Am J Perinatol 2019; 36(10): 1079-1089
DOI: 10.1055/s-0038-1675618
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Cardiovascular and Metabolic Risk in Women in the First Year Postpartum: Allostatic Load as a Function of Race, Ethnicity, and Poverty Status

Madeleine U. Shalowitz
1   Department of Pediatrics, NorthShore University HealthSystem Research Institute, Evanston, Illinois
2   Department of Pediatrics, University of Chicago Pritzker School of Medicine, Chicago, Illinois
Christine Dunkel Schetter
3   Department of Psychology, University College of Los Angeles, Los Angeles, California
Marianne M. Hillemeier
4   Department of Health Policy and Administration, Pennsylvania State University, University Park, Pennsylvania
Vernon M. Chinchilli
5   Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
Emma K. Adam
6   School of Human Development and Social Policy, Northwestern University, Evanston, Illinois
Calvin J. Hobel
7   Department of Obstetrics, Gynecology, and Pediatrics, Cedars-Sinai Hospital, Los Angeles, California
Sharon Landesman Ramey
8   Department of Psychology, Virginia Technical Carilion School of Medicine and Research Institute, Roanoke, Virginia
9   Department of Psychiatry, Virginia Technical Carilion School of Medicine and Research Institute, Roanoke, Virginia
Maxine Reed Vance
10   Baltimore Healthy Start, Baltimore, Maryland
Patricia O'Campo
11   Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
John M. Thorp Jr
12   Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
Teresa E. Seeman
13   Department of Internal Medicine, UCLA Geffen School of Medicine, Los Angeles, California
14   Department of Epidemiology, UCLA School of Public Health, Los Angeles, California
Tonse N. K. Raju
15   Branch of Perinatal Medicine and Neonatology, Eunice Kennedy Shriver National Institute of Child and Human Development, Bethesda, Maryland
Eunice Kennedy Shriver National Institute of Child Human Development Community Child Health Network › Author Affiliations
Funding The CCHN is supported through cooperative agreements with the NICHD (U HD44207, U HD44219, U HD44226, U HD44245, U HD44253, U HD54791, U HD54019, U HD44226–05S1, U HD44245–06S1, R03 HD59584) and the National Institute for Nursing Research (U NR008929).
Further Information

Publication History

01 August 2018

20 August 2018

Publication Date:
14 December 2018 (online)


Objective Allostatic load (AL) represents multisystem physiological “wear-and-tear” reflecting emerging chronic disease risk. We assessed AL during the first year postpartum in a diverse community sample with known health disparities.

Study Design The Eunice Kennedy Shriver National Institute for Child Health and Human Development Community Child Health Network enrolled 2,448 predominantly low-income African-American, Latina, and White women immediately after delivery of liveborn infants at ≥20 weeks' gestation, following them over time with interviews, clinical measures, and biomarkers. AL at 6 and 12 months postpartum was measured by body mass index, waist:hip ratio, blood pressure, pulse, hemoglobin A1c, high-sensitive C-reactive protein, total cholesterol and high-density lipoprotein, and diurnal cortisol slope.

Results Adverse AL health-risk profiles were significantly more prevalent among African-American women compared with non-Hispanic Whites, with Latinas intermediate. Breastfeeding was protective, particularly for White women. Complications of pregnancy were associated with higher AL, and disparities persisted or worsened through the first year postpartum.

Conclusion Adverse AL profiles occurred in a substantial proportion of postpartum women, and disparities did not improve from birth to 1 year. Breastfeeding was protective for the mother.

Contributing Members

Members of each site are listed below.

 •Baltimore, MD: Baltimore City Healthy Start, Johns Hopkins University

 -Community Principal Investigator: M. Vance

 -Academic Principal Investigator: C. S. Minkovitz; Coinvestigators: P. O'Campo, P. Schafer

 -Project Coordinators: N. Sankofa, K. Walton

 •Lake County, IL: Lake County Health Department and Community Health Center, the North Shore University Health System

 -Community Principal Investigator: K. Wagenaar

 -Academic Principal Investigator: M. Shalowitz

 -Coinvestigators: E. Adam, G. Duncan,* A. Schoua-Glusberg, C. McKinney, T. McDade, C. Simon

 -Project Coordinator: E. Clark-Kauffman

 •Los Angeles, CA: Healthy African American Families, Cedars-Sinai Medical Center, University of California, Los Angeles

 -Community Principal Investigator: L. Jones

 -Academic Principal Investigator: C. Hobel; Co-PIs: C. Dunkel Schetter, M. C. Lu Project Coordinators: F. Jones, D. Serafin, D. Young

 •North Carolina: East Carolina University, NC Division of Public Health, NC Eastern Baby Love Plus Consortium, University of North Carolina, Chapel Hill

