Abstract
Background
Postpartum hypertension is a risk factor for severe maternal morbidity; however, barriers exist for diagnosis and treatment. Remote blood pressure (BP) monitoring programs are an effective tool for monitoring BP and may mitigate maternal health disparities. We aimed to describe and evaluate engagement in a remote BP monitoring program on BP ascertainment during the first 6‐weeks postpartum among a diverse patient population.
Methods and Results
A postpartum remote BP monitoring program, using cell‐enabled technology and delivered in multiple languages, was implemented at a large safety‐net hospital. Eligible patients are those with hypertensive disorders before or during pregnancy. We describe characteristics of patients enrolled from January 2021 to May 2022 and examine program engagement by patient characteristics. Linear regression models were used to calculate mean differences and 95% CIs between characteristics and engagement metrics. We describe the prevalence of patients with BP ≥140/or >90 mm Hg. Among 1033 patients, BP measures were taken an average of 15.2 days during the 6‐weeks, with the last measurement around 1 month (mean: 30.9 days), and little variability across race or ethnicity. Younger maternal age (≤25 years) was associated with less frequent measures (mean difference, −4.3 days [95% CI: −6.1 to −2.4]), and grandmultiparity (≥4 births) was associated with shorter engagement (mean difference, −3.5 days [95% CI, −6.1 to −1.0]). Prevalence of patients with BP ≥140/or >90 mm Hg was 62.3%, with differences by race or ethnicity (Black: 72.9%; Hispanic: 52.4%; White: 56.0%).
Conclusions
A cell‐enabled postpartum remote BP monitoring program was successful in uniformly monitoring BP and capturing hypertension among a diverse, safety‐net hospital population.
Keywords: home blood pressure monitoring, hypertension, postpartum, pregnancy
Subject Categories: Hypertension, Pregnancy, Race and Ethnicity, High Blood Pressure
Nonstandard Abbreviations and Acronyms
- MD
mean difference
- RBPM
Remote Blood Pressure Monitoring Program
Research Perspective.
What Is New?
We show that a cell‐enabled postpartum monitoring program implemented at the hospital level demonstrated similar levels of program engagement and blood pressure ascertainment across racial and ethnic groups across the 6‐week postpartum follow‐up period.
Other factors associated with reduced program engagements were young maternal age (≤25) and having >4 children.
What Question Should Be Addressed Next?
Implementation of a remote blood pressure monitoring program may be a promising method to improve access to care during postpartum, but inequities persist.
Beyond the work of monitoring postpartum blood pressure, what can be done to reduce inequities in postpartum hypertension?
Given high rates of postpartum hypertension in this population, what strategies are most effective for blood pressure monitoring beyond 6‐weeks postpartum?
Severe maternal morbidity and mortality during the postpartum period are increasing in the United States and stark inequities exist across racial lines, 1 with non‐Hispanic Black pregnant patients 2.6 times more likely to experience maternal mortality compared with their non‐Hispanic White counterparts. 2 A primary risk factor for severe maternal morbidity and mortality 3 is postpartum hypertension, defined as elevated blood pressure (BP) occurring within 6‐weeks after delivery. Postpartum hypertension can be hypertension following a pregnancy complicated by chronic hypertension, preeclampsia, or gestational hypertension; and in the case of de novo postpartum hypertension may be new onset. 4 Cardiovascular‐related severe maternal morbidity, which includes conditions such as acute heart failure, myocardial infarction, and stroke, is the leading cause of morbidity and mortality in the postpartum period, 5 thereby underscoring the need for improved diagnosis and treatment of postpartum hypertension, a precursor to many of these conditions.
The American College of Obstetricians and Gynecologists recommends that patients with hypertensive disorders in pregnancy receive a BP check between 7 and 10 days postpartum to check for hypertension. 6 However, adherence to this recommendation is poor and commonly cited barriers to attending in‐person clinic visits, such as work schedules, transportation, challenges with child care, and structural inequities in care, can exacerbate racial disparities in diagnosis and treatment. 7 , 8 , 9 Innovative approaches to improve the monitoring of BP among postpartum patients, specifically among those with preexisting and pregnancy‐related hypertension, are needed. 10
Remote blood pressure monitoring (RBPM) provides a promising opportunity to increase surveillance of BP, identify hypertension in a timely manner, and improve management and treatment. 4 Studies of RBPM programs among patients with hypertensive disorders of pregnancy have been effective in obtaining BP measurements during postpartum time points in accordance with American College of Obstetricians and Gynecologists recommendations, 11 , 12 increasing attendance at the 6‐week postpartum visit from 48.5% to 76.3% for non‐Hispanic Black patients and from 73.1% to 76.7% among non‐Hispanic White patients 13 and reducing hospital readmissions. 14 , 15 One program reported that text‐based postpartum RBPM resulted in >90% overall compliance in daily BP measurement across racial groups, which shows promise for equitable program fidelity 16 ; however, few studies represent samples with a high proportion of low income or minority racial and ethnic groups and nearly all existing RBPM programs require patients to read and speak in English.
Technological options for RBPM include an analog approach where the patient obtains a BP value at home and manually communicates it to their health care provider via text message or a digital approach that links BP readings from a device to clinicians through digital communication. 17 These devices can be Bluetooth‐enabled, often requiring a smart phone as well as connectivity to Wi‐Fi, or cell‐enabled devices that transmit directly through the cellular network. 18 Cell‐enabled technology bypasses the need for personal devices and connectivity data plans. As digital divides persist regarding wireless availability and home broadband across racial and income lines, 19 there is a risk that Bluetooth RBPM may not offer the same clinical benefits to lower income and historically marginalized communities.
In consideration of our safety‐net population, defined by a large proportion of uninsured or Medicaid patients, 20 our program chose to employ a device that is cell enabled, thus removing the need for smartphones, cellular data plans, and access to wireless networks. The purpose of this study was to investigate the impact of the program on BP ascertainment during the first 6‐weeks postpartum; examine differences in program engagement by race or ethnicity, age, hypertension diagnosis related to receiving RBPM cuff, gestational age, parity, delivery type; and describe the distribution of postpartum BP among a diverse patient population.
METHODS
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Implementation of Remote Blood Pressure Monitoring Program
Through a partnership with a cloud‐based software platform, Rimidi, Inc, Boston Medical Center implemented a postpartum RBPM program in April 2020. BMC is New England's largest safety‐net hospital with approximately 2800 deliveries per year. The postpartum RBPM was implemented institution wide as standard of care and enrolls >60 patients each month. Eligible patients were those delivering at ≥20 weeks gestation, including stillbirths and livebirths, with either chronic hypertension, gestational hypertension, preeclampsia, or de novo postpartum hypertension identified during the delivery hospitalization. Diagnoses of gestational hypertension and preeclampsia were made in accordance with American College of Obstetricians and Gynecologists guidelines, 21 requiring a systolic BP ≥140 mm Hg or a diastolic BP ≥90 mm Hg on 2 separate readings, at least 4 hours apart. De novo postpartum hypertension was defined as 2 elevated readings using the criteria above occurring after 12 hours from delivery through hospital discharge. All diagnoses were verified in the electronic medical record by a nurse before patients were approached for study enrollment and consent.
