6

Crosscutting Considerations

INTRODUCTION

Cardiovascular risk during the reproductive period is shaped by factors that extend well beyond individual clinical encounters. Policies that determine insurance coverage and benefits; distribution and capacity of health care providers and systems; organization of care delivery; training and practice environments of clinicians; and experiences of patients, families, and communities all influence whether evidence-based care reaches those who need it.

Earlier chapters describe specific interventions and care models across the reproductive life course. This chapter identifies crosscutting barriers and implementation considerations that affect multiple conditions, settings, and populations. It focuses on how policy-, system-, clinician-, patient-, and community-level factors interact to influence access to health care services, continuity of care, and cardiovascular outcomes before, during, after, and between pregnancies.

This chapter also highlights federal levers—particularly programs administered by the Health Resources and Services Administration (HRSA)—that can support efforts to help populations with the greatest need and enhance consistent access to clinical preventive services and presents findings and conclusions related to these crosscutting considerations, consistent with the committee’s statement of task. The sections that follow are organized around major domains of crosscutting barriers that affect access, delivery, and continuity of preventive cardiovascular services across the reproductive life course.

FRAMEWORK FOR CROSSCUTTING IMPLEMENTATION BARRIERS

Barriers to improving maternal cardiovascular health operate at multiple, interconnected levels:

• Policy and insurance coverage environment, including Medicaid and private insurance coverage, benefit design, and scope-of-practice and telehealth policies;
• Health system capacity, geography, and workforce, including the distribution of maternity care clinicians, hospital and clinic infrastructure, and rural and urban service availability;
• Health care delivery, coordination, and information systems, including how care is organized across settings and specialties and information flows across systems;
• Data and quality infrastructure, including surveillance, electronic health record (EHR) interoperability, and performance measurement to monitor preventive service delivery and outcomes over time;
• Clinician knowledge, training, and practice environments, including training across specialties, guideline uptake, and time and resource constraints;
• Patient-, family-, and community-level factors, including cardiovascular disease (CVD) awareness, trust, competing priorities, and social and economic conditions that shape access and engagement; and
• Historical drivers of differences in health outcomes, including longstanding patterns of disinvestment that influence where services are located and how resources are distributed.

The sections that follow synthesize barriers and implementation challenges at each of these levels, with attention to addressing differences in clinical service availability, supporting community-centered approaches, and targeting services based on need. Box 6-1 highlights key touchpoints for delivering preventive cardiovascular services across the prepregnancy, pregnancy, postpartum, and interpregnancy periods.

POLICY AND COVERAGE ENVIRONMENT

Policy and Systems Barriers

System-level policies exert a profound influence on maternal cardiovascular health outcomes during pregnancy and postpartum. They affect

financial coverage for care and the availability of clinicians and services such as telehealth. For example, Medicaid plays a particularly central role, financing approximately 40–41 percent of all U.S. births (NCHS, 2025), with even higher proportions among patients with lower incomes and in rural and historically underserved communities (MACPAC, 2020).

Historically, Medicaid coverage for postpartum women ended at 60 days following delivery, creating gaps in access to ongoing care for chronic conditions, such as hypertension (HTN), diabetes, or cardiomyopathy, and contributing to missed opportunities for long-term CVD prevention (Luther et al., 2021). The American Rescue Plan Act of 2021 authorized states to extend Medicaid coverage to 12 months postpartum (117th Congress, 2021); as of 2026, nearly all states have done so, representing a policy shift toward improved continuity of care (KFF, 2025c).

Beyond eligibility duration, some states have adopted more expansive postpartum coverage policies or care models, including broader coverage for postpartum visits; however, the scope and implementation of these approaches vary widely (KFF, 2025c). Implementation also varies across states with respect to enrollment and operational processes and expectations for access, provider networks, and care coordination, resulting in geographic differences in access to postpartum follow-up care—particularly for patients with complex CVD risk profiles and those living in high-need communities (Gordon et al., 2023; KFF, 2025c; Lent, 2025; Ranji et al., 2021; Rossier Markus, 2026). Even with extended postpartum eligibility, gaps in coverage before pregnancy, interruptions in enrollment, and variation in benefits and provider participation—particularly in states that have not expanded Medicaid or if Medicaid expansion is reduced in the future—can limit access to continuous preventive care, underscoring that policy barriers may constrain the impact of clinical interventions alone.

State-level scope-of-practice policies also influence how care teams are structured and how effectively they can meet the needs of pregnancy and postpartum women across varying levels of cardiovascular risk. Advance practice practitioners, including nurse practitioners and midwives, are essential members of multidisciplinary teams and play a key role in expanding access, continuity, and patient-centered care (Crowley, 2024). However, women with more complex or higher-risk cardiovascular conditions may benefit from specialist-led oversight, highlighting the value of thoughtful scope-of-practice policies that support appropriate delegation and timely escalation based on patient acuity rather than relying on a uniform approach that could inadvertently constrain workforce capacity and limit access to care.

Telehealth has shown promise in supporting postpartum monitoring and follow-up, particularly for women facing geographic or logistical barriers. However, variability in state policies and uncertainty regarding long-term reimbursement under the Centers for Medicare & Medicaid Services (CMS) continue to pose challenges to sustainable implementation (CMS, 2025b; KFF, 2025c). Workforce and reimbursement considerations underscore the need for balanced, team-based models that support safe, high-quality, and longitudinal cardiovascular care.

Insurance Coverage Limitations

A key challenge for implementing the clinical services discussed in this report is lack of insurance coverage, which affects both delivery and uptake. As Chapter 1 described, the Affordable Care Act (ACA) mandates coverage of preventive services recommended by the U.S. Preventive Services Task Force (USPSTF) and HRSA-supported Women’s Preventive Services

Initiative (WPSI) (KFF, 2025a). The ACA requires that group health plans and issuers of health insurance coverage for groups or individuals cover these services and supports without patient cost-sharing (KFF, 2025a). A variety of these services, such as once-a-year well-woman exams, are key to helping women stay healthy throughout the life course. The ACA requires coverage of pregnancy-related preventive services recommended by USPSTF and WPSI guidelines, including gestational diabetes (GDM) screening, routine blood pressure (BP) measurement as part of preventive care, and low-dose aspirin and folic acid for women at increased risk for preeclampsia and neural tube defects, respectively (CMS, 2025a; KFF, 2025a).

Clinical preventive services not rated A or B by USPSTF or recommended by WPSI guidelines may have varying coverage by insurance plan (CRS, 2025). Services without a USPSTF grade—such as lipid screening for pregnant women or women aged 35 or postpartum HTN monitoring—are not covered as a preventive service under the ACA, limiting the incentive to provide these as routine clinical care. Similarly, healthy diet and physical activity counseling interventions are rated B (USPSTF, 2022) and thus a covered benefit for adults with CVD risks factors but rated C for adults without CVD risk factors (USPSTF, 2020), limiting reimbursement for provision of these services to many individuals. In practice, this coverage framework can impede access to preventive counseling and early risk identification for women who have not previously been screened or diagnosed—particularly those who lacked insurance before pregnancy or whose complications (e.g., APOs) indicate elevated cardiometabolic risk that is not consistently recognized in routine care—because services delivered outside of an A- or B-rated preventive context may require cost-sharing or not be reimbursed.

When services are not reimbursed, clinicians face barriers to incorporating them into practice because most have limited time per visit (Tan and Black, 2018; Yarnall et al., 2003). Clinicians unable to earn financial revenue for services that require additional time are disincentivized to offer them. Similarly, health systems may be less likely to add time to clinical visits to facilitate the implementation of nonreimbursable services (NASEM, 2021), such as obtaining a complete family and pregnancy complications history, a key step in assessing future cardiovascular risk.

