We owe our lives to our mothers. Yet, in many ways, the American healthcare system is failing to care for them beyond pregnancy.
The American Heart Association (AHA) and College of Cardiology know that pregnancy-related complications can indicate a heightened risk of serious chronic illness, such as heart disease, the leading cause of death for women in the United States. However, few mothers who’ve battled—and overcome—pregnancy complications receive the recommended testing and preventative care that could save their lives in the years following delivery.
Despite updated guidelines to document and follow-up on pregnancy-related complications through ongoing primary care, an enormous gap still exists. A wide range of barriers prevent internists and family medicine providers from using maternal health complications as a window into future health outcomes. As a result, Ellen Seely, MD, director of clinical research for Brigham and Women’s Hospital, suggests that one of the most promising ways to bridge this chasm is to educate women directly using technology that fits into their often busy and chaotic lifestyles as moms.
The Current State of Maternal Health in the U.S.
The United States is one of the most affluent countries in the world but maintains the highest maternal mortality rate among 11 developed countries. The data is even more staggering for Indigenous and Black women who are three and a half times more likely to die from pregnancy complications than white mothers. The timing of deaths extends beyond the period during which a woman receives pregnancy care, with nearly 12 percent of the deaths occurring up to one year following delivery, according to the Centers for Disease Control and Prevention (CDC). When healthcare providers fail to correlate pregnancy-related complications with a higher risk for heart disease in the future, more women may die preventable deaths.
On average, pregnant women attend anywhere from seven to twelve prenatal visits to ensure both the mother and the baby are healthy. Moms who experience unexpected health conditions can expect to see their doctor more frequently to minimize the likelihood of early delivery or fatal complications. But, six weeks after the baby is born, maternity care (and health insurance coverage) often ends without a seamless hand-off to ongoing primary care that protects the mother’s health throughout her life.
Pregnancy-related Complications as Predictors of Future Health Issues
In the 1970s, medical reports began linking gestational diabetes and preeclampsia to future cardiovascular disease. Studies showed that gestational diabetes, which currently affects up to nine percent of the U.S. pregnant population, predicts up to a 60 percent chance of a woman developing type 2 diabetes in the next five years when she’s obese. Shortly after, parallel literature revealed similar findings for women who experienced preeclampsia, a hypertensive disorder, during pregnancy. However, it wasn’t until 2011 that the AHA updated evidence-based care mandates to consider a history of pregnancy-related complications as risk factors for heart disease, just like smoking or a family history of heart disease can serve as predictors.
The American Diabetes Association recommends annual screening for anyone who had gestational diabetes to ensure that signs of type 2 diabetes are caught early and addressed before health conditions worsen. If screenings are normal, screening intervals can increase to every three years, but no more than that. But, data from an academic medical center suggests that up to 50 percent of women who have gestational diabetes during pregnancy aren’t screened for type 2 diabetes in the primary care appointments that follow. Without these screenings, many women with a history of pregnancy complications and a higher risk for heart disease are flying under the radar.
The correlation between heart-related pregnancy complications and future heart disease provides a significant opportunity for primary care providers to educate and intervene with preventative lifestyle changes that can reduce the risk of diabetes by over 50 percent. Yet many healthcare providers are still unaware of the link and neglect to document and use pregnancy complications for risk stratification. The consequences can be disastrous for families and society at large.
The Disconnect Between Obstetric and Primary Care
Primary care services are essential to yielding positive health outcomes for women and promoting health equity throughout every stage of life. But, because pregnancy is typically viewed as an isolated event in a woman’s life, it’s rarely used by primary care providers as an indicator of future health outcomes.
Obstetricians are responsible for caring for the mother during pregnancy complications, and a great deal of funding goes into programs that help to educate and care for women during pregnancy. On the other hand, primary care providers are responsible for monitoring the risk of heart disease and intervening to prevent worsening health conditions. This siloed approach to care often results in a fragmented hand-off.
While gestational diabetes and preeclampsia affect one in ten pregnant women, Dr Seely’s research concludes that women are not commonly asked about their pregnancy history during primary care appointments. Part of the problem is inadequate provider education and training in women’s health, as less than 30 percent of medical schools teach from the curriculum with embedded gender-specific topics.
The gap between obstetric care and primary care also exists as a result of the following factors, among others:
- Inconsistent primary care relationships, as 20 percent of adult women don’t have a primary care provider
- Underutilization of primary care services, as new mothers have a high no-show rate in the postpartum years when they’re the primary caregivers of young children and/or obligated to professional commitments
- Time constraints for the provider, as most appointment visits are 15 minutes or less with little time to prep beforehand
- Primary care provider shortages nationwide, especially in rural areas
- Racial and ethnic disparities, with women’s health services being poorly resourced and underfunded in communities of colour