Abstract
Objective
To describe the prevalence of maternal chronic hypertension (MCH), assess how frequently blood pressure is controlled before pregnancy among those with MCH, and explore management practices for antihypertensive medications (AHM) during the pre‐pregnancy and pregnancy periods.
Data Sources, Study Setting, and Study Design
We conducted a descriptive observational study using data abstracted from the Veterans Health Administration (VA) inclusive of approximately 11 million Veterans utilizing the VA in fiscal years 2010–2019.
Data Collection/Extraction Methods
Veterans aged 18–50 were included if they had a diagnosis of chronic hypertension before a documented pregnancy in the VA EMR. We identified chronic hypertension and pregnancy with diagnosis codes and defined uncontrolled blood pressure as ≥140/90 mm Hg on at least one measurement in the year before pregnancy. Sensitivity models were conducted for individuals with at least two blood pressure measurements in the year prior to pregnancy. Multivariable logistic regression explored the association of covariates with recommended and non‐recommended AHMs received 0–6 months before pregnancy and during pregnancy.
Principal Findings
In total, 8% (3767/46,178) of Veterans with a documented pregnancy in VA data had MCH. Among 2750 with MCH meeting inclusion criteria, 60% (n = 1626) had uncontrolled blood pressure on at least one BP reading and 31% (n = 846) had uncontrolled blood pressure on at least two BP readings in the year before pregnancy. For medications, 16% (n = 437) received a non‐recommended AHM during pregnancy. Chronic kidney disease (OR = 3.2; 1.6–6.4) and diabetes (OR = 2.3; 1.7–3.0) were most strongly associated with use of a non‐recommended AHM during pregnancy.
Conclusions
Interventions are needed to decrease the prevalence of MCH, improve preconception blood pressure control, and ensure optimal pharmacologic antihypertensive management among Veterans of childbearing potential.
Keywords: chronic hypertension, comorbidity, maternal, maternity care coordination, pregnancy, veterans, women
What is known on this topic
The number of reproductive‐aged women Veterans has more than doubled in the past 15 years with a greater than 14‐fold increase in the number of deliveries.
Hypertension is the most common chronic medical condition among women Veterans, who represent a diverse patient group with more risk factors for adverse pregnancy outcomes.
Prior to this study, we did not know the prevalence of hypertension prior to pregnancy, known as maternal chronic hypertension, among women Veterans or current management practices.
What this study adds
Eight percent (n = 3767) of women Veterans who had a documented pregnancy in the VA system from 2009 to 2019 had maternal chronic hypertension, which is two to fourfold higher than in the general population.
Approximately one‐fifth of women Veterans with maternal chronic hypertension were prescribed an antihypertensive medication not recommended for use in pregnancy during the six‐month period before pregnancy and one‐sixth while pregnant.
Our study reveals a disparity in the prevalence of maternal chronic hypertension among women Veterans and highlights a need for improved management.
1. INTRODUCTION
Rates of maternal chronic hypertension (MCH) have doubled over the past decade, increasing from 10.9 to 20.5 per 1000 live births from 2007 to 2018 in the United States. As a result, 80,000 pregnancies that resulted in live births in 2018 were complicated by MCH. 1 MCH is defined as elevated blood pressure before pregnancy or before 20 weeks' gestation; it is associated with increased risk of adverse maternal and neonatal outcomes, including severe maternal hypertension, preeclampsia, and small‐for‐gestational‐age neonates. 2 Among patients with chronic hypertension, there is a stepwise increase in risk of adverse hypertension‐related pregnancy outcomes with risk being lowest when blood pressure is controlled without antihypertensive medications (AHMs), higher when controlled with AHMs, and highest when uncontrolled with AHMs. 3 With a growing number of pregnancies complicated by chronic hypertension, pre‐pregnancy blood pressure control represents an important opportunity to decrease adverse pregnancy outcomes.
Women Veterans cared for in the Veterans Health Administration (VA) represent an important population for chronic hypertension management. Hypertension is the most common chronic medical condition among women Veterans, and they are a diverse patient group with many risk factors associated with adverse pregnancy outcomes, including cardiovascular risk factors, advanced maternal age (35+ years old), mental health disorders, psychosocial stressors, and social isolation. 4 Moreover, from 2000 to 2015, the number of reproductive‐aged women VA patients more than doubled to 187,137 Veterans, and the subset of those younger than 35 nearly tripled. 4 For certain clinical conditions, an antihypertensive medication that is not recommended for use in pregnancy may be indicated prior to pregnancy for a reproductive‐aged woman and then discontinued once pregnancy is identified. 5 However, without these clinical indications, potentially teratogenic antihypertensives should be avoided in a person with the potential for pregnancy, especially in the absence of reliable contraception. Unfortunately, women Veterans of childbearing age often fill potentially teratogenic medications without documented receipt of any contraceptive counseling or pregnancy testing. 6 Furthermore, in parallel with the growing number of younger women receiving VA care, the annual number of women with deliveries increased more than 14.4‐fold from 2000 to 2015. 4 Women Veterans are eligible for VA‐paid maternity benefits through referral to civilian providers, resulting in potentially increased fragmentation in prenatal care—especially relevant to chronic disease management. 7 However, we do not know the prevalence of MCH among women Veterans or how often hypertension is controlled prior to pregnancy. Furthermore, provider prescribing patterns and patient‐specific clinical factors associated with prescription of these AHMs are unclear. In this study, we sought to answer four major inquiries about women Veterans using the VA healthcare system: (1) The prevalence of MCH; (2) Among those with MCH, the percentage with uncontrolled blood pressure in the year prior to pregnancy identification; (3) The prevalence and clinical factors associated with being prescribed at least one AHM not recommended for use in pregnancy during the 6 months prior to pregnancy and during the pregnancy; (4) The prevalence and clinical factors associated with being prescribed AHMs recommended for use in pregnancy during the 6 months prior to pregnancy and during the pregnancy.
2. METHODS
2.1. Study design
We conducted an observational study using data from the VA's electronic medical record system (EMR) on 11 million Veterans utilizing the VA in fiscal years (FY) 2010–2019, October 2009 through September 2019. 8 Data used for this project were previously gathered for a project which included all VA patients, independent of presence of surgery or mental illness. 8 The institutional review board waived informed consent. Measures were defined from the VA's Corporate Data Warehouse, a snapshot of the EMR updated nightly. Variables included dates and types of care, diagnoses, procedures, prescription medications, blood pressure readings, and heights and weights of Veterans of US military service using the VA for care.
