Blood pressure self-monitoring in pregnancy (BuMP) feasibility study; a qualitative analysis of women's experiences of self-monitoring

What are the barriers to health professionals' training on gender-affirming care from patients' and clinicians' perspectives?

OBJECTIVE

The aim of the study is to identify the barriers to gender-affirming health care education for providers from the perspectives of patients and providers.

METHODS

A qualitative study based on grounded theory was conducted. Participants included transgender and gender diverse (TGD) patients seeking care, as well as resident physicians and attending physicians involved in care of patients seeking gender-affirming care. Semi-structured interviews were conducted over Zoom application and telephone calls. The study was conducted in Boston, Massachusetts, USA from November 2022 until February 2023.

RESULTS

Nine attending physicians, eight resident physicians, and fifteen patients were interviewed. Attending physicians noted barriers to include lack of formal training in medical school and residency, lack of adequate opportunities for faculty development to appropriately train resident physicians, lack of opportunities for trainees to provide dedicated clinical care, lack of community engagement initiatives, and need for additional training centered on cultural sensitivity and inclusivity. Resident physicians noted a lack of robust and longitudinal didactic curriculum, deficiency in dedicated clinical time, and inadequacy in interprofessional training as major barriers to their training. They noted that they generally felt unprepared to care for TGD patients. Patients' barriers included difficulty building trust in medical providers' knowledge and skills, being addressed with incorrect names and pronouns, lacking a sense of belonging as a patient, as well as difficulty in arranging care due to lack of a centralized care system.

CONCLUSION

Barriers to gender-affirming education include lack of adequate and formal training, lack of professional development opportunities, inadequacy in a multidisciplinary approach to treatment and education, and inadequacy in cultural and sensitivity training. Findings of this qualitative study based on interviews may help facilitate addressing such barriers through creation of routine lecture-based didactic opportunities for providers, investment in faculty development, creation of gender-affirming clinics, providing opportunities for trainees to provide longitudinal care to TGD patients, creation of interdisciplinary training modules, community engagement, and implementation of a multidisciplinary care model, which may help improve gender-affirming care in the long-run.

Quality framework for remote antenatal care: qualitative study with women, healthcare professionals and system-level stakeholders

BACKGROUND

High-quality antenatal care is important for ensuring optimal birth outcomes and reducing risks of maternal and fetal mortality and morbidity. The COVID-19 pandemic disrupted the usual provision of antenatal care, with much care shifting to remote forms of provision. We aimed to characterise what quality would look like for remote antenatal care from the perspectives of those who use, provide and organise it.

METHODS

This UK-wide study involved interviews and an online survey inviting free-text responses with: those who were or had been pregnant since March 2020; maternity professionals and managers of maternity services and system-level stakeholders. Recruitment used network-based approaches, professional and community networks and purposively selected hospitals. Analysis of interview transcripts was based on the constant comparative method. Free-text survey responses were analysed using a coding framework developed by researchers.

FINDINGS

Participants included 106 pregnant women and 105 healthcare professionals and managers/stakeholders. Analysis enabled generation of a framework of the domains of quality that appear to be most relevant to stakeholders in remote antenatal care: efficiency and timeliness; effectiveness; safety; accessibility; equity and inclusion; person-centredness and choice and continuity. Participants reported that remote care was not straightforwardly positive or negative across these domains. Care that was more transactional in nature was identified as more suitable for remote modalities, but remote care was also seen as having potential to undermine important aspects of trusting relationships and continuity, to amplify or create new forms of structural inequality and to create possible risks to safety.

CONCLUSIONS

This study offers a provisional framework that can help in structuring thinking, policy and practice. By outlining the range of domains relevant to remote antenatal care, this framework is likely to be of value in guiding policy, practice and research.

Facilitators and barriers to home blood pressure monitoring among pregnant women in Ghana: a mixed-methods analysis of patient perspectives

BACKGROUND

The benefit of home blood pressure monitoring during pregnancy and in low-resource settings is incompletely understood. The objective of this study was to explore the experiences, barriers, and facilitators of home blood pressure monitoring among pregnant women in Ghana.

METHODS

This concurrent triangulation mixed-methods study was conducted at an urban tertiary hospital in Ghana. Participants were recruited from adult pregnant women presenting for routine antenatal care. Upon enrollment, participants' demographics and history were collected. At the next study visit, participants received audiovisual and hands-on training on using an automatic blood pressure monitor; they then monitored and logged their blood pressure daily at home for 2-4 weeks. At the final study visit, verbally administered surveys and semi-structured interviews assessed participant's experiences. Quantitative data were analyzed using R version 4.2.2, and frequencies and descriptive statistics were calculated. Qualitative data were imported into DeDoose 9.0.78 for thematic analysis.

RESULTS

Of 235 enrolled participants, 194 completed surveys; of those, 33 completed in-depth interviews. Participants' mean age was 31.6 (SD 5.3) years, 32.1% had not previously given birth, and 31.1% had less than a senior high school education. On a 4-point Likert scale, the majority reported they "definitely" were able to remember (n = 134, 69.1%), could find the time (n = 124, 63.9%), had the energy (n = 157, 80.9%), could use the blood pressure monitor without problems (n = 155, 79.9%), and had family approval (n = 182, 96.3%) while engaging in home blood pressure monitoring. 95.88% (n = 186) believed that pregnant women in Ghana should monitor their blood pressure at home. Qualitative thematic analysis demonstrated that most participants liked home blood pressure monitoring because of increased knowledge of their health during pregnancy. While most participants found measuring their blood pressure at home doable, many faced challenges. Participants' experiences with five key factors influenced how easy or difficult their experience was: 1) Time, stress, and daily responsibilities; 2) Perceived importance of BP in pregnancy; 3) Role of family; 4) Capability of performing monitoring; 5) Convenience of monitoring.

CONCLUSIONS

Among pregnant women in urban Ghana, home blood pressure monitoring was perceived as positive, important, and doable; however, challenges must be addressed.

Self-monitoring blood pressure in Pregnancy: Evaluation of health professional experiences of the BUMP trials

BACKGROUND

The BUMP trials evaluated a self-monitoring of blood pressure intervention in addition to usual care, testing whether they improved detection or control of hypertension for women at risk of hypertension or with hypertension during pregnancy. This process evaluation aimed to understand healthcare professionals' perspectives and experiences of the BUMP trials of self-monitoring of blood pressure during pregnancy.

METHODS

Twenty-two in-depth qualitative interviews and an online survey with 328 healthcare professionals providing care for pregnant people in the BUMP trials were carried out across five maternity units in England.

RESULTS

Analysis used Normalisation Process Theory to identify factors required for successful implementation and integration into routine practice. Healthcare professionals felt self-monitoring of blood pressure did not over-medicalise pregnancy for women with, or at risk of, hypertension. Most said self-monitored readings positively affected their clinical encounters and professional roles, provided additive information on which to base decisions and enriched their relationships with pregnant people. Self-monitoring of blood pressure shifts responsibilities. Some healthcare professionals felt women having responsibility to decide on timing of monitoring and whether to act on self-monitored readings was unduly burdensome, and resulted in healthcare professionals taking additional responsibility for supporting them.

CONCLUSIONS

Despite healthcare professionals' early concerns that self-monitoring of blood pressure might over-medicalise pregnancy, our analysis shows the opposite was the case when used in the care of pregnant people with, or at higher risk of, hypertension. While professionals retained ultimate clinical responsibility, they viewed self-monitoring of blood pressure as a means of sharing responsibility and empowering women to understand their bodies, to make judgements and decisions, and to contribute to their care.

Using self-monitoring to detect and manage raised blood pressure and pre-eclampsia during pregnancy: the BUMP research programme and its impact

Raised blood pressure affects around ten percent of pregnancies worldwide, causing maternal and perinatal morbidity and mortality. Self-monitoring of blood pressure during higher-risk or hypertensive pregnancy has been shown to be feasible, acceptable, safe, and no more expensive than usual care alone. Additionally, self-testing for proteinuria has been shown to be just as accurate as healthcare professional testing, creating the potential for monitoring of multiple indicators through pregnancy. The work suggests however, that an organisational shift is needed to properly use and see benefits from self-monitored readings. This paper describes the findings from a large programme of work examining the use of self-monitoring in pregnancy, summarising the findings in the context of the wider literature and current clinical context. The BUMP Research Programme developed and tested self-monitoring and self-testing interventions for pregnancy. The work showed that self-monitoring during pregnancy was feasible, acceptable, safe, and no more expensive, but did not improve the detection or control of hypertension.

Exploring perceptions and operational considerations for use of a smartphone application to self-monitor blood pressure in pregnancy in Lombok, Indonesia: protocol for a qualitative study

INTRODUCTION

Hypertensive disorders of pregnancy (HDP) are a leading cause of maternal deaths globally and require close monitoring of blood pressure (BP) to mitigate potential adverse effects. Despite the recognised need for research on self-monitoring of blood pressure (SMBP) among pregnant populations, there are very few studies focused on low and middle income contexts, which carry the greatest burden of HDPs. The study aims to understand the perceptions, barriers, and operational considerations for using a smartphone software application to perform SMBP by pregnant women in Lombok, Indonesia.

METHODS AND ANALYSIS

This study includes a combination of focus group discussions, in-depth interviews and workshop observations. Pregnant women will also be provided with a research version of the smartphone BP application to use in their home and subsequently provide feedback on their experiences. The study will include pregnant women with current or past HDP, their partners and the healthcare workers involved in the provision of antenatal care services within the catchment area of six primary healthcare centres. Data obtained from the interviews and observations will undergo thematic analyses using a combination of both inductive and deductive approaches.

ETHICS AND DISSEMINATION

The study was approved by the World Health Organization (WHO) and Human Reproduction Programme (HRP) Research Project Review Panel and WHO Ethical Review Committee (A65932) as well as the Health Research Ethics Committee, Faculty of Medicine, Universitas Mataram in Indonesia (004/UN18/F7/ETIK/2023).Findings will be disseminated through research publications and communicated to the Lombok district health offices. The analyses from this study will also inform the design of a subsequent impact evaluation.

