Obstetric Patients and Healthcare Providers Perspectives to Inform Mobile App Design for Physical Activity and Weight Control During Pregnancy and Postpartum in a Rural Setting

Figures & data

Table 1 Focus Group and Interview Questions According to Domains of the Health Belief Model

Domain (HBM^Citation31)	Questions
	Pregnant	Postpartum	Healthcare Provider
Perceived severity and susceptibility	Q1. What do you think are the risks of gaining a lot of weight or sitting too much during pregnancy? Do you worry about these things happening to you?	Q1. What do you think are the risks of gaining a lot of weight or sitting too much after pregnancy? Do you worry about these things happening to you?	Q1. Do many of your patients exceed guidelines for appropriate gestational weight gain? If so, is this something you are concerned about? Why? Q2. Are many of your patients physically inactive or mostly inactive during and after pregnancy? If so, is this something you are concerned about? Why?
Perceived barriers	Q2 Why it is hard to get exercise when you are pregnant? Q3. What would make it easier for you to get exercise during pregnancy?	Q2. Why it is hard to get exercise after having a baby? Q3. What would make it easier for you to get exercise after having a baby?	Q3. Do you use any strategies for helping women to stay within appropriate gestational weight gain guidelines during pregnancy? If so, what are these strategies? How successful have they been? What about after pregnancy? What strategies do not seem to work? Do you have any ideas about why they have or have not worked? Q4. What strategies have you found to be successful for helping women to become/stay active during pregnancy? What about after pregnancy? What strategies do not seem to work?
Perceived benefit	Q4. Some people have used a mobile app to help people control their weight and to help them be active. What do you think about this? Do you think this would work here? Why or why not?	Q4. Some people have used a mobile app to help people control their weight and to help them be active. What do you think about this? Do you think this would work here? Why or why not?
Cue-to-action	Q5. What features would you like to see in an app that would help you with your weight control and/or physical activity levels?	Q5. What features would you like to see in an app that would help you with your weight control and/or physical activity levels?	Q6. What information would you like an app to contain to assist your patients with weight status and/or physical activity levels during pregnancy and postpartum?
Self–efficacy	Q6. Do you think you would be able to get more exercise and keep a healthy weight during pregnancy if you used an app?	Q6. Do you think you would be able to get more exercise and keep a healthy weight after having a baby if you used an app?

Figure 1 Breakdown of focus group and interviews among pregnant women, postpartum women, and healthcare providers.

Table 2 Pregnant and Postpartum Participant Characteristics

	Pregnant (n=14)	Postpartum (n=13)
Age (y)	29.86 ± 4.42	31.0 ± 2.92
BMI (kg/m^2)	28.82 ± 4.34	27.59 ±6.8
Gestation Week/Postpartum week	22.32±8.75	14.58 ± 7.37
Marital Status
Married	12 (85.7%)	12 (92.3%)
Single	2 (14.3%)	1 (7.7%)
Annual Income
<10,000	1 (7.1%)	1 (7.7%)
10,001–20,000	1 (7.1%)	0 (0.0%)
20,001–40,000	1 (7.1%)	0 (0.0%)
40,0001–60,000	0 (0.0%)	2 (15.4%)
60,001–80,000	3 (21.4%)	4 (30.8%)
>80,000	8 (57.1%)	6 (46.2%)
Subjective Assessment of Income
Struggle to get by	2 (14.3%)	2 (15.4%)
Have enough to get by	11(78.5%)	7 (53.9%)
Have more than enough	1 (7.1%)	3 (23.1%)
No response provided	0 (0.0%)	1 (7.7%)
Race/ethnicity
Caucasian	13 (92.9%)	11 (84.6%)
African American	0 (0.0%)	1 (7.7%)
Latina	1 (7.1%)	1 (7.7%)
Highest Level of Education Completed
High School/GED	2 (14.3%)	2 (15.4%)
Associate’s Degree	2 (14.3%)	0 (0.0%)
Bachelor’s Degree	6 (42.9%)	8 (61.5%)
Master’s Degree	4 (28.6%)	2 (15.4%)
PhD or higher	0 (0.0%)	1 (7.7%)
Physical Activity Level*
0 days	0 (0.0%)	2 (15.4%)
1–2 days	6 (42.9%)	3 (23.1%)
3 days	1 (7.1%)	5 (38.5%)
4–5 days	4 (28.6%)	3 (23.1%)
6-7 days	3 (21.4%)	0 (0.0%)
Self-reported Health Status
Poor	0 (0.0%)	0 (0.0%)
Fair	0 (0.0%)	2 (15.4%)
Good	4 (28.6%)	3 (23.1%)
Very Good	7 (50.0%)	6 (46.2%)
Excellent	3 (21.4%)	2 (15.4%)
Parity (current or at most recent pregnancy)
Nulliparous	7 (50.0%)	5 (38.5%)
Multiparous	7 (50.0%)	8 (61.5%)

Notes: *The number of days per week a participant reported exercising. Data presented as Mean ± SD or # of people (%).

