In this novel Australian HCP survey, most respondents (85%) were aware that both GH and PE increase the long-term risk of CVD and ‘always’ (78%) ask about HDP history. Despite this reasonably high awareness of HDP being linked to future CVD risks, we identified significant knowledge gaps regarding individual conditions. All professions had consistently lower knowledge scores regarding conditions after GH. This may be because GH is seen as a more benign form of HDP, although studies show GH has similar CVD risk to preeclampsia [4, 14].
Within the context of the selected sample of HCPs, findings were expected to reflect a ‘best-case’ scenario of knowledge as their specialised training theoretically indicates high overall knowledge. Of the total respondent number (n = 573), 48 (8%) were excluded for not answering the key risk question asked (‘Do you think that there is an increased risk of developing future cardiovascular disease after gestational hypertension or preeclampsia?’) and 46 of the n = 492 respondents (9%) for being unsure or not believing there are health risks after HDP. Therefore, even in this sample, with sufficient interest in the topic to undertake the survey, a minority had very low or incorrect overall knowledge. Education developed will need to cater to HCPs with no pre-existing knowledge as well as focus on the specific gaps identified by the survey.
International studies exploring HCPs knowledge have reported overall low knowledge [13]. These studies feature results from highly specialised HCPs with substantial involvement in maternity and women’s health care. Only one study has examined knowledge of HCPs on long-term health risks after both PE and GH, whilst all others focus on risks after PE only [15]. In line with another study that found that higher knowledge was associated with belonging to a particular profession [16], we found higher knowledge among medical professionals compared with midwives. However, in contrast to an American study that found obstetricians generally had more awareness of CVD after PE than internal medicine physicians [17], cardiologists were the highest scoring profession in this survey, DRANZCOG GPs and obstetricians were quite similar.
This study identified some significant knowledge gaps amongst specialist HCPs. Our study findings resonate with those from similarly targeted HCPs in Canada, Germany, Nigeria and the USA conducted between 2007 and 2017 [13]. Therefore, from a global perspective, this reinforces the research to practice gap in yet another country a few years on. With international guidelines, including ISSHP 2018 [2], specifically targeted to assist HCPs on an international scale to better manage and address health after HDP, this practice gap would be expected to narrow.
Given the different scope of practice of various professions, different knowledge and knowledge gaps were expected, and our results can help tailor future education of different HCPs on this topic. For example, options might include improving knowledge about the risks associated with GH amongst specialist GPs and obstetricians. Once this educational material has been piloted with the specialised HCPs, it may be adapted to suit a broader distribution which would include, for example, GPs without specialist qualification in women’s health.
In this study, the condition following PE or GH associated with the highest knowledge was chronic hypertension, consistent with previous HCP studies [15,16,17,18]. Knowledge was lowest with regards to PVD and diabetes across all groups. The wide range of knowledge levels displayed within this study concerning risk of recurring HDP was an unexpected finding and suggests further need for maternity care provider education on this topic.
Only one-third of respondents were aware that risks start to manifest under 10 years after an HDP pregnancy, which may negatively impact on timely follow up and counselling of affected women. In combination with predominantly low to moderate knowledge of most individual CVD conditions explored within this study, this suggests opportunities are currently being lost to discuss preventive strategies that could improve women’s health trajectories. The majority of participants were female. Given that midwifery is a predominantly female occupation in Australia, and GPs and obstetricians closer to 50:50, the response rate of male versus female within these three professions is not unexpected. However, given that a minority of Australian cardiologists are female, the high fraction of cardiology respondents being women suggests bias in this sample.
As with all surveys, it is uncertain how representative it is of the population under study i.e. it is unknown whether knowledge of non-respondents is comparable to that of respondents. Furthermore, the number of respondents in all included subgroups are a small proportion of the national registers (particularly cardiologists) which suggests volunteer bias and also affects generalisability. However, non-representative national HCP numbers along with a highly specialised sample of HCPs can be noted within all research addressing HCP knowledge [13]. This study was also subject to sample limitations as specialised maternity and women’s health HCPs with prior knowledge of the link between HDP and CVD were included in the analysis e.g. the targeting of GP distribution to DRANZCOG holders. This was, however, a deliberate decision, since it can reasonably be expected that these specialised GPs have highest, relative knowledge. Therefore, the knowledge gaps that were found can be expected to extend to the wider Australian GP population. In addition, we targeted these specialised GPs with awareness that response rates to GP surveys are generally very low. For example, recruited numbers were < 15% in this study despite various, targeted recruitment strategies in place [19]. A more general/inclusive spread of midwives, GPs, obstetricians would likely have lesser knowledge than our sample as fewer maternal health qualifications (GPs) and/or not be interested enough in the topic to take the survey. Therefore, when designing education it would be wise to cater for no higher than the levels of knowledge exhibited in our sample, and also cater for lower levels of knowledge.
Our custom-created knowledge score is both a strength, as it allows for a summary of findings across all the conditions and risks, and a limitation, as assigning cut-points is an arbitrary designation. Having included the distractor conditions (breast cancer, leukaemia and seizures) may also have altered the overall score. However, we believe it is important that knowledge is both of conditions that actually do occur more often after GH/PE, plus not incorrectly believing these women are at increased risk of more conditions than they are.
What are the implications?
Research on increased CVD risk after HDP emerged in the early 2000s with the first systematic review published in 2007 [20]. Since then, further research has supported these findings [7], providing close to two decades worth of data signalling the link between HDP and increased CVD risk. Given the length of time that this topic has been addressed in research, it can be an expectation that this knowledge would by now have been translated into practice, particularly amongst our sample that was most likely to include ‘best-case knowledge’ HCPs. That our results did not find this suggests both an even greater knowledge gap in those unaware of the link as well as amongst the non-specialised groups, and ongoing failure to close the knowledge to practice gap on health after HDP. Therefore, this study is valuable from the public health perspective, given the wider context of prevalence and importance of cardiovascular disease in women.
ISSHP [2] and SOMANZ [3] recommendations suggest regular follow-up after HDP as well as counselling about women’s individual long-term CVD risk. Designing suitable education for HCPs, appropriate for general use in the Australian healthcare setting and trialling their implementation, would be an important step towards closing the knowledge gap. It is important to establish preferred content and presentation of education for post-HDP health for clinicians, as well as gain insight on enablers and barriers to referral, access and uptake of follow up consultations.
