Health care is facing the emergence of a new range of systems, services, and applications using electronic communication. Electronic health (eHealth) is the network of technology applications regarding health issues, including, for example, Web-based informative programs, remote monitoring, teleconsultation, and mobile device–supported care [1]. As the health care costs in developed countries continue to increase, policies for cost reduction without concessions to the quality of care are being imposed. Unrestricted by time and place, eHealth applications also provide solutions for patient empowerment and value-based health care [2]. Patient empowerment is assumed to improve patient participation in medical decision making, commitment to treatment, and thus, health outcomes [3-5]. The boost in patient engagement can be an important factor for the improvement of quality of care and patient safety [6].

Young women in their reproductive years are frequent users of internet, social media, and smartphone apps [7]. The internet is ever more utilized for the search of health information on prenatal, perinatal, and postnatal topics [8]. Furthermore, the Web is also used as a forum for the exchange of experiences and peer support [9]. Figure 1 shows multiple domains of perinatal care in which eHealth is already being used by patients and health care providers.

Protocols of professionals’ associations and institutions contain little communication regarding eHealth. No statements are made regarding eHealth in guidelines from the British Royal College of Obstetricians and Gynaecologists, the National Institute for Health and Care Excellence, and the American College of Obstetrics and Gynecology. The Dutch Association of Obstetrics and Gynecology notes that developments in eHealth should be actively implemented in obstetric healthcare to induce the shift of scheduled care to the home setting and thus lower the in-hospital care burden [10].

eHealth has the potential to fulfill a key role in the transformation of the health care system for both patients and caregivers. However, questions are raised if eHealth can deliver the quality of care that is required to remain or even improve health outcomes. It is evident that there is a need for guidance and management of quality standards. Issues of costs and reimbursement; safety of data collection; and storage, privacy, and reliability of information on websites and in apps should also be taken into account.

Our aim is to provide a comprehensive and contemporary overview of the literature on eHealth in perinatal care and assess the applicability, advantages, limitations, and future of this new generation of pregnancy care.

Literature search and reference screening provided 71 studies of interest (see Multimedia Appendix 1 for the flow diagram of selection of studies). All articles were categorized in 6 domains, which will be addressed accordingly: information and eHealth use, lifestyle (gestational weight gain, exercise, and smoking cessation), gestational diabetes, mental health, low- and middle-income countries, and telemonitoring/teleconsulting (see also Figure 1). Tables 1-3 show the overview of 71 publications in 6 domains of perinatal care in which eHealth use in patient care was described, implemented, or compared with standard care.

In 15 studies, the characteristics of eHealth users in the perinatal period were described (Table 1). Around 88% (31/35) of participants owned a smartphone [11]. Usage of websites and pregnancy apps for medical information varies from 50% to 98% [7,11-14]. Online information-seeking behavior is common in pregnant women in general and it is not restricted to women with a special profile based on age, education, or social support [7]. Increased knowledge on pregnancy complications has also shown to reduce maternal anxiety and costly hospital visits [15,16]. Factors associated with app use in pregnancy are younger age, nulliparity, lower self-rated health, and higher education. Furthermore, 25.6% (56/219) of questioned women showed interest in a tailored pregnancy app initiated by their health care provider [7,14].

The most searched topics are fetal development, pregnancy complications, healthy lifestyle during pregnancy, generic and specific guidance/advices during pregnancy, and lactation [13,17]. Although they value the Web-based medical information as moderately reliable, 71.3%-75.1% (582/800) of the women do not discuss the information found on internet with their gynecologist [17,18]. One study reported that their lifestyle app helped women to initiate the conversation with their health caregiver on this subject [19].

There is an increasing use of internet for health information, including the perinatal period. However, websites are often contradictory and this may lead to confusion [20]. eHealth may be helpful to address questions through informative websites, apps, and peer support platforms designed by health professionals. Furthermore, eHealth may provide possibilities for decision support in more complicated pregnancies [21].

The effect on health is the most important issue to address in the effective implementation of eHealth in perinatal care. Parameters for quality standards include disease outcomes, enhancing patient adherence to treatment, reducing overuse, and increasing access to care [29]. Results of the search showed that most publications focus on the improvement of lifestyle (gestational weight gain, exercise, smoking cessation), gestational diabetes monitoring, mental health, care in lower- and middle-income countries, and telemonitoring.

Examining patients’ satisfaction with eHealth interventions, users describe high convenience and acceptance resulting in more patient activation and education. Patients report less concerns and anxiety and are comfortable with fewer clinic visits. Satisfaction rates vary between 86% and 95% in e-mental health studies and 90% (46/51) in home-monitored induction patients, who were very glad to stay in their own homely ambience as long as possible [73,79].

On the health care providers’ point of view, adaptation of obstetricians and midwives to eHealth solutions has not been widely described. Only 1 qualitative study interviewed 12 health care providers in obstetric departments. Concerns were raised on implementation barriers and potential medico-legal risks, but if addressed properly, implementation was considered feasible. Some clinicians admitted to have insufficient familiarity and skill with eHealth limiting their engagement and comprehension of the possibilities that eHealth technologies can confer to perinatal care. Overall, these clinicians regarded telemedicine as an additional parallel service rather than integrated into the antenatal care model [27].

