Pregnancy-related complications affect women from minoritized racial and ethnic groups at a substantially higher rate compared to non-Hispanic White women.
In May 2023, the American Heart Association (AHA) launched a campaign to address inequities in maternal health outcomes among Hispanic/Latina women in particular, with a focus on increasing awareness regarding the importance of managing blood pressure during pregnancy. As noted in the AHA press release describing this initiative, Hispanic/Latina women may develop hypertension at younger ages and have higher average blood pressure compared with women from other non-Black racial and ethnic groups.1
Through social media outreach and other resources, the AHA’s awareness campaign aims to engage and educate Hispanic/Latina women on the topic and encourage them to visit their health care provider or pharmacy to check their blood pressure, continue to self-monitor, and follow established lifestyle guidance on maintaining healthy blood pressure.1
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We interviewed the following experts to further discuss disparities in cardiovascular and maternal outcomes in this patient population:
- AHA volunteer expert Johanna Contreras, MD, cardiologist and associate professor of medicine at the Icahn School of Medicine at Mount Sinai in New York, New York, medical director of the Hispanic Heart Center at Mount Sinai
- Natalie Cameron, MD, internal medicine specialist and instructor of general internal medicine at Northwestern University Feinberg School of Medicine in Chicago, Illinois
- Aarthi Sabanayagam, MD, cardiologist and associate clinical professor of cardiology at the University of California San Francisco (UCSF) School of Medicine and co-director of the UCSF Pregnancy and Cardiac Treatment Program
- Nicole Mitchell, MD, obstetrician and gynecologist and faculty director of the OB/GYN Diversity and Inclusion Program at Keck School of Medicine at the University of Southern California in Los Angeles, California
The AHA notes that “adverse outcomes related to cardiovascular diseases disproportionately affect Hispanic/Latina mothers.” What are some examples of these outcomes, and what factors may be driving these disparities?
Dr Contreras: Many factors are driving these disparities, including social determinants of health. Findings show a lack of prenatal care, as many Hispanic/Latina women do not have insurance2 and often do not receive preventative medications before pregnancy. These women tend to have a lower level of education and socioeconomic status, and they have jobs or multiple jobs that usually do not provide health insurance. In some cases, they depend on insurance from their partner or husband, and many times those are absent.
There is also a higher incidence of hypertension, hypercholesterolemia, and diabetes in Hispanic/Latina women, which can vary by country of origin and immigration status.3 All of these factors are well known to be associated with an increased risk of cardiovascular disease (CVD). Often, during pregnancy or due to the stress of pregnancy, these factors can manifest or worsen during pregnancy, making them difficult to treat and control and likely increasing the risk of CVD—which is the leading cause of maternal mortality.4
Additionally, Hispanic/Latina women have been underrepresented at every level, including in clinical trials.
Dr Cameron: From 2019 to 2020, maternal mortality increased significantly—from 12.6 to 18.2 per 100,000 live births—among Hispanic individuals in the US, representing a 44% relative increase in just 1 year.5 Similar increases were not seen among non-Hispanic White individuals. Although we do not yet know the cause of this increase, the COVID-19 pandemic has likely played a key role.
Given that CVD is the leading cause of maternal mortality,4 understanding the influence of the pandemic on cardiometabolic complications of pregnancy, such as hypertensive disorders of pregnancy and gestational diabetes, in Hispanic individuals is essential.
From 2007 to 2019, Hispanic individuals showed the greatest annual percent change in the incidence of new-onset hypertensive disorders of pregnancy compared to other racial and ethnic groups, with a 7.7% increase per year among those in urban areas.6
In 2019, the risk of gestational diabetes was about 1.15 times higher among Hispanic women compared with non-Hispanic White women.7 We are still working to understand how the pandemic has influenced prevalence and disparities in these complications and maternal mortality.
Drivers of disparities in adverse pregnancy outcomes are complex and multifaceted. Key contributors are differences in access to healthy and affordable foods, safe places to exercise and play, health care access and health insurance coverage, and reliable interpretation services for those who do not speak English. Historical and structural racism have perpetuated these disparities.
