Digital Health, Maternal Care Reimagined
Santosh Pandipati, MD | Maternal-Fetal Medicine | Co-Founder & Chief Medical Officer, e-Lōvu Health
In the United States we spend a staggering $126 billion annually on pregnancy, postpartum, newborn, and pregnancy complication care (JAMA 2020). Yet we rank the worst in maternal mortality among high income nations, 64th worldwide among all nations (World Bank, 2020), and suffer from significant and unjustifiable racial inequities in outcomes. Even Caucasian mothers, though historically more advantaged, fare worse than mothers in other high income nations. Tragically, 80% of U.S. maternal mortality is preventable (CDC) and nearly half of patients skip or delay prenatal care — perhaps not entirely their fault as 1 in 3 U.S. counties are maternity care deserts (March of Dimes). How did we get into this abysmal predicament?
Top 4 Reasons for Today’s Patient Crisis
Reason 1: An Outdated Care Model
In 1930 in an effort to standardize care and improve maternal and infant outcomes, the Children’s Bureau invented the current prenatal care model of 12–14 doctor visits during pregnancy followed by delivery, and then one or two postpartum visits. Prenatal visits at pre-specified time intervals entailed collecting various vital sign information with equipment only available at the clinician’s office. This care model has the right intention of monitoring a mother’s health status over the course of her pregnancy, but lacks evidence. This inflexible, imprecise, one-size-fits all approach has led to significant data gaps along a mother’s pregnancy journey.
Reason 2: Perverse Payment Structures
Based on this 90-year old care paradigm insurance plans pay a global fee to obstetricians. There is a disincentive to reduce the number of visits for those who don’t need them even if they are doing fine, and no incentive to increase visits for those who may be getting sick, or are already sick. Additionally, the modern healthcare delivery system has been built around assigning diagnoses that justify receipt of payment for certain “covered” treatments. But this fee-for-service paradigm only works after the fact: one has to already be obese to receive nutrition counseling, or already depressed to receive mental health care, or already hypertensive to receive medications, lifestyle counseling services, monitoring devices, etc. The perverseness of this reimbursement model is clear: it’s not that doctors oppose preventive wellness services, but rather there is no clear mechanism of reimbursement for offering these services. Doctors and healthcare systems have to make ends meet: staff need to be paid, equipment needs to be purchased, credentials need to be maintained. One can rightfully wonder whether the modern healthcare delivery system truly desires to eliminate disease, or rather to perpetuate its existence by treating, but not wholly curing, people?
Reason 3: Doctors Are Not Prepared For Today’s Patients
Women have had a deep sense of the inadequacy of the current care paradigm for some time. Low value visits, often just 10 minutes or less, with their obstetricians at seemingly arbitrary time intervals are insufficient to address innumerable questions: what should they eat, how should they exercise, what over-the-counter medicines and supplements are safe, how should they prepare for delivery and the immediate days at home with their newborn, are various aches and pains minor or do they signal serious trouble ahead, how to handle developing anxiety surrounding parenthood/breastfeeding/body image/etc., why are they feeling sad after their baby was born, how do they tell their boss about their pregnancy, what do they do about their abusive spouse, is wildfire smoke inhalation bad for their baby, how to afford getting to prenatal visits when earning an hourly wage? Doctors are not trained to answer most of these questions.
So why do patients go to their prenatal visits? With the hopes of having at least their most pressing questions answered, but more importantly, to hear their babies’ hearts beating within their wombs. And those women who are seeing their obstetrician gynecologist for non-pregnancy concerns? They put up with delays and cancellations, even though they’ve been suffering from painful periods, vaginal bleeding, uncomfortable intercourse, or are in need of a pap smear, breast exam, contraception, or a myriad other concerns because they know their doctors are doing something crucially important: helping to bring a life into the world.
Reason 4: Health Inequities — FemTech of Today is Missing a Unique Opportunity to Help Clinicians Help Patients
Patients are desperate for self-empowerment over their health and wellbeing. Those with means are willing to pay for what their insurance companies, employers, and doctors are not providing them. The well-insured, well-employed, or wealthy can sign up for services through a variety of digital health platforms to address their mental and physical health needs, their questions surrounding having a beautiful and de-medicalized birth experience, and how they can best care for their newborns. There are even services where patients can get one-off obstetrical consultations outside of their regular ob/gyn. These mothers are not waiting for the traditional healthcare industry to catch up.
