The Medical University of South Carolina Medical Center in Charleston has a unique telemedicine program in place to help pregnant and postpartum women.
The program is called Listening to Women and Pregnant and Postpartum People, or LTWP. The technology vendors are REDCap and Twillio. It’s a mid-maturity program that is responding to behavioral health needs of pregnant women, and has recently expanded to newborn virtual home visitation for all mothers with births in the hospital.
Pregnancy-related maternal mortality
Mental health conditions are the leading cause of pregnancy-related maternal mortality due to suicide and drug overdose.
Many of these deaths and maternal and child morbidity associated with mental health conditions can be prevented or improved by better screening and access to mental health and substance use disorder treatment.
Unfortunately, most women will not be screened – and less than 25% will make it to treatment, said Dr. Constance Guille, director of the Women’s Reproductive Behavioral Health Division at the Medical University of South Carolina, as well as a professor in the departments of psychiatry and OB/GYN.
“Key patient-, provider- and systems-level barriers prohibit adoption of evidence-based recommendations and care coordination across pregnancy and the postpartum year,” she continued. “The breadth of recommended screenings, and the depth of knowledge needed to adequately assess and appropriately connect pregnant and postpartum women to treatment and/or resources is difficult to obtain in our current health systems.
“Insufficient time, unfamiliarity with screening tools, and lack of knowledge about perinatal mood and anxiety disorders, perinatal substance use disorders, intimate partner violence, SDH and the availability of treatment services are reasons cited for not adopting screening and referral practices,” she said.
Potent barriers to treatment
Individual patient factors such as lack of knowledge about perinatal mood and anxiety disorders, perinatal substance use disorders, and stigma are potential barriers to treatment.
“Treatment services often are located in a system outside of where pregnant and postpartum women receive OB or PED care, resulting in a lack of communication and coordination of care between providers,” Guille explained. “Care is further fragmented across health systems where past screening and treatment information is not available to current providers.
“Mental health screening in routine prenatal care is conducted face-to-face with a healthcare provider, but prior research demonstrates that patients are more likely to endorse more stigmatized conditions or behaviors when asked via technology.”
Dr. Constance Guille, Medical University of South Carolina
“There are evidence-based practices to increase screening and referral to treatment for perinatal mood and anxiety disorders, perinatal substance use disorders, intimate partner violence and SDH, and improve patient, provider and systems of care communication and coordination, which have the potential to reduce maternal mortality; however, there are no systems of care that address all these elements concurrently, resulting in knowledge gaps regarding the best model to support better screening, referral, attendance to treatment, and communication and care coordination during pregnancy and the postpartum year,” she continued.
Better systems of care are needed to improve screening, referral and attendance to mental health and substance use disorder treatment for pregnant and postpartum women, she contended.
“Text/phone-based screening and referral to maternal mental health treatment overcome the many patient, provider and healthcare-system barriers to treatment,” she said.
How LTWP works
LTWP is designed to fill these gaps with a scalable, easy-to-use and low-resource intervention.
“Mental health screening in routine prenatal care is conducted face-to-face with a healthcare provider, but prior research demonstrates that patients are more likely to endorse more stigmatized conditions or behaviors when asked via technology,” Guille noted.
“We choose simple SMS text messaging, because it is convenient and accessible to almost all patients,” she continued. “For women screening positive, we choose to have a care coordinator with a masters in clinical social work to contact the patient by phone, which provides confidentiality and is convenient for the patient.”
The care coordinator can understand the patient’s social and mental health needs and work with the patient to put a treatment plan in place that ensures there are not any barriers to access that care plan.
“LTWP employs care coordinators with a clinical MSW, because the extant training and skillsets that are prerequisite to MSW licensure are the exact same skills required for the LTWP care coordinator – for example, accurate assessment of MH/SUD/intimate partner violence, appropriate use of motivational interviewing, and identifying SDH and referrals to resources,” Guille explained.
“This pragmatic approach prevents dilution of a care coordinator’s effect when implemented outside of a controlled study setting, and reduces the cost associated with additional training and retraining due to staff turnover,” she added.
A pragmatic, quasi-experimental study
The Medical University of South Carolina evaluated LTWP in a pragmatic, quasi-experimental study of 3,535 pregnant women receiving prenatal care in a single large urban OB practice.
The study was designed to compare two separate cohorts of pregnant women – those who received prenatal care January 2017 to December 2019 when screening, brief intervention and referral to treatment was completed in person versus pregnant women who received prenatal care January 2020 to April 2021 when screening, brief intervention and referral to treatment was completed via LTWP.
“The aim of the study was to determine if the proportion of women receiving LTWP were more likely to be screened, screen positive, be referred for treatment and attend treatment compared with women receiving in-person screening, brief intervention and referral to treatment,” Guille explained.
“In‐person screening, brief intervention and referral to treatment was completed in 65.2% of pregnant and postpartum women,” she continued. “Conversely, 98.9% of pregnant women agreed to take part in LTWP, and 71.9% completed the text screening. Pregnant women enrolled in LTWP were significantly more likely to be screened, screen positive, be referred to treatment, and attend treatment, compared to in‐person screening, brief intervention and referral to treatment.”
Health equity
Racial disparities identified with in-person screening, brief intervention and referral to treatment were not present with LTWP. Black pregnant women compared with white pregnant women enrolled in-person screening, brief intervention and referral to treatment were significantly less likely to attend treatment; however Black and white pregnant women were equally as likely to attend treatment with LTWP.
“The clinical trial was designed to approximate routine clinical care by using existing clinic staff such as nurses to enroll pregnant and postpartum women in LTWP during prenatal care,” Guille concluded. “With minimal training, nurses began successfully enrolling pregnant and postpartum women in LTWP.”
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