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

  • BMJ Global Health, Volume 6, No. 2, Year 2021

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Study Justification:
– The COVID-19 pandemic has led to the rapid implementation of telemedicine for maternal and newborn healthcare.
– This study aims to document the experiences of healthcare professionals globally in providing telemedicine for maternal and newborn healthcare during the pandemic.
– The findings will provide valuable insights into the challenges and successes of telemedicine in this context.
Highlights:
– Telemedicine was used by 58% of health professionals surveyed.
– Key telemedicine practices included online birth preparedness classes, antenatal and postnatal care by video/phone, a COVID-19 helpline, and online psychosocial counseling.
– Challenges reported included lack of infrastructure and technological literacy, limited monitoring, financial and language barriers, lack of non-verbal feedback and bonding, and distrust from patients.
– Telemedicine was considered an important alternative to in-person consultations, but health providers emphasized the lower quality of care and risk of increasing inequalities in access to healthcare.
– Clear guidelines for care provision and approaches to minimizing socioeconomic and technological inequalities in access to care are urgently needed.
Recommendations:
– More research is needed to understand the effectiveness, efficacy, and quality of telemedicine for maternal healthcare in different contexts before considering long-term adaptations in care provision away from face-to-face interactions.
– Clear guidelines for telemedicine provision and approaches to minimize socioeconomic and technological inequalities in access to care should be developed.
– Efforts should be made to address the challenges reported, such as improving infrastructure and technological literacy, providing adequate monitoring, addressing financial and language barriers, and building trust with patients.
Key Role Players:
– Healthcare professionals (midwives, nurses, obstetricians/gynecologists, neonatologists, etc.)
– Health systems experts
– Maternal health epidemiologists
– Public health researchers
– Infectious diseases experts
– Infection prevention and control experts
Cost Items for Planning Recommendations:
– Infrastructure development (e.g., improving internet connectivity, providing necessary equipment)
– Training and capacity building for healthcare professionals in telemedicine
– Development and dissemination of clear guidelines for telemedicine provision
– Research funding for studying the effectiveness and quality of telemedicine in maternal healthcare
– Language translation services for telemedicine consultations
– Public awareness campaigns to promote telemedicine and address patient distrust
– Monitoring and evaluation of telemedicine programs to ensure quality and equity in care provision

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a global mixed-methods study of healthcare providers, which provides a good foundation. The study collected data from 1060 maternal and newborn health professionals and used both quantitative and qualitative analysis. However, the abstract does not provide specific details about the sampling method or the representativeness of the sample. To improve the evidence, the abstract could include information about the sampling strategy and any limitations of the study. Additionally, the abstract could provide more specific findings and conclusions from the study, such as the percentage of health professionals who reported using telemedicine and the main challenges they faced. This would make the evidence more actionable and informative.

Introduction The COVID-19 pandemic has led to a rapid implementation of telemedicine for the provision of maternal and newborn healthcare. The objective of this study was to document the experiences with providing telemedicine for maternal and newborn healthcare during the pandemic among healthcare professionals globally. Methods The second round of a global online survey of maternal and newborn health professionals was conducted, disseminated in 11 languages. Data were collected between 5 July and 10 September 2020. The questionnaire included questions regarding background, preparedness and response to COVID-19, and experiences with providing telemedicine. Descriptive statistics and qualitative thematic analysis were used to analyse responses, disaggregated by country income level. Results Responses from 1060 maternal and newborn health professionals were analysed. Telemedicine was used by 58% of health professionals and two-fifths of them reported not receiving guidelines on the provision of telemedicine. Key telemedicine practices included online birth preparedness classes, antenatal and postnatal care by video/phone, a COVID-19 helpline and online psychosocial counselling. Challenges reported lack of infrastructure and technological literacy, limited monitoring, financial and language barriers, lack of non-verbal feedback and bonding, and distrust from patients. Telemedicine was considered as an important alternative to in-person consultations. However, health providers emphasised the lower quality of care and risk of increasing the already existing inequalities in access to healthcare. Conclusions Telemedicine has been applied globally to address disruptions of care provision during the COVID-19 pandemic. However, some crucial aspects of maternal and newborn healthcare seem difficult to deliver by telemedicine. More research regarding the effectiveness, efficacy and quality of telemedicine for maternal healthcare in different contexts is needed before considering long-Term adaptations in provision of care away from face-To-face interactions. Clear guidelines for care provision and approaches to minimising socioeconomic and technological inequalities in access to care are urgently needed.

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 application of telemedicine for maintaining the provision of maternal and newborn healthcare during the COVID-19 outbreak. The survey targeted midwives, nurses, obstetricians/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 A team of international collaborators adapted the questionnaire 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 Kiswahili). The questionnaire is available publicly44 and the questions relevant to telemedicine are provided in online supplemental file 1. bmjgh-2020-004575supp001.pdf 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 qualitative analyses were done simultaneously in a concurrent 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 dissemination of the survey by the Ministry of Health in Kazakhstan. A sensitivity analysis was conducted, showing that in Kazakhstan 67% of respondents used telemedicine vs 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 overarching 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 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.

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Based on the provided description, the study focuses on the application of telemedicine for maintaining the provision of maternal and newborn healthcare during the COVID-19 pandemic. The findings highlight the experiences of healthcare providers globally and the challenges and successes they encountered with telemedicine. Some potential innovations or recommendations to improve access to maternal health based on the study could include:

1. Developing clear guidelines: Clear guidelines for the provision of telemedicine in maternal healthcare should be developed and disseminated to healthcare providers. These guidelines should address issues such as best practices for remote consultations, ensuring patient privacy and confidentiality, and addressing technological barriers.

