Randomized comparison of a reduced-visit prenatal care model enhanced with remote monitoring

Exploring the impact of integrating telehealth in obstetric care: A scoping review

BACKGROUND

The use of telemedicine has spread to all areas of medicine, including obstetrics, over the last few decades.

OBJECTIVE

To identify and map the diversity and applicability of telemedicine in the obstetric literature, in the antenatal, intrapartum or postnatal period. To assess patient satisfaction and possible areas for future development.

METHODS

This scoping review was conducted following the Joanna Briggs Institute (JBI) methodological guidelines for scoping reviews and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and its extension for scoping reviews (PRISMA-ScR). We searched the databases PubMed (Medline), CINAHL, CENTRAL (Cochrane Library), EMBASE Ovid and Scopus. We also searched Google Scholar, clinicaltrial.gov, the WHO International Clinical Trials Registry Platform (ICTRP-WHO) and the reference lists of the included studies. We included any primary study design that focused on a population of women in the antenatal, intrapartum or postnatal period. Studies selection and data extraction were performed blindly and independently by two authors. We summarised the results narratively and used graphs and tables to present key concepts thematically.

RESULTS

We included 66 studies. We categorised the studies according to population, type of intervention, outcomes and user satisfaction. Most of the studies involved pathological (36%) and physiological (30%) pregnancy management, the type of intervention was mainly divided into televisits or video calls with professionals (43%) and the use of specific apps or devices (40%). The maternal outcomes studied were mainly quantitative, i.e., improvement in blood chemistry tests or vital parameters (65%) and treatment adherence (frequency of follow-up visits or keeping appointments, 27%). Patient satisfaction was positive in the majority of cases.

CONCLUSIONS

There is still little international agreement on the concept and possible applications of telemedicine in obstetrics, although it is increasingly being used in clinical practice. Studies have shown positive results in terms of improved care, particularly in terms of treatment adherence and as an alternative strategy in the management of pregnancy, postpartum and abortion care. Both patients and health professionals were satisfied with it, especially when offered as a complement or alternative to the traditional method of face-to-face visits. Future developments seem to be the time and cost-saving potential of telemedicine and its application to couples' infertility.

The Impact of Telehealth on Obstetrical Outcomes during the COVID-19 Pandemic

OBJECTIVE

 Nationwide, obstetric clinics modified prenatal care to include telehealth visits in response to the coronavirus disease 2019 (COVID-19) pandemic, enabling the opportunity to investigate its impact on patient outcomes. We hypothesized that use of prenatal telehealth visits would increase the number of prenatal visits, decrease the frequency of urgent triage/emergency department (ED) visits, and improve perinatal outcomes. This study aimed to determine the impact of telehealth on number of obstetric prenatal visits and urgent triage/ED visits amidst the COVID-19 pandemic.

STUDY DESIGN

 This is a retrospective cohort of patients from a federally qualified health center in central Texas. Patients with a singleton gestation who delivered after 32 weeks were included. Comparison groups were made between those patients who delivered between May 2020 and December 2020 (presumed modified prenatal visit schedule with in-person and telehealth) and those patients delivering between June 2019 and February 2020 (the traditional care model with in-person visits only). Multivariable linear and logistic regression models were used to estimate differences in the number of prenatal visits and unscheduled triage/ED visits.

RESULTS

 A total of 1,654 patients were identified with 801 (48.4%) patients undergoing modified prenatal care and 853 (51.6%) patients receiving traditional care during the study period. No significant differences were seen in overall prenatal attendance or triage/ED presentations. However, when stratified by parity, multiparous patients undergoing modified prenatal care were less likely to experience an urgent triage/ED presentation (8.7 vs. 12.7%; odds ratio, 1.69; 95% confidence interval, 1.10-2.61).

CONCLUSION

 When compared with a traditional prenatal visitation cohort prepandemic, patients who received modified telehealth prenatal care during the COVID-19 pandemic had similar prenatal attendance and unscheduled emergency presentations. However, multiparous patients experienced a decreased rate of unscheduled emergency presentations. Supplementing prenatal care with telehealth may provide overall comparable prenatal care delivery.

KEY POINTS

· Use of telehealth has the potential to improve prenatal care.. · The COVID-19 pandemic allowed for comparison to traditional prenatal care.. · Multiparous patients had a decreased frequency of ED visits.. · Similar prenatal attendance was seen between both prenatal models..

Impact of Digital Health Interventions on Birth Equity: A Review

The rise in smartphone utilization and technology uptake has popularized digital health interventions as a means of supporting healthy pregnancies and optimizing maternal and child health. Digital health interventions include several modalities, such as telemedicine, remote patient monitoring, smartphone applications, web-based interventions, wearables, and health information technology. However, the impact of these interventions on improving maternal and infant health outcomes by race and socioeconomic status to achieve birth equity is unknown. This review summarizes current literature on the impact of digital health interventions on the outcomes of communities of color and lower socioeconomic status in the United States. We demonstrate there is emerging evidence of the impact of digital health interventions on maternal health outcomes, particularly for telemedicine, but evidence specifically focused on assessing outcomes by race and ethnicity and for other modalities, like mHealth apps or wearables, is limited. Digital health interventions may play a part in birth equity initiatives, but should not be considered a standalone solution, and instead should be integrated into other existing efforts to achieve birth equity, like diversifying the clinician workforce, expanding access to high-quality prenatal and postpartum care, or delivering respectful maternity care.

Telemedicine utilization and perceived quality of virtual care among pregnant and postpartum women during the COVID-19 pandemic

INTRODUCTION

The aim of this research was to examine the association between perceived quality of care during the COVID-19 pandemic and the modality of maternity care visits, virtual or in-person.

METHODS

This study utilized an online nationwide survey about experiences in prenatal and postpartum care between 18 April and 6 August 2020. Perceived quality of care was categorized into worse care, better, or the same care as compared to before the pandemic. Barriers were categorized into five groups: (1) concern for the privacy of health information, (2) not having a private or quiet place, (3) lack of physical exam or measurements, (4) quality of care, and (5) technology issues. Data analyses included bivariate analyses and multivariate logistic regression.

RESULTS

The majority (75.3%) of modified visits utilized telemedicine. Over half of the women took at-home measurements and the majority were successful. Barriers to care included a lack of a quiet or private space to conduct their visit. Women expressed concerns about a lack of measurements and a lower quality of care. Women who received telemedicine visits perceived worse care as compared to women who received in-person care visits (OR = 5.62; 95% CI 5.01-6.31).

DISCUSSION

Previous studies have shown that pregnant patients are generally satisfied with virtual care during the pandemic. This study provides insight from a large nationwide sample of women and geographic variation in satisfaction and perceived quality. These findings highlight barriers and potential solutions to improving patients' perceived quality of virtual maternity care, and thus future uptake of high-quality, virtual care.

The COVID-19 Pandemic and Routine Prenatal Care: Use of Online Visits

OBJECTIVE

To evaluate whether prenatal visits or screening/testing were fewer or occurred later during the initial phase of the COVID-19 pandemic in 2020 (CINT) as compared to the prior year (PreCINT).

METHODS

A retrospective cohort study compared CINT (n = 2,195) to PreCINT (n = 2,395) at seven public hospitals in New York City. The primary outcome was total number of prenatal-care visits. Secondary outcomes were components of prenatal-care visits completion, timing of standard pregnancy screening tests, and adverse neonatal outcomes.

RESULTS

CINT patients had more total prenatal-care visits (B = 1.30, 95% CI:1.04, 1.56, p < 0.001), lower odds for initiation of prenatal care which was inadequate according to widely used criteria (OR:0.39, 95% CI:0.34, 0.45, p < 0.001), and lower gestational age at initial visit (B=-4.51, 95% CI:-5.10, -3.93, p < 0.001) than PreCINT patients. In-person visits did not differ between the two groups. PreCINT patients had no televisits, while CINT patients had a median of one televisit (Median = 1, p < 0.001). CINT patients had increased odds for group B Streptococcus screening (OR:1.27, 95% CI: 1.10, 1.48, p = 0.001), quadrivalent screening (OR:1.30, 95% CI:1.15, 1.48, p < 0.001), and anatomy sonogram (OR:2.30, 95% CI:2.04, 2.59, p < 0.001) but decreased odds for glucose challenge test screening (OR:0.81, 95% CI:0.72, 0.91, p < 0.001). Adverse neonatal outcome did not differ between CINT and PreCINT pregnancies.

CONCLUSIONS FOR PRACTICE

Despite the difficulties and perceived dangers of in-person visits during the COVID-19 pandemic, the COVID-19 pandemic had little negative impact upon the outpatient prenatal care received by patients in this hospital system.

Sudden Shift to Telehealth in COVID-19: A Retrospective Cohort Study of Disparities in Use of Telehealth for Prenatal Care in a Large Midwifery Service

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic created disruption in health care delivery, including a sudden transition to telehealth use in mid-March 2020. The purpose of this study was to examine changes in the mode of prenatal care visits and predictors of telehealth use (provider-patient messaging, telephone visits, and video visits) during the COVID-19 pandemic among those receiving care in a large, academic nurse-midwifery service.

METHODS

We conducted a retrospective cohort study of those enrolled for prenatal care in 2 nurse-midwifery clinics between 2019 and 2021 (n = 3172). Use outcomes included number and type of encounter: in-person and telehealth (primary outcome). Comparisons were made in frequency and types of encounters before and during COVID-19. A negative binomial regression was fit on the outcome of telehealth encounter count, with race/ethnicity, age, language, parity, hypertension, diabetes, and depression as predictors.

RESULTS

When comparing pre-COVID-19 (before March 2020) with during COVID-19 (after March 2020), overall encounters increased from 15.9 to 19.5 mean number of encounters per person (P < .001). The increase was driven by telehealth encounters; there were no significant differences for in-person prenatal visit counts before and during the pandemic period. Direct patient-provider messaging was the most common type of telehealth encounter. Predictors of telehealth encounters included English as primary language and diagnoses of diabetes or depression.

DISCUSSION

No differences in the frequency of in-person prenatal care visits suggests that telehealth encounters led to more contact with midwives and did not replace in-person encounters. Spanish-speaking patients were least likely to use telehealth-delivered prenatal care during the pandemic; a small, but significant, proportion of patients had no or few telehealth encounters, and a significant proportion had high use of telehealth. Integration of telehealth in future delivery of prenatal care should consider questions of equity, patient and provider satisfaction, access, redundancies, and provider workload.

