SummaryBackground

Little evidence is available on the use of telehealth for antenatal care. In response to the COVID-19 pandemic, we developed and implemented a new antenatal care schedule integrating telehealth across all models of pregnancy care. To inform this clinical initiative, we aimed to assess the effectiveness and safety of telehealth in antenatal care.

Methods

We analysed routinely collected health data on all women giving birth at Monash Health, a large health service in Victoria (Australia), using an interrupted time-series design. We assessed the impact of telehealth integration into antenatal care from March 23, 2020, across low-risk and high-risk care models. Allowing a 1-month implementation period from March 23, 2020, we compared the first 3 months of telehealth integrated care delivered between April 20 and July 26, 2020, with conventional care delivered between Jan 1, 2018, and March 22, 2020. The primary outcomes were detection and outcomes of fetal growth restriction, pre-eclampsia, and gestational diabetes. Secondary outcomes were stillbirth, neonatal intensive care unit admission, and preterm birth (birth before 37 weeks' gestation).

Findings

Between Jan 1, 2018, and March 22, 2020, 20 031 women gave birth at Monash Health during the conventional care period and 2292 women gave birth during the telehealth integrated care period. Of 20 154 antenatal consultations provided in the integrated care period, 10 731 (53%) were delivered via telehealth. Overall, compared with the conventional care period, no significant differences were identified in the integrated care period with regard to the number of babies with fetal growth restriction (birthweight below the 3rd percentile; 2% in the integrated care period vs 2% in the conventional care period, p=0·72, for low-risk care models; 5% in the integrated care period vs 5% in the conventional care period, p=0·50 for high-risk care models), number of stillbirths (1% vs 1%, p=0·79; 2% vs 2%, p=0·70), or pregnancies complicated by pre-eclampsia (3% vs 3%, p=0·70; 9% vs 7%, p=0·15), or gestational diabetes (22% vs 22%, p=0·89; 30% vs 26%, p=0·06). Interrupted time-series analysis showed a significant reduction in preterm birth among women in high-risk models (–0·68% change in incidence per week [95% CI −1·37 to −0·002]; p=0·049), but no significant differences were identified in other outcome measures for low-risk or high-risk care models after telehealth integration compared with conventional care.

Interpretation

Telehealth integrated antenatal care enabled the reduction of in-person consultations by 50% without compromising pregnancy outcomes. This care model can help to minimise in-person interactions during the COVID-19 pandemic, but should also be considered in post-pandemic health-care models.

Funding

None.

IntroductionIn March, 2020, health-care systems around the world had to rapidly adjust to cope in response to the COVID-19 pandemic. Services for many subacute aspects of health care were cancelled or completely shifted to telehealth for care delivery; however, maternity care presented a unique challenge, since it cannot be cancelled nor converted to a completely digital format. In Australia, the antenatal care schedule has remained largely unchanged since introduction by the UK Government in 1929,1Ministry of Health
Maternal mortality in childbirth. Ante-natal clinics: their conduct and scope. with the majority of antenatal appointments occurring within the hospital environment, where up to 96% of women in Australia give birth.2Australian Institute of Health and Welfare
Australia's mothers and babies data visualisations. In response to concerns that hospitals would be overwhelmed by COVID-19 cases, antenatal care delivery had to be adapted to protect pregnant women and staff from unnecessary exposure to SARS-CoV-2.On March 13, 2020, the Australian Government announced a temporary change in public health funding through the Medicare Benefits Schedule to support telehealth use in health-care delivery. Telehealth models have previously been implemented in high-cost settings that have extensive technological infrastructure and support systems in place, or in specific patient groups who live remote to specialist care.3Telemedicine applications in obstetrics and gynecology., 4de Mooij MJM Hodny RL O'Neil DA et al.OB Nest: reimagining low-risk prenatal care.Little evidence is available on telehealth use in antenatal care delivery;3Telemedicine applications in obstetrics and gynecology., 5Magann EF McKelvey SS Hitt WC Smith MV Azam GA Lowery CL The use of telemedicine in obstetrics: a review of the literature. thus, in response to the COVID-19 pandemic, in the Australian state of Victoria a large health-care network developed a new integrated antenatal care schedule incorporating telehealth for consultation delivery via voice calls or video calls across all models of pregnancy care. On March 23, 2020, this integrated antenatal care schedule was implemented across three maternity hospitals within the Victorian health-care system, with the aim of reducing in-person consultations by up to 66%, while maintaining a high standard of antenatal care.Research in context

