WASHINGTON — Cardiovascular conditions are a leading cause of pregnancy-related deaths in the United States, and many opportunities to identify and manage risk are being missed before, during, and after pregnancy — including between pregnancies — says a new report from the National Academies of Sciences, Engineering, and Medicine. To help reduce deaths and cardiovascular complications among mothers, the report calls for stronger clinical preventive services, better follow-up after delivery, and improved care coordination across the reproductive life course.

More than three-quarters of pregnancy-related cardiovascular deaths are potentially preventable, the report says. However, although data on maternal mortality indicate that 57 percent of deaths occur between seven days and one year postpartum, preventive care related to cardiovascular risk is often concentrated in prenatal care and the immediate postpartum period, with less attention on counseling prior to pregnancy, postpartum follow-up, care transitions, and longer-term cardiovascular risk.

“Pregnancy can reveal cardiovascular risk that may not have been recognized before, but prevention cannot stop at delivery,” said Tracy A. Lieu, research scientist and former director of the Division of Research, Kaiser Permanente Northern California, and chair of the committee that wrote the report. “Too often opportunities are missed when care is fragmented, follow-up ends too early, or women are not connected to ongoing preventive care. We need to strengthen prevention and continuity of care before, during, and after pregnancy.”

The committee reviewed nine clinical preventive services for maternal cardiovascular health and found sufficient evidence to support immediate implementation of guidance in two areas.

First, treatment of chronic hypertension during pregnancy should aim to achieve a blood pressure target of less than 140/90 millimeters of mercury. The committee found substantial evidence that this approach reduces severe-range hypertension, preeclampsia, medically indicated preterm birth, and related adverse outcomes, without evidence of harm to fetal growth.

Second, postpartum hypertension management should be enhanced for women with chronic high blood pressure or other hypertensive disorders of pregnancy, the report says. Moderate evidence suggests that programs combining remote or self-measured blood pressure monitoring with structured clinical follow-up improve early blood pressure assessment, engagement in care, and short-term blood pressure control during the postpartum period.

These two recommendations do not encompass all aspects of cardiovascular prevention around pregnancy, the report notes. Rather, they reflect the areas where evidence is currently strong enough to support immediate implementation, while other areas need additional research.

Prevention Across the Reproductive Life Course
Pregnancy can function as a physiologic stress test, revealing previously unrecognized cardiovascular and metabolic vulnerability. Hypertensive disorders of pregnancy — including chronic high blood pressure and preeclampsia — and gestational diabetes can signal elevated risk not only during pregnancy but also in the postpartum and interpregnancy periods and later in life.

To address missed opportunities for prevention, the report recommends broader action to improve access to care, including maintaining continuity of insurance coverage, strengthening care transitions and care coordination, and expanding evidence-supported telehealth approaches.

Women at elevated cardiovascular risk need more reliable transitions from delivery hospitalization to outpatient postpartum care and from obstetric care to primary care, as well as specialty care when needed, the report says. This should include clearer accountability for follow-up care, better communication across clinicians, and support for high-priority preventive services in the months after delivery.

Other barriers can also interfere with follow-up care, including limited transportation, child care, time away from work, and broadband access for telehealth, and fragmented systems of care. The report recommends that federal and state partners support strategies to reduce these barriers and strengthen continuity of care across the reproductive life course.

The Health Resources and Services Administration — which supports women’s preventive services guidelines, maternal health programs, telehealth and rural health initiatives, and health centers that care for large numbers of lower-income women — is well positioned to help expand preventive cardiovascular services, the report says. HRSA should support systems and programs that reduce barriers to care and improve postpartum care transitions, including building clinical workforce capacity and expanding patient and clinician education. HRSA should use funding incentives, technical assistance, workforce support, and data tools to help Federally Qualified Health Centers and related community-oriented programs expand preventive cardiovascular services across the reproductive life course.

Research and Data Gaps
HRSA and other federal agencies, researchers, sponsors, and partner organizations should advance a broader research agenda to investigate several other approaches to preventive services that show promise, but that do not yet have enough evidence to support formal implementation recommendations, the report says. These include screening for urgent maternal warning signs, structured cardiovascular risk assessment tools, integrated cardio-obstetrics care models, supportive services such as doulas and peer navigators, telehealth applications, and interventions to improve transitions from postpartum care to long-term preventive care.

Undertaken by the Committee on Clinical Preventive Services for Addressing Cardiovascular Disease Risk to Reduce Pregnancy-Related Deaths Among Women, the study was sponsored by the U.S. Department of Health and Human Services.

The National Academies of Sciences, Engineering, and Medicine are private, nonprofit institutions that provide independent, objective analysis and advice to the nation to solve complex problems and inform public policy decisions related to science, engineering, and medicine. They operate under an 1863 congressional charter to the National Academy of Sciences, signed by President Lincoln.

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