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Use of Race, Ethnicity, and National Origin in Studies Assessing Cardiovascular Risk in Women With a History of Hypertensive Disorders of Pregnancy

  • Amy Johnston
    Correspondence
    Corresponding author: Ms Amy Johnston, University of Ottawa Heart Institute, Room H-2258, 40 Ruskin Street, Ottawa, Ontario K1Y 4W7, Canada. Tel,: +1-613-620-0902.
    Affiliations
    School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada

    Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada

    Brain and Heart Nexus Research Program, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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  • Victrine Tseung
    Affiliations
    Brain and Heart Nexus Research Program, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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  • Sonia R. Dancey
    Affiliations
    School of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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  • Sarah M. Visintini
    Affiliations
    Berkman Library, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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  • Thais Coutinho
    Affiliations
    Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada

    Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada

    Canadian Women’s Heart Health Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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  • Jodi D. Edwards
    Affiliations
    School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada

    Brain and Heart Nexus Research Program, University of Ottawa Heart Institute, Ottawa, Ontario, Canada

    IC/ES, Ottawa, Ontario, Canada
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Open AccessPublished:August 20, 2021DOI:https://doi.org/10.1016/j.cjco.2021.08.002

      Abstract

      Women with a history of hyperBtensive disorders of pregnancy (HDP) are at particularly high risk for cardiovascular disease (CVD) and CVD-related death, and certain racial and ethnic subpopulations are disproportionately affected by these conditions. We examined the use of race, ethnicity, and national origin in observational studies assessing CVD morbidity and mortality in women with a history of HDP. A total of 124 studies, published between 1976 and 2021, were reviewed. We found that white women were heavily overrepresented, encompassing 53% of all participants with HDP. There was limited and heterogeneous reporting of race and ethnicity information across studies and only 27 studies reported including race and/or ethnicity variables in at least 1 statistical analysis. Only 2 studies mentioned the use of these variables as a strength; several others (k = 18) reported a lack of diversity among participants as a study limitation. Just over half of included articles (k = 68) reported at least 1 sociodemographic variable other than race and ethnicity (eg, marital status and income); however, none investigated how they might have worked synergistically or antagonistically with race and/or ethnicity to influence participants’ risk of CVD. These findings highlight significant areas for improvement in cardiovascular obstetrics research, including the need for more robust and standardized methods for collecting, reporting, and using sociodemographic information. Future studies of CVD risk in women with a history of HDP should explicitly examine racial and ethnic differences and use an intersectional approach.

