Abstract
Background
Hypertensive disorders of pregnancy affect up to 20% of pregnant individuals and significantly increase long-term cardiovascular disease (CVD). The postpartum period presents an opportunity for early intervention, yet it remains one of the most underused windows for preventive care.
Rationale
Traditional postpartum care models end at 6 weeks, missing critical windows for education, hypertension management, and preventive CVD care. Moreover, cardiovascular screening in primary care often fails to recognize hypertensive disorders of pregnancy as a risk factor, and CVD risk assessment in women remains suboptimal.
Summary
Healthy Hearts is an innovative, postpartum hypertension transitional care program consisting of timely, personalized nurse-navigated care, blood pressure management, and cardiovascular risk assessment extending through 14 weeks postpartum. The Healthy Hearts program has demonstrated increased patient engagement with early postpartum office visits, reduced postpartum hospitalizations, and improvement in transitional longitudinal care.
Key words: cardio-obstetrics, cardiovascular risk assessment, extended postpartum care, hypertensive disorders of pregnancy, multidisciplinary teams, primary care linkage, transitional care
Visual Summary
Visual Summary.
The Healthy Hearts Postpartum Hypertension Program
Illustration summarizing the Healthy Hearts program model, showing the 14-week extended postpartum care timeline, integration of early cardiovascular risk assessment, and coordinated transition to primary care. BP = blood pressure; CVD = cardiovascular disease; HDP = hypertensive disorders of pregnancy.
Hypertensive disorders of pregnancy (HDP) affect 1 in 5 pregnant individuals and account for 7% of maternal deaths. HDP are adverse pregnancy outcomes associated with maternal and fetal morbidity, mortality, and high health care costs.1 Black birthing individuals are disproportionately affected, with a 1.5- to 2-fold higher risk of HDP and 3- to 4-fold greater risk of cardiovascular mortality from pregnancy-related cardiovascular causes.1 While recognized as significant risk enhancers for cardiovascular disease (CVD), HDP continue to be underappreciated in clinical practice.1
Take-Home Messages
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Extending postpartum hypertension care through 14 weeks postpartum supports hypertension management, reduces postpartum hospitalizations for hypertension, and facilitates cardiovascular risk stratification of an at-risk population, although strategies to sustain long-term patient engagement are needed.
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The Healthy Hearts program demonstrates that comprehensive postpartum hypertension care can be scalable, equitable, and preventive.
There is substantial variability in national postpartum visit attendance rates, ranging from 24.9% to 96.5%, with only 72% of women attending at least 1 visit and fewer than 65% of individuals with Medicaid completing a routine postpartum visit.2 Increasing postpartum patient engagement requires innovative strategies to optimize patient-centered care and promote equitable care delivery.3 In response, the Healthy Hearts (HH) postpartum hypertension program was developed to address this gap by managing postpartum hypertension, educating patients on long-term cardiovascular risk, and facilitating linkage to primary care (PC).
Project Rationale
CVD is the leading cause of death for women in the United States and the primary contributor to preventable maternal mortality.1 HDP are major drivers of this risk and are associated with a 2- to 4-fold increased likelihood of developing chronic hypertension, coronary artery disease, stroke, and heart failure.4 Over 50% of pregnancy-related deaths occur between 7 days and 1 year postpartum, and most of them are preventable. The postpartum period presents a critical opportunity for early intervention, as most care models conclude by 6 weeks and rarely include long-term CVD risk assessment and transition to longitudinal preventive care.1
Project Description
The HH program redefines postpartum care by integrating cardiovascular prevention and expanding follow-up to 14 weeks, surpassing the conventional 6-week standard.3 Its multidisciplinary model integrates patient-centered navigation, blood pressure (BP) monitoring, cardiovascular risk assessment, and facilitated PC engagement for individuals with HDP. Postpartum patients eligible for the program were identified during their delivery hospitalization using an electronic health record referral order. Inclusion criteria include delivery at our institution, planned postpartum follow-up at the HH clinic, and a diagnosis of HDP, defined as chronic hypertension, gestational hypertension, pre-eclampsia (with or without severe features), eclampsia, or chronic hypertension with superimposed pre-eclampsia. Patients were excluded if they delivered at an outside facility, elected follow-up at another clinic, or cited distance as a barrier. Patients who declined HH follow-up still received standard postpartum care and were encouraged to establish or continue PC after postpartum care concluded.
