Mothers prefer a hybrid model of postpartum care: a pilot mixed method study

Abstract

Background

Telehealth, including video consultation (VC), has become prevalent during the COVID-19 pandemic. However, the experience and concern of women using VC for postpartum care has yet to be adequately studied but is crucial for their adoption. The study aimed to assess the experience and attitude of postpartum mothers (PPM) towards using VC as a novel model of care delivery and the factors that could potentially affect their adoption.

Method

Data were gathered from PPM participating in VC using Zoom platform for postpartum care using mixed method. In-depth interviews (IDI) of twenty-five PPM were audio-recorded, transcribed verbatim and audited for accuracy. Thematic analysis was conducted to identify themes relating to perceived threat, usefulness, ease of use, and attitudes toward using VC in postpartum care. The themes are reported based on the “Health Information Technology Acceptance Model” framework. Preliminary quantitative data on the acceptability of VC were collected using structured surveys.

Results

PPMs valued convenience, accessibility, and personalised care VC offered to address their immediate postpartum concerns. They perceived VC as suitable for seeking medical opinions, improving confidence in parent crafting, and providing better care access. They recognised the lack of physical examination as a major limitation in VC and proposed a hybrid postpartum care model, combining VC and in-person consultation to cater to individual needs and preferences. PPMs alluded to trust in the care providers, flexibility in VC appointment timings and enhanced interface of remote platforms as enablers for VC adoption. Preliminary quantitative data shows that PPMs found VC saved time (100%), energy (98%), and money (90%) and was appropriate (94%), easy to use (96%), acceptable (96%) for postpartum care.

Conclusion

PPMs favoured combining VC and in-person consultation to mitigate their concerns and personalise their care needs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-024-06963-5.

Introduction

Mothers face numerous challenges in the early postpartum period, such as physical recovery, hormonal changes, sleep disruption, infant care, and altered relationships [1]. The ACOG recommends comprehensive postpartum care, including assessments of physical, social, and psychological well-being, infant care, sexuality, contraception, and health maintenance [2]. Continuous, personalized care is essential for the well-being of mothers and infants. The WHO also recommends at least three postnatal care visits after discharge of a postpartum mother (PPM) [3]. However, fulfilling these visits can be difficult due to the many commitments during this postnatal period, such as childcaring, physical recovery and social obligations. Additionally, limited access and availability hinder the provision of these services according to recommendations [4].

Telehealth refers to the systematic provision of healthcare services over physically separate environments via Information and Communications Technology [5]. The Covid-19 pandemic has transformed the provision of medical services, with telehealth applications in various fields of medical practice, including its replacement for physical consultations [6]. The known advantages include ease of use, convenience and increased accessibility [7, 8]. Research has shown that this mode of care delivery has been widely accepted and comparable to conventional physical consultations [9]. In the area of postpartum care, telehealth has been extended to postnatal depression monitoring and contraception counseling with favorable results [10, 11].

In Singapore, a highly developed urban island-state, over 33,000 multi-ethnic Asian women require postpartum care annually [12]. The current postpartum care model is a single face-to-face visit with the obstetrician or primary care physician (PCP) between 6 and 8 weeks after birth of the newborn. There is growing emphasis on returning to primary care after childbirth, particularly for uncomplicated delivery [13]. PCPs are easily accessible within the community, often offering same-day consultations [14]. They are well-trained to deliver comprehensive postpartum care. Ong et al. revealed the desire of local PPMs to contact a healthcare provider for professional support during the early postpartum period [15]. PCPs can provide this form of support. PCPs had highlighted inadequate contact time to address a multitude of issues within a single visit [16, 17]. Concurrently, PPMs reported lower satisfaction with rushed medical consultations and were less likely to bring up postpartum issues [18, 19]. Such barriers result in poor quality of postpartum care with fewer crucial matters being sufficiently addressed.

