Racism and Postpartum Blood Pressure in a Multiethnic Prospective Cohort
Abstract
BACKGROUND:
Postpartum hypertension is a key factor in racial-ethnic inequities in maternal mortality. Emerging evidence suggests that experiences of racism, both structural and interpersonal, may contribute to disparities. We examined associations between gendered racial microaggressions (GRMs) during obstetric care with postpartum blood pressure (BP).
METHODS:
We conducted a prospective postpartum cohort of 373 Asian, Black, and Hispanic people in New York City and Philadelphia. At delivery, we administered the GRM in obstetrics scale. We measured BP for 3 months using text-based monitoring. We estimated place-based structural racism with the Structural Racism Effect Index. We used mixed models to estimate associations between GRM and mean postpartum systolic BP and diastolic BP. We adjusted for race-ethnicity, education, body mass index, chronic hypertension (diagnosed at <20 weeks of gestation), age, and the Structural Racism Effect Index. We examined effect modification by hypertensive disorder of pregnancy and place-based structural racism.
RESULTS:
A total of 4.6% of participants had chronic hypertension, 20.9% had pregnancy hypertension, and 13.4% had preeclampsia, comprising a hypertensive disorder of pregnancy subgroup (n=117). A total of 37.5% of participants experienced ≥1 GRM. Participants who experienced ≥1 GRM versus none had 1.88 mm Hg higher systolic BP from days 1 to 10 (95% CI, −0.19 to 3.95) and 2.19 mm Hg higher systolic BP from days 11 to 85 (95% CI, 0.17–4.22). Associations followed a similar pattern for diastolic BP and were stronger among the hypertensive disorder of pregnancy subgroup. Participants experiencing GRM and a high Structural Racism Effect Index had systolic BP 7.55 mm Hg (95% CI, 3.41–11.69) and diastolic BP 6.03 mm Hg (95% CI, 2.66–9.41) higher than those with neither.
CONCLUSIONS:
Structural racism and interpersonal racism are associated with increased postpartum BP, potentially contributing to inequities in postpartum morbidity and mortality and lifecourse cardiovascular disease.
Graphical Abstract
Get full access to this article
View all available purchase options and get full access to this article.
Supplemental Material
References
1.
Ananth CV, Brandt JS, Hill J, Graham HL, Grover S, Schuster M, Patrick HS, Joseph KS. Historical and recent changes in maternal mortality due to hypertensive disorders in the United States, 1979 to 2018. Hypertension. 2021;78:1414–1422. doi: 10.1161/HYPERTENSIONAHA.121.17661
2.
Hoyert DL. Maternal mortality rates in the United States, 2022. 2024.
3.
Hoyert DL. Maternal mortality rates in the United States, 2021. National Center for Health Statistics; 2023. https://stacks.cdc.gov/view/cdc/124678. doi: 10.15620/cdc:124678
4.
Karaye IM, Nasir R, Infante O, Ali H, Tiwari O, Marium A, Hackett M. Racial, age, and regional disparities in maternal mortality in the USA, 1999–2020. J Racial Ethn Health Disparities. 2023;11:2265–2270. doi: 10.1007/s40615-023-01694-3
5.
Angley M, Clark C, Howland R, Searing H, Wilcox W, Won SH Severe Maternal Morbidity in New York City, 2008–2012. New York City Department of Health and Mental Hygiene; 2016.
6.
Minhas AS, Ogunwole SM, Vaught AJ, Wu P, Mamas MA, Gulati M, Zhao D, Hays AG, Michos ED. Racial disparities in cardiovascular complications with pregnancy-induced hypertension in the United States. Hypertension. 2021;78:480–488. doi: 10.1161/HYPERTENSIONAHA.121.17104
7.
Trost S, Beauregard J, Chandra G, Njie F, Berry J, Harvey A, Goodman DA. Pregnancy-related deaths: data from maternal mortality review committees in 36 US States, 2017–2019. CDC. 2022. https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc.html
8.
Ananth CV, Brandt JS, Hill J, Graham HL, Grover S, Schuster M, Patrick HS, Joseph KS. Historical and recent changes in maternal mortality due to hypertensive disorders in the United States, 1979 to 2018. Hypertension. 2021;78:1414–1422. doi: 10.1161/HYPERTENSIONAHA.121.17661
9.