By providing this overview of the literature, we aimed to assess the applicability, advantages, and limitations of the use of eHealth in perinatal care. This review showed that eHealth interventions have a very broad, multilevel field of application focused on perinatal care in all its aspects. Most of the reviewed 71 articles were published after 2013, suggesting this novel type of care is an important topic of clinical and scientific relevance. Women of reproductive age seem to be interested in eHealth, as shown by their frequent use of smartphone, internet and apps, and searches for pregnancy information. Most health outcomes for perinatal eHealth interventions were generally positive, either resulting in positive effects (lifestyle, mental health) or providing multiple advantages while health outcomes were found equal (diabetes care). The implementation of telemonitoring was not studied extensively, but research provided important effects and advantages on facilitation of new care models. Patient and care provider satisfaction with eHealth interventions rates are generally good, with rates up to 95%.

Despite the promising preliminary results as reviewed above, research in eHealth has progressed much slower than developments in the health technology industry. A great amount of the reviewed articles on this subject addressed more than health outcomes or satisfaction rates alone. Advances in (implementation of) apps and devices and patient-generated data are retained by legal and financial concerns. Possible privacy risks involve a lack of control to collection of data and the use by third parties afterwards.

In the United States, eHealth legislation, secured in the Fair Information Practice principles (part of the Health Insurance Portability and Accountability Act), is lacking protection for endpoint users: the patients. End-to-end data encryption can be used to protect the useful patient data. Combined with authentication and access control mechanisms for patients as well as care providers, eHealth technologies can further enhance final security control [106]. The development of the Telemedicine for Medicare Act of 2015 may accelerate the removal of barriers and limitations regarding use of telehealth between different states in the United States [107].

In the framework of European law, eHealth is simultaneously a health care service and an information service with corresponding legislation [108]. eHealth developers have to mind general legislation regarding privacy protection (Dir 95/46/EC, Arts 8-12), electronic identification services, e-Commerce directive (eg, online contracting), safety requirements of medical devices, and general product safety and liability requirements. In answer to the interstate developments in eHealth care, the Cross Border Directive was initiated in 2011 in the European Union (EU). The objective of the initiatives within this directive is to turn telemedicine into a standard medical service, accessible to every European patient and fully covered by the respective social security system. Difficulties arise on liability and creating uniform rules in the EU, as member states have very intrinsic differences in national rules on health care, privacy, and liability. One advice would be for each member state to provide a legal framework for telemedicine, whereas the role of the EU would be limited to regulation [108].

The costs associated with development, purchase, and maintenance of eHealth equipment have dropped in recent years due to technological advancements [107]. Primary investments to implement eHealth in perinatal care are now attributed to personnel costs for both providers and technical support. However, to deliver care with the help of eHealth can also create savings on personnel costs and clinic visits. A systematic review of economic evaluation in telehealth solutions concluded that 29 out of 39 studies (74%) reported cost-effective, economically beneficial eHealth interventions in different conditions and diseases. The conclusion highlighted the fact that many studies did not report all recommended economic outcome items, leading to inconsistent analyses [109].

The challenges for reimbursement are delaying the widespread adoption of eHealth in all ranges of sections of hospital care. Coverage is fragmented, varying at level of country, within hospitals in the same country and within different specialties of health care [29]. Health insurance companies seem to be inclined to cover only well-researched eHealth interventions with according economic evaluations. The use of low-risk, inexpensive care models can operate as opportunities to objectify possible reduction in health care costs.

Successes will motivate policy makers and drive the insurance market for additional coverage. Rigorous medical evidence can act as an extra stimulant; however, the duration and costs of designs and trials need to be taken into consideration [107].

This review provided an overview of eHealth as the next-generation perinatal care. Textbox 1 provides a condensed summary of the advantages (as described in Principal Findings) and disadvantages (as described in Additional Considerations) of the implementation of eHealth in perinatal care. If eHealth is to achieve its full potential, it should attain all domains of quality in care including safety, timeliness, effectiveness, efficiency, and patient centeredness. Cost-effectiveness assessment is needed to rationalize embracement and reimbursement. Policy makers should consider the international frameworks of legislation to support and implement this new form of care.

We accentuate that more research is needed, including economic evaluation of eHealth interventions. Growing engagement of calls for funding have responded: more large funding associations focus on the use of eHealth, warranting the qualitative impact of the studies in the application designs [110]. In addition, the potential of technology raised a nearly quadrupled amount of money in venture capital funding, from US $1.1 billion in 2011 to US $4.3 billion in 2015 [111].

Despite the challenges of privacy, liability, and costs, eHealth is very likely to disperse globally in the next decade. Some even state health care is approaching a tipping point [112]. The current shift to patient-centered care and increased patient empowerment underlines the need for revising current medical practice. eHealth has the potential to be integrated into standard care and deliver a revolution in perinatal health.