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