Telehealth in the Prenatal and Postpartum Periods

Abstract

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.

The author provides current evidence on telehealth in the prenatal and postpartum periods, including new hybrid care models and the application of telehealth modalities on clinical outcomes.

Summer Sherburne Hawkins, PhD, MS

If there is a silver lining of the COVID-19 pandemic, it is the delivery of health care remotely, beyond the confines of traditional clinic settings. In one study of commercially-insured patients who gave birth (N = 45,203), researchers found that approximately 1% of participants had a telehealth prenatal visit from 2018 through January 2020; this number rose to a high of 17.3% in November 2020 and then declined to 9.9% by October 2021 (Acharya et al., 2023). These trends mirror outpatient visits via telehealth more broadly (Lo et al., 2022). Is telehealth here to stay?

The prenatal and postpartum periods present unique opportunities and challenges to incorporate telehealth: increasing appointment adherence balanced against essential screening, monitoring, and treatment that is well-suited to in-person visits. These issues are even more pressing during a time of increasing maternal mortality, particularly among women of color (Hoyert, 2023). Thus, it is important to review the changes in telehealth that have occurred in recent years and consider the future of telehealth for the prenatal and postpartum periods as we emerge from the COVID-19 pandemic.

The Health Resources & Services Administration (2022) defined telehealth as “the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, health administration, and public health (para. 1).” Telehealth encompasses a broader array of services than telemedicine and includes non-clinical and clinical services. The four main types of telehealth technologies include the following: 1) live, two-way interactions used for consultative, diagnostic, and treatment services, primarily videoconferencing but also audio-only interactions; 2) store-and-forward imaging, the electronic transmission of medical information such as digital images; 3) remote patient monitoring, the electronic collection and transmission of individual health and medical data to a provider; and 4) mobile health or mHealth, health care and public health practice and education supported by mobile devices (Health Resources & Services Administration, 2022; Presidential Task Force on Telehealth, 2020). A range of pregnancy-related services can be offered via telehealth technologies (Society for Maternal-Fetal Medicine, 2023; Weigel, 2020). In the prenatal period, telehealth can be used for routine prenatal care, such as remote patient monitoring, screening, consultation with specialists, genetic counseling, and ultrasound reading. In the postpartum period, continuity of care can be improved through virtual follow-up visits, lactation support, and counseling on contraception. Services can also be rendered during the entire perinatal period, including screening and treatment for mental health concerns and monitoring for diabetes and hypertension.

Telehealth Before COVID-19

Telehealth services have been shown to increase access to care, particularly for populations in underserved areas and with fewer resources, and to produce comparable or better outcomes than in-person care (DeNicola et al., 2020; Society for Maternal-Fetal Medicine, 2023; Wu et al., 2022). DeNicola et al. (2020) conducted a systematic review of 32 studies on the effectiveness of telehealth interventions for improving obstetric outcomes. While they did not examine birth outcomes specifically, they found that text-based interventions increased smoking cessation while text- and web-based interventions increased exclusive breastfeeding and breastfeeding continuation. In one of the included studies, a text-based intervention increased the number of blood pressure measurements in the postpartum period. Wu et al. (2022) conducted an integrative review of 13 studies on virtual prenatal care visits (articles published through 2020), including five studies in which researchers changed protocols in response to the COVID-19 pandemic; they found no differences in birth outcomes between in-person and virtual care models. They also found high patient and clinician satisfaction with telehealth services, high patient confidence in the care they received, and favorable ratings of patient-provider interactions. All five of the studies that included timelines of prenatal visits had varied schedules that ranged from five to nine in-person visits and four to six virtual visits. During the virtual appointments, patients reported their weight and blood pressure, and fetal heart rate was collected through a Doppler while the provider listened remotely (Wu et al., 2022). Carrandi et al. (2023) conducted a systematic review and found some evidence that mHealth interventions during pregnancy, including a range of telehealth technologies, may be cost-effective and “low cost,” but more evidence is needed regarding the cost-effectiveness of mHealth interventions related to improvements in health outcomes and longer-term health service use.

While professional organizations have endorsed the integration of telehealth into obstetric services to increase access to services (American College of Nurse-Midwives, 2022; Presidential Task Force on Telehealth, 2020; Society for Maternal-Fetal Medicine, 2023), the online nature of telehealth itself and related policies have created their own barriers (Gajarawala & Pelkowski, 2021; Society for Maternal-Fetal Medicine, 2023). Telehealth practitioners can provide services across geographic borders, but the lack of multistate licensure limits the scope of delivery. Health care providers must comply with licensure and be appropriately credentialed to deliver services. Physicians need the necessary hardware, software, and secure internet connection to guarantee quality care, patient safety, and privacy, and technologies must be HIPAA compliant. In addition, patients need high-speed broadband internet and hardware to engage in telehealth services. Health care providers need to ensure that the patient-physician relationship is valued in the telehealth treatment plan and their practices are compliant with state laws. When information is transmitted electronically versus in-person, risks exist regarding the potential for inaccuracy of data transmission and misdiagnosis. Malpractice insurance may not cover telehealth, and health care providers need to ensure their liability insurance policies cover telehealth malpractice. Lastly, reimbursement for telehealth services is often less than in-person visits and varies by insurance providers and by state.

