The research team included 9 academic clinicians from the University of Canberra’s health disciplines of nutrition and dietetics, midwifery, nursing, pharmacy, and exercise physiology in addition to 3 academics from the faculty of business, government, and law. In late 2022, the research team carried out a nonsystematic literature search of GDM apps available on the market. A paucity of smartphone apps, covering all essential components for the holistic management of GDM, was identified (refer to Multimedia Appendix 1) [29]. Following a round table discussion, the research team put together a “wish list” of functions they would like included in an app of this kind (refer to Multimedia Appendix 2). The team brainstormed potential names for the app and came up with SugarMumma as it conjured happy “sweet” thoughts. In previous years, dietary advice has been heavily focused on eliminating sources of simple carbohydrate, like sucrose, from the diet—an approach that was highly restrictive. Currently, a whole diet approach is recommended where women are encouraged, as part of this approach, to consume carbohydrate foods (including simple sugars) in amounts tailored to the individual [11,12].

To complement the research team’s “wish list,” a series of HCC and HP consultations were planned. A study information flyer was circulated through the university’s intranet and via the research team’s broader professional networks. Key stakeholders of interest included HCCs with lived experience of GDM and HPs with a current role in GDM management. Following this recruitment drive, didactic interviews (n=3) and individual interviews (n=2) were undertaken online via Teams (Microsoft Corp) in March 2023 at a time that suited participants. CKA, DD, and MEH facilitated these due to their extensive experience as qualitative researchers.

The interview schedule was developed by the research team following a review of the relevant literature [1-4,8,10,12]. Questions revolved around essential features to include in the app and were kept deliberately open, enabling participants to talk with minimum interruption and without judgment. At the end of each interview, participants were given the opportunity to clarify their views and to add any information relating to the topic that may have been missed. All interviews were audio recorded in addition to the lead facilitators (CKA, DD, and MEH) taking handwritten notes. These recordings were then transcribed verbatim by four research assistants (EM, TA, CPJC, and NRI), cross-checked for consistency and entered into a word processing document.

Data were analyzed using a 6-step thematic process as described by Braun and Clarke [35]: (1) familiarization with the data, (2) generating initial codes, (3) interpreting and sorting codes into themes, (4) reviewing themes for coherent patterns, (5) defining and naming the themes, and (6) producing the report. CKA, DD, NRI, EM, CPJC, and TA analyzed all interviews, generating initial codes and discussing the preliminary findings with the broader team. Following this, CKA and NI inserted these codes under relevant themes using an inductive process.

Credibility was addressed by researcher triangulation throughout the analytical process, with CKA, MB, and DD having considerable professional experience working with HCCs with GDM, and MEH having extensive expertise in qualitative research. Feedback from the researchers was discussed at meetings until consensus was reached. The resulting themes, incorporating key recommendations, were then passed on to the app development company.

The research team engaged an app development company to design the prototype based on information and recommendations from phases 1 and 2. A series of online meetings was undertaken in April and June 2023 between the research team and the app developer to figure out essential and desired features that also heeded budgetary constraints. In addition, it is important to note that social cognitive theory (a behavioral change model) [36] was used as a foundational anchor for the development of SugarMumma. From the end of June 2023 to mid-October 2023, the app developer worked on an initial prototype, suitable for both iOS and Android devices. The React Native framework was determined to be the best “fit” for SugarMumma’s evolution. It is designed to provide a seamless development experience with five key benefits (Table 1).

The Agile project management methodology was then used [37]. App features were developed in short sprints, which enabled individual features to evolve in a modular framework. This process allowed for scalable additions and removals to be completed efficiently [38]. Prior to initiating the second round of key stakeholder feedback, lead research facilitators (DD, MEH, and CKA) undertook their own user acceptance testing (UAT). Testing included checking functionality and ensuring clinical information was accurate. No problems were identified. The final version of SugarMumma and hosting website were ready by early October 2023 for key stakeholder UAT.

HCCs and HPs from phase 2 were notified by email in mid-October 2023 about the completion of SugarMumma’s initial prototype and, if they agreed to continue with their involvement, were given 7 days to access the app. They were encouraged to operate the app as if it were for their own use. Following the UAT, individual interviews with an HCC (n=1) and HPs (n=5) were undertaken with the same methods as described in phase 2. The only difference was during data analysis where a more deductive approach was taken compared to phase 3, as the aim was to review the actual app (not simply a wish list) and to ascertain if it met HCCs' needs. Finally, recommendations were passed on to the app company for consideration in future development of SugarMumma.

This study was supported by funding from the Australian Digital Translation Fund. Before each phase of this study, participants (both HCCs and HPs) gave informed written consent. Ethical approval was granted by the University of Canberra’s Human Research Ethics Committee (reference 202311994). All participant details were kept confidential with pseudonyms used to ensure anonymity. HCCs each received a compensation of Aus $100 (US $64.87). HPs provided their time free of charge.

See Table 2 for participant characteristics.

Data analysis revealed two themes resulting from phase 2: functionality and individualized care. Interviews had an average duration of 45 minutes each (both didactic and individual).