Program Protocol
After eligibility criteria is confirmed, an order for enrollment in the postpartum RBPM program is entered into the electronic medical record and the patient is provided with a BP cuff. The postpartum nurse fits the patient for the appropriate cuff size, distributes a cell‐enabled BP cuff, and provides direct teaching about taking an accurate BP measurement. If needed, a translator is included in this process. Patients are also provided with written education materials in English, Spanish, Portuguese, or Haitian Creole, the 4 languages that >90% of the birthing population at Boston Medical Center speak. The materials also contain a quick response link to a video demonstrating proper use and reiterating teaching points in their primary language.
An initial reading using the cell‐enabled cuff is obtained by a nurse and validated against a hospital sphygmomanometer to confirm accuracy. Patients are instructed to take their BP once daily for 6‐weeks. The device is synchronized to the electronic medical record. After each measurement, the data are instantly transmitted to a provider‐facing web‐based portal via the local cellular network as well as uploaded to a flow sheet in the patient's record. Data transmitted to the web portal include systolic BP, diastolic BP, heart rate, and date and time the measure was taken.
Figure 1 displays the algorithm for care. Patients with missing readings receive automated text messages reminding them to take their BP regularly. If a patient goes 3 days without providing a BP measurement, an automated text message is sent to remind them to monitor their BP. For patients who do not provide a measurement for 7 consecutive days, a nurse sends a personalized message encouraging the patient to check their BP. The nurse additionally notifies the patient's prenatal provider and recommends BP monitoring at the next postpartum visit. During the 6‐week follow‐up period, up to 3 personalized messages are sent. Patients with readings ≥160/110 mm Hg receive an automated text advising them to repeat their BP measurement and seek emergency care if BP remains elevated. All data are transmitted to a population management view in the web portal with alerts that highlight patients with missing readings or BP readings ≥140/90 mm Hg.
Figure 1. Algorithm for patient outreach, postpartum remote blood pressure monitoring program (2021–2022).
BP indicates blood pressure.
The nurse calls any patient with BP measures ≥140/90 mm Hg to review symptoms and context. Anyone with concerning symptoms such as headache or shortness of breath is instructed to go to labor and delivery triage for in‐person evaluation. Those who are asymptomatic and do not carry other significant cardiovascular risk factors are managed remotely with medication initiation or titration. Antihypertensive medications are initiated in partnership with a physician according to an algorithm that includes BP parameters and symptoms reported by the patient. At the end of the 6‐week postpartum period, patients receive a secure text notifying them they can stop checking their BP daily and that they are being discharged from the program. After the 6‐week follow‐up period, all patients are linked to primary care either with the help of their community health center, the hospital clinic‐based postpartum care coordinator, or a primary care bridge clinic nested in the obstetrics and gynecology department staffed by family medicine providers.
In the early phase of this program, there was limited nursing support to monitor the portal and respond directly to elevated BP. Starting in April 2022, nurse coverage expanded to 30 hours a week and since then all patients are also booked for a video‐based telemedicine visit within 24 to 48 hours after discharge. In this visit, the nurse observes the patient taking a BP at home and can evaluate the measurement in real time. The nurse also reviews key teaching points about postpartum hypertension and preeclampsia.
Program Evaluation
We conducted an analysis to evaluate engagement with the postpartum RBPM program and examined BP measures through 6‐weeks postpartum. We included all eligible patients who delivered between January 2021 through May 2022. BP data for this analysis were extracted in July 2022; therefore, all patients included in this analysis had the full 6‐weeks of follow‐up. We restricted the analysis to patients who had ≥2 BP measurements during the RBPM. The reason for this minimum is that a single measure is obtained at device distribution, and we sought to capture those who recorded at least 1 home measure. We excluded patients enrolled in the RBPM program from April to December 2020, as the data in these initial months of the program were not systematically integrated with electronic medical record data. Data collected from the monitoring program, including date and time of reading, systolic measure, and diastolic measure, were merged with sociodemographic and clinical information from hospital birth logs and hospital readmission data. Information obtained from the birth logs included gestational age at delivery, race and ethnicity, gravidity, parity, and delivery type. Maternal race and ethnicity is self‐identified by each patient as this is the protocol for patient registration in the electronic medical record, but we cannot negate the possibility that it may have been administratively assigned for some patients. The study was approved by the Boston University Medical Campus Institutional Review Board.
Engagement Metrics
The primary engagement measures during the 6‐weeks postpartum included frequency of use, defined as number of BP measurements ascertained, and duration of participation in the program, defined as day of last measurement during the 6‐week (42‐day) program. Given that patients may have taken multiple BP readings on the same day, we included only the first BP reading of the day when assessing frequency of use.
Postpartum Blood Pressure
In addition to engagement metrics, we examined postpartum BP ranges that align with American Heart Association classifications (≥2 BP readings at any point during monitoring) of normal: <120/and <80 mm Hg; elevated: 120 to 129/and <80 mm Hg; hypertension stage 1: 130 to 139/or 80 to 90 mm Hg; and hypertension stage 2: ≥140/or ≥90 mm Hg. 22 Patients without at least 2 BP measurements in a single category could not be classified into a BP range category.
Statistical Analysis
We examined demographic and pregnancy characteristics of patients using descriptive statistics, including means and SD or frequency and percentages, where appropriate. We then evaluated frequency of use and duration of participation by calculating mean±SD and median (interquartile range) values overall and by selected demographic (maternal race and ethnicity and age) and pregnancy characteristics (hypertension type, gestational age, parity, and delivery type). Additionally, we performed both univariate and multivariate linear regression models to calculate crude and adjusted mean differences (MD) and 95% CIs of engagement measures by patients' characteristics. In multivariate models, maternal race and ethnicity and age were used for adjustment, acknowledging that maternal race and ethnicity does not reflect biological differences but instead serves as a proxy for exposure to structural racism. 23 An emphasis was placed on evaluating how engagement may vary across race and ethnicity to thoroughly examine how well the program improves equity in BP ascertainment across the full 6‐week postpartum period. Accordingly, we examined the proportion of patients who provided at least 1 BP measure within each postpartum week by race and ethnicity to evaluate retention.