The ability to use and benefit from preventive services—especially for low-income individuals facing cost-related barriers to care—relies on insurance coverage (Mahajan et al., 2021; Mahmoudi et al., 2018), which has been associated with narrowing differences in the use of evidence-based preventive services across racial and ethnic groups and improved uptake among uninsured low-income adults who gain Medicaid (Cagdas and Holding, 2018). However, coverage for pregnancy is complicated because Medicaid varies by state, especially for postpartum services, as described earlier in this chapter (Gomez et al., 2022). Federal eligibility restrictions and state

variation in Medicaid coverage create additional gaps for some immigrant populations (KFF, 2025b; Ranji et al., 2022).

Some women do not become eligible for Medicaid until pregnancy and may experience gaps in coverage before pregnancy and after pregnancy-related coverage ends, which can limit access to preventive care and other evidence-based recommended services before, during, and after pregnancy, including well-woman care and contraceptive counseling and coverage (Gomez et al., 2022; Gordon et al., 2023; MACPAC, 2018). If initial access to care is the first prenatal visit, opportunities to identify cardiovascular risk factors earlier—such as at WPSI-recommended annual well-woman visits that are generally covered under the ACA—may have been limited for women who lacked insurance before pregnancy, and follow-up evaluation and treatment after screening may still be difficult to obtain or afford. During the prepregnancy period, women who lack insurance or routine access to primary care may have limited access to services such as counseling to promote a healthy diet and physical activity, even if they have cardiovascular risk factors (Ranji et al., 2025).

Gaps in coverage also arise for those able to benefit from ACA requirements. When services are coded or billed as diagnostic rather than preventive purposes—for example, in the context of a patient’s symptoms—they may not be covered without cost-sharing (CMS, 2024; Hoagland et al., 2025). Further clarification of billing and coding of preventive services may facilitate uptake.

Finally, maternity care is an area of underreimbursement (ACOG, n.d.). Though services such as behavioral counseling interventions for healthy weight and weight gain in pregnancy are rated B by USPSTF and thus considered a covered benefit (USPSTF, 2021), most maternity care (including prenatal, labor and delivery, and postpartum) is reimbursed through bundled payments, with a single lump sum for the entire “episode” of care, regardless of how many services—including preventive—are provided (ACOG, n.d.). From a clinician or health care delivery system perspective, this bundling may contribute to underreimbursement and disincentivize providing time-intensive individual preventive services and postpartum follow-up care (ACOG, n.d.; CMS, 2019; Parham et al., 2025), when women are at high risk for cardiovascular complications and pregnancy-related death. In recognition of these limitations, the American College of Obstetricians and Gynecologists (ACOG) has outlined an approach to transition away from that payment model by supporting standard evaluation and management codes for prenatal and postpartum visits, with broader coding changes anticipated in 2027 (ACOG, 2026).

HEALTH SYSTEM CAPACITY, GEOGRAPHY, AND WORKFORCE

Workforce Attrition and Maldistribution

Workforce dynamics further intensify structural challenges to clinical care. Obstetricians and gynecologists are increasingly leaving geographic regions characterized by high malpractice risk, restrictive reproductive laws, and chronically low Medicaid reimbursement (Stoneburner et al., 2024; Weiner, 2023). These trends reflect not only individual decisions but also broader health system dynamics, including consolidation of care delivery and financial pressures that disproportionately affect community-based and independent practices. The result is a maldistribution of clinicians, with a growing concentration in metropolitan and affluent communities and fewer specialists serving rural or historically underserved urban areas. As discussed in Chapter 2, the March of Dimes 2024 Maternity Care Deserts Report underscores the magnitude of this challenge: more than one-third of U.S. counties lack obstetric clinicians or birthing facilities, representing 1,104 counties and affecting more than 2.3 million women of reproductive age; in 2022, women living in these counties gave birth to more than 150,000 babies (Stoneburner et al., 2024). These access gaps are especially consequential for women with high-risk pregnancies who require higher levels of obstetric and subspecialty care, which are frequently concentrated in larger metropolitan centers and absent from many of the counties identified as maternity care deserts (Stoneburner et al., 2024). These shortages not only denote reduced access to obstetric care but also weaken the capacity for integrated cardiovascular risk management in the peripartum and postpartum periods.

These challenges are compounded by broader workforce shortages across the United States (AAMC, 2024). Declining numbers of obstetricians, family physicians practicing maternity care, cardiologists, and midwives in high-need areas strain the U.S. system’s ability to deliver comprehensive postpartum follow-up (Barreto et al., 2017a; Glenn, 2024; Stoneburner et al., 2024). Simultaneously, shortages of nurses and advanced practice practitioners (Mercer, 2024), who are essential for staffing remote monitoring programs, managing dashboards, and triaging urgent symptoms, further limit capacity. Midwives and advanced practice practitioners play critical roles in prenatal and postpartum care, including management of hypertensive disorders and timely escalation when needed; however, limitations in workforce availability, scope-of-practice alignment, and access to timely specialist consultation can constrain care delivery, particularly for patients with higher-acuity needs (Glenn, 2024; Stoneburner et al., 2024). High patient volumes and compressed appointment times reduce opportunities for counseling on long-term cardiovascular prevention. In areas

where maldistribution is most acute, wait times for cardiology or specialty maternal health appointments may be weeks to months (AMN Healthcare, 2025). In these settings, models that combine local care teams with remote or telehealth specialty consultation may help extend expertise and provide clinical backup without requiring onsite specialists. These delays during the critical early postpartum period amplify cardiovascular risk at a time of heightened vulnerability.

Maternity Care Shortage Areas

Maternity care desert areas refer to counties where no hospital offers obstetric care, no birth center is available, and no obstetrician-gynecologist or certified nurse-midwife practices (Stoneburner et al., 2024). While rural counties are most visibly affected as a result of hospital closures and workforce shortages, similar challenges exist in urban neighborhoods where decades of disinvestment have produced Health Professional Shortage Areas (Stoneburner et al., 2024). Women living in these communities face additional logistical barriers to care, including public transportation, lack of child care, and limited broadband access—all of which can delay or prevent timely postpartum BP monitoring and cardiovascular follow-up (Ganguly et al., 2025; Heaman et al., 2015; Stoneburner et al., 2024).

These patterns reflect differences in service availability across communities that influence whether cardiovascular risk is identified and addressed during pregnancy and postpartum. Efforts to equalize access to health care services and provide targeted support for groups with the greatest needs will require strategies that address both the geographic distribution of services and local barriers faced by patients and families.

CARE DELIVERY, COORDINATION, AND INFORMATION SYSTEMS

Effective cardiovascular prevention and management during pregnancy and postpartum require coordinated care across obstetrics, primary care, cardiology, and other specialties, supported by robust information systems. However, care delivery is often disjointed across settings and over time.

Fragmented Care Across the Reproductive Life Course

Fragmented care has historically been a barrier for patients of reproductive age (Clancy and Massion, 1992; McCloskey et al., 2021). It may arise from lack of longitudinal care from the absence of a longitudinal medical home, lack of coordination among multiple clinicians, or both (ACOG et al., 2018). Some women enter pregnancy—and receive obstetric care during

pregnancy—without an established primary care clinician (e.g., an internist, family medicine physician, or nurse practitioner). Others receive obstetric care during pregnancy but transition back to adult medicine postpartum. Without proactive communication among clinicians, these transitions can result in gaps in follow-up and missed opportunities for cardiovascular risk management.

