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A double-edged sword-telemedicine for maternal care during COVID-19: Findings from a global mixed-methods study of healthcare providers

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Introduction The COVID-19 pandemic has led to a rapid implementation of telemedicine for the provision of maternal and newborn healthcare. The objective of this study was to document the experiences with providing telemedicine for maternal and newborn healthcare during the pandemic among healthcare professionals globally. Methods The second round of a global online survey of maternal and newborn health professionals was conducted, disseminated in 11 languages. Data were collected between 5 July and 10 September 2020. The questionnaire included questions regarding background, preparedness and response to COVID-19, and experiences with providing telemedicine. Descriptive statistics and qualitative thematic analysis were used to analyse responses, disaggregated by country income level. Results Responses from 1060 maternal and newborn health professionals were analysed. Telemedicine was used by 58% of health professionals and two-fifths of them reported not receiving guidelines on the provision of telemedicine. Key telemedicine practices included online birth preparedness classes, antenatal and postnatal care by video/phone, a COVID-19 helpline and online psychosocial counselling. Challenges reported lack of infrastructure and technological literacy, limited monitoring, financial and language barriers, lack of non-verbal feedback and bonding, and distrust from patients. Telemedicine was considered as an important alternative to in-person consultations. However, health providers emphasised the lower quality of care and risk of increasing the already existing inequalities in access to healthcare. Conclusions Telemedicine has been applied globally to address disruptions of care provision during the COVID-19 pandemic. However, some crucial aspects of maternal and newborn healthcare seem difficult to deliver by telemedicine. More research regarding the effectiveness, efficacy and quality of telemedicine for maternal healthcare in different contexts is needed before considering long-term adaptations in provision of care away from face-to-face interactions. Clear guidelines for care provision and approaches to minimising socioeconomic and technological inequalities in access to care are urgently needed.
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GalleA, etal. BMJ Global Health 2021;6:e004575. doi:10.1136/bmjgh-2020-004575
A double- edged sword—telemedicine
for maternal care during COVID-19:
ndings from a global mixed- methods
study of healthcare providers
Anna Galle ,1 Aline Semaan,2 Elise Huysmans,2 Constance Audet,2
Anteneh Asefa ,2 Therese Delvaux,3 Bosede Bukola Afolabi ,4
Alison Marie El Ayadi ,5 Lenka Benova2
Original research
To cite: GalleA, SemaanA,
HuysmansE, etal. A double-
edged sword—telemedicine for
maternal care during COVID-19:
ndings from a global mixed-
methods study of healthcare
providers. BMJ Global Health
2021;6:e004575. doi:10.1136/
bmjgh-2020-004575
Handling editor Seye Abimbola
Additional material is
published online only. To view,
please visit the journal online
(http:// dx. doi. org/ 10. 1136/
bmjgh- 2020- 004575).
Received 27 November 2020
Revised 3 February 2021
Accepted 10 February 2021
For numbered afliations see
end of article.
Correspondence to
Dr Anna Galle;
anna. galle@ ugent. be
© Author(s) (or their
employer(s)) 2021. Re- use
permitted under CC BY- NC. No
commercial re- use. See rights
and permissions. Published by
BMJ.
ABSTRACT
Introduction The COVID-19 pandemic has led to a
rapid implementation of telemedicine for the provision of
maternal and newborn healthcare. The objective of this
study was to document the experiences with providing
telemedicine for maternal and newborn healthcare during
the pandemic among healthcare professionals globally.
Methods The second round of a global online survey
of maternal and newborn health professionals was
conducted, disseminated in 11 languages. Data were
collected between 5 July and 10 September 2020. The
questionnaire included questions regarding background,
preparedness and response to COVID-19, and experiences
with providing telemedicine. Descriptive statistics and
qualitative thematic analysis were used to analyse
responses, disaggregated by country income level.
Results Responses from 1060 maternal and newborn
health professionals were analysed. Telemedicine was
used by 58% of health professionals and two- fths of
them reported not receiving guidelines on the provision
of telemedicine. Key telemedicine practices included
online birth preparedness classes, antenatal and
postnatal care by video/phone, a COVID-19 helpline and
online psychosocial counselling. Challenges reported
lack of infrastructure and technological literacy, limited
monitoring, nancial and language barriers, lack of non-
verbal feedback and bonding, and distrust from patients.
Telemedicine was considered as an important alternative
to in- person consultations. However, health providers
emphasised the lower quality of care and risk of increasing
the already existing inequalities in access to healthcare.
Conclusions Telemedicine has been applied globally to
address disruptions of care provision during the COVID-19
pandemic. However, some crucial aspects of maternal
and newborn healthcare seem difcult to deliver by
telemedicine. More research regarding the effectiveness,
efcacy and quality of telemedicine for maternal healthcare
in different contexts is needed before considering long-
term adaptations in provision of care away from face-
to- face interactions. Clear guidelines for care provision
and approaches to minimising socioeconomic and
technological inequalities in access to care are urgently
needed.
INTRODUCTION
The WHO declared COVID-19 a pandemic
on 11 March 2020, as a consequence of the
more than 118 000 cases spread over 110
countries and the sustained risk of further
global spread.1 The overall response strategy
in many countries for fighting the pandemic
included early diagnosis, patient isolation,
monitoring of contacts, isolation of suspected
Key questions
What is already known?
Telemedicine is the delivery of healthcare services
by healthcare professionals from distance through
using information and communication technologies
for the exchange of valid and correct information.
Telemedicine for maternal and newborn health can
safely be used to deliver certain components of care
in highly controlled settings where the technology is
available and accessible to patients.
Telemedicine has been applied rapidly and on a
wide scale during the COVID-19 pandemic to replace
face- to- face visits along the continuum of maternal
and newborn healthcare.
What are the new ndings?
Maternal and newborn healthcare providers globally
considered telemedicine of benet during the pan-
demic and applied it on a wide scale for different
aspects of maternal and newborn healthcare.
The rapid adaptation to provision of care via tele-
medicine was not optimally supported by guidelines,
training for health providers, adequate equipment,
reimbursement for cost of connectivity and insur-
ance payments for care provided remotely.
Healthcare providers worldwide reported not being
able to reach a substantial group of families by tele-
medicine and encountered different barriers in pro-
viding high- quality maternity care by telemedicine,
and such challenges were more prominent in low-
income and middle- income countries.
2GalleA, etal. BMJ Global Health 2021;6:e004575. doi:10.1136/bmjgh-2020-004575
BMJ Global Health
and confirmed cases, and some extent of lockdown.2 In
this context, the vital role of telemedicine, video consul-
tations in particular, rapidly increased in order to reduce
the risk of transmission, especially in settings where
insufficient personal protective equipment was available
for the health workforce. The call for implementing
telehealth rapidly has never been louder, especially in
high- income countries (HICs) where technological
resources are widely available.3–5 As a consequence, an
updated framework for telemedicine in the COVID-19
pandemic for aiding national governments in defining
their strategy against COVID-19 was proposed at the start
of the pandemic, advising telehealth for all routine care
and (suspected) COVID-19 positive cases with mild symp-
toms.4 This framework and other variations have been
used on a large scale by governments and health systems
globally to define and implement their public health
response to the COVID-19 outbreak while maintaining
the provision of essential health services and avoiding the
so- called ‘COVID-19 collateral’.4 6 7
According to the WHO, telehealth is the delivery of
healthcare services by healthcare professionals from
distance through using information and communication
technologies for the exchange of valid and correct infor-
mation.8 Sometimes the term telemedicine is specifically
used to refer to service delivery by physicians only, while
telehealth includes service provision by nurses, pharma-
cists and other health professionals. In a broader defini-
tion, the term telehealth also includes the interactions
between healthcare providers (eg, delivery of training,
team meetings) and the interaction of a patient with
technology in the absence of a health provider (eg, an
automated phone line, a health application (app) on a
mobile phone).9 In this paper, we use the terms telemed-
icine and telehealth synonymously and interchangeably.8
A wide variety of telehealth interventions exists today,
including the use of mobile phone apps, online health
education modules, web portals, wearable devices, text
messaging (SMS) and live audio- visual communication.9
The benefits of investing in telemedicine (sometimes
also referred to as m- health or e- health10–12) have been
discussed in the literature mainly from a public health
perspective, documenting the many successes in different
health service domains and countries,13–15 ranging from
economic efficiency to overcoming distance barriers in
remote areas.16 Telemedicine applications seem most
commonly used and evaluated for the management
of chronic diseases and mental disorders in HICs.17–20
Recently, the use of telehealth has expanded dramatically
during the COVID-19 pandemic due to the necessity of
maintaining service provision while ensuring physical
distancing as a strategy for slowing down the transmis-
sion of the virus, and limited accessibility of healthcare to
both patients and providers.3
Previous epidemic outbreaks and events disruptive to
health systems showed the potential of telemedicine in
avoiding further spread of an epidemic disease and main-
taining some provision of general healthcare.4 A mobile
app named Ebola Contact Tracing could successfully
monitor and trace contacts of confirmed cases during
the Ebola virus outbreak in Sierra Leone and healthcare
providers were educated and trained via a virtual tuto-
rial.21 22 Studies also explored the use of telehealth in the
context of natural disasters and conflicts, with promising
results. In the aftermath of two hurricanes in the USA in
2017, telemedicine was successfully used for the imple-
mentation of free two- way video consultations for victims,
although the lack of infrastructure and Wi- Fi access were
cited as serious challenges.23
Since the start of the COVID-19 pandemic, telehealth
has been increasingly implemented in many countries
and different health domains to maintain health service
provision to some extent.24 Several studies have reported
positive results in terms of providers’ and patients’ experi-
ences, and clinical outcomes,25 26 but the evidence base so
far is limited and covers a narrow range of health services
and contexts. For handling confirmed COVID-19 cases
with mild symptoms, the maximum use of telemedicine
for guaranteeing providers’ and other patients’ safety has
not been questioned as an essential part of reducing the
spread of the virus.27 28 On the other hand, the necessity
for and evidence regarding providing some elements of
care for healthy pregnant women and newborns through
telemedicine remain scarce.29
The evidence on telehealth interventions in maternal
and newborn healthcare before the COVID-19 pandemic
is mixed. Two recent systematic reviews found that tele-
health interventions were associated with improvements
in obstetric outcomes, perinatal smoking cessation,
continuation of breast feeding, monitoring of high-
risk pregnancies and early access to medical abortion
services.30 31 The included studies presented a wide
variety of telehealth interventions in maternal healthcare,
including use of mobile phone apps, wearable devices,
SMS and live audio- visual communication. However, only
studies conducted in HICs and China, a rapidly growing
middle- income country (MIC), were included in both
reviews. Robust evidence from low/middle- income coun-
tries (LMICs) is lacking, mainly due to poor methodical
quality of studies and their narrow scope (often focusing
on a single application in a specific setting).32 SMS support
Key questions
What do the new ndings imply?
Pre- existing inequalities in access to high- quality care might have
increased by the large scale and rapid implementation of telemedi-
cine during the COVID-19 pandemic in different settings.
Uptake of telemedicine by women was hampered by various factors
such as internet connection problems, lack of the necessary equip-
ment, digital illiteracy, and distrust.
In- depth research is needed to formalise evidence- based guide-
lines for the implementation of telemedicine along the continuum
of maternal and newborn care, as lessons learnt for building back
beyond the COVID-19 pandemic and also for future emergency
preparedness.
GalleA, etal. BMJ Global Health 2021;6:e004575. doi:10.1136/bmjgh-2020-004575 3
BMJ Global Health
for women during pregnancy seemed the most prom-
ising and commonly evaluated telehealth intervention in
low- income country (LIC) contexts, and was associated
with increased utilisation of healthcare, early initiation
of breast feeding, uptake of recommended prenatal and
postnatal care (PNC) consultations, skilled birth atten-
dance and infant vaccination.10 15 32 33 Telehealth appli-
cations for maternal health have been implemented also
in conflict settings and among migrant women before
the COVID-19 pandemic, where they appear useful for
providing maternal health education.34–36
The importance of telehealth for maintaining the
provision and use of essential maternal and newborn
health services during the COVID-19 pandemic has been
highlighted by the WHO.29 In its operational guidance
for the COVID-19 context, the WHO identified health
interventions during the antenatal, intrapartum and
postnatal periods as essential services, and suggested the
use of telemedicine when the technology is available.29
Evidence regarding its implementation, effectiveness,
feasibility, cost- effectiveness and health outcomes is begin-
ning to emerge but remains scarce. Available reports,
mostly commentaries and grey literature, have high-
lighted some challenges and concerns for implementing
telemedicine in maternal and newborn health alongside
its advantages. The availability of technology and connec-
tivity seem to pose a serious bottleneck, together with
high start- up costs and lack of health insurance reim-
bursement for care provided remotely.37 38 Concerns
regarding a ‘digital divide’, meaning increasing maternal
and newborn health disparities and inequities as a conse-
quence of access to technology and connectivity, have
also been raised.39 40
Despite the efforts to supplement the reduction in
the provision of in- person maternal and newborn care
by telemedicine during COVID-19, little is known about
the actual implementation of these efforts and barriers to
their effectiveness as perceived by healthcare providers.
