3

Overview of Existing Clinical Guidelines and Coverage and Gaps

INTRODUCTION

This chapter describes the current landscape of clinical preventive services that relate to cardiovascular risk in and around pregnancy and where important gaps remain. Building on the background Chapter 1 provided, this chapter focuses on preventive services that are relevant across the reproductive life course—from prepregnancy and pregnancy through the postpartum and interpregnancy periods—and have implications for cardiovascular health.

This chapter has three main goals. First, it briefly outlines the guideline and coverage infrastructure that shapes which clinical preventive services are routinely offered to women who are of reproductive age, pregnant, or postpartum. Second, it highlights selected services that are especially important for cardiovascular risk around pregnancy, such as hypertension (HTN) screening and treatment; diabetes, lifestyle, and behavioral counseling; lipid management; contraception; and lactation support, and summarizes how current guidelines and coverage policies address these services, along with remaining gaps and opportunities to strengthen practice and coverage. Third, it identifies crosscutting gaps in preventive services guidance and explains how the committee used those gaps, together with its guiding principles in Chapter 1, to identify priority clinical services and associated research questions for formal evidence review.

The examples in this chapter are not intended as a comprehensive catalog of all existing guidelines or preventive services that might influence cardiovascular risk around pregnancy. Rather, they illustrate the kinds of

services that matter most for this report’s charge and show how guidance and coverage align—or fail to align—with women’s needs across the reproductive life course.

GUIDELINE AND COVERAGE LANDSCAPE

As Chapter 1 described, several national guideline bodies play key roles in determining which preventive services are recommended and often which services are covered without cost-sharing. The U.S. Preventive Services Task Force (USPSTF) issues recommendations on clinical preventive services for asymptomatic adults and children, including screening, counseling, and preventive medications (USPSTF, n.d.). The Women’s Preventive Services Initiative (WPSI) develops recommendations on preventive services for women’s health (WPSI, n.d.-a), and Bright Futures provides guidance on pediatric and adolescent preventive care (AAP, 2024). Under the Affordable Care Act (ACA), most private health plans and Medicaid expansion programs are required to cover, without patient cost-sharing, services that receive an A or B grade from USPSTF, are WPSI recommended, or are endorsed by Bright Futures.

Other professional societies also issue guidelines that strongly influence clinical practice but do not directly determine coverage requirements. For pregnancy and cardiovascular disease (CVD), these include the American College of Cardiology and American Heart Association (ACC/AHA), American Heart Association/American Stroke Association (AHA/ASA), American College of Obstetricians and Gynecologists (ACOG), Society for Maternal-Fetal Medicine (SMFM), American College of Nurse Midwives, American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American Diabetes Association (ADA), and Endocrine Society. These organizations provide detailed recommendations on topics such as managing hypertensive disorders of pregnancy (HDPs), diabetes care before and during pregnancy, lipid management, and lifestyle counseling. Their guidance frequently but not always aligns with USPSTF, WPSI, or Bright Futures recommendations. Therefore, how well these organizations’ recommendations have translated into coverage can vary across payers and states.

A patchwork of payers and programs shapes coverage. Coverage for preventive or primary care before and after pregnancy may change or even be nonexistent for some women, compared to the source or extent during pregnancy. For many women of reproductive age, preventive services are financed through employer-sponsored or marketplace plans that are subject to the ACA’s coverage requirements (CMS, 2025). In contrast, Medicaid plays a central role for pregnant and postpartum women, particularly in states that have expanded eligibility and adopted extended postpartum coverage. Chapter 6 describes these coverage arrangements. In this chapter,

the committee focuses on how these coverage frameworks interact with specific preventive services, such as whether a service is tied to a USPSTF A or B grade or WPSI recommendation, and whether postpartum women retain coverage long enough to receive recommended follow-up services months or even years after.

COMMITTEE APPROACH TO REVIEWING GUIDELINES AND IDENTIFYING GAPS

Consistent with its guiding principles in Chapter 1—including taking a life-course perspective, emphasizing the postpartum period, focusing on services with the potential to reduce severe maternal morbidity (SMM) and mortality, and attending to women who face the greatest barriers to care—the committee systematically reviewed preventive services guidance relevant to cardiovascular risk in and around pregnancy. This review centered on USPSTF, WPSI, and Bright Futures recommendations, given their direct connection to coverage, and also drew on guidelines from professional societies, such as ACC/AHA, ACOG, SMFM, AAFP, ADA, Endocrine, and AHA/ASA, and international guidance from government-affiliated bodies, such as the U.K. National Institute for Health and Care Excellence (NICE).

For each guideline source, the committee examined how recommendations addressed women who are of reproductive age, pregnant, or postpartum; whether adverse pregnancy outcomes (APOs) were explicitly recognized as indicators of elevated cardiovascular risk; and how timing, frequency, and setting of services were specified across the prepregnancy, prenatal, and postpartum periods. The committee also considered how recommendations aligned with or diverged from each other and with the coverage frameworks described.

