Keywords
hypertension - postpartum - remote monitoring - telehealth - blood pressure - COVID-19
The novel coronavirus disease 2019 (COVID-19) pandemic is rapidly increasing the use
of telehealth and remote patient monitoring. To promote social distancing, health
care providers are reducing nonessential outpatient visits and replacing face-to-face
visits with virtual ones. Prior barriers to use these technologies are being addressed
at the state and national levels as part of pandemic response. Given the concurrent
crisis of increasing maternal mortality rates, postpartum women are an important population
who stand to benefit from the innovative transformations in health care service delivery
during COVID-19.
Postpartum follow-up is an essential component of pregnancy care, as half of all maternal
deaths occur after delivery.[1] Hypertensive disorders accounted for 6.9% of maternal deaths in the United States
between 2011 and 2016, and more than 60% of deaths due to gestational hypertensive
disease occur during the first 6 weeks postpartum.[1] However, only 52% of women with severe pre-eclampsia attend their 6-week postpartum
follow-up, and of those who are able to access postpartum care, one in five is persistently
hypertensive.[2] Shifting from a strategy of in-person office visits to televisits in response to
the COVID-19 pandemic may actually increase access to postpartum follow-up among women
with hypertensive disorders of pregnancy.
The American College of Obstetricians and Gynecologists (ACOG) established guidelines
for appropriate health care delivery during the COVID-19 pandemic, emphasizing virtual
visits, remote patient monitoring, and mobile health care (grouped together as “telehealth”).[3] However, implementation of these technologies is not widespread and evidence is
still limited. With a nod to the adage, “necessity is the mother of invention,” the
need for social distancing in response to the COVID-19 pandemic may prove to be a
catalyst for innovation in postpartum care. Any upsurge of remote monitoring for postpartum
hypertension during COVID-19 must be accompanied by concurrent study of its broader
public health impacts.
Guidelines for Postpartum Blood Pressure Monitoring
Guidelines for Postpartum Blood Pressure Monitoring
ACOG recommends blood pressure monitoring in the hospital during the first 72 hours
after delivery, the duration of a typical postpartum stay.[4]
[5]
[6] After discharge, a blood pressure check between 7 and 10 days postpartum at the
hospital or a comparable outpatient facility is advised, prior to the routine visit
at 6 weeks.[4]
[6] While blood pressure goals for women with hypertensive disorders may require initiation
of antihypertensive therapy, the overall approach to hypertension management in the
postpartum period is varied in general, and the range of approaches in the time of
COVID-19 remains unknown.[4]
[5]
[6] Remote blood pressure monitoring can serve as a way to improve adherence to the
above recommendations after delivery. A systematic review of telehealth in obstetrics
and gynecology found that remote monitoring not only addressed barriers to care but
also had particularly beneficial health outcomes for women with gestational diabetes
and hypertension.[7] Among postpartum women, remote monitoring can identify those with severe hypertension
and by early initiation of antihypertensive therapy may reduce hospital readmissions
and associated complications.[8]
Current Evidence for Postpartum Remote Blood Pressure Monitoring
Current Evidence for Postpartum Remote Blood Pressure Monitoring
Remote monitoring technologies have demonstrated promise for improving outcomes such
as increased engagement with care, decreased hospital readmissions, and decreased
use of antihypertensive medication in nonobstetric populations. However, more long-term
follow-up data are lacking. Among postpartum women, data on both short-term and long-term
outcomes are limited as well. Data from pilot studies indicate remote blood pressure
monitoring is feasible and acceptable to patients and providers. Specifically, most
women reported that they found the technologies easy to use, would recommend them
to other women, and preferred this model of hypertension management to in-person clinic
visits.[8]
[9]
[10] One study found remote postpartum blood pressure monitoring increased in-person
care engagement, with 88% of women who used remote monitoring attending their in-person
6-week postpartum visit, compared with a baseline attendance rate of 66%.[10] Furthermore, 82% of patients expressed relief in knowing that a nurse was monitoring
their blood pressure on a daily basis.[10] In another study that coupled home blood pressure cuffs with text message reminders
for remote postpartum blood pressure monitoring, 84% of participants were able to
obtain at least one blood pressure reading at home within the first 10 days postpartum,
consistent with ACOG guidelines, compared with 30 to 50% of patients receiving a single
office-based blood pressure reading.[11]
Home telemonitoring following hypertensive pregnancies may additionally serve to reduce
disparities in postpartum care. Black women are at higher risk of developing hypertensive
disorders of pregnancy and at higher risk of death and poor pregnancy outcomes due
to hypertension compared with nonblack peers.[12]
[13] In a small trial, black women attended standard in-person visits significantly less
than nonblack women (70 vs. 33%, p < 0.001), but when engaged in a virtual blood pressure monitoring program, both black
and nonblack women demonstrated compliance rates of more than 90%.[14]
While this early literature in the postpartum population is promising, further study
is needed to identify strategies to engage and retain participation in telehealth
and to assess the long-term outcomes such as hospital readmissions, maternal mortality,
and future cardiovascular health.
