7

Recommendations

INTRODUCTION

Based on the review of the evidence in Chapters 2–6, this chapter presents three types of recommendations from the committee to strengthen prevention, early identification, and management of cardiovascular risk across the reproductive life course: (1) clinical preventive services with sufficient evidence to support implementation; (2) crosscutting system and workforce strategies to improve access, continuity, and quality of preventive cardiovascular care; and (3) research and data infrastructure priorities needed to strengthen the evidence base (see Box 7-1 for a high-level summary of the committee’s 12 recommendations). Consistent with the committee’s statement of task, the recommendations in this chapter are directed to the Health Resources and Services Administration (HRSA) and related federal agencies. In March 2025, the creation of an Administration for a Healthy America (AHA) was announced, which proposed merging certain HRSA functions into AHA and shifting others within the U.S. Department of Health and Human Services (HHS, 2025). Although the recommendations are directed to federal agencies as organized in January 2026, they are intended to apply to any future agency or entity responsible for the relevant functions.

CLINICAL SERVICES RECOMMENDATIONS

Based on its review of clinical preventive services in Chapters 4 and 5, the committee identified two with substantial or moderate evidence that

they improved health outcomes or closely related intermediate outcomes. Based on that evidence, the committee makes two recommendations. Many of the other services reviewed showed promise based on evidence that they improved process outcomes but limited evidence that they improved intermediate or health outcomes. The absence of a recommendation should not be interpreted as meaning that a given service should not be provided, only that the current evidence does not yet support a formal recommendation. Effective implementation of these services depends on not only clinical efficacy but also addressing workflow, workforce, data, and access-related barriers that can limit real-world adoption.

Prenatal Blood Pressure Target

Substantial evidence shows that treating chronic hypertension in pregnancy to achieve blood pressure (BP) targets of <140/90 mmHg reduces severe-range hypertension (HTN), preeclampsia, indicated preterm birth, and related adverse outcomes, with no demonstrated harm to fetal growth.

Recommendation 1: The Health Resources and Services Administration should support implementation of clinical care models and educational efforts that enable clinicians and pregnant women with preexisting chronic hypertension to implement antihypertensive therapy to achieve a blood pressure standard of <140/90 millimeters of mercury during pregnancy.

This recommendation aligns with professional society practice advisories. For example, the Society for Maternal-Fetal Medicine advises antihypertensive treatment for mild chronic HTN in pregnancy to a goal BP of <140/90 mmHg (SMFM, 2022), and the American College of Obstetricians and Gynecologists advises using 140/90 mmHg as the threshold to initiate or titrate medication for chronic HTN in pregnancy (rather than waiting for severe-range BPs) (ACOG, 2022).

Implementation considerations for HRSA include building the infrastructure and support that will allow safety-net and maternity care sites to

operationalize these lower BP targets in routine care. Key elements include funding and technical assistance for standardized, evidence-based treatment protocols (such as electronic health record [EHR] order sets and clinical decision support including use of established implementation resources, such as the Centers for Disease Control and Prevention [CDC] Hypertension Control Change Package for pregnancy and postpartum care¹); reliable BP measurement and documentation workflows; and team-based care models that engage obstetrics, family medicine, internal medicine, specialists, nursing, pharmacy, and community health workers.

HRSA can also prioritize strategies that expand access to affordable, pregnancy-safe antihypertensive medications and structured home BP monitoring during pregnancy (e.g., through grant funds or optimization of the 340B drug pricing program), alongside culturally and linguistically appropriate patient education materials so that pregnant women understand BP goals and treatment options. When paired with defined clinical response protocols, remote monitoring may support earlier identification of uncontrolled BP and timely medication adjustment, consistent with the evidence summarized in Chapter 5. Such approaches may be particularly important in settings where transportation instability, workforce shortages, or geographic barriers limit consistent access to in-person prenatal care. Strengthening data systems and quality measures to track BP control and outcomes among pregnant patients with chronic HTN can help identify and address disparities in care.

Research Recommendation

Although high-quality randomized evidence supports initiating or titrating antihypertensive therapy for mild chronic HTN in pregnancy using a 140/90 mmHg threshold (with improved maternal and perinatal outcomes and no demonstrated increase in small-for-gestational-age birth weight), the U.S. trial evidence base is largely confined to pregnant women with chronic HTN diagnosed before 20 weeks’ gestation. Accordingly, these data should not be interpreted as establishing optimal BP treatment targets for the full spectrum of hypertensive disorders of pregnancy (HDPs) (e.g., gestational hypertension or preeclampsia without severe features).