In addition to formal guideline documents, the committee drew on its clinical and research expertise, information from stakeholder input and public comment, and the epidemiologic patterns summarized in Chapters 1 and 2. These inputs helped the committee identify where clear, actionable preventive services guidance already exists and where gaps or inconsistencies limit the ability of clinicians and health systems to deliver coordinated, evidence-informed care for cardiovascular risk around pregnancy. This review revealed that while many preventive services relevant to cardiovascular risk are addressed in existing guidelines, they are often fragmented across disciplines, inconsistently incorporate pregnancy-related risk enhancers, or lack clarity regarding timing and coordination across the reproductive life course. These observations provide the foundation for the focused discussion that follows.

The sections that follow use selected clinical preventive services to illustrate this landscape, highlighting both alignment and gaps. The chapter

then synthesizes what is known about crosscutting limitations and time period–specific gaps in preventive services guidance and describes how these findings informed the committee’s identification of potential research topics and, ultimately, nine priority clinical services for formal evidence review in Chapter 4.

EXISTING CLINICAL PREVENTIVE SERVICES AND RELATED GAPS

As noted in the introduction, this section does not catalog every preventive service relevant to pregnancy-related cardiovascular risk. Instead, it highlights selected services that are central to this report’s charge and illustrates how guidelines and coverage do—or do not—support coordinated cardiovascular risk prevention around pregnancy. For each topic—cardiometabolic risk, medications and services, lifestyle and behavior services, substance use disorders, and reproductive planning—the committee considered why the service matters for CVD risk, what guidelines and coverage frameworks provide, how the service is used, the main implementation barriers, and where gaps remain in guidance in that area. See Appendix A for a table summarizing relevant USPSTF, WPSI, and Bright Futures covered services and Appendix B for a table on recommendations/clinical care guidelines from relevant professional societies.

Cardiometabolic Risk Detection and Management

Hypertension and Cardiovascular Optimization Around Pregnancy

screening for HDP via blood pressure measurement throughout pregnancy (USPSTF, 2021d, 2023c). As long as women have insurance and access to primary care, these services are generally covered and available.

The 2025 AHA/ACC/ACOG HTN guidelines include recommendations for management in pregnancy. To prevent maternal morbidity and mortality, the guidelines advise treating pregnant women with chronic HTN to achieve a goal blood pressure of <140/90 mmHg (ACOG Committee on Clinical Practice Guidelines et al., 2025; Jones et al., 2025; Tita et al., 2022). AHA/ACC and other sources recommend against atenolol, ACE inhibitors, angiotensin II receptor blockers, direct renin inhibitors, dual endothelin receptor antagonists, and mineralocorticoid receptor antagonists in women planning pregnancy or who are pregnant and switching to labetalol or extended-release nifedipine for blood pressure control if possible (Abalos et al., 2018; Bellos et al., 2020; Bennett et al., 2025; Easterling et al., 2001; Jones et al., 2025; Moretti et al., 2012; Park et al., 2021; Pucci et al., 2015).

blood pressure monitoring, or telehealth) for postpartum surveillance or screening or explicitly integrate HDP history into long-term preventive services frameworks.

Diabetes Screening and Treatment Before, During, and After Pregnancy

GDM is common, affecting 5–9 percent of U.S. pregnancies (CDC, 2024b). It is associated with a substantially increased risk of future diabetes and CVD, with cumulative diabetes incidence approaching 50 percent within 5–10 years (Selen et al., 2023) and an approximately twofold increased risk of subsequent cardiovascular events (Bellamy et al., 2009; Selen et al., 2023; Yu et al., 2019).

USPSTF recommends universal screening for GDM during pregnancy (USPSTF et al., 2021b) and screening adults aged 35–70 who are overweight or obese for diabetes or prediabetes (USPSTF et al., 2021a). Since women diagnosed with GDM are at an increased risk of future diabetes diagnosis, “WPSI recommends screening for type 2 diabetes in women with a history of GDM who are not currently pregnant and who have not previously been diagnosed with type 2 diabetes; initial testing is ideally within the first year postpartum and can be done as early as 4–6 weeks postpartum” (WPSI, 2022b). ACA-compliant plans generally cover these services without cost-sharing.

Transitions of care are another barrier. Primary care clinicians may not always be aware that their patients had GDM during pregnancy, and women may not be counseled about the need for ongoing diabetes and cardiovascular screening postpartum. Proposed strategies include postpartum “passports” and explicit handoffs between obstetric and primary care clinicians (ACOG, 2018b; ADA Professional Practice Committee, 2024a).

On a patient level, competing demands, lack of time, child care issues, challenges with fasting while lactating and caring for an infant, and

inadequate knowledge about the risk for diabetes are also factors. These barriers and facilitators occur across individual, interpersonal, health system, and community levels and affect GDM testing, treatment, and postpartum follow-up (see Figure 3-1) (Simmons et al., 2024).

