Effectiveness of telemedicine for pregnant women with gestational diabetes mellitus: an updated meta-analysis of 32 randomized controlled trials with trial sequential analysis

Development and early implementation of telemonitoring of complicated pregnancies - A qualitative study with the perspectives of health professionals

BACKGROUND

Telemonitoring may offer promising opportunities in health care. In obstetric health care, there is a need to expand and improve digitalization. Nevertheless, there is limited knowledge based on healthcare professionals' perspectives regarding the use of telemedicine and remote cardiotocography during pregnancy, as well as its implementation.

AIM

To explore the perspectives of health-care professionals who manage telemonitoring of complicated pregnancies.

DESIGN AND SETTING

A qualitative interview study undertaken in a hospital with a tertiary obstetric unit in Northen Denmark.

METHODS

Based on a purposive sample strategy, 11 semi-structured interviews of health-care professionals involved in the management of telemonitoring in women with complicated pregnancies were conducted and analyzed using a reflexive thematic analytical approach.

FINDINGS

The findings are assembled into two main themes. The experience of relevance to own practice: included the embedded potentials in telemonitoring providing women-centred care, but also challenges related to the implementation of a new technology. Experience of challenges and potential in day-to-day operation: included frustrations regarding the technological devices and software, working experiences increasing confidence in telemonitoring, and perspectives on the required interdependence across departments.

CONCLUSION

This study adds important knowledge to support awareness and reflection on how challenges impact the successful implementation of telemonitoring in obstetric and midwifery care. This includes knowledge of important processes and resources to ensure ongoing implementation and evaluation. Implementation strategies and collaborations to support a multiple-level system change, such as an interdisciplinary team, seem crucial to minimize challenges, build shared visions, and engage staff.

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.

Changes in screening, diagnosis, management, and outcomes of gestational diabetes during the COVID-19 pandemic: A systematic review

Background

Gestational diabetes mellitus (GDM) is the most common medical complication of pregnancy, and it can lead to complications for the mother and the infant/fetus. This was especially evident during the COVID-19 pandemic. Therefore, the present systematic review aimed to describe the changes in screening, diagnosis, management, and outcomes of gestational diabetes during the COVID-19 pandemic.

Methods

The systematic review was conducted from December 2019 until January 1, 2022. To find articles related to the purpose of the study, PubMed, Scopus, Web of Science, and WHO were searched using relevant and validated keywords using MeSH/Emtree.

Results

In total, 675 entries were ascertained from the database inquiry, and 17 scholarly works were deemed suitable for inclusion in the final review. The salient conclusions derived from this review were as follows: (a) During the COVID-19 pandemic, there was a significant decrease in the use of OGTTs and a rise in the use of HbA1c assays for both GDM screening and diagnosing. (b) A predominant number of physicians incorporated some variation of telemedicine to remotely supervise and conduct follow-up evaluations of patients with GDM. Various strategies are presented for the provision of prenatal care to women afflicted with GDM, such as concentrating on high-risk demographics, the initiation of lifestyle modifications at early stages, and the implementation of remote patient monitoring techniques. The 'single test procedure' is identified as the most suitable for the preliminary screening of GDM. The OGTT should be assigned clinical precedence in patients at high risk during the ongoing COVID-19 pandemic. Additionally, Medical Nutrition Therapy (MNT) was established as the primary management strategy, and the most influential determinant of the transition from dietary adjustments to pharmacotherapy was the Fasting Blood Glucose (FBG) levels during the second trimester.

Conclusion

Suggested strategies for GDM screening and management during the pandemic integrated into routine antenatal care, emphasized the importance of remote diabetes education and technology utilization during health emergencies.

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.

Diabetes in pregnancy: Women's views of care in a multi-ethnic, low socioeconomic population with midwifery continuity-of-care

BACKGROUND

Diabetes in pregnancy is diagnosed in 6% of pregnancies annually in Aotearoa-New Zealand, disproportionately affecting multi-ethnic, low socio-economic women. Little is known about the care experience of this population within the model of midwifery continuity-of-care, including views of telehealth care.

AIM

Increase understanding of the experience of diabetes in pregnancy care, including telehealth, among multi-ethnic, low socio-economic women receiving midwifery continuity-of-care.

METHODS

Qualitative interview study with primarily indigenous and migrant women who had diabetes in pregnancy and gave birth 6-18 months previously. Interviewers were matched with participants by ethnicity. Transcripts were analysed using Framework analysis.

RESULTS

Participants were 19 women (5 Māori, 5 Pacific Peoples, 5 Asian, 4 European). Data analysis revealed three key themes: 1) 'shock, shame, and adjustment' to the diagnosis 2) 'learning to manage diabetes in pregnancy' and 3) 'preparation for birth and beyond' to the postpartum period.

DISCUSSION

Receiving the diagnosis of diabetes in pregnancy was a shock. Managing diabetes during pregnancy was particularly challenging for indigenous and migrant women, who wished for better access to culturally appropriate dietary and lifestyle information. Women appreciated having options of telehealth and face-to-face consultations. Preparation for birth and postpartum diabetes follow-up were areas requiring significant improvement. Challenges were mitigated through care from a consistent diabetes specialist midwife and community-based midwifery continuity-of-care.

CONCLUSION

Midwives were the backbone of diabetes in pregnancy care for this multi-ethnic, low socio-economic population. Care could be improved with more culturally appropriate diet and lifestyle information, better birth preparation, and expanded postpartum diabetes support.

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.

Development and validation of interprofessional health education module for the management of gestational diabetes mellitus

BACKGROUND

Gestational diabetes mellitus (GDM) is a glucose intolerance that shows its first onset during pregnancy. In India, GDM affects as many as 5 million women annually. The interprofessional collaborative educational intervention is crucial for GDM management. This study illustrates the collaborative effort in developing and validating an interprofessional health education module designed for healthcare professionals during consultation sessions with GDM patients.

MATERIALS AND METHODS

The investigation involved three stages: 1) needs assessment for module contents and objectives, 2) health education module development by an interprofessional team, and 3) module validation. We received ethics approval from the institution's ethics committee.

RESULTS

The interprofessional team developed and validated the evidence-based English-printed module. The module had 27 units and covered six topics: an introduction to GDM and its management, dietary recommendations for GDM, exercise, yoga recommendations for GDM, weight control, and postpartum care.

CONCLUSION

The interprofessional team developed the educational module, wherein there is an integration of the domains of exercise and yoga along with medicines and nutrition therapy. The module was developed based on local requirements and evidence-based practices. Healthcare professionals can use the interprofessional health education module when advising diabetic pregnant patients.

Internet-Based Interventions for Preventing Premature Birth Among Pregnant Women: Systematic Review

BACKGROUND

Premature birth rates have slightly increased globally, making its prevention critical for both short-term and long-term health outcomes. Various interventions have been developed in response to the multifaceted risk factors for premature birth, including internet-based programs. These programs offer accessibility and enhanced engagement; however, their overall efficacy in preventing premature births requires thorough evaluation.

OBJECTIVE

This systematic review aims to identify the study designs and assess the effectiveness of internet-based interventions in preventing premature birth among pregnant women.

METHODS

A comprehensive search of the MEDLINE, Embase, CINAHL, and Cochrane Library databases was conducted to identify randomized trials and quasi-experimental studies evaluating internet-based interventions for premature birth prevention in pregnant women. The search was inclusive, with no restrictions based on language or geographical location, allowing for a comprehensive global perspective. The time frame for the inclusion of studies extended until February 2023. The risk of bias (RoB) in each study was independently assessed by 3 authors forming pairs, using the revised Cochrane RoB tool (RoB 2) for randomized trials, as per the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Owing to heterogeneity in populations, measurements, and interventions, a meta-analysis was not conducted.

RESULTS

This review included 26 articles, comprising 12 intention-to-treat and 14 per-protocol studies. The overall RoB was high in most intention-to-treat studies and of some concern in most per-protocol studies. The target populations varied, including nonspecific pregnant women, those with gestational diabetes mellitus (GDM) or those at risk of GDM, individuals with anxiety or depression, and those experiencing preterm labor. Psychosocial, physiological, and wellness health outcomes were evaluated. Internet-based interventions effectively reduced stress/distress in nonspecific pregnant women but not in those experiencing preterm labor. Their effectiveness in reducing anxiety and depression varied, with inconsistent results among different groups. In women with GDM or those at risk of GDM, interventions successfully controlled fasting plasma glucose and 2-hour postprandial plasma glucose levels but did not consistently manage glycated hemoglobin levels. These interventions did not reduce the incidence of premature births across the various populations studied. The effectiveness of these internet-based interventions in addressing substance or alcohol abuse and insomnia also varied.

