Promoting maternal heart health for one, for all
Nanette K. Wenger, MD, emphasizes the urgent problem of maternal mortality and shares her expert advice on public education, access to care and CVD management during and after pregnancy.
Many people are familiar with the adage: “Happy wife, happy life.” Nanette K. Wenger, MD, FAHA, is ready to establish a new one in a similar vein: “Healthy mom, healthy baby, healthy family, healthy community.”
Wenger is widely regarded as the trailblazer for women’s heart health, and she knows better than anyone, perhaps, how dire maternal mortality rates are nationally and internationally.
“Maternal mortality in the United States is far higher than in any industrialized country, and a substantial portion of that is cardiovascular. That is why at the American Heart Association, we’re so concerned about maternal mortality,” said Wenger, who is professor emeritus of medicine in the division of cardiology at the Emory University School of Medicine, a consultant to the Emory Heart and Vascular Center and founding consultant to Emory Women’s Heart Center in Atlanta.
In fact, the Heart Association released a new toolkit in October, “Advancing Maternal Heart Health: Closing the Gaps in Cardiovascular Care,” that addresses this challenge and provides a pathway for health professionals to care for pregnant women during this critical time. Wenger shared highlights from this and other available resources and research in session Sunday’s session, “Pioneering Progress in Maternal Heart Health: Research, Risk and Response Across Borders.”
Establish, extend and unite care
Wenger said the high maternal mortality rate in the U.S. stems from poor heart health of too many women before pregnancy. In her early days of practicing medicine, she said the study of heart disease in women was nonexistent and pregnancy was a natural part of a woman’s life. Fortunately, this viewpoint has evolved, but cases of cardiovascular complications in pregnancy are still widely underrecognized and undertreated.
“I think both patients and providers are not aware of the long-term consequences both for the mother and for her offspring,” she said.
Training in cardio-obstetrics is excellent, but the buck doesn’t stop there. Wenger said the maternal health crisis demands attention at every level of health care, particularly within primary care, because family physicians, nurse practitioners and physician assistants are frequently the ones treating pregnant women in rural or impoverished communities.
“It’s a team that’s involved in the care of the pregnant patient, and every one of them should be aware of the importance of maternal heart health,” she said.
In her keynote presentation, “The Fourth Trimester of Pregnancy — Challenges and Opportunities,” Wenger stressed the need to bridge the gap among health care professionals and across a woman’s maternal journey. This includes additional investment in the “fourth trimester” — the critical three-month period after delivery.
“Intensive care during the fourth trimester is really important,” she said. “The standard six-week checkup is good for women who had an ostensibly normal pregnancy, but if there have been complications in pregnancy, the women must be seen earlier and more intensively.”
At Emory, cardiologists attend postpartum appointments for women with preeclampsia to establish contact and transition care. It’s no longer acceptable to stop treating a pregnant woman at time of delivery, she said.
“Women who’ve had preeclampsia are more likely to develop risk factors such as diabetes, high cholesterol, high blood pressure, etc., even during their reproductive years,” Wenger said. “We’ve also learned that their babies are at increased risk of developing risk factors earlier in life.”
Prepare, prevent and educate
The biggest challenges in improving maternal mortality are public and patient education and access to health care, Wenger said. Many women, especially those with low income or who are members of historically excluded racial/ethnic groups, may arrive at the hospital at the time of delivery without having received peripartum care. Being pregnant with an already diminished state of health increases a woman’s risk of complications during and after pregnancy.
The bulk of maternal cardiovascular complications are avoidable but go unnoticed — for instance, hypertension has been overlooked because it’s asymptomatic during pregnancy, Wenger said. This improved once the U.S. Preventive Services Task Force released its recommendation to measure blood pressure at every obstetrical visit.
There is also scientific evidence that low-dose aspirin taken throughout the second and third trimesters by women at high risk of preeclampsia significantly lowers that risk, Wenger said.
“More recently, there has been an exciting study organized by OBGYNs in cooperation with cardiologists showing that more aggressive lowering of elevated blood pressure during pregnancy is associated with better outcomes both for the mother and the baby,” she said.
Women need more heart health education, Wenger noted, including how to practically achieve the association’s Life’s Essential 8™ — a checklist for lifelong health — whether they are pregnant, may get pregnant or have been pregnant, especially with complications.
“A woman who goes home from the hospital after delivery has all kinds of stress, and a lot of her attention goes into caring for the baby, but she also needs to care for herself,” Wenger said. Postpartum women need to eat and drink healthfully, avoid smoking, prioritize sleep, strive for an ideal weight and regularly monitor blood pressure, blood sugar and blood lipids, she said. Women may also be able to find exercise classes that allow new mothers to work out with their babies.
Wenger also wants communities to become more involved in the fight to prevent maternal deaths and improve women’s heart health. Countries throughout Central and South America dedicate a day, known as Corazón de Mamá (A Mother’s Heart), to educating women on cardiovascular health. The American Heart Association works with InterAmerican Heart Foundation and the Inter-American Society of Cardiology to support local advocacy, provide public education, programming and resources to promote heart health. Some countries provide government support for these educational efforts, Wenger said.
Extending postpartum health insurance coverage from six weeks to a minimum of three months is another change that would make a significant impact on maternal heart health. In her home state of Georgia, Wenger said women on Medicaid currently have 12 months of health insurance coverage after delivery. Efforts such as the association’s Research Goes Red, and resources like the new maternal health toolkit and guides from other organizations, including the American College of Cardiology and American College of Obstetricians and Gynecologists, also go far in educating health care professionals — who can pass along their knowledge in treating patients.
“The biggest takeaway is we really have to pay attention to the woman after pregnancy to be sure about her heart health and to see that she stays healthy,” Wenger said.
The session concluded with additional discussions on collaborative efforts to reduce maternal mortality as well as a moderated panel that shared insights and solutions to improve heart health for mothers, their babies, their families and their communities around the globe.