Lipid Assessment and Management

For women with familial hypercholesterolemia, prior premature ASCVD, or other high-risk profiles, lipid assessment and management before and after pregnancy are important components of long-term cardiovascular prevention (Arnett et al., 2019; Grundy et al., 2019). They may

need ongoing low-density lipoprotein (LDL)-lowering therapy across the reproductive years, yet pregnancy and breastfeeding raise complex questions about when to stop, modify, or restart therapy. This underscores the critical need for shared decision-making and thorough risk–benefit discussions in this population, akin to those for women with established ASCVD.

ACC/AHA cholesterol guidelines and National Lipid Association consensus documents acknowledge pregnancy considerations, generally advising discontinuation of most systemic lipid-lowering agents before and during pregnancy, with bile acid sequestrants as a potential option when treatment is necessary (AHA, n.d.; National Lipid Association, n.d.). In 2021, the U.S. Food and Drug Administration (FDA) removed the contraindication against statins in pregnancy but continues to advise that most patients stop statins once they learn they are pregnant, with continuation considered only in select very high-risk cases (FDA, 2021). Breastfeeding is generally not recommended if statins are required.

These guidance documents recognize pregnancy and reproductive plans as important in lipid management (Kirkpatrick et al., n.d.). However, they do not provide detailed, pregnancy-specific drug algorithms or standardized approaches to lipid screening and counseling before, during, and after pregnancy.

Women with familial hypercholesterolemia or other very high-risk phenotypes may be on statins, nonstatin therapies (i.e., ezetimibe, PCSK9 inhibitors, and bempedoic acid), or other agents when they decide to attempt pregnancy, and unplanned pregnancies while on lipid-lowering therapies can occur. Evolving guidance and limited pregnancy-specific safety data contribute to uncertainty regarding when to discontinue statins before pregnancy, whether continuation is appropriate in select high-risk cases, which non-statin options may be considered, and how to manage therapy in the postpartum period, particularly during breastfeeding (FDA, 2021; Henry et al., n.d.; National Lipid Association, n.d.). Hydrophilic statins, such as pravastatin, have been studied in pregnancy because their physicochemical properties and placental transport suggest more limited fetal exposure than some lipophilic statins, but evidence directly comparing placental transfer across agents remains limited (Chang et al., 2021; Fokina et al., 2022; Nanovskaya et al., 2013; Vahedian-Azimi et al., 2021). Recent meta-analyses found no significant association between first-trimester exposure to statins and congenital malformations (Christensen et al., 2025; Karadas et al., 2022).

Practical issues that preventive services guidance do not address adequately include:

• Screening and treatment in women of reproductive age under 40 at increased risk of CVD who desire pregnancy or are not using reliable contraception;
• How to approach lipid screening and treatment for women with PCOS or infertility before assisted reproduction;
• How to manage statins and other lipid-lowering therapies in women with very high cardiovascular risk who are planning pregnancy or have unplanned pregnancies, including when to continue statins, when to use LDL apheresis, and which nonstatin agents have sufficient pregnancy safety data); and
• How and when to restart statin therapy in the postpartum period, especially for women who are breastfeeding, and what counseling language to use.

These challenges are magnified because physiologic lipid levels rise substantially during pregnancy (Agarwala et al., 2024)—even in women without preexisting dyslipidemia—and evidence to guide interpretation and treatment thresholds in this setting is limited.

• No pregnancy-focused preventive service for lipid assessment. USPSTF and WPSI recommendations on screening and statins are framed for general adult populations and do not address the timing, frequency, or interpretation of testing as part of prepregnancy care, in the immediate postpartum period, or between pregnancies for women with APOs.
• Limited integration of pregnancy history and reproductive plans into lipid management. While some cardiology and lipid guidelines describe pregnancy complications and PCOS as risk-enhancing factors, this information has not been incorporated systematically into preventive services guidance that drives coverage decisions and routine screening and counseling (Agarwala et al., 2024; Safwan et al., 2024; Teede et al., 2023b).
• Unclear pathways for high-risk women. For women with familial hypercholesterolemia or established ASCVD, expert reviews and consensus statements suggest approaches such as prepregnancy counseling, temporary discontinuation of statins before pregnancy, use of bile acid sequestrants or omega-3 fatty acids in pregnancy, and LDL apheresis in selected cases, but these strategies are not framed as standard preventive services and depend highly on local specialist availability (Henry et al., n.d.).
• Postpartum and lactation uncertainty. Guidance on when to recheck lipids postpartum, how to integrate testing into broader cardiometabolic follow-up after APOs, and how to counsel women about restarting statins or other agents while breastfeeding remains limited and is not reflected in USPSTF or WPSI recommendations.

Given the limited and evolving evidence on lipid-lowering therapy during pregnancy and lactation, that the mainstay method (statins) is generally not recommended during breastfeeding in the United States and the lack of trials that directly link lipid-focused interventions around pregnancy to maternal cardiovascular events or pregnancy outcomes, the committee judged that lipid assessment and management would be difficult to address as a discrete preventive clinical service within this report. Nevertheless, lipid disorders remain an important part of the cardiovascular risk profile for many women of reproductive age, particularly those with PCOS, diabetes, familial hypercholesterolemia, prior APOs, or established ASCVD. The committee therefore viewed lipid assessment and counseling—especially in the context of prepregnancy and postpartum care—as an area where future preventive services guidance could more explicitly incorporate pregnancy history and reproductive plans into cardiovascular risk management.

