The research discussed here meets our standards of evidence for being methodologically strong and allowing for causal inference, unless otherwise noted. Each strong causal study reviewed has been assigned a letter, and a complete list of causal studies can be found at the end of this review, along with more details about our standards of evidence and review method. The findings from each strong causal study reviewed align with one of our eight policy goals from Table 1. The Evidence of Effectiveness table (Table 2) displays the findings associated with telehealth (beneficial/equivalent, null,ii or detrimental) for each of the strong studies (A through H) in the causal studies reference list. For each indicator, a study is characterized based on findings for the overall study population; subgroup findings are discussed in the narrative. The Evidence of Effectiveness table also includes our conclusions about the overall impact on each studied policy goal.
Outcomes are classified as “beneficial or equivalent” rather than “null” in our table if a better or equivalent outcome between the treatment and control groups was achieved and was a desired outcome in the study’s hypothesis. For example, if the provision of prenatal care through telehealth produced outcomes equivalent to (but no better than) services provided through in-person care in a given study, that would be considered a “beneficial or equivalent” outcome if the intervention was intended to produce outcomes at least as good as in-person care. On the other hand, if a technological enhancement to traditional care was intended to produce better outcomes than traditional care alone, but failed to do so, then the finding is classified in our table as “null” rather than “beneficial or equivalent.” The assessment of the overall impact for each studied policy goal weighs the timing of publication and relative strength of each study, as well as the size and direction of all measured indicators.
Of the eight causal studies included in this review, one examined how outcomes differed by race or ethnicity (beyond simply presenting summary statistics or controlling for race/ethnicity). The study used a subgroup analysis to determine the effectiveness of a telephone intervention program and found that preterm births and low birth rates decreased significantly for Black women while White women saw no significant effects.G,51 Another study examined how results differed by language spoken, but all other studies only used race or ethnicity as a control variable rather than conducting a subgroup analysis of differential impacts. A rigorous evaluation of a policy’s effectiveness should consider whether the policy has equitable impacts and should assess the extent to which a policy reduces or exacerbates pre-existing disparities in economic and social wellbeing.
Table 2: Evidence of Effectiveness for Perinatal Telehealth by Policy Goal
|Policy Goal||Indicator||Beneficial or Equivalent Impacts||Null Impacts||Detrimental Impacts||Overall Impact on Goal|
|Access to Needed Services||Perceived Quality of Prenatal Care||A||Positive|
|Total Reported Care Time||A|
|Adherence to ACOG Care Guidelines*||A, H|
|Healthy and Equitable Births||Cesarean Deliveries||A||Mostly Positive|
|Preterm Births||A, G||D|
|Parental Health and Emotional Wellbeing||Pregnancy-Related Stress||A||Mixed|
|Gestational Weight Gain||C|
|Sedentary Behavior During Pregnancy||C|
|Caloric and Fat Intake||B, C|
|Maternal Blood Glucose Values||D|
|Postpartum Physical Activity||B|
|Healthy Postpartum Weight||B|
|Postpartum Hypertension Readmissions||H|
|Optimal Child Health and Development||Exclusive Breastfeeding||E||B, F||Mixed|
|Partial Breastfeeding||E, F||B|
* ACOG guidelines for prenatal care (explored in Study A) include receiving the influenza vaccine, a Tdap booster, mid-pregnancy education, and screenings for Streptococcus and depression. One of the ACOG guidelines for postpartum care (explored in Study H) includes receiving a blood pressure reading within 10 days after giving birth.
** The authors of this study note that “this is likely of little significance since the prevalence [of gestational diabetes] shown is consistent with what would be expected in a low-risk obstetric cohort” (638.e7).
