Rural-urban residence and sequelae of hypertensive disorders of pregnancy in the first year postpartum, 2007 – 2019

Abstract

Objectives:

To estimate the association between rural residence and sequelae of hypertensive disorders of pregnancy (HDP) in the first year postpartum.

Study design:

We used the Maine Health Data Organization’s All Payer Claims Data to identify women with HDP who delivered during 2007–2019 and did not have chronic hypertension or pre-pregnancy cardiac conditions (n=8882). We used Cox proportional hazards modeling to estimate rural-urban hazard ratios (HR) and 95% confidence intervals (CI), adjusting for HDP subtype, age, insurance, nulliparity, and co-morbidities. Results were stratified by HDP subtype and timing of acute care visits.

Main outcome measures:

Risk of at least one emergency room or inpatient visit related to hypertension or cardiovascular conditions in the first year postpartum and receipt of outpatient antihypertensive medications from 4 days to 1 year postpartum, separately.

Results:

Overall, risk of at least one acute care visit in the first year postpartum was not different between rural vs. urban women (4.2% vs. 4.2%; adjusted HR 0.98; 95% CI 0.79,1.21), and outpatient receipt of antihypertensive medication was not different (12.9% vs. 12.8%; adjusted HR 0.99; 95% CI 0.87, 1.12). However, stratified analyses suggested some differences (e.g. preeclampsia with severe features: acute care visit adjusted HR 1.54; 95% CI 0.95, 2.49).

Conclusions:

Rural and urban women do not differ in the risks of these common HDP sequelae, though rural women may have increased risk by HDP subtype or timing of acute care visit. Future research should investigate postpartum interventions for reducing HDP sequelae in rural and urban women.

INTRODUCTION

Hypertensive disorders of pregnancy (HDP) affect an estimated 10% of pregnancies in the US (1) and are a major contributor to maternal morbidity and mortality worldwide (2). HDP are also a leading cause of postpartum readmissions (1) and women whose pregnancies are complicated by HDP have higher readmission rates than those without HDP (3). Rates of HDP have risen markedly in recent years, with new-onset HDP doubling between 2007 and 2019 in the US (4). Both the American Heart Association and the American College of Obstetricians and Gynecologists (ACOG) recognize that pregnancy complications are an important predictor of future cardiovascular risk (5) as HDP is associated with more than double the lifetime risk of severe cardiac complications (6). Cardiovascular disease is now the leading cause of pregnancy-related deaths in the US (7), highlighting the critical role that HDP plays in maternal health.

Examining rural-urban disparities in pregnancy outcomes is a priority of ACOG given the unique challenges of providing perinatal care in rural areas and the known health disparities between rural and urban women in the US (8). Not only has the overall burden of HDP increased since the mid-2000s, but pre-pregnancy hypertension and new-onset HDP have been consistently higher among rural women (4, 7). Overall, women living in rural areas have a 65% higher maternal mortality rate as compared to women living in large urban areas in the US (9).

Despite these rural-urban disparities, no prior study has examined the difference in hypertensive or cardiovascular sequelae of HDP between rural and urban women in the first year postpartum. Therefore, our objective was to estimate the risk of having an acute care encounter related to hypertension or cardiovascular conditions in the first year postpartum and receipt of outpatient postpartum antihypertensive medications, separately. We used public and private medical and pharmacy claims data from Maine, which is the US state with the largest percentage of residents living in a rural area (10).

METHODS

Data source

We used the Maine Health Data Organization’s All Payer Claims Data (APCD) to identify women with HDP who delivered during 2007–2019. APCD data include dates of service, provider and place of service, and diagnosis, procedure, and payment information for medical and pharmacy claims paid for Maine residents by public payers and private insurers as required by Maine statute and rules (11). The Maine APCD data must meet internal quality standards before being released.

Deliveries were identified using International Classification of Diseases Clinical Modification (ICD-CM)-9 and −10 diagnosis and procedure codes from a code list published by the Alliance for Innovation in Maternal Health (12), to which we added delivery-related current procedural terminology (CPT) codes. Professional and institutional claims were scanned for unique delivery events. Women with a livebirth or stillbirth were included and linked to their insurance information, enabling us to track women over time even if their insurer changed over the study period. Consistent with prior studies, we restricted the analysis to women who were continuously enrolled in health insurance for a minimum specified duration (13, 14), from approximately 4 months of pregnancy (or earlier) through at least 2 months’ postpartum, with a 1-month gap in insurance allowed.

