Perceptions and Challenges of Telehealth Obstetric Clinics Among Pregnant Women in Hong Kong: Cross-Sectional Questionnaire Study

Introduction

Rapidly evolving innovations in technology have enabled efficient and effective communication across the world in numerous ways. This evolution has dramatically revolutionized the delivery of medical care. During the COVID-19 pandemic, the sudden need to reduce disease transmission accelerated the transformation of health care services from traditional in-person consultations to innovative telehealth delivery [1]. Telehealth is defined as the use of digital technology to remotely distribute and facilitate health-related services in an interactive manner [2].

Telehealth has been used in obstetrics to provide prenatal care, maternal and fetal medicine consultations with the interpretation of ultrasound videos or images for fetal anomalies, and genetic counseling [3]. Telemedicine clinics integrated into routine clinical practice could reduce the number of in-person clinical visits, increase patient satisfaction, and decrease prenatal stress without altering other maternal and fetal outcomes [4]. Studies have shown telehealth clinics for prenatal care can lead to higher patient satisfaction [5], improved patient confidence in self-monitoring [6], and cost savings [7]. The potential use of telehealth for providing obstetric care in Hong Kong has not been explored. Therefore, it is important to address patients’ concerns to facilitate its smooth implementation in this field. Accordingly, this questionnaire study aimed to investigate pregnant women’s attitudes, expectations, acceptance, and conception of potential limitations related to the implementation of telehealth obstetric clinical services in Hong Kong.

Methods

Overview

This was a prospective cross-sectional questionnaire study carried out at Queen Mary Hospital, Hong Kong. The hospital provides in-person tertiary specialist care for general obstetric and gynecological issues, as well as high-risk pregnancies. It does not currently offer any telehealth obstetric clinics. Regarding standard prenatal care, all pregnant women receive routine prenatal blood tests, Down syndrome screening, a midtrimester morphology scan, a 75-gram oral glucose tolerance test, and group B streptococcus screening with advancing gestations. Women attend the prenatal clinics at regular intervals, where maternal and fetal well-being is assessed through activities such as blood pressure measurement, urine dipstick tests for protein and glucose, measurement of symphysis-fundal height, and checking the fetal heartbeat using a handheld Doppler machine.

In this study, pregnant and postpartum women were identified by research assistants in the prenatal clinic and postpartum wards, respectively. Eligible participants were aged 18 years or older in their first pregnancy or after their first delivery. Multiparous women were excluded from recruitment due to their prior experience with prenatal care, which could potentially lead to differing perceptions and expectations of telehealth in prenatal care. The questionnaire, available in both English and Chinese, was designed by the study team. The participants were required to provide informed consent before answering the questionnaire. They were given the option to complete the questionnaire in either physical or digital format, based on their preference. The questionnaire was anonymous, and pretesting was conducted with pregnant women to ensure that the questions were easily comprehensible. The questionnaire was provided to the participants at various stages of pregnancy: before 18 gestational weeks during their initial prenatal visit, between 24 and 31 gestational weeks during the standard 75-gram oral glucose tolerance test, and after delivery.

Ethics Approval

This study received ethical approval from the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (UW21-418). All enrolled participants gave informed consent. The study data were anonymous.

Statistical Analysis

We collected basic demographics including maternal age, education level, ethnicity, socioeconomic status, previous experience with and frequency of using any format of telecommunication, and experiences and frequency of attending telehealth clinics. We investigated participants’ preferences for telehealth clinic services, expectations regarding the implementation of telehealth clinics, perceptions of the feasibility and limitations associated with adopting telehealth clinics, and their privacy concerns. The 5-point rating scale was used accordingly for the required sections. To allow for a 4.5% margin of error at a 95% CI, a sample size of 500 was required. We aimed to enroll roughly equal proportions of participants in the predetermined gestational groups. Statistical analysis was performed using SPSS Statistics software (version 26.0; IBM Corp). Demographic characteristics and questionnaire responses were presented as mean and SD or n and percentage (%). A comparison of questionnaire responses between prenatal and postpartum participants was performed using the chi-square test. Ordinal logistic regression analyses were performed to investigate the association between gestational age and attitudes toward telehealth clinics for outcomes on a 5-point rating scale. Multinomial logistic regression analyses were conducted for categorical outcomes. Covariates (education level, monthly household income, and previous experience with videoconferencing apps) were included in the model for adjusted odds ratios (aORs). P<.05 was considered statistically significant.

