Usability Study of the Mommy-Be App: Exploring the Experience of Breastfeeding Mothers in Eastern Indonesia

The rise of mobile health (mHealth) apps has brought attention to their potential in supporting breastfeeding mothers and preventing postpartum depression (PPD). This study aims to evaluate the usability of Mommy-Be, a mobile phone app designed to support breastfeeding women and help them to acknowledge of their mental health and breastfeeding e�cacy during lactation period. This study combines quantitative and qualitative methods, that asses Mommy-Be app's usability among breastfeeding mothers using the Mobile Application Usability Questionnaire (MAUQ) and conducted in-depth interviews with a subset of participants. The study included 50 breastfeeding mothers in Makassar, Indonesia, who were primarily between the ages of 19 and 42 and had diverse educational and employment backgrounds. Four weeks after using the Mommy-Be app, revealed a generally positive impression of the application. Based on MAUQ three dimensions, ease of use, interface satisfaction, usefulness, this study has been determined that the utilization of a Mommy-Be application is both acceptable and feasible as a mobile health (mHealth) solution for breastfeeding mothers. The mothers experience revealed diverse user impressions of the Mommy-Be application. Participants generally found it easy to use, with a favorable interface preference. Participants expressed various bene�ts of using Mommy-Be, including increased awareness of breastfeeding activities, assistance in meeting nutritional needs, and early detection of postpartum depressive disorders. However, challenges were identi�ed, such as the inability to export data, lack of module integration, and dependence on an active internet connection. To enhance the application's utility, participants suggested improvements, such as data export capabilities, better module integration, consideration of the target audience's resources regarding internet access and the inclusion of educational content, such as the provision of interconnection with multiple lactation counsellors.


Introduction
In recent years, the use of mobile health (mHealth) applications has gained signi cant attention in the healthcare eld.mHealth apps have the potential to become powerful tools in supporting breastfeeding mothers and preventing postpartum depression (PPD).Scienti c literature acknowledges the importance of breastfeeding as a means to promote both maternal and child health.Similarly, the prevention and management of PPD signi cantly contribute to the overall well-being of mothers.Several scienti c articles have recognized the potential of mHealth apps in addressing these concerns.An intervention study evaluated the usefulness of mHealth app in supporting breastfeeding mother, and this study state the app could be a useful self-management tool for Thai breastfeeding mothers.Furthermore, the qualitative analysis showed that the app supports breastfeeding on demand, but its ow and inputs should be more intuitive [1].A systematic review and meta-analysis on 15 RCTs highlighted that mHealth apps can play a vital role in providing breastfeeding education, counseling, and support to mothers.
Interventions based on mHealth can signi cantly improve the rate of postpartum exclusive breastfeeding, breastfeeding e cacy, and participants' attitudes toward breastfeeding, and reduce health problems in infants [2].Another systematic review on effectiveness of technology-based interventions in promoting breastfeeding, have proven to be effective to improve antenatal care and postnatal care services, especially those that are aimed at changing behavior of pregnant women and women in postnatal period.This study also found that mHealth apps can provide accurate and reliable information on breastfeeding practices, allowing mothers to make informed decisions.The mHealth role delivered through smartphones have the potential to reach a large number of women, thanks to the widespread availability and usage of smartphones or android platform.This indicates that mHealth apps are a feasible solution to support breastfeeding mothers on a large scale, especially in low-and middle-income countries [3].
Numerous studies have investigated the effectiveness of mHealth apps in supporting breastfeeding mothers, demonstrated that mHealth apps can signi cantly improve breastfeeding self-e cacy and satisfaction among mothers compared to traditional supportive methods.Enhanced self-e cacy is a crucial factor in successful lactation, as it helps mothers develop con dence and cope with the challenges of breastfeeding.Furthermore, mHealth apps can track breastfeeding patterns, offer reminders, and provide immediate access to lactation consultants, thus promoting successful and sustained breastfeeding [4]- [7].