This paper documents the findings of a rapid online
global survey of maternal and newborn health profes-
sionals during the COVID-19 pandemic, focusing on
their experience of providing care to pregnant and post-
partum women and their newborns using telemedicine.
METHODS
Study design
We present the findings from the second round of a
repeated cross- sectional online survey of maternal and
newborn healthcare providers. We focus on the appli-
cation of telemedicine for maintaining the provision of
maternal and newborn healthcare during the COVID-19
outbreak. The survey targeted midwives, nurses, obste-
tricians/gynaecologists, neonatologists and other health
professionals. An invitation to complete the survey was
distributed to those who responded to the first round of
the survey, and to other healthcare providers through
personal networks of the multicountry research team
members, maternal/newborn platforms and social media
(eg, Facebook, Twitter, WhatsApp groups). Additional
details about the study design, sampling and findings of
the first round of the survey were published previously.41
Questionnaire
A team of international collaborators adapted the ques-
tionnaire used in the first round of the survey in light
of the evolving situation of the pandemic. The team
included health professionals and experts in health
systems, maternal health epidemiologists and public
health researchers, acknowledged in a previously
published commentary42 and paper based on the first
round of the global survey.41 The core structure of the
first survey round was maintained and we collected data
on respondents’ background, preparedness for COVID-
19, response to COVID-19 and own work experience
during the pandemic. We additionally aimed to expand
our understanding and explore some of the themes that
were developed during analysis of the responses received
during the first round more in depth.43 We added a
section on the use of telemedicine, where we asked
participants whether they used technology to counsel or
provide care to women or their babies remotely, and if
so, which services. We asked whether they received any
guidelines on telemedicine provision. Finally, we also
asked whether they used telemedicine in the same way
compared with before the pandemic, more, or only
started since the beginning of the pandemic.
In open text responses, we asked respondents to
share the top three successes and challenges that they
experienced using telemedicine. Further, respondents
could share their general concerns about providing care
during the pandemic in an open text box at the end of
the questionnaire. The questionnaire was available in 11
languages (English, French, Arabic, Italian, Portuguese,
Spanish, Japanese, German, Dutch, Russian and Kiswa-
hili). The questionnaire is available publicly44 and the
questions relevant to telemedicine are provided in online
supplemental file 1.
Data processing and analysis
We included responses collected between 5 July 2020
and 10 September 2020. We cleaned the 1331 responses
received by removing duplicate submissions (n=14),
refusals to participate (n=131), submissions with more
than 85% of questions with missing answers (n=46)
and submissions from respondents who skipped all the
telemedicine questions (n=80). Quantitative and qual-
itative analyses were done simultaneously in a concur-
rent design. Quantitative analysis involved producing
descriptive statistics (frequencies and percentages) using
Stata/SE V.14. Descriptive statistics revealed the over-
representation of healthcare providers from Kazakhstan
in our sample. This was a result of a proactive dissemina-
tion of the survey by the Ministry of Health in Kazakh-
stan. A sensitivity analysis was conducted, showing that
in Kazakhstan 67% of respondents used telemedicine vs
4GalleA, etal. BMJ Global Health 2021;6:e004575. doi:10.1136/bmjgh-2020-004575
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52% from other MICs. We did not apply any statistical
corrections for the sampling because this mixed- methods
analysis did not aim to make generalisable statements
about telemedicine use by country income levels. The
Kazakhstani responses were taken into consideration
when summarising and interpreting the qualitative data.
All open- ended text responses were translated to
English by AG (fluent in Spanish, Portuguese, English,
Dutch and French) and by AS (Arabic), with additional
assistance from the research team with translating and
interpreting responses received in other languages.
Responses to open- ended questions were analysed using
Braun and Clarke’s six- phase framework for thematic
analysis and inductive coding.43 This framework involves
a reflexive process of moving forward (and sometimes
backward) through data familiarisation, coding, theme
development, revision, naming and writing up. The
open- ended responses were read and reread in order
to generate initial ideas. Data were then systematically
coded by one researcher (AG), and the developed codes
and themes were discussed on a weekly basis with the
multidisciplinary coauthor team (including a midwife,
nurse, medical doctor, anthropologist, maternal health
epidemiologist and quantitative public health scientist).
Inconsistent codes were rejected or adapted and over-
arching themes were developed. The last two phases
involved refining the themes extracted from the data,
adding quotes and double checking if the themes really
reflected the respondents’ experiences and perceptions
with feedback from the coauthor group. Throughout
this process, we paid special attention to the context in
which the participants’ experiences and thoughts were
rooted (ie, country, position in the team, cadre). Finally,
the continuum of maternal and newborn care was used as
a framework for visualising the results.45
Patient and public involvement
No patient or public involvement took place in the design
or conduct of this study. We involved health professionals,
experts in health systems, infectious diseases, infection
prevention and control, and health epidemiologists, and
public health researchers from various global settings in
the design of this study and the survey tool. We intend to
disseminate the main results to several stakeholders and
health professionals globally by social media and personal
contacts, including to the participants of the study.
RESULTS
Table 1 displays the background characteristics of the 1060
survey participants included in the analysis. Respond-
ents worked in 71 different countries, most commonly
in Kazakhstan (n=507), the Democratic Republic of the
Congo (n=43), Italy (n=43), Nigeria (n=37) and Japan
(n=34). The most common cadres of health professionals
in the sample were nurses (29%), midwives and nurse-
midwives (25%), and obstetricians/gynaecologists (21%).
The majority of respondents identified as women (78%).
Table 1 Respondents’ background and workplace
characteristics (n=1060*)
n (%)
Country income level†
High- income 277 (26)
Middle- income 682 (64)
Low- income 101 (10)
World region
East Asia and Pacic 41 (4)
Europe and Central Asia 675 (64)
Latin America and Caribbean 66 (6)
Middle East and North Africa 53 (5)
North America 25 (2)
South Asia 27 (2)
Sub- Saharan Africa 173 (16)
Cadre
Midwife/nurse- midwife 257 (25)
Nurse 312 (29)
Obstetrician/gynaecologist 223 (21)
Neonatologist/paediatrician 73 (7)
Medical doctor (no specialisation) 126 (12)
Other 54 (5)
Position
Head of facility 44 (4)
Head of department or ward 103 (10)
Head of team 87 (8)
Team member 237 (22)
Interim member 74 (7)
Independent or self- practicing 110 (10)
Other 360 (34)
Gender
Female 826 (78)
Male 213 (20)
Prefer not to mention 7 (2)
Type of care provided (multiple responses
allowed)
Outpatient ANC 402 (38)
Home- based childbirth care 76 (7)
Outpatient PNC 321 (30)
Outpatient breastfeeding support 255 (24)
Inpatient ANC 284 (27)
Inpatient childbirth care 362 (34)
Inpatient PNC 325 (31)
Surgical care 169 (16)
Neonatal care (small and sick newborns) 157 (15)
Home visits 152 (14)
Community outreach 204 (19)
Family planning provision or counselling 251 (24)
Abortion care 139 (13)
Post- abortion care 189 (18)
Continued
GalleA, etal. BMJ Global Health 2021;6:e004575. doi:10.1136/bmjgh-2020-004575 5
BMJ Global Health
Respondents were involved in providing outpatient ante-
natal care (ANC) (38%), outpatient PNC (30%), inpa-
tient childbirth care (34%) and inpatient PNC (31%).
Three- quarters of respondents worked in public health
facilities, almost half worked in urban settings (large and
small cities), and 22% worked in villages or rural areas.
Among the entire sample, 58% of health professionals
reported using some form of telemedicine (figure 1).
This includes all those who used telemedicine more
than before the pandemic, in the same way as before
the pandemic, and those who started using telemedicine
since the beginning of the pandemic. Three- quarters of
respondents from LICs were not using telemedicine at
all at the time of their response, compared with 41% of
those working in HICs and 24% in MICs. The percentage
of healthcare providers introducing telemedicine since
the beginning of the pandemic was higher among those
who worked in HICs and MICs (18% and 16%, respec-
tively) compared with LICs (1%).
Among the 612 respondents who provided healthcare
using telemedicine, 65% used telemedicine to provide
routine ANC, 59% used it to provide childbirth prepa-
ration sessions, half provided routine PNC and breast-
feeding counselling, 40% provided family planning
counselling and 17% abortion care. Thirty- nine per cent
of respondents using telemedicine reported that they did
not receive guidelines on this mode of care provision.
The qualitative analysis focused on the main prac-
tices and challenges for implementing telemedicine
during COVID-19 among maternal healthcare providers
worldwide. We identified elements of care along the
continuum of maternal and newborn healthcare which
were commonly provided using telemedicine (figure 2).
Those were further classified into different telemedicine
practices within five broad categories: (1) education and
counselling by telemedicine, (2) reducing or eliminating
personal visits, (3) replacing in- person consultations
by telemedicine, (4) setting up hotlines or information
lines, and (5) providers connecting to one another by
telehealth. The practices are explained more in detail in
table 2, including the perceived benefits by providers and
rationale for using them during the pandemic. Further-
more, we found eight general themes (not related to a
specific component of care or practice) concerning the
challenges encountered when providing telemedicine:
lack of infrastructure, technological illiteracy, remote
monitoring limitations, financial barriers, lack of non-
verbal feedback, limited bonding, language barriers and
distrust (figure 2).
Practices
The application of telemedicine along the five broad
categories was slightly different according to the context,
but they seemed to commonly exist in every world region.
Healthcare providers using telemedicine were in general
positive and enthusiastic about its potential for contin-
uing healthcare provision during the pandemic without
a transmission risk. For example, a midwife from Norway
commented that ‘telehealth is a brilliant way to have a
look and give advice without being in touch.’
Providing online group birth preparedness classes
during pregnancy was one of the most popular newly
introduced telehealth practices mentioned by respon-
dents. They explained that telemedicine was a good
alternative to face- to- face classes because education and
counselling is an element of care which does not involve
a physical examination. This care can be delivered easily
by Zoom or other video- conferencing platform/mobile
app, as explained by a midwife from Costa Rica: ‘It has
been possible to continue childbirth preparation courses
through teams or zoom. Furthermore most of the users
have smartphones that allow them to access platforms to
receive additional information afterwards.’ Respondents
who mentioned using online group birth preparedness
classes mostly worked in HICs or MICs, indicating that
n (%)
Other 147 (14)
Works in more than one health facility
Yes 742 (70)
No 300 (28)
Primary workplace
Referral hospital 202 (19)
District/regional hospital 196 (18)
Health centre 91 (8)
Polyclinic or clinic 280 (26)
Birth centre 111 (10)
Independent or self- practicing 67 (6)
Other 94 (9)
Primary workplace sector
Public (national) 532 (50)
Public (university or teaching) 107 (10)
Public (district level or below) 168 (16)
Private for prot 28 (3)
Private not- for- prot 25 (3)
Independent or self- practicing 63 (6)
Other 88 (8)
Type of area
Large city (>1 million inhabitants) 355 (33)
Small city (100 000–1 million inhabitants) 246 (23)
Town (<100 000 inhabitants) 149 (14)
Village/rural area 236 (22)
Other 43 (4)
Workplace characteristics
Facility provides caesarean section 535 (50)
Facility accepts referrals from other facilities 672 (63)
*Differential number of missing values across variables.
†According to the World Bank classication.84
ANC, antenatal care; PNC, postnatal care.
Table 1 Continued
6GalleA, etal. BMJ Global Health 2021;6:e004575. doi:10.1136/bmjgh-2020-004575
BMJ Global Health
this switch to remote technologies in the provision of
health education, in particular group sessions, might
have been less common and/or accessible in LICs. Note-
worthy, formally organised group classes are less common
in general in some regions (eg, in many African coun-
tries health information is provided to women before/
after the start of the regular ANC consultations in health
facilities, rather than specially organised birth prepared-
ness classes46 47), which might also explain why online
group classes during the pandemic were not a commonly
reported practice in those settings.
The second telehealth practice concerned the
reduction or elimination of non- essential personal
consultations. Providers did not seem to have a stan-
dard definition of what they considered as ‘essential’
versus ‘non- essential’ health consultations. Healthcare
providers used email and/or WhatsApp to send prescrip-
tions and laboratory results to their patients if needed.
