Hypertension during pregnancy increases the likelihood of harm to mother and baby, including a higher lifetime risk of heart disease and stroke. Most pregnancy-related deaths stemming from hypertension are preventable, however.
Identifying a physician who’s responsible for continuity of care ensures timely diagnosis and treatment of hypertension during pregnancy, which happens in about 16% of hospital deliveries. The AMA is collaborating with other organizations on quality improvement guidance to help clinicians optimize care for patients with this condition.
The “Hypertension in Pregnancy Change Package,” which was developed by the Centers for Disease Control and Prevention (CDC), offers a variety of evidence-informed implementation strategies and corresponding tools practices can use to better diagnose and manage this condition during pregnancy and the postpartum period.
The change package includes tools and resources for any physician or health professional who cares for people who are pregnant or in the postpartum period. This includes: ob-gyns, family doctors, internists, cardiologists, endocrinologists, emergency physicians, nurses, medical assistants, nurse practitioners, physician assistants and pharmacists.
Michael Rakotz, MD, a family physician who is the AMA’s group vice president for improving health outcomes, said the Association supports key strategies that the change package covers. These include:
- The diagnosis and treatment of hypertension.
- The prophylactic use of aspirin to reduce preeclampsia and related complications.
- The use of self-measured blood pressure monitoring that can help individuals and their care teams detect and manage hypertension in a timely way.
- Postpartum counseling on long-term cardiovascular risk.
Women need counseling on the importance of getting follow-up care after giving birth. Rates of follow-up visits after delivery are historically low, however, resulting in missed opportunities to identify and address cardiovascular risk.
“It is important to incorporate strategies for postpartum-risk counseling and continued long-term monitoring of women with conditions that arise during pregnancy, including hypertension,” Dr. Rakotz said.
The AMA has a long history of supporting hypertension management in primary care settings. AMA MAP™ Hypertension is an evidence-based quality improvement program that provides a clear path to significant, sustained improvements in BP control. With the AMA MAP program, health care organizations can increase BP-control rates quickly. The program has demonstrated a 10% increase in BP control in six months with sustained results at one year in primary care settings.
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Give care teams the right tools
The change package is a product of Million Hearts, a national initiative co-led by CDC and the Centers for Medicare & Medicaid Services to prevent acute cardiovascular events. It was developed in partnership with AMA, American Academy of Family Physicians, American College of Nurse-Midwives, American College of Obstetricians and Gynecologists, American College of Osteopathic Obstetricians and Gynecologists, National Association of Nurse Practitioners in Women’s Health, and the Society for Maternal-Fetal Medicine.
The change package encompasses these four areas.
Key foundations. Outlines ways to change fundamental policies and processes at the practice level, such as identifying a clinical champion to make hypertension in pregnancy a practice priority. There’s also a section on respectful and culturally safe care.
“This is probably the best place to focus initial quality improvement efforts,” said Hilary K. Wall, MPH, CDC’s senior scientist for Million Hearts.
Equipping care teams. Details strategies related to training and preparing clinicians and other care team members to focus on hypertension in pregnancy.
“This includes supporting the use of appropriate labs and medications and supporting accurate blood pressure measurement,” said Wall.
Population health management. Outlines approaches to proactively monitor and manage hypertension in pregnancy on panels of patients, such as finding potentially undiagnosed chronic hypertension and using practice data to drive improvement.
Individual patient supports. Lists ways that practices can support individual patients at the point of care to better manage their hypertension.
“We’ve included a robust section on assessing and addressing the social drivers of health in this change package,” said Wall.
Inequities in hypertension in pregnancy
Hypertension in pregnancy doesn’t affect everyone equally, noted Dr. Rakotz.
“Underlying factors such as health care access and quality, availability of nutritious affordable food, safe places to be physically active, and structural racism—including systemic racial and gender bias within the health care system—contribute to disparities,” he said.
One in five Black women and one in six American Indian or Alaska Native women have hypertension during deliveries. The prevalence of hypertension in pregnancy is also higher for women who are 35 or older, live in the South and Midwest, rural counties or in areas with the lowest median household income.
The Hypertension in Pregnancy Change Package (HPCP) “allows clinical teams to focus on the strategies that will offer the greatest impact as they support and care for the specific needs of their patients,” said Dr. Rakotz.
“By contributing to the Million Hearts HPCP, the AMA hopes to be a part of the solution when it comes to improving care for patients with hypertension during pregnancy,” said Dr. Rakotz.
Starting this summer, the Million Hearts Hypertension in Pregnancy Action Forum will offer an opportunity for clinical, public health, and community-based partners to exchange best and promising practices, identify solutions to common obstacles, and share resources related to improving hypertension management for women during and after pregnancy.
Those interested in taking part should email [email protected] and include “Join MH Action Forum” in the subject line.