HDPs do share overlapping vascular biology and confer elevated downstream cardiovascular risk, raising a critical research question: do the benefits of tighter BP control in pregnancy extend beyond chronic HTN? Several international guidelines have adopted more unified approaches to treatment thresholds/targets across HDP, often recommending medication in pregnancy when BP is persistently equal to or greater than 140/90 mmHg

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¹See https://millionhearts.hhs.gov/tools-protocols/action-guides/hypertension-pregnancy-change-package/index.html (accessed February 11, 2026).

across HDP subtypes (e.g., chronic HTN or gestational HTN) and aiming for targets near 135/85 mmHg or diastolic ~85 mmHg (Magee et al., 2022a,b; NICE, 2023). In part, these approaches recognize the potential to reduce progression to severe-range HTN and related complications without clear evidence of fetal harm. In the U.S. context, however, evidence supporting specific antenatal BP targets outside of chronic HTN remains limited, underscoring the need for prospective studies designed to evaluate whether broader application of lower treatment thresholds or targets improves outcomes in gestational HTN and preeclampsia without severe features, without increasing fetal growth restriction or other adverse neonatal outcomes.

Recommendation 2: Federal government funders should prioritize clinical trials and implementation-effectiveness studies to determine optimal prenatal and early postpartum blood pressure thresholds, targets, and treatments for hypertensive disorders of pregnancy during the prenatal and postpartum periods.

Enhanced Postpartum Hypertension Management

HDPs are a leading contributor to severe maternal morbidity (SMM) and mortality in the postpartum year, a time when many women experience gaps in access to timely care. Enhanced postpartum HTN management programs consistently improve early BP ascertainment, engagement in care, and short-term BP control, although current evidence does not yet demonstrate direct reductions in SMM, mortality, or long-term cardiovascular outcomes. The improvements in process measures and short-term BP control are clinically meaningful, given the biological importance of managing chronic HTN and the elevated risk of complications after delivery. Providing support for approaches such as self-measured BP monitoring with structured clinical follow-up offers a practical pathway to strengthen postpartum care and support improvement in communities with worse outcomes.

Recommendation 3: The Health Resources and Services Administration should support clinical programs and education that strengthen postpartum hypertension management for women with chronic hypertension or other hypertensive disorders of pregnancy. Efforts should focus on approaches with demonstrated benefit to increase early blood pressure (BP) assessment, improve engagement in follow-up care, and enhance short-term BP control—such as remote or self-measured BP monitoring paired with timely clinical review and treatment adjustment.

Effective postpartum HTN programs need to account for clinical workflow, patient access, and follow-up capacity. HRSA-supported settings

could consider offering validated at-home BP cuffs, consistent training on self-measured BP techniques, clear thresholds for clinician review, and standardized workflows and other supports for reliable, timely treatment adjustment. In practice, BP device selection can be challenging because relatively few home BP monitors have been independently validated for use during pregnancy and the postpartum period; sites may need a defined process for selecting devices from validated-device registries, confirming cuff sizing, and updating device lists over time. Ensuring that women can be reached after hospital discharge—through phone, text, telehealth, or in-person visits—is central to program success. Implementation also needs to address known challenges with remote patient monitoring, including clinician workload related to data review, alert fatigue from inaccurate or poorly contextualized high BP readings, variability in patient digital literacy, and limitations in EHR interoperability, that can delay timely recognition and response. These barriers underscore the importance of structured workflows, clear accountability, and ongoing evaluation of implementation strategies. Sites may also need to address practical barriers, such as lack of education materials in other languages, Internet connectivity limitations, and interruptions in health insurance during the postpartum period. Embedding services in team-based care models and aligning them with existing maternal health quality initiatives could help achieve comparable results across communities.

CROSSCUTTING RECOMMENDATIONS

Implementing clinical preventive services at scale requires continuity of insurance coverage, reliable transitions across care settings, workforce capacity, and standardized data and quality measurement. Even when effective clinical services exist, preventable cardiovascular morbidity and mortality can persist because of fragmented postpartum follow-up, financial and system barriers to care, and inconsistent quality standards. The following recommendations describe HRSA levers—often in partnership with states and other federal agencies—to address these barriers and reduce differences in outcomes across communities. Effective implementation of these recommendations will require coordinated engagement across obstetrics, primary care, cardiology, and other relevant specialties to ensure continuity of cardiovascular risk management across the reproductive life course.

Improve Access, Continuity, and Coordination of Preventive Cardiovascular Care Across the Reproductive Life Course

Recommendation 4: The Health Resources and Services Administration, working with federal and state partners, including the Centers for

Medicare & Medicaid Services and state Medicaid agencies, should support and incentivize systems and programs that reduce financial barriers to care, strengthen care transitions, and improve coordination of preventive cardiovascular care across the prepregnancy, pregnancy, postpartum, and interpregnancy periods.

