This cross-sectional study examines data from the National Center for Health Statistics to determine rates of de novo hypertensive disorders of pregnancy among individuals with a first live birth according to racial and ethnic subgroup.
Key Points
Question
What are patterns in the rates of de novo hypertensive disorders of pregnancy (HDP) in the United States from 2011 to 2019 among individuals in Asian and Hispanic subgroups with a first live birth?
Findings
In this cross-sectional study, HDP rates significantly increased in all racial and ethnic groups. In 2019, the highest HDP rate among non-Hispanic Asian subgroups was in Filipina individuals, and the highest HDP rate among Hispanic/Latina subgroups was in Puerto Rican individuals.
Meaning
Rates of HDP increased in all subgroups with considerable heterogeneity among non-Hispanic Asian and Hispanic/Latina individuals.
Abstract
Importance
De novo hypertensive disorders of pregnancy (HDP) are associated with adverse maternal and offspring outcomes. Heterogeneity among racial and ethnic subgroups may be masked with aggregate reporting of race and ethnicity, such as Asian or Pacific Islander or Hispanic.
Objective
To determine patterns in de novo HDP rates among individuals in Asian and Hispanic subgroups with a first live birth in the United States in the period 2011 through 2019.
Design, Setting, and Participants
This serial cross-sectional analysis used data from 2011 through 2019 for individuals aged 15 to 44 years with singleton first live births obtained from the US National Center for Health Statistics natality database.
Exposures
Stratification by self-report of maternal race and ethnicity: Hispanic/Latina (overall and Hispanic/Latina subgroups [Central/South American, Cuban, Mexican, and Puerto Rican]), non-Hispanic Asian and Pacific Islander (overall and non-Hispanic Asian subgroups [Asian Indian, Chinese, Filipina, Japanese, Korean, and Vietnamese]), non-Hispanic Black, non-Hispanic White.
Main Outcomes and Measures
De novo HDP was defined as new-onset hypertension during pregnancy (gestational hypertension or preeclampsia). Age-standardized rates of HDP (per 1000 live births) and respective mean annual percent change in race and ethnicity groups and subgroups were calculated.
Results
Among 13 238 918 individuals, the mean (SD) age was 26.3 (5.8) years. Overall, HDP rates increased 7.3% per year (95% CI, 6.5%-8.1%), from 57.2 (95% CI, 56.8-57.6) per 1000 live births in 2011 to 99.7 (95% CI, 99.2-100.2) per 1000 live births in 2019. Rates of HDP significantly increased in all racial and ethnic groups and subgroups over the study period. The highest HDP prevalence among non-Hispanic Asian subgroups in 2019 was in Filipina individuals (92.5 [95% CI, 86.3-98.8] per 1000 live births), and the highest among Hispanic/Latina subgroups in 2019 was in Puerto Rican individuals (98.6 [95% CI, 94.2-102.9] per 1000 live births) with significant heterogeneity observed among subgroups across the study period.
Conclusions and Relevance
Rates of HDP among individuals with a singleton first live birth increased in the United States from 2011 to 2019 across all race and ethnicity subgroups, with considerable heterogeneity in HDP rates in non-Hispanic Asian and Hispanic/Latina subgroups.
Introduction
De novo hypertensive disorders of pregnancy (HDP), which include gestational hypertension and preeclampsia, are related to increased risk of future adverse cardiovascular outcomes in both the pregnant individual and offspring.1,2 In the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be (nuMoM2b) cohort, Hispanic and Asian females were less likely to experience HDP (10.6% and 8.5%, respectively) compared with non-Hispanic Black females (16.7%) and non-Hispanic White females (13.7%).3 However, it is unclear if there is heterogeneity HDP among Asian and Hispanic subgroups, who are frequently aggregated into single categories that do not reflect differences related to social determinants, immigration patterns, or cultural behaviors. Such heterogeneity among Asian and Hispanic subgroups has been observed for gestational diabetes rates in the United States between 2011 and 2019.4 National rates of HDP have been increasing in the United States,1 but trends in HDP have not been described among Asian and Hispanic subgroups. We aimed to quantify HDP trends in the United States from 2011 through 2019 among detailed racial and ethnic subgroups to inform management and prevention.
Methods
This study was exempt from review by the Northwestern University institutional review board because it uses public, deidentified data. Reporting follows guidelines from Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).
