Take one look at some of the maternal health data in this country and it’s hard to argue with the fact that the U.S. is not just in the midst of a pandemic, but also a maternal health crisis.
Here’s a grim glimpse: About 700 women die every year in the United States due to pregnancy or delivery complications (with 60,000 “near-miss” deaths every year), the number of reported pregnancy-related deaths has increased from 7.2 deaths for every 100,000 births in 1987 to 16.9 deaths for every 100,000 births in 2016 in this country, and wide racial disparities exist across the board with Black, American Indian, and Alaska Native women being two to three times more likely to die from pregnancy-related causes than white women.
“Before the pandemic, with all of the different touchpoints across the healthcare system and different clinics — from diagnosis and referral to treatment — we lose women,” says Karen Tabb Dina, Ph.D., an associate professor in social work at the University of Illinois who studies health disparities in women’s health.
Now, with The American College of Obstetricians and Gynecologists (ACOG) recommending providers maximize the use of telehealth for prenatal care — and women being seen in-person fewer times — some experts worry more women will get lost in the shuffle.
To be fair, there’s potential for virtual prenatal care to fill some of the gaps that currently exist in prenatal and postpartum care (a virtual appointment is after all, by many standards, easier to make it to than an in-real-life one). But risk of the opposite — worsening an already deep gash across socioeconomic and race lines and a lack of treatment for an incredibly in-need population — is there, too.
It’s too soon to definitively say what postpartum care means for soon-to-be and new moms who are buying blood pressure cuffs and being referred to telepsychiatry. But as rates of perinatal mood and anxiety disorders (PMADs) rise amidst a pandemic, here’s a more nuanced look at the effect virtual care could have on moms.
What Is Virtual Prenatal and Postpartum Care In the First Place?
In the U.S., when you find out you’re pregnant, you’re usually seen in-person around eight weeks of pregnancy. Of course, not everyone is. Pre-pandemic, just about one-fourth of pregnant women reported that they didn’t receive any prenatal care in the first trimester, according to the Centers for Disease Control and Prevention (CDC).
Today, even as the country begins to re-open, many in-person first visits are being pushed back beyond eight weeks and initial visits are taking place via telemedicine, out of an abundance of caution.
“The hope is that even with virtual care, we are still performing all the same screens that we would do in an in-person visit,” says Tejumola M. Adegoke, MD, MPH, an ob-gyn at Boston Medical Center and an instructor in obstetrics and gynecology at Boston University School of Medicine. She means screens like the Edinburgh Postnatal Depression Scale commonly used to catch perinatal or postpartum depression, as well as checks such as blood pressure and weight.
In a COVID world, virtual visits are complemented with in-person ones, particularly for ultrasounds and blood work. In some cases, in-person visits are reduced.
Some initial research suggests that virtual prenatal care models — where some in-person visits were replaced with remote ones (that included self-monitoring of blood pressure and weight) — were not linked with adverse birth outcomes or complications in pregnancy. Often, patients reported higher satisfaction with digital appointments, too.
But these studies were done in mainly white, usually wealthy, and privately-insured populations, says Dr. Adegoke. “It's not clear if we did similar studies in populations that had more people with lower socioeconomic status’ or of racial and ethnic minorities if the results would be the same.”
It’s an important note. After all, there’s no way to talk about maternal health without talking about both racial and socioeconomic disparities and discrimination in the healthcare system. “We know that some poor prenatal outcomes are due to a lack of access to prenatal care and we also have evidence of people having poor birth outcomes, in part because their concerns are not adequately addressed during pregnancy or they don't seem to get adequate evaluation or treatment,” says Dr. Adegoke.
And while the benefits of virtual care exist, so too do the risks.
The Upsides of Digital Prenatal and Postpartum Care
In many ways, virtual care helps decrease barriers to care, explains Dr. Adegoke. With a virtual appointment, you don’t need access to transportation, you don’t need to take as much time away from work, and you likely don’t need to find childcare.
This could strip away layers of angst. “So much anxiety is wrapped up in getting to treatment,” says Paige Bellenbaum, LMSW, chief external relations officer for The Motherhood Center of New York, a PMAD treatment center that pivoted their business online when the COVID pandemic hit. “With virtual care, you don't have to get the baby dressed, you don't have to worry about forgetting anything, you don’t have to worry if the baby might burst out in tears on the train. You're in the comfort, yet the confines, of your own home.”
For racial minority women, and for Black women in particular, virtual visits also come with “fewer touchpoints and possibly fewer discriminatory experiences or encounters,” says Tabb Dina, who notes that this could be one potential benefit to the new trend in care. “A telehealth appointment is a special moment to be able to communicate with your ob-gyn. Maybe people will disclose more or less about perinatal mental health — that we don't know.”
The Potential Setbacks of Virtual Care Could Be Even Worse for Black Women
The idea of logging on for a digital appointment with your ob-gyn, joining a virtual support group (both The Motherhood Center and Postpartum Support International host them regularly), or seeing a therapist via a screen sounds nice. But in lower-income, rural areas, there isn’t always bandwidth (in every sense) to do so, says Tabb Dina. “It's great if you can access those resources, but if you can’t, are we going to see a deepening to the existing disparities we already see?”
