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. 2026 Aug 7;9(8):e2626970. doi: 10.1001/jamanetworkopen.2026.26970

Care Navigation, Self-Measured Blood Pressure, and Health Coaching for Postpartum Care

A Randomized Clinical Trial

Megan R Knutson Sinaise 1,✉, Kristine Buchholz 1, Scott Hetzel 2, Melissa Neal 1,3, Sonja Ryser 1, Elizabeth Albert 1, Kristin Hildebrandt 4, Heather M Johnson 5,6, Kara K Hoppe 1
PMCID: PMC13451979  PMID: 42566217

This randomized clinical trial examines the effectiveness of an intervention consisting of postpartum health coaching and blood pressure self-monitoring to increase health care engagement and blood pressure control among individuals with hypertension during pregnancy.

Key Points

Question

Does health coaching with self-measured blood pressure monitoring during the first year after delivery improve health care engagement and blood pressure control among patients who experienced hypertension in pregnancy?

Findings

In this randomized clinical trial involving 140 postpartum women, those who received the health coaching intervention were more likely to attend a primary care visit within the first postpartum year and achieve better blood pressure control compared with control participants who received standard of care.

Meaning

The findings of this trial indicate that health coaching with self-measured blood pressure monitoring may be effective in lowering the risk of long-term uncontrolled hypertension.

Abstract

Importance

Hypertensive disorders of pregnancy (HDP) affect 10% to 16% of US pregnancies and increase the risk of developing cardiovascular disease. Guidelines recommend that individuals who experience this diagnosis attend a primary care visit within 12 months post partum to evaluate and manage cardiovascular health.

Objective

To evaluate the preliminary effectiveness of a postpartum health coaching intervention in improving health care engagement and blood pressure (BP) control among individuals with hypertension during pregnancy.

Design, Setting, and Participants

This randomized clinical trial was conducted from February 2023 to April 2025 at a community hospital in the Midwestern US. Eligible participants were postpartum women aged 18 years or older with an HDP diagnosis who met one of the following criteria: (1) confirmed diagnosis of chronic hypertension (high BP [≥130/80 mm Hg] before pregnancy or before 20 weeks’ gestation), (2) continued use of antihypertensive medications at 6 weeks post partum, and (3) persistent uncontrolled hypertension not managed with antihypertensive drugs (≥130 and/or ≥80 mm Hg) at 6 weeks post partum. All participants completed a remote BP monitoring program. Participants were randomly assigned to receive a health coaching intervention (Staying Healthy After Childbirth–My Hypertension Education And Reaching Target Post Partum; intervention group) or standard of care (control group). The primary analysis followed the intention-to-treat principle.

Intervention

Participants in the intervention group performed self-measured BP monitoring and received telephone calls from a health coach biweekly for 2 to 6 months post partum and then monthly for 6 to 12 months post partum. Participants were encouraged to create health goals and were supported in their efforts with evidence-based health information. Coordination of care with the participant’s primary care physician occurred as needed. Participants in the control group received usual care as indicated by their designated clinician.

Main Outcomes and Measures

The primary outcome was attendance at a primary care visit by 12 months post partum. Secondary outcomes included BP control (<130/<80 mm Hg) and engagement in health-promoting behaviors, such as eating a healthy diet and exercising, by 12 months post partum.

Results

A total of 140 postpartum participants were randomly assigned 1:1 to the intervention group (n = 70; mean [SD] age, 33.4 [5.0] years) or control group (n = 70; mean [SD] age, 33.3 [5.1] years). Two participants had missing primary outcome data. At the time of trial enrollment, 44 participants (63.8%) in the control group and 40 (57.1%) in the intervention group were using an antihypertensive medication. At 6 weeks post partum, the mean (SD) self-measured systolic BP and diastolic BP measurements were 118.8 (8.3) mm Hg and 78.9 (6.9) mm Hg, respectively, in the control group and 119.0 (9.6) mm Hg and 79.3 (7.3) mm Hg, respectively, in the intervention group. Primary care visit attendance was significantly higher in the intervention group than the control group (49 of 69 [71.0%] vs 27 of 69 [39.1%]; relative risk [RR], 2.00 [95% CI, 1.34-2.97], P < .001). The intervention group also demonstrated greater reductions from baseline to 12 months post partum in systolic BP (mean difference, −5.6 [95% CI, −9.4 to −1.7] mm Hg, P = .005) and diastolic BP (mean difference, −4.5 [95% CI, −7.7 to −1.3] mm Hg, P = .006). BP control (<130/80 mm Hg) was significantly more likely among the participants in the intervention compared with the control group (26 of 47 [55.3%] vs 19 of 61 [31.1%]; RR, 1.73 [95% CI, 1.13-2.66]; P = .02). No significant differences in health behaviors were observed between groups.

Conclusions and Relevance

The health coaching intervention combined with self-measured BP monitoring significantly increased health care engagement and BP control by 12 months post partum. These findings support health coaching as an effective strategy for reducing long-term uncontrolled hypertension among patients with HDP.

