Trends in prepregnancy cardiovascular health in the United States, 2011–2019

Abstract

Objective To evaluate contemporary patterns in prepregnancy cardiovascular health (CVH) in the United States (US). Methods We conducted a serial, cross-sectional study of National Center for Health Statistics Natality Data representing all live births in the US from 2011 to 2019. We assigned 1 point for each of four ideal prepregnancy metrics (nonsmoking and ideal body mass index [18.5–24.9 kg/m 2 ] provided by maternal self-report, and absence of hypertension and diabetes ascertained by the healthcare professional at delivery) to construct a prepregnancy clinical CVH score ranging from 0 to 4. We described the distribution of prepregnancy CVH, overall and stratified by self-reported race/ethnicity, age, insurance status, and receipt of the Women, Infants, and Children program (WIC) for supplemental nutrition. We examined trends by calculating average annual percent changes (AAPCs) in optimal prepregnancy CVH (score of 4). Results Of 31,643,982 live births analyzed between 2011 and 2019, 53.6% were to non-Hispanic White, 14.5% non-Hispanic Black, 23.3% Hispanic, and 6.6% non-Hispanic Asian women. The mean age (SD) was 28.5 (5.8) years. The prevalence (per 100 live births) of optimal prepregnancy CVH score of 4 declined from 42.1 to 37.7 from 2011 to 2019, with an AAPC (95% CI) of -1.4% per year (-1.3,-1.5). While the relative decline was observed across all race/ethnicity, insurance, and WIC subgroups, significant disparities persisted by race, insurance status, and receipt of WIC. In 2019, non-Hispanic Black women (28.7 per 100 live births), those on Medicaid (30.4), and those receiving WIC (29.1) had the lowest prevalence of optimal CVH. Conclusions Overall, less than half of pregnant women had optimal prepregnancy CVH, and optimal prepregnancy CVH declined in each race/ethnicity, age, insurance, and WIC subgroup between 2011-2019 in the US. However, there were persistent disparities by race/ethnicity and socioeconomic status.

Optimizing Prepregnancy Cardiovascular Health to Improve Outcomes in Pregnant and Postpartum Individuals and Offspring: A Scientific Statement From the American Heart Association

“…Fewer than half of birthing individuals have favorable prepregnancy CVH (using an abbreviated CVH defined as absence of obesity, hypertension, diabetes, and smoking). 23 Furthermore, prepregnancy CVH declined between 2011 and 2019 in all subgroups (race and ethnicity, geography, and socioeconomic status); lower CVH persisted among non-Hispanic Black females, pregnant individuals living in the South and Midwest United States, and those with Medicaid insurance during pregnancy. 23,24 With regard to specific factors, <50% of birthing individuals in 2018 had a normal prepregnancy body mass index (18.5–24.9 kg/m 2 ).…”

“…23 Furthermore, prepregnancy CVH declined between 2011 and 2019 in all subgroups (race and ethnicity, geography, and socioeconomic status); lower CVH persisted among non-Hispanic Black females, pregnant individuals living in the South and Midwest United States, and those with Medicaid insurance during pregnancy. 23,24 With regard to specific factors, <50% of birthing individuals in 2018 had a normal prepregnancy body mass index (18.5–24.9 kg/m 2 ). 25,26 Levels of CVH metrics are highly correlated between the prepregnancy period and pregnancy.…”

Association of Birth Year of Pregnant Individuals With Trends in Hypertensive Disorders of Pregnancy in the United States, 1995-2019

“…Poor cardiovascular health prior to pregnancy is an important risk factor for HDP, as well as other important outcomes, including severe morbidity of pregnant individuals, mortality of pregnant individuals, and cardiovascular health of offspring into adolescence. 19 , 20 , 21 , 22 , 23 , 24 In the Hyperglycemia and Adverse Pregnancy Outcome Study, pregnant individuals with poor cardiovascular health at a mean gestational age of 28 weeks were more than 9 times more likely than those with ideal cardiovascular health to develop preeclampsia. 24 A recent report from the NVSS highlighted the decline in preconception health among pregnant individuals, with the overall percentage of individuals in the US entering pregnancy with favorable cardiovascular health decreasing from 42.1% to 37.7% between 2011 and 2019.…”

“… 24 A recent report from the NVSS highlighted the decline in preconception health among pregnant individuals, with the overall percentage of individuals in the US entering pregnancy with favorable cardiovascular health decreasing from 42.1% to 37.7% between 2011 and 2019. 20 Among the components of cardiovascular health, obesity has had the largest increase in prevalence from 6.2% in the 1976-1980 period to 32.7% in the 2017-2018 period. 25 The population-attributable fraction for HDP associated with obesity is estimated to be between 25% and 30% and has not changed significantly between 2011 and 2019, 21 which suggests that obesity may be only partially associated with trends in HDP.…”

“…Although our study is ecological and cannot identify factors associated with trends, increasing incidence of HDP among younger generations may reflect adverse trends in preconception health. Poor cardiovascular health prior to pregnancy is an important risk factor for HDP, as well as other important outcomes, including severe morbidity of pregnant individuals, mortality of pregnant individuals, and cardiovascular health of offspring into adolescence . In the Hyperglycemia and Adverse Pregnancy Outcome Study, pregnant individuals with poor cardiovascular health at a mean gestational age of 28 weeks were more than 9 times more likely than those with ideal cardiovascular health to develop preeclampsia .…”