Evidence before this study

Telehealth has been implemented for the provision of pregnancy care in high-income, low-income and, middle-income countries. We searched PubMed and Ovid databases from database inception to March, 2020, for articles published in English, using the search terms “telehealth” OR “telemedicine” AND “pregnancy” OR “antenatal care” OR “obstetrics” OR “maternity”. Studies or reviews that focused specifically on the use of telehealth or telemedicine for the delivery of routine antenatal care were identified from abstract review. A 2020 systematic review found that targeted telehealth interventions have been associated with improved pregnancy outcomes, such as smoking cessation and higher breastfeeding rates. The use of telehealth interventions has also been associated with a reduced number of unplanned in-person visits in high-risk pregnancies, while maintaining similar pregnancy outcomes. This review identified 19 studies done in low-risk pregnancies (n=6827) and 13 studies in high-risk pregnancies (n=1514); however, the majority of included studies focused on targeted use of telehealth, such as for smoking cessation, health and wellbeing in pregnancy, influenza vaccinations, or diabetes management. Three studies were done in high-risk pregnancies alone (n=353) that assessed the use of telehealth to minimise in-person antenatal attendances. All three studies engaged considerable infrastructure comprised of web-based support tools for the management of blood sugar levels in gestational diabetes, or remote monitoring devices, such as blood glucose meters, blood pressure monitors, and pulse oximetry monitors. The use of these tools across the three studies was associated with a reduction in the number of unscheduled visits. None of the included studies specifically assessed the virtual delivery of routine antenatal care using telehealth. However, virtual obstetric services have been developed, predominately within the USA. Although evidence from these programmes indicate that women provided with virtual care had similar pregnancy outcomes to those given conventional care and patient satisfaction with virtual care is good, these models often incorporated additional technological infrastructure to support home monitoring and were used in small patient populations.

Added value of this study

The widespread integration of telehealth into the delivery of antenatal care for both low-risk and high-risk pregnancy care models is achievable. To our knowledge, this is the first low-cost model of telehealth integrated antenatal care. We found that telehealth integrated antenatal care was achievable in a publicly funded health-care system. Rapid replacement of around 50% of in-person antenatal consultations with virtual telehealth visits was not associated with a change in adverse pregnancy outcomes or complications when compared with conventional antenatal care. Although the motivation for this change in care was driven by the COVID-19 pandemic, pregnancy outcomes were not influenced directly by COVID-19 in pregnancy since no COVID-19 cases were reported in our study population during the study period.

Implications of all the available evidence

Telehealth can be incorporated into antenatal care delivery for both low-risk and high-risk pregnancies, not only for targeted strategies such as diabetes management and smoking cessation, but also for routine antenatal care visits. Our findings indicate that antenatal care delivered using telehealth is likely to result in the same or improved outcomes when compared with conventionally delivered care; thus, future research is needed to ensure these findings are maintained over a longer period and after the COVID-19 pandemic. Existing literature indicates that telehealth applications are associated with a high level of patient satisfaction. Although this model of care will assist with the development of resilient, personalised health systems, the cost-effectiveness of telehealth in antenatal care remains to be determined.

Little evidence was available to inform this clinical initiative; thus, we aimed to assess the uptake and safety of telehealth integrated antenatal care for low-risk and high-risk pregnancies. Since physical examination is not possible during telehealth consultations, we hypothesised whether the use of telehealth integrated antenatal care might adversely impact on the ability to detect common complications of pregnancy, particularly those contingent on physical examination, such as pre-eclampsia and fetal growth restriction.

