Assessment of the Burden of Maternal Hypertensive Disorders and the Quality of Care in China: A Systematic Analysis of the Global Burden of Disease (GBD) 2021 Study

Weiwei Wang; Xun Jiang; Jiayao Long; Juanjuan Chen; Jingsi Chen; Yong Wang

doi:10.2147/IJWH.S631515

. 2026 Sep 30;18:631515. doi: 10.2147/IJWH.S631515

Assessment of the Burden of Maternal Hypertensive Disorders and the Quality of Care in China: A Systematic Analysis of the Global Burden of Disease (GBD) 2021 Study

Weiwei Wang ¹, Xun Jiang ², Jiayao Long ², Juanjuan Chen ², Jingsi Chen ², Yong Wang ^1,^✉

PMCID: PMC13635284 PMID: 42835395

Abstract

Objectives

This study aims to analyze the disease burden and quality of care associated with maternal hypertensive disorders in China over time and across age groups from 1990 to 2021.

Methods

This study employs statistical methods, including joinpoint regression analysis, decomposition analysis, age-period-cohort analysis, and the quality-of-care index, to assess the disease burden of maternal hypertensive disorders in China between 1990 and 2021. It uses an ARIMA model to forecast the disease burden for the period 2022–2035.

Results

Compared with 1990, the decline in the number of deaths, death rate, number of DALYs, and DALYs rate in 2021 was over 80% in each case, at 89.66%, 87.50%, 84.97% and 82.97%, respectively; the decline in the number and rate of prevalence, as well as the number and rate of incidence, ranged between 35% and 45%. The burden of disease has shifted from the 20–24 age group to the 30–34 age group (peak in number of cases) or the 25–29 age group (peak in rates). ARIMA forecasts that these rates will continue to decline through to 2035, although the rate of decline in incidence and prevalence will slow. The quality-of-care index rose steadily from 2003 to 2021.

Conclusion

The overall burden of maternal hypertensive disorders in China is declining. Based on the observed epidemiological trends: the quality of care is relatively low among both younger and older age groups; blood pressure management across the entire reproductive lifespan could be optimized in the future.

Keywords: maternal hypertensive disorders, burden of disease, quality of care index, global burden of disease study, China

Introduction

Maternal hypertensive disorders (MHD) are a group of pregnancy-specific blood pressure abnormalities that include gestational hypertension, preeclampsia/eclampsia, chronic hypertension, and chronic hypertension complicated by preeclampsia.¹ This category of diseases is one of the major causes of maternal and perinatal incidence and death rates worldwide;^2–4 globally, approximately 5–15% of pregnant women are affected by MHD.⁵ Although the incidence and death rates of MHD have declined significantly in developed countries as a result of social progress, it remains a major problem in developing countries.⁶ As the world’s largest developing country, China has seen improvements in healthcare services for pregnant women in recent years. However, adjustments to fertility policies such as the “universal two-child” and “three-child” policies, coupled with rising proportions of older and multiparous pregnant women,⁷^,⁸ have increased the risk of maternal hypertensive disorders, and the burden of these conditions remains severe. Maternal hypertensive disorders must be treated promptly and effectively; otherwise, they may cause serious and long-term harm to both the mother and her child. MHD may not only lead to serious complications in pregnant women, such as dementia, renal failure, heart failure, and postnatal depression,^9–12 but may also significantly increase the risk of fetal growth restriction, abnormal growth, placental abruption, and even death.^13–15 Survivors also face a significantly increased long-term risk of developing attention-deficit/hyperactivity disorder, asthma, and diabetes,^16–18 placing a heavy burden of disease on both individuals and their families.

The mechanisms underlying maternal hypertensive disorders (MHD) have not yet been fully elucidated, but current epidemiological studies suggest that multiple factors are involved. Maternal underlying diseases such as trans-fatty acid intake, a history of migraine, sexually transmitted infections, a history of leukemia or lymphoma, and obesity,^19–23 as well as advanced maternal age (35 years or older), multiple pregnancies, conception via assisted reproductive technology (in vitro fertilization), a history of first-time pregnancy or caesarean section, and a long interval between pregnancies, are all significant risk factors for maternal hypertensive disorders.^24–26 Furthermore, low socioeconomic status, inadequate antenatal care, and poor access to healthcare services can further increase the risk of adverse pregnancy outcomes.²⁷^,²⁸ In recent years, rising economic standards have led to a more Westernized lifestyle, resulting in an increased prevalence of metabolic disorders among women of childbearing age, which in turn raises the likelihood of developing MHD.²⁹ The epidemiological characteristics and etiological spectrum of MHD are constantly evolving; therefore, it is necessary to quantify trends in the incidence, death, and disability burden of MHD across different age groups and over long time series.

Although previous studies have provided preliminary descriptions of the epidemiology of maternal hypertensive disorders using global burden of disease data, most existing analyses have focused on the global or regional macro-level; a systematic, dynamic, and multidimensional assessment of maternal hypertensive disorders in China remains to be further investigated. The quality of care index (QCI) is a newly proposed comprehensive evaluation tool for assessing the quality of healthcare services, developed by researchers through principal component analysis based on six key disease indicators (mortality, incidence, prevalence, YLLs, YLDs, and DALYs).³⁰ This index is a relative measure; its values are standardized on a scale of 0–100 based on the current analysis dataset, with higher scores indicating relatively higher quality. However, there is currently a lack of research on the application of the QCI index to the long-term assessment of maternal hypertensive disorders in China, as well as on comparisons of the quality of care across different age groups. Joinpoint regression analysis, age-period-cohort models, decomposition analysis, ARIMA forecasting, and other methods are commonly used in previous GBD-related studies; however, most studies have been limited to a single or a small number of analytical methods. This study combines the above methods with the QCI index assessment to form a multi-method integrated analytical framework. This framework aims to fully exploit the time-series data in the GBD 2021 database to gain a comprehensive understanding of trends in the burden of maternal hypertensive disorders and changes in the quality of care across different age groups in China from 1990 to 2021. This will provide a scientific basis for formulating precise prevention and control strategies and optimizing the allocation of health resources for maternal hypertensive disorders in China.