An extensive search of the peer-review literature in addition to qualitative interviews with HCCs and HPs informed development of SugarMumma, a smartphone app for the management of GDM. Key considerations were the importance of functionality and individualized care. Our findings are consistent with similar work of this kind [29].

Good functionality, reliable information in addition to key utilities such as BGL monitoring, appointment reminders, and ability to generate health reports if desired are key features of SugarMumma. Similarly, Garnweidner-Holme et al [25] stressed the importance of a simple and easy-to-navigate menu design for pregnancy-related apps. Nevertheless, in phase 4, HPs suggested the inclusion of more dropdown menus and less text, believing this would enhance user-friendliness.

Safiee et al [29] previously identified that app first impressions are provoked by the simplicity of language and attractive visuals. Likewise, participants in our study highlighted a preference for images and icons over words to facilitate easy interpretation of BGLs, medications, exercise, and weight data (with relevant feedback) [29,39-41].

Previous studies have reported some women’s difficulty in remembering the copious amounts of information provided during antenatal care appointments [19,29,42]. A “one-stop shop” of credible resources to assist women in managing GDM is one of the proposed benefits of SugarMumma [41,42]. A qualitative study of mHealth apps identified that users rely on recommendations from a wide range of sources including strangers, friends, authoritative figures including HPs, and recognizable branding to inform app selection [42-44]

Frontline intervention for GDM management requires dietary monitoring [45,46]. Electronic food diary systems provide an opportunity for improved self-management, beneficial to both HCCs with GDM and HPs [46]. Our study indicated some participants considered carbohydrate monitoring to be a more important feature than BGL surveillance. Nevertheless, the measurement of food in grams was reported to be confusing. This correlates with similar work by Safiee et al [29], where they found that participants preferred measurements in bowls or teaspoons over dimensions in grams [29].

Participants in our study believed the generation of multifactorial reports (eg BGL or Food or Activity) to be an important function along with notetaking with the ability to contextualize data [44,46]. Similar literature has highlighted a desire for direct in-app communications with HPs, which is currently lacking in many diabetes apps [44,47]. Falsification in reporting BGLs due to HCCs embarrassment or for the purpose of receiving positive feedback has been acknowledged previously [19,29]. Automatic but consensual transfer of data from HCCs' mobile phones to their HP may negate this risk.

Visual cues are a powerful tool in engaging user experience, with consideration to culture and varying degrees of health literacy. Images may assist culturally and linguistically diverse users to navigate the app where their preferred language is not available and has the potential to diminish feelings of social exclusion. Inclusivity may also be fostered by adjusting illustrations to be appropriate for different ethnic groups [42]. Feedback from the initial prototype of SugarMumma described the overall design and language largely appropriate for the target audience. Nevertheless, it is currently only available in English.

Access to service provision for GDM management can be challenging based on factors including rurality or competing demands. These challenges are compounded by the overwhelming and drastic increase in the frequency of antenatal consultations associated with a GDM diagnosis [45,48]. HCCs and HPs alike identify the challenges in accessing health services for GDM management, including absence from work, reduced income, travel, and inconvenience (particularly if parenting other children) [29,48]. The use of smartphone apps such as SugarMumma as an adjunct for GDM management may help decrease travel time, minimize unnecessary appointments, reduce absence from work, and potentially lower stress [49,50].

Our research has not only informed the initial stages of app development but also provided a pathway for further refinements. mHealth has an increasingly complementary role to current GDM management interventions, in the context of a limited number of HPs and an increasing number of GDM diagnoses [29]. The SugarMumma app has been designed with the long-term goal of seamless integration with existing documentation systems, to be used as an adjunctive tool to standard GDM interventions. When introduced immediately following diagnosis, HPs perceive similar GDM management apps as appropriate tools for management [40,41].

Women receive a significant amount of support and monitoring during their pregnancy; however, both HCCs and HPs suggest that this level of support and follow-up is often abandoned postbirth [45]. Considering the impact of the baby’s health on motivation for GDM management, loss of motivation is unsurprising after birth [19]. We hope to expand the functionality of the SugarMumma app to include provision for women during the postnatal period by highlighting the risk of type 2 diabetes mellitus and importance of ongoing screening.

There are some limitations that must be acknowledged. This study contained only a small sample size of HCCs and HPs, thus limiting the rigor of our results. We acknowledge that our participants' views may not reflect those living with GDM or caring for HCCs with GDM elsewhere. Most of our participants were female HPs without lived experience of GDM. This may have influenced the support needs and app functions emphasized in our findings. The small number of interviews was due to participant scheduling constraints. It is also important to point out that the SugarMumma app has been designed as an adjunct to usual maternity care and in no way should replace the individual advice provided by a HP.

With the increased number of people using smartphones in their daily lives, mHealth apps are being considered as a novel way to manage chronic conditions such as GDM. This study has revealed that key stakeholders appreciate features including simplicity, regular notifications, appealing visual aids, and positive feedback. Future work is planned to enhance the current prototype.