Barriers and facilitators to self-measured blood pressure monitoring among US-resettled Arab refugees with hypertension: a qualitative study

BACKGROUND

Minoritized communities including refugees are at an increased risk of poorly controlled hypertension. Evidence indicates that self-measured blood pressure monitoring (SMBP) is an effective method to improve blood pressure control in patients with hypertension. However, it has not been studied among refugee populations. The objective of this study is to examine barriers and facilitators to SMBP among Arab refugees resettled in the United States (US) with diagnosed hypertension.

METHODS

A total of 109 participants were recruited through a Federally Qualified Health Center system that is a major provider of healthcare to refugees in San Diego, California. Participants completed a questionnaire and were interviewed using in-depth, semi-structured interviews. Interviews were transcribed and translated, and data were coded using inductive thematic analysis and organized based on the theory of care-seeking behavior.

RESULTS

Several barriers to engaging in effective SMBP monitoring were identified. Clinical and sociodemographic barriers included reliance on public monitors and poor hypertension literacy. Psychosocial barriers of affect, norms, and habits included fear and anxiety from hypertension, cultural stigma of illness, and conditional SMBP with symptoms, respectively. Utility psychosocial barriers included lack of SMBP prioritization in treatment and perceived inaccuracy of home monitors. Family members' support with home monitoring served as an important facilitator to SMBP.

CONCLUSIONS

There are several barriers to effective SMBP among the US-resettled Arab refugee population that may reflect unique cultural and care-seeking behaviors. Tailored public health and clinical interventions are needed to support refugee patients and providers to improve hypertension self-management behaviors for this unique population.

A longitudinal qualitative study of women's experiences of postnatal care following hypertensive disorders of pregnancy

PROBLEM

There has been little focus on women's views of care and recovery following pregnancy complicated by hypertensive disorders of pregnancy [HDP] despite long-term implications for maternal health.

BACKGROUND

Increasingly in clinical research, areas of interest include the extent to which women are involved in postnatal care planning, perceived value of routine postnatal contacts, lifestyle behaviour advice, and extent to which ongoing concerns about HDP could be discussed with healthcare professionals.

AIM

This study explored women's experiences of birth-recovery up to 12 months following HDP.

METHODS

A longitudinal qualitative study using semi-structured interviews at four and 12 months postpartum. Twenty-four women who each had a form of HDP, were recruited using a maximum variation, purposive sampling strategy from four National Health Service maternity units in London, 21 of whom were interviewed at both time points. Data were collected and analysed by timepoint following a recurrent, cross-sectional cohort approach using template analysis methodology.

FINDINGS

Four main themes and ten sub-themes were identified. Main themes included: assumptions about blood pressure; perinatal experiences; postnatal care pathways; and managing complex health conditions.

DISCUSSION

Postnatal care needs to be tailored to women's individual needs following HDP, with ongoing review by relevant clinicians during and beyond the first six weeks. Many women with HDP have ongoing information needs about hypertensive status, treatment and prognoses, and future birth planning.

CONCLUSION

Policy makers, health providers and funders cannot continue to ignore the need to ensure postnatal services meet the needs of women who have experienced medically complex pregnancies.

Telehealth in antenatal care: recent insights and advances

BACKGROUND

For decades, antenatal care in high-resource settings has involved 12-14 face-to-face visits across pregnancy. The COVID-19 pandemic forced many care providers to rapidly embrace telehealth to reduce face-to-face visits. Here we review recent advances in telehealth used to provide antenatal care.

MAIN BODY

We conducted a narrative review examining the impact of telehealth on obstetric care. Two broad types of telehealth are used in antenatal care. The first is real-time telehealth, where consultations are done virtually instead of face-to-face. The second is remote monitoring, where in-clinic physical examinations are replaced with at-home alternatives. These can include blood pressure monitoring, fetal heart rate monitoring, and emerging technologies such as tele-ultrasound. Large cohort studies conducted during the pandemic era have shown that telehealth appears not to have increased adverse clinical outcomes for mothers or babies. However, further studies may be required to confidently conclude rare outcomes are unchanged, such as maternal mortality, serious morbidity, or stillbirth. Health economic studies suggest telehealth has the potential to reduce the financial cost of care provision. Telehealth in antenatal care seems to be acceptable to both pregnant women and healthcare providers.

CONCLUSION

Adoption of telehealth technologies may improve the antenatal care experience for women and reduce healthcare expenditure without adversely impacting health outcomes for the mother or baby. More studies are warranted to confirm telehealth does not alter the risk of rare outcomes such as maternal or neonatal mortality.

Ability and accuracy of patient-performed blood pressure monitoring among pregnant women in urban Ghana

BACKGROUND

Patient-performed blood pressure monitoring in pregnancy is rarely performed in low- and middle-income country settings, including Ghana. The clinical efficacy of home blood pressure monitoring relies on a pregnant patient being able to independently execute the correct steps to position and use a blood pressure monitor and to achieve accurate blood pressure measurements.

OBJECTIVE

This study aimed to (1) assess whether pregnant women can correctly use an automatic blood pressure monitor to check their blood pressure before and after a brief training and (2) determine whether blood pressure values measured by pregnant women using an automatic monitor are similar to values measured by a healthcare provider using a standard clinic monitor.

STUDY DESIGN

This was a cross-sectional study conducted at the Korle Bu Teaching Hospital, a tertiary hospital in Accra, Ghana. Participants were adult pregnant women presenting for their first prenatal care visit. Data collection was performed by 2 Ghanaian physicians. Information on demographics, obstetrical history, and past medical history was collected. A brief training was provided on the correct use of the blood pressure monitor, including a verbal script, annotated photographs, and a hands-on demonstration. Pre- and posttraining assessments using a 9-item checklist of correct preparation, position, and use of an automatic blood pressure monitor were performed. Following a modified British Hypertension Society protocol, a series of 4 blood pressure measurements were taken, alternating between provider performed using a clinic monitor and patient performed using an automatic monitor intended for individual use and validated in pregnancy.

RESULTS

Among 176 participants, the mean age was 31.5 years (±5.6), and 130 (73.9%) were multiparous. Regarding socioeconomic characteristics, 128 (72.7%) were married, 171 (97.2%) had public insurance, and 87 (49.7%) had completed ≤9 years of formal education. Regarding clinical blood pressure issues, 19 (10.9%) had a history of a hypertensive disorder in a previous pregnancy, and 6 (3.4%) had chronic hypertension. Before receiving any training, 21 participants (12.1%) performed all 9 steps correctly to prepare, position, and use the automatic blood pressure monitor. Comparing pretraining vs posttraining ability, statistically significant increases were seen in the correct performance of each step and the mean number of steps performed correctly (6.1±1.8 vs 9.0±0.2, respectively; P<.001) and proportion performing all 9 steps correctly (12.1% vs 96.6%, respectively; P<.001). The mean difference between doctor-performed and patient-performed blood pressure measurements was 5.6±4.8 mm Hg for systolic blood pressure values and 3.4±3.08 mm Hg for diastolic blood pressure values, with most differences within 5 mm Hg for both systolic blood pressure values (102/176 [58.0%]) and diastolic blood pressure values (141/176 [80.1%]).

CONCLUSION

After a brief training, pregnant women in Ghana demonstrated that they are able to use an automatic blood pressure monitor to check their blood pressure correctly and accurately.

Validation of the AViTA BPM636 upper arm blood pressure monitor in adults and pregnant women according to the ANSI/AAMI/ISO 81060-2:2013

OBJECTIVE

To evaluate the accuracy of the AViTA oscillometric upper arm home blood pressure (BP) monitor in adult and pregnant populations according to the American National Standards Institute/Association for the Advancement of Medical Instrumentation/ International Organization for Standardization (ANSI/AAMI/ISO) Universal Standard (ISO 81060-2:2013).

METHODS

BP measurements on the upper arm were performed on 85 adult subjects and 46 pregnant subjects. The AViTA BPM636 and a standard mercury reference sphygmomanometer were applied and followed the same arm sequential BP measurement method. The universal cuff of the test device was used for arm circumference of 22-42 cm.

RESULTS

For validation criterion 1, the mean ± SD of the differences between the test device and reference BP readings was 1.1 ± 5.49/2.9 ± 5.17 mmHg (systolic/diastolic) for adults; and -2.2 ± 5.93/1.5 ± 4.92 mmHg (systolic/diastolic) for pregnant women. For criterion 2, the SD of the averaged BP differences between the test device and reference BP per adult subject was 4.45/4.20 mmHg (systolic/diastolic) and per pregnant women was 4.66/3.96.

CONCLUSION

The AViTA BPM636 had passed the criteria of the ANSI/AAMI/ISO 81060-2:2013 protocol and can be recommended for home BP measurements in adults and pregnant populations.

Pregnant women's attitudes to and experiences with a smartphone-based self-test for prediction of pre-eclampsia: a qualitative descriptive study

OBJECTIVES

To explore attitudes to and experiences using a smartphone-based self-test for prediction of pre-eclampsia among pregnant women.

DESIGN

A qualitative, descriptive study.

SETTING

An obstetrical care unit at a university hospital in Denmark.

PARTICIPANTS

Twenty women who had participated in the Salurate trial, a clinical trial testing the efficacy of a smartphone-based self-test for prediction of pre-eclampsia, were purposefully chosen for the study, using maximum variation sampling.

DATA COLLECTION AND ANALYSIS

Data were collected by semistructured, individual, face-to-face interviews conducted from 4 October 2018 to 8 November 2018. Data were transcribed verbatim and analysed by means of thematic analysis.

