Dr. Rohan D’Souza has had a front-row seat to devastating cardiovascular events in pregnant women. But many of them, he says, are preventable.
Cardiovascular events are a leading cause of death during and after pregnancy, in high-, middle- and low-income countries.
Dr. D’Souza, a maternal-fetal medicine specialist and associate professor of obstetrics and gynaecology at McMaster University in Hamilton, says, “A considerable number of people with and without known heart disease, experience severe cardiovascular events, like heart failure or arrhythmia during pregnancy, labour or postpartum. Many of these events occur due to delays in accessing care, as well as diagnosing and treating the condition early. Our multi-provincial, interdisciplinary team, including people with lived experience, seeks to address the rising rates of these events.”
The Canadian Network of Networks to Reduce Cardiovascular Mortality and Morbidity in Pregnancy (CaNCaM-Preg), has been awarded $5 million over five years through the Research Networks of Excellence in Women’s Heart and/or Brain Health, a new initiative funded by Heart & Stroke, along with partners Brain Canada and the Canadian Institutes of Health Research – Institute of Gender and Health.
Heart & Stroke asked Dr. D’Souza how the network will change things for the better.
Are healthcare providers aware of the risk of cardiovascular problems in pregnancy?
Dr. D’Souza: As medical students, we learn that pregnancy is a time of great change, especially for the heart. The volume of blood increases by 40%, the resistance to blood flow decreases by 30% and the heart rate increases by 10-20%. While most pregnant women are able to cope with these changes, some are not. Not everyone recognizes the potential for things going wrong early in pregnancy, or the need to understand risk factors for severe cardiovascular events and be proactive. Besides, not all healthcare providers receive specialized training required to recognize and treat serious cardiovascular events in pregnancy.
What are the major reasons for having a heart-related problem in pregnancy?
Dr. D’Souza: Some people are born with a heart condition, which we call congenital heart disease. In most cases, these conditions are treated with medications or surgery during childhood, but problems may arise during pregnancy. Sometimes a heart condition may arise later in life, called acquired heart disease. An example is rheumatic heart disease — when rheumatic fever damages the heart valves — which affects people from lower-income countries and lower socio-economic statuses. Often, these people have not been diagnosed before, and may go into heart failure during pregnancy or in labour. Finally, there are some people without a cardiac diagnosis, that might not be able to cope with the profound cardiovascular changes of pregnancy.
Are these rare events becoming more common?
Dr. D’Souza: The demographics of the pregnant population are changing. For example, countries such as Canada have a rising immigrant population, which increases the chance of encountering people who have rheumatic heart disease. New heart disease in pregnancy is becoming more common as people are getting pregnant at an older age, with, have higher body weights, and experiencing and conditions like high blood pressure and diabetes before they get pregnant. These are some of the factors contributing to severe cardiovascular events, and they're likely going to continue to rise.
How will CaNCaM-Preg make a difference?
Dr. D’Souza: As part of a related initiative – The Canadian Obstetric Survey System (CanOSS), we are setting up a network of all 289 hospitals in Canada that provide pregnancy care. As part of the first program of CanCaM-Preg, we will help hospitals caring for people with severe cardiovascular events in pregnancy review these events systematically and find the root causes that led to the event.
Our network — made up of clinicians, researchers, social scientists and people with lived experience — will then work together to find solutions, which will reduce severe cardiovascular events in pregnancy.
How will this survey system help prevent cardiac events?
Dr. D’Souza: Our approach will help us find out what happened from the start of pregnancy until the severe cardiovascular event occurred and beyond. Some questions we will be able to answer include:
- Did this person have risk factors that were not identified?
- Was there a delay in making the diagnosis of a heart condition or treating it?
- Was diagnosis or treatment delayed because the person was pregnant?
- Did this person receive differential care because they’re from a marginalized community?
- Was there limited access to care because they're from a remote community?
Each case will be reviewed by an external group of experts including nurses, midwives, family doctors, obstetricians and cardiologists, to see what could have been done differently and make recommendations at a local, provincial and federal level. By putting these recommendations into practice, we hope to prevent these events from happening in the future.
What are some of the challenges around adopting this process and making change?
Dr. D’Souza: Hospital teams are overworked. Because of this funding for our Network of Excellence, we will be able to recruit and train research nurses and assistants to identify all severe cardiovascular events and collect data in a way that’s sensitive and accurate.
Another issue is trust. It takes time for hospitals to build trust and agree to sharing sensitive data on serious events within a network. Over the past few years, we have been working very hard to build this trust, which has resulted in most hospitals agreeing to share anonymized data to bring about positive change.
Finally, Heart & Stroke’s Research Networks of Excellence announcement put an emphasis on multi-provincial, interdisciplinary teams and having people with lived experience. This encouraged us to bring together people who are trusted and who trust us, to work towards a common goal.
What other initiatives will CaNCaM-Preg be undertaking?
Dr. D’Souza: In addition to developing a network of all hospitals across Canada, CaNCaM-Preg will also develop a network of all large hospitals in Canada that provide specialized care for people with heart disease – The Canadian Cardio-OBstetrics (CanCOB) Network. This network will address two important challenges:
First, it will aim to improve cardiovascular health of those with known heart disease, during and between pregnancies. Second, it will aim to improve pregnancy outcomes in people living with heart valve disease, which mostly affects people from Indigenous and other marginalized communities.
What kind of impact do you see this research network having?
Dr. D’Souza: Cardiovascular events during pregnancy are life-changing. They don’t just affect the person experiencing them but ripple through their family, community and healthcare system. When a mother survives, her quality of life is profoundly impacted – sometimes permanently. These events are devastating, but they are also increasingly preventable with the right strategies.
CaNCaM-Preg has united the most skilled and dedicated clinicians and researchers in the field of heart disease and pregnancy under the shared mission of “strong hearts, safe pregnancies.” What makes this network unique is its collaboration with those who have lived experience; women who have faced heart disease during pregnancy. This partnership ensures that we’re addressing not only the clinical aspects, but also the human side of these challenges, identifying root causes and designing solutions that are both effective and equitable.
The impact of this work has the potential to extend far beyond Canada. As CaNCaM-Preg identifies and implements strategies that reduce severe cardiovascular events, it will serve as a model for countries worldwide grappling with similar challenges. By leading with innovation, collaboration and compassion, this network can change the narrative for countless families and communities, making a lasting difference for generations to come.
- Learn more about women’s unique risk factors for heart disease and stroke