Hypertension is a leading cause of poor pregnancy outcomes and disproportionately affects black women. At Boston Medical Center (BMC), pregnant black women have a three times higher risk of hypertensive complications, with an incidence of 30% and accounting for 40% of all preterm births. In 2014 the U.S. Preventive Services Task Force recommended 81mg (prenatal) aspirin (PNA) for at-risk women to reduce the incidence of hypertension by 24%, preterm birth by 14%, and IUGR by 20%. ACOG affirmed this in 2018. BMC, a racially diverse, urban safety-net hospital, introduced an implementation project of these guidelines.
We developed a mixed-methods analysis to understand the baseline knowledge and beliefs of our patients, providers, and pharmacists and to collect data using surveys, interviews, and focus groups to understand what issues were creating barriers to the implementation. Multimodal educational interventions were created and disseminated among these stakeholders.
We found that at baseline 73% of BMC pharmacists and 85% of a nationally surveyed cohort were unaware of the USPSTF guidelines. Initially, only 30% of BMC and 11% of national pharmacists felt “very comfortable” dispensing PNA. When we surveyed our patients, 57% of English speakers and 89% of Spanish speakers were distrustful of prenatal aspirin’s safety. We also identified low health literacy about hypertension, as 38% of patients surveyed had never heard of preeclampsia. Although in our system, prenatal intakes were primarily performed by nurse practitioners and certified nurse-midwives, 85% of PNA prescriptions were written by ob-gyns, with only 5% each written by nurse practitioners, certified nurse-midwives, and family medicine providers. We noted that providers and patients who experienced or managed complicated pregnancies were more likely to adopt PNA.
In response to this information we developed stakeholder-directed educational and structural materials to both raise the profile of the prevalence and seriousness of hypertensive disease in pregnancy as well as the safety and value of aspirin. In the midst of our initiative the lay press publications on disparities in black maternal outcomes by Propublica and NPR highlighted the relevance of this issue in the quest to improve maternal and infant outcomes for all mothers.
Our materials include patient educational cards and posters (also in Spanish and Haitian Creole), provider algorithms, and EHR smart phrases for screening and prescribing. All are available to download on our website. We worked with local and national retail pharmacies and were successful in getting CVS, Walgreens, and Walmart to remove their precaution labels on aspirin prescribed to women with an active prenatal vitamin prescription.
During the 18 months since our implementation of educational interventions, the acceptance and adoption of PNA among all stakeholders has improved to over 90% for patients with one high-risk factor, though results are not yet at goal for those with two or more moderate risk factors. Our research tells us that pharmacists and patients have an insufficient knowledge of either the profound harms due to preeclampsia or the safety and effectiveness of aspirin. Providers who have a variety of professional degrees and experience may also lack an understanding of the need to screen all pregnant women and prescribe for those who are eligible. We have found it particularly effective to inform all women at their diagnosis of hypertension in pregnancy about their future risk and the opportunity for reduction with aspirin as preconception counseling. It is also effective to engage interprofessional teams to do this education for the highest risk group. Patients need reinforcement to improve what we know is mixed compliance due to persistent concern of aspirin's harm.
In a time when the profound short and long-term harm of hypertension to women and families is so clearly visible, it is our personal responsibility to ask questions of our teams and understand whether we have effectively addressed all preventable harm to our patients. One publication this year projected a $2.18 billion yearly healthcare cost from preeclampsia. We have one solution in our hands: harm reduction for 7¢ a day. We can't afford to stop talking about aspirin.