This did not seem to be a completely new practice, but
was more commonly performed since the beginning of
the pandemic (as women and their families were discour-
aged from visiting health facilities unless absolutely neces-
sary) and easily accepted by patients and implemented by
providers. Medical abortion was an example of a service
mentioned within this theme. A doctor from Cameroon
described how he assisted women with an abortion, by
providing a medical prescription and a cervical- ripening
agent remotely, to reduce the time spent with the patient
in person: ‘One of the biggest successes of telemedi-
cine is preparing women with abortion remotely for
surgical aspiration. I come to perform it when ready.’ He
mentioned this telehealth practice was routine before
the pandemic.
Third, providers commonly reported the application of
telemedicine to replace face- to- face consultations. Prac-
tices that fall under this theme include conducting ante-
natal and postnatal consultations through video/phone
calls (mostly WhatsApp) instead of in- person visits in the
health facility or at the woman’s home. Contrary to the
exchange of prescriptions and lab results, this seemed
Figure 1 Percentage of respondents currently using technology to counsel or provide care to women or their babies remotely
as compared with before the COVID-19 pandemic, by country income level (%, n=1060).
Figure 2 Key types of practices and challenges of providing care through telemedicine along the continuum of maternal and
newborn healthcare (n=612) users of telemedicine during COVID-19 pandemic.
GalleA, etal. BMJ Global Health 2021;6:e004575. doi:10.1136/bmjgh-2020-004575 7
BMJ Global Health
an application of telemedicine newly introduced since
the beginning of the COVID-19 pandemic. Respondents
and patients in some countries were not able to access
health facilities due to strict curfews, lockdowns, public
transport bans and closures of health facilities, making
face- to- face consultation almost completely impos-
sible. Telehealth was described as a solid alternative to
compensate the lack of face- to- face consultations to some
extent, although with limitations. A nurse- midwife from
Uganda commented that ‘through phone calls to post-
natal mothers on breastfeeding, cord care, and thermal
care, babies have survived although they were not able
to access the health facilities for postnatal care.’ The
practice of remote blood pressure or fetal heartbeat
monitoring by women themselves (self- monitoring) was
not reported by respondents, indicating that this was not
a common practice in our sample. Importantly, respon-
dents reported cancelling some antenatal and postnatal
consultations without replacement by any form of tele-
health, especially for pregnancies considered low risk.
Currently, the WHO recommends eight ANC contacts
for a low- risk pregnancy.48 Some providers reported
reverting to a reduced number of ANC visits by using the
pre-2016 WHO recommendation of four focused ANC
visits.49 A midwife from Kenya explained that conducting
fewer ANC consultations was done in order to reduce the
Table 2 Commonly reported uses of telemedicine in maternal healthcare related to the COVID-19 pandemic and providers’
insights and perceived benets
Practices Use of telemedicine Provider’s insights and perceived benets
Education and counselling of women
and their families
Providing birth preparedness classes by video Allows ongoing provision of important
educational and supportive care.
Convenient because women and their
partners can participate and continue with other
tasks (caring for other children, for example) and
do not need transport.
Postnatal (breastfeeding) counselling and
support by video
During the COVID-19 pandemic women often
had less access to support from family and
friends, making postnatal support by healthcare
providers (in particular, midwives) even more
crucial.
Psychosocial counselling by phone/video Useful to address the generally increased
levels of anxiety during the COVID-19 pandemic.
Effective to provide information and highly
demanded by women and their families
(especially regarding COVID-19 risks and
potential negative consequences for mother and
baby if infected).
Reducing or eliminating personal
visits
Prescriptions (contraception, medication,
medical abortion pill) by WhatsApp/email
Lab results exchange by WhatsApp/email
Visits to the facility can be avoided by giving
prescriptions and/or medications for longer
periods than usual.
Face- to- face consultation time can be
reduced or eliminated when people receive
digital information/prescriptions/lab results.
Replacing in- person consultations
with telemedicine
Antenatal and postnatal care consultations by
phone/video
More often used if pregnancies were low risk,
while high risk often continued with in- person
visits.
Often a personal decision by the health
provider whether to replace in- person visits by
telehealth or not, because of the lack of ofcial
guidelines.
Easy to schedule a convenient time for
woman and health provider.
Setting up hotlines or information
lines to provide guidance on care
seeking
Women with (potential) signs of labour are
recommended to call the maternity ward
before going to the hospital
Institutional hotline for all questions regarding
maternity care during COVID-19
Hospital visits can be avoided by giving
correct information and telephone counselling
for women with questions or early signs of the
start of labour.
Providers connecting to one another
to provide better care coverage/
quality
Increased professional communication,
collaboration and training:
Exchange through WhatsApp/email/
phone
Online seminars/training sessions
Online simulations
Highly used for interdisciplinary care for
pregnant and/or postpartum women suspected
or conrmed with COVID-19.
Useful for discussing concerns regarding
high- risk patients.
Potential to avoid referrals by receiving input
from experts.
8GalleA, etal. BMJ Global Health 2021;6:e004575. doi:10.1136/bmjgh-2020-004575
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risk of infection during an ANC visit: ‘Overall, we have
less consultations because we give women less appoint-
ments so that we reduce the risk of being contaminated
during consultation.’
Respondents reported that care during labour and
delivery was provided in person during the COVID-19
pandemic. Women continued to be advised to give birth in
health facilities. Nevertheless, many healthcare providers
reported a decrease in the number of facility- based births
during the pandemic. The only new applications of tele-
health for intrapartum care during the pandemic were
that women in labour were requested to make a phone
call before travelling to the hospital. In addition, in
circumstances of shortened hospital stays after childbirth
(in some cases just a couple of hours after birth up to a
maximum of 48 hours for a normal delivery), the first
days of postpartum care were almost entirely delivered by
outpatient care, which was frequently done by telehealth.
Some respondents mentioned that only the 6- week post-
partum visit was retained as an in- person visit, because
it coincides with the newborn’s vaccination schedule.
Respondents also reported that women were more in
need of guidance and support during the postpartum
period (for example with breast feeding), in part also
due to reduced informal support by friends and family.
The fourth telehealth practice was established as
healthcare providers tried to respond to what they
described as higher levels of anxiety, psychosocial prob-
lems, questions and insecurity among pregnant and
postpartum women, all instigated by the pandemic.
Women wanted more information about the effects of a
COVID-19 infection on pregnancy and newborn, as well
as information about COVID-19- related restrictions and
procedures in the hospital. Healthcare workers reported
using online consultations, phone calls and text messages
to provide this information and support. Some health
facilities also temporarily installed telephone hotlines to
answer patients’ questions. Telehealth seemed to grant
healthcare providers, midwives in particular, a feeling
of connectedness with and care for their patients under
the difficult circumstances of COVID-19. A midwife from
Bangladesh described how telehealth combated loneli-
ness and even saved lives: ‘By providing telehealth first of
all women are not completely alone. Besides that, it also
has saved lives because I advised women by the phone
to come on time for the delivery and provided remote
abortion care.’
Fifth, beyond the application of telemedicine as a means
of contact between patients and providers, we found that
many providers reported a positive effect of the pandemic on
collaboration between health facilities and among healthcare
providers. They reported an increase in the use of telecom-
munication for exchange of information and expertise both
among colleagues and at institutional levels. A midwife from
Germany explained how team work improved as a conse-
quence: ‘One of the successes during COVID in my organi-
zation were the more frequent team meetings, partially done
online, which enabled uniform action against the spread of
the virus.’ Healthcare providers also mentioned improved
interdisciplinary collaboration by sharing guidelines (mostly
clinical COVID-19 protocols) and updates by WhatsApp/
email/phone calls. The restrictions regarding physical
training courses also increased providers’ participation in
online training modules and simulations.
Challenges
Among the healthcare providers providing telemedicine
(n=612), almost half (n=282, 46%) reported challenges
with this mode of service provision in open text responses.
The decision to offer telehealth often seemed a personal
decision made by health providers, based on a risk–benefit
assessment. Eight broad categories of challenges were iden-
tified: lack of infrastructure, technological illiteracy, remote
monitoring limitations, financial barriers, lack of non- verbal
feedback, limited bonding, language barriers and distrust.
Among respondents using telemedicine in the same way
as before the pandemic only the first two challenges were
reported. Among respondents introducing telemedicine
during the pandemic or using it more than before, all eight
challenges were reported.
Lack of infrastructure
Most healthcare providers seemed to use their own smart-
phone for providing telehealth services and one of the
biggest challenges reported was poor internet connection
and/or regular interruptions in connectivity. This was a
global problem reported by providers from both LMICs and
HICs. As noted by a midwife in the USA: ‘Trying to connect
with women from rural areas with poor wi- fi service was a
challenge.’ In LICs, electricity cuts were also mentioned by
several respondents, affecting their ability to provide tele-
health, as described by a midwife in Nepal: ‘The electricity
cuts are bothering the most. Besides, internet fall outs.’
Technological illiteracy
Lack of skills to manage the software and devices for
conducting telehealth seemed a major obstacle for both
women and health providers. While people might have
access to the necessary equipment (such as a smartphone),
they were reluctant to use it for telehealth because they do
not know how to handle the technology correctly. Installing
and using the necessary app on a mobile phone or program
on the computer seemed the most difficult step for many
people, although it was difficult to understand at which point
problems emerged from providers’ reports. A midwife from
France noted that: ‘Women do not always understand how
to use the technology properly.’ Also at the provider’s side
a midwife from Argentina mentioned a lack of technolog-
ical skills: ‘Many providers do not use telemedicine because
learning the skills to do it are a personal responsibility instead
of an institutional responsibility.’
Remote monitoring limitations
Healthcare providers reported that their inability to perform
physical examinations (such as fetal heartbeat monitoring,
blood pressure measurement or assessing fundal height)
was one of the most important shortcomings of antenatal,
GalleA, etal. BMJ Global Health 2021;6:e004575. doi:10.1136/bmjgh-2020-004575 9
BMJ Global Health
postnatal and neonatal consultations through video/phone
calls. A neonatologist in Japan who was providing care for
women and their newborns after discharge described the
most important challenges as follows: ‘When I do an online
consultation I cannot do any direct examination, I cannot
observe any reaction to an examination and I cannot do any
medical scan.’
Financial barriers
While many providers were very enthusiastic about the use
of telemedicine, they also noted that it is not affordable for
many of their patients because they lack the financial means
to purchase the necessary technical devices or airtime (also
called talk- time or data allowance). WhatsApp (installed on
a smartphone) was mentioned as communication medium
most often and also preferred by healthcare providers, but
it became clear that not everyone had a smartphone at their
disposal. This was a recurring theme in both LMICs and
HICs. A medical doctor in India wrote that ‘the use of the
phone, SMS and WhatsApp is a success for telemedicine but
only 30% of the people have a smartphone.’
Respondents themselves faced financial burdens from the
use of telemedicine on two levels: not being able to afford the
equipment and lack of reimbursement. Several mentioned
the absence of reimbursement for costs they incurred while
providing telemedicine (including the telehealth consulta-
tion itself and its associated internet/phone/data costs).
Respondents from LICs particularly reported that there
was no standard way of getting reimbursed for providing
telehealth consultations. Many patients did not have insur-
ance or insurance companies did not cover the telemedi-
cine consultations. Providers did not know how to invoice
the telemedicine consultations as patients were not coming
personally anymore. In addition, particularly midwives often
mentioned the burden of having to pay the internet/phone
costs from their own pocket; this was perceived as a serious
additional barrier. These financial issues were affecting
healthcare providers’ willingness and ability to provide
care, as noted by a midwife in Kenya in regard to the cost
of mobile data: ‘Sometimes I cannot do a follow up of the
patients because of lack of airtime.’
Lack of non-verbal feedback
Many healthcare providers reported they could not be
assured that the health information was well understood
by women because they could not read their facial and/or
body expressions. Midwives reported this problem more
frequently than obstetricians. A midwife in Nigeria elabo-
rated: ‘I don't like offering remote care. I feel that if you are
not seeing the non- verbal cues and facial expression of your
patient, you will not truly know if they are ok.’
Limited relationship and bonding
Closely related to the lack of non- verbal feedback, also the
relationship and bond between the midwife and a woman
was affected by telemedicine. This was described by a
midwife in the USA as follows: ‘Technology is a good tool,
but does not replace face- to- face conversations, palpating
a mom’s abdomen, and listening to the baby’s heart rate
in order to form warm, trusting bonds between a patient
and the midwife.’ This theme was typical among midwives
who felt that the personal interaction was part of ‘being a
midwife’: ‘My main concern is that we are not at the bedside
as midwives traditionally are’, noted a midwife in the USA.
