We are pleased to have the opportunity to express our views regarding the Agency for Healthcare Research and Quality’s (AHRQ) draft comparative effectiveness review on the Management of Postpartum Hypertensive Disorders of Pregnancy.
The National Center for Health Research (NCHR) is a nonprofit think tank that conducts, analyzes, and scrutinizes research on a range of health issues, with a particular focus on which prevention strategies and treatments are most effective for which patients and consumers. We do not accept funding from companies that make products that are the subject of our work, so we have no conflicts of interest.
The abysmal maternal mortality rate and its striking racial disparities in the U.S. must be addressed. Approximately 53% of maternal deaths occur postpartum – between one week and one year after delivery.1 Of these, about 6.5% are caused by hypertensive disorders of pregnancy. Data on 1,018 pregnancy-related deaths among residents of 36 states from 2017 to 2019 found that 84% of these deaths were preventable.
We applaud the AHRQ for completing this comprehensive review to help healthcare providers and policy-makers develop clinical practice guidelines that are designed to enhance care for women during this critical period. This review highlights the importance of the postpartum period in the health of women and children. According to the American College of Obstetricians and Gynecologists (ACOG), postpartum care should be considered an ongoing process rather than an isolated visit. We agree with ACOG that “the lack of policies substantially benefitting early life in the United States constitutes a grave social injustice: those already most disadvantaged in our society bear the greatest burden.”2
The review focuses on practical issues regarding the effectiveness of home blood pressure monitoring and diuretics, as well as the best regimens for magnesium sulfate use for pre-eclampsia. The agency points out the need for additional quality research into the comparative benefits and harms of both commonly-used and alternative antihypertensives, the impact of home blood pressure monitoring on clinical outcomes, and the best use of magnesium sulfate to reduce side effects and toxicity. The comparative review found mixed outcomes across studies, many studies with a short duration of follow-up, and too few studies to draw conclusions about long-term effects.
We are encouraged by the agency’s conclusion that home blood pressure monitoring may be beneficial. During the COVID-19 pandemic, many healthcare providers turned to at-home patient monitoring tools to keep track of vital patient information without requiring in-person office visits. AHRQ found that home blood pressure monitoring not only improves the likelihood that patients will check their blood pressure but also helps reduce racial disparities in adherence to recommended blood pressure surveillance. For example, one randomized controlled trial of a text-message-based blood pressure surveillance program found that the blood pressure measurement and reporting rate was over 90% for Black and non-Black women – representing a 50% absolute reduction in racial disparity.3 Of the 103 women in each arm of the trial, no women in the treatment arm required hospital readmission, compared to four women in the control arm. Therefore, we urge policymakers to use these findings to make home blood pressure monitoring accessible to a wider range of patients. This may mean requiring insurers to extend postpartum medical coverage for a longer period of time and ensuring that medical devices are covered for postpartum women.
NCHR appreciates the opportunity to comment on AHRQ’s review. We are encouraged by the focus on the important issue of maternal mortality and look forward to seeing a meaningful response by policymakers.
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- Trost S, Beauregard J, Chandra G, et al. Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US States, 2017-2019.
- McKinney J, Keyser L, Clinton S, Pagliano C. ACOG Committee Opinion No. 736: Optimizing Postpartum Care. Obstetrics & Gynecology. 2018;132(3):784. doi:10.1097/AOG.0000000000002849
- Hirshberg A, Sammel M, Srinivas S. Text message remote monitoring reduced racial disparities in postpartum blood pressure ascertainment. American Journal of Obstetrics and Gynecology. 2019;221(3):283-285. doi:https://doi.org/10.1016/j.ajog.2019.05.011