Protecting Maternal Heart Health

Prevention and Care Before, During, and After Pregnancy

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Amy Geller and Tracy A. Lieu, Editors

Committee on Clinical Preventive Services for Addressing Cardiovascular Disease Risk to Reduce Pregnancy-Related Deaths Among Women

Health Care and Public Health Program Area

Center for Health, People, and Places

Consensus Study Report

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International Standard Book Number-13: 978-0-309-60571-7
Digital Object Identifier: https://doi.org/10.17226/29425

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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2026. Protecting Maternal Heart Health: Prevention and Care Before, During, and After Pregnancy. Washington, DC: National Academies Press. https://doi.org/10.17226/29425.

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COMMITTEE ON CLINICAL PREVENTIVE SERVICES FOR ADDRESSING CARDIOVASCULAR DISEASE RISK TO REDUCE PREGNANCY-RELATED DEATHS AMONG WOMEN

TRACY A. LIEU (Chair), Kaiser Permanente Northern California; JAMA

BRENDA J. BAKER, Emory University

RACHEL M. BOND, Dignity Health Arizona; Creighton University School of Medicine

THOMAS E. DOBBS III, University of Mississippi Medical Center

CORNELIA R. GRAVES, Tennessee Maternal Fetal Medicine; St. Thomas Health Systems

KATHRYN J. LINDLEY, Vanderbilt University Medical Center

DARYL J. SELEN, Women and Infants Hospital and Brown University

ANNA MARIA SIEGA-RIZ, University of Massachusetts Amherst

STEVEN M. SMITH, University of Florida

CHIEN-WEN TSENG, University of Hawai‘i at Manoa (retired)

RACHEL PERAGALLO URRUTIA, University of North Carolina at Chapel Hill

JANET WEI, Cedars-Sinai Medical Center

National Academy of Medicine Fellows

2024–2026 National Academy of Medicine Fellow to Advance State Health Policy

YOHUALLI B. ANAYA, University of Wisconsin—Madison

2023–2025 Gant/American Board of Obstetrics and Gynecology Fellow

MICHELLE DEBBINK, University of Utah

Study Staff

AMY GELLER, Study Director

AISHA BHIMLA, Program Officer (until August 2025)

L. BRIELLE DOJER, Research Associate (until December 2025)

MADELEINE DEYE, Research Associate (as of June 2025)

DARA ANCONA, Associate Program Officer (as of September 2025)

ELLA CASTANIER, Senior Program Assistant (until September 2025)

KATIE PETERSON, Senior Program Assistant (as of September 2025)

ROSE MARIE MARTINEZ, Senior Board Director (until January 2026)

SHARYL NASS, Senior Program Director

Y. CRYSTI PARK, Program Coordinator (until October 2025)

Consultants

JOE ALPER, Independent Science Writer

TASHA BIGELOW, Definitive Editing

TORREY ROBINSON, University of Mississippi Medical Center

KAREN WILLIAMS, Independent Consultant

Reviewers

This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.

We thank the following individuals for their review of this report:

WENDY BENNETT, Johns Hopkins University

JOAN E. BRILLER, University of Illinois at Chicago

ANDRIA CORNELL, Association of Maternal and Child Health Programs

KARINA DAVIDSON, Northwell Health

NORA DRUMMOND, University of Michigan

AFSHAN HAMEED, University of California, Irvine

SADIYA SANA KHAN, Northwestern University

SANDRA LLOYD, Health Resources and Services Administration (retired)

GBENGA OGEDEGBE, New York University

ALAN TITA, University of Alabama at Birmingham

JANET S. WRIGHT, Consultant, Washington, DC, Centers for Disease Control and Prevention (retired)

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report, nor did they see the final draft before its release. The review of this report was overseen by GEORGE J. ISHAM, HealthPartners (retired) and RITA F. REDBERG, University of California, San Francisco. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.

Contents

PREFACE AND ACKNOWLEDGEMENTS

ACRONYMS AND ABBREVIATIONS

SUMMARY

1 INTRODUCTION AND COMMITTEE APPROACH

Committee Statement of Task

Background

U.S. Preventive Services Task Force

Women’s Preventive Services Guidelines

Bright Futures

U.S. Preventive Services Task Force, Women’s Preventive Services Initiative, and Bright Futures Guidelines Relevant to Cardiovascular Disease and Pregnancy

Information Gathering

Guiding Principles and Framework

Report Terminology

Approach to Evidence Review

Conclusions and Recommendations Framework

Report Overview

References

2 CARDIOVASCULAR DISEASE AND PREGNANCY

Introduction

Physiologic Adaptations of Pregnancy and Mechanisms Linking Pregnancy and Cardiovascular Disease