Nevertheless, local PCPs had alluded that PPMs could be cared for in the primary care setting, given the multiple opportunities for interaction with the PPM at both well-baby checks and neonatal jaundice follow-ups [16]. Poon et al. informed that PCPs were receptive to offering telehealth to complement routine postpartum care to improve comprehensive consultation for women during this critical period [20]. Furthermore, a retrospective study on telehealth implementation reported a 90% increase in attending a postpartum visit in the post-implementation group compared to the pre-implementation group [21].

Telehealth, including video consultations (VC), uses audio and video technology for healthcare delivery. A review of 25 studies on VC identified factors influencing its use, such as technology concerns, service changes, ease of use, benefits awareness, access, cost, and privacy [22]. However, postpartum care studies were excluded in this review. Poon et al. noted similar concerns among PCPs, who currently use VC for stable long-term conditions and acute respiratory infections [16]. Understanding local Asian postpartum mothers’ perspectives is crucial for successful VC application in postpartum care [23]. This study aims to assess their attitudes and factors affecting VC adoption, as part of a pilot to evaluate VC’s feasibility as a model of postpartum care delivery in the community and primary care setting.

Methods

Study design

A mixed-methods approach evaluated the PPMs’ experiences and attitudes toward using video consultations as a virtual consultation modality. In-depth interviews (IDI) were conducted on PPM after the VC to collect qualitative data on their experiences with the VC model of care. Preliminary quantitative data on the acceptability of VC were collected using structured questionnaires. A mixed method approach was used to triangulate the findings of the qualitative data with the quantitative data.

Theoretical framework

The Health Information Technology Acceptability Model (HITAM) guides qualitative data analysis in this study. HITAM, a conceptual framework, assesses factors influencing the acceptance of health information technology (HIT) by stakeholders. It extends existing behavioural models to explain why individuals accept or resist HIT solutions. The model identifies behavioural, normative, and efficacy beliefs as precursors to perceived threat, usefulness, and ease of use, leading to behavioural intentions [24]. HITAM has been used in telecare adoption for older patients with multimorbidity and to explore primary care physicians’ views on telecare for postpartum care [20, 25].

Study site

The study was conducted at two public primary care clinics in Bukit Merah and Sengkang estates, located in southern and eastern Singapore, respectively. Bukit Merah, a mature estate, and Sengkang, home to many young families, allowed for the recruitment of mothers of varied ages and parity. These clinics offer comprehensive primary care, including antenatal, postnatal, and lactation counselling. At the time of the study, clinic visits were the only mode of usual care delivery offered to the mothers.

Study period

The study was conducted from December 2021 to December 2022.

Study population

The study included PPMs aged 21 years and above in their immediate postpartum period (within four weeks postpartum), able to communicate in English, give consent and access VC via Zoom. PPMs not registered at the clinic before the first VC were excluded.

Study procedure

Recruitment and consent taking procedure

Eligible PPMs were recruited from December 2021 to August 2022. Research team members (ASM and ZP) at the study sites informed PCPs and nurses about the eligibility criteria. During neonatal jaundice follow-ups, PCPs and nurses identified suitable PPMs and referred them to the clinical research coordinators to assess eligibility and gauge interest. Interested PPMs were approached face-to-face by clinical research coordinators, and informed written consent was obtained before VC.

Postpartum consults

PPMs who consented were invited to postpartum consults, with partners or relatives allowed to join. They received instructions and links to pre- and post-consult questionnaires. Pre-consult questionnaires were completed before each consult. Two VCs with the PCP were scheduled: the first within four weeks, visit 1 (VC1), and the second within eight to twelve weeks, visit 2 (VC2), post-birth. PPMs with breastfeeding issues could choose lactation nurse counseling via VC or in-person. PCPs could switch VCs to in-person consults if needed, after the initial VC consult. Post-consult questionnaires were completed within a week after each consult. An independent researcher conducted IDIs via audio phone, and PPMs received an SGD20 (~ USD15) grocery voucher for their participation.

Data collection and interview

Each PPM was assigned a unique ID for confidentiality. Pre- and post-consult questionnaire data were collected via FormSG^®, a secure online platform. Additional services provided to the PPMs (mental health counselling, lactation counselling) were recorded manually and uploaded to RedCap^® for analysis [26].

