Telehealth in pregnancy

Telehealth lifestyle interventions are gaining increasing popularity for use in pregnancy for management of complications such as gestational diabetes¹ and for monitoring of blood pressure.² Telehealth has also been used in trials in low-income and middle-income countries, particularly in rural communities where access to antenatal care is challenging.³ The option of using telehealth in antenatal care has been brought sharply into focus with the coronavirus disease 2019 (COVID-19) pandemic. Pregnant women are considered a vulnerable group and are therefore advised to be stringent with public health measures such as social distancing and self-isolation to lower their risk of exposure to the virus. This advice has led to recommendations to limit face-to-face consultations and for rapid implementation of remote access to antenatal care throughout the UK.⁴ The methods and outcomes of the GLOW randomised controlled trial done by Assiamira Ferrara and colleagues⁵ and published in The Lancet Diabetes and Endocrinology are therefore are therefore of interest and are particularly relevant during the current COVID-19 pandemic.

GLOW was a randomised trial of a weight management intervention delivered by telephone during a pregnancy with an aim of reducing gestational weight gain in women with overweight or obesity (BMI 25·0–40·0 kg/m²). Eligible women were at 8–15 weeks' gestation and received two face-to-face consultations and 11 telephone sessions using behavioural strategies to improve weight, diet, and physical activity. Women in the intervention group had less gestational weight gain (GWG) and improved lifestyle and metabolic parameters than did those in the usual care group. 96 (48%) of 199 women in the lifestyle intervention group and 134 (69%) of 195 women in the usual care group exceeded Institute of Medicine guidelines for rate of GWG per week (relative risk 0·70, 95% CI 0·59–0·83). Compared to usual care, women in the intervention group also had reduced calorie intake, reduced proportion of calories they obtained from saturated fat, and less sedentary behaviour. Metabolic markers including insulin, homoeostatic model assessment of insulin resistance, and leptin were also lower in the intervention group than in the usual care group.

Lifestyle interventions in pregnancy are difficult to undertake and often labour intensive.⁶ Use of telehealth has been increasingly adopted in management of obesity in the general population.⁷ The GLOW trial reports a robust approach of delivering a telehealth weight management intervention in pregnancy with success at reducing GWG. Detailed descriptions of the intervention, including the lengths of consultations and an estimate of the costs are included, which are helpful for considering implementation of the intervention in health services. Of note, the trial was not powered to look at perinatal outcomes and no differences in perinatal complications were observed. Indeed, a previous individual patient data meta-analysis, including data from 36 randomised trials (12 526 women), showed that interventions that reduce GWG do not have an effect on key maternal and fetal outcomes, except caesarean section rates.⁸ Much debate remains about why these lifestyle interventions have had no effect on clinical outcomes and whether there are wider implications for the long-term health of the mother and her family.

In the rapid implementation of delivery of remote antenatal care in response to COVID-19 there remain many uncertainties. There is limited knowledge about women's views of use of telehealth for monitoring pregnancy complications although available data suggests that women find this to be a positive experience.⁹ There is concern that most of the trials of telehealth technologies have been done in highly selected groups and so the findings might not be applicable to the wider population. Notably, the GLOW trial also had very strict eligibility criteria, and in particular excluded women with mental health problems and other medical comorbidities, which will likely limit its generalisability. Concerns about usability of technology, reliability of data, and ability to inform clinical decision making have also been raised¹⁰ and critical evaluation of the changes in practice will be needed. The GLOW trial suggests that an appropriate and effective telehealth intervention, when delivered by skilled researchers, offers promise to reduce excess GWG in overweight and obese pregnancy. With continuing development and refinement of technologies, such studies provide important lessons that can be applied and used more widely.

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