This month, Million Hearts 2022, an initiative that focuses on improving the nation’s cardiovascular health, hosted a forum to explore innovative solutions for hypertension in pregnancy and postpartum.
Some of the most forward-thinking leaders in the space weighed in on the problem, including Wanda D. Barfield, MD, MPH, FAAP, Director of CDC’s Division of Reproductive Health; Eleni Tsigas of the Preeclampsia Foundation; Lauren Demosthenes, MD, OB-GYN at PRISMA Health Upstate; Sindhu Srinvas, MD, MSCE, and Adi Hirshberg, MD, of the Heart Safe Motherhood Program at the University of Pennsylvania; and Natalie Bello, MD, MPH, of Columbia University.
These leaders discussed the benefits of self-measured blood pressure monitoring for identifying and controlling hypertensive disorders in prenatal and postpartum care, as well as technology’s role in improving outcomes and access to care for the most vulnerable.
See below for a summary of the forum and access the full recording here.
Background & Introduction
Dr. Wanda D. Barfield, Director of CDC’s Division on Reproductive Health
Each year, 700 women die during or within one year of the end of pregnancy in the U.S. as a result of pregnancy or delivery complications. Most of these deaths are preventable. Although the risk of dying is low, some are at higher risk than others due to racial disparities — Native American, Native Alaskan, and Black women are much more likely to die from pregnancy-related complications than non-minority women. One in three of those deaths is caused by heart disease and stroke, and one in four by heart conditions.
About 50K women suffer from severe pregnancy conditions, and even more have conditions during pregnancy that give a window into their future health. For example, hypertensive disorders of pregnancy can cause serious problems for the mother and her unborn baby, such as low birthweight, infant death, and preterm birth (which feeds into another generation of cardiovascular issues). Women who experience these disorders are at increased risk of cardiovascular disease in the 10 years following delivery, making identification and control of hypertensive disorders an important concern across a woman’s lifespan, and particularly during the perinatal period.
The death of a woman during pregnancy, at delivery, or soon after delivery is a tragedy for society and for her family. These women are dying at a period when they should have a great deal of support in healthcare and in their communities. Opportunities for life-saving interventions exist, including self-measured blood pressure monitoring (SMBP).
Eleni Tsigas of the Preeclampsia Foundation
It’s important to understand the scope of the problem (cardiovascular and pregnancy-related problems) from the patient lens:
- A history of preeclampsia puts a woman at higher risk for cardiovascular disease, but there are no real resources to answer questions about where I can go to be screened or treated, or what options are available to me.
- Chronic hypertension is an independent risk factor for preeclampsia, and a lot of women have untreated high BP. But who’s paying attention to my BP levels and risk factors? What can I do to help reduce the risk for preeclampsia in pregnancy?
- COVID has accelerated telehealth for prenatal care, so I'm now expected to take my BP from home (a critical factor for recognizing preeclampsia). How am I supposed to know how to do this? If I can’t afford a cuff, what are my options? Does my insurance cover it?
- ACOG guidelines include a requirement for a postpartum BP check one week after delivery, but how am I going to get out of the house with a brand new baby, and why should I go to the trouble if I'm feeling fine?
Underlying all of these unknown questions is a woman’s frequent feeling that she isn’t being listened to by her doctors.
The Preeclampsia Foundation is filling these gaps in patient education through online resources, social media campaigns, and partnerships with patient providers to deliver education materials to moms.
The Foundation has a workshop with patient and provider perspectives on barriers and facilitators to cardiovascular disease risk-reduction, and are in the midst of creating a surgical U.S. directory of experts and clinics who have advanced knowledge of these questions.
They’ve created a cuff kit program to address the technology divide, supplying cuffs and patient education materials to providers doing telehealth with high risk populations who otherwise wouldn’t have access to them. The Foundation has also partnered with researchers for virtual intervention to reduce cardiovascular disease risks for preeclampsia survivors.
INNOVATIONS TO ADDRESS AND REDUCE RISK
Reduced In-Person Visits and Increased Access Through Remote BP Monitoring
Dr. Lauren Demosthenes, OB-GYN at PRISMA Health Upstate
One thing I have always questioned is the 12-14 prenatal visit schedule for low-risk women. Many women have to hire babysitters, miss work, deal with transportation issues, and overcome other social barriers to attend what is often only a ten-minute visit, usually to take vital signs and receive education materials.
I had an interest in redesigning prenatal care to be easier and more efficient for both patient and provider. I investigated what was going on around the country to safely reduce the in-person visit schedule: with Mayo Clinic and OBNest, GW-MFA and Babyscripts, University of Utah, University of Michigan and others.
