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Smart Technology in Obstetrical Care

Using Telehealth Approaches to Address Social Determinants of Health and Improve Pregnancy and Postpartum Outcomes

DIXON-SHAMBLEY, KAMILAH MA, MD*; GABBE, PATRICIA T. MD, MPH*,†

Author Information
Clinical Obstetrics and Gynecology: June 2021 - Volume 64 - Issue 2 - p 333-344
doi: 10.1097/GRF.0000000000000611
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Abstract

One of the first documented uses of telehealth in obstetrics and gynecology was reported by Boehm and Haire.1 This group detailed the use of a Telecopier to transmit fetal monitoring tracings from rural hospitals in Tennessee to Vanderbilt University in Nashville. Once the tracings were transmitted, rural hospitals would have consultations with physicians on further management of the tracings for the patients at the outlying hospitals. In this earliest example, telehealth was used to provide needed consultative services in a manner that was acceptable and cost-effective.1 The application (app) of telehealth in the field of obstetrics and gynecology has expanded to services including but not limited to providing remote consults in rural areas that do not have [maternal-fetal medicine (MFM)] specialists, mobile apps to monitor glucose levels for patients with gestational diabetes, and the use of telehealth technologies to conduct prenatal care appointments. Furthermore, with the focus on the importance of postpartum care, especially because women with insurance coverage through Medicaid have very low rates of postpartum visit attendance, a direct reflection of the social determinants of health (SDOH), telehealth has been employed to address the needs of mothers after their delivery. It has been shown that postpartum visits can be conducted using telehealth technologies.2 These visits can even include wound checks after cesarean deliveries using pictures or videos to detect potential infections.

With the onset of the coronavirus disease 2019 (COVID-19) pandemic and the desire to maintain the physical distancing of patients, many providers have depended on the use of telehealth to promote wellness at a distance. With this need to provide remote care, came updates in both technologies and provider comfort with telehealth services. A study conducted at Columbia Presbyterian Hospital found that during the rapid transition to telehealth services for prenatal care, providers believed the services increased access for their patients. In addition, when questioned regarding their likelihood of using telehealth before and after its implementation during the COVID-19 outbreak, 45% of providers reported that they would have used telehealth before and 89% reported that they would continue to use it after.3 With this expansion of use due to the COVID-19 pandemic, these technologies will only become more prevalent as time goes on.

While the technology has changed significantly, telehealth in its core is not a new concept. An early report detailed the benefits of the use of the telegraph in connecting remote patients to their physicians, especially in a time when transportation was limited.4 Today, transportation continues to be a significant SDOH barrier and telehealth an important modality to connect patients with physicians. The Health Resources and Services Administration (HRSA) now defines telehealth as the use of “electronic information and telecommunication technologies to support long-distance clinical health care, patient and professional health-related education, public health, and health administration.”5 Currently, the terms telemedicine and telehealth have been used interchangeably.

Telecommunication devices include the use of fax machines, e-mail, computers, laptops, tablets, and smartphones. Each can be connected to either high-speed internet or use wireless functionality to establish connections. Other terminology which may be encountered includes e-health and m-health which refers to electronic health and mobile health, respectively. Generally, mobile health is reserved for mobile health apps, for example, using phones and laptops. This broad definition of telehealth has included the development of a wide range of services to address the needs of patients. These services can range from patient portals in the electronic medical record (EMR), the use of e-tracking of disease indicators like blood pressure or blood glucose, remote video consultations, plug-in devices such as stethoscopes, text messaging of health information, and the use of mobile apps for the education of patients. Given the complexity and the expense of linking and acquiring telehealth modalities, for example, mobile phones, laptop computers, access to patient portals in EMRs, how do women with limited incomes, living in disadvantaged neighborhoods overcome the SDOH barriers to access telehealth? Examples are provided in Table 1.

