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Does race or ethnicity play a role in the origin, pathophysiology, and outcomes of preeclampsia? An expert review of the literature

      The burden of preeclampsia, a substantial contributor to perinatal morbidity and mortality, is not born equally across the population. Although the prevalence of preeclampsia has been reported to be 3% to 5%, racial and ethnic minority groups such as non-Hispanic Black women and American Indian or Alaskan Native women are widely reported to be disproportionately affected by preeclampsia. However, studies that add clarity to the causes of the racial and ethnic differences in preeclampsia are limited. Race is a social construct, is often self-assigned, is variable across settings, and fails to account for subgroups. Studies of the genetic structure of human populations continue to find more variations within racial groups than among them. Efforts to examine the role of race and ethnicity in biomedical research should consider these limitations and not use it as a biological construct. Furthermore, the use of race in decision making in clinical settings may worsen the disparity in health outcomes. Most of the existing data on disparities examine the differences between White and non-Hispanic Black women. Fewer studies have enough sample size to evaluate the outcomes in the Asian, American Indian or Alaskan Native, or mixed-race women. Racial differences are noted in the occurrence, presentation, and short-term and long-term outcomes of preeclampsia. Well-established clinical risk factors for preeclampsia such as obesity, diabetes, and chronic hypertension disproportionately affect non-Hispanic Black, American Indian or Alaskan Native, and Hispanic populations. However, with comparable clinical risk factors for preeclampsia among women of different race or ethnic groups, addressing modifiable risk factors has not been found to have the same protective effect for all women.
      Abnormalities of placental formation and development, immunologic factors, vascular changes, and inflammation have all been identified as contributing to the pathophysiology of preeclampsia. Few studies have examined race and the pathophysiology of preeclampsia. Despite attempts, a genetic basis for the disease has not been identified. A number of genetic variants, including apolipoprotein L1, have been identified as possible risk modifiers. Few studies have examined race and prevention of preeclampsia. Although low-dose aspirin for the prevention of preeclampsia is recommended by the US Preventive Service Task Force, a population-based study found racial and ethnic differences in preeclampsia recurrence after the implementation of low-dose aspirin supplementation. After implementation, recurrent preeclampsia reduced among Hispanic women (76.4% vs 49.6%; P<.001), but there was no difference in the recurrent preeclampsia in non-Hispanic Black women (13.7 vs 18.1; P=.252). Future research incorporating the National Institute on Minority Health and Health Disparities multilevel framework, specifically examining the role of racism on the burden of the disease, may help in the quest for effective strategies to reduce the disproportionate burden of preeclampsia on a minority population. In this model, a multilevel framework provides a more comprehensive approach and takes into account the influence of behavioral factors, environmental factors, and healthcare systems, not just on the individual.

      Key words

      Introduction

      Racial and ethnic disparities in outcomes are pervasive in obstetrics.
      • Culhane J.F.
      • Goldenberg R.L.
      Racial disparities in preterm birth.
      • David R.
      • Collins Jr., J.
      Disparities in infant mortality: what’s genetics got to do with it?.
      • Timofeev J.
      • Singh J.
      • Istwan N.
      • Rhea D.
      • Driggers R.W.
      Spontaneous preterm birth in African-American and Caucasian women receiving 17α-hydroxyprogesterone caproate.
      • Willis E.
      • McManus P.
      • Magallanes N.
      • Johnson S.
      • Majnik A.
      Conquering racial disparities in perinatal outcomes.
      Black women have the highest rates of severe maternal mortality compared to other racial and ethnic groups.
      • Liese K.L.
      • Mogos M.
      • Abboud S.
      • Decocker K.
      • Koch A.R.
      • Geller S.E.
      Racial and ethnic disparities in severe maternal morbidity in the United States.
      In the most recent maternal mortality report, the Centers for Disease Control and Prevention confirms that Black women continue to have a maternal mortality rate 2.5 to 3 times higher than White women (14.7 vs 37.1 deaths per 100,000 live births).
      • Hoyert D.L.
      • Miniño A.M.
      Maternal mortality in the United States: changes in coding, publication, and data release, 2018.
      As we are increasingly more informed on how race is a proxy for life experience
      • Lu M.C.
      • Halfon N.
      Racial and ethnic disparities in birth outcomes: a life-course perspective.
      and structural and societal racism
      • Matoba N.
      • Suprenant S.
      • Rankin K.
      • Yu H.
      • Collins J.W.
      Mortgage discrimination and preterm birth among African American women: an exploratory study.
      • Mustillo S.
      • Krieger N.
      • Gunderson E.P.
      • Sidney S.
      • McCreath H.
      • Kiefe C.I.
      Self-reported experiences of racial discrimination and black-white differences in preterm and low-birthweight deliveries: the CARDIA study.
      • Braveman P.
      • Heck K.
      • Egerter S.
      • et al.
      Worry about racial discrimination: a missing piece of the puzzle of black-white disparities in preterm birth?.
      • Fryer K.E.
      • Vines A.I.
      • Stuebe A.M.
      A multisite examination of everyday discrimination and the prevalence of spontaneous preterm birth in African American and Latina women in the United States.
      that directly affects women of different races and ethnicities, we must also examine maternal health outcomes from a life course perspective. The purpose of this expert review is to examine the existing literature on the influence of race and ethnicity in the origin, pathophysiology, and outcomes of preeclampsia.

      Race and Ethnicity: Categories, Definitions, and Limitations

      This review will use the Office of Management and Budget’s categorizations for race and ethnicity (Figure 1).
      Office of Management and Budget
      Revisions to the standards for classification of federal data on race and ethnicity.
      Although there are considerable limitations to this method, this classification system has been primarily used in the medical literature, because it has been historically used in the US census and population-level data. Race is defined with at least the following 5 minimum standards: American Indian or Alaskan Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, and White. Ethnicity is defined dichotomously as Hispanic or Latino or non-Hispanic.
      Figure thumbnail gr1
      Figure 1Categories of ethnicity and race (Office of Management and Budget)
      Johnson. Race and ethnicity in preeclampsia. Am J Obstet Gynecol 2022.
      The major limitation of the use of race and ethnicity in medical research is that race is a socially derived label that can either be self-reported or assigned.
      • White K.
      • Lawrence J.A.
      • Tchangalova N.
      • Huang S.J.
      • Cummings J.L.
      Socially assigned race and health: a scoping review with global implications for population health equity.
      ,
      • Mersha T.B.
      • Abebe T.
      Self-reported race/ethnicity in the age of genomic research: its potential impact on understanding health disparities.
      The assignment of one’s race or ethnicity is not rooted in scientific evidence to justify biological or genetic differences. Human population studies continue to find more genetic variations within racial groups than among them.
      • Maglo K.N.
      • Mersha T.B.
      • Martin L.J.
      Population genomics and the statistical values of race: an interdisciplinary perspective on the biological classification of human populations and implications for clinical genetic epidemiological research.
      For these reasons, the validity of race as an indicator of distinct, genetically different population groups has been questioned.
      • Mohsen H.
      Race and genetics: somber history, troubled present.
      Many researchers have shifted paradigms, defining race as a social construct based on phenotypic and genetic expressions rather than as a biological construct.
      • Ford M.E.
      • Kelly P.A.
      Conceptualizing and categorizing race and ethnicity in health services research.
      In addition, many individuals self-identify with more than 1 racial or ethnic group, which can be difficult to ascertain in research when choices may not be adequately comprehensive.
      • Kaufman J.S.
      How inconsistencies in racial classification demystify the race construct in public health statistics.
      Finally, although ethnicity in medical research has traditionally been a dichotomy of Hispanic and non-Hispanic,
      • Gimenez M.E.
      Latino/“Hispanic”—who needs a name? The case against a standardized terminology.
      ethnicity has also been described as attributable to one’s culture, language, country of origin, or traditions, which can leave out populations of interest when these categories are defined by investigators for a scientific inquiry.
      • Mersha T.B.
      • Abebe T.
      Self-reported race/ethnicity in the age of genomic research: its potential impact on understanding health disparities.
      Using the existing categorizations of race and ethnicity in medical research and literature is limited by the assignment of race (self-identified vs researcher- or healthcare worker–assigned) and failure to differentiate subgroups (eg, Asian race includes Indian, Samoan, Japanese, and Chinese individuals). Across the United States, studies vary in the amount of racial and ethnic diversity. Most studies that address the disparities focus on Black and White populations. Data on Asian, American Indian or Alaskan Native, and mixed-race individuals are often limited because of the small numbers of poorly designed studies that collapse them into the “other” racial groups.