The pre-consult questionnaire gathered sociodemographic data (maternal age, ethnicity, marital status, education, housing, financial status, child’s birth date, and parity), while the post-consult questionnaire used the Patient Attitude Towards Video Consult (PAT-VC) to assess perspectives and satisfaction with VC [27–29]. With permission, the PAT-VC questionnaire was adapted from Barson et al., as the setting was changed from the original questionnaire by replacing “hospital” with “a primary care clinic or GP”. The questionnaire consists of sixteen items ranked on a 5-point Likert scale (‘totally disagree’ to ‘totally agree’) to assess the participants’ perceived usefulness, benefits, confidentiality, efficiency and satisfaction with VC [29]. Subsequently, the responses were categorized into three groups (1) Strongly agree and agree, (2) Neutral, (3) Strongly disagree and disagree.

The IDI used a semi-structured topic guide developed from literature and team discussions, focusing on PPMs’ experiences, usability, utility, and intention to use VC (Supplementary file 1). The topic guide was pilot-tested and refined after the initial two IDIs. IDIs, lasting 25 to 45 min, were audio-recorded, stored on encrypted devices, and securely transferred to professional transcribers.

Data analysis

Audio-recorded qualitative data were transcribed verbatim and thematically analyzed. Two investigators (ASM, ZP) independently coded the initial transcripts under the HITAM framework. Subsequent transcripts were coded by ASM and YY using NVivo© software. The investigators regularly discussed and resolved any coding disagreements. The research team then reviewed and refined the codes to identify patterns. Analysis was concurrent with data collection, achieving data saturation when no new codes emerged, and sufficient data had been gathered to address the acceptance of VC among PPMs [30]. It was determined that collecting additional information would not provide further insights into their acceptance of VC.

The preliminary quantitative data analyses were performed using Python 3.9 with pandas library, R 3.5.2 and RStudio, IBM Statistical Package for Social Sciences (SPSS) version 26. Data were presented as frequencies and percentages for categorical variables. Continuous variables of age and number of children were dichotomized for statistical analyses.

Results

Participants

Out of 56 PPMs approached, 30 consented to participate (53.6% response rate). Those who declined cited time constraints, lack of interest, or other commitments. Five PPMs were lost to follow-up: two after consenting and three after the first VC. Two PPMs had their husband or mother join the VC. All PPMs completed the pre-consult questionnaires, and 25 completed both post-consult questionnaires and IDIs. None were accompanied during the IDIs.

Participant characteristics

The sociodemographic data for the 30 PPMs are detailed in Table 1. Most were aged 30–34 years (50%), Chinese (70%), and had a university or post-tertiary education (86.7%). Nearly all (96.7%) did not receive medical subsidies and lived in HDB (Housing and Development Board or Singapore’s public housing) 4 to 5 room flats (66.7%), indicating higher socioeconomic status. About half (56.7%) had normal vaginal births, and around two-thirds (63.3%) were first-time mothers. Mixed feeding (breastfeeding and formula) was practiced by 83.4%, with 60% experiencing breastfeeding difficulties.

Table 1.

Demographic of postpartum mothers

Characteristics	n (%)
Total	30 (100)
Age
20–24	1 (3.3)
25–29	5 (16.7)
30–34	15 (50)
35–39	9 (30)
Ethnicity
Chinese	21 (70)
Malay	1 (3.3)
Indian	5 (16.7)
Others	3 (10)
Highest Qualifications
Secondary	1 (3.3)
A-level/ Diploma (ITE/ Polytechnic/ Private school)	3 (10)
University/ Post-tertiary	26 (86.7)
Housing Type
Rental room/ apartment	3 (10)
HDB* 1–3 room flat	5 (16.7)
HDB* 4–5 room flat	20 (66.7)
Maisonette/ Executive Condominium	2 (6.6)
Medical subsidy
Yes	1 (3.3)
No	29 (96.7)
Type of birth
Assisted birth	2 (6.6)
Caesarian section	11 (36.7)
Normal vaginal birth	17 (56.7)
Number of children
1	19 (63.3)
2	10 (33.3)
3 or more	1 (3.4)
Current child feed
Breastfeeding only	4 (13.3)
Formulae feed only	1 (3.3)
Mixed feed (breastfeeding and formulae feeds)	25 (83.4)
Breastfeeding difficulty
No	12 (40)
Yes	18 (60)