Pregnancy-Specific Preventive Medications and Services

Low-Dose Aspirin to Prevent Preeclampsia

significant increases in placental abruption, postpartum hemorrhage, fetal intracranial bleeding, or congenital anomalies with daily low-dose aspirin. Overall maternal and fetal harms appear to be small, particularly when used in women at increased risk for preeclampsia (Henderson et al., 2014; USPSTF, 2021a). Questions remain about optimal dosing; relative benefits in different risk profiles, including women with obesity and different HDP phenotypes; and best strategies to systematically identify and offer low-dose aspirin to all eligible women.

Lactation

women with cardiovascular risk factors or pregnancy complications. A meta-analysis of eight studies that included over 1 million women found that breastfeeding compared to no breastfeeding was associated with a 10–12 percent risk reduction for future CVD, coronary heart disease, stroke, and fatal CVD (Tschiderer et al., 2022). An immediate protective effect has also been shown for women with cardiometabolic pregnancy complications; during the postpartum period, those who breastfed ≥6 months had significantly lower triglycerides, fasting serum glucose, ratio of cholesterol to HDL-C, and higher HDL-C compared to those who did not (Yu et al., 2020). Thus, there is a growing body of evidence linking longer durations of breastfeeding (e.g., greater than 6 months) to improved maternal cardiometabolic health, potentially through hormonal effects of oxytocin and prolactin on vascular remodeling and metabolic profiles, suggesting the importance of breastfeeding for maternal health (Villarreal et al., 2025). Observational studies suggest that the potential benefits for maternal health span multiple systems, including metabolic, cardiovascular, endocrine, and hematologic domains, and may extend to long-term health outcomes (see Figure 3-3), although the strength of evidence varies and may be influenced by confounding factors.

These barriers occur at multiple levels—including the health system, workplace, community, and clinical training—and have potential strategies to address them (see Figure 3-4). Because these barriers are largely structural—encompassing workplace policies, insurance coverage, access to trained support, and health system practices—lactation continuation should not be framed solely as an individual choice or responsibility. Efforts to improve maternal cardiovascular outcomes through lactation support therefore require coordinated action across policy, health systems, and community settings rather than reliance on individual behavior change alone. In many clinical settings, nurses, midwives, and lactation consultants provide much of the hands-on breastfeeding education and support; therefore, gaps

in training, resources, and institutional support across the broader maternity care team—not only physicians—can affect lactation success.

A 2025 consensus report from the National Academies of Sciences, Engineering, and Medicine provides a comprehensive review of breastfeeding, and the policies, programs, and investments to better understand the landscape of breastfeeding promotion, initiation, and support across the United States (NASEM, 2025).

Lifestyle and Behavioral Services

Lifestyle Behaviors (Diet, Physical Activity, Weight, Sleep, and Stress)

Tobacco and Alcohol Use

long-term cardiovascular risk through endothelial dysfunction, oxidative stress, and promotion of atherosclerosis (Gould et al., 2020; Messner and Bernhard, 2014).

Excessive alcohol use increases the risk of HTN, coronary artery disease, stroke, arrhythmias, cardiomyopathy, and heart failure (Georgescu et al., 2024; Piano et al., 2025). During pregnancy, any alcohol use is considered unsafe and is a leading preventable cause of miscarriage, stillbirth, and fetal alcohol spectrum disorders. Recent surveillance indicates that roughly 1 in 7 pregnant women report current alcohol use and about 1 in 20 report binge drinking in the last 30 days (CDC, n.d.; Green et al., 2023). These exposures can also complicate efforts to manage other cardiovascular risk factors, including blood pressure, weight, glucose, and mental health (Evans et al., 2023; Habersham et al., 2025).

USPSTF recommends screening adults 18+ years, including pregnant women, for unhealthy alcohol use in primary care and providing brief behavioral counseling interventions to those engaged in risky or hazardous drinking (Grade B) (USPSTF, 2018). Professional societies and public health agencies similarly recommend routine use of validated alcohol screening tools (e.g., AUDITC and single-question screeners) and brief interventions for women of reproductive age and throughout pregnancy and the postpartum period (AWHONN, 2023; Graves et al., 2020; Green et al., 2023). USPSTF issued the current operative recommendation statement in 2018 and is updating this topic.

These recommendations are tied to coverage requirements in many ACA-compliant plans when delivered in eligible settings and can be incorporated into well-woman, prenatal, and postpartum visits.

states and evidence of relapse after delivery (Kipling et al., 2024). Counseling and pregnancy-specific self-help materials can substantially increase cessation rates (ACOG, 2020b), but underreporting of tobacco use, limited time in visits, and competing priorities can impede consistent delivery of intensive behavioral support.