RESULTS

Qualitative thematic analysis resulted in the identification of three main themes: Raising awareness, self-testing has the potential to be an integrated part of pregnancy and trusting in technology. Two subthemes were identified under each main theme.

CONCLUSIONS

The smartphone-based self-test for prediction of pre-eclampsia has potential to be integrated into antenatal care, and women found it feasible to use. However, testing affected the participating women psychologically, leading to feelings of worry as well as safety. Therefore, if self-testing is implemented, it is important to take actions to handle adverse psychological side effects, including increasing knowledge on pre-eclampsia and having healthcare professionals ongoingly address the psychological state of women throughout pregnancy. In addition, it is essential to emphasise the importance of subjective bodily sensations during pregnancy, including fetal movements. Further studies on the experience of being labelled low risk versus high risk for pre-eclampsia are warranted since this was not investigated in this trial.

Benefits and barriers of home blood pressure monitoring in pregnancy: perspectives of obstetric doctors from a Ghanaian tertiary hospital

BACKGROUND

Delayed diagnosis of preeclampsia contributes to maternal morbidity and mortality. Patient-performed home blood pressure monitoring facilitates more frequent monitoring and earlier diagnosis. However, challenges may exist to implementation in low- and middle income-countries.

METHODS

This cross-sectional mixed methods study evaluated obstetric doctors' perspectives on the benefits of and barriers to the implementation of home blood pressure monitoring among pregnant women in Ghana. Participants were doctors providing obstetric care at Korle Bu Teaching Hospital. Electronic surveys were completed by 75 participants (response rate 49.3%), consisting of demographics and questions on attitudes and perceived benefits and challenges of home BP monitoring. Semi-structured interviews were completed by 22 participants to expand on their perspectives.

RESULTS

Quantitative and qualitative results converged to highlight that the current state of blood pressure monitoring among pregnant women in Ghana is inadequate. The majority agreed that delayed diagnosis of preeclampsia leads to poor health outcomes in their patients (90.6%, n = 68) and earlier detection would improve outcomes (98.7%, n = 74). Key qualitative benefits to the adoption of home blood pressure monitoring were patient empowerment and trust of diagnosis, more quantity and quality of blood pressure data, and improvement in systems-level efficiency. The most significant barriers were the cost of monitors, lack of a communication system to convey abnormal values, and low health literacy. Overall, doctors felt that most barriers could be overcome with patient education and counseling, and that benefits far outweighed barriers. The majority of doctors (81.3%, n = 61), would use home BP data to inform their clinical decisions and 89% (n = 67) would take immediate action based on elevated home BP values. 91% (n = 68) would recommend home BP monitoring to their pregnant patients.

CONCLUSION

Obstetric doctors in Ghana strongly support the implementation of home blood pressure monitoring, would use values to inform their clinical management, and believe it would improve patient outcomes. Addressing the most significant barriers, including cost of blood pressure monitors, lack of a communication system to convey abnormal values, and need for patient education, is essential for successful implementation.

Self-monitoring of blood pressure in pregnancy: A mixed methods evaluation of a national roll-out in the context of a pandemic

Objective

To evaluate how English maternity units implemented self-monitoring of blood pressure (SMBP) in pregnancy in response to the COVID-19 pandemic.

Design

Mixed methods including surveys, anonymised patient data and in-depth interviews with women.

Setting

Maternity units across England.

Participants

45 maternity units completed a survey about the implementation of SMBP (supported by the provision of guidance and blood pressure monitors) during the pandemic, 166 women completed a survey about their experiences of SMBP, and 23 women took part in in-depth interviews. Clinical data from 627 women undertaking SMBP were available from 13 maternity units.

Results

SMBP was predominantly used to provide additional BP monitoring for hypertensive or high-risk pregnant women. Overall maternity units and women were positive about its use in terms of reducing the need for additional face-to-face contacts and giving women more control and insight into their own BP. However, there were challenges in setting up SMBP services rapidly and embedding them within existing care pathways, particularly around interpreting readings and managing the provision of monitors.

Conclusions

A considerable proportion of maternity units in England commenced a SMBP service for hypertensive or high-risk women from March 2020. There is a need for further research into appropriate care pathways, including guidance around white coat or masked hypertension and the use of SMBP postnatally.

Perceptions and experiences of blood pressure self-monitoring during hypertensive pregnancy: A qualitative analysis of women's and clinicians' experiences in the OPTIMUM-BP trial

BACKGROUND

Self-monitoring of blood pressure (BP) has been shown to be effective at improving BP control in the general population. The OPTIMUM-BP feasibility study was a prospective randomised controlled trial of self-monitoring of BP (SMBP) during hypertensive pregnancy.

OBJECTIVE

To explore experiences, perceptions, and use of the OPTIMUM-BP self-monitoring intervention.

STUDY DESIGN

Qualitative study within the OPTIMUM-BP feasibility trial. Semi-structured interviews with a purposive sample of pregnant women with chronic hypertension (n = 24) and their clinicians (n = 8) as well as 38 ethnographic observations of antenatal visits.

RESULTS

Women found self-monitoring of BP feasible and acceptable and were highly motivated and pro-active in their monitoring, reporting greater control and knowledge of BP and reassurance. Women's persistence with SMBP was driven by a perceived need to safeguard the pregnancy, particularly among those taking antihypertensive medication. Clinicians also described the intervention as acceptable, though BP variability could cause uncertainty. Clinicians used different heuristics to integrate home and clinic readings. Observations suggested close working relationships between women and clinicians were key for confident integration of self-monitoring.

CONCLUSIONS

Self-monitoring of BP was acceptable both to pregnant women with hypertension and their clinicians. More research is needed to understand BP variability within pregnancy to help interpret and integrate home BP readings for improved BP management. Clinical pathways that use BP self-monitoring should aim to maintain the continuity of care and relationships that are valued and appear pivotal for the confident and safe use of self-monitoring in pregnancy.

Self-monitoring of blood pressure among women with hypertensive disorders of pregnancy: a systematic review

BACKGROUND

The World Health Organization (WHO) recommends self-monitoring of blood pressure (SMBP) for hypertension management. In addition, during the COVID-19 response, WHO guidance also recommends SMBP supported by health workers although more evidence is needed on whether SMBP of pregnant individuals with hypertension (gestational hypertension, chronic hypertension, or pre-eclampsia) may assist in early detection of pre-eclampsia, increase end-user autonomy and empowerment, and reduce health system burden. To expand the evidence base for WHO guideline on self-care interventions, we conducted a systematic review of SMBP during pregnancy on maternal and neonatal outcomes.

METHODS

We searched for publications that compared SMBP with clinic-based monitoring during antenatal care. We included studies measuring any of the following outcomes: maternal mortality, pre-eclampsia, long-term risk and complications, autonomy, HELLP syndrome, C-section, antenatal hospital admission, adverse pregnancy outcomes, device-related issues, follow-up care with appropriate management, mental health and well-being, social harms, stillbirth or perinatal death, birthweight/size for gestational age, and Apgar score. After abstract screening and full-text review, we extracted data using standardized forms and summarized findings. We also reviewed studies assessing values and preferences as well as costs of SMBP.

RESULTS

We identified 6 studies meeting inclusion criteria for the effectiveness of SMBP, 6 studies on values and preferences, and 1 study on costs. All were from high-income countries. Overall, when comparing SMBP with clinic-monitoring, there was no difference in the risks for most of the outcomes for which data were available, though there was some evidence of increased risk of C-section among pregnant women with chronic hypertension. Most end-users and providers supported SMBP, motivated by ease of use, convenience, self-empowerment and reduced anxiety. One study found SMBP would lower health sector costs.

CONCLUSION

Limited evidence suggests that SMBP during pregnancy is feasible and acceptable, and generally associated with maternal and neonatal health outcomes similar to clinic-based monitoring. However, more research is needed in resource-limited settings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021233839 .

Agreement between self-reported and researcher-measured height, weight and blood pressure measurements for online prescription of the combined oral contraceptive pill: an observational study

OBJECTIVES

To compare agreement between self-reported height, weight and blood pressure measurements submitted to an online contraceptive service with researcher-measured values and document strategies used for self-reporting.

DESIGN

An observational study.

SETTING

An online sexual health service which provided the combined oral contraceptive pill, free of charge, to users in Southeast London, England.

PARTICIPANTS

Between August 2017 and August 2019, 365 participants were recruited.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome, for which the study was powered, was the agreement between self-reported and researcher-measured body mass index (BMI) and blood pressure measurements, compared using kappa coefficients. Secondary measures of agreement included sensitivity, specificity and Bland Altman plots. The study also describes strategies used for self-reporting and classifies their clinical appropriateness.

RESULTS

327 participants fully described their process of blood pressure measurement with 296 (90.5%) classified as clinically appropriate. Agreement between self-reported and researcher-measured BMI was substantial (0.72 (95% CI 0.42 to 1.0)), but poor for blood pressure (0.06 (95% CI -0.11 to 0.23)). Self-reported height and weight readings identified 80.0% (95% CI 28.4 to 99.5) of individuals with a researcher-measured high BMI (≥than 35 kg/m²) and 9.1% (95% CI 0.23 to 41.3) of participants with a researcher-measured high blood pressure (≥140/90 mm Hg).

CONCLUSION

In this study, while self-reported BMI was found to have substantial agreement with researcher-measured BMI, self-reported blood pressure was shown to have poor agreement with researcher-measured blood pressure. This may be due to the inherent variability of blood pressure, overdiagnosis of hypertension by researchers due to 'white coat syndrome' or inaccurate self-reporting. Strategies to improve self-reporting of blood pressure for remote prescription of the combined pill are needed.

Effect of Self-monitoring of Blood Pressure on Diagnosis of Hypertension During Higher-Risk Pregnancy: The BUMP 1 Randomized Clinical Trial

IMPORTANCE

Inadequate management of elevated blood pressure (BP) is a significant contributing factor to maternal deaths. Self-monitoring of BP in the general population has been shown to improve the diagnosis and management of hypertension; however, little is known about its use in pregnancy.

