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Antenatal care is one of the most commonly accessed routine medical services in the world. Although considerable progress has been made to improve outcomes for pregnant women (eg, according to UNICEF the global maternal mortality rate declined by 38% between 2000 and 2017), complications of pregnancy and childbirth remain the leading cause of morbidity and mortality in women of reproductive age globally.1 In line with the UN Sustainable Development Goals, provision of high quality antenatal care is therefore essential for ensuring the safety of pregnant women and their offspring.2 Since 2017, WHO has recommended that antenatal care models include a minimum of eight contacts during pregnancy (double the previous recommended minimum of four visits), to reduce the risk of perinatal mortality, and to promote a positive pregnancy experience and increase satisfaction with care.3 The new recommendation is expected to increase the quality of antenatal care by leading to the detection of more maternal and fetal problems. The updated care model is also expected to increase the number of women who have a positive pregnancy experience since supportive care relationships take time to establish. WHO communicated a clear message about the importance of providing a positive pregnancy experience, emphasising that medical safety, if only measured in terms of maternal and perinatal morbidity and mortality, is not enough.

ave a positive pregnancy experience since supportive care relationships take time to establish. WHO communicated a clear message about the importance of providing a positive pregnancy experience, emphasising that medical safety, if only measured in terms of maternal and perinatal morbidity and mortality, is not enough. A small but growing body of evidence suggests that antenatal care models using integrated telehealth could be medically safe for women, including women with pre-existing medical conditions or those developing pregnancy-related complications.4, 5 Integrated telehealth in antenatal care reduces the number of physical visits, but maintains the number of contacts between the pregnant women and their care providers. Such an approach is ideal for use during epidemics6 since the risk of overcrowding in clinics will be reduced. In The Lancet, Kirsten Palmer and colleagues7 evaluated the effectiveness and safety of implementing integrated telehealth services in the delivery of antenatal care during the COVID-19 pandemic. The unexpected onset of the pandemic prompted the rapid adoption of telehealth for antenatal care services in a large health service in Melbourne, Australia. The authors did a population-based interrupted time-series analysis to assess the impact of telehealth integration into antenatal care. The first 3 months of telehealth integrated care (2292 births) were compared with conventional care delivered between January, 2018, and March, 2020 (20 031 births). The main pregnancy outcomes were defined as detection and outcomes of fetal growth restriction, pre-eclampsia, and gestational diabetes. The study concluded that telehealth integrated antenatal care reduced in-person consultations by 50% without compromising pregnancy outcomes. Compared with the conventional care period, during the integrated care period no significant differences were identified with regard to the number of babies with fetal growth restriction (birthweight below the third percentile; 2% vs 2%, p=0·72, for low-risk care models; 5% vs 5%, p=0·50 for high-risk care models), pregnancies complicated by pre-eclampsia (3% vs 3%, p=0·70; 9% vs 7%, p=0·15), or gestational diabetes (22% vs 22%, p= 0·89; 30% vs 26%, p=0·06).

mber of babies with fetal growth restriction (birthweight below the third percentile; 2% vs 2%, p=0·72, for low-risk care models; 5% vs 5%, p=0·50 for high-risk care models), pregnancies complicated by pre-eclampsia (3% vs 3%, p=0·70; 9% vs 7%, p=0·15), or gestational diabetes (22% vs 22%, p= 0·89; 30% vs 26%, p=0·06). The situation provided a unique research opportunity, since all women receiving antenatal care were included in the new integrated service and therefore the usual risk of selection bias in studies was avoided. Pregnant women, who would be less likely to agree to participate in a randomised controlled trial, were included in this study sample and thereby contributed to a generalisable study outcome. However, this rapid adoption of services also had considerable scientific limitations. The short time available before implementation did not allow for the normal rigorous planning of research design. Furthermore, the short 3-month study period following implementation of integrated antenatal care reduces the strength of the study conclusions since there is a possibility that differences in outcomes will change and develop further over time. Moreover, the initial significant increase in the number of appointments that women did not attend (1589 [8%] of 20 154 consultations in the integrated care period vs 8538 [5%] of 165 263 consultations in the conventional care period; p<0·001) requires further investigation. This increase in non-attendance is of concern since studies have shown that the health-related worries of pregnant women increased markedly at the beginning of the pandemic8 and that domestic violence has also increased during the pandemic, which can be considered a pandemic on its own.9 If the integrated telehealth model contributed to previously unidentified barriers to care, this could result in serious implications for the overall wellbeing of pregnant women.

beginning of the pandemic8 and that domestic violence has also increased during the pandemic, which can be considered a pandemic on its own.9 If the integrated telehealth model contributed to previously unidentified barriers to care, this could result in serious implications for the overall wellbeing of pregnant women. To determine whether integrated telehealth antenatal care models are safe, pregnancy must be considered as a physical, social, cultural, and emotional life event. The concept of safety must therefore be expanded beyond medical outcomes to also include positive pregnancy experiences. According to a scoping systematic review,10 a positive pregnancy experience involves “maintaining a healthy pregnancy for mother and baby”, but it also comprises “maintaining physical and sociocultural normality” during pregnancy; the “effective transition to positive labour and birth”; and “achieving positive motherhood” by building maternal self-esteem, competence, and autonomy. Pregnancy experience is seldom included as a primary outcome in intervention studies, and such evidence is not always reflected during the development of national or local guidelines in maternity care. Yet, the provision of care cannot be considered effective if the experience of care is poor.11 Therefore, studies such as that by Palmer and colleagues7 provide an important starting point, but their findings are not conclusive with regard to the safety and effectiveness of integrated antenatal care models. Data on the perspective of the public and health-care professionals are urgently needed, and should be carefully included in future study designs, rather than being included as an afterthought. An expanded concept of safety in antenatal care provision, which includes measurements of positive pregnancy experiences, is essential for the provision of high quality care.

-care professionals are urgently needed, and should be carefully included in future study designs, rather than being included as an afterthought. An expanded concept of safety in antenatal care provision, which includes measurements of positive pregnancy experiences, is essential for the provision of high quality care. © 2021 Oscar Wong/Getty Images2021