TABLE 1 - Examples of Telehealth Modalities Used to Address the Social Determinants of Health in Obstetrics and Gynecology
Telehealth Modality Social Determinants of Health Examples for Obstetrics and Gynecology
Lifeline—Low-income broadband access from the Federal Communication Commission subsidizes voice, internet, and video services Provides low-cost monthly voice and text messaging on “government smartphones” for low-income households up to 135% of the Federal Poverty Level. Provides a link to essential services Allows ample texting for follow-up appointments, eg, but difficult for patients to wait “on hold” for appointments and use up their monthly voice time allotments
Electronic medical record patient portal, desktop or laptop computer, or app on a smartphone. For example, MyChart in the Epic electronic medical record Two-way communication between provider and patient. Increases health literacy and self-advocacy Requests for advice, progress notes, laboratory reports. May misinterpret results and provider notes
Telehealth-video conference Examples: Embedded EHR app, Doximity, FaceTime, UpDox Access to medical care in a format that reduces lost time from work and costs for gas money, transportation and parking with fewer missed appointments Reduces in-person visits, used for prenatal care, postpartum care with wound monitoring, contraception counseling, lactation counseling. Includes plug-in devices to transmit information, such as maternal blood pressure and fetal heart rate
Telehealth HIPAA-compliant group platforms Example: Zoom for Health; Microsoft Teams Group level education, eg, Moms2B at The Ohio State University Pregnancy and first year of life group education sessions; mental health support groups; pregnancy treatment programs for opioid use disorder
EHR indicates electronic health record; HIPAA, Health Insurance Portability and Accountability Act.

SDOH

Expansion of medical services through telehealth modalities has enabled the provision of services to patients to address a collection of factors in a person’s environment, the SDOH, which influence the health of the individual. The World Health Organization (WHO) defines the SDOH as the “conditions in which people are born, grow, work, live, and age and the wider set of forces and systems shaping the conditions of daily life.”6 These include but are not limited to, access to health care services, to transportation, technology, food, and safe housing, as well as the quality of education, presence of discrimination, racism, lack of social support systems, exposure to crime, and health literacy, to name a few.7 The effects of SDOH are far-reaching; they have generational effects on the health of individuals. In obstetrics and gynecology, the stark reality of the SDOH are measured by the Black-White disparities in maternal and infant mortality rates (IMRs) and the birth outcomes of prematurity and low birth weight newborns. IMR, the death of a live-born infant in the first year of life per 1000 live births, reflects the health of the mother and infant as well as the community in which they live.8 In turn, the IMR reflects the SDOH and at its source, systemic racism.9 Ten years ago to better understand the etiology and address the high black IMR in our city, we started Moms2B, an Ohio State Wexner Medical Center program to eliminate Black-White disparities and reduce infant mortality. In this program, described later, we learned first-hand the hard reality of the SDOH and why disparities exist. We learned that pregnant women living in disadvantaged neighborhoods often exist on monthly incomes of $1000 or less. We saw repeated evictions that uprooted families and put infants in unsafe sleeping environments. We witnessed the impact of hunger and lack of access to good, healthy food while pregnant and postpartum. We heard how losing a job while pregnant, without maternity benefits, leads to utility disconnections, then to eviction and the homeless shelter. We heard how taking 2 hours on public transportation causes delays getting to work or a medical appointment. We saw Black fathers in our Dads2B program, struggling to find work that will pay the utilities, the rent and put food on the table. We learned about long-standing structural discrimination with real estate covenants, banks red-lining, and freeways built through once vibrant neighborhoods. Later in this paper, we describe how we transitioned the weekly in-person, neighborhood-based Moms2B sessions to a virtual format using telehealth to ameliorate the SDOH.

The focus of public health efforts has been to address these determinants to truly influence the health of the population and for health systems to address these factors when they affect the individual. Today the necessary access to technology speaks to the large impact telecommunication and telehealth has had on our society. Telecommunication devices are ever-present, and they influence the education, employment, and health of the individual. When an individual cannot access a telecommunication device, they lack the ability to gain health literacy and advocate for themselves. Acknowledging that telecommunication is a basic necessity, the Communication Commission (FCC) subsidizes a program (Lifeline) to provide broadband connections to allow low-cost access, with some limits, to phones, internet, and video services.10