Rurality of maternal residence was categorized according to Rural-Urban Commuting Area (RUCA) codes published by the US Department of Agriculture (15). These ZIP code-level codes are more accurate measures of rural residency than county-level designations and are based on population density, level of urbanization, and daily commuting patterns of residents (16). We collapsed RUCA codes into urban (metropolitan) vs. rural (large rural, small rural, and isolated rural areas) based on a categorization scheme published by the New England Rural Health RoundTable (17).

Hypertensive disorders of pregnancy (HDP) were identified using a method implemented by the Vaccine Safety Datalink (18). Claims met the definition of HDP if there were 2 or more outpatient visits with non-severe HDP diagnosis codes or at least 1 inpatient visit with non-severe or severe HDP diagnosis codes from 20 weeks of gestation until 42 days’ postpartum (Supplemental Table 1).

We then categorized pregnancies by HDP subtype only using the medical claims up until the day of delivery. We did this to avoid post-pregnancy data solely determining HDP subtype since this could have artificially inflated associations between HDP subtype and study outcomes (e.g. postpartum inpatient visits related to preeclampsia could elevate associations between preeclampsia and postpartum acute care encounters). Pregnancies with chronic hypertension and pre-existing hypertensive or cardiovascular conditions were identified by scanning claims from 12 months prior to pregnancy until 20 weeks’ gestation and were excluded. The resulting ‘new-onset’ HDP was categorized into gestational hypertension, preeclampsia without severe features, and preeclampsia with severe features including eclampsia and HELLP (hemolysis, elevated liver enzymes, low platelet count syndrome) (Supplemental Table 1). For pregnancies with multiple HDP subtypes, we selected the HDP subtype with the most severe HDP features.

We excluded pregnancies with implausible gestational age for livebirth or stillbirth (i.e. less than 20 weeks), multifetal gestations, no insurance coverage during the month of delivery, time to next pregnancy less than 60 days, and women who were less than 16 or greater than 55 years old at the time of delivery (Supplemental Figure 1).

Main study outcomes

We estimated the risk of having at least one acute care encounter (emergency room and/or inpatient visit) related to hypertension or cardiovascular conditions in the first year postpartum and the receipt of postpartum antihypertensive medications from 4 days to 1 year postpartum, separately. We used a previously established method to identify emergency room and inpatient encounters using claims data (19). Antihypertensive medications included angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, diuretics, calcium-channel blockers, vasodilators, beta blockers, renin inhibitors, magnesium sulfate, and all combinations of these medications (Supplemental Table 2). We considered receipt of an antihypertensive medication ≥ 4 days postpartum as an outpatient prescription, as the average length of delivery hospitalization is less than 4 days (20) and medications dispensed as part of an inpatient visit were not captured in our data.

Statistical analysis

We used Cox proportional hazards modeling to estimate rural-urban hazard ratios (HR) and 95% confidence intervals (CI) for HDP overall and by HDP subtype, adjusting for maternal age, public insurance, year of delivery, nulliparity, prenatal depression, and gestational diabetes. Overall models were also adjusted for HDP subtype. Observations were censored upon loss of health insurance, start of next pregnancy, or at 12 months, whichever came first. For visualization, we used inverse probability of treatment weighting to construct covariate-weighted cumulative hazard curves (21).

We conducted two sensitivity analyses. One analysis was restricted to deliveries during or after 2013, when ACOG updated their guidance on preeclampsia diagnosis (22), to see if our findings held when we examined recent deliveries. The second analysis restricted study outcomes to 43 to 365 days’ postpartum, to examine HDP sequalae after the traditional 42-day postnatal period, when women usually transition from OB/Gyn care to primary care. Though ACOG recently updated its guidance to reflect the need for individualized and ongoing postpartum care beyond the first 42 days, this period reflects the practice used during the study years where a 6-week postpartum follow-up visit marked the end of the postpartum period (23). Moreover, data from maternal mortality review committees revealed that approximately 20% of maternal deaths occurred between 43 and 365 days postpartum and cardiomyopathy was the leading cause of deaths in this time period, highlighting the need to examine this time period separately (24–26).

SAS version 9.4 was used for statistical analysis.