 -Community Principal Investigators: S. Evans, J. Ruffin, R. Woolard

 -Academic Principal Investigator: J. Thorp; Co-Is J. DeClerque, C. Dolbier, C. Lorenz

 -Project Coordinators: L. S. Sahadeo, K. Salisbury

 •Washington, DC: Virginia Tech Carilion Research Institute, Virginia Tech, Washington Hospital Center, Developing Families Center

 -Community Principal Investigator: L. Patchen

 -Academic Principal Investigator: S. L. Ramey; Academic Coprincipal Investigator: R.Gaines Lanzi

 -Coinvestigators: L. V. Klerman, M. Miodovnik, C. T. Ramey, L. Randolph

 -Project Coordinator: N. Timraz

 -Community Coordinator: R. German

 -Data Coordination and Analysis Center DCAC (Pennsylvania State University)

 -PI: V. M. Chinchilli

 -Coinvestigators: R, Belue, G. Brown Faulkner,* M, Hillemeier, I. Paul, M. L. Shaffer

 -Project Coordinator: G. Snyder

 -Biostatisticians: E. Lehman, C. Stetter

 -Data Managers: J. Schmidt, K. Cerullo, S. Whisler

 -Programmers: J. Fisher, J, Boyer, M. Payton

 -National Institutes of Health Program Scientists: V. J. Evans and T. N. K. Raju, NICHD; L. Weglicki, National Institute of Nursing Research, Program Officers: M. Spittel* and M. Willinger, NICHD; Y. Bryan,* NINR.

 •Steering Committee Chairs: M. Phillippe (University of Vermont) and E. Fuentes-Afflick* (University of California - San Francisco School of Medicine)

* Indicates those who participated in only the planning phase of the CCHN.


This paper has been designated as a Core Paper of the CCHN, as it reflects major ideas and work considered central to our network. Accordingly, the last designated author is the network itself preceded by the names of those on the writing team who directly prepared this paper listed in the order the team judged best reflects its relative contributions.

