Abstract
BACKGROUND:
The COVID-19 pandemic greatly impeded the provision of public healthcare within a healthcare system that was already under considerable strain. Routine patient care services were impacted during that time, leading to the promotion of telemedicine as a means of maintaining uninterrupted healthcare services. Telemedicine involves the utilization of electronic technology and communication to provide health-related information and medical care to individuals who are physically separated from healthcare professionals.
MATERIALS AND METHODS:
To assess the feasibility of utilizing telemedicine for providing women's health services, we conducted a six-month analysis of data collected from the Department of Obstetrics and Gynecology's teleconsultation application at AIIMS, Mangalagiri. Our objective was to evaluate the practicality of telemedicine in delivering diverse healthcare services to women. Our institution offered two types of telehealth services: a “call-based”approach and an “app-based” approach. We examined several parameters within the data, including the distribution of ages, the geographic locations of teleconsultation registrations, whether the registrations were new or follow-up cases, the various presenting complaints, the recommended treatments, the number of consultations (single or multiple), and whether cases required in-person or hospital visits. Additionally, we also compared patient responses between these two modalities.
RESULTS:
The “call-based” consultation method was preferred by the majority of our patients (94%). The registered cases included both related to obstetrics and gynecology, with a higher proportion of complaints relating to gynecological issues (82.5%). We were able to make a diagnosis in 77% of cases, while in 20% of cases, additional physical examinations and diagnostic tests were necessary. Follow-up appointments were recommended for 53% of patients. The success rate of consultations for patients seeking obstetrics and gynecology services showed a statistically significant difference (P value < 0.001). The vast majority of patients (99%) expressed high satisfaction with the consultation process.
CONCLUSION:
During the COVID-19 pandemic, telemedicine proved to be an effective approach in mitigating the overcrowding of hospitals and preventing the spread of infection. Its success suggests that telemedicine can be a viable option for managing elective gynecology matters and low-risk obstetric cases in the future, thereby alleviating the strain on healthcare systems.
Keywords: COVID-19, Gynecology, Obstetrics, Pandemic, Telemedicine
Introduction
The delivery of public healthcare in an already overburdened healthcare system in India wassignificantly hampered by the COVID-19 pandemic. On March 11, 2020, WHO declared COVID 19 as a pandemic.[1] Since then, there havebeen significant changes in the standard of patient care, and to restrict the spread of illness, numerous hospitals had to stop providing routine outpatient services. Due to the risk of acquiring COVID-19 infection, even patients were reluctant to visit hospitals. Hence, out of necessity, telemedicine was promoted as a method of continuity of healthcare services and to contain the spread of infection.[2] Telemedicine refers to the use of electronic information and communication technology to deliver health or medical information when the healthcare worker and patient are parted by physical distance.[3] The benefits of telemedicine are reducing physical visits to the hospital for minor conditions, easier access forconsulting a specialistespecially for people residing in remote locations or in environment with limited resources, and reduction in healthcare costs. The drawbacks are the lack of physical assessment of the patient and the challenges associated with computerized prescription of investigations and drugs.[4,5] In developed nations worldwide, various telehealth services are widely implemented even before the onset of COVID-19 pandemic. The application of telehealth services remained at its infancy in the discipline of obstetrics and gynecology. The first usage of telemedicine in obstetrics for fetal assessment was described in 1979 by Boehm and Haire.[6] There are several practical benefits for it, like providing preconception counseling, obstetric and postpartum care, wellness programs, addressing fertility issues, and access to contraception. The counseling and support offered to women through telemedicine will be very beneficial in ensuring that they receive timely intervention for a variety of ailments during this pandemic because they are a vulnerable segment of society. The disruption of routine delivery of sexual and reproductive health (SRH) services, such as obstetric care, safe abortion services, contraception, prevention and treatment of HIV/AIDS, and other sexually transmitted diseases, is one of the known effects of delayed access to healthcare due to lockdown and pandemic situation on women.[3] The rise in domestic violence and sexual abuse are other issues that demand attention.[7] The Government of India and the National Medical Commission of India released new standards for the use of telemedicine during this pandemic, which was a blessing for our patients at that time.[3] Since then, other hospitals and clinics around the nation have expanded their use of telemedicine services. To avoid the transmission of infection by minimizing face-to-face encounters, the integration of telemedicine into regular practice became anecessity. Our hospital's telemedicine program, which began on April 15, 2020, came to our aid, allowing us to provide care for a significant number of women and children who needed it during this pandemic. As part of this study, we chose to examine the data from our teleconsultation application at the Department of Obstetrics and Gynecology during a period of six months to determine whether telemedicine services are practical for delivering different women's health services.