Materials and Methods

Data Sources

All data used in this study were obtained from the 2021 Global Burden of Disease Study (GBD) database. This database integrates data from multiple sources, including vital statistics systems, cause-of-death investigations, censuses, household surveys, specialized disease registries, and health service utilization data. It covers a continuous time series from 1990 to 2021 and provides estimates of the burden of disease for more than 300 diseases and injuries at the global, regional, and national levels.^31–33 This study extracted data on maternal hypertensive disorders in China from the IHME’s official global health data exchange platform (https://vizhub.healthdata.org/gbd-results/) based on the following criteria: “Estimate” selected “Cause of death or injury”. “Measure” selected “Deaths”, “DALYs (Disability-Adjusted Life Years)”, “YLDs (Years Lived with Disability)”, “YLLs (Years of Life Lost)”, “Prevalence”, “Incidence”. “Metric” selected “Number” and “Rate”. “Cause” selected “Maternal hypertensive disorders”. “Age” selected “Age-standardized”, “10-54 years”, and other included age subgroups. “Sex” selected “Female”. “Year” selected “1990–2021”. Since the data used in this study are publicly available worldwide, no ethical approval is required, and the study complies with the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) statement.³⁴

Disease Definition

In the International Classification of Diseases, 10^th Revision (ICD-10) coding system, the codes for maternal hypertensive disorders range from O10 to O16.9,³⁵ and primarily include four subtypes: (a) Gestational hypertension is defined as hypertension that develops after 20 weeks of gestation, with two or more blood pressure readings exceeding 140/90 mmHg. (b) Preeclampsia is defined as blood pressure readings exceeding 140/90 mmHg and proteinuria exceeding 0.3 g/L, regardless of whether target organ damage is present. (c) Severe preeclampsia is defined as severe hypertension (>160/100 mmHg) or other signs of target organ damage (liver: thrombocytopenia, elevated liver enzymes, coagulation abnormalities; kidneys: elevated creatinine; central nervous system: headache or visual disturbances). (d) Eclampsia is defined as hypertension accompanied by seizures, with or without proteinuria.³⁶

Statistical Analysis

This study employs a variety of statistical methods to conduct a complementary systematic analysis, aiming to comprehensively analyze the patterns of disease burden evolution across five dimensions: “trend identification—effect decomposition—attribution quantification—prospective forecasting—quality assessment”. The statistical methods will be described in detail below:

Descriptive Analysis

Descriptive statistical methods were used to analyze the number of cases and corresponding age-standardized rates, along with 95% uncertainty intervals (UIs), for various indicators of maternal hypertensive disorder burden in China in 1990 and 2021. In addition, this study calculated the total percentage change between 1990 and 2021 to reflect the magnitude of long-term trends. All descriptive analyses were performed in R 4.5.2, and the results are presented in a table.

Joinpoint Regression Analysis

To understand the long-term trends in maternal hypertensive disorders from 1990 to 2021 and identify key turning points, the study conducted a joinpoint regression analysis using Joinpoint 5.3.0.0. This analysis primarily divides the time series data into several segments by setting connection points, with each segment fitted with a linear model to capture local variations; the number and locations of the connection points are determined using a Monte Carlo permutation test.³⁷^,³⁸ Key indicators include the annual percentage change (APC) for each time period and the average annual percentage change (AAPC) across all time periods; 95% confidence intervals are also calculated for these key indicators to assess the significance of the changes. If the interval includes 0, the difference is considered statistically significant.^39–41 The results are displayed as a line chart.

Decomposition Analysis

To identify the primary drivers of changes in the burden of maternal hypertensive disorders in China from 1990 to 2021, the study employed Das Gupta’s classic decomposition method to break down the total change into three components: the aging effect, the population effect, and the epidemiological change effect.⁴²^,⁴³ The analysis was conducted using population data for age groups ranging from 10 to 54 years (in 5-year intervals) and the corresponding age-specific burden rates, with the contributions of each of the three effects and their percentages of the total change calculated separately. A positive value indicates that the factor contributes to an increase in the burden, while a negative value indicates that the factor mitigates that increase. The analysis was performed using R 4.5.2.

Age-Period-Cohort Analysis

This study used the APC model to assess the independent effects of three temporal dimensions—age, period, and birth cohort—on the burden of maternal hypertensive disorders. The age effect reflects physiological differences across various stages of the life course. The period effect reflects the impact of macro-level factors, such as environmental conditions, healthcare conditions, or policies, on a population over a specific time period. The cohort effect focuses more on the long-term impact of shared experiences and cultural influences on people born in the same period as they progress through different life stages.⁴⁴ This study covers the period from 1990 to 2021, with data organized into five-year intervals. Age groups range from 10–14 to 50–54, and the periods are divided into 1990–1991, 1992–1996, 1997–2001, 2002–2006, 2007–2011, 2012–2016, and 2017–2021, and birth cohorts are calculated based on these periods and age groups. The analysis was performed using R 4.5.2.