Goel A, Maski MR, Bajracharya S, Wenger JB, Zhang D, Salahuddin S, Shahul SS, Thadhani R, Seely EW, Karumanchi SA, et al. Epidemiology and mechanisms of de novo and persistent hypertension in the postpartum period. Circulation. 2015;132:1726–1733. doi: 10.1161/circulationaha.115.015721
10.
Elgendy IY, Bukhari S, Barakat AF, Pepine CJ, Lindley KJ, Miller EC; American College of Cardiology Cardiovascular Disease in Women Committee. Maternal stroke: a call for action. Circulation. 2021;143:727–738. doi: 10.1161/CIRCULATIONAHA.120.051460
11.
Lewey J, Beckie TM, Brown HL, Brown SD, Garovic VD, Khan SS, Miller EC, Sharma G, Mehta LS; on behalf of the American Heart Association Cardiovascular Disease and Stroke in Women and Underrepresented Populations Committee of the Council on Clinical Cardiology; Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; and Council on Cardiovascular and Stroke Nursing. 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. doi: 10.1161/CIR.0000000000001212
12.
Khosla K, Heimberger S, Nieman KM, Tung A, Shahul S, Staff AC, Rana S. Long-term cardiovascular disease risk in women after hypertensive disorders of pregnancy: recent advances in hypertension. Hypertension. 2021;78:927–935. doi: 10.1161/hypertensionaha.121.16506
13.
Stuart JJ, Tanz LJ, Missmer SA, Rimm EB, Spiegelman D, James-Todd TM, Rich-Edwards JW. Hypertensive disorders of pregnancy and maternal cardiovascular disease risk factor development. Ann Intern Med. 2018;169:224–232. doi: 10.7326/M17-2740
14.
Crear-Perry J, Correa-de-Araujo R, Lewis Johnson T, McLemore MR, Neilson E, Wallace M. Social and structural determinants of health inequities in maternal health. J Womens Health. 2021;30:230–235. doi: 10.1089/jwh.2020.8882
15.
Francis B, Bosah C, Plaisime MV, Ford TN, Keene D, Ray N, Sealy-Jefferson S. A conceptual understanding of the impact of interconnected forms of racism on maternal hypertension through Black women’s lived experiences. SSM Qual Res Health. 2023;4:100329. doi: 10.1016/j.ssmqr.2023.100329
16.
Jones CP. Levels of racism: a theoretic framework and a gardener’s tale. Am J Public Health. 2000;90:1212–1215. doi: 10.2105/ajph.90.8.1212
17.
Lewis JA, Neville HA. Construction and initial validation of the Gendered Racial Microaggressions Scale for Black women. J Couns Psychol. 2015;62:289–302. doi: 10.1037/cou0000062
18.
Sue DW, Capodilupo CM, Torino GC, Bucceri JM, Holder AMB, Nadal KL, Esquilin M. Racial microaggressions in everyday life: implications for clinical practice. Am Psychol. 2007;62:271–286. doi: 10.1037/0003-066X.62.4.271
19.
Gee GC, Ford CL. Structural racism and health inequities: old issues, new directions. Du Bois Rev. 2011;8:115–132. doi: 10.1017/s1742058x11000130
20.
Ford CL, Airhihenbuwa CO. Critical race theory, race equity, and public health: toward antiracism praxis. Am J Public Health. 2010;100:S30–S35. doi: 10.2105/AJPH.2009.171058
21.
Gravlee CC. How race becomes biology: embodiment of social inequality. Am J Phys Anthropol. 2009;139:47–57. doi: 10.1002/ajpa.20983
22.
Krieger N. Embodiment: a conceptual glossary for epidemiology. J Epidemiol Community Health. 2005;59:350–355. doi: 10.1136/jech.2004.024562
23.
Brondolo E, Love EE, Pencille M, Schoenthaler A, Ogedegbe G. Racism and hypertension: a review of the empirical evidence and implications for clinical practice. Am J Hypertens. 2011;24:518–529. doi: 10.1038/ajh.2011.9
24.