There is a lack of data regarding the utilization of telemedicine as a tool in care of women with obstetric and gynecologic healthcare needs during the COVID-19 pandemic. This study was undertaken with an objective to describe the spectrum of diseases requiring teleconsultation services in the Department of Obstetrics and Gynecology and their outcomes.
Materials and Methods
Study design and setting
This was a prospective observational study conducted in the Department of Obstetrics and Gynecology at All India Institute of Medical Sciences, Mangalagiri, located in the state of Andhra Pradesh in India after obtaining Institute Ethics Committee approval. Our objective was to evaluate the practicality of telemedicine in delivering diverse healthcare services to women during the COVID-19 pandemic.
Study participants and sampling
Database for the telehealth services provided by the Department of Obstetrics and Gynecology over a period of 6 months was accessed and analyzed to assess the feasibility of utilizing telemedicine for providing women's health services. All case records with complete data were included, and those withincomplete data were excluded. Consecutive convenience sampling of all case records of teleconsultation services over the past 6 months at obstetrics and gynecology department fulfilling the inclusion criteria was performed.
Our institution offered two types of telehealth services: a “call-based”approach and an “app-based”approach. Teleconsultation services were provided free-of-cost to all patients in both modalities.
In the “call-based” approach, interested patients were asked to call a telephone number designated for teleconsultation with obstetrics and gynecology department. Basic details such as name, age, address, phone number, and chief complaints would be noted during registration. A consultantwould then call back the registered patients through video/audio/normal call as per the requirement. After consultation, the doctor's prescription was scanned and sent through WhatsApp to the patient's mobile phone. In case of the xnon-availability of WhatsApp facility with the patient, a text message prescription was sent.
In the “app-based” approach, a novel app (AIIMS Mangalagiri e-Paramarsh) developed by Centre for Development of Advanced Computing (CDAC) had to be downloaded for consultation from the Google Play Store by the patients. Patients would then raise a consultation request through the app after entering basic details and selecting the department of choice (obstetrics and gynecology). A column to enter the chief complaints was also provided. Consultants would then log in with Doctor's Login ID of our institute, accept the registration request raised by the patient, and then call back through the app. The app also had an inbuilt voice/video calling and document-sharing facility. By entering the details on the prescription page, e-Prescription would be generated. The prescription was sent to the patient for download through the same app.
Data collection tool and technique
Database for the telehealth services provided by the Department of Obstetrics and Gynecology by the two telehealth modalities (“call-based” and “app-based” approach) over a period of 6 months was accessed and analyzed. The various parameters collected during the study were entered in a study proforma and then transferred to Excel Datasheet. Data were analyzed for various parameters such as the age distribution, locality from where teleconsultation registrations were made, whether new or follow-up registration, various presenting complaints, treatment advised, whether single or multiple consultation, and cases called for face-to-face consultation or hospital visit. The patient satisfaction ratings to these two modalities were also compared.
Statistical analysis
Data analysis was done using SPSS Version 23. The categorical variables were summarized as frequency and percentage. The continuous variables were summarized as mean and standard deviation. The association between continuous and categorical variables was assessed using an independent t-test and analysis of variance (ANOVA).P value of less than 0.05 was considered statistically significant.
Ethical consideration
The Institute Ethical Committee approval was taken (AIIMS/MG//IEC/2020-21/74). This was a hospital record-based study, and for the sake of confidentiality, we did not collect any patient identifying information from the records.
Results
A total of 676 participants with complete data were included for final analysis out of the 765 telemedicine registrations[Figure 1]. The majority of the study participants were in 21–45 years age group (78.4), and around 83% were from rural locations[Figures 2 and 3]. Around 7% of participants had connectivity issue during the teleconsultation. The majority of the teleconsultation were through telecall-based (94%). Around 70% consultations were new registrations, and majority of them were elective consultation (98%). Among all consultations, 82.5% were gynecological and 17% were for antenatal ailments[Figure 4]. In 77% of consultations, we were able to make the diagnosis, and in around 15% of consultations, physical examinations were needed. More than 50% consultations were closed with electronic prescription, and for 16% of participants, diagnostic tests were suggested. Around 6% were referred to the hospital on an urgent basis, and 13% were referred to hospital electively. More than 90% of participants were very satisfied with the consultation, and none of the participants were dissatisfied [Tables 1-4].
Figure 1.
Flowchart of teleconsultation cases included for analysis
Figure 2.
Piechart showing age distribution
Figure 3.
Bardiagram showing distribution of locality
Figure 4.
Bar diagram showing chief complaints
Table 1.
