Defining practices suitable for care via teleconsultation in gynaecological and obstetrical care: a French Delphi survey
In the 20th century, new means of communication revolutionised the field of healthcare. For instance, the Royal Naval Hospital initiated a ground-breaking practice in 1975, using telegrams and radiotelephones to analyse the medical issues of merchant marine personnel at sea. Since then, telemedicine has gone from strength-to-strength. Telemedicine refers to medical practitioners using telecommunications tools for remote diagnosis and medical care, including patient education, for teleconsultation, tele-expertise, telemonitoring and even answering questions. Here we use the term teleconsultation to refer to medical consultation or support by healthcare workers using telecommunications technology to provide telemedicine between clinicians and patients (ie, women in the specific area of midwifery). Teleconsultation has demonstrated superior outcomes in managing chronic pathologies (eg, diabetes, psychological conditions), gynaecology and women’s health, leading to higher patient and professional satisfaction compared with routine care. The COVID-19 pandemic accelerated the development of telemedicine, as this form of practice helped to reduce the risk of transmission. In France, teleconsultations by physicians became eligible for reimbursement in 2018, whereas midwives were initially not allowed to bill or be reimbursed for similar teleconsultations. Due to the pandemic, midwives were granted exceptional authorisation to conduct teleconsultations on 20 March 2020. Subsequently, on 20 December 2021, this temporary exception was made permanent and allowed all midwives across France to perform and be remunerated for teleconsultations. General guidelines already existed to guide healthcare professionals in teleconsultation practices, and more specific advice was published for the COVID-19 period. However, to our knowledge, no guidelines have been developed to guide healthcare workers in conducting teleconsultations for women’s gynaecological and obstetrical care outside pandemics. In France, women can be followed by a midwife, an obstetrician-gynaecologist or a general practitioner (GP) of their choice (public or private, community or hospital-based) for pregnancy monitoring and/or preventive gynaecological care. Midwives and GPs are often the primary care providers in the perinatal period, positioning them at the forefront of care and making them integral to the exploration of teleconsultation practices in this context, while gynaecologists, who also provide primary care, offer added expertise towards specialised or high-risk pathological situation. Pregnancy and gynaecological consultations are covered by the national health insurance fund. Accordingly, the main objective of this research was to delineate the scope of teleconsultation services, outside of pandemics, that can be performed effectively as part of the comprehensive gynaecological and obstetrical care of women.   Study design The techniques used to determine consensus are essentially the nominal group technique (ie, small group discussion followed by a vote) and the Delphi technique (ie, vote from a large group followed by individual feedback). We used a Delphi survey to reach an expert consensus on teleconsultation practices suitable for women’s gynaecological and obstetrical care. The methodology involved a multistep process, supervised by a scientific steering committee. The survey unfolded as follows: (1) Initial selection: we identified a comprehensive list of gynaecological and obstetrical care practices suitable for performing by teleconsultation, based on literature and experts’ insights; (2) expert panel formation: a panel of French experts was assembled, comprising midwives, GPs, obstetricians-gynaecologists and patient-users, all actively engaged in women’s gynaecological and obstetrical care; (3) Delphi method implementation: the expert panel participated in a Delphi survey to reach a consensus about each of the candidate practices. The scientific steering committee comprised four midwives (three from the French National College of Midwives), one GP, one obstetrician-gynaecologist and one patient-user representative (from the inter-associative collective around birth). Delphi organisation and questionnaire The Delphi consensus was reached through three rounds of an iterative process that used online questionnaires. These were hosted on the secure LimeSurvey platform and disseminated via email, with follow-up reminders sent after 15 days to non-respondents. The self-administered questionnaire (cf. ) introduced the survey’s objective and specified that the context for teleconsultation had to consider various factors: age, social precarity, vulnerability, women’s isolation, the presence of third parties (eg, family, child, caregiver) and emergency situations. It categorised all perinatal practices into four key domains: prevention (13 practices), gynaecology (33 practices) and antenatal (16 practices) and postnatal care (8 practices). The investigators (AR, LG) proposed these practices based on the literature and French midwifery skills, excluding reasons for consultation that required technical clinical procedures. The scientific steering committee validated the list and the expert panel finalised it. 10.1136/bmjopen-2024-085621.supp1 Supplementary data Establishment and consultation of the expert panel Members of the expert panel assessed the relevance of each teleconsultation practice, using a 9-point Likert scale ranging from 1 (not relevant) to 9 (totally relevant). A rating was mandatory for each practice. In the first round, participants could suggest additional practices they thought should be added to the initial list. A second round focused on practices for which no consensus had been reached. Participants re-evaluated them using the same Likert scale, while