Although this new antenatal care schedule is crucial during the current COVID-19 pandemic, evaluation of the telehealth integrated care model might assist other health services considering such a programme, particularly with the observed resurgence in COVID-19 cases in many countries. Additionally, this evaluation might guide the future use of telehealth integrated antenatal care as part of building resilient health systems better placed to withstand epidemics while providing more individualised patient care.

Results

Between Jan 1, 2018, and March 22, 2020, 20 031 women gave birth at Monash Health with conventional care. Telehealth was integrated into antenatal care delivery across Monash Health on March 23, 2020; thus we assessed comparative outcomes for 2292 women who gave birth between April 20 and July 26, 2020. Thus, the total observational study period assessed outcomes from 23 008 births, comparing all women who gave birth during the 3-month telehealth integrated care with those who gave birth in the 26 months before telehealth implementation.

Women who gave birth during the telehealth integrated care period were slightly older (31·61 vs 31·29 years; p=0·03) than those who gave birth during the conventional care period. No other significant differences between the groups were observed for BMI, smoking, parity, or region of birth (table 1).

Table 1Maternal and antenatal care characteristics in the conventional and telehealth integrated care periods

Data are mean (SD), median (IQR), n (%), or n/N (%).

During the study period, the mean number of antenatal consultations done remained stable at approximately 1400 per week. However, the proportion of consultations delivered via telehealth increased rapidly during the implementation period, with a mean of 766 telehealth consultations done per week (766 [53%] of 1400 consultations via telehealth vs 0·96 [0·06%] consultations during the conventional care period; table 1, figure 2A). Most of these consultations were by video call with 5% done via telephone (data not shown). In low-risk care models women received a mean of five (56%) of nine visits by telehealth, whereas women in high-risk models received four (40%) of ten visits via telehealth (figure 2B).

Figure 2Number of in-person and telehealth consultations delivered per week after telehealth implementation on March 23, 2020

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Absolute number of in-person and telehealth consultations (A) and the percentage of antenatal consultations delivered by telehealth for low-risk and high-risk care models (B) between March 23 and July 20, 2020. The implementation period was defined as March 23–April 19, 2020, and the integrated care period was defined as the period April 20–July 26, 2020.

The total number of appointments that women did not attend was significantly higher in the integrated care period than the conventional care period (1589 [8%] of 20 154 consultations vs 8538 [5%] of 165 263 consultations; ptable 1). However, during the integrated care period, the overall number of appointments that were not attended was similar for both telehealth and in-person consultations (figure 3). A higher number of in-person consultations were missed than telehealth consultations in high-risk care models (figure 3A), whereas the number of telehealth consultations missed was higher than in-person consultations in low-risk care models (figure 3B).

Figure 3Proportion of consultations not attended per week following telehealth implementation

Show full caption

Proportion of missed appointments for in-person and telehealth consultations for high-risk care models (A) and low-risk care models (B). Shaded areas indicate the periods of community lockdown in Melbourne (VIC, Australia) during the COVID-19 pandemic.