We collected data for three time periods: during pregnancy, six months prior to estimated conception, and 7–12 months prior to estimated conception. Conception was estimated at 90 days before a diagnosis code for pregnancy was identified in the EMR. During pregnancy was defined as 90 days before diagnosis of pregnancy through 190 days after that date (280 days). We selected these time periods because pregnancy identification likely occurs in the first trimester as women Veterans must have confirmation of pregnancy in the VA system for initiation of maternity care benefits. 9 Pregnancy averages 280 days, or 40 weeks. 10 , 11 We included all pregnancies not diagnosed as miscarriage; outcome of pregnancy was not ascertained. For women with multiple pregnancies, the first pregnancy during the observation period was used. Women aged 18–50 years at pregnancy identification were included if they had a diagnosis of chronic hypertension before the diagnosis of pregnancy; hypertension diagnosed during pregnancy prior to 20 weeks' gestation could not be identified with confidence. The comparison group classified as “non‐pregnant” consisted of women Veterans ages 18–50 with chronic hypertension who did not have a documented pregnancy within the VA system during the study period. Women in the territories were excluded due to use of pharmacotherapies not approved in the United States (n = 66), as were patients with missing age or diagnosis data (Supplemental Figure 1). AHMs used during hospitalization were excluded.
2.2. Measures and outcomes
Chronic hypertension and pregnancy were defined by ICD‐9/10 diagnosis codes (Appendix A). We defined uncontrolled blood pressure (BP) as ≥140/90 mm Hg on at least one measurement during the 12 months prior to pregnancy. BP measurements included those documented in the EMR from the outpatient context. Inpatient BP, emergency department, and operating room measures were excluded. Sensitivity models examined the 90% of patients with at least two BP readings in the year prior to conception using a definition of chronic hypertension as ≥140/90 mm Hg on at least two measurements during the 12 months prior to pregnancy.
Comorbidities were captured by the Charlson Index 12 , 13 and other indicators of chronic conditions (Appendix A). VA prescription medication fills of 30 or more days were categorized. AHMs were further categorized as not recommended for use in pregnancy (hereafter, “non‐recommended AHM”), recommended for use in pregnancy (hereafter, “recommended AHM”), or “other” (all AHMs and diuretics not included in the previous two categories of “recommended” and “non‐recommended”; Appendix B). 14 , 15 Non‐recommended AHMs were angiotensin‐converting enzyme inhibitors (ACE‐Is), angiotensin receptor blockers (ARBs), aliskiren, atenolol, and spironolactone. We selected these based on the American College of Obstetricians and Gynecologists practice guidelines, which note that the use of ACE‐Is, ARBs, renin inhibitors, and mineralocorticoid receptor antagonists are generally not recommended treatments for pregnant women. 14 , 15 Atenolol was added based on studies showing decreased fetal growth velocity compared with placebo or other AHMs. 5 , 16 Recommended AHMs included labetalol, nifedipine, methyldopa, and hydrochlorothiazide (HCTZ), based on consensus recommendations in obstetrics and gynecology literature. 5 , 14 Previously reported concerns about use of HCTZ being associated with maternal dehydration or neonatal side effects have not been supported in trials, leading to its use in this secondary role. 5 Combination compounds of recommended AHMs with other AHMs/diuretics were categorized as “other” AHMs. Combinations of recommended AHMs with non‐recommended AHMs were considered non‐recommended. Individuals prescribed both recommended and non‐recommended AHMs were included in the non‐recommended category. Individuals prescribed both recommended and other AHMs were included in both the “recommended AHM” and “other” categories; individuals prescribed both non‐recommended and other AHMs were included in both the “non‐recommended AHM” and “other” categories.
Demographic measures included age at pregnancy identification, race (Black, White, other), ethnicity (Hispanic yes/no), marital status, and VA priority, a rating from 1 to 8 capturing eligibility for VA care. For example, VA priority 1 Veterans are 50%–100% disabled by a military service‐connected condition, such as PTSD. VA priority 2 have 30%–40% service‐connected disability, and VA priority 3 have 10%–20% service‐connected disability.
2.3. Analysis plan
Descriptive statistics were tabulated and graphed. Bivariate comparisons to non‐pregnant hypertensive women Veterans were conducted. Multivariable logistic regression estimated associations between demographic and clinical variables with the following: (a) non‐recommended AHM received before pregnancy, (b) non‐recommended AHM received during pregnancy, (c) recommended AHM received before pregnancy, and (d) recommended AHM received during pregnancy. Results were presented as odds ratios with their 95% confidence intervals (OR). To present the sample in a manner inviting comparison to other published works, descriptive measures cover the 12 months before conception, while the covariates in the multivariable models match the assessment period (0–6 months prior to estimated conception; 280 days of pregnancy). Multivariable models adjusted for age, race, ethnicity, VA priority status, marital status, and comorbidities.
3. RESULTS
From FY 2010 to 2019, 8% (3767/46,178) of women Veterans with a documented pregnancy in the VA EMR had MCH, compared with a 23% prevalence of chronic hypertension in their non‐pregnant counterparts aged 18–50. After exclusions for missing data among those with MCH, the analytic sample numbered 2750 (Supplemental Figure 1). Among women Veterans with a pregnancy in the observation period, the mean age of included women was 35.1 years (SD = 5.8) with 52% Black, 44% White, 4% Asian/Pacific Islander, and 7% Hispanic/Latino. Most (67%) belonged to VA Priority Group 1 (Table 1). More than 60% had a chronic pain disorder, 43% had major depressive disorder, and 28% were identified as having PTSD in the year before pregnancy. Among those with MCH meeting inclusion criteria, 60% had uncontrolled BP on at least one measurement and 31% had uncontrolled BP on at least two measurements in the year prior to pregnancy. Regarding cardiovascular risk factors, 29% were overweight/obese, 18% had hyperlipidemia, and 11% had diabetes mellitus (Table 2).
TABLE 1.
