Racial Differences in Adverse Pregnancy Outcomes and Incident Hypertension: A Mediation Analysis

Authors

• Lucia C. Petito, Northwestern University Feinberg School of Medicine
• Xiaoning Huang, Northwestern University Feinberg School of Medicine
• C. Noel Bairey, Barbra Steisand Women's Heart Center, Smidt Cedars-Sinai Heart Institute
• Natalie Bello, Barbra Steisand Women's Heart Center, Smidt Cedars-Sinai Heart Institute
• Janet Catov, University of Pittsburgh
• Ernesto Licon, University of California Irvine School of Medicine
• Abbi Lane, University of South Carolina
• David M. Haas, Department of Obstetrics and Gynecology Indiana University
• Lisa D. Levine, University of Pennsylvania
• Rebecca B. McNeil, RTI International Durham
• Eliza Miller, Columbia University Irving Medical Center
• Uma M. Reddy, Columbia University Irving Medical Center
• Bethany Barone Gibbs, West Virginia University Morgantown
• George Saade, Macon & Joan Brock Virginia Health Sciences at Old Dominion UniversityFollow
• Lauren Theilen, University of Utah Health Sciences Center Salt Lake City UT
• Laura E. Wiener, RTI International
• Brian M. Mercer, Case Western Reserve University School of Medicine
• Hyagriv N. Simhan, University of Pittsburgh School of Medicine
• Lynn M. Yee, Northwestern University Feinberg School of Medicine
• Philip Greenland, Northwestern University Feinberg School of Medicine
• William A. Grobman, The Ohio State University Wexner Medical Center
• Sadiya S. Khan, Northwestern University Feinberg School of Medicine

ORCID

0000-0001-7925-5302 (Saade)

Document Type

Article

Publication Date

2026

DOI

10.1161/jaha.123.035681

Publication Title

Journal of the American Heart Association

Volume

15

Issue

13

Pages

e035681

Abstract

Background

Adverse pregnancy outcomes (APOs) are associated with increased hypertension risk. Black women experience higher rates of APOs and hypertension compared with White women, but whether APOs contribute to Black-White hypertension disparities remains unknown.

Methods

The nuMoM2b-HHS (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be-Heart Health Study) prospectively recruited nulliparous pregnant people at 8 US centers (2010-2013) with follow-up 2 to 7 years postpartum (2014-2017). Race, which represents a social construct, was self-identified. The primary outcome was incident hypertension at follow-up. APOs included hypertensive disorders of pregnancy, preterm birth, and small-for-gestational age birth. Potential confounders (psychological health, social factors, and health behaviors) were assessed via validated questionnaires. We used targeted maximum likelihood-based estimation to estimate Black-White hypertension differences that would remain if racial disparities in APOs were eliminated.

Results

Among 3335 participants (17% Black; 83% White; mean [SD] age, 27.6 [5.1] years), APO incidence was higher in Black versus White individuals (rate differences [RDs] per 1000 births: hypertensive disorders of pregnancy: 52.5 [95% CI, 20.0-85.1]; preterm birth: 45.4 [95% CI, 20.8-70.1]; small-for-gestational age: 102.4 [95% CI, 75.8-129.1]). Incident hypertension at median 3 years postpartum was higher in Black versus White individuals (RD, 107.1 [95% CI, 69.6-144.4]). APOs mediated the racial disparity in hypertension; eliminating Black-White disparities in APOs would decrease the Black-White disparity in hypertension by 18.2% for hypertensive disorders of pregnancy (RD, 87.6 [95% CI, 36.1-139.2]), 16.3% for preterm birth (RD, 89.6 [95% CI, 41.7-137.6]), and 13.9% for small-for-gestational age (RD, 92.2 [95% CI, 41.6-142.9]).

Conclusions

Black-White differences in hypertension were partially mediated by APOs. APOs may represent a pregnancy-specific pathway contributing to racial disparities in hypertension.

Rights

© 2026 The Authors.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Original Publication Citation

Petito, L. C., Huang, X., Bairey Merz, C. N., Bello, N., Catov, J., Licon, E., Lane, A., Haas, D. M., Levine, L. D., McNeil, R. B., Miller, E., Reddy, U. M., Barone Gibbs, B., Saade, G., Theilen, L., Wiener, L. E., Mercer, B. M., Simhan, H. N., Yee, L. M.,…Khan, S. S. (2026). Racial differences in adverse pregnancy outcomes and incident hypertension: A mediation analysis. Journal of the American Heart Association, 15(13), Article e035681. https://doi.org/10.1161/jaha.123.035681

Repository Citation

Petito, L. C., Huang, X., Bairey Merz, C. N., Bello, N., Catov, J., Licon, E., Lane, A., Haas, D. M., Levine, L. D., McNeil, R. B., Miller, E., Reddy, U. M., Barone Gibbs, B., Saade, G., Theilen, L., Wiener, L. E., Mercer, B. M., Simhan, H. N., Yee, L. M.,…Khan, S. S. (2026). Racial differences in adverse pregnancy outcomes and incident hypertension: A mediation analysis. Journal of the American Heart Association, 15(13), Article e035681. https://doi.org/10.1161/jaha.123.035681