Creating equitable remote antenatal care: the importance of inclusion

A rapid and substantial shift to various forms of remote consultations has been a major feature of the response to the covid-19 pandemic. Maternity care—accessed by around 650,000 women a year—is one important example. [1] From March 2020, virtual consultations were recommended where possible. [2] Over 80% of antenatal consultations, which are a bedrock of safety and support for pregnant women, were conducted remotely. [3]

Remote care, provided over the phone or via other technologies, is not new. But it has never been offered on this scale before. [4] The real world experiment wrought by the pandemic represents a valuable opportunity for learning. Especially important in such scrutiny will be questions of equality, diversity, and inclusion in remote care.

These questions are important because poor outcomes of pregnancy and birth are spread unevenly across the population. Confidential inquiries into maternal deaths and morbidity in the UK (MBRRACE-UK) reveal a disturbing pattern of increasing inequality for women of ethnic minority backgrounds and for women with complex social factors. One of the striking features of the current covid-19 pandemic is its amplification of these inequalities. Mortality rates from the coronavirus are highest for Black, Asian, and minority ethnic groups, and pregnancy and childbirth do not escape these effects. [5] The first UK study to estimate the incidence of admission to hospital with covid-19 in pregnancy showed the highest proportion (56%) of women were from ethnic minority groups. [6]

The rapid shift to remote antenatal care is an understandable—and rational—response to the imperatives of the pandemic. It clearly has many potential benefits, including the ability to maintain some level of service while controlling infection risk. Yet despite the hope and hype surrounding telehealth, the current evidence base is weak, with few good quality studies.

Though some research has reported promising results in terms of safety and experience, it is far from conclusive. One problem is that many studies have assessed hybrid pathways or remote monitoring of isolated components of the maternity care pathway, such as home-monitoring of blood pressure or glucose levels. [7,8] It is not clear how easily these findings can be extrapolated into scenarios where most or all antenatal care is being provided remotely.

A perhaps less obvious problem, but one that is highly consequential for understanding and addressing inequalities, is that studies of remote antenatal care typically under sample the groups who experience worse maternity outcomes. Much of the existing evidence on effectiveness and safety comes from studies characterised by remarkably poor inclusion of women of ethnic minority backgrounds, refugees, people experiencing homelessness, people with poor fluency in English, or those experiencing domestic abuse. These are exactly the groups at risk of being socio-economically and digitally excluded from care, and the same groups who are at risk of poor outcomes.

The exclusion of less privileged voices from the evidence base about remote care reflects a more widespread and longstanding “orthodoxy of sameness” in health research. [9] David Leslie and colleagues have recently drawn attention to the algorithmic biases in artificial intelligence that risk entrenching and augmenting existing health inequalities. [10] Caroline Criado Perez’s 2019 book “Invisible Women” exposed the enduring male default bias in medical research. [11] Evidence from maternity care research, while obviously not suffering from lack of data on women in general, may be vulnerable to similarly serious gaps when it comes to data on ethnicity, race, and socio-economic status.

These current lacunae in the evidence for remote antenatal care matter: it is not safe to assume that all pregnant women have the same needs and expectations of care. The lure of digital transformation in healthcare is powerful and difficult to resist. An understanding of what good remote antenatal care looks like is urgently needed to help shape post-pandemic pathways that offer appropriate support for every pregnant woman. Remote care promises valuable gains for women and health professionals. But in locking in the wins for some, we must be wary of locking out others. [12] Creating equitable antenatal care pathways requires intentional and sustained effort not only to prevent new harms, but also to reduce existing institutional racism and structural inequalities in healthcare and research about healthcare.

Lisa Hinton, Senior Research Associate, THIS Institute.

Karolina Kuberska, Research Associate, THIS Institute.

Francesca Dakin, Research Assistant, THIS Institute.

Mary Dixon-Woods, The Health Foundation Professor of Healthcare Improvement Studies and Director of THIS Institute, Department of Public Health and Primary Care, University of Cambridge. 

Christine Ekechi, Consultant Obstetrician & Gynaecologist, Queen Charlotte’s & Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK and Co-Chair, Race Equality Taskforce, The Royal College of Obstetricians & Gynaecologists, UK

Competing interests: none declared


  1. Office for National Statistics. Births in England and Wales: 2019., 2020.
  2. Royal College of Obstetricians & Gynaecologists, Royal College of Midwives. Coronavirus (COVID-19) Infection in Pregnancy: information for healthcare professionals., 2021.
  3. Jardine J, Relph S, Magee LA, et al. Maternity services in the UK during the coronavirus disease 2019 pandemic: a national survey of modifications to standard care. BJOG 2020 doi: 10.1111/1471-0528.16547 [published Online First: 2020/09/30]
  4. Doraiswamy S, Abraham A, Mamtani R, et al. Use of Telehealth During the COVID-19 Pandemic: Scoping Review. J Med Internet Res 2020;22(12):e24087. doi: 10.2196/24087
  5. Razaq A, Harrison D, Karunanithi S, et al. BAME COVID-19 Deaths – what do we know? Rapid data and evidence review: ‘hidden in plain sight’. Oxford: The Centre for Evidence-Based Research, 2020.
  6. Knight M, Bunch K, Vousden N, et al. Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population based cohort study. BMJ 2020;369:m2107. doi: 10.1136/bmj.m2107 [published Online First: 2020/06/10]
  7. Alves DS, Times VC, da Silva EMA, et al. Advances in obstetric telemonitoring: a systematic review. Int J Med Inform 2020;134:104004. doi: 10.1016/j.ijmedinf.2019.104004 [published Online First: 2019/12/10]
  8. Hinton L, Tucker KL, Greenfield SM, et al. Blood pressure self-monitoring in pregnancy (BuMP) feasibility study; a qualitative analysis of women’s experiences of self- monitoring. BMC Pregnancy Childbirth 2017;17(1):427. doi: 10.1186/s12884-017-1592- 1 [published Online First: 2017/12/21]
  9. Healy B. Challenging Sameness: Women in Clinical Trials. Science Meets Reality: Recruitment and Retention of Women in Clinical Studies, and the Critical Role of Relevance. Bethesda, MD: National Institutes of Health, Office of Research on Women’s Health, 2003:16-18.
  10. Leslie D, Mazumder A, Peppin A, et al. Does “AI” stand for augmenting inequality in the era of covid-19 healthcare? Bmj 2021;372:n304. doi: 10.1136/bmj.n304 [published Online First: 2021/03/17]
  11. Criado-Perez C. Invisible Women: Data Bias in a World Designed for Men. London: Abrams Press 2019.
  12. Secretary of State for Health and Social Care, Department of Health and Social Care,. Integration and Innovation: working together to improve health and social care for all. UK: APS Group on behalf of the Controller of Her Majesty’s Stationery Office,, 2021.