Telehealth During COVID-19

COVID-19 was declared a global pandemic in March 2020, and telehealth as we knew it changed almost overnight. The Centers for Medicare & Medicaid Services (2022) issued a waiver, effective March 1, 2020, to expand reimbursement for telehealth services, and many commercial insurers followed suit. To maintain access to care and social distancing, governments, states, and health insurance programs suspended restrictions on services covered and the geographic location of services, increased payment for services, changed or suspended licensing rules, allowed prescriptions based on virtual visits, eliminated cost-sharing for telehealth services, and increased reimbursement for providers (Lo et al., 2022).

Not only did telehealth subsequently expand during the pandemic, but also research on telehealth on obstetric care increased precipitously. Using a database of commercially insured patients (N = 35,112), Kern-Goldberger et al. (2023) found that telehealth visits during pregnancy increased to 17.2% in 2020, but the number of prenatal care visits did not change. The rate of severe maternal morbidities and stillbirths remained consistent over time, and the preterm birth rate decreased significantly compared to prior years. Boguslawski et al. (2022) compared prenatal care use and outcomes between patients in a telehealth-supplemented prenatal care model during the pandemic to a cohort of patients immediately before the pandemic. They found that patients in the telehealth-exposed cohort were more likely to initiate prenatal care in the first trimester and to receive recommended diabetes screening and ultrasounds; they found no differences in the number of prenatal care visits or pregnancy-related complications.

It is also important to monitor the potential unintended consequences of telehealth. In a retrospective cohort study, Zafman et al. (2023) found that women who gave birth to neonates who were small for gestational age during COVID-19 were more likely to have undetected fetal growth restriction than a cohort who gave birth to neonates who were small for gestational age before COVID-19 but had more telehealth visits and fewer fundal height measurements and growth ultrasounds. The authors suggested that additional self-assessments or third trimester ultrasounds may need to be incorporated in prenatal care schedules (Zafman et al., 2023).

While national guidelines recommend a total of 12 to 14 prenatal visits throughout pregnancy (Kilpatrick et al., 2017) and a comprehensive postpartum visit no later than 12 weeks after birth (McKinney et al., 2018), perhaps telehealth technologies can modify this paradigm. Despite the focus on the quantity of visits, debate also exists about what constitutes adequate and quality prenatal care. Michel and Fontenot (2023) proposed that the current prenatal care structure based on the number of in-person visits without discussions of quality of care does not address barriers to access related to socioeconomic, employment, or other circumstances. New, hybrid, prenatal care models have the potential to increase uptake, but they also need to address other barriers to access, including internet and equipment availability. In a review of 42 studies, Cantor et al. (2022) found evidence that a reduced in-person prenatal care schedule supplemented with telehealth for women with low-risk pregnancies was associated with similar clinical outcomes as in-patient care and had higher patient satisfaction.

While evidence grows on the feasibility and safety of hybrid prenatal models, it is still unclear how to best deliver this modified care schedule. Peahl et al. (2021) presented guidelines for a model of care based on two principles: care related to essential services that is delivered in-person when required and video visits for other services and flexible services that allow patients to tailor support to meet their needs through opt-in programs. They developed a 4-1-4 prenatal plan that included four in-person contacts, one obstetric ultrasound, four virtual contacts, and flexible opt-in options for psychosocial support. This flexible, patient-centered care model is being evaluated. Butler Tobah et al. (2019) conducted a randomized controlled trial (RCT) to test a hybrid care model consisting of eight in-person visits, six virtual visits (phone or online communication) with fetal Doppler and sphygmomanometer home monitoring devices, and access to an online community of pregnant women versus usual care with 12 in-person prenatal visits. They found that patients in the hybrid prenatal care group had higher reported satisfaction and lower pregnancy-related stress but no differences in perceived quality of care, maternal and fetal clinical outcomes, or adherence to recommended prenatal services. The latter hybrid care model had fewer appointments but was considered more favorable by patients without compromising safety or adherence to clinical guidelines (Butler Tobah et al., 2019).