Demographic characteristics of women Veterans ages 18–50 with maternal chronic hypertension (MCH) (N = 2750) versus Non‐pregnant women Veterans ages 18–50 with chronic hypertension (N = 72,605).
| Pregnant | Non‐pregnant | |||
|---|---|---|---|---|
| N or Mean | % or SD | N or Mean | % or SD | |
| Age in years (range 18–50) a | 35.12 | 5.84 | 42.84 | 6.12 |
| Hispanic ethnicity | 196 | 7.1 | 3803 | 5.4 |
| Race | ||||
| Black | 1371 | 52.2 | 35,670 | 50.1 |
| Asian, Native American, Hawaiian | 109 | 4.2 | 3363 | 4.7 |
| White | 1145 | 43.6 | 32,173 | 45.2 |
| Marital status | ||||
| Married | 1179 | 43.0 | 35,479 | 46.8 |
| Divorced | 861 | 31.4 | 31,093 | 41.0 |
| Never married | 682 | 24.9 | 7590 | 10.0 |
| Widow | 21 | 0.8 | 1640 | 2.2 |
| VA Priority Group | ||||
| 1: 50–100% service‐connected disability | 1852 | 67.4 | 38,888 | 57.1 |
| 3: 10–20% service‐connected disability | 588 | 21.4 | 15,152 | 22.2 |
| 5: Low income | 300 | 10.9 | 13,635 | 20.0 |
| 2, 4, 6, 7: Other groups | 10 | 0.4 | 488 | 0.7 |
Note: Rows do not sum to full sample sizes due to item‐specific missing data.
Age at time of pregnancy identification or earliest outpatient encounter in FY10‐FY19.
TABLE 2.
Prevalence of comorbidities among women Veterans with MCH, as percentage.
| 0–12 months prior to pregnancy (N = 2750) | During pregnancy b (N = 2750) | |
|---|---|---|
| Uncontrolled blood pressure a | 60.5 (2+ BP: 30.8) | 44.8 |
| Obese or overweight c | 29.3 | 19.6 |
| Hyperlipidemia | 18.3 | 11.9 |
| Diabetes | 10.8 | 9.1 |
| Chronic kidney disease | 1.4 | 1.0 |
| Lupus | 1.6 | 1.3 |
| Rheumatoid arthritis | 2.6 | 2.2 |
| Thyroid disease | 10.2 | 7.8 |
| Hypercoagulable state | 0.5 | 0.4 |
| History of preeclampsia, eclampsia, gestational hypertension, or gestational diabetes c | 4.3 | |
| Posttraumatic stress disorder | 27.7 | 23.3 |
| Major depressive disorder | 43.1 | 34.9 |
| Schizophrenia or bipolar disorder | 9.6 | 7.9 |
| Eating disorder | 1.1 | 0.8 |
| Chronic pain disorder | 62.5 | 47.9 |
| Nicotine dependence disorder | 13.5 | 9.1 |
| Alcohol or other drug use disorder | 10.8 | 8.6 |
From one documented high blood pressure (BP) reading in the year prior to pregnancy, except where the 2+ high BP designation is noted. All other comorbidities based on diagnosis codes.
Lower prevalence in pregnancy may be reflective of decreased coding for these conditions while receiving civilian pregnancy‐related care.
Conditions complicating one or more pregnancies that occurred prior to or during study period.
Among women Veterans with MCH, 18% (n = 493) received a non‐recommended AHM 0–6 months before pregnancy and 16% (n = 437) received a non‐recommended AHM during pregnancy (Tables 3 and 4; Figure 1). Nineteen percent (n = 526) received a recommended AHM 0–6 months before pregnancy and 25% (n = 684) received a recommended AHM during pregnancy while 18% received other AHMs both before and during pregnancy (Supplemental Tables 1 and 2; Supplemental Figure 2). Half the patients had no VA prescription for AHMs before/during pregnancy. Factors most strongly associated with receipt of non‐recommended AHMs 6 months prior to pregnancy were lupus (OR = 4.73; 1.18–18.94), chronic kidney disease (CKD) (OR = 4.31; 1.80–10.34), diabetes (OR = 3.28; 2.41–4.47), and age with odds of receipt doubling per decade older (OR = 1.97; 1.65–2.36) (Table 3). For non‐recommended AHMs received during pregnancy, the most notable factors were CKD (OR = 3.13; 1.57–6.24), diabetes (OR = 2.25; 1.68–3.01), uncontrolled BP (OR = 2.07; 1.63–2.64) and increasing age (OR = 1.91; 1.58–2.31) (Table 4).
TABLE 3.
During 0–6 months before pregnancy, received antihypertensive medication(s) not recommended for use in pregnancy (N = 2750).
| Factor | Odds ratio | 95% Confidence interval |
|---|---|---|
| Race | ||
| White or unknown (reference) | ||
| Asian | 1.41 | 0.69–2.91 |
| Black | 0.96 | 0.77–1.20 |
| Hawaiian Native/Pacific Islander | 0.81 | 0.32–2.05 |
| Native American | 1.51 | 0.67–3.42 |
| Hispanic ethnicity | 0.63 | 0.40–1.01 |
| Age (in decades) a | 1.97 | 1.65–2.36 |
| VA Priority Group 3 (10%–20% disabled) | 0.91 | 0.70–1.20 |
| VA Priority Groups 2, 4, 5, 6, 7, 8 | 1.06 | 0.76–1.50 |
| Married | 1.04 | 0.84–1.29 |
| Uncontrolled blood pressure a | 1.94 | 1.56–2.40 |
| History of gestational hypertension | 1.42 | 0.87–2.30 |
| Obese or overweight | 1.03 | 0.80–1.34 |
| Hyperlipidemia | 1.24 | 0.91–1.67 |
| Diabetes mellitus a | 3.28 | 2.41–4.47 |
| Chronic kidney disease a | 4.31 | 1.80–10.34 |
| Lupus a | 4.73 | 1.18–18.94 |
| Rheumatoid arthritis | 0.57 | 0.17–1.83 |
| Thyroid disease | 0.96 | 0.66–1.39 |
| Hypercoagulable state | 1.48 | 0.36–5.98 |
| Posttraumatic stress disorder | 0.92 | 0.71–1.21 |
| Major depressive disorder | 0.99 | 0.78–1.25 |
| Schizophrenia or bipolar disorder | 1.20 | 0.81–1.75 |
| Eating disorder | 1.47 | 0.47–4.58 |
| Pain‐related diagnosis | 1.18 | 0.95–1.47 |
| Nicotine dependent | 1.36 | 0.95–1.94 |
| Alcohol or other drug disorder | 0.67 | 0.43–1.03 |
Statistically significant covariates are indicated in bold.
