Redesigning Prenatal Care During the COVID-19 Pandemic

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In the wake of the rapidly evolving COVID-19 pandemic, providers at Michigan Medicine have started a new approach to prenatal care — one that prior research indicates may be right for low risk pregnancies even after the pandemic ends.

"We have three key recommendations for patients receiving routine prenatal care: Limit clinic visits to those that require in-person services (like ultrasounds and lab tests); encourage virtual visits for care that can be done remotely; provide support to pregnant women creatively," says Michigan Medicine obstetrician, gynecologist and researcher Alex Peahl, M.D.

Specifically, because of COVID-19, in-person prenatal care at Michigan Medicine has now been reduced to an initial prenatal visit, an anatomy ultrasound, and the 28-, 36-, and 39-week visits. All labs will be conducted during these visits, rather than in a separate appointment as is sometimes done.

Additional prenatal visits will be conducted through telemedicine platforms such as e-visits or video visits. If the patient has home doppler devices, blood pressure cuffs and scales, the practitioners are asking them to use their equipment to monitor their pregnancy in conjunction with their virtual visits.

As always, the women are asked to call their providers if anything feels off or if they have questions.

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"I'm hearing a lot of panic and worry that women coming in for reduced in-person care is not a safe model," says Peahl. "I want our patients to know these models have been used in other top tier medical centers, and providers are achieving all of the recommended care, even with scaling back in-person visits."

For example, the revised schedule means that rather than being done in separate visits, the gestational diabetes screening and the Tdap vaccine can be given at one time, reducing patients' exposure.

Women with low risk pregnancies shouldn't worry about home monitoring, says Peahl. "I want to offer reassurance for women that this can be helpful but, for a low risk or uncomplicated pregnancy, it's not needed," she says.

"COVID-19 has prompted us to get creative in how we support pregnant patients. We are setting up online groups where patients can be peer mentors and share their lived experience," Peahl says. "This can be important not only during social distancing, but also outside of the pandemic for people who would like extra support."  The team is also working through creating additional resources for prenatal care, such as a program to get more women access to at home monitoring devices.

Pregnancy and COVID-19

Pregnant women should not have direct contact with individuals with COVID-19, or those suspected to have it, according to current guidelines from the United States Centers for Disease Control and Prevention.

Right now, the CDC is not recommending specific measures for pregnant women beyond the infection prevention strategies recommended for everyone: hand washing, social distancing, avoiding crowds and working from home if possible. Pregnant health care workers can still go to work, but should not treat patients who have the virus.

"Data are so far reassuring that pregnant women are not more susceptible to infection, and don't get sicker," Peahl says. "Still, infection control is the biggest priority."

Changing staffing models

To help protect providers, Michigan Medicine has intentionally divided OB-GYN teams into inpatient and outpatient cohorts to minimize exposure of COVID-19 during the pandemic. Peahl, for example, is focused on outpatient care at this time.

She says it remains the top priority of provider teams to give each woman her desired birth experience.

"Overall, we are doing everything we can to meet patients' preferences and values during their birth experience, and the pandemic does not change our approach to routine birth in any way," says Peahl.

To help protect all involved, anyone entering the hospital is screened for symptoms. All surfaces are thoroughly cleaned and, at this time, only one support person is allowed in delivery rooms at Von Voigtlander Women's Hospital.

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Ongoing research on prenatal care

Peahl says these new recommendations are in line with her research on prenatal care over the past two years. Peer countries to the U.S. ask pregnant women to come into their provider's office much less often without any harm to the pregnancy. Research on this approach from other academic medical centers has found positive outcomes.

In the U.S. today, women are asked to spend about 40 hours at prenatal appointments throughout a pregnancy – that's significant time away from work and family life, Peahl says. Making access to high-quality care faster and more convenient could benefit many patients.

"We surveyed patients at Michigan Medicine and found that two-thirds of our patients wanted a reduced visit schedule," says Peahl. "They are also requesting more support in between visits, so what we are delivering is what our patients are requesting."

Although COVID-19 is a stressful time to be pregnant, Peahl notes it's also an opportunity for providers. "We have an opportunity to have a uniquely unified approach to low risk prenatal care," says Peahl, "rather than asking each individual provider to decide the approach for their patients."

Contributors to Michigan Medicine's evolving model of prenatal care include experts in maternal fetal medicine, midwifery, telemedicine and virtual care, members of the University of Michigan Center for Healthcare Engineering & Patient Safety (CHEPS) and more.