The COVID-19 pandemic has forced health systems and providers to reconsider how they deliver routine obstetric care. In an effort to stop the spread of the coronavirus, at the height of the pandemic, providers were encouraged to conduct visits through telemedicine platforms instead of face-to-face. While the benefit of telemedicine to deliver healthcare through a non-traditional method is clear, especially during a pandemic, there are still many unanswered questions, especially in the field of obstetrics. Do patients receive the same quality of care through telemedicine platforms as they receive through face-to-face visits?
Telemedicine has the potential to provide great benefit to patients and healthcare providers. The use of telemedicine has demonstrated improvement in outcomes in individuals with complex medical conditions such as coronary artery disease (1) and useful in managing chronic conditions such as hypertension (2). In obstetrics, the use of telemedicine is not a new concept. The Antenatal and Neonatal Guidelines, Education and Learning System (ANGELS) program in Arkansas through the University of Arkansas for Medical Sciences is a system that allows patients to receive high-risk obstetric care through a telemedicine platform. According to their ANGELS 2018-2019 Annual Report, postpartum complications have consistently decreased since the launch of ANGELS in 2003 (3,4). While ANGELS has been beneficial in coordinating and improving the reach of high-risk maternity services, it is not currently utilized for providing routine obstetric care.
The convenience of telemedicine should not decrease the quality of care accomplished through traditional care. Traditional obstetric care recommends routine prenatal visits every 4 weeks until 28 weeks, then every 2 weeks until 36 weeks and then weekly until delivery (5). During these visits, maternal and fetal well-being are assessed. Mothers are usually assessed through monitoring blood pressure, weight and urinary analysis. Fetal well-being is usually assessed through fundal height and fetal heart rate assessment. To achieve the same quality of care, some telehealth systems incorporate digital health kits with scales and blood pressure monitoring systems in their digital medicine programs. One such system is Connected Maternity Online Monitoring (MOMS) utilized here at the Ochsner Health System in New Orleans. Connected MOMS, launched in 2017, is a telehealth platform supported by a patient’s obstetrician and tech support that allows for remote monitoring of maternal health status that is then incorporated into the electronic medical record (6). During the pandemic, the existence of this telehealth system made transitioning to remote visits seamless. Four times as many patients were enrolled in the program comparing the volume from before and after March 2020 and the overall number of remote visits increased by 7% (7).
Using maternal and fetal outcomes as a primary study endpoint, several studies have demonstrated no significant difference between patients enrolled in traditional antenatal care and those where virtual visits were selectively utilized (8). The timing and frequency of traditional obstetrics visits, as outlined above, is supported by limited evidence and there has been increasing feedback that some appointments are redundant and that goals of care can be adequately met without these additional visits (9,10). In one randomized control trial of 300 obstetrics patients, those who were seen virtually with at-home blood pressure and Doppler monitoring for six of the fourteen visits had increased satisfaction, decreased stress and both maternal and fetal outcomes were similar across those in the intervention group and those who received the standard 14 in-person clinic visits (9). Some conditions, such as gestational diabetes, smoking cessation and maternal mental health lend themselves to virtual systems quite nicely, with applications specially designed for interactive blood glucose management, tobacco use monitoring, for depression screening, and if needed, cognitive behavioral therapy (11). Due to the increased availability and accuracy of remote monitoring of important indicators such as blood glucose, blood pressure and fetal heart rate, incorporating virtual visits into standard low-risk obstetric care is feasible and safe (9). Visits involving imaging and screening should remain in-clinic. Importantly, a routine postpartum visit at 6 weeks from delivery is critical for physical assessment of pelvic healing and psychosocial assessment of maternal well-being (12).
As telemedicine expands, we must consider barriers to access and equity. High quality, accurate, reliable telemedicine services require a stable, high speed internet connection on both ends as well as access to a video device and knowledge of how to use these technologies. Patients living in rural areas have been shown to have consistently worse health status than their urban counterparts and telemedicine has been shown to reduce health disparities in this population (13) but we also know in rural areas, there is less availability of resources needed for telemedicine. According to the 2018 Broadband Deployment Report, over 30% of rural areas and around 35% of tribal areas did not meet the Federal Communications Commission minimum benchmark for high-speed broadband internet (14). Lower income urban patients may also benefit from more flexible, non-traditional appointment times, which may be facilitated by telemedicine as this requires few to no additional staff members and does not require a traditional office space (15). However, as in the rural community, communication infrastructure in urban communities may be lacking. The rate of smartphone ownership and home broadband access is lower in low-income individuals (16). These are all important considerations as telemedicine is expanding. We do not want the use of telemedicine to further increase our gap in health disparities.
Telemedicine can be successfully implemented to replace some, but not all, routine obstetric visits with comparable quality of care, outcomes, and patient satisfaction for some patient populations. However, Ob/Gyns must be cautious to ensure all patients have equitable access to not further health disparities among reproductive age women. Ob/Gyns should reflect on the makeup of their practice, and for the time being the prevalence of SARS-CoV-2 in their community, when deciding how to implement virtual care. For now, patients can learn how to use an at-home Doppler and Bluetooth-connected blood pressure cuff, but Ob/Gyns still want face-to-face visits at key milestones, and of course, during the most important in-person visit – the birth!