Before hospital discharge, the program's nurse navigator met with eligible postpartum patients to assess interest and provide bedside education on the importance of BP monitoring postpartum. All patients were provided a validated BP monitor, taught proper home use of the device, and scheduled for a 3-day postpartum BP check, per American College of Obstetricians and Gynecologists guidelines.3 To support patient engagement, the nurse navigator maintained ongoing contact through the patient portal and/or phone outreach from hospital discharge through the 14-week follow-up period, offering scheduling support and ongoing education.
The HH clinic operated weekly within an ambulatory care site serving a predominantly under-resourced maternal population. Patients were seen in person by a dedicated advanced practice registered nurse (APRN) at 2, 6, and 14 weeks postpartum for standard wraparound postpartum care, with an added focus on BP management and cardiovascular risk management. There was a deliberate emphasis on establishing or re-establishing with PC. Many individuals in this population had limited health literacy or had historically received health care only during pregnancy. The HH team provided preventive care education, care navigation, and facilitated referrals to PC or reduced-cost community clinics, with access to social work, lactation, diabetes, and mental health services.
At 14 weeks postpartum, the focus shifted to cardiovascular risk stratification, including review of medical history, adverse pregnancy outcomes, and laboratory testing (including lipid panel, lipoprotein (a), high-sensitivity C-reactive protein, and hemoglobin A1c). Laboratory tests were drawn after 12 weeks postpartum to allow for normalization of pregnancy-related hormonal changes.5 Each patient received a wallet-sized “Passport to Heart Health” summarizing BP, weight, laboratory test results, identified CVD risk factors, and a personalized lifetime CVD risk score.6 Tailored counseling and referrals were provided, and patients were encouraged to share the passport with their PC provider to support long-term continuity of care.
Project Deliverables
Implementation of HH included establishment of an institutional review board–approved registry to support ongoing data collection and continuous quality improvement. Deliverables included reporting of demographic and clinical characteristics to define the under-resourced population served; patient engagement through attendance at 2-, 6-, and 14-week postpartum visits; continuity of care indicators such as referrals to and completion of PC follow-up; cardiovascular risk stratification with laboratory testing and lifetime risk scoring at 14 weeks postpartum; and clinical management outcomes including antihypertensive initiation or titration, emergency department referrals, and postpartum hospital readmissions.
Project Outcome, Impact, and Future Directions
Since its launch on October 31, 2023, a total of 241 patients were retrospectively enrolled in the HH program through February 4, 2025. Participant demographics (Table 1) included a median age of 31 years, 35.2% Black race, 41.8% Hispanic ethnicity, 68.5% on Medicaid/Medicare, and 9.5% uninsured. The most common complications in prior pregnancies included pre-eclampsia (25.2%, n = 32), preterm delivery (25.2%, n = 32), miscarriage (18.1%, n = 23), gestational hypertension (5.5%, n = 7), gestational diabetes (4.7%, n = 6), and chronic hypertension (3.9%, n = 5). The most common HDP in indexed pregnancy was pre-eclampsia (40%, n = 105), followed by gestational hypertension (27%, n = 72) (Figure 1). After delivery, 62.2% of individuals were discharged from the hospital on antihypertensive medications, and 75.5% were scheduled for a 3-day in-office BP check before hospital discharge (Figure 2).
Table 1.