Given the expected stabilization of BP after day 14 postpartum, 24 we calculated the prevalence of each BP range during the entire 6‐week postpartum period, within the early postpartum period (days 1–14), and the late postpartum period (days 15–42). We also examined the prevalence of each BP range according to prior diagnoses including chronic hypertension and preeclampsia or gestational hypertension. All statistical analyses were performed using SAS software V9.4. 25
RESULTS
RBPM Population
Among the 1118 patients who received a cell‐enabled cuff, 1033 (92.4%) provided at least 2 BP measurements over the 6‐week program duration (42‐days). The majority of patients, 78.2% (n=808), were eligible for the RBPM due to gestational hypertension, preeclampsia, or superimposed preeclampsia, and the remaining 17.2% (n=133) and 8.9% (n=92) of patients were eligible due to chronic hypertension or de novo hypertension during delivery hospitalization, respectively. Among the patients enrolled, the average maternal age was 30.9 years (SD: 6.2) and over three quarters of patients were either non‐Hispanic Black (40.5%) or Hispanic (36.6%). Demographic and reproductive characteristics varied by preexisting or pregnancy hypertension type. Those with chronic hypertension were older on average (mean age: 33.9 years) and more likely to be non‐Hispanic Black (59.4%) compared with those with gestational hypertension (42.7%), preeclampsia, or de novo postpartum hypertension (43.5%, Table 1).
Table 1.
Demographic and Reproductive Characteristics of Patients Enrolled in Postpartum RBPM, Overall and by Eligibility Criteria, 2021–2022, Boston Medical Center
| Characteristic | Total (n=1033) | Hypertension diagnosis related to receiving BP cuff | ||
|---|---|---|---|---|
| Chronic* (n=133) | Preeclampsia or gestational† (n=808) | De novo postpartum‡ (n=92) | ||
| Birth year, n (%) | ||||
| 2021 | 721 (69.8) | 82 (61.7) | 569 (70.4) | 70 (76.1) |
| 2022 | 312 (30.2) | 51 (38.4) | 239 (29.6) | 22 (23.9) |
| Maternal age, y, mean±SD | 30.9 (6.2) | 33.9 (5.1) | 30.4 (6.2) | 31.3 (6.1) |
| Maternal age, y, n (%) | ||||
| ≤25 | 218 (20.0) | 8 (6.0) | 194 (24.0) | 16 (17.4) |
| ≥26 to ≤30 | 249 (24.1) | 24 (18.1) | 195 (24.1) | 30 (32.6) |
| ≥31 to ≤35 | 311 (30.1) | 47 (35.3) | 242 (30.0) | 22 (23.9) |
| ≥36 | 255 (24.7) | 54 (40.1) | 177 (21.9) | 24 (26.1) |
| Maternal race and ethnicity, n (%) | ||||
| Non‐Hispanic Black | 464 (44.9) | 79 (59.4) | 345 (42.7) | 40 (43.5) |
| Hispanic | 388 (37.6) | 36 (27.1) | 317 (39.2) | 35 (38.1) |
| Non‐Hispanic White | 118 (11.4) | 13 (9.8) | 93 (11.5) | 12 (13.0) |
| Other/unknown | 63 (6.1) | 5 (3.8) | 53 (6.6) | 5 (5.4) |
| Parity, n (%) | ||||
| 1 | 476 (46.1) | 28 (21.1) | 413 (51.1) | 35 (38.0) |
| 2 | 287 (27.8) | 53 (39.9) | 212 (26.2) | 22 (23.9) |
| 3 | 153 (14.8) | 26 (19.6) | 108 (13.4) | 19 (20.7) |
| ≥4 | 117 (11.3) | 26 (19.6) | 75 (9.3) | 16 (17.4) |
| Preterm (<37 weeks), n (%) | 175 (16.9) | 30 (22.6) | 139 (17.2) | 6 (6.5) |
| Delivery type, n (%) | ||||
| Vaginal | 587 (56.8) | 61 (45.9) | 464 (57.4) | 51 (55.4) |
| Cesarean | 446 (43.2) | 72 (54.1) | 344 (42.6) | 41 (44.6) |
Chronic hypertension was defined as SBP ≥140 mm Hg systolic or DBP ≥90 mm Hg before pregnancy or before 20‐weeks of gestation, or use of antihypertensive medications before pregnancy.
Preeclampsia or gestational hypertension defined as SBP ≥140 mm Hg or a DBP ≥90 mm Hg on 2 separate readings, at least 4 hours apart and verified in EMR by nurse.
De novo postpartum defined as 2 elevated readings using the defined criteria occurring after delivery and verified in EMR by nurse.
DBP indicates diastolic blood pressure; EMR, electronic medical record; RBPM, Remote Blood Pressure Monitoring; and SBP, systolic blood pressure.
RBPM Program Engagement
Descriptive statistics of program engagement metrics are presented in Table 2. Over the 6‐week program, patients measured their BP an average of 15.2 days (SD: 10.2), with minimal differences by race and ethnicity. We also evaluated the last day of recorded BP measurement, and on average patients reported their last measurement around the 30.9th (SD: 11.7) day of follow‐up over 6‐weeks. Univariate and multivariate linear regression models were conducted to examine demographic and reproductive characteristics in relation to engagement metrics. Compared with non‐Hispanic White patients, non‐Hispanic Black (adjusted MD, −1.5 [95% CI, −3.5 to 0.5]) and Hispanic patients (adjusted MD, −1.2 [95% CI, −3.3 to 0.9]) reported roughly 1 day fewer of BP measurements but had similar durations of program engagement. Those ≤25 years of age provided on average 4.3 fewer days (95% CI, −6.1 to −2.4) of measurements and ended their engagement in the program 3 days (95% CI, −5.1 to −0.9) earlier in comparison to their counterparts aged 26 to 30 years old, after adjustment for race and ethnicity. Those with de novo postpartum hypertension had a lower frequency of use on average (MD, −2.3 days [95% CI, −4.5 to −0.2]) compared with those with preeclampsia/gestational hypertension and parous patients with ≥3 prior deliveries had a shorter engagement in the program (MD, −3.5 days [95% CI, −6.1 to −1.0]) than those with no prior deliveries.
Table 2.
