By: Dr. Azuka Ezeike, MBBS, FWACS (Obstetrics and Gynaecology), MSc (Public Health). Medical review and editorial support by the DLHA Team.
A young black female doctor seated and looking attentively at an open laptop placed on a table during a telemedicine session.
Antenatal care is specialised care given to mothers and their unborn babies before birth. The introduction of antenatal care has led to a significant drop in maternal and neonatal deaths. Over the years, the model of antenatal care has evolved from the traditional method of antenatal care which may consist of up to 12 visits, to focused antenatal care which involves four visits and now to the new ANC model which consists of at least eight visits.
Low antenatal coverage has been a common problem in the African sub-region due to several constraints. Data from UNICEF shows that Antenatal coverage in most African countries from 2016-2022 was less than 80% with some countries having values below 30%. However, the same data showed that most countries in North America had up to 100% coverage.
Telemedicine can be defined as using telecommunications technologies to support the delivery of medical, diagnostic, and treatment-related services where distance is a critical factor. Telemedicine has many advantages including increased access, convenience, economic savings and increased efficiency. However, it takes away physical contact and examination, and fears have been expressed in some quarters that this may lead to late or delayed diagnosis.
The COVID-19 pandemic brought about a paradigm shift in the approach to healthcare. This produced a transformation in health service delivery. This led to increase in the delivery of health services through telemedicine. Telemedicine has been successfully practised in many Western countries with amazing results but the practice is yet to find a firm footing in Africa.
The use of telemedicine in the management of chronic diseases is well documented but the scope has recently expanded to antenatal care. Because of the proven benefits of telehealth, the American College of Obstetricians and Gynaecologists (ACOG) have endorsed it as a technology that should enhance but not replace the current standard of care. The World Health Organization (WHO) recognises mhealth (the use of mobile and wireless technologies to support the achievement of health objectives) as having the potential to transform the face of health service delivery globally.
The article aims to provide information on:
How is Telemedicine Utilised in Antenatal Care?
Telemedicine can range from simple phone consultations to being used as an aid for robotic surgeries in a remote location.
The most common means of delivery of telemedicine is through video and audio technologies (applications) in computers and mobile phones
Telemedicine can be delivered in two ways: [1, 2]
This involves face-to-face virtual consultations via video conferencing or audio consultations.
This involves home monitoring of parameters in the mother and baby and transmitting the results to the health care providers.
A component of remote monitoring is designated as the ‘store and forward’ method in which case digital images are transmitted to the physician to interpret at their convenience.
Remote monitoring is achieved by using wearable and portable devices to monitor vital parameters. In pregnant women, it involves:
Pregnant women are allowed to monitor their blood pressure at home with portable devices and keep a record. The recordings are subsequently transmitted to the healthcare providers for interpretation. Evidence from the BUMP 2 clinical trial showed that this method was as accurate as clinic readings.
The baby's heart rate can be monitored at home by the mother using a hand-held Doppler device. The heart rate pattern over time (cardiotocography) can also be traced with remote portable cardiotocograph devices and transmitted to the doctor for interpretation. [1]
This involves the home measurement of the symphysis fundal height by the pregnant woman. This is used to assess the growth of the baby, This may be associated with variation in home-measured value compared to clinic value. Training of the women during clinic visits would help reduce errors. [3]
This is still a developing technology. It involves teaching the pregnant woman to do a home ultrasound with hand-held ultrasound devices. [4] The images are later transmitted to the healthcare provider for interpretation and further management.
A hybrid model has been practised in some facilities in which most of the antenatal appointments are virtual with physical consultations done at critical points in the pregnancy like 28 and 36 weeks while the rest of the consultations are done virtually. [5]
Antenatal care in Africa is limited by several factors. These are the factors that are responsible for the poor antenatal coverage. [6, 7] They include:
The topography of many rural communities in Africa limits access to healthcare for the inhabitants. Some of the communities lack healthcare facilities and people may have to travel distances to access healthcare. Transportation to the nearest health facility may involve navigating through waterways or very bad roads. The lack of a reliable transport system even worsens the situation. This difficulty may lead to missed antenatal care appointments or the inability to have any form of care during pregnancy
There is a huge deficit of health professionals in Nigeria. This means that there are fewer nurses and doctors available to take care of pregnant women. It is not uncommon to see women spend almost the whole day at an antenatal care clinic because of limited personnel. Most facilities are also under-equipped thereby leading to delayed or inappropriate care. This may result in multiple visits to the facility
Poverty. lack of education and cultural barriers pose constraints to optimal antenatal care coverage in Africa. The uneducated woman may not see the need to have antenatal care, and even when they see the need it may not be affordable. This inability to afford care may be due to a lack of insurance coverage resulting in increased out-of-pocket spending on health. Cultural barriers that limit the autonomy of women are also a contributory factor.