*HDB = Housing and Development Board (Singapore’s public housing which is managed by the Housing and Development Board)

Additional services provided to the postpartum mothers

Five PPMs (17%) received mental health counselling; 2/5 (40%) preferred a face-to-face counselling and rest (3/5, 60%) were managed via VC. A total of 19 PPMs were referred for lactation counselling; almost two-thirds (12/19, 64%) of PPMs preferred lactation counselling via VC instead of a hands-on lactation service (Table 2).

Table 2.

Comparison of additional services provided to mother based on their parity (n = 30)

Services provided (n, %)	Parity (n, %)
	Primiparous (n = 19)	Multiparous (n = 11)
Mental health counselling (5, 17%)
• Face-to-face consultation	0	2 (40%)
• Video consultation	3 (60%)	0
Lactation services (19, 63%)
• Face-to-face consultation	4 (21%)	1 (5%)
• Video consultation	1 (5%)	13 (68%)

Postpartum mothers’ attitude towards the use of video consultation

Findings from in-depth interviews: Four main themes, according to HITAM framework were identified: perceived threat, perceived usefulness, perceived ease-of-use, and attitude and behavioural intention [24]. A summary of the themes and subthemes are listed in Table 3.

Table 3.

Mothers’ experience of using video consult for their postpartum care

Themes	Subthemes
Perceived threat	• Coping with postpartum care • VC preferred for non-serious and non-urgent issues
Perceived Usefulness	• VC compared with a face-to-face consultation • Team-based service in VC • Prior personalised or related experience in VC adoption • Concern over communication • Perception about data security over VC
Perceived Ease-of-Use	• VC technology self-efficacy and familiarity • Privacy concerns limits usability
Attitude & Behavioural Intention	• Trust in public sector service providers • Prior established rapport supports VC • Valuing personalised and comprehensive care over VC • Preference for a hybrid model of care delivery • Moving forward: Improving intent to use

VC: video consultation

Perceived threat

Coping with postpartum care

Many PPM acknowledged the need for assistance during the postpartum period. The level of assistance required varied based on factors like prior experience and social support. PPMs appreciated that VC offered a reliable platform to address their concerns and provided essential support during this critical time, particularly for those without other support networks.

“Other moms might not have other source of information. Might not have parents or might have other people to help them with all these things., Medical team will be helpful for her through her journey. Because for me, my parents are not (in) Singapore. And I don’t have much experience with baby as well as my husband. We are really thankful for Doctor and the rest of the team because they were able help us with the issues that we’ve faced on for the past few weeks that we have our baby”, 28-year-old, 2 children.

VC preferred for non-serious and non-urgent issues

PPMs found VC useful for addressing non-urgent concerns and managing less serious medical conditions. However, they preferred in-person consultations for urgent issues like severe pain, heavy postpartum bleeding, and blocked ducts to avoid harm to themselves or their child.

“If you need, if you have like blocked ducts, or whatever. Or if you are still bleeding heavily, of course these require the mother should go down personally, ”, 33-year-old, 2 children.

Perceived usefulness

VC compared with a face-to-face consultation

All PPMs acknowledged the advantages of VC over face-to-face consultations, appreciating its convenience and accessibility. This model allowed busy PPMs to manage postpartum care at home, despite their many commitments. Most PPMs expressed “no difference in interacting with their doctors compared to meeting in person”.

“I was able to talk to the lactation consultant as well as Doctor post-delivery. And I feel it’s very convenient firstly because I can do it at my own home. I don’t have to spend time, spend money, to actually travel. At the same time, I can be comfortable with my own space.”, 28-years-old, 2 children.

However, many PPMs felt VC was inadequate for concerns needing physical interaction, like wound examinations or hands-on breastfeeding support.

“The video consult won’t be useful if I want the doctor to straightaway have a check on my wound ”, 39-years-old, 4 children.