Trial Registration

ClinicalTrials.gov Identifier: NCT05685251

Introduction

Cardiovascular disease (CVD) is the leading cause of mortality for women in the US and globally.1,2,3 Hypertensive disorders of pregnancy (HDP) affect 10% to 16% of pregnancies in the US, and rates are rising worldwide.4,5,6,7 HDP are associated with a 5-fold increased risk of chronic hypertension; 4-fold increased risk of incident heart failure; and a 2-fold increased risk of coronary heart disease, stroke, and death.4,8,9,10

More frequent follow-up with clinicians is associated with better blood pressure (BP) control.11,12 However, 60% of postpartum patients do not attend a postpartum appointment. Barriers to the 6-week postpartum visit include unstable housing, transportation limitations, and communication difficulties, which reduce the likelihood of visit attendance.13,14 In a previous trial, 30% of postpartum patients had unresolved hypertension.15 Self-measured blood pressure (SMBP) monitoring is a widely accepted strategy to address gaps in access to care, ability to better detect BP changes, and provision of earlier treatment. Meta-analyses have shown SMBP monitoring is cost-effective and improves BP control, especially when combined with other interventions.16,17,18,19,20,21 To prevent adverse health events in the postpartum period and to reduce the risk of long-term cardiovascular conditions, integrated interventions are needed that promote transition of care, SMBP monitoring, and health behavior change. Health coaching has emerged as an effective strategy to manage hypertension and support behavior change.22 A systematic review of randomized clinical trials reported that health coaching reduces BP, improves dietary behaviors, and increases self-efficacy.17 The prenatal and interpregnancy periods provide an opportunity to increase engagement with the health care team and make health behavior changes to improve cardiovascular health.18,19,20,21

We adapted the previously published young-adult hypertension coaching intervention, called My Hypertension Education And Reaching Target (MyHEART),23,24 to serve the needs of postpartum individuals with HDP, which resulted in Staying Healthy After Childbirth–My Hypertension Education And Reaching Target Post Partum (STAC–MyHEARTp; hereafter, health coaching intervention). This intervention was designed to provide BP monitoring and health coaching to improve postpartum care engagement, BP control, and health-promoting behaviors through the first postpartum year. In this trial, we aimed to evaluate the preliminary effectiveness of this health coaching intervention in improving health care engagement and BP control among individuals with hypertension during pregnancy.

Methods

Trial Design

Our team conducted a social media poll to determine what postpartum patients with hypertension preferred in a health coaching intervention: (1) initiation of postpartum health coaching between 4 and 6 weeks after birth, (2) health coaching every other week, (3) continued health coaching for 6 to 12 months after birth, and (4) video calls with the health coach. Based on these results, this single-site randomized clinical trial was created and recruited patients who participated in STAC, a clinical, 6-week remote BP monitoring program.25,26,27 The UnityPoint Health-Meriter and the University of Wisconsin-Madison School of Medicine and Public Health Institutional Review Boards approved this trial. The trial protocol is available in Supplement 1. All participants provided written informed consent. We followed the Consolidated Standards of Reporting Trials (CONSORT) reporting guideline.28

STAC (hereafter BP monitoring program) provides an upper arm, wireless BP monitor (UA-651-BLE; A&D Medical), training on how to measure BP at home, daily SMBP monitoring, and surveillance and treatment using a hypertension delegation protocol by a specialized nursing team at UnityPoint Health-Meriter Hospital in Madison, Wisconsin. Created in 2017, this BP monitoring program has reduced postpartum readmission rates and improved patient experiences.26

Trial Outcomes

The primary outcome was participant attendance at a primary care visit by 12 months post partum, as this end point is recommended for patients who experience HDP.19 Secondary outcomes included mean systolic BP (SBP) and diastolic BP (DBP); BP control, defined as lower than 130/80 mm of mercury (mm Hg); and adherence to health-promoting behaviors, such as engaging in exercise and eating a healthy diet, by 12 months post partum.

Participants

Patients were recruited between February 2023 and April 2024. The BP monitoring program’s nursing team was informed of the trial’s eligibility criteria, and potential participants were identified and referred by the lead nurse to the trial coordinator (M.R.K.S.) at approximately 6 weeks post partum. The primary inclusion criteria included (1) at least 18 years of age at the time of enrollment; (2) English and/or Spanish language proficiency; and (3) at least 1 of these 3 conditions: confirmed diagnosis of chronic hypertension (defined as high BP, ≥130/80 mm Hg, before pregnancy or before 20 weeks’ gestation),29 continued use of antihypertensive medications, or persistent uncontrolled hypertension not managed with antihypertensive medications (≥130 and/or ≥80 mm Hg) on program completion. The trial coordinator contacted potential participants by telephone to explain the trial, confirm interest and eligibility, and enroll and randomize those eligible. Exclusion criteria were inability to participate in health coaching, history of medically determined CHF, current or future participation in another trial on BP management or control, inability to read or communicate in English or Spanish, and currently receiving dialysis or care from a nephrologist (Figure 1).

Figure 1. Consolidated Standards of Reporting Trials Flow Diagram.