The impact of antenatal telehealth services on maternal and neonatal outcomes, a comparison of results before and during the COVID-19 pandemic: A systematic review and meta-analysis (The impact of telehealth services on maternal and neonatal outcomes)

OBJECTIVE

This review was conducted to examine the effectiveness of antenatal follow-up using telehealth in the pre-COVID-19 and active pandemic periods.

DESIGN

A systematic review and meta-analysis of randomized controlled trials.

METHODS

Searches were conducted from inception to September 2023 through PubMed, the Cochrane Library, EBSCO, Embase, Web of Science, all via Ovid SP, the National Thesis Center, TR Index, Turkiye Clinics, and DergiPark Academic. Data were combined in the meta-analysis. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool and quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation guidelines.

RESULTS

The meta-analysis examining the effectiveness of antenatal telehealth services included 35 studies with a total sample size of 16 033. The combined results of the studies revealed that antenatal telehealth services were similar to face-to-face follow-ups for many maternal and newborn health outcomes. Maternal outcomes included abortion, preterm delivery, gestational diabetes, weight gain, hypertensive disorders, maternal hospitalization, number of antenatal follow-ups, use of induction, vaginal and instrumental delivery, planned and emergency cesarean section, shoulder dystocia, episiotomy, perineal laceration, childbirth under the supervision of qualified personnel, breastfeeding problems and postpartum depression. Neonatal outcomes included an APGAR score of <7, neonatal hypoglycemia, hyperbilirubinemia, admission into the neonatal intensive care unit, respiratory distress syndrome, neonatal death, birth weight, low birth weight and macrosomia. However, statistically significant reductions in excessive weight gain (p<0.001) and a 1.23-fold increase in vaccination administration (p=0.001) were observed with telehealth services. Additionally, the effects of telehealth services on preterm and cesarean delivery rates were similar in the pre-pandemic and pandemic periods.

CONCLUSION AND IMPLICATIONS FOR PRACTICE AND RESEARCH

This review reveals that while antenatal telehealth services are comparable to face-to-face care in terms of multiple pregnancy, delivery, and neonatal outcomes, they contribute to improvements in preventing extreme weight gain and vaccination hesitancy. These findings suggest that the telehealth method can be used as an alternative to face-to-face monitoring in antenatal follow-ups.

Telemedicine for Routine Prenatal Care: Use and Satisfaction During the COVID-19 Pandemic

INTRODUCTION

Telemedicine use in prenatal care has greatly expanded without substantial research. Optimizing user experiences can increase telemedicine's utilization to support care access. The purpose of this study was to explore patient and provider experiences using telemedicine for routine prenatal care during the COVID-19 pandemic, identifying factors affecting its utilization and satisfaction.

METHODS

In this mixed methods study, online surveys and semi-structured interviews with pregnant and postpartum patients and perinatal providers across the United States were used to explore experiences with telemedicine and prenatal care during the COVID-19 pandemic. Data were collected from July to December 2021. Survey findings were analyzed using descriptive and inferential statistics, and interviews were thematically coded and analyzed, followed by mixed methods analysis.

RESULTS

Results of 946 surveys (750 patients and 196 providers) and 30 interviews (15 patients and 15 providers) met inclusion for analysis. Telemedicine was utilized by 42% of patients and 72% of perinatal provider participants. The primary reason patients did not use telemedicine was because it was not offered. Patients and providers who did not use telemedicine expressed the following main concerns with virtual care: uncertainty about care quality, particularly when blood pressure and the fetal heart rate were not assessed, and potential challenges with developing trusting patient-provider relationships. Patients and providers who used telemedicine rated their experience as mild to moderate satisfaction across the 6 Telehealth Usability Questionnaire domains. Satisfaction scores were not dependent on whether physical examination components were included in virtual visits.

DISCUSSION

Providing patients with the choice to use telemedicine as needed or combined with in-person visits for routine prenatal care may increase care utilization. Although not directly linked with satisfaction, interest in using telemedicine would likely increase for patients and providers concerned with care quality if blood pressure and fetal heart rate are assessed during virtual visits.

Beyond the First Trimester: Social Determinants of Delayed Prenatal Care at a Community Health Center Using the PRAPARE Tool

Social determinants of health have been used to explore associations with pregnancy outcomes and the birth weight of infants; however, research employing individually based social risk measures has not examined associations among underserved populations, including pregnant persons at community health centers. Data were collected from a sample (n = 345) of pregnant persons who sought care at a community health center between January 2019 and December 2020. Social risks of pregnant patients were measured using the PRAPARE tool. First, associations between patients' social risks and trimester in which they initiated care were assessed using ANOVAs, grouping social risk by PRAPARE social determinant domains (persona characteristics, family and home, money and resources, and social and emotional health). ANOVAs were stratified by ethnicity. Next, a multivariate logistic regression examined associations between social measures and seeking care after the first trimester. Patients who sought care in the first trimester reported more financial needs than those who sought care in the second (p = .02) or the third (p = .049). Hispanic patients who sought care in the first trimester reported more monetary needs than those who sought care in the second trimester (p = .048), and non-Hispanic patients who sought care in the first trimester reported greater family and home needs than those who sought care in the second trimester (p = .47). Those who experienced stress were 3.07 times as likely to seek care after the first trimester as those who reported no stress. CHC may reduce social risk among poor and underserved communities by reducing barriers to access to care.

Defining practices suitable for care via teleconsultation in gynaecological and obstetrical care: a French Delphi survey

OBJECTIVE

Delineate the scope of teleconsultation services that can be effectively performed to provide women with comprehensive gynaecological and obstetrical care.

DESIGN

Based on the literature and experts' insights, we identified a list of gynaecological and obstetrical care practices suitable for teleconsultation. A three-round Delphi consensus survey was then conducted online among a panel of French experts. Experts using a 9-point Likert scale assessed the relevance of each teleconsultation practice in four key domains: prevention, gynaecology and antenatal and postnatal care. Consensus was determined by applying a dual-criteria approach: the median score on a 9-point Likert scale and the percentage of votes either below 5 or 5 and higher.

SETTING

The study was conducted at a national level in France and involved multiple healthcare centres and professionals from various geographical locations.

PARTICIPANTS

The panel comprised 22 French experts with 19 healthcare professionals, including 12 midwives, 3 obstetricians-gynaecologists, 4 general practitioners and 3 healthcare system users. Participants were selected to include diverse practice settings encompassing hospital and private practices in both rural and urban areas.

PRIMARY AND SECONDARY OUTCOME MEASURES

The study's primary outcome was the identification of gynaecological and obstetrical care practices suitable for teleconsultation. Secondary outcomes included the level of professional consensus on these practices.

RESULTS

In total, 71 practices were included in the Delphi survey. The practices approved for teleconsultation were distributed as follows: 92% in prevention (n=12/13), 55% in gynaecology (n=18/33), 31% in prenatal care (n=5/16) and 12% in postnatal care (n=1/9). Lastly, 10 practices remained under discussion: 7 in gynaecology, 2 in prenatal care and 1 in postnatal care.

CONCLUSIONS

Our consensus survey highlights both the advantages and limitations of teleconsultations for women's gynaecological and obstetrical care, emphasising the need for careful consideration and tailored implementation.

Retrospective Use of Patients' Characteristics to Assess Variation in Prenatal Care Utilization

OBJECTIVE

We used patients' medical and psychosocial risk factors to explore prenatal care utilization and health outcomes to inform prenatal care tailoring.

STUDY DESIGN

This retrospective cohort study assessed patients who gave birth at an academic institution from January 1 to December 31, 2018, using electronic health record (EHR) data. Patients were categorized into four phenotypes based on medical/psychosocial risk factors available in the EHR: Completely low risk; High psychosocial risk only; High medical risk only; and Completely high risk. We examined patient characteristics, visit utilization, nonvisit utilization (e.g., phone calls), and outcomes (e.g., preterm birth, preeclampsia) across groups.

RESULTS

Of 4,681 patients, the majority were age 18 to 35 (3,697, 79.0%), White (3,326, 70.9%), multiparous (3,263, 69.7%), and Completely high risk (2,752, 58.8%). More Black and Hispanic patients had psychosocial risk factors than White patients. Patients with psychosocial risk factors had fewer prenatal visits (10, interquartile range [IQR]: 8-12) than those without (11, IQR: 9-12). Patients with psychosocial risk factors experienced less time in prenatal care, more phone calls, and fewer EHR messages across the same medical risk group. Rates of preterm birth and gestational hypertension were incrementally higher with additional medical/psychosocial risk factors.

CONCLUSION

Data readily available in the EHR can assess the compounding influence of medical/psychosocial risk factor on patients' care utilization and outcomes.

KEY POINTS

· Medical and psychosocial needs in pregnancy can inform patient phenotypes and are associated with prenatal care use and outcomes.. · Patient phenotypes are associated with prenatal care use and outcomes.. · Patients with high psychosocial risk spent less time in prenatal care and had more phone calls in pregnancy.. · Tailored prenatal care models may proactively address differences in patient's needs..

Antenatal Care: A Comparative Review of Guidelines

Importance

Antenatal care plays a crucial role in safely monitoring and ensuring the well-being of both the mother and the fetus during pregnancy, ultimately leading to the best possible perinatal outcomes.

Objective

The aim of this study was to review and compare the most recently published guidelines on antenatal care.

Evidence Acquisition

A descriptive review of guidelines from the National Institute for Health and Care Excellence, the Public Health Agency of Canada, the World Health Organization, and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists regarding antenatal care was conducted.

Results

There is a consensus among the reviewed guidelines regarding the necessary appointments during the antenatal period, the proper timing for induction of labor, the number and frequency of laboratory examinations for the assessment of mother's well-being, and management strategies for common physiological problems during pregnancy, such as nausea and vomiting, heartburn, pelvic pain, leg cramps, and symptomatic vaginal discharge. In addition, special consideration should be given for mental health issues and timely referral to a specialist, reassurance of complete maternal vaccination, counseling for safe use of medical agents, and advice for cessation of substance, alcohol, and tobacco use during pregnancy. Controversy surrounds clinical evaluation during the antenatal period, particularly when it comes to the routine use of an oral glucose tolerance test and symphysis-fundal height measurement for assessing fetal growth, whereas routine cardiotocography and fetal movement counting are suggested practices only by Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Of note, recommendations on nutritional interventions and supplementation are offered only by Public Health Agency of Canada and World Health Organization, with some minor discrepancies in the optimal dosage.

Conclusions

Antenatal care remains a critical factor in achieving positive outcomes, but there are variations depending on the socioeconomic status of each country. Therefore, the establishment of consistent international protocols for optimal antenatal care is of utmost importance. This can help provide safe guidance for healthcare providers and, consequently, improve both maternal and fetal outcomes.

