By Rebecca H. Allen, MD, MPH, Editor

SYNOPSIS: In this nested case-control study in the Boston area, there was no association between testing positive for COVID-19 during pregnancy or on admission to labor and delivery and the number of in-person prenatal care visits.

SOURCE: Reale SC, Fields KG, Lumbreras-Marquez MI, et al. Association between number of in-person health care visits and SARS-CoV-2 infection in obstetrical patients. JAMA 2020; Aug. 14. doi: 10.1001/jama.2020.15242. [Online ahead of print].

When the COVID-19 pandemic began in the United States, there was little evidence to guide prenatal care providers on how to continue to provide necessary obstetric care. Some providers opted to space out prenatal care visits and use telehealth; some did not. A concern that resulted during and after the quarantine was that patients did not seek and are still not seeking necessary medical attention because of fear of contracting COVID-19 in outpatient offices, emergency departments, and hospitals. The authors of this study wanted to examine the association between office visits and the risk of SARS-CoV-2 infection in the obstetric population, since this is a group of patients who require frequent visits.

The study population included all women delivering at four hospitals in Boston between April 19 and June 27, 2020. During this time period, all obstetrical patients were tested for COVID-19 using nasopharyngeal swabs on admission to labor and delivery. Cases were patients who tested positive during this time period either during pregnancy or on admission to labor and delivery. Cases were matched with up to five control patients on gestational age, race/ethnicity, insurance type, and SARS-CoV-2 infection rate in the patient’s ZIP code. The electronic medical record was queried to determine the number of in-person visits from March 10, 2020, (two weeks prior to the closure of nonessential businesses in Massachusetts) to the date of the SARs-CoV-2 infection diagnosis. The association between the number of in-person visits and the odds of infection was assessed, controlling for age, body mass index, and essential worker occupation.

During the study time period, 2,968 patients delivered and 111 (3.7%) tested positive for COVID-19. Of these patients, 45 tested positive antenatally and 66 tested positive on admission to labor and delivery. After excluding patients who lived outside of Massachusetts and those who had missing data, 93 cases were matched with 372 controls. The mean number of in-person visits was 3.1 (standard deviation [SD], 2.2) for cases and 3.3 (SD, 2.3) for controls. The odds ratio was 0.93 (95% confidence interval, 0.80-1.08) for the association between in-person visits and a positive coronavirus diagnosis. Results were similar when excluding patients who had a household member with a known SARS-CoV-2 infection.

COMMENTARY

Reassuringly, this study found no association between the number of in-person prenatal care visits and the risk of COVID-19 infection. At the time, Massachusetts was affected greatly by the coronavirus pandemic, with Boston being a hotspot. The American College of Obstetricians and Gynecologists (ACOG) provided guidance to its members on how to conduct prenatal care during the pandemic. This guidance included the following:¹

• Spacing out appointments;
• Choosing to continue in-person prenatal care appointments for patients who are not sick, if staffing is available, but spacing out in-person appointment times where appropriate to reduce the number of patients in the office or facility at one time;
• Postponing some nonemergent gynecologic or well-woman appointments to facilitate social distancing and to maintain availability to accommodate medically necessary appointments (but not postponing appointments for which a delay will negatively affect patient health and safety);
• Alternating or reducing prenatal care schedules;
• Grouping components of care together (e.g., vaccinations, glucose screenings, etc.) to reduce the number of in-person visits;
• Conducting telehealth appointments.

Notably, ACOG emphasizes that these decisions need to be made at the local level, considering the risk of coronavirus transmission in the community at the time. Nevertheless, based on this study, ACOG has updated its guidance to say, “Emerging evidence suggests that with the appropriate precautions, in-person obstetric healthcare can be safely performed and is not likely to be an important risk factor for infection.”¹

Certainly, with appropriate precautions, in-person medical visits can be continued. There are many aspects of prenatal care that should not be delayed and need an in-person visit. On the other hand, many providers who began to implement prenatal care visits by telehealth were satisfied with the experience as long as they had the appropriate administrative, staff, and computer support.² At one New York City hospital, from March 9 to April 12, 2020, approximately one-third of prenatal care visits were conducted via telehealth. Patient barriers to telehealth, especially using video technology, were noted, such as the need for continuous WiFi connection and home monitoring devices as well as the technology being cumbersome when interpreters were needed.

In general, the COVID-19 pandemic has provided an opportunity to revisit the concept of prenatal care. There have been several calls to revise the frequency of prenatal care visits from the current 12 to 14 individual patient visits to a more flexible schedule of eight to nine visits.³ Furthermore, some advocate for models that include telemedicine routinely, not just during a pandemic. It is unclear, however, if payment models would support these changes and whether telemedicine reimbursement will continue after the pandemic. The delivery of prenatal care does have value, but likely can be individualized to a particular patient’s needs to make the system more efficient for the provider, patient, and healthcare system overall. Although my practice in Rhode Island did space out prenatal care visits during the height of the COVID-19 pandemic and employed limited telemedicine (telephone only), we are now back to routine practice as rates of infection have subsided.

REFERENCES

1. The American College of Obstetricians and Gynecologists. COVID-19 FAQs for obstetrician-gynecologists, obstetrics. https://www.acog.org/clinical-information/physician-faqs/covid-19-faqs-for-ob-gyns-obstetrics
2. Madden N, Emeruwa UN, Friedman AM, et al. Telehealth uptake into prenatal care and provider attitudes during the COVID-19 pandemic in New York City: A quantitative and qualitative analysis. Am J Perinatol 2020;37:1005-1014.
3. Peahl AF, Gourevitch RA, Luo EM, et al. Right-sizing prenatal care to meet patients’ needs and improve maternity care value. Obstet Gynecol 2020;135:1027-1037.