A Qualitative Examination of Patient Experiences and Determinants of Virtual Postnatal Follow-Up Visits

Objective: This study aimed to understand the perceptions of new mothers using virtual care in the form of video conferencing to gain insight into the social and environmental determinants that could potentially impact compliance for post-natal follow-up visits. Methods: Semi-structured interviews were conducted with 15 patients of Kingston Health Sciences Centre. The interviews were 20-25 minutes in length and recorded through an audio recorder. Thematic analysis was conducted in order to derive the major themes explored in this study. Results: In general, new mothers reported high satisfaction with virtual care, emphasizing benets related to comfort, convenience, communication, socioeconomic factors, and the ease of technology use. Conclusions: Not only can virtual care address many of the barriers that new mothers face in accessing in-person healthcare services, but virtual care can also elucidate various social and environmental determinants responsible for facilitating access to postnatal follow-up care. Further research and clinical endeavours should focus on these various determinants (and the ways they intersect) and how they underpin patient perceptions of virtual and in-person care. Such a lens not only addresses the struggle of long-term patient compliance to maternal health care, but will additionally shed light on how to make obstetric care more equitable.


Introduction
A signi cant proportion of women experience medical complications such as hypertension and diabetes in the postpartum period1 , 2.
Many of these conditions require and bene t from ongoing medical care, as long-term prognosis could lead to an elevated risk of cardiovascular disease and mortality1 , 2 , 3. Hypertensive disorders and gestational diabetes have been associated with a 50-300% increase in risk for cardiovascular disease4 , 5. A multitude of factors related to pregnancy and associated medical complications can signi cantly affect the quality of life of new mothers6 , 7 , 8 , 9. Thus, clinical intervention in the postpartum period is signi cant in reducing maternal morbidity and increasing quality of life. However, the burden and demands of dealing with pregnancy and the post-partum period along with the pre-existing barriers in accessing health care (socio-demographic and geographical) can all negatively impact patient compliance in attending postnatal follow-up clinics10 , 11. Telemedicine can serve to improve accessibility to postnatal healthcare services for this unique patient population and thus enhance patient care12 , 13. Virtual care allows patients to consult with their healthcare provider through digital technologies. Virtual care can be conducted through various modalities, such as email, text messaging, or audio-videoconferencing and through personal digital devices, such as a smartphone or tablet, without any additional infrastructure required14 , 15 , 16.

Social Determinants of Health in New Mothers
The World Health Organization de nes the social determinants of health as the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life17. The Social Determinants of Health (SDoH) framework posits that biological outcomes and access to health care are mediated by social inequalities18. In particular, gender uniquely intersects with other social and environmental determinants. As such, new mothers are often burdened by a unique set of challenges and can be disproportionately limited in their access to health care. Immigration status, language pro ciency, Aboriginal status, food insecurity, poverty and rurality are known determinants that make it di cult for mothers to obtain the care they need19. However, the SDoH may uniquely impact health and healthcare access for new mothers given that considerations around accessibility may be different. Therefore, the objective of this study was to understand the experiences of new mothers using virtual visit for postnatal follow-up visits and to understand if virtual care can address challenges related to health care access.

Methods
Semi-structured interviews were conducted with patients being seen at the Kingston Health Sciences Centre (KHSC) for maternal postnatal follow-up virtual visits with an obstetric medicine physician. Virtual visits, via video conferencing, were supported by the Ontario Telemedicine Network (OTN)20. 31 patients who completed a virtual visit appointment between February and August 2020 were invited to participate in this study 21. A medical secretary invited all potential participants by telephone. It was decided to recruit a limited number of participants to maintain a strong level of rigor in the data collection and analysis. The purpose of using semi-structured interviews in qualitative research is to guide interviewees to speak about their lived experiences with a phenomenon openly without a pre-set answer21.
The interviews were conducted over the telephone and recorded using an audio recorder and lasted 20-25 minutes. Ethics approval was obtained by the Queen's University Health Sciences Research Ethics Board.
Two study team members (S.C. and M.S.), a research associate and a medical student, conducted the telephone interviews. It was made known to the participants that the research team sought to better understand how the potential barriers of virtual care. Field notes were taken during the interviews. The interviews were transcribed verbatim by a hired transcriptionist, and the transcripts coded by S.C. and M.S. The data was coded using NVivo 12.0. Braun and Clarke's thematic analysis approach was used throughout the coding process for identifying, analyzing and reporting patterns within the data22. Consensus of the coding themes was reached through an interactive process, where S.C. and M.S. came together at every 5 th stage of the coding process to review and re ne the parent and subthemes.

