A $.03 pill that could prevent maternal deaths; Part 5

Why does uptake of Low Dose Aspirin (LDA) still remain low?

Despite compelling evidence, ACA coverage requirements, and medical society endorsements, LDA use remains deeply underutilized in the U.S., for a few reasons:

1. Inconsistencies in risk assessment and provider knowledge gaps - A 2024 study found that physician knowledge about LDA for preeclampsia prevention was inconsistent and highly variable. Busy OBGYN practices with high patient volumes, and the complexity of formal risk-stratification tools means that providers may miss the window for prescribing.

2. Bottlenecks in risk-stratification - Current USPSTF and ACOG guidelines focus aspirin on "high risk" or "moderate risk"; patients, requiring providers to conduct systematic risk assessments.  In practice, this creates a bottleneck: missed risk stratification leads to missed prescriptions.   The emerging evidence for universal prescribing suggests that moving away from risk-gating may be more effective in high-risk populations, where most patients are eligible anyway.

3. Information gaps in patient awareness - Many pregnant people are wary of taking medication during pregnancy, and this can become a barrier. Without a clear conversation about the evidence and safety profile of LDA with their provider, many patients do not start or adhere to taking LDA.

A 2024 systematic review found key barriers to aspirin use: limited information on
its recommendation, medication access difficulties, sociocultural factors, and inconsistent reinforcement during prenatal visits.

4. Timing to initiate - LDA must be initiated before 16 weeks to be effective, so early first-
trimester prenatal care is essential. In the U.S., barriers like lack of insurance, transportation issues, and provider shortages often prevent high-risk women from accessing care in time for the intervention.

5. Dose confusion - In the U.S., aspirin comes in 81 mg tablets. Some providers tell patients to take one tablet; international guidelines and emerging evidence suggest two (162 mg) may be more effective. Without updated guidance on dosing, providers and patients may be using a dose that is less effective than what the evidence now supports.
6. Systemic issues in documentation and follow-through - There is no consistent method to track aspirin adherence across prenatal visits.

Looking ahead

While preeclampsia is not fully preventable, severe preeclampsia may be much more preventable than current medical practice reflects. The USPSTF, ACOG, the Society for Maternal-Fetal Medicine, and FIGO all recommend LDA for high-risk pregnancies. The barriers are systemic, behavioral, and structural.

Meaningful progress would include the following:

• First-trimester risk assessments as a standard part of every prenatal intake visit.
• EHR-embedded protocols that flag eligible patients and generate automatic prescriptions.
• Universal LDA prescribing in settings serving high-risk populations.
• Patients receive clear, evidence-based information about why LDA can protect them.
• Better research, including more diverse clinical trial populations and prospective comparative dose studies to refine the guidance.

Written by Brittany de Soto Palmer