Language barriers
Language barriers were perceived to be more problematic
during telemedicine compared with in- person consultations.
Healthcare providers found it easier to overcome language
barriers during in- person visits by using body language,
which was not feasible virtually. Also, the use of interpreters
was sometimes not possible or more problematic for online
consultations compared with face- to- face visits. A nurse-
midwife from the USA described how both language barriers
and financial barriers hampered access to telehealth: ‘Using
medical interpreters over the video is a real challenge.
Furthermore, our most disadvantaged patients also have
limited access to telephone or video.’
Distrust
Healthcare providers perceived that some patients had little
trust in the care provided through telemedicine and were
reluctant to accept it. One specific problem perceived by
health providers was that undocumented migrants refused
telehealth consultations because they were afraid to be
recorded during such interactions and feared a possible
prosecution. A midwife in the USA explained: ‘Many of
my patients are not documented or are in the U.S. tempo-
rarily, and are thus reluctant to participate in video and tele-
phone visits due to well- grounded fears of information being
recorded or listened to by government agencies.’
DISCUSSION
This study used a rapid global online survey to understand
the care process adaptations used by more than a thou-
sand maternal and newborn health providers from over 70
countries during the COVID-19 pandemic. We found that
telemedicine was frequently used for various services along
the continuum of maternal and newborn healthcare and
differed somewhat across contexts. The choice of providing
telemedicine was often a personal decision of each health
professional, rather than a health facility policy, or a country
guideline. This means that some healthcare providers
reported that personal financial costs were a serious barrier
to provision. Telemedicine was already practised to a certain
extent before the pandemic by two- fifths of the respondents,
but more widely implemented during the pandemic by one
in five. Some healthcare providers also introduced telemedi-
cine for the first time during the pandemic. Health providers
implementing telemedicine for the first time or using it more
often during the pandemic faced more challenges than those
using it to the same extent as before. Globally, maternal and
newborn health providers in LICs seem to face more severe
barriers to implement telehealth practices compared with
those in middle- income and high- income settings.
10 GalleA, etal. BMJ Global Health 2021;6:e004575. doi:10.1136/bmjgh-2020-004575
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In this paper, we show that maternal and newborn health
professionals adapted the provision of care using telemed-
icine during the COVID-19 pandemic in many different
ways, even within similar settings. The lack of evidence-
based consolidated national or global guidelines together
with a legal framework on the usage of telehealth might
explain these findings.9 16 Among healthcare providers who
were using telemedicine, two- fifths reported that they did
not receive any guideline on the provision of care through
telemedicine. Currently, guidelines on telemedicine mostly
originate from national medical specialty societies outside
maternal healthcare provision and are not tailored to the
context of a pandemic, limiting their transferability to other
health domains and contexts.9 Furthermore, health systems
and governments did not seem to be prepared for the rapid
evolution of the pandemic, and maintaining the provision of
maternal and newborn healthcare might not have been their
first priority. Only after the first pandemic peak in March/
April 2020 did the first reports of a potential disruptive effect
of the pandemic on maternal and newborn care provision
start to emerge,7 50–53 allowing more coordinated action from
stakeholders and governments.
Our study showed that several factors played a role in the
decision of healthcare providers on whether to implement
telehealth during COVID-19, for which care and to which
patients. These factors included a risk–benefit assessment,
personal preference of the provider and patient, financial
consequences and health status of the women (low- risk vs
high- risk pregnancies). Some healthcare providers declared
that they only saw women with a high- risk pregnancy and
shifted entirely to telemedicine for low- risk women. Other
providers and facilities shifted to the previous recom-
mendation of four focused ANC visits for low- risk preg-
nancies,48 49 replacing some of the remaining visits with
telemedicine consultations or a hotline in case of emergen-
cies and questions. A recent publication from India described
a similar approach here advising face- to- face ANC provision
for high- risk pregnant women and a reduced number of
visits for low- risk women, although they also claimed that
more robust data are needed to evaluate the effectiveness of
their approach.54 Obstetric care is characterised by unpre-
dictability; women may develop complications throughout
their pregnancy, even when they were classified as low risk.55
As a consequence, a low- risk profile might change to high
risk rapidly without warning. Such changes in risk status may
go unnoticed, given that healthcare providers reported that
providing care via telehealth risks losing certain essential
information (related to non- verbal feedback and physical
examinations), which they believed might affect the quality
of care. Previous evidence showed that receiving fewer ANC
consultations than the recommended has a negative effect
on maternal and newborn health outcomes.56–58 Unfortu-
nately, evidence- based guidelines about the ideal number
of telehealth visits versus face- to- face visits during pregnancy
and post partum are lacking, together with guidelines on the
integration of home- based equipment (eg, blood pressure
monitor, glucometer, urine analysis test strips) which could
provide important information to increase care quality
and detection of possible complications. In- depth research
is needed to assist healthcare providers with guidance on
how to implement telehealth along the continuum of
maternal and newborn healthcare, and ensure the provision
of high- quality maternal health services through blended
approaches.
Our study showed that many providers experienced
serious challenges in organising and conducting telecon-
sultations. The most important challenges when providing
telehealth included lack of infrastructure, technological illit-
eracy, financial barriers, remote monitoring limitations, lack
of non- verbal feedback, limited bonding, language problems
and distrust from patients. Lack of infrastructure varied from
internet connection problems to a lack of smartphones and/
or other devices at one or both sides of the clinical encounter
(providers and patients). While the lack of internet and
equipment was most often reported in LICs,59 it appeared to
be a global problem according to our data and also common
among health providers being familiar with telemedicine
(ie, those using it already before the pandemic). Our study
showed that a large proportion of healthcare providers and
patients do not have easy and affordable access to telemed-
icine equipment and mobile/data networks. Furthermore,
recent research has revealed a gender gap in mobile internet
use in LMICs with women being 20% less likely to use mobile
internet than men.60 Given that maternal health is primarily
directed to women and that majority of maternal healthcare
workers are women, this gender gap will negatively affect
the use of telehealth for maternal healthcare. If telehealth
is intended to fill the gaps of healthcare provision during
periods of disruptions to healthcare supply and utilisation,
or even an essential part of the general healthcare system,
this access issue will need to be addressed, possibly through
government subsidies or grants for the most disadvantaged
groups.61
Technological illiteracy was another problem commonly
reported in our study by respondents from all types of coun-
tries. Offering education programmes, investing in user-
friendly software and social outreach programmes might
all be strategies to reduce technological illiteracy and the
hidden digital inequality and health disparities62 that might
emerge with wider telemedicine use. Financial issues in
using telehealth seemed most problematic in LICs for both
providers and patients, according to our study. A big share
of women cannot afford to buy airtime for consultations and
do not have access to (smart) phones. Healthcare providers
also reported struggling to afford equipment and airtime. In
addition, especially healthcare providers from LMICs found
it difficult to get paid for telehealth consultations due to a
lockdown and/or lack of reimbursement system (by a health
institution or social security system). In contrast, health
providers in HICs often had access to phones and internet
offered by their institutions. Furthermore, health insurance
companies are increasingly covering the main part of the
telehealth consultations in line with regular care in several
HICs, which makes the financial compensation for telehealth
less problematic for them.63–65 It is noteworthy that rapidly
evolving technological solutions are coming up in both LICs
GalleA, etal. BMJ Global Health 2021;6:e004575. doi:10.1136/bmjgh-2020-004575 11
BMJ Global Health
and HICs (for example, by allowing money transfer by SMS
or WhatsApp66 67), which might overcome certain barriers
for providing telehealth in the future.
In our study, telemedicine was mostly performed by
conducting video consultations without reports of patients
self- monitoring of vital signs, fetal heartbeat or glucose levels.
Providers reported this as a challenge (described as ‘remote
monitoring limitations’) and serious risk for guaranteeing
high- quality care. Indeed, very little is known about the bene-
fits and risks of introducing this simplified method and scope
of telehealth for providing maternal and newborn health-
care worldwide. Currently, evaluation studies or randomised
controlled trials are hardly available within the literature
regarding this new way of healthcare provision, and more
research is definitely needed to discover its impact on women
and newborns’ health outcomes.
Distrust, language problems, lack of non- verbal feedback
and bonding were reported as barriers to telemedicine in our
study. A study in Bangladesh reporting very similar barriers
with telemedicine explained this by emphasising that a
provider’s physical presence can easily express empathy and
compassion nonverbally, while this is much more difficult
during a telehealth consultation.68 A similar concern was
reported by midwives in our study who revealed they could
not build a warm and trusting bond with the women by tele-
health consultations.
Healthcare providers who introduced telemedicine during
the pandemic or used it more often faced more serious
barriers compared with those using telemedicine in the same
way as before. Most of the reported challenges in this study
seem related to the rapid scale- up of telemedicine, whereby
face- to- face consultations were almost completely impossible
due to several COVID-19- related restrictions. We assume
health providers using telemedicine to the same extent as
before the pandemic faced fewer challenges, allowing a
more balanced and natural way of telemedicine provision.
The latest evidence from other health domains shows that
digital modes of communication work best for patients and
clinicians who have already previously established relation-
ships, with a flexible use of telecommunication according
to patient condition and background.18 We believe that also
in maternal healthcare a more balanced and natural combi-
nation of face- to- face and telemedicine contacts between
women and health providers, under more flexible circum-
stances, might improve the experience of women and health-
care providers with telemedicine consultations in the future.
Contrary to the challenges of telemedicine, the benefits of
telehealth applications in maternal healthcare are well docu-
mented. Many studies show that shifting to telemedicine for
certain aspects of care is equally beneficial as face- to- face
care when it comes to health outcomes and patient satisfac-
tion.69–72 However, it is important to note that these studies
mainly derive from the USA and are conducted in a highly
controlled setting with adequate equipment for remote
monitoring of blood pressure and blood glucose levels.69 70 72
One study in Japan also reported successful telemedicine
provision during COVID-19 by documenting their remote
ANC consultation procedure that included the mailing
of a cardiotocograph and a sphygmomanometer to each
pregnant woman’s home for remote monitoring.73 Unfortu-
nately, these telehealth interventions do not correspond with
the global practice of telehealth during the pandemic, where
it has been applied in very different ways and under subop-
timal circumstances. Furthermore, telehealth is an already
dynamic and rapidly evolving field, resulting in additional
challenges for in- depth monitoring and evaluation of new
applications.16
Our study suggests that vulnerable groups are at risk of
being excluded from telemedicine, perhaps even higher
than from routine in- person maternal healthcare. Given
that groups such as single women, adolescents, migrants and
women of low socioeconomic status already face challenges
in reaching face- to- face maternal healthcare services,74–76 it is
crucial that shifting to telehealth does not exacerbate these
inequalities. It is important to note that even with concrete
guidelines regarding the implementation of telehealth, a
one- size- fits- all model will not be appropriate. Each country
must continually assess which groups of society are vulner-
able to exclusion and fairly support those at the highest risk.77
Our study showed that in general, providers appreciated
the application of telemedicine and that it was often the only
way to ‘connect’ with women, families and their newborns.
Midwives reported higher levels of loneliness and depres-
sion among both pregnant and postpartum women, which
is in line with the first studies in the field of maternal mental
health during the COVID-19 era and previous epidemic
outbreaks.78–80 On one hand the virtual meetings, coun-
selling and support by midwives can help women, but on
the other they are only partially doing ‘the job’ because of
the lack of physical contact and bonding. More research is
needed on how the mental health needs in the perinatal
period can be addressed by telehealth during a pandemic or
similarly disruptive situations.81 82
Lastly, the COVID-19 pandemic seemed to boost the
communication and interdisciplinary management of care
between healthcare providers by mobile technologies. Our
study showed that the increased ability to reach colleagues
and specialists for advice was valuable to healthcare providers
during the pandemic, besides receiving up- to- date guidelines
by virtual communication. Furthermore, they explained
it could avoid unnecessary referrals between hospitals by
soliciting advice from experts by phone. A Cochrane review
also showed that mobile health communication between
providers probably decreases the time to deliver health-
care, as well as the number of face- to- face appointments,83
both essential aspects of the global strategy to reduce the
spread of the COVID-19 virus. It is critical that this improved
collaboration and communication will be continued after
the pandemic, as the benefits and lessons learnt will be
important to tackling long- standing issues such as communi-
cation during the referral process.
Limitations
Limitations of our study are the sample bias and lack of repre-
sentativeness, due to the convenience sampling approach.
We received few responses from professionals working in
12 GalleA, etal. BMJ Global Health 2021;6:e004575. doi:10.1136/bmjgh-2020-004575
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lower level facilities, particularly in LICs, which might itself
be related to limited access to the internet in these settings.