Demographic and Characteristics of Participants Enrolled in the Healthy Hearts Program (N = 241)
| Average age, y | 31 |
| Race | |
| White | 100 (42.9) |
| Black/African American | 82 (35.2) |
| Asian | 4 (1.7) |
| Other | 47 (20.2) |
| Ethnicity | |
| Not Hispanic or Latina | 135 (58.2) |
| Hispanic or Latina | 97 (41.8) |
| Preferred language | |
| English | 170 (72.6) |
| Spanish | 54 (23.1) |
| Creole | 6 (2.6) |
| Marital status | |
| Single | 99 (42.5) |
| Married | 90 (38.6) |
| Significant other | 33 (14.2) |
| Divorced | 8 (3.4) |
| Employment status | |
| Employed | 107 (52.2) |
| Unemployed | 88 (42.9) |
| Self-employed | 6 (2.9) |
| Other | 4 (2.0) |
| Insurance | |
| Medicaid/Medicare | 159 (68.5) |
| Private insurance | 49 (21.8) |
| Uninsured | 22 (9.5) |
| Smoking status | |
| Never | 192 (82.8) |
| Former | 34 (14.7) |
| Current | 6 (4.9) |
| Average body mass index (kg/m2) | 34 (n = 138) |
| Prior adverse pregnancy complications | |
| Chronic hypertension | 5 (3.9) |
| Gestational hypertension | 7 (5.5) |
| Pre-eclampsia | 32 (25.2) |
| Eclampsia | 2 (1.6) |
| Postpartum hypertension | 2 (1.6) |
| Gestational diabetes | 6 (4.7) |
| Preterm delivery | 32 (25.2) |
| Small gestational age | 2 (1.6) |
| Stillbirth | 3 (2.4) |
| Placental abruption | 4 (3.1) |
| Miscarriage | 23 (18.1) |
| Induced termination | 11 (8.7) |
| Average number of prior pregnancies | 2.8 |
| Average living children | 2.3 |
| Average gestational age | 37.2 wk |
| Mode of delivery | |
| Vaginal | 115 (49.3) |
| Cesarean section | 118 (50.6) |
Values are n (%).
Figure 1.
Distribution of Hypertensive Disorders of Pregnancy Diagnosis by Phenotype
Proportion of patients in the Healthy Hearts program diagnosed with gestational hypertension, pre-eclampsia without severe features, and pre-eclampsia with severe features. Percentages reflect the baseline diagnostic distribution of enrolled participants. HDP = hypertensive disorders of pregnancy; HTN = hypertension.
Figure 2.
Postpartum Care Engagement in Healthy Hearts Program Among Women With Hypertensive Disorders of Pregnancy
The figure shows the percentage of patients scheduled for a 3-day blood pressure check, completion rates of 2-, 6-, and 14-week postpartum visits, and the percentage discharged on antihypertensive therapy. HH = Healthy Hearts; HDP = hypertensive disorders of pregnancy.
In-office postpartum visit completion rates for HH were 87.9% at 2 weeks, 85.8% at 6 weeks, and 38.4% at 14 weeks (Figure 2). Among patients who completed laboratory tests and the 14-week visit, 6% had an optimal CVD profile, 36% had 1 major CV risk factor, and 28% had ≥2 major CV risk factors (Figure 3). Individual laboratory values varied across patients and were used to guide cardiovascular risk stratification, lifestyle counseling, and specialist referrals when indicated.
Figure 3.
Lifetime Risk Score for Cardiovascular Disease by Risk Stratum
Percentage of participants across cardiovascular risk strata defined by risk factor burden: optimal cardiovascular health, ≥1 not optimal factor, ≥1 elevated factor, 1 major risk factor, and ≥2 major risk factors. CV = cardiovascular; CVD = cardiovascular disease.
By the 14-week visit, 51.9% of women remained on 1 antihypertensive, 6.4% on ≥2, and 41.6% on none. Of the 241 patients who completed at least 1 visit, 70% received a PC referral, and 64% had a scheduled or completed visit within 6 months postpartum. At 30 days, out of 241 patients, 44 (9%) patients required an emergency department visit/triage for postpartum hypertension. Only 2.9% of all patients in the program (7 of 241) required readmissions for postpartum hypertension. Of all patients who presented to the emergency department at our institution with postpartum hypertension during study period (n = 95), only 7 (7.4%) were participants in Healthy Hearts (Figure 4).
Figure 4.
Summary of 14-Week Outcomes: Acute Care Use, Medication Use, and Primary-Care Linkage
Summary of 14-week program outcomes, including emergency department visits, hospital readmissions, antihypertensive medication use at the 14-week visit, and documented linkage to primary care. ER = emergency room; HH = Healthy Hearts; HTN = hypertension; PC = primary care.