It is also important to note how patients interact with the various forms of telehealth modalities. In a study of pregnant patient’s interactions with telehealth and mobile health, it was noted that patients had higher “influenceability” meaning they were more likely to be influenced by information from internet sources they interacted with frequently to gain information.11 They also found that 22% of their study population used mobile health apps during their pregnancy. In the population who were more likely to use mobile health apps, they self-reported to be “less healthy,” were younger, and were primiparous.11 Knowing how patients interact with telehealth options will help to best target their needs. DeNicola et al,12 reviewed the use of telehealth to improve health outcomes in obstetrics and gynecology. Through the evaluation of 47 studies, they found the benefit of the telehealth modalities, namely the use of text messaging technologies in supporting patients in smoking cessation, breastfeeding, and use of contraceptives. Text messaging technologies were found to be associated with a reduction in self-reported smoking at 30 days. In addition, they noted that the text-based technologies contributed to higher rates of continued breastfeeding and exclusive breastfeeding. The use of text messaging was also beneficial in the continuation rates of oral contraceptives and depot medroxyprogesterone acetate injections. Text messaging costs less than voice messaging. In our experience, pregnant and postpartum women using government-subsidized mobile phones respond more readily to text messaging than voice calls.

The first text-based national telehealth education modality in prenatal care was text4baby. Text4baby disseminates pregnancy and newborn information to mothers through the first year of life of the child. It is tailored to the mother’s gestational age and is free for the participants. Of participants surveyed, 95% would recommend Text4baby to a friend, demonstrating satisfaction with the program.13

Access to prenatal care in the first trimester is considered a key public health measure. Yet, women of color, women without insurance, women at most risk for poor pregnancy outcomes consistently are more likely to receive prenatal care later in their pregnancies.14 Telehealth has the potential to improve access to prenatal care. van den Heuvel et al,15 detailed the benefits of telehealth in prenatal care including improved patient satisfaction and engagement and decreased clinic visits as well as remote monitoring and access to care in low/middle-income communities. They also described limitations including reimbursement, legal issues, and technical support.

As mentioned earlier, to achieve health equity and the barriers presented by the SDOH, physicians must advocate for their patient’s access to telehealth. Moreover, if a patient lacks access to these modalities, it is possible that other factors such as transportation may be challenging as well, and the use of remote telehealth options would further influence the health of the patient and their family.

SDOH contribute heavily to obstetric outcomes, and, like other fields of medicine, emphasis has been placed on thoroughly addressing these factors with patients.16 American College of Obstetrics and Gynecology (ACOG) advocates for the assessment of different aspects of SDOH in patients including access to safe housing, food, assessment of safety in the home, and the employment status of the patient. In addition, ACOG recognizes that discrimination contributes to the SDOH and encourages the role of the physician as an advocate for the patient through referral to social services and involvement in legislation to promote equity in the services available for their patients.

Gadson et al17 describe a potential link between SDOH and the health behaviors which inform prenatal care utilization and racial disparities in care. They posit that each has an influence on the other. For example, they detail a study which showed that uninsured women had a higher likelihood of experiencing discrimination which in turn could contribute to later entry to prenatal care. They comment on the need for continued integration of services that combine prenatal care needs with interventions to address SDOH. Highlighted interventions include the use of community health workers to provide psychosocial surveys and the repeated assessment of social determinants during prenatal care.

It is important to clarify the various ways in which telehealth technologies can be leveraged to address the SDOH to meet the needs of patients. Addressing the SDOH for a patient requires a full assessment of their needs. One way to do this has been the integration of the SDOH information into the EMR. Cantor and Thorpe18 reported the success of the integration of SDOH data into the EMR and some of the pitfalls in doing so. One of the major barriers they addressed was the selection of specific surveys and their implementation and how to develop a workflow as the information reported changed for the patient. Buitron de la Vega et al19 expanded on these concerns and detailed how to implement a referral system connected to ICD-10 diagnoses generated from a standardized SDOH screening conducted in a general internal medicine office. Their aim was to address some of the challenges seen in using the EMR to assess SDOH, namely the lack of consistency in some practices and ensuring that if certain needs were identified, appropriate referrals can be made to address those issues. They found the most reported SDOH issues were unemployment, food insecurity, and being able to purchase medications. By streamlining the referrals, they hoped to increase the uptake of services by their patients.

