Hypertensive Disorders in Pregnancy and Mortality at Delivery Hospitalization — United States, 2017–2019

Hypertensive disorders in pregnancy (HDPs), defined as prepregnancy (chronic) or pregnancy-associated hypertension, are common pregnancy complications in the United States.* HDPs are strongly associated with severe maternal complications, such as heart attack and stroke (1), and are a leading cause of pregnancy-related death in the United States.† CDC analyzed nationally representative data from the National Inpatient Sample to calculate the annual prevalence of HDP among delivery hospitalizations and by maternal characteristics, and the percentage of in-hospital deaths with an HDP diagnosis code documented. During 2017-2019, the prevalence of HDP among delivery hospitalizations increased from 13.3% to 15.9%. The prevalence of pregnancy-associated hypertension increased from 10.8% in 2017 to 13.0% in 2019, while the prevalence of chronic hypertension increased from 2.0% to 2.3%. Prevalence of HDP was highest among delivery hospitalizations of non-Hispanic Black or African American (Black) women, non-Hispanic American Indian and Alaska Native (AI/AN) women, and women aged ≥35 years, residing in zip codes in the lowest median household income quartile, or delivering in hospitals in the South or the Midwest Census regions. Among deaths that occurred during delivery hospitalization, 31.6% had any HDP documented. Clinical guidance for reducing complications from HDP focuses on prompt identification and preventing progression to severe maternal complications through timely treatment (1). Recommendations for identifying and monitoring pregnant persons with hypertension include measuring blood pressure throughout pregnancy,§ including self-monitoring. Severe complications and mortality from HDP are preventable with equitable implementation of strategies to identify and monitor persons with HDP (1) and quality improvement initiatives to improve prompt treatment and increase awareness of urgent maternal warning signs (2).

Delivery hospitalization data for 2017-2019 were analyzed from the National Inpatient Sample, a nationally representative sample of all U.S. hospital discharges.¶ CDC identified delivery hospitalizations among females aged 12-55 years using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis and procedure codes pertaining to delivery and diagnosis-related group delivery codes.** HDPs were categorized using ICD-10-CM diagnosis codes†† for chronic hypertension,§§ pregnancy-associated hypertension,¶¶ and unspecified maternal hypertension. Deaths were identified based on patient hospital discharge disposition.

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Weighted annual prevalence (percentage) and 95% CI for HDP overall and by each type were calculated. Change in annual prevalence of HDP overall and by type was assessed using a linear trend test. Pooling data from this period, CDC calculated the weighted prevalence and 95% CIs for HDP by selected maternal characteristics (i.e., age group, race and ethnicity, and primary payer at delivery hospitalization) and characteristics of the community in which they lived (i.e., county-level rural-urban classification, zip code-level median household income, and hospital region).*** Rao-Scott chi-square tests of independence were used to assess whether HDP prevalence differed by characteristics. Percentage of deaths during delivery hospitalization with a documented HDP diagnosis code were calculated. All analyses were conducted using SAS software (version 9.4; SAS Institute); SAS survey procedures and weighting were used to account for complex sampling in the National Inpatient Sample. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.†††

During 2017-2019, the prevalence of HDP among delivery hospitalizations increased from 13.3% to 15.9% (Figure 1), an increase of approximately 1 percentage point annually. Linear trend tests suggested that change in annual prevalence of HDP overall, pregnancy-associated hypertension, and chronic hypertension increased during 2017-2019, while prevalence of unspecified maternal hypertension remained stable. The prevalence of pregnancy-associated hypertension increased from 10.8% to 13.0% and that of chronic hypertension increased from 2.0% to 2.3%.

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During 2017-2019 combined, prevalence of HDP overall was 14.6%. Prevalence varied overall and by HDP type for all maternal characteristics evaluated in the study (Table). Prevalence of any HDP was higher among delivery hospitalizations to women aged 35-44 (18.0%) and 45-55 years (31.0%) than to younger women, to Black (20.9%) and AI/AN (16.4%) women than to women of other racial and ethnic groups, to those residing in rural counties (15.5%) and in zip codes in the lowest median household-level income quartile (16.4%) than those residing in metropolitan or micropolitan counties or in zip codes in higher household-level income quartiles, or delivering in hospitals in the South (15.9%) or Midwest (15.0%) U.S. Census regions than in other Census regions. These differences in HDP prevalence were similar across HDP types.

Among maternal deaths that occurred during delivery hospitalization, 31.6% had any HDP documented and 24.3% had pregnancy-associated hypertension documented. Chronic or unspecified maternal hypertension was documented in 7.4% of deaths §§§ (Figure 2).

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