The COVID-19 outbreak represents a significant and urgent threat to global health. On 30 January 2020, COVID-19 has been declared as “public enemy number one” and “a very high level of global risk” by WHO.[16, 17] As of March 23, 186 countries worldwide had reported confirmed COVID-19 cases, including more than 10,000 confirmed cases in America, Germany, France, Italy and Iran. In this study, many pregnant women were found postponing or canceling their scheduled ANC visits on their own, which was related to the severity of the epidemic situation in different areas, especially in the severe epidemic areas. Meanwhile, the needs of pregnant women for e-health have exceeded our expectation. Data showed that more than 15,000 consultations were conducted through the platform till March 15. To the best of our knowledge, this is the first time to focus on the characteristics of online obstetric consultation for pregnant women during the COVID-19 outbreak.
Changes in obstetric care-seeking behaviour during the COVID-19 outbreak.
In our study, we discussed the associations between the distribution of the amount of online consultation and trimesters or the severity of the epidemic in different area. The distribution of the amount of online consultation were significantly different not only in different areas, but also in different trimesters. The more severe the epidemic was and the more advanced the pregnancy was, the higher the percentage of second category (changed their schedules of ANC and/or delivery as well as method of delivery) was. During the COVID-19 outbreak, emergency traffic bans limited accessibility of some medical resource for pregnant women, and fear of viral transmission also prevented pregnant women from seeking routine ANC, especially in severe epidemic areas. All of these phenomena can explain the cause of the highest concern of second category in the areas with severe epidemic. Unlike the first and the second trimester, the need for more frequent ANC in the third trimester is already a huge challenge for pregnant women. In our hospitals, there were 16,120 outpatient visits in Obstetrics Clinic of the First Affiliated Hospital of Chongqing Medical University in last February, compared with 6,859 in February 2020. Furthermore, this difference was more dramatic in Maternal and Child Health Hospital of Hubei Province, because more than 21,000 outpatient visits were reduced in February 2020, compared with that of last February (27254 visits VS 5410 visits). The sharp decline of outpatient visits further reflected that pregnant women postponed or canceled scheduled ANC visits on their own. This phenomenon raised our concerns over a series of potential irreversible obstetric adverse events.
Significance of ANC.
In order to detect maternal complications, reduce adverse pregnancy evens and promote doctor-patient communication, 8 “contacts” is recommended between a pregnant woman and a healthcare provider according to WHO.[19, 20] Referring to the ANC guideline developed by America, Britain, Canada, and WHO, based on Chinese condition, Guideline of Preconception and Prenatal Care (2018) which was released by Chinese Medical Association, Chapter of Perinatal Medicine (the corresponding author, Professor Qi, is included) recommends 7–11 “contacts”. If there are high risk factors, the frequency should be increased appropriately. This guideline is widely applied by almost all domestic ANC institutions in China. Benefiting from the widespread application of the ANC guideline, birth defects and cesarean section rates have been reduced, and many other adverse pregnancy outcomes have been avoided in China.[21–27] Nevertheless, during the COVID-19 outbreak, the routine ANC for pregnant women who are considered to be susceptible are extremely challenged.[28, 29] In the past month, we noticed that some highly recommend antenatal check-ups had been canceled or postponed beyond its opportune gestational age by many pregnant women. The phenomenon might related to the delayed detection of fetal malformation and a significant increasing incidence of diabetes, macrosomia and obesity due to lack of nutritional interventions or routine physical activities. What’s more, some pregnant women wanted to be hospitalized earlier to wait for the onset of labour or to have a cesarean in advance driven by an idea that as time went on, the chance of infection would increase. On the other hand, some pregnant women with indications of hospitalization blindly refused to be hospitalized for fear of infection with COVID-19. To prevent irreversible obstetric adverse events, some highly recommended antenatal check-ups must be conducted on time, and when it comes to conduct ultrasound examination for confirming intrauterine pregnancy and Nuchal Translucency (NT) measurement, screening for foetal aneuploidy, oral glucose tolerance test (OGTT), etc., pregnant women have to visit hospital in person. And prompt hospitalization were highly recommended in the following circumstances, approaching terminal gestational age, pregnancy with severe maternal medical condition, with signs of labor, etc..
A novel mode of ANC plan with full application of e-health.
In our survey, most of the participants were the first time to experience e-health. What’s more, 91.95% pregnant women reported that they preferred e-health rather than a visit to hospital during the COVID-19 outbreak in the severe epidemic areas. The majority of pregnant women were completely or comparatively satisfied with e-health, and most of online obstetric consultations were completely or mostly solved. Except the second category, most pregnant women are more likely to consult about the first and third category, which probably due to the familiarity of e-health among the public. This result was consistent with the report of China Internet network information center (CNNIC) in June 2019. Actually, the “e” in e-health not only stands for “electronic”, but also means telemedicine, telecare, clinical information systems, and other non-clinical systems used for education, public health, medical management and so on. E-health has made some achievements in the management of chronic diseases such as diabetes and hypertension disorders.[31, 32] The application of e-health in obstetrics is mainly reflected in the abortion of unplanned pregnancy in the first trimester.  The popularity of wearable devices promotes quantitative health management. Nevertheless, “e-health” cannot save everything. Some highly recommended antenatal check-ups and timely hospitalization are still necessary. Our domestic clinical ANC guideline is divided into health education and guidance, routine health care and auxiliary examination. According to the investigation of online obstetric consultation during the COVID-19 outbreak, we recommend to combine e-health with the ANC guideline in the following three aspects: (1) management of mental health, routine health education and care, authoritative prevention education on PHEs; (2) auxiliary procedures done through e-health for necessary check-ups recommended in hospital by obstetricians, such as making appointments, consulting examination reports etc.; (3) interventions of some maternal medical conditions performed through e-health, including gestational diabetes mellitus, hypertension disorders, etc., which had been fully applied in non-pregnant people. We hold that the full application of e-health and prenatal care is highly recommended to be included in the contingency ANC plan during PHEs, which will be beneficial for pregnant women and mitigate the risk of adverse pregnancy outcomes.