Employing telehealth to boost maternal health equity

Being Black and pregnant in America can be a deadly combination. With Black women being twice as likely to die during or soon after childbirth than white women, interventions to improve Black maternal outcomes are urgently needed. Some healthcare organizations are turning to virtual care tools to close the care gaps facing the Black birthing population.

Data highlights a shocking chasm between Black and white pregnancy outcomes in the United States. The Centers for Disease Control and Prevention (CDC) reveals that the maternal mortality rate for Black women was 69.9 deaths per 100,000 live births in 2021, which is 2.6 times the rate for white women.

The factors driving this disparity include various social determinants of health (SDOH) barriers to maternal healthcare, such as transportation and income. One California-based health system seeks to break down these barriers through virtual healthcare.

The UC Davis Health system is creating a new telehealth program to expand access to prenatal and postnatal care for Black patients.

"It's beyond just giving someone a bus ticket," said Ijeoma Uche, MPH, co-leader of the telehealth project, in an interview. "It is truly meeting them where they are on their phone, which is something they use every single day. And there's a sense with telehealth, in general, of how we can truly provide patient-centered care and meet moms where they are."

The Association of American Medical Colleges has recognized the program with a Telehealth Equity Catalyst Award totaling $27,000. The funds will be used to establish video-based perinatal care for Black patients across the UC Davis network. However, as Uche and the UC Davis team work to launch the program, they must ensure that challenges to virtual care access do not hinder the program's goals.

Barriers to maternal care access

Access to prenatal care, which encompasses prenatal and postnatal care, is essential for maternal and infant well-being.

It's beyond just giving someone a bus ticket. It is truly meeting them where they are on their phone, which is something they use every single day.

The prenatal period ranges from the moment a person is pregnant to when they give birth, while the postnatal, or postpartum, period extends from childbirth to a few years after, explained Uche, who is also a second-year medical student at UC Davis, and co-founder of the Birth By Us app that offers pregnancy and postpartum care resources for Black birthing people.

Within the realm of research, the postpartum period ends a year after childbirth, but in real life, this period can extend further.

"It's really interesting because when we talk to mamas and birthing people, they always say that we're forever in postpartum," Uche said.

However, she added that there is a greater emphasis on prenatal care than care during the postpartum period in the U.S. healthcare system. This is a significant oversight as Commonwealth Fund data shows that 52% of maternal deaths occur after birth, with 21% occurring between one and six weeks postpartum.

"Once you have your baby, a lot of that care then transitions into the newborn," Uche said. "And moms only see their providers once in a six-week period of time. ... Although it's very natural, [giving birth is] still a very intensive experience and procedure, specifically if you get a C-section. Imagine you go in, and you have this big procedure, and then your doctor tells you, 'I'll see you in six weeks.' And now, on top of that, you're going home with a new person that you're trying to learn [to care for] and managing your healing process and this huge transition of your life."

Unless it is a high-risk pregnancy, new mothers are generally left to manage the stressors of the postpartum period on their own. As a result of their new and busy schedules, Uche noted they are less likely to attend their postpartum visits.

Add to that the U.S. does not have a mandated maternity leave period. As a result, mothers, especially single mothers, are often not able to take time off from work or find child care to make it to their postpartum appointments, she said.

Then, there is the issue of health insurance coverage. Most health plans cover birthing people through pregnancy; some continue coverage one year postpartum. However, because the postpartum period extends well beyond a year, new mothers might find it hard to find a plan to cover all their needs.

These challenges multiply for women of color. Research shows that Black and Hispanic women have significantly less access to paid leave through their employers or government programs and are more likely to be uninsured than their white and Asian counterparts.

In addition to patient-facing barriers, there are challenges on the provider side that influence postpartum care access. As a result of staffing shortages, obstetricians and gynecologists are often overworked and burned out.

"Gynecology is such a special art, and it takes so much physically and mentally to go through everything to be an amazing physician for your patient. But in terms of what is set in place to allow them to bring their best self every single day and be able to accommodate all the needs their patients have on time with these guidelines, it is beyond them," Uche said.

The American College of Obstetricians and Gynecologists (ACOG) advises that the first postpartum checkup should occur within three weeks. However, patients might be forced to see a new healthcare provider if their current provider is unavailable within that time frame. Uche noted that this means patients start new relationships with their providers after undergoing major life changes to which the provider was not privy.

Using telehealth to close maternal care gaps

Though telehealth was not a new care delivery modality when the pandemic hit, the public health emergency spurred adoption and utilization to new heights. In the maternal care space, telehealth offers pregnant people a convenient and effective way to connect with healthcare providers.

"That opened so many doors, especially as we take into consideration moms who are struggling to find child care or struggling to get the car at a certain time if she's sharing a car or her partner is not there to be able to take care of the needs for her to even [be able to] attend that visit," Uche said. "So, I think that technology within itself has catapulted this sense of access to care."

The new program at UC Davis Health aims to use telehealth to build more than just a sense of access to care -- its goal is true access to care for Black patients. The program will enable Black patients to participate in postpartum visits through video-based telehealth, alleviating numerous barriers to care access.

"Instead of saying you can come in, we can give them the option to have this visit with their provider in the comfort of their home and see if that allows them to attend more visits and be more proactive and active in their own care," Uche said.

The program not only aims to increase the number of Black patients who attend postpartum visits but also to boost patient satisfaction and make these results sustainable in the long term.

To achieve these goals, the UC Davis Health team will track the program's efficacy. James Marcin, M.D., director of the Center for Health and Technology at UC Davis Health, explained that a digital health equity dashboard will be used to monitor not only whether a telehealth visit was successful but also reasons for failure, such as technical issues or a lack of cell service or Wi-Fi among the patients.

This tracking is critical because as telehealth utilization grew during the pandemic, it became clear that not all groups had equitable access to virtual care modalities. Race, age, location of residency and primary language all play a role in determining access to telehealth.

UC Davis Health, which utilizes telehealth systemwide, has taken steps to mitigate these barriers, according to Marcin. For example, the health system has expanded the number of languages available for patient education regarding how to use telehealth.

Assessing patient needs will be critical to building the program, which is still in the early stages of development. As the UC Davis team works on program development, it is committed to keeping the community's needs front and center, adjusting program protocols as required.

"One big thing about just this intervention is that it is something that moms are asking for, and I've always had this saying, 'first you listen, and then you build,'" Uche said. "And that's what we're trying to do here. ... It's [about] listening and amplifying the voices of communities that are going through these struggles, [people] who see what works for them and what doesn't work for them. And our job is just to continue to build, listen, reiterate, and then go back to the drawing map if need be."

Anuja Vaidya has covered the healthcare industry since 2012. She currently covers the virtual healthcare landscape, including telehealth, remote patient monitoring and digital therapeutics.