If you’re pregnant or trying to conceive right now, you might be wondering what your prenatal care is going to look like this year, as the ripple effects of the coronavirus pandemic play out. What’s changing for pregnant women, and what’s staying the same? Have you been able to bring your partner with you during ultrasounds? Are you doing your own bump measurements at home? Are you having more virtual visits than in-office checkups?
We interviewed Tali Bogler, a family doctor and low-risk obstetrics provider, to find out more. In addition to serving as chair of family medicine obstetrics at St. Michael’s Hospital in Toronto, Bogler runs the Pandemic Pregnancy Guide, an Instagram account and online resource for expecting couples, and she’s the author of the updated interim schedule for children and pregnant women during the COVID-19 pandemic.
Q: Are pregnant women still having the same number of prenatal appointments right now?
The total number of prenatal visits has not changed during COVID-19, but the mode of delivery of these visits that has changed: certain in-person appointments have been converted to virtual prenatal appointments. There's no consensus in the literature about the optimal number of prenatal visits, nor is there a Canadian guideline that recommends a perfect number. In developed countries, we typically see on average 7-11 prenatal visits during the course of a woman’s pregnancy.
Keep in mind that prenatal visits are not just important for health reasons, but also for the psychological care of pregnant women (i.e. preparing moms for childbirth and transitioning into parenthood). With reduced prenatal visits, research has shown that pregnant patients feel less satisfied with their care and perceive that the gaps between visits are too long. Prenatal visits might offer women a source of support and reassurance during a major life transition! To be quite honest, we don’t know whether an increase in virtual prenatal visits and fewer in-person prenatal visits will impact (positively or negatively) the level of support women feel during their pregnancy. We’re actually trying to look at that right now by asking pregnant or recently delivered women to tell us about their top concerns and overall experience during COVID-19 in a 10-minute survey—please fill it out if you can. Researchers at the University of Toronto are planning on studying this as well.
Q: What about if you have a high-risk pregnancy?
In terms of high-risk pregnancies, these women often follow their own unique schedule, tailored to their specific medical needs. Often high risk-pregnancies need more frequent ultrasounds, and ultrasounds, of course, cannot be done virtually. Ultimately, the frequency of prenatal visits needs to be determined by the medical and psychosocial needs of the pregnant woman and the baby.
Q: Is the six-week postpartum appointment virtual right now, too? I've always thought that six weeks is a long time for a postpartum woman to go before seeing a doctor. (If you have a midwife, you get several home visits before the six-week mark.)
This really depends on your provider. Obstetricians typically see their patients at the six-week postpartum mark, and for the most part, during COVID-19, this has now been converted to a virtual visit. Some OBs are offering these postpartum virtual appointments earlier than six weeks, which I agree can be a great thing for postpartum women. There is so much focus on prenatal care, and I think many postpartum moms feel lost in our system once they deliver, especially when the focus shifts towards the baby.
For family medicine obstetrics providers like me, we often see the mom and baby 24 to 48 hrs after they’re discharged from the hospital. Each time the baby comes in for a weight-check for example, the mom is also seen. This is what makes family medicine obstetrics an amazing model of care: Essentially, the mom and baby are considered one unit upon discharge and typically the mom will be seen as frequently as the baby in the postpartum period. (The same model applies to midwifery.) By seeing them together, we can address baby’s weight and feeding challenges, postpartum blues and anxiety, screen for postpartum depression, and answer those new parenting questions all at once. It’s sort of a one-stop shop.
To reduce exposure to COVID-19, we are trying to limit the amount of in-person time spent at each visit whenever possible. That’s why some of the more routine questions might be emailed to parents to complete prior to the visit, or followed-up with a phone call after the visit.
Q: Will the number of ultrasounds be limited? Or more standardized? I know rules have been changing about who can attend, like no partners allowed. Will that be enforced for the foreseeable future? Are technicians adapting to let partners attend ultrasounds virtually?
The number of ultrasounds has not changed during the pandemic. But in most ultrasound departments, pregnant individuals are being asked to come to their appointment without a partner. These policies were put in place to lower the risk of exposure to the pregnant woman, staff at the clinic and other patients. It’s unclear when these restrictions will be lifted; all hospitals are following the guidelines set out by their public health officials. Depending on the hospital or clinic and the privacy rules in place, some imaging clinics or departments might not be allowing partners to attend ultrasounds virtually (i.e. through video calling) due to issues around privacy and recordings. I strongly feel that clinics need to adapt swiftly to ensure that there are innovative technologies in place in order for all partners to attend ultrasound appointments virtually.