Access to Needed Services
Telehealth services can connect infants, pregnant women, and families to critical health care even when there is a dearth of providers physically present in their communities. Telehealth options can also safely reduce the number of in-person visits that families must attend while maintaining the quality of perinatal care. This review identified two randomized controlled trials (RCTs) since 2000 examining how telehealth can enhance access to needed services during the prenatal-to-3 period. A study using data from 2014 to 2015 examined the effectiveness of a reduced-visit prenatal care model (“OB Nest”) in Rochester, Minnesota, that included a number of telehealth components in addition to eight onsite appointments (compared to 12 onsite appointments in the control group).A The telehealth group received six virtual visits with a nurse, either on the phone or online, home monitoring devices (including fetal heart rate and blood pressure monitors), and access to an online community of other pregnant women.A The goal of the study was to determine whether “a reduced-frequency prenatal care model is as safe as the standard model of care for low-risk pregnant women” which typically involves 12 to 14 in-person visits (p. 638.e1).A Whereas ACOG suggests the 12- to 14-visit approach, the World Health Organization recommends just eight for low-risk pregnancies.38
The authors found that the OB Nest participants were significantly more satisfied with their prenatal care, and the perceived quality of care and adherence to ACOG prenatal guidelines did not differ significantly between the groups; the OB Nest group received necessary care (influenza vaccine, Tdap booster, mid-pregnancy education, screenings for Streptococcus and depression) at similar rates as the control group. This outcome is considered beneficial or equivalent rather than “null” in our table of impacts because equivalent care between the groups is considered a desired result. The OB Nest patients received significantly more minutes of care (401.2 compared to 167.1), but had an average of 2.8 fewer in-person appointments with clinicians. One important limitation of this study was that the sample was comprised primarily of college-educated White women of high socioeconomic status, which precludes generalizability to more diverse populations. More research on diverse populations is needed to develop the evidence base. Nevertheless, the study suggests that telehealth can be used to deliver components of prenatal care while reducing the total number of in-person visits required. Positive clinical outcomes from the OB Nest program are discussed in the sections of this review on healthy births and parental health.
A second study, using data from 2016 to 2017, examined the effectiveness of remote blood pressure testing for postpartum women with hypertension, compared to in-person visits.H The ACOG guidelines recommend that postpartum women have a blood pressure recording in the first 10 days after giving birth. The participants randomly assigned to the remote monitoring group were given an at-home blood pressure cuff and were sent reminders to text their readings to their providers. The control group was simply instructed to visit their prenatal clinic for a blood pressure reading 4 to 6 days postpartum. The authors found a large, statistically significant benefit in the intervention group for achieving at least one blood pressure reading in the first 10 days after birth: 92.2 percent of the remote group met the guideline compared to 43.7 percent of the office group.H The control group also saw a significantly higher likelihood of hospital readmission for hypertension than the treatment group (3.9% compared to 0%).
Healthy and Equitable Births
Three recent RCTs examined the effects of telehealth on healthy and equitable births, with mostly equivalent results, indicating that remote care can produce outcomes similar to in-person care while removing barriers such as geography and transportation time or costs. The OB Nest study described previously found no significant differences between the telehealth group and the usual care group on a variety of birth outcomes, including Cesarean deliveries,iii preterm births, birthweight, and Apgar scores.A
A 2012 study, using data collected from 2007 to 2009, examined the role of telehealth in promoting healthy birth outcomes in women with gestational diabetes, which affects more than 200,000 pregnancies each year in the US and is becoming more common.D Participants were randomly assigned either to a treatment group in which they transmitted their blood glucose values to their provider four times daily via the Internet or a toll-free phone line, or a control group in which they maintained records in a notebook and reviewed them with providers at in-person prenatal visits. In the telehealth group, providers were able to respond to patients’ input by sending a response through text or voice messages. The authors had hypothesized that the treatment group would see better glucose control and pregnancy outcomes as a result of the greater contact and feedback from their health care provider. However, the authors found that although the treatment group had a more efficient, streamlined option for transmitting their data to providers, no significant differences in maternal or infant outcomes were realized. Maternal blood glucose values, infant birthweight, and gestational age at delivery were all better in the treatment group than the control group, but the differences did not rise to the level of statistical significance. These outcomes are classified as “null” rather than beneficial or equivalent because the intervention was intended to produce better outcomes among the treatment group but failed to do so at a significant level.
A third study, analyzing data collected over five years starting in 1990, examined the effectiveness of a telephone intervention aimed at reducing low birthweight and preterm births, with a focus on improving outcomes for Black women in particular.G Participants randomized to the telephone intervention received usual prenatal care plus one to two telephone calls per week from a nurseiv between 24 and 37 weeks of gestation, whereas the control group received usual care but no additional phone calls. The phone calls involved discussions of the mother’s health status and daily health behaviors and the nurses provided recommendations. Over 500 participants were in each group. The authors found a significant, 26 percent reduction in low birthweight births in the intervention group among Black women, and most of the difference was for mothers over age 19. Preterm births were also significantly reduced among Black women by 27 percent in the intervention group, again primarily for mothers over 19 years old. No significant benefit was found for White women. Given the increased prevalence of mobile phones in the 20 years since this study was conducted, it is possible that the intervention may be even more effective now than when access to the telephone was often limited to home landlines.
