1 Introduction
The postpartum period is a critical opportunity to engage in collaborative patient care that is focused on improving short- and long-term cardiometabolic outcomes. More than half of pregnancy-related deaths occur after the birth of the infant, and substantial morbidity arises in the early postpartum period.1,2 The first 2 weeks postpartum are a particularly high-risk period for severe cardiovascular maternal morbidity and hospital readmission for patients with and without preexisting heart disease.3 During these early weeks, approximately 60% of pregnancy-associated heart failure (HF) cases occur, and the risk of hemorrhagic stroke is increased by >4-fold, with marked racial and ethnic disparities seen in event rates across all major cardiovascular outcomes.4-6
Individuals at higher risk include not only those with cardiac conditions but also those with risk factors such as hypertension, obesity, and dyslipidemia as well as risk enhancers such as an adverse pregnancy outcome (APO) (ie, gestational diabetes, hypertensive disorders of pregnancy [HDP], and preterm birth). Pregnancy serves as a stress test imparting insight into future cardiovascular health. It also provides an opportunity to engage individuals who might otherwise have limited interaction with the medical system early in the life course to implement primary and secondary preventive strategies. The optimization of postpartum care in this at-risk population is a complementary and essential intervention to improve long-term health outcomes. As such, the American College of Obstetricians and Gynecologists (ACOG) identifies postpartum care as a “gateway opportunity” to individualize longitudinal care that is responsive to identified healthcare needs.7
The provision of comprehensive postpartum care is a key strategy to improve peripartum cardiovascular health and reduce inequities. Barriers to care during this vulnerable period are numerous and include navigating a fragmented healthcare system, scheduling challenges, travel limitations, lack of childcare, as well as frequent pediatric visits.8 Although a lack of access is often cited as a barrier to care, one study examined 431,969 commercially insured patients and found that 40% did not attend a postpartum visit within 8 weeks of discharge.9 Insufficient patient understanding of the importance of postpartum care and high out-of-pocket costs also discourage attendance. Further, racial and ethnic disparities in the receipt of postpartum care are influenced by structural racism and inequities in social drivers of health, such as housing, food security, language barriers, and healthcare system distrust.10
This document provides a recommended strategy for the optimization of postpartum care for patients with and at risk for short- and long-term cardiovascular disease (CVD). Understanding and following a structured approach to the provision of postpartum care for all individuals with or at risk for CVD is a crucial first step toward eliminating excess maternal morbidity and mortality (Figure 1).