The prevalence of documented cardiovascular-related pregnancy complications: cross-sectional study in an academic primary care centre

Summary

This study offers initial insights into the lack of documentation of pregnancy complications in EMRs, revealing a missed opportunity to identify and manage females at increased risk of CVD. EMRs function as an efficient tool to facilitate documentation of medical histories, which is the first step in enabling clinicians to better manage patient outcomes. Improvement of documentation of pregnancy complications in the EMR has the potential to ensure greater physician awareness of patient history and bridge transitions in care.^18,25

Owing to opportunities for shared obstetric care in AFHT, several healthcare providers other than the GP could be involved in a patient’s intrapartum and postpartum care, which could potentially lead to increased gaps in communication and information flow. Several scenarios in shared care could lead to differences in documentation of pregnancy complications and communication. Patients may have been cared for by their primary family doctor with care transferred to an obstetrical provider before the complication occurring. Without detailed discharge summaries, documentation within the EMR or direct communication between the obstetrician and family physician, there are few possibilities to truly understand which of these scenarios each of the shared care patients falls under, thereby introducing numerous possibilities in the lack of documentation and follow-up.²⁶

Strengths and limitations

This study has several limitations and, in particular, has implications on generalisability to other clinical and geographic settings. The participants in this sample were predominantly white, highly educated with adequate financial stability each month, and had access to a Diabetes Education Centre, a breastfeeding clinic, and an AFHT in a large tertiary care hospital. They likely had higher levels of health literacy and self-advocacy than the general public. Furthermore, 36% of them received obstetric care from their regular family doctor (see Supplementary Box S3), facilitating ready access to information about complications. This is a higher rate than seen provincially or nationally.²⁷ Even within this high socioeconomic community with access to several tertiary care services, there was a notable gap in documentation of pregnancy complications and, consequently, follow-up. Therefore, these findings would possibly be worse in settings with ethnic minorities and low socioeconomic strata. This inference further emphasises the need to find solutions to bridge the lacunae in documentation and communication of pregnancy complications.

Maternal recall surveys have been shown to have high specificity and negative predictive value, indicating that self-reporting of pregnancy complications experienced 3–6 years ago is likely to be accurate. Aspects of pregnancy such as birth weight, PTB, and pre-eclampsia have been seen to be accurately reported by females decades after a pregnancy.²⁸ Despite that, there is still an element of recall bias, since some of the pregnancies in this study dated back >10 years. There may also have been self-selection bias in completing the survey resulting in the low response rate and the small sample size. Although the prevalence of pregnancy complications in this study is mostly similar to national figures, a larger sample size would provide opportunity for regression analyses, where correlations between OCP and pregnancy complication follow-up could be further investigated.

Differences in EMR systems between the family practice and hospital departments is probably one of most notable limitations in ensuring adequate postpartum follow-up. In Canada, a patchwork of EMR systems has developed as a result of decentralised administration of health care from the federal government to individual provinces, and from the provinces to the local level. Due to a lack of computer literacy, low compatibility with other systems, time constraints, and inadequate clinician involvement, the adoption of EMR across the nation has suffered.²⁹ These barriers are seen at the provincial level as well.²¹ In Ontario, EMRs are mostly used in family practices, as is the case for the AFHT in this study.¹⁸ However, owing to differences in software used between the family practice and the hospital, successful interdepartmental communication is inadequate, resulting in missed opportunities of chronic disease prevention as evident in this study.

Comparison with existing literature

This study highlights several gaps in communication and clinical practice as identified in previous studies. In a survey assessing GP knowledge, attitudes, and practices regarding pregnancy complications, only 50% of family physicians reported collecting pregnancy history from their patients.³⁰ Similarly, only 62% of the participants in thissample who self-reported a pregnancy complication in the survey had it recorded in their EMR. The lack of communication between OCPs and GPs likely plays a major role in suboptimal documentation of these patients. MacDonald et al¹⁶ reported that 83% of maternity care providers in Ontario claimed they inform GPs about the patient’s pregnancy complication, notably HDP, which is incongruous with the 58% of the GPs who reported they were informed of the same. There is a clear discrepancy between what the GPs believe they are told and what the OCPs believe they are informing.¹⁶ Lack of information flow is amplified because of the absence of standardised transfer of care protocols that include pregnancy complications. This is contrary to, for example, protocols in midwifery care.³¹ As a result, GPs often rely on their patient and/or OCP to relay pregnancy-related information, which may not be sustainable or efficient for patient care.

Similar to national figures, responders had a 7% and 10% overall prevalence of GDM and HDP, respectively. GDM was reasonably well captured, which may be because of the early introduction of GDM management guidelines in 2008 and a greater proportion of studies conducted on diabetes and GDM.³² Although GDM was well documented, postpartum 75 g OGTT was suboptimal, despite access to comprehensive programmes in self-management of diabetes via Diabetes Education Centres,³³ revealing a gap in practice.

HDP was not as well documented as GDM, where only 50% of the participants had their blood pressure documented within 6 months of delivery. HDP has only been established as an independent risk factor for CVD in the last decade.^14,34,35 While the Society of Obstetricians and Gynaecologists of Canada (SOGC) has postpartum guidelines for monitoring patients with HDP, there is no guideline specific to primary care, which is where much of the postpartum cardiovascular risk management occurs.^34,35 GPs may lack awareness of SOGC guidelines, possibly owing to their target audience being obstetrical providers and gynaecologists.¹⁷ Since HDP was first recently added as a cardiovascular risk factor by the Canadian Cardiovascular Society in 2016 and then by Hypertension Canada in 2018,^11,12 the uptake of the clinical guidelines by GPs may potentially be evident in the coming years.

Interestingly, the prevalence of PTB in this sample (12%) was higher than national figures (8%).³⁶ On further examination, one-third had a PTB pregnancy complicated by intrauterine growth restriction (IUGR), HDP, and GDM— all of which are established factors associated with PTB.³⁷ Furthermore, of the responders who experienced PTB owing to factors other than HDP, GDM, and IUGR (n = 8), seven (88%) were aged 30–39 years and one (13%) was a current/previous smoker (data not shown), factors that have been associated with an increased risk of PTB.³⁸ Finally, the small sample number is likely playing an important role. Because of heterogeneous factors associated with PTB,³⁹ its prevalence may not accurately predict the isolated burden of the syndrome in this sample.

Implications for research and practice

Pregnancy offers a unique window to a woman’s future health. The link between pregnancy complications and future CVD provides physicians with perhaps the earliest opportunity for disease prevention. GPs deal with preventive medicine and motivational interviewing on a daily basis and are therefore well positioned to identify and counsel patients at increased risk of chronic disease. This study reinforced the need for a multifaceted approach to improve documentation and management of obstetric complications to improve future cardiovascular health. In addition to systemic changes that would facilitate or mandate sharing of information between care providers, there is a need for improved knowledge translation in primary care as well as tools to improve documentation and follow-up.

After this study, the team initiated several strategies to address some of these gaps. Patient education postcards were developed that encouraged patients to share their pregnancy history with their family doctor. Additionally, a well-designed e-Module series on HDP is in development for family medicine residents; currently, these topics receive scant attention within postgraduate curricula. Finally, the research team is leading an initiative to design and develop an EMR-based tool that facilitates information gathering, documentation, and management of pregnancy complications. Through multidisciplinary collaborations, it seeks to enable females and their physicians to improve postpartum cardiovascular risk management and to achieve improved long-term health goals.