MANUSKRIP

LITERATURE REVIEW
PEMANTAUAN IBU DAN JANIN

Disusun Oleh:
Fuji Rahmanida
(PO71241230194)

Mata Kuliah:
Evidance Based
Dosen Pengampu:
Dewi Nopiska Lilis., M.Keb

POLITEKNIK KESEHATAN JAMBI JURUSAN KEBIDANAN

PROGRAM STUDI DIV KEBIDANAN
TAHUN 2023
 ABSTRAK

Perkembangan teknologi memberikan pengaruh dalam meningkatkan

kesejahteraan ibu dan janin dari waktu ke waktu. Secara ilmiah penggunaan
teknologi telah terbukti memiliki peranan besar untuk menekan angka kematian ibu
dan kecacatan pada janin. Penulis melakukan telaah literature sederhana
menggunakan 5 artikel dan jurnal yang berhubungan dengan teknologi pemantauan
kesejahteraan ibu dan janin dalam periode 3 tahun terakhir dengan tujuan untuk
mengetahui keefektifan teknologi pemantauan ibu dan kesejahteraan janin.

PENDAHULUAN karditografi, auskultasi, ultrasonografi,

Pemantauan masalah kesehatan dan fetal electrocardiografi.
ibu hamil dan kesejahteraan janin selalu Pemantauan ibu dan
menjadi bagian penting pada masa kesejahteraan janin berbasis teknologi
perinatal. Pemantauan ibu dan digunakan untuk menggali informasi
kesejahteraan janin dari waktu ke dan mengidentifikasi adanya keadaan
waktu. Sudah banyak teknologi yang patologis pada janin. Pemantauan
digunakan untuk memantau bagaimana dilakukan bertujuan untuk menekan
keadaan janin, setiap teknologi tingginya angka kematian ibu dan janin.
memiliki kegunaannya masing-masing Menurut data kesehatan dunia/ WHO
sehingga penggunanya disesuaikan (World Health Organization)
dengan kebutuhan ibu hamil dan ditemukan kejadian sebanyak 295.000
janinnya. wanita meninggal selama kehamilan
Teknologi yang digunakan dan persalinan pada tahun 2017. Jumlah
dalam pemantauan ibu dan ini dinilai masih tinggi walaupun sudah
kesejahteraan janin terbagi menjadi dua ada penurunan dalam dua decade
yaitu invasive dan non invasive. Untuk terakhir (WH0, 2019). Berdasarkan data
teknologi invasive terdiri dari internal dari Sampling Registration System
electerol fetal dan internal electronic (SRS) tahun 2018, kejadian AKI di
contraction monitoring. Sedangkan Indonesia paling tinggi terjadi di fase
untuk teknologi non invasive yaitu persalinan dan post partum yaitu
sebesar 76%, 24% pada saat kehamilan, yang digunakan 3 tahun terakhir.
36% saat persalinan dan 40% setelah Pencarian artikel melalui website yaitu
persalinan (Kemenkes, 2021). Pubmed dan google scholar dengan
Berdasarkan latar belakang yang sudah kata kunci “Monitoring, Fetal,
dipaparkan diatas penulis tertarik untuk Maternal, Application, dan
menggali lebih banyak mengenai Technology”.
beberapa teknologi yang dapat
menunjang kesejahteraan ibu dan janin. HASIL
Dari hasil pencarian database
METODE dengan pendekatan telaah literature
Metode penulusuran yang sederhana dengan menggunakan kata
digunakan dalam penulisan ini melalui kunci yang telah ditentukan.
pendekatan Telaah Literature Didapatkan 5 artikel yang sesuai pada
sederhana, dengan cara mengumpulkan Tabel 1.
5 artikel/ jurnal dengan tahun publikasi

(Tabel 1)
Teknologi Pemantauan Ibu dan Kesejahteraan Janin
Judul Metode Hasil
Wireless, remote solution Prospective Pengukuran DJJ dan MHR Invu,
for home fetal and Case Study masing-masing berasal dari EKG
maternal heart rate (Studi Kasus janin dan EKG ibu, berkolerasi
monitoring. Prospektif). tinggi dengan pengukuran CTG
pada DJJ dan MHR. Yang penting,
Penggunaan jaringan dan Invu dirancang untuk dapat
solusi jarak jauh serta digunakan sendiri oleh orang awam
pemantauan pada detak (wanita hamil atau pasangannya dan
jantung janin dan ibu untuk memberikan pemantauan
dirumah. janin dengan 1 penempatan sabuk,
yaitu tidak diperlukan reposisi
(Muhammad Mhajna., et. sensor). Sistem ini menggunakan
al) teknologi nirkabel pasif untuk
memungkinkan pemantauan seluler
pasien aman dan non-invasif di
klinik dari dari jarak jauh. Standar
layanan pemantauan janin saat ini
tidak memungkinkan pemantauan
jarak jauh atau di rumah, dan
 memerlukan tenaga medis
professional untuk menerapkan dan
menafsirkannya.
Effectiveness of Remote Literature Pemantauan ibu dan janin jarak jauh
Fetal Monitoring on Systematic nampaknya mengurangi kejadian
Maternal-Fetal (Literatur asfiksia neonatal dan biaya
Outcomes: Systematic Sistematis) perawatan kesehatan dibandingkan
Review and Meta dengan pemantauan janin rutin.
Analysis. Untuk memperkuat klaim mengenai
efektifitas pemantauan ibu dan janin
Efektivitas Pemantauan jarak jauh, diperlukan penelitian
Janin Jarak Jauh pada Ibu lebih lanjut yang dirancang dengan
– Janin. Hasil: Tinjauan baik, terutama pada ibu hamil yang
Sistematis dan Analisis beresiko tinggo, seperti ibu hamil
Meta. dengan diabetes, ibu hamil dengan
hipertensi, dan lain sebagainya.
(Suya., et. al)
Maternal health care Analysis of the Dalam aspek pemantauan informasi
wearing equipment basic situation janin, desain interaktif APP medis
based on fetal of the seluler terutama ditujukan untuk
information monitoring. research pemantauan janin dan kontak cepat
objects. dengan staf medis. Eksperimen
Pelayanan kesehatan ibu (Analisis tersebut membuktikan bahwa
memakai peralatan situasi dasar perangkat keras peralatan mencapai
berdasarkan pemantauan objek tujuan pengumpulan data, dan
informasi janin. penelitian). kemudian memberikan umpan balik
kepada pengguna lunak computer
(Junyang Peng., et. al) seperti APP, sehingga pengguna
dapat memahami informasi secara
akurat. Hal ini juga dapat
memberikan ibu hamil informasi
untuk memantau janin didalam
perut dirumah atau ditempat kerja.
Penggunaan Mobile Literature Penggunaan aplikasi mHealth
health (mHealth) review berbasis sistem pakar terbukti
Berbasis Sistem Pakar efektif dalam meningkatkan
Pada Pemantauan Tanda pemantauan kehamilan, khususnya
Bahaya Kehamilan: pada pemantauan tanda bahaya
Literature Review. kehamilan sehingga dapat dilakukan
peringatan dini kehamilan resiko
(Pindi Kurniawati., dkk) tinggi. Aplikasi ini bermanfaat bagi
ibu hamil dan petugas kesehatan.
Aplikasi ini diperlakukan oleh ibu
dan petugas kesehatan dalam
memantau kehamilannya secara
efektif, mudah, dan hemat biaya.
 Pemanfaatan Aplikasi Literature Penelitian ini dilakukan terhadap
Self-Care Ibu Hamil review pengembangan aplikasi self-care
Selama Pandemi di berbasis mobile smartphone pada
Negara Maju dan ibu hamil pekerja (PWW), yang
Berkembang: Sebuah berfokus pada empat hal penting
Tinjauan Pustaka. yaitu tidur dan istirahat, makan,
aktivitas fisik dan manajemen stress
(Adilah Nurazizah., dkk) yang dirasakan, berhasil
meningkatkan praktik self-care
mandiri dan kepedulian terhadap
pola hidup sehat selama hamil pada
PWW. Penyediaan aplikasi berbasis
teknologi tentang kehamilan harus
dikelola dengan baik dan dipastikan
validitas informasinya ya karena
manfaatnya dinilai sangat besar,
apalagi untuk ibu hamil besar.
Aplikasi ini memiliki akses internet
dan mampu beroperasi dengan baik
sebagai aplikasi berbasis teknologi
untuk mencari informasi selama
kehamilan.

PEMBAHASAN pemantauan DJJ jarak jauh secara rutin

Pemantauan ibu dan dapat secara signifikan mengurangi
kesejahteraan janin sangat penting penggunaan layanan kesehatan dan
untuk selalu di perhatikan. Beberapa beban ibu hamil saat bepergian ke
penelitian telah membuktikan bahwa rumah sakit klinik untuk pemantauan
ada banyak teknologi yang perinatal. Pemantauan jarak jauh
memudahkan dalam proses pemantauan dengan perangkat pasif yang dapat
ibu dan kesejahteraan janin. Dalam menampilkan EKG janin dan EKG ibu
studi literature ini, penulis secara akurat berpotensi meningkatkan
mengumpulkan 5 artikel/ jurnal yang akses terhadap layanan obstetric,
terkait dengan pemantauan ibu dan termasuk bagi wanita di daerah
kesejahteraan janin. Artiker/ jurnal pedesaan. Selain itu, pemantauan jarak
didapat dari beberapa sumber jurnal jauh secara nirkabel memungkinkan
periode 3 tahun terakhir. Menurut wanita hamil untuk bergerak selama
penelitian M. mhajna (2020) penerapan persalinan, sehingga dapat
meningkatkan pengalaman persalinan,
mempersingkat waktu persalinan, dan
menurunkan resiko operasi caesar.
Pemantauan ibu dan janin jarak
jauh dapat mengidentifikasi tanda-tanda
hipoksia janin secara tepat waktu
dengan melakukan pemantauan
dimanapun dan kapanpun, hal ini
penting untuk mengurangi asfiksia
neonatal, terutama pada ibu hamil
beresiko tinggi. Pemantauan ini
menunjukan pemantauan ibu dan janin
jarak jauh mempunyai dampak yang
signifikan terhadap peningkatan
outcome ibu dan bayi, namun hal ini
tidak berarti bahwa pemantauan jarak
jauh dapat menggantikan komunikasi
tatap muka antara dokter dan pasien,
yang diperlukan untuk pengambilan
keputusan bersama (Suya., et. al, 2023).
Untuk memantau informasi janin
secara real time dan memastikan
kesehatan ibu hamil itu sendiri dan
janinnya selama hamil, dalam penelitian
ini di rancang semacam alat kesehatan
berupa sabuk perawatan perut, yang
dipakai oleh ibu hamil dapat dipantau
oleh APP medis seluler modern, dan
memverifikasi kinerja terkait desain
melalui serangkain eksperimen.
Eksperimen tersebut membuktikan
bahwa perangkat keras peralatan
mencapai tujuan pengumpulan data, dan
kemudian memberikan umpan balik
kepada pengguna dan rumah sakit
melalui perangkat lunak computer
seperti APP, sehingga wanita hamil
menerima informasi dan terhubung
dengan cepat kerumah sakit (Junyan
Penga., et. al, 2020).
Kemajuan teknologi informasi
dan komunikasi dalam dunia kesehatan
semakin berkembang. Rekam medis
elektronik, sistem pembayaran,
pelayanan kesehatan dan monitoring
pemberian obat merupakan salah satu
pemanfaatan teknologi dalam
kesehatan. Dengan adanya pemanfaatan
teknologi ini, aktivitas menjadi lebih
mudah, akurat, dan cepat.
Electronic Health (e-health)
merupakan salah satu bentuk dari
kemajuan teknologi dan komunikasi,
dengan jenis yang paling banyak
dikembangkan adalah mobile health.
Mobile health sebagai salah satu model
dari electronic health merupakan jenis
yang paling banyak dikembangkan saat
ini. Peningkatan aplikasi mHealth
berbasis sistem pakar terbukti efektif
dalam meningkatkan pemantauan
kehamilan, khususnya pada pemantauan
tanda baya kehamilan sehingga dapat
dilakukan peringatan dini kehamilan
resiko tinggi (Kurniawati, dkk, 2023).
Penggunaan aplikasi self-care
menjadi solusi alternative khususnya
bagi ibu hamil. Beberapa negara telah
mengmbangkan aplikasi self-care untuk
mudahkan ibu hamil untuk mengakses
berbagai informasi terkait
kehamilannya sekaligus meingkatkan
kemampuan ibu untuk menjaga
kesehatannya, dinegara maju seperti
Inggris, terdapat aplikasi perawatan diri
yang memberikan informasi terkait
kesehatan fisik ibu hamil, kesehatan
mental, dan emosional. Di Rusia,
terdapat aplikasi self-care yang
berfokus pama pemantauan kesehatan
ibu hamil dari jarak jauh. Aplikasi self-
care yang memiliki fitur unggulan yaitu
edukasi ibu hamil sesuai minggu
kehamilan, pemeriksaan rutin gejala
dan resiko psikososial, teleconsultation
dan janji temu, serta kerjasamanya
dengan layanan Uber untuk
mempermudah akses ke pelayanan
kesehatan telah digunakan di Amerika
Serikat. Sedangkan aplikasi self-care di
negara berkembang seperti Indonesia,
China, Uganda dan Iran berfokus pada
fitur telekonsultasi dan fitur edukasi
terkait kehamilan untuk ibu hamil. Di
perlukan penelitian lebih lanjut untuk
mengevaluasi penggunaan teknologi
informasi dan komunikasi dalam bentuk
self-care bagi ibu hamil, terutama ibu
hamil yang beresiko (Nurazizah., dkk,
2023).
KESIMPULAN
Hasil studi literature terhadap 5
artikel/ jurnal yang dilakukan penulis
menunjukan bahwa terkait dengan
pemantauan ibu dan janin berbasis
teknologi memiliki efek positif yaitu (1)
untuk mengukur dan mengetahui
informasi detak jantung janin dalam
Rahim, (2) untuk mengurangi waktu
tunggu ibu hamil, memastikan bahwa
ibu hamil merasa lebih nyaman, dan
memberi mereka manfaat sosial dan
ekonomi, (3) mudah digunakan dalam
kehidupan sehari-hari, (4) memiliki
sifat yang portable, (5) memudahkan
pemantauan terhadap ibu dan
kesejahteraan janin. Selain efek positif,
didapatkan memiliki efek negative juga
atau kekurangan dari pengaplikasian
teknologi pada pengguna yang
berdomisili di daerah-daerah terpencil
yang memang masih kesulitan untuk
menjangkau jaringan data seluler.
SARAN dan maternal heart rate
Berbagai masalah dapat monitoring.
diketahui lebih awal jika klien lebih Nurazizah A, dkk (2023). Pemanfaatan
sering di monitor, namun berbagai Aplikasi Self-Care Ibu Hamil
alasan yang muncul seperti kondisi Selama Pandemi di Negara
sakit, ibu bekerja dan jarak rumah yang Maju dan Berkembang:
jauh menjadikan kendala untuk dapat Sebuah Tinjauan Pustaka.
memonitor secara berkala. Namun Peng Junyan., et al (2020). Maternal
dengan adanya teknologi ini dapat Health Care Wearing
digunakan untuk mengirimkan data Equipment Based on Fetal
setelah perekaman dilakukan, sehingga Information Monitoring.
keluarga dapat melakukan pemantauan
terhadap ibu dan janin. Sistem ini juga
memungkinkan komunikasi antara klien
dan tenaga kesehatan secara jarak jauh.

DAFTAR PUSTAKA

Kurniawati Pindi, dkk (2023).

Penggunaan Mobile Health
(m-Health) Berbasis Sistem
Pakar Pada Pemantauan
Tanda Bahaya Kehamilan:
Literature review.
Li Suya., et al (2023). Effectiveness of
Remote Fetal Monitoring on
Maternal-Fetal Outcomes:
Systematic Review and Meta
Analysis.
Mhajna M., et al (2020). Wireless,
remote solution for home fetal
L
A
M
P
I
R
A
N
Original Research
Wireless, remote solution for home fetal and maternal
heart rate monitoring
Muhammad Mhajna, MsC; Nadav Schwartz, MD; Lorinne Levit-Rosen, MD; Steven Warsof, MD; Michal Lipschuetz, RN, MPH;
Martin Jakobs, MD; Jack Rychik, MD; Christof Sohn, MD; Simcha Yagel, MD

BACKGROUND: Access to prenatal care can be challenging due to
physician shortages and rural geography. The multiple prenatal visits
performed to collect basic fetal measurements lead to significant
patient burden as well. The standard of care tools for fetal moni-
toring, external fetal heart rate monitoring with cardiotocography, as
used today, must be applied by a medical professional in a healthcare
setting. Novel tools to enable a remote and self-administered fetal
monitoring solution would significantly alleviate some of the current
barriers to care.
OBJECTIVE: To compare maternal and fetal heart rate monitoring data
obtained by ‘Invu system’ (a wireless, wearable, self-administered, fixed-
location device containing passive electrical and acoustic sensors) to
cardiotocography, toward a true remote fetal monitoring solution.
MATERIALS AND METHODS: A prospective, open-label, multi-
center study evaluated concurrent use of Invu and cardiotocography in
pregnant women, aged 18 to 50 years, with singleton pregnancies

32þ0 weeks’ gestation (NCT03504189). Simultaneous recording
sessions from Invu and cardiotocography lasted for
30 minutes. Data
from the 8 electrical sensors and 4 acoustic sensors in the Invu belt were
acquired, digitized, and sent wirelessly for analysis by an algorithm on
cloud-based servers. The algorithm validates the data, preprocesses the
data to remove noise, detects heartbeats independently from the two data
sources (electrical and acoustic), and fuses the detected heartbeat
arrays to calculate fetal heart rate (FHR) and maternal heart rate (MHR).
The primary performance endpoint was Invu FHR limit of agreement
within  10 beats per minute (bpm) of FHR measured with
cardiotocography.
RESULTS: A total of 147 women were included in the study analysis.
The mean (SD) maternal age was 31.8 6.9 years, and the mean
gestational age was 37.7 2.3 weeks. There was a highly significant
correlation between FHR measurements from Invu and cardiotocography
(r ¼ 0.92; P<0.0001). The 95% limits of agreement for the difference, the
range within which most differences between the two measurements will
lie, were -8.84 bpm to 8.24 bpm. Invu measurements of MHR were also
very similar to cardiotocography and were highly significantly
correlated (r ¼ 0.97; P<0.0001). No adverse events were reported during
the study.
CONCLUSION: Although captured by very different methods, the FHR
and MHR outputs wirelessly obtained by the Invu system through passive
methods were very similar to those obtained by the current standard of
care. The limits of agreement for FHR measured by Invu were within a
clinically acceptable  8 bpm of cardiotocography FHR. The Invu device
uses passive technology to allow for safe, non-invasive and convenient
monitoring of patients in the clinic and remotely. Further work should
investigate how remote perinatal monitoring could best address some of
the recent challenges seen with prenatal care and maternal and fetal
outcomes.
CLINICAL TRIAL INFORMATION: Registration date: April 20,
2018; First participant enrollment: February 28, 2018; ClinicalTrials.
gov registration NCT03504189; https://clinicaltrials.gov/ct2/show/
NCT03504189
Key words: fetal heart rate, fetal monitoring, passive, remote prenatal
monitoring, wireless monitoring

P renatal care has experienced recent

challenges, with reduced availabil-
ity of obstetric services due in large part
to a growing shortage of obstetrician-
gynecologists as well as higher-risk
women pursuing pregnancy.1,2 Preg-
nant women may have a difficult time
obtaining quality perinatal care because
of the need for serial clinic visits to ac-
quire fetal measurements, and the
Cite this article as: Mhajna M, Schwartz N, Levit-Rosen
L, et al. Wireless, remote solution for home fetal and
maternal heart rate monitoring. Am J Obstet Gynecol
MFM 2020;XX:x.ex-x.ex.
2589-9333
ª 2020 The Author(s). Published by Elsevier Inc. This is an
open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.ajogmf.2020.100101
increasing difficulty in accessing expert
perinatal care, especially in rural
locations.
Cardiotocography (CTG) is the cur-
rent standard of care for external moni-
toring of a fetus during a non-stress test
(NST) and a contraction stress test
(CST), as well as during labor.3 At pre-
sent, CTG can be applied only by a
medical professional because CTG
Doppler sensors must be placed accu-
rately for a robust signal and may need to
be repositioned with fetal or maternal
movement.4 In addition, CTG uses
Doppler ultrasound, which actively de-
posits energy into the tissue, to record
fetal and maternal signals.4 Other limi-
tations of CTG include episodic mea-
surement in the clinic or hospital, lack of
automated analysis, and lower utility in
pregnant women with high body mass
index (BMI).5,6
Remote monitoring could improve
the ability of pregnant women to obtain
prenatal care. Remote monitoring has
shown benefits in high-risk pregnancies,
including in women with gestational
hypertensive disorders and gestational
diabetes,7e9 and in low-risk
pregnancies.10e12 Additional potential
benefits of remote monitoring could
include increased compliance with pre-
natal healthcare, increased access to
prenatal healthcare for women in rural
locations, and connected care between
multiple providers.
For a remote, outpatient fetal moni-
toring program to be successfully
implemented, the monitoring device
must do the following: (1) be designed

