Authors: Teresa Janevic (1Columbia University Mailman School of Public Health, Department of Epidemiology), Frances M. Howell (1Columbia University Mailman School of Public Health, Department of Epidemiology), Micki Burdick (2University of Pennsylvania Perelman School of Medicine, Department of Obstetrics and Gynecology), Sarah Nowlin (3Mount Sinai Health System, Center for Nursing Research and Innovation; 4Icahn School of Medicine at Mount Sinai, Department of Population Health Science and Policy), Sheela Maru (5Icahn School of Medicine at Mount Sinai, Department of Global Health and Health Systems Design; 6Icahn School of Medicine at Mount Sinai, Department of Obstetrics, Gynecology, and Reproductive Science), Natalie Boychuk (1Columbia University Mailman School of Public Health, Department of Epidemiology), Oluwadamilola Oshewa (2University of Pennsylvania Perelman School of Medicine, Department of Obstetrics and Gynecology), Maria Monterroso (2University of Pennsylvania Perelman School of Medicine, Department of Obstetrics and Gynecology), Katharine McCarthy (4Icahn School of Medicine at Mount Sinai, Department of Population Health Science and Policy), Daniel A. Gundersen (7Rutgers Robert Wood Johnson Medical School, Institute for Nicotine and Tobacco Studies), Alva Rodriguez (5Icahn School of Medicine at Mount Sinai, Department of Global Health and Health Systems Design), Cecilia Katzenstein (8Icahn School of Medicine at Mount Sinai, Department of Medical Education), Regina Longley (8Icahn School of Medicine at Mount Sinai, Department of Medical Education), Kellee White Whilby (9University of Maryland School of Public Health, Department of Health Policy and Management), Alison Lee (10Icahn School of Medicine at Mount Sinai, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine), Camila Cabrera (6Icahn School of Medicine at Mount Sinai, Department of Obstetrics, Gynecology, and Reproductive Science), Jennifer Lewey (11University of Pennsylvania Perelman School of Medicine, Division of Cardiovascular Medicine), Elizabeth A. Howell (2University of Pennsylvania Perelman School of Medicine, Department of Obstetrics and Gynecology), Lisa Levine (2University of Pennsylvania Perelman School of Medicine, Department of Obstetrics and Gynecology)
Categories: Article, racism, pregnancy, postpartum, hypertension, systolic blood pressure, diastolic blood pressure
Source: Hypertension (Dallas, Tex. : 1979)
Authors: Teresa Janevic, Frances M. Howell, Micki Burdick, Sarah Nowlin, Sheela Maru, Natalie Boychuk, Oluwadamilola Oshewa, Maria Monterroso, Katharine McCarthy, Daniel A. Gundersen, Alva Rodriguez, Cecilia Katzenstein, Regina Longley, Kellee White Whilby, Alison Lee, Camila Cabrera, Jennifer Lewey, Elizabeth A. Howell, Lisa Levine
Postpartum hypertension is a key factor in racial-ethnic inequities in maternal mortality. Emerging evidence suggests that experiences of racism, both structural and interpersonal, may contribute to disparities. We examined associations between gendered racial microaggressions (GRM) during obstetric care with postpartum blood pressure (BP).
We conducted a prospective postpartum cohort of 373 Asian, Black, and Hispanic people in New York City and Philadelphia. At delivery we administered the GRM in obstetrics scale. We measured BP for 3 months using text-based monitoring. We estimated place-based structural racism with the Structural Racism Effect Index (SREI). We used mixed models to estimate associations between GRM and mean postpartum systolic BP (SBP) and diastolic BP (DBP). We adjusted for race-ethnicity, education, BMI, chronic hypertension (diagnosed <20 weeks gestation), age, and SREI. We examined effect modification by hypertensive disorder of pregnancy (HDP) and place-based structural racism.
4.6% of participants had chronic hypertension, 20.9% had pregnancy hypertension, and 13.4% had preeclampsia, comprising a HDP subgroup (n=117). 37.5% of participants experienced ≥1 GRM. Participants who experienced ≥1 GRM vs. none had 1.88 mmHg higher SBP Day 1–10 (95%Confidence Interval (CI)=−0.19,3.95) and 2.19 mmHg higher SBP Day 11–85, (95%CI=0.17,4.22). Associations followed a similar pattern for DBP and were stronger among the HDP subgroup. Participants experiencing GRM and high SREI had SBP 7.55 mmHg(95%CI=3.41,11.69) and DBP 6.03 mmHg(95%CI=2.66.9.41) higher than those with neither.
