Hans van den Heuvel

2 Mental Health E-mental health has already proven to be successful in general population mental health management. 56 In 16 studies the applicability on screening for and treatment of postpartum depression was investigated (Table 2). The prevalence of postpartum depression is 3-15%. These women are reluctant to seek medical attention despite the heavy burden of disease, most notably because of the fear of their child being taken away from them. 57,58 Both screening with telephone (alpha coefficients of 0.72-0.94), app (sensitivity 72% and specificity 73%) and iPads were found feasible and acceptable 58-60 . E-health programs (e.g. online sessions based on cognitive behavior therapy) effectuate significant reductions in the depression scales and on symptom scores compared to treatment as usual. 61-64 Besides this significant effect size favoring e-health, in one intervention group the depression scores reduced also more quickly compared to the waiting list comparator group 63 . Perceptions of peer and social support significantly improved and higher support was significantly related with lower depression symptoms. 65 An antenatal, first trimester e-health intervention on depressive symptoms showed 80% intervention response and 60% remission (n=12). 63 Low and middle-income countries Limited resources and poor information is still leading to preventable maternal and neonatal deaths in low and middle-income countries. The availability of mobile phones (in Africa and South-East-Asia over 69-90%) gives rise to the implementation of e-health interventions and remote care. For more detailed information in this distinct population where e-health applications are widely used, we refer to two recently published systematic reviews (Table 2). In summary: the interventions did increase antenatal care attendance, facility and service utilization, skilled support at birth and vaccination rate. 66 Most of included studies were of poor methodological quality or did not assess health outcomes. 67 Insufficient information was provided to evaluate the impact of e-health solutions on maternal and fetal outcomes in these countries. 67 Telemonitoring and teleconsulting Telemonitoring of pregnancy is perceived to be one of the most promising answers to the possibilities of e-health in pregnancy. Several hardware and software systems involving more complex remote monitoring are described lately (Table 2). An integrated system for maternal monitoring of glucose, weight, pulse and blood pressure and a chat feature for clinician-patient contact is now in test. 68 Yi et al. developed an Android based mobile terminal for wireless fetal monitoring and uterine contractions tracking. 69 Using this system, patients in rural areas are providedwith telemonitoringwithout travelling or hospitalization. Several other telemonitoring devices for cardiotocography have been tested in pilot settings or prospective cohorts and found feasible. 70-72 Currently the effects of maternal and fetal telemonitoring in high-risk pregnancies on outcome, satisfaction and costs are under research compared to hospital admission (the HOTEL trial, registered under No. NTR6076). LITERATURE OVERVIEW OF E-HEALTH IN PERINATAL CARE 25