      Résumé

      Les femmes ayant des antécédents de troubles hypertensifs de la grossesse (THG) présentent un risque particulièrement élevé de maladies cardiovasculaires (MCV) et de décès liés à ces dernières, et certaines sous-populations raciales et ethniques sont touchées de manière disproportionnée par ces maladies. Nous avons examiné l’utilisation de la race, de l’ethnicité et de l’origine nationale dans les études observationnelles évaluant la morbidité et la mortalité liées aux MCV chez les femmes ayant des antécédents de THG. Un total de 124 études, publiées entre 1976 et 2021, ont été examinées. Nous avons constaté que les femmes blanches étaient fortement surreprésentées, puisqu’elles constituaient 53 % de l’ensemble des participantes atteintes de THG. Les renseignements relatifs à la race et à l’ethnicité étaient limités et hétérogènes d’une étude à l’autre, et seules 27 études ont indiqué avoir tenu compte de variables relatives à la race ou à l’ethnicité dans au moins une analyse statistique. Seules deux études ont mentionné l’utilisation de ces variables comme un point fort; plusieurs autres (k = 18) ont signalé un manque de diversité parmi les participantes comme une limite de l’étude. Un peu plus de la moitié des articles inclus (k = 68) ont fait état d’au moins une variable sociodémographique autre que la race et l’ethnicité (p. ex., l’état matrimonial et le revenu); aucun toutefois n’a étudié la manière dont ces variables auraient pu agir en synergie ou en opposition avec la race ou l’ethnicité pour influencer le risque de MCV des participantes. Ces résultats mettent en évidence des points importants à améliorer dans la recherche sur l’obstétrique cardiovasculaire, notamment la nécessité de méthodes plus fiables et normalisées en matière de collecte, de communication et d’utilisation des données sociodémographiques. Les prochaines études sur le risque de MCV chez les femmes ayant des antécédents de THG devraient examiner explicitement les différences raciales et ethniques et adopter une approche intersectionnelle.
      Cardiovascular disease (CVD) is the leading cause of hospitalization among Canadian women,
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      Women with a history of hypertensive disorders of pregnancy (HDP), which affect 5%-10% of all pregnancies, are at particularly high risk for CVD and CVD-related death.
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      Substantial heterogeneity exists in the association between HDP and CVD, such that certain racial and ethnic subpopulations (eg, non-Hispanic black and American Indian or Alaska Native women) are disproportionately affected by these conditions.
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      as inconsistent and incomplete reporting in primary studies can lead to information about race and ethnicity becoming unusable.
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      Although often used interchangeably, race and ethnicity have different meanings and are distinct social constructs.
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      There are currently no globally accepted definitions of race and ethnicity.
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      However, in general, race is used to categorize individuals on the basis of perceived physical differences, such as skin colour.
      In contrast, ethnicity refers to membership of a cultural group and may be tied to an individual’s nationality, language, or religion, among other factors.
      Although these constructs are commonly reported in health research,
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      they are far more subjective than an individual’s age or sex,
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      often resulting in their being weakly measured, poorly analyzed, and inadequately reported.
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      Because the use of race and/or ethnicity can affect the quantification of cardiovascular risk estimates, it is imperative that researchers (1) carefully report on and discuss why race and ethnicity variables are used, (2) discuss how these variables are assessed, and (3) discuss the potential implications of study findings based on their use.
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      Four-year review of the use of race and ethnicity in epidemiologic and public health research.
      Critically, others
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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.
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      Four-year review of the use of race and ethnicity in epidemiologic and public health research.
      ,
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      Levels of racism: a theoretic framework and a gardener's tale.
      note the need to avoid erroneously attributing disparities in health outcomes to specific racial or ethnic groups without attempting to understand or investigate the underlying causes of disparities. To this end, a 2020 report
      published by the Canadian Institute for Health Information outlined proposed standards for collecting race and indigenous identity data in health care, noting a lack of consensus on data collection standards for these variables. Further, as recently as March 2021, Ontario-based administrative health data provider ICES
      Be part of a Peoples’ Panel to guide how race and ethnicity data are used in health research in Ontario Toronto, ON: IC/ES.
      announced a call for participants to become members of a “People’s Panel” with the goal of creating of a race and ethnicity data framework “to ensure the anti-racist use of race, ethnicity and immigration data.”
      ICES
      In: @ICESOntario, editor. We’re recruiting Ontarians to be part of a People’s Panel to ensure the anti-racist use of race, ethnicity and immigration data Please share widely.
      Medical journals are also taking note of the need for more careful consideration of the terminology used when describing race and ethnicity. For example, a 2021 Journal of the American Medical Association
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      The reporting of race and ethnicity in medical and science journals: comments invited.
      editorial discussed revisions to its submission requirements on race and ethnicity and announced a formal request for input on ways to improve.
      Given recent and increasing calls for improved reporting and analysis of race and ethnicity, coupled with the serious short and long-term consequences that HDP can have on women’s cardiovascular health and its increasing global prevalence
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      • Wapner R.J.
      Pre-eclampsia rates in the United States, 1980-2010: age-period-cohort analysis.
      ,
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      Recent advances in the understanding of the pathophysiology of preeclampsia.
      —especially among racial and ethnic subpopulations
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      Recent advances in the understanding of the pathophysiology of preeclampsia.
      ,
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      The burden of hypertensive disorders of pregnancy in Africa: a systematic review and meta-analysis.
      —it is prudent to examine how researchers have used race and ethnicity in studies assessing CVD risk in women with a history of HDP. To address this gap, in this rapid review, we conducted a new analysis examining the use of race, ethnicity, and national origin in prior observational studies assessing CVD morbidity and mortality in women with a history of HDP.

      Methods

      A rapid review is a type of evidence synthesis produced using streamlined systematic review (SR) methodology to address a predefined research question(s) and the most rigorous methods that a reduced timeframe allows.
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      A scoping review of rapid review methods.
      As noted by Polisena et al.,
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      there is no standardized approach to conduct a rapid review, as the methods used should be tailored to meet the specific needs of the study (eg, the expertise of the research team, nature of the evidence base, research question[s], and study aims) as well as those of the end user.
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      Some of the more common methodologic strategies used in rapid reviews include (1) the use of recently published SRs as a starting point in identifying eligible literature,
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      (2) literature screening and inclusion by a single reviewer,
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      (3) limiting the breadth of evidence synthesis to a descriptive summary/categorization of data,
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      (4) narrowing study eligibility criteria (eg, including literature published in English only),
      • Pham M.T.
      • Waddell L.
      • Rajić A.
      • Sargeant J.M.
      • Papadopoulos A.
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      Implications of applying methodological shortcuts to expedite systematic reviews: three case studies using systematic reviews from agri-food public health.
      and (5) omitting a formal risk of bias assessment or quality appraisal of included studies.
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      Implications of applying methodological shortcuts to expedite systematic reviews: three case studies using systematic reviews from agri-food public health.
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      Critically, in their comparison of rapid and systematic reviews addressing similar research questions , Watt et al.
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      found that the conclusions of reviews conducted using either approach were similar.

      Review context

      This review adds novel information to previous work
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      Four-year review of the use of race and ethnicity in epidemiologic and public health research.
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      that explored the use of race and ethnicity in epidemiologic and health services research. We build on this literature by focusing our exploration of these concepts within the context of studies estimating cardiovascular risk in women with a history of HDP.