Results

Participant Information

Between November 6, 2021, and August 12, 2022, a total of 670 women were recruited from the clinic and completed the questionnaire. Among them, 6 women were excluded due to having more than 50% of their data missing, leaving 664 participants for the final analysis: 269 (40.5%) before 18 weeks of gestation, 198 (29.8%) between 24 and 31 weeks, and 197 (29.7%) after delivery. Multimedia Appendix 1 contains the participants’ basic demographic information. The majority of the participants were Chinese (622/664, 93.7%), between 31 and 40 years old (476/664, 71.7%), and educated to a tertiary level or above (535/664, 80.6%). Moreover, 93.1% (618/664) had previous experience with videoconferencing apps, and 74.7% (496/664) had heard of telehealth clinics before the questionnaire. However, only 9% (60/664) had attended a telehealth clinic before.

Preferences Regarding Telehealth Clinic Services

Almost half (329/664, 49.8%) of the participants thought face-to-face consultations were better than telehealth clinics, and only 7.3% (48/664) agreed vice-versa (Table 1). The participants did not show a preference for telehealth clinics over in-person consultations for routine prenatal checkups and certain clinical issues, including vaginal bleeding, vaginal discharge, skin itchiness, reduced fetal movement, uterine contractions, suspected leakage of amniotic fluid, and fever. As gestation advanced (from before 18 weeks to between 24 and 31 weeks) and after delivery, an increasing number of participants began to consider telehealth clinics as a viable option for assessing the aforementioned conditions, although the overall acceptance was still low, at 12.2% (81/664) for routine prenatal checkups, 11.5% (76/664) for vaginal bleeding, 19.4% (128/664) for vaginal discharge, 9.7% (64/664) for reduced fetal movement, 9.4% (62/664) for uterine contractions, and 8.2% (54/664) for suspected leakage of amniotic fluid. In contrast, telehealth clinics were deemed to be an acceptable alternative for prenatal educational talks, prenatal and postpartum exercise classes, and addressing breastfeeding issues when compared to traditional face-to-face visits.

The perceived benefits of telehealth clinics included shorter traveling and waiting times, the possibility of overseas consultations, reduced risk of contracting infectious diseases, improved accessibility, and lower costs. However, the most prevalent concern regarding telehealth clinics was the potential for errors or delays in diagnosis (488/664, 73.8%), followed by challenges with obtaining medication prescriptions (430/664, 65.2%), limited interactive engagement with medical professionals (392/664, 59.3%), privacy issues linked to network security (390/664, 58.8%), discomfort related to exposing private body parts (369/664, 55.7%), and technical problems (304/664, 45.9%).

Expectations Regarding the Implementation of Telehealth Clinics

Only 24.2% (161/664) of the participants agreed that telehealth clinics should be launched for obstetric services (Table 2). The majority (577/664, 88.1%) preferred live video to web-based text and chat (47/664, 7.2%) or audio (31/664, 4.7%) consultations. The expected public health benefits of telehealth clinics were reduced waiting and traveling times; reduced spread of infectious diseases; reduced workload for medical professionals; increased speed of making diagnoses, referrals, and providing treatment; and higher accessibility to medical services.

Feasibility and Limitations of Telehealth Clinics

The participants’ perceptions regarding the acceptability of transitioning from the conventional prenatal care model to a telehealth clinic are shown in Table 3. They expressed a high level of comfort with several aspects, including discussing investigation results, conducting urinary dipstick tests at home, participating in history-taking, self-measuring blood pressure with electronic devices, and providing personal information for identity verification. However, they were less confident when it came to self-administering rectal and vaginal swabs under supervision, conducting physical examinations, measuring symphysis-fundal height under supervision, arranging further investigations, listening to fetal heartbeats using a hand-held Doppler machine, and making diagnoses.

Privacy And Medicolegal Perspectives Regarding Telehealth Clinics

Half (336/664, 50.8%) of the participants believed that the current laws and guidelines were insufficient to protect patients’ rights (Table 4). A significant proportion of the participants were worried about legal issues stemming from wrongful diagnosis and treatment (511/664, 77.4%), inappropriate use of the telehealth consultation records (464/664, 70.1%), and leaking of personal information (401/664, 60.6%). Moreover, 47.1% (312/664) agreed the consultation should be recorded by the patients, and 58.2% (385/664) expected a written record following a telehealth consultation. The majority of participants agreed that new legislation should be established to govern the protection of confidentiality (531/664, 80.2%), acquisition of consent (541/664, 81.7%), and storage of medical records (522/664, 78.9%). More participants demonstrated confidence in the implementation of telehealth clinics when accompanied by the enforcement of stricter laws and guidelines.