Specific implementation strategies could include the following:

• Standardize care transitions and accountability. Identify women at elevated cardiovascular risk before discharge from delivery hospitalization. For those with pregnancy-related cardiovascular conditions and risk factors, ensure warm handoffs from obstetric clinicians to primary care and specialty clinicians, with clear documentation of who is accountable for follow-up. In addition, schedule key follow-up visits before discharge (e.g., BP checks within 72 hours for severe HTN, follow-up within 7–10 days when indicated, and comprehensive preventive visits by 12 weeks postpartum), using telehealth options where feasible.
• Align payment and coverage with preventive services. Support 12-month postpartum coverage, and promote no-cost coverage of high-priority preventive services and devices (e.g., validated BP monitors) for reproductive-age and postpartum women. In addition, encourage reimbursement for care coordination, remote monitoring, and interprofessional consultations that support longitudinal cardiovascular risk management.
• Enable care continuity when telehealth is used across state lines. Collaborate with states and other federal partners to support licensure reciprocity or compacts and payment policies that facilitate continuity of telehealth-based follow-up through the first postpartum year, especially when women relocate or receive care across state lines.
• Engage patients, and address nonfinancial barriers. Support models that address transportation, child care, time away from work, and other nonfinancial costs that limit access to appointments. Ensure patients and their families understand the purpose of care transitions and follow-up plans so they can navigate fragmented systems and advocate for needed care.

HRSA could use its innovation-focused programs, such as Healthy Start, State Maternal Health Innovation, and rural grants, to fund and evaluate local models that implement these strategies.

Expand Access to Preventive Cardiovascular Services Through Telehealth and Rural Health Programs

Many reproductive-age and postpartum women face barriers to preventive cardiovascular services because of geographic distance, transportation challenges, child care demands, work schedules, and fragmented transitions of care. These barriers are particularly pronounced in rural and underserved communities, where safety-net providers are often the primary source of maternal health care and maternity care and specialist shortages limit local options. HRSA has unique levers—through its telehealth, rural health, and maternal health grant programs—to expand access to preventive cardiovascular services and strengthen continuity of care beyond delivery hospitalization and any single clinical setting. By aligning telehealth expansion, rural initiatives, and safety-net partnerships around preventive cardiovascular care across the reproductive life course, HRSA can help equalize access to services and target support to groups with the greatest needs.

The committee’s evidence review found the strongest support for telehealth-enabled approaches that include self-measured or remote BP monitoring paired with a structured clinical response—such as nurse- or protocol-driven triage workflows, defined escalation pathways, and timely medication adjustment—which improve early BP ascertainment and short-term control (see Telehealth section of Chapter 5 for more information). Evidence for other maternal health–focused telehealth applications remains limited and has not yet been sufficient to demonstrate reductions in maternal cardiovascular morbidity or mortality. However, telehealth is best understood as a delivery modality that can reduce systems barriers to timely follow-up—especially during the postpartum year, when missed care and fragmented transitions are common—and extend evidence-based services and specialty support (e.g., medication titration, diabetes follow-up, counseling, and care coordination) to communities with limited in-person access. For these reasons, the committee recommends that HRSA prioritize telehealth for high-value, evidence-supported use cases while using its telehealth and rural programs to implement, evaluate, and iteratively improve other telehealth-supported models with attention to safety, reducing health disparities, and improving outcomes.

Recommendation 5: The Health Resources and Services Administration should leverage its telehealth, rural health, and maternal health programs to reduce geographic, financial, and system barriers to preventive cardiovascular services—prioritizing telehealth-supported models with demonstrated benefit (e.g., remote/self-measured BP monitoring with structured triage protocols and medical adjustment pathways) and supporting evaluation of other telehealth applications—during

the prepregnancy, pregnancy, postpartum, and interpregnancy periods, particularly for communities with the greatest needs.

HRSA can operationalize these strategies through the Office for the Advancement of Telehealth, including the Telehealth Resource Center Program, which provides technical assistance, training, and implementation support to health systems and community providers adopting telehealth models. These resources can complement HRSA’s maternal and rural health programs by accelerating spread of standardized workflows, disparity-focused implementation, and outcome measurement. Effective implementation will also depend on coordination with emergency departments (EDs) and emergency medical services, which are often points of first contact for pregnant or postpartum women with acute cardiovascular symptoms and play a critical role in timely recognition, stabilization, and referral back to outpatient follow-up. Implementation strategies could include the following.

