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Nursing
Original research
Midwives’ experience of telehealth and remote care: a systematic mixed methods review
  1. Bethany N Golden1,
  2. Shaimaa Elrefaay2,
  3. Monica R McLemore3,
  4. Amy Alspaugh4,
  5. Kimberly Baltzell1,
  6. Linda S Franck1
  1. 1Department of Family Health Care Nursing, School of Nursing, University of California San Francisco, San Francisco, California, USA
  2. 2Department of Community Nursing, School of Nursing, University of California San Francisco, San Francisco, California, USA
  3. 3Child, Family, and Population Health Nursing Department, University of Washington, Seattle, Washington, USA
  4. 4The University of Tennessee Knoxville College of Nursing, Knoxville, Tennessee, USA
  1. Correspondence to Bethany N Golden; bethany.golden{at}ucsf.edu

Abstract

Introduction Increasing the midwifery workforce has been identified as an evidence-based approach to decrease maternal mortality and reproductive health disparities worldwide. Concurrently, the profession of midwifery, as with all healthcare professions, has undergone a significant shift in practice with acceleration of telehealth use to expand access. We conducted a systematic literature review to identify and synthesize the existing evidence regarding how midwives experience, perceive and accept providing sexual and reproductive healthcare services at a distance with telehealth.

Methods Five databases were searched, PubMed, CINHAL, PsychInfo, Embase and the Web of Science, using search terms related to ‘midwives’, ‘telehealth’ and ‘experience’. Peer-reviewed studies with quantitative, qualitative or mixed methods designs published in English were retrieved and screened. Studies meeting the inclusion criteria were subjected to full-text data extraction and appraisal of quality. Using a convergent approach, the findings were synthesized into major themes and subthemes.

Results After applying the inclusion/exclusion criteria, 10 articles on midwives’ experience of telehealth were reviewed. The major themes that emerged were summarized as integrating telehealth into clinical practice; balancing increased connectivity; challenges with building relationships via telehealth; centring some patients while distancing others; and experiences of telehealth by age and professional experience.

Conclusions Most current studies suggest that midwives’ experience of telehealth is deeply intertwined with midwives’ experience of the response to COVID-19 pandemic in general. More research is needed to understand how sustained use of telehealth or newer hybrid models of telehealth and in-person care are perceived by midwives.

  • Telemedicine
  • Reproductive medicine
  • Health Equity
  • Health Services
  • Maternal medicine

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi-org.ezproxy.u-pec.fr/10.1136/bmjopen-2023-082060

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    Strengths and limitations of this study

    • Adherence to the inclusion and exclusion criteria and the search strategies informed by Population, Intervention, Comparison, Outcome to identify midwives’ experience and perception of using telehealth.

    • Use of the Consolidated Criteria for Reporting Qualitative Research and the Strengthening the Reporting of Observational Studies in Epidemiology checklists to enhance detailed extraction of data and results.

    • Use of a convergent integrated approach to synthesize the findings across studies from diverse types of study designs.

    • A limited set of studies met the inclusion and exclusion criteria.

    Introduction

    The World Health Organization (WHO) recommends using telehealth and other digital interventions for its potential to increase access and strengthen healthcare systems.1 The pace of telehealth utilization accelerated in an effort to reduce the risk of transmission among patients and healthcare workers during the COVID-19 pandemic.2 3 As part of a global response, many sexual and reproductive health providers in Europe, Australia, Asia, Africa and the United States of America (USA) quickly integrated diverse telehealth models and used remote technologies to continue providing essential services.4 5 Concurrently, as telehealth transformed clinical practice and provider–patient interactions, WHO maintained the urgent need to invest in midwifery workforce and midwifery-led models and promote midwifery leadership in health systems worldwide.6 7 Midwives were identified as ‘pivotal’ to meet the 2030 Sustainable Development Goals.7 The focus on midwives’ vital contributions is evidenced in part from cross-cultural studies that demonstrate midwifery-led care improves health outcomes, decreasing preterm births, caesarean sections and medical interventions while maintaining patients’ experience.6 8–11

    Systematic reviews are needed to examine the research on midwives’ experience, perception and acceptability of telehealth in relation to their full scope of clinical practice. Midwifery models of care worldwide vary due to unique cultural, social and political environments with localized characteristics and constraints by setting.12 Yet, the model is rooted in the relational aspect between the person seeking care and the midwife.13 Midwifery has been traditionally practiced in person. Understanding midwives’ experiences of telehealth will highlight which transferrable skills and adaptive strategies are needed to uphold key facets of care that promote positive health outcomes as it evolves in the telehealth environment. Therefore, the aim of this systematic review is to summarize and synthesize the existing evidence on how midwives experience, perceive, and accept providing sexual and reproductive healthcare at a distance using telehealth. The main question for this systematic review is: how do midwives experience clinical practice at a distance when participating in telehealth?