Dr Mitchell: CVD affects 1% to 4% of nearly 4 million pregnancies in the US each year8 and is now the leading cause of death in pregnant and postpartum women, accounting for 26.5% of US pregnancy-related deaths, or 4.23 deaths per 100,000 live births. For comparison, that’s almost twice the rate found in the United Kingdom.4
The rising trend in maternal deaths due to CVD appears to be due to acquired rather than congenital heart disease, such as the effects of hypertension acquired during one’s lifetime. The most common conditions include heart failure, myocardial infarction, arrhythmia, and aortic dissection.
Disparities are present amongst these statistics, especially when considering race/ethnicity and age. Per the American College of Obstetricians and Gynecologists (ACOG), non-Hispanic Black women have a 3.4 times higher risk of dying from CVD-related pregnancy complications compared with non-Hispanic White women, independent of other variables.9
Between 2011 and 2013, there were 43.5 pregnancy-related deaths per 100,000 live births for non-Hispanic Black women compared with 11.0 and 12.7 pregnancy-related deaths per 100,000 live births for Hispanic and non-Hispanic White women, respectively.9 Age older than 40 years increases the risk of myocardial infarction in pregnancy by 30 times compared to the risk for women younger than 20 years.10
Reasons for these disparities include a combination of structural, institutional, and systemic barriers such as racial and ethnic bias, access to care, and overt systemic racism.
Dr Sabanayagam: Some examples of these outcomes are pre-eclampsia around the peripartum period during pregnancy. When women are affected by adverse pregnancy outcomes such as pre-eclampsia, gestational diabetes mellitus, placental diseases, and low-birthweight babies, they are at increased risk for CVD later in life, such as stroke, myocardial infarction, and coronary artery disease.
Factors that drive disparities in outcomes in both African American and Hispanic women are highly complex and multifactorial in nature. Some of the factors are age, educations levels, employment and insurance coverage, language literacy, and access to care both during pregnancy and in the postpartum period. The COVID-19 pandemic brought many of these disparities to the forefront, highlighting the importance of understanding the associated factors when providing care to these women.
In addressing these disparities, why is the emphasis on managing blood pressure during pregnancy especially important?
Dr Contreras: Hypertension is highly prevalent in Hispanic/Latina women and in certain countries, including Mexico and Puerto Rico, and it has been found to be a top risk factor for disease and for pre-eclampsia and eclampsia during pregnancy.
It is important that all adult women know their blood pressure before pregnancy and to understand what the numbers mean and how to manage blood pressure.
Dr Cameron: Hypertensive disorders of pregnancy are important risk factors for maternal morbidity and mortality. Managing blood pressure before pregnancy, during pregnancy, and in the postpartum period may prevent other adverse pregnancy outcomes, such as maternal death and delivering a small for gestational age infant. Emerging evidence also suggests the potential for intergenerational transmission of poor cardiovascular health and high blood pressure from mother to baby.11
Dr Mitchell: Controlling blood pressure is extremely important to begin addressing these statistics. Hypertension affects up to 10% of pregnancies, and severe and early-onset hypertension put women at increased risk of cardiac problems during pregnancy or postpartum.12 For example, in pregnancies complicated by hypertension, the incidence of myocardial infarction and heart failure is 13-fold and 8-fold higher, respectively, than in healthy pregnancies.13
Dr Sabanayagam: Pre-eclampsia affects approximately 2% to 8% of pregnancies; however, it affects 30% of pregnancies in those with underlying chronic hypertension.14,15 The recent CHAP (Chronic Hypertension and Pregnancy) trial from the University of Alabama showed a 20% reduction in pregnancy complications of pre-eclampsia and pre-term births in women who were treated for hypertension with stricter cutoffs of 140/90 mm Hg instead of 160/105 mm Hg.16
What are key recommendations for physicians in terms of addressing this issue and advising patients on reaching and maintaining healthy blood pressure?
Dr Contreras: Patients should be advised to know their numbers, take their blood pressure at home, and understand when it is high so they can seek treatment.
Providers should understand that many medications to control blood pressure are contraindicated during pregnancy, so it is important to change those when patients are looking to become pregnant or are pregnant.
