Cardiovascular Disease in Pregnancy: Challenges, Care and Collaboration in Low- and Middle-income Countries

Cardiovascular disease (CVD) is a leading cause of indirect maternal death globally and accounts for more than one-third of pregnancy-related maternal deaths.¹ CVD in pregnancy encompasses a range of cardiac conditions, including congenital heart disease, hypertensive disorders of pregnancy, peripartum cardiomyopathy and rheumatic heart disease (RHD).² While congenital heart disease is most prevalent in western countries, RHD remains the dominant cardiovascular condition in low- and middle-income countries (LMICs).^3,4 CVD in pregnancy is a high-risk state and poses significant risks to both the mother and the fetus, leading to complications such as preterm birth, low birthweight, and increased maternal morbidity and mortality.⁴ Early identification of the disease is therefore essential to prevent adverse outcomes.^2,5

The burden of CVD in pregnancy is significantly higher in LMICs, where inadequate access to specialised maternal and cardiovascular care exacerbates adverse outcomes. In Pakistan, a review of 28 pregnant women with cardiac disease reported a maternal mortality rate of 14.2%, with peripartum cardiomyopathy being the most common condition (42.9%), followed by RHD (32.1%).¹ Another large-scale echocardiographic screening study in Pakistan, involving 15,068 asymptomatic pregnant women, identified structural heart disease in 3.8% of participants, left ventricular systolic dysfunction in 2.2%, valvular heart disease in 1.2% and congenital heart disease in 0.5% of participants.² In a similar study in India, of the 14,275 consecutive women screened, 353 (2.5%) were found to have a structural abnormality on screening transthoracic echocardiogram.³ In Sri Lanka, according to data from the Maternal Death Surveillance and Response system between 2006 and 2018, heart disease accounted for 17.25% of maternal deaths, with RHD as the leading cause of heart disease (21.1%).⁴ RHD is one of the leading causes of CVD in pregnancy and disproportionately affects LMICs.⁵ A systematic review and meta-analysis by Lamichhane et al. identified a pooled prevalence of RHD of 2.79 per 1,000 in South Asia, with the highest prevalence observed in Pakistan at 8.0 per 1,000.⁶ These findings underscore the pressing need for improved cardiac care and early screening interventions for pregnant women in resource-limited settings.

Despite these alarming statistics and the increasing recognition of CVD as a significant contributor to maternal mortality, there is a substantial gap in the literature regarding the specific challenges faced by pregnant women with CVD in LMICs. Most existing studies focus on prevalence and outcomes, leaving the challenges that prevent effective management unexplored. Research estimates that up to 68% of pregnancy-related deaths due to CVD could be avoided through enhanced awareness, preventive measures and appropriate treatment strategies.⁷ However, this lack of research limits the development of targeted interventions necessary to reduce the burden of CVD-related maternal mortality in these regions. In developing countries, the concept of a multidisciplinary ‘pregnancy heart team’ remains weak.^8,9 Additionally, risk prediction tools and most guidelines on the management of pregnant women with cardiac disease are based on data from high-income countries, and their applicability in resource-limited settings remains uncertain due to disparities in healthcare infrastructure, financial constraints and access to specialised care.¹⁰

This review highlights the specific challenges faced by pregnant women with CVD in LMICs (Figure 1 ) and provides insights to guide future research, policy-making, and clinical practice to enhance cardiovascular care during pregnancy in LMICs. By addressing the existing gaps in knowledge, we seek to identify key barriers to diagnosis, treatment and long-term management, including healthcare disparities, socio-economic factors and policy gaps. Addressing these challenges is essential to reduce maternal morbidity and mortality, improve perinatal outcomes and inform global health policies.