Future Research Directions for Postpartum Remote Monitoring
Future Research Directions for Postpartum Remote Monitoring
Scale-up of remote postpartum blood pressure monitoring during COVID-19 provides an
important opportunity for research. Outstanding questions remain around potential
limitations. For example, barriers in access to the technologies needed for these
protocols may inadvertently contribute to inequities in care. Between 4 and 8% of
women do not have access to smartphones, precluding any remote monitoring protocols
that utilize smartphone apps.[10]
[15] Furthermore, the women who do not have smartphone access are likely those who face
significant challenges in accessing clinic-based care and follow-up, among other social
determinants of health that put them at risk for poor health outcomes. Protocols such
as the one described by Hirshberg et al that relied on text messaging only,[11]
[14] rather than Bluetooth enabled smartphone apps, may be more feasible to implement
equitably. To ensure that scale-up of this intervention does not inadvertently perpetuate
inequities, rather than diminish them, data on these protocols in more diverse populations
are also needed. Similarly, the majority of studies on remote blood pressure monitoring
were conducted in English-speaking populations, and phone-accessible translation services
and multilanguage text messaging options will be critical to establishing more robust
evidence for deploying remote monitoring universally and equitably.[8]
[9]
[10]
[11]
The impact of changes in insurance coverage for telehealth and blood pressure cuffs
during COVID-19 is also a critical area for research. Prior to the pandemic, limited
insurance coverage during the postpartum period, as well as for telehealth visits,
presented a major barrier to scaling up remote hypertension monitoring. Typically,
telehealth appointments are not covered by health insurance in the same way as in-person
appointments. Prior to COVID-19, only 19 states allowed Medicaid coverage of telehealth
care,[16] although Medicaid programs are rapidly expanding coverage for telehealth during
the pandemic.[17] Home blood pressure cuffs—typically difficult to obtain by Medicaid enrollees—are
also becoming more available during COVID-19.[18]
[19] However, despite these changes, a significant remaining limitation is that this
coverage expires 60 days after delivery.[20] As remote monitoring is more widely implemented during COVID-19, research is needed
to examine the impact of telehealth and home blood pressure cuff Medicaid coverage
on access to postpartum hypertension care as well as on maternal morbidity and mortality.
Surveillance data on the impact of systemic changes due to COVID-19 may support future
expansions of Medicaid coverage for postpartum women.[21] Expansion of postpartum telehealth care and broader insurance coverage during this
period may improve access not only to postpartum hypertension care but also to other
critical services, including breastfeeding support, contraception counseling, and
screening for postpartum depression.
Opportunity within a Pandemic
Opportunity within a Pandemic
Even in the best of times, close postpartum follow-up of women with hypertensive disorders
is a challenge. Today's acute need for physical distancing in response to the COVID-19
pandemic poses even greater risk to this important component of pregnancy care. Remote
blood pressure monitoring may mitigate some of this risk and preliminary data suggest
high levels of patient satisfaction, increased patient engagement in postpartum care,
and improved medication compliance. However, research is needed to assess the efficacy
and impact of remote blood pressure monitoring in the postpartum period on clinical
outcomes including hospital readmissions, short-term medical complications of hypertension,
and long-term cardiovascular health for patients with hypertensive disease of pregnancy.
While the imperative to roll out telehealth care for postpartum hypertension exists,
several barriers must be overcome including affordable home devices, accessible education
on blood pressure cuff use in multiple languages, and an effective virtual clinical
protocol. Closely evaluating the clinical outcomes and health care disparities that
follow the rapid implementation of home blood pressure monitoring in the postpartum
period during COVID-19 will provide valuable lessons for research and clinical care
after the pandemic. The COVID-19 pandemic presents a rapid care redesign opportunity
to establish telehealth protocols that if carefully monitored for equity and quality
may improve care for postpartum women in the long term.
