Sharla M. Smith, PhD, MPH^1*, Shea Kempsen, MPH¹, Claire Metcalf, MPH candidate¹, Oluoma Obi, MPH¹, Elizabeth Madrigal, MPH¹, Kionna L. Henderson, PhD, MPH², Megha Ramaswamy, PhD, MPH³

¹University of Kansas Medical Center, Kansas City, KS, USA

²Research Scientist II, Health and Wellness Center, Baylor Scott & White Health and Wellness Center, 4500 Spring Avenue, Dallas, TX 75210, USA

³Professor and Chair, Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA

^*Corresponding Author: Sharla M. Smith, PhD, MPH, Associate Professor, Director, Kansas Birth Equity Network, University of Kansas Medical Center, Kansas City, KS, USA.

Received: 10 March 2026; Accepted: 17 March 2026; Published: 25 March 2026

Article Information

Citation: Sharla M Smith, Shea Kempsen, Claire Metcalf, Oluoma Obi, Elizabeth Madrigal, Kionna L Henderson, Megha Ramaswamy. Closing the Gap Between Recommendation and Uptake: Provider Communication About Low-Dose Aspirin for Preeclampsia Prevention. Journal of Pediatrics, Perinatology and Child Health. 10 (2026): 40-50.

DOI: 10.26502/jppch.74050232

Abstract

Keywords

Hypertensive disorders; Pregnancy; Women; United States; Maternal; Preeclampsia; Worldwide

Article Details

1. Introduction

Hypertensive disorders of pregnancy (HDPs),including preeclampsia, gestational hypertension, eclampsia, and HELLP syndrome, are a leading cause of preventable maternal morbidity and mortality in the United States [1-3], defined by systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg on two occasions at least four hours apart [4]. Preeclampsia affects 2-8% of pregnancies and accounts for more than 70,000 annual maternal deaths worldwide [5], with approximately 60% considered preventable [6]. HDP-related mortality has severe racial and ethnic disparities, with a higher proportion of pregnancy-related deaths attributed among Black (8.2%) and Hispanic (9.7%) women compared to White women (6.7%) in the United States [7,8] Systemic bias [8], inadequate counseling [9], and low uptake of preventative therapies [10] impede clinical and holistic improvements.

Low-dose aspiring (81 mg/day) reduces preeclampsia risk by 10-24% and is recommended by the U.S. Preventive Services Task Force (USPSTF), American College of Obstetricians and Gynecologists (ACOG), and Society for Maternal-Fetal Medicine (SMFM) for initiation between 12- and 16-weeks’ gestation in high-risk individuals [11]. Despite these recommendations, preeclampsia incidence has changed little since guideline adoption [3,12]. Provider counseling practices, including how clinicians communicate risk, prescribe LDA, and navigate patient-level barriers, represent a critical and under-researched area. This study characterizes provider counseling and management of HDPs, implementation of evidence-based LDA prophylaxis, and provider-identified barriers and facilitators to guideline adherence.

2. Methods

This cross-sectional, mixed-methods study combined an online survey and semi-structured interviews with perinatal care providers at two Midwest academic medical centers (2021-2022). The study was approved by the Institutional Review Board of the University of Kansas Medical Center; written informed consent was obtained from all participants, who received gift card incentives.

The survey was distributed electronically to attending physicians, residents, fellows, and midwives (n=74). The instrument addressed six domains: demographics, education and awareness,monitoringand recommendations, LDA use, barriers and facilitators, and postpartum follow-up. Data was analyzed using SAS 9.4; categorical variables are reported as frequencies and proportions (Table 1).

Table 1: Survey Respondent Demographics (N=74).

From survey respondents, a purposive sample of 13 providersparticipatedin virtual, 30-60-minute semi-structured interviews (4 family medicine physicians, 8 OB/GYN physicians, 1 nurse-midwife).Interview guides addressed HDP counseling, LDA prescribing, barriers to uptake, and postpartum preeclampsia management.Questions were tailored to each participant’s survey responses. Interviews were recorded and transcribed verbatim. Two reviewers conducted deductive thematic analysis with established intercoder reliability to develop code summariesand overarching themes. The five themes identified include Initiating Conversations, Low-dose Aspirin Prescription, Barriers to LDA uptake, Facilitators to LDA uptake, and Postpartum Preeclampsia Diagnosis (Table 2).

Table 2: Interview Participant Demographics (N=13).

