US Maternal Health Crisis Endures
Recent Centers for Disease Control and Prevention data showed that maternal mortality continues to rise in the United States, ranking it 35th of 38 countries that belong to the Organisation of Economic Co-operation and Development, with a rate of 23.8 maternal deaths per 100 000 live infant births.2,3 The most recent maternal mortality rate for non-Hispanic Black women, specifically, is 55.3 maternal deaths per 100 000 live infant births, which is 2.9 times higher than for non-Hispanic White women (19.1 per 100 000). In addition, the rate for Hispanic women rose from 12.6 per 100 000 in 2019 to 18.2 per 100 000 in 2020, a 44% increase in a single year.2
Telehealth’s Potential Impact on Maternal Health Outcomes
The first 2 years of the COVID-19 pandemic resulted in a 38-fold increase in overall telehealth utilization.4 In particular, telehealth shows great promise to improve access to maternal health care given challenges of transportation and rurality, as well as other SDOHs, which tend to disproportionately impact economically and socially marginalized pregnant people.5,6 Emerging studies have suggested that using telemedicine for perinatal care compared with in-person appointments results in higher patient satisfaction and lower patient stress that is statistically significant.7 Additionally, there has been no observed statistical difference in health care provider satisfaction, perceived quality of care, cesarean delivery rates, or severe maternal mortality or morbidity.8,9 These studies, however, have involved patients who were classified as low risk, had private health insurance, and/or did not relate demographic data to patient outcomes. As more research is published, it will be imperative to determine whether disparities from in-person health care persist, are reduced, or are widened in telehealth settings.10
Is Telehealth Missing the Mark When It Comes to Equity?
It is difficult to answer whether telehealth is missing the mark regarding equity with current data, and that’s the issue. Existing maternal telehealth literature is not consistent in reporting patient race and ethnicity, insurance type, education or income levels, and other demographics in methodology and findings. The lack of inclusion and/or standardization of these variables prevent accurate comparisons across populations and is concerning because research has shown that racial and ethnic minority groups on average receive lower-quality, less accessible health care that can impact long-term health outcomes.11,12 Maternal telehealth outcome data must be collected and assessed by social, economic, and racial and ethnic demographic factors to understand how further improvements can be made to meet the diverse needs of patients and determine whether maternal telehealth can be used as a means to address the maternal health crisis within the United States.
Areas to Advance Maternal Health Equity With Telehealth Care Delivery
Now is the critical time to take key steps to explore telehealth’s effects across different patient populations. Identified below are 4 key areas for health care providers and researchers to consider when using telehealth to advance maternal health equity:
Be flexible in care delivery methods.13,14 Pregnant and postpartum people have varied internet connectivity and access based on their economic, educational, and social backgrounds. Consequently, creating more options for how patients can engage with their health care providers is imperative. This variety in connectivity is known broadly as the “digital divide.” As a documented SDOH, the digital divide necessitates flexibility in provider delivery methods to ensure pregnant and postpartum people everywhere get the care they need.15 Telemedicine needs to demonstrate an equivalent or higher quality of care to help address the divide and not exacerbate it. In some studies, alternative telehealth methods and/or supplementary platforms, such as audio-only visits, text message notifications, and messaging groups, have been shown to be effective in increasing or maintaining patient health fluency, adherence, and outcomes.13,16,17 However, some major challenges remain, such as coverage and payment for these innovative models (particularly for uninsured and underinsured people) and connectivity issues in rural areas.
Meet pregnant and postpartum people where they are now. Considerations include improving “Webside manner,” tailoring health messages to the specific needs of pregnant and postpartum people, and considering culturally appropriate materials to include a focus on health equity throughout pregnancy and beyond.18 Health care providers could identify and meet pregnant people’s expectations through toolkits, interpreter services (several companies now provide Health Insurance Portability and Accountability Act of 1996–compliant telehealth interpretation), and digital literacy screenings, which can all impact patient-physician interactions and knowledge sharing.14,19
Examine electronic health record data through an equity lens.20 Analyzing electronic health record data retrospectively can be a cost-effective way of comparing clinical outcomes, but this addresses questions of health equity only when patient data include demographic information, such as race or ethnicity. Incentivizing the standard collection of patient demographic data can aid in identifying and addressing barriers to a healthy pregnancy.21
Invest in and conduct research focused on SDOHs. Randomized clinical trials and mixed-methods research that compares maternal health outcomes, patient experience, and cost-effectiveness between a control group (in-person appointments) and experimental group (telehealth appointments) would help expand the understanding of how telehealth can improve access and outcomes associated with prenatal care. These findings should be stratified by SDOHs, such as insurance type, income level, and race and ethnicity. When possible, incorporating principles of equity-centered community design to co-create alongside those who are considered high risk for maternal morbidity and mortality increases the likelihood of generating lasting change.22
Time to Act
While telehealth has been shown to be beneficial for some pregnant and postpartum people, it may not be the best approach to obstetric care for all patient demographics. As access to telehealth services grows, health equity must be a factor in determining when and whether to rely on telehealth to provide care and whether telehealth can reduce the maternal health crisis. Doing so has the potential to save and improve the lives of pregnant and postpartum people across the United States.
Conflict(s) of Interest