Abstract

Background Early‑onset hypertensive disorders of pregnancy (eHDP) are associated with more severe maternal and infant outcomes than later‑onset disease. However, little has been done to evaluate population‑level trends. Therefore, in this paper, we seek to address this understudied area by describing the geospatial and temporal patterns of county‑level incidence of eHDP and assessing county‑level demographics that may be associated with an increased incidence of eHDP.

Methods Employing Kentucky certificates of live and stillbirth from 2008–2017, this ecological study detected county‑level clusters of early‑onset hypertensive disorders of pregnancy using SaTScan, calculated average annual percent change (AAPC) with a join point analysis, and identified county‑level covariates (% of births to women ≥ 35 years of age, % with BMI ≥ 30 kg/m2 , % currently smoking, % married, and % experienced eHDP) with a fixed‑effects negative binomial regression model for longitudinal data with an autoregressive (AR) correlation structure offset with the natural log of the number of births in each county and year.

Results County‑level incidence of eHDP had a non‑statistically significant increase of almost 3% (AAPC: 2.84, 95% CI: ‑4.26, 10.46), while maternal smoking decreased by almost 6% over the study period (AAPC:‑5.8%, 95%CI: ‑7.5, ‑4.1), Risk factors for eHDP such as pre‑pregnancy BMI ≥ 30 and proportion of births to women ≥ 35 years of age increased by 2.3% and 3.4% respectively (BMI AAPC:2.3, 95% CI: 0.94, 3.7; ≥ 35 years AAPC:3.4, 95% CI: 0.66, 6.3). After adjusting for race, county‑level proportions of college attainment, and maternal smoking throughout pregnancy, counties with the highest proportion of births to women with BMI ≥ 30 kg/m2 reported an eHDP incidence 20% higher than counties with a lower proportion of births to mothers with a BMI ≥ 30 kg/m2 and a 20% increase in eHDP incidence (aRR = 1.20, 95% CI: 1.00, 1.44). We also observed that counties with the highest proportion vs. the lowest of mothers ≥ 35 years old (> 6.1%) had a 26% higher incidence of eHDP (RR = 1.26, 95%CI: 1.04, 1.50) compared to counties with the lowest incidence (< 2.5%). We further identified two county‑level clusters of elevated eHDP rates. We also observed that counties with the highest vs. lowest proportion of mothers ≥ 34 years old (> 6.1% vs. < 2.5%) had a 26% increase in the incidence of eHDP (RR = 1.26, 95% CI: 1.04, 1.50). We further identified two county‑level clusters of elevated incidence of eHDP.

Conclusions This study identified two county‑level clusters of eHDP, county‑level covariates associated with eHDP, and that while increasing, the average rate of increase for eHDP was not statistically significant. This study also identified the reduction in maternal smoking over the study period and the concerning increase in rates of elevated pre‑pregnancy BMI among mothers. Further work to explore the population‑level trends in this understudied pregnancy complication is needed to identify community factors that may contribute to disease and inform prevention strategies.

Document Type

Article

Publication Date

6-2023

Notes/Citation Information

© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Digital Object Identifier (DOI)

https://doi.org/10.1186/s12884-023-05699-y

Funding Information

This manuscript was supported by the Education Research Center (ERC) through Grant 6U54OH007547 and Berea College through the Olive Ruth Russel Fellowship. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIOSH/CDC or Berea College.

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