Ethical approval

This study was determined to be exempt from human subject review by the University of Southern Maine’s Institutional Review Board.

RESULTS

Characteristics of persons with HDP

Among 119,422 unique pregnancies identified during 2007–2019 that met inclusion criteria, there were 8,882 with new-onset HDP (7.4%). Rates of new-onset HDP increased from 5.3% in 2007 to 9.5% in 2019, with the steepest increase for years 2015 to 2019; estimates were similar between rural and urban women (Figure 1).

Figure 1.

Percentage (and 95% confidence interval) of pregnancies with hypertensive disorders of pregnancy by rurality of maternal residence, Maine 2007– 2019

Rural residents comprised two-thirds (65%) of pregnancies with HDP (Table 1). HDP pregnancies in rural residents were among women who were more likely to be younger (mean age 27.2 vs. 28.7 years old) and have public insurance (54% vs. 47%) and were less likely to be nulliparous (36% vs. 45%) and have prenatal depression (22% vs. 25%) than their urban counterparts. Approximately one-third of both rural and urban HDP pregnancies were delivered by Cesarean section, 10% were preterm deliveries, and 71% were to women who had continuous insurance coverage for the first year postpartum. The proportion of new-onset HDP pregnancies with gestational hypertension was lower among rural vs. urban women (34% vs. 41%), while the proportion with preeclampsia without severe features was higher (52% vs. 44%), and the proportion with preeclampsia with severe features, eclampsia, and HELLP was similar (13.8% vs. 14.3%). Receipt of antihypertensive medication within 3 days of delivery was similar between rural and urban women (6.1% vs. 7.1%).

Table 1.

Characteristics among 8882 Maine pregnant women aged 16–55 years with hypertensive disorders of pregnancy who delivered in 2007–2019, according to rurality of residency

Characteristics	Rural	Urban
No. of respondents (n, %)	5796, 65.3	3086, 34.7
Age, in years (mean)	27.2	28.7
Mode of delivery (n, %)
Vaginal	3711, 64.0	2058, 66.7
Cesarean	2153, 37.2	1028, 33.3
Continuous insurance for 12 months postpartum	4110, 70.9	2193, 71.1
Insurance type (n, %)
Public	3149, 54.3	1448, 46.9
Private	2647, 45.7	1638, 53.1
Medical comorbidities (n, %)
Gestational diabetes	752, 13.0	367, 11.9
Prenatal depression	1283, 22.1	784, 25.4
Nulliparity (n, %)	2085, 36.0	1392, 45.1
Preterm delivery (n, %)	557, 9.6	317, 10.3
Subtype of hypertensive disorder of pregnancy (n, %)
Gestational hypertension	1989, 34.3	1276, 41.4
Preeclampsia without severe features	3009, 51.9	1368, 44.3
Preeclampsia with severe features, eclampsia, and HELLP	798, 13.8	442, 14.3
Receipt of antihypertensive medication within 3 days of delivery (n, %)	355, 6.1	217, 7.0

Abbreviation: HELLP=hemolysis, elevated liver enzymes, low platelets

Rurality of residence defined by United States Department of Agriculture 2010 Rural-urban Commuting Area Codes categorized according to definitions published by the New England Rural Health RoundTable.

Risk of acute care encounter related to hypertension or cardiovascular conditions in the first year postpartum

Among women with HDP, the risk of having at least one acute care encounter related to hypertension or cardiovascular conditions in the first year postpartum was 4.2% over the study period. For both rural and urban women, the risk of having at least one of these encounters in the first year postpartum was higher among HDP pregnancies with severe features: gestational hypertension (3.7% for rural and 3.3% for urban), preeclampsia without severe features (3.5% and 4.8%), and preeclampsia with severe features, eclampsia, and HELLP (8.0% and 5.4%) (Table 2). Among those with acute care encounters, 9.8% of rural and 15.3% of urban women had at least one visit related to cardiovascular conditions. Overall, the risk of having at least one acute care encounter related to hypertension or cardiovascular conditions in the first year postpartum was not different between rural and urban women with HDP (4.2% vs. 4.2%; adjusted HR 0.98; 95% CI 0.79,1.21), and the first encounter occurred most frequently within the first 42 days postpartum (Table 3, Figure 2). Examination of effect modification by HDP subtype showed generally null findings for each subtype; however, point estimates for gestational hypertension and preeclampsia with severe features suggested a higher risk of acute care encounters for rural vs. urban women (gestational hypertension: adjusted HR 1.16, 95% CI 0.79, 1.71; preeclampsia with severe features: adjusted HR 1.54, 95% CI 0.95, 2.49) and, for preeclampsia without severe features, a lower risk for rural vs. urban women (adjusted HR 0.72, 95% CI 0.53, 0.99).