Healthcare System and Infrastructure Challenges

Developing healthcare systems in LMICs contribute significantly to poor maternal cardiovascular health outcomes. The infrastructural challenges stem from several foundational gaps, including workforce shortages, limited resources, lack of technological integration, urban–rural healthcare disparities and poor follow-up systems. In addition to primary care deficits, substantial gaps exist in both ambulatory and hospital-based cardiovascular care. Many facilities lack 24-hour obstetric cardiac support, functional operating theatres for cardiac interventions, and coordinated referral pathways between community clinics and tertiary centres.¹¹

The presence of skilled healthcare workers is crucial for the sustainability of a healthcare system. Although nearly all countries face a shortage of healthcare workers, this problem is magnified in LMICs, where the WHO estimates a projected shortfall of 11 million healthcare workers by 2030.¹² LMICs experience a constant loss of healthcare workers because of poor working conditions, lack of infrastructure, low wages, heavy workloads and the high disease burden.¹³ Due to these conditions, healthcare workers either leave the profession or migrate to developed countries.¹⁴ This shortage, common across LMICs, is particularly severe in rural and remote areas.¹³ According to the World Bank, 42.7% of the world population resides in rural areas, whereas only 38% of the nursing workforce and less than a quarter of the physician workforce serve these areas.¹⁵ Therefore, it is necessary to increase the healthcare workforce to provide sufficient and timely care to those in need. Reducing the disparity between healthcare provision in urban and rural areas is equally essential. An excellent example is the Rwanda Human Resources for Health Program, a collaboration between the Rwandan government, USAID and other US institutions. This programme deployed US faculty to train Rwandan healthcare providers, resulting in triple the number of specialist physicians, double-trained nurses, a 30% reduction in neonatal mortality, and the creation of a sustainable medical education infrastructure.¹⁶

Another challenge faced in LMICs is the paucity of available resources, health services, such as multidisciplinary teams, and specialised healthcare facilities. In addition, the limited availability of ambulatory services and the depletion of available equipment contribute to the higher incidence of maternal deaths and untreated or undiagnosed cardiovascular complications.¹⁷ Despite the widespread digitalisation of healthcare in developed countries, many LMICs face significant challenges in incorporating these technological advances into their healthcare services. Because of financial constraints and lack of digital and health literacy, digital health technologies are either perceived as too difficult or not useful compared with pre-existing systems.¹⁸ These limitations not only affect the speed of healthcare provision, but also delay the development of essential referral systems, ultimately worsening maternal and fetal outcomes. Lack of resources also affects the continuity of healthcare, and thus fragments antenatal, intrapartum and postnatal services. Despite all these challenges, some landmark steps have been taken in digital health. India’s National Telemedicine Service, locally known as eSanjeevani, was successful in the integration of technology into healthcare systems. The initiative trained over 100,000 healthcare workers on telemedicine protocols and conducted over 10 million consultations online, reducing travel costs by 47%, improving rural access to specialist care and decreasing diagnosis delays by 31%. This programme not only addressed geographic maldistribution, but also maximised existing workforce capability.¹⁹

Therefore, to improve maternal and fetal outcomes, it is necessary to invest in programmes for a greater number of healthcare professionals as well as specialised cardiovascular care centres. To aid in the betterment of these conditions, the integration of technology into healthcare provision remains of utmost importance.

Sociocultural Challenges

Sociocultural barriers significantly impact maternal health-seeking behaviours in LMICs. Women in developing countries often have low health literacy, which prevents them from recognising symptoms and understanding the risks associated with CVD during pregnancy, leading to delays in seeking care. In 2019, Pakistan’s literacy rate was 58%, with women having a lower literacy rate (44%) than men (69%).²⁰ A study assessing health literacy in Zambia found that 46.5% of male participants and 24.5% of female participants possessed high health literacy, highlighting a significant gender disparity.²¹ A study conducted in Senegal found that most pregnant women had a low education status and were not able to recognise the risks associated with their condition and its potential effects on pregnancy outcomes.²²

Additionally, cultural norms in some regions discourage women from visiting hospitals and leave them with limited access to medical care. Many women rely on traditional birth attendants or midwives and give birth at home without adequate medical supervision, where complications from CVD usually go unrecognised and untreated. In rural areas of Pakistan, 90% of births are attended by traditional birth attendants.²³ Approximately 30% women in LMICs deliver at home, with higher rates among women with low education, those living in rural areas and those from lower socio-economic groups.²⁴ Similarly, a study from Mali reported that women mostly gave birth at home, given that it was the only method familiar to them, with assisted delivery considered only in complications.²⁵ Furthermore, cultural norms required husbands to accompany their wives to health facilities, but they were mostly unavailable, limiting women’s access to care.²⁵