While effective handoffs and interdisciplinary coordination are essential, obstetric clinicians also serve as a critical source of women’s health care beyond pregnancy and reproductive organs. Given that many women of reproductive age engage with the health care system primarily through obstetric or gynecologic care, these clinicians are uniquely positioned—and bear responsibility—to identify, communicate, and initiate management of cardiometabolic risk factors; primary care clinicians are equipped to provide prepregnancy counseling and sustained follow-up and management after hypertensive disorders of pregnancy (HDP) and GDM. Expanding the focus of obstetric care to more fully encompass whole-person cardiovascular and metabolic health, particularly after adverse pregnancy outcomes (APOs), represents a key opportunity to reduce the impact of fragmentation and improve long-term outcomes. While transitions to primary care and specialty services remain vital, meaningful progress will require a shared accountability model in which obstetric clinicians not only facilitate handoffs but also actively frame pregnancy as a sentinel health event and ensure that cardiovascular risk is recognized, documented, and addressed across the reproductive life course.

Care Transitions and Interdisciplinary Coordination

At the clinician and health care system–level, transitions of care remain a major barrier to maternal heart health. Effective cardiovascular prevention requires seamless coordination among obstetrics, cardiology and other specialties, primary care, nursing, and allied health professionals, such as upon transition from the labor and delivery hospital episode of care to the outpatient postpartum care team. Yet discharge summaries frequently underreport pregnancy complications, such as HDP, peripartum cardiomyopathy, or GDM, as major cardiovascular risk enhancers (Brown et al., 2013). This constitutes missed opportunities to apprise primary and specialty clinicians and result in delayed recognition of long-term risk. One practical approach adopted by some clinical groups, health systems, and state perinatal quality collaboratives (e.g., the HRSA Alliance for Innovation on Maternal Health [AIM] Postpartum Discharge Transition bundle) is to standardize a minimum postpartum care summary that is reliably transmitted to the next clinician/team (see Box 62) (ACOG, 2018b; MSPQC, n.d.).

Clarifying Roles and Accountability Across Specialties

Professional societies recommend that individuals with chronic medical conditions, especially those at risk of future CVD (e.g., diabetes and HTN), have close follow-up with an obstetrician/gynecologist, primary care clinician, or endocrinologist for ongoing postpartum care (ACOG, 2018a; ADA, 2025; Adam et al., 2023; Poon et al., 2023). ACOG recommends that each such woman and her obstetric team work together to identify a clinician to take charge of care in the postpartum period and beyond (ACOG, 2018a).

Interdisciplinary coordination is critical for ensuring preventive clinical services are delivered consistently. Cardiology, endocrinology, obstetrics, primary care, anesthesia, and other specialties all have roles in preventing, identifying, and managing cardiovascular risk during and after pregnancy. Role ambiguity—whether obstetricians, primary care physicians, or

cardiologists bear responsibility for longitudinal follow-up—creates uncertainty and often results in missed opportunities for early intervention.

In low-volume settings, maintaining skills to manage complex cardiovascular conditions can be difficult, underscoring the importance of risk-appropriate care, clear transfer and consultation pathways, and team-based models that support timely escalation when higher-level care is needed. A shared understanding of scope of practice, responsibilities, and referral pathways—for midwives, physicians (including specialists, obstetrician-gynecologists, family physicians, and hospitalists), advanced practice practitioners, and other clinicians—is important to ensure that patients receive timely and appropriate care.

Strengthening Transitions to Primary Care

Primary care serves as the central setting for long-term cardiovascular risk management across the reproductive life course. Transitions to primary care after delivery are a particular point of vulnerability. For the postpartum visit, care teams can help coordinate this, provide all patients with guidance about the value and timing of primary care follow-up (e.g., yearly visits for all women and more frequent visits for those with medical complications, such as diabetes or HTN), and identify appropriate care settings for continuing care outside of pregnancy, either within the current practice or via referral. Protocols to ensure that discharges from labor and delivery are accompanied by scheduled follow-up and care navigation may help address fragmentation and support expanded access for all communities.

To help bridge the gap between medical conditions diagnosed in pregnancy (e.g., GDM, HDP) and the postpartum period, the International Federation of Obstetrics and Gynecology has developed a postpartum passport to help reduce the risk of future health events, especially cardiovascular events (Nguyen-Hoang et al., 2023). Other possible approaches to improving care transitions include updating problem lists in EHR systems to include complications during pregnancy, such as GDM, HDP, and preeclampsia, to create a record of these diagnoses for future encounters with the same medical record system. The obstetric care team could identify who will manage diabetes, HTN, and CVD in the postpartum period, then provide warm handoffs to the relevant clinician(s) (see Box 6-3 for key elements of a warm handoff).

Team-Based and Multidisciplinary Models

The American College of Cardiology has developed a toolkit for health care organizations that wish to start multidisciplinary postpartum maternal health clinics to provide BP management, screening for cardiovascular risk

factors, and treatments and lifestyle modifications to prevent future CVD (Countouris et al., 2025). Similarly, because GDM is known to increase future risk of diabetes, increasing access to endocrinologists as part of multidisciplinary care teams can help reduce that risk (Adam et al., 2023).

Patient-centered medical homes and group-based care models can also help bridge the gap between pregnancy care and postpartum primary care (Chuang et al., 2017; Crowley, 2024). These community-centered approaches and team-based models are examples of tailored support based on local needs. Forming a multidisciplinary team that includes doulas, midwives, and community health workers with maternal health training can address the transition between pregnancy and the postpartum period

(Bohren et al., 2017; Johantgen et al., 2012; Kangovi et al., 2014). WPSI could consider whether cardiac conditions in pregnancy, APOs, or both should have care navigation to support these transitions.

Information Systems

Health information technology challenges may compound system issues that cause fragmentation of care (Kim et al., 2024). Unimpeded access to clinical data by all of a patient’s clinicians helps ensure that resources reach those who need them and supports effective implementation of guideline-based care. EHR silos can limit the timely sharing of clinical information

crucial to managing evolving cardiovascular problems, including visit notes, consults, echocardiograms and their reports, B-type natriuretic peptide trends, BP monitoring data, and current medication lists. Additionally, International Classification of Diseases (ICD) codes have demonstrated low sensitivity (26–29 percent) for severe maternal morbidity (SMM) and cardiovascular SMM (Boulet et al., 2024; Malhamé et al., 2020), with an abrupt decrease in the incidence of SMM during the transition between ICD-9 and ICD-10 attributed to coding differences (Metcalfe et al., 2021). Improving the interoperability of EHR systems and ensuring codes accurately capture SMM is key to supporting coordinated care when more than one health system is involved.

CLINICIAN KNOWLEDGE, TRAINING, AND PRACTICE ENVIRONMENT

Clinicians play a key role in reducing patients’ risk for pregnancy-related cardiovascular events through the care they provide. Challenges that occur at the individual clinician level may require changes in training and clinical practice. The needs for prevention, management, and follow-up of pregnancy-related CVD occur before, during, and after pregnancy, requiring that both obstetric and nonobstetric health professionals acquire and maintain the relevant clinical management skills.

Effective clinical care requires standardization and coordination among health professionals with variable training, expertise, and scope of practice. Clinical settings also vary widely, and clinicians have finite time amid busy patient schedules. Barriers that clinicians may face in providing effective and efficient care include the following:

• Pregnancy-related CVD prevention and follow-up postpartum often fall to nonobstetric clinicians, who are the main care providers for patients before and after pregnancy.
• Pregnancy-related cardiovascular prevention and care needs to be standardized across different training levels and professions (physicians, physician assistants, nurse practitioners, nurse midwives, and others).
• Individual clinicians differ in awareness, understanding, and adoption of evidence-based clinical guidelines related to pregnancy-related cardiovascular risks and events.
• Time and resource constraints hinder clinicians in providing all necessary and recommended care.
• Clinical settings vary, each with its own unique challenges and advantages for implementing recommendations for pregnancy-related cardiovascular prevention and treatment.

• Diagnostic and treatment criteria for major cardiovascular risk factors—including HTN, diabetes, and lipid disorders—differ during and outside of pregnancy, creating challenges for clinicians in aligning care plans and integrating pregnancy-related events (e.g., APOs) into long-term cardiovascular risk assessment and incorporating APOs into long-term cardiovascular risk stratification.