Forde AT, Lewis TT, Kershaw KN, Bellamy SL, Diez Roux AV. Perceived discrimination and hypertension risk among participants in the multi-ethnic study of atherosclerosis. J Am Heart Assoc. 2021;10:e019541. doi: 10.1161/JAHA.120.019541
25.
Lee K, Pellowski JA, Brayboy LM, Thompson KD, Dunsiger S. The association of racism and discrimination in disparities of hypertensive disorders of pregnancy in the United States: an analysis of PRAMS data. Matern Child Health J. 2024;28:969–978. doi: 10.1007/s10995-023-03885-0
26.
Francis B, Pearl M, Colen C, Shoben A, Sealy-Jefferson S. Racial and economic segregation over the life course and incident hypertensive disorders of pregnancy among black women in California. Am J Epidemiol. 2024;193:277–284. doi: 10.1093/aje/kwad192
27.
Hilmert CJ, Dominguez TP, Schetter CD, Srinivas SK, Glynn LM, Hobel CJ, Sandman CA. Lifetime racism and blood pressure changes during pregnancy: implications for fetal growth. Health Psychol. 2014;33:43–51. doi: 10.1037/a0031160
28.
Gee GC, Spencer MS, Chen J, Takeuchi D. A nationwide study of discrimination and chronic health conditions among Asian Americans. Am J Public Health. 2007;97:1275–1282. doi: 10.2105/AJPH.2006.091827
29.
LeBrón AMW, Schulz AJ, Mentz G, Reyes AG, Gamboa C, Israel BA, Viruell-Fuentes EA, House JS. Impact of change over time in self-reported discrimination on blood pressure: implications for inequities in cardiovascular risk for a multi-racial urban community: ethnicity & health. Ethn Health. 2020;25:323–341. doi: 10.1080/13557858.2018.1425378
30.
Nadimpalli SB, Dulin-keita A, Salas C, Kanaya AM, Kandula NR. Associations between discrimination and cardiovascular health among Asian Indians in the United States. J Immigr Minor Health. 2016;18:1284–1291. doi: 10.1007/s10903-016-0413-3
31.
Parker SE, Ajayi A, Yarrington CD. De novo postpartum hypertension: incidence and risk factors at a safety-net hospital. Hypertension. 2022;80:279–287. doi: 10.1161/hypertensionaha.122.19275
32.
Asch DA, Volpp KG. On the way to health. LDI Issue Brief. 2012;17:1–4.
33.
Lopes Perdigao J, Lewey J, Hirshberg A, Koelper N, Srinivas SK, Elovitz MA, Levine LD. Furosemide for accelerated recovery of blood pressure postpartum in women with a hypertensive disorder of pregnancy. Hypertension. 2021;77:1517–1524. doi: 10.1161/HYPERTENSIONAHA.120.16133
34.
Parker RA, Paterson M, Padfield P, Pinnock H, Hanley J, Hammersley VS, Steventon A, McKinstry B. Are self-reported telemonitored blood pressure readings affected by end-digit preference: a prospective cohort study in Scotland. BMJ Open. 2018;8:e019431. doi: 10.1136/bmjopen-2017-019431
35.
Howell FM, McCarthy KJ, Boychuk N, Burdick M, Nowlin S, Maru S, Oshewa O, Monterroso M, Rodriguez A, Katzenstein C, et al. Racism in obstetric care: a psychometric study of the Gendered Racial Microaggressions Scale among global majority birthing people in obstetric contexts. BMC Pregnancy Childbirth. 2024;24:448. doi: 10.1186/s12884-024-06642-5
36.
Dyer Z, Alcusky MJ, Galea S, Ash A. Measuring the enduring imprint of structural racism on American neighborhoods. Health Aff (Millwood). 2023;42:1374–1382. doi: 10.1377/hlthaff.2023.00659
37.
Structural Racism Effect Index. Background. https://www.sreindex.com/background
38.
Espinoza J. Gestational hypertension and preeclampsia: ACOG practice bulletin, number 222. Obstet Gynecol. 2020;135:e237–e260. doi: 10.1097/AOG.0000000000003891
39.
Harawa NT, Ford CL. The foundation of modern racial categories and implications for research on black/white disparities in health. Ethn Dis. 2009;19:209–217.
40.
