Within the United Kingdom, nearly half of all pregnancies are unplanned [1], and abortion rates are at an all-time high [2]. These trends suggest that reproductive health services are failing to meet people’s needs. Contraceptive use remains inconsistent, with almost 1 in 5 women of reproductive age in England reporting using no contraception or unreliable methods [3], and the use of hormonal contraception is decreasing [4]. Unplanned pregnancies are disproportionately concentrated among underserved populations [5], including those living in poverty and individuals from ethnic minority groups, and are associated with a range of adverse outcomes such as preterm birth, involvement of children’s social care services, financial adversity, and health inequalities [6]. As such, unplanned pregnancy remains a significant public health concern and a key driver of disparities in maternal and child health.

At the same time, the health of individuals entering into pregnancy (whether planned or unplanned) presents additional challenges. More than 90% of women in the United Kingdom have at least one modifiable risk factor associated with adverse pregnancy outcomes [7] including maternal and neonatal morbidity and mortality. Yet, the majority of women, and their partners, make no health or lifestyle changes in preparation for pregnancy [8]. This lack of planning and preparation represents a missed opportunity to optimize health before conception, improve pregnancy outcomes, and reduce longer-term risks for both parent and child. Contributing to this gap is the fact that discussions around pregnancy preferences and preconception health are not routine in health and social care settings [9,10], even for people with preexisting conditions, those taking medications, or those with social risk factors.

Furthermore, reproductive health discourse and interventions often overlook the role of men, despite evidence linking paternal nutrition, body composition, and lifestyle behaviors to sperm quality and offspring health outcomes [11,12]. This underscores the need for a more inclusive, holistic approach to reproductive health.

There is an unmet and expressed need among people of reproductive age for better support with their reproductive health [9,13]. Combining this need with the challenges outlined above highlights the importance of adopting a more proactive, person-centered approach to supporting reproductive decision-making. Reproductive life planning [14] offers such an approach, enabling individuals to reflect on their reproductive intentions, align these with their health and life circumstances, and access the information and care needed to achieve their goals.

While health care professionals have a vital role to play in delivering this support, additional approaches are needed to extend reach and accessibility. Digital health interventions (DHIs) offer a promising approach, with emerging evidence suggesting that they can overcome barriers of distance, accessibility, stigma, and judgment [15] and can improve preconception health [16]. However, evidence on their effectiveness in supporting contraception use remains limited [17,18].

The development of any new DHI should follow a systematic, theory-driven process to maximize its potential for effective real-world implementation. In line with Medical Research Council guidance on complex interventions [19,20], such development should be reported transparently to strengthen the evidence base, enhance reproducibility, and allow others to assess its relevance across contexts. Despite these imperatives, the intervention development phase remains relatively underreported, which poses issues with transparency, quality, and user-centeredness [21].

This paper aims to describe the systematic development and pilot testing of Orchid, a novel DHI to support people of reproductive age to understand their pregnancy preferences and develop a reproductive life plan (RLP).

Our development of Orchid followed the Intervention Mapping (IM) framework [22], as used by other digital health programs [23].

Informed by the results of our needs assessment and input from our codevelopment group, we identified specific performance objectives for subpopulations, based on reproductive preferences. For example, taking folic acid for those actively planning a pregnancy or consistent and correct contraceptive use for those wishing to avoid pregnancy. See Table S2 in Multimedia Appendix 1 for more examples.

Our scoping review identified 5 key behavioral determinants that are underlying drivers of behavior change: (1) knowledge [30], (2) self-efficacy [31,32], (3) social support [31], (4) intrinsic motivation [30], and (5) autonomy [30]. We explored the relationships between performance objectives and behavioral determinants and identified change objectives and practical strategies for each target behavior.

We applied the Capability, Opportunity, Motivation–Behavior (COM-B) model [33] when developing Orchid. This model was selected because each of the behavioral determinants we had identified (knowledge, self-efficacy, social support, intrinsic motivation, and autonomy) aligns with one or more of the COM-B components, providing a comprehensive framework for influencing behavior change within Orchid. We systematically mapped each component of the COM-B model to Orchid’s proposed content and features, linking them to the specific objectives identified during the planning phase (Table 1). This ensured that theory directly informed Orchid’s design, aligning practical features with the mechanisms expected to support behavior change. We also identified several behavior change techniques [34-37], including goal setting and reminders, feedback, habit stacking, action planning, information, and education. These techniques were incorporated into Orchid to support the COM-B framework, enhance engagement, and increase the likelihood of successful behavior change.

Ethical approval for the health care pilot was granted by the NHS London, Riverside Research Ethics Committee (Ref: 24/LO/0421). Informed consent was obtained from all Orchid users; they were provided with a participant information sheet and were required to provide consent before using Orchid. Informed consent was also obtained from all users, nonusers, and HCPs who participated in an interview. Participants who took part in interviews were given a £25 (US $33) voucher.