MONTH 2020 AJOG MFM 1

Original Research

data from each sensor are sent to an

AJOG MFM at a Glance analog-to-digital (A/D) conversion
Why was this study conducted? module, which samples the analog sig-
True remote, self-administered maternal and fetal heart rate monitoring has not nals at 250 Hz and sends packets by
been widely implemented with available technologies. Remote fetal heart rate Bluetooth to a mobile device, which
(FHR) monitoring may improve access to prenatal care, reduce the burden of transmits the signal securely to the cloud
clinic visits for pregnant women, and allow for connected care. for processing (Figure 2a). After the data
are acquired, they are digitized and sent
Key findings wirelessly for analysis on cloud-based
Remote, passive, wireless FHR monitoring with electrical and acoustic sensors in servers by an algorithm (Figure 2a-e).
the ‘Invu system’ showed measurements that were highly correlated with car- The goal of the algorithm is to fuse the
diotocography. Maternal heart rate measured with the Invu system was also independent information gathered from
highly correlated with that measured by cardiotocography. the acoustic sensors (phonocardiogram
[PCG]) and electric sensors (electrocar-
What does this add to what is known? diogram [ECG]) to obtain FHR and
Reliable FHR measurements can be obtained from a remote, wireless abdominal MHR.
belt self-applied by a pregnant woman who can remain mobile during moni- The algorithm consists of the
toring. The Invu system provides a beat-to-beat calculation of heart rate. following: (1) data validation; (2) data
preprocessing to remove noise; (3)
heartbeat detection independently from
for self-application by the patient and As a first step toward validating data electrical signals and acoustic signals;
without the need for device reposition- obtained by the Invu system, the objec- and (4) fusion of the detected heartbeats
ing by a healthcare professional; (2) ac- tive of this study was to compare from electrical and acoustic signals to
quire valid data that accurately maternal and fetal heart rate monitoring calculate the FHR and MHR curves.
distinguish between maternal heart rate data obtained by Invu to those obtained
(MHR) and fetal heart rate (FHR); (3) by the standard of care, CTG. Data validation
continuously monitor FHR during a Each channel of raw data is examined to
pregnancy; (4) have a very low rate of Materials and methods determine whether it contains valid data.
false-positive results (ie, detecting a fetal A prospective, open-label, multicenter The electrical channel is determined to
heartbeat when there is none) to prevent study (NCT03504189) evaluated con- contain a valid signal if the maternal
false reassurance outside of a clinical current use of Invu and CTG in pregnant ECG can be detected, because the
environment; and (5) be comfortable. women. The study was conducted in maternal ECG has a large enough
However, currently available technology accordance with the principles set forth amplitude to appear with adequate
does not allow for true remote prenatal in the Declaration of Helsinki and in quality in all electrical channels. Acoustic
FHR monitoring. compliance with International Confer- signals are examined for their validity
“Invu” was designed to be a fully ence on Harmonisation-Good Clinical using a linear support vector machine
remote, medical-grade maternalfetal Practice standards. The local Institu- trained on the root mean square of the
monitoring solution that addresses each tional Review Board at each study site PCG signals. Acoustic channels that are
of the aforementioned challenges. Invu is approved the protocol (Hadassah-He- suspected of containing only noise are
composed of a wearable, self- brew University Medical Center: EC # considered invalid. If the data are valid,
administered, fixed-location device con- HMO-0116-17, MoH# 20174697; Hei- they are passed to the next step; if they
taining passive bio-potential (electrical) delberg University: CIV-17-05-019406; are not valid, the algorithm discards the
sensors and acoustic sensors (Figure 1). University of Pennsylvania IRB: PRO- data from that channel for the next steps
The Invu belt contains multiple sensors to TOCOL#: 828202; EVMS: Chesapeake of the analysis.
acquire a consistent and robust signal that IRB Pro00022598).
overcomes variability in body habitus or The Invu (Nuvo-Group, Ltd, Tel Aviv, Data preprocessing
changes in fetal position. The FHR and Israel) wearable belt contains 8 electrical Acoustic signals and electrical signals are
MHR outputs are based on underlying sensors and 4 acoustic sensors. The independently filtered using several
fetal and maternal electrocardiography acoustic sensors are highly sensitive mi- prespecified digital filters optimized to
(ECG) data, respectively, which allow for crophones that transduce sound waves capture the relevant physiological signals
beat-by-beat precision of heart rate (HR) into an analog electrical signal. The and to reduce unwanted signals or noise
calculations. This, in turn, enables robust biopotential sensors measure small po- (Figure 2b). The electrical signal filtering
discrimination of FHR and MHR, sepa- tential or voltage changes on the skin includes the following: (1) high-pass
rating the data into 2 corresponding that arise from physiological signals, filtering using an inverse moving-
channels for calculation and including the cardiac electrical signals average filter with a duration of 201
visualization. generated during each heartbeat. Raw milliseconds; (2) low-pass filtering with

2 AJOG MFM MONTH 2020

 Original Research

a 12th-order Butterworth filter, with a

FIGURE 1
cut-off frequency of 85 Hz; and (3)
The Invu wearable belt is a self-administered device consisting of 8
powerline filtering using a notch filter
electrical sensors and 4 acoustic sensors worn by the pregnant woman. The
centered at the powerline frequency (for accompanying monitoring system also contains an algorithm that remotely
this study, 60 Hz in the United States, analyzes the data for fetal heart rate (FHR) and maternal heart rate (MHR),
and 50 Hz in Germany and Israel). An and a data visualization layer, which can be accessed through 1 of 2 mobile
additional inverse moving median filter apps that provide tailored information to either the healthcare provider or to
(101-millisecond duration) is used to the pregnant woman
eliminate low-frequency noise in signals
with high levels of noise. Acoustic signals
are preprocessed with multiple bandpass
filters of varying bandwidth, in the range
of 1095 Hz. Signals are then equalized
in magnitude and enhanced for their
peaks.

Heartbeat detection
Electrical signals
The electrical signals are analyzed 1
channel at a time. The maternal QRS
complexes are detected on each channel
using a peak detection algorithm and are
cross-correlated between multiple chan-
nels to obtain a single array of QRS
timepoints. After identifying the location
of maternal QRS complexes, which
define the maternal heartbeats, an adap-
tive maternal ECG template is con-
structed based on cross-correlation
analysis of adjacent beats. This is per-
formed for each of the detected heart-
beats, enabling extraction of the maternal
ECG signals from the electrical signals.
Once the maternal ECG is extracted from
the signal, it is then subtracted from each
channel of electrical data, leaving the fetal
ECG data and noise not eliminated in the
preprocessing step.
The remaining data are processed to
enhance the fetal ECG. The signal is
bandpass filtered using a Butterworth
filter with cutoff frequencies of 15 Hz
and 85 Hz. The signal is further
enhanced by using a sliding window
median-absolute-deviation operator.
Independent component analysis is then
performed on the signal. The resulting
signals (Figure 2c) are processed for fetal
QRS detection. This step involves similar
techniques applied in the detection of
the maternal QRS complexes, such as
peak detection and cross-correlation.
The end result is a data stream with an-
notations of maternal and fetal QRS
occurrences.
Mhajna et al. Wireless, remote perinatal monitoring. AJOG MFM 2020.
Acoustic signals
Each channel is examined to determine
whether PCG signals are contained
within the data. The algorithm de-
termines whether the acoustic signals
are “true” heart sounds, for example,
S1 (when the atrioventricular valve
closes at the beginning of systole) and
S2 (when the aortic valve and pulmo-
nary valve close at the end of systole),
by performing peak detection on the
filtered data. This is achieved by
calculating a slow envelope of the an-
alytic Hilbert transform of the signal,
finding all of the zero crossings of the
derivative of the signal (corresponding
to locations of peaks in the signal),
discarding peaks that are not promi-
nent, and grouping peaks into 2 groups
according to shape and size using a
Gaussian mixture models clustering
algorithm. An initial estimate of the
beat-to-beat interval of each PCG
group is calculated. Missing beats are
identified and added as appropriate. In
parallel, an autocorrelation function is
calculated for the envelope of the PCG
signal. The algorithm then determines
whether or not the heart sounds are
coming from the same source, and
segments the data into 2 streams to
represent the 2 sources (S1, S2). After
the segmentation, the acoustic signals
are classified as either maternal or fetal
(Figure 2d) using the maternal QRS
positions detected by the ECG pro-
cessing algorithm as a reference. If the
cross-correlation of the PCG data and
the maternal QRS data is high, then
the PCG data stream is classified as
maternal. If the cross-correlation of the
PCG data with the maternal QRS is
low, then cross-correlation is per-
formed with the fetal heartbeats
calculated from the ECG algorithm. If
this correlation is high, the PCG data
stream is classified as fetal. If neither
correlation is high, the acoustic signal
and the respective detected heartbeats
are discarded.
Data fusion
The results from the independent an-
alyses of electrical and acoustic signals
are grouped to extract the final
maternal and fetal heart rates. The
time-stamped annotations of detected
heartbeats of electrical data and
acoustic data are combined, recog-
nizing that the electrical signal anno-
tations are shifted earlier in time from
the acoustic annotations of the same
heartbeat. A local score is calculated
per annotation to measure the local
variation in time differences between
nearby electrical signal and acoustic

MONTH 2020 AJOG MFM 3

Original Research

signal annotations. The algorithm finds

the most uniform heart rate vector by
modulating the time difference be-
tween electrical and acoustic annota-
tions. Missing electrical annotations or
acoustic annotations can be added if
there is a corresponding signal in the
other data stream, as long as the
addition increases the global score of
the annotations. The annotations are
fused into 1 data stream of 1 annota-
tion per heartbeat, and heart rate is
calculated as beats per minute.
FIGURE 2
Diagram of the Invu algorithm that separately analyzes (a) the biopotential
and acoustic signals collected from the wearable sensor belt in a series of
signal-processing steps described in the diagram. b, Signals are
preprocessed to capture the relevant physiological signals and to reduce
unwanted signals or noise. c, The algorithm separates 1 input data stream
into 2 groups: a maternal electrocardiogram (ECG) and a nonmaternal ECG.
In the fetal ECG, detailed information can be made available to providers,
including QRS morphology, and P-R, S-T, and Q-T intervals. d, After
segmenting, the acoustic signals are classified as either maternal or fetal,
using the maternal QRS positions detected by the ECG processing algorithm
as a reference. e, See Figure 3 for detailed fetal heart rate and maternal heart
rate generation

Study population
Women between the ages of 18 and 50
years were eligible to participate in this
study if they had a singleton pregnancy

32þ0 weeks’ gestation. Exclusion
criteria included the following: a pre-
pregnancy body mass index of
45 kg/
m2 or 15 kg/m2; multiple gestation;
presence of a fetal anomaly; uncon-
trolled maternal hypertension; an
implanted electronic device (eg, pace-
maker, defibrillator); or a skin condition
in the abdominal area (eg, wound, skin
rash). All patients provided written
informed consent to participate in the
study.

Recordings
An Invu belt and an Avalon FM-30 Fetal
Monitor CTG device (Philips Health-
care, Andover, MA) were placed on the
woman’s abdomen concurrently. MHR
was also recorded by the CTG device’s
pulse oximeter. The Invu belt was placed
on the woman’s abdomen first, a vali-
dated signal was obtained, and then the
CTG sensors were placed in between the
2 straps of the Invu belt. Signals were
acquired and fetal and maternal heart
rate were measured simultaneously us-
ing both instruments. Each recording
session lasted at least 30 minutes, ac-
cording to current clinical practice
guidelines.6

Endpoints
The primary performance endpoint was
Invu FHR limit of agreement (LOA)
within 10 beats per minute (bpm) of Mhajna et al. Wireless, remote perinatal monitoring. AJOG MFM 2020.

FHR measured with CTG. A co-primary

4 AJOG MFM MONTH 2020


FIGURE 2
Continued
Mhajna et al. Wireless, remote perinatal monitoring. AJOG MFM 2020.
performance endpoint was Invu MHR
LOA within 7 bpm of MHR measured
with CTG. Safety was assessed by reports
of adverse events.
Statistical analysis
Descriptive statistics (eg, mean, standard
deviation [SD]) were calculated for
continuous variables. The correlation
and mean difference (95% confidence
interval [CI]) between Invu and CTG
measures of FHR and MHR were
calculated. BlandAltman plots were
generated to show the agreement be-
tween the 2 monitoring methods by
plotting the difference in measurement
between the 2 methods vs the average in
measurement of the 2 methods. All sta-
tistical analyses were performed with
SAS v9.4 (SAS Institute, Cary, NC)
Results
A total of 147 women were included in
the performance analysis set (2
participants who enrolled in the study
were excluded from the analysis because
of a technical failure during the proced-
ure). Two patients who were screened for
the study did not enroll (1 patient
withdrew consent, and 1 patient was
pregnant with twins). The mean (SD)
maternal age was 31.8 (6.9) years, and
the mean (SD) pre-pregnancy BMI was
26.1 (6.2) kg/m2. The mean gestational
age was 37.7 (2.3) weeks.
An illustrative sample of the FHR and
MHR tracings obtained by Invu and
CTG are shown in Figure 3. In this
example, a baseline FHR of approxi-
mately 140 bpm was measured by both
devices, with moderate FHR variability
in highly similar patterns. It should be
noted that in contrast to CTG, Invu FHR
and MHR are not averaged signals, they
are displayed as beat-to-beat measure-
ments of HR. This is evident in the
higher variability and temporal resolu-
tion of the data.
Original Research
There was a highly significant corre-
lation between FHR measurements from
Invu and CTG (0.92; P < .0001;
Figure 4A). The mean bias (95% CI)
between Invu and CTG FHR measure-
ments was 0.30 (0.77, 0.18) bpm.
The 95% limits of agreement for the
difference, the range within which most
differences between the 2 measurements
will lie, were 8.84 bpm (95%
CI, 10.05, 7.63), 8.24 bpm (95% CI,
7.03, 9.45) (Figure 4B).
The Invu measurements of MHR were
also very similar to those of CTG
(Figure 5A). The measurements were
highly significantly correlated (0.97; P <
.0001). The mean bias (95% CI) between
Invu and CTG MHR measurements was
0.28 (0.24, 0.33) bpm (Figure 5B). The
95% limits of agreement for the MHR
difference were 5.30 bpm (95%
CI, 6.09, -4.51), 5.86 bpm (95% CI,
5.07, 6.65). No adverse events were re-
ported during the study.
MONTH 2020 AJOG MFM 5
Original Research
FIGURE 3
Fetal heart rate (FHR) and maternal heart rate (MHR) over time show highly similar measurements of baseline heart
rate and variability between (top) Invu and (bottom) cardiotocography (CTG). Note the lack of movement artifacts in
FHR traces from Invu
Mhajna et al. Wireless, remote perinatal monitoring. AJOG MFM 2020.
Comment
Principal findings
Although captured by very different
methods, the FHR and MHR outputs
obtained by Invu were very similar to
those obtained by the current standard
of care. The fusion of data from wireless,
passive electrical and acoustic sensors
and the unique placement of the sensors
enabled the measurement of FHR in a
reliable manner.
Results
The limits of agreement for FHR
measured by Invu were within  8 bpm
of the CTG FHR, a clinically acceptable
range to recognize common clinical
phenomena including bradycardia,
tachycardia, accelerations, and de-
celerations.13 Most FHR clinical phe-
nomena are defined as an increase/
decrease of 15 bpm from baseline, which
could be detected given a 8 bpm limit
6 AJOG MFM MONTH 2020
of agreement.13 Clinical practice guide-
lines state that moderate FHR variability,
between 5 and 25 bpm, is considered
normal.6,13 Baseline HR variability can
range from 312 bpm as measured with
standard CTG, and which increases with
gestational age.14,15 Moreover, FHR cal-
culations derived from CTG have pre-
viously been shown to have a high degree
of inaccuracy when compared with those
derived from fetal ECG-based measure-
ments.16 Thus, given the known limita-
tions of CTG, some of variability
quantified by the limits of agreement in
this study may be due to error in CTG
measurements and not Invu
measurements.
Clinical implications
Routine implementation of remote FHR
monitoring could significantly reduce
healthcare use and the burden on the
pregnant woman of traveling to the
clinic for prenatal monitoring. True
remote monitoring with a passive device
that can accurately present fetal ECG and
maternal ECG has the potential to
improve access to obstetrical services,
including for women in rural areas and
those affected by the shortage of
obstetrician-gynecologists. In addition,
wireless, remote monitoring can allow a
pregnant woman to be mobile during
labor, which may improve the woman’s
labor experience, shorten the labor time,
and decrease the risk of cesarean
delivery.17
Doppler-based and fetal electrode-
based methods to measure FHR differ
in their core technology. Because of the
underlying technology, Doppler-based
methods cannot provide true beat-by-
beat heart rate calculations but, rather,
an approximation. Fetal electrode-based
methods can provide accurate timing of
each beat, and compute the RR interval
 Original Research

FIGURE 4
A, Fetal heart rate (FHR) values from Invu and cardiotocography (CTG) were highly significantly correlated with each
other. B, BlandLAltman plot shows the mean bias (L0.30 bpm) and the upper and lower 95% limits of agreement
(L8.84 bpm [95% confidence interval, L10.05, L7.63], 8.24 bpm [95% confidence interval, 7.03, 9.45]) for Invu FHR,
relative to CTG FHR

Mhajna et al. Wireless, remote perinatal monitoring. AJOG MFM 2020.

and derive a beat-by-beat heart rate
accordingly. This reduced resolution of
information available from Doppler-
based methods may account for differ-
ences seen in indices and measures
derived from FHR when recorded in the
2 different methods, potentially leading
to misinterpretations and poor clinical
decisions in the last minutes of labor.18
Obtaining true beat-by-beat heart rate
is important when analyzing heart rate
variability, as it may provide additional
information on the well-being of the
fetus.19,20 The Invu device uses the FECG
to calculate a true beat-by-beat FHR,
which can provide an accurate measure
of FHR variability, improving upon the
indirect method of measuring FHR us-
ing CTG.21 The same phenomenon ap-
plies to MHR recording, which is usually
monitored using photoplethysmography
(PPG). For example, heart rate vari-
ability indices derived from PPG differ
from those recorded simultaneously
from ECG.22 Interestingly, there are data
linking MHR variability to maternal
mental health, raising the prospects for
accurate and remote MHR tracings
serving as biomarkers of disease.23,24
Therefore, the ability to provide true
beat-to-beat FHR and MHR measure-
ments remotely and noninvasively may
expand the clinical toolbox of obstetrics
in the future.13
Another limitation of traditional
CTG-based FHR measurements relates
to the impact of MHR artifacts, which
can result in potentially dangerous
consequences for the fetus.25 Although a
noninvasive system to measure FHR will
inherently capture maternal recordings,
the large amplitude of the maternal
signal ensures that it can be captured
with sufficient signal-to-noise ratio to
validate it and eliminate it from the raw
signal. In contrast to strategies that rely
on a single or a few biosensors to capture
FHR and MHR signals, the use of data
from multiple biosensors (8 ECG and 4
acoustic) in the Invu system allows the
algorithm to remove the maternal ECG
from contaminating the fetal ECG,
essentially performing signal ambiguity
detection, thereby reducing artifacts and
the likelihood of errors in FHR calcula-
tion and interpretation.26
Research implications
The FHR obtained from the Invu
system is based on a true fetal RR
interval, calculated from the fetal ECG
(Figure 2c), allowing for high tempo-
ral data resolution and potentially for
advanced analysis of FHR variability
such as phase-rectified signal aver-
aging, which may enable potentially
superior diagnostic capabilities based
on FHR variability as compared to
CTG.27,28 Furthermore, noninvasively
recording fetal ECG is challenging, but
important as it allows healthcare pro-
viders to identify abnormalities in the
fetal ECG.29 Future versions of the
Invu system may present maternal
ECG and fetal ECG information, such
as the QRST waveform, to healthcare
providers after studies have validated
the ECG output of Invu, which could
be explored as a means of assessing
both fetal and maternal cardiovascular
disease.
In addition to reliably obtaining
MHR and FHR tracings, there is also
the potential to build on the multiple
sensors, automated algorithm, and

MONTH 2020 AJOG MFM 7

Original Research

FIGURE 5
A, Maternal heart rate (MHR) values from Invu and cardiotocography (CTG) were highly significantly correlated with
each other. B, BlandLAltman Plot shows the mean bias (0.28 bpm) and the upper and lower 95% limits of agreement
(L5.30 bpm [95% confidence interval, L6.09, L4.51], 5.86 bpm [95% confidence interval, 5.07, 6.65]) for the Invu
MHR, relative to the CTG MHR

Mhajna et al. Wireless, remote perinatal monitoring. AJOG MFM 2020.