Training and Scope of Practice

Obstetric and nonobstetric health professionals provide care to prevent or reduce pregnancy-related cardiovascular events. Nonobstetric primary care health professionals generally offer the majority of care before and after pregnancy, even for patients with pregnancy-related CVD. Unclear handoffs and inconsistent guidance about primary care responsibilities for postpartum risk assessment and follow-up—particularly after APOs—can hinder implementation of recommended care and guidelines especially since pregnancy-related care is not within their traditional scope of practice (Davis et al., 2025; Murray Horwitz et al., 2022). This may mean that nonobstetric clinicians, such as internists, some family physicians not providing obstetrics care, pediatricians, nurse practitioners, and physician assistants, may need additional training to reduce pregnancy-related cardiovascular complications. Although family physicians are trained in obstetrics in residency, only 7 percent do so (Barreto et al., 2017b), and they may benefit from continuing education in pregnancy-related and postpartum care.

Prepregnancy Care Skills

Building capacity for nonobstetric clinicians in prepregnancy counseling and asking about pregnancy history is one important strategy. Clinicians support patients with pregnancy timing (contraception) and counseling to understand that optimizing health in advance increases the likelihood of a safe and healthy pregnancy. To implement cardiovascular risk reduction, nonobstetric primary care clinicians may need training and expertise in prepregnancy counseling. While primary care clinicians are well trained in preventive care, such as screening and treatment of cardiovascular risks, they may be less familiar with counseling to reduce pregnancy-related cardiovascular risks or asking about pregnancy history. Training could include the following:

• Talking to patients about their intentions for pregnancy (ACOG, 2019);
• Counseling on how health status before pregnancy—including managing modifiable cardiovascular and metabolic risk factors—can

• improve pregnancy outcomes and supporting preventive actions, such as starting prenatal vitamins, discontinuing tobacco, alcohol, and illicit substances, and working toward evidence-based targets for body weight, dietary patterns, and physical activity;
• Asking about past pregnancies and complications, such as preeclampsia, eclampsia, or GDM that indicate future cardiovascular risk—including for future pregnancies—and assessing whether referral to an obstetrician or specialist for further prepregnancy health optimization and counseling is warranted;
• Assessing the need to screen for cardiovascular risk factors, such as HTN, diabetes, and hyperlipidemia, before pregnancy, as well as family CVD history; and
• For patients with known cardiovascular risk factors or other health conditions, working on optimal management, such as BP and blood glucose control for HTN and diabetes, respectively.

Pregnancy and Postpartum Care Skills

Most patients revert to their primary care clinicians by 6–12 weeks after delivery. As discharge summaries do not consistently contain important cardiovascular-related pregnancy complications or may not be available due to incompatible EHR systems, nonobstetric clinicians need to know to ask about pregnancy history and pregnancy-related cardiovascular events and provide appropriate follow-up. This could involve closer monitoring and interventions to reduce the subsequent lifelong increased risk for HTN, diabetes, and CVD.

During pregnancy and postpartum, patients with conditions such as preeclampsia or eclampsia may seek care for acute symptoms, such as headache, abdominal pain, and shortness of breath, and be triaged or treated by nonobstetric health professionals in emergency departments (EDs), urgent care, and community clinics. To reduce pregnancy-related cardiovascular morbidity and mortality during and after delivery, emergency medicine physicians and other clinicians in these acute care settings need to be able to recognize the acute symptoms of cardiovascular and cardiopulmonary disorders and complications (e.g., preeclampsia and pulmonary edema) (Mitchell et al., 2023). A 2023 systematic review found that 4.8–12.2 percent of postpartum patients have at least one ED visit within 6 weeks after delivery, indicating that EDs are a common first point of contact for acute postpartum symptoms (Mitchell et al., 2023). Nonobstetric clinicians may be knowledgeable in dealing with acute, potentially life-threatening cardiovascular symptoms but do so primarily in nonpregnant patients and have less experience and training in caring for pregnant or postpartum patients. Professional societies have developed preeclampsia risk-factor screening

checklists/tools to improve identification of patients at increased risk and guide preventive interventions (e.g., low-dose aspirin) (March of Dimes, 2024; SMFM et al., 2026). Implementing these tools effectively will require training of nonobstetric clinicians providing care in these acute settings.

Additional training may be warranted to ensure that clinicians of all specialties can implement primary care–oriented recommendations. Although relevant preventive care guidelines and toolkits are available (e.g., WPSI Guidelines and Agency for Healthcare Research and Quality’s Toolkit for Improving Perinatal Safety),¹ not all specialties are exposed to them in training and practice, which can affect uptake. Additional efforts may be required to address this barrier and ensure ownership of guideline implementation across specialties and clinical settings when appropriate (Wang et al., 2023). In both primary care and acute care settings, it is also important to recognize that patients are cared for by advanced practice practitioners. Thus, pregnancy-related cardiovascular risk prevention and triage of symptoms fall within the scope of their training. Certified nurse midwives, who specialize in the care of women, including childbirth, may similarly benefit.

Practice Protocols and Guideline Implementation

For pregnancy-related CVD and CVD in general, extensive recommendations and guidelines exist on when and how to screen for and manage risk factors, such as weight, HTN, and diabetes, both during and outside of pregnancy. However, not all clinicians consistently implement these recommendations (Pepió Vilaubí et al., 2018; Runciman et al., 2012). While this is partly the result of barriers such as inadequate time or resources, financial cost for patients, or patient preferences, challenges also exist at the clinician level to implement evidence-based guidelines (Arnett et al., 2019; Tan and Black, 2018). Patients may not receive recommended care if clinicians are not aware of, up to date on, or able to track their own services or whether patients have received such care.

In one study, only 38 percent of CVD patients in the primary care setting received recommended guideline therapy for prevention (Pepió Vilaubí et al., 2018). A 2003 study found that patients received only 54.9 percent of recommended care (McGlynn et al., 2003). Reasons for limited guideline uptake may include (Cabana et al., 1999) the following:

• Lack of awareness or familiarity with guidelines, as guidelines change and new ones are issued; continuing medical education is needed;

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¹ See https://www.womenspreventivehealth.org/wellwomanchart/ and https://www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/index.html (accessed December 21, 2025).

• Variation in clinical interpretation or perceived applicability of guidelines across patient populations and care settings;
• Outcome expectancy;
• Clinical inertia; and
• Difficulty incorporating guidelines and recommendations into existing practices.

The pace and breadth of clinical innovations are rapid and broad, and clinicians need ongoing support to facilitate active and complete uptake of existing guidelines (e.g., USPSTF diabetes screening and WPSI well-woman preventive visits) and any new guidelines to help reduce cardiovascular risk. In addition, the quality of training programs may affect trainee exposure to guidelines during undergraduate and graduate medical education. As guidelines evolve, continuing medical education structures are important to ensure that clinicians remain aware of changes they should be incorporating.

Time and Resources

Caring for patients in the outpatient context requires skillful management of acute concerns, ongoing chronic conditions, and incorporation of preventive health measures to maintain optimal health. Helping patients prevent and manage illness in this comprehensive way requires time in the clinical visit to adequately address each item on the patient’s and clinician’s agenda.

Comprehensive care also requires supporting patients as they navigate a complex health system, including initiating referrals and coordinating care in conjunction with specialists and other clinicians (AAFP, 2026). Primary care clinicians providing this type of first-contact and longitudinal health care frequently identify a mismatch between the time required to fulfill these expectations and the time provided (Nguyen et al., 2024; Østbye et al., 2005; Porter et al., 2023). A simulation study estimated that for a nationally representative panel of 2,500 adults, such a clinician working alone would require 26.7 hours per day to deliver guideline-recommended preventive services (e.g., USPSTF and Advisory Committee on Immunization Practices guidelines), chronic disease, and acute care, including documentation and inbox management (Porter et al., 2023).