Our sample might over- represent higher qualified cadres
of health professionals in settings with limited use of tech-
nology among lower cadres of staff, and under- represent
overwhelmed providers, and those with limited access to
internet connection. This is particularly relevant for the topic
of this analysis, as we might overestimate the use of telehealth
because of the sample that we reached. Another limitation
of this study is the cross- sectional design, whereby we only
captured the experiences of providers at one given moment.
While we could grasp from the responses which telemedi-
cine practices were applied more often or introduced during
the pandemic, it was not always clear to determine to what
extent these practices were used before the pandemic.
Follow- up research, using a longitudinal design, could deter-
mine to what extent certain telehealth applications continue
and evolve over time and after the pandemic, assessing their
perceived benefits and challenges for maternal healthcare
provision in the long term. Lastly, the findings related to the
positive effect of the crisis on professional telecommunica-
tion and collaboration were presented briefly and grouped
together as one telehealth practice because they were not
the focus of our study. Nevertheless, they are equally impor-
tant, especially for improving maternal health outcomes
and health providers’ work satisfaction. We believe further
research is needed with regard to this particular aspect of tele-
health, to support long- term improvements in collaboration
and multidisciplinary teamwork among health providers.
CONCLUSION
Maternal and newborn health providers considered tele-
health to be an important alternative to providing certain
health services during the first months of the COVID-19
pandemic. It gave them the possibility to connect with
patients and interact with other health professionals without
being exposed to the risks of in- person contact, or when
facing restrictions to movement. Furthermore, telehealth
seems to be less time- consuming (sometimes with equal
financial compensation) and can easily be combined with
other duties at home or in health facilities. However, more
research is needed to understand the consequences of an
extensive telehealth consultation schedule in maternal and
newborn health during the COVID-19 pandemic. Some
authors already pointed to the risk of loneliness and depres-
sion for women giving birth during the pandemic, where the
lack of interpersonal contact during the postpartum period
and increased stress levels seemed serious triggers. We believe
the negative consequences might go beyond that, taking into
account the reduced number of in- person ANC visits and
digital inequality that goes hand in hand with providing tele-
health. Illiterate, migrant, poor and ethnic minority women
appear to be particularly left behind in accessing maternal
health by telehealth. More research regarding the effective-
ness and efficacy of telehealth for maternal healthcare in
different contexts is highly needed before implementing
such adaptations in the long term and on a large scale,
particularly to avoid an increase in the existing wide inequal-
ities in access to maternal healthcare worldwide.
Author afliations
1ICRH, Department of Public Health and Primary Care, Ghent University, Gent,
Belgium
2Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
3Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
4Department of Obstetrics and Gynaecology, University of Lagos, Idi- Araba, Nigeria
5Obstetrics, Gynecology and Reproductive Sciences, University of California, San
Francisco, California, USA
Twitter Anteneh Asefa @AntenehAsef, Bosede Bukola Afolabi @Coolgynae and
Lenka Benova @lenkabenova
Acknowledgements We would like to thank the study participants who took time
to respond to this survey during the second round, despite the ongoing difcult
circumstances and high workload. We acknowledge the Institutional Review
Committee at the Institute of Tropical Medicine for providing helpful suggestions on
this study protocol, and for the expedited review of this study. We thank all study
collaborators, translators and colleagues who distributed the invitation for this
survey and provided suggestions on the questionnaire, including the coauthors of
this paper.
Contributors LB conceptualised the study and obtained funding. All authors
contributed to the design of the study and development of the survey tool. AG
analysed the qualitative data and AS analysed the quantitative data. AG, AS
and LB wrote the original draft of the manuscript. All authors contributed to the
development of the manuscript, and read and approved the nal version.
Funding This study was funded by the Institute of Tropical Medicine’s COVID-19
Pump Priming fund supported by the Flemish Government, Science and Innovation.
LB is funded in part by the Research Foundation- Flanders (FWO) as part of her
senior postdoctoral fellowship.
Competing interests None declared.
Patient consent for publication Not required.
Ethics approval This study was approved by the Institutional Review Committee at
the Institute of Tropical Medicine (Antwerp, Belgium) on 20 March 2020 (approval
reference 1372/20). Respondents provided informed consent online by checking a
box afrming that they voluntarily agreed to participate in the survey.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available upon request. Anonymised data
analysed during the current study will be made available from the corresponding
author upon reasonable request.
Supplemental material This content has been supplied by the author(s). It has
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of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and
responsibility arising from any reliance placed on the content. Where the content
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AntenehAsefa http:// orcid. org/ 0000- 0003- 4470- 1848
Bosede BukolaAfolabi http:// orcid. org/ 0000- 0002- 7511- 7567
Alison MarieEl Ayadi http:// orcid. org/ 0000- 0003- 2674- 4887
REFERENCES
1 WHO. WHO Director- General’s opening remarks at the media
brieng on COVID-19 - 11 March 2020. Available: https://www.
GalleA, etal. BMJ Global Health 2021;6:e004575. doi:10.1136/bmjgh-2020-004575 13
BMJ Global Health
who. int/ director- general/ speeches/ detail/ who- director- general- s-
opening- remarks- at- the- media- brieng- on- covid- 19--- 11- march-
2020 [Accessed 13 Oct 2020].
2 Haug N, Geyrhofer L, Londei A. Ranking the effectiveness of
worldwide COVID-19 government interventions. medRxiv 2020.
3 Smith AC, Thomas E, Snoswell CL, etal. Telehealth for global
emergencies: implications for coronavirus disease 2019 (COVID-19).
J Telemed Telecare 2020;26:309–13.
4 Ohannessian R, Duong TA, Odone A. Global telemedicine
implementation and integration within health systems to ght the
COVID-19 pandemic: a call to action. JMIR Public Health Surveill
2020;6:e18810.
5 Bashshur R, Doarn CR, Frenk JM, etal. Telemedicine and the
COVID-19 pandemic, lessons for the future. Telemed J E Health
2020;26:571–3.
6 Bokolo Anthony. Use of telemedicine and virtual care for remote
treatment in response to COVID-19 pandemic. J Med Syst
2020;44:132.
7 Graham WJ, Afolabi B, Benova L, etal. Protecting hard- won gains
for mothers and newborns in low- income and middle- income
countries in the face of COVID-19: call for a service safety net. BMJ
Glob Health 2020;5:e002754.
8 WHO Global Observatory for eHealth. Telemedicine: opportunities
and developments in member states: report on the second global
survey on eHealth. World Health organization; 2010. https:// apps.
who. int/ iris/ handle/ 10665/ 44497
9 Tuckson RV, Edmunds M, Hodgkins ML. Telehealth. N Engl J Med
2017;377:1585–92.
10 WHO. Monitoring and evaluating digital health interventions, 2016.
Available: https://www. who. int/ reproductivehealth/ publications/
mhealth/ digital- health- interventions/ en/#. X50Simip8k8. mendeley
[Accessed 31 Oct 2020].
11 Ngidi WH, Naidoo JR, Ncama BP, etal. Mapping evidence of
interventions and strategies to bridge the gap in the implementation
of the prevention of mother- to- child transmission of HIV programme
policy in sub- Saharan countries: a scoping review. Afr J Prim Health
Care Fam Med 2017;9:e1–10.
12 Nair U, Armeld NR, Chateld MD, etal. The effectiveness of
telemedicine interventions to address maternal depression:
a systematic review and meta- analysis. J Telemed Telecare
2018;24:639–50.
13 Monaghesh E, Hajizadeh A. The role of telehealth during COVID-19
outbreak: a systematic review based on current evidence. BMC
Public Health 2020;20.
14 Novara G, Checcucci E, Crestani A, etal. Telehealth in urology: a
systematic review of the literature. how much can telemedicine
be useful during and after the COVID-19 pandemic? Eur Urol
2020;78:786–811.
15 Mbuthia F, Reid M, Fichardt A. mHealth communication to
strengthen postnatal care in rural areas: a systematic review. BMC
Pregnancy Childbirth 2019;19:406.
16 Chang H. Evaluation framework for telemedicine using the logical
framework approach and a shbone diagram. Healthc Inform Res
2015;21:230–8.
17 Armeld NR, Bradford M, Bradford NK. The clinical use of Skype-
For which patients, with which problems and in which settings? A
snapshot review of the literature. Int J Med Inform 2015;84:737–42.
18 Ignatowicz A, Atherton H, Bernstein CJ, etal. Internet
videoconferencing for patient- clinician consultations in
long- term conditions: a review of reviews and applications
in line with guidelines and recommendations. Digit Health
2019;5:205520761984583.
19 Bashshur RL, Shannon GW, Bashshur N, etal. The empirical
evidence for telemedicine interventions in mental disorders. Telemed
J E Health 2016;22:87–113.
20 Zhou X, Snoswell CL, Harding LE, etal. The role of telehealth in
reducing the mental health burden from COVID-19. Telemed J E
Health 2020;26:377–9.
21 Innovations for Poverty Action. Reducing Ebola Virus Transmission:
Improving Contact Tracing in Sierra Leone. Available: http://www.
poverty- action. org/ study/ reducing- ebola- virus- transmission-
improving- contact- tracing- sierra- leone [Accessed 20 Nov 2020].
22 Using mobile technology to improve maternal health and ght Ebola
2. Available: http://www. grameenfoundation. org/ press- [Accessed
20 Nov 2020].
23 Uscher- Pines L, Fischer S, Tong I, etal. Virtual rst responders:
the role of direct- to- consumer telemedicine in caring for people
impacted by natural disasters. J Gen Intern Med 2018;33:1242–4.
24 Mehrotra A, Ray K, Brockmeyer DM. Rapidly Converting to “Virtual
Practices”: Outpatient Care in the Era of Covid-19. NEJM Catalyst
2020 https:// catalyst. nejm. org/ doi/ full/ 10. 1056/ CAT. 20. 0091
25 Khairat S, Pillai M, Edson B, etal. Evaluating the telehealth
experience of patients with COVID-19 symptoms: recommendations
on best practices. J Patient Exp 2020;7:665–72.
26 Aziz A, Zork N, Aubey JJ, etal. Telehealth for high- risk pregnancies
in the setting of the COVID-19 pandemic. Am J Perinatol
2020;37:800–8.
27 Monaghesh E, Hajizadeh A. The role of telehealth during COVID-19
outbreak: a systematic review based on current evidence. BMC
Public Health 2020;20:1193.
28 Greenhalgh T, Koh GCH, Car J. Covid-19: a remote assessment in
primary care. BMJ 2020;368:m1182.
29 WHO. Maintaining essential health services: operational guidance
for the COVID-19 context: interim guidance, 1 June 2020. Available:
https:// apps. who. int/ iris/ handle/ 10665/ 332240
30 Xie W, Dai P, Qin Y, etal. Effectiveness of telemedicine for pregnant
women with gestational diabetes mellitus: an updated meta- analysis
of 32 randomized controlled trials with trial sequential analysis. BMC
Pregnancy Childbirth 2020;20:198.
31 DeNicola N, Grossman D, Marko K, etal. Telehealth interventions to
improve obstetric and gynecologic health outcomes. Obstet Gynecol
2020;135:371–82.
32 Lee SH, Nurmatov UB, Nwaru BI, etal. Effectiveness of mHealth
interventions for maternal, newborn and child health in low- and
middle- income countries: systematic review and meta- analysis. J
Glob Health 2016;6:010401.
33 Abaza H, Marschollek M. mHealth application areas and technology
Combinations*. A comparison of literature from high and low/middle
income countries. Methods Inf Med 2017;56:e105–22.
34 UNRWA. An application that tracks the health of mother and child:
every pregnant women’s dream! Available: https://www. unrwa. org/
newsroom/ features/ application- tracks- health- mother- and- child-
every- pregnant- women’s-dream [Accessed 20 Nov 2020].
35 Improving the health care of pregnant refugee and migrant women
and newborn children (2018). Available: https://www. euro. who. int/
en/ publications/ abstracts/ improving- the- health- care- of- pregnant-
refugee- and- migrant- women- and- newborn- children- 2018
36 Hughson J- AP, Daly JO, Woodward- Kron R, etal. The rise of
pregnancy apps and the implications for culturally and linguistically
diverse women: narrative review. JMIR Mhealth Uhealth
2018;6:e189.
37 Fryer K, Delgado A, Foti T, etal. Implementation of obstetric
telehealth during COVID-19 and beyond. Matern Child Health J
2020;24:1104–10.
38 View of challenges in telemedicine implementation for pregnancy
care during the Covid-19 pandemic. Available: http:// jurn alke pera
wata nglobal. com/ index. php/ jkg/ article/ view/ 156/ 76 [Accessed 11
Jan 2021].