Table 3 Healthcare Provider Characteristics

	Healthcare Providers (n=11)
Age (y)	39.11 ± 12.26
BMI (kg/m^2)	26.5 ±4.48
Sex
Male	5 (45.5%)
Female	6 (54.5%)
Race
Caucasian	11 (100%)
Highest Level of Education Completed
Associates Degree	1 (9.1%)
Bachelor’s Degree	0 (0.0%)
Master’s Degree	1 (9.1%)
PhD, MD, or higher	9 (81.8%)
Job Title
Obstetrician/MD	7 (63.6%)
Certified Midwife	2 (18.2%)
Postpartum Nurse	1 (9.1%)
Women’s Health Physical Therapist	1 (9.1%)
Physical Activity Level
0 days	1 (9.1%)
1–2 days	3 (27.3%)
3 days	2 (18.2%)
4–5 days	5 (45.5%)
6-7 days	0 (0.0%)

Note: Data presented as Mean ± SD or # of people (%).

Table 4 Pregnancy Focus Group Responses

Question	Theme	Examples
Do you worry about the risk of gaining too much weight or sitting too much during pregnancy?	Pregnancy-related health concerns	“My job, I sit, like you cannot stand and see clients. I mean I have, but it’s not- so I worry. I do worry about sitting too much and how it will eventually, as I grow, how it will cramp everything up and I slouch a lot more. So I am like, wondering if I am like suffocating the baby. But I know like some of the risks of like being sedentary are like, higher rates of cholesterol and higher blood pressure and higher, like higher weight gain. And I do not want to … yeah.” “I was really sick in my first trimester. Like, I could not get out of bed. I was sick all day, every day. And I did not exercise at all, like at all. I have just recently started walking every day trying to do like a mile or two, but I am going to ease in, try to do more eventually. But I was really worried about like laying in bed and sitting all day because, you know, I know that you are supposed to get exercise, but I was not doing any of it.”
	Issues with weight control	“I actually had just started to lose weight when I found out I was pregnant. My best friend was getting married in July, February I started losing weight. And by April, I found out I was pregnant. My goal was 50 pounds, I actually made it to like 46 before the wedding. But I do not wanna gain all of that back, and then, you know, have more trouble losing it again. That’s a big worry for me, is that I would gain too much, and then be like, how am I ever gonna lose this back?” “Well I just know, this time around I was less active than I was my first pregnancy, partly because I am chasing a toddler and a couple of years older and just work and all the demands. And I have noticed that I know- I have gained more weight this time, which I am not happy about.” ^(Theme 1: Physical activity as critical for weight control)
Why is it hard to get exercise after baby?	Pregnancy related symptoms/physical limitations	“And then I just feel like my lung capacity, like because of everything that’s changing. I just feel like it’s harder to breathe.” “I couldn’t- I’d walk outside and try to walk and I’d puke because I got hot.” “Especially when your body, like when your belly changes and your center of [gravity]. Because I mean, I climb in and out of the ambulance and I have been doing it for 8 years. But I feel out of the ambulance the other day because- trying to get my leg up that high to climb in it.”
	Uncertainty about what to do	“Do not know how hard to push it. Like I am really like- I will push it til I am, like, laying on the ground. It’s like, okay, we need to step back a little bit, like we are not doing that right now. That’s not the goal. And knowing that, like, okay I can do this weight but should I? Is it going to hurt the baby? Is it going to hurt me?” ^(Theme 2: Need for evidence-based exercise information) “I have stopped doing speed workouts because of like, I do not know how intense I can go. And I have stopped doing a lot of strength training because I do not know what moves I can do. And I Google things and like research things. And I found this YouTube video of a woman doing these Pilates exercises. And it was every- like once she started doing it, it was like everything I read that you should not do. So I was like, I just do not know.” ^(Theme 2: Need for evidence-based exercise information) “Yeah, I’m on what to expect. They tell you like safe sleep positions, and sex, and non-stress, but they don’t really tell you what you need, like what type of exercise would be most beneficial.” “I think my concern is, like, it’s similar to yours in that I do not really know what I can do. And I also do not trust an instructor- like if it’s a group class to be able to tell me if it’s appropriate for my body because I have had people tell me something that’s appropriate and then it does not feel right. Or … And the other thing is that I think like a lot of exercise programs are created for a biological, like a biologically male pelvis, and they are not necessarily created for a female pelvis. So why would they be OK for a pregnant woman either? So there’s just like general concerns in terms of how somebody can actually instruct me.” ^(Theme 2: Need for evidence-based exercise information)
