The number of pregnancies complicated by high blood pressure doubled in the United States — to around 80,000 cases a year — between 2007 and 2018, according to preliminary research presented at the American Heart Association’s Scientific Sessions 2020 this month. The researchers reviewed 50 million live births between 2007 and 2018 from the national CDC Natality Database. The team also found that the risk of prepregnancy hypertension was more than twice as high for non-Hispanic Black women than it was for white and Hispanic women — a significant finding since CDC data shows that Black women are 3 times more likely to die of childbirth than white women. In addition, women living in rural areas were 20 percent more likely to have high blood pressure before pregnancy than their counterparts living in urban communities. What’s going on? Obesity is one of the leading contributors to high blood pressure, a health crisis that’s also on the rise throughout the United States. According to the CDC, nearly half of American adults are obese, and women are more likely than men to be severely obese (have a BMI over 40). But obesity is not the only factor. “These rural-urban and race-based disparities are likely related to social determinants of health and systemic racism within our society that create gaps in preventative health,” says Natalie A. Cameron, MD, a resident in the department of medicine at Northwestern University’s Feinberg School of Medicine in Chicago, who led the study. Social determinants of health include things that are often out of a person’s control, such as where they live and work, which, in turn, can affect what kinds of pollutants or otherwise harmful exposures they may encounter. Social determinants can also impact what kinds of foods certain people can afford, which foods are in close proximity to them, and whether or not they have access to healthcare. Women living in rural areas are more likely to be uninsured than women who live in urban areas, meaning they may have less access to preventative care, according to the U.S. Census Bureau. These women are also more likely to die of heart disease, cancer, and stroke, the CDC reports. According to Eliza C. Miller, MD, an assistant professor of neurology at Columbia University, who was not involved with the new study, in addition to insurance barriers, there are fewer doctors in rural areas, making it more difficult to access preventative or specialty care. “Access to care is huge and we know that there are just not enough doctors in rural locations that are available to women, so that may be part of those disparities,” says Dr. Miller. “There are also well-documented disparities in maternal health as far as racial disparities go.” Black, American Indian, and Alaska Native women are twice as likely to die as a result of pregnancy than white women, according to the CDC. “The reasons for that are very complex but likely have to do with the systemic racism in our country that permeates the healthcare system. I do not see this as a genetic thing, this is about disparities,” says Miller. A study published in the August 2020 issue of the journal Hypertension found that Black Americans who experienced lifetime discrimination were nearly 50 percent more likely to develop hypertension than study participants who reported rarely feeling discriminated against. In addition, white American households are 20 percent more likely to have private health insurance than Black American households, according to the U.S. Department of Health and Human Services Office of Minority Health. Not having health insurance or being underinsured limits a person’s access to preventative care and screenings that catch conditions such as high blood pressure. As a result, insurance can be a significant barrier that causes a person to live with undiagnosed hypertension. While some of the pregnancy complications related to high blood pressure may be attributed to more women having babies later in life, when hypertension becomes more common, the study also found that complications were trending up in women as young as 15 to 24 years old. “I’m not surprised to see that younger women are being diagnosed with hypertension because I see that all the time, it’s a lot more common than we think it is. What I hope this study shows is that we are finding it more and diagnosing it more and that is why the numbers are higher, because then we can treat it. But if simply more women have hypertension, that is terrible news,” says Miller. What does this trend mean for maternal health? Women with high blood pressure prior to pregnancy have a higher risk of kidney failure, cesarean sections, preterm deliveries, and post-pregnancy cardiovascular disease. Their babies are also more at risk of being admitted to the neonatal ICU after delivery, says Dr. Cameron. And while maternal stroke is not very common, hypertension is the biggest risk for having a stroke while pregnant, says Miller. “Women who have preexisting hypertension should be seen by an obstetrician who specializes in women with high risk pregnancies in addition to a regular midwife or ob-gyn because they are at a far higher risk of getting things like preeclampsia, which is life-threatening,” says Miller, noting that finding a physician that specializes in high-risk pregnancies is likely much more difficult in rural areas. Getting hypertension diagnosed as early as possible after onset is critically important to managing it, even if that diagnosis comes during pregnancy, she says “One thing that I really wish is that women would go to the doctor when they weren’t pregnant. It doesn’t mean they can’t get pregnant if they have high blood pressure, it just means they need to be watched carefully. You can’t get treated if you don’t know you have the condition,” says Miller.
