To improve maternal health, report says to start before pregnancy

By Laura Williamson, American Heart Association News

AnnaStills/iStock via Getty Images
(AnnaStills/iStock via Getty Images)

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A woman's heart health prior to becoming pregnant greatly affects her risk for pregnancy-related complications and the long-term cardiovascular health of both mother and child, according to a new report that calls for greater attention to the issue.

Improving maternal heart health during this critical period could help break the generational cycle of poor cardiovascular health that has become a growing problem in the U.S., particularly among women whose health is affected by structural racism and other adverse social conditions, according to a new American Heart Association scientific statement published Monday in Circulation.

"If you optimize the pre-pregnancy health of the mother, that optimizes her health during pregnancy, which affects the health of the child later in life," said Dr. Holly Gooding, vice chair of the statement writing committee. Gooding is medical director of adolescent medicine at Children's Healthcare of Atlanta and an associate professor in the department of pediatrics at Emory University in Atlanta.

Cardiovascular disease accounts for more than 1 in 4 pregnancy-related deaths in the U.S., and rates of pregnancy-related complications have been climbing, according to the report. Nearly 1 in 5 pregnancies are complicated by high blood pressure, gestational diabetes, premature births or low birthweights. High blood pressure disorders such as preeclampsia and eclampsia have nearly doubled over the past decade. These types of adverse pregnancy outcomes have been shown to raise the risk for cardiovascular disease later in life for both mother and child.

Studies show Black women are disproportionately affected. As pregnancy-related deaths in the U.S. have been rising, Black women face triple the risk of dying from pregnancy-related complications than white women.

"This statement looks upstream at what the potential contributors to that rising burden may be," said Dr. Sadiya Khan, writing committee chair and an assistant professor of medicine at Northwestern University Feinberg School of Medicine in Chicago.

The new AHA report summarizes current evidence linking a woman's heart risk factors before and between pregnancies to pregnancy-related complications and the subsequent cardiovascular health of mother and child. It calls for investigating more ways to improve women's health throughout the childbearing years, starting in early childhood. And it emphasizes the need for policy-level changes to dismantle structural racism and other adverse social factors that create barriers to better maternal health.

"Identifying ways to intervene and equitably promote health is critical," Khan said.

A 2021 AHA scientific statement addressed cardiovascular health among pregnant and postpartum women. The new statement focuses on a woman's health prior to becoming pregnant and between pregnancies.

Because a woman can get pregnant unexpectedly, the writing committee chose to define pre-pregnancy broadly, as any time during her childbearing years, Gooding said. For most women, that period is between ages 15 and 44, though it varies by individual.

"We avoided defining it on purpose, because that's something further study needs to address," Khan said. "When is the opportune time prior to pregnancy to intervene? On a population and public health level, we want to take a life-course perspective on this, begin focusing on prioritizing cardiovascular health at that time when a person comes of reproductive age."

The best way to achieve good heart health – at any age – is by following the key health measures and behaviors set forth in AHA's Life's Essential 8, Khan said. These include not smoking, getting enough sleep and physical activity, maintaining a healthy weight, eating a healthy diet and controlling blood pressure, blood glucose and cholesterol levels.

But the responsibility for helping women achieve those goals has to include health care professionals and policymakers, she said. Ensuring women have access to primary care throughout the life course, including before they are interested in becoming pregnant, as well as access to insurance to cover pregnancy prevention and pregnancy-related care, is critical. Having enough doctors to see them and making sure their cardiovascular risk factors are monitored also matters.

"It's a natural conclusion to say we should all prioritize cardiovascular health, but it's important we not put the onus just on the individual," Khan said.

The statement says future research should focus on finding evidence-based strategies to reduce maternal health risks and how such strategies might reduce the burden of cardiovascular disease more broadly.

Khan said some of this work has already begun.

She's a co-investigator in the AHA's Health Equity Research Network on Disparities in Maternal-Infant Health Outcomes, which is looking at innovative and cost-effective strategies for improving access to health information and care before, during and after pregnancy for Black and Native American women and those living in rural areas.

In 2021, the federal Office of Minority Health launched a free e-learning program to build maternal health care professionals' knowledge and skills related to cultural competency. And last year, the White House published a blueprint for addressing maternal health that includes efforts to strengthen economic and social supports for women before, during and after pregnancy. It also includes programs to reduce high blood pressure for Native Americans and veterans of childbearing age.

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