    Methods

    The search strategy was informed by the aims of the review and Population, Intervention, Comparison, Outcome (PICO) statements.14 15 The systematic search strategy was designed for five electronic databases: PubMed, CINHAL, PsychInfo, Embase and the Web of Science. MESH terms and keywords were applied for each concept in the PICO14 (online supplemental material). Definitions and PICO inclusion and exclusion criteria for articles published between 1 January 2010 and 22 August 2022 are shown in table 1. The search start date corresponds with the WHO’s first definitions of telehealth and telemedicine, and the end date is when the literature search was completed. Reference lists of the selected studies and literature reviews were searched manually.

    View this table:
    Table 1

    Operation definitions and eligibility criteria

    Patient and public involvement

    None.

    Data collection management

    The results of the search strategy were compiled and managed in Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia). Articles were selected for eligibility by applying the inclusion and exclusion criteria at three steps in the screening process: title review, abstract review, and the full-text review. Two reviewers (BNG, SE) independently screened articles at the abstract and full text levels by using the software’s voting system: ‘yes’ or ‘no’ or ‘can’t tell’ and convened to reach an agreement for inclusion or exclusion. Special attention was given at the full text review step to double-checking the studies’ characteristics and comparing author names to ensure studies with same datasets were not included. The reviewers resolved conflicts, by engaging in open discussion to understand each’s other rationales and presenting evidence to reach consensus for inclusion.

    Data collection

    Data collection and extraction began with reviewing each identified study for key data items. Key data items were organized in a spreadsheet and included author/publication date/journal, setting for data collection, purpose/aim, sample method, stated method/design, theoretical/concept framework, findings/outcomes, model of technology/comparator and strengths and limitations. For quantitative studies, measurement tools (validated or non-validated), statistics and results were also extracted. For studies that reported telehealth experience of multiple types of providers, such as physicians and nurses, only the data pertinent to midwives was extracted. If needed, lead authors were contacted for additional data and clarification regarding findings specific to midwives. The systematic review protocol was developed in accordance with PROSPERO guidelines but was conducted in partial fulfilment of a PhD course and therefore was not permitted to be registered.

    Appraisal of the quality of studies

    Using the Mixed Method Appraisal Tool version 2018, the two independent reviewers (BNG/SE) appraised the quality of the studies.16 17 Reviewers independently assessed each article, then convened to determine consensus. The reviewers discussed all disputed criteria and presented evidence from the study for their assessment and then reached agreement to their final decisions. For reporting purposes, in additional to the appraisal descriptions, metrics are used to indicate low/medium/high-quality studies.18 Due to the dearth of published studies available for this review, the MMAT appraisal was used to assess quality but did not determine exclusion.19

    Data analysis

    To integrate the findings from the diverse study designs in the final sample, a convergent approach of transforming quantitative results to qualitative results was used, as recommended by JBI Manual for Evidence Synthesis.20 21 Quantitative data was extracted, then ‘qualitized’ as written text.21 Findings from qualitative studies were extracted verbatim and combined with the newly transformed ‘qualitative’ results derived from the quantitative findings, allowing for a narrative interpretation.21 Collectively, the findings were combined, sorted into groups and pooled into themes. The extracted key data items were also identified and compiled to create categories and collapsed for synthetiation.21

    Results

    Search results

    The search strategy yielded 6486 article titles. After removing duplicates, 3840 titles were screened, and 176 titles remained for abstract review. The two reviewers independently screened the abstracts resulting in 30 articles. One study was identified from bibliographies of three systematic reviews. 31 full-text articles were reviewed separately by the two reviewers, and 21 were excluded. 10 full-text studies were ultimately included in this review (see figure 1). Three lead authors were contacted for additional data and clarification regarding findings specific to midwives.22–24

    Figure 1
    Figure 1

    Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram. From Page et al.41

    Selected studies: design type, settings/services and aims

    The 10 studies meeting the review inclusion/exclusion criteria represented the views of 3354 midwives regarding telehealth in their midwifery practice. Of the 10 selected studies, 3 studies reported the telehealth experience of multiple types of providers (physicians, nurses, midwives), therefore only data pertinent to midwives was extracted.22–24 Tables 2 and 3 show the characteristics of each included study and table 4 displays the key thematic findings for each study.