      Race, Racism, and Preeclampsia

      There are 3 domains or types of racism—structural or institutionalized racism, personally mediated or individual-level discrimination, and internalized racism—that have all been recognized as mediators of health outcomes.
      • Jones C.P.
      Levels of racism: a theoretic framework and a gardener’s tale.
      • Bailey Z.D.
      • Krieger N.
      • Agénor M.
      • Graves J.
      • Linos N.
      • Bassett M.T.
      Structural racism and health inequities in the USA: evidence and interventions.
      • Williams D.R.
      • Lawrence J.A.
      • Davis B.A.
      Racism and health: evidence and needed research.
      Structural racism is defined as “the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, healthcare, and criminal justice.”
      • Bailey Z.D.
      • Krieger N.
      • Agénor M.
      • Graves J.
      • Linos N.
      • Bassett M.T.
      Structural racism and health inequities in the USA: evidence and interventions.
      Increasing the measurements of structural racism, defined most frequently in research as racial inequity (ratio of Black to White population estimates) in educational attainment, median household income, employment, imprisonment, and juvenile custody, was associated with a 5% increase in Black infant mortality (relative risk, 1.05; 95% confidence interval [CI], 1.01–1.10).
      • Wallace M.
      • Crear-Perry J.
      • Richardson L.
      • Tarver M.
      • Theall K.
      Separate and unequal: structural racism and infant mortality in the US.
      Black women from an urban population were found to have increased rates of adverse pregnancy outcomes with increasing rates of neighborhood segregation.
      • Salow A.D.
      • Pool L.R.
      • Grobman W.A.
      • Kershaw K.N.
      Associations of neighborhood-level racial residential segregation with adverse pregnancy outcomes.
      Personally mediated racism has also been linked to adverse pregnancy outcomes with 36.9% of Black women (95% CI, 32.9–40.9) and 5.5% of White women (95% CI, 4.5–6.5) reporting chronic worry about racial discrimination.
      • Braveman P.
      • Heck K.
      • Egerter S.
      • et al.
      Worry about racial discrimination: a missing piece of the puzzle of black-white disparities in preterm birth?.
      Because it relates to hypertensive diseases, it has been posited that ethnic differences in elevated blood pressures in response to the chronic stress from the experience of racial discrimination contribute to poorer cardiovascular health for Black women and men.
      • Clark R.
      • Anderson N.B.
      • Clark V.R.
      • Williams D.R.
      Racism as a stressor for African Americans. A biopsychosocial model.
      ,
      • Clark R.
      Self-reported racism and social support predict blood pressure reactivity in blacks.
      The studies to date that have examined the association between preeclampsia and racism have mostly grouped preeclampsia with other conditions under the category of hypertensive disorders of pregnancy, thereby limiting our data on preeclampsia itself.
      • Grobman W.A.
      • Parker C.B.
      • Willinger M.
      • et al.
      Racial disparities in adverse pregnancy outcomes and psychosocial stress.
      To elucidate an answer, researchers need to consider the National Institute on Minority Health and Health Disparities Research Framework (Figure 2).
      National Institute on Minority Health and Health Disparities
      NIMHD Minority Health and Health Disparities Research Framework.
      Figure thumbnail gr2
      Figure 2The NIMHD Research Framework
      The domains and levels of influence are described to reflect the interaction among the determinants of health.
      NIHMD, National Institute on Minority Health and Health Disparities.
      Johnson. Race and ethnicity in preeclampsia. Am J Obstet Gynecol 2022.
      Traditionally, preeclampsia research focused on the biological influence on an individual level. A multilevel approach would be more comprehensive and take into account the influence of behavioral factors, environmental factors, and healthcare systems, not just the factors related to the individual. Including a focus on the interpersonal, community, or a societal influence would be more comprehensive because it would account for cumulative or interactive effects of multiple determinants.
      • Alvidrez J.
      • Castille D.
      • Laude-Sharp M.
      • Rosario A.
      • Tabor D.
      The National Institute on Minority Health and Health Disparities Research Framework.
      Finally, the behaviors of healthcare professionals should be examined with a critical lens and examine how medical systems perpetuate racism.
      • Pereda B.
      • Montoya M.
      Addressing implicit bias to improve cross-cultural care.
      This can take the form of implicit biases about groups that may lead to differential treatment. In a group of medical students, 73% endorsed at least 1 false belief related to the biological differences in pain between people of Black race and people of White race and more often reported lower pain ratings for Black (vs White) targets.
      • Hoffman K.M.
      • Trawalter S.
      • Axt J.R.
      • Oliver M.N.
      Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites.
      Racial inequities in the administration of epidural analgesia
      • Glance L.G.
      • Wissler R.
      • Glantz C.
      • Osler T.M.
      • Mukamel D.B.
      • Dick A.W.
      Racial differences in the use of epidural analgesia for labor.
      and then experience, assessment, and treatment of postpartum pain have also been identified.
      • Johnson J.D.
      • Asiodu I.V.
      • McKenzie C.P.
      • et al.
      Racial and ethnic inequities in postpartum pain evaluation and management.
      The health equity framework integrates the individual-level biomedical and behavioral causes of a maternal disease, with the population-level differences in the sociocontextual environment, which might be the drivers of disparities in disease rates among groups (Figure 3). In the framework, social determinants of health contribute to the circumstances around health, economic opportunity, and chronic stressors. Differences in exposure and opportunities then contribute to disparate outcomes. As we investigate ways to reduce the disparities in outcomes, a health equity framework will help address the drivers more comprehensively. This can take the form of years of oppression that causes excess stress on the body or weathering that can affect one’s health.
      • Hibbs S.D.
      • Rankin K.M.
      • DeSisto C.
      • Collins Jr., J.W.
      The age-related patterns of preterm birth among urban African-American and non-Latina white mothers: the effect of paternal involvement.
      ,
      • Mendez D.D.
      • Hogan V.K.
      • Culhane J.F.
      Institutional racism, neighborhood factors, stress, and preterm birth.
      It could also be the implicit or explicit biases acted on by healthcare providers that result in inequitable treatment.
      • Hoffman K.M.
      • Trawalter S.
      • Axt J.R.
      • Oliver M.N.
      Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites.
      ,
      • Johnson J.D.
      • Asiodu I.V.
      • McKenzie C.P.
      • et al.
      Racial and ethnic inequities in postpartum pain evaluation and management.
      ,
      • Johnson T.J.
      • Hickey R.W.
      • Switzer G.E.
      • et al.
      The impact of cognitive stressors in the emergency department on physician implicit racial bias.
      Figure thumbnail gr3
      Figure 3The health equity framework
      The framework describes the way racism works through social determinant of health to impact maternal health along the life course.
      Johnson. Race and ethnicity in preeclampsia. Am J Obstet Gynecol 2022.