Results
Out of 31 potential participants, 15 participants were interviewed from July-August 2020. 6 patients declined to participate in the study. 9 participants signed up to participate but did not end up completing the interview following multiple attempts at follow-up. The ages of participants ranged from 22 to 41 years. All participants identi ed as female, and majority of participants were married, Canadian-born and of white/Caucasian ethnicity, employed, living in Kingston, ON, and had a bachelor's degree or above (Table 1). Details on travel distance, travel time, number of virtual care visits, and the medical pro les of the participants are listed in Table 2.

Challenges of Being a New Mother
Across the interviews, participants spoke broadly about their mothering experiences. Many participants spoke speci cally to the challenges of being a new mother and changes they have adopted to their daily lives since having a child. Some of the changes included having to prioritize their child's needs, adopting new routines, and balancing multiple con icting priorities. Challenges associated with these changes included scheduling di culties for healthcare appointments or other daily activities, increased demands for planning and arranging the day, di culty breastfeeding, time constraints associated with a busier lifestyle, and the overall burden of care on new mothers.

Bene ts of Virtual Care
In describing experiences with virtual care, participants overall spoke very positively. Some of the factors that contributed to participants' positive experiences with virtual visit included those that facilitated comfort and convenience for participants, including not needing to take time off work and lose a day of income: You didn't feel a disconnect. I was able to speak freely with [obstetrics physician] and in the comfort of my own o ce. I have a door, I was able to shut the door and just have the meeting during my lunch hour so it was perfect.
It's great because I don't have to worry about getting ready and making child care arrangements. I can just put my son in the chair next to me and it makes it far more accessible. Neither of us has to take time off work really.
Many participants revealed virtual care served to alleviate various di culties associated with the domestic tasks of new mothers. These di culties included working around the child's eating and sleeping schedule, working around the schedules of multiple children in the household, or working around the schedules of their caregivers or family members. Additional challenges included barriers associated with travel time, distance, nding parking, and cost.
It made it a lot easier 'cause it was a lot less time consuming, not having to pack up and go out. I can even do it while the baby was napping and not have to mess up their schedule, like, kids' schedules. It was a lot easier.
I found it much easier to just be able to be at home, not have to worry about getting the kids ready and long care rides or have to worry about ndings someone to watch them. They were very good if I needed to take care of the baby for a second or breastfeed. There's a lot you do.
Participants also found virtual care to be relieve emotional stress related to attending the hospital.
Saving gas money, parking money, and I hate driving so it was a huge emotional stress driving to Kingston every single time. My mental health was much better for not having to go at that time.
I think just in general making people's life better. You don't have people getting on the road on an icy day that they don't need to. I just think there's a lot of bene ts to society with something like this.
Additional bene ts of virtual care included fostering long-term compliance to obstetric follow-up care by facilitating emotional support and rapport with the obstetric medicine physician.
Kingston's a far drive for me so when I was near the end, especially when you're heavily pregnant, I already had that emotional support and I could trust my doctor, so just being able to do a virtual visit was huge for me. It helped my husband not have to arrange his schedule for work and it helped me still stay reassured that everything was going to be ne.
Honestly, it helped big time because I can still see [the healthcare provider] and still communicate then instead of wasting money on transportation and having to do extra time trying to get her [child] ready, getting everything done and being there on time. Where here you can just do it through the phone. If I can still be feeding her and still be doing it so it helps in the long run.

Challenging Aspects of virtual visit and Virtual Care
Few participants spoke to the negative aspects of using virtual visit. While many of the participants in this study did not experience technological di culties, some inferred that poor internet connectivity, audio issues, and technology could serve as barrier for older patients. One participant spoke to these challenges in the context of living in a rural town: For me it's easy to navigate. If it was my parents it would be a nightmare. They're…needs to be seen in person. It's just not gonna happen.
Accessibility, we're in a rural area and we don't really even have high speed internet. We're lucky we're still not dial-up…My parents live in a place where it's hard to even get any internet. They live ve minutes down the road and you have to pay for one of those special satellite things to come or get the tower in order to even get internet.