I really do feel for pregnant women during this time. I remember when I was pregnant with my twins and was at risk for preterm labour at 23 or 24 weeks. I required frequent ultrasounds to measure my cervix. I can’t imagine how nerve wracking it would have been to attend those ultrasounds solo.
Q: Some women say they’re feeling rushed through their appointments and their scans. I saw one pregnant woman posting that she felt like she was “treated like a germ or sick person the whole time.” It’s understandable, but it’s also very sad—pregnancy is supposed to be such a special and exciting time in your life. Does this worry obstetricians?
It’s upsetting to hear that some women might feel this way. I know that our team has been particularly sensitive to our pregnant population during this unprecedented time, and that we’ve been doing everything we can to ensure that our patients feel safe and heard.
Perhaps part of the misunderstanding is that health care providers are trying to be as efficient as possible during visits in order to reduce the amount of face-to-face time, in order to reduce exposure to both the patient and healthcare staff. However, there is a big difference between rushing and being efficient, and all healthcare providers need to be extra aware of this. We need to be transparent with our patients on why we’re doing things a certain way. Communication has always been critical in healthcare—now more than ever. We also need to find innovative ways to connect with patients in order for patients to feel heard and supported. This was one of the main reasons why we created @PandemicPregnancyGuide.
Q: I saw an online tutorial for teaching expectant moms how to measure their own belly size. Is that something women are being told to do? Or do pregnant women want to do it themselves because it’s reassuring to them?
We are not routinely asking women to do self-administered symphysis fundal height (SFH) measurements at home, but you might be asked to try this measurement at home in lieu of an in-person prenatal visit. It's actually not that tricky to do—all you need is a flat surface and a measuring tape. However, we really do not have properly designed studies looking at the accuracy of self-measurements and detecting fetal growth issues. We posted a video on how to do the self-measurement and a lot of my patients have been really excited to tell me that they did the measurement at home. For my expecting parents, it’s the first time they have been involved in this capacity to collect their own data. It seems like there is a real sense of empowerment in women doing their own measurements.
Q: What about people who are investing in all the tech devices for self-monitoring at home? What do you think of patients buying their own fetal dopplers or blood sugar testing kits?
Doing home measurements and purchasing gadgets can be empowering and exciting, but at the same time, we need to make sure they’re safe, and that there is evidence to support their use at home. I’ll break it down by each type of device:
Doppler or a doptone: The simple answer is, if something wasn’t recommended prior to COVID-19, it shouldn’t be recommended during COVID-19. Doptone can cause a lot of unnecessary anxiety when not done properly. (Today’s Parent had a previous article on this.) After 24 weeks gestation, pregnant women can just use fetal movement—meaning kick counts—instead of a doppler.
Blood pressure: I strongly feel that accurate home blood pressure machines are necessary if we’re doing virtual prenatal visits. In my opinion, simply asking questions about signs and symptoms of high blood pressure and preeclampsia is less than ideal, and cannot replace accurate blood pressure readings. At the beginning of the pandemic, I was advising patients to go to their local pharmacy (always going at less busy times, and wiping down the machines prior to using, etc.) but pharmacies have now closed off their blood pressure machines, so this is less of an option now. For my patients with private insurance/drug coverage, I am actually prescribing a blood pressure machine so they can get the machine covered by their insurance. But what about patients who do not have private insurance and cannot afford BP machines? A lot of these gadgets and devices are not accessible to women from all incomes.
Sugar testing kits: These are advisable for women who have been diagnosed with gestational diabetes. These women need to monitor their sugars at home and many ”Diabetes in Pregnancy" programs have converted some of their in-person visits to virtual. Alternating visits can be done safely if women can accurately measure their sugar readings at home.
Q: Speaking of gestational diabetes, have there been any changes to the glucose test? Are moms still going in for that? It can be a long time to hang out in a waiting room.
We are still recommending screening for gestational diabetes in all pregnant women regardless of risk factors. This occurs between 24-28 weeks gestational age, or earlier, if you have risk factors. The oral glucose challenge test (i.e. that delicious tasting sugary drink) and then testing your blood one to two hours after is still the gold standard screening test for gestational diabetes. It's understandable that many women do not want to wait at the lab for one to two hours, though. I have suggested that providers write on the blood requisition, “Please allow the patient to wait in their car or in a private room while waiting for the blood test.”