The use of telehealth to address three of the most pressing maternal health outcomes in the prenatal and postpartum periods, hypertension, gestational diabetes mellitus, and mental health issues, has been a recent focus of research/Kalafat et al. (2020) found that home blood pressure monitoring in the prenatal period was associated with reductions in prenatal visits, prenatal hospital admissions, and diagnosis of preeclampsia, with no differences in maternal, fetal or neonatal outcomes between home monitoring and conventional care. Telehealth-related interventions for monitoring, managing, and treating hypertension in the postpartum period have also expanded through innovative advances (Kumar et al., 2022). Xie et al. (2020) found that telehealth interventions for pregnant women with gestational diabetes mellitus were associated with improvements in glycemic control and reductions in cesarean, macrosomia, pregnancy-induced hypertension or preeclampsia, and preterm birth compared to women in standard care. There is rising interest and an increase in research being conducted on mobile health technologies, including mobile apps, to self-manage blood glucose during pregnancy (fewer for the postpartum period) and interventions to improve clinical outcomes such as glycemic control (Edwards et al., 2022). Hanach et al. (2021) found that telehealth-based interventions that were web- or phone-based were associated with improvements in symptoms of postpartum depression compared to standard care, and participants had high levels of completion and satisfaction with the technology-based interventions. Despite the widespread availability of mobile apps aimed at addressing symptoms of depression and/or anxiety in the prenatal and postpartum periods, few have been clinically tested, and among those that have, there is no evidence of their effectiveness in reducing symptoms compared to usual care (Tsai et al., 2022).

While the pandemic shifted much of our health care out of necessity, it is important to consider whether providers and patients would choose to use telehealth technologies in the prenatal and postpartum periods. In a systematic review, Ghimire et al. (2023) identified 23 studies on the implications of virtual, synchronous prenatal care on the experiences, needs, and preferences for care. They found that pregnant women and health care professionals reported higher satisfaction with virtual than in-person care, and women with low- and high-risk pregnancies preferred a hybrid model of care. They also found that virtual prenatal care reduced travel time, time away from work, clinic wait time, and no-shows, actors that likely contributed to higher satisfaction. Marshall et al. (2023) surveyed women (N = 1,978) who sought telehealth visits in the prenatal or postpartum periods during the first year of the COVID-19 pandemic. More than half of women who received care in either period had at least one telehealth visit, and among those who used telehealth, more than 80% reported a high quality of care defined as convenient, easy, safe, and with good information. In this study, approximately one-third of women reported being open to telehealth visits in the future (Marshall et al., 2023). Together, these findings suggest that women and health care providers are willing to continue to use a hybrid model of virtual and in-person care in a post-COVID-19 world.

Telehealth After COVID-19

While the COVID-19 public health emergency ended on May 11, 2023, the Consolidated Appropriations Act of 2023 extended many of the telehealth flexibilities authorized during the public health emergency through December 31, 2024 (Health Resources & Services Administration, 2023). The United States Centers for Medicare & Medicaid Services (2023) encouraged states to continue covering telehealth services through Medicaid, but coverage varies by state. Private health insurance coverage of telehealth also varies by commercial plan now that the public health emergency has ended. Many of the barriers to telehealth that were identified before COVID-19 will return if these measures do not extend beyond 2024 and become permanent. Health care providers must continue to be vigilant about changes in coverage of telehealth technologies across insurance providers to help their patients navigate this rapidly evolving landscape. The flexible integration of telehealth will truly support a patient-centered model of quality care in the prenatal and postpartum periods.

The exploding field of telehealth is exciting but presents challenges in synthesizing research because of the breadth of what is considered telehealth. Research is needed on emerging telehealth technologies and evaluations of hybrid care models. While not truly distinct, both streams of research will help inform the other. Ultimately, more focused reviews of the evidence will inform what technology or care model works best for what populations, for what outcome(s), and under what circumstances.

Stepping back, there is a need to document the heterogeneity of telehealth technologies and interventions and to develop and hone the scope as findings emerge. For example, a plethora of mHealth apps in mental health are available, but few have been clinically tested (Tsai et al., 2022), and knowledge is limited about emerging technologies more broadly, including wearable devices and apps (DeNicola et al., 2020). Rigorous evaluations, particularly through RCTs, will help evaluate the effectiveness of new technologies and modified care models on clinical outcomes, safety, and patient and provider satisfaction. A gap in research also exists regarding telehealth technologies and care models for the postpartum period, which is a critical time to facilitate continuity of care to help address maternal morbidities that continue after birth.

Put simply, telehealth emerged to increase access to care. However, inequities in maternity care exist across the United States related to geography, health insurance status, socioeconomic circumstances, and race and ethnicity, among others. Telehealth in the prenatal and postpartum periods has the potential to reduce disparities in care and clinical outcomes but needs to be thoughtfully executed to prevent increasing disparities (Ukoha et al., 2021). Studies designed with a health equity lens will be critical to evaluate the availability, accessibility, and uptake of telehealth services and identify who is benefitting (and who is not). Policies can also support the equitable implementation of telehealth by mandating payment parity, expanding insurance coverage for at-home monitoring, increasing access to broadband internet, and increasing funds for telehealth research (Presidential Task Force on Telehealth, 2020; Society for Maternal-Fetal Medicine, 2023; Ukoha et al., 2021). Although the idea of returning to a pre-COVID-19 era might seem appealing, it is crucial to recognize that the pandemic transformed telehealth. The adaptations and flexibilities that were introduced during the COVID-19 crisis need to be permanently implemented. If this transition takes place, it is undeniable that telehealth will become a lasting fixture in health care.

Biography

Summer Sherburne Hawkins, PhD, MS, is an associate professor, School of Social Work, Boston College, Chestnut Hill, MA.