Table 2.

Postpartum sequelae of 8882 Maine pregnant women aged 16–55 years with hypertensive disorders of pregnancy who delivered in 2007–2019, according to rurality of residency and subtype of disease

	Total HDP	Gestational hypertension	Preeclampsia without severe features	Preeclampsia with severe features, eclampsia, and HELLP
	Col %	Col %	Col %	Col %
Rural (n)	5796	1989	3009	798
ER visit or inpatient admission within 12 months related to HTN or cardiovascular condition	244, 4.2	74, 3.7	106, 3.5	64, 8.0
Visit for cardiovascular condition	24, 9.8	12, 16.2	Suppressed	Suppressed
Receipt of antihypertensive meds ≥ 4 days postpartum	750, 12.9	169, 8.5	328, 10.9	253, 31.7
Urban (n)	3086	1276	1368	442
ER visit or inpatient admission within 12 months related to HTN or cardiovascular condition	131, 4.2	42, 3.3	65, 4.8	24, 5.4
Visit for cardiovascular condition	20, 15.3	Suppressed	Suppressed	Suppressed
Receipt of antihypertensive meds ≥ 4 days postpartum	394, 12.8	105, 8.2	175, 12.8	114, 25.8

Abbreviations: ER= emergency room; HTN= hypertension; HELLP= hemolysis, elevated liver enzymes, low platelets

Results were suppressed if based on fewer than 10 observations, per the terms and conditions of the Maine Health Data Organization Data Use Agreement.

Table 3.

The association between living in a rural area and postpartum sequalae with effect modification by hypertensive disorders of pregnancy (HDP) category among pregnant women aged 16–55 years with HDP in Maine, 2007 – 2019

		Having an ER visit or inpatient admission related to HTN or cardiovascular condition in the first 12 months postpartum		Receipt of antihypertensive medications 4–365 days postpartum
	Residence	HR	95% CI	HR	95% CI
Model 1a
All HDP	Rural	0.99	0.80, 1.22	1.01	0.89, 1.14
	Urban	Reference		Reference
Gestational hypertension	Rural	1.13	0.77, 1.66	1.04	0.81, 1.33
	Urban	Reference		Reference
Preeclampsia without severe features	Rural	0.73	0.54, 1.00	0.84	0.69, 1.01
	Urban	Reference		Reference
Preeclampsia with severe features, eclampsia, and HELLP	Rural	1.48	0.92, 2.36	1.26	1.01, 1.58
	Urban	Reference		Reference
Model 2b
All HDP	Rural	0.98	0.79, 1.21	0.99	0.87, 1.12
	Urban	Reference		Reference
Gestational hypertension	Rural	1.16	0.79, 1.71	1.06	0.82, 1.35
	Urban	Reference		Reference
Preeclampsia without severe features	Rural	0.72	0.53, 0.99	0.83	0.68, 1.00
	Urban	Reference		Reference
Preeclampsia with severe features, eclampsia, and HELLP	Rural	1.54	0.95, 2.49	1.28	1.02, 1.61
	Urban	Reference		Reference

^aUnadjusted

^bAdjusted for age, public insurance, nulliparity, gestational diabetes, and prenatal depression. “All HDP” models were also adjusted for HDP subtype.

Abbreviations: ER, emergency room; HTN, hypertension; HDP, hypertensive disorders of pregnancy; HELLP, hemolysis, elevated liver enzymes, and low platelets; HR, hazard ratio

Rurality of residence defined by United States Department of Agriculture 2010 Rural-urban Commuting Area Codes categorized according to definitions published by the New England Rural Health RoundTable.

Figure 2.