      Eligibility criteria

      We used recently published SRs/meta-analyses to populate an initial list of potentially eligible primary studies. Full descriptions of eligibility criteria for both SRs and primary studies are provided in Supplemental Tables S1 and S2, respectively. Briefly, SRs were eligible for inclusion if authors included observational studies (ie, cohort studies, case-control studies, and cross-sectional studies) examining CV morbidity and mortality in women with a history of HDP. Specific CVDs of interest included heart failure, arrhythmias, ischemic heart disease (including coronary heart disease and myocardial infarction), stroke, and death from CV causes. In addition to these CV outcomes, SRs that included studies examining the association between HDP and chronic hypertension (HTN) were also of interest because of its robust association with CVD risk and mortality.
      • Whelton P.K.
      • Carey R.M.
      • Aronow W.S.
      • et al.
      2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
      Included primary studies obtained from published SRs and the literature search update (see Literature Search and Screening section) were screened for inclusion according to the inclusion criteria shown in Supplemental Table S2. Conference abstracts, letters, case reports, opinion pieces, and studies published in languages other than English were excluded. No restrictions were placed on year of publication for primary studies.

      Literature search and screening

      Two literature searches were designed and carried out by an experienced research librarian (S.V.) on May 20, 2021, in MEDLINE (see Supplemental Tables S3 and S4 for full search details). The first search was carried out to identify recently published SRs. The second literature search was used to identify recently published primary studies. Both searches comprised terms related to pregnancy-induced hypertensive disorders and were informed by previously conducted systematic literature searches.
      • Vahedi F.A.
      • Gholizadeh L.
      • Heydari M.
      Hypertensive disorders of pregnancy and risk of future cardiovascular disease in women.
      ,
      • Wu R.
      • Wang T.
      • Gu R.
      • et al.
      Hypertensive disorders of pregnancy and risk of cardiovascular disease-related morbidity and mortality: a systematic review and meta-analysis.
      The first search was limited to English-language SRs or health technology assessments published from 2020 to present.
      Strings Attached: CADTH's Database Search Filters Ottawa, ON: CADTH.
      The second search also incorporated terms relating to coronary artery disease, heart failure, stroke, and myocardial infarction, and was limited to English-language observational studies
      • Fraser C.
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      Identifying observational studies of surgical interventions in MEDLINE and EMBASE.
      published from 2019 to present. A gray literature search was not undertaken. All results were exported to Covidence (Melbourne, Australia), and duplicates were eliminated using the platform’s duplicate identification feature.
      Deduplicated search results were imported into DistillerSR (Ottawa, Canada), which was used to facilitate the screening and data extraction process for our race and ethnicity analysis. SRs and primary studies were managed in separate project folders. First, the titles/abstracts of all records identified through literature searches were screened for inclusion by a single author (A.J.) against the eligibility criteria. The full text of all records identified as potentially eligible based on the results of the title/abstract screen were then assessed for full eligibility. The included study lists of fully eligible SRs were then imported into EndNote (New York, NY) bibliographic software and the platform’s duplicate identification feature was used to remove duplicate records. All deduplicated records were then imported into DistillerSR and the full texts screened for inclusion.

      Extraction of race and ethnicity data from primary studies

      All data were independently extracted by three authors (A.J., V.T., S.D.) into customized extraction forms housed in DistillerSR. Pilot tests were completed on 5 studies by all reviewers, and adjustments were made as required before full data extraction began. Two reviewers (A.J., S.D.) audited extracted data for completeness and accuracy. When necessary, disagreements were resolved by consensus.
      Data extracted from fully eligible primary studies included:
      • Study characteristics (author name, publication year, journal name and type, funding, country of conduct, cardiovascular outcomes reported, study design, data source, aims and objectives)
      • Race, ethnicity, and geographical origin of participants (geographical origin or participants; if and where race and ethnicity were reported in the study; the terms used to describe race and ethnicity; how race and ethnicity were defined, assessed, and reported; whether and how race and ethnicity were included in analyses; and number of participants by race or ethnic category by HDP diagnosis)
      • Other sociodemographic characteristics reported by authors (eg, participant income, marital status, education, employment, religious affiliation)
      Study and population characteristics were only extracted if they were relevant to this review. For example, information about irrelevant exposures and comparison groups such as gestational diabetes or women with a history of normotensive pregnancies was not extracted. Further, in the event of a composite exposure (eg, maternal placental syndrome), only information about participants with HDP was extracted. If the geographic location of participants was not stated, the location of the corresponding author was extracted in its place. Supplemental material and previously published methods were not routinely collected or examined for information of interest unless authors explicitly reported that information pertinent to this review was reported elsewhere (eg, supplemental analyses by race or ethnicity or demographic information presented for the study population). Studies were considered to have included participants of a single race or ethnicity if authors made explicit statements such as “black women.”

