TELEHEALTH IN THE PREGNANCY-PUERPERAL PERIOD: COMPLEMENTARY HEALTH STRATEGY IN A PANDEMIC SCENARIO

Objective: to reflect on the use of Telehealth in the context of the COVID-19 pandemic for women in the pregnancy-puerperal period. Method: this is a reflection based on the literature with an approach on Telehealth as a tool for virtual health care in the pandemic context. Therefore, this reflection addresses the use of Telehealth, showing the particularities of adopting remote appointments, with their applicability and limitations, considering the socioeconomic and racial aspects that are intrinsically associated with public health issues. Results: Telehealth is a tool for coping with COVID-19, as it minimizes the exposure of pregnant and puerperal women during consultations in the health units. In Brazil, it is observed that this strategy is still incipient. This is intensified as we relate the socioeconomic and racial issues to the maternal mortality rates, especially among black-and brown-skinned women. Conclusion: this reflection shows that Telehealth is an important care strategy for women in the pregnancy-puerperal period and, in this perspective


INTRODUCTION
With the emergence of the pandemic caused by the new coronavirus (SARS-CoV-2), humanity is faced with the challenge of containing the dramatic global health crisis, especially considering the high transmissibility and mortality in the pandemic scenario.Given this situation, many developed countries have adopted a series of measures with the objective of combating spread of the COVID-19 disease.In this context, Telehealth platforms emerge as useful tools to manage the challenges faced by the health network in response to the pandemic 1 .
To use these platforms, electronic health apps (e-health) can be employed as a solution to support health care, as they contribute to controlling dissemination of COVID-19, as established by the World Health Organization (WHO).Although these tools have been available for a long time, the current historical moment may be favoring the definitive adoption of Telehealth on a large scale in the health systems at a global level for all population groups [2][3] .
With regard to women's health, prenatal, delivery and puerperal care was adapted in many countries to protect pregnant women and health professionals from unnecessary exposure to SARS-CoV-2.In Australia and the United Kingdom, for example, Telehealth appointments have reduced faceto-face consultations by 50%, without compromising pregnancy outcomes, a reality which indicates that this care model can help minimize personal interactions during the COVID-19 pandemic, although it can also be considered as post-pandemic health care models 4 .
In Brazil, on the other hand, although the use of technologies for virtual health care began decades ago, it was only with the exponential increase in the number of COVID-19 cases that it was possible to observe the expansion of initiatives related to Telehealth, which were developed with the objective of facilitating access to the health services, even for women in the pregnancy-puerperal period 5 , in order to promote guarantee of their universal rights, provided by the Unified Health System (Sistema Único de Saúde, SUS).
In addition to the health issues that emerged with the pandemic, there is a need to direct actions towards the social repercussions of the pandemic scenario, which, in Brazil, historically dates back to discussions about public health.Such repercussions reveal the structural demands of the SUS in facing the pandemic, with the challenge of reflecting on the social and economic vulnerabilities represented by the social determinants of health, which can contribute to worsening of COVID-19.This complex interaction of social and environmental factors capable of amplifying the negative effects of the disease can be defined as a "syndemic" 6 .
Considering the syndemic theory in women's health care during the pregnancy-puerperal period, it is verified that the pandemic exacerbated inequalities in this segment, which was already affected by structural public health problems, such as poor quality prenatal care and racial disparities in access to the services.These problems are added to the absence of face-to-face consultations and education in health activities, which interfere with maternal and perinatal outcomes.In addition to that, COVID-19 presents an increased risk of morbidity and mortality when compared to non-pregnant women 7 .This fact is supported by the findings published in a Brazilian study that revealed 124 deaths, from February to June 2020, of pregnant or postpartum women, representing a 12.7% mortality rate due to the disease through the notifications of Severe Acute Respiratory Syndrome (SARS) 8 .
In this context, this reflection arises from the initiative of the Support Program for Teaching Extension (Programa de Apoio à Extensão Docente, PaexDoc) of Universidade Federal da Bahia (UFBA), entitled "Teleguidance on COVID-19 for Pregnant and Puerperal women", developed from September to December 2020 in Salvador-BA, which facilitated women's access to the guidelines pertaining to the pregnancy-puerperal period and COVID-19, considering the importance of Teleguidance to control spread of this disease.

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In this article, the term Telehealth was chosen because it is understood, based on the literature, that it is a more comprehensive term and that it contemplates the diversity of virtual health care.Therefore, this reflection is justified by the importance of encouraging the implementation of new care technologies in Brazil, which are already used and valued in other countries in the obstetric area, prior to the pandemic.To such end, the objective was to reflect on the use of Telehealth in the context of the COVID-19 pandemic for women in the pregnancy-puerperal period.