Team-based service over VC

PPMs appreciated the team-based care provided via VC. However, one PPM felt it might be resource-intensive to offer team-based services to all and stressed the need for individualized care. Some PPMs preferred combining lactation and doctor consultations for prompt and optimal support. One PPM suggested adding a mental health counselor to address potential mental health issues.

“ I will think that it (doctor and nurse consultation) is better to be offered together. Like I have a concern at that point in time and I do the video consult (with doctor), then the lactation consultation is available for me to straightaway ask questions, or show if the latching is correct.”, 39-years-old, 4 children.

“It will be good if there is some psychologist around also during that video consult.” 37-year-old, 1 child.

Prior personal or related experiences in VC adoption

PPMs cited a previous positive experience in telehealth as a facilitator to receiving postpartum care over VC. Having undergone a similar consult enabled the PPM to see the value of VC for uncomplicated issues.

“I have a previous experience myself for video consult. I will be very open to video consult if it is very straightforward consultation.”, 30-year-old, 1 child.

Other PPMs expressed they were keen for VC after their friends and family communicated positive experiences on telehealth.

“Yes, my friend did have some appointment … she did mention to me is a lot more convenient because she can do it in the office. She don’t have to take leave or time-off. Due to our work, it is difficult to be away. She did mention that it’s so much easier to have the time, just half an hour time, just to go for the video consult. Instead of taking half day leave. Also my family members have had tele-consultation when they are sick. So I think tele-consultation for my friends and family, did have some influence on me.”, 38-year-old, 1 child.

Concern over communication

Some PPMs raised doubts about the reliability of connectivity for VC. They were worried that poor connectivity might interrupt the consulting process, affecting effective communication and prolonging the consult time.

“ I think if I find that, sometimes the connection is too bad, or in terms of technology wise, the consult is actually a waste of time because most of the time you have to repeat yourself, or the doctor have to repeat himself or herself. Which make the consult pretty long and at the end of the day, you don’t benefit from it.”, 36-year-old, 2 children.

Despite such concerns, most PPMs felt they did not experience any issues with connectivity during the consult.

Perception about data security over VC

Possible breaches of privacy and confidentiality that may occur over the online platform made the PPMs uncomfortable. This was particularly due to a potential need for consult for postpartum concerns deemed more intimate, such as lactation services or mental health wellness.

“It depends because there’s a case of privacy and how encrypted the websites are. Or the call is because the last thing you want is for it to be hacked for whatever reason.”, 28-year-old, 1 child.

“…about lactation services, then you are videoing yourself in a more intimate manner. That that could be a thing that people might not be comfortable with. I mean you cannot say this is not a concern, that’s why my lactation service I prefer face to face.” 33-year-old, 1 child.

Perceived ease of use

VC technology self-efficacy and familiarity

All PPMs were confident using the virtual platform for VC. They noted increased digital health use during the COVID-19 pandemic and among younger generations, boosting their confidence. The platform’s user-friendly and intuitive design further enhanced their self-efficacy.

“I am okay with the setup, because I’m quite familiar with Zoom. I use it quite a lot. I already have a camera at home. I have a mic. I already set up on the computer desktop, but even if I use on the phone, it’s also quite easy. I mean it’s very user-friendly and it’s quite straightforward ”, 33-year-old, 2 children.

However, some PPMs noted that older or less tech-savvy individuals might need guidance using the platform. One PPM suggested providing a demo during the initial clinic consult.

“for people who are not tech savvy they need to have guidance on how to do it so the first consult (consultation) done at the clinic. Maybe not the doctor but somebody else that can guide them what to do and what to expect, like give them a demo.”, 36-year-old, 2 children.

Privacy concerns limits usability

PPMs were concerned about privacy during VC, unsure if the consult was private due to limited views of the consulting room. They cited hesitancy to discuss personal issues outside their homes or with family members present

“I think in terms of privacy, let’s say its at home, if our parents are around, then we will try to avoid. Because the conversation probably not suitable. Or even like a video consult requires us to show certain parts of our body, to show that lump here, that pain here. Then it wouldn’t be as comfortable as in person. I may have privacy here, but over the video consultation, even though I’m seeing the doctor just in the screen, I don’t know whether anyone else is standing nearby looking at the screen that I can’t see.”, 38-year-old, 1 child.

