Social Determinant Pathways to Hypertensive Disorders of Pregnancy Among Nulliparous U.S. Women

Hypertensive disorders of pregnancy are a leading cause of maternal morbidity and mortality in the United States and impact Black mothers at disproportionately higher rates. Hypertensive disparities among racialized groups are rooted in systemic inequalities, and we hypothesize that clinical markers of allostatic load capture embodied disparities in stressors that can link upstream social determinants of health with downstream hypertensive outcomes.

We analyzed observational cohort data from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (n = 6,501) and developed a structural equation model linking latent social determinants of health, longitudinal markers of allostatic load across gestation, and hypertensive pregnancy outcomes in a multigroup framework.

Non-Hispanic Black mothers-to-be (n = 1,155) showed higher rates of hypertensive disorders of pregnancy (32%) than non-Hispanic white women (n = 5,346, 23%). Among both groups, the social environment showed stronger direct effects on allostatic markers than via behaviorally mediated dietary, exercise, or smoking pathways. Demographic aspects of the social environment (e.g., household income, partnered status) were the most salient predictor of hypertensive risk and showed stronger effects among Black women.

Embodied stress rooted in the social environment is a major path driving maternal hypertensive disparities in the United States, with effects that vary across racialized groups. These pathway findings underscore the greater impact of systemic stressors relative to individual health behaviors. More comprehensive and detailed analyses of sociostructural domains are needed to identify promising avenues for policy and intervention to improve maternal health.