Quality of the network and connectivity
| Items | Sub-group | Frequency (%) |
|---|---|---|
| Whether patients were available when the call back was done or their number was not reachable due to network issue (first call) | Yes | 673 (99.6) |
| No | 3 (0.4) | |
| Connectivity issues encountered when the call back was made | Yes | 48 (7.1) |
| No | 628 (92.9) |
Table 4.
Comparison of outcomes of teleconsultation between obstetrics and gynecology patients
| Items | Sub-group | Obstetrics case n=117 | Gynecology case n=555 | P |
|---|---|---|---|---|
| Type of registration | New | 111 (94.8) | 352 (63.4) | <0.001 |
| Follow-up | 6 (5.2) | 203 (36.6) | ||
| Ability to make diagnosis | Able | 111 (95.7) | 413 (74.6) | <0.001 |
| Unable diagnostic test needed | 2 (1.7) | 39 (6.7) | ||
| Unable physical examination needed | 4 (2.6) | 103 (18.7) | ||
| Outcome of the intervention | Condition resolved | 86 (74.1) | 311 (56.3) | 0.001 |
| Awaits further tests and assessment | 31 (25.9) | 231 (41.5) | ||
| Condition unresolved despite the treatment | 0 (0.0) | 13 (2.2) | ||
| Recommendations | Order a diagnostic test | 19 (16.4) | 93 (16.7) | <0.001 |
| Reassure | 4 (3.4) | 69 (12.3) | ||
| Electronic prescription | 90 (76.7) | 262 (47.3) | ||
| Urgent referral to the hospital | 3 (2.6) | 39 (7.1) | ||
| Elective referral to hospital/specialist | 1 (0.9) | 92 (16.7) | ||
| Patient satisfaction scores | Very satisfied | 104 (89.7) | 507 (91.4) | 0.560 |
| Satisfied | 13 (10.3) | 48 (8.6) |
Table 2.
Basic and clinical characteristics of teleconsultation
| Items | Sub-group | Frequency (%) |
|---|---|---|
| Telehealth opted | Telecall-based method | 638 (94.4) |
| Mobile app-based method | 38 (5.6) | |
| Type of consultation | New registrations | 467 (69.1) |
| Follow-up registrations | 209 (30.9) | |
| Nature of consultation | Elective | 661 (97.8) |
| Urgent | 15 (2.2) | |
| Type of patients | Antenatal cases | 117 (17.3) |
| Gynecology cases | 558 (82.5) | |
| Postnatal cases | 1 (0.1) | |
| Chief complaints | Obstetric ailments | 117 (17.3) |
| WDPV, PID | 47 (7.0) | |
| Abnormal uterine bleeding | 168 (24.9) | |
| Urinary complaints | 39 (5.8) | |
| Infertility | 30 (4.4) | |
| Oncology | 1 (0.1) | |
| Post-menopausal | 5 (0.7) | |
| Review of reports | 219 (32.4) | |
| Adnexal mass | 5 (0.7) | |
| Contraception | 2 (0.3) | |
| Medical disorder/issues | 11 (1.6) | |
| Breast-related issues | 8 (1.2) | |
| General enquiries/advice | 14 (2.1) | |
| Others | 5 (0.7) |
WDPV=White discharge per vaginum, PID=Pelvic inflammatory diseases
Table 3.
Outcome characteristics of the telemedicine consultation
| Items | Sub-group | Frequency (%) |
|---|---|---|
| Ability to make diagnosis | Able to make diagnosis | 523 (77.4) |
| Unable to diagnostic and needed investigations | 39 (5.8) | |
| Unable to diagnostic and needed physical examination needed | 106 (15.7) | |
| Recommendations | Order a diagnostic test | 111 (16.4) |
| Reassurance | 72 (10.7) | |
| Electronic prescription | 350 (51.8) | |
| Urgent referral to the hospital | 42 (6.2) | |
| Elective referral to hospital/specialist | 93 (13.8) | |
| Outcome of the intervention | Condition resolved | 397 (58.7) |
| Awaits further tests and assessment | 259 (38.3) | |
| Condition unresolved despite the treatment | 12 (1.8) | |
| Follow-up advised | Yes | 355 (52.5) |
| No | 313 (46.3) | |
| Referral (out hospital/outside) | Our hospital | 34 (5.0) |
| Outside hospital | 8 (1.2) | |
| Not referred | 634 (93.8) | |
| Patient satisfaction scores | Very satisfied | 616 (91.1) |
| Satisfied | 60 (8.9) | |
| Not satisfied | 0 (0) |
Type of registration: 95% of obstetric and 63% of gynecology consultations were new, and the differences in type of registration between obstetric and gynecology consultations were statistically significant (P value ≤ 0.001).
