Pre-Pregnancy Hypertension Among Women in Rural and Urban Areas of the United States

Natalie A. Cameron, Rebecca Molsberry, Jacob B. Pierce, Amanda M. Perak, William A. Grobman, Norrina B. Allen, Philip Greenland, Donald M. Lloyd-Jones, Sadiya S. Khan*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Background: Rates of maternal mortality are increasing in the United States with significant rural-urban disparities. Pre-pregnancy hypertension is a well-established risk factor for adverse maternal and offspring outcomes. Objectives: The purpose of this study was to describe trends in maternal pre-pregnancy hypertension among women in rural and urban areas in 2007 to 2018 in order to inform community-engaged prevention and policy strategies. Methods: We performed a nationwide, serial cross-sectional study using maternal data from all live births in women age 15 to 44 years between 2007 and 2018 (CDC Natality Database). Rates of pre-pregnancy hypertension were calculated per 1,000 live births overall and by urbanization status. Subgroup analysis in standard 5-year age categories was performed. We quantified average annual percentage change using Joinpoint Regression and rate ratios (95% confidence intervals [CIs]) to compare yearly rates between rural and urban areas. Results: Among 47,949,381 live births to women between 2007 and 2018, rates of pre-pregnancy hypertension per 1,000 live births increased among both rural (13.7 to 23.7) and urban women (10.5 to 20.0). Two significant inflection points were identified in 2010 and 2016, with highest annual percentage changes between 2016 and 2018 in rural and urban areas. Although absolute rates were lower in younger compared with older women in both rural and urban areas, all age groups experienced similar increases. The rate ratios of pre-pregnancy hypertension in rural compared with urban women ranged from 1.18 (95% CI: 1.04 to 1.35) for ages 15 to 19 years to 1.51 (95% CI: 1.39 to 1.64) for ages 40 to 44 years in 2018. Conclusions: Maternal burden of pre-pregnancy hypertension has nearly doubled in the past decade and the rural-urban gap has persisted.

Original languageEnglish (US)
Pages (from-to)2611-2619
Number of pages9
JournalJournal of the American College of Cardiology
Issue number22
StatePublished - Dec 1 2020


  • disparities
  • hypertension
  • maternal morbidity
  • race/ethnicity
  • rural

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

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