TELEHEALTH IN THE PANDEMIC CONTEXT FOR WOMEN IN THE PREGNANCY-PUERPERAL PERIOD: APPLICABILITY AND LIMITATIONS
In Brazil, although Telehealth has its first development stages from the 1980s onwards, even today there are not sufficiently well-developed governmental initiatives 9 .However, driven by the fight against the COVID-19 pandemic, the country used several strategies related to Telehealth, through the creation of state contingency plans for the pandemic, with regard to assistance involving this technology 5 .In addition to that, this tool was incorporated into supplementary health and some professional councils created regulations for its use and establishment.
With the advance of the pandemic, governmental organizations and professional bodies structured themselves to publish documents for the regulation of Telehealth, such as Ministerial Ordinance No. 467/2020 which provides for Telemedicine actions and measures to deal with the public health emergency in relation to COVID-19.Later, other entities and councils of professional categories, such as the Federal Council of Nursing (Conselho Federal de Enfermagem, COFEN), authorized and standardized teleconsultations as a way to fight against the pandemic [5][6][7][8][9][10] .
With recognition of these entities, Telehealth assumes an important role in the adaptation scenario of the health organizations and services in the face of the pandemic and presents itself as an ideal strategy to promote social distancing during the current COVID-19 pandemic, as it enables minimizing the rapid spread of SARS-CoV-2.
The effective use of Telehealth even emerges in the context in which spread of the disease has imposed broad adoption of measures to control circulation of the virus, including the closing of health facilities, which culminated in absence and/or reduction of care, especially at the outpatient level 6 .Such weakness in several health care points reverberated more severely in the risk groups, such as pregnant and puerperal women, who were already living with barriers to accessing prenatal and maternity health services in a broad manner, a reality that precedes the pandemic scenario.
This reality was further aggravated during the pandemic period and the entire health care for women was affected, for example, with the reduction or absence of prenatal consultations and restricted access to routine exams during the pregnancy-puerperal period, to prevent complications and monitor the healthy development of pregnancy and the puerperium.In addition to that, diverse evidence indicates that pregnant and puerperal women are at an increased risk for the development of the severe form of COVID-19 when compared to non-pregnant women, which is intensified when they have some preexisting comorbidity [11][12] .
Considering the need to maintain health care during the pandemic, virtual appointments were made available in the Primary Care network, although not all women served by the SUS reap the benefits.This is due to some limitations regarding the use of Telehealth in the care provided to women in the pregnancy-puerperal period, compromising health care.It is inferred that the main limitation is related to the fragility of the connections and to the cost involved in the use of mobile data, mainly for people living in rural or remote areas who need access to more specialized care 11 .
Thus, it is understood that the lack of broad access to virtual technologies constitutes a disadvantage for women in the pregnancy-puerperal period who need prenatal and postpartum consultations.It is also necessary to consider the economic issue that can contribute to hindering 5/9 many women's access to the Internet and/or mobile devices.Thus, it is a detrimental factor that culminates in the lack of assistance in primary care and maternity hospitals and, consequently, influences perinatal outcomes.
It is notable that the harms are intensified when the social, economic and racial disparities are analyzed, as digital exclusion is a reality present in approximately 30% of the Brazilian homes, with black-/brown-skinned and lower social class women having the highest difficulty accessing the Internet.They become more exposed to situations of vulnerability caused by the pandemic 5 .
It is emphasized that, regarding the percentage of hospitalized pregnant women with a death outcome, nearly 7% corresponded to white-skinned women and that the double of these cases (14.2%) were mixed race and black-skinned.It is also observed that more black-skinned pregnant women are hospitalized due to SARS, a reality that can be associated with barriers encountered in early access to the health services.In addition, it is verified that, when these women are hospitalized, they are in more precarious health conditions, requiring specialized care 13 .Thus, it is observed that the COVID-19 pandemic disproportionately affected women, mainly those exposed to contexts of greater vulnerability, since the social determinants directly implicate the prognoses and the exorbitant increase in maternal mortality 11 .
Considering the magnitude of the effects of the pandemic, it is worth mentioning that, despite the limitations presented in relation to the unequal access of women to the health services, Telehealth can be applied in all care segments during the pregnancy-puerperal period, regardless of the social context.
Therefore, Telehealth includes education in health actions, risk stratification, counseling and assessment of potential inequalities, among other aspects related to the care provided to women in the pregnancy-puerperal period.This has been recommended since 2017 by the American College of Obstetrics and Gynecology (ACOG) in an opinion issued for preparation in public health calamity situations in relation to care during outbreaks of infectious diseases 14 .
In this sense, Telehealth for pregnant and puerperal women can be used as a complementary strategy with its use in the outpatient setting, such as alternating with face-to-face consultations, carrying out individual educational activities and in virtual groups for pregnant women, guidelines on self-care and care with the newborn, assessment of risk situations that require urgent/emergency care and monitoring, among other aspects 15 .
The effectiveness of Telehealth appointments was also revealed in a study where the authors evidenced that virtual consultations combined with face-to-face consultations do not affect detection and treatment of common pregnancy complications, including pre-eclampsia, fetal growth restriction and diabetes pregnancy when compared to conventional prenatal care 4 .Thus, such evidence reasserts the relevance of this tool in health care for women in the pregnancy-puerperal period, especially because it is understood that quality prenatal care influences the reduction of maternal-fetal morbidity and mortality rates.
Although the literature and successful international experiences point to the benefits of implementing virtual appointments, the national strategies are still timid with regard to women's health.It is observed that there is scarcity of this type of care provided by the SUS and by the supplementary health system.Currently, although this issue is in evidence in the health sector, few initiatives and strategies are effectively perceived in order to expand women's access to Telehealth, and few are the measures implemented to minimize the social inequalities that translate into barriers for accessing virtual appointments.
In some states, such as Bahia, "The Guide for Teleconsultation and Telemonitoring in the Scope of Primary Care" was created, in which a strategy for teleconsultation and telemonitoring for the population in general is presented 16 .It is important to emphasize that there was no deepening of the specificities of risk groups or situations, as in the context of women's health in its various population segments, such as women in the pregnancy-puerperal period.