Detection and Control of Pregnancy Hypertension Using Self-Monitoring of Blood Pressure With Automated Telemonitoring: Cost Analyses of the BUMP Randomized Trials

BACKGROUND

Pregnancy hypertension continues to cause maternal and perinatal morbidity. Two linked UK randomized trials showed adding self-monitoring of blood pressure (SMBP) with automated telemonitoring to usual antenatal care did not result in earlier detection or better control of pregnancy hypertension. This article reports the trials' integrated cost analyses.

METHODS

Two cost analyses. SMBP with usual care was compared with usual care alone in pregnant individuals at risk of hypertension (BUMP 1 trial [Blood Pressure Monitoring in High Risk Pregnancy to Improve the Detection and Monitoring of Hypertension], n=2441) and with hypertension (BUMP 2 trial, n=850). Clinical notes review identified participant-level antenatal, intrapartum, and postnatal care and these were costed. Comparisons between trial arms used means and 95% CIs. Within BUMP 2, chronic and gestational hypertension cohorts were analyzed separately. Telemonitoring system costs were reported separately.

RESULTS

In BUMP 1, mean (SE) total costs with SMBP and with usual care were £7200 (£323) and £7063 (£245), respectively, mean difference (95% CI), £151 (-£633 to £936). For the BUMP 2 chronic hypertension cohort, corresponding figures were £13 384 (£1230), £12 614 (£1081), mean difference £323 (-£2904 to £3549) and for the gestational hypertension cohort were £11 456 (£901), £11 145 (£959), mean difference £41 (-£2486 to £2567). The per-person cost of telemonitoring was £6 in BUMP 1 and £29 in BUMP 2.

CONCLUSIONS

SMBP was not associated with changes in the cost of health care contacts for individuals at risk of, or with, pregnancy hypertension. This is reassuring as SMBP in pregnancy is widely prevalent, particularly because of the COVID-19 pandemic.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03334149.

Are Providers Adequately Screening for Anxiety Symptoms During Pregnancy?

OBJECTIVE

To examine the difference in prevalence of self-reported anxiety symptoms throughout pregnancy compared to clinical diagnosis of an anxiety disorder by a provider.

DESIGN

Secondary data analysis of a prospective cohort study of 50 pregnant individuals.

SETTING/LOCAL PROBLEM

Pregnant individuals commonly experience heightened anxiety symptoms, which are associated with adverse perinatal outcomes. However, a diagnosis of an anxiety disorder by a health care provider is less common, which may result in insufficient mental health intervention.

PARTICIPANTS

Pregnant individuals were recruited at their first prenatal appointment and followed until birth.

INTERVENTION/MEASUREMENTS

We examined anxiety symptoms using the Edinburgh Postnatal Depression Scale Anxiety subscale. We conducted a medical record review to examine if pregnant individuals were clinically diagnosed with an anxiety disorder.

RESULTS

Based on an Edinburgh Postnatal Depression Scale Anxiety subscale cutoff score of ≥5, 40% (n = 20) of individuals experienced anxiety symptoms during pregnancy. However, only 16% (n = 8) of participants were diagnosed with an anxiety disorder by a health care provider.

CONCLUSION

Anxiety symptoms are prevalent throughout pregnancy and may be underdiagnosed by health care providers. An intervention to increase clinical diagnosis of an anxiety disorder and subsequent referral to a mental health specialist may be indicated.

Telegenetics to provide comprehensive prenatal diagnosis

Telehealth is an effective way to increase access to genetic services and can address several challenges, including geographic barriers, a shortage of interpreter services, and workforce issues, especially for prenatal diagnosis. The addition of prenatal telegenetics to current workflows shows promise in enhancing the delivery of genetic counseling and testing in prenatal care, providing accessibility, accuracy, patient satisfaction, and cost-effectiveness. Further research is needed to explore long-term patient outcomes and the evolving role of telehealth for prenatal diagnosis. Future studies should address the accuracy of diagnoses, the impact of receiving a diagnosis in a virtual setting, and patient outcomes in order to make informed decisions about the appropriate use of telemedicine in prenatal genetics service delivery.

Facilitators and barriers to home blood pressure monitoring among pregnant women in Ghana: a mixed-methods analysis of patient perspectives

BACKGROUND

The benefit of home blood pressure monitoring during pregnancy and in low-resource settings is incompletely understood. The objective of this study was to explore the experiences, barriers, and facilitators of home blood pressure monitoring among pregnant women in Ghana.

METHODS

This concurrent triangulation mixed-methods study was conducted at an urban tertiary hospital in Ghana. Participants were recruited from adult pregnant women presenting for routine antenatal care. Upon enrollment, participants' demographics and history were collected. At the next study visit, participants received audiovisual and hands-on training on using an automatic blood pressure monitor; they then monitored and logged their blood pressure daily at home for 2-4 weeks. At the final study visit, verbally administered surveys and semi-structured interviews assessed participant's experiences. Quantitative data were analyzed using R version 4.2.2, and frequencies and descriptive statistics were calculated. Qualitative data were imported into DeDoose 9.0.78 for thematic analysis.

RESULTS

Of 235 enrolled participants, 194 completed surveys; of those, 33 completed in-depth interviews. Participants' mean age was 31.6 (SD 5.3) years, 32.1% had not previously given birth, and 31.1% had less than a senior high school education. On a 4-point Likert scale, the majority reported they "definitely" were able to remember (n = 134, 69.1%), could find the time (n = 124, 63.9%), had the energy (n = 157, 80.9%), could use the blood pressure monitor without problems (n = 155, 79.9%), and had family approval (n = 182, 96.3%) while engaging in home blood pressure monitoring. 95.88% (n = 186) believed that pregnant women in Ghana should monitor their blood pressure at home. Qualitative thematic analysis demonstrated that most participants liked home blood pressure monitoring because of increased knowledge of their health during pregnancy. While most participants found measuring their blood pressure at home doable, many faced challenges. Participants' experiences with five key factors influenced how easy or difficult their experience was: 1) Time, stress, and daily responsibilities; 2) Perceived importance of BP in pregnancy; 3) Role of family; 4) Capability of performing monitoring; 5) Convenience of monitoring.

CONCLUSIONS

Among pregnant women in urban Ghana, home blood pressure monitoring was perceived as positive, important, and doable; however, challenges must be addressed.

Developing initial programme theories for a realist synthesis on digital clinical consultations in maternity care: contributions from stakeholder involvement

Background

The COVID pandemic prompted an increase in the use of digital clinical consultations (telephone or video calls) within midwifery and nursing care. This paper reports on a realist review project related to maternity care that seeks to illuminate for whom such consultations can safely and acceptably be used, how, for what purposes and in what contexts.

Aims

This paper addresses the first phase of a realist enquiry - initial programme theory development - focusing particularly on the role of stakeholder involvement (including digital transformation leaders, midwives, obstetricians, service users and community organisations).

Methods

Three sub-stages of initial programme theory development are described highlighting the contribution of stakeholder groups to each stage: (i) consultation to focus the review question, (ii) focused searching and (iii) further consultation.

Results

Realist literature searching strategies yielded limited theory-rich evidence on digital consultations. Stakeholders provided essential additional contributions resulting in the development of 13 initial programme theories and a conceptual framework.

Conclusions

More research on the implementation of virtual midwifery/nursing consultations is needed. Nursing/midwifery digital researchers should involve stakeholders to help shape research priorities, deepen contextual understanding and sense-check emerging findings.

Using self-monitoring to detect and manage raised blood pressure and pre-eclampsia during pregnancy: the BUMP research programme and its impact

Raised blood pressure affects around ten percent of pregnancies worldwide, causing maternal and perinatal morbidity and mortality. Self-monitoring of blood pressure during higher-risk or hypertensive pregnancy has been shown to be feasible, acceptable, safe, and no more expensive than usual care alone. Additionally, self-testing for proteinuria has been shown to be just as accurate as healthcare professional testing, creating the potential for monitoring of multiple indicators through pregnancy. The work suggests however, that an organisational shift is needed to properly use and see benefits from self-monitored readings. This paper describes the findings from a large programme of work examining the use of self-monitoring in pregnancy, summarising the findings in the context of the wider literature and current clinical context. The BUMP Research Programme developed and tested self-monitoring and self-testing interventions for pregnancy. The work showed that self-monitoring during pregnancy was feasible, acceptable, safe, and no more expensive, but did not improve the detection or control of hypertension.

Telehealth use in maternity care during a pandemic: A lot of bad, some good and possibility

BACKGROUND

To reduce transmission risk during the COVID-19 pandemic, 'telehealth' (health care delivered via telephone/video-conferencing) was implemented into Australian maternity services. Whilst some reports on telehealth implementation ensued, there was scant evidence on women and midwives' perspectives regarding telehealth use.

METHODS

A qualitative study was conducted in Australia during 2020-2021 using two data sources from the Birth in the Time of COVID-19 (BITTOC) study: i) interviews and ii) surveys (open-text responses). Content analysis was utilised to analyse the data and explore telehealth from the perspective of midwives and women accessing maternity care services. In-depth interviews were conducted with 20 women and 16 midwives. Survey responses were provided from 687 midwives and 2525 women who were pregnant or gave birth in 2021, generating 212 and 812 comments respectively.

FINDINGS

Telehealth delivery was variable nationally and undertaken primarily by telephone/videoconferencing. Perceived benefits included: reduced COVID-19 transmission risk, increased flexibility, convenience and cost efficiency. However, women described inadequate assessment, and negative impacts on communication and rapport development. Midwives had similar concerns and also reported technological challenges.

CONCLUSION

During the COVID-19 pandemic, telehealth offered flexibility, convenience and cost efficiency whilst reducing COVID-19 transmission, yet benefits came at a cost. Telehealth may particularly suit women in rural and remote areas, however, it also has the potential to further reduce equitable, and appropriate care delivery for those at greatest risk of poor outcomes. Telehealth may play an adjunct role in post-pandemic maternity services, but is not a suitable replacement to traditional face-to-face maternity care.

Integrating technologies to provide comprehensive remote fetal surveillance: A prospective pilot study

OBJECTIVE

To determine the feasibility of extending remote maternal-fetal care to include fetus well-being.

METHODS

The authors performed a prospective pilot study investigating low-risk pregnant participants who were recruited at the time of their first full-term in-person visit and scheduled for a follow-up telemedicine visit. Using novel self-operated fetal monitoring and ultrasound devices, fetal heart monitoring and amniotic fluid volume measurements were obtained to complete a modified biophysical profile (mBPP). Total visit length was measured for both the in-person first visit and the subsequent telemedicine encounter. A patient satisfaction survey form was obtained.