Descriptive Statistics and Results of Univariate and Multivariable Linear Regression Models for Frequency and Duration of RBPM Program Engagement
| Characteristic | Total (n=1033) | Descriptive statistics of compliance metrics | Model 1: crude | Model 2: adjusted* | |||||
|---|---|---|---|---|---|---|---|---|---|
| Frequency of use | Duration of participation | Frequency of use | Duration of participation | Frequency of use | Duration of participation | ||||
| No. (%) | Mean±SD | Median (IQR) | Mean (SD) | Median (IQR) | Mean difference (days) (95% CI) | Mean difference (days) (95% CI) | |||
| Overall | 15.2 (10.2) | 13 (7 to 21) | 30.9 (11.7) | 36 (22 to 41) | |||||
| Maternal race and ethnicity | |||||||||
| Non‐Hispanic Black | 464 (44.9) | 15.0 (10.2) | 13 (7 to 21) | 31.7 (11.5) | 37 (26 to 41) | −1.9 (−3.9 to 0.2) | 0.7 (−1.7 to 3.0) | −1.5 (−3.5 to 0.5) | 1.1 (−1.2 to 3.4) |
| Hispanic | 388 (37.6) | 14.6 (10.0) | 13 (6 to 21) | 29.5 (12.0) | 34 (19 to 41) | −2.3 (−4.4 to −0.3) | −1.5 (−3.9 to 0.9) | −1.2 (−3.3 to 0.9) | −0.4 (−2.8 to 2.0) |
| Non‐Hispanic White | 118 (11.4) | 16.9 (10.7) | 15 (8 to 26) | 31.0 (11.8) | 35 (24 to 41) | Reference | Reference | Reference | Reference |
| Other/unknown | 63 (6.1) | 16.2 (9.7) | 15 (8 to 22) | 32.9 (9.9) | 38 (27 to 41) | −0.7 (−3.9 to 2.4) | 1.8 (−1.7 to 5.4) | −0.6 (−3.7 to 2.4) | 2.0 (−1.5 to 5.5) |
| Maternal age, y | |||||||||
| ≤25 | 218 (20.0) | 11.3 (8.3) | 10 (5 to 15) | 27.4 (12.0) | 29 (18 to 39) | −4.8 (−6.1 to −2.5) | −3.3 (−5.4 to −1.2) | −4.3 (−6.1 to −2.4) | −3.0 (−5.1 to −0.9) |
| ≥26 to ≤30 | 249 (24.1) | 15.5 (10.0) | 14 (7 to 23) | 30.6 (11.7) | 36 (22 to 41) | Reference | Reference | Reference | Reference |
| ≥31 to ≤35 | 311 (30.1) | 16.3 (10.3) | 15 (8 to 23) | 32.4 (11.0) | 37 (26 to 41) | 0.8 (−0.9 to 2.4) | 1.8 (−0.1 to 3.7) | 0.7 (−1.0 to 2.4) | 1.7 (−0.2 to 3.6) |
| ≥36 | 255 (24.7) | 16.7 (10.9) | 15 (7 to 25) | 32.3 (11.5) | 38 (26 to 42) | 1.2 (−0.6 to 2.9) | 1.6 (−0.4 to 3.7) | 1.1 (−0.7 to 2.8) | 1.6 (−0.4 to 3.6) |
| Hypertension diagnosis related to receiving RBPM cuff | |||||||||
| Chronic | 133 (12.9) | 16.1 (10.1) | 15 (8 to 22) | 32.8 (11.8) | 39 (28 to 42) | 0.8 (−1.0 to 2.7) | 2.1 (0.0 to 4.3) | −0.1 (−2.0 to 1.8) | 1.1 (−1.1 to 3.2) |
| Preeclampsia or gestational | 808 (78.2) | 15.2 (10.2) | 13 (7 to 22) | 30.6 (11.7) | 35 (22 to 41) | Reference | Reference | Reference | Reference |
| De novo postpartum | 92 (8.9) | 13.2 (9.7) | 11 (5 to 19) | 30.3 (11.4) | 35 (21 to 41) | −2.0 (−4.2 to 0.2) | −0.3 (−2.8 to 2.2) | −2.3 (−4.5 to −0.2) | −0.5 (−3.0 to 2.0) |
| Gestational age, weeks | |||||||||
| Preterm (<37) | 152 (14.7) | 14.9 (9.5) | 14 (7 to 22) | 31.0 (11.1) | 35 (23 to 41) | −0.3 (−2.1 to 1.4) | 0.2 (−1.8 to 2.2) | −0.4 (−2.1 to 1.3) | 0.1 (−1.9 to 2.1) |
| Term (≥37) | 881 (85.3) | 15.2 (10.3) | 13 (7 to 21) | 30.9 (11.8) | 36 (22 to 41) | Reference | Reference | Reference | Reference |
| Parity | |||||||||
| 1 | 476 (46.1) | 14.8 (9.8) | 13 (7 to 21) | 30.7 (11.2) | 34 (24 to 40) | Reference | Reference | Reference | Reference |
| 2 | 287 (27.8) | 15.9 (10.5) | 14 (7 to 23) | 31.5 (11.9) | 28 (22 to 41) | 1.2 (−0.3 to 2.7) | 0.8 (−0.9 to 2.5) | −0.1 (−1.6 to 1.4) | −0.6 (−2.4 to 1.2) |
| 3 | 153 (14.8) | 15.2 (10.1) | 13 (7 to 21) | 31.1 (11.7) | 36 (22 to 41) | 0.5 (−1.4 to 2.3) | 0.3 (−1.8 to 2.5) | −1.6 (−3.5 to 0.4) | −1.9 (−4.2 to 0.3) |
| ≥4 | 117 (11.3) | 14.8 (11.0) | 12 (5 to 22) | 29.8 (12.9) | 35 (20 to 41) | 0.0 (−2.0 to 2.1) | −1.0 (−3.3 to 1.4) | −2.2 (−4.4 to 0.0) | −3.5 (−6.1 to −1.0) |
| Delivery type | |||||||||
| Vaginal | 587 (56.8) | 14.9 (10.3) | 13 (7 to 21) | 30.5 (11.8) | 35 (22 to 41) | Reference | Reference | Reference | Reference |
| Cesarean | 446 (43.2) | 15.5 (10.0) | 14 (7 to 22) | 31.4 (11.5) | 36 (24 to 41) | 0.6 (−0.6 to 1.9) | 0.8 (−0.6 to 2.3) | 0.4 (−0.9 to 1.6) | 0.5 (−0.9 to 2.0) |
IQR indicates interquartile range; and RBPM, Remote Blood Pressure Monitoring.
Adjusted model for maternal race or ethnicity was adjusted for maternal age. Adjusted model for maternal age was adjusted for maternal race and ethnicity. All other adjusted models were adjusted for hypertension diagnosis related to receiving RBPM cuff, gestational age, parity, and delivery type of study pregnancy.
To assess program retention, we also examined the proportions of patients who provided at least 1 BP measurement during each week postpartum (Figure 2). During the first week postpartum, >90% of patients recorded at least 1 BP measure with no difference in engagement between race and ethnicity subgroups. Although there was retention in participation at each postpartum week, we observed similar rates of program fatigue week to week among racial and ethnic groups, with roughly half of all patients engaging with the program for the full duration.