digitized data to incorporate the use of
machine-based learning to identify
novel biomarkers of maternal and fetal
well-being. This would set the stage for
developing novel tools in an effort to
improve prenatal care and pregnancy
outcomes.
Strengths and limitations
The strengths of the study are the large
study population used to validate the
device, and the inclusion of women with
high BMI.
One limitation of this study was
that the Invu belt was administered by
research staff in a medical setting and
not self-administered in the pregnant
woman’s home. However, the primary
objective in this study was to demon-
strate the ability to reliably obtain
MHR and FHR tracings that are
similar to those obtained with CTG,
which must be applied by a healthcare
professional. Invu is indeed designed
to be self-administered by a lay person
without the need for sensor reposi-
tioning. Importantly, these capabilities
were tested in a human factors
usability study, which demonstrated
successful self-administration without
the assistance of a medical professional
(in preparation), potentially over-
coming 1 of the major limitations of
CTG for fetal monitoring. Future in-
vestigations are warranted to demon-
strate at-home monitoring by the
device in a real-world setting. The
study enrolled only pregnant women
without pathology before labor, which
may not adequately represent compli-
cated FHR patterns, such as those
found in active, awake fetuses and
during the second stage of labor, and
which need further study using the
Invu system.13,30 In addition, maternal
uterine activity was not reported
concurrently in this article. The Invu
system can measure maternal uterine
activity and results will be reported in
a separate publication.
The present study was limited to
women presenting from 32 weeks to
term; future investigations will need to
include women from 24 weeks onward,
the gestational age range at which CTG is
currently performed.
Conclusion
Invu’s FHR and MHR measurements,
derived from fetal ECG and maternal
ECG, respectively, correlated highly
with CTG measurements of FHR and
MHR. Importantly, Invu is designed to
be self-administered by a lay person
(the pregnant woman or her partner)
and to provide fetal monitoring with 1
placement of the belt (ie, no sensor
repositioning needed). The system uses
passive, wireless technology to allow
for safe, noninvasive, mobile moni-
toring of patients in the clinic and
remotely. The current standard of care
for fetal monitoring does not currently
allow for remote or at-home moni-
toring, and requires a medical profes-
sional to apply and interpret. Remote
perinatal monitoring could address
some recent challenges seen with pre-
natal care and maternal and fetal
outcomes. n
Acknowledgments
Medical writing and editorial support was pro-
vided by Agnella Izzo Matic, PhD, CMPP (AIM
Biomedical, LLC) and Amit Reches, PhD

8 AJOG MFM MONTH 2020


(Nuvo-Group, Ltd) and was funded by Nuvo-
Group, Ltd.
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Author and article information
From the Nuvo-Group, Ltd (Mr Mhajna), Tel-Aviv, Israel;
Department of Obstetrics and Gynecology (Dr Schwartz),
Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA; Obstetrics & Gynecology Division (Dr
Levit-Rosen, Mr Lipschuetz, and Dr Yagel), Hadassah-
Hebrew University Medical Center, Jerusalem, Israel;
Eastern Virginia Medical School (Dr Warsof), Norfolk, VA;
Department of Neurosurgery (Dr Jakobs), University
Hospital, Heidelberg, Germany; The Fetal Heart Program
(Dr Rychik), The Children’s Hospital of Philadelphia,
Philadelphia, PA; Department of Obstetrics and Gyne-
cology (Dr Sohn), University Hospital, Heidelberg,
Germany
Received Nov. 22, 2019; revised Feb. 19, 2020;
accepted March 7, 2020.
SW, JR, CS, and SY own stock in Nuvo-Group. SY
serves on the advisory board of Nuvo-Group. MM is an
employee of Nuvo-Group. The other authors report no
conflict of interest.
This study was funded by Nuvo-Group, Ltd (Tel Aviv,
Israel). Nuvo-Group participated in the study design, data
collection, data analysis and interpretation. Nuvo-Group
and the authors participating in writing the report and
in the decision to submit the article for publication.
These data were presented in part at the 66th Annual
Meeting of the Society for Reproductive Investigation in
Paris, France, March 1216, 2019.
Corresponding author: Muhammad Mhajna, MsC.
muhammad.mhajna@nuvocares.com
 Journal of Infection and Public Health 13 (2020) 2009–2013

Contents lists available at ScienceDirect

Journal of Infection and Public Health

journal homepage: http://www.elsevier.com/locate/jiph

Original Article

Maternal health care wearing equipment based on fetal information

monitoring
Junyan Peng a , Yicheng Huang b , Kanbin Yu c , Renjie Fan d , Jia Zhou e,∗
a
Department of Equipment, Huashan Hospital, Fudan University, Shanghai 200040, China
b
Department of Asset Management, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
c
Purchasing Center, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, 200090, China
d
Purchasing Center, Gongli Hospital Affiliated to the Second Military Medical University, Shanghai 200135, China
e
Department of Medical Equipment, Shanghai Pulmonary Hospital Affiliated to Tongji University, Shanghai, 200433,China

a r t i c l e i n f o a b s t r a c t

Article history: In order to monitor the fetal information in real time and ensure the health of the pregnant women
Received 18 May 2019 themselves and their fetuses during pregnancy, a kind of health wearing equipment, abdominal care
Received in revised form 23 July 2019 belt is designed in this study, which can be worn by pregnant women and can be monitored by modern
Accepted 30 July 2019
mobile medical APP, and verifies the related performance of the design through a series of experiments.
The results show that the safety, practicability and aesthetics of the abdominal care belt designed in this
Keywords:
study are all up to the standard. Therefore, the abdominal care belt designed in this study is a relatively
Fetal monitoring
successful product, which is expected to be applied in the future and enter the market, so that pregnant
Pregnant women
Health wearing equipment
women during pregnancy can be more relaxed and convenient.
Abdominal care belt © 2019 Published by Elsevier Limited on behalf of King Saud Bin Abdulaziz University for Health
Mobile medical APP Sciences. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

Introduction
Eugenic birth and good childbearing are very important for
every family, and the health problems of pregnant women and the
information monitoring of fetuses are always important links dur-
ing pregnancy [1]. With the implementation of the second-child
policy in China, the number of pregnant women will increase dra-
matically, and the health of pregnant women will gradually get the
attention of the society [2].
In the process of fetal growth and development, various abnor-
mal conditions occur from time to time, which can lead to
congenital diseases at birth. Whether the fetus is normal is the
most basic and important information of fetal heart rate and fetal
movement [3]. Monitoring the information of fetus can discover
the abnormal condition in the process of fetal growth and devel-
opment, so as to take timely treatment measures, which plays an
important role in ensuring eugenic birth and improving the birth
quality of our population, so it is very necessary [4].
∗ Corresponding author at: Department of Medical Equipment, Shanghai Pul-
monary Hospital Affiliated to Tongji University, Zhengmin Road No. 507, Yangpu
District, Shanghai, 200433, China.
E-mail address: zhoujia cyw@163.com (J. Zhou).
Pregnant women’s health problems and fetal health data moni-
toring have always been an important part of the perinatal period,
but the shortage of medical resources has prevented pregnant
women’s health problems and fetal data monitoring from receiving
the medical or health care they hoped for. With the development
of mobile medical treatment and wearable equipment, the origi-
nal medical resources in China have been made inadequate. Lack
of adequate monitoring and improvement of fetal health data and
maternal health issues has created a new breakthrough. At present,
various wearable devices are springing up in the market, and most
of them use mobile phones or other terminal devices as transmis-
sion and display. With the rise of intelligent hardware, wearable
technology and equipment have become a hot spot in research
and product development. Wearable devices can be applied in the
fields of measurement, monitoring, treatment and rehabilitation
for wearers in the medical field.
Pregnant women and pregnant women’s families tend to pay
more attention to the health of the fetus, while ignoring the waist
and back condition of the pregnant women themselves, so many
pregnant women’s health care wearing equipment before also lack
solutions to this problem. After summarizing and sorting out the
shortcomings and loopholes of some pregnant women’s health-
care wearing equipment before, taking mobile medicine as an entry
point, a health-care wearing device, abdominal brace, is designed
for monitoring fetal information and protecting the waist and

https://doi.org/10.1016/j.jiph.2019.07.031
1876-0341/© 2019 Published by Elsevier Limited on behalf of King Saud Bin Abdulaziz University for Health Sciences. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
2010 J. Peng et al. / Journal of Infection and Public Health 13 (2020) 2009–2013
Fig. 1. Big data on maternal health and fetal care.
back of pregnant women, which integrates safety, comfort, effec-
tiveness and beauty. It not only reduces the burden of pregnant
women physically, but also reduces the fetal heart rate of the
fetus. Real-time monitoring of fetal movement and so on is carried
out. Finally, the feasibility of this method is proved by simulating
pregnant women’s experiment. Therefore, this study is of great sig-
nificance to alleviate the physical discomfort of pregnant women
during pregnancy and ensure the smooth delivery of pregnant
women.
Methods
Analysis of the basic situation of the research objects
Pregnant women do not attach importance to their waist and
back health problems, which is in sharp contrast to their atten-
tion to fetal health [5]. Through Google, Baidu and other search
engines, the key words of fetal heart monitoring, fetal movement,
fetal heart health, fetal health, maternal waist and back health,
maternal lumbar disc herniation, maternal low back pain, mater-
nal abdominal support are searched and compared. The results are
shown in Fig. 1.
From Baidu search results, it can be clearly seen that the domes-
tic concern for fetal health is far greater than that of maternal waist
and back health. From the result of Bing search, although there are
few searches for maternal waist and back health, the search volume
of pregnant women’s abdominal support is similar to that of fetal
heart monitoring. Google search results show that fetal movement
is the most frequently searched keyword, followed by low back pain
and abdominal support [6]. It can be seen that compared with the
international concern for pregnant women’s low back health, the
domestic concern for pregnant women’s low back health is insuf-
ficient. Pregnant women’s attention to fetal health, their neglect
of waist and back health, the importance of telemedicine in med-
ical institutions, and excessive consumption of medical resources,
from these aspects, there is a greater demand for mobile medical
products related to waist and back health of pregnant women.
During the period of late perinatal health care, the main work
of pregnant women is to do a good job of family self-monitoring
and prevent and deal with complications of pregnancy [7]. The best
way during this period is to carry out in-hospital observation, but
the lack of medical resources cannot guarantee that every pregnant
woman can get enough and medical care. Family independent test-
ing is a more convenient and effective method. Family fetal monitor
and portable fetal monitor can effectively enable pregnant women
to self-monitor according to their needs and reduce the number of
times they enter the hospital for testing.
According to the function of pregnant women mobile medical
APP obtained from user survey, the corresponding data standard
values are given. According to the feedback from users and medical
staff, the fetal detection should be comprehensive, which includes
two aspects: fetal heart rate and fetal movement. The detection of
fetal heart rate and fetal movement in hospital is mainly carried out
in six aspects, including baseline rate, variation frequency, variation
amplitude, variation rate of increase, variation deceleration and fre-
quency of fetal movement. Each item is divided into three stages.
The total score is 11–12 for reactive type, 8–10 for poor response
type and 7 for non-reactive type. The main function of mobile fetal
heart and fetal movement monitoring is to determine whether the
baseline rate of fetus is normal or not and whether the number of
fetal movements is normal. The most important function is to detect
whether the fetal heart rate is in the 110–160 beats/minute inter-
val, whether the fetal movement is greater than five times every
half hour. Recorded data are submitted to relevant organizations
for analysis when required.
Design of wearing equipment for pregnant women’s health care
Through consulting the literature on maternal waist and back
health and analyzing the needs of users and the existing bracket
products, based on the needs of users, the design of the bracket in
the real-time monitoring of perinatal fetus and wearable equip-
ment for maternal health care should focus on improving the
comfort of pregnant women, reducing the burden on the waist
and back of pregnant women, and improving the health status of
the waist and back of pregnant women. Therefore, in the choice of
materials and components for the design of bracket belt, the elastic
belt chooses 48 mm knitted elastic belt with loose and soft texture
 J. Peng et al. / Journal of Infection and Public Health 13 (2020) 2009–2013 2011

and cotton elastic yarn as the main material, while the connector
chooses soft and strong adhesion, which is easy to use and has high
endurance bonding belt (also known as magic sticker).
In the selection of fetal monitoring module, there are four
choices for fetal monitoring fetal heart rate detection module at
the present stage: the first is through a common stethoscope, the
second is through the integration of electronic stethoscope, the
third is the integration of common Doppler fetal heart rate moni-
tor, and the fourth is the integration of new combined ECG and ECG
sound measurement equipment. Through comparison and analy-
sis, the choice of fetal monitoring module at this stage should be
to select Doppler fetal heart rate and monitoring instrument with
mature technology. Medical silica gel instead of coupling agent can
meet the needs of convenience and comfort, and the combination
of ECG sound measurement equipment and fetal movement detec-
tor based on stethoscope principle can be the first choice for the
follow-up development.
In the design of mobile medical APP, first of all, it should be
Fig. 2. Dimension drawing (Unit: centimetre).
designed according to the user’s needs. In the overall interface
design, the color selection takes into account the mood of preg-
nant women who are about to become mothers. According to the
user’s survey, blue and green should be used as the main color,
and saturation, color purity should not be too high. As a medical
product of APP, the blue color is also in line with the current med-
ical field. The color matching can easily make users trust APP and
enhance their recognition of medical professionalism. Considering
that most users are under 30 years old, their color matching should
also consider certain fashion sense. In the main functions such as
fetal heart rate, detection, contact doctor and other functions, but-
ton color matching should also choose appropriate color matching
such as saturation, high purity and eye-catching red. In order to
reduce the user’s operation steps as much as possible, the key func-
tions of contacting doctors and fetal monitoring should be simple
and clear to users, and users can quickly transfer to the two func-
tions whenever they use APP. The main function of APP for medical
staff is to contact patients and check cases. For these two functions,
it should be able to switch between the two functions quickly so
that medical staff can quickly understand the patient’s situation and
complete communication. In the interface style, simple and gener-
ous flat design should be chosen, because flat style can cope with
different sizes of operation interface, enable users to complete more
interaction in limited operating space, and avoid complex opera-
tions, and reduce non-functional elements. Using more simple and Fig. 3. Belly band effect.
clear characteristic elements to design, users can more easily access
to information.
As a mobile medical APP, its main function is to monitor data and In this scheme, the shoulder bearing part, back supporting
contact hospital doctors. The function of fetal monitoring and con- structure, bracket structure and bracket tension structure are sep-
tact doctors should be closely linked, so that it can quickly switch arated, and the back supporting structure is the core. The shoulder
to contact doctors after monitoring results. According to the oper- load-bearing parts and bracket tension parts are sutured to the
ation process and the conclusion of the investigation and analysis, back-support structure, which increases the height of the back sup-
the APP interface should be concise, clear and highlight the pur- port, protects the user’s back more effectively, and is also conducive
pose of use. Its function fully meets the needs of users, without to the production of products.
other complex irrelevant functions, which is used to monitor fetal The effect of the brace is shown in Fig. 3 below.
health and contact medical staff. Two pairs of elastic bands are added to the stretching parts of
the bracket, which can make the bracket structure more fixed and
increase the bracket effect. At the same time, the upper bracket
stretching elastic band adopts the way of adjusting at both ends to
Results give users a larger range of adjusting sizes, so that the product can
adapt to users of different body sizes.
Physical analysis of maternal health care wearing equipment
Mobile medical APP based on fetal information monitoring in
In the scheme design, after abandoning the idea of using a maternal health care wearing equipment
bracket or a single structure separation for the previous two
schemes, the third scheme is chosen as the final scheme after the The general idea of the mobile medical APP for fetal monitoring
prototype product is manufactured and tested. designed in this study is to enable users to obtain fetal information
Fig. 2 below is the dimension diagram of the product (unit: cm). in the least operating steps, and to contact the relevant medical
2012 J. Peng et al. / Journal of Infection and Public Health 13 (2020) 2009–2013
Fig. 4. Operation process of APP for pregnant women.
staff for remote diagnosis at any time according to the needs, and
to provide consultation for other pregnant women. In the pregnant
women’s version, there are three main functions: fetal monitoring,
contacting doctors and related information.
The operation flow of APP is shown in Fig. 4 below.
Testing and result analysis of maternal health care wearing
equipment
For safety reasons, pregnant women are not selected to conduct
research. 4–5 healthy subjects are selected to simulate pregnant
women through weight-bearing. Subjects with abdominal weights
of 10 kg water belt simulate pregnant women. After standing for
10 min, they walk 200 m at a slow speed. After sitting for 20 min,
the subjects’ cervical curvature is measured and their feelings are
recorded with the background photograph of the measuring plate
(Male subjects should double their testing time depending on their
gender). After a short rest, the subjects wear braces and repeat
the steps two to three times. After the subjects are loaded with
10 kg water belt, the force point is fixed in L3-S1 region where
the lumbar vertebrae of pregnant women have problems. Before
wearing the product, most of the subjects do not feel too much
during the first three minutes of the standing test, and after three
minutes almost all of the subjects begin to feel waist discomfort.
Under self-regulation, the posture of standing is gradually changed
to form the posture of standing with abdomen raised and upper
body backward, which is commonly used by pregnant women.
Observed after 10 min standing test, it can be found that the
change of lumbar stress point protrusion is obvious, and the
same problem appears in the subsequent 200 m slow walking test.
However, due to the equipment problems of simulating pregnant
women in sitting posture test, it is not effective to simulate fetal
vertebral compression and the weight does not belong to human
abdominal tissue. The test results are not clear.
After wearing the product, it is found that although the pro-
totype product does not include the backrest fixing module, its
support and protection effect on the waist and back is more obvi-
ous. After standing test for nine minutes, the subjects begin to feel
mild discomfort. In subsequent observation, it is found that the
subjects’ standing posture is significantly different from that of the
non-wearing product, and no protrusion is observed in the lumbar
weight-bearing area. Subjects are satisfied with the convenience of
wearing the product. The product has a significant supporting effect
on the waist and back. The effect of reducing abdominal weight and
relieving waist discomfort is obvious. It can be considered that the
effectiveness of the product is achieved.
In the aspect of fetal information monitoring, the interactive
design of mobile medical APP is mainly aimed at fetal monitoring
and rapid contact with medical staff. The experiment proves that
the hardware of the equipment achieves the purpose of collecting
data, and then feeds back to users and hospitals through computer
software such as APP, so that users can accurately understand the
information in three-step operation, and convey the information
to medical staff. It can also provide pregnant women with the sci-
entific and authoritative information they need, store and analyze
their medical information, and help pregnant women to quickly
connect with hospitals, counseling and so on.
From this point of view, starting from the actual needs of med-
ical staff and pregnant women’ s families, and combining with
the theory of industrial design, the real-time fetal monitoring and
wearable equipment for maternal health care during pregnancy
designed by the research is a user-centered product that meets the
needs of users.
Discussion
With the rapid development of wearable technology, its appli-
cation scope gradually expands to various industries, and the
technology of wearable equipment for pregnant women will
be more and more. With the strong support of the state for
telemedicine, the corresponding technology will also develop
rapidly. Pregnant women can monitor the fetus in the abdomen
at home or in the workplace. Medical staff can also see fetal ECG
data at the other end of the network, which improves the utiliza-
tion of medical instruments and the efficiency of medical staff. The
large amount of fetal ECG data collected and stored can also be used
for large data analysis of the current physical condition of the fetus
in China, statistics of high incidence and causes, and has medical
value for disease prevention and treatment.
The abdominal brace of maternal health care based on fetal
information monitoring is studied in this study. Through further
modification and improvement in the later period, it is believed that
it can be applied and entered the market. The continuous develop-
ment and marketing of maternal health care wearing equipment
provides more and more convenient medical services for pregnant
women, and makes people more and more reassured about the
health problems of pregnant women and fetuses. In the future,
pregnant women will be more relaxed and more comfortable dur-
ing pregnancy.
 J. Peng et al. / Journal of Infection and Public Health 13 (2020) 2009–2013
However, there are still some limitations in this study. For safety
reasons, the subjects are not pregnant women. Therefore, the fetal
condition cannot be monitored. In the later research work, the
experimental design will be improved to make the experimental
equipment safer and more reliable. In this way, pregnant women
can voluntarily participate in the experiment, which can better
achieve the purpose of the experiment and design better wearable
equipment to serve more pregnant women.
Conflict of interest
None declared.
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[4] Garabedian C, Jonckheere JD, Butruille L, Deruelle P, Storme L, Houfflin-Debarge
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[5] Mccall BJ, Tilse M, Burt B, Watt P, Barnett M, McCormack JG. Infec-
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[6] Jou J, Kozhimannil KB, Abraham JM, Blewett LA, McGovern PM. Paid maternity
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 JMIR MHEALTH AND UHEALTH Li et al

Review

Effectiveness of Remote Fetal Monitoring on Maternal-Fetal

Outcomes: Systematic Review and Meta-Analysis

Suya Li1*, MSN; Qing Yang1*, MSN; Shuya Niu2, BS; Yu Liu1, BS
1
Nursing Department, Tongji Hospital, Tongji Medical College, HuaZhong University of Science and Technology, Wuhan, China
2
Zhongnan Hospital of Wuhan University, Wuhan, China
*
these authors contributed equally

Corresponding Author:
Yu Liu, BS
Nursing Department
Tongji Hospital, Tongji Medical College
HuaZhong University of Science and Technology
No. 1095 Jiefang Rd
Wuhan, 430030
China
Phone: 86 13995579713
Email: hust512@sohu.com

Abstract
Background: To solve the disadvantages of traditional fetal monitoring such as time-consuming, cumbersome steps and low
coverage, it is paramount to develop remote fetal monitoring. Remote fetal monitoring expands time and space, which is expected
to popularize fetal monitoring in remote areas with the low availability of health services. Pregnant women can transmit fetal
monitoring data from remote monitoring terminals to the central monitoring station so that doctors can interpret it remotely and
detect fetal hypoxia in time. Fetal monitoring involving remote technology has also been carried out, but with some conflicting
results.
Objective: The review aimed to (1) examine the efficacy of remote fetal monitoring in improving maternal-fetal outcomes and
(2) identify research gaps in the field to make recommendations for future research.
Methods: We did a systematic literature search with PubMed, Cochrane Library, Web of Science, Embase, MEDLINE, CINAHL,
ProQuest Dissertations and Theses Global, ClinicalTrials.gov, and Open Grey in March 2022. Randomized controlled trials or
quasi-experimental trials of remote fetal monitoring were identified. Two reviewers independently searched articles, extracted
data, and assessed each study. Primary outcomes (maternal-fetal outcomes) and secondary outcomes (health care usage) were
presented as relative risks or mean difference. The review was registered on PROSPERO as CRD42020165038.
Results: Of the 9337 retrieved literature, 9 studies were included in the systematic review and meta-analysis (n=1128). Compared
with a control group, remote fetal monitoring reduced the risk of neonatal asphyxia (risk ratio 0.66, 95% CI 0.45-0.97; P=.04),
with a low heterogeneity of 24%. Other maternal-fetal outcomes did not differ significantly between remote fetal monitoring and
routine fetal monitoring, such as cesarean section (P=.21; I2=0%), induced labor (P=.50; I2=0%), instrumental vaginal birth
(P=.45; I2=0%), spontaneous delivery (P=.85; I2=0%), gestational weeks at delivery (P=.35; I2=0%), premature delivery (P=.47;
I2=0%), and low birth weight (P=.71; I2=0%). Only 2 studies performed a cost analysis, stating that remote fetal monitoring can
contribute to reductions in health care costs when compared with conventional care. In addition, remote fetal monitoring might
affect the number of visits and duration in the hospital, but it was not possible to draw definite conclusions about the effects due
to the limited number of studies.
Conclusions: Remote fetal monitoring seems to reduce the incidence of neonatal asphyxia and health care costs compared with
routine fetal monitoring. To strengthen the claims on the efficacy of remote fetal monitoring, further well-designed studies are
necessary, especially in high-risk pregnant women, such as pregnant women with diabetes, pregnant women with hypertension,
and so forth.

