RPM Could Be the Key to Reducing Disparities in Maternal and Infant Care-The HSB Blog 11/1/21

Our Take:

Digital health solutions like remote patient monitoring devices are developing broad-based solutions for maternal-child health disparities by addressing both social determinants of health and clinical gaps. Close monitoring after delivery is life-saving for mothers because almost 50% of maternal morbidity and death happens after delivery. In addition, following the pandemic, healthcare providers have adopted remote patient monitoring devices for prenatal and postpartum care as a necessary precaution for keeping pregnant mothers and newborns away from exposure to illness and preventing the spread of the COVID virus.

Key Takeaways:

Preterm birth and its complications are the second largest contributor to infant death in the U.S. and preterm birth rates have been increasing for five years.
According to the March of Dimes 2020 Report, 7M women of childbearing age live in maternity care deserts and 50% of U.S. counties lack a single obstetrician.
Medicaid covers 42% of all births and is the largest payer for maternity care in the US.
Association of Maternal and Child Health Programs was awarded $4 million to promote telehealth services, remote pregnancy monitoring, and delivering trauma-informed perinatal and behavioral health care.

The Problem:

The United States has the worst maternal mortality rate of any developed country especially when one considers the amount the U.S. spends on per capita care. About 900 women die each year during pregnancy or delivery, or within a year of delivery-related causes, and the preterm birth rate among Black women is 50% higher than the rate among all other women. According to the Commonwealth Fund, the maternal death ratio for Black women (37.1 per 100,000 pregnancies) is 2.5 times the ratio for white women (14.7) and three times the ratio for Hispanic women (11.8). In addition, mothers in rural communities equally have challenges in accessing quality maternal healthcare services due to hospital closures, workforce shortages, and social determinants of health gaps. Certain counties are referred to as maternity care deserts because maternity healthcare services are either limited or absent. According to the March of Dimes 2020 Report, 7 million women of childbearing age live in so-called “maternity care deserts” (defined as communities where access to maternity health care services is limited or absent).

A number of factors all contribute to the divide in maternal health, these include racial distrust of the healthcare system and healthcare information, poor access to healthcare information, a shortage of healthcare providers for maternal and child care, particularly those with similar racial and ethnic backgrounds. For example, according to Healthcare IT News, over one-third of women reported that they don't make it to all of their prenatal visits and about 50% of U.S. counties lack a single obstetrician or gynecologist. This is of particular concern given the American College of Obstetrics and Gynecologists (ACOG) recommends an average of 12-14 prenatal care appointments, and that is for women with low-risk pregnancies. Moreover, women in underserved communities often have to make tradeoffs such as unpaid time away from work, caring for loved ones, or lack of transportation, all of which increase the cost and inconvenience of being able to make an appointment. The inability to keep scheduled appointments could lead to complications and possibly easily preventable deaths.

In addition, Medicaid is the largest payer for maternity care in the United States and as a result a key player in ensuring quality maternal and perinatal healthcare coverage. Medicaid and its reimbursement policies have a significant impact on current maternal care protocols as well as enhancing maternal and perinatal health outcomes. Not surprisingly, as the public health program for people with low incomes, women in Medicaid, are reported to have a higher rate of births reported as low birth weight compared to women that are privately insured. While remote patient monitoring and other digital tools hold great potential in improving access to coverage and care they have not been broadly adopted. For example, prior to the pandemic, only 21 States permitted Medicaid reimbursement for remote patient monitoring, and since the onset of the pandemic, only 8 more states have included reimbursement for remote patient monitoring in their Medicaid programs.

The Backdrop:

Digital health solutions for maternal and child care whose adoption was spurred on by COVID have improved access to timely care for mothers in diverse communities by allowing healthcare providers to meet mothers where they are. Since COVID would expose mothers to potential disease it made it difficult for pregnant mothers to comply with appointments and needed care. This lead to a significant increase in telehealth and remote patient monitoring for delivering maternal and child care. According to BMC Pregnancy and Childbirth, 36% of women reported using telemedicine for prenatal appointments during the pandemic, and 71% of new and expectant mothers reported being worried about exposure to COVID from in-person prenatal visits.