On other condition, breastfeeding challenging situation often collocate mother into risk of Postpartum Depression (PPD).There's an immerse literature stated that breastfeeding and PPD are two inferential causes related to each other on two pathways, it can be a cause or an effect [8], [9].Similar to breastfeeding, mHealth approach in preventing PPD also provide a positive outcome.According to 9 RCTs with a total of 1958 women with PPD nds that the EPDS and anxiety scores were signi cantly lower in the telehealth group compared with the control group.Signi cant subgroup differences were found in depressive symptoms according to the severity of PPD, telehealth technology, speci c therapy, and follow-up time [10].A study investigated the effects of mobile health application designed based on mindfulness and social support theory on parenting self-e cacy and postpartum depression symptoms of puerperae, shows perceived social support, maternal parental self-e cacy were signi cantly higher and postpartum depressive symptoms was signi cantly lower from using the app [11].A randomized controlled trial on a large sample in Japanese mothers, imposes higher self-e cacy, less loneliness, and fewer perceived barriers to healthcare access compared to those in regular care group [12].
The use of mHealth apps to help breastfeeding mothers and prevent postpartum depression (PPD) holds a lot of promise.These apps, can play an important role in improving the well-being of breastfeeding mothers and reducing the prevalence of PPD by providing accurate information, support, and early intervention.Uncertainty about the su ciency of the baby's milk intake is a major concern for breastfeeding mothers, particularly in the rst week after birth.This uncertainty, which is frequently fueled by a mother's inability to recognize breastfeeding patterns based on frequency and duration of sessions, can erode a mother's con dence and lead to stressful situations.Furthermore, maternal mental health during breastfeeding is still poorly understood, particularly in developing countries.As a result, there is a need to bridge the gap by raising mothers' awareness of potential mental health challenges while breastfeeding.Therefore, the purpose of this study is to evaluate the usability and utility of Mommy-Be, a mobile app designed to support breastfeeding women and raise their mental health awareness during the breastfeeding period in Middle Indonesia.

Study Design
This study employs a combination of quantitative and qualitative research methods.The usability of the Mommy-Be application was evaluated using a quantitative methodology.A quantitative descriptive analysis was conducted to examine the utilization and acceptance of Mommy-Be, employing the Mobile Application Usability Questionnaire (MAUQ).The chosen tool exhibits resemblances in terms of language and context to the instrument's original development and validation [13].The instrument comprises a total of eighteen items, which are categorized into three domains: ease of use (consisting of ve items), satisfaction and interface (consisting of seven items), and usability (consisting of six items).This study also used a single group pre-post approach (pretest-posttest only design), with participating mothers being assessed for breastfeeding e cacy using the BSEF-SF [14] and potential postpartum depression using the EPDS [15] instrument before and after the Mommy-Be experiencing period.A qualitative methodology was employed, utilizing in-depth interviews with a speci c subset of breastfeeding mothers.This subset was chosen selectively from 50 participants who possessed an Android cellphone or tablet and expressed willingness to utilize the application for a continuous duration of one to four weeks.The objective of this interview was to acquire a thorough comprehension of the utilization and acceptability of the Mommy-Be application in assisting breastfeeding mothers and enhancing awareness regarding their mental health conditions.In addition to this, the participants were also extended invitations to participate in telephone interviews subsequent to their completion of the application for a continuous duration of four weeks.

App Description
The study employed a research methodology that involved the utilization of a mobile health application known as Mommy-Be, an acronym for Mother Oriented Mental Health Monitoring and Breastfeeding Evaluation.The software application referred to as "Mommy-Be" is designed with the speci c purpose of providing support and facilitating access to a range of resources for mothers who have recently undergone childbirth and are actively involved in the act of breastfeeding.This application comprises a range of modules and features that have the potential to enhance lactation productivity and raise awareness of mental health disorders among breastfeeding mothers.
