Working to advance, support the growing field of cardio-obstetrics
February 02, 2024
5 min read
Key takeaways:
- The subspecialty of cardio-obstetrics must expand to meet a rapidly growing and diverse patient population.
- Many women in need of cardio-obstetrics care do not currently have access.
CVD remains the leading cause of pregnancy-related death in the United States, yet across the country access to cardio-obstetrics care ranges from uneven to unavailable, depending entirely on where a woman lives.
With fragmented care as the reality for many pregnant women with CVD or at CV risk living in the U.S., the need for cardio-obstetrics providers is growing as the pregnant population is changing, according to Healio | Cardiology Today Editorial Board Member Mary Norine Walsh, MD, MACC, medical director of heart failure and cardiovascular research at St. Vincent Heart Center in Indianapolis and past president of the American College of Cardiology. Women are increasingly older at the time of a first pregnancy, with more comorbidities including obesity, diabetes and hypertension, all of which increase the risk for CVD. Women from underrepresented racial or ethnic groups or those living in rural areas have even greater CV risk. That growing need for care is coupled with legislative changes impacting maternal health, Walsh said, with many states restricting abortion rights for patients, including those with CVD.
Healio spoke with Walsh about the evolving cardio-obstetrics field, maternal health and mortality disparities in the U.S., and the importance of advocacy.
Healio: What is cardio-obstetrics? How do we define this field?
Walsh: The term “cardio-obstetrics” is new, but the care of women who are pregnant and have CVD or CV risk is not new at all. Decades ago, what we now call cardio-obstetrics was largely the care of women with, for example, congenital heart disease, who wished to become pregnant or were pregnant. Those women were cared for at very specific centers by specialists who focused on congenital heart disease and pregnancy complications. The field has evolved because, increasingly, women who are pregnant or wish to become pregnant are at risk for CVD or already have CVD.
The other driver behind this growing subspecialty is the continuing increase in maternal mortality in the United States. This “new field” — the care of women before during and after pregnancy — is being codified somewhat differently because, through data, we found that working in teams to include cardiologists, maternal-fetal medicine and high-risk OB physicians, doulas, midwives, nurses, nurse practitioners, anesthesiologists (and others), is needed to focus on these patients. Health systems need to focus on these patients. When we say cardio-obstetrics, we are saying we are paying special attention to the CV needs of women before during and after pregnancy in a way we have not done before.
Healio: Why is the population in need of this care growing? Who are these women?
Walsh: There are many factors. Women are increasingly older at the time of a first pregnancy. There is a growing population of people with diabetes, obesity and, very importantly, hypertension. With the increasing age of women at first pregnancy, there is a higher likelihood there is preexisting CVD even if we don’t know it. The incidence of gestational hypertension is growing.
The other issue is the U.S. has a still-growing maternal mortality rate that is higher than any other developed nation. A lot of the attention has to do with systems approaches to care that simply are not working in the U.S. There are women not being seen who need to be seen. There are insurance coverage issues impacting women, including the lack of expansion of Medicaid after childbirth and beyond. This is not just who is taking care of which patients and what conditions they may have. A lot of this has to do with how state, local and federal agencies are helping to reduce this increasing maternal mortality rate.
Healio: In the December issue of JACC: Case Reports, which was dedicated to cardio-obstetrics, a guest article highlighted the critical need for access to cardio-obstetrics care, noting such care is unavailable for the many people who need it. How do we fix that?
Walsh: The good news is there is a lot of interest in cardio-obstetrics on the cardiology side, especially among early-career cardiologists.
The ACC recently held a CME course specific to cardio-obstetrics, co-chaired by Kathryn Lindley, MD, FACC, and Natalie Bello, MD, MPH, FACC. This course will be offered annually, bringing together diverse faculty. Education is one part of this; training is another. A recent survey asked cardiologists and trainees about how much training they have had in the discipline of cardio-obstetrics. Most responded they had either no exposure to pregnant women or very little exposure. That was a key piece of data that helped launch the members’ section of Cardio-Obstetrics and Reproductive Health at the ACC. The need for work in this area became clear to the [ACC]. Interest is good. We now need people to be trained and then filter out across the country. This is such a big problem; there are patients in every hospital who need care. Teams must be up to speed on how to work together, how to provide the best follow-up care, knowing what imaging should be done and when. It will take a few years for those who are in training to go out into the workforce.
Healio: In 2018, you introduced the hashtag #CardioObstetrics on social media to help boost discussion and increase advocacy related to maternal health care. In the 6 years since, what has changed?
Walsh: At that American College of Obstetricians and Gynecologists meeting in 2018, I gave a talk that touched on how we need to work together — cardiologists and OB/GYNs — as a team. I proposed the hashtag to share information from our journals, findings from randomized controlled trials and other information. That is how it started and it has grown. There is a lot of information sharing online using that hashtag today.
The advocacy piece is interrelated but somewhat separate. What needs to happen with cardio-obstetrics mostly happens on a state level. That is because most states have their own maternal mortality committees. If a woman dies and it is considered a pregnancy-related death, these multidisciplinary state committees review the information to determine what happened. Additionally, funding for pregnancy care is largely based on Medicaid and Medicaid expansion and that also occurs at the state level. Data clearly show that states that opted to expand Medicaid serve patients with multiple diseases in a more evidence-based fashion than states that opt out, and pregnant women fall into that group. The variability in how women fare from state to state is shocking. Not everyone can get on a plane or drive 8 hours to access health care. Where you live, what your ZIP code is, matters. Changes in the OB/GYN workforce due to new legislation restricting women’s health care matters. Advocacy matters. I encourage everyone to get involved however they can.
People can look for opportunities with their ACC Chapter and connect with other advocacy groups. In Indiana, several of us have formed the Good Trouble Coalition, which is a grassroots group of health care and public health stakeholders who collaborate to educate, empower and facilitate political advocacy in the areas of patient-centered care, public health, and health equity. If you are in Indiana, join us, and also look for every opportunity that you can to advocate for change that can affect our patients.
Reference:
For more information:
Mary Norine Walsh, MD, MACC, can be reached at macwalsh@iquest.net; X (Twitter): @minnowwalsh.
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