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Effects of the COVID-19 Pandemic on the Use of Telehealth for Antenatal Care

Editor


Introduction

Antenatal care (ANC) is essential for positive pregnancy outcomes,1 enabling prevention, detection, and treatment of conditions that may compromise pregnancy.2 The recommendation for ANC in Australia is to have the first comprehensive assessment within 10 weeks of pregnancy, and seven or more consultations for multiparous women and 10 or more consultations for nulliparous women. ANC consultations are scheduled throughout the pregnancy to incorporate assessments, tests, vaccinations, and other related services that are specific to milestones of fetal growth and gestation age.2 In 2019, 57% of pregnant women in Australia had 10 or more antenatal visits, while teenagers, women who smoked during pregnancy, and multiparous women had fewer visits.3

The COVID-19 pandemic began in early 2020, resulting in many face-to-face visits being replaced by telehealth consultation when physical examination was not required.4,5 In one study, the authors claimed that telehealth could replace up to 50% of face-to-face visits without compromising pregnancy outcomes.6 However, telehealth needs to be used with caution7 to avoid lowering quality of care,8,9 increasing women’s distress,10 and widening disparities due to language barriers, technological difficulties,8,11 unfavorable attitudes among health care providers, and altered financial incentives.11

In Australia, 75% of births occur in public hospitals. The remaining births occur in private hospitals. ANC is available at public and private hospitals, and private consultation rooms of general practitioners and specialists. Telehealth consultations have been permitted through the Medical Benefits Schedule since 2011–2012, enabling medical practitioners to be reimbursed by Medicare for telehealth consultations provided outside of public hospitals.

In March 2020, in response to the COVID-19 pandemic, funding rules limiting the reimbursement for services offered by telehealth were relaxed.12 The total number of claims for ANC face-to-face visits outside of public hospitals fell by 8.0% in 2020.13 Most of the reduction was offset by telehealth, resulting in an overall 1% reduction in ANC services. Use of telehealth accounted for 9.3% of all ANC services. However, information on the use of telehealth and ANC visits at public hospitals, where the majority of births occur was not reported. At the individual level, it is not known how the increase in telehealth offsets the reduction in the number of face-to-face visits, nor the groups of women who were most affected.

Our Local Health District (LHD) in New South Wales (NSW), Australia, covers one of the most affected areas by COVID-19 in Australia.14 It also has one of the most diverse populations with two-thirds of pregnant women born overseas15 compared with one-third across Australia.16,17 Different social and economic backgrounds and health care practices of an individual’s country of origin result in variation in utilization of reproductive health service.15,18

The aims of this study were to examine changes in the use of telehealth and the combination of telehealth and face-to-face consultations for ANC in the LHD’s public hospitals subsequent to the COVID-19 pandemic, and to identify the groups of women that were most affected. Such information is useful for service providers to optimize planning and delivery of ANC services to ensure equitable utilization.

Materials and Methods

SETTING

The LHD has three public hospitals providing obstetric services. The largest is a tertiary referral hospital, where the first cases of severe COVID-19 in NSW were treated. That hospital is also a level 6 maternity hospital that can care for mothers and babies of all levels of complexity. The medium hospital is a major hospital with a level five maternity service for mothers and babies with normal to high complex care needs. The smallest hospital has a level three maternity service for mothers and babies with normal care needs19 and is located 12 km from the tertiary hospital.

The hospitals provide ANC services for women who plan to give birth at the hospital, where public patients are cared for by medical doctors and midwives or shared with private general practitioners. There are two types of midwifery care: midwifery “caseload continuity” of care that involves the same midwife during the entire pregnancy, and team midwifery where a woman is cared for by a team of midwives.20

DATA

We used eMaternity data, the Maternity Information System for the LHD that is part of a state-wide Ministry of Health maternity database system. The data set recorded information on women who gave birth in the three public hospitals of the LHD. The database contains inpatient documentation and outpatient electronic medical records. The data included information on demographic characteristics (age, country of birth, interpreter required, and postcode, which was used to derive Socio-Economic Indexes for Areas—Index of Relative Socio-Economic Disadvantage), general health factors (body mass index, smoking status during pregnancy), reproductive history (parity, conception method), hospital name, mode of care, and details of the current pregnancy.

Data on women who gave birth in any of the LHD’s public hospitals between January 2018 and January 2020, before the pandemic began (the “before” group), and women who gave birth between December 2020 and June 2021 (the “after” group) were analyzed. To assess the full effect of the pandemic, data of women who conceived before the pandemic but gave birth after the pandemic started were not used since their ANC consultations could have occurred both before and after the start of the pandemic. Only data of public patients who had a singleton birth were included.

