Telehealth Interventions to Improve Obstetric and Gynecologic Health Outcomes: A Systematic Review

Examining use of telehealth in jails: linking women to community OUD services

BACKGROUND

Opioid use disorder (OUD) remains a significant health care need for women, particularly those involved in the criminal legal system (CLS). There are no studies to date that focus on the utilization of telehealth as a platform for assessment and linkage to medications to treat opioid use disorder (MOUD) at community re-entry for women, despite the fact that women have unique risk factors that may contribute to opioid relapse in the community. The purpose of this mixed-methods study is to provide an overview of the innovative use of telehealth for linking incarcerated women to community MOUD treatment in the Kentucky-hub of the Justice Community Opioid Innovation Network (JCOIN).

METHODS

This study incorporates qualitative and quantitative data collection with MOUD providers, recovery staff involved in peer navigation services, and women who are incarcerated to understand perceptions of the use of telehealth prior to jail release as a linkage to community services.

RESULTS

Findings from this study suggest overall support for the use of telehealth between community MOUD treatment providers and women who are incarcerated using videoconferencing technology. On average, there was very little variation in provider favorable feedback related to clinical engagement or in face-to-face comparability, as well as how telehealth allowed the participant to discuss personal and sensitive issues during the clinical assessment.

CONCLUSIONS

Study findings suggest benefits associated with the use of telehealth in increasing access to treatment for women with OUD. Jails are critical venues for telehealth interventions because they provide the opportunity to reach women who have been actively using illicit substances, often have advanced-stage substance use disorders which have compromised their health and mental health, and often have not been previously identified as needing treatment.

TRIAL REGISTRATION

This study was originally registered on 8/23/19, ClinicalTrials.gov, #NCT04069624.

A multi-faceted exploration of unmet needs in the continuing improvement and development of fertility care amidst a pandemic

PURPOSE

The continuous improvement and development of fertility care, internationally, requires ongoing monitoring of current delivery processes and outcomes in clinical practice. This descriptive and exploratory mixed-methods study was conducted in eight countries (Brazil, China, France, Germany, Italy, Mexico, Spain and the United Kingdom) to assess the unmet needs of fertility patients (male and female), and existing challenges, barriers and educational gaps of physicians and laboratory specialists involved in human fertility care during the COVID-19 pandemic.

MATERIALS AND METHODS

The study was deployed sequentially in two phases: 1) in-depth 45-minute semi-structured interviews (n=76), transcribed, coded and thematically analysed using an inductive reasoning approach, 2) an online survey (n=303) informed by the findings of the qualitative interviews, face validated by experts in reproductive medicine, and analysed using descriptive and inferential statistical methods.

RESULTS

The integrated results of both phases indicated numerous areas of challenges, including: 1) investigating male-related infertility; 2) deciding appropriate treatment for men and selective use of assisted reproductive technology; and 3) maintaining access to high-quality fertility care during a pandemic.

CONCLUSIONS

The paper presents a reflective piece on knowledge and skills that warrant ongoing monitoring and improvement amongst reproductive medicine healthcare professionals amidst future pandemics and unanticipated health system disruptions. Moreover, these findings suggest that there is an additional need to better understand the required changes in policies and organizational processes that would facilitate access to andrology services for male infertility and specialized care, as needed.

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.

Virtual Compared With In-Office Postoperative Visits After Urogynecologic Surgery: A Randomized Controlled Trial

OBJECTIVE

To compare patient satisfaction, health care resource utilization, and adverse events among patients receiving a virtual video compared with in-office postoperative visit after urogynecologic surgery. We hypothesized that virtual video visits would be noninferior to in-office visits.

METHODS

This was a randomized noninferiority clinical trial of patients undergoing surgery for pelvic organ prolapse and urinary incontinence at a single academic tertiary referral center. Participants were randomized to receive either a virtual video postoperative visit or a standard in-office postoperative visit. The primary outcome was patient satisfaction measured by the validated PSQ-18 (Patient Satisfaction Questionnaire-18) (noninferiority margin 5 points) at the 6-week postoperative visit. Secondary outcomes included PSQ-18 domain scores (noninferiority margin 0.5 points) and composite health care resource utilization and adverse events after the 6-week postoperative visit up to 12 weeks after surgery (noninferiority margin 10%). A sample size of 100 participants (50 per group) would allow 80% power to assess a 5-point noninferiority margin on the total PSQ-18 with an SD of 10 and α=0.05.

RESULTS

From January 2023 to September 2023, 265 patients were screened for eligibility, and 104 were randomized. A total of 100 participants (50 per arm) completed the study and were included in the analysis. The mean±SD age of all participants was 57.0±13.2 years. The mean±SD PSQ-18 total score was 75.18±8.15 in the virtual group and 75.14±8.7 in the in-office group. The mean PSQ-18 total score was 0.04 points higher (ie, greater degree of satisfaction) in the virtual group, with a 95% CI of -2.75 to 2.83, which met the criterion for noninferiority. Between-group differences for all PSQ-18 domain scores likewise met criterion for noninferiority. Composite health care resource utilization was 14.0% lower in the virtual group than in the in-office group (20.0% vs 34.0%, 95% CI, -28.0% to 1.0%). For composite adverse events, the between-group difference was 2.0% (2.0% in virtual group vs 0.0% in in-office group, 95% CI,-3.0% to 8.0%).

CONCLUSION

Virtual video postoperative visits were noninferior to in-office visits with regard to patient satisfaction, health care resource utilization, and adverse events and can be offered as an alternative to in-office visits for postoperative follow-up after urogynecologic surgery.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT05641077.

Academy of Breastfeeding Medicine Clinical Protocol #19: Breastfeeding Promotion in the Prenatal Period (Revised 2024)

Background: The Academy of Breastfeeding Medicine revised the 2015 version of this clinical protocol to review the evidence and provide recommendations related to breastfeeding promotion in the prenatal period. Key Information: Promoting and normalizing breastfeeding in the prenatal period can improve breastfeeding outcomes including initiation and duration of breastfeeding. Ideally, prenatal interventions should be a part of a comprehensive longitudinal breastfeeding support program. Recommendations: Clinicians or other health workers should discuss breastfeeding at each prenatal visit. Counseling topics should include the health benefits of breastfeeding versus not breastfeeding, the basics of breastfeeding (e.g., physiology, positioning), what to expect of hospital-based and immediate postpartum breastfeeding support (i.e., Baby-Friendly Ten Steps), and the risks of unnecessary supplementation. Medical, anatomical, and other risk factors for breastfeeding challenges should be identified, and targeted anticipatory guidance should be given. Prenatal counseling should include distribution of structured breastfeeding education at low literacy levels and in the parent's preferred language. Counseling should be culturally sensitive and patient-centered, including family members when appropriate. Prenatal support may integrate various health workers (e.g., medical doctors, midwives, community health workers, lactation consultants, among others) and include various modalities including telecommunication. Enhancing breastfeeding education for prenatal care providers is also imperative. Additional themes related to implementation of recommendations for specific populations are also reviewed.