CONCLUSIONS

Internet-based interventions show promise in improving psychosocial health and managing blood sugar to prevent premature birth, highlighting variability in effectiveness across different risk factors. Further research, including clinical trials, is vital for developing, evaluating, and disseminating effective, safe internet-based interventions. Establishing standardized measurement tools and rigorous evaluation processes is crucial for enhancing these interventions' effectiveness and reliability in clinical practice, significantly contributing to preventing premature births and improving maternal health outcomes.

TRIAL REGISTRATION

PROSPERO CRD42021278847; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021278847.

Impact of Antenatal Care Modifications on Gestational Diabetes Outcomes During the COVID-19 Pandemic

BACKGROUND

Many of the adverse outcomes of gestational diabetes mellitus (GDM) are linked to excessive fetal growth, which is strongly mediated by the adequacy of maternal glycemic management. The COVID-19 pandemic led to a rapid adoption of virtual care models. We aimed to compare glycemic management, fetal growth, and perinatal outcomes before and during the COVID-19 pandemic.

METHODS

A retrospective cohort study was conducted between 2017 and 2020. Singleton pregnancies complicated by GDM were included in the study. The cohort was stratified into "before" and "during" COVID-19 subgroups, using March 11, 2020, as the demarcation time point. Women who began their GDM follow-up starting March 11, 2020, and thereafter were allocated to the COVID-19 era, whereas women who delivered before the demarcation point served as the pre-COVID-19 era. The primary outcome was the rate of large-for-gestational-age (LGA) neonates. Secondary outcomes included select maternal and neonatal adverse outcomes.

RESULTS

Seven hundred seventy-five women were included in the analysis, of which 187 (24.13%) were followed during the COVID-19 era and 588 (75.87%) before the COVID-19 era. One hundred seventy-one of the 187 women (91.44%) followed during COVID-19 had at least 1 virtual follow-up visit. No virtual follow-up visits occurred before the COVID-19 era. There was no difference in the rate of LGA neonates between groups on both univariate (5.90% vs 7.30%, p=0.5) and multivariate analyses, controlling for age, ethnicity, parity, body mass index, gestational weight gain, chronic hypertension, smoking, and hypertensive disorders in pregnancy (adjusted odds ratio [aOR] 1.11, 95% confidence interval [CI] 0.49 to 2.51, p=0.80). In the multivariate analysis, there was no difference in composite neonatal outcome between groups (GDM diet: aOR 1.40, 95% CI 0.81 to 2.43, p=0.23; GDM medical treatment: aOR 1.20, 95% CI 0.63 to 2.43, p=0.5).

CONCLUSIONS

After adjusting for differences in baseline variables, the combined virtual mode of care was not associated with a higher rate of LGA neonates or other adverse perinatal outcomes in women with GDM. Larger studies are needed to better understand the specific impact of virtual care on less common outcomes in pregnancies with GDM.

Effectiveness of remote monitoring for glycemic control on maternal-fetal outcomes in women with gestational diabetes mellitus: A meta-analysis

BACKGROUND

The current pandemic and future public health emergencies highlight the importance of evaluating a telehealth care model. Previous studies have reached mixed conclusions about the effectiveness of remote monitoring on glycemic control and maternal and infant outcomes in women with gestational diabetes mellitus (GDM).

OBJECTIVES

This meta-analysis aimed to evaluate the effectiveness of remote blood glucose monitoring for women with gestational diabetes mellitus and to provide evidence-based guidance on the management of women with gestational diabetes mellitus for policymakers and healthcare providers during situations such as pandemics or natural disasters.

METHODS

The Cochrane Library, PubMed, Web of Science, EBSCO, Embase, Medline, CINAHL databases, and ClinicalTrials.gov were systematically searched from their inception to July 10, 2021. Randomized controlled trials (RCTs) published in English with respect to remote blood glucose monitoring in women with GDM were included in the meta-analysis. Two independent reviewers performed data extraction and assessed the quality of the studies. Risk ratios, mean differences, 95% confidence intervals, and heterogeneity were calculated.

RESULTS

A total of 1265 participants were included in the 11 RCTs. There were no significant differences in glycemic control and maternal-fetal outcomes between the remote monitoring group and a standard care group, which included glycosylated hemoglobin (HbA1c), fasting blood glucose, mean 2-h postprandial blood glucose, caesarean birth, gestational weight gain, shoulder dystocia, neonatal hypoglycemia, and other outcomes.

CONCLUSION

This meta-analysis reveals that it is unclear if remote glucose monitoring is preferable to standard of care glucose monitoring. To improve glycemic control and maternal-fetal outcomes during the current epidemic or other natural disasters, the implementation of double-blind RCTs in the context of simulating similar disasters remains to be studied in the future.

Technology and health inequities in diabetes care: How do we widen access to underserved populations and utilize technology to improve outcomes for all?

Digital health technologies are being utilized increasingly in the modern management of diabetes. These include tools such as continuous glucose monitoring systems, connected blood glucose monitoring devices, hybrid closed-loop systems, smart insulin pens, telehealth, and smartphone applications (apps). Although many of these technologies have a solid evidence base, from the perspective of a person living with diabetes, there remain multiple barriers preventing their optimal use, creating a digital divide. In this article, we describe many of the origins of these barriers and offer recommendations on widening access to digital health technologies for underserved populations living with diabetes to improve their health outcomes.

Telemedicine in the treatment of gestational diabetes: An observational cohort study on pregnancy outcomes and maternal satisfaction

AIMS

Gestational diabetes treatment requires several outpatient consultations from diagnosis until delivery in order to prevent hyperglycaemia, which is associated with maternal and fetal complications. There is limited evidence in the literature about telemedicine superiority in improving pregnancy outcomes for women with gestational diabetes. The primary aim of the study was to evaluate maternal and fetal outcomes, while the secondary aim was to estimate the degree of satisfaction with gestational diabetes treatment, comparing telemedicine versus outpatient care.

METHODS

This observational cohort study involved 60 consecutive women with gestational diabetes treated at the Diabetology Unit of Ferrara: 27 were followed up through a weekly remote control method (telemedicine group) and 33 in ambulatory clinics every 2 or 3 weeks (conventional group). After giving birth, 56 women responded to the modified Oxford Maternity Diabetes Treatment Satisfaction Questionnaire to assess their satisfaction with diabetes care.

RESULTS

No statistically significant differences were found in most of the maternal and neonatal parameters evaluated in both groups. The questionnaire scores were positive in all areas investigated. Telemedicine follow-up made women feel more controlled (p = 0.045) and fit better with their lifestyle (p = 0.005). It also emerged that almost all women treated with telemedicine would recommend this method to a relative or a friend.

CONCLUSIONS

Telemedicine follow-up proved to be safe both in terms of metabolic control and pregnancy outcomes; furthermore, it significantly decreased the need for outpatient consultations and increased women's satisfaction. Studying the impact of telemedicine is also necessary, considering the current difficulties associated with the Sars-COV-2 pandemic.

The evolution of health system planning and implementation of maternal telehealth services during the COVID-19 Pandemic

Background

Differential access to healthcare is associated with disparities in maternal outcomes. Telehealth is one approach for improving access to maternal services. However, little is known regarding how health systems leverage telehealth to close the access gap.

Objective

This study examines how health systems have approached decisions about using telehealth for maternal services before and during the COVID-19 public health emergency and what factors were considered.

Methods

We conducted semi-structured interviews with 15 health system leaders between July and October 2021 and June and August 2022. We used a rapid analysis followed by a content analysis approach.

Results

Five health systems did not provide maternal telehealth services before the PHE due to a lack of reimbursement. Two health systems provided limited services as research endeavors, and one had integrated telehealth into routine maternity care. During the PHE, all transitioned to telehealth, with the primary consideration being patient and staff safety. At the time of the interview, key considerations shifted to patient access, patient preferences, patient complexity, return on investment, and staff burnout. However, several barriers impacted telehealth use, including coverage of portable devices and connectivity. These issues were reported to be common among underinsured, low-income, and rural patients. Health systems with particularly advanced capabilities worked on approaches to fill access gaps for these patients.

