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. 2021 Jan 2;124:108273. doi: 10.1016/j.jsat.2020.108273

Integrated substance use and prenatal care delivery in the era of COVID-19

Elizabeth W Patton a,b,, Kelley Saia a,b, Michael D Stein c
PMCID: PMC7979279  PMID: 33771277

Abstract

The COVID-19 pandemic has directly impacted integrated substance use and prenatal care delivery in the United States and has driven a rapid transformation from in-person prenatal care to a hybrid telemedicine care model. Additionally, changes in regulations for take home dosing for methadone treatment for opioid use disorder due to COVID-19 have impacted pregnant and postpartum women. We review the literature on prenatal care models and discuss our experience with integrated substance use and prenatal care delivery during COVID-19 at New England's largest safety net hospital and national leader in substance use care. In our patient-centered medical home for pregnant and postpartum patients with substance use disorder, patients' early responses to these changes have been overwhelmingly positive. Should clinicians continue to use these models, thoughtful planning and further research will be necessary to ensure equitable access to the benefits of telemedicine and take home dosing for all pregnant and postpartum patients with substance use disorder.

Keywords: Prenatal care, Substance use treatment, COVID-19, Telemedicine


Substance use disorder (SUD) during pregnancy is a growing public health concern in the United States. From 2009 to 2014, rates of opioid use disorder documented at the time of delivery rose nationally from 1.5/1000 to 6.5/1000, with rates varying across states (e.g. 0.7/1000 in Washington DC, to 48.6/1000 in Vermont) (Haight et al., 2018). Clinicians should coordinate prenatal and substance use care to optimize pregnancy outcomes.

The traditional U.S. model of prenatal care consists of 12–14 in-person office visits for low-risk patients who deliver at full term (total visit range reflects different delivery dates). We know that prenatal care improves perinatal outcomes (American Academy of Pediatrics, 2017; Conway & Kutinova, 2006; DeMasi et al., 2017; McDuffie et al., 1996; Yan, 2017). For women with SUD, integrated prenatal care has brought SUD care, including medications for opioid use disorder (MOUD) and psychiatric medication management and counseling, into the traditional prenatal visit structures (Saia et al., 2016; Saia et al., 2017). Adequate prenatal care, defined as early initiation and sustained attendance, is associated with improved perinatal outcomes with a dose-response effect (Kotelchuck, 1994; Osterman & Martin, 2018; Laditka et al., 2005; Loftus et al., 2015; Carter et al., 2016; Nam et al., 2019; Cox et al., 2011; Debiec et al., 2010). Yet an in-person, office-based obstetrical model may present unintended barriers to care access for pregnant women who may not be able to easily obtain transportation or take time off work (Gadson et al., 2017). For women with SUD, additional barriers to consistent participation in in-person prenatal care include stigma, difficulty accessing the health care system, and SUD management needs (e.g., daily dosing at a methadone clinic or participating in a residential treatment program).

The COVID-19 pandemic has increased use of telemedicine (visits done by phone, video, or both). Prior to COVID-19, clinicians had used telemedicine successfully for chronic disease management such as diabetes (Totten et al., 2016; Polinski et al., 2016); yet data in obstetric care were more limited. Studies demonstrated patient and provider satisfaction without changes in maternal or neonatal outcomes when compared to traditional care (Butler Tobah et al., 2019; Dalfrà et al., 2009; Homko et al., 2007; Homko et al., 2012; Kruger et al., 2003; Marko et al., 2019; Peahl et al., 2020; Pérez-Ferre et al., 2010a; Pérez-Ferre et al., 2010b; Pflugeisen & Mou, 2017). However, telemedicine studies primarily included privately insured, well-resourced, majority white populations; we know little about the experiences of low-income pregnant women with SUD. As socioeconomic status, technology access, and varying health literacy may limit patients' ability to access telemedicine, telemedicine could exacerbate disparities (Gadson et al., 2017; Onwuzurike et al., 2020; Peahl et al., 2020; Raman, 2020; Zephyrin & Nuzum, 2020). Expansion of telemedicine services did directly impact MOUD accessibility; in mid-March, as the U.S. Department of Health and Human Services lifted restrictions on telemedicine, the Drug Enforcement Administration allowed authorized prescribers to initiate new patients on buprenorphine via telemedicine (Bailey, 2020).