Structural and interpersonal racism are associated with increased postpartum BP, potentially contributing to inequities in postpartum morbidity and mortality and lifecourse cardiovascular disease.
Postpartum hypertension has emerged as a key factor in racial and ethnic inequities in maternal mortality. (1) The US maternal mortality rate is 2–3 times higher among Black birthing people than non-Hispanic White birthing people,(2)^,^ and from 2019–2021 increased most markedly among Hispanics (3,4). South Asians, often overlooked in maternal health statistics, have increased risk of severe maternal morbidity (5), and increased risk of preeclampsia with cardiovascular complications, relative to White birthing people. (6) These disparities extend into the first year postpartum, when over half of pregnancy-related deaths occur (7), and hypertensive disorders of pregnancy, HDP (including those diagnosed during pregnancy as well as new hypertension postpartum) are leading contributors to morbidity and mortality.(8) It is well established that HDP is associated with both immediate and long-term morbidity and mortality with an increased risk of cardiovascular events both within the postpartum period and years later.(9–11) What’s more, the postpartum period is an opportune time to implement prevention programs and connect birthing people to primary or specialist care to reduce lifecourse risk of cardiovascular disease. (12,13) Thus, an urgent need exists to identify underlying contributing factors to postpartum hypertension in birthing people most affected by maternal health inequities.
Racism has been identified as a fundamental cause of maternal health disparities (14) and may influence postpartum blood pressure at several interconnected levels. (15,16) (Figure S1) Gendered racial microaggressions (17) (GRM) are a type of interpersonal racism resulting from beliefs or prejudices based on the person’s race and gender, and are “subtle, daily, and unintentional racial slights committed against members of racialized groups”.(18) Structural racism is the manifestation of historical and current oppression that shapes neighborhoods and institutions, resulting in differential access to opportunity and resources. (19,20) Through a process of embodiment (21,22), these historical and current day experiences shape biology. Structural and interpersonal racism have been associated in most, but not all studies, with elevated blood pressure in adults (23,24), and during pregnancy.(25–27) Although much of this research focuses on Black people in the U.S., evidence also exists of associations between racism and blood pressure in Asian and Hispanic groups.(28–30) However, evidence is lacking regarding the influence of racism on hypertension in the postpartum period.
To fill this gap, we conducted a prospective cohort of postpartum Global Majority (Asian, Black, and Hispanic) people from four maternity hospitals in New York City and Philadelphia. We implemented text-based home blood pressure monitoring with telemonitoring. We gave participants received a validated BP monitor at discharge and delivered text-based prompts asking them to report blood pressure values for 3 months. Our study included birthing people with and without HDP because many patients with ER visits and postpartum readmission due to hypertension had normal blood pressure at the time of discharge.(31) Our objective was to assess associations between GRM with postpartum blood pressure, with the hypothesis that people with ≥1 GRM during pregnancy and delivery would have higher postpartum systolic (SBP) and diastolic (DBP) than those with none. We further hypothesized that associations would be more pronounced among patients living in neighborhoods strongly affected by structural racism or patients with hypertensive disorders of pregnancy.
The data that support the findings of this study are available from the corresponding author upon reasonable request.
We analyzed data from a prospective postpartum cohort of n=419 birthing people who delivered live born infants at four hospitals in New York City, NY and in Philadelphia, PA. Sample size was determined to provide sufficient power to detect clinically meaningful differences in mean SBP and DBP between two groups with high and low levels of exposure to GRM. Participants were recruited prior to postpartum discharge between March 2022- October 2022, and followed for three months. Eligible patients self-identified their race or ethnicity as Asian, Black, or Hispanic, spoke English or Spanish, and had a cell phone. Research coordinators obtained informed consent, administered a baseline survey programmed in Research Electronic Data Capture (REDCap), available in English or Spanish. The Spanish version of the consent and surveys were certified and translated from English by a professional translation service and reviewed by two Spanish-speaking members of the research team for accuracy. Patients self-administered the survey on a tablet while on the postpartum unit, assisted by the research coordinator when necessary. The coordinator enrolled patients in a text-based blood pressure home monitoring system created by Penn Way to Health (W2H)(32). Way to Health is an evidence-based patient engagement platform that integrates wireless devices, clinical trial randomization and enrollment processes, messaging (text, e-mail, or voice), self-administered surveys, automatic transfers of financial incentives, electronic health record integration and secure data capture for research and clinical programs. Participants were compensated up to a total of $100 in electronic gift cards for completing all research activities within the 3-month study period. This study was approved by institutional review boards at the Perelman School of Medicine at the University of Pennsylvania, Icahn School of Medicine at Mount Sinai, and Columbia University Irving Medical Center, and received approval from NYC Health and Hospitals research committee.
