Rural-urban residence and sequelae of hypertensive disorders of pregnancy in the first year postpartum, 2007 – 2019

Hypertensive disorders of pregnancy (HDP) affect an estimated 10% of pregnancies in the US [1] and are a major contributor to maternal morbidity and mortality worldwide [2]. HDP are also a leading cause of postpartum readmissions [1] and women whose pregnancies are complicated by HDP have higher readmission rates than those without HDP [3]. Rates of HDP have risen markedly in recent years, with new-onset HDP doubling between 2007 and 2019 in the US [4]. Both the American Heart Association and the American College of Obstetricians and Gynecologists (ACOG) recognize that pregnancy complications are an important predictor of future cardiovascular risk [5] as HDP is associated with more than double the lifetime risk of severe cardiac complications [6]. Cardiovascular disease is now the leading cause of pregnancy-related deaths in the US [7], highlighting the critical role that HDP plays in maternal health.

Examining rural-urban disparities in pregnancy outcomes is a priority of ACOG given the unique challenges of providing perinatal care in rural areas and the known health disparities between rural and urban women in the US [8]. Not only has the overall burden of HDP increased since the mid-2000s, but pre-pregnancy hypertension and new-onset HDP have been consistently higher among rural women [4], [7]. Overall, women living in rural areas have a 65% higher maternal mortality rate as compared to women living in large urban areas in the US [9].

Despite these rural-urban disparities, no prior study has examined the difference in hypertensive or cardiovascular sequelae of HDP between rural and urban women in the first year postpartum. Therefore, our objective was to estimate the risk of having an acute care encounter related to hypertension or cardiovascular conditions in the first year postpartum and receipt of outpatient postpartum antihypertensive medications, separately. We used public and private medical and pharmacy claims data from Maine, which is the US state with the largest percentage of residents living in a rural area [10].

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