      The Role of Race and Ethnicity on the Prevalence of Preeclampsia

      The prevalence of preeclampsia is reported to be 2% to 8%.
      • Ananth C.V.
      • Keyes K.M.
      • Wapner R.J.
      Pre-eclampsia rates in the United States, 1980–2010: age-period-cohort analysis.
      An increased rate of preeclampsia among non-Hispanic Black women compared with non-Hispanic White women has been found in a number of studies,
      • Wolf M.
      • Shah A.
      • Jimenez-Kimble R.
      • Sauk J.
      • Ecker J.L.
      • Thadhani R.
      Differential risk of hypertensive disorders of pregnancy among Hispanic women.
      ,
      • Breathett K.
      • Muhlestein D.
      • Foraker R.
      • Gulati M.
      Differences in preeclampsia rates between African American and Caucasian women: trends from the National Hospital Discharge Survey.
      and Black race has been cited as a risk factor for preeclampsia.
      • Dekker G.A.
      Risk factors for preeclampsia.
      • Roberts J.M.
      • Cooper D.W.
      Pathogenesis and genetics of pre-eclampsia.
      • Gyamfi-Bannerman C.
      • Pandita A.
      • Miller E.C.
      • et al.
      Preeclampsia outcomes at delivery and race.
      In a study using data from the National Inpatient Sample (NIS), the largest publicly available all-payer hospital inpatient care database in the United States, 4.7% of the 177,000 deliveries included were complicated by preeclampsia.
      • Fingar K.R.
      • Mabry-Hernandez I.
      • Ngo-Metzger Q.
      • Wolff T.
      • Steiner C.A.
      • Elixhauser A.
      Delivery hospitalizations involving preeclampsia and eclampsia, 2005–2014: statistical brief #222.
      Black women experienced preeclampsia or eclampsia in 69.8 of every 1000 deliveries, compared with 43.3 per 1000 deliveries in White women, 46.8 per 1000 deliveries in Hispanic women, 28.8 per 1000 deliveries in Asian or Pacific Islander, and 46.6 per 1000 for all women, overall.
      • Fingar K.R.
      • Mabry-Hernandez I.
      • Ngo-Metzger Q.
      • Wolff T.
      • Steiner C.A.
      • Elixhauser A.
      Delivery hospitalizations involving preeclampsia and eclampsia, 2005–2014: statistical brief #222.
      Preeclampsia is understudied among the American Indian and Alaskan Native populations, but the prevalence is estimated to be 7% to 11%.
      • Zamora-Kapoor A.
      • Nelson L.A.
      • Buchwald D.S.
      • Walker L.R.
      • Mueller B.A.
      Pre-eclampsia in American Indians/Alaska Natives and whites: the significance of body mass index.
      Higher rates of preeclampsia have also been found in the American Indian and Alaskan Native populations compared with non-Hispanic White women (odds ratio [OR], 1.17; 95% CI, 1.06–1.29).
      • Zamora-Kapoor A.
      • Nelson L.A.
      • Buchwald D.S.
      • Walker L.R.
      • Mueller B.A.
      Pre-eclampsia in American Indians/Alaska Natives and whites: the significance of body mass index.
      The sum of the data appears to indicate an increased prevalence of preeclampsia among Black and American Indian or Alaskan Native women.
      Racial differences have also been reported in the timing of preeclampsia diagnosis (early vs late gestation). In a cohort of 9149 women who were prospectively evaluated for preeclampsia risk factors, compared with their White counterparts, women who self-identified as a member of the Black race were more likely to develop early preeclampsia (<34 weeks’ gestation) (OR, 3.64; 95% CI, 1.84–7.21) and late preeclampsia (≥34 weeks gestation) (OR, 2.97; 95% CI, 1.98–4.46).
      • Poon L.C.
      • Kametas N.A.
      • Chelemen T.
      • Leal A.
      • Nicolaides K.H.
      Maternal risk factors for hypertensive disorders in pregnancy: a multivariate approach.
      Women who self-identified as Indian or Pakistani (OR, 2.66; 95% CI, 1.29–5.48) or mixed race (OR, 3.31; 95% CI, 1.55–7.06) were more likely than their White counterparts to develop late preeclampsia.
      • Poon L.C.
      • Kametas N.A.
      • Chelemen T.
      • Leal A.
      • Nicolaides K.H.
      Maternal risk factors for hypertensive disorders in pregnancy: a multivariate approach.
      The prevalence of new-onset postpartum hypertensive disorders has reported rates ranging from 0.3% to 27.5%, with Black race and Latino ethnicity described as risk factors.
      • Sibai B.M.
      Etiology and management of postpartum hypertension-preeclampsia.
      A recent retrospective cohort study indicated that women with new-onset postpartum preeclampsia (n=121) were more likely to be of non-Hispanic Black race (31.4% vs 18.0%; P<.01).
      • Redman E.K.
      • Hauspurg A.
      • Hubel C.A.
      • Roberts J.M.
      • Jeyabalan A.
      Clinical course, associated factors, and blood pressure profile of delayed-onset postpartum preeclampsia.
      Postpartum preeclampsia contributes to hospital readmission rates, severe maternal morbidity, and mortality.
      • Al-Safi Z.
      • Imudia A.N.
      • Filetti L.C.
      • Hobson D.T.
      • Bahado-Singh R.O.
      • Awonuga A.O.
      Delayed postpartum preeclampsia and eclampsia: demographics, clinical course, and complications.
      Given that more than one-third of maternal deaths occur in the postpartum period, a focus on postpartum preeclampsia is imperative to decrease the US maternal mortality rates.
      • Petersen E.E.
      • Davis N.L.
      • Goodman D.
      • et al.
      Vital signs: pregnancy-related deaths, United States, 2011–2015, and strategies for prevention, 13 states, 2013–2017.
      One explanation for the increased prevalence of preeclampsia among Black women has been postulated to be related to the increased incidence of chronic hypertension in that population, resulting in misclassification of chronic hypertension as solely pregnancy-related hypertension, or to the increased risk of developing preeclampsia or eclampsia or pregnancy-aggravated hypertension among women with chronic hypertension.
      • Samadi A.R.
      • Mayberry R.M.
      • Reed J.W.
      Preeclampsia associated with chronic hypertension among African-American and white women.
      An observational study of 101 women appears to challenge that theory.
      • Bryant A.S.
      • Seely E.W.
      • Cohen A.
      • Lieberman E.
      Patterns of pregnancy-related hypertension in black and white women.
      Among women without chronic hypertension, Black women were more likely to be diagnosed with preeclampsia (78% vs 53%; P=.04) and more likely to have had systolic blood pressures of >160 mm Hg (43% vs 17%; P=.01). In addition, this study found that Black multiparous patients with chronic hypertension were more likely than White multiparous patients to receive a diagnosis of preeclampsia (80% vs 27%; P=.01).
      • Bryant A.S.
      • Seely E.W.
      • Cohen A.
      • Lieberman E.
      Patterns of pregnancy-related hypertension in black and white women.
      Obesity,
      • Snowden J.M.
      • Mission J.F.
      • Marshall N.E.
      • et al.
      The impact of maternal obesity and race/ethnicity on perinatal outcomes: independent and joint effects.
      sleep-disordered breathing,
      • Facco F.L.
      • Parker C.B.
      • Reddy U.M.
      • et al.
      Association between sleep-disordered breathing and hypertensive disorders of pregnancy and gestational diabetes mellitus.
      and diabetes,
      • Ackerman C.M.
      • Platner M.H.
      • Spatz E.S.
      • et al.
      Severe cardiovascular morbidity in women with hypertensive diseases during delivery hospitalization.
      all risk factors for preeclampsia, are more prevalent among Black women and American Indian or Alaskan Native women.
      • Wolf M.
      • Shah A.
      • Jimenez-Kimble R.
      • Sauk J.
      • Ecker J.L.
      • Thadhani R.
      Differential risk of hypertensive disorders of pregnancy among Hispanic women.
      ,
      • Facco F.L.
      • Parker C.B.
      • Reddy U.M.
      • et al.
      Association between sleep-disordered breathing and hypertensive disorders of pregnancy and gestational diabetes mellitus.
      ,
      • Bornstein E.
      • Eliner Y.
      • Chervenak F.A.
      • Grünebaum A.
      Racial disparity in pregnancy risks and complications in the US: temporal changes during 2007–2018.
      ,
      • Bartsch E.
      • Medcalf K.E.
      • Park A.L.
      • Ray J.G.
      High Risk of Pre-eclampsia Identification Group. Clinical risk factors for pre-eclampsia determined in early pregnancy: systematic review and meta-analysis of large cohort studies.
      Using Washington state hospital–linked birth discharge data, investigators found an association between the American Indian or Alaskan Native race and preeclampsia after adjusting for sociodemographic and clinical confounders (OR, 1.17; 95% CI, 1.06–1.29). However, after adjustment for body mass index, the odds of preeclampsia (OR, 1.05; 95% CI, 0.95–1.16) was no longer statistically significant.
      • Zamora-Kapoor A.
      • Nelson L.A.
      • Buchwald D.S.
      • Walker L.R.
      • Mueller B.A.
      Pre-eclampsia in American Indians/Alaska Natives and whites: the significance of body mass index.
      These findings are aligned with other more recent data that indicate obesity as a risk modifier may depend on race or ethnicity. In a birth certificate study, it was found that the effects of maternal race, ethnicity, and obesity were not uniform, varying among racial groups and also by the specific outcome being analyzed.
      • Snowden J.M.
      • Mission J.F.
      • Marshall N.E.
      • et al.
      The impact of maternal obesity and race/ethnicity on perinatal outcomes: independent and joint effects.
      In a study examining the relationship between severe preeclampsia and preexisting medical comorbidities, the effect of comorbidities on preeclampsia risk was least pronounced in Hispanic women and most pronounced in non-Hispanic Black women with similar comorbidities. This effect persisted in the presence of adverse sociodemographic factors in both groups and is consistent with what has been labeled the “Hispanic paradox.”
      • Carr A.
      • Kershaw T.
      • Brown H.
      • Allen T.
      • Small M.
      Hypertensive disease in pregnancy: an examination of ethnic differences and the Hispanic paradox.
      ,
      • Yeo S.
      • Wells P.J.
      • Kieffer E.C.
      • Nolan G.H.
      Preeclampsia among Hispanic women in a Detroit health system.
      The “Hispanic paradox” is a term used to describe the epidemiologic mystery of why Hispanic individuals in the United States live longer than their White counterparts despite generally lower socioeconomic status and healthcare access.
      The Hispanic paradox.
      Over time, it has also been used to describe scenarios where other health outcomes are better than expected among Hispanic women.
      • Carr A.
      • Kershaw T.
      • Brown H.
      • Allen T.
      • Small M.
      Hypertensive disease in pregnancy: an examination of ethnic differences and the Hispanic paradox.
      ,
      • Brown H.L.
      • Chireau M.V.
      • Jallah Y.
      • Howard D.
      The ”Hispanic paradox”: an investigation of racial disparity in pregnancy outcomes at a tertiary care medical center.

