Association between Elevated Postnatal Blood Pressure and Postpartum Acute Care Utilization in a Southeastern U.S. Health Care System, 2021 to 2023

Clara E. Busse; Catherine J. Vladutiu; Brian W. Pence; Christine Tucker; Katherine Tumlinson; Alison M. Stuebe

doi:10.1055/a-2591-8090

American Journal of Perinatology, Table of Contents

Am J Perinatol
DOI: 10.1055/a-2591-8090

Original Article

Association between Elevated Postnatal Blood Pressure and Postpartum Acute Care Utilization in a Southeastern U.S. Health Care System, 2021 to 2023

Clara E. Busse

¹Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina

²Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina

,

Catherine J. Vladutiu

³Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina

,

Brian W. Pence

⁴Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina

,

Christine Tucker

¹Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina

,

Katherine Tumlinson

²Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina

⁵Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina

,

Alison M. Stuebe

¹Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina

³Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina

› Author Affiliations

Abstract

Objective

Hypertensive disorders of pregnancy are a leading cause of pregnancy-related deaths in the United States and approximately 70% occur after birth. We estimated the crude and adjusted association between elevated postnatal blood pressure (BP) and acute care utilization (visits to the Emergency Department, obstetric triage, urgent care facility, or hospital readmission) in the first 12 weeks after discharge from the birth hospitalization.

Study Design

We constructed a retrospective cohort of birthing people aged ≥18 years who gave birth to ≥1 liveborn infant at >20 weeks of gestation from July 1, 2021, to December 31, 2022, at a quaternary maternity hospital in the Southeastern United States using electronic health records. Elevated BP was defined as ≥3 values of systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg between birth and discharge from the birth hospitalization. Crude and adjusted multivariable binomial regression models estimated risk differences comparing the 12-week risk of the postpartum acute care utilization (PACU) outcomes among birthing people with elevated postnatal BP to those without.

Results

In this cohort of 6,041 birthing people, 13.3% (n = 804) had any PACU within 12 weeks of discharge from the birth hospitalization. The unadjusted 12-week risk of PACU was 6.5 percentage points higher among those with elevated postnatal BP compared to those without (95% confidence interval [CI]: 4.7 and 8.4). After adjusting for potential confounders, the 12-week risk of PACU was 6.0 percentage points higher among those with elevated postnatal BP compared to those without (95% CI: 4.2 and 7.8).

Conclusion

Postnatal BP is a simple indicator of postpartum health status that may be used to flag individuals in need of more intensive postpartum counseling and follow-up.

Key Points

Elevated postnatal BP is associated with postpartum acute care use.
People used acute care for BP-related reasons and reasons not related to BP.
Tracking postnatal BPs may be a simple way to find people who need extra support.

Keywords

blood pressure - hypertension - acute care - emergency department - hospital readmission - obstetric triage - postpartum - maternal health