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KEYWORDS
remote fetal monitoring; maternal outcomes; fetal outcomes; review
Introduction
Fetal safety has always been a top priority for perinatal care.
According to the World Health Organization, as of 2019, there
were an estimated 2 million stillbirths, most of which can be
prevented by safe and quality care, timely emergency care, and
accurate recording [1]. Fetal monitoring is the primary means
of monitoring to assess fetal safety and contributes to reducing
the risk of stillbirth by detecting fetal hypoxia as early as
possible [2,3]. Previous studies have repeatedly demonstrated
the clinical value of fetal monitoring in reducing adverse
perinatal outcomes (eg, neonatal cerebral palsy,
hypoxic-ischemic encephalopathy, or stillbirth) [4,5].
Traditional antenatal care is resource intensive and not friendly
to underserved settings. Beyond that, routine prenatal monitoring
is only suitable for hospital settings, which means that pregnant
women require regular outpatient follow-up [6]. Recurrent
outpatient visits also pose additional travel risks (eg, falls,
collisions, and bumps), especially for high-risk pregnant women.
Telemedicine refers to the long-distance transmission of medical
information between medical workers and patients through
telecommunication technology [7], which has many potential
advantages such as reducing outpatient time, alleviating the
shortage of medical resources, reducing transportation costs
and medical costs, and so forth [8-10]. Remote monitoring using
telephones, websites, portable devices, and so forth during
pregnancy is becoming more and more popular [11,12].
Systematic reviews have demonstrated the feasibility and
superiority of telemedicine in obstetrics [13], focusing on blood
pressure (BP) management [14,15], blood glucose management
[16], and weight management [17] during pregnancy. However,
we are not yet clear about the benefits or dangers of remote fetal
monitoring. The primary objective of this systematic review
was to assess the effectiveness of remote fetal monitoring for
improving maternal-fetal outcomes. In addition, we also sought
to analyze the cost-effectiveness of remote fetal monitoring
compared to conventional prenatal monitoring.
Methods
Reporting Standards
This systematic review and meta-analysis was carried out
according to the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses guidelines of 2009 [18] and was
registered on PROSPERO as CRD42020165038.
Literature Retrieval
In total, 9 web-based databases were searched in March 2022,
including PubMed (January 1966-March 2022), Cochrane
Library (January 1947-March 2022), Web of Science (January
1990-Mar 2022), Embase (January 1974-March 2022),
MEDLINE (January 1950-March 2022), CINAHL (January
1982-March 2022), ProQuest Dissertations and Theses Global
(January 1899-March 2022), ClinicalTrials.gov (January
1997-March 2022), and Open Grey (January 1980-March 2022).
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Search terms generated from the inspection of relevant papers
were wielded to search for eligible studies, such as fetal, remote,
telemetry, monitor, and so forth. The full search strategy was
available in Multimedia Appendix 1 and was rerun before the
final analysis.
Inclusion Criteria
Studies were considered eligible if they simultaneously met the
following criteria: (1) pregnant women; (2) randomized
controlled trials (RCTs) or quasi-experimental trials; (3) fetal
monitoring data were transmitted to the central monitoring
station by remote monitoring terminals; and (4) outcomes
included at least 1 maternal-fetal outcome or health resource
usage. There were no restrictions on language, nationality, or
publication status.
Exclusion Criteria
Studies meeting any of the following criteria were excluded:
(1) no control group in the study; (2) comparative studies of 2
or more remote monitoring technologies; and (3) the full text
was still unavailable after contacting the original authors. Studies
were not excluded due to monitoring settings (hospital, home,
community setting, or mixed).
Outcome Measures
The primary outcomes were maternal-fetal outcomes (cesarean
section, induced labor or miscarriage, instrumental vaginal birth,
spontaneous delivery, gestational weeks at delivery, premature
delivery, birth weight, and so on). The secondary outcomes
were health care usage, which was assessed by on-site
appointments, home visits, duration in the hospital, prenatal
costs, and so on.
Study Selection
A 3-step screening identified articles that met the inclusion and
exclusion criteria were literature retrieval, preliminary screening
(title and abstract), and full-text screening. Literature retrieval
was conducted by 2 investigators. All searched articles were
uploaded into the reference management tool of EndNote.
Articles with the same author, year, title, and so on were
identified and removed by EndNote. Subsequently, 2
independent investigators (SYL and QY) selected all articles
by evaluating the title and abstract after the removal of
duplicates. Finally, the same 2 investigators (SYL and QY)
identified the ultimately eligible articles by screening
independently the full text according to the inclusion and
exclusion criteria. In addition, the first author (SYL)
hand-searched the references of the ultimately included literature
to identify further publications. Any discrepancies and
disagreements were finally resolved by consultation with a third
reviewer (YL). We also contacted the original authors for
verification if there were any uncertain technical types.
Data Extraction
Data from included studies were extracted by SYL and then
cross-checked by another author (QY). A standardized data
extraction form was designed by the research team and included
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 JMIR MHEALTH AND UHEALTH
the following data: (1) basic information of included studies
(first author, year of publication, country, and study design);
(2) characteristics of participants (maternal age, gestational
weeks, sample size, and attrition rate); (3) characteristics of
interventions (trial settings, duration of the intervention,
monitoring personnel, monitoring content, feedback types, and
technical support); and (4) outcomes measurement
(maternal-fetal outcomes and health care usage). For insufficient
data, we contacted the original authors via email. The
standardized data extraction form was available in Multimedia
Appendix 2.
Quality Assessment
Independently, the quality of eligible studies was assessed by
2 reviewers (SYL and QY) according to the Cochrane Risk of
Bias Tool [19], which consisted of 7 items (random sequence
generation, allocation concealment, blinding of participants and
personnel, blinding of outcome assessment, incomplete outcome
data, selective reporting, and other bias) with the responses of
“low risk,” “high risk,” and “unclear risk.” The research was
considered high quality with a low risk score on at least 4
domains, which must include 3 key domains (random sequence
generation, allocation concealment, and incomplete outcome
data) [20]. Consensuses between 2 investigators (SYL and QY)
were reached by discussion with a third reviewer (YL).
Figure 1. Flow diagram of study selection.
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Data Synthesis and Statistical Analysis
Quantitative analysis of included studies was carried out in
Review Manager (RevMan) software (version 5.4). Continuous
variables were presented as mean difference (MD), and
dichotomous variables were described as risk ratio (RR) with
a 95% CI. The statistical heterogeneity of selected studies was
assessed by the chi-square test combined with I2. Heterogeneity
was divided into nonsignificant heterogeneity (I2 ranging from
0% to 40%), moderate heterogeneity (I2 ranging from 30% to
60%), substantial heterogeneity (I2 ranging from 50% to 90%)
and considerable heterogeneity (I2 ranging from 75% to 100%)
[19]. When I2<40%, the fixed-effects model was adopted;
otherwise, a random effect model was considered. In addition,
sensitivity analysis and subgroup analysis were used to explore
the sources of heterogeneity if needed.
Results
Study Selection
A total of 9337 studies were initially retrieved by searching 9
databases. After the 3-step screening, 8 studies met the inclusion
and exclusion criteria. From a manual search of related
references, 1 additional study was included. Finally, 9 RCTs
were included in the systematic review and meta-analysis. The
results of 1 study were published in 2 articles [21,22]. The
detailed flow diagram of study selection is shown in Figure 1.
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Study Characteristics
The characteristics of 9 RCTs are outlined in Table 1, involving
1128 participants from 6 countries. Seven studies were from
developed countries (1 from the United States [23], 3 from the
United Kingdom [24-26], 2 from the Netherlands [21,22], and
1 from Finland [27]). Only 2 studies were performed in
developing countries (1 from China [28] and 1 from Mexico
[29]). Eight of the screened studies were monocentric, and 1
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was multicenter [26]. On the duration of interventions, 7 studies
were carried out in the prenatal period [21-23,25,26,28,29], and
2 studies were conducted during labor [24,27]. In terms of
participants, most of the included studies recruited high-risk
pregnant women [21,22,25,26], and the remaining studies
recruited low-risk pregnant women [23], late pregnant women
[28], and pregnant women facing labor [24,25], respectively.
The pooled mean age of pregnant women was 29.28 (SD 5.03)
years in 6 RCTs [21-23,25-27].
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Table 1. Characteristics of included studies.

Author, year, Study design Participants Duration Sample, N Attrition Major characterization Major results
country rate (%)
Butler Tobah et al, 2-arm RCT,a Low-risk preg- <13 weeks IGb: 11 IG: OB Nest care (8 on- Pregnancy outcomes
2019, United monocentric nancies (IG： of gestation N=134; site appointments, 6 re- (cesarean, delivery,
States [23] 29.5±3.3 years; to deliver mote visits via phone or miscarriage, and
CGc:
CG：29.7±3.6 web-based communica- preterm delivery);
N=133
years) tion) neonatal outcomes (low
CG: usual care (12 birth weight, and
prescheduled prenatal neonatal asphyxia);
clinic appointments) health care usage (on-
site appointments, re-
mote visits, and inpa-
tient days)
Wang et al, 2019, 2-arm RCT, Late pregnan- 36-41 weeks IG: N=80; 0 IG: remote FHRd moni- Neonatal outcomes
China [28] monocentric cies (IG：22-40 of gestation CG: N=80 toring (3-4 times daily); (neonatal asphyxia and
years; CG：22- to deliver CG: own fetal move- nonstress test）
38 years) ment count (3 times
daily) and routine outpa-
tient FHR monitoring
Tapia-Conyer et al, 2-arm RCT, High-risk preg- 27-29 weeks IG: N=74; 12 IG: wireless maternal- Pregnancy outcomes
2015, Mexico [29] monocentric nancies (<19 or of gestation CG: N=79 fetal monitoring (1- to (preterm, preeclampsia,
>35 years) to deliver 2-week intervals); CG: and eclampsia); neona-
conventional care tal outcomes (low birth
(standard midwifery weight); adherence
visits)
Dawson et al, 2-arm RCT, High-risk preg- 12 weeks of IG: N=43; 0 IG: domiciliary monitor- Pregnancy outcomes
1999, United multicenter nancies (IG： gestation to CG: N=38 ing daily via DFMe (weeks of gestation at
Kingdom [26] 25.7 ± 5.0 deliver system; CG: convention- delivery, spontaneous
years; CG： al care (standard mid- delivery, cesarean deliv-
27.2 ± 6.3 wifery visits) ery, operative vaginal
years) delivery, and induced
labor); neonatal out-
comes (neonatal asphyx-
ia); health care usage
(on-site appointments,
home visits, inpatient
days, and cost-effective-
ness)
Birnie et al, 1997, 2-arm RCT, High-risk preg- 32-43 weeks IG: N=76; 0 IG: domiciliary monitor- Pregnancy outcomes
the Netherlands monocentric nancies (IG： of gestation CG: N=74 ing daily via portable (weeks of gestation at
[21] 29.6±5.8 years; to deliver cardiotocography; CG: delivery, cesarean deliv-
CG：30.9±5.8 in-hospital monitoring ery, and induced labor);
years) daily neonatal outcomes
(birth weight); health
care usage (inpatient
days and cost-effective-
ness)
Monincx et al, 2-arm RCT, High-risk preg- 32-43 weeks IG: N=76; 0 IG: domiciliary monitor- Pregnancy outcomes
1997, the Nether- monocentric nancies (IG： of gestation CG: N=74 ing daily via portable (spontaneous delivery,
lands [22] 29.6±5.8 years; to deliver cardiotocography; CG: operative vaginal deliv-
CG：30.9±5.8 in-hospital monitoring ery, and perinatal mor-
years) daily tality); neonatal out-
comes (neonatal asphyx-
ia and neurological opti-
mality scores)
Dawson et al, 2-arm RCT, High-risk preg- 26-41 weeks IG: N=40; 5 IG: domiciliary monitor- Pregnancy outcomes
1989, United monocentric nancies (IG： of gestation CG: N=17 ing daily via DFM sys- (weeks of gestation at
Kingdom [25] 28.78±5.85 to deliver tem; CG: conventional delivery, cesarean deliv-
years; CG： hospital care ery, and induced labor)
26.06±3.51
years)

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Author, year, Study design Participants Duration Sample, N Attrition Major characterization Major results
country rate (%)
Calvert et al, 1982, 3-arm RCT, Patients facing During labor IG: N=100; 0 IG: remote monitor car- Pregnancy outcomes
United Kingdom monocentric labor (≤37 CG: diotocography (patients (spontaneous delivery,
[24] weeks of gesta- N=100 could get out of bed to cesarean delivery, and
tion) walk or sit); CG: con- operative vaginal deliv-
ventional bedside car- ery); Neonatal out-
diotocography comes (neonatal asphyx-
ia)
Haukkamaa et al, 2-arm RCT, Patients facing During labor IG: N=31; 0 IG: FHR monitored by Pregnancy outcomes
1982, Finland [27] monocentric labor (IG： CG: N=29 telemetry (patients were (cesarean delivery, oper-
28.35±3.75 encouraged to sit or ative vaginal delivery,
years; CG： walk); CG: FHR moni- and induced labor)
28.1±3.7 years) tored by conventional
cardiotocography

a
RCT: randomized controlled trial.
b
IG: intervention group.
c
CG: control group.
d
FHR: fetal heart rate.
e
DFM: domiciliary fetal monitoring.

The frequency of fetal monitoring and guidance varied among

Characteristics of Interventions
The characteristics of interventions are described in Table 2.
Most of the included studies were undertaken at home
[21-23,25,26,28], with 3 exceptions occurring in rural clinics
[29] and hospitals [24,27]. Pregnant women in the control groups
received “conventional care,” including routine outpatient
monitoring, in-hospital monitoring, or conventional bedside
cardiotocography. Pregnant women in the intervention groups
received remote fetal monitoring with web, Bluetooth, or
telephone. Of the included studies, 5 RCTs only supervised
fetal heart rate [24-28], and the remaining 4 RCTs monitored
extra BP [21-23,29], blood glucose [29], height [29], weight
[29], or temperature [21,22].
the included studies as did the form of feedback. Due to the
different stages of pregnancy, the frequency of fetal monitoring
ranged from 3 to 4 times daily to biweekly. There were many
ways to achieve one-to-one, personalized, and exclusive
guidance, including phone visits, on-site appointments, or family
visits. In addition, 2 other studies, which occurred during labor,
used the obstetrical telemetry system to remotely monitor the
fetus in real time [24,27]. During the birth process, the pregnant
women in the conventional group were nursed in bed, whereas
those with telemetry equipment were encouraged to get out of
bed to walk or sit on a chair.

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Table 2. Characteristics of interventions.

Author, year, Monitoring per- Monitoring locus Monitoring content Feedback Technical support
country sonnel
Butler Tobah et al, Patient, nurse, Domiciliary FHR,a BPb • Transmission of data via a Home digital sphygmo-
2019, United and obstetrician phone or the institution’s elec- manometer, handheld fetal
States [23] tronic medical record system Doppler, and patient web
• Personalized guidance by tele- portal
phone visits or on-site appoint-
ments

Wang et al 2019, Patient and obste- Domiciliary FHR • Transmission of data via phone Portable intelligent medical
China [28] trician • Personalized guidance via terminal system
telephone if necessary

Tapia-Conyer et al, Nurse and obste- Rural clinics FHR, BP, blood • Transmission of data through MiBebe fetal remote monitor
2015, Mexico [29] trician glucose, height, a Bluetooth interface and web prototype, Bluetooth, and pa-
and weight access tient web portal
• Personalized consultations via
fetal monitoring visits

Dawson et al 1999, Patient, communi- Domiciliary FHR • Transmission of data via tele- DFMc system
United Kingdom ty midwife phone using modems
[26] • Personalized surveillance and
care for each pregnant woman

Birnie et al 1997, Investigator, mid- Domiciliary FHR, BP, and tem- • Transmission of data via tele- Portable cardiotocography
the Netherlands wife, and physi- perature phone and public telephone network
[21] cian • Personalized consultations via
telephone if necessary

Monincx et al Investigator, mid- Domiciliary FHR, BP, and tem- • Transmission of data via tele- Portable cardiotocography
1997, the Nether- wife, and physi- perature phone and public telephone network
lands [22] cian • Personalized consultations via
telephone if necessary

Dawson et al 1989, Patient, midwife Domiciliary FHR • Transmission of data via tele- DFM system
United Kingdom phone fetal monitoring systems
[25] • Personalized guidance via reg-
ular family visits

Calvert et al 1982, Midwife Hospital FHR • Transmission of data via an Obstetrical telemetry system
United Kingdom obstetrical telemetry system
[24]
Haukkamaa et al Midwife Hospital FHR • Transmission of data via an Obstetrical telemetry system
1982, Finland [27] obstetrical telemetry system

a
FHR: fetal heart rate.
b
BP: blood pressure.
c
DFM: domiciliary fetal monitoring.

influenced by the lack of blinding. Based on the above reasons,

Risk of Bias
Overall, the quality of included studies was moderate, 4 of which
(44%) were high-quality research [21-23,26]. The studies
showed the main bias in the blinding of participants and
personnel, which might be caused by the nature of interventions.
In addition, 1 study (11%) showed a high risk of bias for random
sequence generation because of grouping according to the
hospital number [24]. Fortunately, all outcomes were obtained
from medical records, so the outcome assessment would not be
the blinding of outcome assessment of included studies was
assessed as “low risk of bias.” Three RCTs (22%) reported clear
data loss, with attrition of 11% [23], 12% [29], and 5% [25],
respectively. One of the studies had a relatively large difference
in attrition between the groups (20% and 4%, respectively), and
it was unclear whether the loss to follow-up varied [29]. Three
studies (22%) used intention-to-analysis [21-23] (Figures 2 and
3).

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Figure 2. Risk of bias in each study.

Figure 3. Overall risk of each type of bias.

Synthesis of Results
The review extracted 8 maternal-fetal outcomes and the pooled
analyses are presented in Table 3.

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Table 3. Effect estimates of 8 outcomes.