	Uncertainty about what your body is telling you	“That piece of advice is totally discouraging because your body is doing something completely different than it has ever done before. So ‘listen to your body’ is like, I don’t know what the hell my body is doing” ^(Theme 2: Need for evidence-based exercise information) “I know sometimes I cramp when I run. And I do not know if I am like constipated, because that’s like constant too or if it’s like the pressure of the baby, like this is the first. I am not- I am also not familiar with like what sensations are normal or not. Like nothing happens, I thankfully have not bled. But like when I, I ran a half marathon a few weekends ago and like the entire time I was like, I was a little crampy so I was like, am I killing- am I doing something really, really, wrong? Everyone tells me I can, but like, is this normal? Is this not normal?” ^(Theme 2: Need for evidence-based exercise information)
	Logistical concerns/time/work/other children/lack of support	“I have been very tired this pregnancy. Like I do not remember with the first pregnancy being so tired and I exercised a lot with him, did great with him. But now it’s like, you cannot- I cannot wake up early to do it, I cannot stay up late. He’s almost three and I am chasing him around and I am just tired.” “But I have a 4-year-old at home, so I still have to be a mom at the same time. He goes to preschool 2 days a week, he’s with me the rest of the time. So there’s not a whole lot of sitting.” “Because especially, you know, if it comes around- my second pregnancy, I’ll have a child I’m chasing.”
	Fear of causing harm to the unborn baby or themselves	“I was waiting tables when I first found out I was pregnant. And it was nothing for me to lift 5-gallon buckets of ice. And here I am, you know, 3 months pregnant. And they are like, what are you doing? And I am like uh- oh! You know. So I do not necessarily think about, right off the bat, oh, I should not be doing this. And then you think afterwards, of, did I do something to hurt the baby? So you have that fear of not knowing what level you should go to.” ^(Theme 2: Need for evidence-based exercise information)
	Lack of motivation	“Well, the first trimester, it was really hard for me just to get the motivation to go, not, like once I got out I felt like I could do it but the motivation. The second I did really good, like I was running 5–6 miles. And then when I hit about 26 weeks, I was down to about 1-2 miles.” “I’m very much, you know, like a goal person. Like, if you have something that says, OK, you need to walk a mile today, ok I’ll walk a mile today. Or you know, something like that. But I’ve lost all motivation to get up and go.”^(Approaches for addressing concerns through key mobile app features)
What things could make it easier?	Community/support system	“Also, like if you had someone, like if your partner wanted to do it with you because it’s always- for me, it’s a lot easier to do stuff if I got someone doing it with me.” ^(Approaches for addressing concerns through key mobile app features) “Maybe a way in the app you can link to other people in your area that even if it’s not- even if you can’t meet up, you can still be like, oh well I’ve walked today. Have you done what you’re supposed to do?” ^(Approaches for addressing concerns through key mobile app features)
	Knowledge about what do to and how to do it	“The other thing I was thinking of in regards to like pregnancy movement is, what are some movements that you could do that would be specific to helping your body birth the baby? So like, you know, not just keeping yourself healthy, but like how can you strengthen your abdomen, your pelvic floor, to help?” ^(Theme 2: Need for evidence-based exercise information)
	Convenient, time-efficient workouts	“I think ways to do stuff around the house with like …. Because, I mean, I know, like, when we were in high school, like working out for softball and tennis and stuff like, they’d be like go get a kitchen chair and do this against each chair and stuff like that. Maybe stuff to, if you have this at your house, you can use this to do that.” “But, like, 15 minutes is probably all that I’ll have to myself.”
What features would you like to see?	Goal tracking and progress tracking for encouragement	“I’m a very visual person too, I like that- like again, closing the rings. Like visualizing it. So like something with check marks or something, like each week you met your goal, 3 out of 3 workouts or whatever the goal is.” ^(Approaches for addressing concerns through key mobile app features) “Kind of like a goal oriented thing. Like, because I have already been told that I am at risk for preeclampsia, I want to be able to work, like work to- I want to be able to track how I can improve, I guess, throughout the time and hopefully reduce the chances of anything bad happening.”
	Push notifications and reminders	“I like them. They motivate me. They really do.” ^(Approaches for addressing concerns through key mobile app features) “I like those, because if I’m like, oh you’re almost there, to close all your rings, I’m like okay. I’ll just get up and like walk around the house or something. Just like close my rings.”^(Approaches for addressing concerns through key mobile app features)