    View this table:
    Table 2

    Characteristics of qualitative studies

    View this table:
    Table 3

    Characteristics of quantitative studies, quantitative thematic/content analysis, descriptive analysis and mixed methods

    View this table:
    Table 4

    Key themes and findings by author

    The study designs can be broadly categorized as qualitative (n=4),23 25–27 quantitative (n=1),28 quantitative with content/thematic analysis (n=2),22 29 quantitative with descriptive analysis (n=1)30 and mixed methods (n=2).24 31 The settings of nine studies were Australia (n=4),24 25 28 30 England (n=1),27 France (n=1),31 Switzerland (n=2)23 29 and the USA (n=1).26 One large worldwide study conducted thematic analysis of open-ended survey questions about telehealth and reported with exemplar quotes from midwives in Nigeria, Costa Rica, Norway, Uganda, Kenya, Bangladesh, Germany, USA, Nepal, France and Argentina.22 The settings of clinical telehealth services differed widely across the studies: antenatal/pregnancy-related, birth and post partum (n=8)23–30 plus gynaecology, family planning and abortion (n=2).22 31

    The telehealth mode for connecting with patients also varied across the studies: telephone only (n=2),27 28 telephone and videoconferencing (n=3)24 25 30 instant messaging only (n=1)23 and all modalities plus text (n=3).22 29 31 A single study used dedicated software,31 and one study did not specify the mode of telehealth.26 Notably, three studies explored midwives’ perceptions of telehealth for labour triage and postpartum care were conducted prior to the COVID-19 pandemic by phone or instant messaging service.23 27 28 Nine studies (n=10) were approved by Institutional Review Board or Ethics Committee, one research study was exempt (n=10).29

    The complete MMAT quality appraisal results are reported (online supplemental material). Five studies scored 80% achieving high quality25–28 31 and the other five studies scored 60% achieving medium quality.22–24 29 30 Issues in quantitative studies ranged from sampling methods that were not representative of the target population,28 30 lack of indicators of low non-response bias,22 30 the need for greater explanation of high non-response rate29 and limited information about the development of measurements.22 29 Qualitative studies were negatively assessed for narrow thematic definitions in analysis compared with presented data,25 insufficient data presented to substantiate principal finding,27 lack of appropriate methods for stated qualitative approach26 and lack of a clear qualitative approach with inadequate discussion of positionality.23 Each quantitative and qualitative components of the mixed methods studies were strong when assessed independently, however, the lack of integration of data24 and insufficient explanation of divergences between qualitative and quantitative data31 negatively impacted the scores of these studies.

    Common themes across study findings

    Five major themes with subthemes were found from the synthesis of the findings from the 10 studies. In addition to the descriptions below, a matrix of themes, their definitions and subthemes is provided in figure 2.

    Figure 2
    Figure 2

    Matrix of theme and subthemes.

    Integrating telehealth in clinical practice during the COVID-19 pandemic and beyond: perceived gains and losses

    Telehealth as an essential tool for the COVID-19 pandemic

    Seven studies found telehealth was both imposed on and implemented by midwives during COVID-19 to reduce risk of transmission of infection.22 24–26 29–31 It was considered a solid and essential tool healthcare delivery during the pandemic,22 24 25 29 31 but described as inferior to face-to-face visits and physical contact.22 25 31 However, some midwives perceived telehealth as personally beneficial as it enabled them to continue to work,29 31 to reduce their risk of infection,29 to maintain an income and to create a better balance between their personal lives and work during the pandemic.31 The possible role of telehealth post-pandemic as hybrid with in-person was viewed positively by midwives in two studies.25 30

    Concerns about the practice of midwifery going remote

    For many midwives, sharing physical presence with patients was deemed as essential for midwifery.22 25 29 31 Midwives were concerned about making errors in remote assessments and/or inadequately addressing certain health issues.23 Being unable to complete a physical assessment during virtual visits created anxiety.30 Midwives perceived there was insufficient data comparing maternal outcomes between in-person prenatal care and telehealth visits to justify telehealth adoption in routine practice.24 Some midwives perceived no advantage to using telehealth for remote treatment.29