Conclusion

Some health systems prioritized telehealth to improve access to high-quality maternal services for patients at the highest risk of adverse outcomes. However, policy and patient-level barriers to equitable implementation of these services persist.

Demand and Requirements for a Digital Healthcare System to Manage Gestational Diabetes in Patients and Healthcare Professionals: A Cross-sectional Survey

This study aimed to assess the current status of gestational diabetes mellitus (GDM) diagnosis and management, and the demand for a digital healthcare system, in order to develop an optimal digital-based management model for GDM. An anonymous online survey was conducted targeting pregnant/postpartum women (Group W), internal medicine physicians (Group P), and obstetricians (group O) from September 6, 2022 to December 31, 2022. The survey assessed the women's knowledge of GDM and gathered information about healthcare professionals' (HCPs) current GDM management practices. All groups were asked about their acceptance of and demands for a digital healthcare system for GDM. Statistical comparisons between groups were conducted using the chi-square test or Fisher's exact test where appropriate. A total of 168 participants were in Group W, 185 in Group P, and 256 in Group O. Participants from all groups recognized the need for a digital healthcare system for GDM (Group W: 95.8%, Group P: 85.9%, Group O: 60%). However, HCPs showed less willingness to integrate these systems into their clinics than pregnant/postpartum women. Essential features identified were recording blood glucose levels and insulin, along with automatic data linkage from self-monitoring devices. Group W showed a higher preference for lab test access, search functionality, and fetal weight assessment than groups P and O (all P < .0001), while Groups P and O had a greater preference for recording insulin and maternal body weight compared to Group W (P = .0141 and .0023, respectively). Both pregnant/postpartum women and HCPs acknowledged the benefits of utilizing a digital healthcare system for managing GDM. However, there were differences in perspectives among these groups.

15. Management of Diabetes in Pregnancy: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Do digital health interventions hold promise for stroke prevention and care in Black and Latinx populations in the United States? A scoping review

BACKGROUND

Black and Latinx populations are disproportionately affected by stroke and are likely to experience gaps in health care. Within fragmented care systems, remote digital solutions hold promise in reversing this pattern. However, there is a digital divide that follows historical disparities in health. Without deliberate attempts to address this digital divide, rapid advances in digital health will only perpetuate systemic biases. This study aimed to characterize the range of digital health interventions for stroke care, summarize their efficacy, and examine the inclusion of Black and Latinx populations in the evidence base.

METHODS

We searched PubMed, the Web of Science, and EMBASE for publications between 2015 and 2021. Inclusion criteria include peer-reviewed systematic reviews or meta-analyses of experimental studies focusing on the impact of digital health interventions on stroke risk factors and outcomes in adults. Detailed information was extracted on intervention modality and functionality, clinical/behavioral outcome, study location, sample demographics, and intervention results.

RESULTS

Thirty-eight systematic reviews met inclusion criteria and yielded 519 individual studies. We identified six functional categories and eight digital health modalities. Case management (63%) and health monitoring (50%) were the most common intervention functionalities. Mobile apps and web-based interventions were the two most commonly studied modalities. Evidence of efficacy was strongest for web-based, text-messaging, and phone-based approaches. Although mobile applications have been widely studied, the evidence on efficacy is mixed. Blood pressure and medication adherence were the most commonly studied outcomes. However, evidence on the efficacy of the various intervention modalities on these outcomes was variable. Among all individual studies, only 38.0% were conducted in the United States (n = 197). Of these U.S. studies, 54.8% adequately reported racial or ethnic group distribution. On average, samples were 27.0% Black, 17.1% Latinx, and 63.4% White.

CONCLUSION

While evidence of the efficacy of selected digital health interventions, particularly those designed to improve blood pressure management and medication adherence, show promise, evidence of how these interventions can be generalized to historically underrepresented groups is insufficient. Including these underrepresented populations in both digital health experimental and feasibility studies is critical to advancing digital health science and achieving health equity.

Effects of online support and social media communities on gestational diabetes: A systematic review

BACKGROUND

Gestational diabetes mellitus (GDM) is a common complication in pregnancy that can lead to negative maternal and fetal outcomes. Online support interventions have been suggested as a potential tool to improve the management of GDM.

OBJECTIVE

This systematic review aimed to summarize the effectiveness of social media and online support interventions for the management of GDM.

METHODS

We conducted a thorough systematic search across Web of Science, Scopus, and PubMed, following PRISMA guidelines, and supplemented it with a manual search. Our results included both qualitative and quantitative research. We rigorously assessed quantitative studies for bias using ROBINS-I and RoB 2 tools, ensuring the reliability of our findings.

RESULTS

We incorporated a total of 22 studies, which were comprised of ten qualitative and twelve quantitative studies. Online support interventions were found to have a positive impact on promoting self-care and improving healthcare outcomes for women with GDM. Individualized diet and exercise interventions resulted in lower odds of weight gain and GDM diagnosis, while online prenatal education increased breastfeeding rates. In addition, telemedicine options reduced the need for in-person clinical visits and improved patient satisfaction.

CONCLUSIONS

Online support interventions show potential to improve outcomes in patients with GDM in this small literature review. Future research is also necessary to determine the effectiveness of different types of online interventions and identify strategies to improve engagement and the quality of the information provided through online resources.

Effectiveness of mobile health interventions for pregnant women with gestational diabetes mellitus: a systematic review and meta-analysis

Gestational diabetes mellitus is a growing global health problem. Inadequate management during pregnancy can lead to maternal and foetal complications. Currently, mobile health (mHealth) delivers healthcare services, playing an increasingly important role in the management of blood glucose in GDM. This study aimed to systematically evaluate the effectiveness of mHealth intervention in pregnant women with GDM. Based on randomised controlled trials of mHealth application in GDM patients searched from the database, literature screening, data extraction, and quality evaluation were conducted independently by two researchers. Statistical analysis was performed using Review Manager 5.4 software. The review included 27 studies with a total of 3483 patients. The results showed a significant improvement in glycemic control. In addition, mHealth interventions could reduce the occurrence of adverse pregnancy outcomes and improve self-management ability. In a subgroup analysis, recording of delivery mode and WeChat combined phone call indicated significant differences with mHealth interventions. It was suggested that mHealth interventions imposed a positive effect on glycemic control and reduction of adverse pregnancy outcomes in GDM patients. Our results demonstrated that the application of mHealth interventions can act as an effective and feasible approach to self-management to promote the self-management level and awareness of GDM patients.

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.

Supporting the Management of Gestational Diabetes Mellitus With Comprehensive Self-Tracking: Mixed Methods Study of Wearable Sensors

BACKGROUND

Gestational diabetes mellitus (GDM) is an increasing health risk for pregnant women as well as their children. Telehealth interventions targeted at the management of GDM have been shown to be effective, but they still require health care professionals for providing guidance and feedback. Feedback from wearable sensors has been suggested to support the self-management of GDM, but it is unknown how self-tracking should be designed in clinical care.

OBJECTIVE

This study aimed to investigate how to support the self-management of GDM with self-tracking of continuous blood glucose and lifestyle factors without help from health care personnel. We examined comprehensive self-tracking from self-discovery (ie, learning associations between glucose levels and lifestyle) and user experience perspectives.

METHODS

We conducted a mixed methods study where women with GDM (N=10) used a continuous glucose monitor (CGM; Medtronic Guardian) and 3 physical activity sensors: activity bracelet (Garmin Vivosmart 3), hip-worn sensor (UKK Exsed), and electrocardiography sensor (Firstbeat 2) for a week. We collected data from the sensors, and after use, participants took part in semistructured interviews about the wearable sensors. Acceptability of the wearable sensors was evaluated with the Unified Theory of Acceptance and Use of Technology (UTAUT) questionnaire. Moreover, maternal nutrition data were collected with a 3-day food diary, and self-reported physical activity data were collected with a logbook.