Q: What does this mean for lower-income moms, women with less education, or more vulnerable women, like those with mental health struggles? Who gets missed when patients are told to do virtual care or self-monitor more?
This is definitely an issue. We’re seeing how the pandemic has highlighted so many health care gaps that exist in our country, especially for the most vulnerable. These populations need more individualized and tailored approaches and consistent in-person care with their maternity care provider.
To do proper virtual care, patients need access to technological devices, a stable internet connection, and to have some level of technological literacy. At St. Michael’s Hospital for example, some of our patients do not have fixed addresses, and might not have cell phones, either. Successful programs will need to provide our most vulnerable patients with the necessary devices—as well as internet data—to those who need it most.
For pregnant women who might be experiencing heightened levels of anxiety during the pandemic, frequent virtual check-ins might be especially helpful. A recent study was actually just published that showed how virtual mental health therapy for anxiety is as good as in-person face-to-face therapy, which is encouraging. There are lots of virtual mental health services, including psychiatric support, available to expecting and postpartum moms during COVID-19.
Q: What are the options for prenatal classes? Are they happening on Zoom?
Lots of support programs and prenatal classes are trying to pivot to virtual options such as Zoom. This is one of the main reasons we created @PandemicPregnancyGuide! It’s sort of like a virtual prenatal class and support group with a focus on COVID-19 related concerns and questions. We did an Instagram Live one-hour breastfeeding prenatal class, which was led by one of our incredible lactation consultants at St.Michael’s Hospital. Prior to COVID-19 this would have been an in-person class.
Some of the other resources I have been providing my GTA patients with include Welcome to Parenting, a Toronto Public Health free online prenatal program that you can access anytime and anywhere; Markham Prenatal, a free 4-week live webinar prenatal class series where the instructors are registered nurses; Toronto Yoga Mamas; and She Found Health, an online prenatal class developed by two Canadian family medicine obstetrics providers (this one costs $197).
Q: Do you think you’ll see an uptick in women considering home births, or choosing a midwife-assisted birth in the hospital?
I think we’re going to have to wait until the 2019-2020 data is published to really know whether there is an uptick in patients choosing midwives and/or home births. We know that some women choose home births for various reasons, including having control over their environment or the comfort of being in their own home. Although there have been some people who have been proponents of home births during the pandemic, I think there have been many misconceptions in the media about the safety of delivering in a hospital versus outside the hospital during COVID-19. First of all, you need to be a “good candidate” for a home birth regardless of COVID-19. And just because you want a home birth doesn’t mean that it will end up being a home birth—it depends on how the delivery is going. At any point, if things are not going as planned or expected, you might need to be transferred to the hospital, so you need to consider what potential delays might exist in your local area during COVID-19 (like delays with getting an ambulance, delays with screening upon entering the hospital, etc.)
I think pregnant women should know that hospitals are an extremely safe place to deliver, and we have all the necessary infection control precautions in place to limit exposure to COVID-19. Honestly, I feel safer going into the hospital for work than going grocery shopping (where there is no screening)! We’re prepared for any scenario that arises.
You should also know that midwives are also limiting the number of support people who can attend your labour and delivery at home or in a birthing centre. It is not more flexible than our hospital policies regarding support people—midwives have guidelines in place as well. Your medical team attending your labour and delivery outside of the hospital will need to have sufficient PPE supply, including enough masks for other members of the household who might be attending your labour and delivery.
Q: Do you think there are any improvements to prenatal care coming out of all these changes and adaptations?
Yes, let’s talk about the silver linings. There are certainly some pros, especially for second-time moms who know the drill, and might likely be busier with work and family responsibilities. With more virtual visits, they’ll miss less work and might not have to find childcare for their older children. Prenatal visits, blood work, and ultrasounds take up a huge amount of time in our already busy schedules! And if you have to travel a long distance to get to your appointments, staying home is definitely an advantage. But the truth is, we really don’t know yet how this will impact feelings of support and whether these changes are welcomed or might lead to more anxiety in expectant parents. In general, this has certainly caused all of us in healthcare to stop and reflect and ask some really important questions: How can we deliver more innovative and efficient care to our expectant and postpartum parents even when this is all over? And some of the changes we are seeing right now might in fact be here to stay even post COVID-19.