Title: Optimising the management of blood pressure following hypertensive pregnancy to reduce cardiovascular risk
Funder: Department of Health and Social Care

Abstract: Background Hypertension in pregnancy affects around one in ten women, of whom approximately half need antihypertensive medication. Following birth, blood pressure (BP) at six weeks postnatal is related to long-term BP and women with pregnancy hypertension have a doubled risk of subsequent cardiovascular disease compared to normotensive women. Current postnatal hypertension management can be haphazard with short-term fluctuations in BP, a transition from maternity to primary care oversight, overstretched clinical services and women with priorities focussed on their new baby. Few data exist to guide improved care at this important time and these issues have only been compounded by the recent pandemic. Aims and objectives The overarching aim of this programme is to develop and test the clinical and cost-effectiveness of an intervention to support self-management of antihypertensive medication following a hypertensive pregnancy with the aim of improving long-term BP control and therefore reduce adverse cardiovascular outcomes and the associated costs to the NHS. Key research questions What is usual care following a hypertensive pregnancy, where does clinical responsibility lie and how could a self-management intervention best fit with current care pathways? (WS1) What is the optimal self-management intervention for postnatal hypertension? (WS2) How can health equity best be ensured in postnatal hypertension self-management? (WS3) Does BP self-management in women following a hypertensive pregnancy lead to lower diastolic BP after six months compared to usual care? (WS4) Is postnatal BP self-management a cost-effective use of health care resources? (WS5) These will be linked by patient and public involvement throughout and carefully disseminated including a comprehensive knowledge mobilisation process. Methods The programme will utilise a range of methods culminating in a trial: WS1 Online surveys plus one-to-one interviews and focus groups (women and clinicians) to understand usual postnatal hypertension care. WS2 Iterative self-management intervention development with co-production and qualitative research. WS3 Qualitative work specifically targeting women s experiences of care transitions following hypertensive pregnancy, accessibility for all and health equity in practice. WS4 Randomised Controlled Trial of BP self-management for women requiring postnatal antihypertensive treatment, with qualitative process evaluation (SNAP2). WS5 Economic evaluation including within-trial cost and outcomes evaluations and long-term economic modelling. WS6 Integrated patient and public involvement accompanied by knowledge mobilisation with wider stakeholders from intervention conception to dissemination and commercialisation. Timelines for delivery The programme will run for five years led by a programme management group overseen by a programme steering committee. Anticipated impact and dissemination This work has the potential for substantial impact on long term women s health following hypertensive pregnancy, reducing cardiovascular risk for millions of women over a twenty-year period. If our preparatory work is confirmed in the proposed programme then a relatively simple short-term intervention could have profound implications. Our emphasis on PPI and health equity (including consideration of different socio-economic and ethnic groups) aims to ensure that any such gains are applicable across the population and not simply for those of white ethnicity or higher socioeconomic status. Dissemination will be wide and broad, engaging with policy makers, industry and relevant patient groups.

Lay abstract: Background High blood pressure (BP) during and following pregnancy affects around 80,000 women each year and can lead to very serious problems for women such as pre-eclampsia or stroke. In the longer term, women who had high BP in pregnancy have an increased risk of heart attack and stroke and this seems to be linked to their blood pressure in the early weeks following birth. Preliminary work suggests that allowing women to measure their own BP and adjust their own medication in the first six months following birth leads to long term reductions in BP. These reductions last after medication is stopped, perhaps due to direct effects on the heart. Aim To test whether women with high BP, through self-monitoring and adjusting their own medication, can achieve lower blood pressure than is usual in the weeks, months and years following birth. Design and methods The programme includes: 1. Development work with pregnant and postnatal women, healthcare professionals and policy makers to help understand how the NHS looks after women with high BP following birth, how new developments might fit with existing care pathways and to co-design and optimise an intervention supported by a smartphone app. [workstreams 1&2] 2. A trial of 628 women who have had a pregnancy complicated by high blood pressure will either monitor and manage their own BP medication or follow usual NHS care. Alongside this we will explore the experiences of women and health care professionals and whether investing NHS money in this intervention is justifiable. [WS4&5] 3. Throughout the programme, we will focus equitably on the needs of postnatal women, to ensure that successful results from the research are ready to put into practice immediately. This emphasis on health equity aims to make the research relevant to women from all backgrounds, not just middle-class white people. [WS3&6] Patient and public involvement We are working with Sandra Igwe (Motherhood Group), Marcus Green (Action on Pre-eclampsia), Birth Companions, the Muslim Women s Network, and collaborators who have lived experience of blood pressure problems in pregnancy, to ensure we engage with a diverse mix of women who are currently or recently pregnant and our research, the intervention and study materials are sensitive, suitable and fit with the attitudes and needs of women. This work, already started and to continue throughout the programme, will be central to our success. Getting the results out Making sure our findings are shared with healthcare professionals, the general public and the academic community is vital. We will deliver: information for study participants, pregnant and postnatal women and the wider public; high-impact papers and conference presentations for academics, policy insights for commissioners of health, and practical tools for the NHS.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: CARDIOVASCULAR;REPRODUCTIVE HEALTH AND CHILDBIRTH