Regarding fetal growth restriction, no significant differences were identified in the proportion of babies born with a birthweight below the 3rd percentile in the integrated care period when compared with the conventional care period for low-risk care models (39 [2%] of 1767 singleton births in the integrated care period vs 322 [2%] of 15 470 singleton births in the conventional care period; p=0·72) or high-risk models (25 [5%] of 474 singleton births vs 192 [5%] of 4186 singleton births; p=0·50). No significant differences were identified in the proportion of babies born with a birthweight below the 10th percentile in the integrated care period when compared with the conventional care period for low-risk care models (167 [10%] of 1767 singleton births in the integrated care period vs 1506 [10%] of 15 470 singleton births in the conventional care period; p=0·71) or high-risk care models (61 [13%] of 474 singleton births vs 580 [14%] of 4186 singleton births; p=0·55; table 2). In interrupted time-series analysis, no significant differences were identified in the rate of change per week in the number of babies born with a birthweight below the 3rd percentile after the introduction of telehealth compared with the conventional care period in low-risk care models (0·06% change per week [95% CI −0·07 to 0·20]; p=0·37) or high-risk care models (–0·14% change per week [–0·41 to 0·13]; p=0·31; table 3). Similarly, no significant differences were identified in the number of babies born with a birthweight below the 3rd percentile born at or after 40 weeks' gestation for the conventional care period and integrated care period (Table 2, Table 3). Compared with the conventional care period, no differences in the number of women who were induced for suspected fetal growth restriction per week were identified during the telehealth integrated care period for low-risk care models (–0·19 [95% CI −0·40 to 0·03]) or high-risk care models (–0·008 [–0·37 to 0·36]), or for the number of women who were induced before 39 weeks resulting in a baby with a birthweight above the 10th percentile (table 3).

Table 2Maternal and neonatal complications in low-risk and high-risk care models

Data are n/N (%) or median (IQR). The conventional care period was defined as Jan 1, 2018, to March 22, 2020, the implementation period as March 23 to April 19, 2020, and the integrated care period as April 20 to July 26, 2020. NICU=neonatal intensive care unit.

Table 3Interrupted time-series analysis for maternal and neonatal outcomes in conventional and integrated care periods for low-risk and high-risk care models

Data are percentage change per week (95% CI). NICU=neonatal intensive care unit.

Additionally, no significant differences were identified in the incidence of stillbirth overall between the integrated and conventional care periods (1% in the integrated care period vs 1% in the conventional care period, p=0·79 for the low-risk care models; 2% vs 2%, p=0·70 for high-risk care models), or when crude rates were assessed for either care model (table 2). A 0·22% reduction in the number of stillbirths per week was observed after the integration of telehealth in high-risk care models when compared with conventional care (95% CI −0·47 to 0·03; p=0·09), but this difference was not statistically significant (table 3).Compared with the conventional care period, in the implementation period, an initial decline was observed in the number of women diagnosed with pre-eclampsia in both low-risk care models (six [1%] of 536 women in the implementation period vs 455 [3%] of 15 493 women in the conventional care period) and high-risk care models (six [4%] of 149 women vs 328 [7%] of 4538 women; table 2). However, the number of pre-eclampsia diagnoses during the integrated care period was similar to that in the conventional