Maternity Care, Interrupted

Before the coronavirus pandemic, a handful of maternity care providers were experimenting with video visits, tools to allow at-home monitoring, and texting platforms to engage more women in care and offer ongoing, customized support. While clearly some parts of maternity care can’t be shifted to virtual formats — most prominently, hands-on care from doulas, midwives, and obstetricians during childbirth — many can be facilitated by digital health tools. In this roundup, we spoke to maternity care innovators at academic medical centers, nonprofits, and technology startups to find out how they’ve scaled their efforts during the pandemic.

Since the novel coronavirus made its appearance in the U.S., the health care system has gone through rapid changes to protect patients as well as providers from infection. Some of the biggest disruptions have been in maternity care — forcing changes some say are decades overdue. “Prenatal care hasn’t looked very different than the care my mother received and not dramatically different from what my grandmother received,” says Erin Clark, M.D., associate professor and division director of maternal–fetal medicine at the University of Utah Health. “How many areas of medicine can you say that about?”

Flipping the Switch to Virtual Care

Before COVID-19, Clark had been testing whether virtual visits made it easier for women to access prenatal care. In her 2015 trial, patients were offered five to seven in-person prenatal visits for ultrasounds, diabetes screenings, and other services and an average of four virtual visits. They were also prescribed fetal dopplers, blood pressure monitors, and scales and trained by providers on how to use them to report readings.

It turned out participants were just as satisfied with virtual visits as they were with in-person prenatal care. “Women needed very little convincing this was a good idea,” Clark says, noting that some drive three or four hours each way to her office. For many, the out-of-pocket cost of supplies (from $50 to $100) was easily justified, because virtual visits save on time away from work and money spent on gas and childcare.

Before the pandemic, about 20 percent of expectant mothers at University of Utah Health were using virtual prenatal care, with more shifting to this system as providers came on board. Now, nearly all women, except those near the end of their pregnancy or those with very high-risk pregnancies, are being cared for this way. Because they already had the infrastructure and a model in place, flipping the switch to virtual has been relatively straightforward.

Telehealth in the Safety Net

Maternity care providers and researchers at the University of California San Francisco–Zuckerberg San Francisco General Hospital were also testing virtual visits before the pandemic as part of the SF Respect Initiative, which engaged families covered by Medicaid in designing new prenatal care models. In January, they began exploring whether having virtual prenatal visits would reduce barriers to care for patients who sometimes miss appointments because of work or lack of transportation or childcare. By late March, the use of telehealth had shifted from a pilot to common practice. UCSF maternity providers now conduct about 70 percent of prenatal and postpartum visits via video or phone. Malani Nijagal, M.D., associate professor of obstetrics and gynecology, says video visits have been an effective way to connect with women, particularly after childbirth when she wants to gauge their mood and well-being. “I’m able to pick up cues — including whether they are smiling and interacting,” she says.

To ease the process for patients and providers, Nijagal and Courtney Lyles, Ph.D., a health services researcher at UCSF, have created a website offering guidance to other safety-net providers adopting telehealth to serve patients with limited English proficiency and/or limited digital literacy; it is based on lessons from their experiences helping patients use an online portal. Lyles also helps run S.O.L.V.E. Health Tech, a “health equity accelerator” that seeks to ensure health apps and other technologies are designed with and for low-income people. “There’s a myth that low-income patients don’t want tools to help them with their health,” Lyles says. “They just want to be in on the design and have [the tools] make sense for them.”

On-Demand Services, Including Mental Health

In Massachusetts, the state’s Medicaid agency has sought to increase access to care during the pandemic through a contract with Maven, which offers telehealth services from 20 different types of maternity providers (for fertility and pregnancy care, birth planning, mental health counseling, lactation coaching, and pediatric services) via on-demand chats and video appointments. In March, Maven signed a contract with Massachusetts to provide telehealth services to any Medicaid beneficiary who has COVID-19 symptoms or concerns. To help Maven scale up quickly, Massachusetts officials batch-processed the licenses of physicians willing to provide telemedicine in their state. Since March, the company has been offering more than 10,000 physician appointments a week to the state’s Medicaid beneficiaries.

During the pandemic, demand for mental health counseling among all of Maven’s clients has surged, with many pregnant women feeling anxious about the threat of the virus and how it will impact their delivery. “We’ve seen a 500 percent increase over the last month,” says Kate Ryder, Maven’s founder and CEO. “Typically, we see the most mental health usage during postpartum months, but now we’re seeing it in pregnancy.”

Speeding Discharges After Delivery

Even though hospitals have been isolating COVID-19 patients from others, many women are wary of delivering their babies in the hospital. Some have also been alarmed by reports that COVID-19-positive women may be separated from their babies after childbirth. There’s been an uptick in interest in birthing centers or home births, which can be as safe as hospitals for women with low-risk pregnancies but are not options for all women.

To help get new mothers out of the hospital as quickly as possible, Penn Medicine has been scaling a program it had in place before the pandemic. Healing at Home, piloted last year, provides mothers who meet certain clinical criteria the option of being discharged one day after childbirth. The hospital had previously required a two-day stay, but in surveys 80 percent of women said the hospital disrupted their rest and bonding with their newborns. The program offers mothers support after discharge: a chatbot answers questions via text, enables early and repeated screening for postpartum depression, and offers advice on lactation and other common concerns. The automated questions and answers are monitored by clinicians, who respond within an hour if there is additional need.

