Introduction

The COVID-19 pandemic, declared by World Health Organisation in March 2020, has left an indelible mark on healthcare systems worldwide, prompting a paradigm shift in the delivery of medical services. As traditional healthcare structures faced unprecedented challenges during COVID-19, the need for innovative approaches became apparent. In response, telehealth emerged as a promising solution, providing a virtual platform to bridge the gap between healthcare providers and patients. The obstetric field worldwide, in particular, witnessed a surge in the adoption of virtual clinics, enabling the provision of prenatal care, consultation, and monitoring remotely.

Indeed, the rise in popularity of telehealth in obstetrics has been noted by The American College of Obstetricians and Gynaecologists (ACOG ) [1], and existing literature has demonstrated comparable outcomes of patient satisfaction with antenatal virtual clinic as compared with in person consultation. [2]. A recent systematic review of the use of virtual clinics in O&G evaluated 47 studies of which 19 were in low-risk obstetrics and 13 were in high-risk obstetrics. Findings showed the successful monitoring and communication of home blood sugar and blood pressure data between patient and provider, supporting the utility of telehealth even in high-risk obstetrics [3]. Moreover, the success of telehealth was further demonstrated in the United Kingdom, where the National Health Service (NHS) rapidly and successfully adopted telemedicine as an alternative to face-to- face consultation during the COVID-19 pandemic and hundreds of women demonstrated high satisfaction with the social medial based antenatal support service during periods of lockdown.

In light of these global trends, it is crucial to explore whether the people of Hong Kong are receptive to the concept of telehealth within obstetric units. Hong Kong's healthcare system, known for its efficiency and quality, faces the ongoing challenge of catering to a dense population with limited resources. Adopting virtual clinics could potentially address these constraints, offering a sustainable solution for obstetric care. However, understanding the perception and acceptance of such an approach by the local population is imperative before implementing telehealth services in Hong Kong.

In our unit, expectant mothers attending the booking visit between 10th to 12th week of gestation in Tsan Yuk Hospital were offered an early pregnancy dating scan and Down’s syndrome screening. If they were screened positive, a face-to-face consultation with a midwife would be arranged for explaining the results and offering the options of non-invasive prenatal testing (NIPT), invasive testing (such as chorionic villus sampling or amniocentesis) or expectant management.

This cross-sectional questionnaire study aims to delve into the perception and acceptance of virtual clinics in obstetric practice by investigating the attitudes, expectation, concerns, and preferences of pregnant individuals, in Hong Kong regarding the implementation of virtual clinics in obstetric practice and preference of clinic type if they were screened positive for Down’s syndrome. The findings will contribute to evidence-based decision-making regarding the integration of telehealth services, ultimately striving for improved accessibility, enhanced patient experiences, and optimised resource allocation within Hong Kong's obstetric units.

Methods

This was a prospective cross-sectional study. Questionnaires were distributed in a paper format to pregnant ladies attending their first antenatal visit in Tsan Yuk Hospital between April and August 2021 during the COVID-19 pandemic time. The questionnaire was available in Chinese and English. The questionnaire was anonymous and all women gave informed consent for the questionnaire and for the publication. All patients were treated in accordance with the Declaration of Helsinki. Questions were divided in different parts - (1) Basic demographics (e.g. Their age, parity, income, education level, travelling time to clinic), (2) Awareness of virtual clinic (e.g. If they have heard about or experience about virtual clinic) (3) Preference of virtual clinic (e.g. If Down’s syndrome is screened positive, if they wish to be notified via face-to-face vs virtual clinic, factors that may encourage or discourage subject to attend virtual clinic) (4) Expectation and preference of virtual clinic (e.g. If patient thinks virtual clinic can be implemented in Hong Kong, and what form of virtual clinic do they prefer). The ethical approval from the Institutional Review Board of the University of Hong Kong/ Hospital Authority Hong Kong West Cluster has been obtained. (UW 21-298).

Statistical Analysis

To compare demographics between groups, Pearson Chi- square test and Fisher’s Exact test were used for categorical data. The multiple logistic regression analysis was performed by including factors found to be significant at the level of p<0.1 in the univariate analysis. To compare significant differences when there was no COVID-19 and during COVID-19 pandemic, McNemar test was performed for categorical data. Analyses were conducted with SPSS software version 26. P-value of < 0.05 was considered statistically significant.

