Most at-risk women skip blood pressure screenings after giving birth
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Only 13.7% of women diagnosed with a hypertensive disorder of pregnancy attended a blood pressure screening within 7 to 10 days of delivery despite recommendations to do so, according to a study published in the Journal of Women’s Health.
“Hypertensive disorders of pregnancy are a major cause of maternal morbidity and mortality both during and after pregnancy,” author Sheree L. Boulet, DrPH, MPH, of the department of gynecology and obstetrics at the Emory University School of Medicine in Atlanta, told Healio.
Hypertensive disorders of pregnancy (HDP) include eclampsia, preeclampsia and gestational hypertension and accounted for 44% of pregnancy-related deaths between 1 and 6 days postpartum from 2011 to 2015 in the United States, according to the researchers.
Further, the researchers said, BP typically declines immediately following delivery and then rises, peaking between 3 and 6 days postpartum — after most women have been discharged from the hospital.
ACOG recommends that women with HDP have a BP screening visit between 7 and 10 days after delivery or earlier if symptoms develop.
“However, there is little information on how many women actually return for the follow-up visit and on the characteristics of women who are least likely to attend the visit,” said Boulet. “This information is critical for informing targeted efforts to increase postpartum care engagement, particularly for historically underrepresented women who have the highest risk for adverse pregnancy outcomes.”
The researchers conducted a population-based cohort study of pregnant patients who delivered at Grady Memorial Hospital, a large public safety-net hospital in Atlanta that primarily serves low-income patients from Georgia’s Fulton and DeKalb counties, between July 1, 2016, and June 30, 2018.
The study examined 1,260 deliveries that were complicated by HDP diagnosed during pregnancy or within 3 days postpartum. Participants were predominantly non-Hispanic Black (80.8%), insured by Medicaid or Medicare (89%), had a parity of two or more (63.3%) and had less than adequate prenatal care utilization (55.7%). Also, 46.2% were diagnosed only with gestational hypertension.
According to the findings, there were 173 BP screening visits within 10 days of delivery, meaning only 13.7% of the cohort returned for screening within the recommended window. Bivariable analysis found associations between BP visit attendance and HDP diagnosis, discharge with BP medication, race/ethnicity, mode of delivery, parity, gestational diabetes, chronic diabetes and prenatal care utilization index.
There also was an association between more severe HDP diagnosis and higher attendance rates for BP screenings, suggesting a heightened concern for complications or more effective provider counseling, Boulet said.
Compared with women with gestational hypertension, women with preeclampsia with severe features were more than twice as likely to attend a BP screening visit (adjusted risk ratio [RR] = 2.1; 95% CI, 1.35-3.27).
Also, women who had cesarean deliveries were more likely to attend postpartum BP screenings than women with vaginal deliveries (aRR = 1.55; 95% CI, 1.05-2.27).
Women who had inadequate (aRR = 0.42; 95% CI, 0.26-0.67) or intermediate (aRR = 0.4; 95% CI, 0.21-0.74) utilization of prenatal care were less likely to attend BP screening visits than women who had adequate prenatal utilization.
When the researchers analyzed the data including women who attended a BP screening at any point within the early postpartum period, the overall attendance at BP screenings within 3 weeks postpartum nearly doubled to 23.8% (n = 300). The median time between delivery and postpartum BP screenings was 10 days, with a range of 5 to 22 days.
“We were surprised that only approximately 14% of women attended a BP screening visit within 10 days of delivery. Even when the window was expanded to 3 weeks, still only a quarter of women returned for a BP check,” Boulet said.
Still, the researchers said, the medical community has a long way to go in improving attendance at BP screenings as HDP increases risks for acute renal failure, disseminated intravascular coagulation, stroke, eclampsia and pulmonary edema, impacting maternal morbidity and mortality.
“Our study population included deliveries at an urban, public institution in Georgia. The prevalence of hypertensive disorders of pregnancy in our populationexceeds national rates, and many in this population, similar to other urban hospital settings, are challenged with social and structural barriers to accessing care,” Boulet said.
Although results from studies at other hospitals may differ from these findings, Boulet said overall rates of postpartum visit attendance in the U.S. remain suboptimal and suggest a critical need to enhance postpartum care engagement.
“Clinicians and health systems should consider alternatives to in-person visits for blood pressure screening such as home visiting or remote blood pressure monitoring,” Boulet said.
The researchers also suggested that maternal BP screenings could be incorporated into newborn well-child visits.
Counseling patients on the importance of postpartum BP monitoring and identifying and addressing barriers to attending the follow-up BP check prior to delivery discharge is also important.
Looking ahead, the researchers said they will continue to explore the need for these screenings and more effective means of providing them.
“The next step is to develop and test interventions to improve rates of postpartum blood pressure monitoring among patients at risk for hypertensive complications,” Boulet said.
Reference:
Perspective
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HDP is the number one cause of cardiovascular mortality and morbidity in young women nationwide, and minority women are at highest risk. HDP can subsequently predict which women may be at increased risk of future development of cardiovascular disease later in life, likely because women who experience HDP are at increased risk of developing essential hypertension in the first 5 years after delivery. If elevated blood pressure is left untreated, it could increase the risk for myocardial infarction and heart failure by a factor of 2 to 4.
According to this study, women with HDP account for up to 44% of pregnancy-related deaths in the first 6 days after birth. Non-Hispanic Black women enrolled in Medicaid in the Atlanta area were at highest risk of HDP and tended to have more serious diagnoses. Once discharged from the hospital in the early postpartum period, women with worsening hypertension tend to remain undiagnosed or experience complications.
Furthermore, women with HDP are less likely to attend their blood pressure screening visit despite national ACOG guidelines and recommendations by their providers at 10 days postpartum. The authors further described a scant 14% compliance rate among women who experienced preeclampsia with severe features, a higher-risk phenotype of HDP. Most notably, these are non-Hispanic Black women who are multiparous and carry additional comorbidities placing them in the highest-risk category.
Attendance patterns are important predictors of success. More research is needed to describe and develop treatment strategies that mitigate gaps in hypertension management for these busy mothers. Further research should include risk factor management and early cardiovascular preventive strategies.
A systems-based approach to developing a strong referral program could provide an innovative approach to reaching high-risk postpartum women who need treatment the most.
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