Birth records from the National Center for Health Statistics (NCHS) identifying all individuals with a singleton first live birth who were aged 15 to 44 years in the United States were used to quantify HDP rates from 2011 through 2019. Records from non-US residents and nonsingleton births were removed, and those missing HDP or pregestational hypertension data were excluded. Birth records are completed by the attendant clinician at birth, who compiles data from various sources, including maternal self-report, prenatal records, labor and delivery records, admission history and physical examination, or delivery record, as detailed in the NCHS protocol.5 Hypertensive disorder of pregnancy was defined per NCHS as gestational hypertension (antenatal pregnancy-induced hypertension or preeclampsia), which excludes chronic (prepregnancy) hypertension.
Additional data included age at delivery, racial and ethnic identity, education, insurance, and receipt of prenatal care. Maternal race and ethnicity were self-identified and categorized as Hispanic, non-Hispanic Asian or Pacific Islander, non-Hispanic Black, or non-Hispanic White. To appropriately characterize the Hispanic and non-Hispanic Asian groups, individuals were categorized in non-Hispanic Asian subgroups (Asian Indian, Chinese, Filipina, Japanese, Korean, Vietnamese) and Hispanic subgroups (Central and South American, Cuban, Mexican, Puerto Rican).
Age-standardized rates of HDP (per 1000 singleton first live births) were calculated overall, in race and ethnicity groups, and in non-Hispanic Asian and Hispanic subgroups. Rates were standardized to the age distribution of individuals who gave birth in 2011 (the beginning of the study period and to align with a recent NCHS analysis).4 A secondary analysis to compare differences in HDP rates between racial and ethnic groups and subgroups adjusted for prepregnancy body mass index and diabetes and gestational diabetes was performed for the subset from 2016 through 2019 (when these data were universally available) with additional information in the eMethods in the Supplement. Statistically significant differences in HDP rates were identified with nonoverlapping CIs. Trends in HDP rate were quantified by weighted mean annual percent change, using Joinpoint Regression software version 4.7.0.0.6 All other analyses were conducted using SAS Enterprise Guide version 7.1. Statistically significant trends were identified with 2-sided P values less than .05 and mean annual percent change CIs excluding 0.
Results
Among 13 238 918 individuals aged 15 to 44 years with singleton first live births from 2011 to 2019 (mean [SD] age, 26.3 [5.8] years), 20.6% were Hispanic/Latina, 7.8% were non-Hispanic Asian or Pacific Islander, 14.1% were non-Hispanic Black, and 55.9% were non-Hispanic White (eTable 1 in the Supplement). Characteristics of individuals in non-Hispanic Asian and Hispanic/Latina subgroups are shown in Table 1 and Table 2, respectively. Characteristics in the overall population and among major racial and ethnic groups are shown in eTable 1 in the Supplement and in each year, 2011 through 2019, in eTable 2 in the Supplement.
Table 1. Maternal Characteristics in Individuals Aged 15 to 44 Years With Singleton First Live Births in Non-Hispanic Asian Subgroups in the United States, 2011 to 2019.
| No. (%)a | ||||||
|---|---|---|---|---|---|---|
| Asian Indian | Chinese | Filipina | Japanese | Korean | Vietnamese | |
| No. | 284 390 | 235 515 | 111 633 | 27 630 | 64 038 | 51 192 |
| Age, mean (SD), y | 29.5 (4.0) | 30.8 (4.4) | 30.0 (5.4) | 33.2 (4.7) | 32.2 (4.3) | 30.1 (4.9) |
| Education | ||||||
| Less than high school | 1922 (0.7) | 2667 (1.1) | 202 (0.2) | 20 (0.1) | 49 (0.1) | 756 (1.5) |
| High school graduate | 16 867 (5.9) | 18 720 (7.9) | 10 970 (9.8) | 1840 (6.7) | 2744 (4.3) | 10 291 (20.1) |
| Any college | 245 448 (86.3) | 196 761 (83.5) | 91 000 (81.5) | 23 301 (84.3) | 57 843 (90.3) | 36 328 (71.0) |
| Insurance | ||||||
| Medicaid | 40 945 (14.4) | 46 550 (19.8) | 18 942 (17.0) | 2084 (7.5) | 8465 (13.2) | 15 769 (30.8) |
| Private insurance | 219 668 (77.2) | 140 600 (59.7) | 75 968 (68.1) | 21 223 (76.8) | 47 794 (74.6) | 32 138 (62.8) |
| Self-pay | 5676 (2.0) | 38 277 (16.3) | 2387 (2.1) | 622 (2.3) | 2121 (3.3) | 1430 (2.8) |
| Other | 5047 (1.8) | 4416 (1.9) | 7465 (6.7) | 1635 (5.9) | 2686 (4.2) | 1599 (3.1) |
| Receipt of prenatal care | ||||||
| Starting first trimester | 221 446 (77.9) | 185 657 (78.8) | 84 220 (75.4) | 21 407 (77.5) | 50 079 (78.2) | 39 279 (76.7) |
| Starting second trimester | 32 297 (11.4) | 26 275 (11.2) | 14 252 (12.8) | 2733 (9.9) | 6804 (10.6) | 7907 (15.4) |
| Starting third trimester | 10 164 (3.6) | 12 695 (5.4) | 3508 (3.1) | 837 (3.0) | 2550 (4.0) | 1944 (3.8) |
| No prenatal care | 1965 (0.7) | 1017 (0.4) | 811 (0.7) | 154 (0.6) | 346 (0.5) | 684 (1.3) |
Percentages for categorical maternal characteristics account for missing data.