All user data collected through Orchid were handled in accordance with data protection regulations. Email addresses were stored separately from the main dataset, and all analytical data were pseudonymized prior to analysis. All data were stored in the University College London Data Safe Haven and were only accessible to authorized members of the research team.

We conducted in-depth interviews with 10 HCPs. The NPT [41] framework was used to analyze the data, exploring the effectiveness of the training, the likelihood of adoption, implementation, and sustainment of Orchid. Outcome data were limited by the short-term nature of the pilot project, and we therefore focused on the intervention performance.

Training was feasible in all 3 clinical settings and was scheduled during each site’s regular training program. In-person sessions were preferred to live online training, but HCPs agreed that online was sometimes more practical. Most HCPs found the training stimulating and understood the importance of the topic. New learning and increased confidence were commonly reported, and HCPs appreciated receiving detailed practical tips that they could immediately incorporate into their clinical practice. The inclusion of men in the RLP message was novel for most and several specifically commented on their cognitive engagement with the training, saying,

Most HCPs said that being able to use Orchid within the training would have increased their confidence in sharing the tool with patients:

Despite this, most HCPs found signposting patients to Orchid acceptable, although some demonstrated limited engagement; one HCP said,

Many HCPs felt that reminders or brief refresher sessions would be useful:

and emphasized the need for more collective action to support sustained uptake of Orchid. Having a local champion at a site was seen as valuable in maintaining momentum, as illustrated by one HCP:

HCPs found it feasible to incorporate opportunistic RLP and preconception information into certain consultations, particularly those relating to women’s health, baby clinics, vaccination clinics, chronic disease clinics, and male fertility. One HCP noted

However, HCPs agreed that it was more challenging to introduce these topics in other consultations:

and many acknowledged that such discussions were not always possible:

Overall, views were mixed on the impact on consultation times; while some HCPs were hesitant to raise the topic for fear of it leading to a longer consultation, others acknowledged that Orchid could “save time maybe because … we can refer directly to the app and say, look, we have good information there” (MP01).

Importantly, where HCPs had mentioned Orchid to patients, the response was consistently positive:

At the GP practice, text messages were used to promote Orchid. While HCPs were supportive of this method of recruitment, “I think the text message is absolutely excellent,” they did share concerns about potential pitfalls:

In total, 153 people signed up to Orchid, of whom 109 (71%) were females and 44 (29%) were males. Most people found out about Orchid via a text message from their GP (102/153, 66.6%), followed by clinical consultation (19/153, 12.4%) and posters in waiting rooms (15/153, 9.8%). The most common reason for using Orchid was “I want reliable information” (48/153, 31.3%), followed by “just curious” (36/158, 23.5%). Sociodemographic data of Orchid users can be seen in Table 2.

Of the 106 nonpregnant female users, 72 (68%) received a pregnancy preference group (Table 3). Of the 119 people who were eligible to complete an RLP pathway (3 pregnant females, 72 females who received a pregnancy preference group, and 44 males), 32 (26.9%) did so (Table 3). There was no difference in completion by ethnicity. More details of who was eligible for the different features can be found in the Multimedia Appendix 1.

In total, 5 users and 2 nonusers were interviewed, and we also received written feedback (via Accurx text messaging) from 2 additional nonusers.

This study set out to codevelop and pilot Orchid, a novel DHI, to support people of reproductive age to understand their pregnancy preferences and form an RLP. Guided by the IM framework [22], we codeveloped Orchid through iterative co-design with end users and a multidisciplinary clinical academic team. The pilot study, conducted across 3 NHS settings, demonstrated that integrating Orchid into real-world clinical contexts was feasible and acceptable. HCPs were generally comfortable recommending Orchid to patients, and users valued its content and design. Although uptake was lower than anticipated, the data collected provide important insights for refinements needed for wider implementation.

Using IM [22] enabled transparent, evidence-based codevelopment grounded in behavioral theory and user needs. The structured process supported iterative refinement and ensured alignment between Orchid’s purpose, content, delivery, and intended behavior change outcomes, avoiding assumption-led development. By mapping performance objectives and determinants to theory-based methods, grounding Orchid in COM-B [33], and incorporating behavioral determinants identified in the literature [24], we specified hypothesized mechanisms of action aligned with behavior change techniques shown to increase engagement [43]. This systematic approach enhances transparency and has been associated with improved DHI quality and effectiveness [44,45]. IM’s emphasis on needs assessment and stakeholder involvement further ensured that Orchid was relevant, inclusive, and user-centered, which was reflected in strong acceptability among health professionals and diverse users [46,47].

Implementation within health care settings proved feasible, with training integrating well into existing sessions and HCPs generally finding it acceptable to recommend Orchid. However, barriers emerged, including time constraints, competing clinical priorities, and difficulty raising reproductive health in unrelated consultations, which are common concerns [13,48,49]. Users found it acceptable to be recommended Orchid and valued its digital format due to the convenience, autonomy, and privacy it affords, consistent with previous findings [13].

