How midwives implemented teleconsultations during the COVID-19 health crisis: a mixed-methods study

How to Implement Digital Clinical Consultations in UK Maternity Care: the ARM@DA Realist Review

Background

Digital transformation is a key component within the National Health Service Maternity Transformation Programme. The COVID-19 pandemic led to an acceleration of digital innovation, in particular, the use of digital clinical consultations (telephone/video consultations). The ways in which digital clinical consultations can be optimised and utilised alongside the traditional maternity care pathway remains unclear, however, with particular concerns about the potential for digital care to exacerbate inequalities.

Objective

To explore how digital clinical consultations can be implemented in a clinically safe, appropriate and acceptable way within UK maternity services? For whom? In what settings? And for what purposes?

Design

A realist synthesis combining an evidence review of diverse sources (2010 to the present) from Organisation for Economic Co-operation and Development countries with insights from key stakeholder groups (healthcare professionals, service users and community organisations).

Data sources

There were three main sources: (1) published primary and secondary research; (2) grey literature (such as policy documents and maternity safety reports); and (3) stakeholder insights.

Methods

A realist synthesis adopts a theory-driven approach which seeks to understand how a complex programme works, for whom and under what circumstances. The review had three iterative phases: (1) refining the review focus and developing initial programme theories; (2) retrieval of evidence for data extraction and analysis (using on a realist logic to identify key contexts, mechanisms and outcomes); and (3) testing and refining the programme theories.

Results

The final synthesis included 93 evidence sources (reviews, reports and 77 primary studies), with priority given to UK-focused studies. Study samples included a focus on healthcare professionals (n = 17), women (n = 45, of which 14 focused on vulnerable groups) or both (n = 15). Clinical and safety-related outcomes were reported in 12 studies. Fifteen programme theories were developed. A conceptual framework was produced that illustrates the inter-relationship between key contexts in maternity care through which different interactions activate mechanisms to produce outcomes of interest. The findings suggest that digital clinical consultations can be acceptable and appropriate if implementation includes personalisation and informed choice for women, as well as support and autonomy for staff. The relationship and connection between women and their healthcare professional are proposed as key mechanisms that support safety and engagement in care.

Limitations

Some of the evidence lacked details regarding specific settings, interventions or sample characteristics. This limits the extent to which findings can be applied to micro-level contexts. Stakeholder groups contributed key insights to the review at all stages. In spite of efforts to achieve diversity within these groups, there may have been experiences or identities that were missed.

Conclusions

Four 'CORE' implementation principles were identified to guide future practice and research: C - Creating the right environment, infrastructure and support for staff; O - Optimising consultations to be responsive, flexible and personalised to different needs and preferences; R - Recognising the importance of access and inclusion; and E - Enabling quality and safety through relationship-focused connections.

Future work

Future research should embed equity considerations and should focus on understanding digital clinical consultation within specific maternity systems (like triage/helplines), services (such as specialist outpatient clinics) or groups of women (e.g. with digital literacy or communication needs).

Funding

This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research as award number NIHR134535.

Tailored Prenatal Care Delivery for Pregnant Individuals: ACOG Clinical Consensus No. 8

SUMMARY

Prenatal care is one of the most common preventive services in the United States; it is designed to improve the health and well-being of pregnant and birthing individuals and their children through evidence-based services. Despite the prevalence of prenatal care, formalized models of prenatal care delivery have changed little since they were first published in 1930. The purpose of this Clinical Consensus document is to offer guidance on a transformative approach to the provision of prenatal care in three key areas: 1) addressing unmet social needs, 2) frequency of prenatal visits and monitoring, and 3) incorporation of telemedicine and alternative care modalities. Implementing a sustainable paradigm shift in a century-old care-delivery approach will take time; however, this document will guide maternity care professionals and their teams in the use of new prenatal care delivery models.

Optimising digital clinical consultations in maternity care: a realist review and implementation principles

OBJECTIVES

The COVID-19 pandemic has led to increased use of digital clinical consultations (phone or video calls) within UK maternity services. This project aimed to review the evidence on digital clinical consultations in maternity systems to illuminate how, for whom and in what contexts, they can be used to support safe, personalised and equitable care.

DESIGN

A realist synthesis, drawing on diverse sources of evidence (2010-present) from OECD countries, alongside insights from knowledge user groups (representing healthcare providers and service users).

METHODS

The review used three analytical processes (induction, abduction and retroduction) within three iterative stages (development of initial programme theories; evidence retrieval and synthesis; validation and refinement of the programme theories).