Program Design Principles for Telehealth-Supported Models

• Use structured protocols and escalation pathways. Define measurement frequency, thresholds that trigger outreach, response time expectations, and clear accountability regarding who reviews data, who contacts patients, who adjusts medication, and when to escalate to urgent or emergent care.
• Specify minimum outcome reporting. At a minimum, report process and intermediate outcomes (e.g., BP ascertainment within defined time windows, time-to-treatment or time-to-control adjustment, BP control, and postpartum visit completion), and stratify results by key variables (e.g., race and ethnicity, rurality, insurance, and language). When feasible, link to clinical outcomes (e.g., emergency department [ED] visits, readmissions, and SMM).
• Plan for access from the start. Budget for devices and connectivity supports, offer low-bandwidth options (including phone and text where appropriate), provide language-accessible materials, and include training and technical support for patients and staff.

Telehealth-Supported Models for Postpartum and Interpregnancy Care

Expand the use of telehealth to support postpartum BP monitoring, diabetes follow-up, and cardiovascular counseling, including remote monitoring programs that combine home devices (e.g., BP cuffs and glucometers or continuous glucose monitors) with clinical review and follow-up. Telehealth can also facilitate coordination and warm handoffs from obstetric

care to longitudinal primary care, supporting sustained cardiovascular risk management beyond the immediate postpartum period. Use State Maternal Health Innovation programs and other HRSA-funded collaboratives to test and spread telehealth-supported models of postpartum cardiovascular follow-up, particularly in rural and underserved areas.

Rural Health Initiatives Focused on Preventive Cardiovascular Services

Leverage HRSA’s Federal Office of Rural Health Policy—including programs such as the Rural Maternity and Obstetrics Management Strategies (RMOMS)—to strengthen preventive cardiovascular care in rural communities where obstetric and specialty care are often unavailable or distant. Support rural demonstration projects that test innovative models of postpartum and interpregnancy cardiovascular risk assessment and follow-up (e.g., telehealth-enabled cardio-obstetrics consultations, mobile clinics, and shared-care models linking rural sites with regional hubs), with attention to sustainability and transferability.

Partnerships with Safety-Net and Maternal Health Programs

Encourage partnerships among HRSA-funded entities (e.g., federally qualified health centers [FQHCs] and Look-Alike health centers [which meet health center requirements but do not receive Section 330 funding], rural health clinics, and critical access hospitals) and state and local partners that serve reproductive-age and postpartum populations, including Title V Maternal and Child Health Services Block Grant programs; Healthy Start; and Maternal, Infant, and Early Childhood Home Visiting (MIECHV) programs. Evidence-based home visiting programs supported through MIECHV reach pregnant and postpartum women at elevated social and medical risk and offer a structured mechanism for reinforcing postpartum follow-up, BP monitoring, medication adherence, and linkage to primary care. Use these partnerships to strengthen transitions of care from obstetric to primary care and from emergency or urgent care settings back to outpatient follow-up, including shared protocols for warm handoffs, care navigation, and telehealth-supported follow-up for women at increased cardiovascular risk. Provide technical assistance and targeted funding incentives to help safety-net clinicians integrate preventive cardiovascular services (e.g., cardiovascular disease [CVD] risk assessment based on pregnancy history, BP and diabetes screening, and counseling on contraception and interpregnancy intervals) into routine maternal and primary care.

Strengthen Maternal Cardiovascular Data, Research, and Quality Standards

Recommendation 6: The Health Resources and Services Administration, in partnership with the Centers for Disease Control and Prevention, Centers for Medicare & Medicaid Services, National Institutes of Health, Agency for Healthcare Research and Quality, and other research funders and partners, should expand and standardize maternal health data collection, research–practice collaboration, and quality measurement to support the delivery of preventive cardiovascular services across the reproductive life course.

Key elements could include the following:

Build on Existing Quality Improvement and Dissemination Platforms

Expand the Alliance for Innovation on Maternal Health safety bundles—structured sets of practices designed to improve quality of care—to include standardized approaches and metrics for postpartum cardiovascular follow-up (e.g., BP monitoring after HDP, diabetes screening after gestational diabetes [GDM], and documentation of pregnancy complications as CVD risk enhancers). Use State Maternal Health Innovation programs and similar collaboratives to test and disseminate data standards and parsimonious measures related to CVD prevention across the reproductive life course.

Strengthen Research–Practice Networks and Implementation Learning

Expand partnerships with practice-based research networks and FQHC consortia to evaluate cardiovascular risk screening tools, care models, and preventive service delivery in community-based settings, including underserved communities. Support implementation studies and quality-improvement projects, such as registry-based interventions to improve postpartum primary care transitions, that generate practice-based evidence for scalable models.

Improve Coding, Linkage, and Longitudinal Measurement

Address barriers in International Classification of Disease coding for pregnancy-related cardiovascular conditions and adverse pregnancy outcomes (APOs) to improve surveillance, reimbursement, and accountability. Expand HRSA’s Uniform Data System (UDS) to include measures of pregnancy-related cardiovascular preventive services (e.g., postpartum BP follow-up after HDP, diabetes screening after GDM, and documentation of

pregnancy history and outcomes in primary care), and promote stratified reporting to assess differences in outcomes across populations.

