Lancet Series calls for reimagined maternal
A new Lancet Series argues that cardiovascular care in pregnancy must shift from reacting to crises to anticipating and managing long-term risk, stating up
Up to one-quarter of maternal deaths might be avoided with earlier identification of cardiovascular risk, according to a new Lancet Series. The publication states that cardiovascular disease complicates up to 15% of pregnancies and accounts for up to one-third of maternal deaths, a substantial portion of which is potentially preventable.
New onset conditions like gestational hypertension, maternal stroke, or peripartum cardiomyopathy signal this heightened risk. The Series contends that care too often focuses on responding to adverse events rather than acting before complications develop. It calls for a fundamental reimagining of maternal health to prioritize cardiovascular wellbeing across a woman's lifespan, not only around delivery.
A long-term perspective on pregnancy risk
The cardiovascular implications of pregnancy extend far beyond delivery, serving as an early signal for future health. For example, the Series notes that gestational hypertension is associated with a six-times higher risk of subsequent chronic hypertension. Pre-eclampsia is linked with up to a 3.5-times increased risk of heart failure later in life.
These pregnancy complications can unveil underlying vulnerabilities. The report argues that maternal health is still measured largely by outcomes at delivery, a definition that overlooks these longer-term consequences and has shaped research to neglect them.
Missed opportunities across the care continuum
Opportunities for early intervention are being missed from preconception through to long-term follow-up. The preconception period is an underused window to identify and modify risks, especially as more women with increased cardiometabolic risk factors like older age, obesity, and diabetes are becoming pregnant. In the USA, first births among women aged 35 years or older increased by 25% between 2016 and 2023.
Gaps are pronounced in low-income and middle-income countries, where up to 50% of rheumatic heart disease diagnoses are made for the first time during pregnancy. Poor access to antenatal care remains a key predictor of maternal morbidity and mortality, disproportionately affecting people from lower socioeconomic groups and minority populations. After childbirth, women often face fragmented care, and those at increased future cardiovascular risk can be lost to follow-up.
Implementing effective interventions
The challenge is to implement interventions effectively and consistently, adapting approaches to local resources. The Series outlines different strategies for various settings.
Standardization of cardiovascular assessment is also needed. The American Heart Association has published a framework for postpartum cardiovascular prevention after adverse pregnancy outcomes. It includes assessment of blood pressure, lipids, and BMI, with guidance for transition from obstetric to primary care. The Series suggests alignment across medical societies could support more consistent implementation.
When risk is identified, it must lead to action. Hypertension should be treated according to standard guideline thresholds regardless of age. The established practice of lifelong diabetes screening after gestational diabetes could provide a model for offering annual assessment of blood pressure and lipids after other adverse pregnancy outcomes.
Addressing evidence gaps
The report highlights a critical evidence gap, noting that pregnant and postpartum women, along with women planning pregnancy, are often excluded from pharmaceutical trials. This creates uncertainty about the safety and effectiveness of much-needed cardiometabolic treatments for these populations. With more than 2 billion women of reproductive age globally, the Lancet Series concludes that cardiovascular health must become central to maternal care.