Conditions and Risk Factors Associated with Cardiovascular Disease in Pregnancy

Pregnancy-Related Mortality and Morbidity

Prepregnancy, Prenatal, Postpartum, and Interpregnancy Care

Health Care Use and Access to Preventive Services for Women

Community-Based Models of Maternity Care and Cardio-Obstetrics

Concluding Considerations

References

3 OVERVIEW OF EXISTING CLINICAL GUIDELINES AND COVERAGE AND GAPS

Introduction

Guideline and Coverage Landscape

Committee Approach to Reviewing Guidelines and Identifying Gaps

Existing Clinical Preventive Services and Related Gaps

Gaps In Existing Preventive Services Guidance for Pregnancy and Cardiovascular Risk

Committee Process for Identifying Priority Clinical Services and Research Questions

References

4 PREVENTIVE SERVICES TO ADDRESS GAPS IN CARDIOVASCULAR RISK: SCREENING, EARLY DETECTION, AND CLINICAL MANAGEMENT

Introduction

Screening and Early Detection

Prenatal Blood Pressure Target

Enhanced Postpartum Hypertension Management

Urgent Maternal Warning Signs

Structured Cardiovascular Risk Assessment Tools

Life’s Essential 8

Evidence Review, Part 2

References

5 PREVENTIVE SERVICES TO ADDRESS GAPS IN CARDIOVASCULAR RISK: CARE DELIVERY AND SUPPORTIVE SERVICES

Introduction

Care Delivery and Supportive Services

Telehealth

Integrated Cardio-Obstetrics Care Models

Supportive Services

Transition from Postpartum Care

Summary

Conclusion

References

6 CROSSCUTTING CONSIDERATIONS

Introduction

Framework for Crosscutting Implementation Barriers

Policy and Coverage Environment

Health System Capacity, Geography, and Workforce

Care Delivery, Coordination, and Information Systems

Clinician Knowledge, Training, and Practice Environment

Patient, Family, and Community-Level Factors

Historical Drivers of Differences in Maternal Cardiovascular Outcomes

Data and Quality Infrastructure for Maternal Cardiovascular Health

Federal Levers: Health Resources and Services Administration Opportunities to Address Crosscutting Barriers

Crosscutting Conclusions

Concluding Observations

References

7 RECOMMENDATIONS

Introduction

Clinical Services Recommendations

Crosscutting Recommendations

Cardiovascular Disease and Pregnancy Research Recommendations

Concluding Observations

References

APPENDIXES

A Affordable Care Act–Covered Clinical Preventive Services

B Clinical Service Guidelines from Professional Societies Related to Cardiovascular Disease and Pregnancy

C Search Strategy for Evidence Reviews

D Methods for the Structured Evidence Review

E Public Meeting Agendas

F Committee Members, Fellows, and Staff Biosketches

Preface and Acknowledgements

Pregnancy is a focal point in the life course of many women. It is also a time of vulnerability and opportunity: a physiologic stressor that can reveal unrecognized conditions, period when new health problems emerge, and window into conditions that can persist or worsen in the postpartum period and beyond. U.S. women suffer the highest rate of maternal mortality among high-income nations,¹ and this rate has more than doubled in the past 2 decades.² Cardiovascular conditions are the leading cause of these deaths,³ most of which are potentially avoidable.⁴

Clinical services hold promise to prevent pregnancy-related cardiovascular morbidity and mortality, but their benefits will only be realized if effective services are selected thoughtfully and delivered consistently. Many clinical preventive services relevant to pregnancy-related health are already recommended by authoritative national committees, but gaps remain. Addressing these needs will have far-reaching benefits.

This study was designed to identify gaps in clinical services to prevent pregnancy-related cardiovascular morbidity and mortality; describe barriers

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¹https://www.commonwealthfund.org/publications/issue-briefs/2024/jun/insights-us-maternal-mortality-crisis-international-comparison (accessed February 23, 2026).

²Fleszar, L. G., A. S. Bryant, C. O. Johnson, B. F. Blacker, A. Aravkin, M. Baumann, L. Dwyer-Lindgren, Y. O. Kelly, K. Maass, P. Zheng, and G. A. Roth. 2023. Trends in state-level maternal mortality by racial and ethnic group in the United States. JAMA 330(1):52–61.

³https://www.cdc.gov/maternal-mortality/php/pregnancy-mortality-surveillance-data/index.html?cove-tab=2 (accessed February 23, 2026).

⁴https://www.cdc.gov/maternal-mortality/php/data-research/mmrc/index.html?cove-tab=4 (accessed February 23, 2026).

to delivering preventive care before, during, and after pregnancy; and suggest strategies to overcome these barriers. The committee assembled to prepare this report was asked to identify areas of need beyond the existing recommendations of expert groups, including the U.S. Preventive Services Task Force (USPSTF) supported by the Agency for Healthcare Research and Quality and the Women’s Preventive Services Initiative (WPSI) of the Health Resources and Services Administration (HRSA). This work was sponsored by HRSA, and we are grateful for its support.

