By Ahizechukwu C. Eke, MD, PhD, MPH
Associate Professor in Maternal Fetal Medicine, Division of Maternal Fetal Medicine, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore
SYNOPSIS: Neighborhood-level socioeconomic inequities in early pregnancy were associated with higher risk of long-term cardiovascular disease in pregnant and postpartum women.
SOURCE: Venkatesh KK, Khan SS, Catov J et al. Socioeconomic disadvantage in pregnancy and postpartum risk of cardiovascular disease. Am J Obstet Gynecol 2024; May 15. doi: 10.1016/j.ajog.2024.05.007. [Online ahead of print].
Cardiovascular disease (CVD) is a leading cause of maternal morbidity and mortality globally.1 Evidence suggests that socioeconomic inequalities during pregnancy and the postpartum period considerably increase the risk of developing CVD.2 Socioeconomic status (SES) is a complex and multifaceted construct encompassing occupation, access to resources, education, and income, all of which can affect maternal health outcomes.3
During pregnancy, socioeconomic inequality can manifest in various forms, including limited access to prenatal care, exposure to environmental toxins and hazards, increased maternal stress, and poor nutrition.4 These factors collectively contribute to adverse pregnancy outcomes, including preeclampsia, exacerbation of existing renal or CVD disease, gestational hypertension, and gestational diabetes mellitus (GDM), which are known risk factors for long-term CVD.4
The postpartum period is a critical window for assessing and mitigating cardiovascular risk in women who have experienced socioeconomic inequities during pregnancy.5 The long-term risks of CVD still are high even after pregnancy-related disorders such as preeclampsia and GDM resolve during and after the postpartum period. For example, women who have a history of preeclampsia are about twice as likely to experience hypertensive disorders of pregnancy, ischemic heart disease, and stroke in their later years compared to women without such history.6 Socioeconomic factors continue to play critical roles in the postpartum period, affecting maternal access to prenatal and postpartum care, adherence to care, and the ability to engage in healthy behaviors that decrease the risk for CVD during pregnancy and postpartum, such as having a good sleep, regular physical activity, and a balanced diet.
Recently, several professional associations have shown increasing interest in this topic, underscoring the necessity to study and understand the association between social determinants of health inequities and long-term cardiovascular outcomes in pregnant and postpartum women. To investigate this association, Venkatesh and colleagues hypothesized that pregnant women living in neighborhoods with greater socioeconomic inequities would have a higher risk of long-term CVD.7
The study was a secondary analysis of the Nulliparous Pregnancy Outcomes Study — Monitoring Mothers-to-be (nuMomM2b), a multicenter prospective study conducted at eight centers within the United States.7 The nuMoM2b cohort enrolled nulliparous women in the first trimester between 2010 and 2013 to examine risk factors for adverse pregnancy outcomes. Pregnant women met the inclusion criteria if they had a singleton viable gestation between six and 13 weeks and an intention to deliver at one of the participating sites or hospitals. Exclusion criteria included being younger than 13 years of age, having a history of three or more pregnancy losses, pregnancies that resulted from donor oocytes, planned pregnancy termination, lethal fetal malformations, fetal aneuploidy, and inability to provide informed consent.7
The exposure was neighborhood-level socioeconomic inequity/disadvantage assessed using the 2015 Area Deprivation Index (ADI), divided into tertiles, measured during the first trimester of pregnancy.7 Participants’ home addresses during early pregnancy were geocoded at the census block level. Tertile groupings were used to stratify risk, with the areas with the lowest ADIs (i.e., the least deprived) designated as the first tertile (T1) and those with the highest ADI (i.e., the most deprived) designated as the third tertile (T3).
The outcomes were the predicted 30-year risk of atherosclerotic CVD (ASCVD) and the predicted 30-year risk of total CVD, a composite of ASCVD, coronary insufficiency, angina pectoris, transient ischemic attack, intermittent claudication, and heart failure, using the Framingham Risk Score measured two to seven years after delivery. Multivariable linear regression and modified Poisson regression models, adjusted for baseline age and individual-level social determinants, such as health insurance, educational attainment, and household poverty, were used for analysis.
After excluding missing variables, the final sample size for the study was 4,309 women. At two to seven years postpartum (median: 3.1 years; interquartile range [IQR], 2.5, 3.7), the median 30-year risk of ASCVD was 2.3% (IQR, 1.5, 3.5), and the median 30-year risk of total CVD was 5.5% (IQR, 3.7, 7.9). A predicted 30-year risk of ASCVD greater than 10% was observed in 2.2% of the women, while 14.3% had a predicted 30-year risk of total CVD greater than 10%. Women living in the highest ADI tertile had a higher predicted 30-year risk of ASCVD (adjusted β, 0.41; 95% confidence interval [CI], 0.19, 0.63) compared to those in the lowest tertile.
Additionally, those in the top two ADI tertiles had higher absolute risks of 30-year total CVD (T2: adjusted β, 0.37; 95% CI, 0.03, 0.72; T3: adjusted β, 0.74; 95% CI, 0.36, 1.13). Similarly, women residing in neighborhoods in the highest ADI tertile were more likely to have a high 30-year predicted risk of ASCVD (adjusted relative risk [aRR], 2.21; 95% CI, 1.21, 4.02) and total CVD ≥ 10% (aRR, 1.35; 95% CI, 1.08, 1.69) compared to women in other tertiles.