OBJECTIVE

To determine whether self-monitoring of BP in higher-risk pregnancies leads to earlier detection of pregnancy hypertension.

DESIGN, SETTING, AND PARTICIPANTS

Unblinded, randomized clinical trial that included 2441 pregnant individuals at higher risk of preeclampsia and recruited at a mean of 20 weeks' gestation from 15 hospital maternity units in England between November 2018 and October 2019. Final follow-up was completed in April 2020.

INTERVENTIONS

Participating individuals were randomized to either BP self-monitoring with telemonitoring (n = 1223) plus usual care or usual antenatal care alone (n = 1218) without access to telemonitored BP.

MAIN OUTCOMES AND MEASURES

The primary outcome was time to first recorded hypertension measured by a health care professional.

RESULTS

Among 2441 participants who were randomized (mean [SD] age, 33 [5.6] years; mean gestation, 20 [1.6] weeks), 2346 (96%) completed the trial. The time from randomization to clinic recording of hypertension was not significantly different between individuals in the self-monitoring group (mean [SD], 104.3 [32.6] days) vs in the usual care group (mean [SD], 106.2 [32.0] days) (mean difference, -1.6 days [95% CI, -8.1 to 4.9]; P = .64). Eighteen serious adverse events were reported during the trial with none judged as related to the intervention (12 [1%] in the self-monitoring group vs 6 [0.5%] in the usual care group).

CONCLUSIONS AND RELEVANCE

Among pregnant individuals at higher risk of preeclampsia, blood pressure self-monitoring with telemonitoring, compared with usual care, did not lead to significantly earlier clinic-based detection of hypertension.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03334149.

Home Blood Pressure Measurement and Self-Interpretation of Blood Pressure Readings During Pregnancy: Hy-Result e-Health Prospective Study

Introduction

Hy-Result is a rule management system designed to help patients to be compliant with the home blood pressure measurement (HBPM) monitoring schedule and to understand their BP readings. The aim of the Hy-Result e-Health prospective study is to evaluate the practice and experience of women using the Hy-Result coaching app for self-interpretation of BP readings during and after pregnancy.

Methods

Participants were asked to: i) measure their BP at home; ii) use the Hy-Result app and send their PDF report to the researcher; iii) answer anonymously to 3 online independent questionnaires (Q).

Results

A total of 107 women accepted to measure their BP and use the app. Among them 82 (77%) performed HBPM and used successfully the system and 72 (88%) shared to the investigator their PDF report by email. Of these, 95% declared the software was “easy” or “very easy” to use; 93% believe the software helps them to monitor their BP more effectively (74% agree, 18% somewhat agree); 94% that the color code classification was “clear”; 76 (93%) affirmed that the app helped them when consulting their physician for their BP evaluation. Majority (87%) perceived the software to be reliable. Furthermore, 71 (87%) said they trust the system and 51 (62%) declared that performing HBPM and self-interpret their readings was “reassuring” whereas 6 (7%) felt that it was “a concern”.

Conclusion

This study shows that the majority (88%) of pregnant women performed HBPM and successfully used the Hy-Result software for self-interpretation of the BP readings. The use of the validated Hy-Result system by pregnant women may thus be recommended in common practice by healthcare professionals and patient associations.

Understanding the Needs of a Mobile Phone-Based Telemonitoring Program for Pregnant Women at High Risk for Pre-Eclampsia: Interpretive Qualitative Description Study

Background

Lack of early risk detection, diagnosis, and treatment of pregnant women at high risk for pre-eclampsia can result in high maternal mortality and morbidity not only in Pakistan but also in other low- to middle-income countries (LMICs). A potential tool for supporting pregnant women at high risk for pre-eclampsia for early detection is telemonitoring (TM). However, there is a limited body of evidence on end-user needs and preferences to inform the design of the TM programs for pregnant women at high risk for pre-eclampsia, specifically in LMICs such as Pakistan.

Objective

This study aims to explore the needs of TM for pregnant women at high risk for pre-eclampsia in Karachi, Pakistan, to inform a potential future feasibility trial of a mobile phone–based TM program.

Methods

An interpretive qualitative description approach was used to conduct and analyze 36 semistructured interviews with 15 (42%) pregnant women and 21 (58%) key informants, including clinicians; nurses; maternal, neonatal, and child health specialists; and digital health experts to explore the perspectives, needs, and preferences of a mobile phone–based TM program to support pregnant women at high risk for pre-eclampsia. Pregnant women were identified through heterogeneous sampling, whereas key informants were selected through purposive sampling. The interview transcripts were analyzed using a conventional content analysis technique.

Results

The following four themes emerged from the analysis of the transcripts: poor use of antenatal care during pregnancy, the value of a TM program in high-risk pregnancy, barriers influencing the adoption of TM programs and potential strategies, and considerations for implementing TM programs. The pregnant women and health care providers were willing to use a TM program as they perceived many benefits, including early identification of pregnancy complications, prompt treatment, convenience, cost-effectiveness, increased sense of empowerment for one’s health care, improved care continuity, and reduced clinical workload. However, some providers and pregnant women mentioned some concerns regarding the adoption of a TM program, including malfunctioning and safety concerns, potential inaccuracy of blood pressure machines, increased clinical workload, and resistance to learning new technology. Our study recommends building the capacity of patients and providers on TM program use, sensitizing the community and family members on the usefulness of the TM program, using an approach incorporating user-centered design and phased implementation to determine the clinical workload and whether additional staff for the TM program is required, and ensuring greater levels of co-design and the engagement of consumer representatives.

Conclusions

Our findings highlight the perceived feasibility of a mobile phone–based TM program for pregnant women at high risk for pre-eclampsia and provide insights that can be directly used for the design of future TM programs with the aim of reducing mortality and morbidity from pre-eclampsia and eclampsia in LMICs.

Patients' and Providers' Perspectives on and Needs of Telemonitoring to Support Clinical Management and Self-care of People at High Risk for Preeclampsia: Qualitative Study

Background

Preeclampsia is one of the leading causes of maternal mortality worldwide, with a global prevalence at 2%-8% of pregnancies. Patients at high risk for preeclampsia (PHRPE) have an increased risk of complications, such as fetal growth restriction, preterm delivery, abnormal clotting, and liver and kidney disease. Telemonitoring for PHRPE may allow for timelier diagnosis and enhanced management, which may improve maternal and perinatal outcomes.

Objective

The objective of this study is to determine the perceptions and needs of PHRPE and their health care providers with respect to telemonitoring through semistructured interviews with both groups. This study explored (1) what the needs and challenges of monitoring PHRPE are during pregnancy and in the postpartum period and (2) what features are required in a telemonitoring program to support self-care and clinical management of PHRPE.

Methods

This study used a qualitative descriptive approach, and thematic analysis was conducted. PHRPE and health care providers from a high-risk obstetrical clinic in a large academic hospital in Toronto, Canada, were asked to participate in individual semistructured interviews. Two researchers jointly developed a coding framework and separately coded each interview to ensure that the interviews were double-coded. The software program NVivo version 12 was used to help organize the codes.

Results

In total, 7 PHRPE and 5 health care providers, which included a nurse practitioner and physicians, participated in the semistructured interviews. Using thematic analysis, perceptions on the benefits, barriers, and desired features were determined. Perceived benefits of telemonitoring for PHRPE included close monitoring of home blood pressure (BP) measurements and appropriate interventions for abnormal BP readings; the development of a tailored telemonitoring system for pregnant patients; and facilitation of self-management. Perceived barriers to telemonitoring for PHRPE included financial and personal barriers, as well as the potential for increased clinician workload. Desired features of a secure platform for PHRPE included the facilitation of self-management for patients and decision making for clinicians, as well as the inclusion of evidence-based action prompts.

Conclusions

The perceptions of patients and providers on the use of telemonitoring for PHRPE support the need for a telemonitoring program for the management of PHRPE. Recommendations from this study include the specific features of a telemonitoring program for PHRPE, as well as the use of frameworks and design processes in the design and implementation of a telemonitoring program for PHRPE.

Pregnant women's experiences with the management of hypertensive disorders of pregnancy: a qualitative study

Background

Hypertensive disorders are a leading cause of mortality and morbidity during pregnancy. Despite multiple national and international clinical guidelines and a plethora of research in the field of optimising management, there has been limited research describing the perspectives and experiences of pregnant women with the management of hypertensive disorders of pregnancy (HDP). Understanding these perceptions and experiences is imperative to the optimisation of HDP management.

Methods

A qualitative study involving face-to-face, in-depth interviews were undertaken with 27 pregnant women diagnosed with and being treated for HDP to explore their perspectives of and experiences with clinical management. Written consent was obtained individually from each participant, and the interviews ranged from 16 to 54 min. Inductive codes were generated systematically for the entire data set. Line-by-line analysis was then performed and nodes were created within NVivo, a qualitative data management software. Data collection was continued until thematic saturation was reached. Thematic analysis was employed to interpret the data.

Results

Three major descriptive themes were discerned regarding the women’s perspectives on and experiences with the management of HDP: attitudes towards monitoring of HDP, attitudes and perceptions towards development and management of complications, and perceptions of pregnant women with chronic hypertension. Trust in the hospital system, positive attitudes towards close blood pressure monitoring as well as self-monitoring of blood pressure, and a realistic approach to emergency antenatal hospital admissions contributed to a positive attitude towards monitoring of HDP. Women with prior experiences of HDP complications, including pre-eclampsia, were more confident in their clinical management and knew what to expect. Those without prior experience were often in shock when they developed pre-eclampsia. Some women with chronic hypertension displayed limited understanding of the potential risks that they may experience during pregnancy and thus lacked comprehension of the seriousness of the condition.