We formed a Community Working Group (CWG) composed of community health workers and educators, obstetricians, doulas, and reproductive justice advocates representing both NYC and Philadelphia. We conducted specific stakeholder meetings with our CWG to review and edit the surveys to ensure the questions came from the patient perspective. The CWG also provided feedback on the study design and procedures, interpreted results, and disseminated preliminary findings.
At the time of study enrollment, research coordinators demonstrated to participants how to use the Omron blood pressure monitor and participants were given a blood pressure monitor with appropriate cuff size to take home. W2H sent participants a text message in English or Spanish asking them to take their blood pressure and return a text with the results twice daily (morning and evening) for 10 days, then twice weekly from 11 to 90 days. The message asked participants to sit in a quiet place to take their blood pressure, and then asked to repeat the measure if elevated or nonsensical. A clinician monitored the W2H results and followed an algorithm to respond to concerning blood pressure values as previously described.(33) Upon completion of data collection, implausibly low (< 60 mm Hg systolic or < 40 mm Hg diastolic) and high (> 262 mm Hg systolic or > 124 mm Hg diastolic) blood pressure measures and measures in which the systolic value was < 10 mm Hg higher than the diastolic value were set to missing.(34) Blood pressure readings were binned in half-day intervals for days 1–10 of study enrollment and biweekly intervals from day 11–90. Due to the low frequency of blood pressure measures received within 12 hours of discharge and at the end of study enrollment, measures were restricted to between 12 hours after delivery and approximately 84 days after delivery. In cases where two blood pressure readings were submitted within two hours, if both diastolic and systolic values were within 20 mm Hg of each other, the last measure submitted chronologically was retained. In situations in which either the diastolic or systolic measures submitted within the two hours were different by greater than 20 mm Hg, measures were visually inspected with a clinician to select the more clinically appropriate value, taking into account the participant’s 90-day blood pressure trajectory. In cases in which measures were submitted within the same half-day/half-week time bin but greater than two hours apart, values were visually inspected for plausibility and the mean value of the two measures was retained.
We used the Gendered Racial Microaggressions Scale (GRMS) which we adapted in English and Spanish for a multiethnic obstetric patient population from a validated 26-item, four-factor scale to assess the frequency (0 = never to 5*= once a week or more*) of gendered racial microaggressions (17) (Supplemental Table 1). The scale measures experiences of microaggression based on the theory of gendered racism. We report the development and psychometric evaluation of the adapted scale elsewhere.(35) In brief, the research team consulted the CWG’s expertise on working with Global Majority birthing people on how to adapt the GRMS to capture experiences of gendered racial microaggressions during obstetric care. The original scale was framed to capture a participant’s experience as a Black woman, while in the adapted version the participant’s perspective from their race and gender positionality is inferred. Examples of items are “I have been disrespected”, “Someone told me to calm down”, and “Someone accused me of being angry when speaking assertively”. Our psychometric analysis found good validity of the adapted GRMS to assess the experiences of GRMS in hospital-based obstetric care settings among multiracial and multiethnic patient populations. The scale performed well in both Black and Hispanic participants, and in both English and Spanish. For this analysis we categorized the GRMS into a two-part variable, comparing those who experienced ≥1 GRM vs. none.
We used the Structural Racism Effect Index (SREI) to measure place-based structural racism. (36) Participant addresses from the EMR were geocoded to census tracts. We included 264 census tracts. The SREI is a publicly available national index designed by Dyer et al to measure community-level structures of inequity in nine built environment, criminal justice, education, employment, housing, income and poverty, social cohesion, transportation, and wealth. Examples of domain items include from the housing “eviction rate”, and from the wealth “median home value”. (37) We split the SREI into quartiles based on the US distribution of the measure, then after examining description associations with blood pressure, we collapsed the middle two categories, resulting in a 3-part variable representing low, medium, and high levels of place-based structural racism.