Table 2. Maternal Characteristics in Individuals Aged 15 to 44 Years With Singleton First Live Births in Hispanic/Latina Subgroups, 2011 to 2019.
| No. (%)a | ||||
|---|---|---|---|---|
| Central and South American | Cuban | Mexican | Puerto Rican | |
| No. | 426 865 | 85 600 | 1 512 478 | 234 303 |
| Age, mean (SD), y | 26.3 (6.2) | 27.1 (5.4) | 23.8 (5.6) | 24.2 (5.6) |
| Education | ||||
| Less than high school | 42 115 (9.9) | 618 (0.7) | 60 002 (4.0) | 2104 (0.9) |
| High school graduate | 94 147 (22.1) | 28 071 (32.8) | 504 932 (33.4) | 66 476 (28.4) |
| Any college | 188 220 (44.1) | 48 180 (56.3) | 586 258 (38.8) | 106 330 (45.4) |
| Insurance | ||||
| Medicaid | 190 677 (44.7) | 42 662 (49.8) | 848 767 (56.1) | 117 125 (50.0) |
| Private insurance | 135 750 (31.8) | 37 090 (43.3) | 439 667 (29.1) | 79 635 (34.0) |
| Self-pay | 42 214 (9.9) | 1660 (1.9) | 94 261 (6.2) | 2965 (1.3) |
| Other | 20 877 (4.9) | 2036 (2.4) | 74 377 (4.9) | 10 656 (4.5) |
| Receipt of prenatal care | ||||
| Starting first trimester | 266 443 (62.4) | 66 089 (77.2) | 1 013 573 (67.0) | 154 262 (65.8) |
| Starting second trimester | 78 508 (18.4) | 11 252 (13.1) | 300 090 (19.8) | 38 970 (16.6) |
| Starting third trimester | 26 804 (6.3) | 2287 (2.7) | 84 592 (5.6) | 9125 (3.9) |
| No prenatal care | 7781 (1.8) | 619 (0.7) | 33 454 (2.2) | 2325 (1.0) |
Percentages for categorical maternal characteristics account for missing data.
Trends in age-standardized rates of HDP and mean annual percent change in HDP rates from 2011 to 2019 are shown in the Figure and listed in eTable 3 in the Supplement. Overall, HDP rates increased 7.3% per year (95% CI, 6.5%-8.1%) from 57.2 (95% CI, 56.8-57.6) per 1000 live births in 2011 to 99.7 (95% CI, 99.2-100.2) per 1000 live births in 2019. Rates of HDP significantly increased in all major racial and ethnic groups and in all subgroups.
Figure. Trends in Age-Standardized Hypertensive Disorders of Pregnancy (HDP) Rates by Race and Ethnicity Among Pregnant Individuals With a Singleton First Live Birth in the United States, 2011 to 2019.
Annual percent changes in rates are listed by racial and ethnic subgroup in eTable 3 in the Supplement.