considering the first-round results. Ratings were again mandatory, and participants were encouraged to justify their choices through comments. The third and final round aimed to reach a consensus, informed by anonymised comments from the previous rounds. In this final round, ratings were optional, allowing experts to abstain if unconvinced. The expert panel comprised professionals from both academic societies and clinical settings, all currently engaged in clinical practice. Selection criteria emphasised diverse practice settings, including hospital and community practices, as well as rural and urban locations. According to these criteria, and by calling on learnt societies, we contacted 24 experts and 22 participated: 12 midwives (hospital-based and/or independent), 3 obstetricians-gynaecologists, 4 GPs and 3 healthcare system users (ie, women from a users’ association). As the list of selected activities was mainly concerned with physiological care, the scientific steering committee felt it was important to involve a larger number of midwives, reflecting the primary role in perinatal care. The guidelines recommend including between 15 and 60 participants, we plan to conduct three rounds including 22 participants. Analysis Consensus was determined by a dual-criteria approach: the median score on a 9-point Likert scale and the percentage of votes either below 5 or 5 or above. If the median score was less than 5 and more than 70% of the expert panel voted the same way, the practice was considered unsuitable for teleconsultation. Conversely, if the median score was greater than or equal to 5 and more than 70% of votes were greater than 5, the practice was considered suitable for these video or audio visits. Practices not meeting these criteria were labelled ‘under discussion’ and underwent further voting. After three voting rounds, practices remaining ‘under discussion’ were concluded to lack consensus.   The techniques used to determine consensus are essentially the nominal group technique (ie, small group discussion followed by a vote) and the Delphi technique (ie, vote from a large group followed by individual feedback). We used a Delphi survey to reach an expert consensus on teleconsultation practices suitable for women’s gynaecological and obstetrical care. The methodology involved a multistep process, supervised by a scientific steering committee. The survey unfolded as follows: (1) Initial selection: we identified a comprehensive list of gynaecological and obstetrical care practices suitable for performing by teleconsultation, based on literature and experts’ insights; (2) expert panel formation: a panel of French experts was assembled, comprising midwives, GPs, obstetricians-gynaecologists and patient-users, all actively engaged in women’s gynaecological and obstetrical care; (3) Delphi method implementation: the expert panel participated in a Delphi survey to reach a consensus about each of the candidate practices. The scientific steering committee comprised four midwives (three from the French National College of Midwives), one GP, one obstetrician-gynaecologist and one patient-user representative (from the inter-associative collective around birth).   The Delphi consensus was reached through three rounds of an iterative process that used online questionnaires. These were hosted on the secure LimeSurvey platform and disseminated via email, with follow-up reminders sent after 15 days to non-respondents. The self-administered questionnaire (cf. ) introduced the survey’s objective and specified that the context for teleconsultation had to consider various factors: age, social precarity, vulnerability, women’s isolation, the presence of third parties (eg, family, child, caregiver) and emergency situations. It categorised all perinatal practices into four key domains: prevention (13 practices), gynaecology (33 practices) and antenatal (16 practices) and postnatal care (8 practices). The investigators (AR, LG) proposed these practices based on the literature and French midwifery skills, excluding reasons for consultation that required technical clinical procedures. The scientific steering committee validated the list and the expert panel finalised it. 10.1136/bmjopen-2024-085621.supp1 Supplementary data   Members of the expert panel assessed the relevance of each teleconsultation practice, using a 9-point Likert scale ranging from 1 (not relevant) to 9 (totally relevant). A rating was mandatory for each practice. In the first round, participants could suggest additional practices they thought should be added to the initial list. A second round focused on practices for which no consensus had been reached. Participants re-evaluated them using the same Likert scale, while considering the first-round results. Ratings were again mandatory, and participants were encouraged to justify their choices through comments. The third and final round aimed to reach a consensus, informed by anonymised comments from the previous rounds. In this final round, ratings were optional, allowing experts to abstain if unconvinced. The expert panel comprised professionals from both academic societies and clinical settings, all currently engaged in clinical practice. Selection criteria emphasised diverse practice settings, including hospital and community practices, as well as rural and urban locations. According to these criteria, and by calling on learnt societies, we contacted 24 experts and 22 participated: 12 midwives (hospital-based and/or independent), 3 obstetricians-gynaecologists, 4 GPs and 3 healthcare system users (ie, women from a users’ association). As the list of selected activities was mainly concerned with physiological care, the scientific steering committee felt it was important to involve a larger number of midwives, reflecting the primary role in perinatal care. The guidelines recommend including between 15 and 60 participants, we plan to conduct three rounds including 22 participants.   