Patterns of Postpartum Ambulatory Care Follow‐up Care Among Women With Hypertensive Disorders of Pregnancy

Abstract

Background Preeclampsia and gestational hypertension are hypertensive disorders of pregnancy (HDP) that identify an increased risk of developing chronic hypertension and cardiovascular disease later in life. Postpartum follow‐up may facilitate early screening and treatment of cardiovascular risk factors. Our objective is to describe patterns of postpartum visits with primary care and women's health providers (eg, family medicine and obstetrics) among women with and without HDP in a nationally representative sample of commercially insured women. Methods and Results We conducted a retrospective cohort study using insurance claims from a US health insurance database to describe patterns in office visits in the 6 months after delivery. We identified 566 059 women with completed pregnancies between 2005 and 2014. At 6 months, 13% of women with normotensive pregnancies, 18% with HDP, and 23% with chronic hypertension had primary care visits ( P <0.0001 for comparing HDP and chronic hypertension groups with control participants). Only 58% of women with HDP had 6‐month follow‐up with any continuity provider compared with 47% of women without hypertension ( P <0.0001). In multivariable analysis, women with severe preeclampsia were 16% more likely to have postpartum continuity follow‐up (adjusted odds ratio, 1.16; 95% CI, 1.2–1.21). Factors associated with a lower likelihood of any follow‐up included age ≥30 years, Black race, Hispanic ethnicity, and having multiple gestations. Conclusions Rates of continuity care follow‐up after a pregnancy complicated by hypertension were low. This represents a substantial missed opportunity to provide cardiovascular risk screening and management to women at increased risk of future cardiovascular disease.

Postpartum counseling in women with hypertensive disorders of pregnancy

“…16,17 There are also emerging data that follow-up with PCP in the 6 to 12 months after delivery is poor, even among women with conditions such as HDP and GDM identified during pregnancy. 18,19…”

Primary Care–Based Cardiovascular Disease Risk Management After Adverse Pregnancy Outcomes: a Narrative Review

“…Unfortunately, recommendations for CVD risk management after APOs are often unmet in primary care. Only about half of patients with medically complicated pregnancies see a PCC during the postpartum year, 15,16 and their PCC (in particular if they are an internist) is unlikely to identify and incorporate pregnancy history into CVD risk assessment. 17,18 In addition, follow-up after APOs is unequal across society.…”

“…17,18 In addition, follow-up after APOs is unequal across society. Hypertensive disorders of pregnancy are less likely to be followed by a primary care visit among Black or Hispanic versus White patients, 15 and are twice as likely to result in a hypertensive postpartum readmission among Black versus White patients. 58 Postpartum incident CVD is 3 times as common among individuals with public versus commercial insurance.…”

“…[1][2][3][4] The most common such APOs are hypertensive disorders of pregnancy, gestational diabetes, and preterm delivery, each affecting ~10% of pregnancies and associated with a doubling or more of 10-year CVD risk [1][2][3][4] (detailed descriptions in Table 1 [3][4][5][6][7][8][9][10][11][12][13][14] ). Despite the connections between APOs and future CVD, only half of patients see a primary care clinician (PCC) in the year after an APO, 15,16 and even fewer receive CVD risk counseling informed by their pregnancy history. 17,18 Missed opportunities to respond to CVD risk after pregnancy likely contribute to sex-based disparities in CVD diagnosis, management, and outcomes.…”

Differential Outcomes for African-American Women with Cardiovascular Complications of Pregnancy

“…After 60 days, women may become uninsured if they do not meet their state's income eligibility requirement [56]. Even among privately insured women with hypertensive disorders of pregnancy, who are at risk for cardiac complications after delivery and later in life, only 18% have follow-up with primary care providers within 6 months after delivery [57]. Low rates of provider follow-up are a missed opportunity to recognize early warning signs of new or worsening CV conditions, optimize risk factors prior to subsequent pregnancy, and discuss effective contraception especially for women with uncontrolled risk factors or high-risk cardiac conditions, in whom repeat pregnancy would confer significant risk.…”