Outcomes Studies, n Participants, n Statistical methods Effect estimates
Cesarean section 6 815 Risk ratio (M-H,a fixed, 95% CI) 0.81 (0.59 to 1.12)

Neonatal asphyxia
Instrumental vaginal birth
Induced labor
Spontaneous delivery
Gestational weeks at delivery
5 859
4 492
4 348
3 432
3 288
Risk ratio (M-H, fixed, 95% CI) 0.66 (0.45 to 0.97)b
Risk ratio (M-H, fixed, 95% CI) 1.21 (0.74 to 1.98)
Risk ratio (M-H, fixed, 95% CI) 0.90 (0.66 to 1.22)
Risk ratio (M-H, fixed, 95% CI) 0.99 (0.89 to 1.10)
Mean difference (IV,c fixed, 95% CI) −0.28 (−0.86 to 0.30)

Premature delivery 2 420 Risk ratio (M-H, fixed, 95% CI) 0.80 (0.44 to 1.46)
Low birth weight 2 420 Risk ratio (M-H, fixed, 95% CI) 1.20 (0.45 to 3.20)

a
M-H: Mantel-Haenszel.
b
Statistically significant at P=.04 level.
c
IV: inverse variance.

Four RCTs (n=348) reported induced labor with an overall rate

Maternal Outcomes
Cesarean section was the most assessed in the included studies,
involving 815 pregnant women from 6 RCTs [21,23-27]. Under
the fixed effect model, the pooled results showed a
nonsignificant difference between the intervention group and
the control group (RR 0.81, 95% CI 0.59-1.12; P=.21), without
any heterogeneity (I2=0%; P=.93; Figure 4).
Instrumental vaginal birth was mentioned in 4 studies involving
492 pregnant women [22,24,26,27]. There was no evidence of
heterogeneity when pooling the 4 studies (I2=0%; P=.88). With
a fixed effect model, the prevalence of instrumental vaginal
birth did not significantly differ between the remote monitoring
group and the routine monitoring group (RR 1.21, 95% CI
0.74-1.98; P=.45; Figure 5).
Figure 4. Forest plot of cesarean section.
of 32% [21,25-27]. Moreover, no significant difference (RR
0.90, 95% CI 0.66-1.22; P=.50) between groups and the
heterogeneity (I2=0%; P=.42) in pooling 4 studies was
demonstrated (Figure 6).
Similarly, no significant difference was found in the risk of
spontaneous delivery (RR 0.99, 95% CI 0.89‐1.10; P=.85)
[22,24,26] or premature delivery (RR 0.80, 95% CI 0.44‐1.46;
P=.47) [23,29], both with no heterogeneity (I2=0%; P=.68 and
P=.45, respectively; Figures 7 and 8). For gestational weeks at
delivery, the overall effect of 3 studies [21,25,26] was also
insignificant (MD −0.28, 95% CI −0.86 to 0.30; P=.35) in the
absence of heterogeneity (I2=0%; P=.68; Figure 9).

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Figure 5. Forest plot of instrumental vaginal birth.

Figure 6. Forest plot of induced labor.

Figure 7. Forest plot of spontaneous delivery.

Figure 8. Forest plot of premature delivery.

Figure 9. Forest plot of gestational weeks at delivery.

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Outcomes of Infants
Five studies (n=859) compared the incidence of neonatal
asphyxia between the intervention group and the control groups,
with an overall prevalence of 11% [22-24,26,28]. Furthermore,
the overall effect of neonatal asphyxia was significant, and the
combined risk ratio was 0.66 (95% CI 0.45-0.97; P=.04) with
Figure 10. Forest plot of neonatal asphyxia.
Figure 11. Forest plot of low birth weight.
Health Care Usage
The outcomes of health care usage were investigated in 3 studies
[21,23,26], involving the number of on-site appointments or
home visits, duration in hospital, medical cost, and so on.
However, none of them was suitable for meta-analysis due to
heterogeneity of evaluation methods and assessment timing or
to a lack of sufficient data.
Butler Tobah et al [23] reported that compared with conventional
nursing, the number of on-site appointments with clinicians and
nurses decreased significantly in the intervention group (11.25
vs 14.69 visits; P<.01), while the duration of time spent on
coordinating care and connected care appointments by phone
or on the internet was higher in the intervention group (401.20
vs 167.10 minutes per woman; P<.01). Similarly, Dawson et al
[26] also reported that the remote group received more home
visits (3.7 vs 1.4 visits; P=.002) and longer home visits (33.5
vs 12.8 minutes per visit; P<.001). There was no significant
difference in the number of antenatal clinic visits between the
2 groups (2.4 vs 3.2 visits; P=.11) [26]. For antenatal inpatient
days, Dawson et al [26] found there were no significant
differences between the 2 groups (3.58 vs 5.13 days; P=.12),
whereas Birnie et al [21] reported longer hospital stays in the
control group (1 vs 7 days; P<.001). Furthermore, no significant
differences in hospital length of stay after delivery [21,23] were
observed across groups.
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an acceptable heterogeneity across studies (I2=24%; P=.26;
Figure 10).
For low birth weight, the pooled results of 2 studies involving
420 newborns showed that no significant difference was
discovered between the intervention group and the control group
(RR 1.20, 95% CI 0.45-3.20; P=.71), without any heterogeneity
(I2=0%; P=.41; Figure 11) [23,29].
Two studies reported cost-effectiveness [21,26]. Birnie et al
[21] indicated that domiciliary monitoring had lower prenatal
costs than in-hospital monitoring (US $1521 vs US $3558 per
woman; P<.001), mainly focusing on nursing care, domiciliary
monitoring, and informal family care. Dawson et al [26] also
supported that the total cost of domiciliary care was €223.83
(US $239.89 in 2023) per woman less than that of conventional
care, consisting of community midwife (time and travel), home
monitoring equipment (capital cost and maintenance), lost
productive output (women and partners), and antenatal clinic
attendances (visits, ultrasound scans, and antenatal inpatient
care) [26].
Discussion
Principal Findings
As far as we know, this is the first article to quantitatively
analyze the effects of remote fetal monitoring. The systematic
review and meta-analysis highlighted that remote fetal
monitoring significantly reduced the risk of neonatal asphyxia
by 34%. Beyond that, remote fetal monitoring was also
beneficial for reducing prenatal costs, which showed some
potential for greater cost-effectiveness.
Comparison With Prior Studies
In previous reviews, the superiority of obstetric remote
monitoring has also been repeatedly emphasized because of
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real-time, periodic, and remote monitoring [3,30,31]. By
integrating 14 studies involving blood glucose, fetal heart rate,
and uterine activity, Lanssens et al found that remote monitoring
reduced low neonatal birth weight and neonatal intensive care
unit admissions, as well as prolonged gestational age [31].
Likewise, a recent systematic review, focusing on obstetric
remote monitoring of BP, uterine contractions, weight, heart
rate, and so forth also supported that telemonitoring during
pregnancy had great potential for promoting better pregnancy
outcomes [3]. However, due to limited research on prenatal
remote monitoring, no further quantitative analysis was carried
out in the above reviews.
This systematic review and meta-analysis, the first to focus
remote monitoring on the fetus, revealed that remote fetal
monitoring reduced the risk of neonatal asphyxia by 34%.
Remote fetal monitoring can identify signs of fetal hypoxia in
time by monitoring wherever and whenever, which is essential
to reduce neonatal asphyxia, especially in high-risk pregnant
women [32]. In terms of cost-effectiveness, only 2 RCTs out
of 9 studies reported cost-effectiveness [21,26]. Both
demonstrated that remote monitoring significantly reduced
prenatal costs, which was consistent with previous studies
[31,33,34]. In Lanssens’ [31] review, 2 retrospective studies
found that remote monitoring significantly reduced health care
costs. In the studies reviewed, cost analysis focused on health
care costs, patient costs, caregiver costs, and productivity costs.
Remote fetal monitoring had additional equipment costs and
maintenance costs, but in the long run, it saved much more than
that, such as time costs, travel costs, or outpatient costs.
In addition, the disadvantages of remote fetal monitoring
remained controversial, such as whether additional cesarean
sections would be added. In this regard, this meta-analysis
covering 9 studies found no consistent evidence of adverse
effects on maternal and infant outcomes, with a small
heterogeneity ranging from 0% to 24%. This might be related
to accurate guidance from midwives or obstetricians on the
remote monitoring team. Nonetheless, a recent review in 2019
evaluated information involving decreased fetal movement in
24 mobile applications, revealing that the information varied
widely and lacked evidence-based clinical advice [35]. Accurate
information about fetal movement is essential for improving
maternal and infant outcomes. Therefore, it is recommended
that health care personnel cooperate with software developers
to jointly develop high-quality prenatal education tools, which
will help to promote more pregnant women to obtain timely
and accurate guidance.
Notably, in the current systematic review and meta-analysis, 7
of the 9 studies were carried out in developed countries, which
were inseparable from the rich medical resources and advanced
medical technologies of developed countries. The latest global
figures showed that in 2020, there were 26 and 17 deaths per
1000 live births in low- and middle-income countries (LMICs),
respectively. However, in high-income countries, the rate only
stood at 3 per 1000 [36]. Given the higher perinatal mortality
rate, the need for remote fetal monitoring in developing
countries may be more urgent. Furthermore, a recent review
focused on LMICs concluded that mobile technology can
overcome economic and geographic barriers by transmitting
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clinical information collected using low-cost devices, thereby
increasing the perinatal care coverage of LMICs [5]. It can be
argued that remote fetal monitoring supported by mobile
technology appears to have greater potential in LMICs, where
antenatal care services need to be improved. Therefore, we
encourage remote fetal monitoring in LMICs to alleviate the
shortage of medical resources and further complement the
benefits of remote fetal monitoring.
Suggestions for Clinical Practice
This systematic review has demonstrated that remote fetal
monitoring has a significant effect on improving maternal and
infant outcomes, but this does not mean that remote fetal
monitoring can replace face-to-face communication between
doctors and patients, which is necessary for shared
decision-making. Remote monitoring breaks through the barriers
of time and distance, so it is reasonable as an effective
complement to traditional outpatient monitoring [37]. Especially
during the COVID-19 pandemic, pregnant women, as a high-risk
group, should not gather in outpatient clinics for a long time.
At this time, remote fetal monitoring not only realizes
noncontact medical services but also ensures the safety of
mothers and babies. Unfortunately, remote fetal monitoring is
rarely implemented in developing countries, especially in areas
with limited medical resources [3]. Therefore, the development
and implementation of remote monitoring technology urgently
need to be put on the agenda. Aside from the technical issues,
another concern of remote fetal monitoring is that authentication
rules, reimbursement policies, data security, legal
responsibilities, and so forth are not yet clear [38]. Although
remote fetal monitoring has not yet shown adverse
consequences, it is still necessary to conduct relevant research
cautiously in combination with the local medical level.
Limitations
There were some limitations worth noting. The diversity of
pregnant women in the current systematic review was the major
limitation, involving low-risk pregnancies, high-risk
pregnancies, late pregnancies, and patients facing labor. Future
research can continue to explore which types of pregnant women
are more suitable for remote fetal monitoring. In addition,
several RCTs included in this meta-analysis were relatively old,
which might limit the direct applicability of the evidence to
current clinical practice. Finally, due to the limited literature,
it was difficult to quantitatively analyze the efficacy of remote
fetal monitoring in health resource usage. Future studies are
expected to assess the cost-effectiveness of remote fetal
monitoring, including implementation costs (technology costs,
medical costs, etc), intervention costs (patient resource costs,
commuting costs, etc), and downstream costs (productivity
costs, future costs, etc) [39]. Likewise, the number of
consultations, length of hospital stay, and patient compliance
or satisfaction cannot be ignored and need to be explored further.
Conclusions
The present systematic review and meta-analysis of 9 studies
highlighted that remote fetal monitoring had a favorable effect
on reducing neonatal asphyxia. Remote fetal monitoring has
not yet found hidden dangers, but more large-scale, multicenter,
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 JMIR MHEALTH AND UHEALTH Li et al

and high-quality studies are still expected to explore its safety fetal monitoring, which will help alleviate the huge medical
and efficacy. At the same time, more research is also expenses.
recommended to further carry out the cost analysis of remote

Conflicts of Interest
None declared.

Multimedia Appendix 1
Search strategy.
[DOCX File , 15 KB-Multimedia Appendix 1]

Multimedia Appendix 2
Data extraction form.
[DOCX File , 25 KB-Multimedia Appendix 2]

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12. Schramm K, Grassl N, Nees J, Hoffmann J, Stepan H, Bruckner T, et al. Women’s attitudes toward self-monitoring of their
pregnancy using noninvasive electronic devices: cross-sectional multicenter study. JMIR Mhealth Uhealth 2019;7(1):e11458.
[doi: 10.2196/11458]
13. van den Heuvel JF, Groenhof TK, Veerbeek JH, van Solinge WW, Lely AT, Franx A, et al. eHealth as the next-generation
perinatal care: an overview of the literature. J Med Internet Res 2018;20(6):e202 [FREE Full text] [doi: 10.2196/jmir.9262]
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14. Tran K, Padwal R, Khan N, Wright MD, Chan WS. Home blood pressure monitoring in the diagnosis and treatment of
hypertension in pregnancy: a systematic review and meta-analysis. CMAJ Open 2021;9(2):E642-E650 [FREE Full text]
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15. Kalafat E, Benlioglu C, Thilaganathan B, Khalil A. Home blood pressure monitoring in the antenatal and postpartum period:
a systematic review meta-analysis. Pregnancy Hypertens 2020;19:44-51. [doi: 10.1016/j.preghy.2019.12.001] [Medline:
31901652]

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16. Li SY, Ouyang YQ, Qiao J, Shen Q. Technology-supported lifestyle interventions to improve maternal-fetal outcomes in
women with gestational diabetes mellitus: a meta-analysis. Midwifery 2020;85:102689. [doi: 10.1016/j.midw.2020.102689]
17. Lau Y, Klainin-Yobas P, Htun TP, Wong SN, Tan KL, Ho-Lim ST, et al. Electronic-based lifestyle interventions in
overweight or obese perinatal women: a systematic review and meta-analysis. Obes Rev 2017;18(9):1071-1087. [doi:
10.1111/obr.12557] [Medline: 28544551]
18. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and
meta-analyses: the PRISMA statement. BMJ 2009;339:b2535 [FREE Full text] [Medline: 19622551]
19. Higgins J, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al. Cochrane handbook for systematic reviews of
interventions (version 6.3). 2022. URL: https://training.cochrane.org/handbook/current [accessed 2022-05-22]
20. Grzeskowiak LE, Smithers LG, Amir LH, Grivell RM. Domperidone for increasing breast milk volume in mothers expressing
breast milk for their preterm infants: a systematic review and meta-analysis. BJOG 2018;125(11):1371-1378 [FREE Full
text] [doi: 10.1111/1471-0528.15177]
21. Birnie E, Monincx WM, Zondervan HA, Bossuyt PM, Bonsel GJ. Cost-minimization analysis of domiciliary antenatal fetal
monitoring in high-risk pregnancies. Obstet Gynecol 1997;89(6):925-929. [doi: 10.1016/s0029-7844(97)00150-6] [Medline:
9170466]
22. Monincx WM, Zondervan HA, Birnie E, Ris M, Bossuyt PM. High risk pregnancy monitored antenatally at home. Eur J
Obstet Gynecol Reprod Biol 1997;75(2):147-153. [doi: 10.1016/s0301-2115(97)00122-x] [Medline: 9447367]
23. Butler Tobah YS, LeBlanc A, Branda ME, Inselman JW, Morris MA, Ridgeway JL, et al. Randomized comparison of a
reduced-visit prenatal care model enhanced with remote monitoring. Am J Obstet Gynecol 2019;221(6):638.e1-638.e8.
[doi: 10.1016/j.ajog.2019.06.034] [Medline: 31228414]
24. Calvert JP, Newcombe RG, Hibbard BM. An assessment of radiotelemetry in the monitoring of labour. Br J Obstet Gynaecol
1982;89(4):285-291. [doi: 10.1111/j.1471-0528.1982.tb04697.x] [Medline: 7073996]
25. Dawson AJ, Middlemiss C, Coles EC, Gough NA, Jones ME. A randomized study of a domiciliary antenatal care scheme:
the effect on hospital admissions. Br J Obstet Gynaecol 1989;96(11):1319-1322. [doi: 10.1111/j.1471-0528.1989.tb03230.x]
[Medline: 2611171]
26. Dawson A, Cohen D, Candelier C, Jones G, Sanders J, Thompson A, et al. Domiciliary midwifery support in high-risk
pregnancy incorporating telephonic fetal heart rate monitoring: a health technology randomized assessment. J Telemed
Telecare 1999;5(4):220-230. [doi: 10.1258/1357633991933756] [Medline: 10829372]
27. Haukkamaa M, Purhonen M, Teramo K. The monitoring of labor by telemetry. J Perinat Med 1982;10(1):17-22. [doi:
10.1515/jpme.1982.10.1.17] [Medline: 7062228]
28. Wang Q, Yang W, Li L, Yan G, Wang H, Li J. Late pregnancy analysis with Yunban’s remote fetal monitoring system.
Int J Distrib Sens Netw 2019;15(3):1550147719832835. [doi: 10.1177/1550147719832835]
29. Tapia-Conyer R, Lyford S, Saucedo R, Casale M, Gallardo H, Becerra K, et al. Improving perinatal care in the rural regions
worldwide by wireless enabled antepartum fetal monitoring: a demonstration project. Int J Telemed Appl 2015;2015:794180
[FREE Full text] [doi: 10.1155/2015/794180] [Medline: 25691900]
30. Snoswell CL, Chelberg G, De Guzman KR, Haydon HH, Thomas EE, Caffery LJ, et al. The clinical effectiveness of
telehealth: a systematic review of meta-analyses from 2010 to 2019. J Telemed Telecare 2021:1357633X211022907. [doi:
10.1177/1357633X211022907] [Medline: 34184580]
31. Lanssens D, Vandenberk T, Thijs IM, Grieten L, Gyselaers W. Effectiveness of telemonitoring in obstetrics: scoping review.
J Med Internet Res 2017;19(9):e327 [FREE Full text] [doi: 10.2196/jmir.7266] [Medline: 28954715]
32. Signorini MG, Lanzola G, Torti E, Fanelli A, Magenes G. Antepartum fetal monitoring through a wearable system and a
mobile application. Technologies 2018;6(2):44. [doi: 10.3390/technologies6020044]
33. Buysse H, De Moor G, Van Maele G, Baert E, Thienpont G, Temmerman M. Cost-effectiveness of telemonitoring for
high-risk pregnant women. Int J Med Inform 2008;77(7):470-476. [doi: 10.1016/j.ijmedinf.2007.08.009] [Medline: 17923433]
34. Lemelin A, Paré G, Bernard S, Godbout A. Demonstrated cost-effectiveness of a telehomecare program for gestational
diabetes mellitus management. Diabetes Technol Ther 2020;22(3):195-202. [doi: 10.1089/dia.2019.0259] [Medline:
31603351]
35. Daly LM, Boyle FM, Gibbons K, Le H, Roberts J, Flenady V. Mobile applications providing guidance about decreased
fetal movement: review and content analysis. Women Birth 2019;32(3):e289-e296. [doi: 10.1016/j.wombi.2018.07.020]
[Medline: 30139669]
36. UNICEF, WHO. Mortality rate, neonatal (per 1,000 live births). The World Bank. URL: https://data.worldbank.org/indicator/
SH.DYN.NMRT [accessed 2022-05-22]
37. Zizzo AR, Hvidman L, Salvig JD, Holst L, Kyng M, Petersen OB. Home management by remote self-monitoring in
intermediate- and high-risk pregnancies: a retrospective study of 400 consecutive women. Acta Obstet Gynecol Scand
2022;101(1):135-144 [FREE Full text] [doi: 10.1111/aogs.14294]
38. Greiner AL. Telemedicine applications in obstetrics and gynecology. Clin Obstet Gynecol 2017 Dec;60(4):853-866. [doi:
10.1097/GRF.0000000000000328] [Medline: 28990981]
39. Gold HT, McDermott C, Hoomans T, Wagner TH. Cost data in implementation science: categories and approaches to
costing. Implement Sci 2022;17(1):11 [FREE Full text] [doi: 10.1186/s13012-021-01172-6] [Medline: 35090508]

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 JMIR MHEALTH AND UHEALTH Li et al

Abbreviations
BP: blood pressure
LMIC: low- and middle-income country
MD: mean difference
RCT: randomized controlled trial
RR: risk ratio

Edited by L Buis; submitted 31.07.22; peer-reviewed by M Kapsetaki, M Bhatta; comments to author 10.11.22; revised version received
29.12.22; accepted 23.01.23; published 22.02.23
Please cite as:
Li S, Yang Q, Niu S, Liu Y
Effectiveness of Remote Fetal Monitoring on Maternal-Fetal Outcomes: Systematic Review and Meta-Analysis
JMIR Mhealth Uhealth 2023;11:e41508
URL: https://mhealth.jmir.org/2023/1/e41508
doi: 10.2196/41508
PMID:

©Suya Li, Qing Yang, Shuya Niu, Yu Liu. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org),
22.02.2023. This is an open-access article distributed under the terms of the Creative Commons Attribution License
(https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work, first published in JMIR mHealth and uHealth, is properly cited. The complete bibliographic information,
a link to the original publication on https://mhealth.jmir.org/, as well as this copyright and license information must be included.