Related: Social Factors Shaping African Women’s Health
In localities where telemedicine is practised, it has been associated with several benefits. These are:
Telemedicine bridges the geographical gap between pregnant women and healthcare facilities. The area of residence, transportation constraints and poor socioeconomic status are some of the limitations to healthcare access in some African localities. Telemedicine bypasses these challenges as healthcare could be accessed by women in remote areas, once there is internet connectivity. This was utilised during the last pandemic in some African countries with some measurable success. [8]
It also reduces the time for follow-up as a review of the patient's results and clinical state does not have to wait till the next available clinic day. In addition, telemedicine enables patients to be reviewed by specialists who may not be available locally.
Telemedicine reduces costs through savings on transportation and the cost of clinic consultations. It also reduces other indirect costs due to loss of man hours at work.
It produces cost savings for healthcare systems due to less pressure on the existing facilities, less use of medical consumables and less manpower requirement.
A comparative cost analysis of conventional care and telemedicine cases for pregnant women with hypertension in pregnancy showed a significant cost reduction with telemedicine. [9]
Loss to follow-up is one of the challenges of healthcare management in Africa. With telemedicine, this is reduced as patients can be contacted via mobile channels.
Telemedicine also enables more regular monitoring of the patient's clinical state as information(data) like blood pressure and baby’s heart rate can be transmitted via phone lines or email.
Remote monitoring in telemedicine leads to the early detection of abnormalities. This leads to timely intervention, which prevents the progression of illnesses and reduces the disease burden.
The ability to consult their healthcare professional from the comfort of their homes is associated with patient satisfaction. Telemedicine also increases self accountability and this gives the patient a sense of being involved in her management. [10]
A study done in Pakistan showed that up to 54% of the women who used telemedicine for their pregnancy care during the COVID-19 period intended to use it again in their subsequent pregnancies.[11]
Related: How to Boost Positive Childbirth Experience in African Women
Most clinics are overpopulated with insufficient staff. Telemedicine is more convenient for health providers as it leads to less patient load and more flexibility.
Though telemedicine services were introduced in some African countries as early as the 1980’s, yet some of the programs couldn't move beyond the initiation phase. The COVID-19 period saw a little improvement in telehealthcare but this was not sustained after the pandemic. [12]
Despite the benefits, there are a lot of challenges and limitations that have hindered the development of telemedicine in Africa and some other parts of the world. [8, 13,14]
These include:
Some localities in Africa lack the infrastructure to host telemedicine programmes because of;
Even where facilities are available, some healthcare workers and patients may lack the necessary digital knowledge to be able to use Information and communication technology (ICT) gadgets and equipment.
There are concerns about reduced quality of care due to the lack of physical examination, reliance on secondary sources of information and lack of nonverbal feedback. However, a study done in Australia that compared conventional antenatal care to telehealth-integrated health care showed no compromise in pregnancy outcomes.
Compared to conventional care, telemedicine is prone to privacy and security risks. The transmission of patient data over the Internet may lead to breaches in confidentiality and data security.
Telemedicine is not captured in the health act of some countries and there are no laws backing the practice. This lack of regulatory framework is a major hindrance in Africa and this exposes providers to malpractice liability.
Telemedicine is not usually covered by health insurance in parts of Africa, where available. This is a constraint for receiving services via this medium. The cost of purchasing smartphones and ICT facilities may be beyond the reach of most health facilities and patients.
Telemedicine is a new field of care. Distrust of the service by the populace may lead to a reluctance to utilisation.