TABLE 4.
During pregnancy, received antihypertensive medication(s) not recommended for use in pregnancy (N = 2750).
| Factor | Odds Ratio | 95% Confidence Interval |
|---|---|---|
| Race | ||
| White or unknown (reference) | ||
| Asian | 1.21 | 0.55–2.69 |
| Black | 1.08 | 0.84–1.35 |
| Hawaiian Native/Pacific Islander | 0.95 | 0.37–2.41 |
| Native American | 1.83 | 0.81–4.15 |
| Hispanic ethnicity | 0.77 | 0.47–1.25 |
| Age (in decades) a | 1.91 | 1.58–2.31 |
| VA Priority Group 3 (10%–20% disabled) | 1.06 | 0.80–1.40 |
| VA Priority Groups 2, 4, 5, 6, 7, 8 | 0.88 | 0.61–1.27 |
| Married | 0.93 | 0.74–1.16 |
| Uncontrolled blood pressure a | 2.07 | 1.63–2.64 |
| History of gestational hypertension | 0.88 | 0.50–1.55 |
| Obese or overweight a | 1.35 | 1.05–1.75 |
| Hyperlipidemia a | 1.38 | 1.03–1.84 |
| Diabetes mellitus a | 2.25 | 1.68–3.01 |
| Chronic kidney disease a | 3.13 | 1.57–6.24 |
| Lupus | 1.98 | 0.40–9.82 |
| Rheumatoid arthritis | 0.60 | 0.15–2.43 |
| Thyroid disease | 0.86 | 0.60–1.24 |
| Hypercoagulable state | 1.41 | 0.45–4.40 |
| Posttraumatic stress disorder | 0.88 | 0.67–1.16 |
| Major depressive disorder | 1.09 | 0.86–1.38 |
| Schizophrenia or bipolar disorder | 1.09 | 0.76–1.56 |
| Eating disorder | 1.96 | 0.73–5.30 |
| Pain‐related diagnosis | 1.17 | 0.93–1.47 |
| Nicotine dependent | 1.42 | 1.00–2.02 |
| Alcohol or other drug disorder | 1.00 | 0.67–1.50 |
Statistically significant covariates are indicated in bold.
FIGURE 1.
Percentage of women veterans with maternal chronic hypertension who received antihypertensive medication(s) not recommended for use in pregnancy (N = 2750).
The most strongly associated factors with receipt of recommended AHMs pre‐pregnancy were uncontrolled BP (OR = 2.07; 1.68–2.53), Black race (OR = 1.65; 1.33–2.04), and increasing age (OR = 1.38; 1.16–1.64). Women with diabetes were less likely to receive a recommended AHM pre‐pregnancy (OR = 0.42; 0.28–0.63) (Supplemental Table 1). For recommended AHMs received during pregnancy, the most strongly associated factors were uncontrolled BP (OR = 2.23; 1.84–2.70), history of gestational hypertension (OR = 2.10; 1.41–3.11), and Black race (OR = 1.52; 1.25–1.85) (Supplemental Table 2). In sensitivity models on the 90% who had more than one BP reading in the year prior to pregnancy, risk factors for use of non‐recommended AHMs were similar both prior to and during pregnancy. One exception was that hyperlipidemia was not a risk factor for receipt of non‐recommended AHMs during pregnancy. For use of recommended AHMs prior to pregnancy, thyroid condition (OR 1.42; 1.03–1.97) was an additional risk factor while overweight/obesity and MDD were no longer associated. Factors associated with receipt of recommended AHMs during pregnancy in these sensitivity models were the same.
4. DISCUSSION
4.1. Principal findings
This national study among women Veterans who had a documented pregnancy in the VA EMR between October 2009 and September 2019 had several notable findings. First, 8% (n = 3767) of pregnant women Veterans had MCH, of whom 60% had at least one uncontrolled BP reading in the year prior to pregnancy. Among those with MCH who met inclusion criteria, approximately one‐fifth were prescribed an AHM not recommended for use in pregnancy during the 6‐month period before pregnancy and one‐sixth during pregnancy. The proportions receiving recommended AHMs were somewhat higher: 19% before and 25% during. The risk factors most strongly associated with receiving a non‐recommended AHM during pregnancy were relevant chronic conditions: CKD and diabetes.
4.2. Results in the context of what is known
We found a higher rate of MCH among women Veterans receiving care in the VA compared to civilian women. 4 , 17 In the civilian population, rates of MCH were 0.9%–1.5% by 2009 after a greater than 50% increase over the previous 10 years. 18 Nationwide cross‐sectional data of live births revealed a near doubling in the rate of MCH from 1% in 2007 to 2% in 2018, with regional subsets of the population such as within the Kaiser Permanente system having rates of MCH up to 4% and self‐reported national data reaching 5%. 1 , 11 , 19 Our study revealed the prevalence of MCH among women Veterans to be 8%, two to fourfold higher than among the general population. To date, no other study has looked at the national prevalence of MCH among women Veterans receiving care within VA.
Chronic hypertension increases with advancing maternal age and thus the greater number of women Veterans of advanced maternal age, reflected in the mean age of our cohort at 35, could have contributed to this higher prevalence of MCH. 1 , 20 Age was thus an independent predictor of both recommended and non‐recommended AHMs. Furthermore, racial disparities in chronic hypertension both within and outside of pregnancy are well established, with hypertension disproportionately affecting Black women, who have larger representation among the women Veteran population. 20 Potential causes for these observed disparities include the multifaceted effects of systemic racism and a higher burden of psychosocial stressors from racial discrimination and caregiving stress. These can be compounded by other factors associated with hypertension that affect many women Veterans at large, including post‐traumatic stress disorder and military sexual trauma. 21 , 22 , 23 The two factors most strongly associated with receipt of an AHM recommended for use in pregnancy both prior to and during pregnancy were uncontrolled hypertension and Black race. This could largely be attributed to the inclusion of HCTZ in the recommended AHM category. Black patients are often prescribed this medication at a higher rate due to studies showing increased effectiveness. 24 Furthermore, HCTZ is often used as a second‐ or third‐line option for patients during pregnancy when BP remains uncontrolled on other agents. 14
Another key difference in our sample versus the civilian population is our inclusion of women with all pregnancies not diagnosed as miscarriages without knowledge of pregnancy outcome such as live birth. It is possible that MCH was a risk factor in miscarriage or stillbirth. 25 Although these differences may account partly for the higher prevalence of MCH found in this study, we expect that the higher numbers reflect an elevated prevalence in this high‐risk population.