With COVID-19 cases rising in Massachusetts, at Boston Medical Center, the RESPECT clinic (Recovery, Empowerment, Social Services, Prenatal care, Education, Community and Treatment), a patient-centered medical home that integrates SUD and prenatal care on-site, shifted to a hybrid telemedicine/in-person prenatal care model. Pre-COVID-19, the clinic conducted all integrated prenatal-SUD care visits in-person; with the COVID-19 hybrid model, we shifted to using telemedicine for many visits, with in-person visits at critical OB milestones (see Table 1 ). Our telemedicine visits were conducted using our hospital's approved platforms (Zoom or Doximity for video enabled visits) or telephone alone, with patient preference determining modality of delivery. Clinicians conducting visits were in dedicated clinic rooms or in other private settings using hospital-approved equipment.

Table 1.

Comparison of pre- and post-COVID-19 models of integrated prenatal and SUD care (IP = in-person; T = telemed; FHT = fetal heart tones; BP = blood pressure; GC/Chl = Gonorrhea & Chlamydia; GBS = group B Strep).

Pre-COVID19 RESPECT clinic schedule – through February 2020
All visits in person (IP)
All visits FHT, BP, weight
COVID-19 RESPECT clinic schedule –March 2020-present
Hybrid modelcombination telemed (T) and in person visits (IP)
Prenatal care SUD care Prenatal care SUD care
First trimester Initial prenatal new patient – labs, exam
12 week – dating ultrasound, genetic screening
Weekly (x 4) recovery check-in, relapse prevention, MOUD efficacy check, support, referrals to individualize recovery care (meetings, counseling, peer mentor)
Urine drug test q visit
*phone follow-ups for resource utilization/RN and LICSW recovery support PRN
Initial prenatal new patient history (T)
12 week – dating US, genetic screening, prenatal labs, exam (IP), FHT/BP/weight
Weekly SUD RN call
Biweekly social work call
Biweekly psychiatry call
Biweekly OB MD call
Urine drug test at in-person visits only
Second trimester 16 week – genetic screening if not done previously
20 week – anatomy survey ultrasound and visit
24 weeks – glucose tolerance testing
28 weeks – CBC, Tdap vaccine Rhogam if indicated, visit
Q 2 week relapse prevention check-in prevention, MOUD efficacy check, support, referrals to individualize recovery care (meetings, counseling, peer mentor)
Urine drug test q visit
*phone follow-ups for resource utilization/RN and LICSW recovery support PRN
16 week (T)
20 week (IP) anatomy survey, visit, FHT/BP/weight
24 week (T)
28 week (IP) – glucose tolerance testing, Tdap vaccine, CBC, Rhogam if indicated, FHT/BP/weight
Weekly SUD RN call
Biweekly social work call
Biweekly psychiatry call
Biweekly OB MD call
Urine drug test at in-person visits
Third trimester 30 weeks – visit; contraceptive counseling; sterilization consent if desired
32 weeks – visit
34 weeks – visit
36 weeks – GBS, CBC, HIV, RPR, repeat GC/Chl, visit
37 weeks and onward – weekly in person visit until delivery
Q 1 to 2 week relapse prevention, MOUD efficacy check, recovery support, referrals to individualize recovery care (meetings, counseling, peer mentor)
Urine drug test q visit
*phone follow-ups for resource utilization/RN and LICSW recovery support PRN
32 week (IP) FHT/BP/weight, contraceptive counseling
34 week (T)
36 week (IP) GBS, CBC, HIV, RPR, repeat GC/Chl, FHT/BP/weight
37 week (T)
38 week (IP) FHT/BP/weight
39 week (T)
40+ week (IP) FHT/BP/weight, delivery planning if undelivered
Weekly SUD RN call
Biweekly social work call
Biweekly psychiatry call
Biweekly OB MD call
Urine drug test at in-person visits
Postpartum 1 weeks PP – incision, mood check
3 week PP check
5 week PP check
exam, labs, mood check, contraception (eg IUD, implant)
1,3,5 week PP visits include relapse prevention, MOUD efficacy check, recovery support, referrals to individualize recovery care (meetings, counseling, peer mentor) 2 week – T
6 week – IP OR T pending pt. pref/needs
Weekly SUD RN call
Biweekly social work call
Biweekly psychiatry call
Biweekly OB MD call
Total visits by type (in person (IP), telemed (T)) 14–16 IP visits for prenatal care depending on delivery date; at the majority of these in person visits, patients also had face to face contact with social work, RN, and psych tailored to their individual needs, with additional phone contacts as needed 8–9 IP prenatal visits depending on delivery date
8 T visits for prenatal care plus additional ~6 phone contacts per month by interdisciplinary staff

