- Reduced visit versus traditional visit schedules for routine antenatal care
- Studies comparing reduced routine antenatal visit schedules with traditional schedules did not find differences between schedules in gestational age at birth, likelihood of being small for gestational age, likelihood of a low Apgar score, likelihood of neonatal intensive care unit (NICU) admission, maternal anxiety, likelihood of preterm birth, and likelihood of low birth weight.
- There is insufficient evidence for numerous prioritized outcomes of interest (e.g., completion of the American College of Obstetricians and Gynecologists (ACOG) recommended services and patient experience measures).
- Qualitative studies reported several potential facilitators and barriers to implementing reduced visit schedules, including:
- Barriers from patient perspective: hesitancy to take on more responsibility and emotional discomfort with reduced visits.
- Barriers from both patient and provider perspectives: reduced visits may lead to important gaps in patient knowledge and pregnant individuals vary in confidence in managing their pregnancy independently.
- Facilitators from provider perspective: reduced visits align with midwifery philosophies of care, improvement in overcrowding (of clinics), may increase clinic time available to be directed to patients with high-risk pregnancies, and patients may value fewer visits and avoiding inconveniences of attending multiple appointments.
- Barriers from provider perspective: reduced visits may compromise patients’ antenatal care and their psychosocial needs, go counter to patients’ familiarity with the traditional model across decades of social networks, and may result in repercussions from management should adverse events occur.
- Televisits for routine antenatal care
- Studies comparing hybrid (televisits and in-person) visits and all in-person visits did not find differences in rates of preterm births, rates of NICU admissions, but found possible greater satisfaction with hybrid visits. However, an additional survey that directly compared televisits and in-person visits found greater satisfaction with in-person visits.
- There is insufficient evidence for numerous prioritized outcomes.
- Qualitative studies reported several potential facilitators and barriers to implementing televisits, including:
- Facilitators from patient and provider perspectives: televisits allow care to be better tailored to the needs of patients; televisits protect patients, providers, and clinics from COVID-19; televisits enhance community and relationship building (although some believed it could hinder); televisits are helped by home monitoring devices use and system supports (e.g., guidance, technology support, translation services).
- Barriers from patient and provider perspectives: potential reduced quality of care with televisits and patients’ psychological apprehension and general desire to be seen in-person.
- Barriers from provider perspective: no or limited IT (information technology) literacy of patient or providers; need for onerous training of providers; perception of the added complexity televisits bring to service delivery; difficulty for patients in the initial set-up; difficulty for patients to describe symptoms virtually; lack of buy-in from health-system leadership; a need to integrate televisits within existing workflows; concerns about potentially liability issues and changes in reimbursement policies; limited evidence (or lack of knowledge of evidence) on the use of televisits for routine antenatal care; and difficulty of transitioning to televisits for patient populations with health disparities and those with difficulty accessing the necessary technology.
- Facilitators from provider perspective: guidelines on which types of antenatal visits are (or are not) appropriate for televisits; user-friendly technology and resources to support and encourage health providers and patients engagement; translation of materials for non-English-speaking patients; patients’ appreciation for continuity of care; provider ease with technology; access to colleagues with prior telehealth experience; improved patient attendance at visits; and ability to manage low-risk pregnancies at home.
- Facilitator from provider and clinic leadership perspectives: training for staff and regular leadership meetings to ease the transition.
- Facilitator from leadership perspective: support for office staff to ease implementation challenges.
- Tradeoffs of barriers and facilitators from provider perspective: lack of privacy for televisits versus increased ability of family to attend and participate in televisits; and reduced training opportunities for junior clinicians versus improved team cohesion and case discussion between senior and junior clinicians with televisits.
- Studies did not evaluate heterogeneity of treatment effects (whether some specific groups of patients may have had better or worse outcomes with reduced routine visits or televisits) or equity issues (whether certain classes of patients might be disadvantaged by reduction in the number of visits or use of televisits).
Background. The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine plan a new evidence-based joint consensus statement to address the preferred visit schedule and the use of televisits for routine antenatal care. This systematic review will support the consensus statement.
Methods. We searched PubMed®, Cochrane databases, Embase®, CINAHL®, ClinicalTrials.gov, PsycINFO®, and SocINDEX from inception through February 12, 2022. We included comparative studies from high-income countries that evaluated the frequency of scheduled routine antenatal visits or the inclusion of routine televisits, and qualitative studies addressing these two topics. We evaluated strength of evidence for 15 outcomes prioritized by stakeholders.
Results. Ten studies evaluated scheduled number of routine visits and seven studies evaluated televisits. Nine qualitative studies also addressed these topics. Studies evaluated a wide range of reduced and traditional visit schedules and approaches to incorporating televisits.
In comparisons of fewer to standard number of scheduled antenatal visits, moderate strength evidence did not find differences for gestational age at birth (4 studies), being small for gestational age (3 studies), Apgar score (5 studies), or neonatal intensive care unit (NICU) admissions (5 studies). Low strength evidence did not find differences in maternal anxiety (3 studies), preterm births (3 studies), and low birth weight (4 studies). Qualitative studies suggest that providers believe fewer routine visits may be more convenient for patients and may free up clinic time to provide additional care for patients with high-risk pregnancies, but both patients and providers had concerns about potential lesser care with fewer visits.
In comparisons of hybrid (televisits and in-person) versus in-person only visits, low strength evidence did not find differences in preterm births (4 studies) or NICU admissions (3 studies), but did suggest greater satisfaction with hybrid visits (2 studies). Qualitative studies suggested patients and providers were open to reduced schedules and televisits for routine antenatal care, but importantly, patients and providers had concerns about quality of care, and providers and clinic leadership had suggestions on how to best implement practice changes.
Conclusion. The evidence base is relatively sparse, with insufficient evidence for numerous prioritized outcomes. Studies were heterogeneous in the care models employed. Where there was sufficient evidence to make conclusions, studies did not find significant differences in harms to mother or baby between alternative models, but evidence suggested greater satisfaction with care with hybrid visits. Qualitative evidence suggests diverse barriers and facilitators to uptake of reduced visit schedules or televisits for routine antenatal care. Given the shortcomings of the evidence base, considerations other than proof of differences in outcomes may need to be considered regarding implications for clinical practice. New studies are needed to evaluate prioritized outcomes and potential differential effects among different populations or settings.
Balk EM, Danilack VA, Bhuma MR, et al. Reduced compared with traditional schedules for routine antenatal visits: a systematic review. Obstet Gynecol. 2023 Jul 1;142(1):8-18. doi: 10.1097/AOG.0000000000005193. Epub 2023 Jun 7. PMID: 37290105.
Balk EM, Danilack VA, Cao W, et al. Televisits compared with in-person visits for routine antenatal care: a systematic review. Obstet Gynecol. 2023 Jul 1;142(1):19-29. doi: 10.1097/AOG.0000000000005194. Epub 2023 Jun 7. PMID: 37290109.
Balk EM, Konnyu KJ, Cao W, Reddy Bhuma M, Danilack VA, Adam GP, Matteson KA, Peahl AF. Schedule of Visits and Televisits for Routine Antenatal Care: A Systematic Review. Comparative Effectiveness Review No. 257. (Prepared by the Brown Evidence-based Practice Center under Contract No. 75Q80120D00001.) AHRQ Publication No. 22-EHC031. Rockville, MD: Agency for Healthcare Research and Quality; June 2022. DOI: https://www.doi.org/10.23970/AHRQEPCCER257. Posted final reports are located on the Effective Health Care Program search page.