39 Hill I, Burroughs E. Maternal telehealth has expanded dramatically
during the COVID-19 pandemic: equity concerns and promising
approaches, 2020. Available: https://www. cent erfo rsoc iali nclusion.
org/ our- work/ what- is- racial- equity [Accessed 10 Nov 2020].
40 Blandford A, Wesson J, Amalberti R, etal. Opportunities and
challenges for telehealth within, and beyond, a pandemic. Lancet
Glob Health 2020;8:e1364–5.
41 Semaan A, Audet C, Huysmans E, etal. Voices from the frontline:
ndings from a thematic analysis of a rapid online global survey of
maternal and newborn health professionals facing the COVID-19
pandemic. BMJ Glob Health 2020;5:2967.
42 Benova L, Sarkar NDP, Fasehun L- KO, etal. A call to action:
documenting and sharing solutions and adaptations in sexual,
reproductive, maternal and newborn health care provision during the
COVID-19 pandemic. Sex Reprod Health Matters 2020;28:1838054.
43 Braun V, Clarke V. Thematic analysis. In: APA Handbook of research
methods in psychology: research designs: quantitative, qualitative,
neuropsychological, and biological. Washington DC: American
Psychological Association, 2012: Vol 2. p57–71.
44 Preparedness and response to COVID-19: a global survey of
maternal and newborn care providers round 2 questionnaire.
Available: https://www. itg. be/ Files/ docs/ MATCO/ Maternal_
COVID19_ Round2_ Survey. pdf
45 Kerber KJ, de Graft- Johnson JE, Bhutta ZA, etal. Continuum of
care for maternal, newborn, and child health: from slogan to service
delivery. Lancet 2007;370:1358–69.
46 Attitude of pregnant women towards group health talk during
antenatal care visit in a Nigerian City. Available: https://www.
researchgate. net/ publication/ 331715857_ Attitude_ of_ Pregnant_
women_ towards_ Group_ Health_ Education_ during_ Antenatal_ Care_
visit_ in_ a_ Nigerian_ City [Accessed 12 Jan 2021].
47 Sharma J, O'Connor M, Rima Jolivet R. Group antenatal care
models in low- and middle- income countries: a systematic evidence
synthesis. Reprod Health 2018;15:38.
14 GalleA, etal. BMJ Global Health 2021;6:e004575. doi:10.1136/bmjgh-2020-004575
BMJ Global Health
48 WHO. New guidelines on antenatal care for a positive pregnancy
experience, 2017. Available: http://www. who. int/ reproductivehealth/
news/ antenatal- care/ en/ [Accessed 14 Oct 2020].
49 Lincetto O, Mothebesoane- Anoh S, Gomez P. Antenatal care
III. Available: https://www. who. int/ pmnch/ media/ publications/
aonsectionIII_ 2. pdf
50 Roberton T, Carter ED, Chou VB, etal. Early estimates of the indirect
effects of the COVID-19 pandemic on maternal and child mortality in
low- income and middle- income countries: a modelling study. Lancet
Glob Health 2020;8:e901–8.
51 Busch- Hallen J, Walters D, Rowe S, etal. Impact of COVID-19 on
maternal and child health. Lancet Glob Health 2020;8:e1257.
52 WHO/Europe Maternal and Newborn Health. Coronavirus and
pregnancy – preserving maternal health across the European region.
Available: https://www. euro. who. int/ en/ health- topics/ Life- stages/
maternal- and- newborn- health/ news/ news/ 2020/ 6/ coronavirus- and-
pregnancy- preserving- maternal- health- across- the- european- region
[Accessed 20 Nov 2020].
53 Coxon K, Turienzo CF, Kweekel L, etal. The impact of the
coronavirus (COVID-19) pandemic on maternity care in Europe.
Midwifery 2020;88:102779.
54 Bindra V. Telemedicine for Women’s Health During COVID-19
Pandemic in India: A Short Commentary and Important Practice
Points for Obstetricians and Gynaecologists. J Obstet Gynecol India
2020;70:279–82.
55 Danilack VA, Nunes AP, Phipps MG. Unexpected complications of
low- risk pregnancies in the United States. Am J Obstet Gynecol
2015;212:809.e1–809.e6.
56 Raatikainen K, Heiskanen N, Heinonen S. Under- attending free
antenatal care is associated with adverse pregnancy outcomes.
BMC Public Health 2007;7:1–8.
57 Dowswell T, Carroli G, Duley L, etal. Alternative versus standard
packages of antenatal care for low- risk pregnancy. Cochrane
Database Syst Rev 2015;2015:CD000934.
58 Kuhnt J, Vollmer S. Antenatal care services and its implications
for vital and health outcomes of children: evidence from 193
surveys in 69 low- income and middle- income countries. BMJ Open
2017;7:e017122.
59 Centre for Disease Control. Uses of telehealth during COVID-19 in
low resource Non- U.S. settings, 2020. Available: https://www. cdc.
gov/ coronavirus/ 2019- ncov/ global- covid- 19/ telehealth- covid19-
nonUS. html [Accessed 30 Sep 2020].
60 The mobile gender gap report 2020, 2020. Available: www. gsma.
com/ r/ gender- gap [Accessed 23 Nov 2020].
61 Oyediran KA, Makinde OA, Adelakin O. The role of telemedicine in
addressing access to sexual and reproductive health services in
sub- Saharan Africa during the COVID-19 pandemic. Afr J Reprod
Health 2020;24:49.
62 Zhai Y. A call for addressing barriers to telemedicine: health
disparities during the COVID-19 pandemic. Psychother Psychosom
2021;90:64–6.
63 Health Advances Blog. The changing fortunes of telemedicine in
Europe – past, present, and future beyond COVID-19. Available:
https:// healthadvancesblog. com/ 2020/ 05/ 06/ the- changing- fortunes-
of- telemedicine- in- europe/ [Accessed 30 Oct 2020].
64 CCHP. State telehealth laws and reimbursement policies report.
Available: https://www. cchpca. org/ telehealth- policy/ state- telehealth-
laws- and- reimbursement- policies- report [Accessed 30 Oct 2020].
65 Society for maternal fetal medicine coding Committee SMFM coding
white paper: interim coding guidance: coding for telemedicine and
remote patient monitoring services during the COVID-19 pandemic,
2020. Available: https:// s3. amazonaws. com/ cdn. smfm. org/
media/ 2264/ c4cc b382 b842 8d22 cbcb 2c5d d560633f- original. png
[Accessed 10 Nov 2020].
66 Technology and Operations Management. M- Pesa: when “mobile
money” revolutionizes banking in Africa. Available: https:// digital.
hbs. edu/ platform- rctom/ submission/ m- pesa- when- mobile- money-
revolutionizes- banking- in- africa/ [Accessed 20 Nov 2020].
67 WhatsApp Blog. Send payments in India with WhatsApp. Available:
https:// blog. whatsapp. com/ send- payments- in- india- with-
whatsapp/? lang= fb [Accessed 20 Nov 2020].
68 Chowdhury SR, Sunna TC, Ahmed S. Telemedicine is an important
aspect of healthcare services amid COVID-19 outbreak: its barriers
in Bangladesh and strategies to overcome. Int J Health Plann
Manage 2021;36:4–12.
69 Pugeisen BM, McCarren C, Poore S, etal. Virtual visits: managing
prenatal care with modern technology. MCN Am J Matern Child Nurs
2016;41:24–30.
70 Pugeisen BM, Mou J. Patient satisfaction with virtual obstetric care.
Matern Child Health J 2017;21:1544–51.
71 Odibo IN, Wendel PJ, Magann EF. Telemedicine in obstetrics. Clin
Obstet Gynecol 2013;56:422–33.
72 DeNicola N, Grossman D, Marko K, etal. Telehealth interventions to
improve obstetric and gynecologic health outcomes: a systematic
review. Obstet Gynecol 2020;135:371–82.
73 Nakagawa K, Umazume T, Mayama M, etal. Feasibility and safety
of urgently initiated maternal telemedicine in response to the
spread of COVID-19: a 1- month report. J Obstet Gynaecol Res
2020;46:1967–71.
74 Ronsmans C, Graham WJ, Lancet Maternal Survival Series steering
group. Maternal mortality: who, when, where, and why. Lancet
2006;368:1189–200.
75 Graham W, Woodd S, Byass P, etal. Diversity and divergence: the
dynamic burden of poor maternal health. Lancet 2016;388:2164–75.
76 Kinney MV, Boldosser- Boesch A, McCallon B. Quality, equity, and
dignity for women and babies. Lancet 2016;388:2066–8.
77 The Lancet .Redening vulnerability in the era of COVID-19. Lancet
2020;395:1089.
78 Wu Y, Zhang C, Liu H, etal. Perinatal depressive and anxiety
symptoms of pregnant women during the coronavirus disease 2019
outbreak in China. Am J Obstet Gynecol 2020;223:240.e1–240.e9.
79 Davenport MH, Meyer S, Meah VL, etal. Moms are not OK:
COVID-19 and maternal mental health. Front. Glob. Womens Health
2020;1.
80 Dodgson JE, Tarrant M, Chee Y- O, etal. New mothers’ experiences
of social disruption and isolation during the severe acute
respiratory syndrome outbreak in Hong Kong. Nurs Health Sci
2010;12:198–204.
81 Hermann A, Fitelson EM, Bergink V. Meeting maternal mental
health needs during the COVID-19 pandemic. JAMA Psychiatry
2021;78:123.
82 Nair U, Armeld NR, Chateld MD, etal. The effectiveness of
telemedicine interventions to address maternal depression:
a systematic review and meta- analysis. J Telemed Telecare
2018;24:639–50.
83 Gonçalves- Bradley DC, J Maria AR, Ricci- Cabello I, etal. Mobile
technologies to support healthcare provider to healthcare provider
communication and management of care. Cochrane Database Syst
Rev 2020;8:CD012927.
84 World Bank. World bank country and lending groups – world bank
data help desk, 2017. Available: https:// datahelpdesk. worldbank.
org/ knowledgebase/ articles/ 906519 [Accessed 10 Nov 2020].
... 4 Consulting a doctor over phone is rather elected. 5 In 2018, digitalization in improvement of public health sector was acknowledged by World Health Assembly. 6 It is seen that the framework for telemedicine aids health care facilities in implementing response on Otorhinolaryngeal care during the pandemic outbreak while also maintaining provision for essential health services. ...
... 6 It is seen that the framework for telemedicine aids health care facilities in implementing response on Otorhinolaryngeal care during the pandemic outbreak while also maintaining provision for essential health services. 5 Telemedicine is also referred to as e-health or tele health. [5][6][7] Like every coin has two sides, this method too faces challenges. ...
... 5 Telemedicine is also referred to as e-health or tele health. [5][6][7] Like every coin has two sides, this method too faces challenges. Factors such as illiteracy, poor network and internet connectivity, inability to convey symptoms clearly, poor treatment compliance by patient, switching doctors, etc. have been the issues in this regard, mostly in the rural set up or middle/low-income countries. ...
Article
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Background: Telemedicine aids health care facilities in implementing response on otorhinolaryngeal care during the pandemic while also maintaining provision for essential health services. This study was taken up to highlight perception of doctors and patients and implementation benefit and drawbacks of telemedicine, despite the continuous effort to help reduce ailments of the patients via reduction in the in-person care during pandemic. Objectives were to assess knowledge, attitude and perception (KAP) among doctors and patients regarding telemedicine during COVID-19 pandemic. To determine the gaps and challenges experienced by the health care providers and the patients by telemedicine consultation.Methods: Cross sectional study conducted among the 18 doctors and house surgeons in department of otorhinolaryngology, KIMS Bhubaneswar and 486 patients who availed telemedicine for consultation from these health care professionals. A semi structured, mixed questionnaire was used. First phase of study was when patient contacted the doctor over phone, second was when doctor called up the patient for follow up and third was when both the doctors and patients were contacted to take their feedback on the study and assess their KAP on telemedicine. Data was analysed using SPSS-23 and Pearson’s correlation was used to determine any association.Results: 81%, 78.5% and 65.2% HCPs had good knowledge, attitude and perception score regarding telemedicine while among the patients the scores for good knowledge, attitude and perception were 42%, 21.4%, 15.4%, respectively. 88% HCPs and 84.8% patients were satisfied with e-health and were willing to continue this technology.Conclusions: The traditional clinic consultation has been modified during the pandemic to prevent and control transmission of the infection though it has both merits and demerits.
... Since the COVID-19 pandemic, the introduction of telehealth consultations into maternity care has become standard 4,5 . The addition of telehealth allows women to access antenatal care remotely without causing detrimental maternal and fetal outcomes 5,6 . ...
... The addition of telehealth allows women to access antenatal care remotely without causing detrimental maternal and fetal outcomes 5,6 . However, certain crucial aspects of antenatal care have so far been hard to deliver in a telemedicine antenatal care model 4 . ...