4.3. Clinical implications
We found that a significant proportion of women Veterans—16 to 18%—were on a non‐recommended AHM 6 months before and during pregnancy. Factors most strongly associated with pre‐pregnancy receipt were lupus, CKD, and diabetes mellitus. While the risks of ACE‐inhibitors and ARBs are more established in the second and third trimesters, uncertainty exists about whether these medications pose a risk during the first trimester of pregnancy. As a result, continuing AHMs not recommended for use in pregnancy, such as ACE‐inhibitors and ARBs, until conception may be important in women who are prescribed these medications for renoprotection. 5 Despite differing conclusions about whether women of childbearing age should be on these AHMs prior to pregnancy, there is definitive consensus that these medications should be switched expediently once pregnancy is identified. 5 Fragmentation in care caused by the separation of VA services from civilian maternity care services increases the likelihood of non‐recommended medications being inadvertently continued during pregnancy. Care fragmentation also limits our ability within the VA system to detect discontinuation of medications by non‐VA clinicians. This is an important miscommunication and makes the inadvertent use of medications that are not safe during pregnancy more likely. Since obstetric care for the VA is provided through referral to civilian obstetricians, the decision to prescribe any AHM that is not recommended for use during pregnancy creates the need for clear patient and provider communication and increased care coordination with obstetricians. 7 , 9
Furthermore, addressing the risk of uncontrolled MCH among women Veterans and mitigating the risk of unsafe antihypertensives during pregnancy may necessitate applying the current VA clinical practice guidelines for hypertension in pregnancy to all women Veterans of childbearing age with chronic hypertension. 7 Key interventions could include increasing BP screening and implementing structured programs for lifestyle modification. Our findings also highlight the need for counseling all Veterans of childbearing potential regarding the risks and benefits of their medications during a potential pregnancy. 7 With more than one‐third of pregnancies among women Veterans being unintended, medications not recommended for use in pregnancy should also be accompanied by contraceptive counseling. 26
4.4. Research implications
Areas for future study include investigating MCH in women Veterans along smaller time increments to estimate its trajectory and including non‐VA prescription data. Given the findings of higher MCH prevalence and increased rates of advanced maternal age among women Veterans, an age‐adjusted comparison of MCH prevalence among women Veterans and their civilian counterparts is also an important area for future study. Additional investigation should also be conducted exploring pregnancy outcomes among all women Veterans with MCH, with particular emphasis on pregnancy outcomes among those on AHMs not recommended for use during pregnancy.
4.5. Strengths and limitations
A major strength of this study is its comprehensive use of data from all women Veterans utilizing the VA for care over the study period. Limitations include dependency on documentation of pregnancy and chronic disease in the VA EMR. Virtually all pregnant veterans receive dual care both within the VA system and outside using VA maternity benefits or secondary insurance coverage. 9 For chronic conditions, the slightly lower prevalence of conditions detected during pregnancy than before pregnancy may have been from decreased coding for these conditions while individuals received maternity care outside the VA. For medications, this separation of maternity care may have resulted in the carrying over of non‐recommended VA medications into the pregnancy period that patients were instructed not to take. Furthermore, medications prescribed by outside providers during the pregnancy period may not have been captured in the VA EMR, resulting in missing information or underreporting. Mitigating this possibility is the low cost of VA pharmacy fills, currently capped at $700/year. 27 Nonetheless, non‐VA fills and possible erroneous carrying over of discontinued VA‐fills into the pregnancy period should be investigated in the future research. Data on contraception should also be obtained, particularly among individuals on medications not recommended for use in pregnancy. With obstetric care for the VA provided through civilian systems, we lacked data within the VA EMR for gestational age and delivery date needed to tailor the estimated pregnancy and pre‐pregnancy time periods. We relied on estimating that all pregnancies within the VA system are identified close to the end of the first trimester and have an average gestational length. The need to estimate conception may have affected our ability to capture all women with MCH, as we relied on a diagnosis of chronic hypertension before a diagnosis of pregnancy, without being able to definitively identify all those who met criteria for MCH based on having a diagnosis of chronic hypertension during pregnancy before 20 weeks' gestation. We also lacked data on pregnancy outcomes. Pregnant veterans may have been motivated to have their pregnancy documented in the VA system as a requirement to access VA maternity benefits, increasing the reliability of pregnancy documentation for intended pregnancies. 9 However, some pregnancies, particularly those that resulted in elective abortion may not have been captured since the VA did not provide maternity care referrals for elective or therapeutic abortion during the study period. 9 To offset high levels of missingness of raw data for overweight, obesity, and CKD, we emphasized using a summative list of diagnosis codes to capture these factors. In describing BP control, more women would have been classified as having chronic hypertension and uncontrolled BP using the new ACC/AHA guidelines. 11 We used the existing definition due to the long observation period (2009–2019) and ACC/AHA acknowledgement that pregnancy remains outside of its scope.
4.6. Conclusions
The prevalence of MCH among women Veterans using the Veterans Healthcare Administration is up to fourfold higher than among civilian women. Many of these individuals have uncontrolled BP in the year prior to pregnancy, and approximately one‐fifth are prescribed at least one AHM that is not recommended for use in pregnancy preceding and/or during pregnancy. Exploring pregnancy outcomes among women Veterans with MCH, especially among those taking potentially harmful AMHs represents an important next step. Improving our understanding of MCH can lead to improved pregnancy‐related care and outcomes for women Veterans and their families.
Supporting information
Supplemental Figure 1. Flowchart of patient inclusion and exclusion criteria.
