Transforming Prenatal Care in Response to COVID-19: Reflections from an academic family medicine practice
By Allison R. Casola, PhD, MPH, CHES, Sarah Hirsh, MD, and Zeynep Uzumcu, MD
Introduction
In light of COVID-19, healthcare systems across the country have been rapidly revising processes and day-to-day procedures to move care online. A multidisciplinary team at the University of Michigan, for instance, has introduced a new prenatal care approach for low-risk pregnancies that limit clinic visits and encourage telehealth visits when possible [1]. Telehealth is becoming ubiquitous, but what does it mean for the state of prenatal care? Certain components of prenatal care, such as imaging, physical examination, routine vital monitoring, and patient counseling may be difficult or near impossible to conduct remotely. Thus, providing the highest-level of prenatal care during our current social-distancing era has posed unique challenges and considerations for both healthcare providers and healthcare systems alike. The purpose of this narrative to is to describe how a large, urban, academic, family medicine clinic in Southeastern Pennsylvania strategically approached and implemented telehealth-based prenatal care; and to discuss how COVID-19 may be ushering in a new chapter of transformed prenatal care.
Providers, patients, and practice norms pre-COVID-19
The Maternal and Child Health (MCH) team– consisting of two full-time faculty attendings, one registered nurse, and one medical assistant — is a relatively small division of a large, academic Department of Family and Community Medicine practice. The team cares for approximately 80–100 obstetrical patients annually. Patients tend to be English speaking, African American or Black women over the age of 18, and about half are publicly insured. Our family medicine residents, under supervision of our MCH attendings, typically follow patients in continuity. The department’s three-year residency program maintains a 10-resident cohort and provides focused training on care for urban and underserved populations. Our family medicine residents also co-manage patients on labor and delivery with obstetrical residents at our institution’s obstetrics practice, while the care of higher risk patients may be entirely taken over by the department of maternal fetal medicine, as needed, during the course of a patient’s prenatal care.
Shifting from in-person care to telehealth during COVID-19
With COVID-19 on the rise in the United States, the Department of Obstetrics and Gynecology (OBGYN) at our Medical Center developed and revised guidelines for outpatient prenatal care. In non-COVID-19 circumstances, a patient may have anywhere from 10–15 prenatal care appointments. However, under revised guidelines general protocol for standard in-person visits with an OB provider were to occur at 12-, 28-, and 36-weeks. At the 12-week visit, a complete physical exam, including a pap smear if needed, would be performed, as well as a bedside ultrasound for dating if a patient was unsure of their last missed period. This process limited exposure for both the OB provider and ultrasound technicians. At the 28-week visit, patients would receive Rhogam (if indicated), Tetanus diphtheria acellular pertussis (Tdap) vaccination, and traditional 20-week anatomy ultrasound (performed in-person, but followed up with telehealth visit to review results). At 36 weeks, a complete group beta-hemolytic streptococcus (GBS) swab would be performed and fetal position would be assessed so that external cephalic version could be scheduled if indicated. All other appointments would be conducted via telehealth.
The family medicine MCH team considered these guidelines and closely reviewed individual patient factors to develop a revised prenatal visit schedule. Specifically, each patient’s chart was critically examined to determine an individualized in-person visit schedule and to identify conditions or concerns that would require more frequent in-person visits. Two residents combed through approximately 60 patient charts, by hand, noting how to update their recommended prenatal care. Conditions and/or concerns included those in high-risk social situations, patients who had missed various testing at the appropriate times during their pregnancy, and patients without blood pressure cuffs at home. Because the proposed telehealth protocol was contingent upon patients having an at-home blood pressure cuff, our nurse practitioner called all OB patients to inquire and discuss options for obtaining one. For some patients, Medicaid would cover the cost of a cuff, while other private insurers would require patients to pay out of pocket.
Once each patient’s care schedule was finalized, the MCH team worked to coordinate timing of in-person visits with any imaging, non-stress test (NST), and required lab visits in order to minimize the number of patient interactions with the healthcare system for the duration of the pregnancy. To ensure smooth implementation, and make adjustments as needed, the MCH team would meet weekly to discuss the patients and any evolving or changing needs related to their prenatal care.
Implications and next steps for the future of prenatal care
Despite efforts to maintain a strategic, consistent protocol, the COVID-19 pandemic makes each day unpredictable. Weekly adjustments and revisions are made to our prenatal care processes, and updated guidelines now recommend additional in-person visits at 8-, 16-, 37-, 38-, and 39-weeks as clinic office visits begin to open up. Yet these frequent changes and the resiliency of healthcare providers in the face of the pandemic has brought to light opportunities to question the “normal” way we deliver prenatal care to patients. How many in-person visits are truly necessary? Even before COVID-19, policymakers and clinical leaders have discussed mechanisms for prenatal care delivery reform as means of improving abysmal maternal and infant health outcomes in the United States [2]. Is telehealth arguably more beneficial for some patients? [3] Through telehealth, patients who may have struggled to get to appointments can now do so from their home. Patients who may have struggled with finding childcare, taking off time from work, or navigating mazes of public transportation can now connect with their provider in between the multitude of other priorities in their life. From a provider perspective, we see patients in their homes, which brings context to our patients’ lives outside of appointments. Prenatal telehealth can also help provide the patient with more ownership and investment in their health through taking their own blood pressure and documenting their kick counts. Telehealth-based prenatal care also has the potential to re-invent traditional group-based care programs. Electronic-based group-care models could provide opportunities for women previously unable to participate given personal, health, or family obligations, and help to increase social interaction and engagement. In the country’s rush to return to normalcy, could this be the time to examine on our longstanding prenatal care routines and think about whether they are something we actually want to rush back to? This could truly be an opportune time to think about transforming our “standard of care” to improve the wellbeing of moms and babies now and those moms-to-be in the future.
References
1. Hauser A. Redesigning Prenatal Care During the COVID-19 Pandemic. Michigan Health Lab. https://labblog.uofmhealth.org/rounds/redesigning-prenatal-care-during-covid-19-pandemic. Published March 25, 2020. Accessed July 9, 2020.
2. Friedman Peahl A, Heisler M, Essenmacher LK, et al. A comparison of international prenatal care guidelines for low-risk women to inform high-value care. Am J Obstet Gynecol. 2020;222(5):505–507. doi:10.1016/j.ajog.2020.01.021
3. Fryer K, Delgado A, Foti T, Reid CN, Marshall J. Implementation of Obstetric Telehealth During COVID-19 and Beyond. Matern Child Health J. June 2020. doi:10.1007/s10995–020–02967–7