	Community component for support and accountability	“I do not like to exercise alone … Support is a big thing. Like I have always had an exercise partner if I want to go exercise. So that’s one thing, you know, my mom was always the person who went with me. She’s still around, but she’s not in great health either, so we cannot- we cannot do the same things anymore. And so that’s, that’s one thing that kind of makes me go, eh, I think I will just sit here instead.” ^(Approaches for addressing concerns through key mobile app features) “So I go to those forums a lot, like what to expect when you are expecting and read about other moms and what they are going through. And if I were to see like, hey, I am a runner. I cannot run anymore, but here’s some really beneficial workouts I am doing that might- we are both due in March. Maybe this would be good for you too. So you’d be able to talk to other moms about stuff they are doing. I do like that a lot.” ^(Approaches for addressing concerns through key mobile app features) “Like if you had someone, like if your partner wanted to do it with you, because it’s always- for me, it’s a lot easier to do stuff if I got someone doing it with me. You know, like me and my mom have been walking together every day and she needs it for her reasons and I need to do it for my reasons but it does help a lot.” ^(Approaches for addressing concerns through key mobile app features) A community-based social feature may also motivate some women through friendly competition, as one woman, pregnant with her first child and working full time as an elementary teacher, suggested, “Okay, I need to do it. [She] did something and she felt like crap today and she still worked out.”^(Approaches for addressing concerns through key mobile app features)
	Individually tailored, time efficient workouts with video demonstrations	“If you have the flexibility, you can account for how a pregnant woman is feeling in a day and that’s forever going to be changing. So I think that the flexibility is nice, but I also like the structure of like knowing that you are getting a well-rounded workout.” ^(Approaches for addressing concerns through key mobile app features) “You could have different, you know, someone could self-identify and say, well, I am a very active person, and maybe someone’s more medium range and then a light range. And then if you classify yourself, whatever range, and then it could give you different ideas for different daily things. So you are not just doing the same thing every day because you are like well, I do not know what else to do. That it would give you some ideas tailored to your kind of activity level group.” ^(Approaches for addressing concerns through key mobile app features) “I like videos for a workout because I am not good at picking stuff out for myself. Like I need someone to set something up for me to hold me accountable Cause I am not good at being like, oh yeah, that’s good for my arms or my legs. Like I need someone to assign that stuff. I have never been good at planning it out myself.” ^(Approaches for addressing concerns through key mobile app features)
	Evidence-based information	“I do use YouTube, but if I’m using YouTube then I’m scrolling and then wondering like well is that appropriate? Is this a trustworthy lady?” ^(Theme 2: Need for evidence-based exercise information) “Like getting expert feedback is very important to me. I’ve heard from the mommy groups and just all that, there’s so much misinformation.” ^(Theme 2: Need for evidence-based exercise information)
	Education and exercise safety	“And like I would like to know, and this is very detailed, of what, how long can I go at my max heart rate? Well, there is one study I read that said you were, they did, they did on female sheep that at 90% of their heart rate, the baby stopped getting oxygen … I have been digging and digging and digging. Like what is, what is too much?” ^(Theme 2: Need for evidence-based exercise information) “Like how- how do you change the way you lift, like it’s supposed to be hips a little more forward than back, you know, things like that. No one really instructs you on that.” ^(Theme 2: Need for evidence-based exercise information) “We all have that concern as to where should I push myself to. To be like, okay I feel this way, but I feel like I could do more at the same time. Being able to have that interaction on the other end that knows what they’re talking about.” ^(Theme 2: Need for evidence-based exercise information)
	Symptom tracking	“I think you definitely need that because I am almost through my second trimester and I still have the days of oh my gosh, I am so nauseous. I am so tired. I have had a lot of dizzy spells, to where every time I stood up I would have to sit back down immediately. So, I mean, you know in that situation, I do not wanna get up and exercise, I am going to die. You know, I was waiting tables and I did not know to limit myself yet because here I am, you know, 8 weeks pregnant, why am I limiting myself? And I passed out in the middle of the restaurant.” ^(Approaches for addressing concerns through key mobile app features) “I was the first person at that office the other week, and there were 3 people who came in and they were all there for an 8 am appointment with her. And I was like oh, so we are triple booking, which sounds terrible for her. So, like, I do not- I have waited for 45 minutes by the time she gets there. I know it’s only gonna be a 5-minute appointment. So it’d be nice to have a note to say like, oh this is what I experienced when I was working out. Because by the time she gets there, I was like yeah, everything’s great. Nothing really to report. And then I leave and I am like, oh shit, there’s like 45 things I wanted to tell her.” ^(Approaches for addressing concerns through key mobile app features) “And so maybe getting that feedback, being able to tell … It’s okay to feel sick right now. Don’t feel like you have to do it if you feel bad.” ^(Approaches for addressing concerns through key mobile app features)