Flow diagram of trial enrollment, randomization, follow-up, and analysis counts. Top center, a light blue rectangle labeled 771 Patients met eligibility criteria. A vertical connector line descends from this box. To the upper right, a large light blue rectangle connected by a rightward arrow lists exclusions: 631 Excluded; 548 Declined to participate; 51 Did not meet B P inclusion criteria; 32 Other reasons. Under Other reasons, indented lines list: 9 Planning to leave geographic area in next 12 mo; 8 Use of illegal drugs other than marijuana in past 30 d; 7 Currently on dialysis or seeing a nephrologist; 2 Inability to participate in health coaching; 2 History of medically determined C H F; 2 Inability to read or communicate in English or Spanish; 1 Current or future next 12 mo participation in another R C T on B P management or control; 1 Between-arm B P difference greater than 20 mm H g. Continuing downward along the central connector, an oval in the middle labeled 140 Enrolled and randomized. Two diagonal connector lines extend down from the oval to two group assignment boxes. Lower left, a light blue rectangle labeled 70 Assigned to intervention group. Below it, a smaller light blue rectangle labeled 19 Lost to follow-up, with indented lines 13 Lost to follow-up and 6 Withdrew from participation. A downward connector continues to a larger light blue rectangle labeled 69 Included in analysis, had primary outcome data and 51 Completed all study activities. Beneath that, a small light blue rectangle reads 1 Excluded because they could not be reached, and E M R data could not be accessed. Lower right, a parallel light blue rectangle labeled 70 Assigned to control group. Below it, a smaller rectangle labeled 9 Lost to follow-up, with indented lines 8 Lost to follow-up and 1 Refused follow-up. A downward connector continues to a larger rectangle labeled 69 Included in analysis, had primary outcome data and 51 Completed all study activities. Beneath that, a small rectangle reads 1 Excluded because they could not be reached, and E M R data could not be accessed.

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BP indicates blood pressure; CHF, congestive heart failure; EMR, electronic medical record; RCT, randomized clinical trial.

Randomization, Blinding, and Treatment Allocation

We used R, version 4.4 (R Project for Statistical Computing), to set up the nonstratified 1:1 block randomization, with random block sizes of 4 or 6, for this trial. This approach ensured an equal balance in sample size for both arms throughout the duration of the trial. The randomization algorithm generated in R was uploaded into the REDCap database. The coordinator was blinded to treatment allocation until randomization occurred in REDCap and the allocation was revealed. Due to the trial’s design, staff and participants were not blinded to group assignments; however, the statistician (S.H.) was blinded to assignments.

Trial Intervention and Procedures

Eligible participants were randomly assigned to receive health coaching (intervention group) or standard of care (control group). The health coach for this trial (M.R.K.S.) was a master’s-level clinical exercise physiologist trained by a behavioral scientist in motivational interviewing,30,31 self-regulation theory,32,33 and the self-determination theory.34,35 This training informed how the coach spoke to participants, with the coach eliciting patients’ own personal health goals rather than telling them what to do; using home BP measurements to ascertain whether the current health goals were effective in managing BP; and building a relationship that supported autonomy, competence, and relatedness.36

For participants who received health coaching, the calls were scheduled every other week for 4 months and then monthly for an additional 6 months. Health coaching calls included review of SMBP monitoring (minimum of 3 measurements since last contact), assessment of the need for primary care physician (PCP) follow-up for hypertensive BPs, and notification of the participant’s clinic if indicated. If a participant did not have a PCP assigned, the health coach helped with obtaining a PCP based on patient’s clinic preference and insurance coverage. Calls also included home weight measurement, review of previous BP goals, and establishment of new personalized SMART (Specific, Measurable, Achievable, Relevant, and Time-bound) goals using a collaborative approach.37,38,39,40 Barriers were discussed, and goals were modified as needed. The health coach followed a semistructured guide to cover data-collection points (ie, BP, weight, adverse events, health goals, and barriers); however, the conversation was not scripted but rather flowed according to what mattered to each participant. Evidence-based content (eg, American Heart Association’s Life’s Essential 8) was incorporated.41

Each call was scheduled for 20 minutes. The National Board for Health and Wellness Coaching requires a minimum of 20 minutes for a coaching session to be considered valid.42 While staffing and budgetary constraints did not allow for fidelity monitoring of calls, the health coach for this trial was the health coach for a previous trial and demonstrated high fidelity to the coaching protocol.24 Between 12 and 13 months after birth, the trial coordinator conducted a final exit interview to assess outcomes.

Self-management behaviors of physical activity and dietary intake were collected at baseline and trial end. These data were collected using 2 validated surveys: Godin Leisure Time Index43 (total score range: 0-20, with higher scores indicating higher level of activity) and the Automated Self-Administered 24-Hour (ASA24) Dietary Assessment Tool (dietary recall; National Cancer Institute, National Institute of Health).44

Control participants received usual care as indicated by their designated clinician. The study team did not interfere with how little or how much the control participants engaged with their health care team throughout the study. These patients were contacted by the study team at enrollment, which included completion of baseline surveys, and at trial end at 12 months post partum for completion of exit surveys.

Sample Size Estimation

The power analysis was informed by baseline data from the BP monitoring program to determine a clinically meaningful increase in attendance at the recommended 12-month follow-up with a PCP after hypertension diagnosis during pregnancy.45 Baseline data demonstrated that 35.2% of participants (38 of 108) in the BP monitoring program who were referred to primary care in the postpartum period for persistent hypertension scheduled an appointment, and only 29.6% of these patients (32 of 108) attended the appointment. However, we were concerned that attendance at postpartum hospital visits would be higher due to the method of visits (eg, telehealth) available because of the COVID-19 pandemic. Therefore, we used a hypothesized control rate of 50%, which was the percentage with the highest variance and the most conservative approach to sample size calculation for binary outcomes. With an effective sample size of 110, we expected an 80% power for the primary end point of a clinically significant increase of follow-up at 12 months post partum from 50% to 75% in a test of 2-independent proportions with a 2-sided P = .05 significance level. With an assumed 20% dropout rate at the trial end, the target sample size was increased to 140.45,46,47 Per the trial protocol, participants were retained in the trial unless they explicitly asked to withdraw.