Advance Patient, Clinician, and Community-Based Education on Pregnancy-Related Cardiovascular Risk

Recommendation 7: The Health Resources and Services Administration should leverage its programs and grantees to expand patient, clinician, and community-based education on pregnancy-related cardiovascular risk, the importance of preventive services, and recognition of urgent maternal warning signs.

Implementation strategies could include embedding a small, consistent set of education messages across HRSA-supported platforms. Education should occur at multiple time points—during prepregnancy and prenatal care, at hospital discharge, during postpartum visits, and in community-based settings—to reinforce key messages and support continuity. Priority topics include (1) pregnancy complications and HDP as markers of increased cardiovascular risk; (2) recommended postpartum preventive follow-up and rationale, including BP follow-up and appropriate screening after GDM; (3) urgent maternal warning signs (UMWS) and when and how to seek emergent care; and (4) how and where to access preventive care across the postpartum year.

Education efforts could include standardized discharge materials, integration of warning-sign checklists into postpartum workflows, clinician-facing continuing education modules on the cardiovascular implications of adverse pregnancy outcomes, and community-based outreach initiatives. Existing public health resources—such as CDC’s Hear Her campaign materials focused on postpartum warning signs (CDC, 2024a)—can be used to support timely recognition of symptoms and appropriate escalation of care.

HRSA could encourage dissemination of culturally tailored education through the range of its activities that reach reproductive-age and postpartum women, including the following:

• Maternal and Child Health Bureau programs, such as Healthy Start, MIECHV, and Title V Maternal and Child Health Services Block Grant activities;
• Bureau of Primary Health Care safety-net settings, such as FQHCs and Look-Alike health centers; and
• Rural and telehealth-supported networks, such as RMOMS and telehealth technical assistance resources, to support adaptation and spread in rural and underserved areas.

Strengthen Workforce Competencies and Team-Based Models for Pregnancy-Related Cardiovascular Disease Prevention

Recommendation 8: The Health Resources and Services Administration should strengthen clinician capacity to deliver preventive clinical services for pregnancy-related cardiovascular disease by embedding core competencies, supporting team-based models, and aligning workforce incentives across its programs.

Core competencies should include the items summarized in Box 7-2. HRSA-supported workforce development grants (HRSA, 2025a,b) could embed these competencies across primary care, obstetrics, cardiology, emergency medicine, and other relevant disciplines, using continuing education, micro-credentials, and community-based training programs, such as the Teaching Health Center Graduate Medical Education Program and primary care fellowships. Implementation strategies could also include structured interdisciplinary learning opportunities—such as cross-specialty rotations, collaborative case conferences, or joint training initiatives—that strengthen shared understanding of pregnancy-related cardiovascular risk and improve coordination during care transitions. HRSA could expand loan-repayment and scholarship incentives to recruit and retain clinicians with expertise in

maternal cardiovascular health in communities with the greatest needs. It could also provide targeted grants so clinicians in rural and small communities can access simulation training and continuing education on pregnancy-related cardiovascular risk.

Leverage Health Resources and Services Administration–Supported Federally Qualified Health Centers and Related Programs to Expand Preventive Cardiovascular Disease Services

Recommendation 9: The Health Resources and Services Administration should incentivize and support Federally Qualified Health Centers and other community-oriented health programs it administers, as applicable, to expand the delivery of preventive clinical services for cardiovascular disease risk reduction during the prepregnancy, pregnancy, postpartum, and interpregnancy periods.

Implementation strategies could include the following.

Reimbursement and Incentives

Expand reimbursement mechanisms beyond bundled payments and performance incentives to encourage consistent provision of evidence-based clinical preventive services (e.g., BP monitoring, lipid and diabetes screening, prepregnancy and contraceptive counseling, and CVD risk education) for reproductive-age and postpartum women. Include reimbursable case management and care coordination so providers in FQHCs and similar settings are paid for the time required to close preventive care gaps and manage complex care transitions.

Use of Electronic Health Records and Decision Aids

Support the development and use of protocols and decision aids that systematically incorporate information on APOs and other complications and cardiometabolic risk factors into ongoing CVD risk assessment and follow-up for reproductive-age, pregnant, postpartum, and interpregnancy patients.

Capacity-Building and Community Partnerships

Provide resources for workforce training, team-based care models, case management, and partnerships with community health workers, doulas, and nurses to strengthen prevention and follow-up services within FQHCs and related HRSA-supported programs.