      Quality assessment

      In accordance with our rapid review protocol, included primary studies were not formally assessed for quality. However, given that we were interested in the reporting and use of race, ethnicity, and national origin in studies of observational design, we noted which studies made use of the Strengthening of Reporting of Observational Studies in Epidemiology (STROBE)
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      • Vandenbroucke J.P.
      Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies.
      guideline or its extension, the Reporting of Studies Conducted Using Observational Routinely Collected Health Data (RECORD)
      • Benchimol E.I.
      • Smeeth L.
      • Guttmann A.
      • et al.
      The reporting of studies conducted using observational routinely-collected health data (RECORD) statement.
      statement, as appropriate. First published in 2007, the STROBE guidelines were created to improve the reporting quality of observational studies.
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      The STROBE guidelines.
      The RECORD extension should be used for observational studies that use routinely collected health data.
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      • Smeeth L.
      • Guttmann A.
      • et al.
      The reporting of studies conducted using observational routinely-collected health data (RECORD) statement.
      Because the STROBE guidelines were published in 2007, we only looked for the use of these guidelines in primary studies published in 2008 or later.
      All included SRs from which most our primary studies were obtained were independently assessed for quality by 2 independent reviewers (V.T., S.D.) using A Measurement Tool to Assess Systematic Reviews” (AMSTAR-2).
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      Discrepancies were adjudicated by a third reviewer (A.J.).

      Results

      We use the term women when reporting all results, as this is the term that was used in all included studies to describe study participants. We recognize that this is a gendered term that may not be generalizable to all study participants and acknowledge that not all currently or previously pregnant persons identify as women.

      Study selection and general characteristics

      After screening 196 records identified through literature search one, we identified a total of 6 SRs, published in 2020
      • Wu R.
      • Wang T.
      • Gu R.
      • et al.
      Hypertensive disorders of pregnancy and risk of cardiovascular disease-related morbidity and mortality: a systematic review and meta-analysis.
      ,
      • Alonso-Ventura V.
      • Li Y.
      • Pasupuleti V.
      • Roman Y.M.
      • Hernandez A.V.
      • Pérez-López F.R.
      Effects of preeclampsia and eclampsia on maternal metabolic and biochemical outcomes in later life: a systematic review and meta-analysis.
      • Giorgione V.
      • Ridder A.
      • Kalafat E.
      • Khalil A.
      • Thilaganathan B.
      Incidence of postpartum hypertension within 2 years of a pregnancy complicated by pre-eclampsia: a systematic review and meta-analysis.
      • Lo C.C.W.
      • Lo A.C.Q.
      • Leow S.H.
      • et al.
      Future cardiovascular disease risk for women with gestational hypertension: a systematic review and meta-analysis.
      • Veiga E.C.A.
      • Rocha P.R.H.
      • Caviola L.L.
      • et al.
      Previous preeclampsia and its association with the future development of cardiovascular diseases: a systematic review and meta-analysis.
      and 2021
      • Dall'Asta A.
      • D'Antonio F.
      • Saccone G.
      • et al.
      Cardiovascular events following pregnancy complicated by pre-eclampsia with emphasis on comparison between early- and late-onset forms: systematic review and meta-analysis.
      (Supplemental Table S5; Figure S1) from which an initial set of 174 potentially eligible primary studies were identified. A total of 524 records were obtained from our second search for recently published primary studies. After excluding records that did not meet our eligibility criteria, a total of 124 primary studies
      • Ray J.G.
      • Vermeulen M.J.
      • Schull M.J.
      • Redelmeier D.A.
      Cardiovascular health after maternal placental syndromes (CHAMPS): population-based retrospective cohort study.
      ,
      • Andersgaard A.B.
      • Acharya G.
      • Mathiesen E.B.
      • Johnsen S.H.
      • Straume B.
      • Øian P.
      Recurrence and long-term maternal health risks of hypertensive disorders of pregnancy: a population-based study.
      • Andolf E.G.
      • Sydsjö G.C.
      • Bladh M.K.
      • Berg G.
      • Sharma S.
      Hypertensive disorders in pregnancy and later dementia: a Swedish National Register Study.
      • Arnadottir G.A.
      • Geirsson R.T.
      • Arngrimsson R.
      • Jonsdottir L.S.
      • Olafsson O.
      Cardiovascular death in women who had hypertension in pregnancy: a case-control study.
      • Arnaout R.
      • Nah G.
      • Marcus G.
      • et al.
      Pregnancy complications and premature cardiovascular events among 1.6 million California pregnancies.
      • Arnott C.
      • Nelson M.
      • Alfaro Ramirez M.
      • et al.
      Maternal cardiovascular risk after hypertensive disorder of pregnancy.
      • Auger N.
      • Fraser W.D.
      • Schnitzer M.
      • Leduc L.
      • Healy-Profitós J.
      • Paradis G.
      Recurrent pre-eclampsia and subsequent cardiovascular risk.
      • Aykas F.
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      • Erden A.
      • et al.
      Persistence of cardiovascular risk factors in women with previous preeclampsia: a long-term follow-up study.
      • Behrens I.
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      • et al.
      Association between hypertensive disorders of pregnancy and later risk of cardiomyopathy.
      • Behrens I.
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      Hypertensive disorders of pregnancy and peripartum cardiomyopathy: A nationwide cohort study.
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      were included for full review (Supplemental Table S6).
      All included primary studies were published between 1976 and 2021, with most studies (72%) published in the last 10 years. Across included studies, we noted a general lack of reporting on the theoretical justification for using (or omitting) race and/or ethnicity in statistical models as well as a lack of justification for, or reflection on, the methods used to classify participants into a particular race and/or ethnicity group. Of the 103 studies published in 2008 or later, only 2
      • de Havenon A.
      • Delic A.
      • Stulberg E.
      • et al.
      Association of preeclampsia with incident stroke in later life among women in the Framingham Heart Study.
      ,
      • Wu P.
      • Chew-Graham C.A.
      • Maas A.H.
      • et al.
      temporal changes in hypertensive disorders of pregnancy and impact on cardiovascular and obstetric outcomes.
      reported making use of the STROBE
      • de Havenon A.
      • Delic A.
      • Stulberg E.
      • et al.
      Association of preeclampsia with incident stroke in later life among women in the Framingham Heart Study.
      or RECORD
      • Wu P.
      • Chew-Graham C.A.
      • Maas A.H.
      • et al.
      temporal changes in hypertensive disorders of pregnancy and impact on cardiovascular and obstetric outcomes.
      reporting guidelines. Only one
      • Wu P.
      • Chew-Graham C.A.
      • Maas A.H.
      • et al.
      temporal changes in hypertensive disorders of pregnancy and impact on cardiovascular and obstetric outcomes.
      included a copy of their checklist summarizing where each item was addressed in their manuscript.
      Most studies used a cohort design (k = 98; 79.0%), 12 were case-control studies (9.7%), and 14 were of cross-sectional design (11.3%). A wide range of HDP diagnoses were reported in included studies, with more than half of participants (or HDP deliveries) having been diagnosed with PE alone or one of 15 author-reported PE subtypes. The authors of about a quarter of included studies (k = 35) reported that HDP diagnoses were obtained using International Classification of Diseases (ICD) codes, and in 19 studies, this information was obtained from participant questionnaires (ie, self-reported obstetric history) (Supplemental Table S7).
      Just over half of included studies (k = 64) reported on the risk or odds of HTN in women with a history of HDP. In 45 of those studies, HTN was the only reported outcome of interest. The second most commonly reported cardiovascular outcome was ischemic heart disease (including coronary heart disease and myocardial infarction), which was reported by 30% of included studies. A similar but slightly lower proportion of studies reported on stroke (27%; k = 34) and a further 24 studies reported on CVD as a composite outcome. An additional 23 studies also reported on cardiovascular mortality. Finally, 13% of included studies reported on heart failure, whereas only 4% (k = 5) reported on risk of cardiac arrhythmia in women with a history of HDP.