Figure 2. Proportion of patients measuring blood pressure by postpartum week and by race and ethnicity.
NH indicates Non‐Hispanic.
Postpartum Blood Pressure
The distribution of patients within BP ranges are displayed in Table 3. The majority of patients (94.2%) had at least 2 BP measurements above the <120/and <80 mm Hg range in the 6‐week postpartum period, with 62.3% reporting ≥2 readings of ≥140/or 90 mm Hg. The highest prevalence of BP ≥140/or >90 mm Hg was observed among non‐Hispanic Black patients (71.9%). We examined the ranges of BP in the early and late postpartum periods. Compared with the early postpartum period, the prevalence of ≥140/or >90 mm Hg in the late postpartum period decreased in all subgroups, but differences by race and ethnicity persisted.
Table 3.
Proportion of Patients in Each Blood Pressure Range by Postpartum Timing, Overall and by Race and Ethnicity
| Blood pressure ranges, n (%) | Total | Race or Ethnicity | ||
|---|---|---|---|---|
| Non‐Hispanic Black patients | Hispanic patients | Non‐Hispanic White patients | ||
| All patients: postpartum days 1–42 | ||||
| n=1001 | n=448 | n=376 | n=116 | |
| SBP <120 and DBP <80 | 58 (5.8) | 19 (4.2) | 33 (8.8) | 5 (4.3) |
| SBP 120–129 and DBP <80 | 37 (3.7) | 13 (2.9) | 14 (3.7) | 7 (6.0) |
| SBP 130–139 or DBP 80–90 | 282 (28.2) | 94 (21.0) | 132 (35.1) | 39 (33.6) |
| SBP >140 or DBP >90 | 624 (62.3) | 322 (71.9) | 197 (52.4) | 65 (56.0) |
| Early postpartum (days 1–14) | ||||
| n=920 | n=408 | n=346 | n=110 | |
| SBP <120 and DBP <80 | 56 (6.1) | 16 (3.9) | 34 (9.8) | 5 (4.6) |
| SBP 120–129 and DBP <80 | 36 (3.9) | 9 (2.2) | 17 (4.9) | 7 (6.4) |
| SBP 130–139 or DBP 80–90 | 286 (31.1) | 107 (26.2) | 121 (35.0) | 40 (36.4) |
| SBP >140 or DBP >90 | 542 (58.9) | 276 (67.7) | 174 (50.3) | 58 (52.7) |
| Late postpartum (Days 15–42) | ||||
| n=742 | n=337 | n=268 | n=87 | |
| SBP <120 and DBP <80 | 148 (19.9) | 45 (13.4) | 66 (24.6) | 26 (29.0) |
| SBP 120–129 and DBP <80 | 46 (6.2) | 18 (5.3) | 19 (7.1) | 7 (8.1) |
| SBP 130–139 or DBP 80–90 | 290 (39.0) | 111 (32.9) | 124 (46.3) | 32 (36.8) |
| SBP >140 or DBP >90 | 259 (34.9) | 163 (48.4) | 59 (22.0) | 22 (25.3) |
DBP indicates diastolic blood pressure; and SBP, systolic blood pressure.
The prevalence of BP ranges by maternal race and ethnicity and for each hypertension diagnosis related to receiving a cuff are presented in Table 4. Those with preexisting chronic hypertension (76.9%) were more likely to have ≥2 BP readings ≥140/or 90 mm Hg in comparison to those with preeclampsia/gestational hypertension (61.5%).
Table 4.
Proportion of Patients in Each Blood Pressure Range by Hypertension Diagnosis Related to Receiving Blood Pressure Cuff, Overall and by Race and Ethnicity
| Blood pressure ranges, n (%) | Total | Race and Ethnicity | ||
|---|---|---|---|---|
| Non‐Hispanic Black Patients | Hispanic Patients | Non‐Hispanic White Patients | ||
| All patients: postpartum days 1–42 | ||||
| n=1001 | n=448 | n=376 | n=116 | |
| SBP <120 and DBP <80 | 58 (5.8) | 19 (4.2) | 33 (8.8) | 5 (4.3) |
| SBP 120–129 and DBP <80 | 37 (3.7) | 13 (2.9) | 14 (3.7) | 7 (6.0) |
| SBP 130–139 or DBP 80–90 | 282 (28.2) | 94 (21.0) | 132 (35.1) | 39 (33.6) |
| SBP >140 or DBP >90 | 624 (62.3) | 322 (71.9) | 197 (52.4) | 65 (56.0) |
| Chronic hypertension: postpartum days 1–42 | ||||
| n=130 | n=78 | n=35 | n=12 | |
| SBP <120 and DBP <80 | 4 (3.1) | 3 (3.9) | 1 (2.9) | 0 (0.0) |
| SBP 120–129 and DBP <80 | 4 (3.1) | 2 (2.6) | 2 (5.7) | 0 (0.0) |
| SBP 130–139 or DBP 80–90 | 22 (16.9) | 11 (14.1) | 5 (14.3) | 5 (41.7) |
| SBP >140 or DBP >90 | 100 (76.9) | 62 (79.5) | 27 (77.1) | 7 (58.3) |
| Preeclampsia/gestational hypertension: postpartum days 1–42 | ||||
| n=782 | n=332 | n=306 | n=92 | |
| SBP <120 and DBP <80 | 40 (5.1) | 14 (4.2) | 22 (7.2) | 3 (3.3) |
| SBP 120–129 and DBP <80 | 26 (3.3) | 8 (2.4) | 9 (2.9) | 6 (6.5) |
| SBP 130–139 or DBP 80–90 | 235 (30.1) | 74 (22.3) | 116 (37.9) | 29 (31.5) |
| SBP >140 or DBP >90 | 481 (61.5) | 236 (71.1) | 159 (52.0) | 54 (58.7) |
DBP indicates diastolic blood pressure; and SBP, systolic blood pressure.
DISCUSSION
The implementation of a cell‐enabled postpartum RBPM program available in multiple languages at an urban safety‐net hospital achieved surveillance of BP in a widely diverse and high‐risk population. This analysis demonstrates that implementation was effective in obtaining postpartum BP measurements across varied racial and ethnic subgroups. Furthermore, we demonstrate high engagement with greater than 90% of patients providing a measurement in the first week of the program and about 50% taking a measurement in the last week of the postpartum period. Previous research has shown this safety‐net population includes approximately 30% non‐English speakers, 70% insured through Medicaid, and a high proportion of comorbidities. 26
Our findings of improved postpartum BP surveillance as a result of RBPM are consistent with numerous other studies 11 , 12 , 14 , 27 , 28 and also contribute to the evidence base that RBPM likely reduces racial disparities in BP surveillance. 16 , 28 , 29 A clinical trial that compared a text‐message based RBPM program to in‐person visits among patients with pregnancy‐related hypertension eliminated previously observed disparities between Black and non‐Black patients in BP measurement over 2‐weeks of follow‐up. 16 Our findings demonstrate that similar levels of measurement exist among Black, White, and Hispanic patients and these similarities persist through 6‐weeks of follow‐up.
