The blog of the Urban Institute
January 3, 2022

Is Maternal Telehealth Improving or Undermining Health Care Access and Equity? It’s Time to Ask Birthing People.

January 3, 2022

Deeply rooted systemic inequities shape our country’s maternal mortality crisis. Because structural racism has driven long-standing racial inequities in health care access and health outcomes, maternal morbidity and mortality rates for Black and American Indian birthing people are two to three times higher than for white people. And early evidence shows that Latino and Black pregnant people were more likely to experience severe COVID-19 illness. (Note: we’ve chosen to use the term “Latino,” but recognize not every member of this group identifies with the term.)

The pandemic necessitated rapid shifts from in-person to virtual care, including changes to federal and state policies, payment rules, and technology developments, facilitating dramatic increases in telehealth use. What remains unclear is whether this telehealth surge is exacerbating or mitigating systemic maternal health inequities.

Building the evidence base on how telehealth shapes maternal and infant health will be key to achieving the best outcomes and ensuring racial disparities don’t widen. Patient voices—especially the voices of patients of color—must be a critical component of this evidence base.

What we know about telehealth outcomes

Though telehealth outcomes data are limited, studies have found that patients and providers have largely been satisfied with virtual care during the pandemic, that a large majority of patients accessed audio-only services, and that there is not substantial evidence of telehealth fraud or misuse.

That said, surveys have found that patients oppose virtual-only care and prefer a hybrid of both in-person and telehealth visits.

But further research has identified disparities in access to broadband internet and needed communication devices, including limited phone minutes and data plans, meaning not everyone has equal access to telehealth. Because people with low incomes and people of color are most likely to face barriers to broadband access, this raises concerns that telehealth could widen racial health disparities.

Studies of maternal telehealth outcomes are particularly scarce. One Australian study found that virtual antenatal care delivered during the pandemic did not worsen birth outcomes, such as preeclampsia, gestational diabetes, and preterm birth, compared with prepandemic rates. Another study of the Welcome Baby home visiting program in Los Angeles County found an increase in the number of monthly visits—most of them virtual—home visitors completed during the pandemic but a decrease in visit length and enrollment rates. And a global survey (PDF) found 58 percent of maternal and infant health providers reported using telehealth but identified patient challenges, like lack of technological capacity and literacy, financial and language barriers, and distrust. In sum, emerging evidence demonstrates both potential advantages and drawbacks to maternal telehealth.

Another study found community characteristics influence who can access telehealth and through what means. Patients in “high social vulnerability” areas (characterized by the Centers for Disease Control and Prevention as having “higher rates of poverty, unemployment, minority status,” and other variables) were more likely to experience discomfort with technology and language barriers. To avoid these barriers, providers in these areas were twice as likely to rely on audio-only telehealth, compared with providers in areas with “low social vulnerability.” Thus, telehealth has potential to reduce or worsen socioeconomic and racial inequities depending on how it is structured and supported and which modalities are permitted.

Overall, maternal health providers, payers, and policymakers believe telehealth will be sustained in some capacity postpandemic. Yet questions remain as to which services can be provided virtually in a high-quality manner, who can effectively provide those services, what telehealth modalities should be used, how telehealth should be paid for, and how telehealth affects existing maternal health inequities.

How researchers can center birthing people when building the evidence base 

Today, many policies supporting telehealth adoption are tied to the federally declared public health emergency and so are temporary. Consequently, stakeholders must decide how to update prepandemic maternal telehealth policies.

At present, patient input has largely only been collected through satisfaction surveys like those mentioned above. To reveal more nuances behind these high-level findings, inform community-driven policies, and ensure policies reduce racial disparities, researchers should engage birthing people across racial and income groups and explore their needs and preferences by asking the following questions.

Services

  • Which services do birthing people prefer to access virtually versus in person and why?
  • If they have accessed maternal telehealth services, do birthing people perceive that quality of care differs from in person?
  • What combination and frequency of virtual and in-person maternal health services is ideal?

Access and barriers to care

  • Does telehealth help alleviate barriers (e.g., lack of transportation, child care)?
  • What barriers does telehealth create?
  • Do patients have access to broadband and needed technology—like smartphones or laptops—for virtual visits? Do patients have stable, accessible, and secure internet connectivity? Do their phone plans have sufficient minutes and/or data to support telehealth visits?
  • Do patients have access to remote monitoring equipment, (e.g., weight scales, blood pressure cuffs)?
  • Is help available when birthing people encounter challenges accessing or using technology for telehealth?
  • Does virtual care feel disjointed from or integrated with in-person care? How could hybrid care be more seamless?

Providers

  • Which provider types would birthing people like to see virtually versus in person?
  • Does interaction quality with different provider types differ virtually versus in person? How is continuity of care with providers affected, if at all?
  • Do patients feel they are being listened to and heard during telehealth visits? Do providers seem more or less attentive virtually?
  • Do the providers birthing people see through telehealth reflect their race, ethnicity, preferred language, and culture? Would they be more in favor of telehealth if it enabled patient-provider racial concordance?

Modalities of care delivery

  • Which modalities—like video, audio only, and text messaging—have patients used for telehealth visits? Which do they prefer and why?
  • Does telehealth visit quality vary by modality? How so?

Maternal health stakeholders agree telehealth is here to stay. But how it will look and what policies will be developed to manage it and produce equitable outcomes remains unclear. Centering birthing people’s preferences across the four domains outlined above in research and policymaking can help ensure services meet the needs of patients.

And centering voices from communities of color specifically is crucial to ensuring policies improve maternal health equity rather than exacerbate long-standing inequities in our health care system. This involves not only engaging diverse consumers but also gathering and analyzing access, utilization, and outcomes data disaggregated by race, ethnicity, and across modalities.


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