ARIMA Model Forecast Analysis

The ARIMA (Autoregressive Integrated Moving Average) model is a classic time series forecasting method. It is robust in fitting linear trends for sequences of moderate length, and model quality can be effectively controlled through differencing and white noise residual tests. This model meets the data conditions and practical application requirements of this study. Therefore, this study employs the ARIMA model to forecast the disease burden of maternal hypertensive disorders in China from 2022 to 2035. Using age-standardized rates (deaths, DALYs, prevalence, and incidence) from 1990 to 2021 as time-series data, the modeling was conducted as follows: First, the stationarity of the series was assessed using the Augmented Dickey-Fuller (ADF) test, and non-stationary series were differenced. Subsequently, the model orders (p, d, q) are identified using the autocorrelation function (ACF) and partial autocorrelation function (PACF) plots. First, the stationarity of the series is assessed using the Augmented Dickey-Fuller (ADF) test, and non-stationary series are treated using difference methods. Subsequently, the model orders (p, d, q) are identified using the autocorrelation function (ACF) and partial autocorrelation function (PACF) plots. Next, the Ljung-Box test is used to examine whether the residuals of the selected model are white noise. If the model residuals exhibit white noise, the model is selected as the final model. Forecasts for each rate value from 2022 to 2035 are then extrapolated and presented in a line chart.⁴⁵^,⁴⁶ The analysis was performed using R 4.5.2.

Analysis of the Quality-Of-Care Index (QCI)

The Quality-of-Care Index is a tool developed by researchers to assess the quality of care for specific diseases, based on six age-standardized core indicators from the GBD database. First, calculate the four secondary indicators based on the six core indicators (death rate, DALY rate, YLD rate, YLL rate, prevalence rate, and incidence rate): (a) MIR (Mortality to Incidence Ratio) = Deaths/Incidence; (b) DRP (DALYs to Prevalence Ratio) = DALYs/Prevalence; (c) YLR (YLLs to YLDs Ratio) = YLLs/YLDs; (d) PIR (Prevalence to Incidence Ratio) = Prevalence/Incidence. Next, a principal component analysis was performed on the four secondary indicators. The first principal component was selected, and the scores were scaled to 0–100 using the Min-Max standardization method to obtain the QCI values.⁴⁷ A higher QCI score indicates better quality of care. This study calculated QCI values for both age-specific and temporal trends. All QCI analyses were performed using R 4.5.2.

Results

The Overall Burden of Maternal Hypertensive Disorders in China

The number of deaths from maternal hypertensive disorders among women aged 10–54 in China fell from 1668.34 (95% UI: 1153.96 to 2246.28) to 172.55 (95% UI: 123.69 to 240.55) in 2021, representing a 89.66% decline compared to 1990. The number of DALYs declined from 116,631.99 in 1990 (95% UI: 84,105.14 to 155,153.89) to 17,529.48 in 2021 (95% UI: 12,863.51 to 23,653.81), representing an 84.97% decline from 1990. The number of YLDs declined from 13,309.89 (95% UI: 6701.54 to 24,136.81) in 1990 to 7488.81 (95% UI: 3745.37 to 12,804.48) in 2021, representing a 43.73% decline compared to 1990. The number of YLLs declined from 103,322.10 (95% UI: 71,532.62 to 139,109.95) in 1990 to 10,040.67 (95% UI: 7204.46 to 13,977.04), representing a 90.28% decline compared to 1990. The number of incidents fell from 1,248,643.60 in 1990 (95% UI: 918,051.14 to 1,748,462.31) to 691,386.56 in 2021 (95% UI: 534,285.97 to 895,789.08), representing a 44.63% decline compared to 1990. The number of prevalence cases declined from 269,812.45 (95% UI: 162,336.38 to 430,903.75) in 1990 to 151,916.84 (95% UI: 92,296.83 to 231,986.50), representing a 43.70% decline compared to 1990 (Table 1).

Table 1.

The Number of Cases of Maternal Hypertensive Disorders in China in 1990 and 2021, and the Corresponding Annual Average Percentage Change (AAPC)

Measure	Cases(95%UI)		Change in Cases (%)	AAPC of Cases (95%CI)
Measure	1990	2021	Change in Cases (%)	1990–2021
Deaths	1668.34(1153.96, 2246.28)	172.55(123.69, 240.55)	−89.66%	−7.11(−7.47, −6.75)
DALYs	116,631.99(84105.14, 155,153.89)	17,529.48(12863.51, 23,653.81)	−84.97%	−5.97(−6.36, −5.59)
YLDs	13,309.89(6701.54, 24,136.81)	7488.81(3745.37, 12,804.48)	−43.73%	−1.87(−2.27, −1.47)
YLLs	103,322.10(71532.62, 139,109.95)	10,040.67(7204.46, 13,977.04)	−90.28%	−7.24(−7.88, −6.60)
Incidence	1,248,643.60(918051.14, 1,748,462.31)	691,386.56(534285.97, 895,789.08)	−44.63%	−1.93(−2.25, −1.60)
Prevalence	269,812.45(162336.38, 430,903.75)	151,916.84(92296.83, 231,986.50)	−43.70%	−1.88(−2.28, −1.47)

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Abbreviations: AAPC, Average annual percentage change; DALY, Disability adjusted life years; YLD, Years lived with disability; YLL, Years of life lost.

The age-standardized death rate from maternal hypertensive disorders in China declined from 0.24 per 100,000 (95% UI: 0.17 to 0.33) in 1990 to 0.03 per 100,000 (95% UI: 0.02 to 0.04), representing a 87.50% decline compared with 1990. The age-standardized DALYs rate declined from 16.68 per 100,000 people (95% UI: 12.01 to 22.19) in 1990 to 2.84 per 100,000 people (95% UI: 2.09 to 3.87), representing a 82.97% decline compared with 1990. The age-standardized YLDs rate declined from 1.84 per 100,000 (95% UI: 0.93 to 3.28) in 1990 to 1.19 per 100,000 (95% UI: 0.60 to 2.01), representing a 35.33% decline compared with 1990. The age-standardized YLLs rate declined from 14.84 per 100,000 (95% UI: 10.27 to 19.97) in 1990 to 1.65 per 100,000 (95% UI: 1.19 to 2.29), representing a 88.88% decline compared with 1990. The age-standardized incidence rate declined from 172.97 per 100,000 (95% UI: 128.59 to 241.62) in 1990 to 110.12 per 100,000 (95% UI: 85.24 to 142.54), representing a 36.34% decline compared with 1990. The age-standardized prevalence rate declined from 37.40 per 100,000 (95% UI: 22.66 to 58.01) in 1990 to 24.15 per 100,000 (95% UI: 14.72 to 36.28), representing a 35.43% decline compared with 1990 (Table 2).