Conclusions

The clinical management experiences of pregnant women with HDP were varied. Many women did not feel that they were well informed of management decisions and had a desire to be more informed and involved in decision-making. Clear, concise information about various facets of HDP management including blood pressure monitoring, prescription of the appropriate antihypertensive agent, and planning for potential early delivery are required.

Self-monitoring of blood pressure for preeclampsia patients: Knowledge and attitudes

Background

Preeclampsia is one of the causes of maternal deaths and is also responsible for complications such as premature births worldwide. In South Africa, hypertensive disorders cause 14% of all maternal deaths. Evidence indicates that it may be beneficial to empower women to monitor their blood pressure (BP) in the comfort of their homes.

Objectives

The purpose of this study was to explore and describe preeclampsia patients’ knowledge and attitudes towards the self-monitoring of their BP.

Method

An exploratory, descriptive and contextual qualitative research study was conducted. Fourteen preeclampsia patients were purposively sampled and participated in the study. In-depth semi-structured interviews were used to collect data. Data were analysed using the thematic analytic approach.

Results

The knowledge and attitudes towards the self-monitoring of blood pressure (SMBP) were explored. Four themes emerged, namely understanding of hypertension disorders during pregnancy, openness on self-monitoring at home, its hindrances and benefits. The participants portrayed limited understanding and knowledge of preeclampsia, yet they had positive attitudes towards monitoring BP themselves and were open and willing to do self-monitoring at home.

Conclusion

The use of SMBP may relieve overcrowding in public healthcare institutions. Encouraging patients to participate in self-monitoring could promote active participation and a positive outlook on their pregnancies. The unavailability and unaffordability of the equipment may pose a challenge to women with a low socioeconomic status.

Changes to management of hypertension in pregnancy, and attitudes to self-management: An online survey of obstetricians, before and following the first wave of the COVID-19 pandemic

OBJECTIVE

This study aimed to understand the views and practice of obstetricians regarding self-monitoring for hypertensive disorders of pregnancy (blood pressure (BP) and proteinuria), the potential for self-management (including actions taken on self-monitored parameters) and to understand the impact of the COVID-19 pandemic on such views.

DESIGN

Cross-sectional online survey pre- and post- the first wave of the COVID-19 pandemic.

SETTING AND SAMPLE

UK obstetricians recruited via an online portal.

METHODS

A survey undertaken in two rounds: December 2019-January 2020 (pre-pandemic), and September-November 2020 (during pandemic) RESULTS: 251 responses were received across rounds one (150) and two (101). Most obstetricians considered that self-monitoring of BP and home urinalysis had a role in guiding clinical decisions and this increased significantly following the first wave of the COVID-19 pandemic (88%, (132/150) 95%CI: 83-93% first round vs 96% (95%CI: 92-94%), (97/101), second round; p = 0.039). Following the pandemic, nearly half were agreeable to women self-managing their hypertension by using their own readings to make a pre-agreed medication change themselves (47%, 47/101 (95%CI: 37-57%)).

CONCLUSIONS

A substantial majority of UK obstetricians considered that self-monitoring had a role in the management of pregnancy hypertension and this increased following the pandemic. Around half are now supportive of women having a wider role in self-management of hypertensive treatment. Maximising the potential of such changes in pregnancy hypertension management requires further work to understand how to fully integrate women's own measurements into clinical care.

"You Probably Won't Notice Any Symptoms": Blood Pressure in Pregnancy-Discourses of Contested Expertise in an Era of Self-Care and Responsibilization

Pregnancy is not a disease or illness, but requires clinical surveillance as life-threatening complications can develop. Preeclampsia, one such potentially serious complication, puts both mother and baby at risk. Self-monitoring blood pressure in the general population is well established, and its potential in pregnancy is currently being explored. In the context of self-monitoring, the information and guidance given to women regarding hypertension, and the literature they themselves seek out during pregnancy, are vital to perceptions of disease risk and subsequent responses to, and management of, any symptoms. Drawing on online, offline, official, and unofficial sources of information, discourses are examined to provide analysis of how self-responsibilization is reflected in contemporary information, advice, and guidance drawn from multiple sources. A paradox emerges between the paternalistic and lay discourses that seek to challenge and regain control. Findings are discussed in the context of Foucault's governmentality and medical power.

Reducing Disparities Using Telehealth Approaches for Postdelivery Preeclampsia Care

The management of hypertensive disease of pregnancy presents an ongoing challenge after patients are discharged from delivery hospitalizations. Preeclampsia and other forms of postpartum hypertension increase the risk for severe maternal morbidity and mortality in the postpartum period, and both hypertension and its associated adverse events disproportionately affect black women. With its ability to transcend barriers to health care access, telemedicine can facilitate high-quality postpartum care delivery for preeclampsia management and thereby reduce racial disparities in obstetric care and outcomes. Here we discuss racial disparities in preeclampsia and the challenge of providing equitable postpartum preeclampsia care. We then describe the utility of novel telemedicine platforms and their application to combat these disparities in preeclampsia care.

Adherence with blood pressure self-monitoring in women with pregnancy hypertension, and comparisons to clinic readings: A secondary analysis of OPTIMUM-BP

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Chronic hypertension and gestational hypertension groups had good adherence to self monitoring of blood pressure (SMBP).

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There was no evidence of adherence varying in different socio-demographic groups.

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The differences between SMBP and clinic BP readings were small.

Objectives

To assess adherence to self-monitoring of blood pressure (SMBP), and differences between SMBP and clinic readings, in a self-monitoring intervention for managing pregnancy hypertension.

Study design

OPTIMUM-BP was an unmasked randomised controlled clinical trial. 154 women with pregnancy hypertension from four maternity units in England were recruited and randomised to SMBP or usual care. This secondary analysis included 91 women randomised to self-monitoring who provided BP readings. Trial instructions were for daily SMBP.

Main outcome measures

Adherence was calculated as proportion of days on which SMBP readings were taken. Proportion of weeks in which at least 4 and at least 2 SMBP readings were taken was also calculated. Mean differences between clinic and SMBP measurements were calculated.

Results

Self-monitored BP data were available for 49 women with chronic hypertension and 42 women with gestational hypertension. Median percentage of days with SMBP readings was 77% (IQR 51, 89) in the chronic hypertension group and 85% (IQR 52, 95) in the gestational hypertension group. Adherence did not vary by different socio-demographic groups. Mean difference (95% CI) between clinic and SMBP for systolic BP was 0.99 mmHg (−1.44, 3.41; chronic hypertension) and 3.76 mmHg (0.75, 6.78; gestational hypertension) and for diastolic BP was 3.03 mmHg (0.93, 5.12; chronic hypertension) and 3.27 mmHg (0.56, 5.98; gestational hypertension).

Conclusions

Adherence to self-monitoring was good and differences between SMBP and clinic readings were small. These findings offer reassurance about the use of self-monitoring at a time when it is being increasingly implemented in maternity settings.

Home blood pressure monitoring in the diagnosis and treatment of hypertension in pregnancy: a systematic review and meta-analysis

BACKGROUND

Home blood pressure monitoring is increasingly used for pregnant individuals; however, there are no guidelines on such monitoring in this population. We assessed current practices in the prescription and use of home blood pressure monitoring in pregnancy.

METHODS

We conducted a systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs). We conducted a structured search through the MEDLINE (from 1946), Embase (from 1974) and CENTRAL (from 2018) databases up to Oct. 19, 2020. We included trials comparing office and home blood pressure monitoring in pregnant people. Outcomes included patient education, home blood pressure device, monitoring schedule, adherence, diagnostic thresholds for home blood pressure, and comparison between home and office measurements of blood pressure.

RESULTS

We included in our review 21 articles on 19 individual studies (1 RCT, 18 observational) that assessed home and office blood pressure in pregnant individuals (n = 2843). We observed variation in practice patterns in terms of how home monitoring was prescribed. Eight (42%) of the studies used validated home blood pressure devices. Across all studies, measurements were taken 3 to 36 times per week. Third-trimester home blood pressure corresponding to office blood pressure of 140/90 mm Hg after application of a conversion factor ranged from 118 to 143 mm Hg (systolic) and from 76 to 92 mm Hg (diastolic), depending on the patient population and methodology. Systolic and diastolic blood pressure values measured at home were lower than office values by 4 (95% confidence interval [CI] -6 to -3) mm Hg and 3 (95% CI -4 to -2) mm Hg, respectively.

INTERPRETATION

Many issues related to home blood pressure monitoring in pregnancy are currently unresolved, including technique, monitoring schedule and target values. Future studies should prioritize the use of validated home measuring devices and standardized measurement schedules and should establish treatment targets.

PROSPERO REGISTRATION

CRD42020147352.

Maternal help seeking about early warning signs and symptoms of pre-eclampsia: A qualitative study of experiences of women and their families

BACKGROUND

Pre-eclampsia is a disorder of pregnancy, where delay in diagnosis and management of warning signs and symptoms can lead to serious morbidity and mortality for women and their infants.

AIM

The aim of this study was to understand factors that influenced women's help seeking in response to the onset of early warning signs and symptoms of pre-eclampsia as well as partners or family members' ability to raise their health concerns with healthcare professionals during the progression of the disorder.

DESIGN AND METHODS

A qualitative narrative research design was used. In depth interviews were used to explore the experiences of 23 women who experienced pre-eclampsia and their families in an urban setting in the UK. Purposive heterogeneity sampling was used to select participants.

RESULTS

Themes associated with help-seeking amongst women included: 1) Risk assessment, 2) Self-monitoring, 3) Organisational constraints. Women categorised as at low risk of hypertensive disorders at their antenatal booking appointment reported a lack of information on pre-eclampsia which affected their ability to seek help as they were unaware of signs and symptoms of the onset of the condition. In contrast women categorised as high risk at this initial appointment considered they were offered too much information about onset of pre-eclampsia, although this facilitated help seeking as they were much more able to recognise signs and symptoms of onset and knew who to contact. Of note is that some women did not experience 'classic' signs and symptoms of pre-eclampsia or were unable to distinguish these from normal signs and symptoms of pregnancy. Some women used self-monitoring, mainly self-initiated and self-taught, of their own blood pressure in order to a) negotiate access to treatment and b) to self-discharge from hospital postnatally.