2. Improving infrastructure and technological literacy: Efforts should be made to improve infrastructure and access to technology in order to overcome barriers to telemedicine. This could include providing training and support to healthcare providers and patients on how to effectively use telemedicine platforms and ensuring reliable internet connectivity in underserved areas.

3. Addressing financial and language barriers: Steps should be taken to address financial barriers that may prevent some individuals from accessing telemedicine services. This could include exploring options for subsidized or low-cost telemedicine consultations. Additionally, language barriers should be addressed by providing interpretation services or multilingual telemedicine platforms.

4. Ensuring quality of care: While telemedicine can be a valuable alternative to in-person consultations, efforts should be made to ensure the quality of care provided through telemedicine. This could involve implementing mechanisms for monitoring and evaluating the effectiveness and safety of telemedicine consultations, as well as addressing concerns about the potential for increased inequalities in access to healthcare.

5. Conducting further research: More research is needed to understand the effectiveness, efficacy, and quality of telemedicine for maternal healthcare in different contexts. This research should explore the experiences and perspectives of both healthcare providers and patients, and should inform the development of evidence-based guidelines and best practices for telemedicine in maternal health.

Overall, the findings from the study suggest that telemedicine has been applied globally to address disruptions in maternal healthcare during the COVID-19 pandemic. However, there are challenges and limitations associated with telemedicine, and further research and innovation are needed to ensure that telemedicine can effectively improve access to maternal health while maintaining the quality of care provided.
AI Innovations Description
The study described in the provided text focuses on the application of telemedicine to improve access to maternal and newborn healthcare during the COVID-19 pandemic. The study surveyed healthcare professionals globally to gather information on their experiences with providing telemedicine for maternal and newborn healthcare.

The key findings of the study include:

1. Telemedicine was used by 58% of health professionals surveyed.
2. Some common telemedicine practices included online birth preparedness classes, antenatal and postnatal care through video/phone consultations, a COVID-19 helpline, and online psychosocial counseling.
3. Challenges reported by healthcare professionals included lack of infrastructure and technological literacy, limited monitoring, financial and language barriers, lack of non-verbal feedback and bonding, and distrust from patients.
4. Telemedicine was seen as an important alternative to in-person consultations, but health providers emphasized the lower quality of care and the risk of increasing existing inequalities in access to healthcare.
5. The study concludes that while telemedicine has been applied globally to address disruptions in maternal and newborn care during the pandemic, certain aspects of care delivery are difficult to deliver through telemedicine. More research is needed to understand the effectiveness, efficacy, and quality of telemedicine for maternal healthcare in different contexts before considering long-term adaptations in care provision away from face-to-face interactions. Clear guidelines for care provision and approaches to minimizing socioeconomic and technological inequalities in access to care are urgently needed.

Based on these findings, a recommendation to develop into an innovation to improve access to maternal health could be the development and implementation of comprehensive telemedicine guidelines specifically tailored for maternal and newborn healthcare. These guidelines should address the challenges identified in the study, such as infrastructure and technological literacy, monitoring, financial and language barriers, and the need for non-verbal feedback and bonding. Additionally, efforts should be made to ensure that telemedicine does not exacerbate existing inequalities in access to healthcare, particularly among vulnerable populations. This could involve targeted interventions to improve technological literacy, access to necessary infrastructure, and language support for patients.
AI Innovations Methodology
Based on the provided description, the study focuses on the application of telemedicine for maintaining the provision of maternal and newborn healthcare during the COVID-19 outbreak. The methodology used in the study includes a repeated cross-sectional online survey of maternal and newborn healthcare providers. Here is a brief description of the methodology used to simulate the impact of recommendations on improving access to maternal health:

1. Survey Design: The study used an online survey to collect data from maternal and newborn healthcare providers. The survey included questions about background, preparedness for COVID-19, response to COVID-19, and experiences with providing telemedicine. Additional questions were added to explore the use of telemedicine, including the types of services provided and whether guidelines were received.

2. Data Collection: The survey was distributed to healthcare providers who responded to the first round of the survey, as well as through personal networks of the research team members, maternal/newborn platforms, and social media. The survey was available in multiple languages to ensure inclusivity.

3. Data Cleaning: The collected responses were cleaned by removing duplicate submissions, refusals to participate, submissions with missing answers, and submissions from respondents who skipped all the telemedicine questions.

4. Quantitative Analysis: Descriptive statistics were used to analyze the quantitative data collected from the survey. This involved calculating frequencies and percentages using statistical software.

5. Qualitative Analysis: Thematic analysis was conducted on the open-ended text responses using Braun and Clarke’s six-phase framework. This involved familiarizing with the data, coding, theme development, revision, naming, and writing up. The analysis was done by one researcher and discussed with a multidisciplinary coauthor team to ensure accuracy and consistency.

6. Contextualization: The findings were analyzed and interpreted, taking into consideration the context in which the participants’ experiences and thoughts were rooted, such as country and position in the healthcare team.

7. Visualization: The continuum of maternal and newborn care was used as a framework to visualize the results, providing a comprehensive view of the impact of telemedicine on access to maternal health.

It is important to note that this methodology focused on collecting and analyzing data from healthcare providers and did not involve patient or public involvement in the design or conduct of the study. The study intends to disseminate the main results to stakeholders and healthcare professionals globally through social media and personal contacts.


Statistics:
Citations: 48
Identifiers:
DOI: 10.1136/bmjgh-2020-004575
Research Areas:
Community Interventions, COVID, Disparities, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants, Technology and Innovations, Workforce
Study Design:
Cross Sectional Study, Exploratory Study
Study Approach:
Mixed-methods, Qualitative, Quantitative
Participants Gender:
Female
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