      The Role of Race and Ethnicity on the Pathophysiology of Preeclampsia

      Abnormalities of placental formation and development,
      • Antwi E.
      • Amoakoh-Coleman M.
      • Vieira D.L.
      • et al.
      Systematic review of prediction models for gestational hypertension and preeclampsia.
      • Madar-Shapiro L.
      • Karady I.
      • Trahtenherts A.
      • et al.
      Predicting the risk to develop preeclampsia in the first trimester combining promoter variant -98A/C of LGALS13 (placental protein 13), black ethnicity, previous preeclampsia, obesity, and maternal age.
      • Rivers E.R.
      • Horton A.J.
      • Hawk A.F.
      • et al.
      Placental Nkx2-5 and target gene expression in early-onset and severe preeclampsia.
      immunologic factors,
      • Best L.G.
      • Nadeau M.
      • Davis K.
      • Lamb F.
      • Bercier S.
      • Anderson C.M.
      Genetic variants, immune function, and risk of pre-eclampsia among American Indians.
      ,
      • Velickovic I.
      • Dalloul M.
      • Wong K.A.
      • et al.
      Complement factor B activation in patients with preeclampsia.
      vascular changes,
      • Duan W.
      • Xia C.
      • Wang K.
      • Duan Y.
      • Cheng P.
      • Xiong B.
      A meta-analysis of the vascular endothelial growth factor polymorphisms associated with the risk of pre-eclampsia.
      and inflammation have all been identified as contributing to the pathophysiology of preeclampsia.
      • Chaiworapongsa T.
      • Chaemsaithong P.
      • Yeo L.
      • Romero R.
      Pre-eclampsia part 1: current understanding of its pathophysiology.
      There has been a desire to investigate genetic causes of preeclampsia. Observations that led to a suggestion of a genetic component to preeclampsia are as follows: (1) studies that found an increased risk of recurrence of preeclampsia in subsequent pregnancies,
      • Christians J.K.
      • Huicochea Munoz M.F.
      Pregnancy complications recur independently of maternal vascular malperfusion lesions.
      • McDonald S.D.
      • Best C.
      • Lam K.
      The recurrence risk of severe de novo pre-eclampsia in singleton pregnancies: a population-based cohort.
      • van Oostwaard M.F.
      • Langenveld J.
      • Schuit E.
      • et al.
      Recurrence of hypertensive disorders of pregnancy: an individual patient data metaanalysis.
      (2) studies that observed an increased risk in first-degree relatives of women with preeclampsia,
      • Serrano N.C.
      • Quintero-Lesmes D.C.
      • Dudbridge F.
      • et al.
      Family history of pre-eclampsia and cardiovascular disease as risk factors for pre-eclampsia: the GenPE case-control study.
      ,
      • Al-Rubaie Z.T.A.
      • Hudson H.M.
      • Jenkins G.
      • et al.
      Prediction of pre-eclampsia in nulliparous women using routinely collected maternal characteristics: a model development and validation study.
      and (3) familial studies that found that a family history of hypertension and cardiovascular disease is associated with the occurrence of preeclampsia.
      • Bezerra P.C.
      • Leão M.D.
      • Queiroz J.W.
      • et al.
      Family history of hypertension as an important risk factor for the development of severe preeclampsia.
      ,
      • Ness R.B.
      • Markovic N.
      • Bass D.
      • Harger G.
      • Roberts J.M.
      Family history of hypertension, heart disease, and stroke among women who develop hypertension in pregnancy.
      Preeclampsia manifests as complex phenotypes, resulting from both maternal and fetal genetic features.
      • Triche E.W.
      • Uzun A.
      • DeWan A.T.
      • et al.
      Bioinformatic approach to the genetics of preeclampsia.
      Candidate genes have been investigated, but much of the focus of racial differences has been on African ancestry.
      Diminished or aberrant human leukocyte antigen G expression patterns may contribute to the development of preeclampsia.
      • Loisel D.A.
      • Billstrand C.
      • Murray K.
      • et al.
      The maternal HLA-G 1597ΔC null mutation is associated with increased risk of pre-eclampsia and reduced HLA-G expression during pregnancy in African-American women.
      Recent studies of women identified as having African ancestry or being a member of the Black race observed an increased risk of preeclampsia when the mother carried the 1597ΔC allele. In contrast, the presence of the 1597ΔC allele in the fetus was not associated with preeclampsia risk.
      • Loisel D.A.
      • Billstrand C.
      • Murray K.
      • et al.
      The maternal HLA-G 1597ΔC null mutation is associated with increased risk of pre-eclampsia and reduced HLA-G expression during pregnancy in African-American women.
      Another effort to explain the higher rates of preeclampsia among Black women has focused on the finding that common coding variants in the apolipoprotein L1 gene (APOL1) are potent risk factors for a spectrum of kidney diseases in Black Americans. Investigators hypothesized that APOL1 variants play a role in the excess risk for preeclampsia among Black women.
      • Dummer P.D.
      • Limou S.
      • Rosenberg A.Z.
      • et al.
      APOL1 kidney disease risk variants: an evolving landscape.
      The study included 121 infants born to women with preeclampsia at 1 center, and 886 women with and without preeclampsia at a second center. The investigators concluded that fetal APOL1 high-risk genotype was associated with the development of preeclampsia in both centers with an OR of 1.84 (95% CI, 1.11–2.93) and 1.92 (95% CI, 1.05–3.49). Maternal APOL1 did not indicate the same effect.
      • Reidy K.J.
      • Hjorten R.C.
      • Simpson C.L.
      • et al.
      Fetal-not maternal-APOL1 genotype associated with risk for preeclampsia in those with African ancestry.
      Researchers theorized that the presence of a high-risk variant of APOL1 protein in the fetus may adversely affect the placental function leading to preeclampsia.
      Soluble fms-like tyrosine kinase (sFlt1), a soluble-deactivating receptor for the vascular endothelial growth factor (VEGF) and the placental growth factor, has been implicated in the pathogenesis of preeclampsia.
      • Levine R.J.
      • Maynard S.E.
      • Qian C.
      • et al.
      Circulating angiogenic factors and the risk of preeclampsia.
      Both VEGF and placental growth factor are potent stimulators of angiogenesis and regulators of endothelial function.
      • Levine R.J.
      • Maynard S.E.
      • Qian C.
      • et al.
      Circulating angiogenic factors and the risk of preeclampsia.
      In a study of more than 600 women, the association between the genetic variation in 6 angiogenesis pathway genes and preeclampsia was investigated in White and Black women from our large case-control study.
      • Srinivas S.K.
      • Morrison A.C.
      • Andrela C.M.
      • Elovitz M.A.
      Allelic variations in angiogenic pathway genes are associated with preeclampsia.
      Notably, 3 single nucleotide polymorphisms (SNPs) in Black women and a different 3 SNPs in White women were associated with preeclampsia.
      • Srinivas S.K.
      • Morrison A.C.
      • Andrela C.M.
      • Elovitz M.A.
      Allelic variations in angiogenic pathway genes are associated with preeclampsia.
      However, the allelic variants that were associated with preeclampsia in each racial group were not associated with differences in the serum sFlt levels within the cases and control subjects in those racial groups.
      • Srinivas S.K.
      • Morrison A.C.
      • Andrela C.M.
      • Elovitz M.A.
      Allelic variations in angiogenic pathway genes are associated with preeclampsia.
      Older studies focused more on oxidative stress and inflammatory pathways with inconsistent results.
      • Abbasi H.
      • Dastgheib S.A.
      • Hadadan A.
      • et al.
      Association of endothelial nitric oxide synthase 894G > T polymorphism with preeclampsia risk: a systematic review and meta-analysis based on 35 studies.
      • Veisian M.
      • Tabatabaei R.S.
      • Javaheri A.
      • et al.
      Association of interleukin-10 -1082G > A polymorphism with susceptibility to preeclampsia: a systematic review and meta-analysis based on 21 studies.
      • Giannakou K.
      • Evangelou E.
      • Papatheodorou S.I.
      Genetic and non-genetic risk factors for pre-eclampsia: umbrella review of systematic reviews and meta-analyses of observational studies.
      In a systematic review of 35 studies looking at the endothelial nitric oxide synthase polymorphism and preeclampsia risk stratified by ethnicity, a higher risk of preeclampsia was observed in the White or mixed-race populations with the 894 guanine>thymine polymorphism but not in those of Asian or African descent.
      • Abbasi H.
      • Dastgheib S.A.
      • Hadadan A.
      • et al.
      Association of endothelial nitric oxide synthase 894G > T polymorphism with preeclampsia risk: a systematic review and meta-analysis based on 35 studies.
      Another systematic review and meta-analysis based on 21 studies investigated the role of interleukin-10 (IL-10) polymorphisms and preeclampsia risk. IL-10–1082 guanine>adenine polymorphism stratified by ethnicity found a markedly increased risk of developing preeclampsia in Asian and mixed-race populations but not in White populations.
      • Veisian M.
      • Tabatabaei R.S.
      • Javaheri A.
      • et al.
      Association of interleukin-10 -1082G > A polymorphism with susceptibility to preeclampsia: a systematic review and meta-analysis based on 21 studies.
      Although some racial and ethnic trends in gene expression have been suggested in the aforementioned studies, more investigation is needed to elucidate the degree to which these genotypes can or cannot affect the risk of preeclampsia in the presence of other clinical risk factors.

      Race, Ethnicity, and Preeclampsia Outcomes: Short-Term Outcomes

      Preeclampsia and its related morbidity are substantial contributors to pregnancy-related deaths in the United States.
      • Petersen E.E.
      • Davis N.L.
      • Goodman D.
      • et al.
      Vital signs: pregnancy-related deaths, United States, 2011–2015, and strategies for prevention, 13 states, 2013–2017.
      The presentation and outcomes of preeclampsia have also been disparate among racial and ethnic groups.
      • Petersen E.E.
      • Davis N.L.
      • Goodman D.
      • et al.
      Racial/ethnic disparities in pregnancy-related deaths—United States, 2007–2016.
      In a study of 473 women with severe preeclampsia, non-Hispanic Black women were more likely to have severe hypertension at presentation (45% vs 32% and 27%; P=.005) and require antihypertensive medications (45.8% vs 36.8% and 25%; P=.01) than White or Hispanic women, respectively. White women had a more frequent diagnosis of HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome than Black women (30 vs 19; P=.03).
      • Goodwin A.A.
      • Mercer B.M.
      Does maternal race or ethnicity affect the expression of severe preeclampsia?.
      In another study of similar size, the increased risk was not confirmed.
      • Williams K.P.
      • Wilson S.
      Ethnic variation in the incidence of HELLP syndrome in a hypertensive pregnant population.
      The infants of Black women also do not fare well. Black infants of women with preeclampsia are more likely than their White counterparts to be very low birthweight and very preterm (OR, 3.77 [95% CI, 2.77–5.13], and OR, 3.66 [95% CI, 2.66–5.03], respectively).
      • Mbah A.K.
      • Alio A.P.
      • Marty P.J.
      • Bruder K.
      • Wilson R.
      • Salihu H.M.
      Recurrent versus isolated pre-eclampsia and risk of feto-infant morbidity outcomes: racial/ethnic disparity.
      Black women with preeclampsia are also more likely to have fetal demise.
      • Shahul S.
      • Tung A.
      • Minhaj M.
      • et al.
      Racial disparities in comorbidities, complications, and maternal and fetal outcomes in women with preeclampsia/eclampsia.
      In a study of 3921 women, despite similar severity of preeclampsia, Hispanic women had lower rates of preeclampsia-related infant morbidity, consistent with the “Hispanic paradox.”
      • Carr A.
      • Kershaw T.
      • Brown H.
      • Allen T.
      • Small M.
      Hypertensive disease in pregnancy: an examination of ethnic differences and the Hispanic paradox.
      Examining the outcomes of the more uncommon complications has been challenged by the use of administrative databases in which the diagnosis of preeclampsia and race and ethnicity may lack specificity.
      • Andrade S.E.
      • Bérard A.
      • Nordeng H.M.E.
      • Wood M.E.
      • van Gelder M.M.H.J.
      • Toh S.
      Administrative claims data versus augmented pregnancy data for the study of pharmaceutical treatments in pregnancy.
      In a study using the NIS, a large publicly available all-payer inpatient care database in the United States, non-Hispanic Black women when compared with non-Hispanic White, Hispanic, and all other women, had a higher rate of preeclampsia-related severe maternal morbidity, including stroke (17.1 vs 6.5, 12.7, and 9.3 per 10,000 deliveries, respectively; P<.01), and pulmonary edema or heart failure (56.2 vs 32.7, 30.2, and 38.4 per 10,000 deliveries, respectively; P<.01).
      • Gyamfi-Bannerman C.
      • Pandita A.
      • Miller E.C.
      • et al.
      Preeclampsia outcomes at delivery and race.
      ,
      • Levine L.D.
      • Nkonde-Price C.
      • Limaye M.
      • Srinivas S.K.
      Factors associated with postpartum follow-up and persistent hypertension among women with severe preeclampsia.
      The disparate outcomes persist into the postpartum period. Black women were more likely to have hospital readmission for cardiovascular disease diagnosis (6.8 vs 1.7 vs 1.0 per 1000 deliveries, respectively; P<.001) than White women.
      • Jarvie J.L.
      • Metz T.D.
      • Davis M.B.
      • Ehrig J.C.
      • Kao D.P.
      Short-term risk of cardiovascular readmission following a hypertensive disorder of pregnancy.
      Black women diagnosed with preeclampsia with severe features have lower rates of postpartum follow-up than women of other racial or ethnic groups (47.0% vs 70.5%; P=.007).
      • Levine L.D.
      • Nkonde-Price C.
      • Limaye M.
      • Srinivas S.K.
      Factors associated with postpartum follow-up and persistent hypertension among women with severe preeclampsia.
      For women with preeclampsia, the risk of maternal mortality is higher for Black women than all other groups (121.8 per 100,000 deliveries [95% CI, 69.7–212.9] vs 24.1 per 100,000 deliveries [95% CI, 14.6–39.8], respectively; P<.01).
      • Gyamfi-Bannerman C.
      • Pandita A.
      • Miller E.C.
      • et al.
      Preeclampsia outcomes at delivery and race.
      Most concerning was the fact that 60% of the maternal deaths are preventable and Black women are more likely to have a preventable death.
      • Mehta P.K.
      • Kieltyka L.
      • Bachhuber M.A.
      • et al.
      Racial inequities in preventable pregnancy-related deaths in Louisiana, 2011-2016.
      Targeted efforts to address preeclampsia reduction in Black women would significantly move the needle in the fight against US maternal mortality for all women.