The COVID-19 pandemic accelerated changes already underway with patients. Doctors performed telehealth visits in record numbers with great patient acceptance. Mobile applications, internet information resources (some reputable and some not), and the emergence of wearable health technologies have empowered patients to abandon traditional care delivery systems. Numerous companies have raced to address this consumer demand. Pregnancy and postpartum-related mobile apps are estimated to be a billion-dollar industry by 2030, and medical, health, and wellness apps are projected to dominate the mobile marketplace in 2023 and beyond.
As FemTech rushes to fill in gaps there is often inadequate science, no mechanism to connect back to patients’ doctors, and no way to build long-term, sustainable improvements in health without deep data insights and cross-talk between service providers. Additionally, existing health inequities are further exacerbated, as the wealthy and healthy thrive while many others are left behind: the uninsured, the underinsured, the geographically and economically isolated, and the victims of systemic societal neglect and bias.
Top 3 Reasons for Today’s Clinician Crisis
There are two sides to every coin: while everyone has been rightfully blasting the proverbial airwaves about the maternal health crisis, very few are blasting the airwaves about the clinician crisis that has been underway and is about to spectacularly explode, especially in women’s health and maternity care.
Currently over 30% of counties in the U.S. lack even a single obstetrical provider, leaving more than 2 million women of child-bearing age without access to any obstetrical care, and an additional nearly 5 million with limited access per the March of Dimes. Lack of access will only get worse: according to the American Medical Association 1 in 5 physicians plan to leave their current jobs within 2 years, while 1 in 3 intend to reduce their work hours. The American College of Obstetrics and Gynecology (ACOG) has already identified a nearly 9,000 ob-gyn physician shortage, which is projected to balloon to a 22,000 physician shortage by 2050. Validating this projection, the number of applicants to ob-gyn residencies fell in 2023 as compared to 2022. Alarmingly, according to a Doximity study in 2018, only 16% of ob-gyns are 40 years old or younger, while 36% are 55 years old or older. An aging and retiring workforce cannot adapt to burgeoning demands and pressures that are bearing down upon it: financial, regulatory, and technological factors have come together to create a perfect storm.
Reason 1: Financial pressures
Doctors-to-be make tremendous financial sacrifices and defer income for many years simply to take the Hippocratic Oath. There are ever increasing education costs for undergraduate and medical school with up to 89% of graduates having an average education debt of $203,000 according to the Association of American Medical Colleges. There is gross underpayment of resident physicians, with an annual average salary of $62,000 over 4 years of training, often working 80 hours per week (that amounts to less than $15 per hour). It should come as no surprise that most physicians defer starting retirement savings until age 40, and also delay childbearing and family-building.
The traditional methods of fee-for-service billing and global payment for pregnancy care are often insufficient to keep general ob/gyns afloat. Per the Kaiser Family Foundation, 42% of deliveries are covered by Medicaid, but Medicaid reimburses clinicians significantly less than commercial payers — sometimes less than half the cost for doing these deliveries. As a result, there is insufficient financial incentive for physicians to care for these patients. Even for privately-insured patients ob/gyns are facing diminishing margins and as a result are adding additional cash-pay cosmetic and lifestyle services simply to make ends meet.
On top of all this, ob/gyns have among the highest malpractice insurance rates as 83% are sued at least once during their career, and 40% have claims filed against them even while they are still in training. Finally, gone are the days of physician-owned practices in most of the country. Nearly 70% are employed by hospitals or corporations, leaving little career or financial autonomy.
Reason 2: Regulatory pressures
In recent years, regulatory pressures have accelerated, now positioning ob-gyns as direct targets of state governments in over half of the nation. Restrictions in family planning access, government interference with physician-patient relationships, and physician encumberment from treating and saving women’s lives before fetal viability have created an unsafe and toxic maelstrom for the unfortunate ob/gyns who find themselves suddenly at risk not only for civil liability, but also for criminal liability simply for practicing scientifically-based medicine. Soul-sapping for clinicians in these situations is their powerlessness in the face of external impositions that violate their moral duty under the Hippocratic Oath to protect the lives of their patients. Alarmingly, 28% of ob/gyn residency programs are currently based in states with pre-viability restrictions on abortion. In restrictive states, clinicians have no recourse left to them as they literally watch their patients suffer and die even when they know what to do to keep them alive and ensure a healthy pregnancy in the future.