As counseling and services to address gaps in cardiovascular risk are addressed, it is important to consider the practical “how” of incorporating added tasks and responsibilities. System-level solutions that enable adding counseling recommendations to visits that already have mismatched time allocation will not only enable clinicians to maintain effective practices but also maximize uptake of recommendations and optimally reduce cardiovascular risk as intended.

Clinical Settings and Institutional Environment

The clinical setting and institutional environment is another category of barriers and enablers that can affect resources and related factors. While large health systems may be able to apply more broad resources to implement quality-improvement initiatives for guideline-recommended care, smaller systems and solo or small group practices may have additional challenges and more limited resources. Some studies suggest that differences in practice size and infrastructure may influence the speed with which new clinical guidelines are disseminated and operationalized, reflecting variation in access to educational resources and clinical decision support, and implementation support rather than differences in clinician intent or quality (Tan and Black, 2018).

Furthermore, some practices may have more limited access to specialty care. This can range from well-integrated systems with shared EHRs; to moderate integration with limited shared EHR capacity; to minimal integration, no shared records, and high administrative hurdles. Rural clinical practices are especially likely to encounter these types of institutional environment barriers (Anzalone et al., 2025; Hilliker, 2026). Strong internal and external referral networks are thus enablers of guideline-based care (Tan and Black, 2018).

Lack of administrative support and staff or administrative difficulties associated with guideline implementation have also been cited as clinical environment barriers (Tan and Black, 2018). Suggested solutions have included improving technical systems and collaborative care integration (Tan and Black, 2018). For example, developing protocols that engage ancillary health staff in the guideline-based ordering of preventive services, such as laboratory tests (e.g., diabetes screening), may promote integration of guidelines into routine clinical practice.

PATIENT, FAMILY, AND COMMUNITY-LEVEL FACTORS

Patient-, family-, and community-level factors play a central role in whether individuals can access and benefit from recommended health care for cardiovascular risk before, during, and after pregnancy. These factors influence both the feasibility of engaging in health care and how well services are responsive to local community needs. Key considerations include the following:

• Cultural relevance, health literacy, and patient engagement. How well information and counseling are understandable, culturally relevant, and responsive to individual preferences can affect engagement in preventive care and chronic disease management (Quansah

• et al., 2024). Adapting communication and care approaches to local contexts supports tailored support based on local needs.
• Awareness, trust, and competing priorities. Awareness of cardiovascular risk, pregnancy-related complications, and long-term effects varies (de Melo Ghisi et al., 2024) and may be influenced by exposure to inconsistent or inaccurate health information, including through social media and other online platforms (OTSG, 2021). Patients may not recognize the importance of prepregnancy counseling or postpartum follow-up or know that pregnancy complications, such as preeclampsia or cardiomyopathy, signal increased long-term cardiovascular risk (Beussink-Nelson et al., 2022; Lewey et al., 2024; Quansah et al., 2024; Slater et al., 2023). Trust in the health system and clinicians, shaped by care experiences and perceived respect or discrimination, influences willingness to seek and continue care (Sherman and Tobb, 2024). Competing priorities, such as work, caregiving responsibilities, and financial pressures, can make it difficult to prioritize appointments and behavioral changes.
• Social factors and logistical barriers. Social and economic conditions—including transportation, housing stability, child care, and broadband access—affect the ability to attend visits, use telehealth, and engage in recommended care (Marcondes et al., 2024; Quansah et al., 2024; Slater et al., 2023). These conditions can limit access that meets people where they are and contribute to differences in service use and outcomes across communities. In some settings, clinical teams may incorporate approaches to identify health-related social needs and connect patients with appropriate community-based resources; however, evidence regarding which screening and referral models most effectively improve health outcomes remains limited (NASEM, 2019a).
• Knowledge of when and how to seek care. Patients may not know to come in for prepregnancy counseling or be aware of symptoms and long-term effects of pregnancy-related cardiovascular conditions (Lewey et al., 2024; Quansah et al., 2024; Slater et al., 2023). This can delay timely recognition of complications, a potentially modifiable factor commonly identified by Maternal Mortality Review Committees (MMRCs) in reviews of pregnancy-related cardiovascular deaths (Briller et al., 2024).

These factors influence whether resources, services, and innovations reach those with the greatest needs and interventions achieve comparable results across populations. Strategies that emphasize community-driven approaches, strengthen community capacity, and provide targeted support

for groups with the greatest needs can help align care with patients’ lived realities.

HISTORICAL DRIVERS OF DIFFERENCES IN MATERNAL CARDIOVASCULAR OUTCOMES

Historical factors—such as policies and structures leading to economic disadvantage and exclusion of women from clinical trials—have contributed to persistent differences in maternal cardiovascular outcomes across racial and ethnic groups (Ferranti et al., 2021; Hailu et al., 2022; NASEM, 2022; Tabb et al., 2022). Black and Native American and Alaska Native women, for example, experience maternal mortality rates 2–3 times higher than their White counterparts, with higher rates of postpartum stroke, cardiomyopathy, and other SMM even after adjustment for socioeconomic status (CDC, 2025). These differences in outcomes are not fully explained by individual risk factors or behaviors (Hill et al., 2025; Taylor et al., 2019). Many of these historical and contemporary policy and institutional patterns continue to shape access to high-quality care and exposure to risk over the life course.

Policies that contributed to patterns of disinvestment in certain neighborhoods have shaped the location of hospitals and specialty services, quality of housing and environmental conditions, and availability of health-supporting resources (Egede et al., 2023; Steil and Arcaya, 2023). More recent policy decisions, including variability in Medicaid expansion and benefits, further contribute to inconsistency in communities’ service availability and access. Environmental exposures, psychosocial stressors, and cumulative disadvantage can compound cardiovascular risk (Blaustein et al., 2024; Münzel et al., 2022; NASEM, 2019b; Navas-Acien et al., 2007).

These historical drivers intersect with the system-, clinician-, and patient-level factors described earlier in this chapter. Communities that have experienced long-term underinvestment in health care infrastructure are more likely to lack obstetric clinicians, experience longer travel distances to delivery facilities, and have limited access to specialty cardiovascular services (Kozhimannil et al., 2025; Stoneburner et al., 2024). Patients in these communities may confront more intense social and economic constraints on their ability to seek and sustain care. In addition, prior negative experiences and longstanding reasons for mistrust of medical institutions may further reduce the likelihood that some patients seek care early when concerning symptoms arise, potentially delaying evaluation and treatment (Quansah et al., 2024; Sherman and Tobb, 2024).

Efforts to improve outcomes for underserved groups and achieve comparable results across populations therefore require more than changes in individual clinical care. They also call for targeted support for groups with

the greatest needs, policies that equalize access to services, and community-centered approaches that strengthen local capacity to address cardiovascular risk before, during, and after pregnancy.

Many of the factors described earlier operate at policy, institutional, and community levels and shape risk exposure, access to care, and quality of care over time. Their contribution to differences in maternal cardiovascular outcomes is increasingly recognized. However, evidence remains limited regarding which prevention strategies most effectively mitigate these upstream contributors within health systems and community settings. Strengthening this evidence base is important to inform interventions that complement clinical preventive services and improve outcomes for populations with the greatest needs.

DATA AND QUALITY INFRASTRUCTURE FOR MATERNAL CARDIOVASCULAR HEALTH

Efforts to improve cardiovascular health during pregnancy and postpartum depend on the ability to identify who is at risk, what services they receive, and what outcomes they experience. However, data and quality infrastructures for maternal cardiovascular health are fragmented and incomplete. Most maternal health surveillance systems are state based and vary widely in participation, data elements collected, and linkage with other health datasets. For example, although the Centers for Disease Control and Prevention (CDC) supports the Pregnancy Risk Assessment Monitoring System,² participation is voluntary, data are based on self-report, and surveillance is limited to a one-time postpartum survey rather than ongoing longitudinal data collection into later postpartum or interpregnancy periods (Shulman et al., 2018).

