Maternal morbidity and mortality rates are considerably higher in the United States than in most peer nations. A troubling gap in the care of postpartum women is likely an important contributor to the problem.

After their six-week postpartum visit with an obstetrician, a woman should transition to a primary care provider for their ongoing care. Too many patients do not do so, as caring for their newborn, returning to their job, or managing the rest of the family can be all-consuming. They may not see a doctor again until their first visit with an obstetrician for their next pregnancy.

For all women, but especially for those following a complicated pregnancy, this gap in care can create a risky situation. Someone who developed hypertension during pregnancy, for example, has a heightened risk for later-onset hypertension, stroke and kidney damage, and readmission to the hospital.

Failing to receive primary care before the next pregnancy represents a missed opportunity, says obstetrician Louise E. Wilkins-Haug, MD, PhD, director of Maternal-Fetal Medicine and one of the clinical leads at the Center for Connected Postpartum Care at Brigham and Women’s Hospital.

“Our center is highlighting this period between pregnancies, when women often fall out of care but could be taking steps to optimize their health, their next pregnancy, and also potentially avoid lifelong complications,” says Dr. Wilkins-Haug, who has spent over 30 years in high-risk obstetrics. “During those two or three years between pregnancies, getting elevated blood pressure under control and managing glucoses and their lipids will set them up for fewer challenges in the next pregnancy.

“We want to engage with women around their care through the immediate postpartum period and then get them back into primary care.”

Targeting Hypertension, Diabetes, and Surgical Complications

Dr. Wilkins-Haug was part of the team that launched the Center for Connected Postpartum Care in March 2023. At the center, experts in maternal-fetal medicine, surgical obstetrics, and internal medicine collaborate to improve care access in the first year following a high-risk pregnancy and to optimize maternal health between pregnancies as well as over the long term.

The center primarily concentrates on individuals with the highest chance of recurrent pregnancy risk and those with greater long-term health morbidity. Leadership identified three areas that could benefit from increased attention in the first year postpartum: hypertension, diabetes, and surgical complications often related to placenta accreta spectrum. Each of the three resulting programs has an obstetric and a medical/surgical lead who partner on the patient’s care with assistance from nursing staff, physician assistants, and a population health coordinator.

The center also coordinates for these individuals important cross-program services such as mental health support, lactation consultation, and family planning referrals.

At the Brigham, Dr. Wilkins-Haug says, obstetrics has partnered with internal medicine to provide co-located prenatal care for women with chronic medical conditions for almost two decades. Extending this concept into the postpartum year is a natural progression.

“For instance, we have very robust programs with endocrinology, neurology, cardiology, and rheumatology, where specialists cross over to provide joint care for women during pregnancy,” she says. “Now we’re taking that idea and applying it to individuals with hypertension, diabetes, and surgical complications postpartum. Having a multidisciplinary approach has been key for our prenatal care, and it’s important for our postpartum care, too.”

Patients Play a Role in Managing Their Hypertension

Hypertension is the most advanced of the Center for Connected Postpartum Care’s three programs, having served roughly 250 patients since its launch in spring 2023.

Endocrinologist Ellen W. Seely, MD, the center’s medicine lead, has partnered with Dr. Wilkins-Haug in co-managing patients with hypertensive pregnancies for over 15 years. An active collaborator with the center is the longstanding Maternal Cardiometabolic Clinic, which is run by primary care physician Ann C. Celi, MD, and addresses the urgent needs of the most ill individuals after hypertensive disease of pregnancy.

As Dr. Seely notes, hypertension comes in various forms that can put patients at risk, such as chronic hypertension, hypertension that came on during pregnancy, chronic hypertension that worsened during pregnancy, and new hypertension that developed following a delivery.

“Let’s say a patient’s blood pressure medications that they were discharged on can be tapered down after their six-week visit,” Dr. Seely says. “Someone needs to oversee that. And it has to be someone who will be comfortable changing medications in a patient who is breastfeeding and remembering that the postpartum period is potentially a runup to another pregnancy where she may have the same pregnancy complications. That’s something we can offer.”

The center has had success in providing hypertensive patients with blood pressure cuffs and monitors through the Home Safe program. Patients receive training on taking their blood pressure at home and then send in results electronically. A population health coordinator, registered nurse, and physician team reviews the results, can adjust medications, and provides feedback to the patient in a timely manner. Utilizing digital communication and virtual visits continues the provider-postpartum person’s connection without the barriers of an in-person visit with a newborn.

“It’s been very encouraging to see how engaged postpartum individuals have been in taking and reporting their blood pressures,” Dr. Wilkins-Haug says. “Having the individual at home participate in their care along with the physician changes the paradigm. It’s not just about coming to see me in the office—it’s an ongoing process in which the patient regularly engages with the office as we help them come out of pregnancy and transition into primary care.”

Built around a structure of both virtual and in-person visits, the center is incorporating home-generated health data and virtual care to redesign care between pregnancies.

Aiming to Transform the Care of Postpartum Women

Research is critical to the Center for Connected Postpartum Care’s mission. One area of focus is implementation—”assessing whom the center isn’t reaching, who isn’t engaging, and whether there’s a better way to do all that,” according to Dr. Wilkins-Haug. Work is also underway to explore how best to risk stratify individuals across all three programs.

In addition, Dr. Seely notes, “We are working to determine the best timing to evaluate risk for cardiovascular disease in women who have had a pregnancy complicated by new-onset hypertension or diabetes with the goal of future disease prevention.”

Through research and clinical care, Drs. Wilkins-Haug and Seely hope the center will help lead the way in transforming the care of postpartum women at both academic medical centers and community hospitals nationwide.

“Our goal is not to have an obstetrics-internal medicine team manage these high-risk patients for two years,” Dr. Wilkins-Haug says. “Our goal is to develop pathways and algorithms that physicians in the community can use to determine what they need to do to get these patients back into primary care.”