ANALYSES

The mean numbers of face-to-face visits, telehealth consultations, and total combined face-to-face visits and telehealth consultations were calculated. The significant differences between the “before” group and the “after” group were determined using one-way analysis of variance for means and chi-squared tests for proportions. Poisson regression was used to identify factors associated with the number of face-to-face visits and telehealth consultations. Adjustment factors included in the modeling were hospital type, mode of care, women’s demographic characteristics, medical history, and reproductive history. Data were analyzed using STATA 14.21

ETHICAL CONSIDERATIONS

Ethics approval was obtained from the Western Sydney LHD Human Research Ethics Committee (2107-13 QA APPROVAL).

Results

WOMEN’S CHARACTERISTICS

There were 19,171 women who gave birth before (767 per month) and 5,479 women who gave birth after the pandemic began (782 per month). Nearly half of the women used the principal referral hospital (46.7% after) (Table 1). Women aged 30–34 years were the largest group (38.1% after). About a third of women were non-Indigenous Australian-born (33.6% after). Women from Southern Asia comprised the greatest immigrant group (31.5% after). About half of the women had a healthy body mass index (47.9% after).

Table 1. Characteristics of Public Patients Who Gave Birth at a Local Health District, Before and After the Start of the Pandemic
  BEFORE (JANUARY 2018–JANUARY 2020) AFTER (DECEMBER 2020–JUNE 2021) p
n % n %
All 19,171 100.0 5,479 100.0  
Hospital         0.001
 Largest—principal referral 9,115 47.5 2,556 46.7  
 Medium—major hospital 7,223 37.7 2,194 4.0  
 Smallest—district hospital 2,833 14.8 729 13.3  
Mode of care         <0.001
 Medical 7,131 37.2 1,919 35.0  
 Team midwifery 8,608 44.9 2,265 41.3  
 Midwifery continuity of care 2,618 13.7 1,180 21.5  
 Shared 814 4.2 115 2.1  
Age (years)         <0.001
 <24 2,177 11.4 531 9.7  
 25–29 5,500 28.7 1,415 25.8  
 30–34 6,990 36.5 2,086 38.1  
 ≥35 4,504 23.5 1,447 26.4  
SEIFA         <0.001
 Worst 4,841 25.3 1,290 23.5  
 Second worst 5,216 27.2 1,458 26.6  
 Second best 4,787 25.0 1,532 28.0  
 Best 4,327 22.6 1,199 21.9  
Country of birth         <0.001
 Non-Aboriginal Australian born 5,839 30.5 1,842 33.6  
 Indigenous 360 1.9 94 1.7  
 Oceania 380 2.0 92 1.7  
 Europe 992 5.2 289 5.3  
 Southern Asia 5,770 30.1 1,727 31.5  
 Central Asia 686 3.6 173 3.2  
 Northeast Asia 1,601 8.4 311 5.7  
 Southeast Asia 1,218 6.4 317 5.8  
 North Africa and the Middle East 1,725 9.0 466 8.5  
 Sub-Saharan Africa 475 2.5 123 2.2  
 Latin America 114 0.6 41 0.7  
Interpreter required         0.308
 No 17,879 93.3 5,142 93.8  
 Yes 1,250 6.5 337 6.2  
Body mass index         <0.001
 Underweight (<18.5) 892 4.7 185 3.4  
 Healthy (18.5 to <25) 9,612 50.1 2,627 47.9  
 Overweight (25 to <30) 5,181 27.0 1,575 28.7  
 Obese (>30) 3,485 18.2 1,092 19.9  
Smoked during pregnancy         0.826
 No 18,089 94.4 5,182 94.6  
 Yes 1,011 5.3 294 5.4  
Reproductive history         0.026
 Nulliparous 7,771 40.5 2,110 38.5  
 Multiparous, no cesarean section 8,345 43.5 2,461 44.9  
 Multiparous, cesarean section 3,055 15.9 908 16.6  
Conception methods         0.005
 Planned spontaneous 12,535 65.4 3,685 67.3  
 IVF 509 2.7 164 3.0  
 Unplanned 6,127 32.0 1,630 29.7  
Gestational age at first comprehensive assessment       <0.001
 Early (≤10 weeks) 10,900 56.9 2,877 52.5  
 Late (>10 weeks) 8,269 43.1 2,602 47.5  

The proportion of women using midwifery “continuity of care” increased from 13.7% before to 21.5% after, while the proportion of women using all other modes of care decreased (e.g., from 44.9% before to 41.3% after for women having hospital-based midwifery; p < 0.001). The proportion of women who had the first comprehensive assessment within 10 weeks of pregnancy reduced from 56.9% before to 52.5% after (p < 0.001).