    Benefits and disadvantages of incorporating telehealth into clinical practice

    In one study, midwives found telehealth convenient and easy to use,31 whereas in three other studies, midwives reported struggling with the technology.22 24 31 Interrupted internet access in remote areas, lack of equipment and larger infrastructure issues were also reported to impede telehealth use.22 24–26 Midwives who opted out of using telehealth perceived it as having little benefit or cited provider or patient preference for in-person.30 Some midwives preferred telephone over other forms of telehealth.23 29 31 In one study, some midwives experienced financial hardship as a result of using telehealth, having to personally cover the cost for internet access, resulting in the inability to follow-up with patients.22

    Balancing increased connectivity with little training and workload

    Lack of training, guidelines and protocols

    Prior to the COVID-19 pandemic, only three studies investigated midwives experience of delivering care via telephone and text.23 27 28 Managing labour via the telephone without formal training has been a requirement for midwives for decades and often goes unrecognized as part of their daily workload.27 28 During the COVID-19 pandemic, concerns about the lack of adequate training to effectively manage pregnancy-related health issues persisted.22 25 Following strict guidelines for remote consults was perceived as potentially detrimental for some patients. In one study, some midwives felt that the use of telephone checklists led to less customized care and some to ‘fall thru the cracks’.27

    Interacting with patients with greater frequency impacts workloads

    Two studies reported that midwives used telehealth to maintain connection and that it increased the frequency of interactions with patients,23 31 and three studies reported that it increased the midwives’ workload, in both hospital and community-based midwives.23 25 28 Midwives, who worked in the community with postpartum mothers in Switzerland, felt conflicted by wanting to be available via instant messaging applications (apps) to patients but not the additional workload it required.23 They were challenged by being placed in a new role as gatekeeper for the health system, receiving requests for help accessing health and social services outside of their scope of practice.23 Whereas midwives in another study reported a benefit of decreased workload by using telehealth. Positive views about telehealth decreasing workload were associated with age 39 and younger, professional experience of 14 years or less, and reimbursement for telehealth services.29 Midwives in England reported that telephone triage consultations served as a means of regulating the workload on maternity wards for other midwives.27

    Challenges with building relationships via telehealth

    Telehealth both disrupts and enhances interaction with patients

    Three studies reported that midwives perceived that telehealth was an obstacle to creating relationships with patients, instead creating a feeling of distance.22 25 31 Some midwives in two studies perceived limitations to telephone interactions specifically such as lacking the ability to visualize non-verbal cues and read body language.22 25 This was reported as particularly troubling when caring for non-native speakers, complicated by difficulty using interpreter services.22 25 However, midwives in one study who used continuity of care models with ongoing patient relationships felt that telehealth created more opportunities to interact and bond with patients and their families.26

    Identified strategies for remote inter-personal communication

    One pre-COVID-19 pandemic study explored midwives’ perspectives on what was necessary to deliver care well over the telephone and identified the following attributes: robust communication and intuition to accurately assess the patient’s health situation; thorough coverage of the medical history and clinical symptoms; and awareness of the patient’s geographical distance from in-person care.27 When speaking to patients, clear expectation setting, logical advice, an agreed on and confirmed summary of the plan were cited as necessary to confirm mutual understanding.27 In-person care for patients who called three times or sounded distress was advised.27 No other studies reported best practices for telehealth in midwifery.

    Centring some patients while distancing others

    Perceived benefits and appropriate telehealth services for patients

    In two studies, midwives perceived successful telehealth as defined by patients: when patients’ needs were met and patients were satisfied with the outcomes.27 31 Midwives cited telehealth benefits for patients as reducing the need for childcare, transportation, reducing geographical distance,26 promoting greater self-care29 and improving continuity of care and access.23–25 31 Childbirth preparation,22 post partum22–24 and lactation consultations22 24 were considered as appropriate telehealth services. Telehealth was seen as means of overcoming patients’ isolation and loneliness, as well as an essential life-saving service for ante partum, post partum,22 31 managing labour and abortion, during the pandemic.22

    Perceived barriers and inequities for patients

    Midwives in two studies perceived that patients felt less cared for with telehealth because of shorter visits and less time to answer patients’ questions.24 25 Midwives reported financial barriers to telehealth for patients who lack access to internet service,22 26 or phones or video-conferencing technology.22 Some midwives reported patient distrust of receiving care via telehealth, especially vulnerable populations concerned with interfacing with government agencies.22 Four studies reported midwives’ concerns about the lack of privacy and safety for patients, in particular the potential harms caused by screening for intimate partner violence and mental health via telehealth.24–26 30