For alcohol, national surveys suggest that screening is performed for many pregnant women, but USPSTF-recommended validated tools and structured brief interventions are used less consistently (Green et al., 2023; Luong et al., 2023). Obstetric and primary care clinicians report variable training and confidence in addressing alcohol and other substance use, and screening rates are lower among women with less formal education, pointing to disparities in implementation (Luong et al., 2023; Thomson et al., 2024).

From a preventive services perspective, recommendations clearly endorse tobacco cessation counseling and alcohol screening and brief interventions, but they are not integrated consistently with broader cardiometabolic risk management around pregnancy. Clinicians may not be aware of the specific Current Procedural Terminology codes related to tobacco and alcohol cessation counseling and screening and brief interventions, which are reimbursed in addition to traditional Evaluation & Management visit codes. Tobacco and alcohol use are often addressed separately from blood pressure, lipids, weight, diabetes risk, and mental health, and postpartum visits may not systematically revisit tobacco and alcohol use even though relapse and ongoing use are common (Kipling et al., 2024). This fragmentation limits opportunities to deliver coordinated, life course–oriented cardiovascular prevention for women who use tobacco or alcohol before, during, and after pregnancy.

Behavioral Health and Substance Use

Substance Use Disorders

differences, including hormonal influences and sex-specific neurobiologic responses, have been associated with more rapid progression from initiation to dependence, greater withdrawal severity, and differential treatment response among women, particularly for nicotine and alcohol use disorders (Bawor et al., 2015; Greenfield et al., 2010; O’Hagan and Wilson, 2018; Perkins and Scott, 2008; Quigley et al., 2021).

Opioid misuse has cardiovascular consequences, including increased risk of infective endocarditis, coronary heart disease, cardiac arrhythmias, and stroke (Evans et al., 2023). Nonacute opioid use is strongly associated with infective endocarditis and myocardial infarction (Singleton et al., 2021) and may contribute to cardiovascular aging through arterial stiffness and changes in heart rate variability (Toska and Mayrovitz, 2023). Opioid use disorder is associated with higher rates of preterm birth, low birth weight, and neonatal abstinence syndrome than in births to women without opioid use disorder. Women with opioid use disorder have high rates of co-occurring mental health conditions and frequently experience social vulnerabilities, including housing instability, intimate partner violence, and delayed or inadequate prenatal care (Barbosa-Leiker et al., 2021; Hahn et al., 2018; Haight et al., 2018; Khan et al., 2022).

Mental Health

complications of pregnancy and the postpartum period. An estimated 10–20 percent of U.S. women experience perinatal depression (Van Niel and Payne, 2020), and a similar proportion have perinatal anxiety (Thornton and O’Conner, 2022). Maternal mental health conditions are now recognized as leading contributors to pregnancy-related morbidity and mortality (CDC, 2025c; Gimbel et al., 2024; Parekh et al., 2025). These conditions are also associated with adverse infant outcomes and impaired bonding and child development (O’Dea et al., 2023; Rogers et al., 2020). At delivery hospitalizations, a mental health diagnosis has also been associated with increased rates of cardiovascular SMM and other cardiovascular conditions and complications (Parekh et al., 2025). Recent expert reviews and AHA scientific statements further emphasize that perinatal mental health conditions are closely linked with maternal cardiovascular health across pregnancy and the postpartum period, including through shared risk factors, physiologic stress responses, and effects on engagement in preventive care (Jowell et al., 2022; Lewey et al., 2024; Sharma, 2025).

Depression and anxiety influence cardiovascular risk indirectly through behavioral pathways. They are associated with higher rates of tobacco and alcohol use, poorer diet and physical activity, sleep disturbance, reduced medication adherence, and lower engagement in preventive and chronic disease care, which collectively contribute to worse blood pressure, glycemic, and lipid control over time (Conner et al., 2009; Davidson, 2012; DiMatteo et al., 2000; Grenard et al., 2011). For women with pregnancy complications that signal elevated long-term cardiovascular risk, such as HDP or GDM, untreated perinatal depression or anxiety can further impede efforts to address cardiometabolic risk in the postpartum and interpregnancy periods.

Bright Futures guidelines recommend routine depression screening in adolescents and structured maternal depression screening at specific well-child visits (e.g., at 1, 2, 4, and 6 months postpartum), recognizing the close link between maternal mental health and child development (AAP, 2025).

WPSI includes depression and anxiety screening as part of its well-woman care framework and highlights perinatal depression preventive interventions in its Well-Woman Chart. These include counseling for women with risk factors, such as a history of depression, current subthreshold depressive symptoms, socioeconomic adversity, recent intimate partner violence, or elevated anxiety symptoms (WPSI, n.d.-b; WSPI, 2025). The WPSI resource guide on screening for anxiety and depression in women explicitly includes pregnancy and postpartum as periods when these conditions are more common. It emphasizes periodic universal screening with appropriate follow-up care (WPSI, n.d.-b; WSPI, 2025).