Similarly, vital records often cannot be linked to hospital discharge data, outpatient medical records, or longitudinal claims, limiting the ability to track cardiovascular risk factors and outcomes. Limited linkage of MMRC data to these sources also constrains retrospective analyses of pregnancy-related deaths (through 1 year postpartum), including assessing preceding cardiovascular risk factors, care pathways, and missed opportunities for prevention. Mortality databases (i.e., vital records) do not consistently capture pregnancy status or link deaths to pregnancy complications, reducing their utility for understanding pregnancy-related cardiovascular deaths and monitoring progress in prevention (ACOG, 2018c). In addition, mortality data do not fully reflect SMM, whose incidence is far more

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² In March 2025, CDC paused data collection through the Pregnancy Risk Assessment Monitoring System.

common and whose drivers warrant further exploration so that effective approaches to prevention can be implemented.

Within health systems and community-based practices, EHR data and registries for HDP, GDM, and other pregnancy-related cardiovascular conditions are not consistently developed or used to monitor follow-up care. Documentation of pregnancy complications as cardiovascular risk enhancers is variable and pregnancy history is often not integrated into existing cardiovascular risk calculators or clinical decision support tools. These limitations make it difficult for health systems, programs, and payers to track whether patients receive recommended preventive services—such as BP monitoring after HDP, diabetes screening after GDM, and transition to primary care—and assess whether interventions are achieving comparable results in different settings and populations.

Quality measurement for maternal cardiovascular prevention remains underdeveloped. The maternal and perinatal quality measures frequently focus on intrapartum care or short-term postpartum outcomes and rarely include longitudinal indicators of cardiovascular preventive care. Measures that do exist are often fragmented across payers and programs and may not be stratified to identify differences in outcomes across populations. As a result, accountability is limited for ensuring that preventive cardiovascular services are delivered consistently before, during, and after pregnancy, particularly for populations with the greatest needs.

A more integrated and standardized approach to data collection, linkage, and measurement—spanning surveillance systems, EHRs, and quality reporting programs—would support efforts to monitor pregnancy-related cardiovascular complications and associated risk factors, track preventive service delivery, and guide targeted support for communities and populations with the highest risk.

FEDERAL LEVERS: HEALTH RESOURCES AND SERVICES ADMINISTRATION OPPORTUNITIES TO ADDRESS CROSSCUTTING BARRIERS

Many of the barriers this chapter describes—gaps in insurance coverage and health care access, shortages of maternity care clinicians, fragmented systems of care, and limited resources in communities with the greatest needs—align directly with HRSA’s mission and programs. Its mission is to “improve health outcomes through access to quality services, a skilled health workforce, and innovative, high-value programs” (HRSA, 2025a). Through its bureaus and offices, HRSA supports expanded access for all communities, community-driven approaches, and tailored support based on local needs, creating important levers to address crosscutting implementation challenges in maternal cardiovascular health.

HRSA works to achieve this mission by supporting health infrastructure needs, including training and distribution of health professionals where they are most needed; financial support for health care providers; and advancing telehealth. Through its programs and services, HRSA also supports individuals facing geographic and economic barriers to health care and those who are medically underserved, including pregnant and postpartum women and residents of rural areas and other communities with the greatest needs. In addition, it administers other federal health programs and maintains data resources that support the health care safety net (HRSA, 2025a). HRSA also oversees programs that provide discounts on prescription drugs for safety-net providers; facilitate organ, bone marrow, and cord blood transplantation; compensate individuals with vaccine injuries; and maintain data on health care malpractice payments (HRSA, 2025a).

Maternal and Child Health Bureau and Community-Driven Approaches

HRSA’s Maternal and Child Health Bureau (MCHB) focuses specifically on meeting the physical and mental health needs of mothers, children, and their families. This includes training the public health workforce to meet these needs, managing guidelines for women’s and children’s health checkups and newborn screenings, and managing the National Maternal Mental Health Hotline (HRSA, n.d.-d). MCHB funds a number of programs that work to improve maternal and child health and can support community-centered approaches to maternal cardiovascular health.

For example, the Healthy Start program funds community projects that provide services such as linking parents to social services and educational programs (e.g., parent skill building); prenatal and postpartum care, screening, and referrals to services for depression and interpersonal violence; health education services; and education and training on best practices for Healthy Start staff and community partners (HRSA, 2025e). Funding goes to communities with infant mortality rates at least 1.5 times the national average or high rates of preterm birth, low birth weight, and maternal illness (HRSA, 2025e). By targeting services based on need and supporting strengthening community capacity, Healthy Start can contribute to addressing crosscutting barriers in communities with the greatest needs.

Through the Maternal, Infant, and Early Childhood Home Visiting program, HRSA and the Administration for Children and Families provide funding for states, jurisdictions, and tribes to develop and conduct programs whereby trained home visitors help pregnant women and parents of young children improve health and well-being for themselves and their families (HRSA, 2025i). The home visitors may provide support, such as encouraging positive habits in pregnancy; providing information on

breastfeeding, safe sleeping habits for babies, and healthy eating; teaching parents about positive and supportive interactions with children; and connecting families to services and resources in their communities (HRSA, 2025i). These evidence-based home visiting models exemplify access that meets people where they are and can be leveraged to address cardiovascular risk factors identified during pregnancy and postpartum and educate women about the need to seek care early when they experience urgent maternal warning signs.

Through the Title V Maternal and Child Health Services Block Grant program, HRSA partners with states and jurisdictions to improve public health systems for mothers; infants, children, and youth, including those with special health care needs; and their families (HRSA, 2024c). Funding is used according to states’ and jurisdictions’ needs and priorities and may be directed to initiatives that help reduce infant deaths; provide women with better access to quality prenatal care, delivery, and postnatal care; provide women and children with low incomes or living in areas where it is difficult to find care with better access to quality preventive and primary care; provide better access to quality care for children with special health care needs; and help eligible pregnant women with infants and children apply for Medicaid (HRSA, 2024c). The program helps to address the unique health needs of women and children in 59 locations (states and jurisdictions); in 2023, it reached approximately 59 million people (HRSA, 2024c; Payne, 2025). Title V investments can be aligned with efforts to address differences in service availability and improve maternal cardiovascular outcomes.

Health Centers and Access

Through its Health Center Program, HRSA funds about 1,400 health centers, which run about 16,200 service sites and offer access to affordable, high-quality primary care, including medical, dental, substance use, mental health, and other services (HRSA, 2025b, 2025g). Health centers are private, nonprofit, or public community-based organizations, serve medically underserved populations, and adjust fees based on the ability to pay. Governed by patient-majority boards, they are patient directed and collaborate with community partners to maximize resources (Anaedozie, 2025). Collectively, in 2024, HRSA-funded health centers served more than 32.4 million patients, the majority of whom are low income (HRSA, 2025g). A substantial proportion of these patients are women of reproductive age (HRSA, n.d-e; Wood et al., 2018), underscoring the central role of health centers in delivering preventive services before, during, and after pregnancy. In 2024, HRSA-funded health centers served 611,000 prenatal care patients and supported 174,000 births (Anaedozie, 2025). Many provide services responsive to health-related social needs. For example,

some have addressed lack of transportation by operating mobile vans or helping with transportation to clinics (HRSA, 2025b). Designation as a Look-Alike³ health center (approximately 155 nationwide in 2024) confers many of the benefits afforded to HRSA-funded health centers, including reimbursement at the Federally Qualified Health Center (FQHC) rate, but without HRSA funding (HRSA, 2025b; NACHC, 2025). Although this report focuses on HRSA-supported health centers, consistent with the committee’s charge, many of the approaches described—such as longitudinal primary care engagement, data integration, team-based care, and structured follow-up—are similarly applicable to other integrated delivery systems and ambulatory primary care infrastructures that serve reproductive-age and postpartum populations.

