The Uptake of Telemedicine in Obstetric Care During the Early Acute Phase of the Coronavirus 2019 Pandemic
Introduction
The coronavirus disease 2019 (COVID-19) pandemic forced rapid adaptation in health care delivery. Medical interventions were postponed and telemedicine was quickly adopted to limit face-to-face interactions and minimize exposure risk.1,2 However, most obstetric care cannot be delayed, posing unique challenges to pregnancy management. We examined associations of patient characteristics, timing of core obstetric services, and select birth outcomes with telemedicine utilization during the initial phase of the COVID-19 pandemic.
Methods
We conducted a retrospective cohort study of patients receiving prenatal care (PNC) at two academic institutions in two different states during the early COVID-19 pandemic era (patients with last menstrual periods December 4, 2019–March 9, 2020). Institutional Review Board approval was obtained at both institutions. PNC telemedicine use, patient characteristics, obstetric services, and birth outcomes were ascertained from electronic medical record data. Health care utilization was examined by timing and number of PNC encounters, ultrasounds, and glucose challenge testing (GCT). Comparisons were made within institution using chi-square and Student’s t tests as appropriate.
Results
A total of 2,006 and 1,246 births occurred at institutions A and B, respectively, and 82.0% and 48.5% of patients had ≥1 telemedicine PNC encounter, respectively (Table 1). Telemedicine utilization was associated with significant patient-level differences at each institution, but in opposing directions. Telemedicine uptake at Institution A was highest among non-Hispanic White or Asian and commercially insured, whereas at Institution B, uptake was highest among non-Hispanic Black or Hispanic and publicly insured. At both institutions, patients with gestational diabetes and COVID-19 infection were more likely to use telemedicine. Telemedicine users initiated PNC earlier, had more total PNC visits, were more likely to have a first trimester ultrasound, and underwent earlier GCT (Table 1). There were no significant differences in cesarean or stillbirth based on telemedicine use at either institution.
| INSTITUTION A | INSTITUTION B | |||||
|---|---|---|---|---|---|---|
| NO TELEMEDICINE (n = 362) | TELEMEDICINE (n = 1,644) | p | NO TELEMEDICINE (n = 642) | TELEMEDICINE (n = 604) | p | |
| Total | 18.0% | 82.0% | 51.5% | 48.5% | ||
| Age (years) | 0.0002 | 0.88 | ||||
| <25 | 25.5% | 74.5% | 52.2% | 47.8% | ||
| 25–29 | 20.7% | 79.3% | 50.4% | 49.6% | ||
| 30–34 | 15.5% | 84.5% | 52.8% | 47.2% | ||
| 35+ | 15.1% | 84.9% | 50.3% | 49.7% | ||
| Race and ethnicity | <0.001 | <0.0001 | ||||
| Asian | 13.4% | 86.6% | 49.2% | 50.8% | ||
| Hispanic | 24.3% | 75.7% | 46.2% | 53.9% | ||
| Non-Hispanic White | 11.4% | 88.6% | 57.7% | 42.3% | ||
| Non-Hispanic Black | 22.7% | 77.3% | 37.3% | 62.7% | ||
| None of the above | 21.7% | 78.3% | 71.4% | 28.6% | ||
| Marital status | <0.001 | 0.16 | ||||
| Not married | 23.4% | 76.6% | 48.9% | 51.1% | ||
| Married or living as married | 13.0% | 87.0% | 53.0% | 47.0% | ||
| Insurance status | <0.001 | 0.0008 | ||||
| Public or other insurance | 24.7% | 75.3% | 45.6% | 54.4% | ||
| Commercial insurance | 13.0% | 87.0% | 55.4% | 44.7% | ||
| BMI | 0.0074 | 0.003 | ||||
| <30 kg/m2 | 15.8% | 84.2% | 52.9% | 47.1% | ||
| ≥30 kg/m2 | 20.8% | 79.2% | 43.4% | 56.6% | ||
| Smoking during pregnancy | 0.0008 | 0.53 | ||||
| No | 17.0% | 83.0% | 51.8% | 48.2% | ||
| Yes | 32.8% | 67.2% | 48.2% | 51.8% | ||
| Parity | 0.21 | 0.23 | ||||
| Nulliparous | 16.3% | 83.7% | 53.3% | 46.7% | ||
| Parous | 18.5% | 81.5% | 49.9% | 50.1% | ||
| Hypertension | ||||||
| Pre-existing HTN | 19.6% | 80.4% | 0.67 | 41.5% | 58.5% | 0.01 |
| HDP (any) | 20.7% | 79.3% | 0.099 | 48.5% | 51.5% | 0.27 |
| Diabetes | ||||||
| Pre-existing diabetes | 17.4% | 82.6% | 0.92 | 36.8% | 63.2% | 0.10 |
