Kaiser Permanente Northern California (KPNC) researchers report that a combination of in-person and telehealth prenatal visits during the COVID-19 pandemic wasn't linked to a higher risk of worse maternal and newborn outcomes, although the rate of neonatal intensive care unit (NICU) admissions rose slightly from March to December 2020.
Published today in JAMA Network Open, the study involved the electronic health records of 151,464 pregnant women who delivered a live or stillborn infant during three periods: July 1, 2018, to February 29, 2020 (T1, unexposed to the mixed in-person and telehealth model); March 1 to December 5, 2020 (T2, partially exposed); and December 6, 2020, to October 31, 2021 (T3, fully exposed).
Average maternal age was 31.3 years, 34.4% were White, 27.9% were Hispanic, 25.8% were Asian or Pacific Islander, 6.6% were Black, 2.6% were multiracial, 2.3% were of unknown race, and 0.4% were American Indian or Alaska Native. Among all pregnant women, 50.1% were unexposed to the intervention, 23.0% were partially exposed, and 26.9% were fully exposed.
KPNC introduced telehealth in prenatal care on March 13, 2020, to reduce pregnant women's unnecessary exposure to SARS-CoV-2, converting in-person visits at 10 to 12, 22, 28, and 32 weeks' gestation to virtual care.
No clinically relevant changes in primary outcomes
The average number of total prenatal visits was comparable in T1 (9.41), T2 (9.17), and T3 (9.15), but the proportion of telehealth visits rose from 11.1% (79,214 visits) in T1 to 20.9% (66,726) in T2, and 21.3% (79,518) in T3. Most virtual visits took place via phone, and the average number of phone and video conferencing visits rose over all three intervals.
NICU admission rates were 9.2% (7,014) in T1, 8.3% (2,905) in T2, and 8.6% (3,615) in T3. An interrupted time series (ITS) analysis found no change in NICU admission risk in T1 (change per 4-week interval, −0.22%), a reduction in risk in T2 (−0.91%), and a slight increase in risk in T3 (1.75%).
No clinically relevant changes were noted among T1, T2, and T3 in risk of preeclampsia and eclampsia (change per 4-week interval, 0.76% in T1; −0.19% in T2; and −0.80% in T3), severe maternal illness (0.12% in T1; −0.39% in T2; and 0.99% in T3), cesarean delivery (0.06% in T1; −0.03% in T2; and −0.05% in T3), preterm birth (0.23% in T1; −0.37% in T2; and −0.15% in T3). Preeclampsia and eclampsia can cause serious pregnancy complications related to high blood pressure.
An opportunity to rethink care
While rates of gestational high blood pressure and depression increased during the pandemic, an ITS analysis found that the risk of these conditions had begun rising before COVID-19.
Similar outcomes by number, method, and care processes of prenatal visits were seen among patients of different races, those with the highest Neighborhood Deprivation Index scores, those who preferred to use a non-English language, rural residents, and those with a low-risk pregnancy.
The results suggest that remote care could have an ongoing role in replacing some prenatal in-person visits, increasing convenience for those who want to be seen at home, without harming disadvantaged people.
Modest differences, however, were noted among some racial groups, including an increased risk in T3 in severe maternal illness among Black women and the risk of a 5-minute Apgar score of less than 7 (with scores of 7 to 10 considered healthy) among Asian and Pacific Islander participants. "These findings need further investigation to understand whether they were directly associated with the multimodal prenatal health care model or exposure to inequitable conditions within or outside of the health care system, or whether they might be chance findings in the context of the large number of regression analyses we performed," the researchers wrote.
They said that telemedicine offers the opportunity to reevaluate and reorganize prenatal care to better serve patients in rural areas and address other access barriers such as lack of transportation and time constraints due to work or childcare.
"The results suggest that remote care could have an ongoing role in replacing some prenatal in-person visits, increasing convenience for those who want to be seen at home, without harming disadvantaged people," lead author Assiamira Ferrara, PhD, said in a Kaiser Permanente press release. "Also, the latest guidelines for prenatal care suggest it is not necessary to be seen in person for every prenatal visit, and some care can be delivered effectively remotely."