancy mHealth coaching program empowers women to improve inadequate nutrition and lifestyle behaviors. Unexpectedly, the program seemed more effective in women living in deprived neighborhoods. It is important to unravel differences in needs and behaviors of specific target groups to further tailor the mHealth program on the basis of demographic characteristics like neighborhood deprivation.

Mobile Health Coaching on Nutrition and Lifestyle Behaviors for Subfertile Couples Using the Smarter Pregnancy Program: Model-Based Cost-Effectiveness Analysis.

BACKGROUND: The health care costs for reproductive care have substantially increased with the use of in vitro fertilization (IVF) treatment. The mobile health (mHealth) coaching program Smarter Pregnancy is an effective intervention to improve nutrition and lifestyle behaviors and pregnancy rates in (sub)fertile couples, including those who undergo IVF treatment. Therefore, we hypothesize that this mHealth program can also reduce health care costs associated with IVF treatment. OBJECTIVE: This study aimed to evaluate the cost-effectiveness of the mHealth coaching program Smarter Pregnancy and compare it to usual care in women of subfertile couples who start their first IVF cycle. METHODS: This model-based cost-effectiveness analysis was performed on data from couples undergoing IVF treatment at the Erasmus MC, University Medical Center Rotterdam. A decision tree model was used to assess the incremental cost-effectiveness ratio (ICER) of ongoing pregnancies and costs of use of the mHealth program as compared to usual care. A probabilistic sensitivity analysis was performed to consider the uncertainty surrounding the point estimates of the input parameters. RESULTS: Based on our model including 793 subfertile women undergoing IVF treatment, use of the mHealth program resulted in 86 additional pregnancies and saved €270,000 compared to usual care after two IVF cycles, with an ICER of -€3050 (95% CI -3960 to -540) per additional pregnancy. The largest cost saving was caused by the avoided IVF treatment costs. Sensitivity analyses showed that the mHealth program needs to increase the ongoing pregnancy rate by at least 51% after two IVF cycles for cost saving. CONCLUSIONS: The mHealth coaching program Smarter Pregnancy is potentially cost saving for subfertile couples preceding their first IVF treatment. Implementation of this mHealth program in routine preconception care for subfertile couples should be seriously considered, given the relatively low costs and promising cost-effectiveness estimates.

Opportunities of mHealth in Preconception Care: Preferences and Experiences of Patients and Health Care Providers and Other Involved Professionals.

BACKGROUND: The importance of the preconception period and preconception care (PCC) are broadly acknowledged and the potential benefits regarding health promotion have been studied extensively. PCC provides the opportunity to identify, prevent, and treat modifiable and nonmodifiable risk factors to optimize the health of couples trying to become pregnant. The prevalence of modifiable and nonmodifiable risk factors in these couples is high, but the uptake of PCC remains low. OBJECTIVE: The aim of this study is to identify the preferences and experiences of women and men (patients) trying to become pregnant and of health care providers and other involved professionals regarding mobile health (mHealth), in particular the coaching platform Smarter Pregnancy, and its potential role in PCC. METHODS: Patients who participated in the Smarter Pregnancy randomized controlled trial (RCT) and health care providers and professionals also involved in PCC were invited to participate in a qualitative study. The barriers, benefits, and opportunities of big data collection by mHealth were discussed in focus group sessions, prompted with statements regarding PCC. RESULTS: We composed five focus groups, consisting of 27 patients in total (23 women and 4 men), who participated in the RCT, and nine health care providers and other professionals. Of the patients, 67% (18/27) were familiar with the concept of PCC, but only 15% (4/27) received any form of PCC. A majority of 56% (combined percentages of statements 1 [n=18], 2 [n=11], and 3 [n=16]) of the patients believed in the benefit of receiving PCC, and all agreed that men should be involved in PCC as well. Patients did not have a problem using anonymized data obtained from mHealth tools for scientific purposes. Patients and health care providers and other professionals both acknowledged the lack of awareness regarding the importance of PCC and stated that mHealth provides several opportunities to support clinical PCC. CONCLUSIONS: Our findings substantiate previous studies addressing the low uptake of PCC due to unawareness or lack of perception of its relevance by couples who are trying to become pregnant. The positive judgment and experiences with mHealth, in particular Smarter Pregnancy, will stimulate future research and further development of effective and cost-effective personalized mHealth apps for patients, health care providers, and other professionals as an add-on to clinical PCC.

Relationship between recurrent miscarriage and early preterm delivery and recurrent events in patients with manifest vascular disease: The SMART study.

BACKGROUND: Women with a complication of pregnancy are at increased risk of cardiovascular morbidity and mortality later in life. Yet, information on risk of recurrent events in women with a previous cardiovascular event is lacking. We aimed to assess the relationship between early preterm delivery, (recurrent) miscarriage and the risk for recurrent cardiovascular events in women with manifest vascular disease. METHODS: We included 1014 women with a mean age of 60 years from the SMART study, a prospective ongoing cohort study among subjects with clinically manifest vascular disease. The included women had a history of ≥1 pregnancy and were followed for the occurrence of subsequent vascular events. The relationship between the pregnancy complications ((miscarriage (gestational age <14 weeks), recurrent miscarriage (≥3 miscarriages) and early preterm delivery (gestational age 14-32 weeks)) and cardiovascular morbidity and mortality were estimated using multivariable adjusted hazard ratios. RESULTS: During a mean follow-up of 5.0 years, 80 women had a recurrent cardiovascular event, of which 28 were fatal. A history of recurrent miscarriage was associated with an increased risk for a recurrent cardiovascular event (hazard ratio 4.3 95% confidence interval 1.7--10.9). In addition, early preterm delivery was related to a 4.1 (95% confidence interval 1.5--11.3) fold increased risk of cardiovascular death in women with previous cardiovascular disease. No statistically significant relationships were found for less than three miscarriages. CONCLUSIONS: In women with previous cardiovascular disease, an obstetric history of recurrent miscarriage is associated with an increased risk of recurrent cardiovascular morbidity and early preterm delivery with cardiovascular mortality.