RESULTS

Ninety-three evidence sources were included in the final synthesis. Fifteen programme theories were developed showing that digital clinical consultations involve different mechanisms operating across five key contexts: the organisation, healthcare providers, the clinical relationship, the reason for consultation and women. The review suggests that digital clinical consultations can be effective and acceptable to stakeholders if there is access to appropriate infrastructure/digital resources and if implementation is able to ensure personalisation, informed choice, professional autonomy and relationship-focused connections. The review found relatively less evidence in relation to safety and equity.

CONCLUSIONS

Due to the complexity of maternity systems, there can be 'no one-size fits all' approach to digital clinical consultations. Nonetheless, the review distills four 'CORE' implementation principles: C-creating the right environment, infrastructure and support for staff; O-optimising consultations to be responsive, flexible and personalised to different needs and preferences; R-recognising the importance of access and inclusion; and E-enabling quality and safety through relationship-focused connections. Service innovation and research are needed to operationalise, explore and evaluate these principles, particularly in relation to safety and equity.

PROSPERO REGISTRATION NUMBER

CRD42021288702.

Mothers' and caregivers' experiences of COVID-19 restrictions during postpartum hospitalisation: a cross-sectional survey in France

BACKGROUND

Transmission of SARS-CoV-2 highlighting the importance of social distancing guidelines. Following a series of lockdowns and the widespread vaccination of the European population, many countries began to lift these restrictions. During this period, while some parents yearned for emotional support and family presence, others found that the solitude facilitated by the restrictions was beneficial for bonding and breastfeeding. In France, postnatal stays are generally longer than in other countries, and the limited availability of home-based follow-up care, combined with pandemic isolation measures, further complicated perspectives on visitation restrictions. Therefore, the objective of this study was to assess the satisfaction of mothers and caregivers regarding these visit restrictions in French maternity settings during the COVID-19 pandemic.

METHODS

We conducted two multicentre descriptives surveys across five French maternity wards (three in Paris and two in Lyon) from June 1st to July 15th, 2021. Participants included mothers, selected based on criteria such as French-speaking, at-term birth (≥ 37 weeks), and hospitalisation with their newborn, as well as caregivers working in the postpartum units. Satisfaction with visitation restrictions was assessed using a four-point Likert scale, which was then dichotomised into "mostly satisfied" versus "mostly dissatisfied" for the analysis. Multivariable logistic regression models were used to identify factors associated with satisfaction.

RESULTS

We analysed complete responses from 430 of the 2,142 mothers (20.1%) and 221 of the 385 caregivers (57.4%) who participated during the study period. The majority of mothers (68.8%, n = 296/430) and caregivers (90.5%, n = 200/221) declare themselves satisfied with the policy of restricting visits to maternity wards. The main source of mother's satisfaction came from a quieter stay, but they regretted the absence of their other children.

CONCLUSIONS

Maternity visit restriction policies were largely supported by mothers and caregivers, especially when partners and siblings were allowed. Revisiting these policies, along with the postpartum stay length, may improve care, though further evaluation in non-pandemic settings is needed.

Defining practices suitable for care via teleconsultation in gynaecological and obstetrical care: a French Delphi survey

OBJECTIVE

Delineate the scope of teleconsultation services that can be effectively performed to provide women with comprehensive gynaecological and obstetrical care.

DESIGN

Based on the literature and experts' insights, we identified a list of gynaecological and obstetrical care practices suitable for teleconsultation. A three-round Delphi consensus survey was then conducted online among a panel of French experts. Experts using a 9-point Likert scale assessed the relevance of each teleconsultation practice in four key domains: prevention, gynaecology and antenatal and postnatal care. Consensus was determined by applying a dual-criteria approach: the median score on a 9-point Likert scale and the percentage of votes either below 5 or 5 and higher.

SETTING

The study was conducted at a national level in France and involved multiple healthcare centres and professionals from various geographical locations.

PARTICIPANTS

The panel comprised 22 French experts with 19 healthcare professionals, including 12 midwives, 3 obstetricians-gynaecologists, 4 general practitioners and 3 healthcare system users. Participants were selected to include diverse practice settings encompassing hospital and private practices in both rural and urban areas.

PRIMARY AND SECONDARY OUTCOME MEASURES

The study's primary outcome was the identification of gynaecological and obstetrical care practices suitable for teleconsultation. Secondary outcomes included the level of professional consensus on these practices.