3. Results

Survey respondents were primarily White (83.8%), aged 25-34 (60.8%) andhelddoctoral degrees (98.6%).As shown in Table 3, 75.7% of providers reported discussing high blood pressure with all pregnant patients; 23.0% distributed educational materials. All providers (100%) reported recommending LDA to high-risk patients, with mostindicatinginitiation at 12-16 weeks’ gestation. High-risk patients were extremely orvery likelyto receive increased monitoring (93.2%). Barriersidentifiedin the survey included structural constraints on appointment attendance, knowledge gaps in LDA dosing, and low patient uptake. Facilitators included LDA’s low cost, over-the-counter accessibility, established safety profile, and widespread public familiarity with aspirin.

Table 3: Survey Results (N=74).

Interviews conducted contained 13 participants, includinga NurseMidwife (n=1,7.7%), OB/GYN Physicians(n=8,61.5%),and FamilyMedicinePhysicians(n=4,30.8%) (Table2).Fivethemes wereidentifiedin physician interviews:1) InitiatingConversations,2) Low-DoseAspirin(LDA)Prescription,3) Barriers to LDA Uptake,4)Facilitators to LDA Uptake,and5)PostpartumDiagnosis,as shown in Table 4.

Table 4: Interview Results (N=13).

Among thoseinitiatingearly counseling, topics included HDP risk factors, a general overview of hypertension in pregnancy, and probing questions to assess patient-specific risk.While all agree that HDP should be discussed during clinical visits, themajority onlyinitiatedin-depthconversations with patients with[13] 1 high-risk factors.One provider noted the absence of a standardized institutional protocol for theinitialprenatal visit,leading to nonstructuredcounselbased on provider subjectivityduring the critical early gestational weeks.

Providers(n=2) 15.3% initiated HDP conversations with all patients, regardless of risk factors.This was particularly important to medical providers that served low-income or uninsured populations.Providers(n=5) 38.5% initiated HDPconversations only with patients perceived as high-risk.Patients with high-risk factors, includingaprevioushistory of cardiovascular disease, preeclampsia, or Black race,had intentional conversations with providersreviewing warning signs andadditionalblood pressure monitoring.

All providers(100%, n=13) agreed thatLDA is a crucial preventive strategy for HDP and early-onset preeclampsia.While recommendationsfor whento start LDA use minimally vary, consensus forcounsel at the end of the first trimesterand into the second trimester wasrecorded.Guidelines for aspirin dosage follow81 mg/day, but guidelines occasionally differed to up to162 mg/day, differing by medical institution and accepted clinical practices.

All providers (100%, n=13) recommended initiating LDA between 12- and 16-weeks’ gestationas directed by most globally accepted guidelines; two suggestedinitiationas early as 5 weeks. One provider reported advising LDA initiation at 18-20 weeks’ gestation for lower-risk patients, diverging from ACOG and USPSTF guidelines.Gestational timelines wereseen as recommendations to follow but varied by risk factor, time with patient, and subjectivity of medical providers.

Limited medication adherencewas identified as the largest barrier to LDA uptake(43%, n=34).Many providers felt that while they always discussed LDA importance,the uptake was dependent on patient responsibility and use.Appointment non-attendance reflected structural barriers including transportation, childcare obligations, insurance limitations, and employment demands.Formally prescribing LDA, rather than simply recommending it, may improve adherence by signaling clinical importance. Some suggested pairing LDA with prenatal vitamins to encourage regular use.Limited appointment attendance (16.5%, n=13)was also mentioned as a barrier to LDA prophylaxis. Providers could not prescribe or suggest LDA usage if patients did not attendperinatal appointments regularly, but accepted common barriers, especially for low-income or uninsured patients.

LDA Uptake facilitators include general low cost as well as the availability ofthemedicationin most general shopping stores. LDA is a low barrier to entry medication which promotes itscontinued use throughoutthepregnancy and postpartum periods.Low-dose aspirin can be found at any drug store or general store andcan be bought over the counter with no insurance premiums or copays.Providers discussedthegeneral acceptability of LDA as safe with common name recognition.

Twenty-six interview comments addressed postpartum preeclampsia, discussing the growth of incidence ratedespite the lack of research on postpartum complications. This may signal agrowing need for acomorbidityfocus in the postpartum period, enhanced by the lack of continuation of care during this time. 7.7% (n=2)ofprovidersdescribedseeing an increasing number of postpartum preeclampsiapatient, noting an increasing number of cases of postpartum preeclampsia requiring hospitalization.46.2% (n=12) addressed postpartum preeclampsia as a clinical concern. The change from OB/GYN provider to family medicine practitionerpost-birth was noted where patients typically “fell through the cracks.”

34.6% (n=9) comments discussed barriers in addressing postpartum preeclampsia, including caring for a newborn, long emergency department wait times, and breastfeedinglogistics. Providers alsoidentifiedthe absence of a formalized handoff between obstetric and primary care settings as a critical systems-level gap, limiting continuity of monitoring after delivery.