Table 2.

The Rates of Maternal Hypertensive Disorders in China in 1990 and 2021, and the Corresponding Annual Average Percentage Change (AAPC)

Measure	Age-Standardized Rates(95%UI)		Change in Rates (%)	AAPC of Rates (95%CI)
Measure	1990	2021	Change in Rates (%)	1990–2021
Deaths	0.24(0.17, 0.33)	0.03(0.02, 0.04)	−87.50%	−7.31(−7.81, −6.80)
DALYs	16.68(12.01, 22.19)	2.84(2.09, 3.87)	−82.97%	−6.18(−6.59, −5.77)
YLDs	1.84(0.93, 3.28)	1.19(0.60, 2.01)	−35.33%	−2.07(−2.48, −1.65)
YLLs	14.84(10.27, 19.97)	1.65(1.19, 2.29)	−88.88%	−7.50(−8.01, −6.99)
Incidence	172.97(128.59, 241.62)	110.12(85.24, 142.54)	−36.34%	−2.12(−2.47, −1.77)
Prevalence	37.40(22.66, 58.01)	24.15(14.72, 36.28)	−35.43%	−2.01(−2.45, −1.56)

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Abbreviations:: AAPC, Average annual percentage change; DALY, Disability adjusted life years; YLD, Years lived with disability; YLL, Years of life lost.

Age Distribution

The results of the analysis by age group show that in 1990, the age group with the highest number of deaths, DALYs, YLDs, YLLs, incidence cases, and prevalence cases was 20–24 years; by 2021, the age group with the highest number of cases for all these indicators had shifted to 30–34 years. In 1990, the 20–24 age group had the highest rates for all indicators except death rate; the 25–29 age group had the highest death rate. In 2021, the age group with the highest rates of death, DALYs, YLDs, YLLs, incidence, and prevalence was 25–29 years. In summary, compared with 1990, the overall disease burden in 2021 has shifted toward the older maternal age group, indicating that perinatal care strategies should prioritize enhanced monitoring and management of older pregnant individuals (Table S1-S2 and Figure S1-S2).

Specifically, in 1990, the number of deaths, DALYs, YLDs, YLLs, incidence cases, and prevalence cases in the 20–24 age group were 488.02 (95% UI: 336.51 to 664.72), 38,730.55 (95% UI: 27,378.95 to 51,624.06), 5714.55 (95% UI: 2485.68 to 11,176.35), 33,016.00 (95% UI: 22,767.88 to 44,970.15), 539,756.53 (95% UI: 327,594.53 to 827,828.66), 115,442.03 (95% UI: 56,141.59 to 206,873.06). In 2021, the number of deaths, DALYs, YLDs, YLLs, incidence cases, and prevalence cases in the 30–34 age group were 44.15 (95% UI: 31.18 to 61.88), 5219.60 (95% UI: 3365.62 to 7575.39), 2678.00 (95% UI: 1191.21 to 4942.09), 2541.60 (95% UI: 1794.78 to 3562.85), 242,420.87 (95% UI: 157,528.08 to 363,388.64), 54,826.54 (95% UI: 28,607.10 to 92,430.72) (Table S1).

In 1990, the death rate for the 25–29 age group was 0.77 per 100,000 (95% UI: 0.52 to 1.04). In 1990, the rates of DALYs, YLDs, YLLs, incidence, and prevalence in the 20–24 age group were 60.06 per 100,000 (95% UI: 42.46 to 80.05), 8.86 per 100,000 (95% UI: 3.85 to 17.33), 51.20 per 100,000 (95% UI: 35.31 to 69.74), 837.00 per 100,000 (95% UI: 508.00 to 1283.72), and 179.02 per 100,000 (95% UI: 87.06 to 320.80), respectively. In 2021, the rate of deaths, DALYs, YLDs, YLLs, incidence, and prevalence in the 25–29 age group were 0.09 per 100,000 (95% UI: 0.06 to 0.12), 10.74 per 100,000 (95% UI: 7.46 to 15.39), 5.25 per 100,000 (95% UI: 2.36 to 9.41), 5.49 per 100,000 (95% UI: 3.92 to 7.75), 484.12 per 100,000 (95% UI: 324.04 to 704.37), and 106.15 per 100,000 (95% UI: 59.15 to 174.49) (Table S2).

Changes in the Burden of Maternal Hypertensive Disorders in China, 1990–2021 (Joinpoint Regression Analysis)

From 1990 to 2021, the overall burden of maternal hypertensive disorders in China showed a declining trend. The AAPC values for the number of deaths, DALYs, YLDs, YLLs, incidence, and prevalence were −7.11 (95% CI: −7.47 to −6.75), −5.97 (95% CI: −6.36 to −5.59), −1.87 (95% CI: −2.27 to −1.47), −7.24 (95% CI: −7.88 to −6.60), −1.93 (95% CI: −2.25 to −1.60), −1.88 (95% CI: −2.28 to −1.47) (Table 1 and Figure 1). The AAPC values for age-standardized deaths, DALYs, YLDs, YLLs, incidence, and prevalence rates were −7.31 (95% CI: −7.81 to −6.80), −6.18 (95% CI: −6.59 to −5.77), −2.07 (95% CI: −2.48 to −1.65), −7.50 (95% CI: −8.01 to −6.99), −2.12 (95% CI: −2.47 to −1.77), and −2.01 (95% CI: −2.45 to −1.56) (Table 2 and Figures 1 and 2).

