A program at the Brigham that focuses on assisting high-risk postpartum patients to transition from obstetric to primary care is now helping other health systems implement the clinical model to care for patients
Hypertension, or high blood pressure, is a leading cause of pregnancy-related death, and over a third of those deaths happen after the usual postpartum period of six weeks after birth.
For patients who have had a hypertensive disorder of pregnancy (HDP), continuing to monitor health after pregnancy is critical; yet 40 percent of patients don’t attend their postpartum medical appointments.
People of color, low-income patients, and non-English speakers are the groups least likely to seek out postpartum care after hypertensive pregnancy—and they’re most at risk for complications.
The Brigham and Women’s Hospital (BWH) Cardiometabolic Clinic in Maternal Fetal Medicine (MFM) strives to ease the transition from obstetric to primary care for all patients with complex hypertensive pregnancies, with an additional focus on improving care for those populations most at risk.
Ann Celi, MD, MPH
Last spring, Ann Celi, MD, MPH, was selected as a Phase 3 awardee of the Hypertension Innovator Award by the U.S. Department of Health for her work in the clinic.
The highly selective award recognizes innovative programs for maternal hypertension.
The BWH Cardiometabolic Clinic in MFM won two previous hypertension innovation awards for sustainable program development in maternal hypertension, with the second award recognizing the work of addressing racial socioeconomic disparities in improving blood pressure control in the postpartum period and at follow-up with primary care teams.
In Phase 3 of the award, the program is supporting 14 other health systems in replicating and implementing the Brigham’s clinical model at different stages across several communities nationwide.
“We are thrilled that we have been able to scale up and share this clinical model with other communities,” said Celi. “When we open our doors and listen, we can successfully reach our patients. This is true not only at the Brigham, but also across the country, in not only hospitals and academic medical centers but different kinds of clinical and nonclinical settings."
Reaching Patients Where They Are
The Cardiometabolic Clinic in MFM began in 2011 at the Brigham as a unique collaboration among experts in primary care, maternal fetal medicine, obstetrics and gynecology, and general medicine.
It is a collaborative program that was conceived by an interdisciplinary group of clinical leaders, including Louise E. Wilkins-Haug, MD, PhD, director of Maternal Fetal Medicine, Ellen Seely, MD, director of clinical research, Division of Endocrinology, Diabetes and Hypertension in the Department of Medicine, as well as Celi and leadership in the Departments of Medicine and Primary Care.
Its primary care leadership includes Lance Rachelefsky, chief of operations, and Dale Adler, MD, executive vice chair of the Department of Medicine.
In the fall of 2020, to address the needs of social distancing, the clinic pivoted to a virtual model, and in February of 2024 returned in a hybrid model.
“Dr. Celi has succeeded in an area that was defined scientifically as critical but that had seen few implementation successes, especially in underserved populations,” said Adler.
“By working creatively and tirelessly for decades, she has made a huge impact on the long-term cardiovascular health of a generation of young mothers.”
Early lessons learned from the cardiometabolic program for patients at highest risk of postpartum hypertension complications helped in launching “Home Safe,” a program within the Department of Obstetrics and Gynecology funded by the Massachusetts Department of Public Health that provides blood pressure monitoring support during the first six weeks after birth.
Home Safe is led by Wilkins-Haug, Seely and Saba Berhie, MD, also of the Division of Maternal Fetal Medicine.
With funding from the Department of Public Health, "Home Safe” has provided blood pressure cuffs at discharge, an Epic enabled app, population health coordination, and virtual visits to over 600 BWH postpartum patients in two years.
Expansion to Massachusetts General Hospital through a Mass General Brigham grant is currently underway.
A Lasting Impact on Health
Marika Hamilton
Marika Hamilton’s son was born in 2020 during the height of the COVID-19 pandemic.
Hamilton had previously experienced preeclampsia—a serious pregnancy complication characterized by high blood pressure—when pregnant with her older children.
So she did everything she could to keep her blood pressure well controlled during this pregnancy.
But after her son’s birth, Hamilton experienced postpartum preeclampsia—a rarer but no less concerning hypertensive condition.
“I thought I was going to die, and I didn’t have an advocate,” Hamilton recalled five years later. Even after she was discharged from the hospital, her blood pressure was not well controlled. Marika spoke to a friend, who spoke to a friend, and, eventually, she connected with Celi.
“I felt like I could trust her [Celi] right off the bat—she saw me, she knew me, and she understood my story,” said Hamilton. “From the moment I met her, I felt she had my best interests at heart, and she proved it.”
Hamilton recalls after-hours phone calls from Celi who would contact her just to check in. Celi gave her tips on how to check her blood pressure and even talked to Hamilton’s husband to explain the seriousness of HDP.
