Digital health and telemedicine in Pakistan: Improving maternal healthcare

1. Introduction
Telemedicine is of great importance in low-income countries like Pakistan, where according to World Bank estimates 63% of the total population resides in rural areas, compared to only 37% in urban areas. As compared to traditional care, telemedicine effectively caters to patients’ needs with greater convenience and lower cost, which is a combination preferred by most. It makes healthcare accessible in remote and isolated places by cutting down transportation costs. Additionally, it saves a lot of commuting time, and patients do not have to take the day off from work, which is essential for many rural citizens due to their poor socio-economic conditions. These factors make it more likely for the otherwise hesitant rural population to seek timely medical care. Telemedicine is essential in urban areas as well; it could ease the burden on understaffed healthcare facilities and prevent over-crowding as many patients receive medical care from the comfort of their homes.

In Pakistan, people from most rural areas must travel long distances to reach hospitals in cities which is expensive and dangerous to maternal and fetal health. Digital health services address these compulsions by connecting patients to their respective doctors through online means. It is reported from a few studies that telemedicine helped to save many lives of patients from Lower- and Middle-Income Countries (LMICs) due to complications that normally led to their deaths due to treatment being delayed. Furthermore, telemedicine is a means to improve maternal care as it achieves more patient satisfaction because of more educational and supportive care with flexible meeting schedules. Maternity care involves many events of emergency that require immediate interventions in presence of a health care provider (HCP). Telemedicine has been successful in monitoring maternal and fetal health during pregnancy, delivery, and post-birth when the patient is far from hospital settings. From minor pregnancy complications such as vomiting, sweating, and mood swings to major emergencies like water breaking and preeclampsia, telemedicine has provided the most effective and patient-friendly interventions. Telemedicine provides more feasible and cost-effective medical care by monitoring patient vitals with the use of mobile devices and smartphones, and interactions with physicians are carried through audio and video calls. In a study consisting of 1060 maternal and fetal HCPs, 60% used telemedicine and responded enthusiastically to its use in the future.

Telehealth could also help provide reproductive counseling to women and girls in Pakistan. Recently, a joint effort by an NGO called Sehat Kahani Pakistan and Ipas (Intelligent Project Automation System) Pakistan has provided 3 days of online training to physicians, teaching them about digital health and telehealth consultations. These physicians are now capable of providing virtual assistance to women for medical abortions and post-abortion contraception. Also, 78 lady health care workers have been taught how to use telehealth services who in turn are reaching out to other girls and women and helping them access these free services.

As compared to traditional medical care, telemedicine regulates patient health even in critical settings and provides urgent treatment as seen with mobile stroke units in most high-income countries. While such advanced and efficient mobile device facilities are yet to be introduced in Pakistan, telemedicine can be practiced simply through smartphones and internet connection.

Pakistan's reliance on telemedicine accelerated during the COVID-19 pandemic. In March 2020, when the number of COVID cases was rising exponentially, the government was forced to impose a nationwide lockdown. This along with the fear of getting infected with the virus resulted in many people opting to seek medical care from the comfort of their homes. A study conducted at a tertiary care hospital in Pakistan found great success in classifying COVID patients according to the severity of their disease. Furthermore, telemedicine facilities were set up by Faisalabad Medical University. Skye IDs (for video consultations) and WhatsApp numbers (for instant messaging) of physicians of different specialties were advertised in local print and electronic media. These cyber consultations helped cater to more patients as it ensured patients with minor illnesses stayed out of the hospital, and hence reduced the burden on overcrowded healthcare facilities. Moreover, it also decreased the transmission of the virus and reduced the number of physicians at risk from close contact with COVID infected patients.

2. Challenges
In 2016, the World Health Organization (WHO) conducted a telemedicine survey and found that Pakistan didn't have any laws or regulations regarding the use of telemedicine. Since health care has been devolved to the provinces, most provincial health departments are unaware of the benefits or existence of telemedicine. Without any regulations or framework, setting up any telemedicine program can be challenging. This is particularly true for international organizations that like a legal safety net before entering new markets. Despite the contributions of various technologies, Pakistan's telemedicine operations remain at a primary level. Except for those regions affected by the earthquake, certain parts of the country lack telemedicine services. Rural and remote regions face a variety of challenges that limit telehealth adoption and progress, despite technological advances. There are several challenges encountered by patients, including access to technology, acceptance of technology, relationship with the provider, and level of health literacy. There is a lot of complexity in healthcare, and patients may find diagnoses difficult to comprehend. In the world of medicine, doctors face many challenges, including practicing “No-Touch” medicine, managing time, and building team relationships. Many of them also face issues with technology literacy, particularly those who were trained many years ago. Professional well-being as well as maintaining medical knowledge and coping with progressively increasing medical information are key challenges for providers. Policy development and establishing a monitoring and adherence system will be the biggest challenges for the healthcare system of Pakistan. Physician accreditation and licensure, reimbursement systems, and liability may need to be reformed to provide reliable services. In addition, an information technology network, and well-trained staff will be required to ensure long-term success.

3. Efforts and recommendations
Obstetric-related-remote monitoring devices and other telemedicine services aim to try and address the maternal health and mortality crises. The former includes i.e. blood pressure monitors, blood glucose testing, and home-based fetal monitors. It not only monitors a patient's health and aids in reducing multiple antenatal and postnatal visits but can also be used to gauge whether a patient has breached the high-risk threshold and determine the need for immediate medical care. Traditionally in Pakistan and other LMICs, many pregnant women suffer grave complications that lead to their deaths, these consequences are easily preventable if women are diagnosed and treated earlier. Postpartum Hemorrhage is one of the most common complications resulting in maternal mortality which occurs due to many reasons, including late administration of blood loss and lack of available blood products for transfusion. A study in Latin America showed that a LMIC compared the implementation of digital health from traditional care on patients in Gynae and Obstetric wards and found a reduction of needing blood transfusion by 7%, Eclampsia by 5.5%, and a significant reduction in perinatal mortality by 29%. They mentioned that regular monitoring of patients' health allowed efficient management which prevented any prognosis. According to severity, HCPs can direct the patient for the most efficient management. Mahdi S et al. emphasizes the introduction of digital health apps and portable sensors to monitor blood pressure, blood glucose, hormone levels, oxygen levels, and auscultation of viscera through glucometers, mobile blood pressure controls, pulse oximeters, and optical stethoscopes respectively. This would provide regular monitoring of maternal and fetal health, indicating the slightest imbalance in body health immediately and preventing life-threatening consequences. An exploratory study by Sulaman H. et al., provides a favorable prospect for the uptake of telemedicine by obstetrics patients across Pakistan, following COVID-19. Further, the study of Akber S. et al. analyzed and reported the effectiveness of a mHealth intervention on infant and young child feeding among children ≤24 months of age in rural Islamabad over a six month duration. Additionally, when the already practiced telemedicine in maternal care of the state is coupled with improving users’ experience (by training consultants and staff) and setting up effective communication in local languages can nurture the future use of telemedicine in obstetrics of the state.