Supplemental Figure 2. Percentage of women veterans with maternal chronic hypertension who received antihypertensive medication(s) recommended for use in pregnancy (N = 2750).
Supplemental Table 1. During 0–6 months before pregnancy, received antihypertensive medication(s) recommended for use in pregnancy (N = 2750).
Supplemental Table 2. During pregnancy, received antihypertensive medication(s) recommended for use in pregnancy (N = 2750).
ACKNOWLEDGMENTS
Ceshae C. Harding was supported by the National Center for Advancing Translational Sciences (NCATS), National Institutes of Health, through Grant Award Number TL1TR002555.
Laurel A. Copeland and Karen M. Goldstein are employed by the Veterans Health Administration, US Department of Veterans Affairs.
This work was supported by Duke University, the Durham VA Health Care System, and the VA Central Western Massachusetts as well as a merit award from VA's Health Services Research and Development service (HX‐09‐335).
This work was also supported by the Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), (CIN 13‐410) at the Durham VA Health Care System. The views are those of the authors and do not necessarily represent the views of the Veterans Health Administration.
The funding sources had no role in the conduct of the study or in the writing or submission of the current report.
APPENDIX A. Chronic medical conditions/comorbidities with associated ICD‐9 and ICD‐10 diagnosis codes
A.1.
| 640–649, 650–659, V22, V23, V24, V27, V28; O09, O10, O11, O12, O13, O14, O15, O16, O2, O3, O4, O6, O7, O8, Z33, Z37, Z34, Z36, Z3A | Pregnancy |
| 293.83, 296.2, 296.3, 296.90, 298.0, 300.4, 309.0, 309.1, 311; F32, F33, F34, F39 | Depression |
| 311, 2962, 2963; F32, F33 | Major depressive disorder (MDD) |
| 30,981, F43.10, F43.11, F43.12 | Posttraumatic stress disorder (PTSD) |
| 295, 2960, 2961, 2964, 2965, 2966, 2967, 2968, F20, F25, F31 | Schizophrenia or bipolar disorder |
| 3000, F41 | Anxiety |
| 303, F102, 3050, F101 | Alcohol use disorder |
| 304, 3052, 3053, 3054, 3055, 3056, 3057, 3058, 3059, F11, F12, F13, F14, F15, F16, F18, F19 | Drug use disorder |
| 3051, V1582, F172 | Nicotine dependence |
| E66, 2780 | Obesity or overweight diagnosis |
| 053, 3372, 338 excluding 338.1 & 338.3, 339, 346, 350, 3511, 3521, 353, 355, 356, 357, 7079, 7105, 712, 713, 714, 715, 716, 720, 721, 722, 7230, 7231, 7233, 7234, 7240, 7242, 7243, 7244, 7245, 725, 7291, 7292, 7295, 7840, B02, G905, G890, G892, G894, G44, G43, G500, G501, G511, G521, G54, G57, G60, G61, L984, M358, M11, M14, M06, M15, M12, M45, M46, M47, M48, M49, M50, M51, M53, M54, M4802, M353, M609, M791, M797, M792, M79609, G441, R51 | Pain‐related disorder |
| 250; E08, E09, E10, E11, E13 | Diabetes mellitus any type (also captured in Charlson) |
| 401, 402, 403, 404, 405; I10, I11, I12, I13, I14, I15, I16 | Hypertension |
| 272; E78 | Dyslipidemia |
| 272.0, 272.2, 272.4; E78.0, E78.4, E78.5 | Hyperlipidemia |
| 710.0; M32 | Lupus |
| 240, 241, 242, 243, 244, 245, 246 | Thyroid disease |
| E01, E02, E03, E04, E05, E06, E07 excluding E07.81 | Thyroid disease |
| D66, D67, D68, 286 | Coagulation disorders |
| 3071, 307.50, 307.5; F50 | Eating disorders |
| Charlson Disorders | |
| 410, 412; I21, I22, I25.2 | Myocardial infarct |
| 39.891, 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, 425.4, 425.5, 425.7, 425.8, 425.9, 428; I43, I50, I099, I110, I130, I132, I255, I420, I425, I426, I427, I428, I429, P290 | Chronic heart failure |
| 093.0, 437.3, 440, 441, 443.1, 443.2, 443.8, 443.9, 447.1, 557.1, 557.9, V43.4; I70, I71, I73.1, I73.8, I73.9, I77.1, I79.0, I79.2, K55.1, K55.8, K55.9, Z95.8, Z95.9 | Peripheral Vascular Disease |
| 362.34, 430, 431, 432, 433, 434, 435, 436, 437, 438; G45, G46, I60, I61, I62, I63, I64, I65, I66, I67, I68, I69, H34.0 | Cerebral vascular disease/stroke |
| 290, 294.1, 331.2; F00, F01, F02, F03, G30, F05.1, G31.1 | Dementia |
| 416.8, 416.9, 490, 491, 492, 493, 494, 495, 496, 500, 501, 502, 503, 504, 505, 506.4, 508.1, 508.8, J40, J41, J42, J43, J44, J45, J46, J47, J60, J61, J62, J63, J64, J65, J66, J67, I27.8, I27.9, J68.4, J70.1, J70.3 | COPD |
| 446.5, 710.0, 710.1, 710.2, 710.3, 710.4, 714.0, 714.1, 714.2, 714.8, 725; M05, M32, M33, M34, M06, M31.5, M35.1, M35.3, M36.0 | Rheumatoid arthritis |
| 531, 532, 533, 534; K25, K26, K27, K28 | Peptic ulcer disease PUD |
| 070.22, 070.23, 070.32, 070.33, 070.44, 070.54, 070.6, 070.9, 570, 571, 573.3, 573.4, 573.8, 573.9, V42.7; B18, K73, K74, K70.0, K70.1, K70.2, K70.3, K70.9, K71.7, K71.3, K71.4, K71.5, K76.0, K76.2, K76.3, K76.4, K76.8, K76.9, Z94.4 | Cirrhosis of the liver |
| 250.0, 250.1, 250.2, 250.3, 250.8, 250.9; E10.0, E10.1, E10.6, E10.8, E10.9, E11.0, E11.1, E11.6, E11.8, E11.9, E12.0, E12.1, E12.6, E12.8, E12.9, E13.0, E13.1, E13.6, E13.8, E13.9, E14.0, E14.1, E14.6, E14.8, E14.9 | Diabetes no complications |
| 250.4, 250.5, 250.6, 250.7; E10.2, E10.3, E10.4, E10.5, E10.7, E11.2, E11.3, E11.4, E11.5, E11.7, E12.2, E12.3, E12.4, E12.5, E12.7, E13.2, E13.3, E13.4, E13.5, E13.7, E14.2, E14.3, E14.4, E14.5, E14.7 | Diabetes with complications |