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Berkala Ilmiah Kedokteran dan Kesehatan Masyarakat Vol.1, No.1(2023), 42-51
ISSN: xxxx-xxxx(e); xxxx-xxxx(p) DOI: 10.28885/bikkm.vol1.iss1.art6
Pemanfaatan Aplikasi Self-Care Ibu Hamil Selama Pandemi di Negara Maju
dan Berkembang : Sebuah Tinjauan Pustaka
Adillah Nurazizah1,Diana Tri Hastuti1, Layrine Imanuke Zalsabila1, Mutiara Pradipta Nur’aini1, Nisrina Ock-
talifa Chumair1, Cahya Tri Purnami*1, Sri Winarni1, Farid Agushybana1
1
Fakultas Kesehatan Masyarakat, Universitas Diponegoro, Semarang, Indonesia
Tinjauan Pustaka
ABSTRAK
Kata Kunci: Kasus kematian ibu, bayi lahir prematur, serta keterbatasan akses
Self-care; Ibu hamil; Mobile app; perawatan intensif ibu hamil meningkat di masa pandemi Covid-19.
E-health; Pandemi Covid-19
Diperlukan sistem perawatan khusus bagi ibu hamil berupa aplikasi
Riwayat Artikel:
Dikirim: 10 Juni 2022
self-care, sehingga ibu hamil bisa melakukan perawatan mandiri tan-
Diterima: 4 Januari 2023 pa harus datang ke pelayanan kesehatan. Tujuan penelitian ini adalah
Terbit: 31 Januari 2023 melihat bagaimana pemanfaatan aplikasi self-care selama pandemi
Korespondensi Penulis: Covid-19 di negara berkembang dan negara maju. Penelitian ini
cahyatp68@gmail.com merupakan literature review dengan melakukan tinjauan pustaka di
berbagai portal seperti Google scholar, Pubmed, dan ScienceDirect.
Penyeleksian dimulai dari 1.604 artikel menjadi 702 hingga kemu-
dian didapatkan hasil sebanyak 14 artikel. Hasil dari penelitian ini
adalah ditemukannya berbagai macam aplikasi self-care dari dela-
pan negara, yaitu Indonesia, India, Amerika Serikat, Cina, Uganda,
Iran, Rusia dan Inggris. Masing-masing aplikasi memiliki kekuran-
gan dan kelebihan. Beberapa negara telah mengembangkan aplikasi
self-care untuk memudahkan ibu hamil dalam mengakses berbagai
informasi terkait kehamilannya sekaligus meningkatkan kemam-
puan ibu dalam menjaga kesehatannya.

Utilization Of Self-Care Applications for Pregnant Women During a Pandemic in

Developed and Developing Countries : A Literature Review
ABSTRACT
Cases of maternal death, premature birth, and limited access to intensive care for pregnant women
have increased during the Covid-19 pandemic. A special care system is needed for pregnant women
in the form of a self-care application, so that pregnant women can carry out independent care without
having to come to a health service. The purpose of this research is to see how self-care applications
are used during the Covid-19 pandemic in developing and developed countries. This research is a
literature review by conducting reviews on various portals such as Google scholar, Pubmed, and Sci-
encedirect. The selection started from 1,604 articles to 702, which resulted in 14 articles. The results
of this study were the discovery of various kinds of self-care applications from eight countries, namely
Indonesia, India, the United States, China, Uganda, Iran, Russia, and the United Kingdom. Each ap-
plication has advantages and disadvantages. Several countries have developed self-care applications
to make it easier for pregnant women to access various information related to their pregnancy while
increasing the ability of mothers to maintain their health.
Keywords: Self care; pregnant mother; Mobile app; E-health; Pandemic Covid-19
1. PENDAHULUAN
WHO menetapkan Covid-19 sebagai pandemi pada tanggal 11 Maret 2020 dan melaporkan lebih

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BIKKM 2023;1(1):42-51 Nurazizah, et al. Pemanfaatan Aplikas...

dari 188 negara mengalami kasus Covid-19. Pandemi Covid-19 berdampak pada pencapaian SDGs
(Sustainable Development Goals) untuk kesehatan dan kesejahteraan, antara lain kematian pada ibu
hamil, kelahiran dan nifas. Hal ini mengkhawatirkan bagi masyarakat khususnya ibu hamil, karena
ibu hamil termasuk dalam kelompok rentan terhadap pandemi Covid-19. Oleh karena itu, perlu adan-
ya pemantauan terhadap kondisi kesehatan ibu hamil secara rutin selama masa pandemi. Covid-19
selama kehamilan sering dikaitkan dengan peningkatan risiko kematian ibu, kelahiran prematur dan
keterbatasan akses unit perawatan intensif.1 Direktorat Kesehatan Keluarga pada 14 September 2021
mencatat sebanyak 1.086 ibu meninggal akibat Covid-19.2
Selama pandemi Covid-19 ini, pemerintah menerapkan kebijakan PSBB (Pembatasan Sosial Ber-
skala Besar). Beberapa pelayanan medis gagal beroperasi secara normal seperti sebelum pandemi,
dan sekitar 75% pelayanan Puskesmas tidak berfungsi. Ada layanan kesehatan yang disediakan, na-
mun sekitar 46% perawatan dihentikan. Hal ini karena kekhawatiran besar dari mereka yang takut
tertular Covid-19, dan masyarakat memilih untuk bekerja di rumah.3
Risiko komplikasi hingga kematian pada ibu hamil disebabkan karena tidak dilakukannya kunjun-
gan antenatal secara teratur dan terus menerus, sehingga ibu tidak dapat mengetahui perkembangan
kehamilan dan janinnya. Salah satu masalah pada ibu hamil adalah kurangnya pengetahuan tentang
kehamilan dan tingginya pengaruh kasus COVID-19 terhadap perawatan dan kunjungan antenatal
ibu hamil.4
Selain itu, situasi selama pandemi dapat menyebabkan terganggunya psikologis ibu hamil, terma-
suk diantaranya kecemasan akan pandemi, pembatasan sosial dan ketidaknyamanan terkait peningka-
tan jumlah kasus COVID-19 setiap hari, serta ketakutan tertular COVID-19.5
Selama pandemi COVID-19, jumlah ibu dan bayi yang meninggal melonjak tajam. Kematian
ibu meningkat dari 300 kematian pada tahun 2019 menjadi sekitar 4.400 kematian pada tahun 2020.
Kematian bayi sekitar 26.000 kematian pada tahun 2019 meningkat sekitar 40% menjadi 44.000 ke-
matian pada tahun 2020.5
Dalam sebuah survei yang pernah dilakukan melalui wawancara singkat kepada 10 ibu hamil yang
datang ke Hall Mariana untuk perawatan Antenatal Care (ANC), ditemukan bahwa 80% dari 10 ibu
hamil belum mengetahui dengan baik mengenai COVID-19, termasuk protokol kesehatan yang harus
diselenggarakan dalam upaya pencegahan infeksi COVID-19. Seluruh ibu hamil merasa kuatir den-
gan kehamilannya di era pandemi COVID-19.6
Seiring berjalannya waktu, teknologi di bidang kesehatan semakin canggih dan berkembang pesat.
Penerapan teknologi informasi dan komunikasi elektronik (TIK) dalam sistem kesehatan membantu
dalam pelayanan kesehatan ibu hamil di berbagai negara, baik negara maju maupun negara berkem-
bang. Pemanfaatan teknologi informasi dan komunikasi (TIK) di bidang kesehatan diharapkan dapat
memberikan kemudahan akses informasi yang dapat dipercaya untuk menjawab pertanyaan, men-
gidentifikasi lokasi yang berisiko tinggi, serta memberikan akses cepat ke fasilitas kesehatan dan
informasi terkait proses pengobatan Covid 19, sehingga ibu hamil dapat menjaga kesehatan dirinya
dan bayinya secara mandiri.7
Petugas kesehatan memanfaatkan teknologi informasi dan komunikasi kesehatan (TIK) dalam
memberikan tindakan peringatan (warning) agar dokter mampu mendeteksi adanya ibu hamil yang
tidak dapat mengakses pelayanan kesehatan. Melalui peringatan, petugas kesehatan dapat menindak-
lanjuti ibu hamil dengan tanggap dan waktu yang tepat. Teknologi mobile mampu membuat petugas
kesehatan terhindar dari permasalahan yang ada, sehingga aksesibilitas terhadap pelayanan kesehatan
meningkat terutama di daerah pedesaan terpencil.8
Berdasarkan data laporan global Newzoo, ponsel pintar (smartphone) menjangkau lebih dari
separuh populasi di dunia dan terus mengalami peningkatan selama 10 tahun.9 Pada tahun 2015, pen-

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BIKKM 2023;1(1):42-51 Nurazizah, et al. Pemanfaatan Aplikas...

ingkatan pengguna ponsel pintar tertinggi mencapai median 54% yang mayoritas berasal dari negara
berkembang seperti Malaysia, Brazil dan China. Peningkatan pengguna internet terbesar mencapai
median 87% yang mayoritas berasal dari negara maju yaitu Amerika Serikat dan Kanada, mayoritas
negara di Eropa Barat, negara Pasifik, Australia, Jepang dan Korea Selatan, serta Israel.10 Pada tahun
2018 hingga 2019, jumlah ponsel pintar terus meningkat mencapai lebih dari 80% populasi di negara
berpenghasilan rendah, dan seterusnya meningkat di negara berpenghasilan tinggi, rendah, maupun
menengah.9 Melihat peluang tersebut, pengembangan aplikasi self-care berbasis teknologi informasi
merupakan bentuk pengembangan pemanfaatan ilmu pengetahuan dan teknologi di bidang kesehatan,
dimana tidak ada batasan ruang dan waktu, tersedianya kemudahan akses dan tidak merepotkan.11
Khususnya, hal ini berguna di masa pandemi Covid-19 yang membawa dampak keterbatasan, terma-
suk dalam hal mengakses pelayanan kesehatan.
Penelitian yang dilakukan terhadap pengembangan aplikasi self-care berbasis mobile smartphone
pada ibu hamil pekerja (PWW), yang berfokus pada empat hal penting yaitu tidur dan istirahat,
makan, aktivitas fisik dan manajemen stres yang dirasakan, berhasil meningkatkan praktik self-care
mandiri dan kepedulian terhadap pola hidup sehat selama hamil pada PWW.11 Penyediaan aplikasi
berbasis teknologi tentang kehamilan harus dikelola dengan baik dan dipastikan validitas informasin-
ya karena manfaatnya dinilai sangat besar, apalagi untuk ibu masa hamil besar. Aplikasi ini memiliki
akses internet dan mampu beroperasi dengan baik sebagai aplikasi berbasis teknologi untuk mencari
informasi selama kehamilan.12
Berdasarkan latar belakang tersebut, maka tujuan dari artikel ini adalah untuk mengetahui bagaima-
na pemanfaatan, keuntungan serta kerugian aplikasi self-care untuk ibu hamil di negara berkembang
dan negara maju selama pandemi, sehingga dapat ditemukan aplikasi yang paling efektif digunakan
sebagai aplikasi perawatan diri atau self-care bagi ibu hamil.

2. METODE
Studi ini adalah literature review atau tinjauan pustaka. Tinjauan pustaka bertujuan untuk mem-
buat analisis dan sintesis dari pengetahuan yang telah diselidiki oleh para peneliti dan praktisi. Proses
penelitian dimulai dengan melakukan pencarian jurnal ilmiah tentang kajian sebelumnya dengan me-
manfaatkan berbagai portal seperti Google Scholar, SINTA, Pubmed dan ScienceDirect. Penelusuran
jurnal ilmiah dilakukan menggunakan berbagai kata kunci seperti self-care, ibu hamil, mobile apps,
e-health, dan pandemi Covid-19. Pencarian dan pengumpulan jurnal ilmiah dilakukan pada bulan

Gambar 1. Diagram Alur Metode Penelitian

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BIKKM 2023;1(1):42-51 Nurazizah, et al. Pemanfaatan Aplikas...

Maret 2022. Penelitian tinjauan naratif ini menetapkan kriteria inklusi dan eksklusi untuk memilih
artikel yang sama (terkait) atau tidak dengan tema yang ditetapkan. Kriteria inklusi yang ditetapkan
antara lain: a) Artikel terkait pemanfaatan aplikasi self-care dan informasi kesehatan bagi ibu hamil
selama pandemi, b) Artikel diterbitkan dalam rentang waktu antara tahun 2019-2022, c) Jurnal ilmiah
adalah artikel asli, teks lengkap dan dapat diakses. Kriteria eksklusi antara lain: a) Hanya dapat diak-
ses dalam bentuk abstrak dan prosiding, b) Artikel hasil review, c) Artikel membahas self-care dan
informasi terkait kesehatan ibu hamil di luar pandemi.

3. HASIL PENELITIAN
Hasil yang diperoleh dari review artikel pada penelitian ini adalah perbandingan e-health di berb-
agai negara. Berikut perbandingan aplikasi self-care untuk ibu hamil yang diterapkan di beberapa
negara di dunia:
Tabel 1. Hasil Analisis Review Artikel
Sumber Data dan
Nama Peneliti dan Desain Jumlah Sampel atau
Metode Pengumpulan Temuan Utama
Tahun Terbit Penelitian Informan
Data
Ardianto Pambudi, Metode Rapid Data diperoleh dari Responden adalah para Indonesia memiliki teknolo-
Nurchim, Agustina Application De- observasi yang dilakukan ibu hamil dan bidan gi informasi kesehatan yang
Srirahayu, 2020 velopment (RAD) melalui wawancara den- dikenal sebagai kesehatan
atau pengembangan gan salah satu bidan digital (telehealth). Fitur un-
aplikasi secara ggulannya adalah ibu hamil
cepat. dapat berkomunikasi dengan
bidan, tersedia hasil pemer-
iksaan dan informasi seputar
kehamilan.
Avishek Choudhury, Quasi-controlled, Survei 2 kelompok: Responden sejumlah India menerapkan intervensi
Onur Ashan, Murari cross-sectional kelompok intervensi 1480 orang dengan aplikasi Mobile For Mother
M. Choudhury, 2021 A (penerima program setiap kelompok (MFM) untuk meningkat-
aplikasi) dan kelompok masing-masing 740 ibu kan kesadaran dan kesehatan
kontrol B (penerima pro- hamil ibu di masyarakat suku dan
gram tradisional) terkait pedesaan, termasuk kesada-
masalah dan kesehatan ran ANC dan tanda-tanda ba-
ibu haya selama kehamilan.
Miaomiao Chen, Cross-sectional Sumber data: pengisian Sampel sejumlah 2.599 China memperkenalkan plat-
Xiyao Liu, Jun Zhang, kuesioner oleh ibu hamil ibu hamil di daerah form YYT (Yue Yi Tong)
Guoqiang Sun, Ying dari berbagai provinsi di epidemik ringan (448), untuk layanan kesehatan
Gao, Yuan Shi, Philip China sedang (1332) dan ibu hamil selama pandemi
Baker, Jing Zeng, Metode : pengumpulan berat (819) Covid-19. E-health mencak-
Yangxi Zheng, Xin data melalui platform up telemedicine, telecare,
Luo, Hongbo Qi, 2020 YYT (Yue Yi Tong) sistem informasi klinis dan
sistem non-klinis lainnya
untuk pekerjaan, kesehatan
masyarakat, dan manajemen
medis.
Angella Musiimenta, Wawancara men- Forum Group Discus- 14 ibu hamil buta huruf Uganda mengimplemen-
Wilson Tumuhimbise, dalam sion (FGD) dengan tiga yang memulai pemer- tasikan aplikasi Multime-
Godfrey Mugyenyi, kelompok ibu hamil iksaan kehamilan di dia berbasis Ponsel untuk
Jane Katusiime, Rumah Sakit Rujukan meningkatkan kesehatan ibu
Esther C Atukunda, Kabupaten Mbarara dengan mengingatkan para
Niels Pinkwart, 2020 ibu untuk menghadiri per-
temuan antenatal, memungk-
inkan penghematan biaya dan
waktu transportasi, menye-
diakan informasi yang dise-
suaikan, agar mudah dipaha-
mi dan diingat.

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BIKKM 2023;1(1):42-51 Nurazizah, et al. Pemanfaatan Aplikas...

Sumber Data dan

Nama Peneliti dan Desain Jumlah Sampel atau
Metode Pengumpulan Temuan Utama
Tahun Terbit Penelitian Informan
Data
Neda Kiani, Asiyeh Quasi-experimental Kuesioner tentang Ak- 93 ibu hamil dengan Di Iran, dilakukan intervensi
Pirzadeh, 2021 tivitas Fisik Kehamilan usia kehamilan 16-20 pendidikan kehamilan meng-
Standar minggu gunakan aplikasi seluler ter-
kait aktivitas fisik ibu hamil
di Isfahan, Iran, selama pan-
demi Covid-19. Penggunaan
mobile apps dapat dimanfaat-
kan untuk mempromosikan
aktivitas fisik ibu hamil sep-
erti yang dilakukan di kelas
tatap muka pada umumnya.
James Bohnhoff, MD; Survei melalui Sumber data: Kuesioner Sampel sejumlah 637 Amerika Serikat menggu-
Alexander Davis, Aplikasi Prenatal yang tertera di aplikasi ibu hamil di Amerika nakan aplikasi MyHealt-
PhD; Wandi Bruine MyHealthyPregnancy Serikat yang rutin hyPregnancy untuk per-
de Bruin, PhD; Tamar (MHP). mengakses sumber awatan ibu hamil selama
Krisnamurti, PhD, Cara: Peserta diminta informasi Covid-19 pandemi Covid-19. Fitur
2021 untuk secara sukarela median 5 termasuk konten pendidikan
mengisi pertanyaan di kehamilan, karakteristik de-
aplikasi mografis dan klinis pengguna,
penghitungan gerakan janin
dan waktu kontraksi, men-
dokumentasikan pengalaman
kehamilan, dan pemerik-
saan rutin gejala dan risiko
psikososial.
Nikolay O Ankudinov, Cross-sectional Aplikasi praktis dari Di Rusia, tersedia aplika-
Alexey F Sitnikov and teknologi informasi si untuk ibu hamil bernama
Fedor A Sitnikov and telemedicine («AIST_ “AIST_SMART” yang bisa
Sergey V Martirosyan, SMART») digunakan di ponsel atau tab-
2021 let. «AIST_SMART» digu-
nakan oleh dokter untuk me-
mantau kesehatan ibu hamil
dari jarak jauh, termasuk se-
lama rawat jalan (di rumah)
dengan infeksi Covid-19 tan-
pa gejala maupun ringan.
Alexandra Rhodes, Metode campuran Menggabungkan survei 436 Ibu Hamil di UK Inggris memiliki aplikasi par-
Sara Kheireddine, An- (Mixed method) berbasis web dengan (Inggris) enting untuk ibu hamil (Baby
drea D Smith, 2020 wawancara telepon Buddy) yang membantu men-
semi-terstruktur pada gubah perilaku ke arah positif
pengguna aplikasi Baby di masa pandemi. Aplikasi ini
Buddy UK. memberikan dukungan kepa-
da calon orang tua dan orang
tua baru dalam menghadapi
kesehatan mental dan fisik,
terutama di masa pandemi.