RESULTS

Ten women between 40 + 1 and 40 + 6 weeks of gestation participated in telemedicine encounters. Nine women (90%) were able to complete remote mBPP assessment. For one participant, fetal assessment was not completed due to technically inconclusive fetal monitoring. Another participant was referred for additional assessment in the delivery room. Satisfactory amniotic fluid volume measurements were achieved in 100% of participants. The telemedicine encounter was significantly shorter (93.1 ± 33.1 min) than the in-person visit (247.2 ± 104.7 min; P < 0.001). We observed high patient satisfaction.

CONCLUSION

Remote fetal well-being assessment is feasible and time-saving and results in high patient satisfaction. This novel paradigm of comprehensive remote maternal and fetal assessment is associated with important clinical, socioeconomic, and logistics advantages.

Evaluating Standard of Care and Obstetrical Outcomes in a Reduced Contact Prenatal Care Model in the COVID-19 Pandemic

INTRODUCTION

We aimed to investigate the impact of reduced contact prenatal care necessitated by the COVID-19 pandemic on meeting standards of care and perinatal outcomes.

METHODS

This was a retrospective case-control study of patients in low-risk obstetrics clinic at a tertiary care county facility serving solely publicly insured patients comparing reduced in-person prenatal care (R) over 12 weeks with a control group (C) receiving traditional prenatal care who delivered prior.

RESULTS

Total 90 patients in reduced contact (R) cohort were matched with controls (C). There were similar rates of standard prenatal care metrics between groups. Gestational age (GA) of anatomy ultrasound was later in R (p = 0.017). Triage visits and missed appointments were similar, though total number of visits (in-person and telehealth) was higher in R (p = 0.043). R group had higher GA at delivery (p = 0.001). Composite neonatal morbidity and length of stay were lower in R (p = 0.017, p = 0.048). Maternal and neonatal outcomes did not otherwise differ between groups. Using Kotelchuck Adequacy of Prenatal Care Utilization index, R had higher rates of adequate prenatal care (45.6% R vs. 24.4% C, p = 0.005).

DISCUSSION

Our study demonstrates the non-inferiority of a hybrid, reduced schedule prenatal schedule to traditional prenatal scheduling. In a reduced contact prenatal care model, more patients met criteria for adequate prenatal care, likely due to higher attendance of telehealth visits. These findings raise the question of revising the prenatal care model to mitigate disparities in disadvantaged populations.

Perinatal Telehealth: Meeting Patients Where They Are

INTRODUCTION

Prior to the coronavirus disease 2019 (COVID-19) pandemic, studies of innovative telehealth perinatal care models showed similar clinical outcomes and perceived quality of care between groups receiving a combination of virtual video and in-person visits. However, these studies included primarily White, English-speaking participants, excluding those who were economically disenfranchised or did not speak English. The purpose of this qualitative study was to describe perinatal patients' and providers' experiences with telehealth during and after the acute phase of the COVID-19 pandemic to inform future utilization of telehealth to drive the delivery of high-quality, accessible, and equitable perinatal care to diverse communities.

METHODS

This descriptive qualitative study included a purposive sample of 14 patients and 17 providers who received or provided perinatal care via telehealth in either a certified nurse-midwifery practice or the nurse-family partnership care model between March 2020 and April 2022. Maximum variation sampling offered a diverse population based on race, ethnicity, and rurality. Researchers conducted 2 rounds of semistructured interviews with a focus on understanding social and geographic context.

RESULTS

Six themes were identified through inductive analysis: (1) unexpected advantages of telehealth, (2) patient empowerment, (3) providers' fear of adverse outcomes, (4) concern for equitable care, (5) strategies to enhance the telehealth experience, and (6) strategies to address access to perinatal telehealth. Patients appreciated the increased ease and reduced cost of accessing visits, which led to fewer missed appointments. Health care providers saw great opportunity in telehealth but expressed concerns about accessibility for patients with language barriers or limited resources.

DISCUSSION

This study provides insight into priorities for continued telehealth utilization focused on providing equitable access to perinatal care. Rather than returning to practices from before the COVID-19 pandemic formed from longstanding routines and perceived limitations, providers are encouraged to capitalize on the rapid innovations in telehealth to build a more effective, equitable, and patient-centered approach to perinatal care.

Creating a Telemedicine Network of Specialists in Maternal-Fetal Medicine: A Prospective Cohort Study

Background: Even before coronavirus disease 2019, integrating telemedicine into routine health care has become increasingly attractive. Evidence regarding the benefits of telemedicine in prenatal care is still inconclusive. As one of the largest sectors of preventive medicine with a relative paucity of specialists in maternal-fetal medicine (MFM), the implementation of telemedicine solutions into prenatal care is promising. Our objective aimed at establishing a telemedicine network of specialists in MFM for interprofessional exchange regarding high-risk pregnancies. Furthermore, the aims were to evaluate the providers' attitude toward the telemedicine solutions and to quantify the number of inpatient appointments that were avoided through interprofessional video consultations. Methods: This prospective trial was part of a larger telemedicine project funded by the European Regional Development Fund. MFM experts were brought together using the ELVI software. A questionnaire was designed for the evaluation of video consultations. The responses were analyzed by the exact McNemar-Bowker test to compare planned procedures before and after video consultation. Results: An interprofessional network of specialists in prenatal ultrasound was established with a total of 140 evaluations for statistical analysis. Interprofessional video communication was viewed favorably by providers. Overall, 47% (33/70) of the scheduled visits were avoided after video consultation. The providers' tendency to refrain from sending their patients to the University Hospital Münster was statistically noticeable (p = 0.048). Conclusions: Interprofessional exchange through video consultation holds great potential in the context of prenatal care. More prospective research is needed to clearly establish the most beneficial standard of care for both patients and providers. Clinical trial registration number: 2019-683-f-S.

Effect of telehealth-integrated antenatal care on pregnancy outcomes in Australia: an interrupted time-series analysis

BACKGROUND

During the COVID-19 pandemic, rapid integration of telehealth into antenatal care occurred to support ongoing maternity care. A programme of this scale had not been previously implemented. We evaluated whether telehealth-integrated antenatal care in an Australian public health system could achieve pregnancy outcomes comparable to those of conventional care to assess its safety and efficacy.

METHODS

Routinely collected data for individuals who gave birth at Monash Health (Melbourne, VIC, Australia) during a conventional care period (Jan 1, 2018, to March 22, 2020) and telehealth-integrated period (April 20, 2020, to April 25, 2021) were analysed. We included all births that occurred at 20 weeks' gestation or later or with a birthweight of at least 400 g (if duration of gestation was unknown). We excluded multiple births, births for which private antenatal care was received, and births to individuals transferred from other hospitals or who had no antenatal care. Baseline demographics, telehealth uptake, and pregnancy complications (related to pre-eclampsia, fetal growth restriction [FGR], gestational diabetes, stillbirth, neonatal intensive care [NICU] admission, and preterm birth [<37 weeks' gestation]) were compared using comparative statistics and an interrupted time-series analysis. Results were stratified by care stream, with high-risk models consisting of obstetric specialist-led care, and all other streams categorised as low-risk models. The impact of the integrated period on outcomes was also assessed with stratification by parity.

FINDINGS

17 873 births occurred in the conventional period and 8131 in the integrated period. Compared with the conventional period, women giving birth during the integrated period were slightly older (30·63 years vs 30·88 years) and had slightly higher BMI (25·52 kg/m2vs 26·14 kg/m2), and more Australian-born women gave birth during the integrated period (37·37% vs 39·79%). There were no significant differences in smoking status or parity between the two groups. 107 (0·08%) of 129 514 antenatal consultations in the conventional period and 34 444 (45·94%) of 74 982 in the integrated period were delivered by telehealth. No significant differences between the conventional and integrated periods were seen in median gestational age at pre-eclampsia diagnosis (low-risk models 37·4 weeks in the conventional period vs 37·1 weeks in the integrated period, difference -0·3 weeks [-0·7 to 0·1]; high-risk models 35·5 weeks vs 36·3 weeks, difference 0·3 weeks [-0·3 to 1·1]), incidence of FGR below the 3rd birthweight percentile (low-risk models 1·62% vs 1·74%, difference 0·12 percentage points [-0·26 to 0·50]; high-risk 4·04% vs 4·13%, difference 0·089 percentage points [-1·08 to 1·26]), and incidence of preterm birth (low-risk models 4·99% vs 5·01%, difference 0·02% [-0·62 to 0·66]; high-risk models 15·76% vs 14·43%, difference -1·33% [-3·42 to 0·77]). Parity did not affect these findings. Interrupted time-series analysis showed a significant reduction in induction of labour for singletons with suspected FGR among women in low-risk models during the integrated period (-0·04% change per week [95% CI -0·07 to -0·01], p=0·0040), and NICU admission declined after telehealth integration (low-risk models -0·02% change per week [-0·03 to -0·003], p=0·018; high-risk models -0·10% change per week, -0·19 to -0·001; p=0·047). No significant differences in stillbirth rates were observed. The proportion of women diagnosed with gestational diabetes was significantly higher in the integrated period compared with the conventional period for both low-risk care models (22·28% vs 25·13%, difference 2·85 percentage points [1·60 to 4·11]) and high-risk care models (28·70% vs 34·02%, difference 5·32 percentage points [2·57 to 8·07]). However overall, when compared with the conventional period, there was no significant difference in proportion of women with gestational diabetes requiring insulin therapy (low-risk models 8·08% vs 7·73%, difference -0·35 percentage points [-1·13 vs 0·44]; high-risk models 14·81% vs 15·71%, difference 0·89 percentage points [-1·23 to 3·02]), or proportion of women with gestational diabetes who gave birth to a baby with macrosomia in the integrated period (low-risk models 3·16% vs 2·33%, difference -0·83 percentage points [-1·77 to 0·12]; high-risk models 5·58% vs 4·81%, difference -0·77 percentage points [-3·06 to 1·52]).

INTERPRETATION

Telehealth-integrated antenatal care replaced around 46% of in-person consultations without compromising pregnancy outcomes. It might be associated with a reduction in labour induction for suspected FGR, particularly for women in low-risk models, without compromising FGR detection or perinatal morbidity. These findings support the ongoing use of telehealth in providing flexible antenatal care.

FUNDING

None.

Clinical efficacy and acceptability of remote fetal heart rate self-monitoring in Southern China

BACKGROUND

Compared to traditional fetal heart rate monitoring (FHR) for the outpatients in clinic, remote FHR monitoring shows real-time assessment of fetal wellbeing at home. The clinical function of remote FHR monitoring in pregnant wome in outpatient is still unclear.

