Postpartum Cardiovascular Health Counseling Rates May Be Lacking in At-Risk Patients

Between 2016 and 2020, postpartum cardiovascular health (CVH) counseling modestly declined among individuals without cardiovascular disease (CVD) risk factors, according to research published in JAMA.

For individuals with CVD risk factors and adverse pregnancy outcomes (APOs), only 60% of individuals in the study said they received CVH counseling at their postpartum visit.

“The postpartum period is an opportune time when there is contact with the health care system, and counseling for CVH could potentially improve CVD-related outcomes during subsequent pregnancies and throughout the life course because individuals with poor CVH are more likely to experience subsequent APOs and CVD later in life,” the study authors said.

The study consisted of a serial, cross-sectional analysis of 2016-2020 data from the Pregnancy Risk Assessment Monitoring System (PRAMS) and included a nationally representative sample of 167,705 individuals who attended a postpartum visit between 4 and 6 weeks after delivery. The participants self-reported data on receipt of CVH counseling; self-reported prepregnancy CVD risk factors such as obesity, diabetes, and hypertension; and APOs such as gestational diabetes, hypertensive disorders of pregnancy, and preterm birth. Most surveyed participants were aged between 20 and 34 years (77.2%), had education beyond high school (67.4%), and were non-Hispanic White (60.2%). Additionally, 26.7% of participants were Medicaid beneficiaries who were between 2 and 6 months postpartum.

When divided into 3 categories—patients with 0, 1, or 2 or more prepregnancy CVD risk factors or APOs—the prevalence of self-reported postpartum CVH counseling declined for all 3 groups between 2016 and 2020.

Among those with no CVD risk factors, the prevalence dropped from 56.2% to 52.8%, with an average annual decrease of 1.4%. The prevalence of CVH counseling declined similarly for individuals with CVD risk factors. For those with 1 risk factor, the prevalence dipped from 58.5% to 57.3%, with an average annual decrease of 0.7%. For those with 2 or more risk factors, prevalence decreased from 61.9% to 59.8%, with an average annual decrease of 0.8%. Reported CVH counseling was slightly higher among individuals with 1 risk factor (relative risk [RR], 1.05; 95% CI, 1.04-1.07) and with 2 or more risk factors (RR, 1.11; 95% CI, 1.09-1.13) compared with those who had no risk factors.

Notably, individuals with a 2020 live birth were more likely to be aged 35 to 39, identify as non-Hispanic White, have higher education, and be enrolled in Medicaid. From 2016 to 2020, the percentage of participants with any prepregnancy cardiovascular risk factors increased from 27.2% to 30.7%, and from 22.3% to 26.1% for any adverse pregnancy outcome. More specifically, there was an increase in self-reported risk factors such as prepregnancy obesity from 23.3% to 27.5%, gestational diabetes from 8.0% to 10.1%, and hypertensive disorders of pregnancy from 9.7% to 12.3%.

Disparities related to social determinants of health were evident, as shown by differences in postpartum follow-up and self-reported CVH counseling. Those who did not attend postpartum visits or omitted responses about counseling and risk factors were more likely to be Hispanic or non-Hispanic Black, possess a high school education or lower, and lack private health insurance. Conversely, among those who attended postpartum visits, there was a slightly higher prevalence of self-reported counseling among individuals from these same demographic groups, regardless of the number of CVD risk factors they had. This finding lines up with prior research that has indicated delayed initiation of prenatal care among those identifying as non-Hispanic Black or having limited educational attainment.

According to the authors, the reasons behind the higher counseling rates among racial and ethnic minority groups and individuals with lower socioeconomic status may stem from clinicians being attuned to the impact of adverse social determinants of health on CVD risk and barriers to care. This may prompt clinicians to prioritize CVH counseling during postpartum visits, although more comprehensive data are essential for a deeper comprehension of these connections.

The authors also said it is possible that individuals attending postpartum visits were more inclined to emphasize and remember CVH counseling compared to those who missed their appointments. This potential bias could lead to an overestimation of self-reported CVH counseling, particularly among individuals from marginalized racial or ethnic backgrounds and those with lower socioeconomic standing.

“The postpartum visit can serve as an important opportunity to screen for cardiovascular risk factors, assess barriers to achieving ideal CVH, and refer to services and clinicians (ie, primary care clinicians, obstetricians, or cardiologists) that best meet a patient’s needs,” the authors said, noting that several gaps exist in the transition to long-term preventive care. “Utilization of the electronic medical record to promote physician communication, document APOs, and design clinical decision support tools may help promote successful care transitions.”

Reference

Cameron NA, Yee LM, Dolan BM, O'Brien MJ, Greenland P, Khan SS. Trends in cardiovascular health counseling among postpartum individuals. JAMA. 2023;330(4):359-367. doi:10.1001/jama.2023.11210