Table 5 Postpartum Focus Group and Interview Responses

Question	Theme	Examples
Do you worry about gaining too much weight or sitting too much after having a baby?	Weight retention and continued weight gain during postpartum	“I do, because I do. I gained- obviously I gained weight when I was pregnant. And part of that was I had some back issues because of the weight gain during my pregnancy. So for me right now, the weight gain … I do not worry about gaining weight after having him, but I do worry about like sitting here. I am not getting very many steps in during the day. I am not very active. So I am worried about like still that back hurting because you are not really losing weight. And then I also worry about just sitting here, you start becoming a little hunch, especially with breastfeeding. So, you know, I do worry about that.” ^(Theme 1: Physical activity as critical for weight control) “It is harder to get active again. And if you, if you do not find yourself like getting up and just doing little things, you find yourself gaining more weight because you have that tendency to like, continue to eat because that’s what you are used to, because you are just carrying a child. So you do not think, oh, I am no longer pregnant, I probably should not be eating like this anymore.”
	Biometric sickness	“Gaining too much weight obviously. High blood pressure, gestational diabetes, just long term, just not being able to get the weight off, obviously, which leads to long-term health problems. Sitting too much. I mean, really, I think it can like increase your chances of having things like hemorrhoids.”
	Physical discomfort or issues	“I do, I have worried about sitting too long, because I went back to work at two and a half weeks, so that was part time and it was flexible. But I had the responsibilities and I did have to sit and take care of stuff. And now my- her birth was very, I did not rip. I did not have any surgical things. It was very -I can bounce, my body bounced back. If you could call it that, healed very quickly. But I could still tell that sometimes I kind of like- my body almost hurt from having sit too long.” “The combination of trying to eat enough to sustain life for your baby, plus finding energy throughout the day. I know the first month or so for me, I felt like I was a zombie and having enough time and energy to actually work out was really tough. But also at the same time making sure that you are not using that as an excuse to eat everything in sight. But at the same time, you are tired.”
	Mental health and PPD	“I think that like, probably the biggest risk would just be even like your mental health with it. Like after I had [my baby], I would notice like, if I was just like- I always joked that I had my square on the couch and I just wanted to stay there, all the time. And I think you can get into kind of like a habit, almost like … and like it can affect your mental health.” “I definitely feel 100% better if I am working out. You know, postpartum. I mean a hundred percent like, you just feel better. Not even like weight wise, just your brain is stimulated and you feel energized. Yeah.”
Why is it hard to exercise after having a baby?	Logistical Concerns	“Yeah, I mean, there’s like a window. There’s like smaller windows of time where your baby needs to eat or he’s gonna be awake and needs your attention so then, there’s like that little window where they nap. So, I mean, there’s all kinds of excuses.” “I think like you are so overwhelmed, like right after you have a baby. Not that you do not worry about it. But I can remember just thinking like one hour at a time, one hour rotation at a time. And like, I remember thinking like, I need to exercise, but like, I just do not have time. Like, I was like, I do not know, when on the three hour rotation I would even fit it in. And then when you first do … When I was first postpartum like right after I was released from the doctor, like I would start walking and stuff in the mornings, and that always did make me feel better.” “I think it’s hard because you are. You do not think about. In my experience- you focus so much on, are the other kids adjusting well to the baby, is the baby doing well, is everything being taken care of. And then you kind of just worry about yourself in a minimal way, which is yeah, for me you’ll be- am I sleeping enough, am I eating or drinking enough water because I am breastfeeding, my health directly affects her health. So. And then the exercise part. I mean, I am just worrying about sleeping enough hours. Like thinking the extra stuff is just harder.”
	Fatigue and other physical recovery issues	“I can remember wanting to go exercise. And then as soon as I would, I would like push it too far and it would make me like exhausted or sore or whatever. Even just basic walks. Like I can remember, as crazy as it is, even going to the grocery sometimes and like, like getting sore from it.”
	Lack of guidance over what you can and cannot do	“I feel like there’s a lot of things that are like, exercises you should do when you’re pregnant. But there’s not a lot like right after, like postpartum because there’s still things that are like healing and recovering.” ^(Theme 2: Need for evidence-based exercise information) “Especially the ab exercises. I was like, am I gonna hurt myself doing that? Like, I did not really have anybody to go to, to be like, is this OK? I mean, I felt OK, but they always make such a big deal out of that. Just, that would be kind of cool to have you know, these are the exercises that you could do and these are the exercises that you should wait four months, or however long to do.” ^(Theme 2: Need for evidence-based exercise information) “So, just knowing what I can do, what I can’t do, and then the opinions of others, because sometimes they make you feel bad and you’re like, I probably should go sit down. I don’t want to have a setback or whatever, but that’s probably, probably it.” ^(Theme 2: Need for evidence-based exercise information)
	Priorities	“I’m just worried about sleeping enough, thinking about the extra stuff is just harder.” “And I can remember some moments like when I feel really overwhelmed. I’m like, you know what, like for this first year, I just can’t fit that in right now. You can only fit so much in and I felt like that’s just something I have to take off my plate.”
What would make it easier for you to exercise after having a baby?	Guidance on what to do/how to exercise properly	“Well it’s kind of weird because you go to your 6-week appointment. She’s like everything looks good, see you for your annual, and you kind of feel like you are just thrown to the wolves … So that’s it, like I just have to go on with my life and I am not going to see you?” ^(Theme 2: Need for evidence-based exercise information) “Especially modifications. Because with me, I have a lot of back problems anyways with my sciatica, and I also have lupus and fibromyalgia. And so any, just getting up and being active as hard as it is with these rugrats running around is pretty much my exercise.” ^(Theme 2: Need for evidence-based exercise information) “And if somebody could, like, offer me something, it would be like, like what reps to do. Like I feel like at one point if I had a set like routine of 30 reps of ABCDE and F and do that every day, and it would at least help tone or maintain or something. I would have done it because what would happen is, I would get those things and then like I would not know what to do.” ^(Theme 2: Need for evidence-based exercise information)