COMMENTARY
To properly comprehend how socioeconomic inequality affects cardiovascular health during pregnancy and postpartum, an intersectional perspective is critically important. Intersectionality takes into account how overlapping social identities — such as gender, race, and ethnicity — interact with socioeconomic status to generate specific health consequences.8 For example, women from racial and ethnic minorities frequently face disadvantages exacerbated by systemic racism. These women are more likely to encounter discrimination in medical settings, leading to adverse pregnancy outcomes. This study showed that those in the most deprived groups had the highest risk of future CVD.
Several studies have demonstrated that Black women experience a greater risk for adverse pregnancy outcomes, such as hypertensive disorders, cardiac diseases, and GDM, with consequent worse cardiovascular outcomes compared to white women, irrespective of their socioeconomic background.9,10 Addressing these inequities requires a comprehensive strategy, including policy adjustments, community interventions, and efforts to eradicate systemic biases and racism in the healthcare system.
Targeted interventions are essential to reduce the increased cardiovascular risk linked to socioeconomic inequities during pregnancy and the postpartum period. Increasing maternal access to comprehensive prenatal and postnatal care is critical.11 This involves implementing policies that ensure all women, regardless of their financial situation, receive timely and adequate medical care during pregnancy. Community-based prenatal care programs that offer guidance on stress reduction, proper nutrition, and healthy pregnancy practices also are essential, especially for women who reside in rural areas and maternity desserts.5,12 Additionally, screening for social determinants of health during prenatal visits and the postpartum period can help identify women who are more vulnerable and provide referrals to appropriate facilities and resources.5,12
Future studies should investigate the complex interactions between socioeconomic inequities, pregnancy outcomes, and long-term cardiovascular health. Longitudinal studies that follow women from conception through the postpartum period and beyond are particularly invaluable for elucidating causal pathways and temporal correlations between social inequities and long-term cardiovascular health.13 Policymakers should prioritize reducing socioeconomic inequities that affect pregnant and postpartum women by addressing the underlying causes of poverty, expanding access to prenatal care education, and enhancing employment and educational opportunities for pregnant and postpartum women.14 By adopting a comprehensive strategy that considers the social determinants of health, we can better support pregnant and postpartum women, ultimately reducing the burden of CVD.
In conclusion, socioeconomic inequities significantly increase the risk of CVD during and after pregnancy. This increased risk is the result of a combination of modifiable and non-modifiable factors, including inadequate access to prenatal and postpartum care, poor nutrition, psychological stress, and structural racism. Addressing these issues requires comprehensive approaches, including community support and appropriate regulatory and policy frameworks. By addressing the social determinants of health, we can promote healthier communities, improve outcomes for mothers and their children, and reduce the risk for long-term CVD.
REFERENCES
- Kotit S, Yacoub M. Cardiovascular adverse events in pregnancy: A global perspective. Glob Cardiol Sci Pract 2021;2021:e202105.
- Simoncic V, Deguen S, Enaux C, et al. A comprehensive review on social inequalities and pregnancy outcome-identification of relevant pathways and mechanisms. Int J Environ Res Public Health 2022;19:16592.
- Nicholls-Dempsey L, Badeghiesh A, Baghlaf H, Dahan MH. How does high socioeconomic status affect maternal and neonatal pregnancy outcomes? A population-based study among American women. Eur J Obstet Gynecol Reprod Biol X 2023;20:100248.
- Girardi G, Longo M, Bremer AA. Social determinants of health in pregnant individuals from underrepresented, understudied, and underreported populations in the United States. Int J Equity Health 2023;22:186.
- Lewey J, Beckie TM, Brown HL, et al. Opportunities in the postpartum period to reduce cardiovascular disease risk after adverse pregnancy outcomes: A scientific statement from the American Heart Association. Circulation 2024;149:e330-e346.
- Seely EW, Celi AC, Chausmer J, et al. Cardiovascular health after preeclampsia: Patient and provider perspective. J Womens Health (Larchmt) 2021;30:305-313.
- Venkatesh KK, Khan SS, Catov J, et al. Socioeconomic disadvantage in pregnancy and postpartum risk of cardiovascular disease. Am J Obstet Gynecol 2024; May 15. doi: 10.1016/j.ajog.2024.05.007. [Online ahead of print].
- Harari L, Lee C. Intersectionality in quantitative health disparities research: A systematic review of challenges and limitations in empirical studies. Soc Sci Med 2021;277:113876.
- Lawson SM, Chou B, Martin KL, et al. The association between race/ethnicity and peripartum hysterectomy and the risk of perioperative complications. Int J Gynaecol Obstet 2020;151:57-66.
- Minhas AS, Ogunwole SM, Vaught AJ, et al. Racial disparities in cardiovascular complications with pregnancy-induced hypertension in the United States. Hypertension 2021;78:480-488.
- 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 2023;147:e76-e91.
- Jowell AR, Sarma AA, Gulati M, et al. Interventions to mitigate risk of cardiovascular disease after adverse pregnancy outcomes: A review. JAMA Cardiol 2022;7:346-355.
- Mahendru AA, Everett TR, Wilkinson IB, et al. A longitudinal study of maternal cardiovascular function from preconception to the postpartum period. J Hypertens 2014;32:849-856.
- Andermann A; CLEAR Collaboration. Taking action on the social determinants of health in clinical practice: A framework for health professionals. CMAJ 2016;188:E474-e483.
Neighborhood-level socioeconomic inequities in early pregnancy were associated with higher risk of long-term cardiovascular disease in pregnant and postpartum women.
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