Comprehensive Postpartum Management for Women with Hypertensive Disorders of Pregnancy

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SUMMARY Hypertensive disorders of pregnancy (HDP) - chronic hypertension, gestational hypertension, preeclampsia, HELLP, and eclampsia - account for a substantial portion of severe maternal morbidity and mortality in the U.S. and occur 2.5 times more frequently among Black compared to non-Black patients. The weeks after birth are crucial for maternal health, especially considering that half of all pregnancy-related deaths occur postpartum. The American College of Obstetricians and Gynecologists recently redefined postpartum care to encompass 12 months after birth and stressed the importance of connecting postpartum patients to primary care clinicians to manage chronic medical conditions. This handoff is critical as 50% of patients with HDP develop chronic hypertension, and patients with HDP have twice the risk of later cardiovascular-related death. In line with this recommendation, Tennessee recently expanded Medicaid coverage to 12 months postpartum. Given that most obstetric clinicians currently do not provide comprehensive primary care, we urgently need models for bridging gaps in care after pregnancy especially for medically vulnerable patients. While interventions such as telemedicine and peer navigation demonstrate promise to improve patient engagement in care and reduce postpartum racial disparities, no randomized trials address system-level initiatives to improve postpartum care for patients with HDP. We propose to build a comprehensive management program for postpartum patients with HDP who are at risk of severe maternal morbidity and mortality. Using a community-engaged approach, we will tailor this program to Black patients who represent a disproportionate share of those affected by postpartum HDP. This program emphasizes three key components: 1) self-monitoring of blood pressures, 2) blood pressure management navigation, and 3) facilitated transition to primary care clinicians for hypertension management. Our multidisciplinary team, including maternal-fetal medicine specialists, certified nurse midwives, program navigators, and social workers will accomplish our specific aims to: 1) conduct rigorous patient engagement that identifies barriers and facilitators to postpartum hypertension care especially among Black patients 2) conduct rigorous clinician engagement that uncovers barriers and facilitators to postpartum hypertension management, and 3) perform a pilot randomized trial comparing usual postpartum care to our comprehensive HDP management program. We hypothesize that our intervention will increase patient engagement with blood pressure monitoring, identify more patients with severe-range blood pressures, and reduce disparities in outcomes between Black and non-Black patients. Our work directly advances integrated models of care using community-engaged research among populations who bear a disproportionate burden of severe maternal morbidity and mortality. The results will produce stakeholder-informed outcomes and key parameter estimates for conducting a robust multicenter trial.