Perceptions of and Confidence in Telehealth Clinics Across Gestations and After Delivery

Table 5 demonstrates how participants’ perceptions of and confidence levels regarding telehealth clinics evolved in relation to prenatal issues and procedures as pregnancy progresses and after childbirth. The acceptance of attending telehealth clinics increased with the experience of pregnancy and delivery. During the postpartum period, compared to before 18 weeks of gestation, significantly more participants agreed that telehealth clinics could be an option for assessing physical symptoms such as vaginal bleeding (aOR 2.105, 95% CI 1.448-3.059), reduced fetal movement (aOR 1.575, 95% CI 1.058-2.345), uterine contractions (aOR 2.906, 95% CI 1.945-4.342), suspected leakage of amniotic fluid (aOR 2.609, 95% CI 1.721-3.954), fever (aOR 1.526, 95% CI 1.109-2.100), and flu-like symptoms (aOR 1.412, 95% CI 1.030-1.936). In addition, their confidence levels grew when it came to tasks like measuring the symphysis-fundal height, arranging further investigations, and making diagnoses with the doctor via the telehealth clinic. However, they exhibited lower confidence levels when it came to medical history-taking.

Discussion

Principal Results

In this study, we found that pregnant women preferred a face-to-face visit (329/664, 49.8%) to a telehealth consultation (48/664, 7.3%). Telehealth clinics were less favored by the participants for physical complaints and routine prenatal care, but they were deemed a desirable option for prenatal educational talks, disclosure of investigation results, postpartum exercise classes, and discussing breastfeeding problems. With advancing gestation and after delivery, we found an increasing acceptance of and confidence in telehealth for tackling certain pregnancy-related physical symptoms and prenatal procedures. The perceived advantages of telehealth clinics were saving time for waiting and transportation, making international consultations feasible, and reducing exposure to infectious diseases. However, the risk of making a wrong diagnosis, lack of interactive efficiency, barriers to obtaining medication prescriptions, exposure of private parts, and wrongful disclosure or misuse of personal information were the main concerns regarding telehealth clinics. Only 24.2% (161/664) of the participants agreed that telehealth clinics should be launched for obstetric services. Participants also felt that enforcing stricter laws and guidelines could facilitate the implementation of telehealth clinics and increase confidence in its use among pregnant women.

Interpretation and Implications

Modern technology enables the prompt distribution of information. There is an expectation that cutting-edge technology can be incorporated into conventional health care to assist in patient care and reduce the need for unnecessary in-person visits. During the COVID-19 pandemic, the imperative to maintain public health without interrupting essential services prompted the exploration and implementation of telehealth. In this context, we examined the willingness to transition traditional in-person prenatal care to telehealth clinics, gauging participants’ confidence in conducting routine prenatal procedures at home. Automated devices designed for self-monitoring of blood pressure have been validated for use during pregnancy [8]. While women can measure symphysis-fundal height themselves, it is worth noting that this method may yield higher intraobserver variations and readings compared to measurements taken by midwives [9]. The feasibility of fetal heart monitoring with a Doppler machine at home has been explored, particularly for identifying fetuses at risk of congenital heart block in pregnant women with anti-Ro antibodies [10,11]. Self-sampling for group B streptococcus screening has also proven to be achievable [12]. A prenatal care model was proposed for restructuring prenatal visits while still delivering essential services. Physical visits were essential for specific appointments, including early pregnancy examinations, fetal viability and dating, a morphology scan at 19 weeks, screening for gestational diabetes and anemia at 28 weeks, pertussis vaccination, group B streptococcus screening and confirming fetal presentation at 36 weeks, conducting cervical assessments, and discussing postterm management at 39 weeks. In between these critical in-person visits, a total of 5 telehealth visits were conducted to monitor maternal vitals and fetal heart rate, as well as address any questions [1]. A randomized controlled trial conducted at a single center found that incorporating telehealth visits alongside fewer physical consultations (8 physical visits and 6 telehealth visits) led to higher patient satisfaction and lower prenatal stress compared to standard conventional prenatal care (12 physical visits). Notably, this shift did not compromise maternal and neonatal outcomes [4].

Another large-scale study examined the application of telehealth in obstetric services in Australia, comparing conventional physical visits to integrated visits. Among women receiving integrated care, only 3 physical visits were needed for low-risk cases and 5 for high-risk cases. Approximately 50% of the consultations were replaced by telehealth visits, and there was no significant difference in the incidence of fetal growth restriction, preeclampsia, gestational diabetes, and stillbirth between both groups [13].