Although obstetric care is not provided in all community health centers, two-thirds of FQHC clinic networks include at least one site that offers prenatal care services, and FQHCs that do not offer prenatal care are required to refer patients to other clinics (Gourevitch and Hatfield, 2023). One-third of low-income U.S. women of reproductive age receive health care services from FQHCs, which also care for 8 percent of all U.S. pregnant women, 18 percent of Hispanic pregnant women, and 10 percent of Black non-Hispanic pregnant women (Gourevitch and Hatfield, 2023).

Both Health Center Program awardees and Look-Alikes are required to provide standardized annual reporting to HRSA’s Uniform Data System (UDS) (HRSA, n.d.-b). UDS captures patient characteristics, services provided, clinical processes and outcomes (clinical quality measures), staffing, and costs/revenues along with some pregnancy-related CVD preventive services, such as Controlling High BP and a diabetes outcome measure (HbA1c/GMI >9 percent), and it also includes disease-management measures, such as statin therapy (HRSA, 2025j, n.d.-a). For maternity care, UDS includes measures such as Early Entry into Prenatal Care and Low Birth Weight. It does not currently capture other metrics on postpartum care to include postpartum BP follow-up after HDP, postpartum diabetes screening after GDM, or documentation of pregnancy complications as cardiovascular risk enhancers (as a defined, reportable measure) (HRSA, 2025j). HRSA’s UDS modernization work has been moving toward more standardized, patient-level data submission, which could make additional standardized measures more feasible if the data elements and definitions are clear (HRSA, 2024a, 2025f, 2025k).

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³ FQHC Look-Alikes are community-based health centers that meet all federal requirements for FQHC designation but do not receive federal grant funding.

Alliance for Innovation on Maternal Health Program

HRSA’s AIM is a national maternal safety and quality-improvement initiative that supports birthing facilities and state-based teams in implementing evidence-informed patient safety bundles, which are structured sets of practices designed to improve the quality of care during delivery and the postpartum period and reduce preventable SMM and deaths (AIM, n.d.; HRSA, 2025c). AIM is implemented through a national technical assistance center and state/jurisdiction capacity awards. As of June 2024, 49 states, the District of Columbia, and Puerto Rico participated, including 2,069 birthing facilities (HRSA, 2025c). For pregnancy-related cardiovascular conditions, the core bundles include Severe Hypertension in Pregnancy, Cardiac Conditions in Obstetric Care, and Postpartum Discharge Transition, which provide an established platform for standardizing recognition, response, care coordination, and postpartum transition processes relevant to cardiovascular risk management (AIM, n.d.). AIM’s reach and bundle-based infrastructure make it a high-leverage mechanism for HRSA to scale standardized cardiovascular safety practices, strengthen postpartum transitions, and support consistent measurement and improvement across diverse settings.

Rural Health and Workforce Initiatives

Women living in rural areas face unique barriers to accessing maternal health care relative to their urban counterparts, including higher rates of maternal mortality and the loss of hospital obstetric units (Martinsen, 2025). HRSA’s Federal Office of Rural Health Policy collaborates with rural communities and other partners to tackle these issues through programs such as its Rural Maternity Obstetrics Management Strategies (RMOMS) Program. From September 2020 to August 2022, RMOMS helped its 2019 cohort provide prenatal, labor and delivery, or postpartum care to nearly 5,000 patients and support over 3,600 deliveries. Its funding allowed these grant recipients to implement telehealth, patient navigation, and direct service expansion initiatives, improving access to maternity care and support services (Martinsen, 2025).

In addition to program investments in maternity care delivery, HRSA’s Bureau of Health Workforce supports training, loan forgiveness programs for practicing in specific geographic areas, and other strategies to strengthen the health workforce in underserved and rural communities (HRSA, 2025h, n.d.-c). Programs such as the National Health Service Corps and Nurse Corps, along with training and residency initiatives, can recruit and retain clinicians and support the team-based care models needed to deliver preventive services across the prepregnancy, pregnancy, postpartum, and interpregnancy periods (HRSA, 2025d).

Data, Research, and Quality Improvement Platforms

In addition to its service delivery and financing programs, HRSA supports data, research, and quality-improvement platforms that can be leveraged to strengthen maternal cardiovascular prevention. These platforms can help address the gaps in data infrastructure and measurement described earlier in this chapter by promoting standardized data collection, linked quality metrics, and practice-based learning across communities and health systems.

HRSA funds 42 State Maternal Health Innovation (SMHI) programs that offer another opportunity to advance data and quality improvement for maternal cardiovascular health. They support state-level initiatives that bring together public health agencies, health systems, clinicians, patients, and community organizations to improve maternal health data systems, develop and test quality measures, and implement maternal health interventions (HRSA, 2024b). SMHI-supported collaboratives could be used to develop and pilot a parsimonious set of measures for pregnancy-related cardiovascular preventive services—such as timely postpartum BP checks, early postpartum visits, transition to primary care, and follow-up testing—and evaluate whether interventions improve outcomes across different populations.

HRSA can also strengthen research–practice partnerships that use EHR data from community-based settings to study and improve cardiovascular preventive care. Practice-based research networks and registry-based quality-improvement initiatives can help evaluate screening tools and care models in real-world settings and support continuous improvement in postpartum follow-up and transitions to primary care. Incorporating implementation science approaches within these platforms could further strengthen understanding of how preventive services are adopted, adapted, and sustained across diverse clinical settings and identify strategies that improve fidelity, scalability, and equity of delivery. One example of such a network is the 3-year National Hypertension Control Initiative. Launched in 2021 by the U.S. Department of Health and Human Services (through HRSA and the Office of Minority Health) and implemented by the American Heart Association, it aimed to increase clinician and staff engagement in evidence-based practices—including use of advanced self-measured BP technology—and the number of adults with controlled HTN (HRSA, 2021). The Chicago Quality Improvement Learning Collaborative, working with six FQHCs, focused on implementing a registry of high-risk prenatal patients to support linkage to primary care (Gemkow et al., 2024); this experience suggests that a flexible, collaborative quality-improvement approach can help optimize care delivery in community-based settings. Another example is the

Oregon Community Health Information Network, which maintains one of the largest shared community health center EHR databases in the United States using a shared electronic health record and supports a national practice-based research network (OCHIN, 2024). Participating FQHCs can leverage this shared infrastructure to generate scalable, longitudinal data across millions of patients.

Finally, HRSA’s UDS, which health centers use to report on services and outcomes, could be expanded to include standardized measures of pregnancy-related cardiovascular preventive services, such as BP follow-up after HDP, diabetes screening after GDM, and documentation of pregnancy complications as cardiovascular risk enhancers. Incorporating these measures into UDS would both incentivize consistent preventive service delivery and provide national data to guide improvements in access, care coordination, and outcomes for populations with the greatest needs.

These data, research, and quality-improvement platforms position HRSA to play a central role in strengthening maternal cardiovascular data infrastructure, advancing practice-based evidence, and promoting quality standards that support preventive services across the reproductive life course.

CROSSCUTTING CONCLUSIONS

This section synthesizes the major crosscutting barriers and conclusions identified across Chapters 1–6 and presents conclusions on access to and delivery of preventive clinical services for CVD risk reduction before, during, and after pregnancy. The preceding sections describe how these domains interact to shape preventive cardiovascular care across the reproductive life course; the conclusions distill those themes and highlight their implications.