From a cardiovascular prevention perspective, current guidelines clearly support screening and preventive counseling for perinatal depression and anxiety but do not explicitly integrate mental health conditions into risk follow-up pathways for women with pregnancy complications. Depression and anxiety are not incorporated systematically into protocols for postpartum HTN management, diabetes follow-up after GDM, or broader cardiometabolic risk assessment after APOs. As a result, women who are both at elevated cardiovascular risk and experiencing perinatal mental health conditions may be less likely to engage in the very preventive services, such as lifestyle interventions, medication management, and longitudinal primary care, needed to reduce their long-term risk. In addition, evidence remains limited on whether interventions to address stress, depression, or anxiety during the postpartum period reduce the development or progression of HTN or CVD or how best to design and integrate behavioral health services into postpartum and longer-term cardiovascular preventive care.

Reproductive Planning

Contraception and Contraceptive Care

For women with cardiac disease, a systematic review estimated that only 63 percent reported receiving contraceptive counseling and 64 percent were using contraception (Feyissa et al., 2024). Many women were not using highly effective methods, and more than half misestimated their pregnancy-related CVD risk. Changes in access to contraception and family planning services may have important implications for cardiovascular risk among women of reproductive age, particularly for those with underlying cardiac conditions for whom pregnancy carries substantial health risks. Reduced access to effective contraception could increase rates of unintended and high-risk pregnancies; evidence suggests that family planning use is associated with fewer high-risk pregnancies overall (Jahanfar et al., 2024).

Women with CVD and CVD risk factors who take potentially teratogenic medications need access to contraceptive counseling that supports their preferences and reproductive goals. Because this includes some cardiovascular, HTN, lipid-lowering, and diabetes medications, contraceptive and family planning counseling is an essential component of care (ADA Professional Practice Committee, 2026; Lindley et al., 2021; Lindley and Teal, 2022; Minga and Dastmalchi, 2025). Ethical and clinical guidance on contraception emphasizes person-centered, noncoercive counseling (ACOG, 2022, 2024, 2025; CDC, 2024c), in recognition of a history of reproductive coercion in health care and evidence that some patients feel pressured by clinicians to start, continue, or stop specific methods (Scholars Strategy Network, 2024; Swan and Cannon, 2024). For women with conditions characterized as modified World Health Organization (mWHO) class IV, where pregnancy carries an unacceptably high risk of maternal mortality, the imperative for highly effective contraception is clear. Women classified as mWHO class III also face substantially elevated maternal cardiovascular

risk, often requiring expert multidisciplinary counseling and careful risk–benefit discussion regarding pregnancy; in these cases, shared decision-making and proactive reproductive planning are particularly important. However, the trade-offs between the risks and side effects need to be considered (see Figure 3-5), underscoring the need for careful shared decision-making in selecting the most appropriate method.

GAPS IN EXISTING PREVENTIVE SERVICES GUIDANCE FOR PREGNANCY AND CARDIOVASCULAR RISK

In addition to the insurance and cost barriers noted in the previous section, the committee found that gaps and misalignments across clinical preventive service guidelines create added challenges for implementing evidence-based practices to reduce cardiovascular risk around pregnancy. For example, USPSTF offers separate recommendations on screening for HDP and low-dose aspirin for preeclampsia prevention in women at high risk, and most private health plans and Medicaid expansion programs are required to cover these services without cost-sharing. In contrast, guidelines such as those from NICE provide more detailed recommendations on exercise counseling and other behavioral strategies in pregnancy (National Institute for Health and Care Excellence, 2019), whereas USPSTF does not offer pregnancy-specific counseling recommendations for preventing or treating HDP. Similarly, WPSI recommends early GDM screening for pregnant women with risk factors and postpartum diabetes screening for women with a history of GDM (HRSA, 2025), whereas USPSTF concludes that evidence is insufficient to support universal early GDM screening before 24 weeks and does not address the postpartum period in its diabetes guidance (USPSTF, 2021b). In other areas, such as glycemic targets before pregnancy or lipid management in women of reproductive age, professional societies offer varying recommendations. Collectively, these gaps and misalignments contribute to uncertainty for clinicians and patients and can hinder coordinated prevention efforts.

The discussion in the earlier sections of this chapter illustrates these issues within specific clinical service areas. The committee’s review highlighted several crosscutting limitations and time period–specific gaps that shaped the long list of research topics and ultimately the priority clinical services selected for formal evidence review this report presents in subsequent chapters.

Crosscutting Limitations

Across guideline sources, the committee identified three overarching limitations. First, pregnancy and the early postpartum period are not consistently framed as key opportunities for CVD prevention. Many recommendations are written for the general adult population, with pregnant and postpartum women either implicitly included, explicitly excluded, or not mentioned. For example, adult recommendations for blood pressure, diabetes, and lipid screening apply in principle to women of reproductive age but rarely address how to implement them before, during, and after complicated pregnancies or use pregnancy history to guide prevention across the life course.

