Many health systems and community organizations across the country have developed telehealth or virtual support programs for people who are pregnant or postpartum. Interest in developing these types of programs has grown exponentially throughout the COVID-19 pandemic. At the same time, the greatest impact of any public health crisis is felt most deeply by populations already experiencing inequities, causing additional trauma and harm as care gaps widen.

In the case of maternal health, Black people who give birth more often experience unacceptably poor maternal health outcomes due to systemic racism as well as implicit and explicit bias. In the rush to quickly create telehealth and virtual supports for people who are pregnant or postpartum, there is a risk of inadvertently increasing stark inequities. What if we use this unique moment to develop asset-based telehealth programs and virtual supports that center Black birthing people?

With this question in mind, the Better Maternal Outcomes team at IHI chartered a 90-day R&D project to develop a preliminary theory of change to support health systems and community-based organizations to develop or modify virtual supports to ensure they are safe, equitable, and honor each individual’s dignity. Our research process included a research scan of peer-reviewed journal articles and literature outside traditional academic publishing channels. We also conducted interviews with context experts (i.e., Black people with lived experience of being pregnant, giving birth, and/or being postpartum), content experts, and IHI stakeholders, including our own Better Maternal Outcomes team. We organized our findings using IHI’s emerging telehealth recommendations and are sharing some key themes and lessons here:

Co-Design with Trust and Human Connection

• Black people with lived experience must be part of the design, development, and implementation of virtual supports. This means engaging with individuals at the earliest stages of an improvement effort, onboarding them to your improvement team, and compensating context experts for their time and thought leadership. Identifying concerns and pain points for virtual supports and understanding how these challenges impact individual’s lives, and developing tests of change for improvement must be designed with Black women, not designed for
  
• Always consider local context, local culture, local assets, and local challenges. Our research suggested that the most successful telehealth support programs and initiatives leveraged a wide range of local community assets and considered specific, local challenges.

Address Access Issues

• Access to devices or sufficient broadband service can be a significant barrier to telehealth and virtual supports. Several successful telehealth programs have invested in providing families with devices or developed partnerships with local businesses or grant programs to do so. Asset mapping with context experts can help identify opportunities to support this investment.
• To increase access, a hybrid approach using both in-person and virtual supports emerged as a promising strategy.
• Assuming access to technology, there is also an opportunity to increase access to services by eliminating the direct and indirect barriers of in-person care delivery.

Protect Privacy

• Telehealth can both increase and decrease real and perceived privacy concerns depending on how it is implemented. While some people may feel comforted and safe taking a telehealth appointment from home, others may be wary of inviting clinicians and other birthing support people into their home.
• Address privacy by explicitly, proactively, and respectfully discussing concerns and comfort level. Co-design and agree to group norms.

Assess Diagnostic Accuracy

• Telemonitoring can offer more effective, efficient, and safe ways to monitor key vitals, e.g., blood pressure.
• Telehealth and virtual supports should consider opportunities to design systems for sharing data across silos, which can help to ensure diagnostic accuracy.

Enhance Communication

• Virtual connections can provide an opportunity for clinicians and birthing support people to engage with the whole family, where appropriate and desired. For example, it may be easier for a spouse or other birthing support person to join a visit if it’s done virtually. While widening the audience during a consultation may be intimidating for providers, most of the context experts and doulas we spoke to consistently pointed to this type of involvement as a net positive for birthing partners.
• A one-to-one visit with a new member of a support or perinatal care group can help set an individual up for success and help them get the most out of participation.

Promote Psychological and Emotional Safety

• The lack of trust between Black birthing people and the health care system, due to the violent history of exploitation of Black people and their bodies in medicine generally (and gynecology, specifically), influences the utilization of care services. This also extends to virtual care settings.
• Designed well, virtual supports and services could create a more psychologically trusting and safe environment by removing the need to be in-person and allowing people to remain in the comfort of their homes or other environment where they feel safe. However, the flip side could also be true, which speaks again to the importance of co-designing with local context experts.
• While virtual doula support looks quite different than traditional doula support, our research suggests that it can still drive safer care and support people both emotionally and psychologically.

Consider Human Factors and System Design

• In addition to co-designing the initial virtual support, programs should be regularly evaluated using continuous quality improvement methods to ensure they are meeting the needs of participants and not increasing inequities.
• Specific human factors that are most important vary widely from region to region. Local adaptation is key.
• It is important to be flexible with modalities for tele-support. In addition to videoconferencing, explore phone-only or text-based modalities.

Over the next several months, the Better Maternal Outcomes team plans to continue gathering feedback from context and content experts to further develop our theory of change. We will also develop a testing plan and identify potential testing partners. If you are interested in engaging more deeply with this work, we encourage you to email maternalhealth@ihi.org or visit www.ihi.org/maternalhealth.

Catherine Mather, MA, is an IHI Project Director.

You may also be interested in:

Supporting New Mothers in the Time of COVID-19

Testing Virtual Ways to Support New Mothers