Data and Learning

Standardize and expand mechanisms for FQHCs to collect, report, and share data on pregnancy-related cardiovascular preventive services and outcomes through HRSA’s UDS, enabling continuous improvement and generating practice-based evidence to inform national guidelines and standards.

Implementation Considerations

Given the complex mix of funding sources that support FQHCs (including HRSA Section 330 funding, Medicaid, Medicare, private insurance, self-pay, and other grants and contracts), robust and stable funding is likely to be important for enabling these centers to provide longitudinal primary care that includes prepregnancy preventive services, prenatal CVD risk assessment, postpartum follow-up, and ongoing CVD risk management across the reproductive life course. Expanding the Community Health Center Fund and ensuring that preventive services relevant to cardiovascular risk are readily reimbursable by Medicaid and other payers could help support this role. Look-Alike health centers may also benefit from aligned incentives and technical assistance tailored to their funding context.

Summary

These crosscutting recommendations aim to make evidence-based preventive services feasible in real-world settings by strengthening access, continuity, workforce support, and measurement. However, important evidence gaps remain. The following research recommendations describe the data infrastructure and study designs needed to strengthen the evidence base and guide future clinical and policy decisions. In Chapters 4 and 5, the committee also identified important research considerations for promising clinical services based on the research questions it reviewed.

CARDIOVASCULAR DISEASE AND PREGNANCY RESEARCH RECOMMENDATIONS

Based on its review, the committee provides three research recommendations to strengthen the evidence base for clinical and policy decisions. These focus on clarifying what outcomes should be measured, building research infrastructure needed to study uncommon but high-impact outcomes, and supporting a full range of studies of services in the 12-month postpartum period.

Strengthen Outcome Selection and Measurement in Maternal Cardiovascular Disease Prevention Studies

Recommendation 10: The Health Resources and Services Administration should initiate collaborations with other government agencies and relevant nongovernmental organizations to develop definitions of core outcomes for use in studies of pregnancy-related cardiovascular morbidity and mortality. Researchers and sponsors (e.g., governmental agencies and foundations) should prioritize evaluating direct effects on health outcomes and on strongly linked intermediate outcomes.

Providing clinical preventive services requires substantial investments by insurers, health care systems, clinicians and staff, and patients. Absence of evidence of effectiveness is not equivalent to demonstrating ineffectiveness; some services without definitive evidence may be adopted. However, robust evidence is highly valuable to policy makers and clinical leaders.

As a sponsor of evaluations and formal research, HRSA could play a critical convening role by working with other governmental agencies and relevant nongovernmental organizations to develop a standard set of definitions of health outcomes and key process measures for studies of pregnancy-related cardiovascular morbidity and mortality. Greater consistency in outcome selection and measurement would enhance comparability across studies and accelerate translation of evidence into clinical and policy decision-making.

When considering possible types of outcomes, it is generally agreed that the best measure of effectiveness of a clinical service is the health outcome it is designed to prevent or promote. For clinical services where these are very uncommon or difficult to measure—they may not occur until many years after pregnancy, for example—it may be necessary to study intermediate outcomes (such as BP) with a clear causal relationship to the health outcome of interest. Other types of outcomes include process measures, such as adherence to a recommended schedule of postpartum visits, or use measures (e.g., outpatient visits, ED visits, or hospitalizations) (see Table 7-1). When selecting process measures for evaluations, researchers and sponsors should prioritize those with a clear, plausible link between adherence to process and health outcomes.

For seven of the nine clinical preventive services the committee reviewed, most available studies primarily used process or use measures rather than health or intermediate outcomes. Although both are common when health outcomes are uncommon or delayed, they are not consistently reliable indicators of benefit. For example, ED visits are generally thought to be undesirable, yet some may prevent worse downstream events, such as myocardial infarction. Similarly, process measures, such as adherence

TABLE 7-1 Types of Outcomes in Studies of Clinical Preventive Services

NOTES: BP = blood pressure; ED = emergency department; HbA1c = hemoglobin A1c; PP = postpartum.

to recommended clinical monitoring schedules, are not robust measures of benefit unless evidence clearly links them to improved health outcomes.

In contrast, studies that focused on health outcomes or intermediate outcomes were available for two of the nine clinical preventive services the committee reviewed. First, as discussed, the committee identified substantial evidence that targeting a BP of <140/90 mmHg for pregnant women with chronic HTN diagnosed before 20 weeks’ gestation improves health outcomes. Second, the committee found moderate evidence that enhanced postpartum HTN management programs can improve short-term BP control among women with HDP, including chronic HTN. In this instance, a clear line of evidence outside of pregnancy links BP control with long-term health outcomes, providing confidence that these interventions provide some benefit. For these two clinical services, the studies with direct evidence that they improved health or intermediate outcomes enabled the committee to make specific recommendations for them.