    One study found that telehealth exacerbated patient distrust, stereotyping and bias among some midwives. Examples of included questioning patients’ ability to pass on relevant clinical data when directly asked, stereotyping of those who overused the telephone consultations as frequent fliers, and biases that patients lie about their health issues so as to be seen in person.27

    Experiences of telehealth by age and professional experience

    One study found that midwives who had more years of professional experience and older age reported increased rates of confidence in managing labour remotely than younger and less experienced midwives. The study also found that anxiety about telehealth was more often experienced by midwives with fewer years of professional experience and those who worked in urban/regional areas compared with those worked in rural/remote areas.28 Another study found that midwives with less professional experience also perceived more ongoing advantages of telehealth than those with more professional experience. The study also found that midwives who were reimbursed via telehealth also were more likely to perceive advantages following the COVID-19 pandemic than those who were not.29

    Discussion

    This review examined research on midwives’ experience, perceptions and acceptance of telehealth in delivering full scope sexual and reproductive care to patients. Overall, the findings suggest that midwives are conflicted about telehealth and its impact on clinical practice, balancing advantages and disadvantages to service delivery, workload, patient interactions, and health equity.

    The concerns expressed by midwives regarding lack of adequate training, technology skills and equipment are consistent with findings from prior research where diverse types of healthcare providers also report concerns about the use telehealth in clinical care delivery. In the review by Wu et al, negative experiences of virtual prenatal visits for prenatal providers and nurses commonly resulted from discomfort with technology, inadequate training and technical difficulties.32 Similarly, in a recent scoping review examining telehealth services, ‘technology and support’ and ‘technological knowledge and training’ were reported among the three greatest challenges of using telehealth for physicians, nurses, therapists, social workers and other staff from diverse specialties.33 To realize WHO recommendations of developing more midwifery-led models of healthcare and telehealth use to strengthen healthcare systems, this research suggests that further work is needed so midwives are adequately trained and equipped to integrate telehealth into practice.

    This review found that midwives commonly have concerns that telehealth is inferior to in-person visits, particularly with respect to physical assessment, missed clinical signs, errors and assessment of patient safety.22 23 25 31 Studies in the present review found that physical presence in an in-person patient-midwife interaction was a ‘hallmark’ characteristic of midwifery.22 25 31 The review by Penny et al supports these findings and similarly noted that registered nurses and midwives are particularly challenged by not being co-located or being able to see patients in person. In-person contact is an important part of their traditional practice and a feature that added value to their practice for many nurses and midwives.34

    A prominent theme of this review, ‘Centring some patients, while distancing others’ described how midwives viewed telehealth as benefiting some patients and disadvantaging others. Advantages included reducing the need for childcare, transportation and overcome geographical distance to improve access26 and continuity of care.25 In the review by Wu et al, prenatal patients reported similar advantages for virtual prenatal visits, except for improved continuity of care, even though the most preferred model of care.32 Reducing geographical distance and travel time was also reported as beneficial for patients by healthcare providers, nurses and patients in various specialties in the review by Jonasdottir et al.33

    Shorter visits with less time for patients’ concerns is a newer finding about midwives’ experience of telehealth, and significant for clinical practice because it could impact individualized patient-centred care and relationship building, all of which are necessary for improving care.35 In the present review, midwives perceived disadvantages of telehealth for patients such as shorter visits with less time for patients’ concerns,24 25 financial barriers for those who lack internet access or devices,22 26 lack of privacy for patients, dangers of remote domestic violence and mental screening,24–26 30 and the creation of greater distrust for those already concerned about interacting with institutions or being recorded.22 The review by Penny et al similarly reported that midwives and nurses’ had concerns about patient safety and privacy with videoconferencing,34 while Wu et al reported the need for reliable internet access, and the potential financial burden of remote equipment needs for prenatal visits like remote dopplers and blood pressure devices.32

    Another new finding of this review is that some midwives questioned patients’ honesty, intentions and ability to self-report, and stereotyped patients who they perceive as overusing services when triaging by phone.27 These experiences can be understood as stigmatising and perpetrating mistrust with patients. Telehealth combined with various forms of bias and concerns about privacy have the potential to deepen mistrust between provider and patients.36 To avoid replicating health inequities and discriminatory practices when using telehealth in reproductive health, further investigations are needed to fill this gap and understand how midwives contribute, perpetuate, and alleviate forms of inequities via telehealth, including multi-level racism and other forms of discrimination based on ethnic, gender, poverty, physical ability and sexual orientation.

