Bridget Desmukes was surprised when Dr. Rita Driggers, Desmukes' OB-GYN in Washington, D.C., recommended low-dose aspirin at her first prenatal appointment this past spring. She knew about daily low-dose aspirin being prescribed to people recovering from a heart attack or stroke. But for pregnant women?
In a past pregnancy, Desmukes, who is now 42, had developed preeclampsia, a potentially serious complication that involves high blood pressure. A small amount of daily aspirin, it turns out, can significantly cut the risk of developing preeclampsia in pregnancy. It's currently recommended for many pregnant women by two influential groups — the American College of Obstetricians and Gynecologists and the U.S. Preventive Services Task Force, an independent panel of experts commissioned by the federal government.
The challenge, some OB-GYNs believe, is getting the word out to women who are at risk that the low-dose aspirin regimen is something that could benefit them. In that way, Desmukes and her husband, Jeffrey, were lucky to hear about it early in her pregnancy.
She says her doctor, an associate professor at Johns Hopkins School of Medicine, "explained to us that because of my age and the fact that I had a history of preeclampsia, aspirin would be recommended for me to take. Just precautionarily — to keep the flow of nutrients and oxygen and everything to the baby and help it continue to thrive and grow."
Desmukes says at first she was hesitant. A nurse by training, she knows any medicine can have side effects and says she prefers a "holistic" approach to her own health. But she also knows the risks of preeclampsia, and how it can be fatal — it's a leading cause of the high maternal mortality rate in the U.S. And as a black woman, Desmukes' risk of dying in childbirth is elevated; maternal mortality rates among black women in the U.S. are about three times those of white women.
She did some research, thought about it, and decided to take the aspirin. She is due in November, and so far everything's going well — no signs of hypertension.
How it works
The cause of preeclampsia in a pregnant woman is still unknown, but the mechanism of danger is clear: Her blood vessels constrict, which means, among other things, blood can't flow easily to her kidneys or brain or uterus. Telltale signs include a terrible headache and swollen hands and feet.
"What aspirin does is relax blood vessels, [which] lowers the blood pressure, but also improves blood flow to the baby, to the kidneys, and to the brain, lowering the chance that the woman would have any complications to her pregnancy that would affect either her or her baby," says Dr. Jodi Abbott, an OB-GYN who specializes in treating high-risk pregnancies at Boston Medical Center and is also an associate professor at Boston University School of Medicine.
Prenatal aspirin can cut the risk of preeclampsia by 24%, according to a comprehensive review of the scientific evidence by the USPSTF in 2014. That guidance described the harms of taking low-dose aspirin in pregnancy as "no greater than small."
"It's been shown to be very safe," says Dr. Nyia Noel, who is Abbott's co-director of the Prenatal Aspirin Project, an initiative at BMC created to increase implementation of the task force's recommendations. "Things that people worry about — such as bleeding in pregnancy or something called placental abruption, which is early separation of the placenta — have not shown to be increased in women on low-dose aspirin."
Now, this is not like taking aspirin for pain relief — that's a much higher dose, usually 325 mg per pill, and one or two pills every four to six hours. In contrast, low-dose aspirin tablets are about 81 mg. They're usually cheap and can be prescribed — they're often covered by insurance — or bought over the counter.
Noel says for her, telling women about the benefits of prenatal aspirin is personal. African American women are more likely than white women to develop preeclampsia, and they're more likely to die from it.
"This topic is very important to me — as a black woman — but also as a black obstetrician-gynecologist in the service of women of color every day," she says. "I've experienced what feels like one degree of separation between myself and women just like me that have died or almost died from preeclampsia," Noel says. "So I really feel aspirin is not the only thing, but it is a step, and women should really feel empowered to speak with their providers about this."
Aspirin coming to a prenatal vitamin near you?
Any woman pregnant with twins or triplets, or who has diabetes or hypertension, or who has had preeclampsia before, is considered at high risk of the condition and should talk to her doctor about taking low-dose aspirin, Abbott says.
Beyond that group of "high risk" characteristics, there are the moderate risk factors — like being pregnant with a first baby, or being obese, or over 35, or African American. Having two or more of those characteristics means low-dose aspirin should be considered for you, too, the guidelines suggest.
Abbott says when you add up the women in all those categories, it equals a whole lot of people.
"Eighty-six percent of our patients [at Boston Medical Center] would be eligible for aspirin based on those criteria," Abbott says. "When you look at a number like 86% you can understand why I would be in favor — as a public health initiative — of all pregnant women getting it."
As Abbott sees it, screening for all those risk factors means someone who could benefit will inevitably get missed. And since she doesn't see significant downsides to low-dose aspirin, she thinks it should just go to everybody who's pregnant.
"My suspicion — if I had to guess ahead 10 years — is that you'll be able to buy, included in your prenatal vitamin, low-dose aspirin," she says.