The application encompasses a collection of modules, which include: The module on infant feeding and growth monitoring focuses on the assessment and management of nutrition in infants.The breastfeeding timer allows users to initiate and terminate the timer in order to document the duration of individual breastfeeding sessions.The module of diaper changes: This module enables users to monitor and record instances of diaper changes, encompassing both wet and soiled diapers.By doing so, it offers valuable information on the su ciency of the baby's breast milk consumption, estimating the frequency of urination and defecation.Growth Metrics: Users have the ability to document their infant's weight, height, and head circumference at various intervals, facilitating the tracking of the infant's growth and development, as well as maintaining records of immunizations.Sleep Tracking: Individuals have the ability to document the sleep patterns of their infants, encompassing both daytime naps and nighttime sleep duration, with the aim of establishing a consistent sleep schedule and facilitating the process of sleep training for mothers.
The Maternal Nutrition Intake Module includes a feature for food logging, where users can document their daily food consumption.By inputting details such as food type, size, and portion, the module can automatically calculate the user's daily caloric allowance requirement.Weight Monitoring: Individuals have the ability to record and monitor their weight longitudinally, enabling them to assess postpartum weight reduction and gain valuable understanding of the potential for post-pregnancy obesity.A module designed for the early detection of postpartum depression and the promotion of increased mental health awareness.
The Mental Health Assessment module offers a questionnaire consisting of 10 items, which serves as a tool for users to assess their mental well-being.Users are able to complete this questionnaire in order to evaluate their mental health.The present assessment encompasses various domains, including stress, anxiety, depression, and overall mental well-being.Identi cation of Risk Factors: The module utilizes the assessment results to identify potential risk factors and delivers personalized feedback to users.This feedback includes information on whether they are at risk of developing speci c mental health conditions, which are linked to their obstetric conditions and nutritional status.

Recruitment
Convenience sampling was used for each participant received an invitation link through the messaging platform WhatsApp, which allowed them to download the Mommy-Be application.Prior to initiating the download process, users are provided with a comprehensive video tutorial that elucidates the steps involved in registering and navigating the application's menu interface.Nursing mothers are provided with limited support from ten skilled research assistants in order to facilitate their pro ciency in utilizing the application until they have effectively mastered all of its available features.This study included breastfeeding mothers with babies under two years, had prior experience with Android phones, and had no history of mental health disorders.In August 2023, a four-week period is designated for granting mothers access to a smartphone application.Subsequently, individuals are requested to provide their signature on a written consent form, indicating their willingness to engage as research participants for a duration of four consecutive weeks.Additionally, they are expected to complete a questionnaire assessing the utility of the Mommy-Be application, based on their personal experience.They were also asked to ll out the breastfeeding e cacy form twice, once before and once after using the app.The EPDS score was calculated using data from the mothers' initial and nal screenings on the app.
Each participant underwent an initial interview before commencing the study protocol, which was followed by a four-week period during which the participants were provided with the application for utilization.Following the designated period, interviews were conducted subsequent to the use of the application in order to evaluate its acceptability and usability.The two sessions were conducted individually and recorded in audio format with the intention of conducting qualitative analysis.The participants were chosen from two primary healthcare centers (Puskesmas) situated in the urban area of Makassar, South Sulawesi, Indonesia.The choice of this facility is predicated upon its appropriateness for accommodating patients who are mothers and children.Furthermore, the choice to employ the identical site as previous investigations [9], [15]- [17] was made with the aim of maintaining coherence in the examination of advancements in maternal and mental health provisions.The study used a Wilcoxon Signed Rank Test to compare Postpartum Depression and Breastfeeding E cacy scores before and after using Mommy-Be.Results in Fig. 1 showed a signi cant decrease in postpartum depression scores after using Mommy-Be, while breastfeeding e cacy scores improved signi cantly.The negative rankings indicate a positive change, indicating the potential positive impact of Mommy-Be on breastfeeding self-e cacy.The results suggest that using Mommy-Be can signi cantly reduce postpartum depression and increase breastfeeding e cacy.