RESULTS

In total, 71 practices were included in the Delphi survey. The practices approved for teleconsultation were distributed as follows: 92% in prevention (n=12/13), 55% in gynaecology (n=18/33), 31% in prenatal care (n=5/16) and 12% in postnatal care (n=1/9). Lastly, 10 practices remained under discussion: 7 in gynaecology, 2 in prenatal care and 1 in postnatal care.

CONCLUSIONS

Our consensus survey highlights both the advantages and limitations of teleconsultations for women's gynaecological and obstetrical care, emphasising the need for careful consideration and tailored implementation.

Midwives' experience of telehealth and remote care: a systematic mixed methods review

INTRODUCTION

Increasing the midwifery workforce has been identified as an evidence-based approach to decrease maternal mortality and reproductive health disparities worldwide. Concurrently, the profession of midwifery, as with all healthcare professions, has undergone a significant shift in practice with acceleration of telehealth use to expand access. We conducted a systematic literature review to identify and synthesize the existing evidence regarding how midwives experience, perceive and accept providing sexual and reproductive healthcare services at a distance with telehealth.

METHODS

Five databases were searched, PubMed, CINHAL, PsychInfo, Embase and the Web of Science, using search terms related to 'midwives', 'telehealth' and 'experience'. Peer-reviewed studies with quantitative, qualitative or mixed methods designs published in English were retrieved and screened. Studies meeting the inclusion criteria were subjected to full-text data extraction and appraisal of quality. Using a convergent approach, the findings were synthesized into major themes and subthemes.

RESULTS

After applying the inclusion/exclusion criteria, 10 articles on midwives' experience of telehealth were reviewed. The major themes that emerged were summarized as integrating telehealth into clinical practice; balancing increased connectivity; challenges with building relationships via telehealth; centring some patients while distancing others; and experiences of telehealth by age and professional experience.

CONCLUSIONS

Most current studies suggest that midwives' experience of telehealth is deeply intertwined with midwives' experience of the response to COVID-19 pandemic in general. More research is needed to understand how sustained use of telehealth or newer hybrid models of telehealth and in-person care are perceived by midwives.

The lived experience of receiving and providing antenatal care during the Covid-19 crisis in Southern Europe: An exploratory qualitative study

OBJECTIVE

The Covid-19 pandemic led to a reorganization of antenatal care including the cancellation or shift into telemedicine of consultations and restrictions to the presence of an accompanying person. The aim was to explore healthcare professionals' and women's lived experience of such reorganisation consequences on the quality of care and specific challenges they faced, with a particular emphasis on telemedicine and equity.

METHODS

Exploratory qualitative study using semi-structured interviews and focus group discussions of women and healthcare providers in New Aquitaine (France) and in the Basque Country (Spain). We collected data from a purposive sampling of women (n = 33) and professionals (n = 19) who had received or provided antenatal care in hospitals and ambulatory facilities between March 2020 and December 2021. Participants' narratives were thematically analysed to identify themes that were subsequently contextualised to the two territories.

RESULTS

Antenatal care professionals and pregnant women experienced strong emotions and suffered from organizational changes that compromised the quality and equity of care. The pandemic and associated restrictions were sources of emotional distress, fear and loneliness, especially among more disadvantaged and isolated women. Among professionals, the lack of adequate means of protection and the multiple changes in caring protocols generated burnout, feeling of abandonment and emotional distress.

CONCLUSIONS

The Covid-19 experience should serve to critically consider the unexpected consequences of reorganising healthcare services and the need to meet patients' needs, with a particular consideration for disadvantaged groups. Future scenarios of telemedicine generalisation should consider a combination of in presence and remote consultations ensuring antenatal care quality and equity.

How should a video-call service for early labour be provided? A qualitative study of midwives' perspectives in the United Kingdom and Italy

PROBLEM

Women in early labour are typically encouraged to delay admission to the maternity unit, but they may find this challenging without appropriate professional support.

BACKGROUND

Prior to the pandemic, research conducted with midwives and women showed positivity towards using video-technology for early labour, with concerns raised about privacy.

AIM

To explore midwives' perspectives on potential use of video-calls during early labour METHODS: A multi-centre descriptive qualitative study was undertaken in UK and Italy. Ethical approval was gained prior to commencing the study and ethical processes were followed. Seven virtual focus groups were conducted with 36 participants, 17 midwives working in the UK and 19 midwives working in Italy. Line-by-line thematic analysis was performed and themes agreed by the research team.

