The American Heart Association (AHA) has released an updated maternal health toolkit regarding cardiovascular postpartum care to provide guidance for implementing evidence-based care across diverse settings. 

Over the last 2 decades, pregnancy-related mortality in the US has increased, with cardiovascular conditions consistently representing a leading cause of pregnancy-related death. High blood pressure (BP) during pregnancy, preeclampsia, and gestational diabetes are associated with significantly greater risk for later heart disease and death from cardiovascular disease (CVD). 

While there are several existing publications providing guidance on pregnancy and cardiovascular health, the AHA launched the Advancing Maternal Health Initiative in July 2022 with the hopes of strengthening maternal cardiovascular care through improving systems of care, expanding professional education and training, and disseminating recommendations that advance high-quality postpartum care, among other aspects. 

“This [toolkit] can be utilized as a comprehensive point of care tool for each birthing patient,” said Carolyn Zelop, MD, FAHA, volunteer member of the AHA’s Advancing Maternal Health Initiative writing group, maternal fetal medicine specialist, and director of fetal echocardiography and perinatal research at the Valley Hospital in New Jersey. “The toolkit is very versatile and can be used to guide clinical care in a variety of health care settings.”

The toolkit…serves as a roadmap for multidisciplinary education for health care professionals in the area of cardio-obstetrics.

The focus areas of the toolkit’s writing group represent a variety of care settings for populations at a disproportionate risk for postpartum maternal morbidity or mortality, including internal medicine and cardiovascular health, nursing maternal health, nurse administration, midwifery model of care, community doula, maternal health, and nursing and emergency medicine.

The toolkit, which is a second iteration of recommendations from the AHA, reflects further refinement based on additional literature review and ongoing clinical dialogue, according to the authors. The refined recommendations are also based on insights gathered through both a postpartum care learning collaborative, made of 15 clinical organizations working through model sharing and peer learning, and a postpartum lived experience collective, a group of 15 community-based organizations representing diverse communities and geographic regions that works collaboratively to share real-world insights, lived experiences, and community-driven strategies.

“The toolkit should be used to guide clinical care algorithms,” Dr Zelop noted. “It also serves as a roadmap for multidisciplinary education for health care professionals in the area of cardio-obstetrics.” 

The recommendations in the toolkit are divided into 4 recommendation groups — standardizing postpartum systems, interdisciplinary care and engagement, advocacy and policy expansion, and risk factor identification and monitoring.

Standardizing Postpartum Systems

The first recommendation from the toolkit highlights standardizing education for all health care professionals who may come in contact with pregnant or postpartum birthing persons. This includes standardizing the length of time that is considered the postpartum period, particularly asking if the patient is pregnant or gave birth in the last year.

Additionally, the first recommendation emphasizes the need to understand postpartum hypertension and cardiovascular risk, as the birthing individual can develop elevated BP and cardiovascular conditions during pregnancy and into the postpartum period.

Assessing and conducting laboratory tests based on American College of Obstetricians and Gynecologists (ACOG) standards of care is also recommended, as well as addressing the need for training in cardio-obstetrics because pregnancy can unmask or lead to acute and chronic CVD. 

This recommendation also emphasizes promotion of equity and inclusivity in postpartum care through language shifts, standardizing culturally and linguistically appropriate terminology, and endorses bias-free, respectful communication training for health care providers to strengthen trust and improve care experiences. 

The toolkit authors also recommend that the role of doulas be expanded and formalized as integrated members of the postpartum care team alongside obstetricians. Doulas included in care teams should receive standardized training to support cardiovascular risk and BP monitoring. 

Interdisciplinary Care and Engagement

The second recommendation from the toolkit endorses patient-centered holistic care as part of standard practice across health care providers and institutions in order to effectively treat the whole person. This should include education on the roles of midwives, doulas, mental health practitioners, community health workers, and trusted community leaders. The toolkit writing group emphasizes that ensuring this collaborative care among providers is essential for creating “a seamless continuum of care that extends beyond insurance coverage” and that “collaboration and respect for all members of the maternity team has a lifesaving and community empowering potential.”