To avoid security breaches, data security should be ensured by using secure software, end-to-end encryption and multi-factor authentication by both health providers and patients.
Telemedicine has the potential to significantly enhance antenatal care in Africa by addressing the continent's unique challenges. Through the many advantages, the gap between healthcare providers and expectant mothers can be bridged, especially in remote areas. With concerted efforts from governments, healthcare providers, and communities, the existing barriers can be overcome. In the presence of enabling conditions, telemedicine can transform antenatal care in Africa, ensuring healthier outcomes for mothers and their babies.
1. Atkinson J, Hastie R, Walker S, Lindquist A, Tong S. Telehealth in antenatal care: recent insights and advances. BMC Medicine. 2023. 21(1):332. doi: 10.1186/s12916-023-03042-y. Available from here.
2. American College of Obstetricians and Gynaecologist(ACOG) Implementing telehealth in practice. Committee opinion Nr. 798. Feb, 2020. [Internet]. Cited 2024 Aug 2..Available from here.
3. Bergman E, Kieler H, Petzold M, Sonesson C, Axelsson O. Self-administered measurement of symphysis-fundus heights. Acta Obstet Gynecol Scand. 2007;86(6):671–7. Avaialble from here.
4. Hadar E, Wolff L, Tenenbaum-Gavish K, Eisner M, Shmueli A, Barbash-Hazan S, et al. Mobile self-operated home ultrasound system for remote fetal assessment during pregnancy. Telemed J E Health. 2022 Jan;28(1):93–101. Available from here.
5. Peahl AF, Smith RD, Moniz MH. Prenatal care redesign: creating flexible maternity care models through virtual care. Am J Obstet Gynecol. 2020 Sep;223(3):389.e1-389.e10. Available from here.
6. Amungulu ME, Nghitanwa EM, Mbapaha C. An investigation of factors affecting the utilization of antenatal care services among women in post-natal wards in two Namibian hospitals in the Khomas region. J Public Health Afr.. 2023 Apr 20 [cited 2024 Aug 2];14(3):2154. Available from here.
7. Okedo-Alex IN, Akamike IC, Ezeanosike OB, Uneke CJ. Determinants of antenatal care utilisation in sub-Saharan Africa: a systematic review. BMJ Open 2019 Oct 1, 9(10):e031890. Available from here.?
8. Chitungo I, Mhango M, Mbunge E, Dzobo M, Musuka G, Dzinamarira T. Utility of telemedicine in sub?Saharan Africa during the COVID?19 pandemic. A rapid review. Hum Behav Emerg Technol. 2021 Dec:843–53. Available from here.
9. Van den Heuvel JFM, van Lieshout C, Franx A, Frederix G, Bekker MN. SAFE@HOME: Cost analysis of a new care pathway including a digital health platform for women at increased risk of preeclampsia. Pregnancy Hypertens. 2021 Jun;24:118. Available from here.
10. Ghimire S, Martinez S, Hartvigsen G, Gerdes M. Virtual prenatal care: A systematic review of pregnant women’s and healthcare professionals’ experiences, needs, and preferences for quality care. Int J Med Inform. 2023 Feb;170:104964. Available from here.
11. Sulaman H, Akhtar T, Naeem H, Saeed GA, Fazal S. Beyond COVID-19: Prospect of telemedicine for obstetrics patients in Pakistan. International Journal of Medical Informatics [Internet]. 2022 Feb 1 [cited 2024 Aug 1];158:104653. Available from here.
12. Dodoo JE, Al-Samarraie H, Alsswey A. The development of telemedicine programs in Sub-Saharan Africa: Progress and associated challenges. Health Technol (Berl) [Internet]. 2022 [cited 2024 Jul 31];12(1):33–46. Available from here.
13. Galle A, Semaan A, Huysmans E, Audet C, Asefa A, Delvaux T, et al. A double-edged sword—telemedicine for maternal care during COVID-19: findings from a global mixed-methods study of healthcare providers. BMJ Global Health. 2021 Feb 1;6(2):e004575. Available from here.
14. Gajarawala SN, Pelkowski JN. Telehealth benefits and barriers. J Nurse Pract [Internet]. 2021 Feb 2;17(2):218–21. Available from here.
Published: August 6, 2024
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