There was significant heterogeneity in HDP rates among non-Hispanic Asian subgroups, with the lowest 2019 rate in Chinese individuals (27.6 [95% CI, 24.1-31.0] per 1000 live births) and the highest 2019 rate in Filipina individuals (92.5 [95% CI, 86.3-98.8] per 1000 live births). Rates of HDP increased fastest in Japanese individuals (the smallest subgroup): 11.3% per year (95% CI, 3.1%-20.2%). Among Hispanic/Latina subgroups, 2019 HDP rates ranged from 69.1 (95% CI, 66.9-71.4) per 1000 live births in Central/South American individuals to 98.6 (95% CI, 94.2-102.9) per 1000 live births in Puerto Rican individuals. Rates of HDP increased fastest in Puerto Rican individuals: 9.5% (95% CI, 5.9%-13.2%) per year. In 2019, HDP rates were 117.3 (95% CI, 115.6-119.0) per 1000 live births in non-Hispanic Black individuals and 108.2 (95% CI, 107.4-108.9) per 1000 live births in non-Hispanic White individuals. Prevalence of additional clinical factors, along with odds of HDP in racial and ethnic groups relative to non-Hispanic White individuals accounting for clinical and sociodemographic factors, are shown in eTables 4-6 in the Supplement.
Discussion
Age-standardized rates of de novo HDP among individuals with a singleton first live birth increased in all non-Hispanic Asian and Hispanic/Latina subgroups in the United States from 2011 to 2019. Significant heterogeneity in HDP rates among non-Hispanic Asian and Hispanic subgroups was masked by aggregation into typical major racial and ethnic categories. Our findings are consistent with patterns of hypertension outside of pregnancy among non-Hispanic Asian and Hispanic/Latina subgroups, which is most prevalent in Filipino and Puerto Rican individuals. However, differences in relative burden of hypertension and HDP among other subgroups may be related to differences by sex, differences in pathophysiologic triggers, sample age differences, and measurement differences.7,8,9
Race and ethnicity are social constructs, not biological factors. Accordingly, the heterogeneity of HDP among non-Hispanic Asian and Hispanic/Latina subgroups is likely attributable to social determinants, including access to health care, place of birth (ie, nativity), residence in rural areas, and structural racism and discrimination.10,11,12 Adjustment for several social determinants did not markedly attenuate relative odds of HDP in this analysis, likely indicating that other unmeasured factors contribute to differences among subgroups. Notably, Hispanic/Latina individuals were younger than non-Hispanic Asian individuals but had higher HDP rates. Identifying social determinants of such patterns of pregnancy-related complications in specific populations may inform approaches for prevention and management of HDP and its sequelae.
Limitations
Limitations of this analysis include potential miscoding of HDP, inability to separately identify HDP subtypes (eg, preeclampsia with severe features or HELLP syndrome [hemolysis, elevated liver enzymes, low platelet count]), and lack of data about behaviors such as dietary pattern. Nevertheless, the NCHS data provide the most comprehensive available characterization of HDP in the United States.
Conclusions
Several factors likely contribute to the growing burden of HDP, including contemporaneous population-level increases in prepregnancy obesity and diabetes, which are known HDP risk factors.13,14 The steady increase in HDP in the United States portends a growing burden of adverse pregnancy outcomes and future cardiovascular disease among young adults that will not be equally borne by all individuals.15 Inequity in HDP and its sequelae may contribute to downstream inequity in health. To reduce persistent HDP disparities by race and ethnicity and prevent consequent cardiovascular disease, culturally tailored and community-informed intervention strategies that aim to both primarily prevent HDP and to secondarily target the long-term sequelae of HDP are urgently warranted.