The collection of all BP measurements, including those within normal range, lends itself to better understanding the patterns of postpartum BP over the 6‐week period. Using the data collected, we examined the prevalence of hypertension throughout the 6‐week period. More than half of all patients had at least 2 separate readings reaching ≥140/or ≥90 mm Hg. Despite relatively similar metrics of program engagement across racial and ethnic groups, racial and ethnic differences in BP ranges were observed among patients in the program. We saw that non‐Hispanic Black patients had the highest prevalence of the most severe BP range (71.9%), and when comparing the late postpartum period to early postpartum, prevalence of ≥140/or >90 mm Hg decreased overall; however, differences by race and ethnicity remained. Disparities in postpartum hypertension have previously been documented, 30 , 31 yet in the context of RBPM strategies to ensure equitable care and access to medication initiation and titration and further evaluation if needed could reduce observed disparities.
The potential benefits of RBPM programs may be amplified in a safety‐net hospital population that historically has fewer health care contacts after delivery 31 , 32 and where postpartum patients would benefit from alternative layers of surveillance. Data show that the proportion of cardiovascular‐related maternal morbidity and mortality increases in the postpartum period. 5 , 32 Although there are currently no data on the impact of RBPM on severe maternal morbidity and mortality, 33 with hypertension serving as an indicator of cardiovascular morbidity, potentially earlier intervention based on data obtained through BP monitoring could mitigate future cardiovascular events. One trial reported reductions in diastolic BP up to 4 years after postpartum RBPM. 34 Furthermore, longer durations of postpartum RBPM, such as the 6‐week program, provide detailed BP surveillance beyond the American College of Obstetricians and Gynecologists recommendation, allowing for the identification of chronic disease in many of our patients. Indeed, our data showed that 32.6% of patients in the RBPM program recorded at least BP measurements of ≥140/or >90 mm Hg after 2‐weeks postpartum. These data are similar to estimates published by Palatnik et al, 27 suggesting there is a large proportion of the birthing population that deserves medication management more urgently outside the cadence of recommendations for a cardiovascular assessment at 3 months postpartum. 35 Of note, when the updated recommendations from American Heart Association/American College of Cardiology were published in 2022, we modified our postpartum protocols to start or titrate antihypertensive medication for 2 or more BP measures over 140/90 mm Hg. This analysis does not reflect that adjustment. Additionally, our data set lacked information on medication prescribed to manage postpartum hypertension, which should be integrated into future analyses.
Strengths
The RBPM program implementation at our institution was guided by health equity principles, specifically that the implementation of digital health technologies should not create or exacerbate health disparities. 36 To this end, we selected a cell‐enabled device that would not require patients to have access to a smartphone or wireless plan. Furthermore, we refined RBPM protocols and workflows to accommodate expansion to non‐English speakers. An example of an update made to the program was using the patient's preferred language from the electronic medical record to dictate if‐then logic to the web portal to implement automated texts in response to missed or elevated BP readings in English, Spanish, and Haitian Creole, the languages spoken by >90% of our patients. The majority of other RBPM programs are available to English‐speaking patients only, which would have excluded roughly 25% of our patients.
The high rates of program engagement in this population underscore the value of this particular technology in addressing the health needs of a publicly insured, racially diverse, and multilingual population. Our data demonstrate that the implementation of cell‐enabled BP monitoring program engages a population with historical barriers to care and that this technology works effectively across a wide urban geography where no‐cost wireless availability is scant. 37 Furthermore, our program was robust to numerous secular changes including the availability of outpatient nursing to support this work, turnover in administration requiring retraining in the durable medical equipment distribution, and, specific to our patient population, the beginning of a significant increase in refugee patients with major health‐related social needs, including housing instability, affecting ability to engage with care. 38
Limitations
Although patient education materials were provided in multiple languages and phone and direct text communication used a medical interpreter, the automated texts as part of the RBPM portal were in English and required modification, limiting our ability to initially provide all parts of the program in a patient's preferred language. Additionally, although we expect the majority of patients to have self‐identified their race and ethnicity, it may have been administratively assigned for some with no way for the research to confirm this. Furthermore, limited literacy may have created barriers to engagement for some patients. The implementation of the program was instituted at the hospital level as standard of care for patients deemed at high risk of postpartum hypertension; therefore, we do not have a contemporaneous reference group to examine the impact of the program on health outcomes. Although this limited the examination of outcomes, the hospital‐wide implementation facilitated high program participation, with >92% of all eligible patients taking a home value. The implementation of the RBPM outside of a research setting may have removed barriers to participation that have previously been noted in other studies, with 26% to 50% declining enrollment. 11 , 14
Engagement in the program over the 6‐week postpartum period decreased over time, with >90% of patients providing BP measurements in the first week to about 50% in the final week. Strategies to improve long‐term engagement in RBPM should be prioritized for future programs to ensure retention among patients whose BP does not reach a normal range within 6‐weeks postpartum. Additionally, program fatigue for this patient population is unique, as patients balance caring for themselves postpartum and their newborns. A postparticipation survey of a different RBPM program found that patients perceived the telehealth medium to be an acceptable burden of care; however, the study population consisted of mostly non‐Hispanic White patients (88%) and there were no considerations for non‐English speakers. 39 In our RBPM program we observed more missing BP patient data toward the end of the 6‐week postpartum period, which may have been due to program fatigue, a well‐known issue with mobile health devices. 40 Therefore, future remedies to minimize program fatigue in RBPM programs should prioritize the needs of a diverse patient population. The initial implementation of the RBPM program was expedited in response to outpatient care access closing in Boston to the COVID‐19 pandemic; however, community‐based consultations during the development of the methodology may have improved engagement through the 6‐week postpartum period.
The eligibility‐criteria included those with a history of hypertension, either preexisting, in pregnancy, or during the delivery hospitalization. Although these conditions capture patients at the greatest risk of hypertensive morbidity in the postpartum period, it is possible that all postpartum patients would benefit from RBPM. A remote monitoring program among patients without a hypertensive disorder of pregnancy found a rate of new‐onset postpartum hypertension of 8%. 41 In our safety‐net hospital, we have previously described a high incidence of de novo postpartum hypertension. 42
CONCLUSIONS
In conclusion, our results support that the implementation of a cell‐enabled RBPM program in a large safety‐net hospital setting may be a promising method to improve equity in access to cardiovascular care in the postpartum period. The program demonstrates its potential as an effective and accessible tool for improving postpartum care and contributing toward the mitigation of maternal health disparities. Future directions include qualitative interviews with providers and patients to understand the facilitators and barriers of RBPM, program modifications to ensure equitable access to medication, and research to better understand persistent disparities in postpartum hypertensive outcomes.
