Examining the Role of Racial and Neighborhood Context in Hypertensive Disorders of Pregnancy: A Multilevel Analysis

PURPOSE: Use administrative patient discharge data from 2018-2020 to examine the independent and potentially interactive associations of patient race and area-level indices of the social vulnerability metric with hypertensive disorders of pregnancy. STUDY DESIGN & METHODS: This retrospective cross-sectional study used administrative discharge records from 198,507 patients who had live births in Illinois over a 3-year period and linked it with the Center for Disease Control (CDC) Social Vulnerability Index (SVI) scores at the zip code level. Multilevel analyses examined patient race after controlling for other patient-level characteristics, and both the total and theme scores of the SVI as predictors of hypertensive disorders of pregnancy; as well as determining the interactions of patient race with both the total and theme SVI scores. RESULTS: Among the 198,507 administrative discharge records, Black women were more likely to have a HDP diagnosis compared to White women residing within the same zip code area (adjusted odds ratio [OR] = 1.12, 95%CI: 1.07, 1.18). Total SVI score (OR = 1.15, 95%CI: 1.05, 1.25). Controlling for other theme scores, the Socioeconomic Status theme score was associated with a greater likelihood of HDP diagnosis; whereas the Minority Status & Language score was associated with a lower likelihood of HDP diagnosis (OR = 0.83, 95%CI: 0.74, 0.92). The SVI theme score for Minority Status & Language significantly interacted with patient race in predicting HDP diagnosis. Specifically, the disparity in HDP diagnosis between Black and White women was more prominent at higher levels of this SVI score. At elevated Minority Status & Language vulnerability, Black women had a significantly greater likelihood of HDP diagnosis compared to White women (OR = 1.27; 95% CI: 1.12-1.44). CONCLUSION: Neighborhood environments inundated with poor social conditions-including structural racism, poverty, residential segregation, systemic bias, and language/communication barriers with providers may significantly increase a person susceptibility to adverse health outcomes. Black women living in socially vulnerable communities face increased risk for HDP, reflecting the compounded effects of these structural inequities. To address the multifaceted social and economic drivers of poor maternal health outcomes, policy reforms are urgently needed at both the federal and state levels. These reforms should include culturally responsive care coordination, expansion of Healthy Food Access programs, and the enactment of maternal health legislation that centers equity and community engagement.