More Than Half of US Women Enter Pregnancy at Higher CVD Risk

Stephanie Edwards

February 24, 2022

Less than half of women in the United States enter pregnancy in favorable cardiovascular health, new research suggests.

In 2019, among women aged 20 to 44 years with live births in the United States, only 40.2% were in favorable cardiovascular health prior to pregnancy, defined as normal weight, no diabetes, and no hypertension.

Although all regions and states showed a decline in prepregnancy favorable cardiometabolic health, there were significant differences among geographic regions in the country, the authors report. "These data reveal critical deficiencies and geographic disparities in prepregnancy cardiometabolic health," they conclude.

"One of the things that we know in the US is that the maternal mortality rate has been increasing and there are significant differences at the state level in both adverse maternal outcomes, such as maternal mortality, as well as adverse pregnancy outcomes," corresponding author Sadiya S. Khan, MD, MS, FACC, Northwestern University Feinberg School of Medicine, Chicago, told theheart.org | Medscape Cardiology.

"These outcomes are often related to health factors that predate pregnancy," Khan explained, "and the processes that begin at the very, very beginning of conception are informed by health factors prior to pregnancy, in particular cardiometabolic factors like body mass index [BMI] or obesity, high blood pressure, and diabetes."

The results were published online on February 14 in a special "Go Red for Women" spotlight issue of Circulation.

Cardiometabolic Health Factors

Using maternal birth records from live births in the Centers for Disease Control and Prevention (CDC) Natality Database between 2016 and 2019, the authors analysed data on 14,174,625 women with live births aged 20 to 44 years. The majority (81.4%) were 20 to 34 years of age, 22.7% were Hispanic or Latina, and 52.7% were non-Hispanic white.

Favorable cardiometabolic health was defined as a BMI of 18 to 24.9 kg/m2, absence of diabetes, and absence of hypertension.

Although all regions and states experienced a decline in favorable cardiometabolic health during the study period of 2016 to 2019, with a drop overall of 3.2% — from 43.5 to 40.2 per 100 live births — it was especially true of the South and Midwest regions.

In 2019, favorable prepregnancy cardiometabolic health was lowest in the South (38.1%) and Midwest (38.8%), and highest in the West (42.2%) and Northeast (43.6%).

State by state, the lowest prevalence of favorable cardiometabolic health was found in Mississippi, at 31.2%, and highest in Utah, at 47.2%.

They also found a correlation between favorable cardiometabolic health and state-level percentages of high-school education or less and enrolment in Medicaid in 2019.

Similar to what has been seen with cardiovascular disease, "we observe that the states with the lowest prevalence of favorable cardiometabolic health were in the Southeast United States," said Khan, "and similar geographic variation was observed with some more patterns in education and Medicaid coverage for birth, and these were used as proxies for socioeconomic status in those areas."

Although Khan notes that the relationships cannot be determined to be causal from this analysis, she said that "it does suggest that upstream social determinants of health are important determinants of cardiometabolic health."

Socioeconomic Intervention

Khan noted that policies at the federal and state level can identify ways to "ensure that individuals who are thinking about pregnancy have access to healthcare and have access to resources, too, from a broad range of health determinants, including housing stability, food security, as well as access to healthcare be optimized prior to pregnancy."

The authors note that this analysis may actually overestimate the prevalence of favorable cardiometabolic health, and data on cholesterol, diet, a distinction between type 1 and type 2 diabetes, and physical activity were not available.

Only individuals with live births were included, which could result in the elimination of a potentially high-risk group; however, late pregnancy losses represent less than 0.3% of all pregnancies, they say.

The authors conclude that "future research is needed to equitably improve health prior to pregnancy and quantify the potential benefits in cardiovascular disease outcomes for birthing individuals and their offspring."

This work was supported by grants from the National Heart, Lung and Blood Institute and American Heart Association Transformational Project Award awarded to Sadiya S. Khan.

Circulation. Published online February 14, 2022. Abstract

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