Also, lifestyle modifications are very important to control blood pressure, such as exercise, low-salt diet, cholesterol control, stress reduction, no smoking, and adequate amounts of good-quality sleep.
Even during pregnancy, it is important to maintain a good level of activity, healthy diet, sufficient sleep, and support.
Dr Cameron: First, we need to move upstream to improve blood pressure control and cardiovascular health before pregnancy. In a recent study, we found that less than one-half of individuals enter pregnancy in favorable cardiometabolic health.17 Emphasizing the importance of optimizing cardiovascular health early in the life course, both at the physician and policy level, is key.
Second, pregnancy is a time of high health care utilization and, therefore, can be an opportunity to empower patients with knowledge regarding cardiovascular health optimization, blood pressure monitoring, and blood pressure goals. Screening for social determinants of health and identifying barriers to controlling blood pressure are essential steps to developing patient-centered plans of care anytime during the peripartum period.
Finally, it is essential to facilitate transitions of care from pregnancy to postpartum. Individuals with hypertension during pregnancy should be seen by a cardiologist or primary care physician for ongoing preventive care and blood pressure management after pregnancy. Unfortunately, many of these patients are lost to follow-up during the first year postpartum. Promoting team-based care and creating systems to facilitate follow-up are key steps to ensuring patients get timely and appropriate care.
Dr Mitchell: On the individual level, physicians should work to identify and mitigate biases during patient care and avoid gaslighting patients to avoid missed diagnoses or inappropriate treatment.
Dr Sabanayagam: Physicians are advised to care for these patients based on their risk profile longitudinally with a multidisciplinary team consisting of internists, cardiologists, obstetricians, and high-risk maternal fetal medicine as well as OB anesthesia, amongst others. ACOG currently recommends a stricter blood pressure target of 140/90 mm Hg during pregnancy, and women with higher blood pressures are advised to start antihypertensive therapy.18
Over the last decade, initiation of 81 mg to 162 mg of aspirin up until delivery has also been advised in some women based on their risk profile, and as early as the 11th week of gestation to reduce the risk of pre-term pre-eclampsia.
What are a few of the most critical measures needed to foster improvement in this area, such as public health efforts and topics of research to focus on?
Dr Contreras: Some of the most pressing needs include early diagnosis, treatment, and medical access, blood pressure control, and addressing disparities and social determinants of health. There also needs to be an increased focus on cooking and eating healthy food.
It is important that all women have basic medical care, preventive medicines, increased health coverage during pregnancy and at least 1 year postpartum, as cardiovascular conditions can manifest during the postpartum period, and it is key to control these conditions to improve long-term patient outcomes. Also, if patients have cardiovascular health issues during pregnancy, they are more likely to develop CVD later in life, so care must continue throughout the patient’s life.
We need to empower women to understand how to take better care of their health. We need to increase our education efforts, and they need to be available in Spanish and culturally sensitive to our patients. We need to eliminate structural racism, discrimination, and unconscious bias in our current health care practices to provide better care to all our patients.
We also need to intensify our efforts to increase representation of Hispanic/Latina women in all aspects of care, especially in clinical trials. We need to understand how disease manifests in these populations and if there are differences that need to be understood and better treated. We do not even have any solid epidemiologic data in many countries, not even in the US, regarding CVD in Hispanic/Latina women.
Dr Cameron: The US has the highest maternal mortality rates among developed countries, with persistent disparities by race and ethnicity. Research must continue to identify the drivers of these disparities to help design targeted public health efforts that equitably improve cardiovascular health during the peripartum period. We must also continue to work with local communities to better understand both their assets and barriers to promoting maternal health, and form partnerships that empower communities to make lasting change.
Dr Mitchell: On the system level, we need to enhance multi-disciplinary education for OB/GYN, emergency, pediatric, and internal medicine to recognize and manage cardiac conditions pre-pregnancy and during pregnancy and postpartum, improve access of care—especially to higher-level specialty care—for patients with cardiac conditions, enhance translation services to address language barriers, enhance education for providers and systems regarding anti-racism and cultural humility and proficiency, and enhance community education programs to help aid in educating and treating cardiac-related conditions.