Telemedicine Follow-up After Medication Management of Early Pregnancy Loss

Objective: Our objective was to evaluate the feasibility of a new protocol for telemedicine follow-up after medication management of early pregnancy loss. Study Design: The study was designed to assess the feasibility of planned telemedicine follow-up after medication management of early pregnancy loss. We compared these follow-up rates with those after planned in-person follow-up of medication management of early pregnancy loss and planned telemedicine follow-up after medication abortion. We conducted a retrospective cohort study, including patients initiating medication management of early pregnancy loss <13w0d gestation and medication abortion ≤10w0d with a combination of mifepristone and misoprostol between April 1, 2020, and March 28, 2021. As part of a new clinical protocol, patients could opt for telemedicine follow-up one week after treatment and a home urine pregnancy test 4 weeks after treatment. Our primary outcome was completed follow-up as per clinical protocol. We also examined outcomes related to complications across telemedicine and in-person follow-up groups. Results: Of patients reviewed, 181 were eligible for inclusion; 75 had medication management of early pregnancy loss, and 106 had medication abortion. Thirty-six out of 75 patients elected for telemedicine follow-up after early pregnancy loss. Of patients scheduled for telemedicine follow-up, 29/36 (81%, 95% CI: 64-92) with early pregnancy loss and 64/69 (93%, 95% CI: 84-98) undergoing medication abortion completed follow-up as per protocol (p = 0.06). Completed follow-up was also similar among patients undergoing medication management of early pregnancy loss who planned for in-person follow-up (p = 0.135). Complications were rare and did not differ across early pregnancy loss and medication abortion groups. Conclusions: Telemedicine follow-up is a feasible alternative to in-person assessment after medication management of early pregnancy loss.

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.

Centering Equity and Fostering Stakeholder Collaboration and Trust-Pillars of the Maternal Health Innovation Program in Maryland

Objective

To describe two main pillars of the Maryland Maternal Health Innovation Program (MDMOM): (1) centering equity and (2) fostering broad stakeholder collaboration and trust.

Methods

We summarized MDMOM's key activities and used severe maternal morbidity (SMM) surveillance and program monitoring data to quantify MDMOM's work on the two pillars. We developed measures of hospital engagement with MDMOM (participation in quality improvement [QI] activities, participation in check-in meetings, staff involvement) and with other partners (participation in QI activities, representation in state-level groups). We examined Bonferroni-adjusted correlations between these hospital engagement measures and with key hospital characteristics: level of maternity care, annual delivery volume, and SMM rate.

Results

Over 100 national and state organizations and individual stakeholders contributed to our building the MDMOM program and implementing key activities centering equity: hospital-based SMM surveillance in 20 of Maryland's 32 hospitals; almost 5,000 trainings offered to perinatal health care providers; two telemedicine/telehealth interventions; training of home visitors and community-based organization staff. Birthing hospitals represent MDMOM's main implementation partners. The strength of their participation in MDMOM QI activities is positively correlated to their participation in check-in meetings and with the degree of involvement by physicians in such activities. Higher engagement in MDMOM QI activities is also positively correlated to hospitals' participation in other state-level maternal health initiatives or groups.

Conclusion

Our experience with the MDMOM program demonstrates that an equity focus and broad stakeholder collaboration building strong relationships and providing implementation support can lead to high levels of engagement in innovative maternal health interventions.

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 telehealth on patient-provider communication in prenatal care for pregnant women from underserved settings

INTRODUCTION

Telehealth has emerged as a promising supplementary modality in prenatal care. However, its impact on patient-provider communication (PPC), especially among pregnant women from underserved settings, requires comprehensive evaluation. This study examined the factors associated with the quality of patient-provider communication during the COVID-19 pandemic among pregnant telehealth users and non-users.

METHODS

Using a cross-sectional study design, 242 women were surveyed (response rate = 23%) regarding their experience with telehealth, quality of PPC, and experiences of discrimination during prenatal care. Multiple regression models were used to identify the factors associated with the quality of PPC during the COVID-19 pandemic. A sub-group analysis explored the factors associated with the quality of PPC separately among telehealth users and non-users.

RESULTS

The majority of the participants were on Medicaid (95%) and self-identified as Black/African American (57.3%). Regression analyses revealed a negative relationship between telehealth use during pregnancy and the quality of PPC (β = -1.13, P = 0.002). Irrespective of the telehealth use, the experience of discrimination was associated with poor quality of PPC among users (β = -3.47, P = .02) and non-users (β = -.78, P = .03), while adjusting for sociodemographic factors and social support during pregnancy.

DISCUSSION

While telehealth offers advantages like convenience, increased accessibility, and continuity of care, challenges in establishing effective PPC in virtual settings have emerged that emphasize the necessity for comprehensive provider training extending beyond technical competencies. The persistent issue of perceived discrimination, impacting PPC across both groups, underscores the necessity to rethink existing strategies of mandatory training to increase providers' knowledge.

Promoting childbirth in a rural health facility: A quasi-experimental study in western Kenya

BACKGROUND

The high maternal and neonatal mortality rate in sub-Saharan Africa could be reduced by using navigation by means of mobile devices to increase the number of women who choose to give birth in a health center (HC) with a skilled healthcare practitioner.

METHODS

A quasi-experimental design was used to test a midwife-delivered navigation by means of mobile phone. A total of 208 women were randomized to two groups (intervention and control). Women in the intervention group received up to three navigation calls from midwives. Women in the control group received usual antenatal education during prenatal visits. Data were collected using semistructured questionnaires. Childbirth location was determined through medical records.

RESULTS

Overall, 180 (87%) women gave birth in a HC with a 3% advantage for the intervention group. A total of 86% (88/102) of the control group gave birth in a HC versus 89% (92/103) for the intervention group (Χ2 = 0.44, p-value = 0.51), with an unadjusted odds ratio of 1.33 (95% CI: 0.57, 3.09). Among those with personal phones, 91% (138/152) had a birth in a HC versus 79% (42/53) in those without a personal phone (Χ2 = 4.89, p-value = 0.03).

CONCLUSIONS

The results of this study indicate that it is feasible to deliver phone-based navigation to support birth in a HC; personal phone ownership may be a factor in the success of this strategy.

Health care use and health consequences of geographic lack of access to abortion and maternity care

BACKGROUND

Recent years have brought substantial declines in geographic access to abortion facilities and maternity care across the US. The purpose of this study was to identify the reproductive health consequences of living in a county without access to comprehensive reproductive health care services.

METHODS

We analyzed National Center for Health Statistics data on all live births occurring in the US in 2020. We used data on locations of abortion facilities and availability of maternity care in order to classify counties by level of access to comprehensive reproductive health care services and defined comprehensive reproductive health care deserts as counties that did not have an abortion facility in the county or in any neighboring county and did not have any maternity care practitioners. We fit modified Poisson regression models with generalized estimating equations to estimate the degree to which living in a comprehensive reproductive health care desert was associated with receipt of timely and adequate prenatal care and risk of preterm birth, controlling for individual-level and county-level characteristics.

RESULTS

In 2020, one third of counties in the US were comprehensive reproductive health care deserts (n = 1082), and 136,272 births occurred in these counties. In adjusted models, there was no difference in prenatal health care use (timeliness or adequacy of care) between persons in comprehensive reproductive health care deserts and those with full access to care, but the risk of preterm birth was significantly elevated (aRR =1.09, 95% CI = 1.06, 1.13).

CONCLUSIONS

Lack of access to comprehensive reproductive health care services may increase the incidence of preterm birth.