RESULTS

We found that the CGM was the most useful sensor for the self-discovery process, especially when learning associations between glucose and nutrition intake. We identified new challenges for using data from the CGM and physical activity sensors in supporting self-discovery in GDM. These challenges included (1) dispersion of glucose and physical activity data in separate applications, (2) absence of important trackable features like amount of light physical activity and physical activities other than walking, (3) discrepancy in the data between different wearable physical activity sensors and between CGMs and capillary glucose meters, and (4) discrepancy in perceived and measured quantification of physical activity. We found the body placement of sensors to be a key factor in measurement quality and preference, and ultimately a challenge for collecting data. For example, a wrist-worn sensor was used for longer compared with a hip-worn sensor. In general, there was a high acceptance for wearable sensors.

CONCLUSIONS

A mobile app that combines glucose, nutrition, and physical activity data in a single view is needed to support self-discovery. The design should support tracking features that are important for women with GDM (such as light physical activity), and data for each feature should originate from a single sensor to avoid discrepancy and redundancy. Future work with a larger sample should involve evaluation of the effects of such a mobile app on clinical outcomes.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03941652; https://clinicaltrials.gov/study/NCT03941652.

Successful implementation of virtual care to overcome the challenges of managing gestational diabetes during the COVID-19 pandemic: a quality improvement project

At the start of the COVID-19 pandemic, the Jim Pattison Diabetes and Pregnancy (JP DAP) clinic quickly switched from in-person to virtual care for patients with gestational diabetes (GDM) to reduce the risk of viral transmission. Poor glycaemic control in pregnancies increases the risk of maternal-fetal complications and thus women with GDM require education, frequent follow-up and treatment to reduce these risks. Delays in care could potentially result in increased maternal-fetal complications. We conducted a prospective, single-centre quality improvement (QI) study of women with GDM who attended the JP DAP clinic and delivered between 1 September 2019 and 31 March 2021. 2123 singleton pregnancies between 1 September 2019 and 31 March 2021 with GDM were analysed for this study. The time of referral to see the endocrinologist was lower than baseline in the first wave but rose significantly in the second wave. No-shows for appointments increased in the first wave but were lower than baseline after the implementation of time slots. There was no special cause variation for maternal-fetal complications pre pandemic, first wave or during the second wave. A patient satisfaction survey reported that 93% of respondents strongly agreed or agreed with the statement 'I was satisfied with the care provided to me over the telephone appointments'. The GDM education package, online educational videos in Hindi and English and the glucometer smartphone application helped to maintain the time of referral to first endocrinologist appointment in the first wave and therefore were considered an effective substitute for in-person education. Despite the delays in care seen in the second wave, there was no increase in maternal-fetal complications. Our clinic plans to continue using virtual tools for the foreseeable future.

A qualitative study of the dynamics of access to remote antenatal care through the lens of candidacy

OBJECTIVE

We aimed to explore the experiences and perspectives of pregnant women, antenatal healthcare professionals, and system leaders to understand the impact of the implementation of remote provision of antenatal care during the COVID-19 pandemic and beyond.

METHODS

We conducted a qualitative study involving semi-structured interviews with 93 participants, including 45 individuals who had been pregnant during the study period, 34 health care professionals, and 14 managers and system-level stakeholders. Analysis was based on the constant comparative method and used the theoretical framework of candidacy.

RESULTS

We found that remote antenatal care had far-reaching effects on access when understood through the lens of candidacy. It altered women's own identification of themselves and their babies as eligible for antenatal care. Navigating services became more challenging, often requiring considerable digital literacy and sociocultural capital. Services became less permeable, meaning that they were more difficult to use and demanding of the personal and social resources of users. Remote consultations were seen as more transactional in character and were limited by lack of face-to-face contact and safe spaces, making it more difficult for women to make their needs - both clinical and social - known, and for professionals to assess them. Operational and institutional challenges, including problems in sharing of antenatal records, were consequential. There were suggestions that a shift to remote provision of antenatal care might increase risks of inequities in access to care in relation to every feature of candidacy we characterised.

CONCLUSION

It is important to recognise the implications for access to antenatal care of a shift to remote delivery. It is not a simple swap: it restructures many aspects of candidacy for care in ways that pose risks of amplifying existing intersectional inequalities that lead to poorer outcomes. Addressing these challenges through policy and practice action is needed to tackle these risks.

Effectiveness of Telemedicine in Managing Diabetes in Pregnancy: A Systematic Review and Meta-Analysis

BACKGROUND

Strict monitoring of blood glucose during pregnancy is essential for ensuring optimal maternal and neonatal outcomes. Telemedicine could be a promising solution for supporting diabetes management; however, an updated meta-analysis is warranted. This study assesses the effects of telemedicine solutions for managing gestational and pregestational diabetes.

METHODS

PubMed, EMBASE, Cochrane Library Central Register of Controlled Trials, and CINAHL were searched up to October 14, 2020. All randomized trials assessing the effects of telemedicine in managing diabetes in pregnancy relative to any comparator without the use of telemedicine were included. The primary outcome was infant birth weight. A meta-analysis comparing the mean difference (MD) in birth weight across studies was applied, and subgroup and sensitivity analyses were performed. The revised Cochrane tool was applied to assess the risk of bias, and the certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

From a total of 18 studies, ten (totaling 899 participants) were used to calculate the effect on infant birth weight. The results nonsignificantly favored the control (MD of 19.34 g; [95% confidence interval, CI -47.8; 86.47]), with moderate effect certainty. Heterogeneity was moderate (I2 = 37.39%). Statistically significant secondary outcomes included differences in two-hour glucose tolerance postpartum (gestational diabetes; two studies: standardized mean difference 9.62 mg/dL [95% CI: 1.95; 17.28]) that favored the control (GRADE level, very low) and risk of shoulder dystocia (four studies: log odds -1.34 [95% CI: -2.61; -0.08]) that favored telemedicine (GRADE, low).

CONCLUSIONS

No evidence was found to support telemedicine as an alternative to usual care when considering maternal and fetal outcomes. However, further research is needed, including economic evaluations.

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.

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.

Trial protocol for the study of recommendation system DiaCompanion with personalized dietary recommendations for women with gestational diabetes mellitus (DiaCompanion I)

Background

Gestational diabetes mellitus (GDM) is a common complication of pregnancy associated with serious adverse outcomes for mothers and their offspring. Achieving glycaemic targets is the mainstream in the treatment of GDM in order to improve pregnancy outcomes. As GDM is usually diagnosed in the third trimester of pregnancy, the time frame for the intervention is very narrow. Women need to get new knowledge and change their diet very quickly. Usually, these patients require additional frequent visits to healthcare professionals. Recommender systems based on artificial intelligence could partially substitute healthcare professionals in the process of educating and controlling women with GDM, thus reducing the burden on the women and healthcare systems. We have developed a mobile-based personalized recommendation system DiaCompanion I with data-driven real time personal recommendations focused primarily on postprandial glycaemic response prediction. The study aims to clarify the effect of using DiaCompanion I on glycaemic levels and pregnancy outcomes in women with GDM.

Methods

Women with GDM are randomized to 2 treatment groups: utilizing and not utilizing DiaCompanion I. The app provides women in the intervention group the resulting data-driven prognosis of 1-hour postprandial glucose level every time they input their meal data. Based on the predicted glucose level, they can adjust their current meal so that the predicted glucose level falls within the recommended range below 7 mmol/L. The app also provides reminders and recommendations on diet and lifestyle to the participants of the intervention group. All the participants are required to perform 6 blood glucose measurements a day. Capillary glucose values are retrieved from the glucose meter and if not available, from the woman's diary. Additionally, data on glycaemic levels during the study and consumption of major macro- and micronutrients will be collected using the mobile app with electronic report forms in the intervention group. Women from the control group receive standard care without the mobile app. All participants are prescribed with insulin therapy if needed and modifications in their lifestyle. A total of 216 women will be recruited. The primary outcome is the percentage of postprandial capillary glucose values above target (>7.0 mmol/L). Secondary outcomes include the percentage of patients requiring insulin therapy during pregnancy, maternal and neonatal outcomes, glycaemic control using glycated hemoglobin (HbA1c), continuous glucose monitoring data and other blood glucose metrics, the number of patient visits to endocrinologists and acceptance/satisfaction of the two strategies assessed using a questionnaire.

Discussion

We believe that the approach including DiaCompanion I will be more effective in patients with GDM for improving glycaemic levels and pregnancy outcomes. We also expect that the use of the app will help reduce the number of clinic visits.

Trial registration number

ClinicalTrials.gov, Identifier NCT05179798.