Ability to make diagnosis: We were able to make a clinical diagnosis in 96% and 75% of obstetricand gynecology consultations, respectively, and the difference in the ability to make the diagnosiswasstatistically significant[Figure 5].
Recommendations: In 77% of obstetrics and 47% of gynecology patients, weprescribed medication via electronic prescription. In 16% of obstetric and 16% gynecology patients, we ordered a diagnostic test. 3% of obstetrics cases and 7% of gynecology cases were referred urgently to hospital. Final treatment recommendations for patients were statistically different between the obstetrics and gynecology patients (P value ≤ 0.001)[Table 4].
Outcome of the intervention: Condition was resolved in 75% of obstetric and 57% of gynecology cases, 26% of obstetric and 42% of gynecology cases awaited further testing, and in 2% of gynecology cases, the condition was unresolved despite the treatment. The difference in the outcome of intervention between obstetric and gynecology cases was statistically significant [Table 4].
Patient satisfaction scores: Most of the patients were very much satisfied with the consultation in both groups. There was no significant difference in patient satisfaction among the obstetrics and gynecology consultations[Table 4].
Figure 5.
Bar diagram showing ability to make diagnosis
Discussion
Telemedicine is an excellent innovation for achieving social distancing, which was one of the preventive measures for containing spread of infection during the COVID-19 pandemic.[2,3] Majority of the study participants were in 21–45 years age group (78.4%), and our study results were consistent with a similar study,[8] which showed that the majority of people who availed telemedicine service were in the age group of 21 to 40 years (70%). This could be probably because the younger age group is more likely to own electronic communication devices and have access to technology. 83% of teleconsultation registrations were from rural locations in our study. This was in contrast with other studies,[8,9] which reported that the majority of the participants who utilized the telemedicine services resided in urban areaswhich reflected the increased use of smartphones and faster net connectivity in urban areas. This discrepancy might be explained by the fact that the majority of our study participantsusedtelecall-based method that did not require a smartphone or an Internet connection, and with the telecall-based technique of approach, only 7% of participants had connectivity issues. Thus, our study results revealed that people from rural locations who have limited access to specialist facilities benefited more from telemedicine services as a result of government-imposed travel restrictions during the pandemic. Whittington et al.[10] in a review article summarized that telemedicine may be helpful for routine maternity care in regions with low resources and the use of remote patient monitoring may be broadened to minimize the transportation and economic stress on pregnant females and improve their satisfaction by reducing the frequency of physical consultations. The majority of consultations in our study was made by newly registered patients and were for elective cases. There were only few emergency cases who utilized teleconsultation services because healthcare facilities continueddealing with emergencies. Among the elective cases, the majority of the consultations were for elective gynecological cases. These results were consistent with a study done by Karwowski et al.[11] which revealed that 76% of obstetrics and gynecology telemedicine consultations were gynecological. Among gynecological cases, the most common complaint reported wasmenstrual abnormalities, followed byinfectious and infertility issues which is consistent with their prevalence in our community. Obstetric consultations comprised 17.3% of all analyzed teleconsultations, which is consistent with the results of Jhirwal et al.[12] and was mainly due to patients'anxiety about the smooth progression of pregnancy. Some patients merely required affirmation that the trajectory of their pregnancy was healthy. In our study, telemedicine services were found to be effective because we were able to make a diagnosis and resolve conditions in 77% and 59% of the cases, respectively. The results were similar to the study done by Moyo et al.[9] in which the telehealth consultants were ableto make a diagnosis and the conditions resolved in 49.3% and 52.2% of the cases, respectively. Follow-up was advised in 53%, whereas 47% participants required only one-time consultation. Study done by Shanbehzadeh et al.[13] reported that the healthcare system was able to effectively contain the contagious disease during the global outbreak because of vigorous and stable patient participation through powerful, beneficial, and inexpensive telemedicine services. Satisfaction levels ranged from satisfied to very satisfied in 99% of patients who attended our telehealth services, and the results were consistent with other similar studies.[9,13] The high levels of patient satisfaction wereattributed to the availability of free specialist consultations in the comfort of their own homes.