      Geographic location of participants

      Figure 1 shows a geographic heat map of the global spread of participants represented in cardiovascular obstetrics (cardio-obstetrics) research as it pertains to women with a history of HDP. Three quarters of participants with a history of HDP (including HDP deliveries) resided in the United States (n = 3,382,939). Of the remaining 1,093,303 participants, most (81%) were from the United Kingdom (n = 363,830; 33.3%), Denmark (n = 193,331; 17.7%), Norway (n = 174,243; 15.9%), and Canada (n = 156,082; 14.3%). The least well represented countries included Turkey (n = 25), India (n = 39), Kenya (n = 63), Chile (n = 71) and Brazil (n = 70). Only one study
      • Osoti A.O.
      • Page S.T.
      • Richardson B.A.
      • et al.
      Postpartum metabolic syndrome after gestational hypertension and preeclampsia, a prospective cohort study.
      involved participants residing in Africa, and no studies involved residents of northern Eurasia (eg, Russia, Tajikistan, Uzbekistan).
      Figure thumbnail gr1
      Figure 1Geographic heat map illustrates the relative number of participants with a diagnosis of hypertensive disorders of pregnancy (HDP) in studies that assessed its association with cardiovascular morbidity and mortality. The number of participants with a history of HDP spanned 5 orders of magnitude; thus, the data are displayed on the log10 scale (eg, 25 is equal to 101.4 on the log10 scale) to facilitate the visual comparison of these large disparities. All raw data and corresponding log10 values are provided in .

