BACKGROUND
Postpartum hypertension is the leading cause of postpartum readmission and has long-lasting
cardiovascular effects. Black patients have higher incidence rates of hypertensive
disorders after delivery and subsequent severe maternal morbidity. Neighborhood advantage,
a marker of social determinants of health, has not been studied concerning postpartum
hypertension. Moreover, the interplay between race and neighborhood advantage and
their effect on postpartum hypertension have not been previously explored.
OBJECTIVE
This study aimed to evaluate the association between neighborhood-level social determinants
of health and postpartum hypertension and explore whether these factors explain previously
documented racial disparities.
STUDY DESIGN
This study included a retrospective cohort of people enrolled in a remote monitoring
program of postpartum hypertension at the time of delivery within 1 health network
from March 2019 to September 2021. Patients were eligible for enrollment after a diagnosis
of hypertensive disorder during pregnancy or delivery. We further limited the cohort
to self-reported Black and White patients with blood pressures recorded at 3 weeks
and 6 weeks postpartum. The neighborhood advantage for each person at the time of
delivery was classified using the area deprivation index, an accepted surrogate of
social determinants of health and our primary exposure. The secondary exposure was
self-reported race. Study outcomes of interest were hypertensive status (stage 1 hypertension:
≥130 to 139/80 to 89 mm Hg; stage 2 hypertension: ≥140/90 mm Hg) at 3 and 6 weeks
after delivery. In addition, hypertensive status by neighborhood area deprivation
index using logistic regression was molded. In secondary analyses, a case-control
cohort matched on the area deprivation index was created, and conditional logistic
regression was used to evaluate race. Finally, mixed-effects models modeling hypertension
by race and clustering within the area deprivation index were used.
RESULTS
Of 4193 people enrolled, 2722 were Black or White and had blood pressure data recorded
at 3 weeks after delivery, and 1126 had blood pressure data recorded at 6 weeks after
delivery. After accounting for prenatal body mass index, smoking status, type of hypertension,
and antihypertensives prescribed at discharge, persons living in the most disadvantaged
neighborhoods were twice as likely (adjusted odds ratio, 2.03; 95% confidence interval,
1.53–2.69) to develop stage 2 hypertension at 21 days after delivery and 1.67 times
more likely (95% confidence interval, 1.06–2.64) to develop stage 2 hypertension at
6 weeks after delivery than persons living in the most advantaged neighborhoods. Both
associations were attenuated after adjusting for race. When people with stage 2 hypertension
were matched on area deprivation index with normotensive counterparts, Black patients
were still 3 to 4 times more likely to develop stage 2 hypertension at 3 (adjusted
odds ratio, 3.00; 95% confidence interval, 1.95–4.63) and 6 (adjusted odds ratio,
4.61; 95% confidence interval, 2.05–10.36) weeks after delivery. This association
remained after clustering within a neighborhood at 3 (adjusted odds ratio, 3.12; 95%
confidence interval, 2.41–4.06) and 6 (adjusted odds ratio, 2.99; 95% confidence interval,
1.96–4.54) weeks after delivery. There was no significant difference in stage 1 hypertension.
CONCLUSION
Neighborhood advantage was associated with the development of persistent hypertension
at 3 and 6 weeks after delivery. This association did not explain the racial disparity
in sustained high blood pressure.
Keywords
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Article info
Publication history
Published online: October 12, 2022
Accepted:
October 8,
2022
Received in revised form:
September 21,
2022
Received:
April 22,
2022
Footnotes
The authors report no conflict of interest.
This work was supported by the National Institutes of Health (NIH) Office of Research on Women's Health Building Interdisciplinary Research Careers in Women's Health scholar funds (grant number K12HD043441 [A.H.]) and by the NIH (grant number UL1 TR001857).
Cite this article as: Lemon LS, Hauspurg A, Garrard W, et al. Neighborhood disadvantage and the racial disparity in postpartum hypertension. Am J Obstet Gynecol MFM 2022;XX:x.ex–x.ex.
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