Hypertension Continues to be a Leading Cause of U.S. Maternal Mortality

The U.S. is in crisis when it comes to pregnancy-related maternal mortality (i.e., maternal deaths during or in the year following pregnancy). In late September 2022, the Centers for Disease Control and Prevention released a new report using 2017-2019 data from Maternal Mortality Review Committees from 36 U.S. states.₁ Researchers concluded that an astounding four of out five maternal deaths in the United States are preventable. Further, this data shows that hypertensive disorders of pregnancy (HDP) persist as a leading underlying cause of pregnancy-related deaths and account for 7% of known U.S. maternal deaths from 2017-2019.¹ Rates of HDP, including gestational hypertension and preeclampsia, are worsening. In fact, they nearly doubled in the last decade alone.² Hypertensive disorders of pregnancy affect Black and Indigenous (American Indian and Alaska Native) women at two to three times the rates of non-Hispanic White women and increase the risk of maternal heart failure and stroke as well as preterm birth and infant mortality.¹

Generation Z and Millennials Are More Likely to Have High Blood Pressure in Pregnancy than Earlier Generations

In August 2022, researchers at Northwestern University published findings from a study that examined hypertension in four generations of more than 38 million birthing persons during their first pregnancies, from 1995 to 2019, ranging from Baby Boomers to Generation Z, respectively.³ The researchers found that birthing persons who are Generation Z (“Gen Zers”) and millennials are approximately two times more likely to be newly diagnosed with HDP compared with birthing persons from the Baby Boomer generation. This is especially intriguing because it held true even after adjusting for age differences during pregnancy. Regardless of age during pregnancy, rates of HDP were higher among birthing persons from more recent generations. It has long been recognized that advanced maternal age is associated with higher rates of HDP and other complications of pregnancy such as gestational diabetes; however, this multi-generational study is unique in its discovery of patterns of hypertension in U.S. pregnancies that are not related to maternal age at first pregnancy.³

Perhaps unsurprisingly, the researchers assert that this finding is most likely related to a generational decline in overall cardiovascular health.⁴ That is, birthing persons are currently entering pregnancy with suboptimal cardiovascular health, frequently related to obesity, a sedentary lifestyle, and poor nutrition. These risks contribute to maternal morbidity and adverse birth outcomes and are associated with poverty, resource deprivation (i.e., food deserts, lack of transportation, lack of healthcare access), and various other social and structural determinants of health that contribute to the HDP disparities observed in Black and Indigenous birthing persons.

2022 Legislation to Address U.S. Maternal Mortality and Optimize Birth Outcomes

In the last two years, PCNA supported multiple maternal-health-related legislative priorities that the House of Representatives eventually passed in early 2022 as part of H.R. 2471, the Fiscal Year 2022 omnibus appropriations package.  Specific priorities passed relevant to improving maternal health outcomes include:

• $83 million, an increase of $20 million, for Safe Motherhood/Infant Health Programs at the Centers for Disease Control and Prevention (CDC), which include Maternal Mortality Review Committees and Perinatal Quality Collaboratives.
• $30 million for the National Institute of Health (NIH) Implementing a Maternal Health and Pregnancy Outcomes Vision for Everyone (IMPROVE), an unprecedented investment in the flagship maternal health research initiative at NIH.
• $748 million, an increase of $35 million, for the Maternal and Child Health Block Grant to fund programs that support the health and well-being of mothers, children, and families.
• $29 million, an increase of $6 million, for State Maternal Health Innovation Grants.
• $6 million, an increase of $1 million, for the Rural Maternity and Obstetric Management Strategies (RMOMS) program.

As a result of this legislation, there are currently multiple, diverse funding mechanisms and requests for applications to support research and innovative projects that aim to optimize U.S. maternal health. This represents an unprecedented opportunity for PCNA and cardiovascular nurses to collaborate across disciplines and sectors to promote cardiovascular prevention before, during, and after pregnancy.

Prevention Takeaways for Cardiovascular Nurses

Let’s consider, again, the recent CDC finding that four out of five U.S. maternal deaths are preventable. In the case of hypertensive disorders of pregnancy, what new approaches to primary and secondary prevention might be critical to actually prevent maternal deaths? Experts^3,5 recommend the following:

• Broaden our perspectives on screening to expand the focus on hypertension prevention in all age groups, from preconception to postpartum and beyond.
• Consider the use of mobile health technologies like wearables and telehealth/remote health to monitor blood pressure and overcome the barrier to healthcare access that can be situational and place-based for many birthing persons before and during pregnancy and postpartum.
• Engage diverse birthing persons, their families, and community champions to co-create programming with healthcare providers, health systems, and advocates aimed at optimizing cardiovascular health and preventing hypertension before pregnancy.
• Implement “whole-person” interventions at the community level that optimize maternal mental and cardiovascular health.
• Listen to women; take seriously their reporting of symptoms and refer them to appropriate follow-up care.

Related Hypertension and Maternal Mortality Resources

• Call to Action: Cardiovascular-Related Maternal Mortality
• Maternal Obesity and Cardiovascular Health
• Adverse Pregnancy Outcomes and CVD
• Cardiovascular Disease is the Leading Cause of U.S. Maternal Death

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[1] Trost SL BJ, Njie F, et al Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US States, 2017-2019. 2022.

[2] Cameron NA, Everitt I, Seegmiller LE, Yee LM, Grobman WA and Khan SS. Trends in the Incidence of New-Onset Hypertensive Disorders of Pregnancy Among Rural and Urban Areas in the United States, 2007 to 2019. J Am Heart Assoc. 2022;11:e023791.

[3] Cameron NA, Petito LC, Shah NS, Perak AM, Catov JM, Bello NA, Capewell S, O’Flaherty M, Lloyd-Jones DM, Greenland P, Grobman WA and Khan SS. Association of Birth Year of Pregnant Individuals With Trends in Hypertensive Disorders of Pregnancy in the United States, 1995-2019. JAMA Netw Open. 2022;5:e2228093.

[4] Tsao CW, Aday AW, Almarzooq ZI, Alonso A, Beaton AZ, Bittencourt MS, Boehme AK, Buxton AE, Carson AP, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Ferguson JF, Generoso G, Ho JE, Kalani R, Khan SS, Kissela BM, Knutson KL, Levine DA, Lewis TT, Liu J, Loop MS, Ma J, Mussolino ME, Navaneethan SD, Perak AM, Poudel R, Rezk-Hanna M, Roth GA, Schroeder EB, Shah SH, Thacker EL, VanWagner LB, Virani SS, Voecks JH, Wang NY, Yaffe K and Martin SS. Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association. Circulation. 2022;145:e153-e639.

[5] Ferranti EP, Jones EJ, Bush S, Hayman LL, Larimer K, Martyn-Nemeth P, Villavaso CD and Coke LA. A Call to Action: Cardiovascular-Related Maternal Mortality: Inequities in Black, Indigenous, and Persons of Color. J Cardiovasc Nurs. 2021;36:310-311.