Nulliparous women in their first and early stages of pregnancy often experience anxiety and lack confidence in self-monitoring, examinations, and managing minor pregnancy concerns. We aimed to understand how different pregnancy experiences influence perceptions of telehealth clinics. As gestation progressed and after delivery, the participants became more familiar with prenatal visit procedures and grew more confident in handling their pregnancies. Thus, they were more open to the idea of telehealth consultations as an option for prenatal monitoring and addressing minor concerns, such as measuring symphysis-fundal height, addressing vaginal bleeding, or monitoring reduced fetal movement. Overall, participants who experienced telehealth clinics reported high satisfaction [5,14]. The acceptance of various prenatal programs varied among the participants, and they were generally more comfortable with telecommunication for services that did not require physical examinations or direct contact, such as educational talks, exercise classes, and addressing breastfeeding concerns. It is important to acknowledge that telehealth clinics cannot completely replace conventional prenatal care, and flexibility should be maintained for women who desire face-to-face consultations.

Understanding patients’ concerns is crucial to customizing care and ensuring the successful implementation of telehealth. Common barriers and anxieties revolve around doctor-patient relationships, the inability to conduct physical examinations, the quality of care, patient confidentiality, cybersecurity, legal and regulatory considerations, and the roles of both clinicians and patients [15]. To address these concerns, there are international and local ethical guidelines available to guide service providers and protect patients’ rights [16,17]. In short, the same principles and standards of care that protect patients during in-person consultations equally apply to telemedicine. Telemedicine should be conducted through a structured and organized platform by adequately trained doctors. Obtaining informed consent is essential to outline the objectives and limitations of telemedicine, as well as to address issues of confidentiality and data protection. Consultation should include appropriate evaluation and treatment, with proper documentation. Moreover, efforts should be made to maintain the doctor-patient relationship to the greatest extent possible.

Strengths and Limitations

The major strength of this study lies in its comparison between women in the antepartum and postpartum periods, shedding light on potential changes in perception and confidence over time. However, this study has several limitations to consider.

First, this study may not have captured the views of the views of ethnic minoritized groups, as the data collection was conducted in Chinese and English, potentially excluding those who do not read those languages. In addition, approximately 80% (535/664) of the participants had a higher level of education, which could affect the generalizability of our findings.

Second, the perspectives of multiparous women, who have prior pregnancy and birthing experiences, might differ from those of nulliparous women. However, we decided to solely evaluate nulliparous women to minimize heterogeneity. Additionally, the postpartum group in our study could provide some insights into the views of multiparous women.

Third, this study did not explore the potential influence of pregnancy complications on participants’ perceptions of telehealth. Women who experience such pregnancy complications might prefer traditional face-to-face consultations. Finally, the participants did not actually experience an obstetric telehealth clinic, which could have positively influenced their perception and acceptance afterward. Our next step could involve an evaluation study to gather their views and satisfaction after attending a telehealth clinic.

Obstetric care is unique because it requires frequent and close monitoring during pregnancy to detect asymptomatic disease early and improve pregnancy outcomes. For example, monitoring blood pressure and urine protein levels helps screen for preeclampsia, and monitoring blood glucose levels is essential for women with gestational diabetes. However, factors such as COVID-19 vaccine hesitancy, concerns about COVID-19–related complications, and uncertainties about the long-term impact of vaccines or infections on the fetus may lead pregnant individuals to isolate themselves and avoid seeking medical help [18]. In such situations, telehealth could be an ideal model to facilitate prenatal care, ensuring that women can access necessary care even when they are hesitant to seek in-person care.

Conclusion

While face-to-face consultations remained the preferred mode of care, telehealth clinics could be an alternative for services that do not require physical examination or contact. Notably, acceptance of and confidence in telehealth grew as pregnancy progressed and after delivery.

To prepare for future unforeseeable infection outbreaks, there is a pressing urgency to incorporate telehealth in the obstetric care model. Various stakeholders and government bodies should invest in and develop a comprehensive telehealth system as a supplementary health care service. Enforcing stricter laws and guidelines can facilitate the implementation of telehealth clinics and increase pregnant women’s confidence in using them for obstetric care. This is a crucial step in laying the groundwork for addressing potential disruptions to face-to-face services and ensuring continuity of care provision should isolation and social distancing measures become necessary in the future.