With the importance of considering SDOH, one important question to ask is do patients in low-income populations have access to the technology to enable the use of telehealth services? Roberts and Mehrotra,20 estimated that 26% of Medicare recipients did not have access to a computer or laptop connected to high-speed internet or a smartphone connected to wireless data. This access gap remains one of the barriers in providing telehealth services to patients in higher need areas. It illuminates the importance of services addressing the lack of connectivity for patients using Medicare insurance as these patients may have additional needs that could be addressed with the help of telehealth. Furthermore, the responsibility for the physician to advocate for their patient’s connectivity has been highlighted as an important way of ensuring health equity.21

Within the obstetrics literature, rural populations that lack access to specialized high-risk obstetric care has been an area of focus. Telehealth can extend patient access to MFM consultations. In one study, offering telehealth MFM consultations to patients in their local hospitals saved money which would have been used for transportation, and the patients could stay in their communities for their care.22 Additional benefits of telehealth in obstetrics includes the use for remote diabetes management and provision of postpartum care.23

Nair et al24 conducted a systematic review to examine the uses of telemedicine in the management of postpartum depression. They included 10 studies in their analysis and concluded that telemedicine is effective in improving treatment efficacy. Each of the studies varied in the telecommunication methods that were used, but they included the use of real-time virtual sessions, Web sites equipped with lessons as well as telephone and e-mail reminders.

Given the variety of services available under the umbrella of telehealth, it is not surprising that there has been extensive discussion regarding the benefits of telehealth. In a systematic review of 85 articles, telehealth was shown to be well received by patients, and they appreciated access to their health team via telehealth modalities.25 The authors also concluded that telehealth is beneficial in the primary care setting by decreasing costs of health care and improving quality. The various interventions included internet-based health coaching, automated calls for appointment reminders and medication counseling, and the use of e-visits.25 In another analysis, Ekeland et al26 further reviewed 80 “heterogenous systematic reviews,” and noted that in 20 of the studies, telemedicine was found to be effective. The benefits of telehealth included smoking cessation, prevention of cardiac disease, management of diabetes, and telepsychiatry. While 19 reviews concluded that there was a potential benefit in the use of telemedicine, 22 studies found limited evidence of its value. These reviews demonstrate that while telemedicine has specific benefits and can be applied to help decrease costs and increase access, caution should be exercised in universally applying telemedicine to solve all health care problems. While the literature shows the benefit and potential benefit of telehealth in primary care settings, it has also been proven to be helpful in specialty care as well such as in obstetrics and gynecology.

Mobile Apps

A mobile app is a software developed to be loaded on a mobile device, such as a smartphone or tablet. The number of apps providing health information as well as monitoring health conditions have rapidly increased in all fields of medicine including obstetrics and gynecology. In a recent count, there were 1800 apps related to obstetrics and gynecology in the Apple store.27 In a systematic review of 245 studies surrounding the use of mobile health apps, Chen et al,28 found that the various uses included apps connected to the medical record for results or appointments, apps for health education, for reminders for medications or appointments and those for recording medical data for patients with chronic conditions. In addition, many social service organizations like Women, Infants, and Children (WIC), for example, have mobile apps to better enable the distribution of services to individuals in need (Table 2).