Effectiveness of a comprehensive telemedicine intervention replacing standard care in gestational diabetes: a randomized controlled trial

AIMS

Telemedicine improves glycemic and perinatal outcomes when used as an adjunct to standard care in gestational diabetes (GDM). Little is known about its effectiveness when used instead of standard care. We aimed to compare the outcomes of telemedicine care and the standard care in women with GDM.

METHODS

In a single-center, parallel, randomized controlled trial, women were randomized to: (1) a telemedicine group, sending glucose readings via an application installed on a smartphone and monthly individual video calls replacing on-site visits or (2) standard care group with routine monthly on-site visits. The primary outcome was the effectiveness of glycemic control. The secondary outcomes were gestational weight gain (GWG) and perinatal data, including birth weight, gestational age, the incidence of the offspring large for gestational age, preterm birth, preeclampsia and cesarean section.

RESULTS

A total of 106 women were randomized to the telemedicine (n = 54) and the standard care group (n = 52). The telemedicine group demonstrated less postprandial measurements above the glycemic target (10.4% [3.9-17.9] vs. 14.6% [6.5-27.1]; p = 0.015), together with lower average postprandial glucose (5.6 ± 0.3 vs. 5.9 ± 0.4; p = 0.004). Percentage of cesarean section was lower in the telemedicine group (9 (17.3%) vs. 18 (35.3%); p = 0.038).

CONCLUSIONS

Telemedicine offers an effective alternative to delivering care to women with GDM. Trial registration NCT05521893, ClinicalTrials.gov Identifier URL: https://www.

CLINICALTRIALS

gov/ct2/show/NCT05521893?term=NCT05521893&draw=2&rank=1.

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.

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.

[Telemedical Support of Feto-Neonatal Care in One Region - Part I: Demand Analysis Using the Example of East Saxony]

Excellence in feto-neonatal care forms the basis for health in adulthood and requires a collaboration of stakeholders in the health care system. As in other regions, demographic changes such as rural depopulation pose a risk to feto-neonatal care in Eastern Saxony. Areas in need of regional, perinatal collaboration have been identified: (I) multi-professional counselling of families with a suspected fetal disease, (II) immediately available expertise of a neonatologist during neonatal resuscitation, (III) evidence-based neonatal antibiotic therapy, (IV) backtransfer of extremely preterm infants or sick neonates, and (V) adequate psychosocial support of families with extremely preterm infants or sick neonates. Telemedicine enables regional partners to communicate efficiently and gives an audiovisual impression of the patient. The Saxony Center for feto/neonatal Health (SCFNH) collaborates with regional partners to establish a feto-neonatal telemedicine network "Sichere Geburt". The network will be scientifically evaluated and might be of help as a model for other regions with structural challenges.

Web-Based Interventions for Pregnant Women With Gestational Diabetes Mellitus: Systematic Review and Meta-analysis

BACKGROUND

Effective management of gestational diabetes mellitus (GDM) is essential because it is one of the most prevalent diseases during pregnancy, and the consequent condition maternal hyperglycemia is closely related to considerable short- and long-term maternal and neonatal complications. Web-based interventions (WBIs), defined as therapeutic interventions offered via the web, have been implemented to assist in managing GDM owing to their advantages of high accessibility and efficiency, but findings across relevant studies are inconsistent.

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the effectiveness of WBIs on glycemic control among pregnant women with GDM; examine whether specific types of intervention interactivity, format, and technology have beneficial effects on maternal glycemic control; and comprehensively assess the efficacy of WBIs in maternal behavioral outcomes, cognitive and attitudinal outcomes, mental health, maternal and neonatal clinical outcomes, and medical service use and costs among pregnant women with GDM.

METHODS

PubMed, Embase, Cochrane Library, Web of Science, CINAHL, and PsycINFO were searched from their respective inception to November 19, 2022, to identify relevant randomized controlled trials and controlled clinical trials. The methodological quality of the included studies was assessed using the Effective Public Health Practice Project tool. Where possible, the data for all outcomes were meta-analyzed using the Stata software (version 12.0; StataCorp). Overall, 3 subgroup analyses and post hoc sensitivity analyses of maternal glycemic control parameters were performed.

RESULTS

Overall, 25 publications arising from 21 randomized controlled trials and controlled clinical trials were included. The overall meta-analyses on glycemic control parameters demonstrated that WBIs could significantly improve fasting blood glucose (standardized mean difference=-1.764, 95% CI -2.972 to -0.557; P=.004) and 2-hour postprandial blood glucose (standardized mean difference=-1.433, 95% CI -2.561 to -0.304; P=.01) compared with the control group, whereas no significant effect was found on glycated hemoglobin and 1-hour postprandial blood glucose. The results of the subgroup analyses indicated that mobile app-delivered interventions with a personalized format and interactive function showed more beneficial effects on maternal glycemic control. Moreover, WBIs could significantly enhance compliance with the self-monitoring of blood glucose; increase the rate of normal vaginal delivery; and decrease the chance of emergency cesarean, admission to the neonatal intensive care unit, and composite neonatal complications. GDM knowledge, risk perception of the disease, self-efficacy, satisfaction with care, and medical service use of the participants in the WBI group were also improved compared with the control group. However, the effectiveness of WBIs on other secondary outcomes was either nonsignificant or uncertain.

CONCLUSIONS

WBIs are a promising approach to GDM management. Personalized, interactive, and mobile app-delivered interventions seem more worthy of being recommended for future clinical practice. Further high-quality studies are required to verify these findings before making broad recommendations.

TRIAL REGISTRATION

PROSPERO CRD42022296625; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=296625.

[Gestational diabetes mellitus (Update 2023)]

Gestational diabetes (GDM) is defined as any degree of glucose intolerance with onset during pregnancy and is associated with increased feto-maternal morbidity as well as long-term complications in mothers and the offspring. Women detected to have diabetes early in pregnancy receive the diagnosis of overt, non-gestational, diabetes (glucose: fasting ≥ 126 mg/dl, spontaneous ≥ 200 mg/dl or HbA_1c ≥ 6.5% before 20 weeks of gestation). GDM is diagnosed by an oral glucose tolerance test (oGTT) or increased fasting glucose (≥ 92 mg/dl). Screening for undiagnosed type 2 diabetes at the first prenatal visit is recommended in women at increased risk (history of GDM/pre-diabetes; malformation, stillbirth, successive abortions or birth weight > 4500 g previously; obesity, metabolic syndrome, age > 35 years, vascular disease; clinical symptoms of diabetes (e.g. glucosuria) or ethnic origin with increased risk for GDM/T2DM (Arab, South- and Southeast Asian, Latin American)) using standard diagnostic criteria. Performance of the oGTT (120 min; 75 g glucose) may already be indicated in the first trimester in high-risk women but is mandatory between gestational week 24-28 in all pregnant women with previous non-pathological glucose metabolism. Following WHO recommendations, which are based on the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study, GDM is defined, if fasting venous plasma glucose is ≥ 92 mg/dl or 1 h ≥ 180 mg/dl or 2 h ≥ 153 mg/dl after glucose loading (international consensus criteria). In case of one pathological value a strict metabolic control is mandatory. After bariatric surgery we do not recommend to perform an oGTT due to risk of postprandial hypoglycemia. All women with GDM should receive nutritional counseling, be instructed in blood glucose self-monitoring and motivated to increase physical activity to moderate intensity levels-if not contraindicated (Evidence level A). If blood glucose levels cannot be maintained in the therapeutic range (fasting < 95 mg/dl and 1 h after meals < 140 mg/dl, Evidence level B) insulin therapy should be initiated as first choice (Evidence level A). Maternal and fetal monitoring is required in order to minimize maternal and fetal/neonatal morbidity and perinatal mortality. Regular obstetric examinations including ultrasound examinations are recommended (Evidence level A). Neonatal care of GDM offspring at high risk for hypoglycaemia includes blood glucose measurements after birth and if necessary appropriate intervention. Monitoring the development of the children and recommendation of healthy lifestyle are important issues to be tackled for the whole family. After delivery all women with GDM have to be reevaluated as to their glucose tolerance by a 75 g oGTT (WHO criteria) 4-12 weeks postpartum. Assessment of glucose parameters (fasting glucose, random glucose, HbA_1c or optimally oGTT) are recommended every 2-3 years in case of normal glucose tolerance. All women have to be instructed about their increased risk of type 2 diabetes and cardiovascular disease at follow-up. Possible preventive meassures, in particular lifestyle changes as weight management and maintenance/increase of physical activity should be discussed (evidence level A).