We obtained information about HDP, gestational hypertension, preeclampsia, BMI, and parity via the participant’s EMR. HDP included gestational hypertension, pre-eclampsia and pre-eclampsia superimposed on chronic hypertension with or without severe features. For purposes of this study, we also included chronic hypertension in the HDP definition. Per the American College of Obstetricians and Gynecologists (ACOG) guidelines,(38) HDP was defined as two blood pressures (BPs) ≥ 140/90 mmHg at least 4 hours apart after 20 weeks with or without proteinuria with severe features based on severe range BP (BPs ≥160/110 mmHg) or lab abnormalities. Chronic hypertension was defined as BP >=140/90 prior to 20 weeks, on an antihypertensive medication in early pregnancy or presenting to care with formal chronic hypertension diagnosis noted in chart.
We used the BMI recorded closest in time to their delivery using the medical record, categorized as underweight (< 18.5kg/m^2^), normal weight (18.5- <24.9), overweight (24.9- <29.9), and obesity class I /II (29.9- < 39.9), and class III (≥ 40). We ascertained sociodemographic characteristics, including race-ethnicity, education, and maternal age from the baseline survey. We define race as a social construct resulting from historical and current day oppression which places persons on a hierarchy due to phenotype.(39) We draw on a relational definition of ethnicity, which describes the process in which people from a shared cultural or geographic background are placed into a social hierarchy.(40) This relational definition is important to understanding how racism can affect diverse ethnic groups. To collect self-reported race and ethnicity, participants were asked whether they consider themselves Hispanic/Latina and to select all racial groups with which they identify (Black or African American, White, Asian, Native Hawaiian/Pacific Islander, Indian American or Alaska Native, Other). Due to small sample sizes in some categories, race-ethnicity was collapsed into four-categories for analyses (Hispanic/Latina, non-Hispanic Black (henceforth Black), non-Hispanic Asian (henceforth Asian), or other/don’t know/prefer not to respond).
For this analysis, we excluded participants who did not report any logical blood pressure measures (n=35) and those who did not complete survey items on our main exposure (n=11), resulting in an analytic sample of n=373, with n=9578 blood pressure measures (Figure S2). We examined bivariate descriptive statistics for associations between participant characteristics with SREI, GRM and mean blood pressure. We fit linear mixed models with repeated measures to estimate associations between GRM and postpartum SBP and DBP. The mixed model included repeated measures by blood pressure time bin (described above) and was clustered at the participant level, with a random intercept by participant. We selected a first order autoregressive covariance structure to account for correlation between observations that are inversely related to the time between observations.(41) We chose covariates for adjustment based on a Directed Acyclic Graph. We adjusted for BMI, race-ethnicity (to account for other exposures due to race besides GRM), education, age, parity, and chronic hypertension. We did not adjust for gestational hypertension or preeclampsia, as these were potentially on the causal pathway. We tested whether associations differed throughout the 3-month postpartum period using a spline, which introduces a piecewise linear function into the model to allow for non-linearity, for time periods (0–10/11–85 days). We chose this spline based on evidence that blood pressure stabilizes approximately day 10–12 postpartum.(42) We examined effect modification with HDP (yes/no) graphically and by introducing an interaction term into the mixed model and outputting stratified estimates. A similar approach was used to test for joint effects interaction of GRM and SREI, except we conducted a sensitivity analysis removing race-ethnicity as a covariate, as some of the social exposure tied to this construct may be on the causal pathway from structural racism to postpartum blood pressure. We conducted all analyses using SAS v. 9.4.
This study was funded by NIH/NIMHD 1R01MD016029–02SI. The funder had no role in the conduct or reporting of the research.
The study sample of n=373 participants was comprised of 10.5% Asian participants, 38.6% Black participants, 40.0% Hispanic participants, and 11.0% who reported other race-ethnicity (Table 1). 52.9% were foreign-born. To respect participants’ self-identification, we report more detailed race, ethnicity, and country of origin in Table S2. Fifteen percent of participants had less than high school diploma, 34.3% had a high school diploma or GED, 24.1% had some college, and 24.4% had a bachelor’s degree or higher. The largest age category was 20–29 years old (42.9%).
