Objective To measure cardiovascular outcomes and risk associated with pregnancy among women diagnosed with rheumatic heart disease (RHD) prior to 20 weeks’ gestation. Design Retrospective cohort study using linked RHD register, midwives, hospital and death records. Setting Population-level analysis of all births to women with RHD in four Australian jurisdictions (covering 71% total / 88% Indigenous population). Sample Females aged 12-44 years with first RHD diagnosis prior to age 35 years with at least one birth record, 2002-2017. Methods Survival methods (incorporating mixed effects and time-varying covariates) estimated proportions and Hazard Ratios. Main Outcome Measures Probability of hospitalisation for new Cardiovascular complications including pulmonary hypertension secondary to left heart disease, heart failure, valvular surgery, stroke, infective endocarditis, atrial fibrillation, acute pulmonary oedema, cardiomyopathy and/or death. Results We identified 558 pregnancies in women with uncomplicated RHD (345 women) and 88 pregnancies in women with complicated RHD (60 women). During pregnancy 4.5% of women with uncomplicated RHD and 31.8% of women with complicated RHD experienced new cardiovascular complications. Cardiovascular complication risk was 3 to 6-fold higher during pregnancy than non-pregnancy and did not differ by RHD stage. Conclusions Women with RHD experienced heightened cardiovascular complication risks during pregnancy in alignment with RHD stage at 20 weeks gestation.

Objective: Rheumatic heart disease (RHD) persists in low-middle-income countries and in high-income countries where there are health inequities. RHD in pregnancy (RHD-P) is associated with poorer maternal and perinatal outcomes. Our study examines health care perspectives of models of care for women with RHD-P. Design: Descriptive qualitative study exploring health professionals’ perspectives of care pathways for women with RHD-P. Setting: Australia Population: Nineteen participants from maternal health and other clinical and non-clinical domains related to RHD-P. Methods: Thematic analysis of semi-structured interviews. Results: A constellation of factors challenged the provision of cohesive women-centred care, related to health systems, workforces and culture. Themes included conduits of care - helping to break down silos of information, processes and access; ‘layers on layers’ – reflecting the complexity of care issues; and shared understandings – factors that contributed to improved understandings of disease and informed decision-making. Conclusions: Pregnancy for women with RHD provides an opportunity to strengthen health system responses, improve care pathways and address whole-of-life health. To respond effectively, structural and cultural changes are required including enhanced investment in education and capacity building – particularly in maternal health – to support a better informed and skilled workforce. Aboriginal Mothers and Babies programs provide useful exemplars to guide respectful effective models of care for women with RHD, with relevance for non-Indigenous women in high-risk RHD communities. For key goals to be met in the context of RHD, maternal health must be better integrated into RHD strategies and RHD better addressed in maternal health.