Gaps in Access and Care Coordination Affect Preventive Service Use

Access to preventive clinical services for CVD risk reduction around the time of pregnancy is shaped by financial and nonfinancial barriers, fragmented delivery systems, and differences in availability across communities. Coverage interruptions—particularly during the transition from pregnancy to postpartum—and variation in benefits and reimbursement for preventive services can limit both delivery and uptake. In many settings, care remains divided across obstetric, primary care, specialty, and emergency care pathways, creating missed opportunities for coordinated screening, counseling, and follow-up, including warm handoffs and care navigation.

Conclusion 6-1: Financial barriers, fragmented care delivery, and uneven availability of services across settings and time points reduce access to, delivery of, and uptake of preventive services for cardiovascular disease during the prepregnancy, pregnancy, and postpartum periods. These systemic limitations impede timely identification and management of cardiovascular risk among women of reproductive age, especially those at elevated risk following pregnancy-related complications.

Gaps in Data Infrastructure and Tracking Hinder Improvement

Data systems to identify and track pregnancy-related cardiovascular complications and associated risk factors are fragmented and often do not support longitudinal follow-up across the reproductive life course. Variation in state participation and data elements across surveillance systems, limited linkage across vital records, clinical records, and claims, and inconsistent documentation of pregnancy complications within EHRs constrain the ability to monitor preventive service delivery and outcomes over time.

Conclusion 6-2: Fragmented and incomplete data infrastructure limits the ability of health care systems, programs, and clinicians to monitor individuals, communities, and populations for pregnancy-related cardiovascular complications and associated risk factors and ensure the delivery and uptake of timely, appropriate preventive services. A more integrated and standardized approach to data collection and linkage is needed to support efforts to improve access to, and continuity of, preventive cardiovascular care across the perinatal, postpartum, and interpregnancy periods.

Quality Standards and Measurement for Maternal Cardiovascular Prevention Are Underdeveloped

Quality standards and measurement approaches for integrating cardiovascular prevention into maternal care remain underdeveloped. Measures are often limited to delivery or short-term postpartum time points and rarely capture longitudinal preventive services (e.g., postpartum BP followup after HDP, diabetes and lipid screening, and documented transition to ongoing primary care). Without aligned measures and incentives, health systems and providers have limited accountability for sustaining preventive care during the postpartum and interpregnancy periods.

Conclusion 6-3: The absence of aligned national quality standards and performance measures for integrating cardiovascular prevention into maternal and postpartum care creates barriers to consistent provision

of preventive clinical services. Without clear guidelines, longitudinal measures, and reimbursement incentives, providers and health systems lack the structures needed to ensure continuity of care and monitor outcomes over time. Establishing standardized, evidence-based quality measures is essential to improving accountability, achieving comparable results across populations, and embedding preventive cardiovascular services into maternal health care.

Gaps in Public Awareness and Community Outreach Reduce Uptake of Preventive Care

Public awareness that CVD is a leading cause of pregnancy-related morbidity and mortality remains limited, and some populations experience a higher burden of APOs. MMRC reports indicate that many pregnancy-related cardiovascular deaths are potentially preventable, highlighting opportunities to improve recognition of risk and timely use of preventive services. Many women of reproductive age have limited awareness of cardiovascular risk factors, the relationship between pregnancy complications (e.g., HDP and GDM) and future risk, and the importance of prepregnancy and postpartum follow-up care. Warning signs and symptoms of cardiovascular conditions during pregnancy and postpartum may not be well recognized.

Conclusion 6-4: Limited public awareness of the relationship between adverse pregnancy outcomes and future cardiovascular risk, combined with a lack of accessible, community-tailored education, reduces the uptake and continuity of preventive care among women of reproductive age. Limited knowledge of what services are needed for comprehensive prepregnancy, postpartum, and interpregnancy care for prevention of cardiovascular disease (CVD) morbidity and mortality, and variable access to reliable information in community settings, hinder timely engagement with clinical services for CVD prevention.

Clinical Workforce Knowledge, Training, and Preparedness Are Insufficient and Inconsistent

Clinicians across care settings—including emergency medical services, EDs, urgent care, primary care, obstetrics, and cardiology—may lack training, standardized protocols, or decision support tools to identify and manage cardiovascular risk in reproductive-age and postpartum women. These gaps can delay or prevent delivery of preventive clinical services, such as BP screening, diabetes and lipid testing, counseling on contraception and cardiovascular health, and timely referral or follow-up. Workforce shortages

and maldistribution, particularly for rural and other communities with the greatest needs, further constrain access to clinicians and teams prepared to deliver preventive services across the reproductive life course.

Conclusion 6-5: Gaps in clinician knowledge, training, and availability undermine the delivery of preventive clinical services for cardiovascular disease (CVD) risk reduction during the prepregnancy, pregnancy, postpartum, and interpregnancy periods. Missed opportunities in high-volume settings—such as primary care and emergency departments—reduce the likelihood that at-risk patients will receive timely screening, counseling, or follow-up. Strengthening and embedding core competencies for pregnancy and CVD into workforce training and preparedness, supporting the use of decision aids in practice, and better integrating team-based models can improve access to and uptake of preventive services and reduce CVD morbidity and mortality.

Engagement with primary care professional societies—including the American Academy of Family Physicians, American College of Physicians, and Society of General Internal Medicine—may further support dissemination of pregnancy-related cardiovascular prevention guidance and strengthen workforce capacity. These organizations have long-standing commitments to preventive care and maternal health and have highlighted challenges related to primary care workforce shortages, which may affect the feasibility of implementing longitudinal cardiovascular risk management across the reproductive life course.

Health Resources and Services Administration–Supported Programs Are Critical for Expanding Preventive Maternal Cardiovascular Care

HRSA-supported safety-net and community-oriented programs—including health centers and maternal and rural health initiatives—are important platforms for expanding access to preventive clinical services for reproductive-age and postpartum women, particularly in communities with the greatest needs. Their community orientation, experience addressing nonfinancial access barriers, and ability to integrate medical and supportive services position them to strengthen continuity of care from pregnancy through the postpartum and interpregnancy periods when supported with aligned incentives, data systems, and workforce capacity-building.

Conclusion 6-6: Health Resources and Services Administration–supported health centers and other community-oriented programs are uniquely positioned to expand the reach of preventive clinical services for cardiovascular disease among women of reproductive age, during

pregnancy, and in the postpartum and interpregnancy periods. Their community orientation and focus on improving opportunity for underserved groups make them vital platforms for strengthening maternal cardiovascular outcomes, particularly if supported through aligned incentives, data systems, and workforce capacity-building.

Although this report focuses on cardiovascular risk across the reproductive life course in relation to pregnancy, the crosscutting barriers and strategies identified in this chapter—particularly those related to care coordination, navigation, shared decision-making, workforce competencies, and longitudinal follow-up—have relevance for perinatal care more broadly. Women with complex or overlapping health conditions often encounter similar fragmentation and uncertainty across care settings. Strengthening these systems may therefore improve maternal outcomes beyond cardiovascular disease alone.

CONCLUDING OBSERVATIONS

Implementing evidence-based preventive services to reduce cardiovascular-related maternal morbidity and mortality requires attention to crosscutting factors beyond individual clinical interventions. Coverage and benefit design, health system capacity and workforce distribution, care coordination and information flow, clinician training and practice supports, and patient and community circumstances each shape whether services reach those who need them during the prepregnancy, pregnancy, postpartum, and interpregnancy periods.

These considerations underscore the importance of coordinated action across payers, health systems, public health agencies, and community partners to strengthen continuity of care, address differences in service availability, and support community-centered approaches. The following chapter builds on these crosscutting barriers and federal levers to present recommendations and research priorities for expanding access to preventive cardiovascular services and achieving comparable results across populations.

REFERENCES