Consensus was determined by a dual-criteria approach: the median score on a 9-point Likert scale and the percentage of votes either below 5 or 5 or above. If the median score was less than 5 and more than 70% of the expert panel voted the same way, the practice was considered unsuitable for teleconsultation. Conversely, if the median score was greater than or equal to 5 and more than 70% of votes were greater than 5, the practice was considered suitable for these video or audio visits. Practices not meeting these criteria were labelled ‘under discussion’ and underwent further voting. After three voting rounds, practices remaining ‘under discussion’ were concluded to lack consensus.   In the first round, we received 22 responses, and in both the second and third rounds 21, with one GP abstaining. Throughout the three rounds, a single practice in postnatal care was added after the first round, for an assessment of 71 total proposed practices. In the first round, 25 practices were approved, 11 excluded and 34 reconsidered by the panel; 1 practice was added (‘postnatal sessions (individual or group)’). In the second round, 8 more practices were approved, 10 excluded and 17 reconsidered. In the third round, 3 more practices were chosen, 4 excluded and 10 still failed to reach a consensus . In the end, 51% of the proposed practices were deemed suitable for teleconsultation (n=36/71), 35% were rejected (n=25/71) and 14% lacked consensus (n=10/71) . The approved practices for teleconsultation were categorised as follows: 92% in prevention (n=12/13), 55% in gynaecology (n=18/33), 31% in prenatal care (n=5/16) and 12% in postnatal care (n=1/9) . Those deemed unsuitable for teleconsultation were distributed as follows: 8% in prevention (n=1/13), 24% in gynaecology (n=8/33), 56% in prenatal care (n=9/16) and 78% in postnatal care (n=7/9) . Lastly, 10 practices remained under discussion—7 in gynaecology, 2 in prenatal care and 1 in postnatal care . Expert comments highlighted the benefits of teleconsultations, such as convenience, faster access to care, availability of healthcare professionals in medical deserts and efficiency in delivering information and routine follow-ups. However, the need for physical examinations or to address sensitive issues or establish a relationship, and some aspects of prenatal and postnatal care were cited as reasons for in-person visits .   Main findings Our consensus survey highlights that experts agree that teleconsultations are convenient and effective: 36 practices were selected as appropriate for teleconsultation. Nonetheless, the rejection and non-acceptance of teleconsultation of practices involving physical examinations, sensitive issues and aspects of prenatal and postnatal care indicate the need for careful consideration of the limitations of relying solely on teleconsultations for these specific cases. Interpretation Our findings align with the existing literature highlighting the effectiveness and convenience of teleconsultations for preventive healthcare. A French qualitative study conducted during the COVID-19 pandemic underscored the utility of teleconsultations in this type of healthcare. The preponderance of validated preventive practices for teleconsultation in our study suggests that this form of practice is eminently suitable for preventive care. This finding has significant ramifications for enhancing access to preventive care, particularly in settings where medical treatment (ie, ‘cure’) often overshadows preventive and supportive care (ie, ‘care’). The French study mentioned just above underlined that midwives adopted teleconsultation not only to sustain continuity of care but also to engage in relational care, thereby accentuating the cure-care dichotomy in clinical practice. In our Delphi survey, most preventive practices proved suitable for teleconsultation, indicating its strong potential in such care. This has important implications for improving access to preventive healthcare, particularly in contexts where treatment is often prioritised over prevention. Experts selected follow-up and post-abortion consultations as suitable for teleconsultation only in round 3. However, the literature appears rather favourable to carrying out abortion follow-up via teleconsultation; it is highly acceptable to women and providers, safe and effective, with a high level of satisfaction among patients and enabling faster access to the abortion. Teleconsultation has demonstrated its utility in the management of voluntary termination of pregnancy (TOP) by medication abortions; it both facilitates access to care and enhances patient satisfaction. For example, ‘Women on Web’, a non-governmental, non-profit organisation, leverages online telemedicine and medication regimen to provide early termination of pregnancy in regions lacking access to safe TOP services. Women’s testimonials indicate that this form of care gives them a general sense of privacy and security. Conversely, some women expressed a preference for face-to-face interactions with physicians. This underscores the necessity of informing women about available service modalities, enabling them to make an informed choice tailored to their comfort and needs. While our findings broadly endorse the utility of teleconsultations, they also suggest limitations, particularly in prenatal and postnatal care where physical examinations and sensitive dialogues are often more effective when conducted in person. This highlights the need for a nuanced approach that considers the specific nature and requirements of individual healthcare practices when considering the appropriateness of teleconsultation. Additionally, societal and healthcare system factors, such as reimbursement policies, can significantly influence the feasibility and acceptability of this modality. For example, in France, teleconsultations are reimbursed by the national health insurance fund just as in-person