Poor Prepregnancy Cardiometabolic Health Observed Across the US

More than half of women who gave birth in the United States in 2019 had poor cardiometabolic health, and temporal trends suggest the situation is getting worse, according to a study published Monday in a special Go Red for Women spotlight issue of Circulation. 

With numerous studies linking pregnancy complications like preeclampsia and gestational diabetes to worse long-term cardiovascular outcomes, the researchers say improving the overall health of women before they become pregnant should be a bigger focus for both policy makers and clinicians in primary care.

Researchers say that although this is an important issue across the entire US, it may be particularly important to target states where a low percentage of women enter pregnancy in ideal cardiometabolic health. Hopefully, future efforts can “identify the factors that may be contributing to that, like access to healthcare, access to healthy foods and green spaces, and neighborhood safety,” lead author Natalie A. Cameron, MD (Northwestern University Feinberg School of Medicine, Chicago, IL), told TCTMD.

Geography as a Surrogate Marker

Using maternal birth records from the US Centers for Disease Control and Prevention, the researchers identified more than 14 million women ages 20 to 44 years who gave birth in the US between 2016 and 2019. Good heart health (defined as a body mass index of 18.0 to 24.9 kg/m² with no hypertension or diabetes) was lowest on average in Southern (38.1%) and Midwest states (38.8%) and highest in the West (42.2%) and Northeast (43.6%).

Commenting on the study, Vesna Garovic, MD, PhD (Mayo Clinic, Rochester, MN), told TCTMD “geography is really serving as a surrogate marker for socioeconomic status, education, and racial disparities in maternal healthcare delivery, which differ from state to state. The same states that have these unfavorable profiles for pregnancy in the United States have unfavorable cardiometabolic profiles for the general population, which sort of has even larger implications for overall health.” But for pregnant women in particular, who are stressed with weight, lipid changes, and fluid retention, the implications are more pronounced, she added.

Cameron was surprised to see such a low percentage of women entering pregnancy with good cardiometabolic health, which declined overall from 43.5% in 2016 to 40.2% in 2019. “I thought that number was pretty low given that these are reproductive-age women,” she said. “We did look at 20- to 44-year-old women, but that's still pretty young to only have 40% entering pregnancy with favorable cardiometabolic health.”

Notably, 81.4% of the population were between 20 and 34 years old. Overall, 22.7% were Hispanic/Latina, 14% were non-Hispanic Black, and 52.7% were non-Hispanic white. While the database used for the study didn’t include any post-pregnancy data, the researchers did observe an inverse correlation between favorable cardiometabolic health and a high school education or less, as well as with Medicaid (P < 0.01 for both).

“There’s definitely a lot more social and economic factors that we need to look into to help design policies,” Cameron said.

“At the individual patient level, we'd love to get more women in with their primary care doctors before pregnancy for a regular checkup to make sure that they have a normal blood pressure, that they don't have diabetes or prediabetes, that they're not smoking, and that they have a normal weight so their doctors can help them manage those conditions if they have them,” she added. “And in that way, they can help maximize the health of their pregnancy and of their baby, too.”

For patients who experience cardiometabolic pregnancy complications, Cameron advised physicians to look for risk factors as early as possible “to try to optimize them for the future pregnancy.” For those who are already entering pregnancy with poor cardiometabolic health, it’s never too late to make improvements, she said.

Garovic said a healthy diet and exercise are important, but physicians need to work with women who want to start families in a timely fashion so that they’re in good health when they become pregnant.  

Unfortunately, the data suggest “that the situation that was bad is getting worse,” she added, noting, however, that “this may be the population that is particularly motivated to pursue these lifestyle modifications in order to achieve their reproductive goals.”

In the future, Garovic would like to see research focused on identifying markers of preclinical abnormalities associated with increased risk for cardiovascular disease beyond what is currently included in typical risk factor stratification. “Prepregnancy and pregnancy outcomes may play a role as to how we assess overall risk, but unfortunately, at this point, even though we are aware that pregnancy complications may increase their risk for both heart disease and stroke, these are not taken into account and calculated in traditional risk scores,” she said.