Dr Sabanayagam: The unfortunate rise in recent years in maternal morbidity and mortality is a public health emergency. There have been large efforts across many public health institutions and professional societies to understand these factors, including the social determinants of health, addressing disparities and the lack of access to care, as well investigating ways to improve early diagnosis and treatment of hypertensive disorders in pregnancy to mitigate both short-term and long-term adverse outcomes.
References
1. American Heart Association. Hispanic women face inequities affecting maternal health outcomes. Published May 8, 2023. Accessed May 31, 2023.
2. Daw JR, Kolenic GE, Dalton VK, et al. Racial and ethnic disparities in perinatal insurance coverage. Obstet Gynecol. 2020;135(4):917-924. doi:10.1097/AOG.0000000000003728
3. Gomez S, Blumer V, Rodriguez F. Unique cardiovascular disease risk factors in hispanic individuals. Curr Cardiovasc Risk Rep. Published online June 2, 2022. doi:10.1007/s12170-022-00692-0
4. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 212 Summary: Pregnancy and heart disease. Obstet Gynecol. 2019;133(5):1067-1072. doi:10.1097/AOG.0000000000003244
5. Hoyert DL. Maternal mortality rates in the United States, 2020. NCHS Health E-Stats. 2022. doi:10.15620/cdc:113967
6. Cameron NA, Everitt I, Seegmiller LE, Yee LM, Grobman WA, Khan SS. Trends in the incidence of new-onset hypertensive disorders of pregnancy among rural and urban areas in the United States, 2007 to 2019. J Am Heart Assoc. Published online January 11, 2022. doi:10.1161/JAHA.121.023791
7. 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. Published online August 17, 2021. doi:10.1001/jama.2021.7217
8. American Heart Association. Maternal health fact sheet. Accessed May 31, 2023.
9. Creanga AA, Syverson C, Seed K, Callaghan WM. Pregnancy-related mortality in the United States, 2011-2013. Obstet Gynecol. 2017;130(2):366-373. doi:10.1097/AOG.0000000000002114
10. De Viti D, Malvasi A, Busardò F, Beck R, Zaami S, Marinelli E. Cardiovascular outcomes in advanced maternal age delivering women. Clinical review and medico-legal issues. Medicina (Kaunas). 2019;55(10):658. doi:10.3390/medicina55100658
11. Khan SS, Brewer LC, Canobbio MM, et al. Optimizing prepregnancy cardiovascular health to improve outcomes in pregnant and postpartum individuals and offspring: a scientific statement from the American Heart Association. Circulation. Published online February 13, 2023. doi:10.1161/CIR.0000000000001124
12. Ying W, Catov JM, Ouyang P. Hypertensive disorders of pregnancy and future maternal cardiovascular risk. J Am Heart Assoc. Published online August 18, 2018. doi:10.1161/JAHA.118.009382
13. McCarthy FP, O’Driscoll J, Seed P, et al. Planned delivery to improve postpartum cardiac function in women with preterm pre-eclampsia: the PHOEBE mechanisms of action study within the PHOENIX RCT. NIHR Journals Library; 2021.
14. Karrar SA, Hong PL. Preeclampsia. StatPearls. 2023.
15. Garovic VD, August P. Preeclampsia and the future risk of hypertension: the pregnant evidence. Curr Hypertens Rep. Published online February 10, 2013. doi:10.1007/s11906-013-0329-4
16. Tita AT, Szychowski JM, Boggess K, et al; on behalf of the Chronic Hypertension and Pregnancy (CHAP) Trial Consortium. Treatment for mild chronic hypertension during pregnancy. N Engl J Med. Published online May 12, 2022. doi:10.1056/NEJMoa2201295
17. Cameron NA, Freaney PM, Wang MC, et al. Geographic differences in prepregnancy cardiometabolic health in the United States, 2016 through 2019. Circulation. Published online February 14, 2022. doi:10.1161/CIRCULATIONAHA.121.057107
18. American College of Obstetricians and Gynecologists. Clinical guidance for the integration of the findings of the Chronic Hypertension and Pregnancy (CHAP) study. Published April 2022. Accessed May 31, 2023.
This article originally appeared on The Cardiology Advisor