Graphs of maternal hypertension trends in China, 1990-2021, using joinpoint regression. Image A depicts joinpoint regression of maternal hypertensive disorder cases in China from 1989 to 2022. The y-axis shows absolute counts for six series: Disability-Adjusted Life Years (DALYs), Deaths, Incidence, Prevalence, Years Lived with Disability and Years of Life Lost. DALYs decline from 1990 to 2004, peak around 2014-2016, then decrease. Deaths drop sharply in the 1990s with annual percent changes between -7.23 and -12.30. Incidence and Prevalence rise from 2005 to 2010, with annual changes of 10.11 and 12.55, respectively, then stabilize. Years of Life Lost consistently declines. Image B shows age-standardized rates for the same metrics over the same period. DALYs and Deaths have annual percent changes ranging from -8.52 to -7.74 and -8.43 to -10.76, respectively. Incidence and Prevalence rise mid-period then decline. Asterisks indicate significant annual percent changes at the 0.05 alpha level. — A joinpoint regression analysis of the burden of maternal hypertensive disorders in China. (A) Joinpoint regression analysis of cases. (B) Joinpoint regression analysis of rates. *indicates that the annual percent change (APC) is significantly different from zero at the alpha 0.05 level. This annotation is automatically generated by the system.

Six graphs show yearly trends in deaths, DALYs, YLDs, YLLs, incidence and prevalence rates. Image A: Mixed bar and line graph (1990-2021). Deaths decline from ~1600 to ~200; rate drops from ~0.25 to ~0.03. Image B: DALYs decline from ~120,000 to ~20,000; rate decreases from ~30 to ~5. Image C: YLDs fluctuate, starting at ~13,000, dropping to ~4,000, then rising to ~8,000-9,000; rate follows similar pattern, starting at ~3.5, dropping to ~1.0, then rising to ~2.0. Image D: YLLs decline from ~100,000 to ~10,000; rate decreases from ~25 to ~2. Image E: Incidence starts at ~1,200,000, drops to ~400,000, then rises to ~800,000-900,000; rate follows similar pattern, starting at ~300, dropping to ~100, then rising to ~180-200. Image F: Prevalence starts at ~250,000, drops to ~80,000, then rises to ~150,000-170,000; rate follows similar pattern, starting at ~60, dropping to ~20, then rising to ~35. — Changes in the number of cases and age-standardized rates of maternal hypertensive disorders in China between 1990 and 2021. (A) The number of deaths and age-standardized deaths rates by year. (B) The number of DALYs and age-standardized DALYs rates by year. (C) The number of YLDs and age-standardized YLDs rates by year. (D) The number of YLLs and age-standardized YLLs rates by year. (E) The number of incidence and age-standardized incidence rates by year. (F) The number of prevalence and age-standardized prevalence rates by year.

**Abbreviations**: DALY, Disability adjusted life years; YLD, Years lived with disability; YLL, Years of life lost.

Temporal patterns vary across age groups. Regarding the number of cases, the number of deaths, DALYs, and YLLs showed a declining trend across all age groups, with the fastest rate of decline observed in the 15–19 age group, where the AAPC values were −9.21 (95% CI: −9.92 to −8.50), −8.85 (95% CI: −9.67 to −8.03), and −9.21 (95% CI: −9.92 to −8.49). The temporal trends in the number of YLDs, incidence cases, and prevalence cases show similar patterns: All four age groups in the 10–29 age range showed a downward trend, with the fastest rate of decline observed in the 20–24 age group, whose AAPC values were −5.57 (95% CI: −5.90 to −5.23), −5.60 (95% CI: −5.86 to −5.35), and −5.58 (95% CI: −5.92 to −5.24); All five age groups in the 30–54 age range showed an increasing trend. The age group with the fastest-rising rates of YLDs and incidence was the 50–54 age group, with AAPC values of 1.95 (95% CI: 1.30 to 2.61) and 2.59 (95% CI: 1.86 to 3.34). The age group with the fastest-rising prevalence was 40–44 years, with an AAPC of 2.03 (95% CI: 1.67 to 2.39) (Table S1 and Figure S3).

Regarding rates, the death rate, DALYs rate, and YLLs rate all showed a downward trend across all age groups, with the fastest rate of decline observed in the 10–14 age group, where the AAPC values were −8.32 (95% CI: −8.69 to −7.95), −8.12 (95% CI: −8.48 to −7.77), and −8.32 (95% CI: −8.69 to −7.95); The temporal trends in YLDs, incidence rates, and prevalence rates show similar patterns: All three age groups in the 30–44 age range showed an increasing trend, with the fastest rate of increase observed in the 40–44 age group, which had AAPC values of 0.89 (95% CI: 0.21 to 1.57), 0.90 (95% CI: 0.39 to 1.42), 0.98 (95% CI: 0.45 to 1.50); All other age groups showed a downward trend, with the fastest decline observed in the 20–24 age group, which had AAPC values of −3.56 (95% CI: −3.80 to −3.32), −3.60 (95% CI: −3.85 to −3.35), and −3.61 (95% CI: −3.82 to −3.41) (Table S2 and Figure S4).

Decomposition Analysis

The decomposition analysis reveals the impact of aging, population, and epidemiological changes on the burden of maternal hypertensive disorders in China. The results show that the correlation rates of all indicators of disease burden from maternal hypertensive disorders in China are declining, and this trend is primarily driven by epidemiological changes. Specifically, 81.64% of the overall change in the death rate is attributable to epidemiological changes, and 79.16% of the overall change in the DALYs rate is attributable to epidemiological changes, 63.96% of the overall change in the YLDs rate stems from epidemiological changes, 80.07% of the overall change in the YLLs rate stems from epidemiological changes, 64.47% of the overall change in the incidence rate stems from epidemiological changes, and 64.21% of the overall change in the prevalence rate stems from epidemiological changes (Table S3 and Figure 3).

A stacked horizontal bar graph showing contributions to total change by effect across measures. — Decomposition analysis of maternal hypertensive disorders in China from 1990 to 2021.