Another tool, Pregnancy Watch, sends twice-daily texts to pregnant and newly postpartum women exhibiting COVID-19 or flu-like symptoms who are sheltering at home. Women who report worsening symptoms such as shortness of breath are immediately triaged to maternal–fetal medicine specialists, who follow protocols for escalation to telemedicine or hands-on care when necessary. Leaders at Penn Medicine’s Center for Health Innovation rolled out this approach in a matter of days, building on groundwork from a 2017 pilot that used text to check in on COPD patients every day and led to a 30 percent reduction in hospital readmissions. “The fundamental premise of Pregnancy Watch is that most women who are infected are better managed at home, but we want to be able to watch over them, offer reassurance, and be able to respond quickly if they are deteriorating,” says Adi Hirshberg, M.D., assistant professor of obstetrics and gynecology.

Identifying and Responding to Postpartum Risk

Before the pandemic, both providers and policymakers were focused on the “fourth trimester” — the months after delivery when women still remain at risk; more than half of pregnancy-related deaths occur after childbirth. Babyscripts is a technology company that offers maternity providers a telehealth platform and educational tools to support patients and keep track of them between office visits. For example, Babyscripts’ clients, mostly large safety-net providers, can prescribe Bluetooth-enabled blood pressure cuffs to track women who develop hypertension during pregnancy. Blood pressure data are captured either multiple times a day or weekly, depending on patients’ particular risks, and then sent wirelessly to Babyscripts, which alerts providers if necessary.

Babyscripts and Penn Medicine have been collaborating on an approach to monitor women’s blood pressure in the months after birth. The work is based on knowledge gained from Penn Medicine’s Heart Safe Motherhood program — which demonstrated that text-based monitoring is more effective in obtaining blood pressures than traditional office-based follow-up — and Babyscripts’ expertise in remote monitoring technology.

Babyscripts can also allow women to chat with a care coordinator, typically a social worker or nurse, who can send educational messages and appointment reminders or offer help connecting to social supports. At one health system, this approach reduced the no-show rate at prenatal visits among Medicaid-insured women from 27 percent to 14 percent, according to the company.

Addressing Health Equity

Concerns about how African American women fare during pregnancy and childbirth have only increased since the pandemic began. They had much higher rates of maternal complications and deaths than white women before COVID-19, and there is evidence that African Americans are contracting the coronavirus at higher rates than whites and dying in disproportionate numbers. “People are already in a situation of vulnerability, and then you add in mass chaos,” says Aza Nedhari, founder and executive director of Mamatoto Village, a Washington, D.C.–based nonprofit that trains and deploys community health workers to offer perinatal supports to women. Ninety percent of Mamatoto’s clients are African American. “As much resilience as exists among our clients, there are vulnerabilities as well. Is this going to be a tipping point for some people? Could this push them into preterm birth or exacerbate comorbidities?” Nedhari says some of her clients are unable to socially distance because they live in multigenerational households or still have to go out to work. She also worries that many live in neighborhoods where local stores are short on supplies and public transportation routes to get to grocery stores are limited or shut down.

Before COVID-19, the perinatal community health workers trained and deployed by Mamatoto Village visited pregnant women and new mothers in their homes to help them navigate the transition from pregnancy to parenthood. They offered support with breastfeeding, managing their health, and addressing social problems and had a remarkable track record of promoting healthy starts. Today, these perinatal health workers are checking in with their clients via video and phone and offering online childbirth and parenting education.

Policies to Transform Maternity Care

It remains to be seen whether the pandemic will have enough force to transform maternity care in the long term. After more patients try virtual prenatal visits, they may come to demand them. In recent months, providers at the University of Michigan have adopted mostly virtual prenatal visits and also created online forums in which pregnant women can share experiences and support one another. And more providers may come to appreciate that remote monitoring tools offer greater oversight of pregnant and postpartum women with particular risks. Still, failsafe systems should be put in place to ensure gaps in care — say, missed lab work — are quickly recognized and addressed. And efforts must be made to monitor the safety and quality of new care models.

To support telematernity care, payment policies would need to change, as highlighted in a recent Commonwealth Fund blog post. Since Medicaid pays for nearly half the births in the U.S., all states would need to reimburse telemedicine services on par with in-person visits. Pre-COVID-19, only 19 states paid for telemedicine services delivered to patients in their home, but in response to the pandemic, 47 states plus Washington, D.C., have expanded the use of telemedicine in their Medicaid programs and 20 states have waived or lowered copayments for telehealth visits for Medicaid beneficiaries. North Carolina’s Medicaid agency recently began paying for blood pressure cuffs to allow pregnant women and other beneficiaries to monitor their blood pressure at home. Medicaid and other payers should also include reimbursement for services provided by community health workers, doulas, and other nonmedical staff who have been shown to be effective in supporting women through pregnancies and in the months after childbirth.

The equitable expansion of telehealth for maternity care also means ensuring we do not leave people behind. While providers say video visits give them a greater window onto prenatal and postpartum health and well-being than phone calls alone, some women don’t have the devices or internet connections to take part in them. Medicaid programs and plans would have to ensure beneficiaries have convenient and affordable options for virtual visits and connected devices. Particular efforts may be needed to scale promising telehealth models that have been developed in rural areas, given that broadband access in some rural communities is spotty. If implemented equitably, telehealth tools could benefit those for whom the status quo has not been working, including rural, black, and low-income women.

Finally, extending Medicaid coverage to a full year postpartum would facilitate telehealth innovations in maternity care — increasing access to care during a critical period and giving mothers and families a strong foundation on which to grow.