Using Home Blood Pressure Checks and Text Reminders to Reduce Postpartum Maternal Mortality
Why It Matters
Photo by Jae Park | Unsplash
Postpartum hypertensive disorders pose a serious health risk to new mothers; nearly 75 percent of maternal deaths associated with hypertensive disorders occur in the postpartum period. In recognition of these risks, the American College of Obstetricians and Gynecologists (ACOG) recommends close monitoring of patients with hypertensive disorders for the first 72 hours postpartum and again at 7 to 10 days after delivery.
For the past decade, the obstetrics department at the Hospital of the University of Pennsylvania (HUP) has tried to lower these risks by checking patients’ blood pressure after they are released from the hospital. Their initial efforts to have patients return to the office for an in-person blood pressure check shortly after discharge yielded disappointing results. Instead of getting discouraged, however, the team revamped their approach and ultimately developed an extremely successful program called Heart Safe Motherhood.
The Hospital of the University of Pennsylvania is part of the Institute for Healthcare Improvement (IHI) Eliminating Inequities and Reducing Postpartum Morbidity and Mortality Learning Community. Participants focus on improving clinical and administrative processes to ensure safer and more equitable postpartum care and support for Black mothers and birthing persons.
HUP’s first post-partum hypertension reduction program was launched in 2012 when the team established a once-a-week clinic for patients who had a hypertensive disorder to come in for a blood pressure check. “We focused on the high-risk patients who were at risk for persistent hypertensive disease,” said Adi Hirshberg, MD, Director of Obstetrical Services. Despite testing weekly, daily, and even walk-in availability, clinic attendance rates were low, and they found significant racial disparities in their data. Between 2012 to 2014, the attendance rate for Black patients was 24.1 percent, compared with 42.5 for non-Black patients.
“We tried various things,” Hirshberg recalls. “We tried text and phone reminders.” But nothing seemed to work. The poor attendance was not entirely surprising, Hirshberg and her colleagues realized. Given the difficulties of venturing out of the house when caring for a newborn — especially for those facing transportation and childcare challenges — it is understandable that a five-minute blood pressure check may not have seemed worthwhile to many patients. Moreover, even when they did come in, the clinic was not a perfect solution, because morbidity can occur before the 7 to 10-day window. The team noted that some patients were readmitted before they were even scheduled to come into the clinic.
They started brainstorming about how to do blood pressure checks while allowing patients to stay at home. “We realized that our patients had cell phones and most of them are young, reproductive-age patients who like to text,” said Hirshberg. “So, we decided to use a text-based approach.”
Starting with a small sample of patients, they gave each one a blood pressure cuff and told them they would receive text messages after discharge instructing them to take their blood pressure at 8:00 am and send in the reading. At 1:00 pm, they would get another text requesting that they send their blood pressure again. The initial response rates were encouraging, but there was room for improvement.
Building on the concept, they carried out six Plan-Do-Study-Act (PDSA) cycles. They tried sending reminder texts at standard times, distributing a patient education flyer at discharge, personalizing the messages (e.g., “Good morning, Alex, time to check your blood pressure”), increasing flexibility (letting the patient choose when to receive the texts), giving them a “snooze” reminder and “countdown” message (e.g., “two days to go”), and sending messages to identified support people. Each of these cycles included five to seven patients. At the end of each iteration, the team interviewed the patients to get their feedback. The personalized texts did not have much effect, but the other five strategies were highly successful, so the team incorporated all of them.
When they achieved a 70 to 80 percent response rate, the team decided to scale up. During the initial PDSA cycles, Hirshberg had been sending out text messages and responding to the blood pressure readings herself. To reach more patients, the messages would need to be automated. The team partnered with Way to Health (W2H), a web-based platform to support sustainable behavior change interventions affiliated with Penn Medicine.
Heart Safe Motherhood is now fully operational at the five obstetric hospitals within Penn Medicine. Nurses and other staff members identify eligible patients and enroll them through the electronic health record (EHR) prior to discharge. The patients then receive automatic text messages in the morning and afternoon for 10 days to ask them to check their blood pressure, starting the day after discharge. Based on the results, the patient receives automated feedback. If the reading is normal, they are given the good news. If it is slightly elevated but not severe, they are informed that continued monitoring is important but that no action is immediately required. If the reading is in the severe range, the patient is asked to check it again, and Hirshberg (or another OB provider) simultaneously gets notified, which triggers a call to the patient to determine next steps.
The results have been remarkable. Compared with the clinic, in which 43 percent of patients had a blood pressure check within 10 days, Heart Safe Motherhood reached 90 percent. They have also seen a reduction in emergency room visits, an increase in postpartum visit attendance, and a decrease in readmissions to the hospital for postpartum hypertension. In addition, the text messaging program eliminated the racial disparity that had existed in the clinic attendance rates. In fact, the rate for Black patients — 93 percent — was slightly higher than the rate for non-Black patients (91 percent).
“Our results have been really awesome, so the health system adopted it across all of the OB hospitals in our system,” said Hirschberg. “We’ve had several hundred thousand blood pressures come through, and the patient engagement is about 90 percent-plus at all sites.” While there are some upfront costs, there are also savings through reduced readmissions, reduced length of stay, and reduced morbidity. “The program seems to pay for itself on the back end,” she said. Hirshberg recognizes that her hospital has the advantages of a large institution, in terms of funding and infrastructure, “but hopefully there can be some lessons learned from what we learned.”
IHI’s Eliminating Inequities and Reducing Postpartum Morbidity and Mortality Learning Community is funded by Merck for Mothers, Merck’s global initiative to help create a world where no woman or birthing person has to die while giving life.
You may also be interested in:
Better Maternal Outcomes Quality Improvement Workbooks — Contain examples and templates to guide QI work focused on improving maternal health outcomes and equity
Reducing Inequities in Postpartum Maternal Morbidity and Mortality