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Am J Perinatol 2023; 40(05): 453-460
DOI: 10.1055/a-1886-5404
SMFM Fellowship Series Article

The Association of Race and Ethnicity with Severe Maternal Morbidity among Individuals Diagnosed with Hypertensive Disorders of Pregnancy

Authors

  • Anna Palatnik 

    1   Division of maternal fetal medicine, Department of obstetrics and gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin

  • Paula McGee

    2   George Washington University Biostatistics Center, Washington, District of Columbia

  • Jennifer L. Bailit

    3   Division of maternal fetal medicine, Department of obstetrics and gynecology, MetroHealth Medical Center-Case Western Reserve University, Cleveland, Ohio

  • Ronald J. Wapner

    4   Division of maternal fetal medicine, Department of obstetrics and gynecology, Columbia University, New York, New York

  • Michael W. Varner 

    5   Division of maternal fetal medicine, Department of obstetrics and gynecology, University of Utah Health Sciences Center, Salt Lake City, Utah

  • John M. Thorp Jr.

    6   Division of maternal fetal medicine, Department of obstetrics and gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina

  • Steve N. Caritis

    7   Division of maternal fetal medicine, Department of obstetrics and gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania

  • Mona Prasad

    8   Division of maternal fetal medicine, Department of obstetrics and gynecology, The Ohio State University, Columbus, Ohio

  • Alan T. N. Tita

    9   Division of maternal fetal medicine, Department of obstetrics and gynecology, University of Alabama at Birmingham, Birmingham, Alabama

  • George R. Saade

    10   Division of maternal fetal medicine, Department of obstetrics and gynecology, University of Texas Medical Branch, Galveston, Texas

  • Dwight J. Rouse

    11   Division of maternal fetal medicine, Department of obstetrics and gynecology, Brown University, Providence, Rhode Island

  • Sean C. Blackwell

    12   Division of maternal fetal medicine, Department of obstetrics and gynecology, McGovern Medical School-Children's Memorial Hermann Hospital, University of Texas Health Science Center at Houston, Houston, Texas
    • for the Eunice Kennedy Shriver National Institute of Child Health Human Development Maternal-Fetal Medicine Units (MFMU) Network

Funding This study was supported by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (grant nos.: HD21410, HD27869, HD27915, HD27917, HD34116, HD34208, U10 HD36801, HD40500, HD40512, HD40544, HD40545, HD40560, HD40485, HD53097, and HD53118) and the National Center for Research Resources (grant nos.: UL1 RR024989 and 5UL1 RR025764). Comments and views of the authors do not necessarily represent views of the National Institutes of Health.
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Abstract

Objective This study aimed to examine whether there are racial disparities in severe maternal morbidity (SMM) in patients with hypertensive disorders of pregnancy (HDP).

Study Design Secondary analysis of an observational study of 115,502 patients who had a live birth at ≥20 weeks in 25 hospitals in the United States from 2008 to 2011. Only patients with HDP were included in this analysis. Race and ethnicity were categorized as non-Hispanic White, non-Hispanic Black (NHB), and Hispanic and were abstracted from the medical charts. Patients of other races and ethnicities were excluded. Associations were estimated between race and ethnicity, and the primary outcome of SMM, defined as any of the following, was estimated by unadjusted logistic and multivariable backward logistic regressions: blood transfusion ≥4 units, unexpected surgical procedure, need for a ventilator ≥12 hours, intensive care unit (ICU) admission, or failure of ≥1 organ system. Multivariable models were run classifying HDP into three levels as follows: (1) gestational hypertension; (2) preeclampsia (mild, severe, or superimposed); and (3) eclampsia or HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome.

Results A total of 9,612 individuals with HDP met inclusion criteria. No maternal deaths occurred in this cohort. In univariable analysis, non-Hispanic White patients were more likely to present with gestational hypertension whereas NHB and Hispanic patients were more likely to present with preeclampsia. The frequency of the primary outcome, composite SMM, was higher in NHB patients compared with that in non-Hispanic White or Hispanic patients (11.8 vs. 4.5% in non-Hispanic White and 4.8% in Hispanic, p < 0.001). This difference was driven by a higher frequency of blood transfusions and ICU admissions among NHB individuals. Prior to adjusting the analysis for confounding factors, the odds ratio (OR) of primary composite outcomes in NHB individuals was 2.85 (95% confidence interval [CI]: 2.38, 3.42) compared with non-Hispanic White. After adjusting for sociodemographic and clinical factors, hospital site, and the severity of HDP, the OR of composite SMM did not differ between the groups (adjusted OR [aOR] = 1.26, 95% CI: 0.95, 1.67 for NHB, and aOR = 1.29, 95% CI: 0.94, 1.77 for Hispanic, compared with non-Hispanic White patients). Sensitivity analysis was done to exclude one single site that was an outliner with the highest ICU admissions and demonstrated no difference in ICU admission by maternal race and ethnicity.

Conclusion NHB patients with HDP had higher rates of the composite SMM compared with non-Hispanic White patients, driven mainly by a higher frequency of blood transfusions and ICU admissions. However, once severity and other confounding factors were taken into account, the differences did not persist.

Key Points

  • Black patients with HDP had higher frequency of SMM compared with non-Hispanic White patients.

  • The SMM disparities were driven by blood transfusions and ICU admissions.

  • After adjustment for confounders, including HDP severity, the significant difference in SMM did not persist.

Keywords

hypertensive disorders of pregnancy - race - ethnicity - preeclampsia - gestational hypertension - maternal morbidity

Note

Presented at the at the 41st annual meeting of the Society for Maternal-Fetal Medicine, Virtual meeting, January 25–30, 2021.


Supplementary Material



Publication History

Received: 07 December 2021

Accepted: 21 June 2022

Accepted Manuscript online:
28 June 2022

Article published online:
29 December 2022

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