Ford C, Harawa NT. A new conceptualization of ethnicity for social epidemiologic and health equity research. Soc Sci Med. 2010;71:251–258. doi: 10.1016/j.socscimed.2010.04.008
41.
Barnett AG, Koper N, Dobson AJ, Schmiegelow F, Manseau M. Using information criteria to select the correct variance–covariance structure for longitudinal data in ecology. Methods Ecol Evol. 2010;1:15–24. doi: 10.1111/j.2041-210x.2009.00009.x
42.
Lopes Perdigao J, Hirshberg A, Koelper N, Srinivas SK, Sammel MD, Levine LD. Postpartum blood pressure trends are impacted by race and BMI. Pregnancy Hypertens. 2020;20:14–18. doi: 10.1016/j.preghy.2020.02.006
43.
Altman MR, McLemore MR, Oseguera T, Lyndon A, Franck LS. Listening to women: recommendations from women of color to improve experiences in pregnancy and birth care. J Midwifery Womens Health. 2020;65:466–473. doi: 10.1111/jmwh.13102
44.
Altman MR, Oseguera T, McLemore MR, Kantrowitz-Gordon I, Franck LS, Lyndon A. Information and power: women of color’s experiences interacting with health care providers in pregnancy and birth. Soc Sci Med. 2019;238:112491–112491. doi: 10.1016/j.socscimed.2019.112491
45.
McLemore MR, Altman MR, Cooper N, Williams S, Rand L, Franck L. Health care experiences of pregnant, birthing and postnatal women of color at risk for preterm birth. Soc Sci Med. 2018;201:127–135. doi: 10.1016/j.socscimed.2018.02.013
46.
Janevic T, Piverger N, Afzal O, Howell EA. “Just because you have ears doesn’t mean you can hear”–perception of racial-ethnic discrimination during childbirth. Ethn Dis. 2020;30:533–542. doi: 10.18865/ed.30.4.533
47.
Harrell T, Howell E, Balbierz A, Guel L, Pena A, Janevic T, Gorbenko K. Improving postpartum care: identifying opportunities to reduce postpartum emergency room visits among publicly-insured women of color. Matern Child Health J. 2022;26:913–922. doi: 10.1007/s10995-021-03282-5
48.
Dmowska A, Fielding‐Singh P, Halpern J, Prata N. The intersection of traumatic childbirth and obstetric racism: a qualitative study. Birth. 2023;51:209–217. doi: 10.1111/birt.12774
49.
Akinade T, Kheyfets A, Piverger N, Layne TM, Howell EA, Janevic T. The influence of racial-ethnic discrimination on women’s health care outcomes: a mixed methods systematic review. Soc Sci Med. 2023;316:114983. doi: 10.1016/j.socscimed.2022.114983
50.
Janevic T, Maru S, Nowlin S, McCarthy K, Bergink V, Stone J, Dias J, Wu S, Howell EA. Pandemic birthing: childbirth satisfaction, perceived health care bias, and postpartum health during the COVID-19 pandemic. Matern Child Health J. 2021;25:860–869. doi: 10.1007/s10995-021-03158-8
51.
Attanasio L, Kozhimannil KB. Health care engagement and follow-up after perceived discrimination in maternity care. Med Care. 2017;55:830–833. doi: 10.1097/MLR.0000000000000773
52.
Ogunwole SM, Oguntade HA, Bower KM, Cooper LA, Bennett WL. Health experiences of African American mothers, wellness in the postpartum period and beyond (HEAL): a qualitative study applying a critical race feminist theoretical framework. Int J Environ Res Public Health. 2023;20:6283. doi: 10.3390/ijerph20136283
53.
Chambers BD, Arega HA, Arabia SE, Taylor B, Barron RG, Gates B, Scruggs-Leach L, Scott KA, McLemore MR. Black women’s perspectives on structural racism across the reproductive lifespan: a conceptual framework for measurement development. Matern Child Health J. 2021;25:402–413. doi: 10.1007/s10995-020-03074-3
54.
Janevic T, Zeitlin J, Egorova N, Hebert PL, Balbierz A, Howell EA. Neighborhood racial and economic polarization, hospital of delivery, and severe maternal morbidity. Health Aff. 2020;39:768–776. doi: 10.1377/hlthaff.2019.00735
55.