Statistical Analysis

Baseline demographic characteristics were summarized using mean (SD), median (IQR), or frequency (%), as appropriate. Race and ethnicity (Black, Hispanic, White, and other [American Indian or Alaska Native, Asian, Asian American, and unknown]) were collected from the electronic health record (EHR). These data were included in this analysis for generalizability and compliance purposes.

The primary outcome analysis followed the intention-to-treat principle. All secondary outcomes were analyzed with a maximum likelihood estimation through mixed-effects constrained longitudinal data analysis (cLDA) using all available data. Due to higher levels of outcome-specific data missingness, outcome-specific denominators are reported. Imputation was not performed for secondary outcomes, consistent with our analytic approach to prioritize observed data for these measures.

The primary outcome and BP control status were assessed using χ2 tests. Evaluation of differences in SBP and DBP was performed via baseline cLDA. BPs were taken in triplicate and averaged for analysis. While BPs were collected from medical records review prior to randomization, the cLDA model only contained data from the 3 time points of the trial. The cLDA made no assumption of the variance-covariance structure using the unstructured estimation of all estimates. Analysis of change in physical activity and dietary intake outcomes from baseline to trial end used nonparametric methods due to non-normally distributed data for both time points and for paired differences. Therefore, Wilcoxon rank sum tests were used to test for differences in changes in physical activity and dietary intake between treatment groups.

This trial was powered for the primary outcome only. P values for secondary outcomes were not adjusted and should be considered exploratory. All analyses were conducted in R, version 4.4 (R Project for Statistical Computing), and all tests had an a priori P = .05 significance level.

Results

Recruitment

The BP monitoring program provided care for 1833 patients during the trial enrollment period, of whom 771 patients met the initial eligibility criteria and were contacted. A total of 140 postpartum women were enrolled and randomly assigned to either the intervention group (n = 70) or control group (n = 70). Of the 631 patients not enrolled, 51 did not meet the BP inclusion criteria, 548 declined participation, and 32 were excluded for other reasons (Figure 1).

Retention and Adherence

Following randomization, 19 patients in the intervention group (27.1%) and 9 in the (12.9%) control group withdrew from the trial, refused follow-up, or were lost to follow-up at trial end. Data on the primary outcome variable of attendance at a primary care visit in the first postpartum year were available for 69 of 70 patients (98.6%) in the intervention group and 69 of 70 patients (98.6%) in the control group. A total of 51 intervention participants (72.9%) and 61 control participants (87.1%) completed the trial exit call by 12 months post partum. Additional details on participant follow-up are shown in Figure 1.

Participant Characteristics

Baseline characteristics were generally similar between groups at enrollment. As shown in Table 1, the mean (SD) age of participants was 33.3 (5.1) years in the control group and 33.4 (5.0) years in the intervention group. Overall, 16 participants (11.4%) were identified in the EHR as Black, 12 (8.6%) as Hispanic, and 105 (75.0%) as White individuals, with 6 participants (4.3%) reported under other race and ethnicity. One hundred three patients (74.3%) were married, and 69 (49.3%) had annual household incomes greater than $100 000.

Table 1. Baseline Demographic Characteristics of Participants.

