Telehealth Systems for Midwifery Care Management during the COVID-19 Pandemic: A Systematic Review

Abstract
Background: Intrinsic features of COVID-19 disease, including the severity of the virus transmission and mortality rates, make it difficult to provide obstetric care to pregnant women. In this regard, telemedicine can provide comprehensive midwifery care relying on new technologies, such as virtual clinic, telehealth, tele-monitoring, m-Health, wearable sensors, and the internet of medical things. The objective of this study is to identify the application and requirements of a telehealth system for midwifery care.
Methods: We conducted a literature search from 2019/12/1 to 2022/10/1 using the following electronic scientific databases: Web of Science, Scopus, PubMed, Science Direct, and Google Scholar. We carried out hand searches from the reference lists of retrieved studies of journals.
Results: We showed that, during COVID-19 pandemic, prenatal care via telehealth increased and telehealth is a good strategy for prenatal and post-partum disease managements. Mental health services are also feasible via telehealth. These new technologies also reduce the risks associated with interpersonal contacts in COVID-19 pandemic.
Conclusion: With the COVID-19 pandemic, telehealth became the norm. The future of medical services will be built around this technology and that is a great opportunity to move toward a great evolution.
Keywords: COVID-19, m-Health, Midwifery care, Pregnancy, Telehealth, Telemonitoring, Virtual clinic
    

Introduction 
COVID-19 pandemic with more than 235 million confirmed positive cases and 4.8 million deaths since the after emergence has put a lot of pressure on the health systems globally (1-3). The increasing burden of infection and the high mortality and morbidity rate has caused health systems to combat it. In the affected countries, national health services are partially close to collapse (1,4,5). The COVID-19 pandemic has had direct and indirect effects on health service provision in all parts of the health system, including reproductive health services, such as maternity care (6). Coronavirus infection and its complications in mothers directly affected health services by increasing the need for special care in the obstetrics ward. Fear, stigma, quarantine, and socioeconomic factors indirectly affected the access to essential health services (7-9).
All pregnant women and newborns should receive high quality healthcare throughout the pregnancy, childbirth, and the postnatal period (10). Recently, around 303,000 women and youngster girls died as a result of pregnancy and childbirth-related problems. Approximately, 99% of maternal deaths occur in restricted-resource organizations and most can be prevented. In the same way, around 2.6 million babies were stillborn, mainly in low-resource settings (11). 
Telehealth, as delivering remote medical services can be used by healthcare providers via technology to communication, education, diagnosis, treatment, through virtual visits in the COVID-19 pandemic (12). Moreover, portable devices such as pulse oximeters, glucometers, portable cardiotocography (CTG), and sphygmomanometers are implemented to monitor mother and fetus wellbeing (13,14). Since telehealth formerly had been proposed as a means to overcome difficulties related to medical care provision (13,15), it may be utilized by medical professionals as a means of maintaining patients’ access to care in the setting of COVID-19 during social isolation (16).
Telehealth has been supported by health care organizations due to the potential to reduce costs and improve access to intensive care (17). In the field of obstetrics and gynecology, Telemedicine also has been used to report ultrasounds and interpretation of tests, patient counseling and tele-consultation, diabetes management, postpartum depression management, and support for postpartum parents and children (18). 
Several studies have been done in the field of telehealth system in pregnancy care (19-21). However, no study was found to identify the requirements of a comprehensive telehealth system for midwifery care. Alves et al, in a related study aimed to identify advances, contributions and limitations of obstetric tele-monitoring using mobile technologies (22). In another study, Daly et al determined the effects of using mobile app interventions, during pregnancy, on healthy maternal behaviors and improving prenatal health outcomes (23,24). The use of different technologies in the provision of midwifery services and care needs to be investigated. Finding their strengths, weaknesses, characteristics, and requirements will help improve their quality in the future. The COVID-19 pandemic has presented an opportunity for the use of telehealth. This is the best opportunity to analyze the use of these technologies in the provision of midwifery services and care, and to review and revise them and fix their flaws for future versions to provide quality services to improve the health of mothers and babies. In this review, we aimed to identify the common requirements, capabilities and requirements of a telehealth system for midwifery care in the COVID-19 pandemic era.

Materials and Methods
We conducted a literature search from 2019/12/1 to 2022/10/1 using the following electronic scientific databases: Web of Science, Scopus, PubMed, Science Direct, and Google Scholar. We carried out hand searches from the reference lists of retrieved studies of journals.