Covariate-adjusted^a cumulative hazard curves for ever having an emergency room or inpatient visit related to hypertension or cardiovascular condition within the first year postpartum among women with hypertensive disorders of pregnancy in Maine, 2007–2019

^a Models adjusted for hypertensive disorders of pregnancy severity, maternal age at time of delivery, public insurance, year of delivery, nulliparity, gestational diabetes, and prenatal depression. Models did not adjust for race/ethnicity because the variable was not available in the dataset

Receipt of an outpatient prescription for antihypertensive medication in the first year postpartum

Receipt of at least one outpatient prescription for an antihypertensive medication ≥4 days after delivery in the first year postpartum was 12.9% for rural women and 12.8% for urban women. Receipt of antihypertensive medication was higher among women with pregnancies with preeclampsia, especially those with severe features (Table 2). Overall, receipt of a prescription for antihypertensive medication was not different between rural and urban women (adjusted HR 0.99; 95% CI 0.87, 1.12) (Table 3, Figure 3). Among those with preeclampsia with severe features there was higher receipt of antihypertensive medications for rural vs. urban women (adjusted HR 1.28; 95% CI 1.02, 1.61), whereas point estimates for those with preeclampsia without severe features suggested lower receipt of antihypertensive medications for rural vs. urban women (adjusted HR 0.83; 95% CI 0.68, 1.00).

Figure 3.

Covariate adjusted^a cumulative hazard curves of receipt of antihypertensive medication between 4 days and 1 year postpartum among women with hypertensive disorders of pregnancy in Maine, 2007–2019

^a Models adjusted for hypertensive disorders of pregnancy severity, maternal age at time of delivery, public insurance, year of delivery, nulliparity, gestational diabetes, and prenatal depression. Models did not adjust for race/ethnicity because the variable was not available in the dataset.

Sensitivity analyses

Results were similar to the overall analysis after we restricted the study population to deliveries since 2013, when ACOG’s updated guidance on preeclampsia was published, indicating a limited effect of the change in definition of HDP on our analysis (Supplemental Tables 3, 4, and 5). Our sensitivity analysis examining study outcomes from 43 to 365 days’ postpartum yielded similar findings to our overall analysis for receipt of antihypertensive medication, but slightly higher adjusted HRs for acute care encounters (e.g., all HDP adjusted HR 1.20, 95% CI 0.81, 1.78), suggesting rural women may be at higher risk for these events after 42 days postpartum than urban women (Supplemental Table 6), though none of the findings were statistically significant.

DISCUSSION

High level summary of findings

Hypertension and cardiovascular-related acute care encounters and antihypertensive medication in the first year postpartum were common among women with new-onset HDP in Maine during 2007 to 2019. Approximately 4% of women with new-onset HDP had at least one acute care encounter and approximately 13% received an antihypertensive medication. The risks of these HDP sequelae in the first year postpartum were similar for women living in rural vs. urban areas, though results suggest rural women may have some increased risk by HDP subtype or timing of acute care visit. Overall, we found prevalence of new-onset HDP increased over time in Maine from 5.3% to 9.5%, with similar trends for rural and urban women.

Consistency with the literature

Our reported risk of acute care encounters for hypertensive or cardiovascular-related conditions of approximately 4% among women with new-onset HDP, with most initial encounters occurring within the first few weeks postpartum, is generally consistent with previous studies. Among a cohort of pregnant women who delivered live births in a large managed care organization in 2018, 4.4% of patients with HDP experienced a readmission for hypertensive diagnosis or stroke within the first 42 days’ postpartum (1). Data from the 2013–2014 Nationwide Readmissions Databases found that the 42-day all-cause readmissions ranged from 2.5% for those with gestational hypertension to 4.6% for those with preeclampsia with severe features, eclampsia, and HELLP (3). A single institution study reported 5.1% had a hypertension-related readmission in the 12 months after delivery for births between 2017 and 2019 (27).

Unlike previous studies of acute care encounters postpartum for women with HDP, we report findings separately for rural and urban women (for each group, 4.2% had at least one acute care encounter in the first year postpartum). Our findings suggest that rural women may have a slightly higher risk of acute care encounters after the first 42 days’ postpartum; further research is warranted to understand this pattern. Only one prior study investigated rural-urban differences in maternal readmission rates, finding that women delivering in rural or small metropolitan hospitals in California in 2011 had higher readmission rates than those delivering in large metropolitan hospitals (28). However, they did not examine readmissions among HDP pregnancies specifically.