FINDINGS

The findings include three main themes: 1) who, where, when and how: key aspects to consider for an effective video-call service in early labour; 2) video-call content and expected contribution; 3) potential barriers to address.

DISCUSSION

Midwives responded positively to the concept of video-calling in early labour and provided detailed suggestions on how an ideal video-call service for early labour should be provided to maximise effectiveness, safety and quality of care.

CONCLUSION

Guidance, support and training should be provided to midwives and healthcare professionals, with dedicated resources for an early labour video-call service that is accessible, acceptable, safe, individualised and respectful for mothers and families. Further research should systematically explore clinical, psychosocial and service feasibility and acceptability.

Primary health care midwives' perceptions on the use of telemedicine during the COVID-19 pandemic in Spain

OBJECTIVE

To explore the experiences of primary healthcare (PHC) midwives with the implementation of telemedicine in pregnancy and puerperium care during the Covid-19 pandemic.

METHOD

Exploratory qualitative study based on an inductive content analysis of 15 semi-structured interviews with intentionally selected PHC midwives in four Spanish Autonomous Regions, during 2021-22.

RESULTS

Five categories were identified: (1) changes in the modality of care in pregnancy and puerperium: prioritization of pregnant women, unprotected puerperium, an increase of home visits and decline of parental education groups, (2) implementation of telemedicine in a changing scenario: the positive and negative side of telemedicine (3) reaction of women to telemedicine (4) strategies implemented by midwives for a humanized care, (5) learning for the future.

CONCLUSIONS

The use of telemedicine by primary healthcare midwives enabled the care of pregnant and postpartum women during the pandemic in Spain. The positive aspects of the implementation of this type of care raise possibilities for change towards a hybrid format of healthcare.

Vitamins and minerals, education, and self-care need during preconception to 1000 days of life in Southeast Asia: An expert panel opinion

Addressing maternal malnutrition and its drivers is paramount in Southeast Asia. This article summarizes the key clinical learnings and evidence-based opinions from the experts to understand the need for vitamins and minerals supplementation, education, and self-care from preconception to the first 1000 days of life, which warranted further attention since COVID-19 pandemic. Evidence describing the importance of vitamins and minerals during preconception, pregnancy, and lactation stages was identified using literature databases. A pre-meeting survey was conducted to determine the current practices and challenges in Southeast Asia. Based on the literature review and clinical experience, experts defined the topics, and an online meeting was held on 13th July 2021. During the meeting, nine experts from Southeast Asia provided evidence-based opinion on the vitamins and minerals supplementation, education, and self-care need during preconception, pregnancy, and lactation stages. The expert opinions underpin maternal malnutrition as a prevalent issue and discuss appropriate interventions and prevention strategies for women in Southeast Asia. The recent pandemic further impacted nutrition status, pregnancy, and neonatal health outcomes. The expert panel emphasized a need to improve existing inadequacies in education, self-care, and social support, and discussed the role of policymakers in addressing the barriers to dietary changes. As inadequacies in regular vitamins and minerals supplementation, education, and self-care for women of reproductive age implicate maternal and child health outcomes, there is an urgent need for addressing malnutrition concerns in this population. Thus, a strong partnership between policymakers, healthcare professionals, and other relevant sectors is required.

Lessons from digital technology-enabled health interventions implemented during the coronavirus pandemic to improve maternal and birth outcomes: a global scoping review

BACKGROUND

Timely access to essential obstetric and gynecologic healthcare is an effective method for improving maternal and neonatal outcomes; however, the COVID-19 pandemic impacted pregnancy care globally. In this global scoping review, we select and investigate peer-reviewed empirical studies related to mHealth and telehealth implemented during the pandemic to support pregnancy care and to improve birth outcomes.

METHODS

We searched MEDLINE and PubMed, Scopus, CINAHL and Web of Science for this Review because they include peer-reviewed literature in the disciplines of behavioral sciences, medicine, clinical sciences, health-care systems, and psychology. Because our investigative searches reviewed that there is considerable 'grey literature' in this area; we did not restrict our review to any study design, methods, or place of publication. In this Review, peer-reviewed preprints were comparable to published peer-reviewed articles, with relevant articles screened accordingly.