Uptake was lower than expected, a common challenge in digital health research [50,51]. Feedback from those who received a GP text message but did not sign up uncovered a perception that Orchid was primarily for people planning a pregnancy, despite our efforts to use neutral “reproductive health” messaging. This highlights the need for tailored recruitment strategies that clearly communicate relevance, though evidence on personalized recruitment remains mixed [52]. Digital recruitment remains cost-effective [50], suggesting optimization is worthwhile [50]. HCPs valued the training but reported that the lack of a live demonstration limited their confidence in signposting, echoing wider evidence that successful DHI implementation requires practical exposure [53]. Addressing these factors is likely to improve recruitment in future roll-outs.

Engagement with Orchid during the pilot was limited, with infrequent use of goal-setting and reminder features. While partly expected due to the short pilot period, users reported barriers such as navigation challenges and not realizing Orchid could be downloaded as an app (where the goal-setting features are optimized). Despite this, users gained new knowledge and described ways in which Orchid informed their reproductive decision-making or led to behavior change, suggesting that even brief interventions can have a meaningful impact [54], as others have also found across a range of health conditions [51,55]. As part of IM step 4 [43], we will refine pathways through Orchid, reduce friction points, and expand features to support more sustained engagement, ahead of larger-scale evaluation (steps 5 and 6).

Existing RLP studies [56] demonstrate high acceptability but limited evidence of effectiveness [56], with most studies focusing on process outcomes, such as knowledge, rather than behavior change outcomes [24]. However, the OptimalMe study [57] found increased use of folic acid and reduced alcohol intake in women planning a pregnancy [57], while digital contraceptive interventions appear to be associated with increased uptake of effective contraception [58], especially post pregnancy, though this is not always the case [59]. As the first UK co-designed, theory-driven, digital RLP integrating reproductive preferences with both contraception and preconception pathways, Orchid fills longstanding gaps in scope, theory, and digital innovation.

As a feasibility and acceptability pilot, this study is limited. Key outcomes, including ongoing engagement, behavior change, and effectiveness, require evaluation in future stages. Additional limitations include the lack of sampling frames at 2 sites, preventing response rate calculation or assessment of generalizability, and uncertainty around exposure to different recruitment methods. The absence of a live app at the time of training may have reduced HCP signposting, and limited visibility of the app means we cannot draw conclusions about platform preference.

Orchid’s systematic development, theoretical foundation, and extensive end-user involvement represent key strengths commonly associated with effective DHIs [19,20,33,44,45,54]. Together, these features position Orchid well to function as an effective intervention for improving reproductive health [60]. Our emphasis on inclusivity is reflected in the diversity of both the codevelopment group and pilot users, including people from more deprived areas, speakers of languages other than English, global majority populations, men, and nonbinary people. The varied pregnancy preferences among users show that Orchid serves diverse needs. A particularly notable strength is Orchid’s explicit inclusion of men, a group often overlooked in preconception and reproductive life planning. The fact that nearly one-third of users were male highlights demand for male-inclusive reproductive health support and demonstrates Orchid’s reach among underserved groups, aligning with emerging evidence that systematically codeveloped DHIs demonstrate greater acceptability and effectiveness [19,20,33,44,45,54].

Orchid has been designed to support national priorities for digital transformation and preventative care, reduction of unplanned pregnancy, and improvements in maternity outcomes. The diversity of pilot users supports our aim of equitable reach. The NHS 10-Year Plan for England [61] prioritizes digital innovation, prevention, and strengthened primary care, and Orchid aligns with each of these aims. By offering accessible, evidence-based reproductive health information and supporting people to articulate and act on their reproductive intentions, Orchid has the potential to enhance digital health literacy, reduce service pressures, and improve patient-provider interactions. By addressing inconsistent contraception use, lack of proactive reproductive life planning, and low awareness of preconception health actions, Orchid can contribute to reducing unplanned pregnancy and improving maternal and neonatal outcomes, as well as longer-term health and development of parents and children.

Orchid is the first DHI co-designed to support reproductive health across the life course in the United Kingdom. The development and pilot testing of Orchid demonstrate the value of using IM to create a theory-driven, codeveloped digital tool for reproductive health. The findings of our pilot suggest that Orchid is both feasible to implement and acceptable to health care providers and users, while highlighting areas for refinement to enhance engagement and relevance. Insights from the pilot will directly inform iterative improvements and the design of a larger-scale implementation evaluation study to evaluate effectiveness. With its evidence-based foundation, user-centered design, and alignment with national health priorities for prevention and digital transformation, Orchid holds promise as a scalable DHI to support reproductive decision-making, reduce unplanned pregnancy, and contribute to better maternal, parental, and child health outcomes across the NHS.