Findings from our study on receipt of antihypertensive medication postpartum among HDP pregnancies are generally in agreement with prior work. In a small study based on chart review from a single medical center, receipt of an antihypertensive prescription at hospital discharge was more likely for those with HDP and proteinuria or preeclampsia with severe features, similar to our findings showing higher receipt of antihypertensive medication between 4 and 365 days’ postpartum for pregnancies with preeclampsia as compared with gestational hypertension (29). Previous studies of receipt of antihypertensive medication were smaller and did not examine rural and urban women separately, nor receipt of antihypertensive medications after hospital discharge, so we were unable to directly compare our findings to prior work.

The increasing prevalence of HDP in our study is generally consistent with national trends. In particular, the steep increase we observed since 2014 aligns with nationally reported birth certificate data and has been attributed to increasing awareness of HDP spurred by ACOG’s more inclusive definition of preeclampsia published in 2013 (4, 22). The increase in HDP may also be attributed to other changes in maternal health factors during the past decade, such as increased rates of obesity and physical inactivity among reproductive age women (4). We found similar rates of new-onset HDP between rural and urban women in Maine, which differs from the persistently higher rate of new-onset HDP for rural women that has been reported nationally and for the Northeast region (4).

Strengths and limitations

Strengths of our study include the large sample size of HDP pregnancies (n=8882) and that we used population-based cohort data across 15 years from a largely rural state. We were able to follow women across insurance providers and included pharmacy claims with prescription fill dates, an advantage over prescription data based on just order dates. In addition, we used survival analysis to account for variations in length of insurance coverage postpartum, avoiding selection bias that could have been introduced if we restricted the cohort to only women with a full year of follow-up.

Our study had some limitations. Beginning in January 2014, our dataset excluded claims related to diagnosis of substance use disorder (SUD) due to redactions by commercial payers and the Maine Health Data Organization, on behalf of the Maine Medicaid program, in response to a federal regulation (30). Without this exclusion we would expect higher rates of HDP sequelae among rural women given that SUD is more prevalent in rural areas in Maine (31), and that when untreated, SUD is associated with poor adherence to perinatal care (32), increasing the risk for HDP. Further, a 2016 Supreme Court decision prohibited states from mandating certain self-funded employee benefit plans submit their claims to All Payer Claims Databases (33). In Maine, up to 10% of claims since January 2016 may be missing because of this decision, making our findings less representative of the State’s population (30). We relied on diagnosis codes for identifying pregnancy conditions, including HDP, which may result in inaccurate identification. The transition from ICD-9-CM to ICD-10-CM in October 2015 could have resulted in an artifactual increase in HDP, though this type of jump in HDP identification was not observed in our data. We were not able to compare HDP diagnosis codes against inpatient medications, blood pressure values, and lab values, as this information is not captured in claims data (1, 34, 35). Finally, though HDP prevalence is higher among Black versus White pregnant persons (4, 36), we were unable to include patient race or ethnicity in our analysis because this data element is not currently available to researchers. Given the largely urban distribution of Maine’s Black population (37), and known race/ethnicity disparities in rates of HDP (4), our results may not reflect nationwide rural-urban disparities.

Conclusion

Further research is needed to determine whether early prescribing of antihypertensive medications, cardiac evaluations, and enhanced postpartum follow-up are effective for reducing the risk of HDP sequelae in the first year postpartum among rural and urban women. Specialized postpartum clinics for women with HDP may offer cost-effective care to this population and could include more frequent and in-home blood pressure monitoring, antihypertensive medication adjustment, lifestyle counseling on diet and exercise, and coordinated transition to primary care or cardiology care (38, 39). Other interventions could include group postpartum care with childcare, transportation assistance, and emphasis on signs and symptoms of cardiovascular complications in postpartum education, along with the incorporation of pregnancy complications in the assessment of cardiovascular health (38–42). Interventions for primary prevention of HDP have been less studied, though a recent meta-analysis suggests that supervised exercise during pregnancy reduces the risk of developing HDP (43). Future research should focus on additional methods for primary prevention of HDP and incorporate interventions applicable to and effective in rural populations.

Highlights.

• New-onset hypertensive disorders of pregnancy (HDP) increased in Maine since 2007

• HDP pregnancies in 2007–2019 were examined for sequalae in the first year postpartum

• Acute care encounters were similar by rurality of residence

• Antihypertensive medication prescriptions were also similar by rurality

• However, risk of these outcomes was common and varied according to HDP subtype