consultations are; this enhances their accessibility. However, this is not universally the case; in some countries, teleconsultations are either not reimbursed or only reimbursed for specific healthcare professionals, which potentially limits their widespread adoption. Our team’s earlier qualitative analysis showed that midwives adopted telemedicine to ensure their patients’ access to continuous care, maintain their professional activity and income and reduce the risks of infection. However, while teleconsultations offered practical benefits during the pandemic, their sustained use afterwards requires careful consideration of technical, regulatory and ethical aspects. These findings provide valuable insights for healthcare providers and policymakers seeking to optimise the use of teleconsultations for women’s gynaecological and obstetrical care. Strength and limitations One of the main strengths of our study is its use of the Delphi method, which allowed us to gather expert consensus on a wide range of practices related to women’s gynaecological and obstetrical care. This method is recognised for its effectiveness in achieving consensus in healthcare settings. However, a related limitation is that the Delphi method relies heavily on the expertise and opinions of the selected panel. While we made efforts to include a diverse range of experts, the results may not fully represent all possible perspectives in the field. Thus, the selection of experts participating in the Delphi, particularly those practicing in rural or urban areas, was therefore carefully considered, but the study was not designed to differentiate the activities that can be carried out by teleconsultation, depending on the area. Further studies would be needed to assess this point, and the appropriateness of teleconsultation in continuity of care by territorial area. Another strength is the high response rate among our expert panel across all three rounds of the Delphi survey, which enhances the reliability of our findings. However, the limitation associated with this is that our panel was predominantly French, which may limit the generalisability of our findings to other cultural or healthcare contexts or places where midwives use different skills from those taught in France. Perspectives Following this Delphi survey, the French College of Midwives (College National des Sage-femme de France) will be able to publish guidelines to help professionals choose the practices they will be willing to perform by teleconsultation. The findings of our study open several avenues for future research and have significant implications for practice. Teleconsultations have shown the potential to enhance access to healthcare, particularly in areas where in-person consultations may be limited by medical demographics, geography or costs. Future research could explore the use of teleconsultations in different healthcare contexts, such as in rural or underserved areas, and for managing other health conditions. In terms of practice, our study suggests both that healthcare providers could benefit from training in the effective use of teleconsultations and that policies could be developed to support their integration into routine care. This is particularly relevant for practices that are currently performed less frequently by midwives, such as those related to infertility and genetics. Our study found no consensus on whether these practices are suitable for teleconsultations, indicating a need for further investigation and potentially, specialised training for midwives. Moreover, our study has broader implications for the transformation of healthcare delivery. By leveraging teleconsultations, we can potentially improve access to care, enhance patient satisfaction and ensure continuity of care, even in challenging circumstances. However, it is crucial to consider the technical, regulatory, and ethical aspects of teleconsultations to ensure their sustainable and effective use after the pandemic.   Our consensus survey highlights that experts agree that teleconsultations are convenient and effective: 36 practices were selected as appropriate for teleconsultation. Nonetheless, the rejection and non-acceptance of teleconsultation of practices involving physical examinations, sensitive issues and aspects of prenatal and postnatal care indicate the need for careful consideration of the limitations of relying solely on teleconsultations for these specific cases.   Our findings align with the existing literature highlighting the effectiveness and convenience of teleconsultations for preventive healthcare. A French qualitative study conducted during the COVID-19 pandemic underscored the utility of teleconsultations in this type of healthcare. The preponderance of validated preventive practices for teleconsultation in our study suggests that this form of practice is eminently suitable for preventive care. This finding has significant ramifications for enhancing access to preventive care, particularly in settings where medical treatment (ie, ‘cure’) often overshadows preventive and supportive care (ie, ‘care’). The French study mentioned just above underlined that midwives adopted teleconsultation not only to sustain continuity of care but also to engage in relational care, thereby accentuating the cure-care dichotomy in clinical practice. In our Delphi survey, most preventive practices proved suitable for teleconsultation, indicating its strong potential in such care. This has important implications for improving access to preventive healthcare, particularly in contexts where treatment is often prioritised over prevention. Experts selected follow-up and post-abortion consultations as suitable for teleconsultation only in round 3. However, the literature appears rather favourable to carrying out abortion follow-up via teleconsultation; it is highly acceptable to women and providers, safe and effective, with a high level of