Anya: An evaluation of the digital health app for women’s health

Context

Maternity care across the 1,001 critical days (conception to age two) is crucial to support new and expectant parents during what can be a challenging time.

Parents may feel a lack of control and acknowledgement over the choices made during and after birth, caused in part by workforce shortages leading to high demands, with inequalities in care outcomes intensifying these issues further. Breastfeeding rates are low in the UK, with any breastfeeding at 6-8 weeks recorded at 54.2% in 2020/21, which may be leading to poorer health outcomes for the baby and parent (NHS Digital, 2021).

In response, the UK government is pushing for improvements in maternity care, with emphasis on reducing the impact of health inequalities through the first ever National Institute for Health and Care Research (NIHR) ‘challenge’, backed with £50 million to tackle maternity disparities (Department of Health and Social Care, 2024).

This foundation has provided the opportunity for innovators such as Anya to support the NHS maternity care setting. Anya is a multi-award-winning app that provides scalable education, support, and communities, on a 24/7 basis to new and expectant parents.

Unity Insights were commissioned by Anya through SBRI phase 2: Health Inequalities in Maternity Care funding (SBRI HEALTHCARE, 2022) to conduct an independent evaluation of Anya’s implementation within Greater Manchester. Primarily, the evaluation sought to address the need to formally evidence the potential monetary benefit generated by the solution against associated costs to support commissioning decisions, whilst also exploring the impact more widely from Health Care Professional (HCP) and service user perspectives, considering health inequalities within the Greater Manchester service region.

Content provided covers antenatal and postnatal topics, across the critical 1,001 days (from conception to age two) to support babies and families, whilst tailoring content to support tackling health inequalities.

Healthcare professional credibility & acceptability

• 90.3% of HCPs are frequently signposting parents to Anya
• HCPs are in near unanimous agreement that Anya’s content is of quality and relevance to users.
• 88.5% of HCPs would recommend Anya to other services.

Anya is credible and acceptable to clinicians, garnering significant support and positive perceptions from HCPs. Addressing barriers and demonstrating tangible system-wide benefits will be crucial for sustained success and broader adoption. Focusing on these areas, Anya can become an integral part of the NHS’s digital health toolkit, enhancing patient care quality.

Workforce & System impact

• 0.24 community appointments may have been avoided per engaged user.
• Other services found smaller usage reductions.
• HCPs are yet to perceive these efficiencies, only 14.8% (n = 4) agree that Anya has reduced workload pressure, which may relate to factors concerning visibility and scale.

In summary, although service system data was not available within the evaluation, data analysis indicates that Anya users were able to overcome maternity related difficulties which would require service use predominantly in the community setting. Greater uptake and usage would be functional to generate further impact, which may lead to HCPs experiencing and having visibility of Anya’s impact on their workload and the wider maternity healthcare system.

Service user acceptability

• 95% or more service users found the items within Anya to be helpful, with 3D interactive breastfeeding animations being the most helpful (Figure 1).
• 89% would recommend the app to other expectant or new parents.
• Health inequalities results support the notion that Anya is inclusive and its userbase is representative of the population that it targets.

Given the evidence, the results support the notion that Anya is inclusive and its userbase is representative of the population that it targets. No concerns are raised from the quantitative evidence that particular groups are being underrepresented or facing additional barriers to access or usage. As a result, Anya can help support efforts to address healthcare inequalities by reaching a diverse audience.

Service user impacts

• An increase in exclusive breastfeeding rates of 2.7% was recorded at birth.
• Breastfeeding rates of 83% within 6-weeks postpartum were observed, compared to Greater Manchester average of 48% at 6-8 weeks.
• A 7.0% decrease was seen in those most nervous, anxious or worried from service user survey responses.
• A 10.9% decrease in unplanned c-sections was reported via the service user survey
• Health inequalities analysis of feeding patterns and mental wellbeing suggested that Anya is equally impactful for users by subdivisions of deprivation, ethnicity and being a non-native English speaker

Overall, the data collected through self-report surveys indicates that Anya is providing support for those breastfeeding , which is potentially allowing an increase in those who wish to breastfeed to be able to overcome difficulties. The extent to which this is occurring, in other words, for how many users and for what length of time, is unknown due to data limitations. Anya’s impact on patients’ mental wellbeing is positive, with a reduction in those reporting to be most stressed or anxious. Additionally, further positive impact may indicatively occur through the favourable reception to usage of the app, although often tied to maternity stage of the user and likely impacted by many external factors. Data collected on birth patterns suggests that Anya is supporting more informed decision making at birth, primarily with fewer unplanned c-sections, correlating with other birth interventions rising and an increase in those feeling in control for the birth of their child. 