A study completed during the COVID-19 pandemic analyzed the use of audio-only telehealth appointments in conjunction with necessary in-person prenatal visits.43 Two groups were compared: women who gave birth at a hospital system in Dallas, Texas between May 1, 2019 and October 31, 2019, and women who gave birth at the same hospital system between May 1, 2020 and October 31, 2020. The women who gave birth in 2020 received up to three audio-only visits in place of up to three traditional in-person visits. The quasi-experimental study found women with more audio-only visits were less likely to have placental abruption, premature delivery, or require transfusion at delivery. Additionally, infant outcomes were equivalent whether mothers received audio-only care or in-person care. Although the study had a large sample size, there were several study limitations including different risk levels among the groups and other sources of selection bias; this study is therefore not included in our Evidence of Effectiveness table, but does suggest potential benefits of telehealth services.43
Parental Health and Emotional Wellbeing
Six of the RCTs identified for this review included an examination of telehealth’s impact on mothers’ health and wellbeing in the perinatal period. Overall, results were mostly beneficial or in the intended direction without reaching statistical significance, demonstrating that care delivered through telehealth can be equally as effective as traditional in-person care. The OB Nest intervention produced a significant reduction in pregnancy-related stress for women in the treatment group compared to the control group.A On a 0- to 2-point scale of prenatal maternal stress, in which higher scores indicated greater stress, the intervention group reported less stress at 14 weeks (average score of 0.32 vs. 0.41 in the control group) and 36 weeks of gestation (0.34 vs. 0.40). However, the incidence of gestational diabetes was found to be higher in the OB Nest group than the control group (4.5% vs. 0%). The authors explained that “this is likely of little significance since the prevalence shown is consistent with what would be expected in a low-risk obstetric cohort”A (p. 638.e7).
A study using data collected from 2005 to 2009 examined the effectiveness of a telephone intervention for supporting women with gestational diabetes to reach a healthy postpartum weight through physical activity and monitoring of caloric and fat intake.B Participants were assigned to either usual care or the intervention group, which was called the “Diet, Exercise and Breastfeeding Intervention” or DEBI. The DEBI group received four in-person sessions and up to 15 telephone calls, including telelactation support in the postpartum period. The usual care group received printed education materials but no other additional support. The authors found that 37.5 percent of the intervention group returned to a healthy postpartum weight 12 months after giving birth (defined as returning to pre-pregnancy weight or achieving a 5 percent reduction from pre-pregnancy weight if overweight), whereas 21.4 percent of the control group did. This difference was not statistically significant. However, among only the women who did not exceed the recommended guidelines for gestational weight gain, the intervention had a significant impact, with a 22.5 percent difference between the share of the intervention and control groups who reached a healthy postpartum weight. The intervention group saw a significant benefit in terms of reducing dietary fat intake, but no significant difference for physical activity.
A study using data collected from 2014 to 2017, which also focused on healthy weight management during pregnancy, found mostly positive, statistically significant results.C Women at 8 to 15 weeks of gestation who were considered overweight or obese based on their Body Mass Index were assigned to receive a telehealth intervention in addition to usual prenatal care (called “GLOW,” or Gestational Weight Gain and Optimal Wellness) or usual prenatal care alone. The intervention group received 11 telephone sessions and one in-person session each at the beginning and end of the intervention. The authors found that 33 percent of the intervention group met the Institute of Medicine guidelines for weekly rate of gestational weight gain, compared to 24 percent of the control group, which was a statistically significant difference. For total gestational weight gain, 41 percent of the intervention group exceeded recommended levels, compared to 66 percent of control participants. Relatedly, the intervention group consumed significantly fewer calories per day (although the difference in fat intake was null) and reported 4.8 fewer sedentary hours per week compared to the control group.