“The timely education and intervention I received have had a lasting impact on my health,” said Hamilton. “I believe that the care provided by Dr. Celi has added years to my life, allowing me to fully enjoy motherhood without the fear of having a stroke and dying like my father did at the age of 44. I am happy to say that I made 44 years this year, and I’m looking forward to many more years of motherhood.”
Celi also helped get Hamilton in for appointments with a renal specialist and the care team at Brigham and Women’s Hospital.
But for women outside Boston, accessing this type of care can be difficult, especially for the millions of people in the 35 percent of counties in the U.S. that don’t have an OBGYN or birthing hospital.
That’s why Celi’s team is focused on sustainably replicating and expanding the Brigham’s clinical model and programs.
This has included expanding the program’s geographical area to support Mass General Brigham (MGB) community postpartum health initiatives such as the Maternal Health Equity Postpartum Program in conjunction with the MGB Community Care Vans and Community Care in Reach Mobile Health Initiative.
Providers in the MGB healthcare system deliver approximately 18,000 babies per year across Massachusetts and Southern New Hampshire, which includes supporting populations at high risk of pregnancy- and postpartum-related complications.
Celi is especially interested in trying to support hypertensive pregnancies in ever-growing maternal care deserts, and she has shifted much of her work to developing multimodal educational tools to support patients and their providers.
On a national level, the team collaborates with federal government agencies such as the Department of Health and Human Services, the CDC, foundations such as the Preeclampsia Foundation and the March of Dimes, and professional societies including the Society for Maternal Fetal Medicine, the American Heart Association, American College of Cardiology and Society of General Internal Medicine.
Celi presents widely on care models and educational tools for patients with HDP. Using an HMS Dean’s award for clinical innovation in collaboration with Ariadne Labs and Chloe Zera, MD, of Beth Israel Deaconess Medical Center, Celi worked on background development to better understand the postpartum transition after pregnancy using qualitative interviews of patients and providers and human-centered engineering design to develop educational tools.
Extending the Work
Using funding from the CVS Health® Foundation, Celi leveraged this experience to develop a patient-owned educational toolkit with the Preeclampsia Foundation, the International Society for the Study of Hypertension in Pregnancy, and the Society of Maternal Fetal Medicine.
It is being tested with birthing populations at BWH right now, and the team is seeking feedback from providers to inform their next steps.
Kirsten Dorans, an assistant professor at the Celia Scott Weatherhead School of Public Health and Tropical Medicine at Tulane University, is collaborating with Celi and her team to further explore the possibility of implementing the toolkit in community clinical and nonclinical spaces in rural and urban regions of need in Louisiana.
“Improving cardiometabolic health across different settings requires collaboration,” said Dorans. “The possibility of working with health centers and doula groups is incredibly powerful and exciting, and I’m looking forward to seeing where the research leads us.”
Studying the tool and lessons learned from her care model with different patient teams, including nursing, nurse midwifery, community health workers, community nurse aides, doulas and patient advocacy groups, Celi agrees that complicated problems need to be addressed in as many spaces as possible.
She recently presented at the Doula Expo by Mama Glow in Brooklyn. “I was there to discuss the risks of CVD with community birth doulas and to empower them to use these tools to help them educate and care for their patients,” she said.
Providing Maximum Access
Since its inception, the Cardiometabolic Clinic has focused on populations at highest risk for poor outcomes. Black women are disproportionately at risk not only of hypertensive disorders of pregnancy (HDP) but also of worse maternal and perinatal outcomes and risk of HDP-related death.
Higher levels of maternal education and socioeconomic status do not confer any protection from these risks.
Hamilton was acutely aware of Celi’s cultural competence in the care she provided. “As a woman of color, I felt seen and heard under Dr. Celi’s care,” she said. “She acknowledged the increased risks that women of color face with preeclampsia and tailored her approach to address my specific needs. This personalized care was instrumental in my treatment.”
Elsie Taveras, MD, MPH, the Chief Community Health and Equity Officer at Mass General Brigham and Executive Director of the Kraft Center for Community Health at Massachusetts General Hospital, leads system-wide strategies to improve health equity and the health of the communities served by Mass General Brigham.
“If we want to improve the lives of all of our patients, we need to be intentional, we need to be connected, and we need to empower patients,” said Taveras.
“This program illustrates the power of connection and empowerment and the ripple effect this can have on the life of a patient, a family, and a community.”
“We want to offer up solutions to help our patients," said Celi. "These are problems that are not easily solved—they require our attention, our most innovative thinking, and an unwavering commitment.”
“I'm really proud of the teams and the people that we've worked with. And I'm so proud of the patients and their courage for confronting these incredibly complicated problems at a difficult time in their life.”
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