Remote patient monitoring is likely to remain a significant factor in prenatal and maternal care following the pandemic. For example, in May 2020 the U.S. Department of Health and Human Services awarded $4 million to the Association of Maternal and Child Health Programs especially to promote telehealth services, remote pregnancy monitoring, and delivering trauma-informed perinatal and behavioral health care. In addition, in November 2020 The Connected Maternal Online Mothering Services (MOM) Act was introduced in the U.S. Senate to establish Medicare and Medicaid coverage for telehealth programs that monitor the health of expectant mothers (the bill has not yet passed).

Implications:

Remote patient monitoring as a healthcare delivery method has tremendous potential to be beneficial to providers, patients, and healthcare systems. Among other things, it could improve access to care, help generate additional data, improve patient, provider communication, reduce cost, and empower patients' in the management of their own care.

Health information generated from using remote patient monitoring devices may help reduce pregnancy-related deaths by improving prenatal care and addressing some of the causes of maternal mortality. Preeclampsia and eclampsia, which is the most common cause of maternal mortality, have been successfully prevented by using the records from remote monitoring devices for postpartum hypertension surveillance. A 2019 study evaluating postpartum text-based remote blood pressure monitoring found that texting was a potentially innovative way of reducing disparities in accessing postpartum care.

Premature babies and babies that have a low Apgar test score (typically performed on a baby at 1 and 5 minutes after birth and indicates how well the baby tolerated the birthing process (the 1-minute test) and how well the baby is doing outside the mother's womb (the 5-minute test) may indicate that the babies require around the clock care. Some studies have shown that these babies can benefit from remote patient monitoring devices that allow health providers to monitor them from the comfort of their homes. At the UVA Children's Hospital, they found that babies did much better in the home environment. Thus, after consultation with the doctor, babies were monitored from home with an iPad, NG tube, a scale, and other devices, and the data collected was stored in the UVA’s Epic EHR.

By generating digital touchpoints remote patient monitoring facilitates a quicker transition of care outside the hospital in addition to reducing the number of in-person maternal care visits. For example, Babyscripts is one of a number of virtual maternal care platforms that combine a mobile app and remote patient monitoring devices to create solutions to address both user and provider gaps. Its remote patient monitoring device has helped reduce prenatal in-person visits schedules and generated digital touchpoints in real-time that generated more data than is usually captured in the hospital. When the data points are unusual the trigger system alerts the provider to respond in a timely manner or alter care plans as needed to avert avoidable complications. Babyscripts services also extend to providers of prenatal or postpartum care to support care coordination and reimbursement. This exemplifies the rounded approach of digital health solutions with remote patient monitoring components and its impact on improving healthcare efficiency care. Furthermore, it enables shorter in-patient stays and avoidable emergency department (ED) utilization which reduces the cost of inpatient services.

Remote patient monitoring has the potential to address health disparities and barriers to care by ensuring that women in underserved communities get access to routine check-ups and prenatal visits thereby improving quality and outcomes. The sustainability of remote patient monitoring for maternal and prenatal care will depend to a large extent on the continuity of policies adopted during the public health emergency which increased use and the amount of reimbursement for remote care. Should these be adopted we believe they will show a substantial return on investment as well as declines in maternal and infant mortality.

Related Readings:

Telemedicine for Prenatal Care: A Systematic Review
Telehealth Offers Relief for Prenatal Care and Newborn Health
Medicaid Coverage of Pregnancy Care Delivered via Telehealth
Maternal Telehealth Has Expanded Dramatically During the COVID-19 Pandemic
Improving Perinatal Care in the Rural Regions Worldwide by Wireless Enabled Antepartum Fetal Monitoring: A Demonstration Project