Age-Period-Coort Analysis (APC)

The results of the age-period-cohort analysis reveal the multidimensional dynamics of the burden of maternal hypertensive disorders in China across various indicators (death rate, DALY rate, prevalence rate, and incidence rate). The results show that all of the above indicators exhibit a significant age-related pattern of first rising and then declining: both death rates and DALYs rates reached peak values in the age group of 20–24 years, while prevalence rates and incidence rates reached peak values in the age group of 25–29 years. The period effect shows that between 1990 and 2021, death and DALYs rates exhibited a continuous downward trend, while incidence and prevalence rates first declined and then increased. The cohort effect shows that both death rates and DALY rates have been gradually declining from earlier birth cohorts to more recent ones. Prevalence and incidence rates first rose and then declined, with the highest prevalence and incidence rates observed in the 1977 birth cohort, with RR values of 1.236 (95% CI: 1.029 to 1.485) and 1.199 (95% CI: 1.010 to 1.422), respectively (Figure 4 and Figure S5–S7).

A three part line graph showing age, period and cohort effects on rate and rate ratio. Image A shows a line graph with ′Age′ on the x-axis and ′Rate′ on the y-axis (0.0 to 0.6). Key points: (15, 0.02), (20, 0.26), (25, 0.56), (30, 0.41), (35, 0.28), (40, 0.16), (45, 0.05), (50, 0.02), (55, 0.01). Peak at (25, 0.56), lowest at (55, 0.01). Image B displays a graph with ′Period′ on the x-axis and ′Rate Ratio′ on the y-axis (0.0 to 2.0). Points: (1995, 1.7), (2000, 1.2), (2005, 1.0), (2010, 0.62), (2015, 0.45), (2020, 0.35). Peak at (1995, 1.7), lowest at (2020, 0.35). Image C shows a graph with ′Cohort′ on the x-axis and ′Rate Ratio′ on the y-axis (0 to 10). Points: (1945, 5.0), (1950, 4.0), (1955, 3.0), (1960, 2.4), (1965, 2.0), (1970, 1.6), (1975, 1.3), (1980, 1.1), (1985, 0.9), (1990, 0.8), (1995, 0.7), (2000, 0.6), (2005, 0.6), (2010, 0.6). Peak at (1945, 5.0), lowest at (2000, 0.6), (2005, 0.6), (2010, 0.6). Age peaks at 25 then declines; period and cohort decline over time. — The impact of age, period and cohort effects on the deaths rates of maternal hypertensive disorders in China from 1990 to 2021. (A) The age effect of deaths rate. (B) The period effect of deaths rates. (C) The cohort effect of deaths rates.

**Abbreviations**: RR, Rate Ratio; DALY, Disability adjusted life years; YLD, Years lived with disability; YLL, Years of life lost.

ARIMA Model Forecast Analysis

The ARIMA forecast results show that the age-standardized death rate decreased from 0.026 per 100,000 (95% UI: 0.024 to 0.027) in 2022 to nearly 0.010 per 100,000 (95% UI: 0.007 to 0.015); The age-standardized DALYs rate declined from 2.692 per 100,000 people in 2022 (95% UI: 2.563 to 2.827) to 1.274 per 100,000 people in 2035 (95% UI: 0.925 to 1.756); The age-standardized prevalence rate is projected to decline from 24.239 per 100,000 (95% UI: 23.707 to 24.770) in 2022 to 21.214 per 100,000 (95% UI: 7.598 to 34.830) in 2035; The age-standardized incidence rate decreased from 108.617 per 100,000 (95% UI: 105.999 to 111.299) in 2022 to 87.842 per 100,000 (95% UI: 60.482 to 127.579) in 2035. In summary, the burden of maternal hypertensive disorders in China has shown a steady downward trend from 2022 to 2035, reflecting the substantial progress the country has made in developing its maternal health care system and standardizing the diagnosis and treatment of hypertension (Table S6 and Figure 5).

Four line graphs showing actual and forecast female death, DALYs, prevalence and incidence rates over time. Four line graphs depict age-standardized rates for females from 1990 to 2035. Each graph includes actual data in a solid line and forecast data in a dashed line with a shaded uncertainty band. Graph A shows the age-standardized death rate decreasing from 0.20 in 1990 to 0.05 in 2020, with a forecast decline to 0.01 by 2035. Graph B illustrates the age-standardized DALYs rate dropping from 15 in 1990 to 5 in 2020, with a forecast reduction to 1 by 2035. Graph C presents the prevalence rate, which initially decreases, then rises to 30 in 2020, with a forecast decline to 21 by 2035. Graph D shows the incidence rate decreasing from 150 in 1990 to 100 in 2020, with a forecast decline to 88 by 2035. The graphs highlight a general downward trend in death and DALYs rates, while prevalence and incidence show more variability. The vertical dashed line marks the transition from actual to forecast data. — ARIMA model predictions of the burden of maternal hypertensive disorders in China from 2022 to 2035. (A) Predicted death rates for females, showing the estimated rates up to the year 2035 based on ARIMA analysis. (B) Predicted DALYs rates for females, showing the estimated rates up to the year 2035 based on ARIMA analysis. (C) Predicted prevalence rates for females, showing the estimated rates up to the year 2035 based on ARIMA analysis. (D) Predicted incidence rates for females, showing the estimated rates up to the year 2035 based on ARIMA analysis. DALY, disability adjusted life years; ARIMA, autoregressive integrated moving average model.