With Babyscripts, which delivers patient education resources via a mobile app and enables remote monitoring of BP and weight, we found that we could reduce visits without affecting patient satisfaction. Despite fewer visits, daily BP readings and trigger alerts when a reading entered the range of risk enabled interventions and made patients and providers feel more secure.
When COVID-19 happened, we knew that our patients and providers would be satisfied with remote care because we had already been on a similar trajectory with successful results.
Ultimately, I think it’s important to empower women to be part of their own care and offer them more convenient ways to participate in their care, and daily remote monitoring is a big part of this.
BP Follow-Up to Identify Postpartum Hypertension
Dr. Sindhu Srinvas and Dr. Adi Hirshberg of the Heart Safe Motherhood Program at the University of Pennsylvania
Despite efforts to increase postpartum visit attendance (expanded schedules, more appointment slots, phone and text reminders), our show rates for postpartum visits could not be improved, with significant differences based on race — the show rate was >50% for non-black women and >25% for black women.
This was obviously a big problem: especially as a lot of these no-show patients were readmitted for morbidity based on postpartum hypertension.
So we thought outside the box. We implemented text-based monitoring, giving patients a BP cuff before discharge and teaching them how to use it in the hospital. Through the program, patients receive reminders twice daily to check their BP, using the cuff that we provide them. We purposefully chose non-bluetooth connected cuffs to provide access to a larger portion of the population, based on what we knew about access to wifi and prevalence of text messaging. We wanted to do something very simple.
Heart Safe Motherhood did a study comparing the HSM program to standard office-based follow-up, and found that text-based monitoring resulted in increased BP ascertainment in the first 10 days after delivery, which is the highest time period for risk of stroke. We also decreased readmissions, and increased the show rate for in-person visits.
What was most striking about the HSM results in a randomized trial was the reduction in racial disparities: 70% to 91% non-black mothers (in-person vs. text), and 33 to 93% black mothers (in-person vs. text). This was an amazing breakthrough in terms of the patients that we care for — the majority of whom are Medicaid and/or black patients.
Two Most Important Aspects of Self-Measured Blood Pressure Monitoring
Dr. Natalie Bello of Columbia University
Device accuracy is very important. Women’s bodies change over pregnancy — they are going to be different than the typical patient and so BP devices need to be specifically tested for accuracy in pregnant populations.
Device aside, proper self-measurement can be difficult — it takes time to educate patients on how to do it properly, and there are significant decisions being made based on BP readings like medication prescription and titration, or sometimes a visit to the ER.
I’m figuring out how to educate women to take their BP properly from home, through Youtube videos, text messaging, and other mediums.
Are messages encrypted?
The program is a HIPAA compliant, bi-directional platform. It is connected to the medical record, and patients are encouraged only to text their BP and no other identifying info.
Cost per patient? Cost to run the operation?
The general cost is providing the cuff — COVID has accelerated payer reimbursement for BP cuffs although the health system was supporting that cost prior to those reimbursements. Evaluating BP is a further cost, but we’ve eliminated that cost by incorporating that task into the nurse and midwife workflow. In terms of ROI, we’ve opened up clinic time, increased phone follow-up, and readmissions have gone from 5% to >1%, which is a significant reduction.
How do you check for accuracy of readings?
Women text in the readings themselves (to eliminate the need for wireless connection). Some send in pictures, others manually enter the reading. If there is a wildly inaccurate reading there is a prompt from the system to repeat with accurate reading.
How does Babyscripts work?
Through the Babyscripts mobile app mothers are connected with a library of educational and practice-specific resources, and sent weekly notifications for their pregnancy. Mothers receive a bluetooth-connected BP cuff through Babyscripts, which automatically sends BP readings into a provider-accessible database. Babyscripts provides a service to flag BP readings in an abnormal range, facilitating interventions, and physicians can also access all BP readings at any time.
What is the ROI?
Babyscripts eliminates the need for patients to drive into the office, and opens more office time for higher acuity patients. Patient satisfaction is high, and the service continues postpartum.
With Babyscripts, we’ve shown the use and benefit of self-monitoring in diverse populations — and when we don’t have the luxury of in-person training, we’re coming up with many different modalities of education. We’ve also seen remarkable increases in patient empowerment with Babyscripts — patients are feeling heard and listened to.
It’s hard to measure all of the downstream effects, but we’re hopeful that this satisfaction translates into other areas like pediatrics. These are women who often have control over the health of their families, and the health impact on the larger community from these small interventions is actually very great. This is not just a pregnancy issue, but a signal for health for women beyond pregnancy — anyone who does primary care should be looking for preeclampsia as a risk factor for cardiovascular disease.
A final word on the importance of SMBP
Monitoring their own BP pre- and postpartum, women get used to knowing what their trends are, and look forward to tracking their levels. When the doctor takes a reading themselves, the patient is not as invested. Self-measurement is a way of engaging and empowering women to take control of their own health.