4. PEMBAHASAN
Aplikasi self-care untuk ibu hamil yang diterapkan di beberapa negara di dunia.

Negara Berkembang
Indonesia
Kematian ibu hamil masih tinggi di Indonesia. Pemanfaatan teknologi informasi dalam bidang
kesehatan yang dikenal dengan istilah kesehatan digital atau telemedicine memiliki banyak manfaat,
antara lain: adanya pertukaran informasi medis bagi pasien dengan tenaga profesional kesehatan, pe-

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BIKKM 2023;1(1):42-51 Nurazizah, et al. Pemanfaatan Aplikas...

layanan medis dalam rangka diagnosis banding, serta akses kesehatan yang lebih efisien dan murah.
Seiring dengan perkembangan bidang teknologi, banyak dikembangkan aplikasi untuk memenuhi
kebutuhan ibu hamil. Aplikasi dapat dijalankan melalui ponsel pintar atau smartphone berbasis An-
droid. Terdapat menu profil, pasien baru, entri data keluhan, entri data kemajuan janin, hasil pemerik-
saan dan data pasien. Menu profil digunakan untuk menampilkan halaman profil. Menu Pasien Baru
digunakan untuk menampilkan halaman formulir Informasi Pasien Baru.13
Menu entri data pengaduan digunakan untuk menampilkan halaman entri data pengaduan. Menu
entri data progres janin digunakan untuk menampilkan halaman data progres janin. Menu hasil pen-
gujian digunakan untuk menampilkan halaman data pengujian. Menu data pasien digunakan untuk
menampilkan data pasien. Aplikasi digunakan bersama oleh dua pengguna, yaitu bidan dan ibu hamil.
Fitur aplikasi memungkinkan ibu hamil untuk dapat berkomunikasi dengan bidan tentang keluhan,
hasil pemeriksaan dan informasi tentang kehamilan.13
Manfaat Telemedicine: 1) Aplikasi ini dapat mempercepat dan mempermudah konsultasi dokter
melalui video conference, chat dan MMS; 2) Aplikasi ini memudahkan pasien untuk berkonsultasi
dengan dokter secara online melalui video conference atau pesan singkat; 3) Aplikasi ini memudah-
kan pasien untuk menjadwalkan konsultasi dan pemeriksaan kesehatannya secara online, melihat
hasil diagnosa dokter dan meresepkan obat. Kelemahannya adalah tidak bisa melakukan pengecekan
jarak jauh menggunakan alat seperti teleradiologi.14

India
MFM (Mobile for Mother) adalah aplikasi mobile yang diluncurkan oleh pemerintah, swasta, be-
berapa institusi nasional dan internasional yang bertujuan untuk mengurangi masalah kesehatan ibu
dan anak di India. Aplikasi ini menghasilkan informasi ilmiah dan bermanfaat mengenai topik yang
berkaitan dengan kehamilan, menyusui, perawatan anak (child care) dan pengasuhan anak (parent-
ing), yang sebagian besar hadir dalam bentuk ilustrasi gambar dan video.15
Fitur aplikasi termasuk formulir pendaftaran, daftar periksa (checklist), pelacakan alarm dan per-
intah instruksional. Aplikasi MFM terdiri dari 4 modul yaitu registrasi, ANC care, intranatal care dan
postnatal care. Aplikasi ini dirancang bagi pengguna dengan literasi rendah untuk beroperasi dengan
harga yang terjangkau, terutama untuk ponsel berkemampuan Java atau berbasis Android secara gra-
tis. Rekaman suara interaktif memungkinkan aplikasi untuk memberikan informasi kesehatan ibu
melalui teks, foto dan suara. Informasi yang diberikan ditulis dalam bahasa Hindi.16
MFM memiliki potensi sebagai alat pendidikan dan penyadaran bagi ibu hamil di masyarakat
pedesaan dan suku dengan memberikan informasi terstruktur tentang kesehatan ibu. Meskipun se-
bagian besar sampel memiliki literasi rendah, intervensi m-Health (mobile Health) MFM efektif
meningkatkan kesadaran kesehatan ibu dan kehamilan dengan mengadopsi informasi kesehatan yang
singkat dan mudah dibaca. Ketersediaan konten audiovisual dan dalam bahasa lokal berkontribusi
pada keberhasilan adopsi m-Health.16

China
China memiliki platform komunikasi online untuk para ibu hamil, terutama di masa pandemi.
Platform dengan nama Yue Yi Tong (YYT) (Yue Yi Tong Science and Technology Co. di Chongqing,
China) berfungsi untuk berkonsultasi dengan dokter kandungan profesional dari rumah mereka, tanpa
harus pergi ke rumah sakit.17
Fitur yang disediakan antara lain pemeriksaan antenatal rutin (laporan pemeriksaan, janji temu
antenatal care, cara dan waktu persalinan serta proses rawat inap), pemeriksaan gejala abnormal dan
penyakit penyerta (comorbid) ibu serta komplikasi kehamilan, dan kebutuhan lain seperti pemantau-

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BIKKM 2023;1(1):42-51 Nurazizah, et al. Pemanfaatan Aplikas...

an jantung janin jarak jauh, resep dan apotek elektronik.17

Untuk peserta, penggunaan platform YYT masih baru dan mereka menggunakannya untuk perta-
ma kali dengan tingkat penggunaan sebesar 89,26% di daerah endemik yang parah. Tingkat kepuasan
penggunaan platform YYT di daerah endemik berat relatif rendah sekitar 87,92% jika dibandingkan
dengan daerah lain yang mencapai 90%. Sebanyak 91,95% ibu hamil lebih memilih menggunakan
platform online daripada melakukan kunjungan ke rumah sakit selama pandemi Covid-19.17 Ibu ham-
il mempertimbangkan penggunaan platform online untuk menghemat waktu, menghemat uang dan
mengurangi risiko tertular Covid-19. Melalui platform YYT, diketahui bahwa kebutuhan ibu hamil
akan informasi kesehatan sangat tinggi.

Uganda
Telehealth disediakan untuk mendukung kelangsungan layanan perawatan kesehatan rutin sela-
ma wabah Covid-19 di Uganda, dengan menggunakan aplikasi ponsel seperti layanan pesan singkat
(SMS) dan panggilan suara di antara aplikasi lainnya. Penerima manfaat dapat berkonsultasi dari
jarak jauh dengan penyedia layanan kesehatan.18
Aplikasi Multimedia berbasis mobile phone ini menggunakan bahasa pemrograman Java dengan
basis data pesan multimedia SQLite. Ada tiga fungsi utama dari aplikasi ini, yaitu: 1) Fungsi Video/
Audio sesuai dengan tahapan kehamilan; 2) Fungsi pengingat janji temu untuk mengatur tanggal dan
perawatan antenatal; serta 3) Fungsi panggilan untuk berkomunikasi dengan petugas kesehatan. Ada
dua modul login dengan kata sandi bergambar untuk akses ke aplikasi.19
Memberikan informasi melalui ponsel mengenai kesehatan ibu serta kesempatan untuk menelepon
saat dibutuhkan dapat meringankan beban biaya transportasi, komitmen waktu dan kerumitan akan
perjalanan jauh untuk mengakses informasi dari klinik. Namun, mengingat sifat multimedia yang
disampaikan dalam bentuk aplikasi, akses hanya dapat berjalan di ponsel pintar, yang hanya dimiliki
oleh beberapa ibu saja.19

Iran
Di Iran, dikembangkan aplikasi mobile yang bertujuan untuk memberikan pendidikan senam
hamil (olahraga) kepada ibu hamil yang dapat dilakukan dimana saja dan kapan saja tanpa harus
hadir langsung ke kelas ibu hamil, terutama karena adanya pembatasan pergerakan selama pandemi
Covid-19. Aplikasi berisi fitur yang menampilkan konten pendidikan yang disiapkan oleh para ahli.
Konten dibuat dalam bentuk multimedia seperti video dan gambar. Konten tersebut menampilkan
gerakan-gerakan sederhana dan aman untuk ibu hamil, juga terdapat program pijat dan relaksasi,
tips mengurangi kelelahan, serta olahraga yang dapat dilakukan ibu hamil dan cara melakukannya
dengan benar. Semua domain dirancang mengikuti prinsip yang sesuai dengan kebutuhan ibu hamil
dan mengutamakan tujuan dari manfaat, hambatan, dukungan sosial dan kenikmatan yang dirasakan.
Konten video edukasi tentang senam kesehatan ibu hamil dan kelancaran persalinan disertai dengan
musik, gambar, GIF, latar belakang warna warni dan menarik untuk mendukung proses pembelajaran
keterampilan fisik dan memunculkan motivasi untuk melakukannya.20
Penggunaan mobile apps untuk senam aktivitas fisik ibu hamil dapat menjadi salah satu alterna-
tif, terutama di masa pandemi Covid-19 yang memberlakukan pembatasan atau social distancing.
Kelemahan dalam artikel yang diulas adalah tidak digambarkannya secara visual deskripsi fitur-fitur
yang ada di aplikasi seluler, sehingga tidak ada deskripsi penggunaannya. Keunggulan dari sistem
yang dirancang di Iran kali ini adalah aplikasi yang cukup spesifik dan terfokus, khususnya pada ak-
tivitas fisik untuk perawatan diri ibu hamil yang sedang mempersiapkan persalinan.20

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BIKKM 2023;1(1):42-51 Nurazizah, et al. Pemanfaatan Aplikas...

Negara Maju
Amerika Serikat
Di Amerika Serikat, Universitas Pittsburgh Medical Center membuat aplikasi bernama My Healthy
Pregnancy (MPH). Di masa pandemi Covid-19, ibu hamil kerap mengalami penurunan motivasi un-
tuk mematuhi pedoman kesehatan sebab kelelahan akibat pandemi. Aplikasi My Healthy Pregnancy
berfungsi sebagai platform yang memberikan informasi kesehatan berbasis bukti kepada ibu hamil,
untuk melawan mis-informasi.21
Fitur yang tersedia termasuk konten pendidikan menurut minggu kehamilan, karakteristik de-
mografis dan klinis pengguna, jumlah gerakan janin dan pengatur waktu kontraksi, peluang untuk
mendokumentasikan pengalaman kehamilan, dan pemeriksaan rutin untuk gejala serta risiko psikoso-
sial.21 Aplikasi ini juga menawarkan sumber daya yang relevan (misalnya layanan kesehatan se-
tempat) atau tindakan (misalnya menghubungi penyedia layanan), tanda atau gejala Covid-19 (alat
skrining Covid-19), pelaporan gejala dengan panduan pencarian pengobatan serta kuesioner perilaku
Covid-19.22
Konten medis di aplikasi My Healthy Pregnancy bersumber dari organisasi dan pedoman ahli sep-
erti American College of Obstetricians and Gynecologists (ACOG), Pusat Pengendalian dan Pence-
gahan Penyakit (CDC) dan publikasi jurnal peer-review. Draf akhir konten akan ditinjau oleh para
profesional medis, termasuk spesialis kedokteran ibu dan janin.21 Perlu adanya panduan khusus ten-
tang aplikasi terkait sumber informasi dari ACOG, CDC dan publikasi jurnal.21

Rusia
Di Rusia, terdapat aplikasi untuk ibu hamil yang mulai beroperasi yaitu “AIST_SMART”. Ap-
likasi ini dapat digunakan di ponsel atau tablet. Pada akun pribadi wanita hamil, mereka mendapat
kesempatan untuk menyimpan buku harian elektronik tentang self-control kesehatan mereka. Hal ini
memungkinkan “AIST_SMART” untuk mengubah data dari bentuk buku ke elektronik. Data medis
pasien dikumpulkan dalam satu database yang dapat dipantau oleh dokter setiap saat. Data tersebut
secara otomatis diproses oleh sistem. Jika tidak terdeteksi adanya kelainan pada ibu hamil, maka data
tersebut tersimpan dalam sistem.23
Teknologi «AIST_SMART» digunakan oleh dokter institusi bersalin di wilayah Sverdlovsk untuk
memantau kesehatan ibu hamil dari jarak jauh, termasuk selama rawat jalan (di rumah) dengan infek-
si Covid-19 tanpa gejala maupun ringan. “AIST_SMART” berperan sebagai asisten intelektual untuk
dokter kandungan/ bidan.23
Ibu hamil wajib mengisi data harian yang dapat dipantau oleh dokter, sehingga jika terjadi sesuatu
pada ibu hamil, dokter dapat mengambil keputusan yang tepat. “AIST_SMART” memungkinkan
umpan balik antara ibu hamil dan dokter/ bidan, sehingga membentuk model keperawatan yang ber-
pusat pada pasien sebagai salah satu prioritas.23

Inggris
Aplikasi Baby Buddy adalah aplikasi kehamilan dan pengasuhan anak (parenting) yang dirancang
dan dikembangkan untuk digunakan oleh semua orang tua di Inggris. Fitur bantuan yang diberi-
kan adalah memberikan akses informasi, memberikan bantuan kepada pengguna yang membutuhkan
peningkatan bonding (ikatan) dengan bayinya, memberikan bantuan terkait kesehatan emosional dan
mental serta kesehatan fisik pengguna.24
Pada fitur akses informasi, terdapat beberapa pilihan konten video terupdate terkait kehamilan dan
perawatan bayi.24 Fitur lain dari aplikasi Baby Buddy adalah fitur Ask Me, Your Appointment, You

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BIKKM 2023;1(1):42-51 Nurazizah, et al. Pemanfaatan Aplikas...

Can Do It, serta You and Your Partner. Fitur tersebut memberikan informasi kepada pengguna dalam
bentuk teks yang dapat diakses kapan saja.24
Aplikasi Baby Buddy diberikan secara gratis dan dirancang agar mudah diakses oleh orang-orang
yang tidak bersekolah atau bekerja dan mereka yang bahasa pertamanya bukan bahasa Inggris. Say-
angnya, aplikasi Baby Buddy hanya digunakan oleh orang tua di Inggris. Aplikasi ini terkesan agak
lambat beradaptasi dengan situasi dan kondisi saat ini, seperti situasi pandemi, sehingga informasi
yang dibutuhkan calon orang tua maupun orang tua baru terkait pandemi dirasa kurang membantu.
Aplikasi ini memiliki fitur yang kurang lengkap. Pengguna merasa tidak mendapatkan informasi,
seperti cara mendapatkan jumlah berat badan bayi yang tepat.24

5. KESIMPULAN
Penggunaan aplikasi self-care menjadi solusi alternatif di masa pandemi, khususnya bagi ibu ham-
il. Selama pandemi, ibu hamil mengalami keterbatasan dalam mengakses unit perawatan intensif
sehingga ibu khawatir dengan kehamilannya. Oleh sebab itu ibu hamil disarankan untuk melakukan
perawatan diri secara mandiri (self-care) di rumah. Beberapa negara telah mengembangkan aplikasi
self-care untuk memudahkan ibu hamil mengakses berbagai informasi terkait kehamilannya sekaligus
meningkatkan kemampuan ibu untuk menjaga kesehatannya. Di negara maju seperti Inggris, terdapat
aplikasi perawatan diri yang memberikan informasi terkait kesehatan fisik ibu hamil, kesehatan men-
tal dan emosional. Di Rusia, terdapat aplikasi self-care yang berfokus pada pemantauan kesehatan
ibu hamil dari jarak jauh, yang sangat dibutuhkan di masa pandemi Covid-19. Aplikasi self-care yang
memiliki fitur unggulan yaitu edukasi ibu hamil sesuai minggu kehamilan, pemeriksaan rutin gejala
dan risiko psikososial, teleconsultation dan janji temu, serta kerjasama dengan layanan Uber untuk
mempermudah akses ke pelayanan kesehatan telah digunakan di Amerika Serikat. Sedangkan ap-
likasi self-care di negara berkembang seperti Indonesia, China, Uganda dan Iran berfokus pada fitur
telekonsultasi dan fitur edukasi terkait kehamilan untuk ibu hamil. Diperlukan penelitian lebih lanjut
untuk mengevaluasi penggunaan teknologi informasi dan komunikasi dalam bentuk aplikasi self-care
bagi ibu hamil selama pandemi di berbagai negara, terutama ibu hamil yang berisiko.

Deklarasi Konflik Kepentingan

Tidak ada konflik kepentingan dalam penyusunan artikel ini.

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covid-19 prevalence. Vol. 11, Journal of Biomedical Physics and Engineering. Shriaz University
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JHCN Journal of Health and Cardiovascular Nursing’ DOI: 10.36082/jhcn.v3i1.998
Volume 3, Nomor 1 Juni Tahun 2023

Penggunaan Mobile Health (mHealth) Berbasis Sistem Pakar Pada Pemantauan

Tanda Bahaya Kehamilan: Literature Review

Pindi Kurniawati1, Sukihananto2, Dinny Atin Amanah3

1,3
Magister Ilmu Keperawatan, Fakultas Ilmu Keperawatan, Universitas Indonesia, Jawa Barat, Indonesia
2
Departemen Keperawatan Komunitas, Fakultas Ilmu Keperawatan, Universitas Indonesia, Jawa Barat, Indonesia

Email: lintang_fight45@yahoo.com

Abstrak
Angka kematian pada ibu cukup tinggi. Ibu hamil perlu memahami tanda bahaya kehamilan untuk mencegah terjadinya
kegawatan. Petugas kesehatan dapat melakukan deteksi dini tanda bahaya kehamilan pada ibu. Saat ini berkembang
pemantauan kehamilan yang dilakukan oleh ibu secara mandiri dengan aplikasi mobile health berbasis pakar. mHealth
berbasis pakar merupakan salah satu upaya yang dapat dilakukan untuk melakukan pemantauan kehamilan. Tujuan studi
literatur ini untuk mengetahui efektifitas penggunaan mHealth berbasis sistem pakar pada pemantauan kehamilan.
Metode: penulisan dalam studi ini menggunakan metode PRISMA untuk mendeskripsikan penerapan mHealth berbasis
sistem pakar pada pemantauan kehamilan. Artikel ilmiah dikumpulkan dari database online yang terdiri dari ClinikalKey
Nursing, Elsevier, Scholar, dan Scopus dari tahun 2017 sampai dengan tahun 2022. Hasil: penggunaan aplikasi mHealth
berbasis sistem pakar terbukti efektif dalam meningkatkan pemantauan kehamilan, khususnya pada pemantauan tanda
bahaya kehamilan sehingga dapat dilakukan peringatan dini kehamilan risiko tinggi. Kesimpulan aplikasi ini bermanfaat
bagi ibu hamil dan petugas kesehatan. Aplikasi ini diperlukan oleh ibu dan petugas kesehatan dalam memantau
kehamilannya secara efektif, mudah dan hemat biaya. Rekomendasi: perlu terintegrasi dengan pelayanan kesehatan baik
puskesmas maupun rumah sakit.

Kata Kunci: Mobile health dalam Kesehatan; Sistem Pakar; Tanda Bahaya Kehamilan

Using Mobile Health Based Expert System In Monitoring Risk Signs Of

Pregnancy: Literature Review

Abstract
The maternal mortality rate is still quite high. Pregnant women need to understand the danger signs of pregnancy to
prevent emergencies. Health workers can also carry out early detection of danger signs of pregnancy in mothers.
Currently, pregnancy monitoring is being carried out by mothers independently with an expert-based mobile health
application. Expert-based mHealth is one of the efforts that can be made to monitor pregnancy. The aimed of this
literature study is to determine the effectiveness of using expert system-based mHealth in pregnancy monitoring. Method:
writing in this study used the PRISMA method to describe the application of expert system-based mHealth in pregnancy
monitoring. Scientific articles were collected from an online database consisting of ClinikalKey Nursing, Elsevier,
Scholar, and Scopus from 2017 to 2022. Results: the use of an expert system-based mHealth application has proven
effective in improving pregnancy monitoring, especially in monitoring pregnancy danger signs so that it can be carried
out early warning of high risk pregnancy. In conclusion, this application is useful for pregnant women and health workers.
This application is needed by mothers and health workers in monitoring their pregnancy effectively, easily and cost-
effectively. Recommendation: it needs to be integrated with health services, both puskesmas and hospitals.