Attitude and behavioural intention

Trust in public sector service providers

PPMs trusted their privacy and confidentiality would be maintained if the VC was offered from “reputable” or “government” service providers. This trust in the service provider influenced their acceptability of the VC.

“I trust that, in terms of like clinic wise, because it is a polyclinic. And I trust that there’s a policy that safeguards the privacy of the patient. So I would definitely be more influenced or assured, that this video consult has the policy to safeguard my privacy”, 39-years-old, 4 children.

Prior established rapport

Most PPMs felt it easier to express their concerns over VC if they had established familiarity with the clinician. They believed this would ensure the clinician has prior knowledge of their background, and such a relationship would support care continuity.

“I mean going to the same doctor knowing your background, I think is easier. I think we will feel more comfortable going back to our own doctors or rather like our gynae whoever we are seeing you know, follow ups in the hospital, because at least the doctor will know (you) throughout your pregnancy.”, 28-year-old, 1 child.

Valuing personalised and comprehensive care

PPMs appreciated the comprehensive care provided via VC, which covered various aspects of postpartum care, including wound management, breastfeeding, emotional support, child-rearing skills, and family planning. They felt the care was tailored to their individual needs.

“We talk(ed) about recovery after the caesarean section and how to take care of the baby. She told me like what kind of places out there that I can look for or explore. She gave me advice (on) breastfeeding because I feel a bit confused (because) different kind of advice from different people. She gives me some direction. She also asked my understanding about the contraception after giving birth. So overall I think the things we have discussed about, what is it I need be concerned about after giving birth. (It) is quite comprehensive, ya”, 38-years-old, 1 child.

“I think the consultation is more specific to my need s and because it’s one to one so it’s more comfortable for me to share.”, 30-years-old, 2 children.

Preference for a hybrid model of care delivery

The PPMs felt the comprehensive postpartum care provided via VC was because it was complemented by in-person visits for specific complaints that required physical examination or hands-on demonstration.

“there was a like lactation nurse on the line who was able to answer my question. And on top of that she also promptly asked whether will I be going to the polyclinic, that’s where I met her. It was very helpful when I saw her, then she taught me different positions to hold my baby. So I think it was a quite pleasant experience “, 34-years-old, 1 child.

Moving forward: improving intent to use

Suggestions to enhance VC adoption included providing supplementary information, an online interactive platform, an appointment booking system, and virtual access to allied health services, including mental health counselors.

“It will be even better if there is a whatsapp or SMS function that you can ask quick question instead of having to arrange for a video conference or an interactive platform so the mum can ask the medical professionals any time they face some problems.”, 38-year-old, 1 child.

“It will be good if there’s a booking system then we can go either online or through an app. So the app or the booking system has the care team’s available timing so up to them to select what suits their timings best”, 39-years-old, 4 children.

“…So will be good if there is some psychologist around also during that video consult. So that can help mothers who are suffering”, 34-years-old, 1 child.

Results of the patient attitude towards video consult (PAT-VC) questionnaire

Preliminary data on PPMs’ attitudes towards video-consulting (PAT-VC) are shown in Figs. 1 and 2, and 3. A total of 94% felt VC was appropriate for the appointment, and 96% found it easy to use. Satisfaction with privacy increased from 92% after VC1 to 100% after VC2. The ability of healthcare providers to understand their condition improved from 80 to 92%. PPMs perceived VC saved time (100%), energy (98%), and money (90%). Most PPMs accepted the use of VC, 96% completed both appointments, and all agreed on the ease of VC after VC2, recommending it to friends and family (100%). Additionally, 96% felt postpartum care appointments were suitable for VC. Some PPMs (32%) initially missed face-to-face interaction, but acceptance increased after the second session, with all agreeing they would not miss it.

Fig. 1.

Results of PAT-VC questionnaire after the first video consult visit

Fig. 2.