Characteristic Participants, No. (%)
Control group (n = 70) Intervention group (n = 70)
Maternal age, mean (SD), y 33.3 (5.1) 33.4 (5.0)
Prenatal BMI, mean (SD) 34.0 (10.3) 31.7 (7.9)
BMI at delivery, mean (SD) 37.5 (9.6) 35.5 (7.1)
Race and ethnicitya
Black 6 (8.7) 10 (14.3)
Hispanic 8 (11.6) 4 (5.7)
White 53 (76.8) 52 (74.3)
Otherb 2 (2.9) 4 (5.7)
Type of insurance
Commercial 23 (32.9) 27 (38.6)
HMO 30 (42.9) 27 (38.6)
Medicaid 15 (21.4) 16 (22.9)
Otherc 1 (1.4) 0
Unknown 1 (1.4) 0
Diabetes 21 (30.4) 15 (22.1)
Type of diabetes
Gestational 20 (95.2) 12 (80.0)
Type 1 0 1 (6.7)
Type 2 1 (4.8) 2 (13.3)
Smoking status
Never smoked 60 (88.2) 58 (85.3)
No longer smoke 7 (10.3) 8 (11.8)
Currently smoke 1 (1.5) 2 (2.9)
Highest educational level
Did not finish high school 2 (2.9) 3 (4.4)
Graduated from high school 6 (8.8) 3 (4.4)
Did not finish college or vocational school 10 (14.7) 9 (13.2)
Graduated from college or vocational school 28 (41.2) 32 (47.1)
At least some postgraduate school 22 (32.4) 21 (30.9)
SMBP monitoring frequency
Not regularly 31 (45.6) 33 (48.5)
>1 per mo 11 (16.2) 8 (11.8)
>1 per wk 17 (25.0) 19 (27.9)
>1 per d 9 (13.2) 8 (11.8)
Current health ratingd
Poor 0 1 (1.5)
Fair 11 (16.2) 16 (23.5)
Good 34 (50.0) 39 (57.4)
Very good 22 (32.4) 11 (16.2)
Excellent 1 (1.5) 1 (1.5)
Gravidity, median (IQR), No. 2.0 (1.0-3.0) 2.0 (1.0-3.0)
Full-term parity, median (IQR), No. 1.0 (1.0-2.0) 1.0 (1.0-2.0)
Preterm parity, median (IQR), No. 0.0 (0.0-1.0) 0.0 (0.0-1.0)
Gestational age, mean (SD), wk 37.6 (2.0) 36.8 (2.5)
Birth weight, mean (SD),g 3026.7 (658.5) 2793.6 (677.9)
Cesarean delivery 36 (51.4) 32 (46.4)
Timing of hypertension diagnosis
Prior to admission 47 (67.1) 46 (67.6)
Intrapartum 14 (20.0) 16 (23.5)
Postpartum 7 (10.0) 6 (8.8)
On readmission 2 (2.9) 0
Type of hypertension
Chronic 29 (41.4) 29 (41.4)
Gestational 22 (31.4) 25 (35.7)
Preeclampsia: mild 6 (8.6) 6 (8.6)
Preeclampsia: severe 13 (18.6) 10 (14.3)
Prepregnancy SBP, mean (SD), mm Hg 129.0 (14.7) 128.7 (12.9)
Prepregnancy DBP, mean (SD), mm Hg 80.9 (9.3) 81.7 (9.4)
24-hr Discharge maximum SBP, mean (SD), mm Hg 134.8 (16.0) 132.6 (11.8)
24-hr Discharge maximum DBP, mean (SD), mm Hg 86.9 (12.2) 85.6 (8.7)
Wk 6 Postpartum SMBP monitoring: SBP, mean (SD), mm Hg 118.8 (8.3) 119.0 (9.6)
Wk 6 Postpartum SMBP monitoring: DBP, mean (SD), mm Hg 78.9 (6.9) 79.3 (7.3)
Prescribed a BP medication 44 (63.8) 40 (57.1)
Thiazide diuretic 3 (4.5) 7 (10.3)
ACE inhibitor 0 2 (2.9)
Dihydropyridine CCB 28 (40.6) 29 (41.4)
β-Blocker 24 (35.3) 17 (25.0)
α-Blocker or β-blocker 1 (1.5) 1 (1.5)
Central agonist 0 1 (1.5)
Loop diuretic 0 1 (1.5)
Always use medicationse 38 (90.5) 35 (92.1)
ASA24 Total calories, mean (SD), No. 2166.8 (676.0) 2358.0 (835.3)
ASA24 Sodium, mean (SD), mg 3693.5 (1412.3) 3956.9 (1692.1)
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Abbreviations: ACE, angiotensin-converting enzyme; ASA24, Automated Self-Administered 24-Hour Dietary Assessment Tool; BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); BP, blood pressure; CCB, calcium channel blocker; DBP, diastolic BP; HMO, health maintenance organization; SBP, systolic BP; SMBP, self-measured BP.

a

Race and ethnicity were obtained from the electronic health record.

b

Other race and ethnicity included American Indian or Alaska Native, Asian, Asian American, and unknown.

c

Other insurance types are unknown.

d

Self-perceived health status.

e

Reported compliance with taking medications as prescribed.

Hypertension types were similar across both groups. In both control and intervention arms, 58 patients (41.4%) had chronic hypertension, 47 (33.6%) had gestational hypertension, 12 (8.6%) had mild preeclampsia, and 23 (16.4%) had severe preeclampsia (Table 1). At the time of enrollment, 44 participants (63.8%) in the control group and 40 (57.1%) in the intervention group were using an antihypertensive medication. At 6 weeks post partum, the mean (SD) SBP and DBP self-measurements were 118.8 (8.3) mm Hg and 78.9 (6.9) mm Hg, respectively, in the control group and 119.0 (9.6) mm Hg and 79.3 (7.3) mm Hg, respectively, in the intervention group. The mean (SD) prepregnancy body mass index (calculated as weight in kilograms divided by height in meters squared) was slightly higher in the control group than the intervention group (34.0 [10.3] vs 31.7 [7.9]). Smoking and exercise levels were low in both groups. The mean (SD) gestational age at delivery was 37.6 (2.0) weeks in the control group and 36.8 (2.5) weeks in the intervention group, and cesarean delivery rates were similar between groups (36 [51.4%] and 32 [46.4%]).

Intervention Engagement and Dose

Participants in the intervention group completed a median (range) of 12 (0-14) coaching calls, with a mean (SD) of 10.5 (4.2) calls. Fifty-six of 69 participants (81.2%) completed all 8 health coaching calls during the high-dose intervention phase (twice-monthly calls) of the trial, with only 8 participants (11.6%) receiving fewer than 4 calls. During the maintenance phase (monthly calls) of the trial, 21 participants (30.5%) received all 6 health coaching calls, while 24 participants (34.8%) received fewer than 3 calls. The median (range) coaching call duration per participant was 21.2 (3-90) minutes. The total median (range) call time for the entire trial period per participant was 226 (0-466) minutes.

Primary Outcome

One participant in the intervention group refused follow-up after initial enrollment, and 1 participant in the control group had missing primary outcome data. Comprehensive postpartum primary care visit attendance was significantly higher in the intervention group than control group (49 of 69 [71.0%] vs 27 of 69 [39.1%]; relative risk [RR], 2.00 [95% CI, 1.34-2.97], P < .001) (Table 2). The mean (SD) time to comprehensive primary care visit was 6.1 (2.5) months in the intervention group and 7.1 (2.8) months in the control group.

Table 2. Primary and Secondary Outcomes.