| 334.1, 342, 343, 344.0, 344.1, 344.2, 344.3, 344.4, 344.5, 344.6, 344.9; G81, G82, G04.1, G11.4, G80.1, G80.2, G83.0, G83.1, G83.2, G83.3, G83.4, G83.9 | Hemiplegia and paraplegia |
| 403.01, 403.11, 403.91, 404.02, 404.03, 404.12, 404.13, 404.92, 404.93, 582, 583.0, 583.1, 583.2, 583.4, 583.6, 583.7, 585, 586, 588.0, V420, V451, V56; N18, N19, N05.2, N05.3, N05.4, N05.5, N05.6, N05.7, N25.0, I12.0, I13.1, N03.2, N03.3, N03.4, N03.5, N03.6, N03.7, Z49.0, Z49.1, Z49.2, Z94.0, Z99.2 | Renal disease |
| 140–149, 150–159, 160–169, 170, 171, 172, 174, 175, 176, 179, 180–189, 190, 191, 192, 193, 194, 195, 200–208, 238.6; C00, C01, C02, C03, C04, C05, C06, C07, C08, C09, C10, C11, C12, C13, C14, C15, C16, C17, C18, C19, C20, C21, C22, C23, C24, C25, C26, C30, C31, C32, C33, C34, C37, C38, C39, C40, C41, C43, C45, C46, C47, C48, C49, C50, C51, C52, C53, C54, C55, C56, C57, C58, C60, C61, C62, C63, C64, C65, C66, C67, C68, C69, C70, C71, C72, C73, C74, C75, C76, C81, C82, C83, C84, C85, C88, C90, C91, C92, C93, C94, C95, C96, C97 | Cancers |
| 456.0, 456.1, 456.2, 572.2, 572.3, 572.4, 572.8; K70.4, K71.1, K72.1, K72.9, K76.5, K76.6, K76.7, I85.0, I85.9, I86.4, I98.2 | Liver failure |
| 196, 197, 198, 199; C77, C78, C79, C80 | Metastatic solid tumor |
| 042, 043, 044; B20, B21, B22, B24 | HIV/AIDS |
APPENDIX B. Drugs prescribed to women Veterans before or during pregnancy
B.1.
| Drug | Category |
|---|---|
| Labetalol, Methyldopa, Nifedipine, Hydrochlorothiazide, HCTZ excluding combination compounds | Recommended for use in pregnancy |
| Benazepril, Captopril, Enalapril, Fosinopril, Lisinopril, Moexipril, Perindopril, Quinapril, Ramipril, Trandolapril, Lotrel | ACE inhibitors, not recommended for use in pregnancy |
| Azilsartan, Edarbi, Candesartan, Eprosartan, Irbesartan, Losartan, Olmesartan, Telmisartan, Valsartan, Benicar, Diovan, Hyzaar, Micardis, Teveten, Tevetin | ARBs, not recommended for use in pregnancy |
| Atenolol | Not recommended for use in pregnancy |
| Spironolactone | Not recommended for use in pregnancy |
| Aliskiren | Not recommended for use in pregnancy |
| ACEi, ARB, atenolol, aliskiren, spironolactone | Not recommended for use in pregnancy |
| Acebutolol, Amiloride, Amlodipine, Bendroflumethiazide, Benzthiazide, Betaxolol, Bisoprolol, Bumetanide, Carvedilol, Chlorthalidone, Chlorothiazide, Clonidine, Diltiazem, Eplerenone, Ethacrynic, Felodipine, Furosemide, Guanabenz(none found), Guanfacine, Hydralazine, Indapamide, Isradipine (none found), Lacidipine, Levamlodipine, Mecaylamine, Methyclothiazide, Metolazone, Metoprolol, Minoxidil, Nadolol (none found), Nebivolol (none found), Nicardipine, Nisoldipine (none found), Pindolol, Reserpine (none found), Sacubitril, Timolol, Torsemide, Triamterene, Trichlormethiazide, Verapamil | Other antihypertensives |
Harding CC, Goldstein KM, Goldstein SA, Wheeler SM, Mitchell NS, Copeland LA. Maternal chronic hypertension in women veterans. Health Serv Res. 2024;59(2):e14277. doi: 10.1111/1475-6773.14277
REFERENCES
- 1. Cameron NA, Molsberry R, Pierce JB, et al. Pre‐pregnancy hypertension among women in rural and urban areas of the United States. J Am Coll Cardiol. 2020;76(22):2611‐2619. doi: 10.1016/j.jacc.2020.09.601 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Ankumah NE, Sibai BM. Chronic hypertension in pregnancy: diagnosis, management, and outcomes. Clin Obstet Gynecol. 2017;60(1):206‐214. doi: 10.1097/grf.0000000000000255 [DOI] [PubMed] [Google Scholar]
- 3. Nzelu D, Dumitrascu‐Biris D, Nicolaides KH, Kametas NA. Chronic hypertension: first‐trimester blood pressure control and likelihood of severe hypertension, preeclampsia, and small for gestational age. Am J Obstet Gynecol. 2018;218(3):337.e1‐337.e7. doi: 10.1016/j.ajog.2017.12.235 [DOI] [PubMed] [Google Scholar]
- 4. Frayne SM, Phibbs CS, Saechao F, et al. Sourcebook: Women Veterans in the Veterans Health Administration. Volume 4: Longitudinal Trends in Sociodemographics, Utilization, Health Profile, and Geographic Distribution. Women's Health Evaluation Initiative, Women's Health Services, Veterans Health Administration; 2018. [Google Scholar]
- 5. Magee LA, Khalil A, Kametas N, von Dadelszen P. Toward personalized management of chronic hypertension in pregnancy. Am J Obstet Gynecol. 2020;226:S1196‐S1210. doi: 10.1016/j.ajog.2020.07.026 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Schwarz EB, Longo LS, Zhao X, Stone RA, Cunningham F, Good CB. Provision of potentially teratogenic medications to female veterans of childbearing age. Med Care. 2010;48(9):834‐842. doi: 10.1097/MLR.0b013e3181e57946 [DOI] [PubMed] [Google Scholar]
- 7. VA/DoD Clinical Practice Guideline for the Management of Pregnancy. Government Printing Office; 2018. [Google Scholar]
