Preferences of Australian healthcare providers regarding education on long-term health after hypertensive disorders of pregnancy: a qualitative study

Co-designing an intervention for cardiovascular disease risk assessment and management after hypertensive disorders of pregnancy in primary care

BACKGROUND

Women with a history of hypertensive disorders of pregnancy are at an increased risk of cardiovascular disease. Although clinical practice guidelines for management of hypertensive disorders of pregnancy recommend involvement of a general practitioner for ongoing cardiovascular disease preventative care, there are no intervention strategies embedded within primary care aimed at improving risk assessment or management for women after hypertensive disorders of pregnancy. The study aim was to co-design an intervention to improve implementation of cardiovascular disease risk assessment and management following hypertensive disorders of pregnancy for primary care settings in a local health district in New South Wales, Australia.

METHOD

Using the Integrated Knowledge Translation framework, a series of five co-design meetings with the investigative team and end users were conducted online. Meetings were informed by the Behaviour Change Wheel framework for intervention development and incorporated research findings from a systematic review and meta-analysis, surveys and an online discussion. Data from activities and audio recordings following each meeting were analysed thematically using inductive-deductive thematic analysis. Results were summarized after each meeting, and findings used to inform ongoing intervention development.

RESULTS

The 18 end users included women with lived experience of hypertensive disorders of pregnancy (n = 8), obstetricians (n = 2), midwives (n = 5) and general practitioners (n = 3). Target priorities were to improve communication between hospital staff and general practitioners following the occurrence of hypertensive disorders of pregnancy and increase the knowledge of general practitioners and women regarding cardiovascular disease prevention after cardiometabolic pregnancy complications. Part 1 of the intervention is set within the hospital setting and delivered via physical resources to address the communication gap between hospital and primary care providers about the occurrence of hypertensive disorders of pregnancy. Part 2 is delivered via an update to an existing general practice education platform and through resources for use within consultations to provide education for women and general practitioners about cardiovascular disease prevention after hypertensive disorders of pregnancy.

CONCLUSION

The Integrated Knowledge Translation and Behaviour Change Wheel frameworks aided in the development of a targeted intervention to improve implementation of cardiovascular risk assessment and management for women after hypertensive disorders of pregnancy, based on gaps identified in current primary care practice.

Women's health and healthcare experiences in the years after gestational diabetes or hypertensive disorders of pregnancy

BACKGROUND

Pregnancy complications, such as gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP), affect a significant proportion of women in Australia, with long-term implications for cardiovascular disease (CVD) risk. Despite existing preventive measures, participation in ongoing health monitoring remains low. This study aims to explore women's preferences and experiences regarding preventive healthcare after GDM and HDP, and to identify their unanswered questions about the association between these conditions and future CVD risk.

METHODS

A participatory, qualitative approach was adopted, involving a Lived Experience Expert Group (LEE Group) to plan, conduct, and interpret focus groups with women who had experienced either GDM or HDP. Participants were recruited through health consumer and community organisations and took part in two focus groups conducted via Zoom. The focus groups involved a stimulus presentation about CVD and GDM or HDP, facilitated group discussion about participants' health and healthcare since their pregnancy, and Nominal Group Technique to prioritise participants' questions about their CVD risk. Focus groups were audio recorded and transcripts from each group were analysed thematically. Synthesised Member Checking was used to verify the trustworthiness of findings.

RESULTS

Twelve women participated in the focus groups, with distinct themes emerging from the GDM and HDP focus groups. Participants were previously unaware of the association between their pregnancy complication and increased risk of future CVD and wished to know more. Three themes were generated from the GDM focus groups: 'a distressing diagnosis'; 'degrees of diabetes'; and 'balancing motherhood and self-care'. Two themes were generated from the HDP focus groups: 'women's concerns were dismissed' and 'wanting follow up at the right time and with the right person'. The 'top ten' questions from each group focussed on improving maternity care, preventing CVD, and (for the HDP group) concerns beyond CVD.

CONCLUSIONS

Women's capacity to engage in preventive health after GDM and HDP is influenced by their maternity care experiences and the accessibility of primary care pathways. Future interventions should focus on improving woman-centred maternity care, ensuring seamless transitions to primary care, and addressing the social determinants of health for new mothers.

Awareness of cardiovascular disease risk and care received among Australian women with a history of hypertensive disorders of pregnancy: a cross-sectional survey

BACKGROUND

Women with a history of hypertensive disorders of pregnancy (HDP), including chronic hypertension, gestational hypertension, and preeclampsia have an increased risk of cardiovascular disease (CVD). Current research suggests that general practitioners are unaware of women's HDP history, and although ideally placed to follow-up with these women, there is limited understanding of current CVD prevention practices in women after HDP. Additionally, preeclampsia confers a higher CVD risk compared to other types of HDP, and Australian research suggests that lower socioeconomic status (SES) is associated with a higher incidence of both HDP and CVD. Therefore, the aim of the analysis was to investigate awareness of CVD risk and care received from health professionals among women with a history of HDP and examine differences between type of HDP and SES.