Keyword: Expert System; Mobile Health; Pregnancy on Emergency

17
JHCN Journal of Health and Cardiovascular Nursing’ DOI: 10.36082/jhcn.v3i1.998
Volume 3, Nomor 1 Juni Tahun 2023

Pendahuluan merespon terhadap tanda-tanda peringatan dini

kegawatan pada ibu hamil (Gillespie, et all,
Angka Kematian Ibu (AKI) saat ini
2021). Pemantauan mencakup data tanda vital,
masih tinggi. Menurut WHO (World Health
hasil pemeriksaan laboratorium, dan
Organization) ditemukan kejadian sebanyak
pemeriksaan klinis untuk mengetahui apakah
295.000 wanita meninggal selama kehamilan
pasien mempunyai resiko yang tinggi atau
dan persalinan pada tahun 2017. Jumlah ini
rendah terhadap potensi bahaya (Killion M. M.
dinilai masih sangat tinggi walaupun sudah ada
(2020). Pada praktiknya, MEWS ini digunakan
penurunan dalam dua dekade terakhir (WHO,
untuk pasien yang dirawat inap.
2019). Berdasarkan data dari Sampling
Pengetahuan tentang tanda bahaya
Registration System (SRS) tahun 2018,
kehamilan wajib pula dimiliki oleh setiap ibu
kejadian AKI di Indonesia paling tinggi terjadi
hamil untuk mengetahui sejauh mana kondisi
di fase persalinan dan post partum yaitu
kehamilannya. Informasi yang diberikan
sebesar 76%, yaitu 24% pada saat kehamilan,
kepada ibu hamil pun haruslah yang benar,
36% saat persalinan dan 40% setelah
tepat dan berasal dari pakar yang
persalinan (Kemenkes, 2021).
berpengalaman. Perkembangan teknologi
Berdasarkan data dari WHO
informasi yang semakin cepat, memungkinkan
menyebutkan bahwa penyebab kematian ibu
petugas kesehatan dapat memberikan
hamil yang terbesar adalah adanya perdarahan,
pelayanan tanpa tatap muka atau secara online.
infeksi, tekanan darah tinggi, abortus yang
Saat ini berkembang adanya e-health yaitu
tidak aman, persalinan yang terhambat, dan
penggunaan teknologi informasi dan
penyebab tidak langsung seperti anemia,
komunikasi dalam kegiatan pelayanan klinis
malaria dan penyakit jantung. (WHO, 2019).
(Soegijoko, 2010). Salah satu yang masuk
Perlu adanya identifikasi dan pencegahan
dalam pengembangan teknologi adalah sistem
secara dini terhadap kondisi kehamilan ibu
informatika berbasis pakar. Sistem pakar
untuk menurunkan tingkat dan kejadian
adalah salah satu bentuk kecerdasan buatan.
kematian pada ibu hamil (Killion M. M. ,
Sistem pakar mampu menentukan keputusan
2020).
dalam bentuk diagnosa, memberikan informasi
Salah satu penilaian terhadap tanda
dan nasihat sebagai solusi dari permasalahan
bahaya kehamilan dituangkan dalam sebuah
yang spesifik. Sistem pakar ini diaplikasikan
sistem yaitu MEWS (Maternity Early Warning
dalam bentuk mobile health sehingga mudah
Score) (Smith, O’Malley, & Cithambaram,
diakses (Sari, I. M., & Thalib, F, 2019).
2022). Berdasarkan studi di UK bahwa
Beberapa studi sebelumnya
perawat sudah menggunakan sistem ini untuk
menunjukkan bahwa penerapan mHealth
bisa memantau, mengidentifikasi dan
berbasis sistem pakar sangat bermanfaat pada
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JHCN Journal of Health and Cardiovascular Nursing’ DOI: 10.36082/jhcn.v3i1.998
Volume 3, Nomor 1 Juni Tahun 2023

pemantauan kehamilan. Hal ini yang berbasis sistem pakar pada pemantauan
menjadikan dasar pengambilan topik pada kehamilan.
studi ini, yaitu tentang efektifitas dan
kekurangan dari aplikasi mHealth berbasis Hasil
sistem pakar pada pemantauan kehamilan.
a. Studi Literatur
Pada gambar 1 menunjukkan proses
Metode
seleksi literatur. Pada empat database
Penulisan dalam studi ini menggunakan elektronik ditemukan 2.420 referensi yang
metode PRISMA untuk mendeskripsikan berhubungan dengan topik. Beberapa
penerapan mHealth berbasis sistem pakar pada artikel dieliminasi karena judul dan abstrak
pemantauan kehamilan, dengan deskripsi tidak komprehensif. Topik tidak
meliputi: berhubungan dengan studi (mHealth
a. Kriteria Kelayakan berbasis sistem pakar dalam pemantauan
Seluruh studi penelitian baik kuantitatif, kehamilan) dan tidak full text (hanya
kualitatif, literature review ataupun abstrak). Sehingga didapatkan 13 literatur
campuran yang menjelaskan tentang yang sesuai untuk dianalisis.
penggunaan mHealth berbasis sistem
pakar pada pemantauan kehamilan. Gambar 1 Proses Seleksi Literatur yang diadaptasi
dari PRISMA (2009)
b. Strategi Pencarian
Penulis menggunakan kata kunci
kegawatan kehamilan, maternity early
warning score, pemanfaatan teknologi
kehamilan, sistem pakar perkembangan
teknologi dan mobile health.
c. Pilihan Studi
Database online yang digunakan adalah
ClinicalKey Nursing, Elsevier, Scopus,
Google Scholar. Artikel yang dipilih
merupakan artikel yang terbit dari tahun
2017 sampai dengan tahun 2022.
d. Sintesis Hasil
Temuan review ini mendeskripsikan dan
menjelaskan tentang penerapan mHealth

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JHCN Journal of Health and Cardiovascular Nursing’
Volume 3, Nomor 1 Juni Tahun 2023
Tabel 1. Karakteristik Artikel yang Dianalisa
No Penulis Tujuan
1 (Kobayashi et al., Menilai kelayakan telekomunikasi
2017) dua arah real-time berbasis tablet
dari kondisi ibu yang dilaporkan
sendiri pada wanita hamil normal
dan berisiko tinggi
2 (Zhang et al., Mengembangkan sistem peringatan
2022) dini pada kehamilan dalam upaya
mengurangi dan mencegah kematian
ibu hamil dan masa nifas pada
wanita beresiko tinggi di China
3 (Purbaningsih & Mengidentifikasi beberapa
Hariyanti, 2020) penelitian tentang pemanfaatan
telehealth pada ibu hamil.
4 (Fouly et al., 2018) Menilai kualitas asuhan pada kasus
kritis maternal.
5 (Smith et al., Untuk mendapatkan wawasan dan
2022) pemahaman, dari sudut pandang
penyedia perawatan ibu bersalin dan
penggunaan aplikasi peringatan dini
pada ibu hamil (MEWS) secara
praktik klinis
6 (Puspitasari et al., Mengetahui pengaruh penggunaan
2020) aplikasi mHealth pada pengetahuan,
sikap dan perilaku pencegahan
adanya tanda bahaya kehamilan
7 (Sari & Thalib, Membuat tool dengan sistem
2019) komputerisasi yang dapat
memberikan informasi tentang
gangguan kehamilan yang akan
membantu dokter kandungan dan
bidan dalam penanganannya
DOI: 10.36082/jhcn.v3i1.998
Hasil
Studi ini menemukan bahwa ibu hamil berisiko
tinggi memiliki sikap positif tentang pemantauan
mandiri berbasis rumah dan menyatakan keinginan
yang kuat untuk menerima aplikasi ini. Sistem
kesehatan bersalin seluler yang dinamis, real-time,
dua arah, dan interaktif dengan aplikasi tablet
dapat mendukung berbagi informasi, konsultasi
cepat, dan inisiasi profilaksis dan pengobatan
ditingkat pasien, penyedia layanan kesehatan pra-
rumah sakit, dan dokter.
Sistem peringatan dini untuk risiko tinggi
kehamilan dan nifas memiliki konten yang luas
dan keandalan tinggi yang akan membantu perawat
untuk mengidentifikasi risiko tinggi kehamilan
saat melahirkan
Telehealth bermanfaat pada pemeriksaan dan
pencegahan kehamilan yang berisiko
Peningkatan jumlah kasus kritis ibu atau “maternal
near miss” dalam penelitian ini mencerminkan
perlunya penerapan pedoman manajemen standar
untuk morbiditas ibu hamil beresiko berat. Oleh
karena itu, audit kualitas perawatan adalah alat
yang berhasil dalam mencatat kesenjangan antara
manajemen yang diterima saat ini dan pedoman
manajemen standar di ICU dan juga mengukur
efek manajemen saat ini di ICU pada mortalitas
dan morbiditas ibu.
Ada 3 hal yang mewakili mengenai gambaran dan
pengalaman penerapan MEWS yaitu bantuan
dalam pelayanan perawatan klinis, dampak pada
beban kerja, dan faktor yang mempengaruhi
penerapan MEWS.
Ada perbedaan dalam pengetahuan ibu hamil
tentang upaya pencegahan kegawatan kehamilan
setelah diberikan edukasi melalui aplikasi mHealth
dibanding buku KIA. Sedangkan pada sikap dan
perilaku tidak menunjukkan ada perbedaan antara
aplikasi mHealth dengan penggunaan buku KIA
pada pemantauan tanda bahaya kehamilan
trimester III.
Adanya sistem pakar membantu para pakar
(dokter, perawat, bidan) dalam merumuskan
diagnosa berdasarkan gejala yang muncul
sehingga penanganan bisa dilakukan lebih cepat
dan tepat. Sistem ini disusun secara lengkap yaitu
meliputi solusi dari diagnosis dan penjelasan
tentang gangguan kehamilan yang muncul serta
dibuat dalam komputerisasi
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JHCN Journal of Health and Cardiovascular Nursing’
Volume 3, Nomor 1 Juni Tahun 2023
No Penulis Tujuan
8 (Inhae & Jiwon, menilai efek intervensi mHealth
2021) pada penggunaan kontrasepsi dan
kejadian kehamilan dimasa dewasa
muncul untuk mengidentifikasi
karakteristik kesuksesan intervensi
mHealth
9 (Carrandi et al., Mengetahui apakah penggunaan
2022) teknologi digital lebih efisien secara
biaya
10 (Phagdol et al., Mengetahui efektifitas aplikasi
2022) mHealth dalam meningkatkan
pengetahuan ibu tentang perawatan
bayi lahir prematur di rumah
11 (Edwards et al., Mengetahui gambaran dan
2021) pengalaman perempuan dengan
riwayat Diabetes Mellitus
Gestasional, dalam penggunaan
sumber mHealth sebelum, selama
dan setelah bersalin. Dan untuk
mengetahui harapan ke depan
tentang mHealth.
12 (Connor et al., Menentukan sejauh mana aplikasi
2018) kesehatan seluler perinatal (aplikasi
mHealth) dapat digunakan dan
diinginkan wanita yang mencari
informasi tentang persalinan
13 (Khanjari et al., Mengetahui pengaruh penggunaan
2021) aplikasi berbasis mHealth pada QoL
(quality of life) dan SOC (sense of
coherence) ibu dengan bayi
premature.
DOI: 10.36082/jhcn.v3i1.998
Hasil
Meta-analisis ini menemukan efek positif dari
intervensi mHealth pada kontrasepsi, sedangkan
dampak pada kejadian kehamilan terbatas. Kami
juga mengkonfirmasi faktor-faktor yang
mendasari efektifitas intervensi mHealth. Temuan
ini menunjukkan bahwa intervensi dengan
mHealth disarankan sebagai strategi yang berguna
untuk mempromosikan kesehatan seksual dan
reproduksi di negara berkembang
Hasil studi awal membuktikan bahwa penggunaan
teknologi digital lebih hemat biaya
Hasil studi menunjukkan bahwa aplikasi mHealth
efektif untuk meningkatkan pengetahuan ibu
tentang merawat bayi premature pasca keluar dari
NICU di rumah
Seluruh partisipan menggunakan mHealth,
mengikuti media sosial untuk informasi diet, dan
adanya dukungan sebaya. Sedikit mHealth yang
direkomendasikan oleh para profesional dan
wanita mendiskusikan ketidakpuasan dengan
informasi yang mereka berikan.
Beberapa wanita menggunakan aplikasi untuk
perubahan perilaku, tetapi tidak menyukai fitur
tertentu dan interaksi yang buruk menghalangi
penggunaannya. Wanita menginginkan sebuah
aplikasi untuk mengatasi kurangnya motivasi dan
mempersiapkan mereka untuk kehamilan yang
sehat di masa depan.
MHealth merupakan aplikasi yang menjadi sumber
dukungan selama melahirkan. Aplikasi mHealth
memiliki fungsi dan keterbatasan. Peserta merasa
didukung ketika menggunakan aplikasi mHealth
karena informasinya dipersonalisasi dan mereka
dapat menggunakan aplikasi untuk terhubung
dengan keluarga dan komunitas daring.
Keterbatasan Aplikasi mHealth yaitu adanya
keterbatasan jaringan, beberapa keluarga tidak
mendukung penggunaannya dan khawatir dengan
keamanannya.
Tidak ada perbedaan antara kelompok dalam skor
QoL dan SOC yang diperoleh pada tahap pre-test.
Untuk kelompok intervensi, setelah pendidikan,
ada peningkatan QoL dan skor SOC
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JHCN Journal of Health and Cardiovascular Nursing’ DOI: 10.36082/jhcn.v3i1.998
Volume 3, Nomor 1 Juni Tahun 2023

b. Manfaat Aplikasi Mobile Health elemen masyarakat. Studi yang dilakukan

Berbasis Sistem pakar dalam oleh Puspitasari bahwa setelah dilakukan
Pemantauan Tanda Bahaya Kehamilan intervensi edukasi dengan aplikasi
Pengembangan aplikasi mobile mHealth terdapat perubahan pada
health berbasis sistem pakar bermanfaat pengetahuan dan sikap ibu hamil terhadap
bagi ibu hamil dan nifas secara langsung kondisi kehamilannya dalam pencegahan
maupun bagi tenaga kesehatan di unit kegawatan kehamilan pada Trimester III
kebidanan (Kobayashi et al., 2017; Zhang bila dibandingkan menggunakan buku
et al., 2022; Phagdol et al., 2022; Cheshire KIA (Puspitasari et al., 2020).
et al., 2021; Cheshire et al., 2021; dan Penelitian lain oleh Kobayashi, et all
Puspitasari et al., 2020). Pengembangan (2017) menemukan bahwa ibu hamil
aplikasi sangat membantu dalam berisiko tinggi memiliki sikap positif
mendeteksi dini kondisi kegawatan pada tentang pemantauan mandiri
ibu hamil. Bahkan perlu untuk kehamilannya dan menyatakan keinginan
diaplikasikan untuk melakukan yang kuat untuk menerima aplikasi ini.
standarisasi di semua unit kebidanan Sistem kesehatan bersalin seluler yang
(Cheshire et al., 2021). dinamis, real-time, dua arah, dan interaktif
Aplikasi mengenai kegawatan dengan aplikasi tablet dapat mendukung
kehamilan ini juga bisa dirasakan berbagi informasi, konsultasi cepat, dan
manfaatnya oleh ibu hamil yaitu dengan inisiasi profilaksis dan pengobatan
adanya akses dalam teknologi informasi ditingkat pasien, penyedia layanan
kesehatan ibu hamil dengan mudah kesehatan pra-rumah sakit, dan dokter.
terhubung, termotivasi dalam pencarian Penelitian oleh Zhang et al (2022) di
pengetahuan mengenai kehamilan yang China terhadap ibu hamil menunjukkan
dialami dan waspada dengan tanda dan bahwa sistem peringatan dini untuk risiko
bahaya kehamilan. Modifikasi sistem tinggi kehamilan dan nifas memiliki
informasi membuat komunikasi menjadi konten yang luas dan keandalan tinggi
efektif. Cost effective yang yang akan membantu perawat untuk
memungkinkan ibu hamil melakukan mengidentifikasi risiko tinggi kehamilan
konsultasi kepada para pakar yang saat melahirkan. Hal ini ada kaitan erat
berkualitas dan profesional tanpa harus dengan pengurangan dan pencegahan
mengeluarkan biaya. Aplikasi ini kematian ibu hamil dan masa nifas pada
dirancang dengan tampilan yang menarik wanita beresiko tinggi di China.
dan penggunaan kata yang sederhana
sehingga mudah dipahami oleh berbagai
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Volume 3, Nomor 1 Juni Tahun 2023

c. Kekurangan aplikasi Mobile Health Connor et al (2018) dalam

berbasis sistem pakar pada
pemantauan kehamilan
Penerapan aplikasi mHealth ini
memiliki beberapa kekurangan.
Kekurangan penerapan aplikasi mHealth
secara umum yaitu tidak dapat mengubah
perilaku dan sikap ibu secara signifikan,
memerlukan kesadaran ibu untuk
melakukan pemeriksaan mandiri, adanya
keterbatasan jaringan, kurangnya
dukungan keluarga, serta kekhawatiran
terhadap keamanan aplikasi (Puspitasari et
al., 2020; Azlina, 2018; dan Connor et al,
2018). Berdasarkan studi yang dilakukan
oleh Puspitasari dengan membandingkan
pemberian informasi menggunakan sistem
aplikasi mHealth dengan buku KIA. Hasil
penelitiannya menunjukkan ada
perbedaan pada pengetahuan ibu hamil
tetapi pada perilaku dan sikap tidak ada
perubahan yang signifikan (Puspitasari et
al., 2020).
Menurut Bhandari et all dalam
penelitiannya juga menjelaskan bahwa
adanya aplikasi mHealth ini sangat
membantu dalam pemantauan kehamilan,
tetapi kesadaran ibu untuk melakukan
pemeriksaan secara mandiri masih rendah.
Pengaruh budaya, akses menuju fasilitas
kesehatan yang tidak mudah, pengeluaran
biaya yang besar serta tingkat
pengetahuan yang berbeda menjadi salah
satu penyebabnya (Azlina, 2018).
penelitiannya menyampaikan adanya
keterbatasan dalam penggunaan aplikasi
ini. Keterbatasan Aplikasi mHealth yaitu
adanya keterbatasan jaringan, keluarga
tidak mendukung penggunaannya dan
khawatir dengan keamanannya. Menurut
kajian yang lain juga menyebutkan bahwa
telaah sikap dan perilaku tidak banyak
berpengaruh. Pengalaman masa lalu,
kondisi saat ini, dan ekspektasi terhadap
masa depan menjadi faktor yang
berpengaruh (Puspitasari et al., 2020).
Pembahasan
Setiap ibu hamil wajib mengetahui
tentang tanda bahaya kehamilan. Tanda
bahaya kehamilan yang perlu diperhatikan
yaitu adanya peningkatan tekanan darah,
infeksi yang ditandai dengan demam tinggi,
hyperemesis gravidarum, anemia dimasa
kehamilan, adanya perdarahan antepartum,
ketuban pecah dini, persalinan ganda dan
adanya penyakit bawaan dari ibu (Azlina,
2018). Wanita dengan kondisi hamil atau
pasca melahirkan terkadang tidak menunjukan
adanya kelainan, namun dari hasil
pemeriksaan klinis ditemukan adanya
ketidaknormalan, seperti adanya infeksi dan
hipertensi. Penggunaan aplikasi ini didasarkan
pada pandangan bahwa observasi variabel
fisiologis dapat mendeteksi kelainan pada ibu
hamil, sehingga petugas dapat merancang
intervensi untuk meminimalkan angka

23
JHCN Journal of Health and Cardiovascular Nursing’ DOI: 10.36082/jhcn.v3i1.998
Volume 3, Nomor 1 Juni Tahun 2023

kejadian morbiditas atau mortalitas ibu (Smith Pakar didefinisikan sebagai seseorang
et al., 2022). yang mempunyai pengetahuan, kemampuan
Kemajuan teknologi informasi dan analisis, pengalaman dan mampu memberikan
komunikasi dalam dunia kesehatan semakin solusi terhadap permasalahan yang muncul
berkembang. Rekam medis elektronik, sistem sesuai dengan pengetahuannya. Sistem pakar
pembayaran, pelayanan kesehatan dan adalah cara untuk melakukan pemecahan
monitoring pemberian obat merupakan salah masalah menggunakan sistem komputer
satu pemanfaatan teknologi dalam kesehatan. berdasarkan pengetahuan dari seorang pakar
Dengan adanya pemanfaatan teknologi ini, yang direkam dalam komputer. Sistem pakar
aktivitas menjadi lebih mudah, akurat dan merupakan bagian dari AI (Artificial
cepat (Smith et al., 2022). Intelligent) atau kecerdasan buatan dengan
Electronic Health (e-health) merupakan utama berupa knowledge base yang berisi
salah satu bentuk dari kemajuan teknologi dan pengetahuan dan mesin inferensi yang
komunikasi, dengan jenis yang paling banyak menggambarkan kesimpulan (Sari, I. M., &
dikembangkan adalah mobile health. Mobile Thalib, F, 2019).
health sebagai salah satu model dari electronic
health merupakan jenis yang paling banyak Kesimpulan
dikembangkan saat ini. Peningkatan jumlah
Penggunaan aplikasi mHealth berbasis
pengguna telepon selular berbasis android,
sistem pakar terbukti efektif dalam
kemudahan akses dan biaya yang terjangkau
meningkatkan pemantauan kehamilan,
menjadi alasan semakin berkembangnya
khususnya pada pemantauan tanda bahaya
aplikasi ini. Kunci utama dalam aplikasi
kehamilan sehingga dapat dilakukan
mHealth adalah kelengkapan fasilitas
peringatan dini kehamilan risiko tinggi.
(feature), kemudahan penggunaan, informasi
Aplikasi ini sangat bermanfaat bagi ibu hamil
yang tepat mengenai pelayanan kesehatan,
pada khususnya dan petugas kesehatan yang
jaringan yang kuat dan stabil serta adanya
mengelola ibu hamil, yang dikembangkan
pengembangan yang konsisten dan terus
dengan tampilan yang mudah diakses sehingga
menerus (Soegijoko, S., 2010). Kelemahan
semua kalangan masyarakat mampu
dari sistem mobile health ini yaitu informasi
mengoperasikan sistem ini.
yang diberikan seringkali tidak bersumber
pada pakar secara langsung, sehingga validitas
Saran
dan kebaruan informasinya dipertanyakan.
Sistem ini perlu terintegrasi dengan
Kolaborasi pengembang aplikasi dengan
pelayanan kesehatan baik puskesmas maupun
beberapa pakar sangat diperlukan untuk dapat
rumah sakit terdekat sehingga ibu hamil yang
menangani permasalahan yang terjadi.
24
JHCN Journal of Health and Cardiovascular Nursing’ DOI: 10.36082/jhcn.v3i1.998
Volume 3, Nomor 1 Juni Tahun 2023

menemukan adanya tanda bahaya kehamilan Applications to Obtain Perinatal Health

pada dirinya mudah untuk mengakses layanan Information. JOGNN - Journal of
kesehatan yang akan dikunjungi untuk Obstetric, Gynecologic, and Neonatal
mendapatkan tindakan dalam waktu yang Nursing, 47(6), 728–737.
cepat. https://doi.org/10.1016/j.jogn.2018.04.1
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Keperawatan, 6(1), 49. Qualitative Exploration Of Women’s
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Carrandi, A., Hu, Y., Karger, S., Eddy, K. E., 98(March 2021), 102995.
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Callander, E. (2022). Systematic Review 2995
On The Cost And Cost-Effectiveness Of Fouly, H., Abdou, F. A., Abbas, A. M., &
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(2021). The Impact Of A Mobile Health Prosiding Seminar Nasional Unimus,

Intervention On The Sense Of Coherence 666–672.
And Quality Of Life Of Mothers With Sari, I. M., & Thalib, F. (2019). Pembuatan
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Phagdol, T., Nayak, B. S., Lewis, L. E., Bhat 103402.
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JHCN Journal of Health and Cardiovascular Nursing’ DOI: 10.36082/jhcn.v3i1.998
Volume 3, Nomor 1 Juni Tahun 2023

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