INCREASE IN TELEHEALTH CONSULTATIONS

The proportion of women who used telehealth increased from 31.6% before the pandemic started to 53.9% after. Of the women who used telehealth after the pandemic, most had from one to three telehealth consultations (81.3% and 79.7%). The mean number of telehealth consultations per woman increased from 0.7 to 1.3, an increase of 0.6 or 85.7% (p < 0.001). The number of telehealth consultations increased among all groups of women, but the largest increase was observed among women who gave birth at the small district hospital (1.2, p < 0.001), women younger than 24 years of age (0.9, p < 0.001), and Indigenous women (1.0, p < 0.001). Women from Latin America had no increase (0.0, p = 0.861) (Fig. 1). However, the number of women in this group was smallest (155, 0.6% of all women) (Table 1).

Fig. 1.

Fig. 1. Changes in antenatal care visits and telehealth consultations after the COVID-19 pandemic started, in western Sydney, New South Wales, Australia. IVF, in vitro fertilization; SEIFA, Socio-Economic Indexes for Areas.

REDUCTION IN ANC VISITS

The proportion of women who had 10 or more visits fell from 46.7% before to 38.0% after (p < 0.001). The mean number of visits per woman decreased from 10.6 to 9.2, a reduction of 1.4 or 13.2% (p < 0.001). All groups of women had fewer visits, but the reduction was most noticeable among women who attended the principal referral hospital (−2.0, p < 0.001), had shared care (−2.0, p = 0.023), were 35 years or older (−1.8, p < 0.001), were from Latin America (−2.3; p = 0.023), and conceived through in vitro fertilization (IVF) (−2.1, p < 0.001), (Fig. 1).

CHANGE IN TOTAL NUMBER OF ANC CONSULTATIONS

The combined number of visits and telehealth consultations decreased from an average of 11.3 to 10.5 per woman, a reduction of 0.8 or 7.1% (p < 0.001). Telehealth accounted for 6.2% of all the ANC services (1 in 15) before the pandemic started and 12.4% (1 in 8) after. The reduction occurred in most groups except for women who attended the small district hospital (which experienced an increase of 0.5 consultations, p < 0.001) and Indigenous women who had a nonsignificant increase of 0.2 consultations (p = 0.363) (Fig. 1).

Women who experienced the largest reduction in ANC face-to-face visits also had the largest reduction in total services. They were women who attended the referral hospital (−1.5 services; p < 0.001), had shared care (−1.4, p = 0.003), were aged 35 years or older (−1.4; p < 0.001), were from Latin America (−2.4; p = 0.002), and conceived through IVF (−1.4; p = 0.002) (Fig. 1).

FACTORS ASSOCIATED WITH ANC SERVICE UTILIZATION

After adjusting for other factors, the pandemic was still associated with significant changes in ANC service. Women had 0.87 times fewer visits (95% confidence interval [CI] = 0.86–0.88, p < 0.001) and 1.71 times more telehealth consultations (95% CI = 1.67–1.76, p < 0.001) than before the pandemic started (Table 2).