care period (49 [3%] of 1768 women in low-risk care models and 47 [9%] of 524 women in high-risk care models; table 2). For pregnancies complicated by pre-eclampsia, no significant difference in the median gestation at birth was identified after telehealth integration when compared with conventional care for women in low-risk care models (38·4 weeks [IQR 37·3–39·3) vs 38·2 weeks [37·2–39·3]; p=0·27) or women in high-risk care models (37·1 weeks [32·6–38·1] vs 36·8 weeks [34·2–38·0]; p=0·99; table 2). The number of women with pre-eclampsia who had severe complications in the integrated care period was too low to make any conclusive inferences, but was similar to that for the conventional care period for the low-risk care model (two [4%] of 49 women in the integrated care period vs 20 [4%] of 455 women in the conventional care period; p=0·94) and high-risk care models (two [4%] of 47 women vs 23 [7%] of 328 women; p=0·48; table 2). No significant differences in the number of pre-eclampsia diagnoses per week were identified after the implementation of telehealth in low-risk care models (0·15% change per week [95% CI −0·03 to 0·34]; p=0·10) or high-risk care models (0·20% [–0·31 to 0·70]; p=0·44) when compared with the pre-trend slope for the conventional care period (table 3).An increase in the incidence of gestational diabetes diagnosed in high-risk care models was observed after telehealth implementation, but this difference was not significant (156 [30%] of 524 women in the integrated care period vs 1178 [26%] of 4538 women in the conventional care period; p=0·06), and no increase was observed among women in low-risk care models (386 [22%] of 1768 women vs 3405 [22%] of 15 493; p=0·89; table 2). No changes were observed in the proportion of women with gestational diabetes requiring insulin or giving birth to a baby with a birthweight above the 97th percentile in the low-risk or high-risk care models (table 2). Across the conventional care period, a small increase in the number of women diagnosed with gestational diabetes per week was observed in low-risk care models (0·04% increase [95% CI 0·02–0·05]; ptable 3). Similarly, in high-risk care models, the number of women with gestational diabetes requiring insulin increased by 0·13% per week (95% CI 0·02–0·25; p=0·03) in the conventional care period, but this increase was not significantly altered with telehealth integration (p=0·73; table 3).No significant differences were identified in the proportion of babies requiring NICU admission born to women in the low-risk models of care (29 [2%] of 1768 babies in the integrated care period vs 237 [2%] of 15 516 babies in the conventional care period; p=0·60; table 2), or the weekly change in rate of NICU admission in the conventional or intergrated care periods. Among women in high-risk care models, a significantly higher proportion of babies were admitted to NICU in the integrated care period than in the conventional period (101 [18%] of 574 babies vs 723 [15%] of 4897 babies; p=0·01; table 2); however, in interrupted time-series analysis no significant differences in the rate of weekly NICU admission were identified after telehealth integration compared with conventional care (–0·44% change per week [95% CI −1·04 to 0·16]; p=0·15; table 3).The proportion of babies born preterm was similar for all time periods for both low-risk care models (82 [4%] of 1768 babies in the integrated care period vs 869 [6%] of 15 516 babies in the conventional care period; p=0·10) and high-risk care models (164 [29%] of 574 babies vs 1307 [27%] of 4897 babies; p=0·34; table 2). However, for women in high-risk care models, the number of preterm births reduced by 0·68% per week (95% CI −1·37 to −0·002; p=0·049) after telehealth integration compared with the conventional care period (table 3).Discussion