Results of PAT-VC questionnaire after the second video consult visit

Fig. 3.

Combined results of PAT-VC questionnaire after the first and second video consult

Discussion

The preliminary findings of the quantitative data echoed that of the qualitative findings. PPMs preferred early postpartum care via VC, particularly for advice and managing non-urgent conditions. They preferred services such as mental health and lactation counselling over VC. High satisfaction with VC is likely due to overcoming barriers of in-person visits like rushed consultations, lack of childcare, long clinic waits, and transportation issues [18, 19, 31–34]. PPMs valued the convenience, accessibility, and personalized care VC provided. Similar to this study, Saad et al. reported high satisfaction among Canadian mothers using VCs for postpartum care, highlighting comfort and convenience [34]. Evidence suggests increased VC access can boost postpartum care attendance, detect and manage complications like postpartum depression [21, 35, 36].

PPMs in this study emphasized the need for additional postpartum support, especially for Singaporean mothers with limited professional help. Previous research indicates a need for more information from healthcare providers [15]. Due to the scarcity of trained midwives, many rely on informal support from family, friends, or nannies [37]. Traditional practices like “smoking” or “roasting”, which involve sleeping above a fire or heating element, pose potential risk associated with exposing infants to heat and smoke [15, 37]. Thus, VC offers a reliable and prompt way for PPMs to receive accurate health information and support during confinement at home.

Prior positive encounters in VCs and ease-of-use of the VC platform eased the PPMs to receive postpartum care over VC. In Singapore, the smartphone penetration is high; the current smartphone penetration in 2023 is 95.1% and is expected to increase to 99.4% by 2028 [38]. In addition, over the past few years, private and public healthcare institutes have widely adopted VC [39, 40]. Furthermore, virtual platforms such as Zoom, Google Meet, and Microsoft Teams have been increasingly employed for work and personal use [41–43]. These enablers support and promote increased adoption of healthcare delivery via VC.

While most (96%) PPMs were satisfied with privacy protection during VC, a few PPMs in the study raised concerns over internet access data security and privacy over the VC. Previous studies that used VC for healthcare delivery have recognized these barriers to implementing VC [44]. Singapore government has developed national telehealth guidelines to safeguard patients’ confidentiality and data protection [5]. During the early uptake of VCs in 2018, the Ministry of Health, Singapore, worked closely with the telehealth industry through a telehealth-specific sandbox. The telehealth sandbox sought to co-create process and governance measures to support an effective and efficient regulatory regime and allow the safe growth of telehealth [45]. This reassures patients of privacy and confidentiality over the VC.

Seventy percent of PPMs in the study reported they would not miss face-to-face interactions with their physicians. Nevertheless, like earlier studies, they noted limitations of VC compared to in-person visits, such as the absence of physical exams and urgent interventions [46, 47]. A systematic review suggests alternating between VC and in-person interactions to overcome telehealth barriers [48]. PPMs in the current study proposed a hybrid postpartum care model, combining VC and in-person consultations to meet individual needs. Furuya et al. describe this hybrid model as alternating in-person and telehealth visits, with initial virtual visits for history-taking and counseling, and in-person follow-ups for physical exams [49]. Peahl et al. reengineered prenatal care during the pandemic by using in-person visits only for services that couldn’t be provided remotely and creating flexible, opt-in programs for psychosocial support. This approach reduced in-person visits and was well-received by patients and providers [50]. The program effectively reduced in-person clinic visits and is highly acceptable for patients and providers [50]. Thus, a hybrid model of VC and in-person care could be practical for early postpartum care, but its cost-effectiveness needs further evaluation.

The PPMs proposed an interactive platform for early postpartum care that offers flexible appointment scheduling and online resources. Such educational tools and web-based resources like videos, articles, and interactive tools on topics such as psychoeducation, breastfeeding, infant care, and self-care can enhance PPMs’ mood and confidence [51–54]. Personalized care through these platforms has proven effective for holistic postpartum management [55]. Remote monitoring of health metrics like blood pressure and weight can help manage co-morbid conditions [56]. Overall, such a platform provides convenient access to care and personalized support for early PPMs.