Sponsors and researchers should prioritize and design studies with adequate power to evaluate health outcomes or, when necessary, intermediate outcomes as their primary endpoints, rather than relying predominantly on process or use measures. Designing studies in this way would facilitate generating evidence that more directly informs the benefits and risks of clinical services, allow for generation of more robust cost-effectiveness information, and support future recommendations and adoption of practices shown to improve outcomes.

Develop a National Clinical Research Network for Severe Maternal Morbidity and Mortality

Recommendation 11: The Health Resources and Services Administration should collaborate with the Centers for Disease Control and Prevention, National Institutes of Health, Centers for Medicare & Medicaid Services, and other national organizations to develop a national research network with diverse settings—potentially by building on an existing program—to conduct multicenter studies to improve severe maternal morbidity and maternal mortality.

This network should be coordinated with broader efforts (described in Recommendation 6) to expand and standardize maternal health data collection for quality measurement and ongoing efforts by the National Institutes of Health (NIH) and CDC.

SMM and maternal mortality are uncommon, making it difficult for studies to achieve sufficient statistical power to draw definitive conclusions about patterns, trends over time, heterogeneity across subgroups, or effects of interventions. While evidence from Maternal Mortality Review Committees (MMRCs) has yielded important insights, a more coordinated and scalable research infrastructure is needed to advance the field.

Research networks that involve a range of health care systems, clinical practice settings, or both have been created by Health and Human Services agencies, including NIH, the Food and Drug Administration (FDA), the Agency for Healthcare Research and Quality, and CDC, and organizations such as the Patient-Centered Outcomes Research Institute (PCORI) to address important ongoing health care issues. Two general models of networks are the following:

• Clinical data research networks, which involve large insurers or health care systems and emphasize using computerized clinical data. They are valuable for studying rare outcomes because they enable data aggregation across large health care entities using standardized definitions and common data models. FDA’s Sentinel Initiative, mandated by Congress in 2007 (FDA, 2024a), illustrates how a federated network can support large-scale, real-world analyses while allowing contributing partners to retain control of patient-level data. It has initiated a set of demonstration projects to inform development of a pregnancy safety study framework focused on drugs and biologics (FDA, 2024b).
• Practice-based research networks, which embed research within real-world care settings—particularly primary care environments that serve women across the reproductive life course. These are

• particularly valuable for evaluating implementation strategies, care delivery models, prevention-oriented interventions, and generalizability especially for populations underrepresented in traditional academic research settings.

Hybrid approaches linking these models allow for identifying risk patterns at scale while also testing how interventions are delivered, adopted, and sustained.

These approaches should be adopted to study SMM and mortality. A national research network would enable policy makers and clinical leaders to gain a clearer picture of the real-world incidence of the different diagnoses involved in SMM and mortality, a greater understanding of what modifiable and other factors precede these adverse outcomes, and insights into trends in these predictors and outcomes over time and across space. Data should be integrated from a range of health care entities, including FQHCs, payers, and other organizations that serve women at elevated risk for pregnancy-related morbidity and mortality. By using shared data standards, distributed analytics, and coordinated governance, a maternal health–focused network could support longitudinal follow-up across the reproductive life course, enable rapid evaluation of preventive interventions and exposures, and facilitate collaboration across academic centers, community hospitals, safety-net systems, and other relevant stakeholders. In addition, such a network would provide infrastructure for observational or interventional multicenter studies of clinical services to reduce maternal morbidity and mortality.

HRSA and partners might consider either forming a new network or adding this structure to an existing program. Efficiency might be gained by building on an existing network or program. For example, NIH has fostered the Implementing a Maternal Health and Pregnancy Outcomes Vision for Everyone initiative (NICHD, n.d.-a), which includes (among other activities) 14 maternal health research centers of excellence in a range of geographic locations, along with a data innovation and coordination hub and an implementation science hub. Collaboration between HRSA and this initiative or another network (e.g., Eunice Kennedy Shriver National Institute of Child Health and Human Development’s Maternal-Fetal Medicine Units Network, FDA’s Sentinel Initiative, or PCORI’s PCORnet) (FDA, 2024a; NICHD, n.d.-b; PCORnet, n.d.) might accelerate the development of large linked dataset studies and large-scale multisite intervention studies to address critical gaps in knowledge on how to prevent SMM and mortality.

Build the Evidence Base for Postpartum Clinical Services to Prevent Cardiovascular Disease

Recommendation 12: The Health Resources and Services Administration, the National Institutes of Health, and other sponsors should support a full spectrum of research on clinical services to reduce the risk of adverse cardiovascular outcomes during the 12 months after delivery. Research should range from early-stage studies to identify potentially effective preventive services to definitive controlled studies to rigorously evaluate the most promising services.