15. Management of Diabetes in Pregnancy: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Telehealth Care for Mothers and Infants to Improve the Continuum of Care: Protocol for a Quasi-Experimental Study

BACKGROUND

Ensuring an appropriate continuum of care in maternal, newborn, and child health, as well as providing nutrition care, is challenging in remote areas. To make care accessible for mothers and infants, we developed a telehealth care system called Portable Health Clinic for Maternal, Newborn, and Child Health.

OBJECTIVE

Our study will examine the telehealth care system's effectiveness in improving women's and infants' care uptake and detecting their health problems.

METHODS

A quasi-experimental study will be conducted in rural Bangladesh. Villages will be allocated to the intervention and control areas. Pregnant women (≥16 gestational weeks) will participate together with their infants and will be followed up 1 year after delivery or birth. The intervention will include regular health checkups via the Portable Health Clinic telehealth care system, which is equipped with a series of sensors and an information system that can triage participants' health levels based on the results of their checkups. Women and infants will receive care 4 times during the antenatal period, thrice during the postnatal period, and twice during the motherhood and childhood periods. The outcomes will be participants' health checkup coverage, gestational and neonatal complication rates, complementary feeding rates, and health-seeking behaviors. We will use a multilevel logistic regression and a generalized estimating equation to evaluate the intervention's effectiveness.

RESULTS

Recruitment began in June 2020. As of June 2022, we have consented 295 mothers in the study. Data collection is expected to conclude in June 2024.

CONCLUSIONS

Our new trial will show the effectiveness and extent of using a telehealth care system to ensure an appropriate continuum of care in maternal, newborn, and child health (from the antenatal period to the motherhood and childhood periods) and improve women's and infants' health status.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN44966621; https://www.isrctn.com/ISRCTN44966621.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/41586.

Exploring the acceptability and experience of receiving diabetes and pregnancy care via telehealth during the COVID-19 pandemic: a qualitative study

BACKGROUND

The COVID-19 pandemic has significantly impacted the delivery of diabetes in pregnancy care and general maternity care. This study aimed to explore the experiences and acceptability of telehealth use in diabetes in pregnancy care during the COVID-19 pandemic, from the perspectives of pregnant women and their clinicians. The secondary aim was to explore the experiences of pregnant women receiving general maternity care via telehealth during the COVID-19 pandemic.

METHODS

In-depth qualitative semi-structured interviews were undertaken and analysed via thematic inductive approaches. The Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies Framework (NASSS) was applied.

RESULTS

Eigthteen interviews were conducted with culturally and linguistically diverse pregnant women and 4 clinicians (endocrinologists and dietitians). All interviewees were satisfied with telehealth as a positive alternative to face-to-face consultations for diabetes care during the COVID-19 pandemic. Numerous benefits of delivering diabetes care via telehealth were discussed and themes centred around greater access to care, economic benefits and improved safety. Most barriers concerned the adopters (clinicians), yet, feasible and realistic suggestions to overcome barriers were voiced. The scope for technology adaptation and ongoing embedment into routine diabetes care was described. Overall, a hybrid flexible delivery model, predominantly consisting of telephone consultations, with some face-to-face consultations for initial diabetes appointments was recommended for future care. The use of telehealth in replacement of face-to-face appointments for general maternity care was perceived as reducing care quality.

CONCLUSION

In this study, telehealth was viewed as acceptable to women and clinicians for diabetes in pregnancy care, supporting the ongoing delivery of a hybrid service model of telehealth and face-to-face care. These findings provide valuable information to improve diabetes in pregnancy services to meet the needs of women during the COVID-19 pandemic and beyond.

Effectiveness of Smartphone-Based Lifestyle Interventions on Women with Gestational Diabetes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

Gestational diabetes mellitus (GDM) is a condition that causes poor glucose tolerance during pregnancy and usually resolves after birth. Having GDM impacts the mother and baby. Smartphone-based lifestyle interventions may offer innovative solutions.

Aim

To examine the effects of smartphone-based lifestyle interventions on compliance, Hemoglobin A1c (HbA1c), maternal outcomes, infant outcomes, psychological status, satisfaction, and cost effectiveness among women with GDM.

Methods

Randomized controlled trials (RCTs) of smartphone-based lifestyle interventions for women with GDM aged over 18 years were included. A systematic search of PubMed, Embase, Web of Science, CINAHL, and Cochrane Library for articles published from January 2007 to March 2022 and updated on 12 October 2022. Data were extracted independently by two researchers, and the risk of bias in individual trials was rated using the Cochrane risk-of-bias tool (RoB 2). Meta-analysis was conducted by using RevMan 5.3.

Results

Ten studies were included involving 1626 participants. The mean ages of the women were 32.42 ±4.68 years. Eight out of 10 studies were conducted in developed countries. Meta-analysis found that smartphone-based lifestyle interventions statistically improved compliance [SMD = 7.36, 95% CI = (4.05 to 10.68), P < 0.0001] and decreased the incidences of neonatal intensive care unit (NICU) admission [RR = 0.64, 95% CI = (0.47,0.86), P = 0.003], compared with controls. However, intervention effects on HbA1c, maternal outcomes, neonatal hypoglycemia, and infant birth weight were non significant. Moreover, the satisfaction of intervention is high in this review. Contrastingly, no significant effects were observed for psychological status and cost-effectiveness.

Conclusion

Smartphone-based lifestyle interventions may improve patient compliance and reduce NICU admissions. These findings may aid in developing future intervention strategies, help elucidate future research directions, and guide clinical practice for women with GDM. Future high-quality RCTs must be further studied at larger scales to examine smartphone-based lifestyle interventions' long-term effects and cost-effectiveness.

Incidence and characteristics of stillbirths before and during the Coronavirus 2019 pandemic

OBJECTIVE

The aim of this study was to determine the incidence and characteristics of stillbirths during the initial wave of the Coronavirus 2019 (COVID-19) pandemic and whether or not this differed from the incidence and characteristics of stillbirths that occurred in the pre-pandemic period.

STUDY DESIGN

This was a single-center retrospective cohort study of pregnant individuals who delivered stillbirths during two different time periods: March-September in 2017, 2018, and 2019 (pre-COVID-19 pandemic period) and March-September 2020 (COVID-19 pandemic period).

RESULTS

No difference in the rate of stillbirths was found between the two time periods. The women who experienced a stillbirth during the pre-pandemic period attended on average more prenatal visits than women who experienced a stillbirth during the pandemic period (p < .05). During the pandemic period, a higher proportion of stillbirths were suspected to be due to poorly controlled hypertension (p = .04).

CONCLUSIONS

The incidence of stillbirth during the pandemic period was similar to that during the pre-pandemic period; however, there were more stillbirths that occurred due to poorly controlled hypertension, a potentially preventable cause of stillbirth, during the pandemic period when compared to those of the pre-pandemic period. While the impact of the disease process of COVID-19 on stillbirth remains uncertain, the change in the provision of prenatal care during the pandemic period may have had unintended consequences with respect to the prevention and management of hypertension and the risk of potentially preventable stillbirths.

Comprehensive self-tracking of blood glucose and lifestyle with a mobile application in the management of gestational diabetes: a study protocol for a randomised controlled trial (eMOM GDM study)

INTRODUCTION

Gestational diabetes (GDM) causes various adverse short-term and long-term consequences for the mother and child, and its incidence is increasing globally. So far, the most promising digital health interventions for GDM management have involved healthcare professionals to provide guidance and feedback. The principal aim of this study is to evaluate the effects of comprehensive and real-time self-tracking with eMOM GDM mobile application (app) on glucose levels in women with GDM, and more broadly, on different other maternal and neonatal outcomes.