... The International Federation of Gynecology and Obstetrics recommends intermittent auscultation when there is no access to cardiotocography machines 16 . In resource-limited settings, the HBM monitor would allow inexperienced operators to accurately record, store, and transmit much longer and clinically 6 (6-7) [4][5][6][7] SUS, System Usability Scale. Raw SUS scores are mean (95% CI), and adjectival rating scale are median (interquartile range) unless otherwise specified. ...
Article
Full-text available
Fetal Cardiography is usually performed using in-hospital Cardiotocographic (CTG) devices to assess fetal wellbeing. New technologies may permit home-based, self-administered examinations. We compared the accuracy, clinical interpretability, and user experience of a patient-administered, wireless, fetal heartbeat monitor (HBM) designed for home use, to CTG. Initially, participants had paired HBM and CTG examinations performed in the clinic. Women then used the HBM unsupervised and rated the experience. Sixty-three women had paired clinic-based HBM and CTG recordings, providing 6982 fetal heart rate measures for point-to-point comparison from 126 min of continuous recording. The accuracy of the HBM was excellent, with limits of agreement (95%) for mean fetal heart rate (FHR) between 0.72 and −1.78 beats per minute. The FHR was detected on all occasions and confirmed to be different from the maternal heart rate. Both methods were equally interpretable by Obstetricians, and had similar signal loss ratios. Thirty-four (100%) women successfully detected the FHR and obtained clinically useful cardiographic data using the device at home unsupervised. They achieved the required length of recording required for non-stress test analysis. The monitor ranked in the 96–100th percentile for usability and learnability. The HBM is as accurate as gold-standard CTG, and provides equivalent clinical information enabling use in non-stress test analyses conducted outside of hospitals. It is usable by expectant mothers with minimal training.
... The community health workers play a critical role in the provision of MCH care. To ensure continuous child health care, it is necessary to protect resources and actively promote children's essential services [14,[35][36][37]. Data on child wellbeing at the community level is critical for responding to service delivery changes and developing future emergency care plans [37]. ...
... To ensure continuous child health care, it is necessary to protect resources and actively promote children's essential services [14,[35][36][37]. Data on child wellbeing at the community level is critical for responding to service delivery changes and developing future emergency care plans [37]. ...
... Digital health plays a critical role in achieving the SDGs. Many women sought virtual consultations or telemedicine for prenatal care and sick infant treatment [35,37]. While they expressed satisfaction with the virtual consultation, some believed it influenced the amount of information disclosed to their providers. ...
Article
Full-text available
Objectives: The COVID-19 pandemic containment necessitated the diversion of substantial health care resources thus affecting the routine essential care, and posing barriers to achieving the Sustainable Development Goals (SDGs). We explored the experiences of vulnerable communities—urban-slum-dwelling women regarding maternal and child health services during COVID-19. Methods: We conducted 48 in-depth interviews in four Indian states—12 in each state among urban-slum antenatal, intra-natal, and postnatal women. We used framework analysis. Results: Amidst the implementation of the mandatory stay-at-home, many women acknowledged that routine immunization services and antenatal check-ups remained uninterrupted, and were mostly provided at the community level. To prevent transmission, the family members and relatives had restricted visits to the health facility during labor or post-delivery. Women preferred to have a shorter hospital stay post-delivery and reduced routine postnatal check-ups for fear of infection. Conclusion: India has a variety of national and state-level programs focused on improving MCH indicators to achieve the SDGs. COVID-19 inadvertently interrupted some components of health services, insinuating the need for a disaster or pandemic-resilient MCH services delivery system.
... Since the beginning of the COVID-19 pandemic, many research studies have highlighted its great impact on mental health in the general population, with increased rates of depression, anxiety and PTSD in comparison with the prevalence of these psychiatric disorders before the COVID-19 pandemic [1]. Several studies have highlighted the negative impacts of COVID-19 pandemic on the access to and quality of maternity health services, in particular in the early phase of the pandemic due to restrictions on partner and visitor attendance [2,3] or due to adaptive practices in maternal care with the use of telemedicine [4]. Women also could potentially be anxious towards a risk of contamination for themselves or their fetus, but also towards vaccination against SARS-CoV-2 and its potential side effects. ...
Article
Full-text available
Background: Birth-related post-traumatic stress disorder occurs in 4.7% of mothers. No previous study focusing precisely on the stress factors related to the COVID-19 pandemic regarding this important public mental health issue has been conducted. However, the stress load brought about by the COVID-19 pandemic could have influenced this risk. Methods: We aimed to estimate the prevalence of traumatic childbirth and birth-related PTSD and to analyze the risk and protective factors involved, including the risk factors related to the COVID-19 pandemic. We conducted a prospective cohort study of women who delivered at the University Hospitals of Geneva between 25 January 2021 and 10 March 2022 with an assessment within 3 days of delivery and a clinical interview at one month post-partum. Results: Among the 254 participants included, 35 (21.1%, 95% CI: 15.1-28.1%) experienced a traumatic childbirth and 15 (9.1%, 95% CI: 5.2-14.6%) developed a birth-related PTSD at one month post-partum according to DSM-5. Known risk factors of birth-related PTSD such as antenatal depression, previous traumatic events, neonatal complications, peritraumatic distress and peritraumatic dissociation were confirmed. Among the factors related to COVID-19, only limited access to prenatal care increased the risk of birth-related PTSD. Conclusions: This study highlights the challenges of early mental health screening during the maternity stay when seeking to provide an early intervention and reduce the risk of developing birth-related PTSD. We found a modest influence of stress factors directly related to the COVID-19 pandemic on this risk.
... Emergent research from other countries has identified similar advantages to remote care, such as increased accessibility and convenience for those facing geographical barriers as well as convenience and communication within and between mental health teams (21,22). Telehealth services also saved client costs, eliminating the need for transport fees, and was in-line with COVID-19 safety guidelines. ...
Article
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Background Mental and behavioral health needs are immense in low-to-middle income countries (LMIC), particularly for adolescents and young adults (AYA). However, access to mental health services is limited in LMIC due to barriers such as distance to a health care site, low number of providers, and other structural and logistical challenges. During the COVID-19 pandemic, these barriers were significantly exacerbated and, thus, mental health services were severely disrupted. A potential solution to some of these barriers is remote delivery of such services via technology. Exploration of AYA experiences is needed to understand the benefits and challenges when shifting to remotely delivered services. Methods Participants included 16 AYA (15–29 years) residing in Lusaka, Zambia who met criteria for a mental or behavioral health concern and received telehealth delivery of the Common Elements Treatment Approach (CETA). AYA participated in semi-structured qualitative interviews to explore feasibility, acceptability, and barriers to telephone-delivered treatment in this context. Thematic coding analysis was conducted to identify key themes. Findings Three major response themes emerged: 1) Advantages of telehealth delivery of CETA, Disadvantages or barriers to telehealth delivery of CETA, 3) AYA recommendations for optimizing telehealth (ways to improve telehealth delivery in Zambia. Results indicate that logistical and sociocultural barriers i.e., providing AYA with phones to use for sessions, facilitating one face-to-face meeting with providers) need to be addressed for success of remotely delivered services. Conclusion AYA in this sample reported telehealth delivery reduces some access barriers to engaging in mental health care provision in Zambia. Addressing logistical and sociocultural challenges identified in this study will optimize feasibility of telehealth delivery and will support the integration of virtual mental health services in the Zambian health system.
... A particular area of concern arises through the replacement of services with digital offerings. For instance, in Brazil, access to virtual maternity care services was more difficult for women who lived in areas without (or with reduced) access to technologies (for international results, see, Galle et al., 2021). Digitalisation may exacerbate inequalities in relation to vulnerable groups, although there may also be some positive effects. ...
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The COVID-19 pandemic disrupted healthcare and societies, exacerbating existing inequalities for women and girls across every sphere. Our study explores health system responses to gender equality goals during the COVID-19 pandemic and inclusion in future policies. We apply a qualitative comparative approach, drawing on secondary sources and expert information; material was collected from March-July 2022. Australia, Brazil, Germany, the United Kingdom and USA were selected, reflecting upper-middle and high-income countries with established public health and gender policies but different types of healthcare systems and epidemiological and geo-political conditions. Three sub-goals of SDG5 were analysed: maternity care and reproductive health, gender-based violence, and gender equality and womens leadership. We found similar trends across countries. Pandemic policies strongly cut into womens health, constrained prevention and support services and weakened reproductive rights, while essential maternity care services were kept open. Intersecting gender inequalities were reinforced, sexual violence increased and womens leadership was weak. All healthcare systems failed to protect womens health and essential public health targets. Yet there were relevant differences in the responses to increased violence and reproductive rights, ranging from some support measures in Australia to an abortion ban in the US. Our study highlights a need for revising pandemic policies through a feminist lens.
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Background: The COVID-19 pandemic brought significant changes in healthcare, specifically the accelerated use of telehealth. Given the unique aspects of prenatal care, it is important to understand the impact of telehealth on healthcare communication, quality, and patient satisfaction. This mixed-methods study examined challenges associated with the rapid and broad implementation of telehealth for prenatal care delivery during the pandemic. Objective: In this study, we examine patients' perspectives, preferences, and experiences during the COVID-19 pandemic, with the aim of supporting the development of successful models to serve the needs of pregnant patients, obstetric providers, and health care systems during this time. Methods: Pregnant patients who received outpatient prenatal care in Cleveland, Ohio participated in in-depth interviews and completed the Coronavirus Perinatal Experiences- Impact Survey (COPE-IS) between January-December 2021. Transcripts were coded using NVivo12 and qualitative analysis used an approach consistent with grounded theory. Quantitative data were summarized and integrated during analysis. Results: Thematic saturation was achieved with 60 interviews. We learned that thirty-five (58.3%) women had prior telehealth experience to their current pregnancy. However, only 5 (8.3%) women had used both in-person and virtual visits during this pregnancy, while the majority, 54 (90%) women, participated in in-person only visits. From the COPE-IS, 59 (100.0%) felt very well supported by their provider, 31 (52.5%) were moderately to highly concerned about their child's health, and 17 (28.8%) reported the single greatest stress of COVID-19 was its impact on their child. Lead themes focused on: establishing patient-provider relationships that supported shared decision-making (SDM), accessing the information needed for SDM, and using technology effectively to foster discussions during the COVID-19 pandemic. Key findings indicated that participants felt in-person visits were more personal, establish greater rapport, and build a better trust in the patient-provider relationship as compared to telehealth visits. Further, participants felt they could achieve a greater dialogue and ask more questions regarding time sensitive information, including prenatal genetic testing information, through an in-person visit. Finally, privacy concerns arose if prenatal genetic testing or general pregnancy conversations were to take place outside of the healthcare facility, compared to in the home or workplace. Conclusions: While telehealth was recognized as an option to ensure timely access to prenatal care during the COVID-19 pandemic, it also came with multiple challenges in the patient-provider relationship. These findings illuminated barriers and opportunities to achieve effective and patient-centered communication with the continued integration of telehealth in prenatal care delivery. It is important to address the unique needs of this population during the pandemic and as healthcare increasingly adopts a telehealth model. Clinicaltrial:
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Background: Limited knowledge exists about the drivers of telehealth use among obstetricians during COVID-19 in the United States. We investigated the use of live video visits by Maternal-Fetal Medicine (MFM) clinicians, the factors associated with use and interest in future use. Methods: We drew survey data from 373 clinicians on two outcomes: (1) use of any (vs. no) live video visits during COVID-19 and (2) among users, the extent of live video use. Bivariate and multivariate logistic regressions quantified the association between predisposing (demographic and practice setting characteristics) and enabling factors (prepandemic telehealth use, structural and perceived patient barriers) and each outcome. Results: During the pandemic, 88% reported any use, a jump from 29% prepandemic utilization. Users (vs. nonusers) were younger (p = 0.02); tended to provide comprehensive prenatal care (p = 0.01) and/or inpatient care (p = 0.02), practice in university settings (p = 0.01), engage in various telehealth modalities prepandemic (p ≤ 0.01), and to perceive challenges with technical (p < 0.01), reimbursement (p = 0.05), and patient barriers to internet or data plan access (p ≤ 0.001). After adjusting for covariates, only prepandemic communication through patient portal (adjusted odds ratio [aOR] = 3.85; 95% confidence interval [CI] = 1.33-11.12), perceived patient access barriers (aOR = 5.27; 95% CI = 1.95-14.23), and practice in multiple versus university settings (aOR = 0.18; 95% CI = 0.06-0.56) remained significantly associated with use. Approximately 44% were high users. Prepandemic ultrasound use (aOR = 1.92; 95% CI = 1.17-3.16), perceived patient access barriers (aOR = 1.85; 95% CI = 1.12-3.06) and Midwest versus North practice location (aOR = 0.46; 95% CI = 0.21-0.98) predicted high use. Among high users, 99% wanted to continue offering video visits. Conclusions: We found widespread use of live video obstetric care by MFM clinicians and continued interest in use postpandemic.