TABLE 2 - Applications (Apps) Available to Address the Social Determinants of Health for Pregnant and Postpartum Women
Examples of Helpful Apps Available at Apple App Store, Google Play Store, or Amazon App Store Social Determinant of Health Addressed by the App Use of App During Pregnancy and Postpartum Period
Babyscripts Text4Baby ACOG SMFM Education and communication at the individual and group level Babyscripts: Obstetric offices subscribe to this program and enroll women in their practices. The app contains preloaded education material and can be personalized to each practice. It includes medical monitoring devices and communication with other women in the practice Text4Baby a free messaging program for underserved pregnant and new mothers. Gestational appropriate educational material is sent weekly via text messages SmileChild underdevelopment to provide pregnancy education on a gaming platform Apps available for professionals include: ACOG from the American College of Obstetrics and Gynecology SMFM from the Society for Maternal-Fetal Medicine
WIC Fresh EBT Food shortage, nutrition depletion, breastfeeding support WIC Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), available for low-income pregnant, breastfeeding and non–breastfeeding postpartum women, and to infants and children up to age 5 if at nutritional risk Fresh EBT; allows recipients to check their Supplemental Nutrition Assistance Program (SNAP) (formerly Food Stamps) benefits balance; includes coupons and grocery store sales
RAINN Domestic violence RAINN Rape, Abuse & Incest National Network operates the National Sexual Assault Hotline; partners with local sexual assault service providers
HUD Resource Locator Housing needs HUD Resource Locator Department of Housing and Urban Development housing resource locator. It should be noted that due to thousands of apps, the waiting time for HUD houses can take years
Irth Health in Her Hue Mahmee Racism Achieving Black-White health equity Irth. “As in Birth” but the developers dropped the ‘B’ for bias. An app to review and rate providers for Black women and their birthing experience Health in Her Hue connects Black women to health care providers Mahmee provides support from pregnancy through the first birthday; also HIPAA compliant and can share medical records with providers
Google Translate iTranslate Language barriers may cause delays in seeking treatment, or symptoms can be misinterpreted Translation apps are available in many languages, either free or low cost. They allow voice and written translation from one language to another. Useful apps include Google Translate and iTranslate
BetterHelp Talkspace Anxiety and depression are common mental health disorders affecting women living in poverty Several apps for individual counseling are available, however, the most popular, BetterHelp and Talkspace charge for therapy sessions
Medicaid Managed Care Organizations provide specific apps to help enrollees access their services Most women with incomes below the federal poverty level qualify for Medicaid Insurance coverage Provide details about insurance benefits, rewards for meeting health guidelines, and usually have transportation options available for medical appointments
Apps for portable devices: Smartphones, tablets and notebooks; examples useful for the social determinants of health.
HIPAA indicates Health Insurance Portability and Accountability Act.

Group Telehealth Options

The use of telehealth specifically for group sessions for patients has been investigated as well. The facilitation of these groups would initially appear to be challenging, but the benefits in providing services for patients who may not have adequate transportation or time to travel to in-person group sessions are significant. Banbury et al29 performed a review investigating the use of telehealth for group therapy sessions. In 15 studies, they found that the use of video conferencing for group therapy was well accepted by the patients and helped overcome barriers of transportation and timing of in-person sessions which may preclude patients from participating. They noted that these sessions provided social support to the participants but that potential distractions and interruptions may occur during video conferences in the home setting. In addition, privacy must be assured for the other participants in the groups. They noted that virtual group sessions had previously been conducted using text-based modalities, but that video conferencing proved to be well received and supportive of therapeutic goals.

Group pregnancy programs during the COVID-19 pandemic were forced to transition to telehealth to protect both providers and patients from infection. McKiever et al30 from our institution report their experience with pregnancies complicated by opioid use disorder that transitioned from weekly in-person group treatment to telehealth. This caused significant disruption in care because attendance in telehealth groups fell, and opioid cravings increased requiring higher dosages for medical assisted treatments. Our own neighborhood-based group pregnancy program underwent a similar transition, but with better attendance, as described in the case that follows.

Case Study of the Transition From an In-person Community Group Program to a Virtual Program During a Pandemic

Moms2B is a community-based group education program that serves low-income women based in Columbus, OH. The program was first developed in 2010 in response to the extremely high IMR in our city overall and especially in Black families. Over time, the program expanded to 8 locations in the zip codes with the highest rates of infant mortality. Overall, 70% of the participants identify as non-hispanic Black, and almost 90% of the participants rely on Medicaid for insurance or are uninsured. On the basis of the Life Course Model,31 the program increases protective factors known to improve pregnancy, postpartum, and infant health. A multidisciplinary team comprised of physicians, early child educators, nurses, social workers, dieticians, community health workers, and patient navigators educate and develop supportive relationships with each woman. Partnering with neighborhood organizations, community centers, and churches, Moms2B hosts weekly education sessions. Each session lasts 2 hours and includes the provision of a heart-healthy meal, case management check-ins with various team members to complete surveys related to SDOH of health and assess the needs of the mother, and then interactive group education sessions. The first hour involves all participants, and in the second hour, the group divides into parenting and pregnant mothers for specific education based on their needs. Participants are invited to bring support people with them to the sessions and a separate program exists to support the Dads in the program named Dads2B. Concurrently, there is childcare available to ensure that mothers can bring their families with them, and transportation is made available to bring the mothers to and from sessions.