RESULTS

The search identified 1851 peer reviewed articles, and after removal of duplicates, using inclusion and exclusion criteria, only 22 studies were eligible for inclusion in the review published from January 2020 to May 2022. mHealth interventions accounted for 72.7% (16 of 22 studies) and only 27.3% (6 of 22 studies) were telehealth studies. There were only 3 example studies that integrated digital technologies into healthcare systems and only 3 studies that developed and evaluated the feasibility of mobile apps. Experimental studies accounted 68.8% of mHealth studies and only 33.3% studies of telehealth studies. Key functionalities of the pregnancy apps and telehealth platforms focused on mental and physical wellness, health promotion, patient tracking, health education, and parenting support. Implemented interventions ranged from breastfeeding and selfcare to behavioral health. Facilitators of uptake included perceived benefits, user satisfaction and convenience. Mobile apps and short messaging services were the primary technologies employed in the implemented mHealth interventions.

CONCLUSION

Although our Review emphasizes a lack of studies on mHealth interventions and data from pregnant women during the COVID-19 crisis, the review shows that implementation of digital health interventions during emergencies are inevitable given their potential for supporting pregnancy care. There is also a need for more randomized clinical trials and longitudinal studies to better understand the effectiveness and feasibility of implementing such interventions during disease outbreaks and emergencies.

Barrier measures implemented in French maternity hospitals during the COVID-19 pandemic: A cross-sectional survey

OBJECTIVES

The objectives of this survey were 1) to describe the changes over time of barrier measures in maternity units, specifically, co-parent visits and women wearing masks in birth rooms, and 2) to identify potential institutional determinants of these barrier measures.

DESIGN

We used an online questionnaire to conduct a descriptive cross-sectional survey from May to July 2021.

SETTING

All districts in mainland France.

PARTICIPANTS

Midwife supervisor of each maternity unit.

MEASUREMENTS

Primary outcomes were "banning of visits" in the postnatal department during the first lockdown (March-May 2020), and "mandated mask-wearing in birth rooms" during the survey period (May-July 2021); the independent variables were maternity unit characteristics and location in a crisis area. Co-parent visits were considered only during the first lockdown as they were mostly allowed afterwards, and the wearing of masks was studied only during the survey period, as masks were unavailable for the population during the first lockdown.

RESULTS

We obtained 343 responses, i.e., 75.2% of French maternity units. Visits to the postnatal department were forbidden in 39.3% of the maternity units during the first lockdown and in none during the study period. Maternity hospitals with neonatal intensive care units were the most likely to ban co-parent hospital visits (adjusted OR 2.34 [1.12; 4.96]). However, those were the maternity units least likely to encourage or require women to wear masks while pushing (adjusted OR, 0.31; 95% confidence interval [CI], 0.11-0.77). Maternity units in crisis areas (i.e., with very high case counts) during the first lockdown banned visits significantly more often (adjusted OR, 1.68; 95% CI, 1.05-2.70).

KEY CONCLUSIONS

Our study showed that barrier measures evolved during the course of the pandemic but remained extremely variable between facilities.

IMPLICATIONS FOR PRACTICE

Maternity units implemented drastic barrier measures at the beginning of the pandemic but were able to adapt these measures over time. It is now time to learn from this experience to ensure that women and infants are no longer harmed by these measures.

Mothers' perspectives on the potential use of video-calling during early labour in the United Kingdom and Italy: A qualitative study

PROBLEM

Women in early labour are typically encouraged to delay maternity unit admission, but they may find this challenging without appropriate professional support.

BACKGROUND

Despite pre-pandemic research which identified potential advantages of video-calling in early labour, implementation of such service has not been reported.

AIM

To explore mothers' perspectives on potential use of video-calls during early labour.

METHODS

A multi-centre descriptive qualitative study was undertaken in UK and Italy. Ethical approval was gained and ethical processes were followed. Six virtual focus groups were conducted with 37 participants, 24 mothers who gave birth in the UK and 13 who gave birth in Italy. Line-by-line thematic analysis was performed and themes agreed.

FINDINGS

Two themes emerged: 1) women's expectations of video-calls' content and features; 2) technological challenges and solutions. Mothers responded positively to the concept of video-calling in early labour. Receiving guidance, information on coping with pain and advice on timely access in early labour was perceived as key. Women highlighted the importance of accessible, reliable and user-friendly technology. Equitable access, technological literacy, acceptability and privacy were considered as challenges to implementation, with solutions proposed to overcome disparities.

DISCUSSION AND CONCLUSION

Guidance and training should be provided to midwives, with designated resources to build a service that is accessible, acceptable, safe, individualised and respectful for mothers and birth companions. Further research should explore feasibility, acceptability, clinical and cost-effectiveness.