Strengths and limitations
Given the pilot nature of this study, we were not powered to detect
statistically significant changes in weight or blood pressure associated
with our intervention. As such, our study is limited by the small sample
size, and an overall enrollment of 37% of eligible, screened
individuals, limiting its generalizability. Additionally, those who
enrolled were more likely to have a pregnancy complicated by
preeclampsia with severe features compared to those who did not enroll.
Eligibility for the study required individuals to have a device with
internet access, which may have limited the economic diversity of
individuals eligible to participate, although we note that no one who
declined to participate cited lack of access to internet as a reason at
our primary site, but two individuals of the 102 screened (2%) at our
secondary site declined to participate due to unreliable phone /
internet service and lack of access to an appropriate device. These
issues related to lack of access to broadband internet likely
disproportionately impact rural populations and limit the
generalizability of our intervention. In the future, engagement with
such an intervention may be increased with the use of an application
(app), simple text message reporting of blood pressures or with
integration into clinical care. Much like the parent HH4M study, the
control arm likely received more information than most receive in
“usual care,” as prior studies have demonstrated that most clinicians
and patients are either unaware or do not communicate the increased risk
of CVD to postpartum individuals with a history of hypertensive
disorder.(12,40) Our physical activity assessments were based on
participant recall and subjective report, rather than objectively
obtained data, such as using actigraphy, and may have been too
insensitive to measure modest change. Given the global COVID-19
pandemic, we chose to pivot our approach to remote recruitment and study
visits and add a second study site, with a change in our protocol after
recruitment of approximately one-third of our planned sample size. In
addition, we were unable to assess if there may have been COVID-related
impacts on our findings.