Mothers are invited to participate during pregnancy and continue the program until their infants turn 1 year of age. Through weekly sessions, mothers are educated and supported on how to navigate their pregnancies safely. Sessions include lessons on safe sleeping, safe spacing of pregnancies, and family planning, management of stress, and lessons on breastfeeding. The success of the program centers on the ability of the participants to interact with a diverse team and make connections with other mothers as well. This model has been demonstrated to contribute to improved birth outcomes in its participants including increased uptake of breastfeeding and a decrease IMR.32,33

In the wake of the COVID-19 pandemic, with the restriction on in-person sessions, Moms2B was forced to transition to a virtual platform to continue its care. Initially, the use of social media platforms, namely Facebook, was leveraged to reach out to participants in the program and provide health education. During COVID-19, as noted earlier, Health Insurance Portability and Accountability Act (HIPAA) regulations allow the use of the Zoom video conferencing platform for groups. The Moms2B program transitioned to a replication of the in-person sessions with virtual lessons using the Ohio State University Carmen Zoom platform. This platform enabled the team to provide uninterrupted password-restricted sessions to only the participants in the Moms2B program. During sessions team members led participants through an hour-long lesson. The lessons mirrored the normal flow of the in-person sessions, but to make them more interactive, the sessions were split into 2 separate 1-hour sessions as opposed to the 2-hour in-person sessions that were normally conducted. One hour was dedicated to general information for all of the mothers, and the second hour was used to address pregnant and parenting education concerns, respectively. In addition to these 10 weekly virtual sessions, there was a weekly session dedicated to babies and one-to-child play for the older children of the mothers. Individual case management was also conducted via telephone calls and text messages. Team members helped mothers complete surveys of the SDOH, and this information was used to conduct needs assessments. For this plan to be successful, it was imperative that the participants could access our lessons. We confirmed that all of the participants had smartphones or other telecommunication devices. In addition, in the planning of the timing of the sessions, it was important to keep in mind that many of the women had older children who depended on the use of the same devices to complete virtual school work with Columbus stay-at-home order in place.

When participants identified food insecurity, they were referred to an area food bank. Through a drive-up system at 2 area organizations, Moms2B staff aided in the distribution of food and goods to the mothers in need. In November 2020, the program began documenting these findings and the services provided in the patient’s EMR.

In exchange for participation in the sessions, the patients were awarded Amazon gift cards which were delivered via email.

To continue enrollment of newly pregnant women in the virtual sessions, the team had to transition to a virtual referral “flyer” rather than the distribution of paper information cards. A new information card was created and distributed electronically to community partners to describe the new changes. In addition, with documentation in the electronic health record, an e-referral was created to aid in the referral of moms from physician and midwife practices. Enrollment continued at about half the pace as before, but women liked the virtual format, and participation in the sessions increased each month.

From April 2020 until December 2020, the program has served over 400 women and provided over 4500 patient contacts through zoom groups. Attendance in virtual groups grows every month. However, overall recruitment of pregnant women into the virtual program declined from 570 the previous year to 310 in 2020. Notably, attendance at postpartum visits increased when telehealth visits became the norm during the pandemic.

We have demonstrated the ability to transition an in-person community-based prenatal education program to a virtual one with the use of telecommunication devices. While initially this transition was put in place to face the immediate concerns during the pandemic, continuing a hybrid model will likely continue once in-person sessions return. One of the greatest benefits of virtual sessions is that the education reaches mothers who would have been unable to attend in-person sessions in the past. As demonstrated by previous research, hopefully, the social benefits of the virtual group sessions can be seen in this population as well.

The reaches of telehealth are vast, and even within the realm of obstetrics and gynecology we can see the benefits of the use of these technologies in connecting patients with services and advocating for their health. Through these modalities, patients can be further empowered to engage with health systems to ensure they have the very best care. While telehealth ultimately works to increase access in care, we can see how it is useful in evaluating and addressing other SDOH as well and the importance of incorporating SDOH assessment in the successful deployment of telehealth strategies to improve outcomes in pregnancy and postpartum.

References

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Keywords:

telehealth; apps; SDOH; Moms2B; disparities; pregnancy

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