OBJECTIVE

To explore the feasibility of remote FHR self-monitoring in singleton pregnant women from southern China.

STUDY DESIGN

This prospective cohort study was conducted at one tertiary center in southern China. Pregnant women used a mobile cardiotocogram device to measure the FHR at least once a week until delivery in the remote group. For the control group, pregnant women underwent traditional FHR monitoring once a week in the outpatient clinic. The rate of cesarean section, risk of postpartum hemorrhage and adverse neonatal outcomes were compared between the two groups. All the pregnant women completed a questionnaire survey to evaluate their acquisition of remote FHR self-monitoring.

RESULTS

Approximately 500 women were recruited in the remote FHR self-monitoring group (remote group), and 567 women were recruited in the traditional FHR monitoring group (control group). The women in the remote FHR monitoring group were more likely to be nulliparous (P < 0.001), more likely to have a higher education level (P < 0.001) and more likely to be at high risk (P = 0.003). There was no significant difference in the risk of cesarean section (P = 0.068) or postpartum hemorrhage (P = 0.836) between the two groups. No difference in fetal complications was observed across groups, with the exception of the incidence of NICU stays, which was higher in the remote group (12.0% vs. 8.3%, P = 0.044). The questionnaire survey showed that the interval time (P = 0.001) and cost (P = 0.010) of fetal heart rate monitoring were lower in the remote group. Regarding age, prepregnancy BMI, risk factors, education level, maternal risk and household income, senior high school (OR 2.86, 95% CI 1.67-4.90, P < 0.001), undergraduate (OR 2.96, 95% CI 1.73-5.06, P < 0.001), advanced maternal age (OR 1.42, 95% CI 1.07-1.89, P = 0.015) and high-risk pregnancy (OR 1.61, 95% CI 1.11-2.35, P = 0.013) were independent factors for pregnant women to choose remote fetal monitoring. Multiparty (OR 0.33, 95% CI 0.21-0.51, P < 0.001), full-time motherhood (OR 0.47, 95% CI 0.33-0.678, P < 0.001) and high household income (OR 0.67, 95% CI 0.50-0.88, P = 0.004) were negatively correlated with the choice of remote FHR self-monitoring.

CONCLUSION

Remote FHR self-monitoring technology has a lower cost and shows potential clinical efficacy for the outpatient setting in southern China. This approach does not increase the risk of cesarean section or adverse neonatal outcomes. It is acceptable among nulliparous pregnant women with a high education level, high household income or high risk. Further research is needed to assess the impact of this technology on obstetric outcomes in different health settings.

Perceptions and Challenges of Telehealth Obstetric Clinics Among Pregnant Women in Hong Kong: Cross-Sectional Questionnaire Study

BACKGROUND

Integrating telehealth in an obstetric care model is important to prepare for possible infection outbreaks that require social distancing and limit in-person consultations. To ensure the successful implementation of obstetric telehealth in Hong Kong, it is essential to understand and address pregnant women's concerns.

OBJECTIVE

This study aimed to assess pregnant women's attitudes, concerns, and perceptions regarding telehealth obstetric clinic services in Hong Kong.

METHODS

We conducted a prospective cross-sectional questionnaire study at Queen Mary Hospital between November 2021 and August 2022. Utilizing a 5-point rating scale, the questionnaire aimed to capture pregnant women's preferences, expectations, feasibility perceptions, and privacy concerns related to telehealth clinic services. We used statistical analyses, including chi-square tests and multinomial logistic regression, to compare questionnaire responses and investigate the association between advancing gestation and attitudes toward telehealth clinics.

RESULTS

The study included 664 participants distributed across different pregnancy stages: 269 (40.5%) before 18 gestational weeks, 198 (29.8%) between 24 and 31 weeks, and 197 (29.7%) after delivery. Among them, 49.8% (329/664) favored face-to-face consultations over telehealth clinics, and only 7.3% (48/664) believed the opposite. Additionally, 24.2% (161/664) agreed that telehealth clinics should be launched for obstetric services. However, the overall preference for telehealth clinics was <20% for routine prenatal checkups (81/664, 12.2%) and addressing pregnancy-related concerns, such as vaginal bleeding (76/664, 11.5%), vaginal discharge (128/664, 19.4%), reduced fetal movement (64/664, 9.7%), uterine contractions (62/664, 9.4%), and suspected leakage of amniotic fluid (54/664, 8.2%). Conversely, 76.4% (507/664) preferred telehealth clinics to in-person visits for prenatal education talks, prenatal and postpartum exercise, and addressing breastfeeding problems. Participants were more comfortable with telehealth clinic tasks for tasks like explaining pregnancy exam results (418/664, 63.1%), self-administering urinary dipsticks at home (373/664, 56.4%), medical history-taking (341/664, 51.5%), and self-monitoring blood pressure using an electronic machine (282/664, 42.8%). %). During the postpartum period, compared to before 18 weeks of gestation, significantly more participants agreed that telehealth clinics could be an option for assessing physical symptoms such as vaginal bleeding (aOR 2.105, 95% CI 1.448-3.059), reduced fetal movement (aOR 1.575, 95% CI 1.058-2.345), uterine contractions (aOR 2.906, 95% CI 1.945-4.342), suspected leakage of amniotic fluid (aOR 2.609, 95% CI 1.721-3.954), fever (aOR 1.526, 95% CI 1.109-2.100), and flu-like symptoms (aOR 1.412, 95% CI 1.030-1.936). They were also more confident with measuring the symphysis-fundal height, arranging further investigations, and making diagnoses with the doctor via the telehealth clinic. The main perceived public health advantage of telehealth clinics was the shorter traveling and waiting time (526/664, 79.2%), while the main concern was legal issues from wrong diagnosis and treatment (511/664, 77.4%).

CONCLUSIONS

Face-to-face consultation remained the preferred mode of consultation among the participants. However, telehealth clinics could be an alternative for services that do not require physical examination or contact. An increased acceptance of and confidence in telehealth was found with advancing gestation and after delivery. Enforcing stricter laws and guidelines could facilitate the implementation of telehealth clinics and increase confidence in their use among pregnant women for obstetric care.

Evaluation of Virtual Prenatal Care for Obstetric Care Delivery During the COVID-19 Pandemic: A Mixed Method Research Study Using the Consolidated Framework in Implementation Research

Background and Objective

Coronavirus 2 (SARS-CoV-2), a novel respiratory virus, rapidly spread, and placed patients at increased risk for short and potentially long-standing medical illnesses. The pandemic necessitated the rapid implementation of virtual prenatal care via telemedicine in obstetrics to maintain social distancing measures. The aim of this study was to assess and understand the patient perspectives of the rapidly implemented virtual prenatal care via a telemedicine model during the Coronavirus disease 2019 (COVID-19) pandemic utilizing the Consolidated Framework in Implementation Research (CFIR).

Methods

Following the implementation of virtual prenatal care in March 2020, pregnant patients at a large urban clinic in the southeastern United States completed a 19-question anonymous survey that included open and closed-ended questions on their experience receiving virtual prenatal care via telemedicine or in-person prenatal care from May to December 2020. The survey and mixed-methods data analysis was guided by the CFIR framework.

Results

A total of 59 patients completed the survey. One-third (31%, n=18) of the patients found virtual prenatal care to be an acceptable alternative model, and half (53%, n=31) found it acceptable only during a pandemic, preferring to return to in-person visits. Qualitative analysis found that some patients were deterred by limited in-person examinations and uncertainty with the virtual platform, while others appreciated the reduced need for transportation, childcare, and time spent.

Conclusion and Global Health Implications

Most patients found virtual prenatal care to be easy to access and an acceptable alternative during the pandemic; however, most would prefer to return to in-person prenatal care visits. Future comparative research studies should examine how, among others, virtual prenatal care versus in-person prenatal care impacts specific maternal and fetal outcomes.

Routine Prenatal Care

The one-size-fits-all model of prenatal care has remained largely unchanged since 1930. New models of prenatal care delivery can improve its efficacy, equity, and experience through tailoring prenatal care to meet pregnant people's medical and social needs. Key aspects of recently developed prenatal care models include visit schedules based on needed services, telemedicine, home measurement of routine pregnancy parameters, and interventions that address social and structural drivers of health. Several barriers that affect the individual, provider, health system, and policy levels must be addressed to facilitate implementation of new prenatal care delivery models.

Ability and accuracy of patient-performed blood pressure monitoring among pregnant women in urban Ghana

BACKGROUND

Patient-performed blood pressure monitoring in pregnancy is rarely performed in low- and middle-income country settings, including Ghana. The clinical efficacy of home blood pressure monitoring relies on a pregnant patient being able to independently execute the correct steps to position and use a blood pressure monitor and to achieve accurate blood pressure measurements.

OBJECTIVE

This study aimed to (1) assess whether pregnant women can correctly use an automatic blood pressure monitor to check their blood pressure before and after a brief training and (2) determine whether blood pressure values measured by pregnant women using an automatic monitor are similar to values measured by a healthcare provider using a standard clinic monitor.

STUDY DESIGN

This was a cross-sectional study conducted at the Korle Bu Teaching Hospital, a tertiary hospital in Accra, Ghana. Participants were adult pregnant women presenting for their first prenatal care visit. Data collection was performed by 2 Ghanaian physicians. Information on demographics, obstetrical history, and past medical history was collected. A brief training was provided on the correct use of the blood pressure monitor, including a verbal script, annotated photographs, and a hands-on demonstration. Pre- and posttraining assessments using a 9-item checklist of correct preparation, position, and use of an automatic blood pressure monitor were performed. Following a modified British Hypertension Society protocol, a series of 4 blood pressure measurements were taken, alternating between provider performed using a clinic monitor and patient performed using an automatic monitor intended for individual use and validated in pregnancy.

RESULTS

Among 176 participants, the mean age was 31.5 years (±5.6), and 130 (73.9%) were multiparous. Regarding socioeconomic characteristics, 128 (72.7%) were married, 171 (97.2%) had public insurance, and 87 (49.7%) had completed ≤9 years of formal education. Regarding clinical blood pressure issues, 19 (10.9%) had a history of a hypertensive disorder in a previous pregnancy, and 6 (3.4%) had chronic hypertension. Before receiving any training, 21 participants (12.1%) performed all 9 steps correctly to prepare, position, and use the automatic blood pressure monitor. Comparing pretraining vs posttraining ability, statistically significant increases were seen in the correct performance of each step and the mean number of steps performed correctly (6.1±1.8 vs 9.0±0.2, respectively; P<.001) and proportion performing all 9 steps correctly (12.1% vs 96.6%, respectively; P<.001). The mean difference between doctor-performed and patient-performed blood pressure measurements was 5.6±4.8 mm Hg for systolic blood pressure values and 3.4±3.08 mm Hg for diastolic blood pressure values, with most differences within 5 mm Hg for both systolic blood pressure values (102/176 [58.0%]) and diastolic blood pressure values (141/176 [80.1%]).

