The Impact of COVID-19 Telehealth Flexibilities on Maternity Care

September 02, 2020

According to CDC, pregnant women with COVID-19 are more likely to experience adverse health outcomes than nonpregnant women. In particular, Black and Hispanic pregnant women are experiencing higher rates of COVID-19 compared to White women. Due to the increased risk factors, pregnant women are encouraged to take precautionary measures to prevent COVID-19, including physical distancing. Pregnant women should also receive appropriate care before, during, and after pregnancy.

Telehealth may provide a solution for maintaining continuity of care while practicing physical distancing. COVID-19 has prompted new temporary telehealth flexibilities, expanding access to care through virtual means. These new flexibilities provide an opportunity to expand access to pregnancy and childbirth services and may help to mitigate adverse health outcomes for pregnant women.

Expanded Access to Maternity Care Providers Via Telehealth

Doula services can significantly impact the health and wellbeing of both pregnant people and their infants by lowering C-section rates and reducing birth complications. Community doula programs provide physical, informational, and emotional support that improve clinical experiences for marginalized communities and yield positive health outcomes for mothers and infants, while also reducing maternity healthcare costs for states. However, the shift in hospital policies due to COVID-19 has limited or shut out doula services from the delivery room. Visitation rules are more restrictive, forcing doula programs to rework how they engage with clients. Many people have been opting for midwifery care as the home becomes a preferred option for prenatal, childbirth, and postpartum services due to COVID-19.

Recent state and federal telehealth flexibilities prompted by COVID-19 have expanded access to doulas and midwives. Temporary federal policies allow primary care providers who deliver care to pregnant women—such as nurse practitioners, physician assistants, and providers in federally qualified health centers—to provide telehealth services. Although Medicaid coverage of doulas is limited, several states have recently accelerated efforts to reimburse for doula services. Some jurisdictions are now allowing Medicaid-enrolled doulas to provide virtual services for pregnant and postpartum people, primarily through telephonic services and live-video interactions.

State and Federal Guidance on Virtual Maternity Care

States and federal agencies are releasing guidance and training for the maternal and child health workforce on telehealth to deliver accessible, affordable, and culturally competent virtual care to underserved communities:

• The HRSA Maternal and Child Health Bureau awarded $15 million of funding through the CARES Act to increase telehealth access and infrastructure for maternal and child health providers and marginalized families, including virtual doula care and remote pregnancy monitoring.
• Rhode Island and Massachusetts introduced legislation to cover both in-person and virtual doula support services in Medicaid.
• New Hampshire introduced legislation to ensure reimbursement parity, expand site of service, and enable nurse midwives to provide services through telehealth for Medicaid and commercial health coverage.
• Alaska expanded coverage through Medicaid to allow for direct entry midwives to deliver telephonic and digital services during the public health emergency.
• New York state released guidance to empower and educate doulas on how to shift in-person programs to virtual birth-doula and postpartum-doula services. The guidance provides doulas with recommendations on how to foster positive communication and build trust through virtual platforms. In particular, one community-based organization in New York provides a doula crash course for labor and delivery nurses on how to “elevate and honor communities of color.”
• The Healthy Mothers, Healthy Babies Coalition of Georgia released a toolkit to prepare doulas for virtual services with clients, outlining appropriate live-video platforms for mobile communication, such as FaceTime, Zoom, and WhatsApp.

Telehealth and Health Equity

Maternal morbidity and mortality rates continue to increase in the United States. Non-Hispanic Black women have higher rates of comorbidities and are three times more likely to die from pregnancy-related complications compared to their non-Hispanic White counterparts. Societal and structural conditions have widened gaps in socioeconomic inequality and access to quality healthcare for communities of color. COVID-19 continues to exacerbate these health disparities.

The expansion of telehealth services has the potential to reduce health disparities in maternity care, bridge cultural gaps, and improve health outcomes by increasing access to affordable services in the home. Doulas are often members of at-risk communities and offer a form of cultural alliance, advocacy, and emotional support for women impacted by racial biases experienced in the healthcare system. By utilizing text messaging and live-video platforms, doulas help clients communicate with their healthcare providers and maintain continuity of care during the postpartum period. Home-visiting offers culturally-relevant services for mothers and links families to resources and education. Positive outcomes have been reported for home visiting telehealth programs as states partner with Medicaid agencies to redesign home visiting programs and expand access to telehealth services for families and providers.

Looking Ahead and Considerations

To expand access to doula and midwifery care, states may consider allowing these providers to practice at the top of their scope and standardize licensure for doulas, which will allow them to be reimbursed by Medicaid and other insurers. To increase access to midwifery care in rural communities with fewer providers, states can look into providing interstate medical licensure compacts to streamline services across state lines and leverage telehealth to extend the reach of providers.

The expansion of telehealth services continues to increase access to quality care and community-based services for at-risk communities. Equipping doulas and midwives with telehealth access bolsters the maternity workforce and creates opportunities for more equitable solutions for underserved communities, which in turn improves health outcomes.