MATERNAL HYPERTENSION

DRIVING DISPARITIES IN BALTIMORE CITY

In Baltimore, maternal hypertension is the leading driver of the Black-white disparity in fetal and infant mortality, making it one of the most significant health factors associated with maternal loss.

In 2022, the Baltimore City Health Department conducted an analysis to assess key drivers of the Black-white racial disparity in fetal and infant mortality in Baltimore City. BCHD selected an analytical approach developed by a CDC-supported national working group, known as the Perinatal Periods of Risk (PPOR) analysis, to improve local maternal and child health data and assessment capacity, particularly in cities with high infant mortality rates. Staff worked with five years of Baltimore City birth and death data, and took care to frame the analysis and findings within the larger influence of systemic/structural racism.

The PPOR analysis found that maternal health contributed to over half (54%) of the racial disparity in Baltimore City. The main drivers of higher than expected infant death between pregnancy and the end of the postpartum year were identified as: hypertension (chronic and gestational) and previous preterm birth.

IMPACTS OF MATERNAL HYPERTENSION

Maternal hypertension during pregnancy is common, and its outcomes can be severe.

For the fetus/infant, effects can include fetal growth restriction or low birth weight, indicated preterm delivery, placental abruption, and fetal death.
For the mother, effects can include the many significant outcomes of preeclampsia, including eclampsia or seizure, pulmonary edema, stroke, cardiovascular disease, and maternal death.

Literature shows that chronic stress and beginning pregnancy with an underlying chronic disease can increase the risk of poor birth outcomes. For Black women, higher rates of stress and underlying disease can often be linked back to the effects of structural racism on their bodies. This has been demonstrated in many studies including early work developed by Arline Geronimus showing how these effects — which she called "weathering" — can lead to poorer outcomes. Baltimore City’s Perinatal Periods of Risk (PPOR) analysis illustrates these same patterns locally.

Better Outcomes

All patients require close observation for signs of hypertension and related disorders, and appropriate management following guidelines from the American College of Obstetricians and Gynecologists. High-quality care, clear communication, and removing implicit bias also help mitigate these risks and improve outcomes.

Moms with poor pregnancy outcomes driven by maternal hypertension, including loss of a baby, often experienced significant gaps in the quality of care throughout their pregnancy. Actions to improve outcomes can include:

Beginning low-dose aspirin to prevent preeclampsia
Assessing signs and symptoms of gestational hypertension and preeclampsia for each patient
Coordinating care between emergency providers and obstetric providers

The gaps were sometimes the result of dismissal of or lack of follow-up for patients' complaints, and some patients perceived this treatment as the result of racial bias.

In Baltimore City, care coordination can help support your patients. It is vital to use the Prenatal Risk Assessment (PRA) at a pregnant patient’s first visit — or whenever you have a concern.

Additional resources to support your clinical practice and patients:

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