Virtual Obstetric Hospitalist Support for Obstetric Emergencies and Deliveries: The Mayo Clinic Experience

Objective: To implement use of obstetric (OB) hospitalist telemedicine services (TeleOB) to support clinicians facing OB emergencies in low-resource hospital settings. Methods: TeleOB was staffed by OB hospitalists working at a tertiary maternity center. The service was available via real-time high-definition audio/video technology for providers at 17 outlying hospitals across a health system spanning two states. The initial 25 service activations are described. Results: TeleOB supported 17 deliveries, two postpartum emergency department (ED) consultations, and four antenatal ED consultations. In 10 of 17 (59%) deliveries, teleneonatology was jointly activated to support neonatal resuscitation. Sixteen (94%) deliveries occurred in multiparas, and five (29%) resulted from spontaneous preterm labor. Eighty percent (20/25) of activations occurred in facilities without maternity services. Conclusions: A TeleOB service staffed by OB hospitalists successfully supports hospitals in an integrated health care system. TeleOB is feasible for support of hospitals with no delivery facilities or with limited maternity care resources.

Effectiveness of mHealth Apps for Maternal Health Care Delivery: Systematic Review of Systematic Reviews

BACKGROUND

Globally, the use of mobile health (mHealth) apps or interventions has increased. Robust synthesis of existing systematic reviews on mHealth apps may offer useful insights to guide maternal health clinicians and policy makers.

OBJECTIVE

This systematic review aims to assess the effectiveness or impact of mHealth apps on maternal health care delivery globally.

METHODS

We systematically searched Scopus, Web of Science (Core Collection), MEDLINE or PubMed, CINAHL, and Cochrane Database of Systematic Reviews using a predeveloped search strategy. The quality of the reviews was independently assessed by 3 reviewers, while study selection was done by 2 independent raters. We presented a narrative synthesis of the findings, highlighting the specific mHealth apps, where they are implemented, and their effectiveness or outcomes toward various maternal conditions.

RESULTS

A total of 2527 documents were retrieved, out of which 16 documents were included in the review. Most mHealth apps were implemented by sending SMS text messages with mobile phones. mHealth interventions were most effective in 5 areas: maternal anxiety and depression, diabetes in pregnancy, gestational weight management, maternal health care use, behavioral modification toward smoking cessation, and controlling substance use during pregnancy. We noted that mHealth interventions for maternal health care are skewed toward high-income countries (13/16, 81%).

CONCLUSIONS

The effectiveness of mHealth apps for maternity health care has drawn attention in research and practice recently. The study showed that research on mHealth apps and their use dominate in high-income countries. As a result, it is imperative that low- and middle-income countries intensify their commitment to these apps for maternal health care, in terms of use and research.

TRIAL REGISTRATION

PROSPERO CRD42022365179; https://tinyurl.com/e5yxyx77.

[Evidence synthesis and recommendations: clinical practice guidelines on drug treatment for hypertension in pregnancySíntese de evidências e recomendações: diretrizes de prática clínica para o tratamento farmacológico da hipertensão arterial na gravidez]

Introduction

Hypertensive disorders during pregnancy are a major cause of severe morbidity, long-term disability, and death. Appropriate pharmacological treatment is essential in the management of these disorders.

Objectives

Synthesize the recommendations developed by the World Health Organization (WHO) to improve the quality of care and health outcomes of adults with high blood pressure, and address aspects of how to implement these recommendations.

Methods

A synthesis was conducted of WHO recommendations: drug treatment for severe hypertension in pregnancy and WHO recommendations: drug treatment for non-severe hypertension in pregnancy. The WHO recommendations follow the GRADE methodology (Grading of Recommendations, Assessment, Development, and Evaluation) for the preparation of guidelines, as described in the WHO Handbook for Guideline Development. In addition, a systematic search for studies carried out in the Region of the Americas was conducted in PubMed, Lilacs, Health Systems Evidence, Epistemonikos, and gray literature to identify barriers, facilitators, and implementation strategies.

Results

Four recommendations were formulated for women with hypertensive disorders. Implementation barriers and facilitators were identified, and indicators were created to assess adherence and outcomes.

Conclusions

The formulated recommendations provide guidance on how to approach drug treatment of hypertension in pregnancy, with considerations for implementation in Latin America and the Caribbean.

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.

Urgent Follow-up after Outpatient Nonstress Tests and the Potential for Fetal Monitoring at Home

OBJECTIVE

 This study aimed to measure the proportion of patients needing urgent clinical follow-up after an abnormal outpatient nonstress test (NST). We further sought to capture the patient perspective on the acceptability of performing NSTs at home.

STUDY DESIGN

 A retrospective cohort study was performed over a 2-year period to determine the frequency of abnormal NSTs in a hospital-based, antepartum testing unit in patients greater than or equal to 32 weeks' gestation. The proportion of patients who delivered within 24 hours of an abnormal NST was also determined. A cross-sectional, web-based patient survey was conducted to obtain insight into the patient's comfort level with potentially performing NSTs at home.

RESULTS

 The chart review yielded 665 patients who underwent 2,122 NSTs at greater than or equal to 32 weeks. Of the 2,122 NSTs, 111 were categorized as abnormal and required urgent clinical follow-up, or 5.2% (95% confidence interval [CI] 4.3, 6.3%). Of the 665 patients, 13 delivered within 24 hours of an abnormal NST, or 2.0% (95% CI 1.0, 3.3%). In the web-based survey, the proportion of respondents who would feel comfortable or very comfortable conducting NSTs at home was 87/125, or 69.6% (95% CI 60.9, 77.1%).

CONCLUSION

 This study revealed that 5.2% of NSTs performed in a hospital-based antepartum testing unit were abnormal and required urgent clinical follow-up. Of the patients being followed in the antepartum testing unit, 2.0% delivered within 24 hours of an abnormal NST. The majority of the survey respondents indicated they would feel comfortable performing NSTs at home. The present study adds important information regarding the risks and benefits of NSTs at home.

KEY POINTS

· Telehealth for NSTs offers advantages over in-person NSTs.. · The proportion of NSTs that need urgent follow-up was 5.2%.. · A majority of patients are interested in telehealth for NSTs.. · Guidelines are needed before adoption of telehealth for NSTs..

The impact of telehealth applications on pregnancy outcomes and costs in high-risk pregnancy: A systematic review and meta-analysis

INTRODUCTION

Telehealth is an applicable, acceptable, cost-effective, easily accessible, and speedy method for pregnant women. This study aimed to examine the impact of telehealth applications on pregnancy outcomes and costs in high-risk pregnancies.

METHODS

Studies were selected from PubMed, Science Direct, Web of Science, EBSCO, Scopus, and Clinical Key databases according to the inclusion and exclusion criteria from January to February 2021. Cochrane risk-of-bias tools were used in the quality assessment of the studies.

RESULTS

Four observational and eight randomized controlled studies were included in this meta-analysis (telehealth: 135,875, control: 94,275). It was seen that the number of ultrasound (p < 0.01) and face-to-face visits (p < 0.01), fasting insulin (p < 0.01), hemoglobin A1C before delivery (p < 0.01), and emergency cesarean section rates (p = 0.05) were lower in the telehealth group. In the telehealth group, the women's use of antenatal corticosteroids (p = 0.03) and hypoglycemic medication at delivery (p = 0.03), the total of nursing interventions (p < 0.01), compliance with actual blood glucose measurements (p < 0.01), induction intervention at delivery (p = 0.003), and maternal mortality (p < 0.001) rates were higher. Two groups were similar in terms of the use of medical therapy, total gestational weight gain, health problems related to pregnancy, mode and complications of delivery, maternal intensive care unit admission, fetal-neonatal growth and development, neonatal health problems and mortality, follow-up, and care costs.

