The SmartMom Program was initially developed in response to a request from the Northern Health Authority in British Columbia to devise a way to overcome barriers to attendance at prenatal classes, such as remote location, inclement weather and road conditions, low socioeconomic status, a lack of instructors, and stigma perceived by parents who are young or Indigenous. A consortium of University of British Columbia–affiliated academic clinicians and perinatal program leaders from British Columbia health authorities, supported by peer-reviewed funding [33], conducted focus groups with expectant parents in British Columbia to elicit their views on how to proceed in the best possible way [32]. An advisory board was created for SmartMom with representation from all regional health authorities in British Columbia, the BC Ministry of Health, the First Nations Health Authority, Perinatal Services British Columbia, Child Health British Columbia, the BC Ministry of Health, the BC Association of Pregnancy Outreach Programs, CanFASD (Canada Fetal Alcohol Spectrum Disorder Research Network), and KidCare Canada. The development of the program was undertaken with content experts from each of these stakeholder groups with a commitment to iterative user-centered program evaluation and ongoing revision. Persons eligible to enroll in SmartMom are able to read in English, have a healthy singleton pregnancy, and receive maternity care in the province of British Columbia.

We conducted 6 semistructured focus groups with people who were pregnant or recently pregnant to explore their information-seeking behaviors during pregnancy, the nature of the information that they were seeking, how they wanted to receive information, and if SmartMom was meeting or could meet these needs (Multimedia Appendix 1). We selected the focus group methodology to understand shared experiences and perspectives as well as to promote the identification and clarification of views through group discussion [34].

Focus groups were conducted between August and December 2020. Eligible participants were older than 19 years, residents of British Columbia, and able to converse in English. Participants were recruited through (1) unpaid promotion on social media (eg, Twitter and Facebook), (2) brochures at maternity clinics, and (3) snowball sampling by recruited participants. We aimed to achieve diversity in terms of rural or urban residents, parity, and relationship and socioeconomic status.

The University of British Columbia Behavioral Research Ethics Board approved this study (H14-03404). Prior to participation, all participants received a description of the study objectives and procedures and provided written informed consent through a web-based form. Participants were informed that the focus group would be recorded, that they could choose to use their first name or a pseudonym, and whether or not to turn their camera on. All transcripts were deidentified prior to analysis. We provided a CAD $25 (US $18) gift card for participation.

Individuals interested in the study contacted our research manager via text messages or email and were provided with details about the study. After an initial discussion, they were sent a link to a digital consent form for review and signature. Participants then completed a demographic questionnaire and reviewed copies of the SmartMom messages. They chose their preferred dates and times for participation, including weekends and evenings. We used videoconference technology (Zoom; Zoom Video Communications, Inc) due to travel restrictions associated with the COVID-19 pandemic.

The focus group discussion was guided by open-ended questions that explored information-seeking behaviors, priority information needs, and current access to information through mobile technology. Each recorded focus group session was transcribed verbatim by a research team member (Emma Martin, BSc) and deidentified prior to analysis. Transcripts were returned to participants for member checking.

We undertook reflexive thematic analysis using a constant comparison method [35]. Thematic analysis is an interpretive analysis to identify common themes that emerge based on the phenomenon under investigation and that resonate with the research question [35,36]. The constant comparison method involves reducing the data to codes that describe the data and comparing the initial coding to emerging themes [37]. After an initial read to become familiar with the data, 2 members of the research team (JBM and AS) independently grouped the data based on the similarities and attached a code (open coding). After another reading of the transcripts and a review of the coding, they grouped these codes into categories (axial coding). They then generated themes that summarized these categories (selective coding) [37]. To enhance rigor, both JBM and AS then independently read through the transcripts again to test themes that fit with the coded data. We also tested and refined themes through several team meetings until consensus was achieved. To promote reliability, SM and PAJ reviewed all coding-in-progress and participated in iterative discussions with the analysts to resolve interpretive disagreements, reaching a consensus in both semantics (words used to describe themes) and interpretation (core properties of themes). There were no substantive changes made following member checking. We used qualitative software NVivo (version 12; QSR International) to organize our analysis of the data.

We analyzed demographic data from questionnaires using descriptive statistics. The demographic data supported our understanding of the study population (eg, age and frequency of mobile phone use) and informed our interpretation of the data. We analyzed demographic data using Microsoft Excel (Microsoft Corporation).

Focus group sessions were led by a perinatal epidemiologist (PAJ) with experience moderating focus groups and conducting qualitative research. Research assistants, who were graduate students, Emma Martin, JBM, and an undergraduate AS, cofacilitated the groups. PAJ is the founder and scientific lead of the SmartMom program. PAJ was not involved in the primary analysis of the data but contributed to the review of coding and participated in all iterative discussions of the analysis.

The aim of reflexive thematic analysis is to be recursive, where the analysis goes back and forth between phases of coding and reviewing themes. To achieve this, all authors engaged in reflexivity throughout the analysis and writing of the results [38]. Throughout the analysis, JBM and AS discussed the influence of their own knowledge of pregnancy experiences on their generation of codes and themes. All study team members considered the influence of age, gender identities, and racial or ethnic backgrounds on our interpretation of data. We discussed the influence of these social locations on all stages of the analytic process in our team meetings.