      Long-Term Implications of Preeclampsia: Future Health

      Survivors of preeclampsia face a 2-fold increased risk of cardiovascular disease, and that risk can be seen within 3 to 5 years after delivery.
      • Cain M.A.
      • Salemi J.L.
      • Tanner J.P.
      • Kirby R.S.
      • Salihu H.M.
      • Louis J.M.
      Pregnancy as a window to future health: maternal placental syndromes and short-term cardiovascular outcomes.
      • Garovic V.D.
      • White W.M.
      • Vaughan L.
      • et al.
      Incidence and long-term outcomes of hypertensive disorders of pregnancy.
      • Behrens I.
      • Basit S.
      • Melbye M.
      • et al.
      Risk of post-pregnancy hypertension in women with a history of hypertensive disorders of pregnancy: nationwide cohort study.
      Black women are more likely to have long-term consequences of preeclampsia, including chronic hypertension and cardiovascular disease progression.
      • Ross K.M.
      • Guardino C.
      • Dunkel Schetter C.
      • Hobel C.J.
      Interactions between race/ethnicity, poverty status, and pregnancy cardio-metabolic diseases in prediction of postpartum cardio-metabolic health.
      Obesity, chronic hypertension, sleep-disordered breathing, and the development of diabetes have been implicated. However, there seem to be short-term differences in the manifestations of the cardiovascular changes after the development of preeclampsia.
      In a cohort of 29 matched case-control pairs of Black women, there was more abnormal cardiac function as evidenced by worse cardiac systolic function (longitudinal strain), increased chamber stiffness (end-systolic elastance), and worse diastolic function as measured by noninvasive echocardiographic tissue Doppler assessment in preeclampsia cases compared with controls.
      • Levine L.D.
      • Lewey J.
      • Koelper N.
      • et al.
      Persistent cardiac dysfunction on echocardiography in African American women with severe preeclampsia.
      These findings persisted 4 to 12 weeks after delivery, and worse diastolic function and increased arterial stiffness were noted in the postpartum period.
      • Levine L.D.
      • Lewey J.
      • Koelper N.
      • et al.
      Persistent cardiac dysfunction on echocardiography in African American women with severe preeclampsia.
      These cardiac changes and propensity to hypertension in the postpartum period are further compounded by low postpartum follow-up rates.
      • Levine L.D.
      • Nkonde-Price C.
      • Limaye M.
      • Srinivas S.K.
      Factors associated with postpartum follow-up and persistent hypertension among women with severe preeclampsia.
      However, novel use of text messaging was associated with a higher adherence rate across all racial and ethnic groups. It appeared to close the disparity gap in postpartum blood pressure management.
      • Levine L.D.
      • Nkonde-Price C.
      • Limaye M.
      • Srinivas S.K.
      Factors associated with postpartum follow-up and persistent hypertension among women with severe preeclampsia.
      ,
      • Hirshberg A.
      • Sammel M.D.
      • Srinivas S.K.
      Text message remote monitoring reduced racial disparities in postpartum blood pressure ascertainment.
      Further studies are needed to examine the trajectory of cardiovascular diseases to identify potential therapeutic targets further and models of care that will address the disparities. Left undeterred, there will continue to be substantial disparities in cardiovascular diseases among different ethnic or racial groups.

      Race, Ethnicity, and Preeclampsia Prevention

      The US Preventive Services Task Force recommended low-dose aspirin for the prevention of recurrent preeclampsia in 2014.
      • Henderson J.T.
      • O’Connor E.
      • Whitlock E.P.
      Low-dose aspirin for prevention of morbidity and mortality from preeclampsia.
      A single-center study evaluating the population-based effect of this recommendation on the prevalence of recurrent preeclampsia found differences among racial and ethnic groups. Although the relative proportion of Hispanic women who experienced recurrent preeclampsia after the implementation of low-dose aspirin was lower in the postaspirin group (76.4% vs 49.6%; P<.0001), there was no difference in recurrent preeclampsia in non-Hispanic Black women (13.7 vs 18.1; P=.252).
      • Tolcher M.C.
      • Chu D.M.
      • Hollier L.M.
      • et al.
      Impact of USPSTF recommendations for aspirin for prevention of recurrent preeclampsia.
      Other therapeutic agents used to prevent preeclampsia, which have been investigated and remain controversial, include heparin,
      • McLaughlin K.
      • Scholten R.R.
      • Parker J.D.
      • Ferrazzi E.
      • Kingdom J.C.P.
      Low molecular weight heparin for the prevention of severe preeclampsia: where next?.
      calcium supplementation,
      • Hofmeyr G.J.
      • Manyame S.
      Calcium supplementation commencing before or early in pregnancy, or food fortification with calcium, for preventing hypertensive disorders of pregnancy.
      and folic acid.
      • Wertaschnigg D.
      • Reddy M.
      • Mol B.W.J.
      • da Silva Costa F.
      • Rolnik D.L.
      Evidence-based prevention of preeclampsia: commonly asked questions in clinical practice.
      ,
      • Hua X.
      • Zhang J.
      • Guo Y.
      • et al.
      Effect of folic acid supplementation during pregnancy on gestational hypertension/preeclampsia: a systematic review and meta-analysis.
      There are insufficient data on racial or ethnic differences to comment on disparities in safety, efficacy, or outcomes.
      Weight loss, particularly through bariatric surgery, has been associated with a reduction in recurrent preeclampsia and adverse pregnancy outcomes in most but not all studies.
      • Ibiebele I.
      • Gallimore F.
      • Schnitzler M.
      • Torvaldsen S.
      • Ford J.B.
      Perinatal outcomes following bariatric surgery between a first and second pregnancy: a population data linkage study.
      • Kwong W.
      • Tomlinson G.
      • Feig D.S.
      Maternal and neonatal outcomes after bariatric surgery; a systematic review and meta-analysis: do the benefits outweigh the risks?.
      • Galazis N.
      • Docheva N.
      • Simillis C.
      • Nicolaides K.H.
      Maternal and neonatal outcomes in women undergoing bariatric surgery: a systematic review and meta-analysis.
      Data on disparities in outcomes and effectiveness are limited.
      • Malik S.
      • Teh J.L.
      • Lomanto D.
      • Kim G.
      • So J.B.
      • Shabbir A.
      Maternal and fetal outcomes of Asian pregnancies after bariatric surgery.
      However, given the well-documented disparities in access to obesity treatment and uptake of bariatric surgery, there would need to be careful consideration of the sample size needed for a meaningful analysis.
      • Byrd A.S.
      • Toth A.T.
      • Stanford F.C.
      Racial disparities in obesity treatment.
      ,
      • Fouse T.
      • Schauer P.
      The socioeconomic impact of morbid obesity and factors affecting access to obesity surgery.
      Finally, although socioeconomic status (SES) has been implicated as a modifiable risk factor for adverse birth outcomes, this relationship has been called into question.
      • Ross K.M.
      • Dunkel Schetter C.
      • McLemore M.R.
      • et al.
      Socioeconomic status, preeclampsia risk and gestational length in black and white women.
      In a cohort of 718,604 Black and White women drawn from a population-based California cohort, high SES in White women was associated with a decreased risk of preeclampsia. However, Black women continued to have a higher risk of developing preeclampsia independent of education (OR, 1.56; 95% CI, 1.48–1.64) or insurance status (OR, 1.55; 95% CI, 1.48–1.63). This phenomenon of Black women not receiving the same protective benefit from the improved sociodemographic factors has been labeled Minorities’ Diminished Returns (MDR).
      • Ross K.M.
      • Dunkel Schetter C.
      • McLemore M.R.
      • et al.
      Socioeconomic status, preeclampsia risk and gestational length in black and white women.
      MDR can be defined as the observation of smaller health gains from SES indicators such as education attainment among ethnic minorities compared with the majority group.
      • Assari S.
      Blacks’ diminished return of education attainment on subjective health; mediating effect of income.
      These findings should not discourage providers from supporting all patients in risk-reducing behaviors. However, they should be aware that even in the absence of these sociodemographic risk factors some racial or ethnic groups continue to be at a higher risk of preeclampsia.

      Future Research and Solutions

      To continue to decrease health disparities, researchers and clinicians should continue to systematically and reliably include race and ethnicity in their studies. Researchers should acknowledge the limitations of race and ethnicity as a scientific variable when critiquing their study design. Kaplan and Bennett
      • Kaplan J.B.
      • Bennett T.
      Use of race and ethnicity in biomedical publication.
      outline some of the challenges in race and ethnicity research—including the importance of distinguishing between a risk factor and a risk marker. However, it is essential that it is done so in a way that does not perpetuate racism. Finding an association between a disease and race and ethnicity does not imply causality. It should prompt us to inspect the underlying intersectionality of health disparities,
      • Louis J.M.
      • Menard M.K.
      • Gee R.E.
      Racial and ethnic disparities in maternal morbidity and mortality.
      • Eichelberger K.Y.
      • Doll K.
      • Ekpo G.E.
      • Zerden M.L.
      Black lives matter: claiming a space for evidence-based outrage in obstetrics and gynecology.
      • Jain J.
      • Moroz L.
      Strategies to reduce disparities in maternal morbidity and mortality: patient and provider education.
      including, but not limited to, the social context of one’s community, socioeconomic factors, and environmental exposures. Finally, translational and clinical research dedicated to health disparities should consider how to ask questions that are not only health equity–focused but also solution-oriented, such as the utilization of the public health critical race methodology.
      • Ford C.L.
      • Airhihenbuwa C.O.
      The public health critical race methodology: praxis for antiracism research.
      Despite the pervasive reports of disparities, strategies to reduce them remain limited in a disease that disproportionately affects the short-term and long-term health of minority populations.
      • Maric-Bilkan C.
      • Abrahams V.M.
      • Arteaga S.S.
      • et al.
      Research recommendations from the National Institutes of Health workshop on predicting, preventing, and treating preeclampsia.
      Considerations for research priorities are listed in the Table.
      TableCritical research gaps in the role of race and ethnicity in preeclampsia
      Research priorityConsideration
      EpidemiologyQuality analyses on outcomes in racial ethnic subgroups
      Mechanisms of diseaseInterventions to address the role of psychosocial stressor on preeclampsia
      ManagementImpact of implicit bias training on preeclampsia recognition and management
      Long-term outcomesEquitable access to postpartum care and care across the life course
      Studies of the postpartum trajectory to cardiovascular disease using the NIMHD Research Framework
      Studies of interventions to decrease the risk of cardiovascular disease using the NIMHD Research Framework
      NIHMD, National Institute on Minority Health and Health Disparities.
      Johnson. Race and ethnicity in preeclampsia. Am J Obstet Gynecol 2022.