CONCLUSION

After a brief training, pregnant women in Ghana demonstrated that they are able to use an automatic blood pressure monitor to check their blood pressure correctly and accurately.

Impact of COVID-19 on pregnant women's health: Consequences in obstetrics two years after the pandemic

The pandemic linked to SARS-CoV-2 has profoundly disrupted the health systems and many studies have led to a better understanding of this virus, which is responsible for severe disease, particularly during pregnancy. Pregnancy is a risk factor for severe COVID-19. Term of pregnancy and vaccination status is the main risk factor in addition to classic comorbidities like general population. COVID-19 during pregnancy is responsible for more maternal death, stillbirth, pre-eclampsia spontaneous and induced prematurity. Vaccination is therefore strongly recommended for pregnant patients. In addition, the COVID-19 pandemic has highlighted a psychological and social dimension that should not be neglected in the management of a pregnant patient. Correlation between immunological changes and clinical impact are described in this review. Many conclusions can now be made and are summarized in this article in order to discuss possible future research.

Reduced-visit antenatal care model combined with telemedicine for low-risk pregnant women: protocol for a randomised controlled trial

INTRODUCTION

Antenatal care (ANC) is a critical measure to reduce maternal and perinatal morbidity and mortality. However, there are issues of too many visits and cumbersome procedures of ANC in many maternity hospitals of China. In the past 2 years, reduced-visit ANC models combined with remote monitoring have been recommended and implemented at most hospitals in China during the COVID-19 pandemic. Nevertheless, due to limited evaluations of the cost-effectiveness, policy-makers remain confused on how to appropriately integrate online delivery strategies with routine models to improve ANC quality and efficiency sustainably at scale. This trial aims to evaluate the effectiveness, acceptability and cost of a reduced-visit ANC model combined with telemedicine.

METHODS AND ANALYSIS

A single-blind, randomised controlled trial will be conducted among low-risk pregnant women at Peking University Third Hospital in Beijing. 1476 patients (738 in each group) would be required, and they will be randomly assigned in a 1:1 ratio to receive the reduced-visit ANC combined with telemedicine services or the routine ANC. The primary outcome is the composite rate of adverse maternal and perinatal outcomes which will be extracted from the medical records. Secondary outcomes include acceptability of ANC models, which is assessed by satisfaction with ANC, pregnancy-related stress and ANC costs measured from the perspectives of both service providers and demanders. Both intention-to-treat and per-protocol analyses will be performed. Non-inferiority tests will be used to compare the two ANC models for the primary outcome. A cost-effectiveness analysis comparing the two ANC models will be conducted by estimating the incremental cost-effectiveness ratios.

ETHICS AND DISSEMINATION

This study was approved by the ethical review committee of the Peking University Third Hospital (Beijing, China). The results of this study will be published in peer-reviewed scientific journals and presented at relevant academic conferences.

TRIAL REGISTRATION NUMBER

NCT05290467.

Telehealth in the Prenatal and Postpartum Periods

The range and use of telehealth technologies in the prenatal and postpartum periods have exploded since the COVID-19 pandemic. Many of the previous barriers to telehealth have been temporarily removed, which allows for the evaluation of new flexible care models and research on telehealth applications to address pressing clinical outcomes. But what will happen if these exceptions expire? In this column, I describe the scope of telehealth technologies in the prenatal and postpartum periods, the policy changes that have contributed to this growth, and research findings and recommendations from professional organizations that support the integration of telehealth into maternity care.

Masked pregnancy-associated hypertension as a predictor of adverse outcomes

BACKGROUND

Masked hypertension has been described in nonpregnant populations as elevated blood pressure in the home setting that is not reproduced on clinical assessment. Patients with masked hypertension have a greater risk of cardiovascular morbidity than patients who have blood pressures within normal range or those with white coat hypertension.

OBJECTIVE

This study aimed to determine whether masked pregnancy-associated hypertension detected on Connected Maternity Online Monitoring, a remote home blood pressure monitoring system, is associated with higher rates of hypertensive disorders of pregnancy during delivery admission and maternal and neonatal morbidities.

STUDY DESIGN

This was a retrospective cohort study of all patients on Connected Maternity Online Monitoring who delivered at 6 hospitals in a single healthcare system between October 2016 and December 2020. Patients were classified as having either normal blood pressure or masked pregnancy-associated hypertension. Masked pregnancy-associated hypertension was defined as remotely detected systolic blood pressure of ≥140 mm Hg or diastolic blood pressure of ≥90 mm Hg after 20 weeks of gestation on 2 occasions before diagnosis in a clinical setting. The chi-square test and Student t test were used for demographic and outcomes comparisons. Logistic regression was used to adjust outcomes by race, insurance, and body mass index.

RESULTS

A total of 2430 deliveries were included in our analysis, including 165 deliveries that met the criteria for masked pregnancy-associated hypertension. Clinically established pregnancy-associated hypertension, defined at the time of delivery, was more common in the masked pregnancy-associated hypertension group than in the normotensive group (66% vs 10%; adjusted odds ratio, 17.2; 95% confidence interval, 11.91-24.81). Patients with masked pregnancy-associated hypertension had higher rates of preeclampsia with severe features on delivery admission than normotensive patients (28% vs 2%; adjusted odds ratio, 23.35; 95% confidence interval, 14.25-38.26). Preterm delivery (16% vs 7%; adjusted odds ratio, 2.47; 95% confidence interval, 1.55-3.94), cesarean delivery(38% vs 26%; adjusted odds ratio, 1.58; 95% confidence interval, 1.13-2.23), small for gestational age (11% vs 5%; adjusted odds ratio, 2.27; 95% confidence interval, 1.31-3.94), and neonatal intensive care unit admission (8% vs 4%; adjusted odds ratio, 2.20; 95% confidence interval, 1.18-4.09) were more common among patients with masked pregnancy-associated hypertension than among normotensive patients.

CONCLUSION

With more outcomes research, remote blood pressure monitoring may prove to be an important tool in identifying pregnancies at risk of complications related to masked hypertension.

Survey of Postpartum People in the United States During the First Wave of the COVID-19 Pandemic to Explore Their Perspective on Support After Discharge

INTRODUCTION

The purpose of this study was to capture the experiences of postpartum people during the first wave of COVID-19, specifically their access to contraception and lactation support.

METHODS

This cross-sectional study surveyed individuals in the United States who used the Ovia Pregnancy and Parenting app. The survey was administered via an email Web link sent to postpartum people who gave birth between March 1, 2020, and June 11, 2020. Quantitative and qualitative analyses were conducted.

RESULTS

A total of 388 postpartum people completed the survey. Most participants had just given birth to their first baby (68.5%; n = 261) at term gestation (37-41 weeks) (92.9%; n = 355). From the qualitative data, using content analysis, we derived 6 themes and 2 subthemes: quarantine, changes in postpartum care, loneliness and isolation, stress, resource changes, and positive impact. The theme loneliness and isolation had 2 subthemes: depression/sadness/hopelessness and anxiety.

DISCUSSION

The experience of being postpartum during the COVID-19 pandemic brought unforeseen challenges. Providing care and support to postpartum people during a pandemic, specifically during a time of quarantine, should be reimagined. Increased use of virtual postpartum care services and expanded mental health support could serve to fill the gaps identified by participants.

Televisits Compared With In-Person Visits for Routine Antenatal Care: A Systematic Review

OBJECTIVE

To compare benefits and harms of televisits and in-person visits in people receiving routine antenatal care.

DATA SOURCES

A search was conducted of PubMed, Cochrane databases, EMBASE, CINAHL, and ClinicalTrials.gov through February 12, 2022, for antenatal (prenatal) care, pregnancy, obstetrics, telemedicine, remote care, smartphones, telemonitoring, and related terms, as well as primary study designs. The search was restricted to high-income countries.

METHODS OF STUDY SELECTION

Double independent screening was done in Abstrackr for studies comparing televisits and in-person routine antenatal care visits for maternal, child, health care utilization, and harm outcomes. Data were extracted into SRDRplus with review by a second researcher.

TABULATION, INTEGRATION, AND RESULTS

Two randomized controlled trials, four nonrandomized comparative studies, and one survey compared visit types between 2004 and 2020, three of which were conducted during the coronavirus disease 2019 (COVID-19) pandemic. Number, timing, and mode of televisits and who provided care varied across studies. Low-strength evidence from studies comparing hybrid (televisits and in-person visits) and all in-person visits did not indicate differences in rates of neonatal intensive care unit admission of the newborn (summary odds ratio [OR] 1.02, 95% CI 0.82-1.28) or preterm births (summary OR 0.93, 95% CI 0.84-1.03). However, the studies with stronger, although still statistically nonsignificant, associations between use of hybrid visits and preterm birth compared the COVID-19 pandemic and prepandemic eras, confounding the association. There is low-strength evidence that satisfaction with overall antenatal care was greater in people who were pregnant and receiving hybrid visits. Other outcomes were sparsely reported.

CONCLUSION

People who are pregnant may prefer hybrid televisits and in-person visits. Although there is no evidence of differences in clinical outcomes between hybrid visits and in-person visits, the evidence is insufficient to evaluate most outcomes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021272287.

A Descriptive Comparative Pilot Study: Association Between Use of a Self-monitoring Device and Sleep and Stress Outcomes in Pregnancy

Pregnancy is a challenging time for maintaining quality sleep and managing stress. Digital self-monitoring technologies are popular because of assumed increased patient engagement leading to an impact on health outcomes. However, the actual association between wear time of such devices and improved sleep/stress outcomes remains untested. Here, a descriptive comparative pilot study of 20 pregnant women was conducted to examine associations between wear time (behavioral engagement) of self-monitoring devices and sleep/stress pregnancy outcomes. Women used a ring fitted to their finger to monitor sleep/stress data, with access to a self-monitoring program for an average of 9½ weeks. Based on wear time, participants were split into two engagement groups. Using a linear mixed-effects model, the high engagement group showed higher levels of stress and a negative trend in sleep duration and quality. The low engagement group showed positive changes in sleep duration, and quality and experienced below-normal sleep onset latency at the start of the pilot but trended toward normal levels. Engagement according to device wear time was not associated with improved outcomes. Further research should aim to understand how engagement with self-monitoring technologies impacts sleep/stress outcomes in pregnancy.