Results

Out of 427 questionnaires distributed and 403 questionnaires had questions completely answered, giving a response rate of 94%. Table 1showed the background characteristics of the cohort. Most respondents were Chinese (90.1%), women aged between 26-35 (66%) with at least tertiary level education or above (81.2%) and in employment (83%). For 47.6% of respondents this was their first pregnancy. 86.1% of women surveyed required one hour or less to travel to the clinic.

Table 1: Demographic of patient’s background

70.4% (285/405) of patients indicated that they would prefer virtual clinics to face-to-face clinics during COVID-19 pandemic, and 30.4% (123/405) believed they would choose virtual clinic if there was no COVID- 19 pandemic (p<0.001) (Table 2). Regarding the preference for type of clinic in obstetric care, only 9.4% (38/405) women stated virtual clinics were better than or similar to in-person clinics. 80.7% of patients thought face-to-face clinic was slightly or much better. (Table 3). Regarding the preference for counselling on positive Down’s syndrome screening, only 15.6% (63/405) of respondents accepted a virtual clinic. (Table 4). Regression analysis showed that pregnant women who were younger than 26 years old (OR: 5.88, 95% CI: 1.03 to 33.49), had monthly household income over $30,000 (OR: 2.89, 95% CI: 1.07 to 7.75) and previously heard of virtual clinics (OR: 2.01, 95% CI: 1.16 to 3.48) were more likely to choose virtual clinic for Down’s syndrome screening counselling clinic. (Table 5)

Table 2: Preference of attending a virtual clinic over a face-to-face clinic

Table 3: Preference of virtual clinic over a face-to-face clinic in Obstetric practice

Table 4: Preference of virtual clinic over a face-to-face clinic if Down’s syndrome screening positive

Table 5: Logistic regression analysis on factors favoring virtual clinic for Down’s syndrome screening

counselling clinic in pregnant women

*Statistically significant (p<0.05). CI-Confidence Interval.

There was no significant difference for women’s choice of clinic regardless of their employment status (p = 0.071) (Table 1). We did not observe a significant difference between nulliparous and multiparous women in terms of their preference for virtual clinic visits over face-to-face clinic visits.

Table 6: Patients’ preference in attending virtual clinic over face-to-face clinic in COVID pandemic versus preference of virtual clinic in Obstetrics practice versus their believes in Obstetric virtual clinic implementing in Hong Kong

*Statistically significant (p<0.05). Categorical data are expressed as N (%).

Among 96% respondents who thought face to face was better for obstetric service, nearly one quarter of them believed that virtual clinic could be successfully implemented in Hong Kong. (p<0.001). Respondents who thought face-to-face clinic is slightly better than virtual clinic (OR: 2.69, 95% CI: 1.59-4.53), or both clinics are similar (OR: 4.51, 95% CI: 1.52-13.34) in Obstetrics practice, and also thought that virtual clinics in obstetrics can be implemented in Hong Kong (OR: 3.45, 95% CI: 2.08-5.71) were more likely to prefer attending a virtual clinic over a face-to-face clinic during the COVID-19 pandemic. (Table 6)

Only 37% (149/403) of patients surveyed had heard of virtual clinics. Internet (52.3%) was the main source of the information, while around one fifth learnt about virtual clinic from hospitals or clinics (Table 7)

Table 7: Sources to learn about virtual clinics

Table 8 summaries the factors affecting the choice of clinic type. Pregnant women cited a lower risk of infection under pandemic conditions (83.2%) as the top benefit of virtual clinic, while the inability to perform fetal heart examination (83%) was the main reason for choosing a face-to-face clinic. On asking which antenatal visit could possibly be replaced by a virtual consultation, 27% indicated the general antenatal visit in the middle of second and third trimester as the preferred ones (i.e. 14-16 weeks and 33 weeks). (Table 9) Furthermore, 23.2% of respondents believed that the initial booking visit could be replaced by a virtual clinic.

Table 8: Factors that may encourage or discourage patient from attending a virtual clinic

Table 9: Opinion from respondent of which antenatal clinic can be replaced by virtual clinic

Categorical data are expressed as N (%).

Over half (59%) of respondents preferred using live video consultations to solve medical issues in virtual clinics compared with telephone consultations or online text chats (20% respectively).

Discussion

Our results show that virtual clinic in Obstetric practice was not well received in our locality at the time of study with 80.7% of patients thought face-to-face clinic was better (Table 3). One of the important factor is the lack of awareness of virtual clinics. Most respondents (63.5%) had never heard of virtual clinics prior to the survey, with 80% of respondents unaware of any providers of such services within our locality. This is reflected in our significant findings that women who were aged below 26, and between 36-40 who had heard of virtual clinics before were more likely to prefer them.