Reason 3: Technological pressures
Enter into this fray the monumental technological changes afoot that are leaving physicians in the dust. The internet revolution has left doctors unprepared for the avalanche of information and misinformation available to patients. Dealing with COVID-19 virus and vaccine misinformation sapped the strength of innumerable clinicians nationwide. Layered onto this have been innumerable blogs, conspiracy theory platforms, pregnancy manuals and “guided” apps of dubious rigor and authenticity that compare fetuses to various fruits and produce.
While patients founder through this morass of misinformation, clinicians are left struggling to work through documentation in clunky electronic medical records (EMRs). That key patient clinical insights are routinely missed due to a fractured information ecosystem where every service provider has a portal, but none truly communicates with each other, isn’t a surprise to anyone practicing current-day medicine. Indeed, EMRs have been attributed to not only patient harms, but also to outright physician attrition from early retirement due to technological frustrations, and even to suicides. Fortune magazine called the EMR morass as “death by a thousand clicks”. Instead of facilitating care delivery, technology from the physician’s perspective has actually interfered with care.
Additionally, the underinsured, uninsured, and publicly insured have often been left out of FemTech solutions, further exacerbating outcome inequities. Over the last decade, many FemTech companies that have erupted onto the scene have also failed to recognize the physician crisis. Indeed, they have inadvertently and all too often created platforms that have further contributed to a fractured clinical landscape and exacerbated physician burnout. As clinicians who directly care for patients are left out of the tech dialogue, frustration, fatigue, and a sense of futility has set in. Burned out, facing these multifactorial pressures, there are few to no incentives for ob-gyns to oblige with recommendations by the Kaiser Family Foundation, ACOG, and other think-tank organizations that have called upon them to reinvent the prenatal care paradigm. For current-day obstetricians it’s often easier to quit than to persevere, much less innovate.
The Crisis No One in FemTech is Talking About
Modern Homo sapiens emerged as a distinct species about 200,000 years ago. During this time our very physiology, as well as all of our agricultural, economic, political, social, and medical systems, evolved during remarkable climate stability, with carbon dioxide (CO2) concentration steady at ~280 parts per million (PPM). In 250 years we have dumped carbon dioxide and other pollutant gases into the atmosphere with abandon, with CO2 concentration currently at 420 PPM, resulting in rapid global temperature rise. We are now in the age of the Anthropocene, where humanity has altered the entire surface of the planet, and with it, the very conditions in which it originally evolved.
For most of human history, healthcare professionals and people at large had to worry about infectious diseases, traumatic accidents, the perils of childbirth, inadequate access to clean water and proper nutrition, and on and on. With the advent of modern sanitation, disinfection, plumbing, antibiotics, cleaner air, cleaner water, seat belts, airbags, OSHA, EPA, big-agro, etc., modern doctors no longer have to worry about keeping their patients safe from everyday hazards, and instead now focus on the diseases of relative human luxury — diseases that fit the classic paradigm of diagnosis and treatment. Heart disease, cancer, nutritional excesses, mental health conditions (due to too many pressures/inadequate time/socioeconomic uncertainties and inequities), and numerous age-related disorders are now at the forefront of care because so many people now live long enough or live in such over-stressed conditions that they suffer from these ailments. With climate change, this is all about to change for billions around the world.
The current climate is already one of crisis for pregnancy health. Air pollution from human fossil fuel combustion (directly from emissions of particulates, ozone, and nitrous oxide, as well as indirectly from wildfires) has been causally attributed to millions of fetal and neonatal deaths globally, low birth weight, premature births, abnormal neurodevelopment, reactive airway diseases, and impaired lung development in children who were exposed in utero. Alarmingly, we have now found black carbon particulates in umbilical cord blood and fetal tissues including livers, lungs, and brains. Excess heat exposure during pregnancy has been causally attributed to low birth weight, premature birth, stillbirths, and increased rates of congenital anomalies in exposed babies such as cataracts and heart defects.
Of course, worsening air and rising heat are leading to a myriad of other problems, including sea level rise threatening millions of coastal inhabitants, increasing frequency and intensity of storms, record flooding as well as record droughts, extreme wildfires, severe fresh water shortages, and uncontrolled spreading of vectors that carry human pathogens (e.g., mosquitoes spreading malaria, Dengue, West Nile virus, Zika virus, etc.) to name just a few. All of these lead to pregnancy harms and to decreased life expectancy of women and infants.