Limitations
The major limitation of teleconsultation was the lack of physical examination of the patients which may be necessary for the diagnosis of few conditions including malignancies.[4] However, despite the lack of examination we were able to arrive at a diagnosis in 77% of the cases by taking a thorough history which signifies the importance of history taking in obstetrics and gynecology.[5] Due to its novelty, the implementation of telemedicine during the COVID-19 pandemic necessitated specialized training for all healthcare professionals to ensure its optimal utilization for patient care.[14]
Conclusion
The majority of teleconsultations focused on gynecological concerns, and the satisfaction level among patients was overwhelmingly high, with no instances of dissatisfaction reported. Telemedicine emerged as an effective solution during the COVID-19 pandemic, effectively mitigating overcrowding in hospitals, and curbing the spread of infections. Moreover, telemedicine has the potential to extend its utility beyond the pandemic, particularly in managing elective gynecology cases and low-risk obstetric situations, thereby alleviating the burden on healthcare systems.
Contribution
VS, DY was involved in data collection and drafting the manuscript, VS, TAB, MT and VKK were involved in conception, literature search, analysis of data and drafting the manuscript.
Ethics committee approval
Approved. ETHICS CLEARANCE CERTIFICATE NO: AIIMS/MG/IEC/2O2O-21/74. The authors certify that the study was conducted in accordance with the ethical principles that have their origin in the Declaration of Helsinki.
Financial support and sponsorship
Nil
Conflicts of interest
There are no conflicts of interest.
Acknowledgement
We would like to thank the entire team of faculty, residents, and healthcare staff of the Department of Obstetrics and Gynecology who provided the teleconsultation services during the COVID-19 pandemic. We would like to thank the entire administration at AIIMS Mangalagiri for permitting us to use the hospital data and records for this study.
References
- 1.World Health Organization Coronavirus disease (COVID-19) pandemic. https://www.who.int/emergencies/diseases/novel-coronavirus-2019 [Google Scholar]
- 2.Sharmila V, ArunBabu T, Balakrishnan P.Optimizing telemedicine for providing obstetric and reproductive health care services during COVID-19 pandemic Int J Community Med Public Health 202073278–83 [Google Scholar]
- 3.Ministry of Health and Family Welfare Govt. of India. https://www.mohfw.gov.in/. Accessed 5 May 2020. https://www.mohfw.gov.in/pdf/Telemedicine.pdf [Google Scholar]
- 4.Sharmila V, Babu TA.Challenges in the diagnosis and treatment of gynecological cancers during the COVID-19 pandemic Cancer Res Stat Treat 20203611–2. doi: 10.4103/CRST.CRST_273_20 [Google Scholar]
- 5.Babu TA, Sharmila V.COVID-19 pandemic: Another nail in the coffin of the “dying art” of the physical examination Cancer Res Stat Treat 20203611–2 [Google Scholar]
- 6.Boehm FH, Haire MF.Xerox telecopier transmission of fetal monitor tracings: A 4-year experience Obstet Gynecol 197953520–3 [PubMed] [Google Scholar]
- 7.Sharmila V, ArunBabu T.The hidden impact of COVID-19 on sexual and reproductive health and rights of women in India Current Women health reviews 202117290–7 [Google Scholar]
- 8.Priyadarshani P, Purwar R, Pipal VR, Mall RP.Patient satisfaction with telemedicine services in obstetrics and gynecology during the COVID-19 pandemic J South Asian FederObstGynae 202113382–6 [Google Scholar]
- 9.Moyo J, Madziyire G.Use of telemedicine in obstetrics and gynaecology in Zimbabwe during a lockdown period Pan Afr Med J 202035(Suppl 2):89. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Whittington JR, Ramseyer AM, Taylor CB.Telemedicine in Low-Risk Obstetrics Obstet Gynecol Clin North Am 202047241–47 [DOI] [PubMed] [Google Scholar]
- 11.Karwowski R, Gasiorowska J.Telemedicine consultations in obstetrics and gynecology-A population based study in Polishspeaking women Ginekol Pol 201889677–81 [DOI] [PubMed] [Google Scholar]
- 12.Jhirwal M, Singh P, Sharma C, Kathuria P, Shekhar S, Meena SP.Awareness and understanding of COVID-19 among pregnant woman in Northern India J Educ Health Promot 202211191. doi: 10.4103/jehp.jehp_980_21 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Shanbehzadeh M, Kazemi-Arpanahi H, Kalkhajeh SG, Basati G. Systematic review on telemedicine platforms in lockdown periods: Lessons learned from the COVID-19 pandemic. J Educ Health Promot. 2021;10:211. doi: 10.4103/jehp.jehp_1419_20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Pasi R, Babu TA, Kalidoss VK. Development and validation of structured training module for healthcare workers involved in managing pediatric patients during COVID-19 pandemic using “Objective Structured Clinical Examination” (OSCE) J Educ Health Promot. 2023;12:15. doi: 10.4103/jehp.jehp_578_22. [DOI] [PMC free article] [PubMed] [Google Scholar]