	Time-efficient and convenient videos or workouts	“Well, the hardest thing is just finding the time and the mental commitment to do it, I guess, because usually when you have a chance and the baby is napping and you feel like you have the opportunity to work out, you feel like you need to do all the other things, the dishes, all the laundry.” “I do all my workouts in my living room at home … because of my husband’s work schedule and breastfeeding and all of the things, that’s the only possible way I can workout.”
	Additional support from others	“I think what would make it easier would be. Having the support of someone that could watch the child while I maybe took a walk around the block. If it was cold or raining, they could not come or just knowing that they are secure in their crib or in a swing. So I could do a 15 minute workout video, something on those lines.” “So having the support, like having, like have friends coming together, say, hey, we’re gonna do this together … But I really feel like groups helping each other is the best. It’s just easiest.” ^(Approaches for addressing concerns through key mobile app features)
What features would you like to see in a mobile app?	Structured plan with videos	“If I don’t follow a schedule and regimen and I try to skip around, I won’t be successful.” ^(Approaches for addressing concerns through key mobile app features) “It’s so hard, because even with structure stuff, it’s almost like you want accountability, so you want the structure, but you cannot, you cannot help all this stuff coming up happening. Because during this phase of your life, you have got so many dependents and so they get sick or this or that happens. So, you know, we had to cancel all my plans this week from Friday to Sunday because 2 of the kids got pinkeye on Thursday. So when I picked them up from their dad, that Friday was just taking care of them. Nothing, nothing got done.” ^(Approaches for addressing concerns through key mobile app features) “But yeah, definitely videos because I worry a lot about when it comes to exercising. I like, I am normally very active. I like having fun and, like do cartwheels, all that kind of fun stuff and rock climbing. But when it comes to doing a set of exercises, maybe with the weights or like Pilates or something like that or yoga, I do worry about form. I feel like if you do it wrong, you are actually hurting yourself. So video does help.” ^(Approaches for addressing concerns through key mobile app features)
	Education for easing back into exercise, teaching them what they can and cannot do	“Or like just as far as milk supply, like are saunas bad, like should you try not to, like sweat, is cardio worse than weight training. So that would be good because it’s like, the one thing I do worry about exercising while nursing. And then just certain, like there’s certain target areas after you have a baby.” ^(Theme 2: Need for evidence-based exercise information) “You know, for what’s hard with postpartum women is your body has changed so much even from if it’s your first child to your second or third child. I mean, my body’s been different every single time. So I know a workout that I did four years ago before I was pregnant is probably not going to do the same as it was then to now … Because my body is so different. So it’d be nice to have that education, that helpfulness. You do not hear a lot of people talk about pelvic floor, but that’s important after you have a baby when you are postpartum.” ^(Theme 2: Need for evidence-based exercise information)
	Progress tracking/goal tracking/workout tracking	“My phone is very important. So something was giving me reminders and what not.” ^(Approaches for addressing concerns through key mobile app features) “I definitely would like to have something that kept obviously the history, where I started and where you I am now, almost like a progress tracker … And again, for me, because my brain’s so scattered, just really just that progress. What did I do the other day? I cannot even remember, let me look on my app and see what workout I did or, you know, some people probably would want like food or water intake. But for me, that’s not the most important part of that.” ^(Approaches for addressing concerns through key mobile app features)
	Push notifications/reminders/encouragement that they are doing well	“You go to your phone and have like, a little encouraging message that encourages you to work out and be better for you and the baby.” ^(Approaches for addressing concerns through key mobile app features) “Exactly. With the amount of other things we’re worrying about, that’d be nice to have a little reminder.” “I think postpartum people just need encouragement that they are doing a good job. Or even trying.” ^(Approaches for addressing concerns through key mobile app features)
	Community support/forum	“I think that postpartum women are too are always looking for people that are in their same boat.” ^(Approaches for addressing concerns through key mobile app features) “You have people to relate to. You know, like if you had a group that was like, all the babies born in August, all the babies born in September. I think I’d be more motivated if I had more people, like in my same boat.” ^(Approaches for addressing concerns through key mobile app features) “Yeah. Just to hear somebody be like ‘I didn’t work out because I was overwhelmed that I wanted to cry’ like, OK. It’s not just me.” ^(Approaches for addressing concerns through key mobile app features)
	Symptom tracking and workouts based on how they feel	“Like you are not feeling- yes, I think that’d be good. Especially like going back to like, it depends on how postpartum you are because like right now, obviously, I am in a whole different state than I was, you know at eight weeks or even six weeks. So yeah, that would be good.” ^(Approaches for addressing concerns through key mobile app features)
	Mental health checking	“I would include something as far as mental, like the mental health component because. You are not alone. Sometimes it’s like even if it’s just something just encouraging you. I know this is tough, Mom, but you got it. You know, it does not have nothing where you have to sit here and read and you have a full reflection, but just a little pop up. You got this, you know, keep it going because, you know, it’s work. It’s hard. It’s hard. And if you do not always have that support, you do not know how much an app just saying there is enough support to keep you going, you know.” ^(Approaches for addressing concerns through key mobile app features) “I think that the emotional section, I think that would be really helpful. I think the tips would be nice. Notifications would probably be good. Even for the emotional stuff, I think that that would be nice, like maybe you are just crying in the shower for the third time in a day or something. You go to your phone and you have like, a little encouraging message and then encourages you to work out to be better for you and the baby. I think that, you know.” ^(Approaches for addressing concerns through key mobile app features) “Is there anything [in the plans for the app] in there for like postpartum depression? I both suffered from it with him. When he was in the NICU obviously we felt our hands are tied. We cannot really do anything for him. We cannot hold him. We cannot- we cannot. We cannot really be his parents. We could not even change his diapers or anything. We could not touch him. No stimulation, period. He had a tube down his throat and everything. So it was rough …. But with him- it hit hard. Like I have never experienced depression ever, ever …. Or something [an app feature] to keep your mind off the negativity. Like to keep the negative thoughts out of your head.” ^(Approaches for addressing concerns through key mobile app features)