Hailu EM, Riddell CA, Bradshaw PT, Ahern J, Carmichael SL, Mujahid MS. Structural racism, mass incarceration, and racial and ethnic disparities in severe maternal morbidity. JAMA Netw Open. 2024;7:e2353626. doi: 10.1001/jamanetworkopen.2023.53626
56.
Cantor AG, Jungbauer RM, Skelly AC, Hart EL, Jorda K, Davis-O’Reilly C, Caughey AB, Tilden EL. Respectful maternity care. Ann Intern Med. 2024;177:50–64. doi: 10.7326/M23-2676
57.
Osborne MT, Shin LM, Mehta NN, Pitman RK, Fayad ZA, Tawakol A. Disentangling the links between psychosocial stress and cardiovascular disease. Circ Cardiovasc Imaging. 2020;13:e010931. doi: 10.1161/CIRCIMAGING.120.010931
58.
Caplan M, Keenan-Devlin LS, Freedman A, Grobman W, Wadhwa PD, Buss C, Miller GE, Borders AEB. Lifetime psychosocial stress exposure associated with hypertensive disorders of pregnancy. Am J Perinatol. 2021;38:1412–1419. doi: 10.1055/s-0040-1713368
59.
Riley LE, Pardo C. Maternal health equity and respectful maternity care. Ann Intern Med. 2024;177:91–92. doi: 10.7326/M23-3186
60.
Representative Lauren Underwood. H.R.959 - Black Maternal Health Momnibus Act of 2021. 2021.
61.
Garrett SB, Walia A, Miller F, Tahir P, Jones L, Harris J, Powell B, Chambers B, Simon MA. Antibias efforts in U.S. maternity care: a scoping review of the publicly-funded health equity intervention pipeline. Clin Obstet Gynecol. 2023;66:110–123. doi: 10.1097/GRF.0000000000000761
62.
Bowleg L. The problem with the phrase women and minorities: intersectionality-an important theoretical framework for public health. Am J Public Health. 2012;102:1267–1273. doi: 10.2105/AJPH.2012.300750
63.
Luo D, Cheng Y, Zhang H, Ba M, Chen P, Li H, Chen K, Sha W, Zhang C, Chen H. Association between high blood pressure and long term cardiovascular events in young adults: systematic review and meta-analysis. BMJ. 2020;370:m3222. doi: 10.1136/bmj.m3222
64.
Allen N, Berry JD, Ning H, Van Horn L, Dyer A, Lloyd-Jones DM. Impact of blood pressure and blood pressure change during middle age on the remaining lifetime risk for cardiovascular disease. Circulation. 2012;125:37–44. doi: 10.1161/CIRCULATIONAHA.110.002774
65.
Nuotio J, Suvila K, Cheng S, Langén V, Niiranen T. Longitudinal blood pressure patterns and cardiovascular disease risk. Ann Med. 2020;52:43–54. doi: 10.1080/07853890.2020.1733648
66.
Ji H, Kim A, Ebinger JE, Niiranen TJ, Claggett BL, Bairey Merz CN, Cheng S. Sex differences in blood pressure trajectories over the life course. JAMA Cardiol. 2020;5:255–262. doi: 10.1001/jamacardio.2019.5306
67.
Geronimus AT. Understanding and eliminating racial inequalities in women’s health in the United States: the role of the weathering conceptual framework. J Am Med Wom Assoc. 2001;56:133-6, 149–150.
Information & Authors
Information
Published In
Copyright
© 2025 American Heart Association, Inc.
Versions
You are viewing the most recent version of this article.
History
Received: 31 July 2024
Accepted: 9 October 2024
Published online: 9 January 2025
Published in print: February 2025
Keywords
Subjects
Authors
Disclosures
None.
Sources of Funding
This study was funded by the National Institutes of Health/National Institute on Minority Health and Health Disparities grant 1R01MD016029-02SI. The funder had no role in the conduct or reporting of the research.
Metrics & Citations
Metrics
Citations
Download Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Select your manager software from the list below and click Download.
View Options
Login options
Check if you have access through your login credentials or your institution to get full access on this article.
Personal login Institutional LoginPurchase Options
Purchase this article to access the full text.
eLetters(0)
eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.
Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.