After the Pandemic: Removing Structural Barriers to Ob/Gyn Care

For MedPage Today‘s “After the Pandemic” series, we asked our editorial board members to discuss what significant and lasting effects the COVID-19 pandemic will have on medicine and the delivery of healthcare.

Here, we interview Loralei Thornburg, MD, a maternal-fetal medicine specialist at the University of Rochester Medical Center in Rochester, New York.

Check out some of our other articles in the series here.

This interview has been lightly edited for clarity and brevity.

Can you share a story about a patient you saw whose situation was influenced by the pandemic? What was the outcome?

Thornburg: One of the biggest issues that I have seen was in my patients who had to work, and had work that had to be done outside the home by either themselves or their partners. I have seen several pregnant people with COVID-19 who either contracted it as frontline workers, or because their children or partners were frontline workers, who then had complications, early deliveries, or hospitalizations.

I have also seen several people deliver with COVID-19, and then not be able to visit their infant in the NICU [neonatal intensive care unit] for 14 days because of quarantine. It was really hard to watch them struggle with this separation and wanting to be with their infants.

We know that COVID-19 has posed unique risks for pregnant and lactating women. Do you foresee risks for infants who were exposed to COVID-19 in utero?

Thornburg: We know from the current literature available that there appears to be very low risk [probably about 2%] of vertical transmission in the womb. It is possible to transmit through infant care in the newborn period when the parent has active COVID-19. However, there are data stating that the breast milk of people who were infected with COVID-19 or vaccinated for COVID-19 contains antibodies. This appears to be the same for both the Pfizer and Moderna vaccines.

Antibodies in the breast milk have been shown to protect infants against infections, so it is hopeful that they will for COVID-19 too. We don’t know of any specific risks to infants exposed to COVID-19 in the womb, but we do know that pregnant people are more likely to be severely ill. Sometimes this can mean that delivery will be needed to protect both the pregnant person and their infant, even if it means a premature birth.

There have been some reports that the pandemic may be associated with a decrease in adverse birth outcomes, such as preterm delivery. How do you think the conditions of lockdowns, remote work, and physical distancing may have impacted pregnant people? Are there opportunities to change how we provide prenatal care based on what we’ve learned from the pandemic?

Thornburg: That has been interesting data to see come out. It suggests what I think many people suspected for a long time, that rest and avoiding illness are likely beneficial to all pregnant people to prevent complications. However, we must strongly temper that with the knowledge that this most likely benefited those who did not have financial pressures when out of work or were able to work remotely.

Essential workers and service workers were not able to benefit from these remote work conditions, or more protected conditions, and were more likely to be low-income and non-white people. As BIPOC [Black, Indigenous, and people of color] people are more likely to have pregnancy complications, and more likely to have preterm — especially very premature — births, this further widens the inequity in outcomes for these populations.

How are you thinking about providing mental health support to pregnant and lactating women after the pandemic?

Thornburg: Mental health concerns are expanding for everyone during this pandemic. The pressures of work changes, work from home, layoffs, and school changes are also consistently putting pressures on families. We have been working with a variety of community organizations, and are lucky to have psychiatric services right in our offices that are specifically focused on the needs of the ob/gyn patient.

However, there is an extensive need for more services in mental health care across this country. We have not yet seen the full impact of the global COVID-19 disruption on the mental health of families and pregnant people, and more support is going to be needed as our economies reopen.

Do you think telehealth will continue as a mode of care for pregnant people? Where is it most useful?

Thornburg: I definitely see telehealth for care delivery continuing, and potentially increasing now that we have that option. There were a lot of insurance barriers to telehealth before the pandemic, but the ability to provide it has been a welcome addition to our care options nationwide.

For specialties like mine where we primarily discuss medical concerns in pregnancy, being able to use telemedicine to help people access specialty care from far out in the community has been key to getting care into low-resource or more rural areas. We have been able to “see” patients from hours away by telemedicine — increasing their ability to access specialist care in a timely fashion, while avoiding a lengthy car trip and associated costs and time away from work/family.

Even for patients for whom distance isn’t a challenge, many essential workers have off-shift or structured work schedules that do not allow them to attend in-person visits easily without losing a work day. Telemedicine visits provide a way to allow people to access medical care during a break or lunch. For those patients who need follow-up after delivery or a surgery, telemedicine has been shown to help postoperative patients avoid unnecessary trips to the hospital — a key benefit to a new parent at home after a delivery or a patient recovering from surgery.

For obstetrical patients, data suggest that audio-only telemedicine visits for routine pregnancy care were not associated with changes in perinatal outcomes, and actually led to increased prenatal care attendance. Other data suggest that perinatal outcomes improved with telehealth interventions, including better access to perinatal smoking cessation services, breastfeeding services, and ability to complete prenatal care.

However, for times that in-person care is needed, with the safety guidelines that have been put in place for many offices, there are clear data that in-person care does not increase the risk of COVID-19 infection for pregnant people, so pregnant people should feel safe visiting their doctor when necessary.

In the coming years, I predict that at-home health devices and testing, as well as the expansion of internet services, will help more care be delivered at home. I am hopeful this will remove many of the barriers that BIPOC pregnant people face when interacting with the healthcare system. To make that a reality, we must realize that there are both urban and rural communities with limited computer and internet access, which must also be addressed.

We know that there has been a sharp decline in cervical cancer screenings during the pandemic. What are some strategies to recover these missed screenings?

Thornburg: The data suggest that many people are putting off care during the COVID-19 pandemic. Many women have put off annual care, with an over 80% decrease in cervical cancer screenings in the Kaiser Permanente Southern California network over the course of the pandemic. These sustained decreases could result in increased rates of cervical cancers and pre-cancers as we make up missed screenings.

In order to address these issues, it is going to be critical that health systems prioritize reopening access to those patients at the highest risk, including those with prior high-risk screenings and those who experienced longest delays. It is possible that self-collected samples that are done at home for some patients may also help us catch up with the backlog, and they have been shown to have excellent sensitivity and specificity in studies. These are potentially a great option for patients who cannot get to a physician due to other barriers, as well as those for whom the exam itself is a barrier to care.

Even if you have put off screenings, keep in mind that not all patients need a Pap smear every year; most patients that do not have a history of abnormal testing only need a test every 3 years. Also, human papillomavirus [HPV] vaccination is probably the best way to prevent cervical cancer if you are eligible. Regardless, keeping up routine medical care is important, so making an appointment to “catch up” with important screenings, such as Pap tests, mammograms, and bone density tests, is a good idea.