    Strengths and limitations

    The strengths of this review include its relevance to current and future telehealth use by providing an emergent understanding of the topic. Five out of the ten studies were published in 2022 and three more since 2020. Two reviewers participated in the study selection process at abstract and full-text levels, minimising selection bias and increasing reproducibility, compared with a single reviewer.37 The majority of studies were published in 2022 and beyond offering emergent insights into telehealth. Rigorous study selection by two reviewers minimizes bias, enhancing reproducibility.36 Notably, a strength of this review is the inclusion of pre-pandemic telephone midwifery services, shedding light on midwives’ experience of decision-making and conducting clinical practice over phone, such as how to communicate with patients to create mutual understandings, the appropriate conditions of when to offer in-person visit and revelations about midwives’ own bias.26 As audio-only services expand, and midwives adapt to new telehealth formats, these findings pave the way for future research inquiries.

    However, limitations entail a small number of studies meeting inclusion and exclusion criteria and a lack of intervention studies. Methodological weaknesses in quantitative, qualitative and mixed-methods studies were identified in the appraisal of quality. None of the cross-sectional surveys were conducted with validated tools or randomized samples, making it difficult to reproduce or meta-synthesize quantitative results. Differences in healthcare delivery systems, standards of care, practice settings (eg, home, clinic and hospital), reimbursement, and scopes of practice impede the comparability and transferability of findings within and between low-resourced and high-resourced countries. While quality appraisal and review stages involved two reviewers, synthesis was done by one researcher, limiting cross-validation. Only studies published in English were included, creating gaps in our understanding that may be explained or explored in other cultural and linguistic contexts.

    This review is unique in that it examines midwives exclusively and the full scope of their clinical practices. In prior research and reviews, midwives’ experiences of telehealth were combined with those of other healthcare professions, such as nurses and physicians, even though practices and clinical responsibilities differ.32 33 38 As recognized by the WHO, midwives often occupy a different role with different training and responsibilities than other healthcare professionals in most health systems, making their experience relevant to growing the workforce.6 Midwives’ telehealth experience is often studied within the discrete confines of their telehealth practice that relates to perinatal care.23 25–30 39

    Future research

    Future research is necessary to deepen our understanding of how midwives experience sustaining telehealth in clinical practice as the public health emergency wanes. Additional research is needed to separate midwives’ experience with the COVID-19 pandemic and their initial experience of telehealth, which occurred simultaneously for many, with their actual experience of ongoing use. How midwives experience the next wave of telehealth models will impact critical issues for the midwifery workforce such as reimbursement, professional satisfaction and workload.

    Implications

    The findings identified in this review serve as starting point to understand midwives’ experience of providing care remotely. As midwifery gains prominence as a public health solution worldwide, much remains unknown about how midwives have adapted their practice to integrate telehealth for ongoing use, what types of training is deemed necessary to re-tool and prepare the workforce, and how telehealth impacts their workload. Identifying and exploring both the challenges midwives encounter and the strategies they use to meet reproductive health needs, to build relationships and assess patients remotely will inform clinical guidelines for clinical and administrative leaders and future training programmes for midwifery educators. Healthcare policy makers and public health experts can harness these experiences to build midwifery care models in concert with telehealth to offer more meaningful, professionally satisfying, and equitable use of technology in the delivery of sexual and reproductive healthcare. This area of research is fast-moving with new evidence which will require updated systematic reviews.

    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

    Ethics statements

    Patient consent for publication

    Ethics approval

    Not applicable.

    Acknowledgments

    We would like to acknowledge Peggy Tahir, research and copyright librarian, at University of California, San Francisco, for her thoughtful feedback and thorough review of the database search strategy and criteria for this review.

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    Footnotes

    • Contributors In collaboration with LSF, BNG conducted the systematic review including study design, search strategy, methodology development, screening, appraisal of quality, thematic analysis and prepared the manuscript, acting as guarantor. SE, as second reviewer, screened abstracts and full text published papers and assessed the quality of the studies. MRM, AA, KB critically reviewed the manuscript to reach the final submitted and approved version. LSF also edited, reviewed and approved the final manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.