Only around 50% of women around the world receive the recommended minimum antenatal care during pregnancy, with lower usage in rural and low-income areas.²⁶ According to a systematic review, women expressed concern about the shortage of female staff in hospitals and reported shame or embarrassment when examined by male staff, which discouraged them from seeking antenatal care.^26,27 Addressing these sociocultural challenges is crucial to improving outcomes in pregnant women with CVD, and requires community-based education programmes and policies that empower women to access essential maternal healthcare services.

Screening, Diagnosis and Management Challenges

Unlike high-income countries (HICs), where risk assessment tools and routine cardiovascular evaluations are integrated into antenatal care, LMICs often lack standardised screening protocols. The absence of such protocols frequently leads to delayed or missed diagnoses, increasing the risk of life-threatening complications. Normal physiological changes during pregnancy, such as increased cardiac output, blood volume expansion and increased heart rate, can mask early symptoms of CVD, making diagnosis more challenging. Consequently, many women present at advanced stages with conditions such as heart failure, arrhythmia or hypertensive emergencies.²⁸ Large-scale echocardiographic screening studies in LMICs have demonstrated the feasibility of detecting asymptomatic structural and functional cardiac abnormalities. Integration of such screening into routine antenatal visits, particularly in high-risk women, could facilitate timely referral and management (NCT04936815).

A significant challenge in diagnosis is the shortage of specialised healthcare providers, including cardiologists and obstetricians with expertise in pregnancy-related cardiovascular conditions, which hinders timely diagnosis. General practitioners and midwives lack the necessary training to recognise subtle cardiac symptoms and diagnose CVD in pregnant women. Even trained cardiologists may have limited experience managing the haemodynamic changes of pregnancy. The establishment of multidisciplinary pregnancy heart teams has been shown to improve outcomes, but such teams are often unavailable in LMICs due to financial and structural constraints. This results in fragmented care, delayed referrals and inconsistent management strategies.²⁹

A major barrier is the availability and affordability of essential cardiovascular medications in LMICs.³⁰ Limited access to diagnostic tools further exacerbates the situation. Many rural hospitals lack functional echocardiography machines, ECG equipment or even basic blood pressure monitors. When these tools are available, they are often outdated, poorly maintained or too expensive for widespread use. Additionally, long waiting times for specialised assessments further delay timely diagnosis and treatment. These diagnostic limitations contribute to an increased burden of undiagnosed or late-stage cardiovascular conditions in pregnancy, leading to poor maternal and fetal outcomes.³¹

Addressing these challenges requires a comprehensive approach. Government policies should prioritise the integration of cardiovascular assessments into routine antenatal care, while global health initiatives and international funding could help bridge existing gaps. Telemedicine and mobile health programmes may also provide an opportunity to enhance CVD screening and follow-up in remote areas where access to specialists is limited.³¹ Increased awareness campaigns targeting healthcare professionals and the public regarding the risks of CVD in pregnancy can help promote early detection and treatment. By improving access to screening, diagnosis and management options, LMICs can significantly reduce maternal mortality associated with CVD and improve overall pregnancy outcomes.

Research Gaps and Policy Limitations

Despite the high burden of CVD in pregnancy in LMICs, research remains inadequate. One major gap in research is the lack of region-specific epidemiological data on CVD in general and CVD in pregnancy in particular.³² Due to a lack of epidemiological data, limited information exists about the prevalence, type and outcome of CVD in pregnancy, leading to a concomitant lack of pathophysiological and pharmacological data as well, which has not only caused inconsistent and fragmented data that show unclear burden estimates, but also causes difficulty in clinical practice and health policy-making.³³

Most LMICs lack national databases and registries, which makes it difficult to assess the burden, trends and associated risk factors in LMIC-specific settings. Not only is the lack of zone-specific guidelines a problem, but the existing global guidelines, for example, those from the WHO or the American Heart Association, are mostly not applicable to LMICs due to geographical variability in disease patterns.³⁴ The absence of national registries and the concomitant inadequate health promotion programmes for pregnant women result in delayed diagnoses and missed prevention opportunities. Strengthening surveillance, expanding maternal health education campaigns, and earmarking funds for CVD-specific programmes could address these deficits.