Search strategy
The detailed search strategies were carried out by the first and correspondence authors with input from all authors and complementary a skilled research librarian. A comprehensive search using keywords headings and all fields for each database was carried out. Search subject headings included the following: COVID 19, SARS-CoV-2 prenatal, pregnancy, telemedicine, telehealth, m-health, and virtual clinic. 
The search strategy is shown as follows:
A: COVID-19 OR “coronavirus” OR coronavirus ORSARS-CoV-2 OR COVID
B: Tele-health OR tele-care OR tele-monitoring OR m-health OR “virtual clinic” OR e-Health OR “virtual visit” OR telemedicine OR tele-homecare OR tele-consultation OR tele-education
C: Prenatal OR pregnancy OR gestation OR childbirth OR postpartum OR midwifery OR antenatal OR parturition
D: [A] AND [B] AND [C] (search strategy of PubMed database mention in appendix 1)

Eligibility criteria
Articles retrieved from above-mentioned databases should meet the following eligibility criteria to be included in this study.
Having a care of prenatal, delivery, postpartum and other midwifery care
The studies examining tele-monitoring or the use of telemedicine for the management of midwifery care
The studies reporting a system or application for telemedicine of midwifery care
Peer-reviewed publications and articles whose full text is available
The studies published from the beginning of the COVID-19 to August 2021
The excluded criteria were as the following: 
Other formats of articles including editorials 
Abstract papers, conference abstracts, and articles without accessible full texts
Non-English language.

Data retrieval
The EndNote software was used to organize the identified studies in the literature review. Search outcome from the databases were combined in a single EndNote library and duplicate articles were removed.

Data screening
First and correspondence authors screened the titles and abstracts of the retrieved articles to find out if they meet inclusion and exclusion criteria of the selected studies. 

Data extraction
In this study, data extraction title included: study design, study title, year of publication, country, study object, requirements, and usages. After selecting the studies, two of the authors extracted data from the articles using standard forms. For this purpose, a standard form was designed to extract the data required for quality assessment and synthesis of evidence, and summary tables were completed. The full text of the articles was read by three authors. Each author thoroughly reviewed the summary tables for relevance and accuracy. Any disagreement between these authors was resolved by the fourth author. The data was entered into the Review Manager software and checked for accuracy. 

Quality assessment
The quality and relevance of the articles were reviewed by three independent and experienced authors. Any differences in judgment were reviewed by the fourth author to reach a consensus.

Results
In this study, 369 articles were retrieved using a methodical search strategy from scientific databases. After a preliminary review of the retrieved articles, 128 duplicates were removed, and the title and abstract of the remaining 241 resources were reviewed. After applying the selection criteria, 203 articles were excluded, and only 17 articles met the inclusion criteria and were included in the final review (Figure 1).
Of the 17 studies on Telehealth, 8 were from the US, 3 from Australia, and the remaining 6 studies were from China, Canada, Poland, Indonesia, N/A, and Sri Lanka. Three studies were conducted by Interventional method (Clinical trial), 2 studies by qualitative and other studies by observational methods, such as time series, cross-sectional study, retrospective cohort study, case report, A Pilot Study Cross sectional and review.
Study population was pregnant or postpartum women in all studies except 2 studies from Indonesia & USA in which study populations were midwives and healthcare providers, respectively.
Studies reported that virtual video visits were used as a tele-visit in 11 studies, telephone in 10, and web-based programs and applications in 10 studies. These technologies provided remote monitoring of patients and fetus in pregnant women, encouraged patients to make antenatal care visits in timely manner, and helped the patients to monitor serum glucose and blood pressure to manage their weight, diet, physical activity, and improve their life style. 
As mentioned in table 1, these remote services require some facilities including high-speed internet access, tablets, smart phones, and special equipment such as blood pressure measuring devices.
Most of the studies reported that virtual video visits are used as a tele-visit. Others reported telephone, web-based programs and applications. These technologies provided remote monitoring of patients and also fetus, encouraged patients to make antenatal care visits in a timely manner, and improved the lifestyle and pregnancy outcomes. During the COVID-19 pandemic, prenatal care via telehealth increased. This strategy leads to decreases in the morbidity, mortality and hospital admissions. These new technologies also reduced the risks associated with interpersonal contacts in COVID-19 pandemic.

