Disparities in low-dose aspirin prescription among patients at risk for preeclampsia

Low-dose aspirin (LDA) reduces preeclampsia risk, yet prescribing rates among eligible pregnant patients remain low. This study aims to determine whether there are disparities in LDA prescription to eligible patients based on race/ethnicity, primary language, or insurance after implementation of a standardized electronic health record (EHR) preeclampsia risk screening tool.

This retrospective cohort study included all patients ≥ age 18 with births at a single academic center from September 2022 to July 2025 who had 1 high or ≥2 moderate preeclampsia risk factors. The primary outcome was rate of LDA recommendation/prescription, determined by recommendation documentation in the risk screening tool or prescription in the EHR medication log. Data were extracted from Epic Clinical Data Warehouse. Chi-square or t-tests were used to compare LDA prescribing rates by race/ethnicity, primary language, and insurance, and multivariable regression models were used.

Of 5737 LDA-eligible patients, 3995 (69.6%) were recommended/prescribed LDA and 1742 (30.4%) were not. Patients recommended/prescribed LDA were more likely to be older, multiparous, English speaking, and privately insured and/or have pregestational diabetes or chronic hypertension, as well as high-risk factors for preeclampsia (p < 0.001). In an adjusted multivariable analysis for age, race, parity, body mass index, language, diabetes mellitus, chronic hypertension [cHTN], and insurance type, Black/African American patients (adjusted OR [aOR] 1.80, 95% confidence interval [CI] 1.36-2.39) and patients with high-risk factors for preeclampsia (aOR 2.66, 95% CI 2.14-3.31) had higher odds of being prescribed/recommended LDA while non-English speaking (Spanish aOR 0.60, 95% CI 0.46-0.78; another language aOR 0.62, 95% CI 0.45-0.85) and publicly insured (aOR 0.80, 95% CI 0.69-0.93) patients had lower odds. Differences in prescription/recommendations by race and insurance were primarily driven by those with moderate risk factors for preeclampsia, while this was not true for differences in prescription for non-English speaking patients.

After implementation of a standardized preeclmapsia risk screening tool, LDA was more often prescribed to eligible Black patients than White, likely reflecting ACOG's inclusion of Black race as a proxy for racism as a preeclmapsia risk factor. However, LDA was less often prescribed to publicly insured or non-English speaking patients, which highlights an opportunity for quality and equity improvement.