Sources of Funding
This work was supported by the National Institutes of Health (R01 HL158864).
Disclosures
None.
Supporting information
Data S1
Acknowledgments
We thank all the postpartum people who participated in this care model whose data supports our research.
This article was sent to Tazeen H. Jafar, MD, MPH, Associate Editor, for review by expert referees, editorial decision, and final disposition.
Supplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/JAHA.123.034031
For Sources of Funding and Disclosures, see page 11.
References
- 1. Callaghan WM, Creanga AA, Kuklina EV. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol. 2012;120:1029–1036. doi: 10.1097/AOG.0b013e31826d60c5 [DOI] [PubMed] [Google Scholar]
- 2. Hoyert DL. Maternal mortality rates in the United States, 2021. 2023.
- 3. Malhamé I, Danilack V, Raker C, Hardy EJ, Spalding H, Bouvier BA, Hurlburt H, Vrees R, Savitz DA, Mehta N. Cardiovascular severe maternal morbidity in pregnant and postpartum women: development and internal validation of risk prediction models. BJOG Int J Obstet Gynaecol. 2021;128:922–932. doi: 10.1111/1471-0528.16512 [DOI] [PubMed] [Google Scholar]
- 4. Kumar NR, Hirshberg A, Srinivas SK. Best practices for managing postpartum hypertension. Curr Obstet Gynecol Rep. 2022;11:159–168. doi: 10.1007/s13669-022-00343-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Petersen EE, Davis NL, Goodman D, Cox S, Mayes N, Johnston E, Syverson C, Seed K, Shapiro‐Mendoza CK, Callaghan W, et al. Vital Signs: pregnancy‐related deaths, United States, 2011–2015, and strategies for prevention, 13 States, 2013–2017. MMWR Morb Mortal Wkly Rep. 2019;68:423–429. doi: 10.15585/mmwr.mm6818e1 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. ACOG Committee Opinion No. 736: optimizing postpartum care. Obstet Gynecol. 2018;131:e140–e150. doi: 10.1097/AOG.0000000000002633 [DOI] [PubMed] [Google Scholar]
- 7. Romagano MP, Williams SF, Apuzzio JJ, Sachdev D, Flint M, Gittens‐Williams L. Factors associated with attendance at the postpartum blood pressure visit in pregnancies complicated by hypertension. Pregnancy Hypertens. 2020;22:216–219. doi: 10.1016/j.preghy.2020.10.003 [DOI] [PubMed] [Google Scholar]
- 8. Bryant AS, Haas JS, McElrath TF, McCormick MC. Predictors of compliance with the postpartum visit among women living in healthy start project areas. Matern Child Health J. 2006;10:511–516. doi: 10.1007/s10995-006-0128-5 [DOI] [PubMed] [Google Scholar]
- 9. Alvarez KS, Bhavan K, Mathew S, Johnson C, McCarthy A, Garcia B, Callies M, Stovall K, Harms M, Kho KA. Addressing childcare as a barrier to healthcare access through community partnerships in a large public health system. BMJ Open Qual. 2022;11:e001964. doi: 10.1136/bmjoq-2022-001964 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Bello NA, Miller E, Cleary K, Wapner R, Shimbo D, Tita AT. Out of office blood pressure measurement in pregnancy and the postpartum period. Curr Hypertens Rep. 2018;20:101. doi: 10.1007/s11906-018-0901-z [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11. Janssen MK, Demers S, Srinivas SK, Bailey SC, Boggess KA, You W, Grobman W, Hirshberg A. Implementation of a text‐based postpartum blood pressure monitoring program at 3 different academic sites. Am J Obstet Gynecol MFM. 2021;3:100446. doi: 10.1016/j.ajogmf.2021.100446 [DOI] [PubMed] [Google Scholar]
- 12. Hauspurg A, Lemon LS, Quinn BA, Binstock A, Larkin J, Beigi RH, Watson AR, Simhan HN. A postpartum remote hypertension monitoring protocol implemented at the hospital level. Obstet Gynecol. 2019;134:685–691. doi: 10.1097/AOG.0000000000003479 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. Khosla K, Suresh S, Mueller A, Perdigao JL, Stewart K, Duncan C, Oladipo V, Fess E, Heimberger S, Rana S. Elimination of racial disparities in postpartum hypertension follow‐up after incorporation of telehealth into a quality bundle. Am J Obstet Gynecol MFM. 2022;4:100580. doi: 10.1016/j.ajogmf.2022.100580 [DOI] [PubMed] [Google Scholar]
- 14. Hoppe KK, Williams M, Thomas N, Zella JB, Drewry A, Kim K, Havighurst T, Johnson HM. Telehealth with remote blood pressure monitoring for postpartum hypertension: a prospective single‐cohort feasibility study. Pregnancy Hypertens. 2019;15:171–176. doi: 10.1016/j.preghy.2018.12.007 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Hirshberg A, Zhu Y, Smith‐McLallen A, Srinivas SK. Association of a remote blood pressure monitoring program with postpartum adverse outcomes. Obstet Gynecol. 2023;141:1163–1170. doi: 10.1097/AOG.0000000000005197 [DOI] [PubMed] [Google Scholar]
- 16. Hirshberg A, Sammel MD, Srinivas SK. Text message remote monitoring reduced racial disparities in postpartum blood pressure ascertainment. Am J Obstet Gynecol. 2019;221:283–285. doi: 10.1016/j.ajog.2019.05.011 [DOI] [PubMed] [Google Scholar]
- 17. Kario K. Home blood pressure monitoring: current status and new developments. Am J Hypertens. 2021;34:783–794. doi: 10.1093/ajh/hpab017 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18. Hare AJ, Chokshi N, Adusumalli S. Novel digital technologies for blood pressure monitoring and hypertension management. Curr Cardiovasc Risk Rep. 2021;15:11. doi: 10.1007/s12170-021-00672-w [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. NW 1615 L. St, Washington S 800, Inquiries D 20036 U 419 4300|M 857 8562|F 419 4372|M. Internet, Broadband Fact Sheet. Pew Research Center: Internet, Science & Tech. Accessed March 22, 2024. https://www.pewresearch.org/internet/fact‐sheet/internet‐broadband/.