Article
Background Digital midwifery services were enabled for the first time in Germany from March 2020 to ensure outpatient midwifery care in times of COVID-19. Methods In February and March 2021, a cross-sectional study with an online survey of midwives and mothers was conducted to find out to what extent digital services were offered by the midwives and used by the women, and to obtain information about the level of satisfaction and potential of digital midwifery care in pregnancy and post partum. Results 1,821 mothers of 18,784 women, who had given birth between May and November 2020 and were asked to participate in the survey, provided feedback (response rate: 9,7%). 1,551 midwives responded to the call to participate in the survey and completed the questionnaire. Around one third of the responding mothers had used digital midwifery services in pregnancy and/or the postpartum period and rated these services positively by over 80%. Half of the responding midwives offered digital services and wished to continue this care option. However, not all services were considered equally suitable for digital implementation. From the respondents' point of view, classes and counselling are very well suited whereas postpartum care often requires the midwife's presence. Mothers and midwives alike saw the advantages in COVID-19 infection control and in saving time and travel. The main challenges were seen in handling IT equipment and providing high quality care despite the lack of physical examination and direct assessment of clinical findings. The mothers wished for more interactivity and networking with each other. Conclusion The COVID-19 pandemic has become a catalyst for digitalisation in midwifery care in Germany. The digital services were, mostly, well accepted and seen to usefully complement the in-person care of midwives. IT-support, guidelines and quality standards could help to optimise the digital services.
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Assessing the effectiveness of non-pharmaceutical interventions (NPIs) to mitigate the spread of SARS-CoV-2 is critical to inform future preparedness response plans. Here we quantify the impact of 6,068 hierarchically coded NPIs implemented in 79 territories on the effective reproduction number, Rt, of COVID-19. We propose a modelling approach that combines four computational techniques merging statistical, inference and artificial intelligence tools. We validate our findings with two external datasets recording 42,151 additional NPIs from 226 countries. Our results indicate that a suitable combination of NPIs is necessary to curb the spread of the virus. Less disruptive and costly NPIs can be as effective as more intrusive, drastic, ones (for example, a national lockdown). Using country-specific ‘what-if’ scenarios, we assess how the effectiveness of NPIs depends on the local context such as timing of their adoption, opening the way for forecasting the effectiveness of future interventions.
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Positive patient experiences are associated with illness recovery and adherence to medication. To evaluate the virtual care experience for patients with COVID-19 symptoms as their chief complaints. We conducted a cross-sectional study of the first cohort of patients with COVID-19 symptoms in a virtual clinic. The main end points of this study were visit volume, wait times, visit duration, patient diagnosis, prescriptions received, and satisfaction. Of the 1139 total virtual visits, 212 (24.6%) patients had COVID-19 symptoms. The average wait time (SD) for all visits was 75.5 (121.6) minutes. The average visit duration for visits was 10.5 (4.9) minutes. The highest volume of virtual visits was on Saturdays (39), and the lowest volume was on Friday (19). Patients experienced shorter wait times (SD) on the weekdays 67.1 (106.8) minutes compared to 90.3 (142.6) minutes on the weekends. The most common diagnoses for patients with COVID-19 symptoms were upper respiratory infection. Patient wait times for a telehealth visit varied depending on the time and day of appointment. Long wait times were a major drawback in the patient experience. Based on patient-reported experience, we proposed a list of general, provider, and patient telehealth best practices.
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The current pandemic of coronavirus disease 19 (COVID‐19) has been a global concern since early 2020, where the number of COVID‐19 cases is also on a rapid surge in Bangladesh with the report of a total of 276,549 cases after the detection of the first three cases in this country on 8 March 2020. The COVID‐19 pandemic has made a seismic shift in the healthcare delivery system, where physician offices have accelerated digital health solutions at record speed, putting telemedicine (i.e., telehealth) at centre stage. Amid the severely contagious COVID‐19, telemedicine has moved from being an optional service to an essential one. As the developing country, there are some barriers to get evenly distributed advantages of this approach due to the digital divides and disparities. In this commentary, we have described the importance of telemedicine service amid the outbreak of COVID‐19 in Bangladesh, the barriers and challenges that the country is facing to implement this approach and the strategies to overcome these barriers in this developing country.
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The outbreak of COVID-19 threatens continued access to non-urgent healthcare including sexual and reproductive health (SRH) services. With the epicentre of the outbreak projected to shift to sub-Saharan Africa (SSA) after making a significant impact in China, Europe, the USA, and South America, it is necessary for countries in this region to begin to plan for how to tackle a rapid surge in cases. Health facilities are already being primed for the increased presentation of COVID-19 cases. As countries prepare, they also need to consider how non-urgent services will not be interrupted. Estimates of a potential disruption in access to long and short-acting contraceptives for up to 12 months will result in an additional 15 million unintended pregnancies and additional 28,000 maternal deaths. Thus, effort must be made to ensure that the gains made in SRH outcomes over several years are not lost. The potential of utilizing telemedicine to continue to offer healthcare services to the population for non-urgent care needs to be considered. It will not only provide for continued access to important services that can be delivered remotely but will reduce the risks of COVID-19 infection for both the client and the health workers. (Afr J Reprod Health 2020 (Special Edition); 24[2]: 49-55).
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Background: The outbreak of coronavirus disease-19 (COVID-19) is a public health emergency of international concern. Telehealth is an effective option to fight the outbreak of COVID-19. The aim of this systematic review was to identify the role of telehealth services in preventing, diagnosing, treating, and controlling diseases during COVID-19 outbreak. Methods: This systematic review was conducted through searching five databases including PubMed, Scopus, Embase, Web of Science, and Science Direct. Inclusion criteria included studies clearly defining any use of telehealth services in all aspects of health care during COVID-19 outbreak, published from December 31, 2019, written in English language and published in peer reviewed journals. Two reviewers independently assessed search results, extracted data, and assessed the quality of the included studies. Quality assessment was based on the Critical Appraisal Skills Program (CASP) checklist. Narrative synthesis was undertaken to summarize and report the findings. Results: Eight studies met the inclusion out of the 142 search results. Currently, healthcare providers and patients who are self-isolating, telehealth is certainly appropriate in minimizing the risk of COVID-19 transmission. This solution has the potential to prevent any sort of direct physical contact, provide continuous care to the community, and finally reduce morbidity and mortality in COVID-19 outbreak. Conclusions: The use of telehealth improves the provision of health services. Therefore, telehealth should be an important tool in caring services while keeping patients and health providers safe during COVID-19 outbreak.
Article
Background: The widespread use of mobile technologies can potentially expand the use of telemedicine approaches to facilitate communication between healthcare providers, this might increase access to specialist advice and improve patient health outcomes. Objectives: To assess the effects of mobile technologies versus usual care for supporting communication and consultations between healthcare providers on healthcare providers' performance, acceptability and satisfaction, healthcare use, patient health outcomes, acceptability and satisfaction, costs, and technical difficulties. Search methods: We searched CENTRAL, MEDLINE, Embase and three other databases from 1 January 2000 to 22 July 2019. We searched clinical trials registries, checked references of relevant systematic reviews and included studies, and contacted topic experts. Selection criteria: Randomised trials comparing mobile technologies to support healthcare provider to healthcare provider communication and consultations compared with usual care. Data collection and analysis: We followed standard methodological procedures expected by Cochrane and EPOC. We used the GRADE approach to assess the certainty of the evidence. Main results: We included 19 trials (5766 participants when reported), most were conducted in high-income countries. The most frequently used mobile technology was a mobile phone, often accompanied by training if it was used to transfer digital images. Trials recruited participants with different conditions, and interventions varied in delivery, components, and frequency of contact. We judged most trials to have high risk of performance bias, and approximately half had a high risk of detection, attrition, and reporting biases. Two studies reported data on technical problems, reporting few difficulties. Mobile technologies used by primary care providers to consult with hospital specialists We assessed the certainty of evidence for this group of trials as moderate to low. Mobile technologies: - probably make little or no difference to primary care providers following guidelines for people with chronic kidney disease (CKD; 1 trial, 47 general practices, 3004 participants); - probably reduce the time between presentation and management of individuals with skin conditions, people with symptoms requiring an ultrasound, or being referred for an appointment with a specialist after attending primary care (4 trials, 656 participants); - may reduce referrals and clinic visits among people with some skin conditions, and increase the likelihood of receiving retinopathy screening among people with diabetes, or an ultrasound in those referred with symptoms (9 trials, 4810 participants when reported); - probably make little or no difference to patient-reported quality of life and health-related quality of life (2 trials, 622 participants) or to clinician-assessed clinical recovery (2 trials, 769 participants) among individuals with skin conditions; - may make little or no difference to healthcare provider (2 trials, 378 participants) or participant acceptability and satisfaction (4 trials, 972 participants) when primary care providers consult with dermatologists; - may make little or no difference for total or expected costs per participant for adults with some skin conditions or CKD (6 trials, 5423 participants). Mobile technologies used by emergency physicians to consult with hospital specialists about people attending the emergency department We assessed the certainty of evidence for this group of trials as moderate. Mobile technologies: - probably slightly reduce the consultation time between emergency physicians and hospital specialists (median difference -12 minutes, 95% CI -19 to -7; 1 trial, 345 participants); - probably reduce participants' length of stay in the emergency department by a few minutes (median difference -30 minutes, 95% CI -37 to -25; 1 trial, 345 participants). We did not identify trials that reported on providers' adherence, participants' health status and well-being, healthcare provider and participant acceptability and satisfaction, or costs. Mobile technologies used by community health workers or home-care workers to consult with clinic staff We assessed the certainty of evidence for this group of trials as moderate to low. Mobile technologies: - probably make little or no difference in the number of outpatient clinic and community nurse consultations for participants with diabetes or older individuals treated with home enteral nutrition (2 trials, 370 participants) or hospitalisation of older individuals treated with home enteral nutrition (1 trial, 188 participants); - may lead to little or no difference in mortality among people living with HIV (RR 0.82, 95% CI 0.55 to 1.22) or diabetes (RR 0.94, 95% CI 0.28 to 3.12) (2 trials, 1152 participants); - may make little or no difference to participants' disease activity or health-related quality of life in participants with rheumatoid arthritis (1 trial, 85 participants); - probably make little or no difference for participant acceptability and satisfaction for participants with diabetes and participants with rheumatoid arthritis (2 trials, 178 participants). We did not identify any trials that reported on providers' adherence, time between presentation and management, healthcare provider acceptability and satisfaction, or costs. Authors' conclusions: Our confidence in the effect estimates is limited. Interventions including a mobile technology component to support healthcare provider to healthcare provider communication and management of care may reduce the time between presentation and management of the health condition when primary care providers or emergency physicians use them to consult with specialists, and may increase the likelihood of receiving a clinical examination among participants with diabetes and those who required an ultrasound. They may decrease the number of people attending primary care who are referred to secondary or tertiary care in some conditions, such as some skin conditions and CKD. There was little evidence of effects on participants' health status and well-being, satisfaction, or costs.
Article
Aim: In Hokkaido, Japan, the number of people suffering from coronavirus disease 2019 (COVID-19) is rapidly increased, and by the end of February 2020, there were already 70 confirmed cases of the disease. We investigated the safety of urgently initiated maternal telemedicine in preventing the spread of the coronavirus infection. Methods: This retrospective, single-institution study examined maternal telemedicine at the department of obstetrics of the Hokkaido University Hospital from March 4 to April 2, 2020. The physicians remotely examined the pregnant women from their homes using a visual communication system which kept communication confidential, performed prenatal checkup and administered medical care according to their various blood pressures, weights and cardiotocograms. Results: Forty-four pregnant women received a total of 67 telemedicine interventions. Thirty-two pregnant women (73%) had complications, and 22 were primiparas (50%). Telemedicine interventions were provided 19 times at less than 26 weeks of gestation, 43 times between 26 and 36 weeks of gestation and 5 times after 37 weeks of gestation. There was one case with an abnormality diagnosed during the remote prenatal checkups, and the patient was hospitalized on the same day. However, there were no abnormal findings observed in mothers and children during the other 66 remote prenatal checkups and medical care. Conclusion: Maternal telemedicine can be safely conducted in pregnant women who are at risk of having an underlying disorder or fetal abnormality 1 month following the start of the attempt. It should be considered as a form of maternal medical care to prevent the spread of COVID-19.