Outcomes Control group (n = 70) Intervention group (n = 70) Estimate (95% CI) P value
Total No. No. (%) Total No. No. (%)
Primary
Attended primary care visit in first year postpartum 69 27 (39.1) 69 49 (71.0) RR: 2.00 (1.34 to 2.97)a <.001
Secondary
12-mo Postpartum SMBP monitoring: SBP, median (IQR), mm Hg 61 126 (123 to 128) 47 120 (117 to 123) Mean difference: −5.6 (−9.4 to −1.7)b .005
12-mo Postpartum SMBP monitoring: DBP, median (IQR), mm Hg 61 84 (82 to 86) 47 79 (77 to 82) Mean difference: −4.5 (−7.7 to −1.3)b .006
12-mo Home BP control (<130/80 mm Hg) 61 19 (31.1) 47 26 (55.3) RR: 1.73 (1.13 to 2.66)a .02
12-mo Self-measured weight, median (IQR), kg 60 88.2 (81.8 to 95.0) 48 83.6 (76.8 to 90.9) Mean difference: −10.2 (−31.3 to 10.8)b .34
12-mo BMI, median (IQR) 60 32.4 (30.2 to 34.7) 48 31.5 (29.0 to 34.1) OR: −0.9 (−4.3 to 2.5) .60
Antihypertensive use at 12-mo post partum 65 22 (33.8) 51 18 (35.3) OR: 1.47 (0.58 to 3.85)c .42
Thiazide diuretic 65 2 (3.1) 51 3 (5.9)
ACE inhibitor 65 0 (0) 51 1 (2.0)
Dihydropyridine CCB 65 14 (21.5) 51 9 (17.6)
β-Blocker 65 7 (10.8) 51 7 (13.7)
ARB 65 1 (1.5) 51 4 (7.8)
Always use medicationsd 22 18 (81.8) 18 17 (94.4) NA NA
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Abbreviations: ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); BP, blood pressure; CCB, calcium channel blocker; DBP, diastolic BP; NA, not applicable; OR, odds ratio; RR, relative risk; SBP, systolic BP; SMBP, self-measured BP.

a

Estimates of RR with control group as the reference.

b

Estimates are mean differences (intervention – control) with 95% CIs.

c

Estimates of OR while controlling for baseline antihypertensive status with control group as the reference.

d

Reported compliance with taking medications as prescribed.

Prespecified Secondary Outcomes

Available data were collected from the EHR on documented SBP and DBP at the comprehensive primary care visit. The mean SBP was 125 (95% CI, 121-130) mm Hg in the intervention group compared with 126 (95% CI, 122-129) mm Hg in the control group (P = .94), and the mean DBP was 82 (95% CI, 79-85) mm Hg compared with 81 (95% CI, 78-83) mm Hg (P = .66).

Reduced SMBP (mean difference: SBP, −5.6 [95% CI, −9.4 to −1.7] mm Hg, P = .005; DBP, −4.5 [95% CI, −7.7 to −1.3] mm Hg, P = .006) and increased BP control rates (<130/80 mm Hg: 26 of 47 [55.3%] vs 19 of 61 [31.1%]; RR, 1.73 [95% CI, 1.13-2.66], P = .02) by 12 months post partum were observed in the intervention group (Table 2). BP profiles of participants were produced (Figure 2) by estimating mean SBP and DBP for all participants up until the baseline, after which we estimated means based on randomization group. These estimates demonstrated that SBP was controlled for both groups when exiting the 6-week BP monitoring program, but participants in the control group did not maintain this control at 12 months post partum compared with the intervention group. When examining antihypertensive medication use at baseline and the end of the trial, there was no statistical difference in rates between arms. Only 1 participant in each arm went from using no antihypertensive medication at baseline to using an antihypertensive drug at the end of trial. Nineteen of the 40 control participants (47.5%) who were using medication at baseline were no longer using antihypertensive medication at the end of the trial, while 10 of 17 intervention patients (37.0%) were no longer using antihypertensive medication at the end of the trial. The remaining patients were consistent in their medication status at baseline and trial end. There were no meaningful changes to whether patients used their medication “all of the time,” with both groups consistently reporting about 90% adherence to medication use.

Figure 2. Line Graphs of Mean Systolic Blood Pressure (SBP) and Diastolic Blood Pressure (DBP) by Time and Randomization Group.

Two-panel line graphs of mean S B P and D B P over time by group. Two side-by-side panels labeled A and B. Panel A title: Mean S B P estimates by time and randomization group. Vertical axis label: S B P, millimeters H g, with tick labels from 110 to 135. Horizontal axis label: Time points, with categories left to right: Prepregnancy, T 1, T 2, T 3, Delivery, Baseline, 6 mo, 12 mo. A black dash-dot line with dark square markers (prerandomization) runs from about 128 point 5 at prepregnancy down to about 123 at T 1 and about 121 point 5 at T 2, up to about 126 point 5 at T 3, up to about 133 point 5 at delivery, then down to about 118 point 8 at baseline; baseline has a vertical 95 percent C I error bar spanning roughly 117 to 120. Two upward black arrows appear under the axis at Delivery and Baseline. Randomization-period series: an orange solid line with circular markers (intervention) at 6 mo about 125 point 5 with an error bar roughly 121 to 130, and at 12 mo about 120 with an error bar roughly 117 to 123; a blue dashed line with diamond markers (control) at 6 mo about 122 with an error bar roughly 116 point 5 to 127 point 5, and at 12 mo about 125 point 5 with an error bar roughly 123 to 128. Panel B title: Mean D B P estimates by time and randomization group. Vertical axis label: D B P, millimeters H g, with tick labels from 70 to 90. A legend in the upper left lists prerandomization as a dark square, intervention as an orange circle, and control as a blue diamond. The prerandomization black dash-dot line with squares is about 81 at prepregnancy, about 76 point 5 at T 1, about 75 at T 2, about 79 at T 3, about 86 at delivery, and about 79 at baseline; baseline has an error bar spanning roughly 78 to 80. Randomization-period points: intervention at 6 mo about 82 with an error bar roughly 78 to 86 and at 12 mo about 79 point 5 with an error bar roughly 77 to 81 point 5; control at 6 mo about 80 point 5 with an error bar roughly 76 to 85 and at 12 mo about 84 with an error bar roughly 82 to 85 point 5. Two upward black arrows appear under the axis at Delivery and Baseline.