- 8. Copeland LA, Zeber JE, Sako EY, et al. Serious mental illnesses associated with receipt of surgery in retrospective analysis of patients in the Veterans Health Administration. BMC Surg. 2015;15:74. doi: 10.1186/s12893-015-0064-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Maternity Health Care and Coordination. Department of Veterans Affairs Veterans Health Administration; 2020. [Google Scholar]
- 10. ACOG Committee opinion No 579: definition of term pregnancy. Obstet Gynecol. 2013;122(5):1139‐1140. doi: 10.1097/01.AOG.0000437385.88715.4a [DOI] [PubMed] [Google Scholar]
- 11. Bello NA, Zhou H, Cheetham TC, et al. Prevalence of hypertension among pregnant women when using the 2017 American College of Cardiology/American Heart Association blood pressure guidelines and association with maternal and fetal outcomes. JAMA Netw Open. 2021;4(3):e213808. doi: 10.1001/jamanetworkopen.2021.3808 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373‐383. doi: 10.1016/0021-9681(87)90171-8 [DOI] [PubMed] [Google Scholar]
- 13. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD‐9‐CM administrative databases. J Clin Epidemiol. 1992;45(6):613‐619. doi: 10.1016/0895-4356(92)90133-8 [DOI] [PubMed] [Google Scholar]
- 14. Battarbee AN, Sinkey RG, Harper LM, Oparil S, Tita ATN. Chronic hypertension in pregnancy. Am J Obstet Gynecol. 2020;222(6):532‐541. doi: 10.1016/j.ajog.2019.11.1243 [DOI] [PubMed] [Google Scholar]
- 15. ACOG Practice Bulletin No . 203: chronic hypertension in pregnancy. Obstet Gynecol. 2019;133(1):e26‐e50. doi: 10.1097/aog.0000000000003020 [DOI] [PubMed] [Google Scholar]
- 16. Butters L, Kennedy S, Rubin PC. Atenolol in essential hypertension during pregnancy. BMJ. 1990;301(6752):587‐589. doi: 10.1136/bmj.301.6752.587 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. Topel ML, Duncan EM, Krishna I, Badell ML, Vaccarino V, Quyyumi AA. Estimated impact of the 2017 American College of Cardiology/American Heart Association blood pressure guidelines on reproductive‐aged women. Hypertension. 2018;72(4):e39‐e42. doi: 10.1161/hypertensionaha.118.11660 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18. ACOG Committee Opinion No. 762: Prepregnancy counseling. Obstet Gynecol. 2019;133(1):e78‐e89. doi: 10.1097/aog.0000000000003013 [DOI] [PubMed] [Google Scholar]
- 19. Marshall CJ, Huma Z, Deardorff J, Britton LE. Prepregnancy counseling among U.S. women with diabetes and hypertension, 2016‐2018. Am J Prev Med. 2021;61(4):529‐536. doi: 10.1016/j.amepre.2021.03.021 [DOI] [PubMed] [Google Scholar]
- 20. Ananth CV, Duzyj CM, Yadava S, Schwebel M, Tita ATN, Joseph KS. Changes in the prevalence of chronic hypertension in pregnancy, United States, 1970 to 2010. Hypertension. 2019;74(5):1089‐1095. doi: 10.1161/HYPERTENSIONAHA.119.12968 [DOI] [PubMed] [Google Scholar]
- 21. Burg MM, Brandt C, Buta E, et al. Risk for incident hypertension associated with posttraumatic stress disorder in military veterans and the effect of posttraumatic stress disorder treatment. Psychosom Med. 2017;79(2):181‐188. doi: 10.1097/psy.0000000000000376 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22. Gaffey AE, Rosman L, Sico JJ, et al. Military sexual trauma and incident hypertension: a 16‐year cohort study of young and middle‐aged men and women. J Hypertens. 2022;40(11):2307‐2315. doi: 10.1097/hjh.0000000000003267 [DOI] [PubMed] [Google Scholar]
- 23. Kalinowski J, Kaur K, Newsome‐Garcia V, et al. Stress interventions and hypertension in black women. Womens Health (Lond). 2021;17:17455065211009751. doi: 10.1177/17455065211009751 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24. Materson BJ, Reda DJ, Cushman WC. Department of veterans affairs single‐drug therapy of hypertension study. Revised figures and new data. Department of Veterans Affairs Cooperative Study Group on antihypertensive agents. Am J Hypertens. 1995;8(2):189‐192. doi: 10.1016/0895-7061(94)00196-i [DOI] [PubMed] [Google Scholar]
- 25. Akbar MIA, Adibrata MA, Aditiawarman ARA, Angsar MD, Dekker G. Maternal and perinatal outcome related to severity of chronic hypertension in pregnancy. Pregnancy Hypertens. 2019;16:154‐160. doi: 10.1016/j.preghy.2019.04.007 [DOI] [PubMed] [Google Scholar]
- 26. Borrero S, Callegari LS, Zhao X, et al. Unintended pregnancy and contraceptive use among women veterans: the ECUUN study. J Gen Intern Med. 2017;32(8):900‐908. doi: 10.1007/s11606-017-4049-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27. VA health care copay rates. https://www.va.gov/health-care/copay-rates/. Accessed October 24, 2021
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplemental Figure 1. Flowchart of patient inclusion and exclusion criteria.
Supplemental Figure 2. Percentage of women veterans with maternal chronic hypertension who received antihypertensive medication(s) recommended for use in pregnancy (N = 2750).
Supplemental Table 1. During 0–6 months before pregnancy, received antihypertensive medication(s) recommended for use in pregnancy (N = 2750).
Supplemental Table 2. During pregnancy, received antihypertensive medication(s) recommended for use in pregnancy (N = 2750).