  • References

  • 1 Marshall NE, Spong CY. Obesity, pregnancy complications, and birth outcomes. Semin Reprod Med 2012; 30 (06) 465-471
  • 2 Lassi ZS, Imam AM, Dean SV, Bhutta ZA. Preconception care: screening and management of chronic disease and promoting psychological health. Reprod Health 2014; 11 (Suppl 3): S5
  • 3 Denney JM, Nelson EL, Wadhwa PD. , et al. Longitudinal modulation of immune system cytokine profile during pregnancy. Cytokine 2011; 53 (02) 170-177
  • 4 Sanghavi M, Rutherford JD. Cardiovascular physiology of pregnancy. Circulation 2014; 130 (12) 1003-1008
  • 5 Melchiorre K, Sharma R, Khalil A, Thilaganathan B. Maternal cardiovascular function in normal pregnancy: evidence of maladaptation to chronic volume overload. Hypertension 2016; 67 (04) 754-762
  • 6 Melchiorre K, Sutherland GR, Liberati M, Thilaganathan B. Preeclampsia is associated with persistent postpartum cardiovascular impairment. Hypertension 2011; 58 (04) 709-715
  • 7 Qiu C, Sorensen TK, Luthy DA, Williams MA. A prospective study of maternal serum C-reactive protein (CRP) concentrations and risk of gestational diabetes mellitus. Paediatr Perinat Epidemiol 2004; 18 (05) 377-384
  • 8 Heitritter SM, Solomon CG, Mitchell GF, Skali-Ounis N, Seely EW. Subclinical inflammation and vascular dysfunction in women with previous gestational diabetes mellitus. J Clin Endocrinol Metab 2005; 90 (07) 3983-3988
  • 9 Appiah D, Schreiner PJ, Gunderson EP. , et al. Association of gestational diabetes mellitus with left ventricular structure and function: The CARDIA study. Diabetes Care 2016; 39 (03) 400-407
  • 10 McEwen BS, Seeman T. Protective and damaging effects of mediators of stress. Elaborating and testing the concepts of allostasis and allostatic load. Ann N Y Acad Sci 1999; 896: 30-47
  • 11 Gruenewald TL, Karlamangla AS, Hu P. , et al. History of socioeconomic disadvantage and allostatic load in later life. Soc Sci Med 2012; 74 (01) 75-83
  • 12 Howard JT, Sparks PJ. The effects of allostatic load on racial/ethnic mortality differences in the United States. Popul Res Policy Rev 2016; 35 (04) 421-443
  • 13 Ramey SL, Schafer P, DeClerque JL. , et al; Community Child Health Network. The preconception stress and resiliency pathways model: a multi-level framework on maternal, paternal, and child health disparities derived by community-based participatory research. Matern Child Health J 2015; 19 (04) 707-719
  • 14 National Heart, Lung, and Blood Institute. Assessing Your Weight and Health Risk. Available at: . Accessed July 12, 2018
  • 15 Waist Circumference and Waist-Hip Ratio. . Report of a WHO Expert Consultation ( 2008 ). Available at: . Accessed September 25, 2014
  • 16 World Health Organization. Blood pressure/hypertension. Available at: . Accessed July 12, 2018
  • 17 Cooney MT, Vartiainen E, Laatikainen T, Juolevi A, Dudina A, Graham IM. Elevated resting heart rate is an independent risk factor for cardiovascular disease in healthy men and women. Am Heart J 2010; 159 (04) 612-619
  • 18 Pearson TA, Mensah GA, Alexander RW. , et al; Centers for Disease Control and Prevention; American Heart Association. Markers of inflammation and cardiovascular disease: application to clinical and public health practice: a statement for healthcare professionals from the Centers for Disease Control and Prevention and the American Heart Association. Circulation 2003; 107 (03) 499-511
  • 19 American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012; 35 (01) 12
  • 20 Arsenault BJ, Rana JS, Stroes ES. , et al. Beyond low-density lipoprotein cholesterol respective contributions of non–high-density lipoprotein cholesterol levels, triglycerides, and the total cholesterol/high-density lipoprotein cholesterol ratio to coronary heart disease risk in apparently healthy men and women. Am Coll Cardiol 2010; 55: 35-41
  • 21 Kumari M, Shipley M, Stafford M, Kivimaki M. Association of diurnal patterns in salivary cortisol with all-cause and cardiovascular mortality: findings from the Whitehall II study. J Clin Endocrinol Metab 2011; 96 (05) 1478-1485
  • 22 Seeman T, Epel E, Gruenewald T, Karlamangla A, McEwen BS. Socio-economic differentials in peripheral biology: cumulative allostatic load. Ann N Y Acad Sci 2010; 1186: 223-239
  • 23 Seeman T. Gruenwald, Karlamangla A, . et al. Modelling multisystem biological risk in young adults: the coronary artery risk development in young adults study. Am J Hum Biol 2010; 22: 463-472
  • 24 Gunderson EP, Lewis CE, Wei GS, Whitmer RA, Quesenberry CP, Sidney S. Lactation and changes in maternal metabolic risk factors. Obstet Gynecol 2007; 109 (03) 729-738
  • 25 Ram KT, Bobby P, Heilpern SM. , et al. Duration of lactation is associated with lower prevalence of metabolic syndrome in midlife—SWAN, the Study of Women's Health Across the Nation. Med J Obstet Gynecol 2008; 198 (03) 268.e1-268.e6
  • 26 Frei R, Haile SR, Mutsch M, Rohrmann S. Relationship of serum vitamin D concentrations and allostatic load as a measure of cumulative biological risk among the US population: a cross-sectional study. PLoS One 2015; 10 (10) e0139217
  • 27 Accortt EE, Mirocha J, Dunkel Schetter C, Hobel CJ. Adverse perinatal outcomes and postpartum multi-systemic dysregulation: adding vitamin D deficiency to the allostatic load index. Matern Child Health J 2017; 21 (03) 398-406
  • 28 Deputy NP, Dub B, Sharma AJ. Prevalence and trends in prepregnancy normal weight - 48 States, New York City, and District of Columbia, 2011-2015. Morb Mortal Wkly Rep 2018; 66 (5152): 1402-1407
  • 29 Rosenberg L, Palmer JR, Wise LA, Horton NJ, Kumanyika SK, Adams-Campbell LL. A prospective study of the effect of childbearing on weight gain in African-American women. Obes Res 2003; 11 (12) 1526-1535
  • 30 Gunderson EP, Sternfeld B, Wellons MF. , et al. Childbearing may increase visceral adipose tissue independent of overall increase in body fat. Obesity (Silver Spring) 2008; 16 (05) 1078-1084
  • 31 Madan JC, Davis JM, Craig WY. , et al. Maternal obesity and markers of inflammation in pregnancy. Cytokine 2009; 47 (01) 61-64
  • 32 Rich-Edwards JW, Fraser A, Lawlor DA, Catov JM. Pregnancy characteristics and women's future cardiovascular health: an underused opportunity to improve women's health?. Epidemiol Rev 2014; 36: 57-70
  • 33 Misra VK, Hobel CJ, Sing CF. Placental blood flow and the risk of preterm delivery. Placenta 2009; 30 (07) 619-624
  • 34 Dahly DL, Adair LS, Bollen KA. A structural equation model of the developmental origins of blood pressure. Int J Epidemiol 2009; 38 (02) 538-548
  • 35 Endres L, Straub H, McKinney C. , et al; Community Child Health Network of the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Post-partum weight retention risk factors and relationship to obesity at one year. Obstet Gynecol 2015; 125 (01) 144-152