37.5% of participants reported at least one GRM (Table 1). Participants who experienced GRM had a higher 3-month postpartum mean SBP of 120.6 mmHg and DBP of 74.5 mmHG compared to 118.47mmHg and 73.08mmHg among those who did not (SBP difference= 2.12, 95%Confidence Interval (CI)= −0.13, 4.37; DBP difference= 1.43, 95%CI= −0.26, 3.12) (Table 2). In models adjusting for race-ethnicity, education, BMI, chronic hypertension, age, and SREI, adjusted difference for SBP was 1.98 mmHg (95%CI=0.07, 3.88) and for DBP was 1.21 mmHg (95%CI= −0.34, 2.76). A model spline for two postpartum time periods (1–11 days, 12–83.5 days) was significant for both systolic and diastolic blood pressure (p=<.001) with differences in the later period of greater magnitude than the earlier period (Table 2). The adjusted SBP difference in the earlier period was 1.81mmHg (95%CI= −0.22, 3.85) and the later period 2.13 mmHg (95%CI=0.13, 4.12), and the adjusted DBP difference in the earlier period was 1.16 mmHg (95%CI= −0.50, 2.83) and in the later period 1.26 mmHg (95%CI= −0.37, 2.89). Given improved model performance based on AIC in the unadjusted model of systolic blood pressure with the model spline compared to without, this effect was retained in all subsequent analyses.
4.6% of participants had chronic hypertension, 20.9% had pregnancy hypertension, and 13.4% had preeclampsia, comprising a high-risk HDP subgroup of n=117. Figure 1 and Table S3 show that GRM differences in SBP and DBP were greater among those with HDP, although the interaction term did not reach statistical significance. For example, the adjusted difference in SBP by any/none GRM among high-risk people was 3.34mmHg (95%CI= 0.09, 6.58). In joint effects analysis of GRM and SREI, we observed the highest 3-month mean postpartum blood pressure among those experiencing GRM and living in a neighborhood with high SREI (SBP=124.92mmHG, DBP=77.72mmHg) and the lowest 3-month mean postpartum blood pressure among those without experiencing GRM and living in a neighborhood with low SREI (SBP= 113.13mmHg, DBP=70.41mmHG). The adjusted SBP difference was 7.55 mmHg (95%CI=3.41, 11.69) and the adjusted DBP difference was 6.03 mmHG (95%CI=2.66, 9.41).
The results of our sensitivity analysis excluding race-ethnicity as a control variable can be found in Tables s4. Removing race-ethnicity did not substantially influence estimates of the joint interaction effects of GRM and experiencing high SREI, although as expected, differences were of a slightly greater magnitude.
We found that GRM during obstetric care was associated with higher SBP postpartum among Global Majority people, and the association was of greater magnitude from 12 days to 3 months postpartum. Associations were more pronounced among people who experienced GRM with HDP. Associations with DBP were of smaller magnitude but followed similar trends. Most importantly, the double burden of GRM and place-based structural racism was associated with markedly elevated both SBP and DBP postpartum blood pressure.
Our findings build on increasing evidence of the influence of racism on maternal outcomes. Experiences of racial/ethnic discrimination during obstetric care have been well-documented in qualitative research, unearthing themes that align well with the items of the GRM scale, for example, including feeling unheard, being ignored, and lack of shared decision making.(43–48) Quantitative research of experiences of racism during obstetric care is more limited (49), but experiences of obstetric racism or perceived racial-ethnic discrimination have been associated with outcomes such as postpartum mental health,(50) lower postpartum visit attendance,(51) and poorer transition to primary care among women with cardiometabolic conditions in pregnancy.(52) Harmful effects of place-based structural racism on maternal health have also been identified in both qualitative (53) and quantitative research (54,55), including HDP.(26) We add to this literature by demonstrating prospective associations between GRM and postpartum blood pressure, potentially contributing to inequities in postpartum maternal morbidity and mortality and lifecourse cardiovascular disease.
Several pathways could account for associations between racism and postpartum blood pressure. Structural racism may influence postpartum hypertension through social determinants of health, psychosocial stress, and by shaping experiences of health care, including GRM. GRM in health care are an important aspect of respectful maternity care, potentially affecting quality of care and increasing psychosocial stress (56). Experiencing GRM could be a marker of poorer quality of care. For example, poorer communication between patient and clinical team could result in a missed opportunity to connect the patient to essential resources. Other downstream effects of poor communication could include poorer adherence to medication or other discharge instructions. Another potentially potent pathway is the stress experienced by the patient experiencing GRM, likely compounded for those living in neighborhoods experiencing high levels of structural racism. Chronic and acute psychosocial stress are known to influence blood pressure (57), overall and in pregnancy (58), but associations with blood pressure have been less explored in the postpartum period. Both quality of care and psychosocial stress are plausible targets for interventions to mitigate racism.