Strengths and limitations

To the best of the authors’ knowledge, this is the first study in an urban setting with easy access to primary healthcare services to explore PPMs’ experiences and attitudes toward VC-based postpartum care. The study’s strength lies in its mixed-method approach with use of the HITAM framework supported by the preliminary data on PAT-VC, which helped understand PPMs’ perceptions and beliefs about VC. The framework identified factors like health status, beliefs, norms, technology reliability, and self-efficacy that influence interactions with health technology, aiding in identifying and addressing concerns or barriers the PPMs may have and tailoring strategies to overcome them (e.g., adopting a hybrid model of postpartum care).

The study included English-speaking PPMs, reflecting Singapore’s high literacy rate (97.1%) and the prevalence of English as the primary language (48.3%) [57]. Most participants had university degrees, aligning with Singapore census data showing 80–90% of mothers aged 25–50 have post-secondary or higher qualifications [57]. However, the high education level of participants limits applicability to those with lower educational or socio-economic status. The underrepresentation of PPMs from lower socioeconomic status groups in the study may be due to several factors, including limited access to technology, lower digital literacy, and potential mistrust of healthcare systems. Future implementation phase will incorporate targeted recruitment strategies to improve the uptake of VC among this group; these will include partnering with community organisations, providing technology support (e.g., lending laptops) and training in the use of virtual platforms. Offering incentives (e.g., lower cost of VC compared to in-person visits) and ensuring culturally sensitive communication will help increase participation from this group. The PAT-VC questionnaire, not yet validated locally, will require future validation studies for broader use.

Conclusion

PPMs favoured VCs to manage their early postpartum concerns and valued the convenience, accessibility and personalized care delivered over the VC. They recognized the lack of physical examination as a significant limitation of using VC and proposed a hybrid postpartum care model, combining VC and in-person consultation to cater to individual needs and preferences. Future studies should evaluate the cost-effectiveness and scalability of such a modality of postpartum care.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Abbreviations

PPM

Postpartum mothers

PCP

Primary care physicians

VC

Video consultation

IDI

In-depth interviews

HITAM

Health Information Technology Acceptance Model

HIT

Health Information Technology

VC1

Visit 1

VC2

Visit 2

PAT-VC

Patient Attitude Toward Video Consult questionnaire

HDB

Housing and development board (public housing by Singapore’s government)

Author contributions

ASM, PZ, NCT conceptualised the study design and facilitated all the interviews and took field notes. LHAK, DLK, YP, YY and SB assisted in data collection. ASM, PZ and YH coded the qualitative data. ASM, ZP and NCT analyzed the data and identified the themes according to the HITAM framework. DXN and EKYL analyzed the quantitative data. ASM and ZP drafted the manuscript. NCT and ASM revised the draft several times before it was finalized. All investigators reviewed and approved the final manuscript before its journal submission.

Funding

The study was supported by NMRC Centre Grant (Cg) Programme (SingHealth Polyclinics): Integrated Platform for Research in Advancing Metabolic Health Outcomes in Women & Children in Asia (I-PRAMHO) Seed Fund (NMRC/CG/C008/2017). The publication cost is supported by SingHealth Polyclinics Centre Grant (CG21APR3006;NMRC/CG3/001/2022-SHP).

Data availability

The data associated with our study will be made available upon reasonable request.

Declarations

Ethics approval and consent to participants

The study was approved by the SingHealth Centralised Institutional Review Board (CIRB 2021/2732). The research was conducted according to International Conference on Harmonisation Guidelines for Good Clinical Practice. All participants signed written informed consent before study activities.

Consent for publication

Not applicable.

Author information

The research team included four female PCP, one male PCP, two female nurses and one female student. The nurses are qualified lactational counselors. ASM and PZ are trained in qualitative and quantitative research. NCT is a trainer and experienced researcher in both qualitative and quantitative research. The PCPs and nurses manage and counsel patients in polyclinics, including mothers, during antenatal and postnatal periods.

Competing interests

The authors declare no competing interests.