The study found a signi cant relationship between the length of time mothers used Mommy-Be and changes in Postpartum Depression Score (EPDS) scores.The correlation coe cient was − 0.379, indicating a weak negative relationship, suggesting a possible association between increased use and lower scores.The correlation coe cient of 0.619, indicating a strong positive relationship, indicated a strong positive relationship between increased use and increased breastfeeding self-e cacy.These ndings support the idea that Mommy-Be use is related to increased breastfeeding con dence and e cacy, indicating its potential therapeutic impact in reducing postpartum depressive symptoms.The MAUQ was used to explore how the mother experience after using this application four week in a row.
The MAUQ was consisting of seven-point Likert scale for subjective opinion from strongly disagree to strongly agree.The descriptive score of 50 participant presented in Table 4.According to the descriptive table's data, the average rating for each participant assessment item is vary between three to six.This shows that users have a different impression after using this app.On the ease-of-use dimension, respondents rated it generally good with an average score of 5.8 to 6.1, meaning that it was easy to master how to use the app and apply it during breastfeeding.This is possible because they are generally already familiar with android apps.For the function dimension of the app interface, especially the interface preference item got the most favorable rating among all with the lowest score of four.The item comfort of use, still within the interface dimension, was rated quite low by mothers with a mean score of 4.3, this may be due to its relation to the comfort of breastfeeding mothers in public making them rate it as such.In the usability dimension, the use of applications that must be based on a strong internet connection received the lowest rating with a mean score of 3.8.This online-based application is a common source of complaints, as it is inconvenient for those who do not always have an active network quota on their mobile devices, in addition to the fact that the environment does not yet show equal distribution of free internet access.So this can be an input for development, that this application needs to consider the resources of the target audience.Each participant must have an active quota and network connection for the Mommy-Be application to function.Range SD Ease of Use The app was easy to use 6.1 3-7 0.9 It was easy for me to learn to use the app 6.0 3-7 0.8 The navigation was consistent when moving between screens 5.8 2-7 1.1 The app's interface allowed me to use all the functions offered by the app 6.0 2-7 1.0 Whenever I made a mistake using the app, I could quickly recover 5.9 2-7 1.2 Interface and Satisfaction I like the interface of the app 5.9 4-7 0.9 The information in the app was well organized, so I could easily nd the information I needed 6.0 2-7 0.9 The app adequately acknowledged and provided information to let me know the progress of my action.

Usability
The app would be useful for my health and well-being 6.0 2-7 1.1 The app improved my access to healthcare services 6.1 3-7 0.9 The app helped me manage my health effectively 6.1 3-7 0.8 This app has all the functions and capabilities I expected it to have 5.6 3-7 0.8 I could use the app even when the Internet connection was poor or unavailable 3.8 1-7 2.0 This mHealth app provided an acceptable way to receive health care services, such as accessing educational materials, tracking my own activities, and performing self-assessments 6.1 2-7 0.9 In addition, this assessment is followed by structured in-depth questions based on the three primary dimensions of the MAUQ, namely ease of use, user interface, and satisfaction with the application, as well as the health utility of the application.Participants who initially opened the link to download the application onto their Android phone remarked on the simplicity of this application's interface.
"with one click, the application is immediately installed, and registering is also very simple, requiring only a cellphone number as identi cation, so I don't have to ll out too much information during registration (18-25 years, primipara, housewife)" This application has the simplest user interface and user experience possible, with an unobtrusive design, clear visibility of each feature, and representative icon images.There are data entry modes with simple options so that users can choose to ll out each information log.
"When you open the menu, everything appears on a pleasant background, the pictures are also appealing, I like the illustrations and the color combinations, which are colors that many women enjoy, and the menus within are also very simple to ll out (25-30 years, multipara, working mother)" Based on the primary reason for developing the Mommy-Be application, it is a bridge to meet the needs of breastfeeding mothers in understanding their breastfeeding activities, assisting them in meeting their nutritional needs while breastfeeding, and increasing their awareness of postpartum depressive disorders with independent early detection at any time, particularly for those who have never had children or previous breastfeeding experience.The following are some of the perceived bene ts they felt after four weeks of intensive use of this application.
