Abstract
Introduction
Hypertensive disorders of pregnancy (HDPs) are a leading contributor to preventable maternal morbidity and mortality and are associated with increased risk of cardiovascular disease. The postpartum period represents a critical opportunity to improve engagement in follow‐up care and support cardiovascular disease prevention after HDP; however, few patient‐facing, postpartum educational tools about HDP have been studied. We sought to develop and evaluate a patient educational discussion guide to support postpartum recovery and promote heart‐healthy behavior after a hypertensive pregnancy.
Methods
We developed an updated three‐page educational discussion guide, “My Health Beyond Pregnancy,” in collaboration with national professional societies and patient advocacy organizations. The guide was designed at a sixth‐grade reading level and in English and Spanish. Postpartum patients with HDP were recruited from an urban academic medical center and affiliated community health centers. Participants reviewed the guide and completed an anonymous survey assessing acceptability, appropriateness, and feasibility using validated measures (AIM, IAM, FIM, respectively) and open‐ended qualitative feedback. Quantitative data were analyzed using non‐parametric tests and qualitative responses were analyzed within the COM‐B framework to determine how the educational tool may impact behavior change.
Results
A total of 100 postpartum patients with HDP participated. The cohort was racially and ethnically diverse, with the majority publicly insured and nearly half having less than a college education. Participants agreed or strongly agreed that the guide was acceptable (95%), appropriate (96%), and feasible (97%). Perceptions did not differ by race, ethnicity, language, education, or insurance type. Qualitative analysis of free‐response questions demonstrated that the guide enhanced behavioral determinants, including psychological capability and reflective motivation by improving understanding of postpartum hypertension and supporting self‐advocacy.
Conclusion
The “My Health Beyond Pregnancy” educational discussion guide was perceived as highly acceptable, appropriate, and feasible among a diverse population of postpartum patients with HDP. By addressing key behavioral determinants and remaining useful across patient populations, the guide shows promise as a scalable tool to support equitable postpartum engagement and cardiovascular risk prevention. Future research should assess its impact on long‐term health behaviors, care engagement, and clinical outcomes.
Keywords: cardiovascular prevention, hypertension, hypertensive disorders of pregnancy, patient education handout, patient engagement, postpartum period, pregnancy complications
1. INTRODUCTION
Hypertensive disorders of pregnancy (HDPs) are among the most common pregnancy complications, affecting 16% of delivery hospitalizations in the United States [1]. HDPs are defined as preexisting or pregnancy‐associated hypertension, including chronic hypertension, gestational hypertension, preeclampsia, and eclampsia [2]. Black, Indigenous, and low‐income birthing patients have the highest prevalence of HDPs in the United States, and more than 20% of maternal deaths are attributable to HDPs [3]. Importantly, recent Maternal Mortality Review Committee data indicate that over 80% of pregnancy‐related deaths are preventable, including those due to hypertensive complications [3]. While there are several structural barriers to care that will likely require policy solutions, strengthening postpartum engagement for individuals with HDP through accessible, responsive education, and follow‐up remains a key opportunity to prevent complications that are largely avoidable with timely care.
In the peripartum period and in the years and decades beyond delivery, HDPs are associated with an increased risk of cardiovascular disease (CVD), including stroke, myocardial infarction, heart failure, cardiomyopathy, and spontaneous coronary artery dissection [4, 5, 6]. HDPs are also associated with the development of intermediate CVD risk factors in the months and years after delivery, including chronic hypertension, hypercholesterolemia, and diabetes [7]; therefore, the postpartum period may provide a window of opportunity to optimize prevention [8]. Optimal multipronged strategies to reduce lifetime health risks in people with chronic conditions depend on strong relationships with prepared providers and ensuring patients are adequately informed, activated, and empowered [9].
The postpartum period after HDP is an important opportunity for care providers to discuss heart‐healthy prevention efforts and encourage a transition back to ongoing primary longitudinal care [10]. However, there are significant disparities by race/ethnicity and socioeconomic status in postpartum visit attendance for patients with HDPs, and only 56.3% of patients with HDP reported receiving postpartum counseling on healthy lifestyle [11]. Thus, patients who have experienced a pregnancy complicated by HDP could greatly benefit from increased access to educational tools that support their care and recovery [12]. However, few patient‐facing educational tools for the postpartum period have been studied, particularly to improve management of long‐term risk after pregnancy complications [13, 14]. We therefore sought to develop and evaluate a patient educational discussion guide to support postpartum care and recovery after a hypertensive pregnancy, incorporating the concerns and voices of patient groups most at risk.