Open in a new tab

Estimates for the prerandomization period are simple means (95% CIs) at each time point. Mean (95% CI) estimates for the randomization period are from results of the constrained longitudinal data analysis model of data from baseline, 6 months, and 12 months. Error bars represent 95% CIs. T1 indicates first trimester; T2, second trimester; and T3, third trimester.

As shown in Table 3, from baseline to 12 months, changes in self-reported physical activity did not differ significantly between groups across the total, mild, moderate, and strenuous physical activity scores. Dietary intake assessed using the ASA24 dietary recall showed marginally greater reductions in total fat and saturated fat consumption (as % of total daily calories) in the intervention group compared with the control group (median [IQR] change: total fat, −2.0% [−8.0% to 4.3%] vs 1.5% [−3.0% to 9.0%], P = .04; saturated fat, −1.0% [−4.0% to 3.0%] vs 0% [−1.0% to 4.0%], P = .046). No significant between-group differences were observed for total calories, fruits, vegetables, whole grains, or fiber, although patterns of improved consumption in the intervention arm are noted. Although no significant difference was noted between groups for sodium intake by 12 months, participants in the intervention arm did report consuming less sodium, nearly 1000 mg less than they reported at trial intake, which is a meaningful change in health behavior that can support BP control.48 Changes in alcohol consumption (wine, beer, or liquor) were similar between groups.

Table 3. Change in Lifestyle Outcomes From Baseline to 12 Months .

Outcome Median change (IQR)a P valueb
Control group Intervention group
Godin Leisure Time Index, No./total No. (%) 63/70 (90.0) 51/70 (72.9)
Total score 3.0 (−3.5 to 19.0) 6.0 (0.0 to 13.0) .34
Mild physical activity score 0.0 (−1.0 to 2.0) 0.0 (−1.0 to 1.0) .92
Moderate physical activity score 0.0 (0.0 to 2.0) 0.0 (0.0 to 2.0) .52
Strenuous physical activity score 0.0 (0.0 to 1.0) 0.0 (0.0 to 1.0) .98
ASA24, No./total No. (%) 54/70 (77.1) 48/70 (68.6)
Total calories −372 (−698 to 280.5) −460 (−849 to 6) .18
Vegetables, cup −0.2 (−1.1 to 0.6) −0.1 (−1.2 to 0.9) .71
Fruits, cup 0.0 (−1.0 to 0.8) 0.0 (−0.2 to 0.7) .43
Whole grains, oz 0.0 (−1.1 to 0.5) 0.0 (−0.7 to 0.7) .64
Total fat, % of calories 1.5 (−3.0 to 9.0) −2.0 (−8.0 to 4.3) .04
Saturated fat, % of calories 0.0 (−1.0 to 4.0) −1.0 (−4.0 to 3.0) .046
Sodium, mg −486 (−1234 to 670) −958 (−1762 to 626) .23
Fiber −3.0 (−8.0 to 2.8) −2.0 (−6.8 to 4.3) .40
Alcohol consumption, No./total No. (%) 34/70 (48.6) 25/70 (35.7)
Wine, drink/d 0.0 (−0.4 to 0.0) 0.0 (0.0 to 0.0) .99
Beer, drink/d 0.0 (0.0 to 0.0) 0.0 (−1.0 to 0.0) .17
Liquor, drink/d 0.0 (0.0 to 0.0) 0.0 (0.0 to 0.0) .56
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Abbreviation: ASA24, Automated Self-Administered 24-Hour Dietary Assessment Tool.

a

Change from baseline to 12 months.

b

P values were calculated using the Wilcoxon rank sum test.

Adverse Events

Adverse events (AEs) were reported by 2 participants in the control group (2.9%) and 7 (10.0%) in the intervention group. In the intervention group, 6 of 7 individuals (85.7%) experienced notable AEs. The following AEs were recorded after discussion of concerning symptoms or uncontrolled hypertension during the health coaching calls and after follow-up with PCP was advised and had occurred: newly discovered cardiac findings (eg, heart murmur, septal thickening with mild left ventricular dilation, leaking valve), symptomatic episodes unrelated to antihypertensive medication use (eg, dizziness, hypotension, tachycardia), and severe chest pain with hypertension (associated with a preexisting condition) that resolved after seeking medical attention advised by the research team. The remaining AEs occurred between calls: infections (lower bowel and gallbladder) and 1 hospitalization for myasthenia gravis exacerbation secondary to heat illness.