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Given this gap, virtual care strategies developed by individual initiatives of professionals and educational and research institutions with expertise in the area of women's health during the pregnancy-puerperal period were essential, as they allowed more visibility for Telehealth care in the obstetric context.As an example of this initiative, the "Fale com a parteira" ("Talk to the midwife") project stands out, a unique initiative carried out by obstetric nurses in several Brazilian states, in order to solve doubts and guide women regarding their demands during the pregnancy-puerperal period.This project was certified as a Nursing Now Brazil initiative for its value in the role of the obstetric nurse in the pandemic scenario 17 .
Another individual initiative that directed its approach to the issues of pregnancy and puerperium in virtual care was "Projeto Vid@ na COVID-19" ("Life during COVID-19 Project"), which was originated in the academic environment at a public university in Bahia in the Nursing area.The project consisted of telemonitoring of women in situations of domestic violence by professionals and/or trained students, in order to investigate possible COVID-19 cases and identify the main health conditions.
Although these initiatives reach the local level, they cannot overcome the limitation related to the lack and/or maintenance of the telephone and/or Internet network for women.There are also no public policies that support the guarantee of virtual care, despite the universalization of access to health care being foreseen as one of the principles of the SUS, mainly if we consider the regional disparities observed in the national territory.
Despite this, successful individual experiences with Telehealth [17][18] , as well as diverse scientific evidence [4][5]9,15 , point to the advantages of virtual resources in adverse situations. Consquently, Telehealth reveals itself as an important strategy to increase the capacity to fight against the coronavirus, as it helps to keep the health services functioning and safer.Thus, its use must be concomitant with conventional health care measures or be used as a complementary health care strategy.

CONCLUSION
Telehealth in the pandemic context for women in the pregnancy-puerperal period is an important strategic tool to fight against the new coronavirus and represents an applicable resource for the maintenance of safer and good quality health care.Despite the limitations to its full implementation, such as the socioeconomic and racial disparities faced by women, it becomes necessary to reflect on possible strategies to overcome such barriers to access the different health care segments for pregnant and puerperal women.
In this perspective, we highlight the need to expand initiatives that ensure the use of health technologies.To this end, public policies must be created to promote the expansion of access to Telehealth, in order to provide resources for the communication media, such as the telephone and Internet network on a universal and equitable basis, considering the social inequities that affect the living conditions and the health of the populations, especially women who are more exposed to situations of vulnerability.Furthermore, it becomes necessary to encourage the development of studies on the theme, in addition to promoting training for health professionals in order to enable them to provide good quality virtual appointments.
We emphasize that, as this is a relatively recent strategy in the context of public health in Brazil, the Telehealth actions performed are still incipient.However, Telehealth has the potential to meet the population's health demands, in addition to being relevant to contain spread of the pandemic.
Finally, making Telehealth more applicable contributes to expanding women's access during the pregnancy-puerperal period, reducing the limitations caused by the socioeconomic and racial disparities, in addition to helping reduce complications and/or risk situations for pregnant and puerperal women due to the absence and/or reduction in face-to-face care.