      Comment

      Racial and ethnic disparities are commonly reported in the preeclampsia literature, and people of Black and American Indian or Alaskan Native races are widely reported to have a higher risk of preeclampsia. However, the contemporary understanding of race as a social construct as opposed to a biological or genetic factor points to race as a risk marker. Differential experiences based on race and ethnicity influence the origins and outcomes of the disease, leading to disparate outcomes. There remain substantial gaps in the literature, most prominently in the strategies to reduce disparities in preeclampsia management and outcomes. Studies of interventions should include a multilevel approach that accounts for the dynamic interplay of multiple levels of influence to be effective.
      • Agurs-Collins T.
      • Persky S.
      • Paskett E.D.
      • et al.
      Designing and assessing multilevel interventions to improve minority health and reduce health disparities.
      Continued research should be made looking at how one’s experience has generational effects on their and their family’s health outcomes. As stated previously, in discussions about health disparities by racial group, it is imperative to separate the social construct of race from what is driving a lot of the observed differences, which is racism.

      References

        • Culhane J.F.
        • Goldenberg R.L.
        Racial disparities in preterm birth.
        Semin Perinatol. 2011; 35: 234-239
        • David R.
        • Collins Jr., J.
        Disparities in infant mortality: what’s genetics got to do with it?.
        Am J Public Health. 2007; 97: 1191-1197
        • Timofeev J.
        • Singh J.
        • Istwan N.
        • Rhea D.
        • Driggers R.W.
        Spontaneous preterm birth in African-American and Caucasian women receiving 17α-hydroxyprogesterone caproate.
        Am J Perinatol. 2014; 31: 55-60
        • Willis E.
        • McManus P.
        • Magallanes N.
        • Johnson S.
        • Majnik A.
        Conquering racial disparities in perinatal outcomes.
        Clin Perinatol. 2014; 41: 847-875
        • Liese K.L.
        • Mogos M.
        • Abboud S.
        • Decocker K.
        • Koch A.R.
        • Geller S.E.
        Racial and ethnic disparities in severe maternal morbidity in the United States.
        J Racial Ethn Health Disparities. 2019; 6: 790-798
        • Hoyert D.L.
        • Miniño A.M.
        Maternal mortality in the United States: changes in coding, publication, and data release, 2018.
        Natl Vital Stat Rep. 2020; 69: 1-18
        • Lu M.C.
        • Halfon N.
        Racial and ethnic disparities in birth outcomes: a life-course perspective.
        Matern Child Health J. 2003; 7: 13-30
        • Braveman P.
        • Heck K.
        • Egerter S.
        • et al.
        Worry about racial discrimination: a missing piece of the puzzle of black-white disparities in preterm birth?.
        PLoS One. 2017; 12e0186151
        • Fryer K.E.
        • Vines A.I.
        • Stuebe A.M.
        A multisite examination of everyday discrimination and the prevalence of spontaneous preterm birth in African American and Latina women in the United States.
        Am J Perinatol. 2019; ([Epub ahead of print])
        • Matoba N.
        • Suprenant S.
        • Rankin K.
        • Yu H.
        • Collins J.W.
        Mortgage discrimination and preterm birth among African American women: an exploratory study.
        Health Place. 2019; 59: 102193
        • Mustillo S.
        • Krieger N.
        • Gunderson E.P.
        • Sidney S.
        • McCreath H.
        • Kiefe C.I.
        Self-reported experiences of racial discrimination and black-white differences in preterm and low-birthweight deliveries: the CARDIA study.
        Am J Public Health. 2004; 94: 2125-2131
        • Office of Management and Budget
        Revisions to the standards for classification of federal data on race and ethnicity.
        Federal Register. 1997; 62: 58781-58790
        • White K.
        • Lawrence J.A.
        • Tchangalova N.
        • Huang S.J.
        • Cummings J.L.
        Socially assigned race and health: a scoping review with global implications for population health equity.
        Int J Equity Health. 2020; 19: 25
        • Mersha T.B.
        • Abebe T.
        Self-reported race/ethnicity in the age of genomic research: its potential impact on understanding health disparities.
        Hum Genomics. 2015; 9: 1
        • Maglo K.N.
        • Mersha T.B.
        • Martin L.J.
        Population genomics and the statistical values of race: an interdisciplinary perspective on the biological classification of human populations and implications for clinical genetic epidemiological research.
        Front Genet. 2016; 7: 22
        • Mohsen H.
        Race and genetics: somber history, troubled present.
        Yale J Biol Med. 2020; 93: 215-219
        • Ford M.E.
        • Kelly P.A.
        Conceptualizing and categorizing race and ethnicity in health services research.
        Health Serv Res. 2005; 40: 1658-1675
        • Kaufman J.S.
        How inconsistencies in racial classification demystify the race construct in public health statistics.
        Epidemiology. 1999; 10: 101-103
        • Gimenez M.E.
        Latino/“Hispanic”—who needs a name? The case against a standardized terminology.
        Int J Health Serv. 1989; 19: 557-571
        • Jones C.P.
        Levels of racism: a theoretic framework and a gardener’s tale.
        Am J Public Health. 2000; 90: 1212-1215
        • Bailey Z.D.
        • Krieger N.
        • Agénor M.
        • Graves J.
        • Linos N.
        • Bassett M.T.
        Structural racism and health inequities in the USA: evidence and interventions.
        Lancet. 2017; 389: 1453-1463
        • Williams D.R.
        • Lawrence J.A.
        • Davis B.A.
        Racism and health: evidence and needed research.
        Annu Rev Public Health. 2019; 40: 105-125
        • Wallace M.
        • Crear-Perry J.
        • Richardson L.
        • Tarver M.
        • Theall K.
        Separate and unequal: structural racism and infant mortality in the US.
        Health Place. 2017; 45: 140-144
        • Salow A.D.
        • Pool L.R.
        • Grobman W.A.
        • Kershaw K.N.
        Associations of neighborhood-level racial residential segregation with adverse pregnancy outcomes.
        Am J Obstet Gynecol. 2018; 218: 351.e1-351.e7
        • Clark R.
        • Anderson N.B.
        • Clark V.R.
        • Williams D.R.
        Racism as a stressor for African Americans. A biopsychosocial model.
        Ann Psychol. 1999; 54: 805-816
        • Clark R.
        Self-reported racism and social support predict blood pressure reactivity in blacks.
        Ann Behav Med. 2003; 25: 127-136
        • Grobman W.A.
        • Parker C.B.
        • Willinger M.
        • et al.
        Racial disparities in adverse pregnancy outcomes and psychosocial stress.
        Obstet Gynecol. 2018; 131: 328-335
        • National Institute on Minority Health and Health Disparities
        NIMHD Minority Health and Health Disparities Research Framework.
        (Available at:)
        • Alvidrez J.
        • Castille D.
        • Laude-Sharp M.
        • Rosario A.
        • Tabor D.
        The National Institute on Minority Health and Health Disparities Research Framework.
        Am J Public Health. 2019; 109: S16-S20
        • Pereda B.
        • Montoya M.
        Addressing implicit bias to improve cross-cultural care.
        Clin Obstet Gynecol. 2018; 61: 2-9
        • Hoffman K.M.
        • Trawalter S.
        • Axt J.R.
        • Oliver M.N.
        Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites.
        Proc Natl Acad Sci U S A. 2016; 113: 4296-4301
        • Glance L.G.
        • Wissler R.
        • Glantz C.
        • Osler T.M.
        • Mukamel D.B.
        • Dick A.W.
        Racial differences in the use of epidural analgesia for labor.
        Anesthesiology. 2007; 106 (discussion 6–8): 19-25
        • Johnson J.D.
        • Asiodu I.V.
        • McKenzie C.P.
        • et al.
        Racial and ethnic inequities in postpartum pain evaluation and management.
        Obstet Gynecol. 2019; 134: 1155-1162
        • Hibbs S.D.
        • Rankin K.M.
        • DeSisto C.
        • Collins Jr., J.W.
        The age-related patterns of preterm birth among urban African-American and non-Latina white mothers: the effect of paternal involvement.
        Soc Sci Med. 2018; 211: 16-20
        • Mendez D.D.
        • Hogan V.K.
        • Culhane J.F.
        Institutional racism, neighborhood factors, stress, and preterm birth.
        Ethn Health. 2014; 19: 479-499
        • Johnson T.J.
        • Hickey R.W.
        • Switzer G.E.
        • et al.
        The impact of cognitive stressors in the emergency department on physician implicit racial bias.
        Acad Emerg Med. 2016; 23: 297-305
        • Ananth C.V.
        • Keyes K.M.
        • Wapner R.J.
        Pre-eclampsia rates in the United States, 1980–2010: age-period-cohort analysis.
        BMJ. 2013; 347: f6564
        • Wolf M.
        • Shah A.
        • Jimenez-Kimble R.
        • Sauk J.
        • Ecker J.L.
        • Thadhani R.
        Differential risk of hypertensive disorders of pregnancy among Hispanic women.
        J Am Soc Nephrol. 2004; 15: 1330-1338
        • Breathett K.
        • Muhlestein D.