Our study committee approached this work with a sense of purpose and openness and demonstrated resilience and pragmatism throughout the collaborative multidisciplinary process. The committee and National Academies of Sciences, Engineering, and Medicine (the National Academies) staff developed this report based on reviews of existing clinical preventive services recommendation statements, reviews of the literature on promising services, and public meetings with experts from HRSA, federal and state health agencies, foundations and other nongovernmental organizations, and patient advocacy groups. We were attuned to changes in the federal government and that policymakers, health care system leaders, clinicians and patients must make practical decisions daily on how to invest finite time and resources based on the evidence available. As a former USPSTF member and physician in a large health care delivery system, I greatly appreciated the ability of our committee members and National Academies team to think pragmatically about how to craft conclusions and recommendations that would best advance women’s pregnancy-related cardiovascular health in diverse real-world settings.

We appreciate the insights shared with us by the speakers at our public meetings, including Angela Aina (Black Mamas Matter Alliance); Onyekachukwu (Onyeka) Anaedozie (HRSA); Annette Ansong (Children’s National Hospital; Association of Black Cardiologists representative); Wendy Bennet (Johns Hopkins University; American Diabetes Association representative); Jessica Brumley (American College of Nurse-Midwives); Sarah Chew (Society for Women’s Health Research); Andria Cornell (Association of Maternal & Child Health Programs); Malamo Countouris (University of Pittsburgh Medical Center); Johannie Escarne (HRSA); Celina Gorre (WomenHeart); Kimberly Gregory (Cedars-Sinai; WPSI); Faihza M. Hill (Indiana School of Medicine; Academy of Family Physicians representative); Rose Horton (NotOnMyWatch Consulting; Association of Women’s Health, Obstetric and Neonatal Nurses); Abbi Lane (University of Michigan); Jennifer Lewey (University of Pennsylvania; American Heart Association representative); Shruthi Mahalingaiah (Harvard University; American Society for Reproductive Medicine representative); Kristi Martinsen (HRSA); Nancy O’Reilly (American College of Obstetricians and Gynecologists); Shirley Payne

(HRSA); Cassandra Phillips (HRSA); Ellen W. Seely (Harvard University; Endocrine Society representative); Kimberly C. Sherman (HRSA); Sindhu K. Srinivas (Society for Maternal-Fetal Medicine; University of Pennsylvania); Eleni Z. Tsigas (Preeclampsia Foundation); Catherine J. Vladutiu (HRSA); Mary Norine Walsh (Ascension; former American College of Cardiology president); Michael Warren (March of Dimes); and Catherine Witkop (Uniformed Services University; WPSI) (see Appendix E for full details). We are especially thankful to the three WomenHeart Champions—Gigi Campos, Kimberly Connell, and Charity Watkins—who shared their personal experiences and gave the committee grounding in the lived experience at the intersection of cardiovascular and women’s reproductive health.

We also greatly benefited from the participation of two National Academy of Medicine Fellows, Michelle Debbink, 2023–2025 Gant/American Board of Obstetrics and Gynecology Fellow, and Yohualli Anaya, 2024–2026 National Academy of Medicine Fellow to Advance State Health Policy, who provided meaningful input to our deliberations and contributions to writing this report. In addition, several consultants made important contributions to this report: Joe Alper, Torrey Robinson, and Karen Williams.

We also thank the team from PICO Portal for their assistance with risk of bias assessments and for their methodological and operational guidance, including Alon Agai, Eitan Agai, Renée F. Wilson, Winifred Yu, Stephanie Qureshi, Ahmed Elmoghazy, Rodrigo Conde, Heba Hussein, and Barkha Sirwani.

The committee’s work would not have been possible without the adept and courageous leadership of our study director, Amy Geller. We benefited from the top-notch contributions of National Academies team members, including Program Officer Aisha Bhimla, Research Associates Luz Brielle Dojer and Maddie Deye, Associate Program Officer Dara Ancona, and Senior Program Assistants Ella Castanier and Katie Perterson. We also thank Alina Baciu, Crysti Park, and Stephanie Puwalski and many other staff members within the Center for People, Health, and Places for their support. We extend appreciation to the National Academies’ Research Center staff for their advice and implementation of the literature searches and evidence review—especially Christopher Lao-Scott, Ann Marie Houppert, and Rebecca Morgan. We thank the National Academies communications staff, including Douglas Sprunger and Marguerite Romatelli. This project also received assistance from Solomon Self (Office of News and Public Information); Misrak Dabi and Thanh Nguyen (Office of the Chief Financial Officer); Leslie Sim, Patti Simon, and Taryn Young (Peer Review Office); and Lori Brenig (Editorial Projects Coordinator). We are extremely grateful for the adept guidance of Senior Board Directors Rose Marie Martinez and Sharyl Nass.

We hope this report facilitates a shared understanding of gaps in clinical services and barriers to providing recommended care and highlights practical steps to strengthen prevention and follow-up—particularly in the postpartum and interpregnancy periods. Ultimately, our aim is to support consistent, evidence-informed care that improves women’s cardiovascular health during pregnancy and throughout life.

Tracy A. Lieu, Chair

Committee on Clinical Preventive Services for Addressing Cardiovascular Disease Risk to Reduce Pregnancy-Related Deaths Among Women

March 2026

Acronyms and Abbreviations