Full Text

References

References
1 Ford ND, Cox S, Ko JY. et al. Hypertensive disorders in pregnancy and mortality at delivery hospitalization - United States, 2017-2019. MMWR Morb Mortal Wkly Rep 2022; 71 (17) 585-591
2 Brown MA, Magee LA, Kenny LC. et al; International Society for the Study of Hypertension in Pregnancy (ISSHP). Hypertensive disorders of pregnancy: ISSHP classification, diagnosis, and management recommendations for international practice. Hypertension 2018; 72 (01) 24-43
3 Trost SL, Beauregard J, Njie F. et al. Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US States, 2017–2019. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2022
4 Pregnancy Mortality Surveillance System. Accessed April 19, 2023 at: https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm
5 Bateman BT, Bansil P, Hernandez-Diaz S, Mhyre JM, Callaghan WM, Kuklina EV. Prevalence, trends, and outcomes of chronic hypertension: a nationwide sample of delivery admissions. Am J Obstet Gynecol 2012; 206 (02) 134.e1-134.e8
6 Behrens I, Basit S, Lykke JA. et al. Association between hypertensive disorders of pregnancy and later risk of cardiomyopathy. JAMA 2016; 315 (10) 1026-1033
7 Petersen EE, Davis NL, Goodman D. et al. Vital signs: pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013-2017. MMWR Morb Mortal Wkly Rep 2019; 68 (18) 423-429
8 Emeruwa UN, Gyamfi-Bannerman C, Wen T. et al. Adverse outcomes during postpartum readmissions after deliveries complicated by hypertensive disorders of pregnancy. Am J Perinatol 2022; 39 (07) 699-706
9 Wen T, Baer RJ, Oltman S. et al. Development of a risk prediction score for acute postpartum care utilization. J Matern Fetal Neonatal Med 2022; 35 (26) 10506-10513
10 Leonard SA, Kennedy CJ, Carmichael SL, Lyell DJ, Main EK. An expanded obstetric comorbidity scoring system for predicting severe maternal morbidity. Obstet Gynecol 2020; 136 (03) 440-449
11 Wagner JL, White RS, Tangel V, Gupta S, Pick JS. Socioeconomic, racial, and ethnic disparities in postpartum readmissions in patients with preeclampsia: a multi-state analysis, 2007-2014. J Racial Ethn Health Disparities 2019; 6 (04) 806-820
12 Wouk K, Morgan I, Johnson J. et al. A systematic review of patient-, provider-, and health system-level predictors of postpartum health care use by people of color and low-income and/or uninsured populations in the United States. J Womens Health (Larchmt) 2021; 30 (08) 1127-1159
13 Attanasio LB, Ranchoff BL, Cooper MI, Geissler KH. Postpartum visit attendance in the United States: a systematic review. Womens Health Issues 2022; 32 (04) 369-375
14 Clinical Clasifications Software Refined (CCSR). Healthcare Cost and Utilization Project. December 9, 2022. Accessed October 5, 2023 at: https://hcup-us.ahrq.gov/toolssoftware/ccsr/ccs_refined.jsp
15 American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Obstetrics. ACOG practice bulletin no. 203: chronic hypertension in pregnancy. Obstet Gynecol 2019; 133 (01) e26-e50
16 Preeclampsia and High Blood Pressure During Pregnancy. The American College of Obstetricians and Gynecologists. Accessed January 25, 2024 at: https://www.acog.org/womens-health/faqs/preeclampsia-and-high-blood-pressure-during-pregnancy?utm_source=redirect&utm_medium=web&utm_campaign=otn
17 Glymour MM, Greenland S. Causal Diagrams. In: Rothman KJ, Greenland S, Lash TL. eds. Modern Epidemiology Third Edition. Lippincott Williams & Wilkins; Philadelphia, PA: 2008: 183-209
18 Roth WD. The multiple dimensions of race. Ethn Racial Stud 2016; 39 (08) 1310-1338
19 Data from: 2010 Rural-Urban Commuting Area Codes (revised 7/3/2019). Accessed May 1, 2025 at: https://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes/
20 Whelton PK, Carey RM, Aronow WS. et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. Hypertension 2018; 71 (06) e13-e115
21 Stuart JJ, Tanz LJ, Missmer SA. et al. Hypertensive disorders of pregnancy and maternal cardiovascular disease risk factor development: an observational cohort study. Ann Intern Med 2018; 169 (04) 224-232
22 Garovic VD, Bailey KR, Boerwinkle E. et al. Hypertension in pregnancy as a risk factor for cardiovascular disease later in life. J Hypertens 2010; 28 (04) 826-833
23 Leon LJ, McCarthy FP, Direk K. et al. Preeclampsia and cardiovascular disease in a large UK pregnancy cohort of linked electronic health records: a caliber study. Circulation 2019; 140 (13) 1050-1060
24 Garovic VD, Dechend R, Easterling T. et al; American Heart Association Council on Hypertension; Council on the Kidney in Cardiovascular Disease, Kidney in Heart Disease Science Committee; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Lifestyle and Cardiometabolic Health; Council on Peripheral Vascular Disease; and Stroke Council. Hypertension in pregnancy: diagnosis, blood pressure goals, and pharmacotherapy: a scientific statement from the American Heart Association. Hypertension 2022; 79 (02) e21-e41
25 Hansen AL, Søndergaard MM, Hlatky MA. et al. Adverse pregnancy outcomes and incident heart failure in the women's health initiative. JAMA Netw Open 2021; 4 (12) e2138071
26 Haas DM, Parker CB, Marsh DJ. et al; NHLBI nuMoM2b Heart Health Study. Association of adverse pregnancy outcomes with hypertension 2 to 7 years postpartum. J Am Heart Assoc 2019; 8 (19) e013092
27 ACOG committee opinion no. 736: optimizing postpartum care. Obstet Gynecol 2018; 131 (05) e140-e150
28 Severe Hypertension in Pregnancy. Alliance for Innovation on Maternal Health. Accessed March 28, 2024 at: https://saferbirth.org/psbs/severe-hypertension-in-pregnancy/
29 Busse CE, Stuebe AM, Tumlinson K. et al. Birthing parent postpartum acute care use: Multilevel opportunities for strengthening healthcare. Birth 2024; 51 (04) 843-854
30 Lewey J, Beckie TM, Brown HL. et al; American Heart Association Cardiovascular Disease and Stroke in Women and Underrepresented Populations Committee of the Council on Clinical Cardiology; Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; and Council on Cardiovascular and Stroke Nursing. Opportunities in the postpartum period to reduce cardiovascular disease risk after adverse pregnancy outcomes: a scientific statement from the American Heart Association. Circulation 2024; 149 (07) e330-e346

Supplementary Material

Supplementary Material