Table 6 Provider Focus Group and Interview Responses

Question	Theme	Examples
Are your patients inactive? Is this something you are concerned about?	Majority of providers expressed concern	“Yeah, I mean, that, that’s the- I mean, first of all, we have a lot of patients coming into pregnancy, you know, in the overweight or obese categories to start with. And of course, that we have a little bit different guidelines for ideal weight gain. So, yeah, that’s a struggle. If I had to just, off the thumb, two thirds of our patients. It’s a struggle.”
	Some are very active, some very inactive; there is a mixture of patients	“A lot of them are very much inactive.” ^(Theme 1: Physical activity as critical for weight control) “They are under the mindset that I am pregnant. I’m building the baby. So I don’t really have to do anything after that.” ^(Theme 1: Physical activity as critical for weight control) “If they aren’t doing it before pregnancy, they don’t pick it up.” ^(Theme 1: Physical activity as critical for weight control) “There’s a lot of variation. I mean, we do have some that are very health conscious that come into the pregnancy, really having a set exercise program. And you know, in those patients, I mean, with proper reassurance that they can safely do quite a bit, they continue on with that. Others, you know, just, just getting them to get from the chair to the exam table is as much as they are going to do.” ^(Theme 1: Physical activity as critical for weight control)
	Cultural influences and misconceptions among patients	“Because, of course, almost all women are worried about weight gain. It’s just ingrained in us. That’s how it is. So women talk about weight gain a lot. And when they asked me about exercise, there is a lot of fear and worry. Like what- what can I do that’s safe?”^(Theme 1: Physical activity as critical for weight control) “It’s something hard because you know, every culture says you’re eating for two, and pregnancy cravings aren’t usually healthy.” ^(Theme 2: Need for evidence-based exercise information)
	Bigger issues to deal with	” … just with all the things you have to cover, it’s not a huge part of what we do” “Well, with weight gain, I mean, my first thing is what have you been doing? I’ve got my basic talk for their OB visit. It’s probably not as in-depth as maybe it should be, but it just kind of gets buried in all of the other education we have to do.”
Do you have specific strategies to help your patients control their weight?	Focus more on diet	“I try to talk to them first about what they’re eating and diet, because that has a lot to do with it.”
	Routine weight checks	“I will say today your weight was this and you have gained one pound since you were here last time and you have gained 10 pounds since your very first visit with us. And I do that every visit. So that’s just part of a routine of what I say. And they get used to hearing me address weight. And again, I do not care if their starting weight was 125 pounds or 300 pounds, I still address it with the exact same manner.” “I try not to overreact about weight gain. I just try to look at the big picture, look at other things they’re doing that are healthy habits.”
Do you have specific strategies for encouraging physical activity?	Not really something covered	“It’s probably not as in-depth as it should be, but it just kind of gets buried in all the other education we have to do.”
	Continue to do what they are already going, if inactive, do not start doing something new	“Well, again, you know, starting what they are able to do and what they are doing currently. I mean, if they say I have got a gym membership, I have been going, ok, build on that. If they are really not doing anything, I mean, start with the basics. Everyone can walk.”^(Theme 1: Physical activity as critical for weight control)
	Integrate activity into daily life	“What I try to do is tell them that when you are going to your normal routine things incorporate the newer things into it. So like if you are going to shop at the mall, maybe instead of parking as close as you can, park as far away as you can, and little things, like or maybe take stairs instead of using the elevator. Sometimes during pregnancy, it’s harder to get patients to do that because they do have that decreased volume of their lungs and so they get dyspnea upon exertion a little bit easier.” ^(Theme 1: Physical activity as critical for weight control)
What features would be best for a mobile app?	Activity logging and goal tracking	“I think a diet log. Something that’s easy to log what they’re eating and when they’re eating would be really helpful.” ^(Approaches for addressing concerns through key mobile app features)
	Information about appropriate weight gain and patterns	”If there were something like in the app where they put in their pre pregnancy weight and height to calculate the BMI and then it gives the recommendation for total pregnancy weight gain based on their BMI, because it’s different for each category, and then they know.” ^(Theme 2: Need for evidence-based exercise information) “Well, and the realization that that weight gain is not linear.” ^(Theme 2: Need for evidence-based exercise information)
	Education about safe exercises and what to avoid tailored to week of pregnancy/postpartum	“ … suggestions for the exercises that are safe in pregnancy, or like the exercise of the day, like a yoga move that like would be helpful for like low back pain if they are, you know- like targeted to what week they are at. You know, if maybe they are at 33 weeks, the yoga move that would be more helpful than something at 10 weeks.” ^(Theme 2: Need for evidence-based exercise information)
	Push notifications with reminders and encouragement	“So, you know that just those little reminders for those moms, cause there’s all kind of negative things out there, so we just need some more positive things to combat all that”^(Approaches for addressing concerns through key mobile app features)
	Symptom tracking with notes about when to contact the provider	“I don’t know how to say like symptom tracker, but like if they’re monitoring their diet, are there things that, they kind of pattern over time. Like oh, this usually doesn’t make me nauseous, or, oh, I noticed that I’ve had heartburn these few nights.” ^(Approaches for addressing concerns through key mobile app features)
	Simplicity for the patient to understand	“Our clinic is very diverse in a lot of different ways. You know, language and educational status. We got patients that are very simple. That, you know, they get their hands on a lot of stuff that the typical person may understand clearly that’s right over their head.” ^(Approaches for addressing concerns through key mobile app features)
Should providers be able to view data from the app?	Majority say no, they already have so much information and data with limited time.	“It is really utilizing a finite amount of time, and deciding which is the best way to use that time. So again, if this is very awkward, if we have to sign into something and dig something up and we have to spend five minutes for a patient, it will not be utilized.”

