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Comment on the Proposed New and Revised PCORI Methodology Standards (2016)
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The COVID-19 pandemic triggered many uncertainties and concerns for pregnant people, who were faced with navigating frequent prenatal and postpartum healthcare visits under risk of COVID-19 exposure. The pandemic has also seen the rapid growth of telehealth as a replacement or supplement to usual, in-person care. Given the increased use of telehealth during the pandemic and its potential staying power afterward, an emergent need arose to better understand the benefits and harms of telehealth strategies to deliver maternal health care through a rapid review of the evidence.
What Does the Evidence Show?
The rapid review identified 41 studies comparing telehealth for the delivery of maternal health care (i.e., prenatal or postpartum care) to usual care published since 2015.
Most often, these studies focused on mental health (12 studies), general maternal care (11 studies), and diabetes (seven studies), though studies also assessed telehealth-delivered care for hypertension (three studies), breastfeeding (three studies), pregnancy-related weight gain, (two studies), smoking cessation (two studies), and asthma (one study).
Over half of the studies (25) used telehealth to supplement usual care, while the remaining 16 studies used telehealth as a replacement for usual, in-person care. Interventions were frequently multimodal (17 studies), meaning they used multiple telehealth strategies for care delivery (for example, video visits plus mobile apps for remote monitoring).
Replacing or supplementing usual maternal care with telehealth led to similar (or occasionally better) maternal, obstetric, and patient-reported outcomes compared to usual care alone, particularly for mental health, general maternal care, and prenatal diabetes. Studies of general maternal care models aimed at reducing the number of in-person visits during the pandemic typically found improved attendance and higher levels of patient satisfaction, a signal that patients find telehealth an acceptable strategy for maternal health care delivery.
Supplemental telehealth for postpartum depression appeared promising, with telehealth-delivered interventions leading to improved symptoms. Remote monitoring may be effective for managing diabetes, but the evidence was inadequate to assess effectiveness of remote monitoring for other conditions such as hypertension. Similarly, insufficient evidence for the less frequently studied conditions, including asthma, pregnancy-related weight gain, smoking cessation, and breastfeeding, means that uncertainty remains regarding the effectiveness of telehealth-delivered care in these clinical areas.
Key Evidence Gaps and Research Priorities
The evidence synthesized in this rapid review indicates that telehealth for maternal health care delivery is a promising alternative and/or supplement to usual, in-person care. Equally important are the evidence gaps identified in this review that point us to future research priorities:
- Health disparities and equity. Identified studies did not provide evidence on how outcomes varied in populations at risk for disparities. This is a critical gap, given the maternal morbidity and mortality health disparities faced by Black women. Future studies should evaluate telehealth in diverse populations, including individuals of advanced maternal age, racial/ethnic minority groups, those living in rural areas, and underserved or vulnerable populations and analyze outcomes by population characteristics in consideration of health disparities and social determinants of health.
- Access to care. While some studies reported healthcare utilization outcomes, future studies should continue to analyze access to care and acceptability of telehealth as a replacement for in-person care, particularly for underserved populations.
- Harms. Studies scarcely reported adverse effects of telehealth interventions, so questions regarding the potential harms of telehealth compared to in-person care persist and need further investigation.
- Evidence across clinical areas. A need remains for high-quality, randomized controlled trials with larger sample sizes for clinical areas not well-represented in the current evidence, such as breastfeeding, hypertension, and asthma. This includes studies evaluating remote monitoring for different clinical conditions in pregnant patients, as this appears to be a promising application of telehealth, though more evidence is needed.
Attending prenatal and postpartum visits has been a challenge for expecting parents long before the rise of COVID-19. With as many as 14 visits as part of routine prenatal care, there are patients who find it difficult or even impossible to adhere to the care schedule due to barriers such as lack of transportation, arranging time off work, securing childcare, and more.
Being able to attend healthcare visits remotely, collect routine health data at home, or communicate with providers digitally could increase access to care for many patients. However, health literacy, digital literacy, and access to technology or an internet connection among other factors means that telehealth can potentially widen existing health disparities in vulnerable and underserved populations.
Future evaluation of telehealth as a supplement or alternative to in-person maternal health care can continue to explore telehealth as a potentially safe, effective, and acceptable option for expecting parents, with an eye toward measuring impact on health disparities and access to care for those who need it most.