CONCLUSION

Women and their families need individualised information on signs and symptoms of pre-eclampsia to facilitate timely and appropriate help seeking. Women often used self-monitoring of their blood-pressure to negotiate for help.

Patient perceptions, opinions and satisfaction of telehealth with remote blood pressure monitoring postpartum

Background

Our aim was to conduct a post participation survey of respondent experiences with in-home remote patient monitoring via telehealth for blood pressure monitoring of women with postpartum hypertension. We hypothesized that the in-home remote patient monitoring application will be implemented with strong fidelity and have positive patient acceptability.

Methods

This analysis was a planned secondary analysis of a non-randomized controlled trial of telehealth with remote blood pressure patient monitoring for postpartum hypertension compared to standard outpatient monitoring in women with a hypertension-related diagnosis during pregnancy. In collaboration with survey experts, we developed a 41-item web-based survey to assess 1) perception of quality of care received, 2) ease of use/ease to learn the telehealth program, 3) effective orientation of equipment, 4) level of perceived security/privacy utilizing telehealth and 5) problems encountered. The survey included multiple question formats including Likert scale responses, dichotomous Yes/No responses, and free text. We performed a descriptive analysis on all responses and then performed regression analysis on a subset of questions most relevant to the domains of interest. The qualitative data collected through open ended responses was analyzed to determine relevant categories. Intervention participants who completed the study received the survey at the 6-week study endpoint.

Results

Sixty six percent of respondents completed the survey. The majority of women found the technology fit easily into their lifestyle. Privacy concerns were minimal and factors that influenced this included age, BMI, marital status, and readmissions. 95% of women preferred remote care for postpartum follow-up, in which hypertensive type, medication use and ethnicity were found to be significant factors in influencing location of follow-up. Most women were satisfied with the devices, but rates varied by hypertensive type, infant discharge rates and BMI.

Conclusions

Postpartum women perceived the telehealth remote intervention was a safe, easy to use method that represented an acceptable burden of care and an overall satisfying method for postpartum blood pressure monitoring.

Trial registration

ClinicalTrials.gov identification number: NCT03111095 Date of registration: April 12, 2017.

Effects of slow and deep breathing on reducing obstetric intervention in women with pregnancy-induced hypertension: a feasibility study protocol

Objective: To evaluate whether a slow and deep breathing (SDB) intervention is acceptable to pregnant women. Methods: The trial aims to recruit 67 pregnant women who have developed pregnancy-induced hypertension (clinicaltrials.gov: NCT04059822). SDB will be undertaken daily for 10 min using a video aid and women will self-monitor blood pressure (BP) daily. At 36-weeks gestation women will complete an online questionnaire. Adherence, recruitment rates, and acceptance of the intervention will be evaluated. Conclusion: The findings from this trial will evaluate if women accept SDB as a treatment method. Initial analysis will evaluate if BP and/or obstetric interventions reduce following SDB intervention.

Current prevalence of self-monitoring of blood pressure during pregnancy: the BUMP Survey

OBJECTIVE

To understand the current prevalence of, and attitudes to, self-monitoring of blood pressure (BP) during pregnancy.

METHODS

Five thousand, five hundred and fifty-five pregnant women from antenatal clinics in 16 hospitals in England were invited to complete a survey.

MAIN OUTCOME MEASURES

The primary outcome was the proportion of women currently BP self-monitoring. Secondary outcomes included self-monitoring schedules and women's interactions with clinicians regarding self-monitoring. Population characteristics including risk factors for preeclampsia, ethnicity and deprivation level were considered.

RESULTS

Completed surveys were received and analysed from 5181 pregnant women (93% response rate). Comparison to hospital demographic data suggests that respondents were representative of the UK population. Nine hundred and eighty-three of 5181 (19%) women were currently self-monitoring their BP, constituting 189 of 389 (49%) hypertensive women and 794 of 4792 (17%) normotensive women. However, only 482 of 983 (49%) reported ever sharing this information with antenatal care teams. Of those who self-monitored, 68% (668/983) were able to provide a previous BP reading, compared with 1% (67/5181) of those who did not self-monitor.

CONCLUSION

Many women are now choosing to self-monitor their BP during pregnancy and clinicians should enquire about this proactively and consider providing better information on BP monitoring. Those who self-monitor appear to have better knowledge about their blood pressure. If these findings were replicated nationwide, around 125 000 pregnant women would be currently self-monitoring BP in the UK, yet only half of these women may communicate their readings to their antenatal care teams, suggesting a missed opportunity for enhanced care. Current trials will make the place of self-monitoring in pregnancy clearer.

[Ambulatory and Home Blood Pressure Measurement in Hypertensive Pregnant Women]

The prevalence of hypertensive disorders in pregnancy (HDP) is 6-8%. Blood pressure measurement (BPM) remains the cornerstone of diagnosis and should be performed in a standardised manner using automated devices. Office BPM represents only a spotty reading in an "artificial" environment failing to diagnose white coat hypertension (WCH). Ambulatory and home blood pressure measurement (ABPM/HBPM) are recommended for the diagnosis and differentiation of hypertension as well as for blood pressure and therapy control in women with HDP. Patient compliance is crucial for the use of both methods. ABPM is an appropriate method for the early identification of WCH and masked hypertension as well as for differentiating WCH from chronic hypertension < 20 week's gestation. HBPM has been shown to reduce the number of antenatal visits and hospital admissions compared to office blood pressure measurement without compromising maternal and fetal outcomes; it also avoids unnecessary antihypertensive medications and reduces the rate of labour inductions and false diagnosis of "preeclampsia". Problems associated with ABPM are its limited availability and inconvenience to patients due to sleep disturbances. Disadvantages of HBPM are the need for patient training, potential measurement errors, and the lack of evidence-based BP thresholds. The widespread use especially of HBPM may contribute to a reduction in workload of obstetric staff in the hospital and may save hospital expense.

Exploring the potential for introducing home monitoring of blood pressure during pregnancy into maternity care: current views and experiences of staff-a qualitative study

OBJECTIVE

One in 20 women are affected by pre-eclampsia, a major cause of maternal and perinatal morbidity, death and premature birth worldwide. Diagnosis is made from monitoring blood pressure (BP) and urine and symptoms at antenatal visits after 20 weeks of pregnancy. There are no randomised data from contemporary trials to guide the efficacy of self-monitoring of BP (SMBP) in pregnancy. We explored the perspectives of maternity staff to understand the context and health system challenges to introducing and implementing SMBP in maternity care, ahead of undertaking a trial.

DESIGN

Exploratory study using a qualitative approach.

SETTING

Eight hospitals, English National Health Service.

PARTICIPANTS

Obstetricians, community and hospital midwives, pharmacists, trainee doctors (n=147).

METHODS

Semi-structured interviews with site research team members and clinicians, interviews and focus group discussions. Rapid content and thematic analysis undertaken.

RESULTS

The main themes to emerge around SMBP include (1) different BP changes in pregnancy, (2) reliability and accuracy of BP monitoring, (3) anticipated impact of SMBP on women, (4) anticipated impact of SMBP on the antenatal care system, (5) caution, uncertainty and evidence, (6) concerns over action/inaction and patient safety.

CONCLUSIONS

The potential impact of SMBP on maternity services is profound although nuanced. While introducing SMBP does not reduce the responsibility clinicians have for women's health, it may enhance the responsibilities and agency of pregnant women, and introduces a new set of relationships into maternity care. This is a new space for reconfiguration of roles, mutual expectations and the relationships between and responsibilities of healthcare providers and women.

TRIAL REGISTRATION NUMBER

NCT03334149.

How do users of a 'digital-only' contraceptive service provide biometric measurements and what does this teach us about safe and effective online care? A qualitative interview study

OBJECTIVES

To describe user experience of obtaining and uploading biometric measurements to a 'digital-only' contraceptive service prior to a prescription for the combined oral contraceptive (COC). To analyse this experience to inform the design of safe and acceptable 'digital-only' online contraceptive services.

SETTING

An online contraceptive service available free of charge to women in South East London, UK.

PARTICIPANTS

Twenty participants who had ordered the combined oral contraceptive (COC) online. Our purposive sampling strategy ensured that we included participants from a wide range of ages and those who were and were not prescribed the COC.

INTERVENTION

A 'digital-only' contraceptive service that prescribes the COCafter an online medical history and self-reported height, weight and blood pressure (BP) with pills prescribed by a GMC registered doctor, dispensed by an online pharmacy and posted to the user.

DESIGN

Semistructured interviews with a purposive sample of 20 participants who were already enrolled in a larger study of this service.

ANALYSIS

Inductive, thematic analysis of the interviews assisted by NVivo qualitative analysis software.

RESULTS

Users valued the convenience of 'digital-only care' but experienced measuring BP but not height or weight as a significant barrier to service use. They actively engaged in work to understand and measure BP through a combination of recent/past measurements, borrowed machines, health service visits and online research. They negotiated tensions around maintaining a trusting relationship with the service, meeting its demands for accurate information while also obtaining the contraception that they needed.

CONCLUSION

Digital strategies to build trusting clinical relationships despite a lack of face-to-face contact are needed in 'digital-only' health services. This includes acknowledgement of work required, evidence of credible human support and a digital interface that communicates the health benefits of collaborating with an engaged clinical team.