eTable 1. Maternal characteristics by race and ethnicity in individuals aged 15-44 years with singleton first live births in the United States, 2011-2019
eTable 2. Maternal characteristics in individuals aged 15-44 years with singleton first live births from 2011 to 2019 in the United States
eTable 3. Age-standardized rates of hypertensive disorders of pregnancy and annual percent change in race/ethnic subgroups in individuals aged 15-44 years with singleton first live births in the United States, 2011-2019
eTable 4. Maternal characteristics in individuals aged 15-44 years with singleton first live births in non-Hispanic Asian subgroups in the United States, 2016-2019
eTable 5. Maternal characteristics in individuals aged 15-44 years with singleton first live births in Hispanic/Latina subgroups, 2016-2019
eTable 6. Odds ratios of age-standardized hypertensive disorders of pregnancy in individuals aged 15-44 years with singleton first live births in racial/ethnic minority groups compared with non-Hispanic White individuals in the United States, 2016-2019
eMethods
References
- 1.Virani SS, Alonso A, Aparicio HJ, et al. ; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee . Heart Disease and Stroke Statistics 2021 update: a report from the American Heart Association. Circulation. 2021;143(8):e254-e743. doi: 10.1161/CIR.0000000000000950 [DOI] [PubMed] [Google Scholar]
- 2.Parikh NI, Gonzalez JM, Anderson CAM, et al. ; American Heart Association Council on Epidemiology and Prevention; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; and the Stroke Council . Adverse pregnancy outcomes and cardiovascular disease risk: unique opportunities for cardiovascular disease prevention in women: a scientific statement from the American Heart Association. Circulation. 2021;143(18):e902-e916. doi: 10.1161/CIR.0000000000000961 [DOI] [PubMed] [Google Scholar]
- 3.Grobman WA, Parker CB, Willinger M, et al. ; Eunice Kennedy Shriver National Institute of Child Health and Human Development Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (nuMoM2b) Network* . Racial disparities in adverse pregnancy outcomes and psychosocial stress. Obstet Gynecol. 2018;131(2):328-335. doi: 10.1097/AOG.0000000000002441 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Shah NS, Wang MC, Freaney PM, et al. Trends in gestational diabetes at first live birth by race and ethnicity in the US, 2011-2019. JAMA. 2021;326(7):660-669. doi: 10.1001/jama.2021.7217 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Centers for Disease Control and Prevention . User guide to the 2019 Natality Public Use File. Published 2019. Accessed January 3, 2022. https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2019-508.pdf
- 6.National Cancer Institute . Joinpoint Regression Program version 4.7.0.0. 2019.
- 7.Thomas IC, Allison MA. Hypertension in Hispanics/Latinos: epidemiology and considerations for management. Curr Hypertens Rep. 2019;21(6):43. doi: 10.1007/s11906-019-0947-6 [DOI] [PubMed] [Google Scholar]
- 8.Satish P, Sadaf MI, Valero-Elizondo J, et al. Heterogeneity in cardio-metabolic risk factors and atherosclerotic cardiovascular disease among Asian groups in the United States. Am J Prev Cardiol. 2021;7:100219. doi: 10.1016/j.ajpc.2021.100219 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Shah NS, Luncheon C, Kandula NR, Cho P, Loustalot F, Fang J. Self-reported diabetes prevalence in Asian American subgroups: Behavioral Risk Factor Surveillance System, 2013-2019. J Gen Intern Med. Published online June 9, 2021. doi: 10.1007/s11606-021-06909-z [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Harris M, Henke C, Hearst M, Campbell K. Future directions: analyzing health disparities related to maternal hypertensive disorders. J Pregnancy. 2020;2020:7864816. doi: 10.1155/2020/7864816 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.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]
- 12.Shah NS, Wang MC, Kandula NR, et al. Gestational diabetes and hypertensive disorders of pregnancy by maternal birthplace. Am J Prev Med. 2022;62(4):e223-e231. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Wang L, Li X, Wang Z, et al. Trends in prevalence of diabetes and control of risk factors in diabetes among US adults, 1999-2018. JAMA. 2021. doi: 10.1001/jama.2021.9883 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Ogden CL, Fryar CD, Martin CB, et al. Trends in obesity prevalence by race and Hispanic origin, 1999-2000 to 2017-2018. JAMA. 2020;324(12):1208-1210. doi: 10.1001/jama.2020.14590 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Tooher J, Thornton C, Makris A, Ogle R, Korda A, Hennessy A. All hypertensive disorders of pregnancy increase the risk of future cardiovascular disease. Hypertension. 2017;70(4):798-803. doi: 10.1161/HYPERTENSIONAHA.117.09246 [DOI] [PubMed] [Google Scholar]
Associated Data
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Supplementary Materials
eTable 1. Maternal characteristics by race and ethnicity in individuals aged 15-44 years with singleton first live births in the United States, 2011-2019
eTable 2. Maternal characteristics in individuals aged 15-44 years with singleton first live births from 2011 to 2019 in the United States
eTable 3. Age-standardized rates of hypertensive disorders of pregnancy and annual percent change in race/ethnic subgroups in individuals aged 15-44 years with singleton first live births in the United States, 2011-2019
eTable 4. Maternal characteristics in individuals aged 15-44 years with singleton first live births in non-Hispanic Asian subgroups in the United States, 2016-2019
eTable 5. Maternal characteristics in individuals aged 15-44 years with singleton first live births in Hispanic/Latina subgroups, 2016-2019
eTable 6. Odds ratios of age-standardized hypertensive disorders of pregnancy in individuals aged 15-44 years with singleton first live births in racial/ethnic minority groups compared with non-Hispanic White individuals in the United States, 2016-2019
eMethods