Second, APOs, such as HDP, GDM, preterm birth, and placental disorders, are not incorporated consistently as risk-enhancing factors in preventive services guidance. Some cardiovascular and stroke guidelines recommend taking a history of APOs when assessing risk and managing HTN or stroke prevention, but this approach is not uniformly reflected in the recommendations that drive screening and counseling in primary care and obstetric settings. In addition, although APOs are associated with elevated long-term cardiovascular risk, incorporation of APO history into formal risk prediction models has not yet consistently demonstrated improved prediction of future cardiovascular events.

Third, guidelines offer limited direction on implementing and coordinating care across specialties and settings. Several professional societies encourage multidisciplinary cardio-obstetrics teams or enhanced postpartum follow-up for women with pregnancy complications, yet the guidance offers little detail on how to operationalize these models, which clinicians are responsible for specific services, and how to manage transitions between obstetrics, primary care, and cardiology or other specialists.

These crosscutting gaps highlight the need for the guiding principles developed by this committee. These principles emphasize a coordinated, longitudinal approach to cardiovascular risk related to pregnancy and the importance of addressing system barriers that contribute to differences in outcomes by geography, insurance coverage, and access to care. The following sections discuss several specific gaps the committee identified in the areas of prepregnancy and prenatal care and postpartum and interpregnancy care and several implementation and system-level areas where preventive services guidance is limited.

Prepregnancy and Prenatal Gaps

Prepregnancy Counseling and Comprehensive Cardiovascular Risk Assessment

WPSI recommends annual well-woman visits to deliver preventive services based on age and risk, and ADA, Endocrine, and other societies provide guidance on prepregnancy counseling for women with diabetes. However, no dedicated preventive services recommendation focuses on comprehensive prepregnancy cardiovascular risk assessment for women who are planning pregnancy, particularly those with chronic conditions (e.g., HTN, diabetes, and kidney disease) or prior APOs. Questions remain regarding the optimal timing, content, and responsible clinician(s) for such visits and whether a structured prepregnancy cardiovascular assessment improves maternal or neonatal outcomes.

Risk-Stratified Screening During Pregnancy

Existing guidelines address specific components of prenatal care, including screening for gestational diabetes at 24–28 weeks’ gestation (ADA Professional Practice Committee for Diabetes, 2026b) and recommending low-dose aspirin for women at increased risk of preeclampsia, initiated between 12 and 28 weeks and ideally before 16 weeks’ gestation (ACOG, 2021; USPSTF, 2021a). At the same time, evidence remains limited or insufficient to support improved maternal or neonatal outcomes from earlier gestational diabetes screening among high-risk women, more intensive blood pressure surveillance beyond routine office measurement in asymptomatic patients, or the routine use of angiogenic biomarker testing or Doppler ultrasound to refine risk stratification for preeclampsia (ACOG, 2020a; Burwick and Rodriguez, 2024; USPSTF, 2021b).

Models of Prenatal Care Delivery

Group prenatal care, multidisciplinary care for pregnant women with cardiovascular risk factors, and telehealth-supported remote monitoring of blood pressure and glucose have been proposed or used in practice. However, these models are not the focus of preventive service recommendations, and their impact on cardiovascular and pregnancy outcomes remains uncertain. These gaps intersect with guiding principles related to aligning with existing preventive service frameworks while giving particular attention to women with higher baseline risk and interventions that could be integrated into routine prenatal care.

Postpartum and Interpregnancy Gaps

Postpartum Blood Pressure Monitoring and Hypertension Management

Despite the well-documented link between HDP and both short- and long-term cardiovascular risk, no USPSTF or WPSI recommendations or reviews of related evidence specifically address postpartum blood pressure monitoring—whether clinic based, home based, or telehealth supported—for women with HTN identified during pregnancy. Questions remain about the most effective frequency, modality, and duration of postpartum blood pressure surveillance and the impact of enhanced postpartum HTN programs on SMM, rehospitalization, and long-term cardiovascular outcomes.

Postpartum Cardiometabolic Screening and Long-Term Risk Assessment

WPSI and ADA provide guidance for diabetes screening after GDM, including early postpartum glucose testing and periodic screening thereafter,

but with less clarity on how to bundle postpartum cardiometabolic services—including blood pressure evaluation, lipid testing, and risk-based initiation of statins or antihypertensive therapy—and define the timing and frequency of such assessments for women with APOs. Guidance also provides limited direction on how clinicians can communicate the long-term cardiovascular implications of pregnancy complications and ensure linkage to ongoing primary care and cardiology or other specialists.

Recognition and Response to Postpartum Warning Signs

The committee noted a lack of preventive services guidance on structured approaches to identifying and responding to postpartum warning signs and symptoms of cardiovascular complications. Examples of such approaches include algorithms for emergency departments or urgent care settings and electronic health record (EHR) alerts for recently pregnant women presenting with chest pain, dyspnea, or neurologic symptoms. These approaches are not addressed by USPSTF, WPSI, or Bright Futures.