"As a new mother, I really don't understand how babies can breastfeed, whether they are full enough, or whether urinating is an indicator that they are getting enough to eat (18-24 year, primipara, working mother)" This application helps me remember yesterday's breastfeeding session, which is the foundation for me to be able to breastfeed more frequently and for longer durations in order to stimulate my milk production (25-30 years, primipara, housewife).
"My child is very active; he occasionally sleeps more in the morning and rises later at night.This application is with me while I breastfeed at night.I am sometimes stressed by their crying, I sometimes feel like I have failed to breastfeed, and at the beginning of my birth I didn't sleep a day or night because of my baby's crying.After lling out the depression screening menu, I was shocked to discover that I have the potential for depression.I will consult a doctor because I am afraid that this will interfere with my lactation (31-35 year, primipara, working mother)" Inadequacies in data export and module integration are among the conditions that may prevent the application from being used to its full potential.Users are unable to retrieve and store data externally regarding a summary of their application-related activities.Also, these applications still lack interconnections between their various educational content, such as breastfeeding problems and solutions, nutrition and diet for breastfeeding mothers, and signs and symptoms of anxiety and depression.
Regrettably, it is not feasible to retain a month's worth of data in PDF format.Despite its utility for future consultations with the pediatrician, the provision of a copy of the document containing the recorded data would undoubtedly prove highly advantageous (25-30-year, multipara, working mother There are also disadvantages associated with the application database, which requires an active internet connection to function properly. I encounter di culties in consistently purchasing a quota, as this application fails to update when I attempt to input data.Speci cally, the data I inputted while away from a Wi-Fi connection was not saved.The availability of an o ine version would potentially enhance our freedom to utilize the application (36-40-year, multipara, housewife) This may be a consideration for developers, as there is the potential to improve the accessibility of this application so that it can be connected in real time in the future, necessitating improvements to user data security and other factors.

Discussion
A stepwise survey involving 50 active breastfeeding mothers from two primary health care centers in Makassar, Indonesia, was completed successfully.Subjects ranged in age from 19 to 42 years old, had multiple pregnancies, and had a fairly high level of education.Notably, the participants included a signi cant number of working people and full-time housewives, re ecting the diverse demographics.The participants were currently breastfeeding infants under six months of age, primarily through vaginal delivery in hospitals.Maternal age, maternity leave duration, transport distances, workplace distances, infant ages, birth intervals, and birth weights exhibit considerable variability, as indicated by standard deviations.The Wilcoxon Signed Rank Test was employed to assess the differences in depression and breastfeeding e cacy scores prior to and following the utilization of Mommy-Be.The ndings demonstrated that the utilization of Mommy-Be led to a notable reduction in postpartum depression scores and a substantial improvement in breastfeeding e cacy scores.The presence of negative ratings suggests that Mommy-Be may have a bene cial effect on breastfeeding self-e cacy.Additionally, a noteworthy inverse correlation was discovered between the duration of Mommy-Be usage by mothers and alterations in postpartum depression scores.This nding implies that heightened Mommy-Be usage might be linked to reduced levels of depression.Furthermore, a robust positive correlation was observed between heightened utilization of Mommy-Be and enhanced self-e cacy in breastfeeding, indicating that it may have a therapeutic effect in mitigating symptoms associated with postpartum depression.
This study provided evidence for the e cacy of Mommy-Be as a supportive tool for breastfeeding mothers, while also highlighting its potential to increase awareness of postpartum depression, a condition that often goes unnoticed.Based on MAUQ three dimensions, ease of use, interface satisfaction, usefulness, this study has been determined that the utilization of a Mommy-Be application is both acceptable and feasible as a mobile health (mHealth) solution for breastfeeding mothers.The mothers experience revealed diverse user impressions of the Mommy-Be application.Participants generally found it easy to use, with a favorable interface preference.However, concerns were raised regarding the comfort of use, especially in public spaces, and the requirement for a strong internet connection.This is due to several challenges such as the high cost of the internet, network congestion such as population density in urban areas which refers to network slowdown [18], and several other issues such as android compatibility and digital literacy.While the comfort of using the app in public is closely related to breastfeeding, normal public breastfeeding remains a problem in this country [19].
