Author ORCID Identifier

Date Available


Year of Publication


Degree Name

Doctor of Philosophy (PhD)

Document Type

Doctoral Dissertation


Public Health


Epidemiology and Biostatistics

First Advisor

Dr. W. Jay Christian

Second Advisor

Dr. Steven R. Browning


Using live and stillbirth records from Kentucky (2008-2017), this dissertation assessed the county-level prevalence and geospatial patterns of early-onset hypertensive disorders of pregnancy (eHDP); examined the geocoding precision of addresses recorded on birth records, and evaluated the association between individual risk factors and environmental metal exposures on eHDP prevalence. After adjusting for maternal demographic factors and pre-existing health conditions, we observed that eHDP prevalence was 38% higher (aPR=1.38, 95%CI:1.16, 1.64) in counties with the highest prevalence of married women (> 53.8%) compared to lower prevalence areas (31.6%) had a 20% higher prevalence of eHDP(aPR=1.20, 95%CI:1.00, 1.44) compared to counties with lower obesity prevalence (< 22.6%) after adjustment. We also identified two county-level clusters of eHDP in Appalachia. In the assessment of geocoding, we found that while address geocoding precision has improved over time, addresses of rural Black women were more likely to imprecisely geocode (aOR=1.41, 95%CI:1.22, 1.62) than rural White women. Adjusting for geocoding imprecision, we further assessed demographic and environmental factors associated with eHDP prevalence by augmenting records with census micro-block group toxicity concentration estimates of arsenic, cadmium, chromium, lead, and mercury from the Risk Screening Environmental Indicators (RSEI) model. Using a latent class analysis, we identified four classes of metal exposures. After adjusting for geocoding, imprecision, maternal demographics, and pre-existing health conditions, we found that women with a higher probability of lead and chromium exposure had a 22% higher prevalence of eHDP (aPR=1.22, 95%CI:1.04, 1.44) compared to women with a low probability of exposure to other considered metals. This study indicates an association between lead, chromium, and eHDP, even after adjusting for important covariates. Further research refining the use of RSEI scores and other exposures in association with eHDP is needed.

Digital Object Identifier (DOI)

Funding Information

This project was supported by the Central Appalachian Regional Education and Research Center (CARERC) through Grant 6T42OH010278. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institute for Occupational Safety & Health (NIOSH) or Centers for Disease Control (CDC).