        • Foraker R.
        • Gulati M.
        Differences in preeclampsia rates between African American and Caucasian women: trends from the National Hospital Discharge Survey.
        J Womens Health (Larchmt). 2014; 23: 886-893
        • Dekker G.A.
        Risk factors for preeclampsia.
        Clin Obstet Gynecol. 1999; 42: 422-435
        • Roberts J.M.
        • Cooper D.W.
        Pathogenesis and genetics of pre-eclampsia.
        Lancet. 2001; 357: 53-56
        • Gyamfi-Bannerman C.
        • Pandita A.
        • Miller E.C.
        • et al.
        Preeclampsia outcomes at delivery and race.
        J Matern Fetal Neonatal Med. 2019; ([Epub ahead of print])
        • Fingar K.R.
        • Mabry-Hernandez I.
        • Ngo-Metzger Q.
        • Wolff T.
        • Steiner C.A.
        • Elixhauser A.
        Delivery hospitalizations involving preeclampsia and eclampsia, 2005–2014: statistical brief #222.
        in: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Agency for Healthcare Research and Quality (US), Rockville (MD)2006
        • Zamora-Kapoor A.
        • Nelson L.A.
        • Buchwald D.S.
        • Walker L.R.
        • Mueller B.A.
        Pre-eclampsia in American Indians/Alaska Natives and whites: the significance of body mass index.
        Matern Child Health J. 2016; 20: 2233-2238
        • Poon L.C.
        • Kametas N.A.
        • Chelemen T.
        • Leal A.
        • Nicolaides K.H.
        Maternal risk factors for hypertensive disorders in pregnancy: a multivariate approach.
        J Hum Hypertens. 2010; 24: 104-110
        • Sibai B.M.
        Etiology and management of postpartum hypertension-preeclampsia.
        Am J Obstet Gynecol. 2012; 206: 470-475
        • Redman E.K.
        • Hauspurg A.
        • Hubel C.A.
        • Roberts J.M.
        • Jeyabalan A.
        Clinical course, associated factors, and blood pressure profile of delayed-onset postpartum preeclampsia.
        Obstet Gynecol. 2019; 134: 995-1001
        • Al-Safi Z.
        • Imudia A.N.
        • Filetti L.C.
        • Hobson D.T.
        • Bahado-Singh R.O.
        • Awonuga A.O.
        Delayed postpartum preeclampsia and eclampsia: demographics, clinical course, and complications.
        Obstet Gynecol. 2011; 118: 1102-1107
        • Petersen E.E.
        • Davis N.L.
        • Goodman D.
        • et al.
        Vital signs: pregnancy-related deaths, United States, 2011–2015, and strategies for prevention, 13 states, 2013–2017.
        MMWR Morb Mortal Wkly Rep. 2019; 68: 423-429
        • Samadi A.R.
        • Mayberry R.M.
        • Reed J.W.
        Preeclampsia associated with chronic hypertension among African-American and white women.
        Ethn Dis. 2001; 11: 192-200
        • Bryant A.S.
        • Seely E.W.
        • Cohen A.
        • Lieberman E.
        Patterns of pregnancy-related hypertension in black and white women.
        Hypertens Pregnancy. 2005; 24: 281-290
        • Snowden J.M.
        • Mission J.F.
        • Marshall N.E.
        • et al.
        The impact of maternal obesity and race/ethnicity on perinatal outcomes: independent and joint effects.
        Obesity (Silver Spring). 2016; 24: 1590-1598
        • Facco F.L.
        • Parker C.B.
        • Reddy U.M.
        • et al.
        Association between sleep-disordered breathing and hypertensive disorders of pregnancy and gestational diabetes mellitus.
        Obstet Gynecol. 2017; 129: 31-41
        • Ackerman C.M.
        • Platner M.H.
        • Spatz E.S.
        • et al.
        Severe cardiovascular morbidity in women with hypertensive diseases during delivery hospitalization.
        Am J Obstet Gynecol. 2019; 220: 582.e1-582.e11
        • Bornstein E.
        • Eliner Y.
        • Chervenak F.A.
        • Grünebaum A.
        Racial disparity in pregnancy risks and complications in the US: temporal changes during 2007–2018.
        J Clin Med. 2020; 9: 1414
        • Bartsch E.
        • Medcalf K.E.
        • Park A.L.
        • Ray J.G.
        High Risk of Pre-eclampsia Identification Group. Clinical risk factors for pre-eclampsia determined in early pregnancy: systematic review and meta-analysis of large cohort studies.
        BMJ. 2016; 353: i1753
        • Carr A.
        • Kershaw T.
        • Brown H.
        • Allen T.
        • Small M.
        Hypertensive disease in pregnancy: an examination of ethnic differences and the Hispanic paradox.
        J Neonatal Perinatal Med. 2013; 6: 11-15
        • Yeo S.
        • Wells P.J.
        • Kieffer E.C.
        • Nolan G.H.
        Preeclampsia among Hispanic women in a Detroit health system.
        Ethn Dis. 2007; 17: 118-121
      1. The Hispanic paradox.
        Lancet. 2015; 385: 1918
        • Brown H.L.
        • Chireau M.V.
        • Jallah Y.
        • Howard D.
        The ”Hispanic paradox”: an investigation of racial disparity in pregnancy outcomes at a tertiary care medical center.
        Am J Obstet Gynecol. 2007; 197 (discussion 197.e7–9): 197.e1-197.e7
        • Antwi E.
        • Amoakoh-Coleman M.
        • Vieira D.L.
        • et al.
        Systematic review of prediction models for gestational hypertension and preeclampsia.
        PLoS One. 2020; 15e0230955
        • Madar-Shapiro L.
        • Karady I.
        • Trahtenherts A.
        • et al.
        Predicting the risk to develop preeclampsia in the first trimester combining promoter variant -98A/C of LGALS13 (placental protein 13), black ethnicity, previous preeclampsia, obesity, and maternal age.
        Fetal Diagn Ther. 2018; 43: 250-265
        • Rivers E.R.
        • Horton A.J.
        • Hawk A.F.
        • et al.
        Placental Nkx2-5 and target gene expression in early-onset and severe preeclampsia.
        Hypertens Pregnancy. 2014; 33: 412-426
        • Best L.G.
        • Nadeau M.
        • Davis K.
        • Lamb F.
        • Bercier S.
        • Anderson C.M.
        Genetic variants, immune function, and risk of pre-eclampsia among American Indians.
        Am J Reprod Immunol. 2012; 67: 152-159
        • Velickovic I.
        • Dalloul M.
        • Wong K.A.
        • et al.
        Complement factor B activation in patients with preeclampsia.
        J Reprod Immunol. 2015; 109: 94-100
        • Duan W.
        • Xia C.
        • Wang K.
        • Duan Y.
        • Cheng P.
        • Xiong B.
        A meta-analysis of the vascular endothelial growth factor polymorphisms associated with the risk of pre-eclampsia.
        Biosci Rep. 2020; 40BSR20190209
        • Chaiworapongsa T.
        • Chaemsaithong P.
        • Yeo L.
        • Romero R.
        Pre-eclampsia part 1: current understanding of its pathophysiology.
        Nat Rev Nephrol. 2014; 10: 466-480
        • Christians J.K.
        • Huicochea Munoz M.F.
        Pregnancy complications recur independently of maternal vascular malperfusion lesions.
        PLoS One. 2020; 15e0228664
        • McDonald S.D.
        • Best C.
        • Lam K.
        The recurrence risk of severe de novo pre-eclampsia in singleton pregnancies: a population-based cohort.
        BJOG. 2009; 116: 1578-1584
        • van Oostwaard M.F.
        • Langenveld J.
        • Schuit E.
        • et al.
        Recurrence of hypertensive disorders of pregnancy: an individual patient data metaanalysis.
        Am J Obstet Gynecol. 2015; 212: 624.e1-624.e17
        • Serrano N.C.
        • Quintero-Lesmes D.C.
        • Dudbridge F.
        • et al.
        Family history of pre-eclampsia and cardiovascular disease as risk factors for pre-eclampsia: the GenPE case-control study.
        Hypertens Pregnancy. 2020; 39: 56-63
        • Al-Rubaie Z.T.A.
        • Hudson H.M.
        • Jenkins G.
        • et al.
        Prediction of pre-eclampsia in nulliparous women using routinely collected maternal characteristics: a model development and validation study.
        BMC Pregnancy Childbirth. 2020; 20: 23
        • Bezerra P.C.
        • Leão M.D.
        • Queiroz J.W.
        • et al.
        Family history of hypertension as an important risk factor for the development of severe preeclampsia.
        Acta Obstet Gynecol Scand. 2010; 89: 612-617
        • Ness R.B.
        • Markovic N.
        • Bass D.
        • Harger G.
        • Roberts J.M.
        Family history of hypertension, heart disease, and stroke among women who develop hypertension in pregnancy.
        Obstet Gynecol. 2003; 102: 1366-1371
        • Triche E.W.
        • Uzun A.
        • DeWan A.T.
        • et al.
        Bioinformatic approach to the genetics of preeclampsia.
        Obstet Gynecol. 2014; 123: 1155-1161
        • Loisel D.A.
        • Billstrand C.
        • Murray K.
        • et al.
        The maternal HLA-G 1597ΔC null mutation is associated with increased risk of pre-eclampsia and reduced HLA-G expression during pregnancy in African-American women.
        Mol Hum Reprod. 2013; 19: 144-152
        • Dummer P.D.
        • Limou S.
        • Rosenberg A.Z.
        • et al.
        APOL1 kidney disease risk variants: an evolving landscape.
        Semin Nephrol. 2015; 35: 222-236
        • Reidy K.J.
        • Hjorten R.C.
        • Simpson C.L.
        • et al.
        Fetal-not maternal-APOL1 genotype associated with risk for preeclampsia in those with African ancestry.
        Am J Hum Genet. 2018; 103: 367-376
        • Levine R.J.
        • Maynard S.E.
        • Qian C.
        • et al.
        Circulating angiogenic factors and the risk of preeclampsia.