We found that our telehealth programme delivered around 50% of antenatal consultations via telehealth without affecting the detection and management of common pregnancy complications, including pre-eclampsia, fetal growth restriction, and gestational diabetes, when compared with conventionally delivered antenatal care.

The COVID-19 pandemic has been the catalyst for change in antenatal care delivery, prompting reduced in-person interactions, but also stimulating funding for telehealth services by the Australian Government.14Australian Government Department of Health
COVID-19 national health plan–primary care package–MBS telehealth services and increased practice incentive payments. Investment in telehealth integration into health care has been suggested not only to enhance preparedness for disasters,15The role of telehealth in the medical response to disasters. particularly when infrastructure remains intact, as observed in the current pandemic,16Virtually perfect? Telemedicine for Covid-19. but also to improve the delivery of patient-centred care.17In-person health care as option B. Evidence in many areas of medicine shows that care delivered via telehealth results in similar health outcomes to traditional in-person consultations.18Flodgren G Rachas A Farmer AJ Inzitari M Shepperd S Interactive telemedicine: effects on professional practice and health care outcomes. In this study, we showed that pregnancy outcomes following the implementation of telehealth in antenatal care seem to be similar to those with conventional in-person care.Although telehealth has been increasingly used in the 21st century, particularly to access specialist care for individuals who live in rural or remote areas, and has been shown to result in similar or improved clinical outcomes to in-person delivered care,18Flodgren G Rachas A Farmer AJ Inzitari M Shepperd S Interactive telemedicine: effects on professional practice and health care outcomes. telehealth has seldom been used in antenatal care.5Magann EF McKelvey SS Hitt WC Smith MV Azam GA Lowery CL The use of telemedicine in obstetrics: a review of the literature., 18Flodgren G Rachas A Farmer AJ Inzitari M Shepperd S Interactive telemedicine: effects on professional practice and health care outcomes., 19DeNicola N Grossman D Marko K et al.Telehealth interventions to improve obstetric and gynecologic health outcomes: a systematic review. The available literature has mainly focused on the use of telemonitoring or mobile health applications for targeted approaches, such as smoking cessation, influenza vaccination, blood pressure monitoring, blood sugar level monitoring, and wellness checks.4de Mooij MJM Hodny RL O'Neil DA et al.OB Nest: reimagining low-risk prenatal care., 19DeNicola N Grossman D Marko K et al.Telehealth interventions to improve obstetric and gynecologic health outcomes: a systematic review., 20Khalil A Perry H Lanssens D Gyselaers W Telemonitoring for hypertensive disease in pregnancy., 21Gyselaers W Lanssens D Perry H Khalil A Mobile health applications for prenatal assessment and monitoring., 22van den Heuvel JFM Kariman SS van Solinge WW Franx A Lely AT Bekker MN [email protected] - feasibility study of a telemonitoring platform combining blood pressure and preeclampsia symptoms in pregnancy care., 23Alves DS Times VC da Silva ÉMA Melo PSA Novaes MA Advances in obstetric telemonitoring: a systematic review., 24Kalafat E Benlioglu C Thilaganathan B Khalil A Home blood pressure monitoring in the antenatal and postpartum period: a systematic review meta-analysis., 25Feroz A Perveen S Aftab W Role of mHealth applications for improving antenatal and postnatal care in low and middle income countries: a systematic review., 26Ming WK Mackillop LH Farmer AJ et al.Telemedicine technologies for diabetes in pregnancy: a systematic review and meta-analysis. In developing our programme, regular antenatal consultations were maintained because fewer consultations have been associated with increased incidence of adverse pregnancy outcomes, patient anxiety, and dissatisfaction with care.27WHO
WHO recommendations on antenatal care for a positive pregnancy experience: summary., 28Dowswell T Carroli G Duley L et al.Alternative versus standard packages of antenatal care for low-risk pregnancy. Therefore, telehealth was integrated into this schedule to maintain regular consultations, but to reduce the need for in-person attendance. We were able to leverage a telehealth system already in use at our health service for the delivery of paediatric telehealth consultations and modify the system for antenatal care. We recognised that a key limitation of telehealth is the inability to do physical examinations, which are essential in antenatal care for detecting hypertensive disorders of pregnancy and aberrant fetal growth; thus we also implemented low-cost measures to support these assessments in settings remote from hospital.Home blood pressure monitoring has the potential to reduce iatrogenic intervention. A 2020 systematic review found that home blood pressure monitoring was associated with reduced incidence of antenatal admission, pre-eclampsia diagnosis, and induction of labour.24Kalafat E Benlioglu C Thilaganathan B Khalil A Home blood pressure monitoring in the antenatal and postpartum period: a systematic review meta-analysis. We observed an initial decrease in the number of pregnancies diagnosed with pre-eclampsia during population lockdown between March 16 and March 31, 2020, in Melbourne, when reductions in hospital attendances to pregnancy assessment units and emergency departments were observed. After lockdown was ended in the state of Victoria on May 31, 2020, a return to baseline was observed for women in low-risk models of care and an increased incidence of pre-eclampsia in women in high-risk models of care initially. Since the data presented was obtained for women who gave birth at hospital during this time, true diagnoses