2. METHODS
2.1. Tool development
The educational discussion guide is an adaptation of the original My Health Beyond Pregnancy tool initially created by the Preeclampsia Foundation and the International Society for the Study of Hypertension in Pregnancy (ISSHP). One of our team members was involved in the late stages of the creation of the original discussion guide. In an effort to address identified barriers to postpartum engagement [10], they reapproached the stakeholders to redesign the guide and support more informed and sustained engagement in follow‐up care. The updated version of My Health Beyond Pregnancy was developed in collaboration with the Preeclampsia Foundation, ISSHP, and the Society for Maternal Fetal Medicine (SMFM). The three‐page, interactive guide is freely available online. One page serves as a goal‐tracker for patients to maintain their health goals (e.g., sleep, healthy eating, and postpartum visit attendance) in the months and years after delivery. There are written information and QR codes that scan to a short video on how to check blood pressure at home, a postpartum nutrition guide, and web pages about postpartum mental health and physical health screenings.
Our adaptation of the educational tool specifically addressed individual‐level barriers and facilitators to optimal postpartum care previously identified by our group and classified into domains using the Capability, Opportunity, Motivation‐Behavior (COM‐B) framework. The COM‐B framework is used to characterize the domains of behavior change [15] and inform behavioral change interventions by characterizing barriers and facilitators into domains that are amenable to specific strategies. We found that the COM‐B domains of psychological capability (e.g., knowledge gaps about navigating postpartum care), physical opportunity (e.g., limited continuity and coordination of follow‐up care), and reflective motivation (e.g., uncertainty around self‐advocacy) were behavioral determinants impacting postpartum care engagement that might be amenable to educational intervention [10].
We sought to create an educational discussion guide that would be accessible and inclusive. It is available in both English and Spanish, is at a sixth‐grade reading level in both languages according to the Flesch–Kincaid test, and features gender neutral language. We iteratively collaborated with 45 national and international stakeholders from professional societies to patient advocacy groups to other research teams, with a particular focus on listening to and integrating feedback from individuals from underserved communities (e.g., Black, Indigenous, other people of color, and non‐English speaking).
2.2. Evaluation
This study was conducted at an urban academic medical center in Eastern Massachusetts. All postpartum patients from the faculty, resident, or midwifery practices were screened for study eligibility during their delivery hospitalization or outpatient postpartum follow‐up visits at the hospital's obstetric clinic or affiliated community health centers. Those with any hypertensive complication of pregnancy who were over 18 and spoke English or Spanish proficiently were eligible for inclusion. We excluded patients who experienced fetal or neonatal loss. We analyzed responses from 100 patients and concluded that the sample had achieved thematic saturation. Recruitment ran concurrently with other quality improvement efforts in this same time frame, including dispensing of blood pressure monitors at hospital discharge and remote blood pressure monitoring outreach. No other quality improvement efforts were providing specific education on HDP or postpartum transitions during the time of recruitment for this study.
After patients gave their informed consent to participate in the study, they were provided a paper copy of the educational discussion guide for postpartum care and recovery in either English or Spanish, according to patient preference (Appendix 1). Patients were given at least 15 min to review the discussion guide before they completed an anonymous online survey using REDCap electronic data capture tools hosted by the “Mass General Brigham” Digital IS, Digital Research Applications [16]. The online survey (Appendix 2) collected patient demographics and examined the perceived acceptability, appropriateness, and feasibility of the discussion guide, and patients’ thoughts and feelings regarding their postpartum care and recovery. The survey also included free‐response questions soliciting qualitative patient feedback about the discussion guide.
The primary outcomes of this study were the perceived acceptability, appropriateness, and feasibility of the discussion guide for postpartum patients. We used a combination of a self‐developed questionnaire and previously validated implementation measures, including the Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of Intervention Measure (FIM).
Demographic factors collected included age, race, ethnicity, weeks since delivery, and education level. Chi‐square analyses were run to examine any significant differences in patient categorical variables by key demographic characteristics. Patient qualitative feedback on the discussion guide was collected and analyzed by two independent reviewers within the COM‐B framework.