To address social needs and to enhance access to postpartum resources, the toolkit authors recommend that referral pathways be established between hospitals, health care providers, and community-based organizations with identified and trained “postpartum care champions” who both advocate for comprehensive maternal care and ensure sustained connections to community-based support services.

Further, partners and chosen family members should be incorporated into postpartum education and support efforts. This recommendation seeks to foster shared responsibility, strengthen support networks, and enhance the well-being of birthing individuals.  

Advocacy and Policy Expansion

The toolkit authors recommend the establishment of a national standard that US federal law should require that all states provide comprehensive Medicaid coverage — including care received in-office, telehealth, home visits, emergency department visits, and/or urgent care centers — through the first 12 months following birth to all postpartum people who meet the Federal Poverty Level guidelines (expect Alaska and Hawaii, who have different criteria). Additionally, private insurers should also provide comprehensive pregnancy-related coverage up to 12 months following birth for their clients.

This coverage may include:

• 7 to 10 day high risk visit (such as BP checks);
• 2 to 3 week initial wellness visit (in-office or telehealth);
• 6-week comprehensive visit;
• Cardiac and mental health screening and BP checks at 2-, 6- and 12-month pediatric visits; 
• Specialty care with a cardiologist and/or endocrinologist;
• Periodic care received in emergency departments or urgent care centers; and,
• Doula and community health worker services.

The recommendation further describes how pediatric out-patient practices should consider employing a family medicine doctor or nurse practitioner who can provide care for postpartum persons at visits that coincide with newborn (initial and vaccine) visits within the first 2 weeks, 42 days, 2 months, 6 months, and 12 months. This should include CVD, hypertension, and mental health screenings, as well as a review of potential signs and symptoms of complications of pregnancy and a comprehensive postpartum assessment per ACOG guidelines.

The recommendations continue to encourage coverage from both Medicaid and private insurers for any prenatal or postpartum service for up to 12 months postpartum, including the opportunity to participate in group-based care and peer monitoring from obstetrical health providers and any evidence-based home visiting service that provides care to pregnant and/or postpartum people. Medicaid reimbursement rates are also recommended to be increased for all birth and postpartum care.

The toolkit authors also recommend that a national database be created for reporting quality performance measures and outcomes, including prenatal, intrapartum, and postpartum care, that can be accessed by those who offer maternity care, such as health care providers and hospital administrators.

Providing standardized postpartum warning sign education to all doulas and community health workers who provide care for all postpartum people is also recommended. 

Risk Factor Identification and Monitoring

The final recommendation in the toolkit highlights the importance of risk factor monitoring during routine preconception and interconception care, including screening for cardiovascular risk factors, such as BP, lipids, weight, and glucose intolerance/diabetes, as well as other, lesser-known biomarkers. 

“While all of the recommendations are salient to optimizing pregnancy health outcomes, risk stratification is perhaps the most important,” Dr Zelop said.

The recommendation also states that health care delivery systems must be sensitive to, trained on, and regularly screen for social determinants of health that may limit access to quality care. 

Further, the toolkit authors recommend that additional studies be conducted to address the gaps in the current literature regarding birthing individual health in cardiology and disparities in representation in research related to sex, gender, race, ethnicity, and reproductive age.

Mental health screenings at multiple touchpoints during the perinatal period through the first year after birth are also recommended to identify and address psychologic, emotional, and behavioral health needs.

Finally, the toolkit authors recommend that patients with CVD who are able to become pregnant should ideally be evaluated before conception to conduct discussions about pregnancy risks, optimization of their cardiovascular health, substitutions for teratogenic medications, and provide education on the need for regular surveillance through pregnancy and postpartum.

This article originally appeared on The Cardiology Advisor