Studies should focus on interventions generalizable to a wide range of settings. They should also be designed with appropriate control groups and sample sizes adequate to provide definitive evidence on whether the intervention reduces adverse cardiovascular outcomes.

The best available evidence on pregnancy-related cardiovascular deaths suggests that more than 80 percent occur between delivery and 12 months postpartum (Briller et al., 2024). Of all deaths, 40 percent were between 43 days and 12 months postpartum, highlighting the need for interventions that address the later postpartum period. The most common causes include postpartum or peripartum cardiomyopathy, other cardiomyopathy, vascular aneurysm/dissection, and hypertensive CVD. MMRCs judged more than 80 percent of these deaths to be preventable, most commonly citing gaps in clinical knowledge or skills, quality of care, continuity or coordination of care, chronic disease management, and access or financial barriers (Briller et al., 2024; CDC, 2024b).

Several of the clinical services this committee reviewed hold promise to address cardiovascular risk in the postpartum period. The committee has recommended increasing support for enhanced postpartum HTN management and identified three other promising approaches that focus on cardiovascular risk reduction during the postpartum period: UMWS screening in outpatients, cardiovascular risk assessment tools, and integrated cardio-obstetrics care. In addition, three other types of services—telehealth, supportive services, and interventions to support postnatal transitions—could reduce cardiovascular risk while aiming to improve outcomes more broadly.

Unfortunately, the weakness of the evidence base for these interventions hampered the committee’s ability to provide robust recommendations. HRSA and other agencies should therefore support well-designed studies based on detailed protocols, careful selection of outcomes, and preintervention identification of appropriate comparison groups. The lack of the latter was a notable problem throughout the literature the committee reviewed. When studies do not use an appropriate comparison group, the effectiveness of the intervention remains questionable.

In addition to study design limitations, fragmented data infrastructure constrains both postnatal care transitions and the evidence base needed to evaluate them. Effective postpartum cardiovascular prevention depends on continuity across delivery hospitals, outpatient obstetric care, and primary care, yet data systems often do not support linkage across these settings. Although many states have health information exchanges intended to facilitate care transitions, these systems frequently prioritize hospital-based data and do not consistently capture outpatient or primary care encounters (Turbow et al., 2026). As a result, postnatal follow-up after pregnancy complications is often not visible across care settings, limiting both care coordination and the ability to study the safety and effectiveness of postpartum interventions.

Well-designed research along the entire continuum is needed to build the robust knowledge base required to address maternal cardiovascular morbidity and mortality. The committee recognizes the need for a stream of research that generates promising leads to support more definitive trials. The most pressing need is for definitive controlled studies evaluating the direct effects of promising clinical services on key maternal cardiovascular outcomes. The interventions should be carefully selected to optimize feasibility and adoption across a range of settings with varying resources. Research designs could include randomized trials (individual or cluster randomization) and nonrandomized trials with carefully identified control groups.

SMM and mortality are the health outcomes of highest impact, but they are challenging to study because they are uncommon. A 2024 study found that 2.5 percent of pregnant women experience SMM, with 12 percent of it between 43 days and 12 months postpartum (Boghossian et al., 2024). At this incidence rate, sample sizes in the tens of thousands in each group would be required to detect a medium-sized effect on SMM in a controlled intervention study.

Given the large sample sizes required to assess primary health outcomes related to perinatal cardiovascular morbidity and mortality, building the evidence base will, of necessity, include intermediate outcomes, such as BP control. The use of intermediate outcomes makes studies more feasible, requiring sample sizes in the hundreds per group. Thoughtful selection of intermediate outcomes with existing strong evidence linking them to pregnancy-related cardiovascular health outcomes can generate evidence robust enough to support future recommendations for the clinical services of interest.

CONCLUDING OBSERVATIONS

These recommendations are intended to reduce preventable cardiovascular morbidity and mortality by strengthening evidence-based clinical care during pregnancy and the postpartum period and addressing system barriers that routinely disrupt continuity of care after delivery. Implementing tighter (<140/90 mmHg) prenatal BP targets for chronic HTN and strengthening postpartum HTN management can improve short-term outcomes directly. The crosscutting recommendations in this report focus on coverage continuity, care transitions, workforce capacity, patient and community education, data standards, and delivery platforms that make consistent prevention feasible in real-world settings.

HRSA is uniquely positioned to accelerate progress by aligning its maternal health, safety-net, rural health, telehealth, and workforce programs around preventive cardiovascular care across the reproductive life course. Because evidence gaps remain for many proposed interventions—especially for uncommon outcomes, such as SMM and mortality—implementation should be paired with standardized measurement and research infrastructure that enables learning across systems, pinpoints groups with worse outcomes, and supports rapid dissemination of effective models.

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