Of our 90 current patients, 79% self-identified as white, 12% as African American, 3% as Hispanic, and 5% as multi-racial; the majority have primary opioid use disorder (OUD) treated with medication, with 53%, 34% and 13% utilizing methadone, buprenorphine, and no MOUD, respectively. These patients are receiving 6–8 telemedicine contacts per month (weekly nurse call, and every other week obstetric MD, psychiatry, and social work calls) as well as biweekly to monthly in-person visits. Telemedicine has provided flexibility for many more patient care touch points than our pre-COVID-19 model, as Table 1 shows.

Our evaluation of this hybrid telemedicine model is ongoing but surprising early positive trends are emerging despite initial trepidation among providers. Most relevant for our clinic, no-show rates for the COVID-19 hybrid model are lower than for the pre-COVID-19 in-person model, when we examine trends over the past year. Comparing October 2019–February 2020 (pre-COVID-19) to March 2020–August 2020 (during COVID-19), no-show rates fell from 34% of visits to 10% of visits, respectively. We are currently developing a mixed-method evaluation of patient and provider experiences with our hybrid model to understand this notably higher visit attendance during the COVID-19 period. In conversation with our clinicians, patients have noted a variety of individualized preferences, including the convenience of not needing transport to or childcare for telemedicine appointments; avoiding a clinical setting or city neighborhood linked to prior substance use; and the effects of social isolation that COVID-19 imposed, which make all visits, telemedicine and in-person, an attractive means of purposeful connection for some patients.

COVID-19 has not only impacted our integrated prenatal-SUD care delivery model, it has also, in our state, impacted MOUD with methadone, the MOUD modality that the majority of our patients use. Our inpatient initiation and titration of methadone for pregnant patients was unaffected by COVID-19 (we still had the ability to admit patients), but we did note a downward trend of patients seeking this titration, from an average of 6 unique patient admissions per month pre-COVID-19 to 1–2 per month during the peak of the COVID-19 pandemic. We hope to understand this trend better through our planned mixed-method study; informally, some patients expressed a desire to avoid coming to the ED (the route by which these patients get admitted) during the pandemic peak, which may have been a contributing factor to the decrease. For our pregnant patients with OUD treated with methadone, the expansion of take-home dosing protocols (in our state ranging from 14 to 28 day dosing) has limited long dosing lines, which were common at busy periods in many of our city clinics, and which some of our patients reported were substance use triggers as well, consistent with prior literature examining relapse triggers (Calvert, 2020a; Kennedy et al., 2013; Preston & Epstein, 2011). Pre-COVID-19, clinicians reserved take-home status for persons who met strict methadone maintenance criteria; including duration of consecutive dosing days, appropriate drug testing results, and engagement in counseling. Our state issued guidance that permitted clinicians to initiate prescriptions via telemedicine rather than by in-person evaluation, enabling buprenorphine prescriptions to be easily incorporated into our hybrid prenatal care model for our pregnant patients on buprenorphine (Calvert, 2020b). The combination of national and state regulatory changes has meant that in our state, COVID-19 has provided many of our patients with more medication initiation, continuation, and dosing options than they had pre-COVID (Haley & Saitz, 2020). A COVID-19 silver lining may be this increased flexibility that balances patient safety, patient-centered services, and necessary regulatory measures. Further research should look at the impact of these changes on pregnant and postpartum patients' recovery trajectories and maternal fetal outcomes.

Can COVID-19-era take home protocols become the new normal? Pregnant persons may be the perfect cohort to maintain take-home status indefinitely, as pregnancy often fuels a heightened motivation for recovery treatment and compliance with traditional take-home criteria. Pregnant persons, regardless of COVID-19 adaptations, may be a subset of methadone clients who should regularly qualify for barrier- free take-home status, especially postpartum. Analysis of the COVID-19-era take-home experiment may provide ample data to support loosening restrictions on methadone treatment for all, but especially for pregnant and postpartum patients. Likewise, analysis of patients' experiences with telemedicine-initiated buprenorphine as part of an integrated hybrid prenatal model may provide an evidence base for continuing telemedicine MOUD initiation and treatment, even after the pandemic subsides.