These outcomes highlight the feasibility of engaging under-resourced patients in structured postpartum care. High early attendance exceeded national averages, reflecting the value of nurse navigation and proactive scheduling. While 14-week visit completion was lower, it marked progress beyond traditional models that rarely extend past 6 weeks. Linking nearly two-thirds of patients to PC and enabling remote BP management demonstrates potential for sustained prevention. Future efforts will incorporate remote BP monitoring and telemedicine services to improve 14-week completion and leverage registry data to guide equity-focused quality improvement and dissemination.
Discussion
Dedicated postpartum hypertension clinic models show that structured pathways improve follow-up and cardiovascular counseling.7,8 Transition clinics increased home BP monitor uptake and facilitated primary-care follow-up, demonstrating the value of coordinated care beyond routine obstetrics.7 More recently, multidisciplinary clinics with telehealth have achieved high attendance and equitable reach across race and insurance, indicating that virtual access can extend care without loss of engagement.8 Among individuals with pre-eclampsia, visit completion was markedly higher with telemedicine than in-person care (≈70% vs 32%), with fewer disparities, underscoring virtual care as a lever for engagement.9
Sustaining engagement beyond 6 weeks remains a challenge. In a retrospective study of 1,480 patients with HDP enrolled in the Systematic Treatment and Management of PostPartum Hypertension Program (STAMPP), only 12% completed cardiology and 19% PC follow-up by 1 year, with lower rates among Black patients and those with public insurance, highlighting persistent inequities despite structured interventions.10 Our findings reinforce the view that structural barriers drive postpartum attrition. The lower 14-week completion rate reflected the complexity of sustaining care as return-to-work obligations, transportation barriers, and insurance disruptions arose, suggesting that expanding telehealth could reduce attrition and maintain continuity.
Only a small number of programs explicitly combine postpartum and cardiovascular care, and most rely on sequential or parallel visits in maternal-fetal medicine and cardiology.7,9 In contrast, HH is APRN-led, with the APRN conducting the entire visit, integrating postpartum recovery, hypertension management, cardiovascular risk stratification, and transition planning. Unlike models focused solely on acute BP checks or later cardiovascular specialty follow-up, HH spans the full early-to-intermediate postpartum arc. Patients attend a structured 3-day BP check, structured 2- and 6-week visits, and complete a prevention-focused 14-week visit with formal cardiovascular risk stratification. This continuum addresses acute hypertension while deliberately bridging patients to PC and cardiology as needed, offering a pragmatic, comprehensive, and scalable framework for long-term prevention.
Conclusions
Healthy Hearts demonstrates that postpartum cardiovascular care can be redefined through structured nurse navigation, early engagement strategies, and deliberate linkage to PC. By extending care, the program reduces preventable morbidity, addresses equity gaps, and establishes a scalable pathway for lifelong cardiovascular disease prevention.
Funding Support and Author Disclosures
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Appendix
For a video summarizing the case, please see the online version of this paper.
Appendix
Care Beyond Delivery: Early Outcomes of an Extended Postpartum Hypertension Program
This video summarizes the Healthy Hearts postpartum hypertension program, describing its APRN-led follow-up model at 2, 6, and 14 weeks postpartum with integrated cardiovascular risk assessment. The presenters review patient demographics, hypertensive disorder distribution, engagement rates, antihypertensive use, acute care outcomes, cardiovascular risk findings, and linkage to primary care. The video concludes by highlighting how this extended postpartum model supports continuity of care and early cardiovascular prevention.
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Associated Data
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Supplementary Materials
Care Beyond Delivery: Early Outcomes of an Extended Postpartum Hypertension Program
This video summarizes the Healthy Hearts postpartum hypertension program, describing its APRN-led follow-up model at 2, 6, and 14 weeks postpartum with integrated cardiovascular risk assessment. The presenters review patient demographics, hypertensive disorder distribution, engagement rates, antihypertensive use, acute care outcomes, cardiovascular risk findings, and linkage to primary care. The video concludes by highlighting how this extended postpartum model supports continuity of care and early cardiovascular prevention.