        N Engl J Med. 2004; 350: 672-683
        • Srinivas S.K.
        • Morrison A.C.
        • Andrela C.M.
        • Elovitz M.A.
        Allelic variations in angiogenic pathway genes are associated with preeclampsia.
        Am J Obstet Gynecol. 2010; 202: 445.e1-445.e11
        • Abbasi H.
        • Dastgheib S.A.
        • Hadadan A.
        • et al.
        Association of endothelial nitric oxide synthase 894G > T polymorphism with preeclampsia risk: a systematic review and meta-analysis based on 35 studies.
        Fetal Pediatr Pathol. 2020; ([Epub ahead of print])
        • Veisian M.
        • Tabatabaei R.S.
        • Javaheri A.
        • et al.
        Association of interleukin-10 -1082G > A polymorphism with susceptibility to preeclampsia: a systematic review and meta-analysis based on 21 studies.
        Fetal Pediatr Pathol. 2019; ([Epub ahead of print])
        • Giannakou K.
        • Evangelou E.
        • Papatheodorou S.I.
        Genetic and non-genetic risk factors for pre-eclampsia: umbrella review of systematic reviews and meta-analyses of observational studies.
        Ultrasound Obstet Gynecol. 2018; 51: 720-730
        • Petersen E.E.
        • Davis N.L.
        • Goodman D.
        • et al.
        Racial/ethnic disparities in pregnancy-related deaths—United States, 2007–2016.
        MMWR Morb Mortal Wkly Rep. 2019; 68: 762-765
        • Goodwin A.A.
        • Mercer B.M.
        Does maternal race or ethnicity affect the expression of severe preeclampsia?.
        Am J Obstet Gynecol. 2005; 193: 973-978
        • Williams K.P.
        • Wilson S.
        Ethnic variation in the incidence of HELLP syndrome in a hypertensive pregnant population.
        J Perinat Med. 1997; 25: 498-501
        • Mbah A.K.
        • Alio A.P.
        • Marty P.J.
        • Bruder K.
        • Wilson R.
        • Salihu H.M.
        Recurrent versus isolated pre-eclampsia and risk of feto-infant morbidity outcomes: racial/ethnic disparity.
        Eur J Obstet Gynecol Reprod Biol. 2011; 156: 23-28
        • Shahul S.
        • Tung A.
        • Minhaj M.
        • et al.
        Racial disparities in comorbidities, complications, and maternal and fetal outcomes in women with preeclampsia/eclampsia.
        Hypertens Pregnancy. 2015; 34: 506-515
        • Andrade S.E.
        • Bérard A.
        • Nordeng H.M.E.
        • Wood M.E.
        • van Gelder M.M.H.J.
        • Toh S.
        Administrative claims data versus augmented pregnancy data for the study of pharmaceutical treatments in pregnancy.
        Curr Epidemiol Rep. 2017; 4: 106-116
        • Levine L.D.
        • Nkonde-Price C.
        • Limaye M.
        • Srinivas S.K.
        Factors associated with postpartum follow-up and persistent hypertension among women with severe preeclampsia.
        J Perinatol. 2016; 36: 1079-1082
        • Jarvie J.L.
        • Metz T.D.
        • Davis M.B.
        • Ehrig J.C.
        • Kao D.P.
        Short-term risk of cardiovascular readmission following a hypertensive disorder of pregnancy.
        Heart. 2018; 104: 1187-1194
        • Mehta P.K.
        • Kieltyka L.
        • Bachhuber M.A.
        • et al.
        Racial inequities in preventable pregnancy-related deaths in Louisiana, 2011-2016.
        Obstet Gynecol. 2020; 135: 276-283
        • Cain M.A.
        • Salemi J.L.
        • Tanner J.P.
        • Kirby R.S.
        • Salihu H.M.
        • Louis J.M.
        Pregnancy as a window to future health: maternal placental syndromes and short-term cardiovascular outcomes.
        Am J Obstet Gynecol. 2016; 215: 484.e1-484.e14
        • Garovic V.D.
        • White W.M.
        • Vaughan L.
        • et al.
        Incidence and long-term outcomes of hypertensive disorders of pregnancy.
        J Am Coll Cardiol. 2020; 75: 2323-2334
        • Behrens I.
        • Basit S.
        • Melbye M.
        • et al.
        Risk of post-pregnancy hypertension in women with a history of hypertensive disorders of pregnancy: nationwide cohort study.
        BMJ. 2017; 358: j3078
        • Ross K.M.
        • Guardino C.
        • Dunkel Schetter C.
        • Hobel C.J.
        Interactions between race/ethnicity, poverty status, and pregnancy cardio-metabolic diseases in prediction of postpartum cardio-metabolic health.
        Ethn Health. 2018; ([Epub ahead of print])
        • Levine L.D.
        • Lewey J.
        • Koelper N.
        • et al.
        Persistent cardiac dysfunction on echocardiography in African American women with severe preeclampsia.
        Pregnancy Hypertens. 2019; 17: 127-132
        • Hirshberg A.
        • Sammel M.D.
        • Srinivas S.K.
        Text message remote monitoring reduced racial disparities in postpartum blood pressure ascertainment.
        Am J Obstet Gynecol. 2019; 221: 283-285
        • Henderson J.T.
        • O’Connor E.
        • Whitlock E.P.
        Low-dose aspirin for prevention of morbidity and mortality from preeclampsia.
        Ann Intern Med. 2014; 161: 613-614
        • Tolcher M.C.
        • Chu D.M.
        • Hollier L.M.
        • et al.
        Impact of USPSTF recommendations for aspirin for prevention of recurrent preeclampsia.
        Am J Obstet Gynecol. 2017; 217: 365.e1-365.e8
        • McLaughlin K.
        • Scholten R.R.
        • Parker J.D.
        • Ferrazzi E.
        • Kingdom J.C.P.
        Low molecular weight heparin for the prevention of severe preeclampsia: where next?.
        Br J Clin Pharmacol. 2018; 84: 673-678
        • Hofmeyr G.J.
        • Manyame S.
        Calcium supplementation commencing before or early in pregnancy, or food fortification with calcium, for preventing hypertensive disorders of pregnancy.
        Cochrane Database Syst Rev. 2017; 9: CD011192
        • Wertaschnigg D.
        • Reddy M.
        • Mol B.W.J.
        • da Silva Costa F.
        • Rolnik D.L.
        Evidence-based prevention of preeclampsia: commonly asked questions in clinical practice.
        J Pregnancy. 2019; 2019: 2675101
        • Hua X.
        • Zhang J.
        • Guo Y.
        • et al.
        Effect of folic acid supplementation during pregnancy on gestational hypertension/preeclampsia: a systematic review and meta-analysis.
        Hypertens Pregnancy. 2016; 35: 447-460
        • Ibiebele I.
        • Gallimore F.
        • Schnitzler M.
        • Torvaldsen S.
        • Ford J.B.
        Perinatal outcomes following bariatric surgery between a first and second pregnancy: a population data linkage study.
        BJOG. 2020; 127: 345-354
        • Kwong W.
        • Tomlinson G.
        • Feig D.S.
        Maternal and neonatal outcomes after bariatric surgery; a systematic review and meta-analysis: do the benefits outweigh the risks?.
        Am J Obstet Gynecol. 2018; 218: 573-580
        • Galazis N.
        • Docheva N.
        • Simillis C.
        • Nicolaides K.H.
        Maternal and neonatal outcomes in women undergoing bariatric surgery: a systematic review and meta-analysis.
        Eur J Obstet Gynecol Reprod Biol. 2014; 181: 45-53
        • Malik S.
        • Teh J.L.
        • Lomanto D.
        • Kim G.
        • So J.B.
        • Shabbir A.
        Maternal and fetal outcomes of Asian pregnancies after bariatric surgery.
        Surg Obes Relat Dis. 2020; 16: 529-535
        • Byrd A.S.
        • Toth A.T.
        • Stanford F.C.
        Racial disparities in obesity treatment.
        Curr Obes Rep. 2018; 7: 130-138
        • Fouse T.
        • Schauer P.
        The socioeconomic impact of morbid obesity and factors affecting access to obesity surgery.
        Surg Clin North Am. 2016; 96: 669-679
        • Ross K.M.
        • Dunkel Schetter C.
        • McLemore M.R.
        • et al.
        Socioeconomic status, preeclampsia risk and gestational length in black and white women.
        J Racial Ethn Health Disparities. 2019; 6: 1182-1191
        • Assari S.
        Blacks’ diminished return of education attainment on subjective health; mediating effect of income.
        Brain Sci. 2018; 8: 176
        • Kaplan J.B.
        • Bennett T.
        Use of race and ethnicity in biomedical publication.
        JAMA. 2003; 289: 2709-2716
        • Louis J.M.
        • Menard M.K.
        • Gee R.E.
        Racial and ethnic disparities in maternal morbidity and mortality.
        Obstet Gynecol. 2015; 125: 690-694
        • Eichelberger K.Y.
        • Doll K.
        • Ekpo G.E.
        • Zerden M.L.
        Black lives matter: claiming a space for evidence-based outrage in obstetrics and gynecology.
        Am J Public Health. 2016; 106: 1771-1772
        • Jain J.
        • Moroz L.
        Strategies to reduce disparities in maternal morbidity and mortality: patient and provider education.
        Semin Perinatol. 2017; 41: 323-328
        • Ford C.L.
        • Airhihenbuwa C.O.
        The public health critical race methodology: praxis for antiracism research.
        Soc Sci Med. 2010; 71: 1390-1398
        • Maric-Bilkan C.
        • Abrahams V.M.
        • Arteaga S.S.
        • et al.
        Research recommendations from the National Institutes of Health workshop on predicting, preventing, and treating preeclampsia.
        Hypertension. 2019; 73: 757-766
        • Agurs-Collins T.
        • Persky S.
        • Paskett E.D.
        • et al.
        Designing and assessing multilevel interventions to improve minority health and reduce health disparities.
        Am J Public Health. 2019; 109: S86-S93