Indigenous Health Disparities in Hypertensive Disorders of Pregnancy Within the United States

This review examines determinants across structural, institutional, interpersonal, and individual domains that contribute to hypertensive disorders of pregnancy (HDPs) in American Indian and Alaska Native (AI/AN) populations and their long-term cardiovascular consequences. It suggests paths forward for equitable research and clinical practice.

AI/AN women have the highest HDP prevalence among all racial and ethnic groups at 9.1% and experience severe maternal morbidity at 1.6 times the rate of non-Hispanic white women. Pre-existing cardiometabolic disease, including obesity affecting 40% and metabolic syndrome affecting up to 55% of AI/AN adults, compounds pregnancy risk. Beyond individual factors, structural determinants, such as the legacy of colonization, racial misclassification, violations of tribal data sovereignty, and disrupted traditional birthing practices, have perpetuated systemic barriers and health inequities. Qualitative evidence documents pervasive discrimination, cultural dismissiveness, and provider bias during perinatal care. Despite the 2-fold increased long-term cardiovascular disease risk from HDPs, AI/AN women face persistent barriers to postpartum follow-up and cardiovascular screening. Effective evidence-based preventive strategies, including low-dose aspirin prophylaxis, blood pressure management, and telehealth-based postpartum monitoring, remain understudied in AI/AN populations. Addressing HDP disparities in AI/AN populations requires moving beyond individual risk factors to confront structural determinants. Meaningful progress requires community-based participatory research that centers tribal data sovereignty, incorporation of Indigenous scholars into research leadership, and policy-level changes. Ultimately, these efforts may expand culturally concordant perinatal care, reduce acute maternal morbidity, and reduce long-term HDP-related cardiovascular risk.