DISCUSSION

Telehealth and routine care yielded similar maternal/neonatal health and cost outcomes. It can be said that telehealth is a safe technique to work with in the management of high-risk pregnancies.

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.

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.

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.

Telehealth as an Effective Care Delivery Method During the COVID-19 Pandemic for the Rhode Island Behavioral Health Population

In response to the COVID-19 pandemic, Rhode Island implemented a telehealth waiver allowing telehealth parity. This study investigated (1) if telehealth allowed for patients who seek mental health services to maintain visit frequency and (2) if subpopulations were less likely to utilize telehealth. We used descriptive statistics to analyze the change in total number of visits, in-person visits from pre-waiver to post-waiver, and a multivariate linear regression to identify relationships between demographics and telehealth utilization. Participants were able to maintain the frequency of visits during the COVID-19 pandemic. Race/ethnicity, age, gender, employment status, and housing status were all statistically significant predictors of telehealth utilization. Telehealth aids in the continuing of care when in-person visits are not a viable option. Access to telehealth is crucial during public health emergencies and aids in maintaining visit frequency. Further research should be done to evaluate subgroups who are less likely to utilize telehealth.

Effectiveness of smoking cessation interventions among pregnant women: An updated systematic review and meta-analysis

OBJECTIVE

To carry out a systematic review of systematic reviews with an update of the existing evidence relating to a broad range of smoking cessation interventions, including psycho-social, digital and pharmacologic interventions, for pregnant women.

DATA-SOURCES

Search was conducted in March 2022 in PubMed, EMBASE, and Cochrane in two stages: 1) a search of systematic reviews and meta-analyses, published from January 2012 through January 2022; 2) an update of those that fulfilled eligibility criteria reproducing the primary search strategy.

STUDY ELIGIBILITY CRITERIA

We selected randomized clinical trials (RCTs) that evaluated the effectiveness of pharmacological, digital, and psychosocial interventions in aged 18 years and over who were daily smokers, and compared these with routine care, less intense interventions or placebo.

STUDY APPRAISAL AND SYNTHESIS METHODS

Data from eligible studies were manually extracted by two authors and reviewed by a third. The quality of the reviews was evaluated using the AMSTAR scale, and risk of bias was measured with the Rob-2 tool and GRADE level of evidence.

RESULTS

The meta-analysis included 63 RCTs (n = 19849 women). The interventions found to be effective were: financial incentives (RR:1.77; 95%CI:1.21-2.58), counseling (RR:1.27; 95%CI:1.13-1.43) and long-term nicotine replacement therapy (NRT) (RR:1.53; 95%CI:1.16-2.01). Short-term NRT, bupropion, digital interventions, feedback, social support, and exercise showed no effectiveness. The GRADE level of evidence was moderate-to-high for all interventions, with the exception of long-term NRT.

CONCLUSIONS

Non-pharmacological interventions for smoking cessation are the most effective for pregnant women. The moderator analysis suggests that pregnant women of low socioeconomic status might benefit less from smoking cessation interventions than women of a high socioeconomic status. These women are usually heavier smokers that live in pro-smoking environments and could require more intensive and targeted interventions.

Assessment of Pregnancy-Related Telehealth Interventions in the United States: A 10-Year Scoping Review

Introduction: Telehealth use in obstetrics has been demonstrated to improve efficiency, access to care, and pregnancy outcomes. Despite reported successful implementation of these programs, information regarding the program variations and its impact on health care costs and outcomes are scarce. Methods: This is a scoping review of pregnancy-related telehealth studies to understand the current landscape of pregnancy-related telehealth interventions as well as to subset those that are used in high-risk pregnancies. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework to guide this review. Results: A total of 70 articles were included in this scoping review. Of those, 53 (75.7%) studies included a pregnant population and 17 (24.3%) studies focused on a rural and/or urban population. Most studies (n = 56; 80%) included some form of synchronous interaction between provider and participant. Patient outcomes included maternal/infant health outcomes (n = 41; 44.1%), patient satisfaction (n = 9; 9.7%), and attendance/compliance (n = 5; 5.4%). Provider-level outcomes included knowledge change (n = 11; 11.8%) and self-efficacy (n = 3; 3.2%). Other outcomes included assessment of costs and patient/provider feasibility and acceptability of the intervention. Overall, there has been a growing trend in articles published on pregnancy-related telehealth studies since 2011, with 2018 having the most publications in a single year. Conclusion: This review suggests a steadily growing body of literature on pregnancy-related telehealth interventions; however, more research is needed to better understand outcomes of telehealth for pregnancy-related care, especially related to patient satisfaction, health disparities, and cost-benefit.

Exploring patients' experiences with telehealth in obstetrics care during the COVID-19 pandemic: A qualitative study

AIM

The aim of this study was to evaluate patients' experiences with telehealth provision of obstetrics and gynecology care during the COVID-19 pandemic qualitatively.

DESIGN AND SETTING

In this study, a qualitative research design, namely descriptive phenomenology, was employed. Participants were recruited from the OB department at UMass Memorial Medical center in Worcester, MA, between 6/2020 and 7/2020.

METHODS

Between June 2020 and July 2020, in-depth interviews were conducted with 18 women receiving care at the Obstetrics and Maternal and Fetal Medicine clinics. Data were analyzed using qualitative thematic analysis, as outlined by Braun and Clarke.

RESULTS

Telehealth is a feasible and safe health-care tool that is available during these unprecedented times. This study provided qualitative evidence based on patients' perspectives and experiences. Participants' meanings in relation to their experiences of using telehealth services emerged from the data in four themes: the overall experience of using modern telehealth platforms, telehealth and its perceived benefits, telehealth and its perceived challenges, and telehealth and its potential future use.

CONCLUSION

While this study highlights areas in telehealth implementation that require improvement, the overall positive experiences and consistent perceived benefits of most participants suggests that telehealth can be an important tool in healthcare delivery for appropriate patients and situations moving forward in a post-pandemic world.

IMPACT

During the global pandemic, telehealth has been recognized to have the potential to play a critical role in healthcare delivery. Establishing qualitative evidence-based practices in the emerging field of telehealth for OB services is pivotal to mitigate potential safety, feasibility, and cost issues that could be associated with the rapid adoption of telehealth. Yet, this qualitative study However highlighted several challenges that are necessary to be addressed in order for telehealth to meet maximum effectiveness and functionality in the future.

