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GalleA, etal. 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: GalleA, SemaanA,
HuysmansE, etal. 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 afliations 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 difcult to deliver by
telemedicine. More research regarding the effectiveness,
efcacy 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 benet 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.
2GalleA, etal. 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.
GalleA, etal. 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
4GalleA, etal. BMJ Global Health 2021;6:e004575. doi:10.1136/bmjgh-2020-004575
BMJ Global Health
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 Pacic 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
GalleA, etal. 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 prot 28 (3)
Private not- for- prot 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 classication.84
ANC, antenatal care; PNC, postnatal care.
Table 1 Continued
6GalleA, etal. 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.
GalleA, etal. 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 benets
Practices Use of telemedicine Provider’s insights and perceived benets
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 ofcial
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 conrmed with COVID-19.
► Useful for discussing concerns regarding
high- risk patients.
► Potential to avoid referrals by receiving input
from experts.
8GalleA, etal. BMJ Global Health 2021;6:e004575. doi:10.1136/bmjgh-2020-004575
BMJ Global Health
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,
GalleA, etal. 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 GalleA, etal. 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
GalleA, etal. 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 non‐verbally, 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 GalleA, etal. BMJ Global Health 2021;6:e004575. doi:10.1136/bmjgh-2020-004575
BMJ Global Health
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 afliations
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 difcult
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 afrming 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
not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been
peer- reviewed. Any opinions or recommendations discussed are solely those
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
includes any translated material, BMJ does not warrant the accuracy and reliability
of the translations (including but not limited to local regulations, clinical guidelines,
terminology, drug names and drug dosages), and is not responsible for any error
and/or omissions arising from translation and adaptation or otherwise.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non- commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the
use is non- commercial. See:http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.
ORCID iDs
AnnaGalle http:// orcid. org/ 0000- 0003- 1427- 5067
AntenehAsefa http:// orcid. org/ 0000- 0003- 4470- 1848
Bosede BukolaAfolabi http:// orcid. org/ 0000- 0002- 7511- 7567
Alison MarieEl Ayadi http:// orcid. org/ 0000- 0003- 2674- 4887
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