The roles of COVID‐19 pandemic exposure and telehealth in prenatal care access for rural and racial minority communities in the United States: A retrospective cohort study

Purpose To examine how COVID‐19 public health emergency (PHE) exposure during pregnancy and telehealth use were associated with rural‐urban and racial/ethnic differences in prenatal care initiation timing and frequency. Methods This retrospective cohort study of 349,682 pregnancies to birthing individuals who received both prenatal and intrapartum care at the 75 health systems in the United States contributing to the National Clinical Cohort Collaborative (N3C) from 6/1/2018 through 5/31/2022. Outcomes included prenatal care initiation timing and the number of prenatal care visits. Prenatal periods were categorized into 3 PHE exposure groups: (1) never, (2) partially, and (3) fully exposed to the PHE. The full‐exposure group was further categorized into telehealth users and those with exclusively in‐person care. Findings The full‐exposure group with telehealth uptake had the earliest prenatal care initiation (median: 9 weeks [interquartile range: 7‐13]) and the most visits (19 visits [12‐20]). In contrast, the full‐exposure group without telehealth use initiated care the latest (11 weeks [8‐21]) and had the fewest visits (13 visits [6‐22]). Rural‐urban disparities persisted; however, telehealth users in both groups had earlier initiation and more visits. Racial and ethnic disparities in timeliness to initiation were most pronounced among the full‐exposure group with telehealth (Black‐White: adjusted hazard ratio [aHR]: 0.76, 95% CI, 0.70‐0.83; Hispanic‐White: aHR: 0.62, 95% CI, 0.58‐0.68), compared to the full‐exposure group with exclusively in‐person care (Black‐White: 0.95 [0.93‐0.94]; Hispanic‐White: 0.80 [0.80‐0.81]). Conclusions Prenatal telehealth care improved early initiation but also exacerbated racial/ethnic disparities in the timeliness of prenatal care access. However, rural‐urban disparities persisted.