      Race and ethnicity

      Use of the terms race and/or ethnicity

      The terms race and ethnicity were reported in some form (eg, ethnic, ethnicities, racial) in less than half of included studies (k = 55). In 15 of these studies,
      • Arnaout R.
      • Nah G.
      • Marcus G.
      • et al.
      Pregnancy complications and premature cardiovascular events among 1.6 million California pregnancies.
      ,
      • Black M.H.
      • Zhou H.
      • Sacks D.A.
      • Dublin S.
      • Lawrence J.M.
      • Harrison T.N.
      • et al.
      Hypertensive disorders first identified in pregnancy increase risk for incident prehypertension and hypertension in the year 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.
      ,
      • Cirillo P.M.
      • Cohn B.A.
      Pregnancy complications and cardiovascular disease death: 50-year follow-up of the Child Health and Development Studies pregnancy cohort.
      ,
      • Haas D.M.
      • Parker C.B.
      • Marsh D.J.
      • Grobman W.A.
      • et al.
      Association of adverse pregnancy outcomes with hypertension 2 to 7 years postpartum.
      ,
      • Kestenbaum B.
      • Seliger S.L.
      • Easterling T.R.
      • et al.
      Cardiovascular and thromboembolic events following hypertensive pregnancy.
      ,
      • Lisonkova S.
      • Razaz N.
      • Sabr Y.
      • et al.
      Maternal risk factors and adverse birth outcomes associated with HELLP syndrome: a population-based study.
      ,
      • Malek A.M.
      • Wilson D.A.
      • Turan T.N.
      • Mateus J.
      • Lackland D.T.
      • Hunt K.J.
      Maternal coronary heart disease, stroke, and mortality within 1, 3, and 5 years of delivery among women with hypertensive disorders of pregnancy and pre-pregnancy hypertension.
      ,
      • Miller E.C.
      • Boehme A.K.
      • Chung N.T.
      • et al.
      Aspirin reduces long-term stroke risk in women with prior hypertensive disorders of pregnancy.
      ,
      • Mongraw-Chaffin M.L.
      • Cirillo P.M.
      • Cohn B.A.
      Preeclampsia and cardiovascular disease death: prospective evidence from the child health and development studies cohort.
      ,
      • Quesada O.
      • Park K.
      • Wei J.
      • et al.
      Left ventricular mass and myocardial scarring in women with hypertensive disorders of pregnancy.
      ,
      • Savitz D.A.
      • Danilack V.A.
      • Elston B.
      • Lipkind H.S.
      Pregnancy-induced hypertension and diabetes and the risk of cardiovascular disease, stroke, and diabetes hospitalization in the year following delivery.
      ,
      • Stuart J.J.
      • Tanz L.J.
      • Missmer S.A.
      • et al.
      Hypertensive disorders of pregnancy and maternal cardiovascular disease risk factor development: an observational cohort study.
      ,
      • Theilen L.H.
      • Meeks H.
      • Fraser A.
      • Esplin M.S.
      • Smith K.R.
      • Varner M.W.
      Long-term mortality risk and life expectancy following recurrent hypertensive disease of pregnancy.
      ,
      • Wu P.
      • Chew-Graham C.A.
      • Maas A.H.
      • et al.
      temporal changes in hypertensive disorders of pregnancy and impact on cardiovascular and obstetric outcomes.
      these terms were used interchangeably (eg, race/ethnicity or race-ethnicity). In six studies,
      • Auger N.
      • Fraser W.D.
      • Schnitzer M.
      • Leduc L.
      • Healy-Profitós J.
      • Paradis G.
      Recurrent pre-eclampsia and subsequent cardiovascular risk.
      ,
      • Bergen N.E.
      • Schalekamp-Timmermans S.
      • Roos-Hesselink J.
      • Roeters van Lennep J.E.
      • Jaddoe V.V.W.
      • Steegers E.A.P.
      Hypertensive disorders of pregnancy and subsequent maternal cardiovascular health.
      ,
      • Langlois A.W.R.
      • Park A.L.
      • Lentz E.J.M.
      • Ray J.G.
      Preeclampsia brings the risk of premature cardiovascular disease in women closer to that of men.
      ,
      • McDonald S.D.
      • Ray J.
      • Teo K.
      • et al.
      Measures of cardiovascular risk and subclinical atherosclerosis in a cohort of women with a remote history of preeclampsia.
      ,
      • Melchiorre K.
      • Sutherland G.R.
      • Liberati M.
      • Thilaganathan B.