Table 7 Participant Identified App Features and Their Application to the Health Belief Model

App Feature Identified	Application to Health Belief Model (Theory of Behavior Change)^Citation31
Progress tracking	Increase self-efficacy: Progress tracking allows participants to self-monitor and track progress towards a goal^Citation76 Online self-monitoring shown to positively influence exercise behavior during and after pregnancy^Citation77
Safe and evidence-based/trustworthy content	Increase self-efficacy: Education which may positively influence self-efficacy^Citation74 Reduce perceived barriers:^Citation79 Increase perceived safety which enhances exercise interventions during and after pregnancy^Citation77 Increase perceived susceptibility and severity: educational components will help pregnant and postpartum understand the negative implications of being inactive
Clear guidance on what can/cannot do	Self-efficacy: Education which may positively influence self-efficacy^Citation74 Reduce perceived barriers: a common barrier to physical activity during pregnancy is a lack of information about what to do;^Citation42 clear information would overcome this barrier Reduce perceived barriers: A common barrier is fear of harm to unborn baby;^Citation42 clear evidence based guidance would assist with overcoming this barrier. Also, guidance will increase perceived safety which enhances exercise interventions during and after pregnancy^Citation77
Community forum (social support)	Cue-to-action: Communication or posts that positively influence pregnant and postpartum women to engage in healthy behaviors
Reminders/Push notifications	Cue-to-action: reminders that trigger a pregnant or postpartum woman to action (eg a reminder to workout).
Time-efficient workouts	Reduced perceived barriers: Overcome the commonly cited barrier of lack-of-time^Citation79 Increase self-efficacy: Allow busy pregnant and postpartum women feel confident in their ability to complete workouts given time constraints
Symptom tracking	Increase self-efficacy and reduce barriers: Provide education about safety and allow them to feel confident that their symptoms are normal and that they can still pursue physical activity (fear of harming unborn child is often a barrier to exercise during pregnancy^Citation42) and increase perceived safety which enhances exercise interventions during and after pregnancy^Citation77

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