A multi-faceted approach is required to address these research and policy gaps, focusing on targeted resource allocation, region-specific epidemiological data collection and the development of population-specific guidelines and policies. Establishing national maternal CVD registries can help track the disease patterns and guide policy-making. Conducting prospective studies on the pregnancy outcomes with CVD in the context of a specific region may also provide much-needed data. Establishing dedicated research funds can help overcome resource-related gaps.

Potential Solutions

At the national level, healthcare infrastructure needs to be improved to fulfil the requirements of both diagnosis and treatment of CVD in pregnant women. This includes the provision of essentials, such as blood pressure monitoring apparatus and echocardiography machines, as well as medication for the treatment of prevalent conditions, especially in rural areas.^35,36 Integration of emergency care as well as specialised doctors, such as cardiologists and obstetricians, is also crucial to ensure timely recognition and treatment of diseases.^37–39 There is growing advocacy for employing midwives to handle childbirth and training them to recognise adverse health effects and promptly refer women to hospitals, which is more beneficial than traditional birth methods.⁴⁰ This step would help women who are unable to reach hospitals in a timely manner because of cultural barriers or distance. With the increase in mobile phone usage in LMICs, the use of telemedicine to facilitate health service delivery has been shown to decrease mortality rates as well, with women in rural areas getting easy access to facilitate their antenatal care visits.^41,42

Women with lower education levels are more likely to experience birth-related complications.⁴³ Raising women’s awareness to identify cardiovascular health issues during pregnancy and encouraging timely health-seeking behaviour can greatly decrease morbidity and mortality. Early recognition of signs and symptoms is crucial to initiate prompt treatment, and this can be achieved by conducting training sessions, peer-led discussions, distribution of linguistically adapted pamphlets and brochures along with the daily newspaper, or through the delivery of awareness messages door-to-door with the help of female health workers in multiple communities. Community-based interventions targeted to educate not only women, but also men of the household, are shown to greatly improve early health-seeking behaviour during pregnancy.⁴²

Maternal health-seeking behaviour is also influenced by government policies. Bangladesh’s Maternal Health Voucher Scheme provided financial incentives for facility-based deliveries, which increased skilled birth attendance from 21% to 64% in programme areas.⁴⁴ Another example is Afghanistan’s Family Health Houses initiative, which increased skilled birth attendance by 37% by working within religious frameworks and demonstrated how culturally aligned policy implementation can transform health-seeking behaviour.⁴⁵

Data and research related to CVD during pregnancy in LMICs are scarce and, given that it is a growing concern in both HICs and LMICs, more research and data resources should be identified to assess the prevalence and risk factors of, and interventions for, CVD in pregnancy. This would enable targeted interventions to be undertaken in specific areas of the country. Table 1 lists the identified challenges in the care system at various levels with possible solutions.

Conclusion

CVD in pregnancy remains a significant challenge, particularly in LMICs, where limited healthcare infrastructure, delayed diagnoses and inadequate access to specialised care contribute to high maternal morbidity and mortality. LMICs continue to face challenges, such as resource constraints, cultural barriers, lack of awareness and insufficient interdisciplinary collaboration between cardiologists and obstetricians.

Reducing the burden of CVD in pregnancy requires urgent, coordinated action, with priorities including contextual data to guide policy, integration of cardiovascular screening into routine antenatal care, development of context-specific guidelines, and expansion of training for healthcare professionals. By identifying and addressing these critical gaps, healthcare systems in LMICs can move toward a more equitable and effective model of care for pregnant women with CVD.