An Action Plan for Hypertension in Pregnancy

There’s both tragedy and recognition in the recent headlines that highlight the rise of Black maternal mortality and morbidity in the U.S., and the role of hypertensive disorders of pregnancy (HDP). Preeclampsia and related hypertensive disorders of pregnancy affect 5-10% of all pregnancies here in the U.S., and Black women are 60% more likely to develop it compared with non-Hispanic white women. We have listened to the experiences of Black women in our community for years, sharing the frustrating truth that their pregnancy and postpartum care is often delayed, their diagnoses denied, and their voices dismissed.

Women’s health nurse and patient advocate Crystal Jackson, RN, MS, MPA, understands this risk all too well — she has experienced preeclampsia in all four of her pregnancies. During her first pregnancy as a 21-year-old nursing student, Jackson realized that her severe headache and blurry vision felt like more than “normal” pregnancy complaints. After taking her own blood pressure at a nearby pharmacy and seeing a reading of 205/110, she and her partner rushed to the emergency department. What she thought would be an overnight stay for observation turned into an emergency c-section at just shy of 34 weeks pregnant.

“This experience changed the way I thought about my body and women’s health in general,” Jackson told us. “I could not fathom how quickly things took a turn for the worse and that I could have lost my life or my baby’s, but the fact of the matter is that preeclampsia kills mothers and babies every day … and the risk is higher for Black women like me.”

There’s been some progress: the 2020s have seen racial disparities in maternal health come into the spotlight, with increased attention to changing healthcare outcomes through data analysis and systemic healthcare improvement like patient safety bundles. As our nation examined its own poor record with inequity, we asked ourselves, “How can we, as providers and patient advocates, take the next step to meaningfully improve outcomes for Black women and their families specifically related to hypertensive disorders of pregnancy?”

That’s where the Racial Disparities Task Force began — a group of maternal health equity thought leaders from research, community based organizations, clinical experience, and lived experiences who came together to build a roadmap for how to address the unacceptably high rates of hypertension-related maternal mortality and morbidity in Black women.

The Racial Disparities Task Force Action Plan, published last month in the Journal of Racial and Ethnic Health Disparities, emphasizes strategic priorities for improving outcomes in Black women who experience hypertensive disorders of pregnancy — some of which were already underway, while others needed more focus and additional funding and resources. While some of these recommendations — which are centered around community engagement, improving healthcare practices, and catalyzing research — may feel like common sense, they attempt to address serious gaps in the way that Black women in the U.S. experience care. The report emphasizes an important fact about racial inequity in preeclampsia care: we cannot do this alone.

The Action Plan builds from the experiences of real women like Jackson, calling upon healthcare providers, healthcare systems, non-profit organizations, and other stakeholders to look deliberately at these actionable strategies within their own programs:

1. Manage patients’ chronic hypertension. Don’t normalize hypertension, even if it’s prevalent in the patients and families you serve.
2. Prescribe low-dose prenatal aspirin for those with two or more moderate risk factors for preeclampsia. Discuss ways to remove stigma or other barriers to adherence.
3. Improve postpartum follow-up with remote patient monitoring, home blood pressure cuffs, social and structural determinants of health screening, and mental health support.
4. Engage Black women and birthing people, their communities, and the scientific community in research; encourage them to participate in research, especially for maternal health.
5. Support Black researchers in their efforts to develop research careers and lead HDP research.
6. Shift the research agenda for HDP management towards precision medicine strategies such as studying variances in hemodynamics and pharmacogenetics.
7. Partner with trusted community organizations and HDP survivors who have established relationships to address these and other strategies.
8. Challenge ourselves to look at our own internal and external practices, and how intentionally we have addressed representation strategies within our own spheres of control.

Ending racial inequity in the U.S. will require all parties to bring intention to their work, beyond simply having women of color in their care or communities. We must involve patients in every step of care to ensure their voices are heard.

The recommendations from the Racial Disparities Task Force emphasize important strategic priorities, and call for action to listen to and amplify the voices and experiences of Black women. They also emphasize the importance of engaging Black women’s communities and fostering collaboration across different sectors to improve healthcare practices and advance necessary research to further diagnosis, treatment, and find a cure. If you, like us, care deeply about ensuring that every woman and her baby makes it safely through preeclampsia, you’ll help us take the next steps to make this action plan a reality.

Cornelia Graves, MD, is a high-risk ob/gyn and maternal-fetal medicine subspecialist with Tennessee Maternal Fetal Medicine, and member of the Preeclampsia Foundation’s Medical Advisory Board and Racial Disparities Task Force. Eleni Tsigas is CEO of the Preeclampsia Foundation and a two-time preeclampsia survivor.

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