As covid-19 has taken over the US, medical providers have looked for any possible way to keep people home and out of hospitals without compromising care. We’re only now coming to grips with the unintended consequences of changes meant to slow the spread of the coronavirus and relieve strain on the medical system.
One of the most significant is that millions of women and babies have become subjects in a hasty experiment. The hypothesis: Would it be better if more prenatal and postpartum care happened at home?
Pregnancy, including birth and aftercare, is the single largest reason for hospital visits in the US, and on average a typical pregnancy will involve between 12 and 14 medical appointments. Proper prenatal visits can prevent life-threatening complications. But limiting in-person care is vital during the pandemic, especially for pregnant women, who are more likely to develop severe or even fatal covid infections.
“It didn’t take long for telehealth visits to explode,” says Melissa Simon, a professor and obstetrician-gynecologist at Northwestern Medicine in Chicago, who mostly sees patients on Medicaid or without health insurance.
That expansion may be a silver lining of the pandemic. Access to prenatal and postpartum care is incredibly unequal in the United States, and experts have long argued that telehealth can help fill in the gaps. That solution, of course, is available only to women who have access to a connected device.
“Covid definitely exacerbated everything”
The use of virtual care, often called telehealth, has grown steadily in many fields of medicine over the last decade. It can be as simple as a phone call or text message, or as complex as a system where patients use monitoring devices to send their vital signs to the cloud.
Obstetrics, however, had largely remained an in-person practice until the current confluence of pandemic-related funding, policy changes, and technological developments began changing things.
For example, pregnant women have traditionally seen a doctor for regular blood pressure checks that could turn up warning signs of preeclampsia, a complication responsible for 70,000 maternal deaths and half a million miscarriages every year worldwide. Now some companies are providing blood pressure cuffs equipped with remote monitoring technology so that women can get checked from home instead.
“Covid definitely exacerbated everything,” says Juan Pablo Segura, the president and cofounder of Babyscripts, one company providing such services. “Our enrollment numbers have increased by 10 times.”
Telehealth is also bringing extra support into women’s hospital rooms at a time when medical facilities have limited the number of people women can have at their bedsides during labor, meaning that some doulas have been excluded. Studies show that having independent representation and help during birth can be the difference between life and death. This is especially true for Black, American Indian, and Alaska Native women, who face maternal mortality rates unheard of elsewhere in the developed world; over half these deaths are preventable.
Tennis player Serena Williams, who almost died when clinicians initially dismissed her concerns about a postpartum pulmonary embolism, subsequently invested in the telehealth platform Mahmee, which provides care coordination for patients seeing providers in different systems. It also employs nurses, lactation consultants, and others who respond to messages and offer women advice or health screenings as issues come up.
Although it wasn’t designed for the pandemic, it’s been a lifeline to many women and their advocates over the past few months.
Ashanti Rivera, a doula in Connecticut, has used the service to visit with women virtually in the delivery room. “If people were nervous about giving birth before, they’re even more nervous about going to the hospital now,” she says. “We’ve used video calls during labor to have a deeper sense of connection—as close to being there as you can be.”
“You’re going to catch serious issues faster”
It’s not only in the run-up to giving birth that technology is being used, however. Services are also being used to provide postpartum support, which is particularly important because women’s hospital stays are shorter during the pandemic. New mothers are generally being sent home with their baby in 24 hours or less, as opposed to the two days that was typical before.
“Lactation education and support, how to heal yourself, how to nourish your body to nourish your baby—those conversations are being stunted to get people out of the hospital faster,” says Melissa Hanna, Mahmee’s cofounder and CEO.
The company also offers at-home screenings for depression, which before the pandemic affected between 15% and 20% of pregnant or postpartum women. Recent evidence suggests as many as a third of women may now be experiencing depression during or after pregnancy.
Hanna points out that a pandemic pregnancy is already stressful enough—but for Black women the confluence of isolation, a pandemic that has had a disproportionate impact on racial minorities, and a months-long reckoning over racist police violence has created conditions uniquely conducive to anxiety and depression. There’s been a significant increase in women being flagged as at risk of depression after taking Mahmee’s screenings, although Hanna says they have yet to properly analyze those patterns.
She recalls an incident in the fall when a woman who had recently given birth messaged the Mahmee team looking for help, worried her three-week-old baby didn’t recognize her.
“I’m just a ball of nerves right now,” she told one of the company’s nurses, according to Hanna. “I’ve got an older Black son living through this chapter of American history and seeing how Black men are treated in this country. I just had a baby. I just don’t feel like myself right now.” The care team called her doctor, who Hanna says replied, “Now that I think about it, she had a really traumatic birth experience. I probably should have checked on her.” The woman—who had reached out to the doctor days before and received no reply—was able to join a support group and receive lactation counseling through the platform.
“By actively listening to women and women’s needs, you’re going to be there faster, to catch really serious issues before they become life-threatening and incredibly costly,” Hanna says.
As with all virtual care, however, these advances come with caveats. One is the need for proper training to use services and monitoring devices.
“Before you give someone a blood pressure cuff, or ask them to order one, you have to train them how to use it,” says Dawn Godbolt, policy director at the National Birth Equity Collaborative. “Right now, the chaos of living in a global pandemic—things like that can be easily missed, and then you have women sitting at home saying, ‘I don’t know how to use this.’”