Descriptive statistics were analyzed using chi‐square tests to analyze categorical variables, and Mann–Whitney U tests were used to examine composite scores of validated measures. All statistical analyses were performed in R.
Qualitative data from free response sections of the survey were examined using the COM‐B model previously described [15]. Our team used this framework to identify how, in these optional free‐response questions, patients might offer insight on the factors that influence their postpartum care and engagement, and to see how the educational discussion guide might impact the barriers and facilitators to patient behavior change in the postpartum period. The COM‐B model provided a structured categorization of patient feedback into three main domains: capability (psychological and physical capacity to engage in the behavior), opportunity (external factors that facilitate or hinder behavior) and motivation (internal processes that influence decision‐making and behavior, including reflective and automatic mechanisms).
Two independent reviewers, bilingual in English and Spanish, conducted a deductive content analysis according to a codebook previously utilized in qualitative analysis [10], mapping each patient response according to the COM‐B domains. A third independent reviewer resolved any discrepancies in the coding to ensure analytical rigor and interrater reliability. This analytical approach allowed for a theoretically grounded interpretation of these patient voices to better understand how our educational discussion guide influences postpartum behavior, specifically access to appropriate and accessible postpartum care and education. This study was approved as an exempt study by the “Mass General Brigham” IRB and conducted in accordance with its policies.
3. RESULTS
3.1. Patient demographics
We recruited 100 postpartum participants with HDP (Figure 1). While they were predominantly English speaking (85%), the minority identified as white (46%), and approximately half had less than a college degree (49%) and the majority of patients were publicly insured (62%). The majority of participants were approached during delivery hospitalization (63%). Over half of patients (55%) were nulliparous, and 70% did not have a known history of hypertension before pregnancy (Table 1).
FIGURE 1.
Recruitment flow diagram.
TABLE 1.
Characteristics of hypertensive postpartum patients.
| Demographic information (N = 100) | n |
|---|---|
| Age | 31.85 (SD = 5.41) |
| Race | |
| Native American or Alaska Native | 1 |
| Asian | 2 |
| Black or African American | 36 |
| Native Hawaiian or Pacific Islander | 1 |
| White | 46 |
| Other | 8 |
| Prefer not to say | 4 |
| Two or more | 2 |
| Ethnicity | |
| Hispanic | 36 |
| Non‐Hispanic | 62 |
| Prefer not to say | 2 |
| Education | |
| Some college or less | 49 |
| College or advanced degree | 50 |
| Language | |
| English | 85 |
| Spanish | 15 |
| Insurance type | |
| Public | 62 |
| Private | 38 |
| Weeks after delivery | |
| One or less | 63 |
| 2–5 | 17 |
| 6–12 | 19 |
| 12+ | 1 |
| First delivery | |
| Yes | 55 |
| No | 45 |
| Pre‐pregnancy hypertension diagnosis | |
| Yes | 29 |
| No | 70 |
| Recruitment site | |
| Postpartum floors | 63 |
| Outpatient appointment | 37 |
3.2. Perceived acceptability, appropriateness, and feasibility
Patients found the discussion guide to be acceptable, appropriate, and feasible to use. On average, 95%, 96%, and 97% of study participants either agreed or strongly agreed with the AIM, IAM, and FIM survey questionnaires, respectively (Figure 2). The acceptability, appropriateness, and feasibility of the tool did not differ by race, ethnicity, language, education, or insurance type.
FIGURE 2.
Study participants’ agreement with Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of Intervention Measure (FIM).
There were no recruitment‐timing differences in composite appropriateness (p = 0.07) or feasibility (p = 0.43). Although acceptability was high in both groups, participants recruited after hospital discharge reported a higher median acceptability score than those recruited during the delivery hospitalization (19 vs. 17, p = 0.04). All participants (100%) agreed or strongly agreed that the information in the educational discussion guide was helpful and easy to understand. After reading the educational discussion guide, 97% felt confident checking their own blood pressure, and 98% felt knowledgeable about caring for their body after pregnancy. Almost all participants (99%) felt confident knowing what to do with concerns about their blood pressure or recovery, and 100% felt confident talking to their healthcare provider about any postpartum health concerns. Additionally, 99% felt knowledgeable about how to live a heart‐healthy lifestyle (Table 2). Half of the respondents (50%) accessed at least one external link in the educational discussion guide through the QR codes. Results did not differ based on patients’ recruitment site, race, ethnicity, language spoken, or education level.