Telehealth Utilization in High-Risk Pregnancies During COVID-19

Purpose

To determine how telehealth has influenced outcomes in high-risk obstetrics patients during the Coronavirus disease 2019 (COVID-19) pandemic.

Methods

A retrospective chart review was conducted to identify patterns in both telehealth and in-person clinic visits among patients of a Maternal Fetal Medicine (MFM) department from the onset of the COVID-19 pandemic from March 2020 until October 2021. For the descriptive analysis, p-values were calculated using Wilcoxon rank sum for continuous variables and chi-square or Fisher exact (where cell n < 5) for categorical variables. Variables of interest were then tested for their univariate association with telehealth utilization using logistic regression. Variables found to meet the criterion of p < 0.2 in the univariate case were introduced into a multivariable logistic model with a backward elimination for determining variable retention. We aimed to analyze whether telehealth visits significantly impacted pregnancy outcomes.

Results

Four hundred nineteen high-risk patients visited the clinic via in-person and/or telehealth appointments during the study period: 320 patients without telehealth visits and 99 patients with telehealth visits. Care provided by telehealth visits was not found to be related to self-reported race (p = 0.81), maternal body mass index (p = 1.0), or maternal age (p = 0.53). Patients with private insurance were more likely to have telehealth visits than patients with public insurance (79.9% vs. 65.5%, p < 0.01). In univariate logistic analyses, patients with diagnoses of anxiety (p < 0.01), asthma (p = 0.03), and depression (p < 0.01), at the time care was established, were more likely to have telehealth visits. Those patients with telehealth visits did not have any statistical differences in mode of delivery (p = 0.2) or pregnancy outcomes (p = 0.12), including fetal demise, preterm delivery, or delivery at term as compared with patients with all in-office visits. In multivariable analysis, patient conditions of anxiety (p < 0.01), maternal obesity (p < 0.01), and twin pregnancy (p = 0.04) were associated with higher rates of telehealth visits.

Conclusion

Patients with certain pregnancy complications elected to have more telehealth visits. Patients with private insurance were more likely to have telehealth visits than patients with public insurance. There are benefits for patients with certain pregnancy complications to incorporate telehealth visits in addition to regularly scheduled in-person clinic visits and may be suitable in a post-pandemic setting as well. Further research in this field is needed to better understand the impact of implementing telehealth in high-risk obstetrics patients.

Mental health-related telemedicine interventions for pregnant women and new mothers: a systematic literature review

BACKGROUND

Pregnancy and the postpartum period are times when women are at increased risk for depression and mental problems. This may also negatively affect the foetus. Thus, there is a need for interventions with low-threshold access and care. Telemedicine interventions are a promising approach to address these issues. This systematic literature review examined the efficacy of telemedicine interventions for pregnant women and/or new mothers to address mental health-related outcomes. The primary objective was to analyse whether telemedicine interventions can reduce mental health problems in pregnant women and new mothers. The secondary aim was to clarify the impact of type of interventions, their frequency and their targets.

METHODS

Inclusion criteria: randomized controlled trials, with participants being pregnant women and/or new mothers (with infants up to twelve months), involving telemedicine interventions of any kind (e.g. websites, apps, chats, telephone), and addressing any mental health-related outcomes like depression, postnatal depression, anxiety, stress and others. Search terms were pregnant women, new mothers, telemedicine, RCT (randomised controlled trials), mental stress as well as numerous synonyms including medical subject headings. The literature search was conducted within the databases PubMed, Cochrane Library, Web of Science and PsycINFO. Screening, inclusion of records and data extraction were performed by two researchers according to the PRISMA guidelines, using the online tool CADIMA.

RESULTS

Forty four articles were included. A majority (62%) reported significantly improved mental health-related outcomes for participants receiving telemedicine interventions compared to control. In particular (internet-delivered) Cognitive Behavioural Therapy was successful for depression and stress, and peer support improved outcomes for postnatal depression and anxiety. Interventions with preventive approaches and interventions aimed at symptom reduction were largely successful. For the most part there was no significant improvement in the symptoms of anxiety.

CONCLUSION

Telemedicine interventions evaluated within RCTs were mostly successful. However, they need to be designed to specifically target a certain mental health issue because there is no one-size-fits-all approach. Further research should focus on which specific interventions are appropriate for which mental health outcomes in terms of intervention delivery modes, content, target approaches, etc. Further investigation is needed, in particular with regard to anxiety.

Virtual prenatal visits associated with high measures of patient experience and satisfaction among average-risk patients: a prospective cohort study

BACKGROUND

Virtual visits have the potential to decrease barriers to prenatal care stemming from transportation, work, and childcare concerns. However, data regarding patient experience and satisfaction with virtual visits remain limited in obstetrics. To address this gap, we explore average-risk pregnant women's experiences with virtual visits and compare satisfaction with virtual vs. in-person visits as a secondary aim.

METHODS

In this IRB-approved, prospective cohort study, we surveyed pregnant women after their first virtual visit between October 7, 2019 and March 20, 2020. Using heterogeneous purposive sampling, we identified a subset of respondents with diverse experiences and opinions for interviews. For comparison, Consumer Assessment of Healthcare Providers and Systems (CAHPS) satisfaction data were collected after in-person visits during the study timeframe from a control cohort with the same prenatal providers. Logistic regression controlling for age, previous pregnancies, and prior live births compared satisfaction data between virtual and in-person visits. Other quantitative survey data were analyzed through descriptive statistics. Free text survey responses and interview data were analyzed using content analysis.

RESULTS

Ninety five percent (n = 165/174) of surveys and 90% (n = 18/20) of interviews were completed. Most participants were Caucasian, married, and of middle to high income. 69% (114/165) agreed that their virtual appointment was as good as in-person; only 13% (21/165) disagreed. Almost all (148/165, 90%) would make another virtual appointment. Qualitative data highlighted ease of access, comparable provider-patient communication, confidence in care quality, and positive remote monitoring experiences. Recognizing these advantages but also inherent limitations, interviews emphasized interspersing telemedicine with in-person prenatal encounters. CAHPS responses after in-person visits were available for 60 patients. Logistic regression revealed no significant difference in three measures of satisfaction (p = 0.16, 0.09, 0.13) between virtual and in-person visits.

CONCLUSIONS

In an average-risk population, virtual prenatal visits provide a patient-centered alternative to traditional in-person encounters with high measures of patient experience and no significant difference in satisfaction. Obstetric providers should explore telemedicine to improve access - and, during the ongoing pandemic, to minimize exposures - using patients' experiences for guidance. More research is needed regarding virtual visits' medical quality, integration into prenatal schedules, and provision of equitable care for diverse populations.

Lessons from digital technology-enabled health interventions implemented during the coronavirus pandemic to improve maternal and birth outcomes: a global scoping review

BACKGROUND

Timely access to essential obstetric and gynecologic healthcare is an effective method for improving maternal and neonatal outcomes; however, the COVID-19 pandemic impacted pregnancy care globally. In this global scoping review, we select and investigate peer-reviewed empirical studies related to mHealth and telehealth implemented during the pandemic to support pregnancy care and to improve birth outcomes.

METHODS

We searched MEDLINE and PubMed, Scopus, CINAHL and Web of Science for this Review because they include peer-reviewed literature in the disciplines of behavioral sciences, medicine, clinical sciences, health-care systems, and psychology. Because our investigative searches reviewed that there is considerable 'grey literature' in this area; we did not restrict our review to any study design, methods, or place of publication. In this Review, peer-reviewed preprints were comparable to published peer-reviewed articles, with relevant articles screened accordingly.

RESULTS

The search identified 1851 peer reviewed articles, and after removal of duplicates, using inclusion and exclusion criteria, only 22 studies were eligible for inclusion in the review published from January 2020 to May 2022. mHealth interventions accounted for 72.7% (16 of 22 studies) and only 27.3% (6 of 22 studies) were telehealth studies. There were only 3 example studies that integrated digital technologies into healthcare systems and only 3 studies that developed and evaluated the feasibility of mobile apps. Experimental studies accounted 68.8% of mHealth studies and only 33.3% studies of telehealth studies. Key functionalities of the pregnancy apps and telehealth platforms focused on mental and physical wellness, health promotion, patient tracking, health education, and parenting support. Implemented interventions ranged from breastfeeding and selfcare to behavioral health. Facilitators of uptake included perceived benefits, user satisfaction and convenience. Mobile apps and short messaging services were the primary technologies employed in the implemented mHealth interventions.

CONCLUSION

Although our Review emphasizes a lack of studies on mHealth interventions and data from pregnant women during the COVID-19 crisis, the review shows that implementation of digital health interventions during emergencies are inevitable given their potential for supporting pregnancy care. There is also a need for more randomized clinical trials and longitudinal studies to better understand the effectiveness and feasibility of implementing such interventions during disease outbreaks and emergencies.

Maternal and perinatal outcomes in mixed antenatal care modality implementing telemedicine in the southwestern region of Colombia during the COVID-19 pandemic

INTRODUCTION

Contingency measures due to the COVID-19 pandemic limited access to routine prenatal care for pregnant women, increasing the risk of pregnancy complications due to poor prenatal follow-up, especially in those patients at high obstetric risk. This prompted the implementation and adaptation of telemedicine.

OBJECTIVE

We aim to evaluate the maternal and perinatal outcomes of patients who received prenatal care in-person and by telemedicine.

METHODS

We conducted a retrospective observational cohort study of pregnant women who received exclusive in-person and alternate (telemedicine and in-person) care from March to December 20,202, determining each group's maternal and neonatal outcomes.

RESULTS

A total of 1078 patients were included, 156 in the mixed group and 922 in the in-person group. The patients in the mixed group had a higher number of prenatal controls (8 (6-9) vs 6 (4-8) p < 0.001), with an earlier gestational age at onset (7.1 (6-8.5) vs 9.3 (6.6-20.3), p < 0.001), however, they required a longer hospital stay (26 (16,67%) vs 86 (9,33%), p = 0.002) compared to those attended in-person; there were no significant differences in the development of obstetric emergencies, maternal death or neonatal complications.

DISCUSSION

Incorporating telemedicine mixed with in-person care could be considered as an alternative for antenatal follow-up of pregnant women in low- and middle-income countries with barriers to timely and quality health care access.

Society for Maternal-Fetal Medicine Special Statement: Telemedicine in obstetrics-quality and safety considerations

The frequency of telemedicine encounters has increased dramatically in recent years. This review summarizes the literature regarding the safety and quality of telemedicine for pregnancy-related services, including prenatal care, postpartum care, diabetes mellitus management, medication abortion, lactation support, hypertension management, genetic counseling, ultrasound examination, contraception, and mental health services. For many of these, telemedicine has several potential or proven benefits, including expanded patient access, improved patient satisfaction, decreased disparities in care delivery, and health outcomes at least comparable to those of traditional in-person encounters. Considering these benefits, it is suggested that payers should reimburse providers at least as much for telemedicine as for in-person services. Areas for future research are considered.