Some Medicaid plans have begun covering at-home blood pressure cuffs and other monitoring equipment. But equity and access remain a challenge, reflecting the wider inequalities across the American health system. There’s an acute shortage of women’s health care in the US—50% of the nation’s counties don’t have a single doctor who specializes in obstetrics and gynecology. In many of those same areas, broadband access is limited too, and outside of cities and major metropolitan areas, 60% of health-care facilities don’t have access to high-speed internet.
This means that problems of access are not necessarily resolved by the expansion of telehealth, and may actually be worsened.
“We have to protect those advances”
One of the other major changes forced through by the pandemic has to do with money. Many health-care providers have called for expansion of maternal telehealth services for years, but lack of insurance reimbursement has been one of the largest barriers. Several federal bills had languished in committee over the last two years, despite many bipartisan cosponsors. Emergency orders and legislation changed all that, almost overnight.
State and federal officials have expand telehealth coverage through Medicaid, which pays for almost half of all births in America, while systems and individual providers have invested more heavily in tools that connect them to patients outside the clinic walls.
The CARES Act, a covid relief package passed in March, included at least $400 million in funding for telehealth programs. Of that, $4 million went to the Maternal Telehealth Access Project, a group tasked with granting money to providers trying to expand virtual care.
Many grantees have asked for basic telehealth equipment, including subscriptions to Mahmee, says Godbolt, who directs the Access Project as part of her work at the National Birth Equity Collaborative. Other common requests have included Wi-Fi hot spots, laptops, iPads, and home monitoring equipment. Others have stepped in to provide services where they are not available: in April, the Nurse-Family Partnership, an organization that sends registered nurses for weekly visits with first-time moms in underserved communities, partnered with Verizon to give more than 2,800 mothers and moms-to-be iPhones and data plans.
Payment for telehealth is a new status quo that many would like to preserve.
Tina Smith, a Democratic senator from Minnesota, has been pushing legislation to expand federal reimbursement for telehealth. “As we emerge from the immediate response to the pandemic, we have to protect those advances,” she says.
“What are we losing when we can’t physically touch each other?”
Even with all these advances, widespread challenges remain, especially for women who didn’t have adequate access to health care in the first place. The pandemic has only made that more difficult, even if devices are paid for.
For Simon, the doctor at Northwestern, it’s been a challenge building relationships and connecting with women remotely. While some patients at her hospital are seeing doctors through video visits, she connects with most of hers by phone.
“Especially for patients who are publicly insured or pregnant patients of color, they’re already at a baseline of mistrust of the medical system,” she says. There is some trial and error. Her patients may also struggle to find privacy, or feel uncomfortable with a doctor seeing into their homes.
Some women may also worry they won’t receive quality care without in-person visits, says Maria Chionchio, who manages the Rhode Island branch of the Nurse-Family Partnership.
“Some moms don’t understand. They just feel that ‘This is a doctor—I have to go in,’” she says. But for women with a lower-risk pregnancy, “it’s safer for them to stay at home and have a telehealth visit.”
Several major health systems have found that—at least for women with low-risk pregnancies—switching some visits to telehealth and monitoring their own blood pressure, weight, and fetal heartbeat resulted in less prenatal stress with no change in outcomes.
Still, there are trade-offs. Deciding which visits to make virtual and which to keep in person has been a controversial topic. Women are more likely to experience life-threatening complications later in pregnancy, for instance. But before 20 weeks, they won’t know that their developing babies are healthy unless doctors can listen to the heartbeat, says Marielle Gross, a bioethicist and obstetrician-gynecologist at University of Pittsburgh Medical Center.
Senator Smith cautions that the excitement about telehealth can’t replace efforts to expand access to in-person care, even if it’s less expensive for providers.
“Imagine that rural mom of color who just does not have the transportation or work schedule that would allow her to go in and get her regular prenatal check-in,” Smith says. “She can do some of that on the phone or on a video conference call, but she can’t do all of it on a video call.”
Gross knows firsthand about problems that can’t be fixed by telehealth alone. Many of her patients live in rural areas, where hospitals have been closing obstetrics units for decades. Some women drive an hour or more to see her.
A mixed approach may be best. “I’m very optimistic that hybrid prenatal care—having telehealth and in-person visits—will extend access and hopefully improve outcomes for everyone, specifically for low-income and minority women,” says Melissa Simon.
“The whole floor is a crack”
In spite of all these advances, however, access to health care for pregnant women remains an issue at every level. Earlier this year, Gross got a call about a woman who had recently given birth at the hospital and then turned up at an emergency room an hour and a half away with full-blown postpartum psychosis. The woman had no car, so she couldn’t get back to the obstetrics department.
“I said to one of the midwives, ‘When she left the hospital, we knew she needed follow-up, we knew she wouldn’t be able to go, and we don’t have a program to close that gap. So how do patients like that get seen?’ [The midwife] just looked at me and said, ‘They don’t.’”
“That’s not falling through the cracks,” says Gross. “It’s like the whole floor is a crack, and there’s a tiny little walkway you have to cross to get care.”
Simon, too, emphasizes the importance of improving women’s ability to receive in-person care. But she hopes some of the changes to telehealth are here to stay. “We just need to figure out the right formula,” she says.
This story is part of the Pandemic Technology Project, supported by the Rockefeller Foundation.