It has recently been estimated that continued emissions based on current international climate policies would lead to a 2.7 degree C average temperature rise by the end of this century, resulting in nearly 4 billion people living in regions of the planet that will be outright dangerous for health. Where will all these people go as their economies disintegrate, political systems crumble, conflicts arise over access to natural resources such as clean water, and their healthcare systems collapse? We are now at risk of leaving future generations less physiologically and neurologically capable of dealing with emerging climatic and social threats than ever before — an intergenerational injustice that bodes poorly upon not just our morality, but also upon our mortality. As guardians and caretakers of the continuation of our species, what can obstetricians do to combat these multifaceted and simultaneous existential threats to human survival with current healthcare system limitations?
The Solutions We Need
We have less healthy populations with more chronic disease burden than ever before who are now presenting to pregnancy. We have antiquated care delivery models that have not adapted to the emergence of modern technologies and scientific advancement. We have worsening inequities between populations that make it ever more difficult to achieve the best of outcomes for all simultaneously. Adding fuel to the fire, many patients live in technological deserts with insufficient data and broadband access that limit their ability to take advantage of digital health technology’s full potential, further widening health disparities. We have an ever worsening environment and very little practical guidance for what people can do to reduce their health risks. We have governments that are actively interfering with human flourishing through frightening interference into the physician-patient relationship thereby actively restricting important interventions on behalf of mothers’ lives under a false guise of morality — and at the same time doing very little to curb pollutant emissions that threaten our species’ existence. Less sinister, but also highly problematic, is clumsy regulatory overreach or sluggish regulation that is slow to adapt to change — either way, choking rapid evidence-based technological development that can have meaningful benefits upon human health.
Amidst all of this, we have witnessed a mushrooming of FemTech companies with immense expertise in numerous verticals, but many only serving to further fragment and extract profit from an already severely fragmented, overpriced, and underperforming care delivery system. Why? In part because we have an investment community that has historically been focused on quick wins as opposed to building sustainable solutions that are profitable, but on a slower timetable. Additionally, and frustratingly, almost no tech entrepreneurs are looking to salvage the rapidly sinking clinician community or to take environmental health considerations into their business equations. Very few dollars are invested in women’s health and research. And while there have emerged some incredible FemTech and general digital health companies over the past few years, they are struggling to connect patients with clinicians in meaningful and insightful ways. As a result, there is inadequate coordination among health and wellness services, a lack of sufficient buy-in from health professionals, and a dearth of real world clinical evidence upon which to base deep data insights to more precisely and personally improve our reproductive lives for the world we find — and will find — ourselves within.
Over time, we have lost deep societal wisdom as social and family networks have fragmented. Gone are the community elders, the wise sages of yore who had hard-earned deep ancestral knowledge on how to birth, how to nourish, and how to prosper in spirit as well as physical health. To truly make a difference, technologies and services will have to be developed that coordinate, collaborate, elevate, and nourish each other, thereby creating a digital-matched-with-human care blanket to wrap around pregnant mothers, their babies, and their families.
We now have access to immense data streams and we have the AI tools to perform synthesis and deep analysis of these data to generate never-before-seen actionable insights in real time. The ultimate dream of precision medicine, with recommendations and guidance modified and personalized to the patient as new data comes in, can finally be realized. This isn’t about AI versus humans, but rather this is about humans who are super-powered by AI, with the aim of returning to not just wisdom, but wisdom based on scientific evidence as well as compassion.
Clinicians can and must continue to set the course, but now technology can intelligently reinforce the messaging and behaviors necessary to achieve the best outcomes for patients at large, for pregnant mothers as they journey from conception through delivery, postpartum, and the rest of their lives, and for their offspring who will become the next generation of human beings. This guidance would come as micro nudges necessary for holistic wellness — from the food we eat to the exercises we do to the environmental exposures we avoid to the social relationships we cultivate to the tools we implement for our mental resiliency, and on and on. This will allow us to finally turn the tables on pathology and restore emphasis on wellness, prevention, and health intergenerationally, and will be essential to ensure the longevity of our species.
With appropriately directed investments and pioneering leaders solutions can be found to our pernicious problems that will yield insights and outcomes previously never dreamed of, and will elevate us to the next generation of healthcare. Collectively we have a lot of work ahead of us. The elephant in the room is calling to us. Let’s get to it.