Telehealth Adoption During COVID-19: Lessons Learned from Obstetric Providers in the Rocky Mountain West

INTRODUCTION

Obstetric providers have used telemedicine to manage gestational diabetes, mental health, and prenatal care. However, the uptake of telemedicine in this field has not been universal. The COVID-19 pandemic catalyzed the adoption of telehealth in obstetric care, which will have lasting effects, especially for rural communities. We sought to understand the experience of adapting to telehealth among obstetric providers in the Rocky Mountain West to identify implications for policy and practice.

METHODS

This study included 20 semi-structured interviews with obstetric providers in Montana, Idaho, and Wyoming. The interviews followed a moderator's guide based on the Aday & Andersen Framework for the Study of Access to Medical Care, exploring domains of health policy, the health system, the utilization of health services, and the population at risk. All the interviews were recorded, transcribed, and analyzed using thematic analysis.

RESULTS

Findings indicate that participants view telehealth as a useful tool during prenatal and postpartum care; many participants intend to continue telehealth practices after the pandemic. Participants shared that their patients reported benefits to telehealth beyond COVID-19 safety, including limiting travel time, reducing time off work, and alleviating childcare needs. Participants expressed concern that expanding telehealth will not equally benefit all patients and could widen existing health inequities.

DISCUSSION

Success moving forward will require a telehealth infrastructure, adaptive telehealth models, and provider and patient training. As obstetric telehealth expands, efforts must prioritize equitable access for rural and low-income communities, so all patients can benefit from the technological advancements to support health.

Effectiveness of Remote Fetal Monitoring on Maternal-Fetal Outcomes: Systematic Review and Meta-Analysis

BACKGROUND

To solve the disadvantages of traditional fetal monitoring such as time-consuming, cumbersome steps and low coverage, it is paramount to develop remote fetal monitoring. Remote fetal monitoring expands time and space, which is expected to popularize fetal monitoring in remote areas with the low availability of health services. Pregnant women can transmit fetal monitoring data from remote monitoring terminals to the central monitoring station so that doctors can interpret it remotely and detect fetal hypoxia in time. Fetal monitoring involving remote technology has also been carried out, but with some conflicting results.

OBJECTIVE

The review aimed to (1) examine the efficacy of remote fetal monitoring in improving maternal-fetal outcomes and (2) identify research gaps in the field to make recommendations for future research.

METHODS

We did a systematic literature search with PubMed, Cochrane Library, Web of Science, Embase, MEDLINE, CINAHL, ProQuest Dissertations and Theses Global, ClinicalTrials.gov, and Open Grey in March 2022. Randomized controlled trials or quasi-experimental trials of remote fetal monitoring were identified. Two reviewers independently searched articles, extracted data, and assessed each study. Primary outcomes (maternal-fetal outcomes) and secondary outcomes (health care usage) were presented as relative risks or mean difference. The review was registered on PROSPERO as CRD42020165038.

RESULTS

Of the 9337 retrieved literature, 9 studies were included in the systematic review and meta-analysis (n=1128). Compared with a control group, remote fetal monitoring reduced the risk of neonatal asphyxia (risk ratio 0.66, 95% CI 0.45-0.97; P=.04), with a low heterogeneity of 24%. Other maternal-fetal outcomes did not differ significantly between remote fetal monitoring and routine fetal monitoring, such as cesarean section (P=.21; I2=0%), induced labor (P=.50; I2=0%), instrumental vaginal birth (P=.45; I2=0%), spontaneous delivery (P=.85; I2=0%), gestational weeks at delivery (P=.35; I2=0%), premature delivery (P=.47; I2=0%), and low birth weight (P=.71; I2=0%). Only 2 studies performed a cost analysis, stating that remote fetal monitoring can contribute to reductions in health care costs when compared with conventional care. In addition, remote fetal monitoring might affect the number of visits and duration in the hospital, but it was not possible to draw definite conclusions about the effects due to the limited number of studies.

CONCLUSIONS

Remote fetal monitoring seems to reduce the incidence of neonatal asphyxia and health care costs compared with routine fetal monitoring. To strengthen the claims on the efficacy of remote fetal monitoring, further well-designed studies are necessary, especially in high-risk pregnant women, such as pregnant women with diabetes, pregnant women with hypertension, and so forth.

The use and role of telemedicine in maternal fetal medicine around the world: an up-to-date

Purpose

The aim of this narrative review is to sumarize data about the use and role of telemedicine in maternal fetal medicine (MFM).

Methods

We searched pubmed and scopus to find articles about telemedicine in MFM by using the terms telmedicine or telehealth and maternal fetal medicine.

Results

Telehealth has been widely used for several medical specialties. During the coronavirus disease 2019 (COVID-19) pandemic, telehealth has gained investment and further research. Even though telemedicine in MFM has not been frequently applied, from 2020 onwards it has increased in both implementation and acceptance worldwide. The need to screen the patients in overloaded centers in a pandemic scenario required telemedicine in MFM, which has exhibited consistently good results concerning health and budget. The aim of this study was to review the telehealth programs and research focused on MFM around the world. Few studies have been applied to MFM and even fewer in developing and undeveloped countries. The majority of studies were concentrated in the USA and in Europe.

Conclusion

Further research is needed, especially in non-developed countries, to comprehend the potential role of telemedicine in MFM for improving the life quality of the patients, health professionals, and to be cost-efficient.

Virtual prenatal care: A systematic review of pregnant women's and healthcare professionals' experiences, needs, and preferences for quality care

INTRODUCTION

Exploitation of telehealth in prenatal care has the potential to reduce the access barrier to care and empower women to participate in their own care. This review aims to assess the practical implications of virtual prenatal care and identify the needs and experiences associated with it.

METHODS

A systematic literature review was conducted in four electronic databases: PubMed, Web of Science, Scopus, and Cochrane. The keywords used were "pregnancy", "virtual visit", "prenatal", and others. The search included all relevant studies published from 2011 to 2021 written in English. Articles mentioning virtual prenatal care incorporating synchronous communication between pregnant women and health care professionals were included. Those unrelated to prenatal care or employing asynchronous means of virtual care were excluded. The review was structured following the PRISMA guidelines. Different quality appraisal methods such as JBI, CASP, NOS, and Cochrane were used to assess the methodological quality of the literature. The data were then analyzed based on the categorization of the studies.

RESULTS

Overall, 2863 articles were identified, of which 19 met the inclusion criteria after removing duplicates, screening of abstracts, and full text-four articles identified from hand-searching were incorporated, making a total of 23 eligible articles for the review. The studies' findings revealed the preference for implementing cost-effective virtual care based on the resource set, technological literacy, and consistent accessibility. Further, no significant differences in clinical outcomes were observed between two modes of care, virtual and in-person. The higher satisfaction by pregnant women and healthcare professionals indicated the continuity of the care. In addition, the hybrid model of virtual prenatal care integrated with traditional in-person care was acceptable to both low-risk and high-risk pregnant women. Virtual prenatal care substantially reduced travel time and absences from work, drops in clinic wait time and no-show rate, limited the risk of exposure during a pandemic, and increased self-accountability.

CONCLUSION

Virtual prenatal care offers predominant advantages over in-person when it is carefully designed with the inclusion of pregnant women and healthcare professionals' needs. Evidence showed that providing adequate technology training, proper instruction, and guidelines for initial setup and assurance of a reliable and accessible system is vital in increasing access to care.

Maternal telehealth: innovations and Hawai'i perspectives

Access to maternal-fetal medicine (MFM) subspecialty services is a critical part of a healthcare system that optimizes pregnancy outcomes for women with complex medical and obstetrical disorders. Healthcare services in the State of Hawai'i consist of a complicated patchwork of independently run community health clinics and hospital systems which are difficult for many pregnant patients to navigate. Maternal telehealth services have been identified as a solution to increase access to subspecialty prenatal services for women in rural communities or neighboring islands, especially during the COVID-19 pandemic. Telehealth innovations have been rapidly developing in the areas of remote ultrasound, hypertension management, diabetes management, and fetal monitoring. This report describes how telehealth innovations are being introduced by MFM specialists to optimize care for a unique population of high-risk patients in a remote area of the world such as Hawai'i, as well as review currently available telemedicine technologies and future innovations.

Benefits and barriers of home blood pressure monitoring in pregnancy: perspectives of obstetric doctors from a Ghanaian tertiary hospital

BACKGROUND

Delayed diagnosis of preeclampsia contributes to maternal morbidity and mortality. Patient-performed home blood pressure monitoring facilitates more frequent monitoring and earlier diagnosis. However, challenges may exist to implementation in low- and middle income-countries.

METHODS

This cross-sectional mixed methods study evaluated obstetric doctors' perspectives on the benefits of and barriers to the implementation of home blood pressure monitoring among pregnant women in Ghana. Participants were doctors providing obstetric care at Korle Bu Teaching Hospital. Electronic surveys were completed by 75 participants (response rate 49.3%), consisting of demographics and questions on attitudes and perceived benefits and challenges of home BP monitoring. Semi-structured interviews were completed by 22 participants to expand on their perspectives.

RESULTS

Quantitative and qualitative results converged to highlight that the current state of blood pressure monitoring among pregnant women in Ghana is inadequate. The majority agreed that delayed diagnosis of preeclampsia leads to poor health outcomes in their patients (90.6%, n = 68) and earlier detection would improve outcomes (98.7%, n = 74). Key qualitative benefits to the adoption of home blood pressure monitoring were patient empowerment and trust of diagnosis, more quantity and quality of blood pressure data, and improvement in systems-level efficiency. The most significant barriers were the cost of monitors, lack of a communication system to convey abnormal values, and low health literacy. Overall, doctors felt that most barriers could be overcome with patient education and counseling, and that benefits far outweighed barriers. The majority of doctors (81.3%, n = 61), would use home BP data to inform their clinical decisions and 89% (n = 67) would take immediate action based on elevated home BP values. 91% (n = 68) would recommend home BP monitoring to their pregnant patients.

CONCLUSION

Obstetric doctors in Ghana strongly support the implementation of home blood pressure monitoring, would use values to inform their clinical management, and believe it would improve patient outcomes. Addressing the most significant barriers, including cost of blood pressure monitors, lack of a communication system to convey abnormal values, and need for patient education, is essential for successful implementation.