"I believe it when there is an expert next to me:" a qualitative analysis on the perceptions and experiences of pregnant women to self-monitor blood pressure in Lombok, Indonesia.

Background: Hypertensive disorders of pregnancy (HDP) are a leading cause of maternal deaths and require close monitoring of blood pressure (BP) to mitigate potential adverse effects. The World Health Organization (WHO) recommends self-monitoring of blood pressure (SMBP) among women with HDP; however, there is limited research on its acceptability and feasibility in low- and middle-income contexts. We explored pregnant women's perceptions and attitudes towards SMBP, as well as practical considerations for SMBP by leveraging a smartphone-based BP measurement application in Lombok, Indonesia.

Methods: Pregnant women with a current or history of HDPs were randomized to participate in focus group discussions (FGDs) regarding their attitudes towards SMBP or provided with a smartphone BP application to provide feedback on conducting SMBP. In-depth interviews (IDIs) were conducted among a subset of FGD participants to further explore perceptions. A second group of participants were provided with a smartphone application to familiarize themselves with SMBP and invited to IDIs to discuss their experiences. Husbands of this second group also participated in separate FGDs. Interviews were double transcribed in Bahasa Indonesia and translated to English for thematic analysis using inductive and deductive approaches.

Results: We enrolled a total of 71 pregnant women, across 11 FGDs and conducted 15 IDIs with participants who used the smartphone for SMBP. Themes emerged related to (i) understanding of and experiences related to BP; (ii) facilitators and motivations for SMBP; (iii) barriers and concerns with SMBP; and (iv) experiences of using a smartphone-based BP application. While SMBP was perceived favorably by some women for convenience and reassurance in monitoring their BP, participants also expressed their reluctance to self-monitor BP due to factors, such as limited understanding of BP and controlling it, gravity of the consequences for their and fetus' health, self efficacy in conducting SMBP appropriately, trust in BP measurement devices, and being a new diagnosis for some women.

Conclusion: For SMBP to be implemented in line with WHO recommendations, efforts are needed to strengthen counselling among women with HDPs, clarify protocols for SMBP and subsequent actions, and provide continued support to pregnant women. Considering varying levels of BP knowledge, future research should examine the implications of introducing SMBP among pregnant women with chronic hypertension versus those with newly onset gestational hypertension, as well as the potential conflation between BP and blood haemoglobin.