In the control group, 2 participants experienced serious events: 1 hospitalization for respiratory failure with COVID-19 and alcohol intoxication, and 1 episode of atrial fibrillation with rapid ventricular response. All AEs were deemed unrelated to the trial.

Discussion

This trial demonstrated a significant increase in attendance at a primary care visit and improved BP control by 12 months post partum among participants in the intervention group compared with the control group. While its occurrence was rare, a primary care visit via telehealth was allowed. Explanations for not attending a primary care visit were not explicitly tracked, but it is understood that barriers to transportation, lack of transportation, and lack of health insurance can all hinder health care engagement.49

Postpartum Care Attendance

These findings highlight the importance of ongoing postpartum contact and continuity of care for individuals with chronic hypertension and/or HDP. The American College of Obstetricians and Gynecologists recommends that postpartum care be viewed as an ongoing process rather than as a single, isolated visit.14 Consistent with these recommendations, this trial provided continued support and facilitated transition to primary care. Among participants who completed the trial, most recommended postpartum health coaching.

BP Control

Participants in the intervention group achieved lowered SBP and DBP as well as better BP control. These findings contribute to a growing body of evidence that SMBP monitoring paired with other interventions can improve hypertension outcomes.16 SMBP monitoring is an evidence-based strategy, and these findings support its integration with behavioral interventions. Health coaching may increase postpartum support, education, and engagement with the health care system, leading to improved health outcomes. Given the low awareness and knowledge of CVD risk after HDP, health coaching provided education and promoted awareness and guideline-recommended follow-up.49,50 There are billable codes51 for this intervention and additional published resources for managing hypertension in postpartum clinical care.52

Health Behaviors

Researchers have studied health coaching to manage chronic diseases in pregnant and nonpregnant populations, and this intervention is offered through in-person appointments, group visits, telephone contacts, mobile applications, and text messaging.38,53,54,55 Our trial did not demonstrate significant differences in health behaviors regarding exercise and nutrition. However, participant recall may not be the best way to evaluate health behaviors.56,57 These findings are consistent with those from a study by Borrowman et al,58 which found that, although a postpartum health coaching intervention increased behavioral skills such as physical activity planning and self-monitoring, it did not result in measurable changes in physical activity. Our health coaching intervention was not an exercise or nutrition-specific program, the health coach supported the participant’s chosen area of health behavior change. Similarly, in a randomized trial to reduce CVD risk, postpartum participants who received educational modules and telephone coaching demonstrated increased knowledge of CVD risk factors, higher self-efficacy for healthy eating, and less physical inactivity compared with participants in the control group; however, the groups did not differ in adoption of a healthy diet or reported levels of physical activity.59

Results of this trial and other studies underscore the challenge of translating knowledge into behavior change. Given the influence of diet and exercise on CVD, future research should explore health coaching interventions and their influence on health behaviors, such as physical activity and nutrition, among postpartum patients at risk for CVD.

Strengths and Limitations

A key strength of this trial is its use of multiple data types and sources, including biometric data (eg, SMBP, weight), validated survey instruments, and EHR data. Although differential attrition in secondary outcomes was observed after randomization (27.1% in the intervention group vs 12.9% in the control group), for the primary outcome, this trial achieved 98.6% retention of participants through 12 months post partum. We acknowledge that differential attrition contributes to outcome-specific data missingness and may introduce bias, particularly if missingness is related to both intervention assignment and outcomes. Accordingly, findings for secondary outcomes should be interpreted as exploratory. The data may be useful in future work regarding hypothesis generation and power calculations. While the 12-month follow-up period provides valuable information, the trial did not capture longer-term effects on BP control, ongoing health care engagement, or longer-term cardiovascular outcomes beyond the first postpartum year.

Other limitations of this trial include its single-site, Midwestern setting and the resources, and infrastructure available for this trial may not be feasible or replicable in other settings; therefore, the findings may not be generalizable to the broader population. Participants who were recruited for this trial all completed the hospital-based 6-week postpartum remote BP monitoring program, which may have increased engagement and bias compared with the general postpartum population. Furthermore, there was a lack of racial heterogeneity in the sample. Future research should consider oversampling racially and ethnically minoritized groups to reduce bias and allow for more meaningful subgroup analyses. Additionally, there was variability in coaching call duration and total engagement time, reflecting a wide range of participation levels that may reduce the consistency of intervention exposure across patients. This variability may contribute to selection bias; those who chose to enroll in the trial might be more likely to engage in healthy behaviors than those who elected not to participate.

Conclusions

The postpartum period provides an opportunity to teach health behaviors that support long-term cardiovascular health and reduce CVD risk. In this randomized clinical trial, a multicomponent intervention combining health coaching and SMBP monitoring significantly increased health care engagement and led to meaningful reductions in SBP and DBP as well as improved BP control by 12 months post partum. Although changes in weight and self-reported nutrition and physical activity did not differ significantly between groups, the observed improvements in clinical outcomes highlight the potential of an integrated postpartum intervention to address hypertension risk and promote cardiovascular health beyond the standard postpartum visit at 6 weeks.

Supplement 1.

Trial Protocol

jamanetwopen-e2626970-s001.pdf (977.5KB, pdf)
Supplement 2.

Data Sharing Statement

jamanetwopen-e2626970-s002.pdf (17.6KB, pdf)

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement 1.

Trial Protocol

jamanetwopen-e2626970-s001.pdf (977.5KB, pdf)
Supplement 2.

Data Sharing Statement

jamanetwopen-e2626970-s002.pdf (17.6KB, pdf)

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