Managing Asthma During Pregnancy and the Postpartum Period

Asthma is one of the most common chronic diseases in pregnancy and is associated with adverse perinatal outcomes. Asthma symptoms worsen in approximately 40% of women, and exacerbations requiring medical intervention occur in at least 20% of women. Factors associated with exacerbation and worsening asthma include multiparity, obesity, Black race, exacerbations before pregnancy, and poor asthma control. Exacerbations are associated with further increased risks for poor perinatal outcomes, including low birth weight, preterm birth, and small for gestational age (SGA) status, as well as an increase in the development of asthma in early childhood. Common medications used for asthma, including short-acting β-agonists and inhaled corticosteroids, are considered safe to use in pregnancy. Whereas guidelines generally suggest traditional step therapy for managing asthma in pregnancy, there are alternative models of care and management approaches that may be effective in pregnancy, but require more research. These include single-inhaler maintenance and reliever therapy, treatment adjustment with FeNO, treatable traits personalized medicine approaches, and telemedicine. Little is known about changes to asthma in the postpartum period. However, low adherence to medication and the potential effects of postpartum depression on asthma exacerbation risk warrant further research.

Adapting a Counseling-Plus-mHealth Intervention for the Virtual Environment to Reduce Sexual and Reproductive Health Risk Among Young Women with Depression

MARSSI (Momentary Affect Regulation - Safer Sex Intervention) is a counseling-plus-mobile health (mhealth) intervention to reduce sexual and reproductive health (SRH) risks for women with depression and high-risk sexual behavior. Due to the COVID-19 pandemic limiting in-person care, we sought to develop the counseling and mhealth app onboarding for virtual implementation. A team with SRH, adolescent medicine, motivational interviewing, cognitive behavioral therapy, and technology expertise adapted the counseling through an iterative consensus process. We identified essential aspects of the counseling, specified the content so the counseling could be delivered in person or virtually with fidelity, and considered best practices for telehealth for the focus population. Virtual counseling retained key elements from in-person counseling while including enhancements with engaging visual and audio-video aids. Instructions and programming were developed to support virtual counseling delivery and onboarding for the mhealth app component of MARSSI. After testing the virtual format in mock sessions, we implemented a small-scale feasibility study in an adolescent medicine clinic with women with depressive symptoms and high-risk sexual behavior age 18-24 years (N = 9). Participants experienced minimal technical difficulties and expressed satisfaction with the virtual format, and all were able to complete app onboarding successfully. Expanding delivery options for SRH interventions to include virtual can improve access, particularly for populations with psychological and environmental barriers to 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.

Impact of telemedicine on antenatal care at a teaching institution in Eastern India: An insight into the future of better India

Objectives

Telemedicine (TM) emergence has been profound in using technology to address the problems of obstetrics in remote and rural places, especially in low-risk pregnancy. Through this study, we made an effort to assess the satisfaction level and concerns of antenatal and postnatal patients who availed the telemedicine facility during the study period. We also made an effort to facilitate improved access to antenatal and postnatal care, especially the low-risk pregnancies through telemedicine for patients from remote areas of eastern India that do not have the availability of specialists.

Materials and Methods

Primary data were collected by means of a telephonic survey of all the antenatal patients who used telemedicine services of AIIMS, Kalyani, based on a preformed questionnaire.

Results

A total of 80 antenatal patients gave consent to participate in the study. Most of the patients were from the upper lower class [43.75%] followed by the lower middle class [35%]. The average gestational age of respondents was 23.95 weeks. Seventy-one out of 80 patients felt that the appointment was made within a reasonable time. Only 12 patients [15.3%] had waiting time greater than 10 min. The average waiting time was 6.93 min. 56.3% of respondents felt that the person who attended their call was very cooperative. 86.3% of respondents strongly agreed that the consultant was able to understand their health issues completely. Eighty percent of the respondents said that they would like to continue using telemedicine in the future. There is a significant difference between those preferring to use telemedicine in the future and those who do not prefer telemedicine in the future. Poor internet facility and privacy were prominent reasons for not opting for telemedicine in the future by some respondents.

Conclusion

From this study, it was concluded that TM certainly has great potential to make health care accessible to people residing in rural and far-off places.

Evaluation of a telehealth program for high-risk pregnancy in a health service provider institution

INTRODUCTION

eHealth offers a solution to current challenges in maternal health. Telemonitoring can rethink antenatal care, achieving more personalized medicine, especially in high-obstetric risk conditions. A home care model mediated by the development of a mobile and web application that seeks support in clinical decision-making was created in our institution. The software architecture consists of an information system (HCIS, Health Care Information System), a database, an authentication server, and an interoperability bus.

METHODS

The usability of the software by patients was assessed using the Information Systems Usability Questionnaire (CSUQ) version 3, as well as the satisfaction of the care model designed through a survey in a prospective observational study in 62 patients with a high-risk pregnancy. Participants were monitored in real-time through blood glucose, blood pressure, and weight measurements, and attended telemedicine appointments with an obstetrician from admission to six weeks postpartum.

RESULTS

The CSUQ results show a good acceptance of the use of the application by patients both in the global score and the different domains, Global, System utility (SYSUSE), Information Quality (INFOQUAL), and Interface quality (INTERQUAL). The satisfaction survey also shows good results in general and by domains.

CONCLUSION

The findings of this study provide some suggestions for the implementation of a technological development and a care model from the patient's perspective.

Telemedicine for Pregnant Women on a Japanese Remote Island: A Two-year Report

Introduction

Remote antenatal checkups were conducted on the northernmost island of Japan to reduce the burden of hospital visits among pregnant women. This study aims to investigate the effectiveness and safety of remote antenatal checkups for pregnant women living on a remote island.

Methods

This observational study included singleton pregnancies on Rebun Island between October 2020 and September 2022. General surgeons conducted medical interviews and performed fetal sonography using an obstetrician videoconference system at the main central hospital. The primary outcomes were the degrees of physical, mental, and economic burdens of hospital visits and the levels of anxiety and satisfaction with remote antenatal checkups as assessed using a questionnaire survey. Moreover, we investigated the incidence of adverse perinatal events, including maternal death, fetal death, neonatal death, severe neonatal neurological disorders, and other obstetric complications.

Results

This study included 16 out of 22 pregnant women from Rebun Island who visited the central hospital. No adverse perinatal events occurred as a result of the remote antenatal checkups. One pregnant woman had gestational diabetes, whereas the others had no obstetric complications. The participants underwent a median of two remote antenatal checkups. According to a questionnaire survey, 90.0%, 80.0%, and 70.0% of the pregnant women perceived improvements in their physical, mental, and economic burdens, respectively. Although 70.0% of the participants experienced anxiety regarding remote antenatal checkups before the introduction, all were satisfied after delivery.

Conclusions

Remote antenatal checkups effectively reduced the burden of hospital visits for pregnant women, who reported high levels of satisfaction. Furthermore, antenatal checkups were safely conducted on remote islands.

Facilitators of and barriers to perinatal telepsychiatry care: a qualitative study

OBJECTIVES

Perinatal mental health disorders such as anxiety, depression and bipolar disorder can negatively impact the health of women and their children without appropriate detection and treatment. Due to increases in mental health symptoms and transmission risks associated with in-person appointments, many clinics transitioned to providing telepsychiatry care during the COVID-19 pandemic. This study sought to identify the facilitators and barriers to receiving perinatal telepsychiatry care from the perspective of patients, clinic staff and psychiatrists.

DESIGN

Qualitative study based on analysis of in depth semistructured interviews.

SETTING

The study was conducted in a virtual specialty mental health clinic in an academic setting.

PARTICIPANTS

Eight patients who had been scheduled for an appointment with the perinatal telepsychiatry clinic between 14 May 2021 and 1 August 2021, seven of whom had attended their scheduled appointment with the clinic and one of whom had not, and five staff members including psychiatrists, navigators and clinic managers, participated in in-depth interviews.

