Principal findings
This study showed that a model based on telehealth and education for the care of obstetric emergencies between two hospitals of medium and high complexity in southwestern Colombia significantly reduces perinatal mortality. The strategy allowed health professionals to optimally direct the management of patients and reduce transfer times to a higher level of complexity, which may be related to these results. An effect statistically significant for maternal outcome was not found, however, a reduction in the need for transfusion of blood products due to postpartum hemorrhage (PPH), as well as the rate of eclampsia was found.
The reduction in perinatal mortality found was an encouraging result for the teams from both institutions and, according to the evidence available in LMIC, can also be the result of strengthening the competencies of health personnel [
30‐
32]. However, the characteristics of the intervened population in Period 2, were different in terms of rurality, with the educational level to changing the found effect.
The institutional factors that directly affect the MMR and the preventable NMMR in up to 90% of the events include the availability of qualified human resources and the logistic conditions of care that allow complete and adequate management [
13,
14]. The use of telemedicine between highly complex hospitals and rural areas lacking specialists and environments with limited infrastructure can improve diagnosis, management, and patient outcomes [
8,
15]. The adoption depends on the acceptability of equipment, effectiveness, feasibility, use of resources, and indications for equity, gender, and rights.
Two meta-analyses in resource-limited settings showed that basic neonatal resuscitation decreased birth-related deaths (RR 0.70, 95% CI 0.59 to 0.84) [
33] and that basic training in neonatal resuscitation decreased the incidence of stillbirth (RR 0.79, 95% CI 0.44 to 1.41), mortality in the first 7 days (RR 0.53, 95% CI 0 .38 to 0.73), neonatal mortality at 28 days (RR 0.50, 95% CI 0.37 to 0.68) and perinatal mortality (RR 0.63, 95% CI 0.42 to 0.94) [
34]. This impact includes delivery care by trained personnel and a reduction in perinatal mortality (RR 0.77, 95% CI: 0.69 to 0.85) [
35]. In our model based on telehealth and education, knowledge of delivery care, monitoring for the detection of cases with nonreassuring fetal states, timely referral of pregnant women at high risk for perinatal mortality, and the standardization of fetal resuscitation in utero, and neonatal resuscitation processes were strengthened.
Although the differences did not reach significance, we consider it essential to highlight the reduction in transfusions and eclampsia events in patients referred to FVL after implementing our model. In the case of PPH, medical treatment in the first stages using intervention packages can determine efficient care without transfusions and surgical interventions. For this reason, the reduction of transfusion requirements may be an indirect marker of the improvement of care in the medium complexity hospital where the bleeding event occurred, especially when the availability of products for transfusion is insufficient for all LMIC needs [
36].
Eclampsia is also a clinical entity sensitive to the quality of care provided during preeclampsia. The disparity in the incidence of eclampsia between ICH and LMICs is related to time management and the availability of resources for care [
20]. Standardized protocols to prevent eclampsia determine that eclamptic seizures occur in less than 0 6% of pregnant women who receive magnesium sulfate [
37]. Additionally, early management of severe hypertension decreases the risk of cerebrovascular accidents and eclampsia [
38], if medications are administered within 30 to 60 minutes after the hypertensive emergency diagnosis [
39]. These principles were used in the educational process by creating mental maps shared between the teams of both hospitals and implemented in the management evaluated by telemedicine for preeclampsia cases, which were probably responsible for decreasing the proportion of patients with eclampsia.
The implementation of a telemedicine service among health providers in a middle-income country aims to overcome the historical barriers defined for this type of service [
40] and demonstrate the effectiveness, viability, use of resources, and implications for equity, gender, and rights that have been established by the WHO [
41].
Tele-emergency services have been considered a potentially life-saving technology, allowing the expansion of the obstetric team during critical events, shortening the time of care, improving coordination and promoting patient-centered care. However, one of the problems that makes the use more difficult is the technology adoption process, especially in low-resource settings with low exposure to technology, for this reason, implementing a support and educational model based on the needs of the less complex hospital was a definitive process for the technology adoption and the final use of the telemedicine service. The results of this project can generate an option for innovation in obstetric care by telehealth, promoting the reporting of similar strategies at a global level. The telehealth application in obstetrics includes prenatal control and sexual and reproductive health, but the care of patients in obstetric emergency settings has not been reported [
42].
Limitations and strengths
Our study has the weaknesses inherent to the “before and after” evaluations, especially the loss of information in the period before implementation, where there were no records of pregnant women in obstetric emergencies treated at HFPS and who were not referred to FVL. The main challenges for adopting a telemedicine program include the administrative commitment of health institutions and insurers, cost-effective infrastructure, and, ultimately, sustainability [
8]. In our case, all the challenges described were presented during the internal structuring process of the telemedicine program. The institutional operational infrastructure was carried out during the 9 months before the start of the teleconsultations. However, the development of solid strategic alliances between both hospitals and the commitment of the health secretaries of Santander de Quilichao and the Cauca Department allowed the consolidation of this strategy.
In Period 1, the education and preparation processes designed between both institutions were essential for the project’s success. Implementing intervention packages with the development of checklists, using modified early warning systems in obstetrics, procedural documentation templates, and simulation educational modules with a demonstrated impact on the management of obstetric emergencies [
42,
43]; these strategies were implemented in FVL in 2017, and adapted for replication in this project. Nevertheless, the experience has shown that change in the actions of medical teams using all these inputs are only possible if they incorporate the concepts of communication, teamwork, and safety culture, even in telehealth processes [
14,
43‐
45]. All these aspects were evaluated for both institutions and permanent monitoring from a more complex level allowed hospital teams of medium complexity to understand and incorporate these concepts, recover security and reliability in the health system and gain adherence to the project, especially when the team was recognized for the good results achieved.
No other models that adopt telehealth and collaborative educational strategies have been proposed in Latin America. Our study promotes the adoption of this type of strategy in developing countries, evidencing that this type of intervention positively impacts the burden of disease represented by obstetric emergencies.
Future implications
There is a regionalization model for obstetric care by levels in Colombia, concentrating very high-risk patients in very high-complexity centers, according to the evidence. In 2015, the American College of Obstetricians and Gynecologists (ACOG) and the Society of Maternal-Fetal Medicine established levels of maternal care [
46], considering that obstetric complications increase in hospitals with a low volume of deliveries and high-risk patients and that almost 59% of births occur in hospitals with less than 1000 deliveries per year where obstetric emergency events may occur. Therefore, efforts must be made in all institutions regardless of the level or volume of care.
Most LMICs do not have many highly trained medical staff members to manage obstetric emergencies and critical obstetric care, these staff members are concentrated in the most complex hospitals [
47]. The possibility of connecting the medical staff of low and high-complexity hospitals optimizes human resources and increases the chances of better maternal and perinatal outcomes. The experience of implementing the model can give impetus to the best use of telehealth strategies. For future projects, it is essential to establish the qualitative measurement of the impact that this program has on every team, which would help support the results of the implementation of technology between two health institutions.