Discussion
The purpose of this study was to understand the experiences of new mothers using virtual care for postnatal follow-up. The data suggests that virtual visits were considered a convenient, low-barrier, and accessible modality for healthcare delivery for postnatal followup care. In the context of being a new mother, virtual visit was able to address many challenges unique to this population, such as scheduling di culties, needing to arrange for childcare, and time constraints due to busier routines. These ndings are consistent with previous literature, where patients found virtual care to be convenient, time-saving, and accessible for patients with unique physical impairments15 , 23.
1.4.1 Virtual care as a means towards patience compliance to follow-up care While there have been relatively limited studies examining the use of virtual care in the form of video conferencing for maternal healthcare in the postpartum period, our results are consistent with previous literature examining patient satisfaction with virtual obstetric care in the prenatal period24. Virtual visits have been found not only be convenient, but to uphold the same level of rapport in the patient-provider encounter. In a U.S.-based cross-sectional survey examining patient's preferences for telehealth visits, almost 1/3 rd of participants expressed a preference for telehealth, and over ½ of participants rated telehealth to be just as good as traditional in person care25.
Likewise, our participants expressed that virtual visit was comparable or even better than in-person visit where follow-up visits do not necessitate being seen for a physical examination.
The participants in this study also expressed enthusiasm for the use of virtual visit in the follow-up care context, where the convenience of being able to see a provider at home for a simple follow-up appointment was signi cant in terms of comfort, convenience, and costs. This is consistent with literature examining patient experiences with telehealth for follow-up care speci cally26. In other studies examining the use of telemedicine for support in early discharge from childbirth, patients also reported feeling con dent with the ease of the technology and did not perceive a threat to their privacy or personal information. In a pilot project based in Sweden, patients reported feeling con dent that their concerns and questions were addressed to the same degree through video conferencing and that communication with their provider was not compromised27. This may be attributed to the fact that younger mothers may already incorporate technology in their daily lives 28. Resultantly, young mothers may more positively take up virtual care in comparison to other patient populations or age groups.
Our participants also expressed how virtual visit was able to address barriers to accessing healthcare related to nancial constraints, distance, travel time, and arranging time off work, which is consistent with previous literature examining the bene ts of virtual care visits in primary care settings. These ndings are also consistent with other studies exploring the use of virtual care in other patient populations 13 , 15 , 23 , 29 Overall, the perceived bene ts of virtual care could provide insight into ways to increase patient compliance to post-natal follow-up care. In another study conducted by researchers at Kingston Health Sciences Centre, it was found that increasing distance from the hospital was signi cantly associated with poorer attendance at follow-up visits. To a less signi cant degree, it was also found that poorer follow up was associated with patients with a greater number of living children and women with no educational certi cate, diploma, or degree10.
In our study, virtual care was found to be highly favored amongst participants living out of the city as they did not have to spend time, costs, and energy to attend to the hospital. Virtual care was also found to be useful for women with multiple children in our study as they were not required to make extra childcare arrangements, nd caretakers, and spend associated costs. This was particularly relevant throughout the ongoing COVID-19 pandemic, as patients were not permitted to bring other children to the visits in order to prevent unwanted exposure. Several other participants recalled that they had forgotten to attend their appointments. However, all felt inclined to use virtual visits once they were reminded to do so through phone call by the clinic secretary due to its perceived ease of use. Other participants alluded that virtual care would not interrupt their source of income as they were able to conduct the virtual session otherwise.

Virtual care and the Social Determinants of Health
Virtual care appears to be an important modality for increasing compliance to post-natal follow-up care. This is likely due to the fact that virtual care addresses the various social and environmental factors that intersect to impact health care access. Income, geography, and educational background are commonly understood as some of the most signi cant social determinants of health18 , 30 , 31. Compounded by domestic tasks and expectations, women may feel overwhelmed, overburdened, or disinclined to attend postnatal follow-up clinics32. Since virtual care can be conducted at a place comfortable for the patient and at their own schedule, it may become easier for women to attend to attend regular follow-up visits for maternal health monitoring. As a result, virtual care should be positioned not only as a tool to facilitate compliance in follow-up, but as a tool to evaluate the various social and environmental determinants that may encourage or deter patients from attending follow-up clinics.
Our study did allude to one major limitation of virtual visit, in that the internet connection can vary considerably between patients and pose a potential barrier for conducting virtual care appointments33. This limitation can be exacerbated by various socioeconomic factors such as rurality or nancial constraints. Patients who are unable to afford a high-speed internet connection or those who live in rural areas with poor connectivity may nd themselves limited in their ability to access virtual care appointments23. This nding is consistent with previous literature indicating that virtual modalities for healthcare delivery in primary care can be limited when it comes to connection issues34 , 35 , 36 , 37 , 38.