RESULTS

Telepsychiatry was perceived by most as preferable to in-person care and easy to attend and navigate. Alternatively, technological difficulties, personal preference for in-person care and scheduling conflicts related to the perinatal period were identified as barriers by some. Participants identified communication between care staff and patients, online patient portals, and appointment reminders as important for facilitating appointment preparedness and attendance.

CONCLUSIONS

The findings from this study suggest that telepsychiatry services are perceived positively by patients and care staff and have the potential to improve access to mental healthcare for perinatal patients.

Patient and provider perspectives on telemedicine use in an outpatient gynecologic clinic serving a diverse, low-income population

OBJECTIVE

To evaluate patient and provider experiences using telemedicine for gynecologic visits among a diverse, low-income population.

METHODS

Patients attending telemedicine visits at a resident-run gynecology clinic completed a modified Telemedicine Usability Questionnaire and providers completed a survey addressing satisfaction and barriers for each visit. The Telemedicine Usability Questionnaire included six subscales to assess telemedicine usability with 1-5 Likert-scale responses. Statistical analyses included Chi-square, Fisher's exact, Wilcoxon rank sum, Wilcoxon signed-rank, and two-sample t-test.

RESULTS

Of 192 patients enrolled, 157 (82%) completed the surveys (87% video visits, 13% telephone visits). Most patients were ethnic minorities (non-Hispanic White-16%, Hispanic-32%, Black-28%, Asian-10%), median age was 40 years (range 18-69), and 63% reported income under $40,000. The total mean Telemedicine Usability Questionnaire score was 4.3/5. The reliability subscale score (3.72/5) was lower compared to all other subscales (p < 0.001). Older respondents were more likely to find telemedicine unreliable (mean age >44 vs <39, p = 0.02). Without telemedicine, 54% would have traveled ≥1 h to appointments, with 46% spending over $35 on travel, and 27% missing ≥ 1 workday. Patients preferred telemedicine for follow-up rather than initial visits (81% vs 33%, p < 0.01). Among providers, residents felt less adequately trained in telemedicine compared to nurse practitioners and fellows (54% vs 46%, p = 0.039).

CONCLUSION

Low-income women utilizing telemedicine for outpatient gynecologic care report positive experiences with improved access to healthcare, cost, and time savings compared to in-person visits. Provider experiences were also positive; however, teaching hospitals must evaluate whether trainee providers feel adequately trained to deliver telemedicine visits.

Impact of the COVID-19 Pandemic on Prenatal Care Utilization at a Public Hospital

OBJECTIVE

The aim of the study is to compare rates of prenatal care utilization before and after implementation of a telehealth-supplemented prenatal care model due to the coronavirus disease 2019 (COVID-19) pandemic.

STUDY DESIGN

Using electronic medical record data, we identified two cohorts of pregnant persons that initiated prenatal care prior to and during the COVID-19 pandemic following the implementation of telehealth (from March 1, 2019 through August 31, 2019, and from March 1, 2020, through August 31, 2020, respectively) at Grady Memorial Hospital. We used Pearson's Chi-square and two-tailed t-tests to compare rates of prenatal care utilization, antenatal screening and immunizations, emergency department and obstetric triage visits, and pregnancy complications for the prepandemic versus pandemic-exposed cohorts.

RESULTS

We identified 1,758 pregnant patients; 965 entered prenatal care prior to the COVID-19 pandemic and 793 entered during the pandemic. Patients in the pandemic-exposed cohort were more likely to initiate prenatal care in the first trimester (46.1 vs. 39.0%, p = 0.01), be screened for gestational diabetes (74.4 vs. 67.0%, p <0.001), and receive dating and anatomy ultrasounds (17.8 vs. 13.0%, p = 0.006 and 56.9 vs. 47.3%, p <0.001, respectively) compared with patients in the prepandemic cohort. There was no difference in mean number of prenatal care visits between the two groups (6.9 vs. 7.1, p = 0.18). Approximately 41% of patients in the pandemic-exposed cohort had one or more telehealth visits. The proportion of patients with one or more emergency department visits was higher in the pandemic-exposed cohort than the prepandemic cohort (32.8 vs. 12.3%, p < 0.001). Increases in rates of labor induction were also observed among the pandemic-exposed cohort (47.1 vs. 38.2%, p <0.001).

CONCLUSION

Rates of prenatal care utilization were similar before and during the COVID-19 pandemic. However, pregnant persons receiving prenatal care during the pandemic entered care earlier and had higher utilization of certain antenatal screening services than those receiving prenatal care prior to the pandemic.

KEY POINTS

· Patients initiated prenatal care earlier during the COVID-19 pandemic.. · Uptake of telehealth services was low.. · Rates of diabetes screening and ultrasound use increased during the pandemic..

Preabortion ultrasound - a patient perspective

PURPOSE

To explore women's perception of the need for an ultrasound scan before medical abortion provided by telemedicine services.

METHODS

We have analysed women's requests for medical abortion through the website www.womenonweb.org from the 1st of January 2019 to the 5th of October 2020. Before receiving abortion drugs for self-managed medical abortion, women received online counselling and were asked to complete an online survey on pre-abortion ultrasound scan and the reasons for having or not having one. The initial dataset included 62641 entries from 207 countries. Each entry corresponded to a person's request for medical abortion. Women reported only one or multiple reasons for not having a pre-abortion ultrasound scan.

RESULTS

Among 59648 women requesting a medical abortion, 45653 (76,54%) did not have any pre-abortion ultrasound scan and specified a reason for that. The countries with the highest rates of women not having a pre-abortion ultrasound scan were Thailand, Poland, Northern Ireland, Mexico, South Korea, Japan, Chile, Indonesia, Germany, and Brazil. The main reasons for not having a pre-abortion ultrasound scan were being confident regarding pregnancy length; and thus, no need for a scan stated by 10910/34390 women (31.7%), lack of resources stated by 10589/34390 women (30.8%), and privacy issues stated by 6472/34390 women (18.8%).

CONCLUSION

Most women opting for medical abortion through telemedicine did not undergo a pre-abortion ultrasound scan. The main reason stated was that women did not find it necessary, lack of resources and privacy issues.

Integration of Telehealth in Routine Perinatal Care: A Model of Care for Primary Healthcare Clinics in Saudi Arabia

This study aims to introduce a new model of antenatal/postnatal care that integrates virtual clinics with the current model of care, including a discussion on the current model, pre-existing barriers, and prenatal framework, and the need for transition to telehealth beyond the pandemic. In antenatal primary health care centers, such as King Abdulaziz Medical City (KAMC), low-risk antenatal/postnatal care receives clinical care through complete physical attendance in antenatal/postnatal clinics in primary care clinics for pregnancy follow-up and in tertiary hospitals for fetal ultrasound and invasive procedures if needed. Pregnancy is confirmed through a regular family medicine (FM) clinic where risk assessment through history, physical examination, and investigations are carried out. If the pregnant woman is at low risk, she will be started on folic acid, 1 mg or 5 mg based on the risk assessment (if it was not received before). Pregnant women will be given a telehealth appointment for the lab results. Concomitantly, the pregnant women will receive an appointment in the antenatal clinics, which board-certified family physicians run. High-risk patients will be referred to the hospital for further care. Current postnatal care is delivered through regular booking with the FM clinic through physical attendance sometimes, and virtual care is provided upon physican/patient request. Current care meets the past quality care and patient expectations. However, with the current Saudi Vision 2030 and after the experience with virtual care during the COVID-19 pandemic, the current services need to move a step forward to meet the rapidly developing medical care/needs in Saudi Arabia. Various challenges must be addressed, and new models must be included in clinical care for pregnant and postnatal women. Introducing virtual antenatal/postnatal care to the current care could be a new era in maternity primary health care; this model will move the clinical care provided to pregnant/postnatal women a step forward that meets the excellence of high-quality, evidence-based medical care.