A study using data collected from 2007 to 2009, which examined the impact of a telehealth intervention on birth outcomes and glucose control in women with gestational diabetes, found null effects on maternal blood glucose values, although they were in the intended direction (lower) in the treatment group.D
The 2018 study discussed previously in the section on access to services, regarding blood pressure recordings, found that the control group saw a significantly higher likelihood of hospital readmission for hypertension than the treatment group (3.9% compared to 0%).H
A 2016 study, with participants from three hospitals, sought to determine the effectiveness of an online, interactive breastfeeding monitoring platform for both increasing breastfeeding and reducing maternal postpartum depression.E Mothers in the intervention group were reminded to record breastfeeding and infant health data in the online platform for 30 days, which provided them with tailored feedback based on their input, whereas the control group received the hospitals’ usual postpartum care. Usual care consisted of “breastfeeding support and education before discharge, one phone call within the first week after hospital discharge, and a list of community breastfeeding resources” (p. 4).E Outcomes for breastfeeding (exclusive and partial) are discussed in the child health section, below, but the study investigated mothers’ postpartum depression outcomes and found no significant difference in scores at 3 months postpartum on the Edinburgh Postpartum Depression Scale. This result is classified as “null” because the platform was intended to produce improvements but did not.
A recent observational study, published in 2021, examined the impact of an 8-week group videoconferencing pilot program aimed at pregnant and postpartum women with perinatal depression symptoms or risk factors for developing depression.39 The study did not have a control group and the sample size was small (47 women), but results were nevertheless promising, showing a decline in symptoms for most women who participated. Given that up to 18 percent of pregnant/postpartum women experience perinatal depression, developing effective and affordable treatments, such as group telehealth programs, may be an important component of addressing this problem—especially with current social distancing requirements for public health.39
Optimal Child Health and Wellbeing
Three RCTs in the US since 2000 have examined the impact of telehealth interventions on children’s health and development in the prenatal-to-3 period, all of which address breastfeeding interventions.B,E,F The 2011 DEBI trial, using data collected from 2005 to 2009, and described in the parental health section above, included a telelactation consultant who encouraged women in the intervention group to breastfeed for at least 6 months, provided a breast pump, and provided one to four phone calls in the first 6 weeks after delivery to discuss the new mothers’ needs and progress with regard to successful breastfeeding.B The authors did not find a significant difference in the likelihood to partially or exclusively breastfeed in the treatment group compared to the control group.
A study using data collected from 2005 to 2007 examined the effectiveness of a telephone peer counseling program provided to participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) who intended to breastfeed or were considering breastfeeding.F Women who were randomly assigned to the control group received WIC’s typical breastfeeding promotion materials, whereas women assigned to the treatment arm received either a “high-frequency” or “low-frequency” peer counselor who initiated either eight or four phone calls, respectively, with the participant. The authors found that the program did not lead to differences in breastfeeding initiation, but the program did significantly affect breastfeeding duration and exclusivity. The intervention increased partial breastfeeding for at least 3 months by 22 percent, an increase of 11 percentage points. Increases were greatest among Spanish-speaking participants (29% increase among the treatment group relative to the control group). For increasing partial breastfeeding for 6 months, Spanish-speaking participants saw a significant increase, but English-speaking participants did not. The only group that saw a benefit for exclusive breastfeeding was also the Spanish-speaking participants; they saw a 20 percent increase in the probability of exclusive breastfeeding for at least 3 months. Interestingly, the authors found no differences between the high- and low-frequency intervention groups, so they pooled the data into a single treatment group.
Finally, the aforementioned 2016 study of an online breastfeeding monitoring platform found significant, positive results for exclusive breastfeeding and partial breastfeeding for at least 3 months:E “The intervention group had higher exclusive breastfeeding rates at 1 month, 2 months and 3 months [postpartum] (63%, 63%, and 55%, respectively) compared to the control group (40%, 19%, and 19%, respectively)” (p. 7). The intervention group was also more likely to breastfeed (whether partial or exclusive) for 3 months compared to the control group (84% vs. 66%).
- An impact is considered statistically significant if p<0.05. Results with p-values above this threshold are considered null or nonsignificant.
- Cesarian deliveries are typically recommended when a vaginal delivery poses safety or health risks, but are not considered by most obstetricians to be the optimal delivery method.
- Phone calls covered: “assessment of health status (perception of uterine contraction and other pregnancy changes, number of meals eaten, number of cigarettes smoked, alcohol and drug use, and ingestion of a prenatal vitamin capsule on the previous day), nursing recommendations based on assessment, and discussion of any additional issues important to the mother” (p. 272).G