METHODS

Analysis of a cross-sectional survey of 293 Australian women with a history of HDP (from 2017 onwards). Data were analysed using basic descriptive statistics. To assess differences in HDP type and SES, one-way ANOVA was used to assess continuous variables and χ2 tests for categorical variables, with P < 0.05 considered statistically significant.

RESULTS

Most women with a history of HDP were unaware of their increased CVD risk (68%). Women with a history of preeclampsia, gestational hypertension or preeclampsia were more aware of CVD risk compared to those with chronic hypertension (p = 0.02). Regardless of HDP type or SES, women post-HDP were less likely to receive assessment and management of lifestyle CVD risk factors compared to blood pressure. Most women felt supported in managing stress and mental health, but not for managing body weight, smoking and sleep.

CONCLUSIONS

Women with a history of HDP are unaware of their increased CVD risk and are not receiving recommended CVD preventative care, irrespective of HDP type and/or SES. Findings should be used to inform development of tailored CVD prevention interventions in the primary care setting for women following HDP.

Exploring Australian knowledge and practice for maternal postnatal transition of care between hospital and primary care: A scoping review

PROBLEM

Despite the significance of the perinatal period, postnatal care remains insufficient for optimising long-term health.

BACKGROUND

The perinatal period is a vulnerable time in a woman's life-course health trajectory. Supporting transitions from hospital to primary care is essential to promote health and guide evidence-based follow-up care.

AIM

The aims are to (i) explore existing knowledge and practice in Australia regarding maternal postnatal transitions of care between hospital and primary care and (ii) understand the enablers and barriers to implementing optimal postnatal discharge and handover of care from the maternity to primary health setting.

METHODS

A scoping review was conducted according to PRISMA-ScR guidelines. Medline, Embase, CINAHL, Scopus and The Cochrane Library were searched using MeSH terms, subject headings and keywords. Full-text articles in English were included from 1st January 2010-8 th June 2024.

RESULTS

Eighteen studies were included, 14 focused on care in specific states and four Australia-wide. Maternal postnatal transition of care between hospital and primary care varied. Critical components of care that were valued by women and healthcare providers and promoted effective care transitions were grouped into four concepts: "Woman-centred discharge planning and process", "Integrated care", "Follow-up care" and "Continuity of care". Discharge communication across Australian health services is diverse. Women and healthcare providers require clear discharge communication that highlights complications, guides follow-up and promotes continuity.

CONCLUSION

Australian postnatal transition between hospital and primary care is inconsistent and ineffective. Lack of robust handover between services hinders evidence-based follow-up care after postnatal discharge from hospital, particularly following pregnancy complications.

Evaluation of a Question Prompt List About Cardiovascular Disease Risk and Prevention After Hypertensive Pregnancy: A Pilot Study

INTRODUCTION

The aim of this study was to pilot test a question prompt list (QPL) about cardiovascular disease (CVD) risk reduction after hypertensive pregnancy (HDP).

METHODS

In a prospective cohort study of adult women who had HDP given the QPL before and surveyed after a physician visit, we assessed perceived person-centred care, self-efficacy for self-management, perceived self-management and QPL feasibility.

RESULTS

Twenty-three women participated: 57% of diverse ethno-cultural groups, 65% < 40 years of age and 48% immigrants. Most scored high for person-centred care (mean 4.1 ± 0.2/5); and moderately for self-efficacy (mean 7.4 ± 0.6/10) and self-management (mean 3.1 ± 0.3/5). Most appreciated QPL design and reported QPL benefits: helped them to prepare for the visit and know what to ask; increased confidence to ask questions, knowledge of the link between HDP and CVD and lifestyle behaviours to reduce CVD risk. Most reported that physicians were receptive to discussing QPL questions.

CONCLUSION

Women appreciated the QPL and knowledge about self-management was high but self-efficacy for or perceived self-management was moderate. It appears feasible to share a QPL with ethno-culturally diverse women who can share it with physicians to facilitate discussions about post-pregnancy HDP-related CVD risk.

PATIENT OR PUBLIC CONTRIBUTION

This study involved women who experienced HDP and engaged ethno-culturally diverse women with lived experience of HDP as study advisors in all stages of the research.

Postpartum care in a cardio-obstetric clinic after preterm preeclampsia: patient and healthcare provider perspectives

BACKGROUND

Despite the significant disruption and health implications of preterm preeclampsia with severe features for birthing people, little is known about how the system of postpartum care might be strengthened for affected families. Multidisciplinary cardio-obstetric clinics are emerging; however, there is limited research on patient and healthcare provider perspectives.

OBJECTIVE

To describe patient and healthcare provider perspectives of services in a cardio-obstetric clinic following preterm preeclampsia with severe features.