Another concern raised by patients was the absence of Doptone examinations and other physical check- ups during virtual clinic visits. Patients may perceive that absence of these medical procedures may compromise their health and possibly affecting maternal and fetal outcomes. Yet these findings may be constrained to our locality only. Indeed, two systematic reviews [3,4] elucidate that incorporating telehealth in obstetric care can maintain or enhance outcomes for both mother and baby. It was found that in studies where patient data (e.g. home blood pressure monitoring) were submitted remotely to the antenatal outpatient clinic, there were fewer scheduled outpatient visits for management of hypertensive diseases or disorders of glucose metabolism in pregnancy [3], all while safeguarding the health of both the mother and the fetus. Another study about remote monitoring of hypertension disease in pregnancy, conducted in Belgium with a study size of 146 patients in 2017, observed a reduction in the progression of gestational hypertensives to preeclampsia as well as a lower need for interventions such as induction of labour and hospitalisation of both mother and neonate [5]. A meta-analysis of remote uterine monitoring to detect the symptoms of pre-term labour demonstrated comparable perinatal mortality rates and increased gestational age at birth when compared with regular care, showing a 20% reduction in preterm births [4].

Survey [6] in a high-risk obstetric population in the United States in 2020 showed that nearly 90% of respondents were satisfied with telehealth care and almost 80% would recommend a telehealth visit, with over 70% preferring a hybrid model. The study also showed a significantly lower rate of cancelled appointments with telehealth, which supports the argument that telehealth may contribute to improved obstetric outcomes by maintaining compliance to follow-up and monitoring.

Other reasons for our respondents not choosing Obstetrics virtual clinic included difficulties in obtaining medication. Medication delivery service was implemented by the Hospital authority of Hong Kong on January 9, 2024. This service can alleviate the difficulty in obtaining medication for virtual clinic patients and potentially enhancing the acceptance of virtual clinic visits.

There was improved acceptability and preference of virtual clinics during COVID-19, which was reflected by our results with 30.4% of respondents preferring virtual clinic when there was no pandemic of COVID- 19 and that improved to 71% preferring virtual clinics during COVID-19 with the benefit of reducing infection risk, reducing need of taking leave from work, shorten travelling and waiting time and high accessibility. In short, our findings seem to support the conclusion that there is an increased acceptance of virtual clinics in our locality following the COVID-19 pandemic. This is concordant with recent study [7] which show a shift towards more positive patient perceptions towards telehealth following the COVID-19 pandemic.

Telehealth may be suitable and more acceptable in a low-risk setting as 83.2% women preferred face-to- face clinic for counselling of positive screening results of Down’s syndrome. Given the sensitivity of this diagnosis, patients may have a greater need for in-person discussions with their healthcare providers to address their concerns, receive emotional support, and make informed decisions regarding their pregnancy.

Furthermore, the reduction in scheduled clinic and unscheduled hospital visits borne by the adoption of telehealth may lead to a significant overall reduction in cost and resources. With the increasing levels of burnout reported in our specialty (of up to 58% in some studies [8] as well as a high attrition rate of 30% as detailed by the last RCOG Workforce Report in 2018, the successful implementation of telehealth may be crucial in reducing burnout as well as retaining O&G specialists.

One limitation of our study was that patients were surveyed at their initial booking visit instead of at multiple timepoints along their entire patient journey. Doing so may have shown changes in attitudes towards virtual antenatal clinics. In a study conducted by Cheung et al.[9], they investigated the acceptance and confidence levels of telehealth in relation to physical symptoms and antenatal procedures as gestation advanced and after delivery. Their findings indicated that as gestation progressed and after delivery, there was an increasing acceptance and confidence in utilizing telehealth for certain physical symptoms and antenatal procedures. This suggests that patients may become more receptive to virtual clinic visits as they progress further into their pregnancy or at the postpartum period.

Conclusion

In conclusion, our study found that COVID-19 pandemic led to increased acceptance of virtual clinics, driven by reduced infection risk and convenience. Concerns about the absence of certain procedures or difficulties in obtaining medicines were identified, but medication delivery services was implemented in Hong Kong which may potentially enhancing the acceptance of virtual clinic visits. Improved awareness, education, and uptake of telehealth are crucial to address reservations and enhance acceptance.

Conflicts of Interest

None declared

References

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Appendix

Table 13 Demographic of those prefer face-to-face clinic only vs virtual clinic in Down’s syndrome

Screening

*Statistically significant (p<0.05). Categorical data are expressed as N (%).