Exploring perspectives, preferences and needs of a telemonitoring program for women at high risk for preeclampsia in a tertiary health facility of Karachi: a qualitative study protocol

Background

In Pakistan, deaths from preeclampsia/eclampsia (PE/E) represent one-third of maternal deaths reported at tertiary care hospitals. To reduce the morbidity and mortality associated with PE/E, an accessible strategy is to support pregnant women at high risk for preeclampsia (HRPE) by closely monitoring their blood pressures at home (i.e., telemonitoring) for the earliest signs of preeclampsia. This could lead to the earliest possible detection of high blood pressure, resulting in early intervention such as through medications, hospitalization, or delivery of the baby. The study aims to explore the perspectives, preferences and needs of telemonitoring (TM) for pregnant women at HRPE in Karachi, to inform future implementation strategies.

Methods

The study will employ an exploratory qualitative research design. The study will be conducted at the Jinnah Postgraduate Medical Centre (JPMC) hospital and Aga Khan University Hospital (AKUH) in Karachi, Sindh, Pakistan. Data will be collected through key-informant interviews (KIIs) and in-depth patient interviews (IDPIs). IDPIs will be conducted with the pregnant women at HRPE who are visiting the out-patient department/ antenatal clinics of JPMC hospital for antenatal check-ups and immunizations. KIIs will be conducted with the obstetricians, Maternal, neonatal and child health (MNCH) specialists and health care providers at JPMC, as well as TM experts from Karachi. Study data will be analyzed through conventional content analysis. Interviews are anticipated to begin in April 2020 and to be completed during the summer of 2020.

Discussion

This is the first study to explore the use of TM program for pregnant women at HRPE in a tertiary health facility in Karachi. The research will help explore perceived benefits associated with the use of a TM program alongside potential facilitators and barriers that may help inform the future implementation of a TM program for pregnant women at HRPE in Karachi.

User Experiences With and Recommendations for Mobile Health Technology for Hypertensive Disorders of Pregnancy: Mixed Methods Study

Background

Hypertensive disorders of pregnancy (HDP) are a primary cause of adverse maternal and neonatal outcomes worldwide. For women at risk of hypertensive complications, guidelines recommend frequent surveillance of blood pressure and signs of preeclampsia. Clinic visits range from every 2 weeks to several times a week. Given the wide ubiquity of smartphones and computers in most countries and a growing attention for self-management, digital technologies, including mobile health (mHealth), constitute a promising component of monitoring (self-measured) blood pressure during pregnancy. Currently, little is known about the experiences of women using such platforms and how mHealth can be aligned with their needs and preferences.

Objective

The objectives were twofold: (1) to explore the experiences of Dutch women who had an increased risk of HDP with a blended care approach (mHealth combined with face-to-face care) for remote self-monitoring of blood pressure and preeclampsia symptoms and (2) to formulate recommendations for the use and integration of mHealth in clinical care.

Methods

Alongside a prospective blended care study (SAFE@home study) that monitors pregnant women at increased risk of HPD with mHealth technology, a mixed methods study was conducted, including questionnaires (n=52) and interviews (n=11). Results were analyzed thematically.

Results

Of the 4 themes, 2 themes were related to the technologies themselves (expectations, usability), and 2 themes were related to the interaction and use of mHealth (autonomy and responsibilities of patients, responsibilities of health care professionals). First, the digital platform met the expectations of patients, which contributed to user satisfaction. Second, the platform was considered user-friendly, and patients favored different moments and frequencies for measuring their blood pressure. Third, patient autonomy was mentioned in terms of increased insight about their own condition and being able to influence clinical decision making. Fourth, clinical expertise of health care professionals was considered essential to interpret the data, which translates to subsequent responsibilities for clinical management. Data from the questionnaires and interviews corresponded.

Conclusions

Blended care using an mHealth tool to monitor blood pressure in pregnancy was positively evaluated by its users. Insights from participants led to 7 recommendations for designing and implementing similar interventions and to enhance future, morally sound use of digital technologies in clinical care.

SAFE@HOME: Digital health platform facilitating a new care path for women at increased risk of preeclampsia - A case-control study

OBJECTIVE

In women at risk of developing preeclampsia, we evaluated the use of a digital health platform for telemonitoring blood pressure and symptoms combined with a minimal antenatal visit schedule.

STUDY DESIGN

A case-control study for women with chronic hypertension, history of preeclampsia, or maternal cardiac or kidney disease. A care path was designed with reduced visits enhanced with a digital platform (SAFE@HOME) for daily blood pressure and symptom monitoring starting from 16 weeks of gestation. Home-measurements were monitored in-hospital by obstetric professionals, taking actions upon alarming results. This prospective SAFE@HOME group was compared to a retrospective control group managed without self-monitoring.

MAIN OUTCOME MEASURES

Primary: healthcare consumption (number of antenatal visits, ultrasounds, admissions and diagnostics), user experiences of the platform. Secondary: maternal and perinatal outcomes.

RESULTS

Baseline characteristics of the SAFE@HOME (n = 103) and control group (n = 133) were comparable. In the SAFE@HOME group, antenatal visits (mean 13.7 vs 16.0, p < 0.001) and ultrasounds (6.3 vs 7.4, p = 0.005) were lower compared to the control group. Admissions for hypertension or suspected preeclampsia were significantly fewer in the SAFE@HOME group (2.9% versus 13.5%, p = 0.004). Telemonitoring participants were highly satisfied using the platform. No differences were observed for maternal and perinatal outcomes.

CONCLUSIONS

Our care path including blood pressure telemonitoring for women at risk of preeclampsia allows fewer antenatal visits, ultrasounds and hypertension-related admissions. We observed no differences in perinatal outcomes. These results suggest that telemonitoring of blood pressure is feasible in a high-risk pregnant population and has the potential to profoundly change antenatal care.

Exploring the Use of Telemonitoring for Patients at High Risk for Hypertensive Disorders of Pregnancy in the Antepartum and Postpartum Periods: Scoping Review

Background

High blood pressure complicates 2% to 8% of pregnancies, and its complications are present in the antepartum and postpartum periods. Blood pressure during and after pregnancy is routinely monitored during clinic visits. Some guidelines recommend using home blood pressure measurements for the management and treatment of hypertension, with increased frequency of monitoring for high-risk pregnancies. Blood pressure self-monitoring may have a role in identifying those in this high-risk group. Therefore, this high-risk pregnancy group may be well suited for telemonitoring interventions.

Objective

The aim of this study was to explore the use of telemonitoring in patients at high risk for hypertensive disorders of pregnancy (HDP) during the antepartum and postpartum periods. This paper aims to answer the following question: What is the current knowledge base related to the use of telemonitoring interventions for the management of patients at high risk for HDP?

Methods

A literature review following the methodological framework described by Arksey et al and Levac et al was conducted to analyze studies describing the telemonitoring of patients at high risk for HDP. A qualitative study, observational studies, and randomized controlled trials were included in this scoping review.

Results

Of the 3904 articles initially identified, 20 met the inclusion criteria. Most of the studies (13/20, 65%) were published between 2017 and 2018. In total, there were 16 unique interventions described in the 20 articles, all of which provide clinical decision support and 12 of which are also used to facilitate the self-management of HDP. Each intervention’s design and process of implementation varied. Overall, telemonitoring interventions for the management of HDP were found to be feasible and convenient, and they were used to facilitate access to health services. Two unique studies reported significant findings for the telemonitoring group, namely, spontaneous deliveries were more likely, and one study, reported in two papers, described inductions as being less likely to occur compared with the control group. However, the small study sample sizes, nonrandomized groups, and short study durations limit the findings from the included articles.

Conclusions

Although current evidence suggests that telemonitoring could provide benefits for managing patients at high risk for HDP, more research is needed to prove its safety and effectiveness. This review proposes four recommendations for future research: (1) the implementation of large prospective studies to establish the safety and effectiveness of telemonitoring interventions; (2) additional research to determine the context-specific requirements and patient suitability to enhance accessibility to healthcare services for remote regions and underserved populations; (3) the inclusion of privacy and security considerations for telemonitoring interventions to better comply with healthcare information regulations and guidelines; and (4) the implementation of studies to better understand the effective components of telemonitoring interventions.

Blood pressure monitoring in high-risk pregnancy to improve the detection and monitoring of hypertension (the BUMP 1 and 2 trials): protocol for two linked randomised controlled trials

INTRODUCTION

Self-monitoring of blood pressure (BP) in pregnancy could improve the detection and management of pregnancy hypertension, while also empowering and engaging women in their own care. Two linked trials aim to evaluate whether BP self-monitoring in pregnancy improves the detection of raised BP during higher risk pregnancies (BUMP 1) and whether self-monitoring reduces systolic BP during hypertensive pregnancy (BUMP 2).

METHODS AND ANALYSES

Both are multicentre, non-masked, parallel group, randomised controlled trials. Participants will be randomised to self-monitoring with telemonitoring or usual care. BUMP 1 will recruit a minimum of 2262 pregnant women at higher risk of pregnancy hypertension and BUMP 2 will recruit a minimum of 512 pregnant women with either gestational or chronic hypertension. The BUMP 1 primary outcome is the time to the first recording of raised BP by a healthcare professional. The BUMP 2 primary outcome is mean systolic BP between baseline and delivery recorded by healthcare professionals. Other outcomes will include maternal and perinatal outcomes, quality of life and adverse events. An economic evaluation of BP self-monitoring in addition to usual care compared with usual care alone will be assessed across both study populations within trial and with modelling to estimate long-term cost-effectiveness. A linked process evaluation will combine quantitative and qualitative data to examine how BP self-monitoring in pregnancy is implemented and accepted in both daily life and routine clinical practice.

ETHICS AND DISSEMINATION

The trials have been approved by a Research Ethics Committee (17/WM/0241) and relevant research authorities. They will be published in peer-reviewed journals and presented at national and international conferences. If shown to be effective, BP self-monitoring would be applicable to a large population of pregnant women.

TRIAL REGISTRATION NUMBER

NCT03334149.