of pre-eclampsia would not have been missed. Furthermore, although the incidence of pre-eclampsia does not inform the timing of diagnosis and whether this was delayed through the use of telehealth, the gestation at birth remained similar to the conventional care period. Considering the reduction in the incidence of preterm births during the initial stages of the COVID-19 pandemic,29Philip RK Purtill H Reidy E et al.Reduction in preterm births during the COVID-19 lockdown in Ireland: a natural experiment allowing analysis of data from the prior two decades. it would be interesting to further assess whether this similar reduction in pre-eclampsia incidence was also more widely observed.Detection of fetal growth restriction is challenging. Our health system predominately uses symphyseal-fundal height measurements for tracking fetal growth across pregnancy, in accordance with current recommended practice for low-risk pregnancies.8Australian Government Department of Health
Clinical practice guidelines. Pregnancy care. Insufficient evidence exists regarding the ability of symphyseal-fundal height measurements to detect fetal growth restriction, with this approach detecting 12–15% of babies with growth restriction in low-risk pregnancies.30Robert Peter J Ho JJ Valliapan J Sivasangari S Symphysial fundal height (SFH) measurement in pregnancy for detecting abnormal fetal growth. Similar symphyseal-fundal heights results are obtained regardless of whether measurements are done by a health-care professional or self-measured.31Bergman E Kieler H Petzold M Sonesson C Axelsson O Self-administered measurement of symphysis-fundus heights. No increases in undetected fetal growth restriction pregnancies or a change in the incidence of stillbirths—for which undetected fetal growth restriction is a major risk factor—were observed.32Selvaratnam RJ Davey MA Anil S McDonald SJ Farrell T Wallace EM Does public reporting of the detection of fetal growth restriction improve clinical outcomes: a retrospective cohort study. This has also not been achieved at the cost of increased iatrogenic intervention, with the balance measure of birth of appropriately grown babies before 39 weeks' gestation remaining stable for women in both low-risk and high-risk models of pregnancy care. Universal third trimester growth surveillance is more accurate for the identification of fetal growth restriction in the low-risk population than symphyseal-fundal heights; thus implementation of such an approach might further assist in reducing poor outcomes associated with fetal growth restriction.33Sovio U White IR Dacey A Pasupathy D Smith GCS Screening for fetal growth restriction with universal third trimester ultrasonography in nulliparous women in the Pregnancy Outcome Prediction (POP) study: a prospective cohort study. There have been concerns that this approach might increase iatrogenic intervention; however, the use of universal third trimester growth surveillance in combination with telehealth has not been assessed previously.Gestational diabetes was assessed as a surrogate marker of clinical care since diabetic management in pregnancy seems to be unaffected by the mode of care delivery,26Ming WK Mackillop LH Farmer AJ et al.Telemedicine technologies for diabetes in pregnancy: a systematic review and meta-analysis. which was supported by the finding that the incidence of insulin-requiring gestational diabetes and macrosomia in the population remained stable across all time periods.A similar number of missed appointments were observed for both in-person and telehealth consultations; however, the influencing factors for this might differ. In-person consultations might have been impacted by concerns of COVID-19 exposure and challenges with attending during lockdown, whereas challenges with technology, communication of appointments, and issues regarding access might have influenced attendance at telehealth consultations.34Scott Kruse C Karem P Shifflett K Vegi L Ravi K Brooks M Evaluating barriers to adopting telemedicine worldwide: a systematic review. To better understand factors that might have influenced missed appointments and identify population groups for whom telehealth might not be suitable, an in-depth review of consumer characteristics is needed. The number of missed appointments in the telehealth integrated period in the last 4 weeks of the study period were lower than that in the conventional care period.

The strengths of this study are the uniformity of implementation of telehealth integrated care across a large health service, with large numbers of births assessed in both the conventional and integrated care periods, which strengthened the findings with minimal missing data. The large sample size is likely to have reduced the impact of bias, since all women assessed would have had telehealth integrated in their pregnancy care, with the exception of women who declined telehealth or could not be contacted for a telehealth consultation, or who had not had antenatal care, but attended the hospital for birth. Furthermore, the outcomes assessed were routinely collected data from all women who gave birth at the health service, enabling reliable assessment across time to review the effect of health-care changes on pregnancy outcomes. We are confident about the safety of this approach for the delivery of antenatal care, since there were no recorded COVID-19 cases in pregnancy in Victoria during the telehealth integrated care period. As such, any potential influence that COVID-19 in pregnancy might have had on these outcomes did not further bias or influence the results. We believe our findings are widely generalisable for implementation or adaption to other health services, since the population included were highly heterogeneous and video call technology is now widely and cheaply available.

Limitations of this study relate to its retrospective nature; however, the major risk of selection bias was minim