Limitations of the study
This study was limited by the relative homogeneity of the sample. As many of the participants were white/Caucasian, married, Canadianborn, middle-class, well educated women, the perceived positive and negative aspects of virtual visit could be different if a more heterogenous sample was interviewed. For example, as Canada is an immigrant-dense country, language barriers, especially if virtual visit is not offered in multiple languages, could potentially be a limiting factor. Overall, however, participants were highly satis ed with the virtual visit platform for postnatal follow-up appointment visits and the comfort and convenience it provides to participants are relevant across patient demographics. The research team also acknowledges that the sample size for this study is relatively small. This could be attributed to a large number of patients who had declined to participate as well as the research team's decision to take an ethnographic approach to the data in order to draw out rich details from the participants.

Future Directions
While this study showed that new mothers found virtual visit to be a suitable modality of healthcare delivery for postnatal follow-visits, our interviews alluded to a variety of challenges that new mothers experience that may differentially impact their ability to seek care. Therefore, future studies should investigate barriers to accessing in-person healthcare services for new mothers in order to better understand the unique determinants and barriers of this patient population. Intersectionality theory would serve well to illuminate the connections between social determinants and barriers to virtual care. Furthermore, virtual care has the potential to signi cantly shift the landscape of healthcare delivery in the COVID era, and further research should speci cally examine patient experiences of virtual visit in relation to the ongoing pandemic.

Conclusion
Qualitative interviews with new mothers who have used virtual care in the form of virtual visit for postnatal follow-up appointment visits revealed high satisfaction with virtual care, emphasizing bene ts in terms of comfort, convenience, communication, socioeconomic factors, and the ease of technology use. In the follow-up care context, our ndings suggest that virtual care increases accessibility and ease of follow-up care for patients with unique barriers to accessing healthcare services. Such a lens not only addresses the struggle of long-term patient compliance to maternal health care, but will also shed light on how to make obstetric care more equitable. Future directions should seek to examine the barriers to accessing in-person healthcare services unique to new mothers and examining the applicability of virtual visit for this patient population in the context of the ongoing COVID-19 pandemic.

Declarations
Ethics approval and consent to participate All procedures in this study were conducted in accordance with the Queen's University Health Sciences Review Ethics Board (# 6026701). Verbal informed consent was obtained from the patient(s) for their anonymized information to be published in this article.
All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication
Verbal consent was obtained from all participants. While the authors of this study understand that the Journal has a rm stance on attaining written consent, we would like to ask the Editors to make an exception for our study. This study was conducted while provincial and institutional lockdowns at the Kingston General Hospital were in place due to COVID-19. At that time, it was discouraged to meet with persons outside the immediate family circle for non-essential activities. Further, many ambulatory clinics at the Kingston General Hospital were reduced or even cancelled in light of COVID-19. Given also that many of our participants lived rurally, these reasons made it extremely di cult for our research team to attain written consent as patients and researchers were both expected to stay at home. While written consent through email is a possible alternative, the Queen's University Health Sciences Research Ethics board also pressed our research team to seek verbal consent primarily as it could potentially place undue burden for patients to have to read and return signature forms over email. We have email records of these requests if the editors would like a copy. For these reasons, our research team decided to attain verbal consent from the participants. Thus, we ask the Editorial Board for consideration over why the research team decided to obtain verbal consent instead.

Availability of data and materials
As per the conditions with the Queen's University's Health Sciences Research Ethics Board, only the study team and the hired transcriber have access to the research data. The author(s) disclosed receipt of the following nancial support for the research, authorship, and/or publication of this article. This work was supported by the PSI Foundation under Grant #19-31.
Authors' contributions M.S. and S.C were involved in recruitment, data collection, data analysis, and the writing of the manuscripts. R.A. was responsible for the conception of the study. L.N. and S.S were involved with recruitment and conceptualizing the recruitment strategy. All authors reviewed all iterations of the manuscript.