- 20. America's Health Care Safety Net: Intact But Endangered. National Academies Press; 2000:9612. doi: 10.17226/9612 [DOI] [PubMed] [Google Scholar]
- 21. ACOG practice bulletin No. 202: gestational hypertension and preeclampsia. Obstet Gynecol. 2019;133:1. doi: 10.1097/AOG.0000000000003018 [DOI] [PubMed] [Google Scholar]
- 22. Understanding blood pressure readings. Accessed March 23, 2024. https://www.heart.org/en/health‐topics/high‐blood‐pressure/understanding‐blood‐pressure‐readings.
- 23. Lett E, Asabor E, Beltrán S, Cannon AM, Arah OA. Conceptualizing, contextualizing, and operationalizing race in quantitative health sciences research. Ann Fam Med. 2022;20:157–163. doi: 10.1370/afm.2792 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24. Palatnik A, Mukhtarova N, Hetzel SJ, Hoppe KK. Blood pressure changes in gestational hypertension, preeclampsia, and chronic hypertension from preconception to 42‐day postpartum. Pregnancy Hypertens. 2023;31:25–31. doi: 10.1016/j.preghy.2022.11.009 [DOI] [PubMed] [Google Scholar]
- 25. SAS/SHARE 9.4: User's Guide. 2nd ed. SAS Institute Inc; 2019. [Google Scholar]
- 26. Murray Horwitz ME, Prifti CA, Battaglia TA, Ajayi AT, Edwards CV, Benjamin EJ, Yarrington CD, Parker SE. Prepregnancy cardiovascular disease risk factors and adverse pregnancy outcomes in a safety‐net hospital. J Women's Health. 2023;32:401–408. doi: 10.1089/jwh.2022.0322 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27. Cairns AE, Tucker KL, Leeson P, Mackillop LH, Santos M, Velardo C, Salvi D, Mort S, Mollison J, Tarassenko L, et al. Self‐Management of Postnatal Hypertension: the SNAP‐HT trial. Hypertension. 2018;72:425–432. doi: 10.1161/HYPERTENSIONAHA.118.10911 [DOI] [PubMed] [Google Scholar]
- 28. Hirshberg A, Downes K, Srinivas S. Comparing standard office‐based follow‐up with text‐based remote monitoring in the management of postpartum hypertension: a randomised clinical trial. BMJ Qual Saf. 2018;27:871–877. doi: 10.1136/bmjqs-2018-007837 [DOI] [PubMed] [Google Scholar]
- 29. Triebwasser JE, Janssen MK, Hirshberg A, Srinivas SK. Successful implementation of text‐based blood pressure monitoring for postpartum hypertension. Pregnancy Hypertens. 2020;22:156–159. doi: 10.1016/j.preghy.2020.09.001 [DOI] [PubMed] [Google Scholar]
- 30. Hauspurg A, Lemon L, Cabrera C, Javaid A, Binstock A, Quinn B, Larkin J, Watson AR, Beigi RH, Simhan H. Racial differences in postpartum blood pressure trajectories among women after a hypertensive disorder of pregnancy. JAMA Netw Open. 2020;3:e2030815. doi: 10.1001/jamanetworkopen.2020.30815 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31. Lopes Perdigao J, Hirshberg A, Koelper N, Srinivas SK, Sammel MD, Levine LD. Postpartum blood pressure trends are impacted by race and BMI. Pregnancy Hypertens. 2020;20:14–18. doi: 10.1016/j.preghy.2020.02.006 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32. Declercq ER, Cabral HJ, Cui X, Liu C, Amutah‐Onukagha N, Larson E, Meadows A, Diop H. Using longitudinally linked data to measure severe maternal morbidity. Obstet Gynecol. 2022;139:165–171. doi: 10.1097/AOG.0000000000004641 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33. Steele DW, Adam GP, Saldanha IJ, Kanaan G, Zahradnik ML, Danilack‐Fekete VA, Stuebe AM, Peahl AF, Chen KK, Balk EM. Postpartum home blood pressure monitoring: a systematic review. Obstet Gynecol. 2023;142:285–295. doi: 10.1097/AOG.0000000000005270 [DOI] [PubMed] [Google Scholar]
- 34. Kitt JA, Fox RL, Cairns AE, Mollison J, Burchert HH, Kenworthy Y, McCourt A, Suriano K, Lewandowski AJ, Mackillop L, et al. Short‐term postpartum blood pressure self‐management and long‐term blood pressure control: a randomized controlled trial. Hypertens Dallas Tex. 1979;2021(78):469–479. doi: 10.1161/HYPERTENSIONAHA.120.17101 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35. Moussa HN, Rajapreyar I. ACOG practice bulletin No. 212: pregnancy and heart disease. Obstet Gynecol. 2019;134:881–882. doi: 10.1097/AOG.0000000000003497 [DOI] [PubMed] [Google Scholar]
- 36. Jaworski BK, Webb Hooper M, Aklin WM, Jean‐Francois B, Elwood WN, Belis D, Riley WT, Hunter CM. Advancing digital health equity: directions for behavioral and social science research. Transl Behav Med. 2023;13:132–139. doi: 10.1093/tbm/ibac088 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37. How Wicked Free Wi‐Fi Works|Boston.gov. 2016. Accessed March 22, 2024. https://www.boston.gov/departments/innovation‐and‐technology/how‐wicked‐free‐wi‐fi‐works.
- 38. Solis S. Massachusetts keeps seeing influx of migrants. Axios 2022. Accessed March 22, 2024. https://www.axios.com/local/boston/2022/11/29/massachusetts‐migrants‐hatian‐influx.
- 39. Thomas NA, Drewry A, Racine Passmore S, Assad N, Hoppe KK. Patient perceptions, opinions and satisfaction of telehealth with remote blood pressure monitoring postpartum. BMC Pregnancy Childbirth. 2021;21:153. doi: 10.1186/s12884-021-03632-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40. Shaw RJ, Steinberg DM, Bonnet J, Modarai F, George A, Cunningham T, Mason M, Shahsahebi M, Grambow SC, Bennett GG, et al. Mobile health devices: will patients actually use them? JAMIA. 2016;23:462–466. doi: 10.1093/jamia/ocv186 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41. Hacker FM, Jeyabalan A, Quinn B, Hauspurg A. Implementation of a universal postpartum blood pressure monitoring program: feasibility and outcomes. Am J Obstet Gynecol MFM. 2022;4:100613. doi: 10.1016/j.ajogmf.2022.100613 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42. Parker SE, Ajayi A, Yarrington CD. De novo postpartum hypertension: incidence and risk factors at a safety‐net hospital. Hypertension. 2023;80:279–287. doi: 10.1161/HYPERTENSIONAHA.122.19275 [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data S1
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.