The need for research on the universal question
But not everyone is convinced — at least at this point — that every pregnant woman should take aspirin. Count Karina Davidson among them. She's the senior vice president for research at Northwell Health and a member of the U.S. Preventive Services Task Force panel that reviewed the evidence on this issue in 2014.
"We know that aspirin prevents the devastating consequences of preeclampsia and of many of the hypertensive disorders of pregnancy for those who are at risk," she says. "For those who are at risk, we absolutely want both clinicians and patients to know they should be discussing whether aspirin is right for them to help them minimize their exposure — and their infants' exposure — to those devastating consequences."
Still, that group's current recommendations stop short of advising prenatal aspirin for all.
"We have a very specific mandate, which is that we make recommendations based on evidence," Davidson says. "When we looked in 2014 we found little evidence that existed that in average-risk populations there was benefit." In other words, there needs to be a benefit to taking aspirin for women currently considered at low risk of developing preeclampsia — not just the absence of significant harm.
In June, the task force began looking to see whether new research has been done since 2014 that would make the group want to change its prenatal aspirin guidance, but that review won't be finished for several years.
Dr. Google, and other barriers
Boston Medical Center's Prenatal Aspirin Project began in 2017 with the goal of getting the word out about the benefits of low-dose aspirin in pregnancy for eligible women and researching the barriers to implementing the task force's recommendations.
Through focus groups, leaders of the project found most of their patients had never heard of preeclampsia. "We also found that they had been told it's not safe to take medications in pregnancy or that aspirin can be dangerous and you shouldn't take it," Abbott says. "[Or they would] go to the pharmacy and the pharmacist would tell them that aspirin was unsafe in pregnancy."
Abbott believes pharmacists may have not been aware of the prenatal aspirin recommendations from the past few years or may have been thinking of the guidance that pregnant women take Tylenol (rather than aspirin) for headaches.
The team at the Prenatal Aspirin Project ended up reaching out to big commercial pharmacies — CVS, Walgreens and Walmart — and got them to remove warnings on prenatal aspirin prescriptions. After having some patients tell them "I got a prescription, but I'm going to Google it before I take it," members of the project team also worked to bump up their Google rankings so the project's advice would appear above information that might be outdated.
Eliminating these barriers is important, Abbott says. "Everybody deserves a healthy baby and a healthy mother, and we're failing at that right now," she says. "This is really an opportunity for all women — but especially for women of color — to be able to claim back some power over their ability to have healthy pregnancies and healthy children."
Of course, low-dose aspirin isn't the only answer to the country's high rate of maternal mortality. "There are certainly other things to be addressed — structural barriers, structural racism involved in the disparities that exist," says Noel.
This tiny pill isn't going to fix all of that. However, Noel says, it has great potential to reduce the number of cases of preeclampsia, a condition that is killing a lot of women.
DAVID GREENE, HOST:
One of the biggest killers of women in childbirth in the United States is something called preeclampsia, a type of high blood pressure in pregnancy. Even when it's not deadly, it can be serious, leading to seizures for the mother or to babies being born prematurely. There is a tiny, inexpensive pill that can cut the risk of preeclampsia. But as NPR's Selena Simmons-Duffin reports, not all women who need it are getting it.
SELENA SIMMONS-DUFFIN, BYLINE: When a woman gets preeclampsia during her pregnancy, her blood vessels constrict. Blood can't flow easily to her kidneys or brain or uterus. That's what's happening inside her body. On the outside...
BRIDGET DESMUKES: My feet were swollen. My hands were swollen.
SIMMONS-DUFFIN: Bridget Desmukes says at the end of her pregnancy eight years ago, something was suddenly very wrong. There was the swelling, and she was incredibly tired. She's a nurse. She knows all about preeclampsia. And she was scared.
DESMUKES: Like, am I going to have a heart attack while I'm going through? You know, am I going to be able to make it through this?
SIMMONS-DUFFIN: She was also aware that, as a black woman, her risk of dying in childbirth is around three times higher than it is for white women.
DESMUKES: You know, we ended up having caesarean section, and they got her out and she was OK. But even through that process, just that fear.
SIMMONS-DUFFIN: That baby who was OK is a big kid now. Her name's Mila. She just turned 8, the middle of five kids.
SIMMONS-DUFFIN: The house is lively and musical.
(SOUNDBITE OF PIANO PLAYING)
SIMMONS-DUFFIN: Desmukes and her husband love having a big family, and now she's pregnant again. Having preeclampsia once means she's at high risk for getting it again. So this time, she's taking low-dose aspirin every day.
(SOUNDBITE OF PILL BOTTLE SHAKING)
SIMMONS-DUFFIN: We're not talking about aspirin for pain relief. Pregnant women are supposed to take Tylenol for things like headaches. These are baby aspirin, just 81 milligrams, what people take every day if they've had a heart attack or stroke.