4. Discussion

This mixed-methods study identified meaningful inconsistencies between provider-reported and provider-described hypertensive disorders of pregnancy (HDP) counseling practices, suggesting that knowledge of recommendations does not consistently translate into clinical action. Although all respondents demonstrated awareness of current low-dose aspirin (LDA) guidelines, providers’ descriptions of practice revealed that counseling was often reserved for patients perceived as high risk rather than delivered consistently across eligible populations. Notably, while 75.7% of survey respondents reported discussing high blood pressure with all pregnant patients, interview data indicated that most providers initiated these conversations selectively, creating missed opportunities for early prevention among patients with moderate-risk factors and those facing socioeconomic barriers to care. Given that a substantial proportion of HDP-related maternal deaths are considered preventable, these findings underscore how inconsistent counseling may deepen existing disparities even when an effective, low-cost, and widely available preventive therapy exists. These findings are consistent with prior literature showing that only about half of eligible nulliparous patients receive guideline-concordant clinician counseling about aspirin prophylaxis and with commentaries arguing that miscommunication around LDA supports broader, more universal prevention approaches [14].

This study also found that the barriers most frequently cited by providers were medication adherence and appointment attendance reflecting structural constraints more than individual patient shortcomings. Framing these challenges as failures of “compliance” risks obscuring the roles of transportation instability, insurance gaps, childcare demands, employment constraints, and limited continuity of prenatal care. Reframing the problem as one of patient activation and health system support better aligns with equity-centered maternal care because it shifts responsibility toward shared decision-making, anticipatory counseling, and interventions that make adherence feasible in daily life. In this context, inconsistent clinical action around LDA recommendation or prescription is not merely a communication issue but a systems issue with implications for maternal outcomes. This interpretation is supported by studies documenting racial disparities in aspirin prophylaxis use, broader evidence linking structural racism and implicit bias to maternal health inequities, and patient-facing information gaps that may limit understanding of preeclampsia prevention outside the clinical encounter [15].

Finally, our findings support universal HDP counseling and more standardized LDA prescribing practices as equitable strategies to reduce practice variation and improve preventive care delivery. Universal counseling would establish a minimum standard of care for all pregnant patients, while formal prescribing rather than informal recommendation alone may better communicate the clinical importance and urgency of aspirin use. Because LDA is inexpensive, widely available, and supported by national recommendations for patients at increased risk of preeclampsia, broader implementation may help mitigate inconsistent recognition of moderate-risk factors and reduce the influence of implicit bias in selective counseling. Providers in this study also emphasized the need for structural reforms, including expanded postpartum Medicaid coverage, stronger continuity of care before and after birth, and community-centered public health education regarding aspirin use in pregnancy. Together, these findings suggest that optimizing HDP prevention requires both standardized clinical protocols and structural support that make adherence possible. This conclusion aligns with USPSTF evidence supporting aspirin to prevent preeclampsia-related morbidity, with recent quality-improvement work focused on improving counseling among patients with moderate-risk factors, and with the growing literature calling for system-level reforms to address persistent racial inequities in maternal health [16-41]

5. Implications

Future efforts to reduce hypertensive disorders of pregnancy should extend beyond selective risk-based counseling to universal low-dose aspirin prescribing supported by strategies that reduce implicit bias and structural barriers to uptake. Standardized early counseling and prescribing, particularly in the 12- to 16-week window, may improve adherence and reduce inequities in maternal outcomes related to race, income, and insurance status.

6. Limitations

While this study has numerous strengths including the mixed-methods design enabling triangulation of findings, and inclusion of providers from multiple specialties and training levels, some limitations exist. Limitations include the small interview sample, limitedproviderdemographic diversity (predominantly White), and geographic concentration at two Midwest academic medical centers. The absence of thepatient'sperspective is a key limitation; future research should integrate patient-reported experiences to fully characterize barriers and facilitators. Future studies should also examine contributions of midwives, community health workers, and doulas, as well as perspectives of racially diverse providers who may offer insights into culturally congruent care.

7. Conclusions

Providersdemonstrategeneral familiarity with LDA guidelines for HDP prevention butexhibitsignificant variation in counseling practices. Reframing patient compliance as patient activation, standardizing prenatal counseling protocols, and expanding postpartum support structures are actionable strategies to improve HDP prevention and management.Policy changes, including universal prescription of low-dose aspirin,could promoteequitablechanges in maternal health outcomes andalleviateHDP-related healthdisparities.

Funding

This work was supported by the National Institutes of Health (NIH), Grant Number 5 K01 HL149977-04.

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