Telemedicine prenatal care and take-home dosing for women with SUD has emerged rapidly as a necessary response to reducing potential patient and clinician exposure to COVID-19. We anticipated that telemedicine prenatal care would pose significant difficulties for our patients with SUD, and for some—especially those with active substance use, concomitant unstable housing, and lack of consistent phone access—it does. Yet for a majority of our pregnant patients with SUD, telemedicine has had many benefits. In addition to the significant reduction in visit “no shows” described here, providers recognize that telemedicine video visits offer rich insights into their patients' lives, including their home environment and their key support people. And telemedicine visits may provide a more focused visit format for clinician and patient, in contrast to the clinic where clinicians juggle multiple patients between exam rooms.

Given concerns about recurrent COVID-19 infection waves, tele-prenatal care is likely here to stay. Even if COVID-19 disappeared tomorrow, key aspects of integrated tele-prenatal care and SUD care will and should remain. Tele-prenatal care allows patients with complex competing demands due to their SUD and their pregnancy to engage in care for both of these health needs more easily, without transportation, childcare, or other logistical concerns.

We are aware of potential downsides of our model. One downside is the technical difficulty of connecting virtually with pregnant patients who may not have stable access to video-enabled phones, the Internet, reliable phone access, or private locations for video or personal telephone calls. Second, our RESPECT clinic functions on a multidisciplinary model that benefits from continuously sharing treatment suggestions tailored to the needs of individual patients; this is often critical when effectively engaging patients with high socioemotional needs (e.g., IPV, relapse, homelessness, interaction with the department of children and family services system). Such teamwork among providers is difficult to ensure virtually. Moreover, the predominance of virtual visits may be isolating for providers who are accustomed to in-person exchanges of clinical ideas; such mutual support among providers, if interrupted, could contribute to an increase in burnout within care teams.

Creative solutions to provider care team burnout, including using similar telephone and video technology for group debriefs and care, and planning for individual clients with unique challenges, will be essential to ensure that tele-prenatal SUD care does not diminish skilled obstetric and SUD care. Both patients and clinicians must benefit from the hybrid model for such models to stand the test of time.