Exploring these findings for health inequalities, results identified equitable impact across subgroups of deprivation, ethnicity and non-native speakers compared to overall results. This paints an encouraging picture of Anya, indicating all potential users were able to achieve desired outcomes.  When considering the evidence in academic literature indicating existing inequalities in maternity care, Anya could contribute to the levelling of outcomes. Additionally, the project team has stated further developments are underway to support users, on top of the current range of language options and there will be more tailoring of the app to users e.g. selectable skin tones for icons and enhancing the suite of animations. These functionalities support the user-centred and inclusive digital health approach detailed within the NHS Digital Inclusion Framework, emphasising the importance of making digital healthcare accessible to everyone, including those who are less fluent in English, likely contributing to positive results for Anya (NHS England, 2023).

Economic case

• Uptake and engagement are key for positive economic returns. The fixed license cost of Anya relative to a variable user benefit means that the more people who use the app, the greater the value realised. 
• Signposting more users to Anya antenatally improves the impact on users and supports the economic case.
• Greater confidence in Anya’s positive impact on the use of birthing interventions such as caesarean sections would strengthen the economic case.
• The impact on mental health for users could lead to further benefits for the health and social care system and should be explored further. 

Recommendations

• Broaden promotional engagement to increase earlier uptake, potentially yielding greater per patient benefits.
• Overcome barriers to data access or collection within the community care setting, to support the validity of results
• Collection of system c-section data to support the depth and validity of results
• Mitigate limitations and investigate HCP perspectives that Anya is yet to impact service usage
• Measurement and embedding of short- and long-term health outcomes of breastfeeding into health economic analysis to support the business case of implementation

Conclusion

Overall, Anya is effective as a tool to support breastfeeding difficulties for new parents, additionally, early results are positive for the broader range service offering of care across the maternity journey. Health inequality analysis indicated Anya delivered equitable access, usage, and outcomes, regardless of individual user or cohort circumstances. Considering these results alongside literature evidence of disparities in access, breastfeeding and mental wellbeing for subgroups by ethnicity, deprivation and non-native English speakers, it suggests the positive result that Anya is levelling up care and addressing these inequalities. While there may be scope to improve the economic impact of the service, notably through driving uptake and engagement, the app appears to be creating system benefits which could outweigh the cost of implementation particularly through potentially avoidable unplanned c-sections. As usage becomes more widespread and over a longer time period, utilising the opportunity to broaden data collection and analysis of service datasets is recommended before drawing definitive conclusions.

Caveats

• System level data was not available from community or secondary care teams, hence all service impacts are indicative results collected via service user survey responses.
• Due to variation and sample sizes within the service user surveys, statistical analysis on impact figures for changes in c-section deliveries (unplanned or planned), average hospital length of stay at birth, community care and primary care appointments avoided were found to not be statistically significant. Therefore, these results should be taken with caution and validated when possible. Within the heath economic modelling, optimism bias has been used to mitigate uncertainty where possible.

References

Department of Health and Social Care. (2024, January). Health Secretary announces new women’s health priorities for 2024. Gov.Uk National Health Service Press Release. https://www.gov.uk/government/news/health-secretary-announces-new-womens-health-priorities-for-2024#:~:text=The%20Health%20and%20Social%20Care,for%20women’s%20health%20in%202024.

NHS Digital. (2021). NHS Maternity Statistics, England—2020-21. NHS England Digital. https://digital.nhs.uk/data-and-information/publications/statistical/nhs-maternity-statistics/2020-21

NHS England. (2023). Inclusive digital healthcare: A framework for NHS action on digital inclusion. https://www.england.nhs.uk/long-read/inclusive-digital-healthcare-a-framework-for-nhs-action-on-digital-inclusion/

SBRI HEALTHCARE. (2022, May). Competition 20 – Health Inequalities in Maternity Care. https://sbrihealthcare.co.uk/competitions/sbri-healthcare-competition-20-health-inequalities-in-maternity-care