Analysis of the Quality-Of-Care Index (QCI)

Analysis of the Quality-of-Care Index (QCI) reveals that, between 1990 and 2021, the QCI for the care of maternal hypertensive disorders in China showed a significant overall improvement, with notable differences across age groups. In terms of age groups (Table S4 and Figure S8), the QCI in 1990 was highest in the 20–29 age group, the peak childbearing age group, and gradually decreased in the younger and older age groups. In 2021, the QCI for the 20–39 age group exceeded 92, with the 30–34 age group reaching 100; however, the QCI remained relatively low for the younger (10–14) and older (50–54) age groups. In terms of time trends (Table S5 and Figure S9), the overall QCI for pregnant and postpartum women aged 10–54 fluctuated downward from 1990 until it reached a low point in 2003, after which it rebounded rapidly, peaking in 2021. This indicates that China has made significant progress in the care of maternal hypertensive disorders in recent years, with the quality of care continuously improving.

Discussion

Based on the 2021 GBD database, this study systematically analyzed the age distribution, temporal trends, key drivers, and quality of care for maternal hypertensive disorders in China from 1990 to 2021, and provided a short-term projection of the future disease burden. The results of this study indicate that the overall burden of maternal hypertensive disorders in China is on a downward trend, with variations observed across different age groups. The age group with the highest burden has shifted to a later stage of childbearing, and the proportion of older pregnant women has increased. Joinpoint regression analysis indicates that YLDs, incidence, and prevalence burdens of maternal hypertensive disorders are all on the rise among women aged 30 and older. The decomposition analysis revealed that epidemiological changes were the primary factor contributing to the decline in all burden indicators. The results of the APC model indicate that maternal hypertensive disorders in China exhibit significant age, period, and cohort effects, with a lower burden observed in more recent birth cohorts. ARIMA forecasts that these rates will continue to decline through 2035, but the decline in incidence and prevalence will slow. The QCI index rebounded rapidly from its low point in 2003, reaching its relatively highest level within this dataset by 2021; but the QCI scores for the younger (ages 10–14) and older (ages 50–54) age groups remain significantly lower. These findings indicate that, although China has made some progress in the prevention and control of maternal hypertensive disorders over the past three decades, potential challenges remain.

This study found that the burden of maternal hypertensive disorders in China is on a downward trend, with the burden of death and disability (death rate, DALYs rate, and YLLs rate) decreasing by more than 80%, while the burden of incidence and prevalence has declined at a relatively slower rate (approximately 35%–45%). In recent decades, China has implemented a series of measures to reduce maternal mortality, such as the launch of the “Reduce Maternal Mortality and Eliminate Neonatal Tetanus” project in the 1990s, which pioneered the establishment of a maternal mortality surveillance and emergency response network in impoverished areas of central and western China; and the implementation of the subsidy policy for hospital deliveries among rural women in 2009, which significantly increased the rate of hospital deliveries and improved the safety of childbirth; Subsequently, the “Healthy China 2030” plan emphasized increasing screening rates for common women’s diseases to facilitate early diagnosis and treatment.^48–51 In addition, the widespread use of antihypertensive medications such as nifedipine, labetalol, and hydralazine, along with improvements in critical care capabilities for both mothers and newborns, will reduce mortality rates and the incidence of complications associated with maternal hypertensive disorders.⁵²^,⁵³ These measures have made a significant contribution to the rapid decline in mortality and the burden of premature mortality from maternal hypertensive disorders; they also explain why “epidemiological changes” were identified as the primary driver of this decline in the decomposition analysis.

In contrast to the significant decline in the burden of mortality and disability, the incidence and prevalence of maternal hypertensive disorders have decreased by less than 40%, and the burden of incidence and prevalence among individuals aged 30 and older is on the rise. First, as public health awareness has increased and medical institutions have expanded their prenatal screening services, more patients with mild or subclinical conditions are being detected at earlier stages.^54–56 Second, improvements in economic conditions and quality of life have led to an increase in overweight and obese women of childbearing age, thereby raising the risk of hypertension among pregnant women.⁵⁷ Finally, the use of assisted reproductive technology (in vitro fertilization) gives women with underlying medical conditions the opportunity to become pregnant, but it also increases their risk of developing hypertension.⁵⁸^,⁵⁹ In summary, all of the above factors may have contributed positively to the downward trend in the burden of maternal hypertensive disorders. In the future, the prevention and control of maternal hypertensive disorders could shift from a focus on “preventing deaths” to “lifecycle health management”, with an emphasis on strengthening primary prevention strategies, such as preconception blood pressure monitoring, weight management during pregnancy, and postpartum risk assessment.

In line with the social trend of women in China delaying childbearing,⁶⁰ the peak age group for the burden of maternal hypertensive disorders has gradually shifted from 20–24 years old in 1990 to 30–34 years old in 2021 (peak in number of cases) or 25–29 years old (peak in incidence rate). Advanced maternal age is a known risk factor for maternal hypertensive disorders. Factors such as the pursuit of higher education and career advancement, the desire for job stability and a high quality of life, and fears and anxieties about marriage and family may lead women to delay childbearing.⁶¹ Coupled with the implementation of the universal two-child policy, this may contribute to an increase in the proportion of older pregnant and postpartum individuals. A retrospective study conducted in China from 2010 to 2021 found that the proportion of older pregnant women increased from 14.6% to 31.6% following the implementation of the two-child policy.⁶² In addition, older women have a higher risk of adverse outcomes related to gestational hypertension and preeclampsia compared to women under 35, particularly among primiparous women.⁶³ This trend toward later childbearing suggests that traditional maternal and child health services, which have historically focused on first-time mothers of childbearing age, are no longer sufficient to meet the needs of current childbearing patterns. Future maternal and child health services should prioritize the management of older pregnant women and mothers (especially older first-time mothers).