Racial disparities in telehealth use during the coronavirus disease 2019 pandemic

OBJECTIVE

To investigate the impact of coronavirus disease 2019 on initial infertility consultations.

DESIGN

Retrospective cohort.

SETTING

Fertility practice in an academic medical center.

PATIENTS

Patients presenting for initial infertility consultation between January 2019 and June 2021 were randomly selected for prepandemic (n = 500) and pandemic (n = 500) cohorts.

EXPOSURE

Coronavirus disease 2019 pandemic.

MAIN OUTCOME MEASURES

The primary outcome was a change in the proportion of African American patients using telehealth after pandemic onset compared with all other patients. Secondary outcomes included presentation to an appointment vs. no-show or cancellation. Exploratory outcomes included appointment length and in vitro fertilization initiation.

RESULTS

The prepandemic cohort vs. the pandemic cohort had fewer patients with commercial insurance (64.4% vs. 72.80%) and more African American patients (33.0% vs. 27.0%), although the racial makeup did not differ significantly between the two cohorts. Rates of missed appointments did not differ between the cohorts, but the prepandemic cohort vs. the pandemic cohort was more likely to no-show (49.4% vs. 27.8%) and less likely to cancel (50.6% vs. 72.2%). African American patients, compared with all other patients, during the pandemic were less likely to use telehealth (57.0% vs. 66.8%). African American patients, compared with all other patients, were less likely to have commercial insurance (prepandemic: 41.2% vs. 75.8%; pandemic: 57.0% vs. 78.6%), present to their scheduled appointment (prepandemic: 52.7% vs. 73.7%; pandemic: 48.1% vs. 74.8%), and cancel vs. no-show (prepandemic: 30.8% vs. 68.2%, pandemic: 64.3% vs. 78.3%). On multivariable analysis, African American patients were less likely (odds ratio 0.37, 95% confidence interval 0.28-0.50) and telehealth users were more likely (odds ratio 1.54, 95% confidence interval 1.04-2.27) to present to their appointments vs. no-show or cancel when controlling for insurance type and timing relative to the onset of the pandemic.

CONCLUSION

Telehealth implementation during the coronavirus disease 2019 pandemic decreased the overall no-show rate, but this shift did not apply to African American patients. This analysis highlights disparities in insurance coverage, telehealth utilization, and presentation for an initial consultation in the African American population during the pandemic.

"We are not there yet": perceptions, beliefs and experiences of healthcare professionals caring for women with pregnancy-related pelvic girdle pain in Australia

BACKGROUND

Pregnancy-related pelvic girdle pain (PPGP) is a common condition worldwide. Women report being unprepared about PPGP, and state they receive little recognition and support from healthcare professionals. Situated within the Common-Sense Model and Convergent Care Theory, this study sought to gain a conceptual understanding of the perceptions, beliefs and experiences of healthcare professionals who provide routine care for women with PPGP in Australia.

METHODS

A qualitative research design, using individual, semi-structured interviews with purposive sampling of healthcare professionals (N=27) consisting of doctors (N=9), midwives (N=9) and physiotherapists (N=9). Most participants were female (22/27) with a range of professional experience. An interview guide consisting of open-ended questions was used with a flexible and responsive approach. Thematic analysis was performed where interview data were transcribed, coded, grouped into meaningful categories and then constructed into broad themes.

RESULTS

Four themes were identified: 1. Identity and impact of PPGP; 2. What works well?; 3. What gets in the way?; and 4. Quality care: What is needed? Healthcare professionals recognised PPGP as a common and disabling condition, which created a large impact on a woman's life during pregnancy. Stepped-level care, including education and physiotherapy intervention, was seen to be helpful and led to a positive prognosis. Barriers at patient, clinician and organisation levels were identified and led to consequences for women with PPGP not receiving the care they need.

CONCLUSION

This study elucidates important implications for health care delivery. Acknowledging that PPGP is a common condition causing difficulty for many women, healthcare professionals identified strong teamwork and greater clinical experience as important factors in being able to deliver appropriate healthcare. Whilst healthcare professionals reported being committed to caring for women during pregnancy, busy workloads, attitudes towards curability, and a lack of formal education were identified as barriers to care. The findings suggest timely access, clear referral pathways and an integrated approach are required for best care practice for women with PPGP. A greater emphasis on the need for multidisciplinary models of care during pregnancy is evident.

Impact of coronavirus disease 2019 on contraception use in France

To limit the spread of the coronavirus disease 2019 (COVID 19), sanitary restrictions have been established since March 2020 in France. These restrictions and the waves of contamination may have had consequences on the use of health products in general, and on the use of contraceptives in particular. We aimed to assess the impact of COVID 19 pandemic from March 16th 2020 to April 30th 2021 in France on reimbursed contraceptives. We analyzed data from the French national health insurance database (SNDS) by extracting all oral contraception (OC), emergency contraception (EC), levonorgestrel-intrauterine system (LNG-IUS), copper-intrauterine device (C-IUD) and contraceptive implant dispensations in 2018, 2019, 2020 and to April 30th 2021. We computed the expected use of contraceptives in 2020 and 2021 without pandemic and its associated sanitary restrictions, by taking the annual trend into account. We assessed the evolution of dispensations by type of contraceptive and by age-groups (≤25 years old, between 25 and 35 and >35 years old) between observed and expected dispensations. After 15 months of pandemic, a decrease of all reimbursed contraceptives dispensations had been estimated, compared with what was expected: -2.0% for OC, -5.0% for EC, -9.5% for LNG-IUS, -8.6% for C-IUD, -16.4% for implant. Women under 25 years old were the most impacted by the decrease. This national study showed that the impact of the COVID 19 crisis was global on all reimbursed contraceptives, with different levels of impact depending on the type of contraceptive, the age-group and the severity of the restriction. OC dispensing decreased marginally compared with expectations. The decrease in long-acting contraceptives dispensing was more pronounced, especially for the implant. These results call for continued monitoring of contraceptive use over the long term and for prioritizing access to sexual health services during crises, especially among the youngest women who were most affected in this study.

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.

Increasing Access: Telehealth and Rural Obstetric Care

Parturients in rural areas face many barriers in access to care, including distance to maternity care sites and lack of maternity providers. Expanding telehealth modalities is recommended to help expand access to care. Although there is increasing evidence in support of telehealth in rural America, the success of telehealth lies in infrastructure (broadband network availability), regional support, and funding.

Telehealth in antenatal care: recent insights and advances

BACKGROUND

For decades, antenatal care in high-resource settings has involved 12-14 face-to-face visits across pregnancy. The COVID-19 pandemic forced many care providers to rapidly embrace telehealth to reduce face-to-face visits. Here we review recent advances in telehealth used to provide antenatal care.