Table 1. Identified features of tele-health systems for midwifery care in the pandemic COVID19

Discussion
In this study, we summarized available data from 13 articles on telehealth systems and midwifery care. The majority of articles were about tele-visits via applications while other studies reported cost and benefits of tele-visits through video calls. Reviewing these articles revealed that high-speed internet is the main requirement for these visits. Zork et al in a related study reported that tele-visits’ prenatal care in the USA, reduce inpatients encounter and reduce risks associated with repeated exposures. They also found that computers, smart phones, tablets, high-speed internet access, and information technology support patients’ needs to purchase special equipment. Staff trainings are also required (25).
Study of Zhu et al showed that prenatal visits and remote monitoring by tele-visits causes presentation of health education also for fetal development monitoring and offering pregnant women good guidance and improve the health outcomes of mother and infant. By tele-visits proportion of scar uterus, hepatitis B virus carrier, maternal mortality and prenatal neonatal mortality decreased in the telemedicine group (26). 
These tele-visits need high internet access, through which you have the opportunity of talking to health care provider, discussing the problems and receiving advice for the following weeks. This kind of tele-visit through video calls seems more cost effective than other types of tele-health monitoring methods, since it only needs an access to high-speed internet and a mobile phone. Another advantage is that no special education is needed for making video calls. Slomski et al reported that the lifestyle intervention for pregnant women through this intervention, strategies for improving weight, diet, physical activity, and stress management were provided. As a result of these sessions, changes were made to improve total calorie intake, reduce sedentary behaviors and insulin resistance markers, and lose weight (27). In a similar study, Palmer et al, pointed that the automated blood pressure monitors is essential to promote healthcare of antenatal, intrapartum, and  postpartum (28). The method which is studied by Slomski’s team was done through telephone sessions; nowadays, everyone has a mobile phone and access to telephones. This has made this intervention so easy and feasible. But the participants should have the compliance of following the intervention advice to improve their lifestyle and gain the expected results. Anyone who follows the instructions can take advantages of improving insulin resistance, expecting the acceptable weight and a normal pregnancy period and delivery with a lower risk of complications. The greatest advantage of these methods is that they decrease the individual contacts, in-person visits and risk of COVID-19 infection during the pandemic.
Huang et al studied women between 8- and 11-week gestation in Australia. They reported that tele-monitoring promotes healthy lifestyle and prevent excess weight gain in early pregnancy. By utilizing the web-based programs, lifestyle intervention in the first-trimester of pregnancy is feasible (29). Jakubowski et al also studied pregnant women in Poland who utilized web-based programs to have access to fasting glucose tests and screening procedures during pregnancy. They suggested that the risks associated with movement and interpersonal contact reduced and patients can arrange some appointments in the form of telehealth (14). The web-based applications are other techniques which were used during pandemic. Although these applications are at hand, they need minimum education and learning, thus the applicants can use it properly. 
Study of Hoppe al. demonstrated that remote blood pressure monitoring could be performed through telehealth. Patients must have some special medical devices, including blood pressure cuff, and oxygen sensor besides smart phones and tablets (30). To achieve the best results, it should be a pre-education for the patients who want to use these medical instruments. They should have some sessions to practice how to use these devices in order to reduce the errors and the measurements (e.g., blood pressure) become more accurate.Their results indicated that tele-health is a promising strategy for postpartum hypertension management to decrease maternal morbidity and hospital readmission. The above-mentioned studies represent that tele-health could be an effective strategy to reduce the risks of pregnancy in patients who have access to technologies and facilities including high speed internet, electronic devices, and medical equipment. Study of Madden et al in the US showed that, up to two-thirds of visits performed via tele-health for genetic counseling appointments and over the study period, the proportion of tele-health visits also increased significantly. This means that tele-health became more popular among the patients and healthcare providers (31). Lackie et al, described the effective implementation of web-based programs and intervention in maternal care (32).

Conclusion
It can be concluded that where telehealth is available to patients, prenatal care visits via tele-visits increased, prenatal morbidity and mortality decreased and better prenatal and postpartum care was achieved. With the pandemic of COVID-19, telehealth becomes the norm and telemedicine will have a great revolution in the future. It is improved and many new techniques and models of health care will be innovated. Considering that the future of medical services will move towards new technologies and it will be a great opportunity to a great evolution, therefore, physicians, healthcare providers and patients should adopt with these changes.

Acknowledgements
The present study was extracted from the research project  with  code  HYPERLINK “http://ethics.research.ac.ir/ IR.ESFARAYENUMS.REC.1398.015”IR.ESFARAYENUMS.REC.1398.015 entitled “Tele-monitoring and telehealth systems in prenatal care” conducted at Esfarayen University of Medical Sciences in 2021. We thank the statistical population and all the participants for taking the time to contribute to the study.