Table 2. Factors Associated with Antenatal Face-to-Face Visits and Telehealth Consultations Among Public Patients (N = 24,560)
  FACE-TO-FACE VISITS TELEHEALTH CONSULTATIONS
IRR 95% CI p IRR 95% CI p
Pandemic            
 Before Reference     Reference    
 After 0.87 0.86–0.88 <0.001 1.71 1.67–1.76 <0.001
Hospital            
 Largest—principal referral Reference     Reference    
 Medium—major hospital 0.8 0.79–0.81 <0.001 5.34 5.14–5.54 <0.001
 Smallest—district hospital 0.9 0.88–0.91 <0.001 2.11 1.99–2.24 <0.001
Mode of care at admission            
 Medical Reference     Reference    
 Team midwifery 0.99 0.98–1.00 0.031 1.19 1.15–1.23 <0.001
 Midwifery continuity of care 0.98 0.97–0.99 0.002 1.99 1.91–2.08 <0.001
 Shared 0.91 0.89–0.93 <0.001 0.74 0.65–0.83 <0.001
Age (years)            
 ≤24 0.96 0.95–0.98 <0.001 1.12 1.08–1.18 <0.001
 25–29 Reference     Reference    
 30–34 1.02 1.01–1.03 <0.001 0.95 0.92–0.98 0.003
 ≥35 1.06 1.05–1.08 <0.001 0.78 0.75–0.81 <0.001
SEIFA            
 Worst Reference     Reference    
 Second worst 1.01 1.00–1.02 0.196 1.06 1.02–1.11 0.005
 Second best 1.02 1.01–1.04 <0.001 1.04 0.99–1.09 0.092
 Best 1.03 1.01–1.04 <0.001 1.1 1.05–1.15 <0.001
Country of birth            
 Non-Aboriginal Australian born Reference     Reference    
 Indigenous 0.97 0.94–1.00 0.072 1.02 0.93–1.12 0.653
 Oceania 0.9 0.87–0.93 <0.001 0.83 0.75–0.91 <0.001
 Europe 0.95 0.93–0.97 <0.001 0.9 0.85–0.96 0.002
 Southern Asia 1.00 0.99–1.01 0.852 1.11 1.07–1.15 <0.001
 Central Asia 1.02 1.00–1.05 0.044 0.81 0.73–0.90 <0.001
 Northeast Asia 0.99 0.97–1.00 0.096 0.83 0.77–0.90 <0.001
 Southeast Asia 0.96 0.95–0.98 <0.001 1.03 0.97–1.09 0.328
 North Africa and the Middle East 0.97 0.95–0.98 <0.001 0.85 0.80–0.91 <0.001
 Sub-Saharan Africa 0.97 0.94–0.99 0.018 0.94 0.86–1.04 0.227
 Latin America 0.97 0.93–1.02 0.253 0.98 0.81–1.19 0.845
Interpreter required            
 No Reference     Reference    
 Yes 0.98 0.96–0.99 0.009 0.57 0.52–0.62 <0.001
Body mass index            
 Underweight (<18.5) 1.00 0.98–1.02 0.673 0.96 0.90–1.03 0.288
 Healthy (18.5 to <25) Reference     Reference    
 Overweight (25 to <30) 1.01 1.00–1.02 0.036 1.00 0.97–1.03 0.917
 Obese (≥30) 1.04 1.03–1.05 <0.001 0.98 0.94–1.02 0.273
Smoked during pregnancy            
 No Reference     Reference    
 Yes 0.93 0.91–0.95 <0.001 1.03 0.98–1.09 0.209
Reproductive history            
 Nulliparous Reference     Reference    
 Multiparous, no cesarean section 0.93 0.92–0.94 <0.001 0.80 0.78–0.83 <0.001
 Multiparous with cesarean section 0.95 0.94–0.96 <0.001 0.59 0.56–0.62 <0.001
Conception methods            
 Planned spontaneous Reference     Reference    
 IVF 1.03 1.01–1.06 0.004 0.98 0.90–1.07 0.684
 Unplanned 0.96 0.96–0.97 <0.001 0.93 0.90–0.96 <0.001
Gestational age at first comprehensive assessment            
 Early (≤10 weeks) Reference     Reference    
 Late (>10 weeks) 0.95 0.95–0.96 <0.001 0.88 0.86–0.90 <0.001

Several groups of women had the lowest utilization of ANC services. Oceanian women had on average 9.8 services before and 9.0 after the pandemic. They had 0.90 times fewer number of visits (95% CI = 0.87–0.93; p < 0.001) and 0.83 times fewer number of telehealth consultations (95% CI = 0.75–0.91; p < 0.001) compared with non-Indigenous Australian born.

Women who smoked during pregnancy had an average of 9.9 services for both before and after, and had 0.93 times fewer number of visits (95% CI = 0.91–0.95; p < 0.001) compared with women who did not. Women with midwifery continuity of care had the most visits and telehealth combined (12.0 before and 11.2 after), had 0.98 times lower number of visits (95% CI = 0.97–0.99; p = 0.002), and 1.99 times more telehealth consultations (incidence rate ratio = 1.99; 95% CI = 1.91–2.08; p < 0.001) compared with women who had medical care.

Discussion

This study sought to examine changes in the use of telehealth consultations and face-to-face visits in an LHD in NSW before and after the start of the pandemic, and to identify the groups of women who were most affected. Despite the benefits that telehealth offers in a pandemic,22 only one out of 15 total services before the pandemic and one out of eight after was a telehealth consultation, much lower than in a general practice setting in another area of Australia, where one in two consultations was done by telehealth.6 Suitable telehealth equipment might not be available or women and health care professionals might not have the skills required, access to facilities, or willingness to engage in telehealth.

Health care professionals and women might be skeptical about using telehealth because of the complex examinations and tests that may be required during consultations. With the increasing use of videoconference and innovative technology, use of telehealth for ANC may increase.