| Gestational diabetes | 10.2% | 89.8% | 0.009 | 22.6% | 77.4% | <0.0001 |
| COVID-19 during pregnancy | 0.77 | 0.02 | ||||
| No | 18.1% | 81.9% | 52.2% | 47.8% | ||
| Yes | 17.0% | 83.0% | 34.1% | 65.9% | ||
| Antenatal care visitsa | ||||||
| Total no. of PNC visitsb | 6.0 ± 3.9 | 10.5 ± 3.0 | <0.001 | 9.5 ± 3.8 | 11.0 ± 3.7 | <0.0001 |
| Total no. of in-person PNC visitsb | 6.0 ± 3.9 | 7.8 ± 2.7 | <0.001 | 9.5 ± 3.8 | 10.0 ± 3.7 | 0.19 |
| GA (days) at 1st in person PNC visitb | 140.9 ± 83.9 | 79.4 ± 43.1 | <0.001 | 99.3 ± 58.5 | 82.9 ± 43.1 | <0.001 |
| Antenatal testinga | ||||||
| No ultrasound | 8.6% | 1.2% | <0.001 | 1.6% | 0.5% | 0.09 |
| No anatomy scan | 8.8% | 1.3% | <0.001 | 5.1% | 1.3% | <0.0001 |
| 1st ultrasound in 1st trimester | 31.8% | 46.8% | <0.0001 | 57.4% | 73.7% | <0.0001 |
| Total no. of ultrasoundsb | 2.2 ± 1.4 | 2.7 ± 1.6 | <0.001 | 5.3 ± 3.9 | 6.4 ± 4.2 | <0.001 |
| Timing of antenatal testinga | ||||||
| GA days at first ultrasoundb | 129.4 ± 63.2 | 105.0 ± 49.0 | <0.001 | 100.5 ± 60.0 | 76.8 ± 38.8 | <0.001 |
| GA days at 1st anatomy scanb | 159.9 ± 37.1 | 144.2 ± 19.4 | <0.001 | 145.0 ± 29.2 | 136.9 ± 15.7 | <0.001 |
| GA days at 1st GCTb | 195.5 ± 31.6 | 189.2 ± 30.3 | 0.002 | 176.5 ± 44.6 | 162.5 ± 53.3 | <0.0005 |
| Perinatal outcomesa | ||||||
| Cesarean birth | 29.6% | 28.5% | 0.69 | 31.0% | 32.0% | 0.71 |
| Stillbirth | 0.8% | 0.4% | 0.27 | 0.8% | 0.5% | 0.73 |
Discussion
With no baseline telemedicine use at either institution, there was rapid adoption of telemedicine for PNC during the early phase of the COVID-19 pandemic. There were notable patient-level and hospital-level differences in telemedicine adoption, consistent with varied implementation in prior studies.3,4 Although patients with gestational diabetes were more likely to use telemedicine, and telemedicine users accessed obstetric services earlier in gestation, this did not translate to observed differences in delivery mode or stillbirth.
Telemedicine may improve access to health care by reducing logistic and economic barriers.5 We found that telemedicine users had at least as many in-person visits as nonusers, suggesting that telemedicine augmented rather than replaced in-person PNC. In a bundled obstetric care payment system, this may be viewed as a value-added service; however, further research should assess whether supplemental telemedicine improves outcomes. Our study highlights successful efforts to maintain adequate PNC provision amidst the acute challenges of the early pandemic.
Conclusions
Obstetric telemedicine was rapidly adopted amidst a public health crisis, but implementation varied across institutions. It remains unclear whether telemedicine promotes or ameliorates disparities in access to obstetric care given the varied findings between institutions. Further research is needed to guide clinicians, administrators, and policymakers as they consider the role of telemedicine during PNC outside the context of a crisis.
Authors’ Contributions
Writing—original draft preparation (equal) and writing—review and editing (lead) by K.M.M. Data curation (equal), methodology, and formal analysis (equal) by L.S.L. Conceptualization (supporting), data curation (equal), and writing—review and editing (supporting) by H.H.B. Data curation (equal), formal analysis, and writing—review and editing (supporting) by R.F.L. Writing—review and editing (supporting) by M.S., J.G., S.C.H., and K.D. Conceptualization (lead), data curation (equal), methodology, formal analysis (equal), writing—original draft preparation (equal), and writing—review and editing (supporting) by J.C.
Disclosure Statement
No competing financial interests exist.
Funding Information
H.H.B., M.S., S.C.H., and J.C. received financial support from Highmark Blue Cross Blue Shield Delaware’s donor-advised fund, BluePrints for the Community, and from Independence Blue Cross from December 1, 2020 to November 30, 2021.
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