To the Editors:
Peahl et al1 recently reported their evaluation of patient and provider experiences with a COVID-19 prenatal care model incorporating telehealth and virtual visits. These authors found “perceived improved access to care” through decreased barriers and “perceived high quality of virtual visits” for low-risk patients. However, these authors also reported that across the pre- and postimplementation periods, the average total visit volume (including both in-person and virtual prenatal visit utilization) de facto fell (–16.1%), which is not in accordance with the perception of patients and providers, and can be of concern. Because Peahl et al1 did not define strict inclusion criteria for their prenatal care model and did not address health outcomes, we believe that the conclusion of their study may be misleading.
Indeed, from a meta-analysis of studies pooling data from 198,993 pregnancies before and 168,295 during the pandemic, respectively, Chmielewska et al2 recently evidenced a significant increase (1.37 [1.22–1.53]) in maternal death that was mainly driven by a reduced access to care and not by direct effect of COVID-19 in pregnant women.
In actuality, Peahl et al1 mainly based their prenatal care model on the low-risk schedule “with additional visits and services as appropriate.”
However, only a strict monitoring protocol, depending on the specific risk involved, can meet the needs for high-risk pregnancies, in a rigorous approach specifically tailored for each condition placing patients at higher risk of adverse maternal or neonatal outcomes.3 For the purpose of maintaining close follow-up for high-risk pregnant women during the first wave of the pandemic in New York, Aziz et al3 organized prenatal care in a telehealth framework, allowing to eliminate “approximately one-half of in-person visits for low-risk patients,” but they detailed recommendations scheduled for high-risk pregnancies, pathology by pathology. Indeed, the separation between high and low risk remains challenging: Butler Tobah et al4 randomized low-risk women to an “OB Nest” protocol or usual care (150 in each arm) using a minimization algorithm excluding women with various high-risk conditions or if “obstetrician judgment determined that the pregnancy was at high risk for complications.” Study team clinicians were aware of the assigned arms and used study exclusion criteria if a high risk appeared later. In this strict context, these authors found that maternal and fetal clinical outcomes were similar between groups.
However, Peahl et al1 did not define their inclusion criteria in such a strict manner.
Footnotes
The authors report no conflict of interest.
References
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