Implementation and System-Level Gaps

Care Coordination and Transitions

Transitions from delivery hospitalization to outpatient care and from obstetrics to primary care and cardiology or other specialists are only addressed sparsely in existing guidelines. The committee noted potential roles for discharge checklists, patient “passports” or action plans, structured referral pathways, and health information technology (e.g., patient portal tools or EHR-based prompts) to support safe transitions, but these strategies are not framed as preventive services with an evidence base for cardiovascular and pregnancy outcomes.

Community-Based Supports and Navigation

Nurse home visiting programs, doulas, community health workers, promotoras, and patient navigators are used in some settings to support postpartum women, particularly those facing social and economic barriers. However, major preventive service guideline bodies do not provide recommendations that link these services to cardiovascular outcomes in the context of pregnancy, and the evidence base for such linkages remains limited. WPSI recently issued its first recommendation related to patient navigation—focused on breast and cervical cancer screening—which is scheduled to take effect in 2026 (HRSA, 2025).

Screening for Social Needs

USPSTF has concluded that evidence is insufficient to determine the balance of benefits and harms of screening for food insecurity in primary care (USPSTF, 2025b), with similarly limited preventive service–oriented guidance on screening for other social needs in prenatal or postpartum care. However, ACOG recommends comprehensive assessments that include social and environmental factors. This disconnect highlights a gap between recognition of social barriers in clinical guidance and the evidence needed to support formal preventive service recommendations.

Mental Health and Cardiovascular Risk

USPSTF and WPSI support screening for depression and anxiety in pregnant and postpartum women. However, existing recommendations do not explicitly address how mental health conditions intersect with cardiovascular risk after complicated pregnancies or integrated approaches to mental health and cardiovascular follow-up might influence outcomes.

COMMITTEE PROCESS FOR IDENTIFYING PRIORITY CLINICAL SERVICES AND RESEARCH QUESTIONS

The committee used its gap scan as a starting point to identify specific clinical services that could meaningfully reduce cardiovascular risk around pregnancy. Consistent with the guiding principles in Chapter 1, it focused on services that (1) address conditions that contribute substantially to pregnancy-related morbidity and mortality, (2) emphasize the postpartum and interpregnancy periods while maintaining a life-course perspective, (3) can be delivered as part of routine clinical care, and (4) could improve outcomes for women who face the greatest barriers to high-quality care.

Drawing on the guideline review summarized earlier in this chapter, the committee compiled an initial list of potential clinical services. Members considered services that directly target cardiovascular risk factors, such as blood pressure, glucose, and lipids; address pregnancy-related complications with long-term cardiovascular implications; or strengthen care coordination and follow-up after complicated pregnancies. To ensure this list reflected the real-world context in which pregnant and postpartum women receive care, the committee also drew on its own clinical and research experience, information from public comment and stakeholder input, and the epidemiologic patterns Chapters 1 and 2 describe.

The committee then organized potential research topics by period (e.g., prepregnancy, prenatal, postpartum, and interpregnancy) and type of service, including screening and management for specific risk factors, bundled

postpartum cardiometabolic care, models of integrated or multidisciplinary care, and approaches to improving transitions and follow-up. This resulted in a list of 20 potential research topics (see Box 3-2); for each, the committee noted whether components were already addressed by USPSTF, WPSI, or other guideline bodies and where important gaps remained, such as on the timing or intensity of services, use of pregnancy history to guide long-term prevention, or implementation models, such as telehealth and team-based care.

To narrow this list, the committee applied the guiding principles as explicit prioritization criteria. In particular, the committee considered the following:

• Burden and potential impact—the extent to which the service addresses conditions that are major contributors to SMM, pregnancy-related death, or long-term CVD in women.
• Alignment with preventive service frameworks—whether the service could be conceptualized and implemented as a clinical preventive service delivered in routine care via screening, counseling, or structured follow-up, for example, rather than as a complex program that depends entirely on local resources.
• Focus on postpartum and interpregnancy care—the degree to which the service capitalizes on the early postpartum period and the years after a complicated pregnancy as opportunities to identify and modify cardiovascular risk.
• Feasibility and actionability—whether the service could be delivered in diverse settings—including primary care, obstetrics, cardiology, and safety-net practices—without requiring highly specialized infrastructure.
• Attention to women facing the greatest barriers—the potential to improve outcomes among women who experience higher rates of cardiovascular complications because of factors such as geography, race or ethnicity, insurance coverage, access to specialists, or other system barriers.

Using these criteria and considering both the biological plausibility of benefit and likelihood of an actionable evidence base, the committee refined its long list into a set of 20 topics representing the most promising and policy-relevant opportunities to improve cardiovascular health around pregnancy (see Box 3-2). Committee members reviewed, discussed, and ranked these topics, with particular attention to how each one addressed the gaps identified in this chapter and aligned with the charge to focus on clinical preventive services.

Through this iterative process, the committee identified nine priority clinical services and associated research questions for formal evidence review. These priority services span the prepregnancy, prenatal, postpartum, and interpregnancy periods and collectively address both individual risk-factor management and the organization of care. The next chapters (Chapters 4 and 5) describe the evidence review methods and present the committee’s findings and conclusions for each of these nine clinical services.

REFERENCES