MAIN BODY

We conducted a narrative review examining the impact of telehealth on obstetric care. Two broad types of telehealth are used in antenatal care. The first is real-time telehealth, where consultations are done virtually instead of face-to-face. The second is remote monitoring, where in-clinic physical examinations are replaced with at-home alternatives. These can include blood pressure monitoring, fetal heart rate monitoring, and emerging technologies such as tele-ultrasound. Large cohort studies conducted during the pandemic era have shown that telehealth appears not to have increased adverse clinical outcomes for mothers or babies. However, further studies may be required to confidently conclude rare outcomes are unchanged, such as maternal mortality, serious morbidity, or stillbirth. Health economic studies suggest telehealth has the potential to reduce the financial cost of care provision. Telehealth in antenatal care seems to be acceptable to both pregnant women and healthcare providers.

CONCLUSION

Adoption of telehealth technologies may improve the antenatal care experience for women and reduce healthcare expenditure without adversely impacting health outcomes for the mother or baby. More studies are warranted to confirm telehealth does not alter the risk of rare outcomes such as maternal or neonatal mortality.

Gestational diabetes mellitus and COVID-19: The epidemic during the pandemic

During the global coronavirus disease 2019 (COVID-19) pandemic, people worldwide have experienced an unprecedented rise in psychological distress and anxiety. In addition to this challenging situation, the prevalence of diabetes mellitus (DM), a hidden epidemic, has been steadily increasing in recent years. Lower-middle-income countries have faced significant barriers in providing accessible prenatal care and promoting a healthy diet for pregnant women, and the pandemic has made these challenges even more difficult to overcome. Pregnant women are at a higher risk of developing complications such as hyper-tension, preeclampsia, and gestational diabetes, all of which can have adverse implications for both maternal and fetal health. The occurrence of gestational diabetes has been on the rise, and it is possible that the pandemic has worsened its prevalence. Although data is limited, studies conducted in Italy and Canada suggest that the pandemic has had an impact on gestational diabetes rates, especially among women in their first trimester of pregnancy. The significant disruptions to daily routines caused by the pandemic, such as limited exercise options, indicate a possible link between COVID-19 and an increased likelihood of experiencing higher levels of weight gain during pregnancy. Notably, individuals in the United States with singleton pregnancies are at a significantly higher risk of excessive gestational weight gain, making this association particularly important to consider. Although comprehensive data is currently lacking, it is important for clinical researchers to explore the possibility of establishing correlations between the stress experienced during the pandemic, its consequences such as gestational gain weight, and the increasing incidence of gestational DM. This knowledge would contribute to better preventive measures and support for pregnant individuals during challenging times.

A systematic review of digital interventions for smoking cessation in patients with serious mental illness

Tobacco smoking is highly prevalent among patients with serious mental illness (SMI), with known deleterious consequences. Smoking cessation is therefore a prioritary public health challenge in SMI. In recent years, several smoking cessation digital interventions have been developed for non-clinical populations. However, their impact in patients with SMI remains uncertain. We conducted a systematic review to describe and evaluate effectiveness, acceptability, adherence, usability and safety of digital interventions for smoking cessation in patients with SMI. PubMed/MEDLINE, EMBASE, CINAHL, Web of Science, PsychINFO and the Cochrane Tobacco Addiction Group Specialized Register were searched. Studies matching inclusion criteria were included and their information systematically extracted by independent investigators. Thirteen articles were included, which reported data on nine different digital interventions. Intervention theoretical approaches ranged from mobile contingency management to mindfulness. Outcome measures varied widely between studies. The highest abstinence rates were found for mSMART MIND (7-day point-prevalent abstinence: 16-40%). Let's Talk About Quitting Smoking reported greater acceptability ratings, although this was not evaluated with standardized measures. Regarding usability, Learn to Quit showed the highest System Usability Scale scores [mean (s.d.) 85.2 (15.5)]. Adverse events were rare and not systematically reported. Overall, the quality of the studies was fair to good. Digitally delivered health interventions for smoking cessation show promise for improving outcomes for patients with SMI, but lack of availability remains a concern. Larger trials with harmonized assessment measures are needed to generate more definitive evidence and specific recommendations.

A Description of Telehealth Use Among Sexually Transmitted Infection Providers in the United States, 2021

BACKGROUND

Telehealth offers one approach to improving access to sexually transmitted infection (STI) prevention and care services. Therefore, we described recent telehealth use among those providing STI-related care and identified opportunities for improving STI service delivery.

MATERIALS AND METHODS

Using the DocStyles Web-based, panel survey conducted by Porter Novelli from September 14 to November 10, 2021, 1500 healthcare providers were asked about their current telehealth usage, demographics, and practice characteristics, and compared STI providers (≥10% of time spent on STI care and prevention) to non-STI providers.

RESULTS

Among those whose practice consisted of at least 10% STI visits (n = 597), 81.7% used telehealth compared with 75.7% for those whose practice consisted of less than 10% STI visits (n = 903). Among the providers with at least 10% STI visits in their practice, telehealth use was highest among obstetrics and gynecology specialists, those practicing in suburban areas, and those practicing in the South. Among providers whose practice consisted of at least 10% STI visits and who used telehealth (n = 488), the majority were female and obstetrics and gynecology specialists practicing in suburban areas of the South. After controlling for age, gender, provider specialty, and geographic location of their practice, providers whose practice consisted of at least 10% STI visits had increased odds (odds ratio, 1.51; 95% confidence interval, 1.16-1.97) of using telehealth compared with providers whose visits consisted of less than 10% STI visits.

CONCLUSIONS

Given the widespread use of telehealth, efforts to optimize delivery of STI care and prevention via telehealth are important to improve access to services and address STIs in the United States.

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.

Vitamins and minerals, education, and self-care need during preconception to 1000 days of life in Southeast Asia: An expert panel opinion

Addressing maternal malnutrition and its drivers is paramount in Southeast Asia. This article summarizes the key clinical learnings and evidence-based opinions from the experts to understand the need for vitamins and minerals supplementation, education, and self-care from preconception to the first 1000 days of life, which warranted further attention since COVID-19 pandemic. Evidence describing the importance of vitamins and minerals during preconception, pregnancy, and lactation stages was identified using literature databases. A pre-meeting survey was conducted to determine the current practices and challenges in Southeast Asia. Based on the literature review and clinical experience, experts defined the topics, and an online meeting was held on 13th July 2021. During the meeting, nine experts from Southeast Asia provided evidence-based opinion on the vitamins and minerals supplementation, education, and self-care need during preconception, pregnancy, and lactation stages. The expert opinions underpin maternal malnutrition as a prevalent issue and discuss appropriate interventions and prevention strategies for women in Southeast Asia. The recent pandemic further impacted nutrition status, pregnancy, and neonatal health outcomes. The expert panel emphasized a need to improve existing inadequacies in education, self-care, and social support, and discussed the role of policymakers in addressing the barriers to dietary changes. As inadequacies in regular vitamins and minerals supplementation, education, and self-care for women of reproductive age implicate maternal and child health outcomes, there is an urgent need for addressing malnutrition concerns in this population. Thus, a strong partnership between policymakers, healthcare professionals, and other relevant sectors is required.