      Preeclampsia is associated with persistent postpartum cardiovascular impairment.
      ,
      • Moe K.
      • Sugulle M.
      • Dechend R.
      • Staff A.C.
      Risk prediction of maternal cardiovascular disease one year after hypertensive pregnancy complications or gestational diabetes mellitus.
      ,
      • Theilen L.H.
      • Fraser A.
      • Hollingshaus M.S.
      • et al.
      All-cause and cause-specific mortality after hypertensive disease of pregnancy.
      authors used the term ethnicity exclusively, and in 12 others,
      • Brown D.W.
      • Dueker N.
      • Jamieson D.J.
      • et al.
      Preeclampsia and the risk of ischemic stroke among young women: results from the Stroke Prevention in Young Women Study.
      ,
      • Canti I.C.
      • Komlós M.
      • Martins-Costa S.H.
      • Ramos J.G.
      • Capp E.
      • Corleta H.
      Risk factors for cardiovascular disease ten years after preeclampsia.
      ,
      • Carleton H.
      • Forsythe A.
      • Flores R.
      Remote prognosis of preeclampsia in women 25 years old and younger.
      ,
      • Edlow A.G.
      • Srinivas S.K.
      • Elovitz M.A.
      Investigating the risk of hypertension shortly after pregnancies complicated by preeclampsia.
      ,
      • Ehrenthal D.B.
      • Goldstein N.D.
      • Wu P.
      • Rogers S.
      • Townsend R.R.
      • Edwards D.G.
      Arterial stiffness and wave reflection 1 year after a pregnancy complicated by hypertension.
      ,
      • Garovic V.D.
      • Bailey K.R.
      • Boerwinkle E.
      • et al.
      Hypertension in pregnancy as a risk factor for cardiovascular disease later in life.
      ,
      • Gaugler-Senden I.P.
      • Berends A.L.
      • de Groot C.J.
      • Steegers E.A.
      Severe, very early onset preeclampsia: subsequent pregnancies and future parental cardiovascular health.
      ,
      • Hauspurg A.
      • Countouris M.E.
      • Jeyabalan A.
      • et al.
      Risk of hypertension and abnormal biomarkers in the first year postpartum associated with hypertensive disorders of pregnancy among overweight and obese women.
      ,
      • McDonald E.G.
      • Dayan N.
      • Pelletier R.
      • Eisenberg M.J.
      • Pilote L.
      Premature cardiovascular disease following a history of hypertensive disorder of pregnancy.
      ,
      • 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.
      ,
      • Riise H.K.R.
      • Sulo G.
      • Tell G.S.
      • et al.
      Association between gestational hypertension and risk of cardiovascular disease among 617 589 Norwegian women.
      ,
      • Smith G.N.
      • Pudwell J.
      • Saade G.R.
      Impact of the New American Hypertension Guidelines on the prevalence of postpartum hypertension.
      study authors only used the term race. Other related terms used to study populations included ethnically,
      • Hovsepian D.A.
      • Sriram N.
      • Kamel H.
      • Fink M.E.
      • Navi B.B.
      Acute cerebrovascular disease occurring after hospital discharge for labor and delivery.
      racially,
      • Garovic V.D.
      • White W.M.
      • Vaughan L.
      • et al.
      Incidence and long-term outcomes of hypertensive disorders of pregnancy.
      and socioeconomically diverse,
      • Hovsepian D.A.
      • Sriram N.
      • Kamel H.
      • Fink M.E.
      • Navi B.B.
      Acute cerebrovascular disease occurring after hospital discharge for labor and delivery.
      and some participants were described as belonging to specific ancestory,
      • Breetveld N.
      • Ghossein-Doha C.
      • van Kuijk S.
      • et al.
      Cardiovascular disease risk is only elevated in hypertensive, formerly preeclamptic women.
      or ethnic group(s).
      • Ditisheim A.
      • Wuerzner G.
      • Ponte B.
      • et al.
      Prevalence of hypertensive phenotypes after preeclampsia: a prospective cohort study.
      ,
      • Funai E.F.
      • Friedlander Y.
      • Paltiel O.
      • et al.
      Long-term mortality after preeclampsia.
      ,
      • Sia W.W.
      • Pertman S.M.
      • Yan R.M.
      • Tsuyuki R.T.
      Are preeclampsia and adverse obstetrical outcomes predictors of cardiovascular disease? A case-control study of women with heart disease.