satisfaction among patients and enabling faster access to the abortion. Teleconsultation has demonstrated its utility in the management of voluntary termination of pregnancy (TOP) by medication abortions; it both facilitates access to care and enhances patient satisfaction. For example, ‘Women on Web’, a non-governmental, non-profit organisation, leverages online telemedicine and medication regimen to provide early termination of pregnancy in regions lacking access to safe TOP services. Women’s testimonials indicate that this form of care gives them a general sense of privacy and security. Conversely, some women expressed a preference for face-to-face interactions with physicians. This underscores the necessity of informing women about available service modalities, enabling them to make an informed choice tailored to their comfort and needs. While our findings broadly endorse the utility of teleconsultations, they also suggest limitations, particularly in prenatal and postnatal care where physical examinations and sensitive dialogues are often more effective when conducted in person. This highlights the need for a nuanced approach that considers the specific nature and requirements of individual healthcare practices when considering the appropriateness of teleconsultation. Additionally, societal and healthcare system factors, such as reimbursement policies, can significantly influence the feasibility and acceptability of this modality. For example, in France, teleconsultations are reimbursed by the national health insurance fund just as in-person consultations are; this enhances their accessibility. However, this is not universally the case; in some countries, teleconsultations are either not reimbursed or only reimbursed for specific healthcare professionals, which potentially limits their widespread adoption. Our team’s earlier qualitative analysis showed that midwives adopted telemedicine to ensure their patients’ access to continuous care, maintain their professional activity and income and reduce the risks of infection. However, while teleconsultations offered practical benefits during the pandemic, their sustained use afterwards requires careful consideration of technical, regulatory and ethical aspects. These findings provide valuable insights for healthcare providers and policymakers seeking to optimise the use of teleconsultations for women’s gynaecological and obstetrical care.   One of the main strengths of our study is its use of the Delphi method, which allowed us to gather expert consensus on a wide range of practices related to women’s gynaecological and obstetrical care. This method is recognised for its effectiveness in achieving consensus in healthcare settings. However, a related limitation is that the Delphi method relies heavily on the expertise and opinions of the selected panel. While we made efforts to include a diverse range of experts, the results may not fully represent all possible perspectives in the field. Thus, the selection of experts participating in the Delphi, particularly those practicing in rural or urban areas, was therefore carefully considered, but the study was not designed to differentiate the activities that can be carried out by teleconsultation, depending on the area. Further studies would be needed to assess this point, and the appropriateness of teleconsultation in continuity of care by territorial area. Another strength is the high response rate among our expert panel across all three rounds of the Delphi survey, which enhances the reliability of our findings. However, the limitation associated with this is that our panel was predominantly French, which may limit the generalisability of our findings to other cultural or healthcare contexts or places where midwives use different skills from those taught in France.   Following this Delphi survey, the French College of Midwives (College National des Sage-femme de France) will be able to publish guidelines to help professionals choose the practices they will be willing to perform by teleconsultation. The findings of our study open several avenues for future research and have significant implications for practice. Teleconsultations have shown the potential to enhance access to healthcare, particularly in areas where in-person consultations may be limited by medical demographics, geography or costs. Future research could explore the use of teleconsultations in different healthcare contexts, such as in rural or underserved areas, and for managing other health conditions. In terms of practice, our study suggests both that healthcare providers could benefit from training in the effective use of teleconsultations and that policies could be developed to support their integration into routine care. This is particularly relevant for practices that are currently performed less frequently by midwives, such as those related to infertility and genetics. Our study found no consensus on whether these practices are suitable for teleconsultations, indicating a need for further investigation and potentially, specialised training for midwives. Moreover, our study has broader implications for the transformation of healthcare delivery. By leveraging teleconsultations, we can potentially improve access to care, enhance patient satisfaction and ensure continuity of care, even in challenging circumstances. However, it is crucial to consider the technical, regulatory, and ethical aspects of teleconsultations to ensure their sustainable and effective use after the pandemic.   Our consensus survey highlights both the benefits and limitations of teleconsultations for women’s gynaecological and obstetrical care, emphasising the need for careful consideration and tailored implementation. Further research and consideration of the potential benefits and drawbacks of teleconsultations in these areas are warranted to ensure optimal care and outcomes for women.   Reviewer comments Author's manuscript   