References

  1. American Academy of Pediatrics Committee on Fetus and Newborn and American College of Obstetrics and Gynecology Committee on Obstetric Practice. (2017). Guidelines for Perinatal Care. 8th edition.
  2. Bailey M. (2020). Relaxed federal policies enable street outreach for substance use. HealthCity. https://www.bmc.org/healthcity/population-health/relaxed-federal-policies-enable-street-outreach-substance-use. (Accessed August 17, 2020).
  3. Butler Tobah YS, LeBlanc A, Branda ME, et al. (2019). Randomized comparison of a reduced-visit prenatal care model enhanced with remote monitoring. American Journal of Obstetrics and Gynecology, 221(6), 638.e1–638.e8. doi: 10.1016/j.ajog.2019.06.034. [DOI] [PubMed]
  4. Calvert, D. (2020a). Alert regarding COVID-19 for opioid treatment programs. Boston, MA: Commonwealth of Massachusetts, Department of Public Health. https://www.mass.gov/doc/alert-regarding-covid-19-for-opioid-treatment-programs/download (Accessed October 22, 2020).
  5. Calvert, D. (2020b). Alert regarding use of telemedicine during public health emergency-COVID-19. Boston, MA: The Commonwealth of Massachusetts, Department of Public Health. Available at https://www.mass.gov/doc/alert-regarding-use-of-telemedicine-during-public-health-emergency-covid-19/download (Accessed October 22, 2020).
  6. Carter EB, Tuuli MG, Caughey AB, et al. (2016). Number of prenatal visits and pregnancy outcomes in low-risk women. Journal of Perinatology, 36(3), 178–181. doi: 10.1038/jp.2015.183. [DOI] [PMC free article] [PubMed]
  7. Conway KS, Kutinova A. (2006). Maternal health: Does prenatal care make a difference? Health Economics, 15(5), 461–488. doi: 10.1002/hec.1097. [DOI] [PubMed]
  8. Cox RG, Zhang L, Zotti ME, Graham J. (2011). Prenatal care utilization in Mississippi: Racial disparities and implications for unfavorable birth outcomes. Maternal and Child Health Journal, 15(7), 931–942. doi: 10.1007/s10995-009-0542-6. [DOI] [PubMed]
  9. Dalfrà MG, Nicolucci A, Lapolla A, et al. (2009). The effect of telemedicine on outcome and quality of life in pregnant women with diabetes. Journal of Telemedicine and Telecare, 15(5), 238–242. doi: 10.1258/jtt.2009.081213. [DOI] [PubMed]
  10. Debiec KE, Paul KJ, Mitchell CM, Hitti JE. (2010). Inadequate prenatal care and risk of preterm delivery among adolescents: A retrospective study over 10 years. American Journal of Obstetrics and Gynecology, 203(2), 122.e1–122.e6. doi: 10.1016/j.ajog.2010.03.001. [DOI] [PubMed]
  11. DeMasi S, Bucagu M, Tunçalp Ö, et al. (2017). Integrated person-centered health care for all women during pregnancy: Implementing world health organization recommendations on antenatal care for a positive pregnancy experience. Global Health Science and Practice, 5(2), 197–201. doi: 10.9745/GHSP-D-17-00141. [DOI] [PMC free article] [PubMed]
  12. Gadson A, Akpovi E, Mehta PK. (2017). Exploring the social determinants of racial/ethnic disparities in prenatal care utilization and maternal outcome. Seminars in Perinatology, 41(5), 308–317. doi: 10.1053/j.semperi.2017.04.008. [DOI] [PubMed]
  13. Haight SC, Ko JY, Tong VT, Bohm MK, Callaghan WM. (2018). Opioid use disorder documented at delivery hospitalization – United States, 1999–2014. MMWR Morbidity and Mortality Weekly Report, 67, 845–849. DOI: 10.15585/mmwr.mm6731a1external icon. [DOI] [PMC free article] [PubMed]
  14. Haley DF & Saitz R. (2020). The opioid epidemic during the COVID-19 pandemic. JAMA. doi: 10.1001/jama.2020.18543. [DOI] [PubMed]
  15. Homko CJ, Deeb LC, Rohrbacher K et al. (2012). Impact of a telemedicine system with automated reminders on outcomes in women with gestational diabetes mellitus. Diabetes Technology and Therapeutics, 14(7), 624–629. doi: 10.1089/dia.2012.0010. [DOI] [PMC free article] [PubMed]
  16. Homko CJ, Santamore WP, Whiteman V et al. (2007). Use of an internet-based telemedicine system to manage underserved women with gestational diabetes mellitus. Diabetes Technology and Therapeutics, 9(3), 297–306. doi: 10.1089/dia.2006.0034. [DOI] [PubMed]
  17. Kennedy AP, Epstein DH, Phillips KA, Preston KL. (2013). Sex differences in cocaine/heroin users: Drug-use triggers and craving in daily life. Drug and Alcohol Dependence, 132(1–2), 29–37. doi: 10.1016/j.drugalcdep.2012.12.025. [DOI] [PMC free article] [PubMed]
  18. Kotelchuck M. (1994). The adequacy of prenatal care utilization index: Its US distribution and association with low birthweight. American Journal of Public Health, 84(9), 1486–1489. doi: 10.2105/ajph.84.9.1486. [DOI] [PMC free article] [PubMed]
  19. Kruger DF, White K, Galpern A, et al. (2003). Effect of modem transmission of blood glucose data on telephone consultation time, clinic workflow, and patient satisfaction for patients with gestational diabetes mellitus. Journal of American Academy of Nurse Practitioners, 15(8), 371–375. doi: 10.1111/j.1745-7599.2003.tb00410.x. [DOI] [PubMed]