METHODS AND ANALYSIS

This randomised controlled trial is carried out in Helsinki metropolitan area. We randomise 200 pregnant women with GDM into the intervention and the control group at gestational week (GW) 24-28 (baseline, BL). The intervention group receives standard antenatal care and the eMOM GDM app, while the control group will receive only standard care. Participants in the intervention group use the eMOM GDM app with continuous glucose metre (CGM) and activity bracelet for 1 week every month until delivery and an electronic 3-day food record every month until delivery. The follow-up visit after intervention takes place 3 months post partum for both groups. Data are collected by laboratory blood tests, clinical measurements, capillary glucose measures, wearable sensors, air displacement plethysmography and digital questionnaires. The primary outcome is fasting plasma glucose change from BL to GW 35-37. Secondary outcomes include, for example, self-tracked capillary fasting and postprandial glucose measures, change in gestational weight gain, change in nutrition quality, change in physical activity, medication use due to GDM, birth weight and fat percentage of the child.

ETHICS AND DISSEMINATION

The study has been approved by Ethics Committee of the Helsinki and Uusimaa Hospital District. The results will be presented in peer-reviewed journals and at conferences.

TRIAL REGISTRATION NUMBER

NCT04714762.

Maternal Perinatal Telemonitoring in the Context of the Coronavirus Disease 2019 Pandemic in a Tertiary Health Center in Peru

OBJECTIVE

This study aimed to describe the characteristics of a telemonitoring program that was rapidly implemented in our institution as a response to the coronavirus disease 2019 (COVID-19) pandemic, as well as the maternal and perinatal outcomes of women who attended this program.

STUDY

DESIGN: Retrospective study of patients via phone-call telemonitoring during the peak period of the COVID-19 pandemic (May 2020-August 2020). Maternal and perinatal outcomes were collected and described. Health providers' satisfaction with the telemonitoring program was assessed via an email survey.

RESULTS

Twenty-three (69.7%) health providers answered the survey. The mean age was 64.5 years, 91.3% were OB/GYN (obstetrician-gynecologist) doctors, and 95% agreed that telemonitoring is an adequate method to provide health care when in-person visits are difficult. The 78.7% of scheduled telemonitoring consultations were finally completed. We performed 2,181 telemonitoring consultations for 616 pregnant women and 544 telemonitoring consultations for puerperal women. Other medical specialties offering telemonitoring included gynecology, reproductive health, family planning, cardiology, endocrinology, and following up with patients with reactive serology to severe respiratory syndrome coronavirus 2 (SARS-CoV-2). The majority of the population attending our telemonitoring program were categorized as the lowest strata, i.e., III and IV, according to the Human Development Index, and approximately 42% were deemed as high-risk pregnant women. Additionally, we reported the perinatal outcomes of 424 (63%) pregnant women, the most relevant finding being that approximately 53% of them had cesarean sections.

CONCLUSION

Telemonitoring is an adequate method of continuing the provision of prenatal care when in-person visits are difficult in situations such as the COVID-19 pandemic. Telemonitoring is feasible even in institutions with no or little experience in telemedicine. The perinatal outcomes in women with telemonitoring seem to be similar to that in the general population.

KEY POINTS

· Telemonitoring for prenatal care is feasible even in low-income countries and in a critical scenario.. · OB/GYN doctors agreed with that telemonitoring is an adequate method to provide prenatal care.. · Maternal and perinatal outcomes are similar in women attending a telemonitoring program..

Use of Telehealth During the COVID-19 Pandemic Among Practicing Maternal-Fetal Medicine Clinicians

Background: Limited knowledge exists about the drivers of telehealth use among obstetricians during COVID-19 in the United States. We investigated the use of live video visits by Maternal-Fetal Medicine (MFM) clinicians, the factors associated with use and interest in future use. Methods: We drew survey data from 373 clinicians on two outcomes: (1) use of any (vs. no) live video visits during COVID-19 and (2) among users, the extent of live video use. Bivariate and multivariate logistic regressions quantified the association between predisposing (demographic and practice setting characteristics) and enabling factors (prepandemic telehealth use, structural and perceived patient barriers) and each outcome. Results: During the pandemic, 88% reported any use, a jump from 29% prepandemic utilization. Users (vs. nonusers) were younger (p = 0.02); tended to provide comprehensive prenatal care (p = 0.01) and/or inpatient care (p = 0.02), practice in university settings (p = 0.01), engage in various telehealth modalities prepandemic (p ≤ 0.01), and to perceive challenges with technical (p < 0.01), reimbursement (p = 0.05), and patient barriers to internet or data plan access (p ≤ 0.001). After adjusting for covariates, only prepandemic communication through patient portal (adjusted odds ratio [aOR] = 3.85; 95% confidence interval [CI] = 1.33-11.12), perceived patient access barriers (aOR = 5.27; 95% CI = 1.95-14.23), and practice in multiple versus university settings (aOR = 0.18; 95% CI = 0.06-0.56) remained significantly associated with use. Approximately 44% were high users. Prepandemic ultrasound use (aOR = 1.92; 95% CI = 1.17-3.16), perceived patient access barriers (aOR = 1.85; 95% CI = 1.12-3.06) and Midwest versus North practice location (aOR = 0.46; 95% CI = 0.21-0.98) predicted high use. Among high users, 99% wanted to continue offering video visits. Conclusions: We found widespread use of live video obstetric care by MFM clinicians and continued interest in use postpandemic.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

Gestational diabetes mellitus in the COVID-19 pandemic: A retrospective study from Hangzhou, China

AIMS

Our study aimed to investigate changes in the prevalence of gestational diabetes mellitus (GDM) in the COVID-19 pandemic and postpandemic era and the risk of adverse pregnancy outcomes in pregnant women diagnosed with GDM during the blockade period.

METHODS

First, we investigated changes in the prevalence of GDM and the population undergoing oral glucose tolerance tests (OGTT) after the COVID-19 pandemic. We then collected clinical information from pregnant women diagnosed with GDM to explore the risk of adverse pregnancy outcomes in pregnant women with GDM during the COVID-19 pandemic.

RESULTS

After the COVID-19 pandemic, the proportion of pregnant women in the total number of outpatient OGTT tests decreased yearly. The ratio was 81.30%, 79.71%, and 75.48% from 2019 to 2021, respectively, with the highest proportion of pregnant women in February 2020 (92.03%). The prevalence of GDM was higher in March 2020 compared to the same period in 2019. However, from 2019 to 2021, the prevalence decreased year by year with 21.46%, 19.81%, and 18.48%, respectively. The risk of adverse pregnancy outcomes for pregnant women diagnosed with GDM during the most severe period of the COVID-19 pandemic did not differ from before the COVID-19 pandemic.

CONCLUSIONS

After the COVID-19 pandemic, the prevalence of GDM increased during the most severe period of the epidemic, but the overall prevalence of GDM decreased year by year. In addition, the pandemic did not change the risk of adverse pregnancy outcomes in pregnant women with GDM.

A Novel, Cardiac-Derived Algorithm for Uterine Activity Monitoring in a Wearable Remote Device

Background: Uterine activity (UA) monitoring is an essential element of pregnancy management. The gold-standard intrauterine pressure catheter (IUPC) is invasive and requires ruptured membranes, while the standard-of-care, external tocodynamometry (TOCO)’s accuracy is hampered by obesity, maternal movements, and belt positioning. There is an urgent need to develop telehealth tools enabling patients to remotely access care. Here, we describe and demonstrate a novel algorithm enabling remote, non-invasive detection and monitoring of UA by analyzing the modulation of the maternal electrocardiographic and phonocardiographic signals. The algorithm was designed and implemented as part of a wireless, FDA-cleared device designed for remote pregnancy monitoring. Two separate prospective, comparative, open-label, multi-center studies were conducted to test this algorithm.

Methods: In the intrapartum study, 41 laboring women were simultaneously monitored with IUPC and the remote pregnancy monitoring device. Ten patients were also monitored with TOCO. In the antepartum study, 147 pregnant women were simultaneously monitored with TOCO and the remote pregnancy monitoring device.

Results: In the intrapartum study, the remote pregnancy monitoring device and TOCO had sensitivities of 89.8 and 38.5%, respectively, and false discovery rates (FDRs) of 8.6 and 1.9%, respectively. In the antepartum study, a direct comparison of the remote pregnancy monitoring device to TOCO yielded a sensitivity of 94% and FDR of 31.1%. This high FDR is likely related to the low sensitivity of TOCO.

Conclusion: UA monitoring via the new algorithm embedded in the remote pregnancy monitoring device is accurate and reliable and more precise than TOCO standard of care. Together with the previously reported remote fetal heart rate monitoring capabilities, this novel method for UA detection expands the remote pregnancy monitoring device’s capabilities to include surveillance, such as non-stress tests, greatly benefiting women and providers seeking telehealth solutions for pregnancy care.