Intervention planning and modification of the BUMP intervention: a digital intervention for the early detection of raised blood pressure in pregnancy

BACKGROUND

Hypertensive disorders in pregnancy, particularly pre-eclampsia, pose a substantial health risk for both maternal and foetal outcomes. The BUMP (Blood Pressure Self-Monitoring in Pregnancy) interventions are being tested in a trial. They aim to facilitate the early detection of raised blood pressure through self-monitoring. This article outlines how the self-monitoring interventions in the BUMP trial were developed and modified using the person-based approach to promote engagement and adherence.

METHODS

Key behavioural challenges associated with blood pressure self-monitoring in pregnancy were identified through synthesising qualitative pilot data and existing evidence, which informed guiding principles for the development process. Social cognitive theory was identified as an appropriate theoretical framework. A testable logic model was developed to illustrate the hypothesised processes of change associated with the intervention. Iterative qualitative feedback from women and staff informed modifications to the participant materials.

RESULTS

The evidence synthesis suggested women face challenges integrating self-monitoring into their lives and that adherence is challenging at certain time points in pregnancy (for example, starting maternity leave). Intervention modification included strategies to address adherence but also focussed on modifying outcome expectancies, by providing messages explaining pre-eclampsia and outlining the potential benefits of self-monitoring.

CONCLUSIONS

With an in-depth understanding of the target population, several methods and approaches to plan and develop interventions specifically relevant to pregnant women were successfully integrated, to address barriers to behaviour change while ensuring they are easy to engage with, persuasive and acceptable.

Experiences of women receiving mhealth-supported antenatal care in the village from community health workers in rural Burkina Faso, Africa

Objective

This qualitative study explored the experiences of women receiving mhealth-supported antenatal care in a village, from community health workers (CHWs) in rural Burkina Faso, Africa.

Intervention

CHWs entered patient clinical data manually in their smartphone during their home visits. All wireless transferred data was monitored by the midwives in the community clinic for arising medical complications.

Methods

Semi-structured interviews were conducted with 19 pregnant women, who were housewives, married and their age ranged from 18 to 39 years. None had completed their formal education. Depending on the weeks of gestation during their first antenatal care visit, length of enrollment in the project varied between three and eight months. Transcripts were content-analyzed.

Results

Despite the fact that mhealth was a novel service for all participants, they expressed appreciation for these interventions, which they found beneficial on three levels: 1) it allowed for early detection of pregnancy-related complications, 2) it was perceived as promoting collaboration between CHWs and midwives, and 3) it was a source of reassurance during a time when they are concerned about their health. Although not unanimous, certain participants said their husbands were more interested in their antenatal care as a result of these services.

Conclusion

Findings suggested that mhealth-supported visits of the CHWs have the potential to increase mothers’ knowledge about their pregnancy and, as such, motivate them to attend more ANC visits. In response to this increased patient engagement, midwives approached women differently, which led to the mothers’ perception of improvement in the patient–provider relationship. Results also indicated that mhealth may increase spousal involvement, as services are offered at home, which is an environment where spouses feel more comfortable.

Home blood pressure in pregnancy-the upper reference limit

OBJECTIVES

To investigate whether the upper home blood pressure reference limit in healthy pregnant women correspond to 135/85 mmHg as used when diagnosing white coat hypertension outside pregnancy.

METHODS

In this prospective observational study 103 healthy, singleton pregnant women with a mean age of 32 ± 4 (±SD) years and with a median pre-pregnancy body mass index of 21 (interquartile range 20-24) kg/m were included. Home blood pressure was measured with the device Microlife® BP 3A Plus twice daily for three days (18 measurements in total) in addition to routine office blood pressure measurements in early (median 12 (weeks)), mid (20) and late pregnancy (35). Upper blood pressure reference limits were calculated as mean +2 SD.

RESULTS

Office blood pressure versus home blood pressure were 115 ± 11/72 ± 7 versus 103 ± 7/64 ± 5 mmHg in early pregnancy, 112 ± 11/74 ± 7 versus 102 ± 7/63 ± 5 mmHg in mid pregnancy and 118 ± 11/75 ± 8 versus 107 ± 8/66 ± 6 mmHg in late pregnancy. The mean difference between office blood pressure and home blood pressure was 10 mmHg. In late pregnancy, the upper reference limit was 140/91 mmHg for office blood pressure and 123/78 mmHg for home blood pressure with slightly lower values in early and mid pregnancy, respectively.

CONCLUSION

In late pregnancy, the upper home blood pressure reference limit in a population of healthy women was 123/78 mmHg. This value questions the generally proposed level of 135/85 mmHg to define white coat hypertension in pregnancy.

Preeclampsia: Risk Factors, Diagnosis, Management, and the Cardiovascular Impact on the Offspring

Hypertensive disorders of pregnancy affect up to 10% of pregnancies worldwide, which includes the 3%–5% of all pregnancies complicated by preeclampsia. Preeclampsia is defined as new onset hypertension after 20 weeks’ gestation with evidence of maternal organ or uteroplacental dysfunction or proteinuria. Despite its prevalence, the risk factors that have been identified lack accuracy in predicting its onset and preventative therapies only moderately reduce a woman’s risk of preeclampsia. Preeclampsia is a major cause of maternal morbidity and is associated with adverse foetal outcomes including intra-uterine growth restriction, preterm birth, placental abruption, foetal distress, and foetal death in utero. At present, national guidelines for foetal surveillance in preeclamptic pregnancies are inconsistent, due to a lack of evidence detailing the most appropriate assessment modalities as well as the timing and frequency at which assessments should be conducted. Current management of the foetus in preeclampsia involves timely delivery and prevention of adverse effects of prematurity with antenatal corticosteroids and/or magnesium sulphate depending on gestation. Alongside the risks to the foetus during pregnancy, there is also growing evidence that preeclampsia has long-term adverse effects on the offspring. In particular, preeclampsia has been associated with cardiovascular sequelae in the offspring including hypertension and altered vascular function.

The patient experience of kidney disease and pregnancy

Achieving parenthood is often a priority and goal for women with chronic kidney disease (CKD). It can be challenging due to medical and emotional complexities around pregnancy planning and care, increased risk of adverse maternal and fetal outcomes, fears about medications such as immunosuppressants and fetal harm, and concerns regarding the impact of pregnancy on women's kidney health. Navigating the pathways for shared decision-making regarding parenthood requires an understanding of the patient's experiences, values, priorities, and needs. In this review, we describe the patient perspective of high-risk pregnancies including those complicated by CKD and outline recommendations for counseling that incorporate these perspectives to improve the patient experience.

Validation of the iHealth Track and Omron HEM-9210T automated blood pressure devices for use in pregnancy

OBJECTIVE

Self monitoring of blood pressure in pregnancy is increasingly popular with both health care professionals and patients. We assessed the validity of the iHealth Track and Omron HEM-9210T automated blood pressure devices (with Bluetooth connectivity) for the use in telemonitoring of blood pressure in pregnancy.

METHODS

In this prospective observational study, the revised 2010 International Protocol of the European Hypertension Society (EHS) was used for the validation of the two devices against auscultatory sphygmomanometry by two independent observers who took 13 same arm measurements in 33 pregnant women, of which 10 were diagnosed with preeclampsia. The measurements were alternated between the test device and a calibrated aneroid sphygmomanometer following the protocol. Both automated devices were assessed sequentially in the same women.

RESULTS

In the group of 33 women, the iHealth Track passed the EHS 2010 validation criteria with 86/98/99 of 99 device-observer systolic measurement comparisons and 88/96/98 of 99 device-observer diastolic measurement comparisons within the 5/10/15 mmHg boundaries respectively. The Omron HEM-9210T passed the same criteria with 85/94/99 of 99 device-observer systolic measurement comparisons and 82/95/99 of 99 device-observer diastolic measurement comparisons.

CONCLUSIONS

The iHealth Track and Omron HEM-9210T automated blood pressure monitors are validated for use in pregnancy. These two devices can now be added to the short list of validated devices in pregnancy and can be used for self-measurement of blood pressure in a telemonitoring setting of pregnant patients with (a high risk of) hypertensive disease.

Blood pressure self-monitoring in pregnancy: examining feasibility in a prospective cohort study

BACKGROUND

Raised blood pressure (BP) affects approximately 10% of pregnancies worldwide, and a high proportion of affected women develop pre-eclampsia. This study aimed to evaluate the feasibility of self-monitoring of BP in pregnancy in women at higher risk of pre-eclampsia.

METHODS

This prospective cohort study of self-monitoring BP in pregnancy was carried out in two hospital trusts in Birmingham and Oxford and thirteen primary care practices in Oxfordshire. Eligible women were those defined by the UK National Institute for Health and Care Excellence (NICE) guidelines as at higher risk of pre-eclampsia. A total of 201 participants were recruited between 12 and 16 weeks of pregnancy and were asked to take two BP readings twice daily three times a week through their pregnancy. Primary outcomes were recruitment, retention and persistence of self-monitoring. Study recruitment and retention were analysed with descriptive statistics. Survival analysis was used to evaluate the persistence of self-monitoring and the performance of self-monitoring in the early detection of gestational hypertension, compared to clinic BP monitoring. Secondary outcomes were the mean clinic and self-monitored BP readings and the performance of self-monitoring in the detection of gestational hypertension and pre-eclampsia compared to clinic BP.

RESULTS

Of 201 women recruited, 161 (80%) remained in the study at 36 weeks or to the end of their pregnancy, 162 (81%) provided any home readings suitable for analysis, 148 (74%) continued to self-monitor at 20 weeks and 107 (66%) at 36 weeks. Self-monitored readings were similar in value to contemporaneous matched clinic readings for both systolic and diastolic BP. Of the 23 who developed gestational hypertension or pre-eclampsia and self-monitored, 9 (39%) had a raised home BP prior to a raised clinic BP.

CONCLUSIONS

Self-monitoring of BP in pregnancy is feasible and has potential to be useful in the early detection of gestational hypertensive disorders but maintaining self-monitoring throughout pregnancy requires support and probably enhanced training.