New Resource Addresses Hypertension in Pregnancy
Aug. 28, 2024, David Mitchell — From 2017 to 2019, hypertension caused 6.3% of pregnancy-related deaths in the United States. During the same period, the prevalence of hypertension in pregnancy increased from 10.8% to 13% — and from 13.3% to 15.9% among patients hospitalized for delivery.
To address these alarming trends, the AAFP has partnered with the AMA, the American College of Nurse-Midwives, the American College of Obstetricians and Gynecologists, the American College of Osteopathic Obstetricians and Gynecologists, the National Association of Nurse Practitioners in Women’s Health, and the Society for Maternal-Fetal Medicine to develop the Hypertension in Pregnancy Change Package. The change package, part of the CDC’s Million Hearts initiative, is designed to help outpatient clinics put efficient and effective systems in place and presents a menu of options from which practices can select specific interventions to improve diagnosis and management of hypertension in pregnancy.
“We know a lot about hypertension and ways to address it in pregnancy, but a lot of those ways can be complicated and hard to implement in practice,” said Scott Hartman, M.D., co-author of the change package, as well as an associate professor of family medicine and maternity care coordinator of the Primary Care Network at the University of Rochester Medical Center. “This is a scientific guide, but also a very practical guide. It covers key foundations and concepts and then shifts to equipping care teams, population health management and then individual patient support. It’s a well thought out, systematic way to approach hypertensive disorders in pregnancy.”
Although the percentage of family physicians who deliver babies has declined in recent years, a 2021 report from the Robert Graham Center found that family physicians deliver up 230,000 babies a year and represent roughly 20% of the physician workforce that delivers babies.
Hartman said the change package offers tools and information that will be useful to most family physicians regardless of whether they deliver babies.
“We care for patients throughout their lifespan,” he said. “We have continuity of care with patients that many other specialists do not, so we see patients of reproductive age. We see pregnant patients, maybe not for pregnancy care, but for other types of care during pregnancy, and then certainly postpartum.”
Report Intervention Use
The CDC is seeking family physicians who are using, or plan to use, any of the interventions in the Hypertension in Pregnancy Change Package. If you plan to do so, please email MillionHeartsHPAF@cdc.gov and include “AAFP member HPCP commitment” in the subject line.
About one-third of hypertensive disorders of pregnancy are diagnosed postpartum, and the care package covers both postpartum counseling and establishing effective transitions of care.
“Traditionally there have not been great, warm handoffs,” Hartman said. “The change package talks about that, and it provides resources for family docs in the postpartum setting, which I think is a really critical piece for us as family docs. We need to develop more extensive handoffs from OB/Gyn and midwifery to family medicine.”
The change package also offers resources for outpatient care of pregnant women and women of reproductive age, including strategies related to
- identification of chronic hypertension in women of reproductive age and early pregnancy;
- early diagnosis of gestational hypertension and preeclampsia;
- prevention of preeclampsia with aspirin prophylaxis in patients at higher risk;
- prescription of antihypertensive treatment when indicated; and
- rapid escalation of care for severe hypertension in pregnancy.
The change package also offers resources for patients.
Hartman said patients are becoming more aware of maternal mortality and related issues following high-profile deaths like those of Chaniece Wallace, M.D., in 2020; Olympic athlete Torrie Bowie in 2023 and Kansas City Chiefs cheerleader Krystal Anderson earlier this year. All three women were Black and died due to complications related to pregnancy. Roughly one in five Black women and one in six American Indian/Alaska Native women have hypertension at delivery, and hypertension in pregnancy contributes to a higher proportion of pregnancy-related deaths among those patient groups.
The change package says that “Underlying factors contributing to these disparities include social drivers/determinants of health such as health care access and quality, and structural racism, including systemic racial bias within the health care system. Further, culturally informed, patient-centered and respectful care that addresses patient communication needs such as health literacy and language barriers can improve engagement and outcomes.”
Hartman said the change package puts an emphasis on “racial equity in general,” and also addresses the role family physicians can play in addressing systemic racism in medicine and in society.
In addition to the change package, Hartman encouraged his fellow family physicians to take advantage of the AAFP’s EveryONE Project, which offers CME and free resources related to addressing health equity, and the Academy’s 20-session, on-demand CME package, 4th Trimester: Optimizing Postpartum Care. He noted that visits at one to two weeks, and six to eight weeks postpartum are important for screening and detecting early postpartum hypertension.
“The fourth trimester is really an area that has not been addressed in health care traditionally,” he said. “It’s been sort of forgotten. There’s been all this emphasis on pregnancy and risk-assessment in pregnancy care, and then in fourth trimester care patients lose touch. Many patients don’t come to their fourth trimester visits. This is a huge area where family docs can really step in, and there is a model for that.”