Web-based interventions for pregnant women with gestational diabetes mellitus: a systematic review and meta-analysis protocol

INTRODUCTION

Gestational diabetes mellitus (GDM) is one of the most prevalent diseases during pregnancy, which is closely associated with many short-term and long-term maternal and neonatal complications and can incur heavy financial burden on both families and society. Web-based interventions have been used to manage GDM because of the advantages of high accessibility and flexibility, but their effectiveness has remained inconclusive. This systematic review and meta-analysis aims to comprehensively investigate the multidimensional effectiveness of web-based interventions for pregnant women with GDM, thereby aiding implementation decisions in clinical settings.

METHODS AND ANALYSIS

This systematic review protocol strictly adheres to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. Six electronic databases (PubMed, Web of Science, Cochrane Central Register of Controlled Trials, Embase, CINAHL and PsycINFO) will be comprehensively searched from their inception to 26 January 2022 to identify randomised controlled trials and controlled clinical trials regarding the efficacy of web-based interventions for pregnant women with GDM on glycaemic control, behavioural outcomes, cognitive and attitudinal outcomes, mental health, maternal and neonatal clinical outcomes, and medical service utilisation and costs. Two reviewers will independently conduct the study selection, data extraction and quality assessment. The methodological quality of included studies will be assessed using the Effective Public Health Practice Project assessment tool. The overall meta-analyses for each of the interested outcomes will be performed if the outcome data are sufficient and provides similar effect measures, as well as subgroup analyses for glycaemic control indicators based on the different types of intervention format, interactivity and technology. We will conduct a qualitative synthesis for studies that cannot be quantitatively synthesised.

ETHICS AND DISSEMINATION

Ethics approval is not required for this review as no human participants will be involved. The results will be disseminated via a peer-reviewed journal or an academic conference.

PROSPERO REGISTRATION NUMBER

CRD42022296625.

Barriers and Facilitators of Using eHealth to Support Gestational Diabetes Mellitus Self-Management (GDM): A Systematic Literature Review of Perceptions of Healthcare Professionals and Women with GDM (Preprint)

Background

Gestational diabetes mellitus (GDM) is one of the most common medical complications during pregnancy. eHealth technologies are proving to be successful in supporting the self-management of medical conditions. Digital technologies have the potential to improve GDM self-management.

Objective

The primary objective of this systematic literature review was to identify the views of health professionals (HPs) and women with GDM regarding the use of eHealth for GDM self-management. The secondary objective was to investigate the usability and user satisfaction levels when using these technologies.

Methods

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) approach, the search included primary papers in English on the evaluation of technology to support self-management of GDM from January 2008 to September 2021 using MEDLINE, CINAHL, Embase, ACM, and IEEE databases. The lists of references from previous systematic literature reviews, which were related to technology and GDM, were also examined for primary studies. Papers with qualitative, quantitative, and mixed methodologies were included and evaluated. The selected papers were assessed for quality using the Cochrane Collaboration tool, National Institute for Health and Care Excellence clinical guidelines, Critical Appraisal Skills Programme Qualitative Checklist, and McGill University Mixed Methods Appraisal Tool. NVivo (QSR International) was used to extract qualitative data, which were subjected to thematic analysis. Narrative synthesis was used to analyze the quantitative data.

Results

A total of 26 papers were included in the review. Of these, 19% (5/26) of studies used quantitative research methodologies, 19% (5/26) used qualitative methods, and 62% (16/26) used mixed methods. In all, 4 themes were identified from the qualitative data: the benefits of using technology, engagement with people via technology, the usability of technology, and discouragement factors for the use of technology. The thematic analysis revealed a vast scope of challenges and facilitators in the use of GDM self-management systems. The challenges included usability aspects of the system, technical problems, data privacy, lack of emotional support, the accuracy of reported data, and adoption of the system by HPs. Convenience, improved GDM self-management, peer support, increased motivation, increased independence, and consistent monitoring were facilitators to use these technologies. Quantitative data showed that there is potential for improving the usability of the GDM self-management systems. It also showed that convenience, usefulness, increasing motivation for GDM self-management, helping with GDM self-management, and being monitored by HPs were facilitators to use the GDM self-management systems.

Conclusions

This novel systematic literature review shows that HPs and women with GDM encountered some challenges in using GDM self-management systems. The usability of GDM systems was the primary challenge derived from qualitative and quantitative results, with convenience, consistent monitoring, and optimization of GDM self-management emerging as important facilitators.

STORK: Collaborative Online Monitoring of Pregnancies Complicated with Gestational Diabetes Mellitus

Background: A novel digital platform, named STORK, was developed in the COVID-19 pandemic when clinic visits were restricted. A study of its clinical use during the pandemic was conducted. The study aims to advance the state of the art in monitoring and care of pregnancies complicated with gestational diabetes mellitus (GDM) via online collaboration between patients and care providers. Methods: This study involved 31 pregnant women diagnosed with GDM and 5 physicians. Statistical comparisons were made in clinic-visit frequency and adverse outcomes between the STORK group and a historical control group of 32 women, compatible in size, demographics, anthropometrics and medical history. Results: The average number of submitted patient measurements per day was 3.6±0.4. The average number of clinic visits was 2.9±0.7 for the STORK group vs. 4.1±1.1 for the control group (p<0.05). The number of neonatal macrosomia cases was 2 for the STORK group vs. 3 for the control group (p>0.05); no other adverse incidents. Conclusions: The patient compliance with the pilot use of STORK was high and the average number of prenatal visits was reduced. The results suggest the general feasibility to reduce the average number of clinic visits and cost, with enhanced monitoring, case-specific adaptation, assessment and care management via timely online collaboration.

Role of Telemedicine in Diabetes Management

INTRODUCTION

Telemedicine is a growing arena that may increase access to care for patients with diabetes. It has more relevance for rural populations or those with limited physical access to health care, for improving diabetes care. Telemedicine can also be used to offer diabetes self-education and transportation barriers for patients living in under-resourced areas or with disabilities.

METHOD

"This review explores the landscape of telemedicine approaches and evidence for incorporation into general practice.

RESULTS & DISCUSSION

Telehealth platforms have been shown to be both feasible and effective for health care delivery in diabetes, although there are many caveats that require tailoring to the institution, clinician, and patient population. Research in diabetes telehealth should focus next on how to increase access to patients who are known to be marginalized from traditional models of health care.

Behavior Change Apps for Gestational Diabetes Management: Design and evaluation of desirable features (Preprint)

Background

Gestational diabetes (GDM) has considerable and increasing health effects as it raises both the mother’s and the offspring’s risk for short- and long-term health problems. GDM can usually be treated with a healthier lifestyle, such as appropriate dietary modifications and sufficient physical activity. Although telemedicine interventions providing weekly or more frequent feedback from health care professionals have shown the potential to improve glycemic control among women with GDM, apps without extensive input from health care professionals are limited and have not been shown to be effective. Different features in personalization and support have been proposed to increase the efficacy of GDM apps, but the knowledge of how these features should be designed is lacking.

Objective

The aim of this study is to investigate how GDM apps should be designed, considering the desirable features based on the previous literature.

Methods

We designed an interactive GDM prototype app that provided example implementations of desirable features, such as providing automatic and personalized suggestions and social support through the app. Women with GDM explored the prototype and provided feedback in semistructured interviews.

Results

We identified that (1) self-tracking data in GDM apps should be extended with written feedback, (2) habits and goals should be highly customizable to be useful, (3) the app should have different functions to provide social support, and (4) health care professionals should be notified through the app if something unusual occurs. In addition, we found 2 additional themes. First, basic functionalities that are fast to learn by women with GDM who have recently received the diagnosis should be provided, but there should also be deeper features to maintain interest for women with GDM at a later stage of pregnancy. Second, as women with GDM may have feelings of guilt, the app should have a tolerance for and a supporting approach to unfavorable behavior.

Conclusions

The feedback on the GDM prototype app supported the need for desirable features and provided new insights into how these features should be incorporated into GDM apps. We expect that following the proposed designs and feedback will increase the efficacy of GDM self-management apps.

Trial Registration

ClinicalTrials.gov NCT03941652; https://clinicaltrials.gov/ct2/show/NCT03941652