Lessons from remote antenatal care during the COVID-19 pandemic: how can we ensure equitable, safe, and patient-centred care?

Antenatal care is essential to supporting a healthy pregnancy. Traditionally, face-to-face consultations allowed for regular assessment and monitoring of the pregnancy, and represented an opportunity to support, reassure, and address concerns about pregnancy, labour, and birth. The onset of COVID-19 brought an abrupt shift to remote care as the primary means to continue providing antenatal care. There is a need – and equally an opportunity – to now evaluate the impact of these new service delivery models on the quality of care and identify key learnings for the future.

In this context, the study by Hinton and colleagues explored the experiences and perspectives of 105 healthcare professionals and 106 pregnant women in the UK who used remote antenatal care during the initial year of the pandemic and mapped the findings broadly to the Institute of Medicine’s six domains of care quality framework1,2. Free-text surveys and semi-structured interviews were conducted between September and December 2020 (a period that included the introduction of a three-tier system of restrictions and the second national lockdown), with responses being recorded and analysed afterwards by four researchers1,3.

The research team reported a range of perceived benefits of antenatal remote care. Potential benefits for patients included improved efficiency and timeliness of care, reducing the time commitment, travel expenses, and the necessity to take time off work for in-person consultations1. The technology also aided in improving access to care and made the arrangement of multidisciplinary meetings easier. For healthcare providers, remote antenatal care allowed for greater work flexibility and the ability for some administrative tasks (e.g., documentation) to be more streamlined, thus allowing more time for interacting with patients instead1. These benefits identified were generally aligned with other studies exploring the views of healthcare providers and patients using remote care tools in other medical specialties during the early phase of COVID-194–8.

Participants also expressed a variety of concerns regarding their experience using remote antenatal care. On effectiveness and safety, both patients and clinicians questioned whether remote antenatal care would be as safe and produce the same outcomes as in-person care. In particular, participants were concerned that the shift from in-person visits might not provide the same opportunities for patients to raise issues such as domestic violence. Patient-centredness was also reportedly negatively affected; participants noted that it was much more difficult to establish, and maintain, doctor-patient relationships via remote channels. With remote care often portrayed as being the only option during the acute stage of the pandemic, patients recounted feeling “lost in the system” and less empowered to make choices surrounding their own care. As in previous studies on the same subject, concerns about equity were also mentioned4,5. Remote antenatal care worked well for English speakers with good digital literacy, adequate access to digital hardware/infrastructure, and pre-existing relationships with their healthcare providers. However, patients from vulnerable groups or lower socio-economic backgrounds who did not meet these criteria risked further digital exclusion. For patients, aspects of antenatal care that relied on relationships, continuity of care, and rapport building, suffered as consultations felt increasingly more transactional despite their increased availability. For healthcare providers and managers, remote antenatal care generated additional workloads, particularly with scheduling difficulties. Other negatives included remote consultations resulting in fewer opportunities for team building, effective communication among staff members, and the fostering of positive work relationships, all of which may have indirect consequences on care efficiency and safety.

The experience gained during the emergency phase of the COVID-19 pandemic, as highlighted by Hinton and colleagues, can provide valuable insights to embrace the full potential of antenatal virtual care moving forward. So, how do we get there? Implementation strategies need to consider and be informed by the evidence and knowledge generated during this emergency phase, engage users (both patients and providers) as part of the process, and rely on platforms that are technologically robust, responsive, and supported by a strategic long-term plan. Implementation needs to be mindful of the safety implications of the use of technology – in the UK, the new “NHS Digital Clinical Safety Strategy” approaches this aspect from two complementary angles: the need to ensure digital technologies are safe, and the need to fully embrace the technologies as tools to solve contemporary safety challenges9,10. This aspect is particularly evident in the case of remote care: while remote care may pose new safety risks associated with the absence of physical examination and virtual communication, it has also emerged as a tool to maximise patient safety through more efficient and timely triage mechanisms. Implementation approaches must be proactive in mitigating the risk of entrenching existing inequities and deepening the digital divide. It is also critical to continuously monitor the impact on quality and safety, moving to data-driven approaches capitalising on linked datasets to measure the impact on quality and safety outcomes. As digital adoption increases, the concept of its ideal implementation continually evolves. Based on the perspectives of both providers and patients, we have previously developed a framework for remote care implementation, outlining the main dimensions to be considered as part of the process: contextual considerations, technology infrastructure, awareness & experience, safety & risk management, strategic planning & supporting policies4.