STUDY DESIGN

Individuals who experienced preterm preeclampsia with severe features and presented to a cardio-obstetric clinic were approached for study participation. Providers were approached if they provided postpartum care to patients with preterm preeclampsia with severe features and considered a referral to the cardio-obstetric clinic. Participants completed a remotely conducted, semistructured interview between March 2022 and April 2023. The interviews were audio-recorded, professionally transcribed, and checked for accuracy. Responses were inductively coded for content analysis around the study questions of clinical referrals, patient education, visit expectations, and care coordination in relation to ambulatory clinical services.

RESULTS

Twenty participants (n=10 patients and n=10 providers) completed interviews. Healthcare system navigation was difficult, particularly in the context of postpartum needs. When patients are informed about their diagnosis, the information could both increase anxiety and be useful for long-term healthcare planning. Language concordant care did not always occur, and both patients and providers described gaps in quality services. Within the theme of responsibility, patients described needing to be vigilant, and providers recognized the gaps in referral and care coordination systems. Comprehensible patient education provided with birthing parents' companions and enhanced systems for care coordination were areas for further improvement in providing postpartum cardio-obstetric care following preterm preeclampsia.

CONCLUSION

This qualitative study identified patients' struggles with a confusing postpartum healthcare system and captured providers' concerns about maintaining consistent care and improving access to long-term healthcare services to improve outcomes for patients at risk of cardiovascular disease.

Postpartum follow-up of women with preeclampsia: facilitators and barriers - A qualitative study

BACKGROUND

Pregnancy causes physiological changes to the maternal organ systems that can be regarded as a cardiometabolic stress test for women. Preeclampsia, a pregnancy complication characterized by new onset of hypertension in combination with proteinuria or end-organ dysfunction, affects approximately 2-8% of pregnancies. Adverse pregnancy outcomes, including preeclampsia, have been described as a failed stress test and have been consistently linked with increased risk of cardiovascular disease later in life. The postpartum period is therefore often regarded as a window of opportunity for cardiovascular disease prevention. However, we lack knowledge about how women with preeclampsia experience current postpartum care in the Norwegian health system. The aim of this qualitative study is to uncover women's perspectives and preferences regarding postpartum follow-up.

METHODS

Semi-structured telephone interviews were conducted with 17 women following a six-month lifestyle intervention study. Participants were 9-20 months postpartum, following a pregnancy complicated by preeclampsia. Data were analyzed using Malterud's systematic text condensation.

RESULTS

We identified five themes, each with 2-3 subthemes, that demonstrate how women with recent preeclampsia experience postpartum follow-up: (1) fear and uncertainty (a body out of balance and facing an uncertain future), (2) a conversation on lifestyle - not really that difficult (preeclampsia as a gateway, a respectful approach, and a desire for more constructive feedback), (3) when your own health is not a priority (a new everyday life, out of focus, and lack of support), (4) motivation for lifestyle changes (an eye opener, lack of intrinsic motivation, and a helping hand), and (5) lack of structured and organized follow-up (there should be a proper system, a one-sided follow-up care, and individual variation in follow-up care).

CONCLUSIONS

Findings from this study highlight the need for more systematic postpartum follow-up for women after a pregnancy complicated by preeclampsia. Further research is required to explore the potential use of standardized guidelines and routine invitations to postpartum care. Furthermore, exploring health care professionals' experiences is crucial to ensure their engagement in postpartum care after complicated pregnancies.

Barriers and Facilitators to Cardiovascular Disease Prevention Following Hypertensive Disorders of Pregnancy in Primary Care: Cross-Sectional Surveys

Women with a history of hypertensive disorders of pregnancy (HDP) have an increased risk of cardiovascular disease (CVD). Guidelines recommend that women diagnosed with HDP should be advised of their increased CVD risk, have regular blood pressure monitoring by their general practitioner (GP), and adopt healthy lifestyle behaviours. However, within Australia, the current practice in primary health care is unknown. The aim of this study was to describe current practices, barriers, and facilitators to the provision of CVD preventative services for women after HDP in the primary care setting and to identify potential strategies to support GPs in providing recommended care. Separate cross-sectional online surveys were undertaken with 35 GPs and 105 women with a history of HDP. Surveys included both closed- and open-ended questions. Closed-ended questions were analysed using basic descriptive statistics, and open-ended questions were themed and tallied. The survey of GPs revealed that GPs are more likely to assess traditional CVD risk markers than lifestyle risk factors or HDP history. GPs identified a lack of resources and skills as barriers to providing CVD preventative care post-HDP. The survey with women after HDP revealed that women with a history of HDP are more likely to be assessed for blood pressure than lifestyle CVD risk factors, and that the women's barriers to obtaining care included difficulty obtaining an appointment and time required for attending appointments. Strategies to improve CVD preventative care were consistent between surveys, where 70% of GPs and 59% of women chose 'increasing women's awareness of increased CVD risk' and 67% of GPs and 55% of women chose 'improving communication between hospitals and primary care' as their preferred strategies. While the findings suggest that women with a history of HDP are receiving advice consistent with guidelines for traditional CVD risk markers, such as blood pressure, they are less likely to receive CVD preventative care for lifestyle or female-specific CVD risk factors.