In New York City, where Black women are 12 times as likely to die from childbirth-related causes as white women, Taraneh Shirazian, MD, an ob-gyn at NYU Langone Medical Center and founder of Mommy Matters notes that many of her Black colleagues who serve Black pregnant women in Harlem feel as though telehealth weakens the connection with a patient. “There is something that's missed in not being present for an appointment.”
Bellenbaum agrees. “I've been doing this long enough to know there's something lost when you don’t have the ability to ask someone, ‘how are you really doing?’ and watch a mom burst into tears because she's in a safe and familiar space.”
One of the things that was really profound about the actual space of The Motherhood Center, she says, is how carefully it was designed to feel anything but clinical: “It’s warm and natural and nurturing, with an on-site nursery.”
Without these types of settings and interactions, Bellenbaum worries that some women are at risk of falling through the cracks and not getting the mental health support that they need.
Venus Standard, MSN, CNM, an assistant professor and certified nurse-midwife in the department of family medicine at The University of North Carolina School of Medicine agrees. “You can disguise something over the phone, where you may not be able to disguise your mood if you're sitting in front of me.”
The ramifications could be worse for Black women, she notes. “For the most part, Black women are not listened to by their providers. I've worked in a variety of different locations and socioeconomic settings and it's the same across the board: Their concerns are discounted, dismissed, or even undervalued when they present with the same exact symptoms or concerns as non-Black women.”
This is coupled with the fact that, even today, half of white medical trainees believe such myths as Black people have thicker skin or less sensitive nerve endings than white people, Standard says. “All of this negatively affects maternal and infant outcomes and it leads to increased maternal morbidity and mortality.”
It’s hard to say how digital care will impact these issues in particular, Standard notes. But, she says, sometimes it is easier for a provider to hear your concerns when you’re standing in front of them. “Although we all vow to do no harm and to care for our patients as best we can, I think with things moving toward virtual care, there could be a backslide and this could have a negative effect.”
Dr. Adegoke adds that she expects the same unfortunate disparities in care delivery that existed before prenatal telemedicine care went mainstream to continue. “We just have to continue to work on getting to a place where all providers are providing equitable care to all of their patients regardless of the way they look.”
Here, some ways to make sure that happens — and make the most out of a virtual visit.
Optimize Your Digital Care
Be your own best advocate—but involve others in your care.
The whole goal of telehealth is to create more touchpoints with your provider, says Dr. Shirazian. “But telehealth is what you make of it,” she says. It’s important to reach out and ask questions if you feel as though something is off or if you’re struggling with symptoms. Standard suggests coming to every appointment, even the digital ones, with a list of questions so that you can make sure your needs are met.
Of course, you shouldn’t have to do all of the work. “We can’t ask moms to throw themselves a life preserver while they’re hardly paddling fast enough to keep out of water,” says Bellenbaum. “Right now, more than ever, it’s a good time for partners to educate themselves so that if mom is struggling, they can be quick to say, ‘I think you need help and here are some ways that we can help you.’” Involve a support person in your appointments and ask them to educate themselves on recognizing signs of PMADs, for example.
“Any telemedicine model needs to have an avenue for a person to say, ‘I really need to be seen in person,’” says Dr. Adegoke. After all, telehealth is best for minor check-ins. And if not properly addressed, issues like hypertension or postpartum complications such as excess bleeding can be life-threatening. The physical also goes hand-in-hand with the mental. “I can't tell you how much maternal anxiety and depression stems from a physical issue as it relates to pregnancy, delivery, or postpartum,” says Bellenbaum. If you feel like there’s something more serious going on or want to be seen in person, say so.
Also, remember: Virtual visits should be similar to in-person care in that your provider should be working with you to monitor your blood pressure and weight during pregnancy and having the same conversations about progress and concerns that you’d have at an appointment in the office. If that’s not happening? “It’s time to start thinking about alternative places to receive care,” says Dr. Adegoke.
Report inequitable care.
Most healthcare institutions have a reporting system for patients who aren’t satisfied with the care they're getting (an office for patient advocacy, for example), says Dr. Adegoke. If you’re concerned about the care you’re getting, it’s crucial to report that. “Prenatal care also really requires a trusting and comfortable relationship between the patient and the provider, so if you’re not happy with the care that you're receiving, if you have questions, or feel like your needs aren’t being met, it's never wrong to request a second opinion. It's never wrong to check with another provider.”
Despite the differences between virtual and in-person care, Bellenbaum notes that virtual care, particularly as it relates to mental health, is effective. “We're learning that even though a relationship is happening through a screen, it's still happening and it's still happening effectively.” Resistant to meeting with a therapist virtually or joining an online support group? “Just take that first step,” says Bellenbaum. “And then you can decide if you feel like it's working or not.”