DESMUKES: And I love the fact that they're itty-bitty.
SIMMONS-DUFFIN: So far, everything's going well. No signs of hypertension. Aspirin works by relaxing blood vessels.
JODI ABBOTT: What it does is lower the blood pressure but also improve blood flow to the baby, to the kidneys and to the brain, lowering the chance that the woman would have any complications to her pregnancy that would affect either her or her baby.
SIMMONS-DUFFIN: That's Jodi Abbott, an OB-GYN at Boston Medical Center who specializes in high-risk pregnancies. She runs the Prenatal Aspirin Project, which does research and advocacy with the goal of getting more women who are at risk of preeclampsia to take low-dose aspirin. Dr. Nyia Noel is her co-director.
NYIA NOEL: This topic is very important to me as a black woman but also as a black obstetrician-gynecologist in the service of women of color every day.
SIMMONS-DUFFIN: Not only are African American women more likely than white women to develop preeclampsia, they're more likely to die from it. Noel tells her patients that low-dose aspirin can reduce the risk of preeclampsia by 24%.
NOEL: It's been shown to be very safe. And things that people worry about, such as bleeding in pregnancy, or something called placental abruption, which is early separation of the placenta, have not shown to be increased in women on low-dose aspirin.
SIMMONS-DUFFIN: It's not just African American women. Lots of women are at risk for preeclampsia. If you're having twins, or if you have a condition like diabetes, for instance, you're considered at high risk, and low-dose aspirin is recommended for you. There are also moderate risk factors, like if you're pregnant with your first baby, you're obese or you're over 35. If you have several of those, aspirin is recommended for you, too. Abbott says, if you add all those things up...
ABBOTT: Eighty-six percent of our patients would be eligible for aspirin based on those criteria. When you look at a number like 86%, you can understand why I would be in favor, as a public health initiative, of all pregnant women getting it.
SIMMONS-DUFFIN: As she sees it, screening for risk factors inevitably means someone who could benefit will get missed. She argues since there aren't significant downsides, all pregnant women should take it.
ABBOTT: And if I would guess ahead to 10 years, my guess is that you'll be able to buy, included in your prenatal vitamin, low-dose aspirin.
SIMMONS-DUFFIN: So coming to a prenatal near you?
ABBOTT: (Laughter) Yes.
SIMMONS-DUFFIN: Not everyone is convinced that a universal approach is a good idea here. Count Dr. Karina Davidson of Northwell Health among them.
KARINA DAVIDSON: I am a member, as a volunteer, of the United States Preventive Services Task Force.
SIMMONS-DUFFIN: This is an influential group. Their current prenatal aspirin recommendations, put out in 2014, do not recommend that women without any risk factors for preeclampsia take low-dose aspirin.
DAVIDSON: When we looked in 2014, we found little evidence that existed that, in average-risk populations, there was benefit.
SIMMONS-DUFFIN: So for average-risk women, the bar is, there has to actually be a benefit?
SIMMONS-DUFFIN: You can't just recommend, take aspirin because - why not?
SIMMONS-DUFFIN: They just began looking to see if new research has come along since 2014 to change their guidance. That review won't be finished for several years. Dr. Jodi Abbott says, in the meantime, the Prenatal Aspirin Project is trying to figure out why more at-risk women aren't taking low-dose aspirin.
ABBOTT: We would have our patients say to us, I got a prescription, but I'm going to Google it before I take it. A lot of references that patients use - including apps, websites, books - say don't take aspirin while you're pregnant.
SIMMONS-DUFFIN: Probably referring to high-dose aspirin for pain relief. Abbott also thinks a lot of doctors, nurses and pharmacists might not be up to date on the low-dose aspirin recommendations.
ABBOTT: A number of commercial pharmacies would put warnings on aspirin, saying, don't take if you're pregnant.
SIMMONS-DUFFIN: The Prenatal Aspirin Project got CVS, Walgreens and Walmart to stop doing that, trying to eliminate that barrier.
ABBOTT: Everybody deserves a healthy baby and a healthy mother, and we're failing at that right now.
SIMMONS-DUFFIN: Of course, Dr. Nyia Noel says, low-dose aspirin isn't the only answer to the country's high rate of maternal mortality.
NOEL: There are certainly other things to be addressed - structural barriers, structural racism involved, and the disparities that exist.
SIMMONS-DUFFIN: This tiny pill isn't going to fix all of that.
NOEL: It's not. But it is something.
SIMMONS-DUFFIN: And, she says, it has great potential to reduce the number of cases of preeclampsia, which kills many women every year.
Selena Simmons-Duffin, NPR News. Transcript provided by NPR, Copyright NPR.