Use of telehealth increased in all groups of women, especially those who attended the smallest district hospital, were younger, or Indigenous. The small district hospital, in addition to having the least involvement with the COVID-19 response, started a program aimed at improving access to ANC services in August 2019, some months before the pandemic started.23 That initiative might be partly responsible for that hospital experiencing the greatest increases in telehealth and the smallest reductions in face-to-face visits, resulting in an overall increase in service utilization.

Younger women may be more “technology savvy” and hence more inclined to adopt telehealth services, consistent with the finding that young people use telehealth more frequently for sexual and reproductive health management.24 Before the pandemic, Indigenous women had been offered an outreach program that incorporated telehealth.25

The proportion of women who had 10 or more visits (46.7%) before the pandemic was lower than the Australian average (57%),3 likely due to the higher proportion of pregnant women born overseas in the LHD.15,16 The average number of visits per woman fell from 10.6 to 9.2, a reduction of 13.2%, greater than the national average reduction of 8.3%.13 The decline observed might partly be reflective of efforts to avoid visiting hospitals to prevent transmission,26 given the three hospitals are located in an area that had one of the highest incidences of COVID-19 in the state.

A reduction in visits was observed most for women who attended the tertiary hospital, had shared care, were older than 35 years, came from Latin America, or had conceived through IVF. Anecdotal evidence in late 2020 suggests that women were hesitant to visit the tertiary hospital due to fear of infection. Women in shared care were similarly affected as they often have more hospital visits during the later stages of pregnancy. Older women and those undergoing IVF might experience more difficulties in conceiving, leading to them being more cautious in general. Latin America has one of the highest number of cases and deaths due to COVID-19 in the world,27 which might be associated with the heightened caution for face-to-face visits that women from this region displayed.

The increase in telehealth consultations did not compensate for the reduction in face-to-face visits. The total reduction of 7.1% was much higher than the 1.0% reported for ANC services outside of hospital.13 This could reflect the severe effects of the pandemic on hospital ANC attendance and a slower take up of telehealth, with the likely demand for phone interpreters to support the high proportion of women born overseas in western Sydney.

Oceanian women and women who smoked during pregnancy had the lowest utilization of ANC services, both before and after. ANC utilization in Oceania is among the lowest in the world.28 Women who smoke during pregnancy may have lower health literacy and poorer motivation to self-care generally and during pregnancy.

Consistent with other studies,29 midwifery “continuity of care” proved to be robust as women who chose this mode of care had the highest number of consultations, both before and after the start of the pandemic. This success of midwifery continuity of care may be attributed to the increased confidence of the women resulting from a trusting relationship with the same midwife.30

STRENGTHS AND LIMITATIONS

This study provides information on the effects of the COVID-19 pandemic on the use of telehealth and face-to-face visits for ANC. Such information is essential for improving ANC but is currently lacking. Data of three-quarters of women who gave birth in public hospitals as public patients were included,16 enabling the results to be representative of the majority of women in western Sydney.

The study was limited by a lack of information on gestational age at each telehealth consultation because telehealth should not replace face-to-face visits at certain stages of pregnancy when procedures such as vaccinations and tests are recommended. As telehealth may range from telephone to live videoconferencing, there can and often is much variation in telehealth consultations and their comparability with face-to-face visits, which we were unable to examine.

We did not examine the effects of telehealth on birth outcomes before and after the pandemic started because apart from telehealth, many other factors associated with the outcomes, for example, exercise and mental health, could have been different during the two time periods. It would be inappropriate to attribute any changes in outcomes to telehealth when other factors did not remain constant. Adequate ANC, an important component of pregnancy care, is essential for positive birth outcomes1 and therefore is itself a valuable measure.

Conclusions

Use of telehealth was limited with only one in eight ANC services being a telehealth consultation after the pandemic started. The increase in telehealth antenatal consultations in the LHD did not compensate for the reduction in the number of face-to-face visits. Most groups of women showed a reduction in the number of visits and the total services, but the reduction was greatest among women who attended the tertiary hospital, had shared care, were older than 35 years, were from Latin America, and conceived through IVF. Efforts should be focused on improving take-up of telehealth consultations, especially among the identified groups. Future studies should examine in detail the barriers to scheduled and quality telehealth, opinions of health professionals, women’s satisfaction, and, especially, birth outcomes.

Authors’ Contributions

All the listed authors meet the authorship criteria by participating in the design of the study, data analyses, interpretation of results, and writing of the article. All authors are in agreement with the content of the article.

Acknowledgments

The authors would like to thank Prof. Steven Leader for his valuable comments, Ms. Olivia Wroth for her professional editing, Ms. Monica Hook for extracting the eMaternity data, and the women whose information was used in the study.

Disclosure Statement

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding Information

No funding was received for this article.

REFERENCES





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