As we know more about the benefits and challenges of remote care, novel research avenues emerge. We now need to understand what works, how, and for which patients – this includes the wider measurement of patient interests and skills, and the need to use mixed-methods and implementation science studies to understand use, usability and uptake alongside impact and effectiveness. Only by addressing these gaps, we will be able to deliver remote care that is truly patient-centred, sustainable, safe, and equitable.

Edmond Li & Dr. Ana Luisa Neves

Edmond Li is a doctoral candidate at the Imperial NIHR Patient Safety Translational Research Centre (PSTRC), Institute of Global Health Innovation, at Imperial College London, where he is studying the effects of poor electronic health record interoperability on patient safety. Dr. Ana Luisa Neves (@ana_luisa_neves) is an advanced fellow and the Associate Director of the Imperial NIHR PSTRC, where she oversees strategic development of the Centre’s research objectives.

References
1. Hinton L, Dakin FH, Kuberska K, et al. Quality framework for remote antenatal care: qualitative study with women, healthcare professionals and system-level stakeholders. BMJ Qual Saf. 2022;0:bmjqs-2021-014329. doi:10.1136/BMJQS-2021-014329
2. Institute of Medicine (US) Committee on Quality of Health Care in America. Six Domains of Health Care Quality | Agency for Healthcare Research and Quality. Accessed February 3, 2022. https://www.ahrq.gov/talkingquality/measures/six-domains.html
3. Institute of Goverment analysis. Timeline-Coronavirus-Lockdown-December-2021. Inst Goverment.org. 2021;(March 2020):2021. https://www.instituteforgovernment.org.uk/charts/uk-government-coronavirus-lockdowns
4. Li E, Tsopra Id R, Jimenez Id G, et al. General practitioners’ perceptions of using virtual primary care during the COVID-19 pandemic: An international cross-sectional survey study. PLOS Digit Heal. 2022;1(5):e0000029. doi:10.1371/JOURNAL.PDIG.0000029
5. Neves AL, Li E, Gupta PP, Fontana G, Darzi A. Virtual primary care in high-income countries during the COVID-19 pandemic: Policy responses and lessons for the future. https://doi.org/101080/1381478820211965120. 2021;27(1):241-247. doi:10.1080/13814788.2021.1965120
6. Neves AL, Dael J van, O’Brien N, et al. Use and impact of virtual primary care on quality and safety: the public’s perspectives during the COVID-19 pandemic. medRxiv. Published online October 22, 2021:2021.10.19.21265193. doi:10.1101/2021.10.19.21265193
7. Neves AL, Lygidakis H, Fontana G. The technology legacy of COVID-19 in primary care. bjgplife.com. Published online 2020. Accessed July 13, 2021. https://bjgplife.com/2020/04/15/the-technology-legacy-of-covid-19-in-primary-care/
8. Neves AL, Li E, Serafini A, et al. Evaluating the Impact of COVID-19 on the adoption of virtual care in general practice in 20 countries (inSIGHT): Protocol and rationale study. JMIR Res Protoc. 2021;10(8):e30099. doi:10.2196/30099
9. Neves AL. The NHS digital clinical safety strategy. BMJ. 2021;375. doi:10.1136/BMJ.N2981
10. Digital Clinical Safety Strategy – Key tools and information – NHS Transformation Directorate. Accessed August 16, 2022. https://transform.england.nhs.uk/key-tools-and-info/digital-clinical-safety-strategy/

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