Lactation companions, such as the Mommy-Be, possess the capacity to offer signi cant assistance to mothers engaged in breastfeeding.The lactation companion application offers signi cant insights into breastfeeding methodologies, alterations in infant nutrition, and breast maintenance.Mothers perceive this application as a valuable tool for enhancing their understanding of lactation and addressing various inquiries that may arise during the breastfeeding process.Breastfeeding exhibits individuality among mothers, with variations in experiences arising from the distinct characteristics of each child.Facilitating maternal self-identi cation during the act of breastfeeding represents a pivotal measure that can enhance mothers' self-e cacy pertaining to lactation [5].The available data provides written instructional materials that aid mothers in gaining a deeper comprehension of their infants' preferences and breastfeeding requirements [6].This software facilitates the mother in documenting the infant's developmental progress, feeding routines, and additional data.This facilitates maternal comprehension of infants' developmental progress and guarantees adequate milk intake.
The incorporation of visually appealing and intuitive app design enhances usability.According to the ndings of this study, users exhibited a favorable reaction towards the visual aesthetics of the application during their initial interaction.Mothers indicate that the app's clean and intuitive interface engenders a sense of comfort and ease in their usage.E cient navigation facilitates the seamless access of diverse application features for mothers.The inclusion of prominently displayed buttons within the app facilitates seamless navigation for mothers.The utilization of visual aids, such as baby growth charts, diagrams and illustrations depicting breastfeeding patterns, serves to enhance maternal comprehension of the provided information [7], [20], [21].Mothers perceive this application as userfriendly due to its e cient registration process and convenient login functionality.
Breastfeeding is a protracted undertaking that can occasionally engender feelings of social seclusion among mothers.This phenomenon has the potential to induce anxiety, particularly among mothers in the immediate postpartum period.Mothers perceive the presence of comparable circumstances in their partners as necessitating assistance and support from external sources to personally navigate the prolonged practice of breastfeeding.A signi cant number of mothers experience a state of depression due to their inability to comprehend their infant's needs, lack of understanding regarding the concepts of satiety and hunger in newborns, and challenges in soothing a restless baby.The exertion of physical pressures has a discernible effect on the experience of fatigue and the occurrence of mental burnout.
Certain users perceive the advantages of utilizing the postpartum depression screening application as a means to authenticate the mood uctuations experienced during the initial week of breastfeeding.The ndings of this screening serve to inform individuals that they possess issues that necessitate the Figures Screenshot from the Mommy-Be app

Table 2 ,
the study group is diverse, with a mean maternal age of 28.5 years and a range of 9 to 42 years.This range's standard deviation of 6.3 shows maternal age variability, re ecting participant individuality.Typical maternity leave is 2.5 months, ranging from 1 to 6 months.The standard deviation from 1700 to 6000.The sample's birth weight variability is shown by the 632.5 standard deviation.The average Mommy-Be use was 13.8 days, ranging from 5 to 30.Standard deviation of 5.3 shows Mommy-Be use duration varies among participants.Moderate prenatal and postpartum depression scores improved slightly.This implies a complicated postpartum mental health trajectory.Postpartum, breastfeeding self-e cacy rises signi cantly.Breastfeeding con dence has increased postpartum.
of 2.4 indicates heterogeneous maternity leave duration choices.Transport distances range from 0.1 to 13 km, but workplaces are 1.7 km on average.The high 3.5 standard deviation emphasizes diversity.Infants are 0.5 to 17.5 months old and average 4.9 months.Infant age variation is shown by the sample's 12.0 standard deviation.The average birth interval is 3.0 years, ranging from 0 to 11.Based on the high standard deviation of 9.5, birth intervals vary widely among participants.Birth weight averages 3093.6 grams, ranging

Table 4
Descriptive quantitative analysis of Mommy-Be Usefulness