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.