This age-period-cohort analysis found that the age effect of the disease burden among pregnant maternal hypertension patients in China follows an inverted V-shaped distribution, with the peak of the disease burden occurring among females aged 20–29. Period effects indicate that both the death rate and the DALYs rate have shown a sustained downward trend, particularly since 2000. Institutional reforms may have played a key role in improving maternal health outcomes, including the launch of a new round of healthcare reforms, the introduction of China’s New Cooperative Medical Scheme (NCMS), and the achievement of universal coverage.⁶⁴^,⁶⁵ The cohort effect shows that the disease burden among recent birth cohorts is significantly lower than that of earlier cohorts. This may be attributed to the combined effects of changes in preconception and prenatal healthy lifestyles (such as a balanced diet and regular exercise),⁶⁶^,⁶⁷ improved health literacy resulting from higher levels of education among women,⁶⁸ and the widespread availability of prenatal care services,⁵⁶ all of which have reduced the risk of developing hypertension.

The ARIMA model’s projections indicate that death rate, DALYs rate, prevalence rate, and incidence rate will continue to decline through 2035, with the death rate approaching zero by 2035. While this is unlikely to be achieved in reality, it does reflect, to some extent, that China is nearing its goal of eliminating deaths from maternal hypertensive disorders. The Quality-of-Care Index (QCI) has risen steadily from its low point in 2003 to its peak in 2021, reflecting the improvements in the quality of care for maternal hypertensive disorders in China over the past two decades. Around 2003, China was in a critical phase of transition for its healthcare system. Although the Rural Cooperative Medical Scheme had been launched, it was still in the pilot phase and had not yet achieved full coverage; primary-level obstetric care capacity was weak; and access to emergency medications and equipment was poor. At the same time, the SARS (Severe Acute Respiratory Syndrome) outbreak that year disrupted the routine delivery of obstetric services at medical institutions, which may have had an indirect negative impact on the standardized management of maternal hypertensive disorders.⁶⁹^,⁷⁰ A series of policies introduced following the 2009 healthcare system reform has driven the continuous improvement of QCI. However, the QCI scores for the younger (10–14 years) and older (50–54 years) age groups remain relatively low. This may be due to the fact that pregnancies in the 10–14 age group are often unplanned, coupled with poor health awareness, delayed prenatal checkups, limited understanding of physiological changes, and insufficient social support, all of which contribute to lower quality of care.⁷¹^,⁷² Most perimenopausal women may have underlying conditions such as obesity and diabetes;⁷³^,⁷⁴ they face a significantly increased risk of developing gestational hypertension, which tends to be more severe and is more likely to lead to serious complications. In summary, personalized intervention strategies should be developed for these two groups in the future.

Based on data from 1990 to 2021 in the GBD 2021 database, this study employed a variety of analytical methods—including Joinpoint regression analysis, decomposition analysis, the APC model, the ARIMA model, and the QCI index—to systematically assess the long-term trends in the burden of maternal hypertensive disorders and the quality of care in China, thereby providing a multidimensional basis for future targeted prevention and control efforts. Although this study has made some important findings, it still has limitations. First, GBD data rely primarily on model estimates, and there may be significant uncertainty in certain age groups (either younger or older age groups), which could, to some extent, affect the identification of inflection points in long-term trends and the accurate estimation of the magnitude of change. Second, ARIMA forecasts are primarily based on extrapolation from historical data and cannot account for potential future changes, such as shifts in healthcare policy, the social environment, or the natural history of diseases. Furthermore, the uncertainty inherent in the GBD baseline estimates is carried over into the forecasting model, which may result in relatively wide confidence intervals for the forecasts; Forecast results should be viewed as reflecting the direction of potential trends rather than precise figures; they should be interpreted with caution when formulating long-term strategies and considered in conjunction with scenario analysis or expert assessments. Finally, this study did not include macro-level social factors (such as the economy, education, and access to healthcare services) in its ecological analysis. In the future, data from China’s actual maternal surveillance system could be used to externally validate the GBD results.

Conclusion

Between 1990 and 2021, the burden of death and disability associated with maternal hypertensive disorders in China declined significantly, while the burden of incidence and prevalence decreased gradually, showing an upward trend among women aged 30 and older. The burden of disease is shifting toward older age groups. Thanks to reforms in the healthcare system and ongoing strengthening of maternal and child health safety strategies, the quality of care for this condition has continued to improve; however, there is still room for improvement in both younger and older age groups. Based on the epidemiological trends observed in the GBD data described above, future efforts should focus on optimizing blood pressure management throughout the entire reproductive lifespan, strengthen preconception and prenatal monitoring for older pregnant women, develop prevention strategies for adolescent pregnancies, and improve chronic disease management for perimenopausal women, thereby continuing to advance the goals of “Healthy China 2030”.

Funding Statement

Guangdong Province Medical Science and Technology Research Fund (C2022104).

Data Sharing Statement

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Ethics Approval and Consent to Participate

The ethics statement is not applicable.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The coauthors declare there are no competing interests.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

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PERMALINK

Assessment of the Burden of Maternal Hypertensive Disorders and the Quality of Care in China: A Systematic Analysis of the Global Burden of Disease (GBD) 2021 Study

Weiwei Wang

Xun Jiang

Jiayao Long

Juanjuan Chen

Jingsi Chen

Yong Wang

Abstract

Objectives

Methods

Results

Conclusion

Introduction

Materials and Methods

Data Sources

Disease Definition

Statistical Analysis

Descriptive Analysis

Joinpoint Regression Analysis

Decomposition Analysis

Age-Period-Cohort Analysis

ARIMA Model Forecast Analysis

Analysis of the Quality-Of-Care Index (QCI)

Results

The Overall Burden of Maternal Hypertensive Disorders in China

Table 1.

Table 2.

Age Distribution

Changes in the Burden of Maternal Hypertensive Disorders in China, 1990–2021 (Joinpoint Regression Analysis)

Figure 1.

Figure 2.

Decomposition Analysis

Figure 3.

Age-Period-Coort Analysis (APC)

Figure 4.

ARIMA Model Forecast Analysis

Figure 5.

Analysis of the Quality-Of-Care Index (QCI)

Discussion

Conclusion

Funding Statement

Data Sharing Statement

Ethics Approval and Consent to Participate

Author Contributions

Disclosure

References

Associated Data

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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