Our findings have implications for clinicians and policy makers to increase focus on intervening on racism during obstetric care as well as cardiovascular health in the postpartum period. Notably, associations between GRM and BP widened after the initial 12 days postpartum, which is the period in which blood pressure is less closely monitored. This points to the potential sustained influence of racism during obstetric care on women’s and birthing people’s cardiovascular health. Clinicians and health systems thus can design postpartum interventions extending later into the postpartum,(11) when BP may continue to be sensitive to social determinants of health such as GRM. Meanwhile, urgency is growing to eliminate disrespect in maternity care(59) and to dismantle structural racism in advance maternal health equity.(14) Policy efforts such as the Momnibus legislation have included targeting social and structural determinants of health.(60) Policy efforts have also included implicit bias training for providers, although the evidence base is currently lacking on effective interventions.(61) Our measure of GRM or similar measures could be evaluated as a performance metric in future research.
A limitation of our study, common to pregnancy cohorts, is that we do not know the pre-conception blood pressure of participants, so we cannot rule out that associations at least in part reflect pre-pregnancy blood pressure. However, the findings were amplified among people with HDP, suggesting that postpartum blood pressure may be sensitive to experiences of care in particular among those with HDP. Further, findings were amplified among those living in neighborhoods with high evidence of structural racism, suggesting a combination of pre-pregnancy and obstetric care influences at play. Our study had other limitations. In our adaption of the GRM scale for a multiracial population, we did not ask respondents to attribute their experiences of microaggressions to their gender or race. Instead, we used an intersectional theoretical approach which assumes that people’s social locations shape their experiences, meaning racial and gender identities cannot be disentangled from lived experiences.(62) We also did not adjust for interpersonal experiences of racism outside of obstetric care. However, in models adjusting for experiences of place-based structural racism, associations between GRM and postpartum BP were robust. Other unidentified confounders may also be at play, e.g. diet, although any individual behaviors could be mechanisms by which racism influences blood pressure and therefore should not be modeled as covariates. Another limitation is the study was conducted only in English and Spanish. Also, some subjects did not complete the entire three months of follow-up, e.g. 69 people (18.5%) did not submit measures after 6 weeks. This group did not differ by GRM exposure or DBP, although mean SBP prior to 6 weeks was slightly higher (122.1 mmHg vs 119.1 mmHg). Therefore, we cannot rule out some influence on our reported associations, although the direction is unclear. Also, the number of postpartum BP measurements was not associated with GRM (p=0.72), reducing the likelihood that unequal follow-up would bias our estimates. We did not collect information on gender, and thus our study does not capture experiences of diverse gender identities. Finally, our study was conducted in two urban areas, thus may not be generalizable to rural settings.
Our study had several strengths, making it one of the most rigorous studies of racism and postpartum health to date. We had repeated measures of blood pressure from a bilingual home monitoring system, paired with detailed prospective psychosocial and medical variables. We used validated measures of racism at multiple levels. Finally, we engaged with a community advisory panel during the design, analysis, and interpretation phases of our study.
Our findings also point to postpartum as a critical period to intervene to disrupt lifecourse CVD inequities faced by Global Majority people. HDP are associated with an increased risk of chronic hypertension in later life, and notably, the highest increase in risk is within the first five years postpartum.(13) Although the magnitude of the differences we identified may appear modest (e.g. 2.13mmHg difference in SBP for any vs. none GRM in Day 11–85), small increases in blood pressure in early adulthood increase risk of later cardiovascular disease.(63) Further, evidence suggests a cumulative effect, such that small increases over time may have deleterious effects.(64) Lifecourse blood pressure trajectories influence later risk of CVD (65). Researchers have identified sex-specific patterning, with women experiencing steeper increases in blood pressure in their thirties.(66) Blood pressure postpartum is a snapshot of vascular aging, contributing to “weathering”, or the cumulative physiologic damage due to lifecourse exposure to socioeconomic disadvantage.(67)
We observed associations of GRM on blood pressure gaining in magnitude in the postpartum period, and a double burden of GRM and place-based structural racism among Global Majority people. Policies and interventions to eliminate and mitigate racism have the potential to reduce postpartum maternal morbidity and mortality, as well as to disrupt lifecourse inequities in cardiovascular disease.