TABLE 2.
Patient agreement with knowledge and attitude questionnaire.
| Patient knowledge and attitudes | Patient agreement (%) |
|---|---|
| I found the information helpful | 100 |
| I found the information easy to understand | 100 |
| I feel confident checking my own blood pressure | 97 |
| I feel knowledgeable about caring for my body after my pregnancy | 98 |
| I feel confident knowing what to do if I have concerns about my blood pressure or my recovery | 99 |
| I feel confident talking to my obstetric and primary care providers about any concerns after my pregnancy | 100 |
| I feel knowledgeable about ways to live a lifestyle that is healthy for my heart | 99 |
3.3. Qualitative feedback
Qualitative feedback collected from the free‐text survey responses were analyzed using the COM‐B methodology. Most responses coded were in the domains of psychologic capability (i.e., increased understanding of postpartum hypertension and cardiovascular risk) and reflective motivation (i.e., proactive health planning and healthcare provider communication). Representative themes and illustrative quotes are presented below according to their COM‐B domain.
3.4. Capability
3.4.1. Psychological capability
Psychological capability enhancers (n = 110) were the most frequently coded. Many patients described how the discussion guide improved their understanding of postpartum hypertension and clarified unfamiliar clinical concepts. One patient wrote, “I didn't know that postpartum hypertension was a thing… I thought it was only possible during pregnancy.” Another noted the discussion guide “tells you why your blood pressure is important and why you should track it.” Spanish‐speaking patients also found the discussion guide to enhance their knowledge, noting “Ahora se donde buscar ayuda y entiendo cosas que no sabía” translated as, “now I know where to look for help and I understand things I hadn't known before.” Patients appreciated the clear structure and checklists of the discussion guide: “There were some things I forgot to cover in my notes that were on the checklist.” Patients frequently described the discussion guide as filling important gaps in previous care and improving preparation for follow‐up appointments.
Barriers (n = 10) often related to unclear terminology or insufficient explanation in the discussion guide. One patient noted, “Helpful, but I didn't know some of the medical terms.” Another patient wrote, “The ‘know your risk’ section could be better explained… it's kind of vague.”
3.4.2. Physical capability
Physical capability was coded less often (n = 6 enhancers, 1 barrier) but was found in comments about self‐care support and visual aids. One patient wrote, “The QR codes were helpful. They teach you how to take care of yourself.” Another patient described a barrier related to oversimplification of the tracking sheet for postpartum health and recovery: “How do you sum up three months of healthy eating in a box?”
3.5. Opportunity
3.5.1. Social opportunity
Social opportunity enhancers were coded in five patient responses. Patients suggested the guide could facilitate shared understanding with partners and normalize maternal health needs. One patient wrote, “It would be helpful for other moms. Dads as well, because they need to know what we go through.” No barriers were identified in this domain.
3.5.2. Physical opportunity
Regarding physical opportunity enhancers (n = 2), patients found the discussion guide physically accessible and easy to engage with. One patient shared, “No crazy words or medical terms, which makes everything really easy. I like the table where I can keep track of everything.” Barriers (n = 2) included feasibility concerns. A patient noted, “Most people will lose the paper chart… maybe an app with reminders?” Another questioned a recommendation in the discussion guide, “Seven to eight hours of sleep with a newborn is a little unreasonable.”
3.6. Motivation
3.6.1. Reflective motivation
Reflective motivation enhancers were common in patient responses (n = 30), while no barriers were identified. The discussion guide prompted planning and active engagement with postpartum care: “Never thought I would need postpartum care, and it helped me to think about the things I need to do after.” Patients also discussed feeling motivated to monitor their health, writing “ahora puedo tener precaución” translated as “now I can be cautious.” One patient wrote, “I normally throw this kind of stuff away, but this I'm going to keep.” Patients also described increased confidence in communicating with their healthcare providers: “Clear and easy to read, makes you feel like you can advocate for yourself in the doctor's office vs. just being passive.”
3.6.2. Automatic motivation
Only one patient response reflected automatic motivation, describing emotional distress around the influx of health information: “All this blood pressure stuff is scary and stressful, especially with a newborn.”