The 16 participants resided in British Columbia, except for 1 participant who resided in eastern Canada (Table 1). Half (n=7, 54%) were aged 30-39 years old. All were born in Canada and reported living with a partner. Of this, 77% (n=10) reported household annual revenue of CAD $75,000 (US $54,879) or more and having a university degree (n=11, 85%). All reported owning a cell phone, using SMS text messaging, using apps, and browsing the internet using their mobile device (Table 2). Of those who discussed phone use (n=10), 80% (n=8) used their phone for 5-6 hours a day or more, while 20% (n=2) used it for 2-4 hours a day. The participants used at least 1 app for prenatal education in 81% (n=13) of the cases. Prior to the focus groups, all participants had an opportunity to review the SmartMom SMS text messaging, and 44% of participants had enrolled in SmartMom during pregnancy. All participants were pregnant or recently pregnant during the COVID-19 pandemic. Themes generated through analysis are presented in Textbox 1 and summarized with representative quotes below.

Participants engaged in a process of seeking and assessing reliable information through Google and social media platforms to address specific pregnancy-related questions, signs, and symptoms. This behavior was amplified as a result of COVID-19 pandemic restrictions on antenatal visits and in-person classes.

Participants were asked about how mobile apps could be tailored to meet their needs.

Most participants liked the simplicity and ease of receiving SMS text messages in the SmartMom program. In comparison, participants felt mobile apps and websites did not offer the same functionality or tailoring. They noted that having the SMS text messages delivered to them reassured them that they were not missing important information:

They also appreciated the opportunity to have optional message streams that were relevant to their pregnancy:

Most participants agreed that additional prenatal content delivered via an app would be beneficial. Participants told us they would like to have push notifications, pregnancy tracking, downloadable content, and a search function in an app. One participant explained how such functions would support their information needs:

Participants also wanted to have the option of connecting to a qualified health care professional through their mobile app.

Our findings suggest that expectant parents are looking for trustworthy, evidence-based information that is locally relevant, delivered with tailored content, and sent to them automatically rather than requiring them to seek information out. The SmartMom prenatal education program was highly valued, as texting made comprehensive information easy to access in addition to being reliable, relevant, timely, and tailored. This finding was similar to the results of our usability study [32]. Participants spoke about how the opportunity to digitally connect with other pregnant people was a benefit of accessing other people’s stories on web-based platforms. These connections and stories offered reassurance and normalized prenatal experiences [39]. A strength-based approach to messaging was also identified as a potential improvement in other prenatal education messages.

This development and usability study of the SmartMom program builds on the findings of our initial study undertaken to inform program development. Different from Munro et al [32], participants in this study were pregnant or recently pregnant during the COVID-19 pandemic, which led to a dramatic shift away from in-person prenatal appointments. Participants spoke about the necessity of having reliable information about pregnancy given the abundance of information available on web-based platforms. They also spoke about the value of social media in pregnancy, which may reflect changes in the use of social media since 2017. To address preferences for social connections in pregnancy, we are conducting a nurse-moderated forum where SmartMom users will be able to converse and exchange information with each other in real time in a digital environment. To understand the association of SmartMom with birth outcomes, we are conducting a prospective observational study. We recently received funding to conduct a cross-Canada RCT of SmartMom to evaluate its impact on maternal, fetal, and newborn outcomes.

There has been a major shift from in-person to digital prenatal education in the last decade [2]. Public health restrictions due to the COVID-19 pandemic have led to an unprecedented acceleration of this shift [40], and reliance on mobile technology for prenatal education will likely persist. Equitable access to web-based education is thus increasingly important. Similar to our findings, a 2018 study in Canada found substantial gaps in both resources and representation in prenatal resources for members of LGBTQIA2S+ communities, teenagers, and individuals with low literacy, disabilities, low socioeconomic status, and immigrants [41]. In Canada, Indigenous communities and remote communities are especially vulnerable to receiving inadequate prenatal education, which is particularly concerning in view of reports of reduced access to aspects of routine screening, such as ultrasonography [42]. Our work has shown to date that a lack of reliable internet or cellular access disproportionally affects Indigenous people, who often live in the most remote locations [43]. To address this, we are developing an offline app that will store SmartMom messaging on a phone. We are exploring how to implement specific functionality preferences identified in this development and usability study in the offline app, such as the desire to pair a texting program with an app and a search function to quickly find information.

This study had several strengths. Our focus group design allowed for a rich discussion of experiences and perceptions as well as the opportunity for clarification and expansion of ideas. Remote participation permitted participation from a cross section of rural, suburban, and urban locations.

There were some limitations. We did not collect data on gender, race, or ethnicity. The majority of participants in this study were educated and economically advantaged, and all had a partner. While our sample lacked a broad diversity of experiences, themes identified in this analysis aligned with answers to open-ended questions by SmartMom participants between 2017 and 2020 as part of the ongoing evaluation of the program [44]. That evaluation (n=970) was undertaken in a diverse group with age, education, and ethnicity, including Indigenous identity, representative of the BC population [44], suggesting that our focus group findings may be generalizable to larger populations.

While pregnant people routinely use apps for prenatal education, they have concerns about the reliability and comprehensiveness of the content. The SmartMom prenatal education program delivered via text was viewed as an improvement in that it was evidence-based, provided comprehensive content without searching, and allowed for tailoring to individual needs through opt-in message streams.

This study offers new patient-oriented parameters to evaluate mHealth education programs.

Current offerings of mHealth prenatal education programs do not address the diversity of pregnant populations today, including Indigenous or LGBTQIA2S+ communities. The shift away from in-person prenatal education to digital mobile technology—accelerated by the COVID-19 pandemic—means that investing in mHealth programs that meet the needs of pregnant people is essential to providing effective prenatal education. Equitable access to mHealth education is also imperative to ensure that all pregnant people may benefit from prenatal education programs.