  20. Laditka SB, Laditka JN, Mastanduno MP, Lauria MR, & Foster TC. (2005). Potentially avoidable maternity complications: an indicator of access to prenatal and primary care during pregnancy. Women Health, 41(3), 1–26. doi: 10.1300/J013v41n03_01. [DOI] [PubMed]
  21. Loftus CT, Stewart OT, Hensley MD, Enquobahrie DA, Hawes SE. (2015). A longitudinal study of changes in prenatal care utilization between first and second births and low birth weight. Maternal and Child Health Journal, 19(12), 2627–2635. doi: 10.1007/s10995-015-1783-1. [DOI] [PubMed]
  22. Marko KI, Ganju N, Krapf JM, et al. (2019). A mobile prenatal care app to reduce in-person visits: Prospective controlled trial. JMIR Mhealth and Uhealth, 7(5), e10520. doi: 10.2196/10520. [DOI] [PMC free article] [PubMed]
  23. McDuffie RS, Beck A, Bischoff K, Cross J, Orleans M. (1996). Effect of frequency of prenatal care visits on perinatal outcome among low-risk women: A randomized controlled trial. JAMA, 275(11), 847–851. doi: 10.1001/jama.275.11.847. [DOI] [PubMed]
  24. Nam JY, Cho E, Park EC. (2019). Do severe maternal morbidity and adequate prenatal care affect the delivery cost? A nationwide cohort study for 11 years with follow up. BJOG, 126(3), 1623–1631. doi: 10.1111/1471-0528.15895. [DOI] [PubMed]
  25. Onwuzurike C, Meadows AR, Nour NM. (2020). Examining inequities associated with changes in obstetric and gynecologic care delivery during the coronavirus disease 2019 (COVID-19) pandemic Obstetrics and Gynecology. doi: 10.1097/AOG.0000000000003933. [DOI] [PubMed]
  26. Osterman, MJK, & Martin JA. (2018). Timing and adequacy of prenatal care in the United States. National Vital Statistics Reports, 67(3), 1–14. [PubMed]
  27. Peahl AF, Novara A, Heisler M, Dalton VK, Moniz MH, Smith RD. (2020). Patient preferences for prenatal and postpartum care delivery: A survey of postpartum women. Obstetrics and Gynecology, 135(5), 1038–1046. doi: 10.1097/AOG.0000000000003731. [DOI] [PMC free article] [PubMed]
  28. Pérez-Ferre N, Galindo M, Fernández MD, et al. (2010a). A Telemedicine system based on Internet and short message service as a new approach in the follow-up of patients with gestational diabetes. Diabetes Research and Clinical Practice, 87(2). doi: 10.1016/j.diabres.2009.12.002. [DOI] [PubMed]
  29. Pérez-Ferre N, Galindo M, Fernández MD, et al. (2010b). The outcomes of gestational diabetes mellitus after a telecare approach are not inferior to traditional outpatient clinic visits. International Journal of Endocrinology. doi: 10.1155/2010/386941. [DOI] [PMC free article] [PubMed]
  30. Pflugeisen BM & Mou J. (2017). Patient satisfaction with virtual obstetric care. Maternal and Child Health Journal, 21(7), 1544–1551. doi: 10.1007/s10995-017-2284-1. [DOI] [PubMed]
  31. Polinski JM, Barker T, Gagliano N, Sussman A, Brennan TA, Shrank WH. (2016). Patients' satisfaction with and preference for telemedicine visits. Journal of General Internal Medicine, 31(3), 269–275. doi: 10.1007/s11606-015-3489-x. [DOI] [PMC free article] [PubMed]
  32. Preston KL, Epstein DH. (2011). Stress in the daily lives of cocaine and heroin users: Relationship to mood, craving, relapse triggers, and cocaine use. Psychopharmacology (Berl), 218(1), 29–37. doi: 10.1007/s00213-011-2183-x. [DOI] [PMC free article] [PubMed]
  33. Raman, S. (2020). COVID-19 amplifies racial disparities in maternal health. Roll Call. https://www.rollcall.com/2020/05/14/covid-19-amplifies-racial-disparities-in-maternal-health/. (Accessed May 23, 2020).
  34. Saia K, Bagley SM, Wachman EM, Patel PP, Nadas MD, Brogly SB. (2017). Prenatal treatment for opioid dependency: Observations from a large inner-city clinic. Addiction Science & Clinical Practice, 12(1), 5. doi: 10.1186/s13722-016-0070-9. [DOI] [PMC free article] [PubMed]
  35. Saia KA, Schiff D, Wachman EM, et al. (2016). Caring for pregnant women with opioid use disorder in the USA: Expanding and improving treatment. Current Obstetrics and Gynecology Reports, 5(3), 257–263. [DOI] [PMC free article] [PubMed]
  36. Totten AM, Womack DM, Eden KB, et al. (2016). Telemedicine: mapping the evidence for patient outcomes from systematic reviews. https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/telehealth_technical-brief.pdf. Accessed May 12, 2020. [PubMed]
  37. Yan J. (2017). The effects of prenatal care utilization on maternal health and health behaviors. Health Economics, 26(8), 1001–1018. doi: 10.1002/hec.3380. [DOI] [PubMed]
  38. Zephyrin L, Nuzum R. (2020). Caring for moms during the COVID-19 pandemic. Commonwealth Fund. https://www.commonwealthfund.org/blog/2020/caring-moms-during-covid-19-pandemic. (Accessed May 23, 2020).

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