4. DISCUSSION
This study assessed the perceived acceptability, appropriateness, and feasibility of an educational discussion guide designed for postpartum patients who experienced HDPs. The investigation focused on how the guide supports patients in the immediate postpartum period and in the weeks following hospital discharge, with particular attention to its impact on diverse populations. The tool was widely regarded as acceptable, appropriate, and feasible by participants from various backgrounds. Notably, 72% of patients identified as Black and/or Hispanic, reflecting communities most affected by HDP‐related maternal morbidity and mortality. Additionally, factors such as race/ethnicity, language spoken, and education level did not significantly influence perceptions of the guide, suggesting it is accessible to individuals with varying health literacy and cultural backgrounds. Its clear language, visual layout, and availability in Spanish were frequently cited by patients as features that improved comprehension and usability. Feedback from optional text boxes reinforced these findings, highlighting the potential importance of culturally and linguistically appropriate educational materials in promoting health equity.
An important objective of the guide was to strengthen patient knowledge and confidence in managing postpartum health after HDP. Results showed that nearly all patients felt confident in monitoring their own blood pressure (97%) and managing recovery (98%). Furthermore, 99% reported confidence in responding to health concerns, and 100% felt comfortable discussing issues with their healthcare provider. Qualitative feedback revealed that patients felt more empowered to advocate for themselves and to identify concerning symptoms, supporting the guide's role in fostering effective patient‐provider communication and self‐management. In addition, half of patients accessed at least one external link using QR codes included in the guide, illustrating the potential of digital resources to extend education beyond clinical settings and qualitative analysis of the free text comments supported this as patients noted the usefulness of these digital tools for ongoing support and learning. The multimodal format—available in both print and digital forms—helps bridge the digital divide and supports continued engagement with postpartum care recommendations. Future research should examine whether engagement with these resources improves knowledge retention, participation in recommended, care, and clinical outcomes.
4.1. Limitations
This study was conducted at a single US teaching hospital and two affiliated healthcare centers, which may limit generalizability to other settings, especially rural areas, resource‐limited environments, or regions outside the United States. Long‐term impact on health management behaviors and clinical outcomes, particularly as this guide addresses individual but not structural determinants of health, remains unknown. Participants who agreed to join the study may have been more motivated to engage in their postpartum care, although very few patients declined enrollment (N = 21, 13%). Further work is needed to understand how to most effectively reach and support patients who may have access to care but lack engagement with their postpartum care team. While the educational discussion guide received positive patient responses regarding its perceived acceptability, appropriateness, and feasibility, its long‐term impact on patients’ health management behaviors and medical outcomes is not yet understood. Our group is now looking at the discussion guide and relationship to patients’ health management behaviors, satisfaction with their postpartum care, and their motivation to engage in their postpartum care and recovery. Future research to examine implementation of this educational discussion guide by clinical and nonclinical workers may help support its potential role to help improve important clinical outcomes, including patients’ engagement with postpartum blood pressure self‐monitoring, follow‐up visit attendance, and blood pressure readings.
5. CONCLUSION
The “My Health Beyond Pregnancy” educational discussion guide for postpartum patients with HDPs was found to be a valuable tool, being perceived as acceptable, appropriate, and feasible across diverse populations in the days and weeks after delivery. Its design supports equitable access to postpartum care, empowers patients to manage their health, and leverages digital resources to enhance learning. An updated version of the guide that incorporates participant feedback is planned. Further work investigating patient activation and engagement with ongoing healthcare as well as further investigation in a variety of healthcare settings, including rural and resource‐limited environments, will also help clarify the guide's long‐term benefits and inform strategies for broader implementation in varied healthcare settings.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
Supporting information
Supporting Information
ACKNOWLEDGMENTS
The authors would like to thank the Preeclampsia Foundation, SMFM, and ISSHP for their collaboration as well as Dr. Julianna Schantz‐Dunn for her leadership and Dr. Ronen Rozenblum for his methodologic insights. This work is funded by the CVS Health Foundation: Mass General Brigham Grant #GR0127667. While the Preeclampsia Foundation, the Society for Maternal Fetal Medicine, and the International Society for the Study of Hypertension in Pregnancy all endorsed the educational tool “My Health Beyond Pregnancy” studied in this manuscript, they did not have any financial or intellectual involvement in this research.
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