      Reporting of race and/or ethnicity information

      The authors of 18 included studies (15%) explicitly reported that study participants were of a single race, ethnicity, or national origin. Specifically, 1 study each included only (South) Korean,
      • Park Y.
      • Cho G.J.
      • Kim L.Y.
      • Lee T.S.
      • Oh M.J.
      • Kim Y.H.
      Preeclampsia increases the incidence of postpartum cerebrovascular disease in korean population.
      Northeastern Brazilian,
      • Dantas E.M.
      • Pereira F.V.
      • Queiroz J.W.
      • et al.
      Preeclampsia is associated with increased maternal body weight in a northeastern Brazilian population.
      American Indian,
      • Best L.G.
      • Lunday L.
      • Webster E.
      • Falcon G.R.
      • Beal J.R.
      Pre-eclampsia and risk of subsequent hypertension: in an American Indian population.
      Iranian,
      • Shahbazian N.
      • Shahbazian H.
      • Ehsanpour A.
      • Aref A.
      • Gharibzadeh S.
      Hypertension and microalbuminuria 5 years after pregnancies complicated by pre-eclampsia.
      Norweigan,
      • Skjaerven R.
      • Wilcox A.J.
      • Klungsøyr K.
      • et al.
      Cardiovascular mortality after pre-eclampsia in one child mothers: prospective, population based cohort study.
      Dutch,
      • Berends A.L.
      • de Groot C.J.
      • Sijbrands E.J.
      • et al.
      Shared constitutional risks for maternal vascular-related pregnancy complications and future cardiovascular disease.
      and black
      • Wichmann J.L.
      • Takx R.A.P.
      • Nunez J.H.
      • et al.
      Relationship between pregnancy complications and subsequent coronary artery disease assessed by coronary computed tomographic angiography in black women.
      women. Two studies each included only white or Caucasian
      • Berends A.L.
      • de Groot C.J.
      • Sijbrands E.J.
      • et al.
      Shared constitutional risks for maternal vascular-related pregnancy complications and future cardiovascular disease.
      ,
      • Manten G.T.
      • Sikkema M.J.
      • Voorbij H.A.
      • Visser G.H.
      • Bruinse H.W.
      • Franx A.
      Risk factors for cardiovascular disease in women with a history of pregnancy complicated by preeclampsia or intrauterine growth restriction.
      and Finnish women,
      • Kharazmi E.
      • Kaaja R.
      • Fallah M.
      • Luoto R.
      Pregnancy-related factors and the risk of isolated systolic hypertension.
      ,
      • Luoto R.
      • Kharazmi E.
      • Whitley E.
      • Raitanen J.
      • Gissler M.
      • Hemminki E.
      Systolic hypertension in pregnancy and cardiovascular mortality: a 44-year follow-up study.
      and 3 studies each included only Japanese,
      • Kurabayashi T.
      • Mizunuma H.
      • Kubota T.
      • Kiyohara Y.
      • Nagai K.
      • Hayashi K.
      Pregnancy-induced hypertension is associated with maternal history and a risk of cardiovascular disease in later life: Japanese cross-sectional study.
      ,
      • Mito A.
      • Arata N.
      • Qiu D.
      • et al.
      Hypertensive disorders of pregnancy: a strong risk factor for subsequent hypertension 5 years after delivery.
      ,
      • Nohira T.
      Hypertension and metabolic abnormalities later in life after preeclampsia.
      and Taiwanese
      • Huang C.-C.
      • Huang C.-C.
      • Lin S.-Y.
      • et al.
      Association between hypertensive pregnancy disorders and future risk of stroke in Taiwan: a Nationwide population-based retrospective case-control study.
      ,
      • Lin Y.S.
      • Tang C.H.
      • Yang C.Y.
      • et al.
      Effect of pre-eclampsia-eclampsia on major cardiovascular events among peripartum women in Taiwan.
      ,
      • Tang C.H.
      • Wu C.S.
      • Lee T.H.
      • et al.
      Preeclampsia-eclampsia and the risk of stroke among peripartum in Taiwan.
      women. Across the other 106 studies, a modest percentage reported any race- and ethnicity-related information (eg, as related to participant characteristics or in their introduction or discussion sections of their article). As summarized in Figure 2, since the 1970s, the average proportion of studies reporting on these sociodemographic constructs has generally increased over time from 33% of articles published from 1978 to 2001 to 67% of articles published in 2018 to 2021 (103% change).
      Figure thumbnail gr2
      Figure 2Number of included studies published from 1978 to 2021 in 6 publication-year categories and the corresponding percentage of studies that mentioned race and/or ethnicity in any way.
      Of the 106 studies that did not explicitly involve participants of the same race or ethnic group, only 65 authors reported information pertaining to race or ethnicity anywhere in their published manuscript. Nearly 68% (k = 44) reported on participant race and/or ethnic group in a results table (eg, participant characteristics), and only 30 (46%) also discussed participant race and/or ethnicity in the results text (Table 1). Only 2 studies
      • Garovic V.D.
      • Bailey K.R.
      • Boerwinkle E.
      • et al.
      Hypertension in pregnancy as a risk factor for cardiovascular disease later in life.
      ,
      • Malek A.M.
      • Wilson D.A.
      • Turan T.N.
      • Mateus J.
      • Lackland D.T.
      • Hunt K.J.
      Maternal coronary heart disease, stroke, and mortality within 1, 3, and 5 years of delivery among women with hypertensive disorders of pregnancy and pre-pregnancy hypertension.
      mentioned the use of race and/or ethnicity variables as a strength of their study; however, several more (k = 18) reported that a lack of racial and/or ethnic diversity among study participants was a study limitation. One study completed in Canada
      • Langlois A.W.R.
      • Park A.L.
      • Lentz E.J.M.
      • Ray J.G.
      Preeclampsia brings the risk of premature cardiovascular disease in women closer to that of men.
      discussed the use of immigration status as a proxy for ethnicity, and another study conducted in The Netherlands
      • Breetveld N.
      • Ghossein-Doha C.
      • van Kuijk S.
      • et al.
      Cardiovascular disease risk is only elevated in hypertensive, formerly preeclamptic women.
      advised their study population involved a “low prevalence of immigrants.”
      Table 1Use of race or ethnicity variables in studies assessing cardiovascular morbidity and mortality in women with a history of hypertensive disorders of pregnancy
      Use of race or ethnicity variablesNumber of studies

      (% of total)
      Position in article
      Among studies that reported on race and/or ethnicity of participants and did not involve 1 race or ethnic group exclusively (k = 65).
       Introduction6 (9.2%)
       Methods41 (63.1%)
       Results (tables)44 (67.7%)
       Results (text)30 (46.2%)
       Discussion21 (32.3%)
       Strengths2 (3.1%)
       Limitations18 (27.7%)
      Stated method of assessment
      Among studies that reported on race and/or ethnicity of participants and did not involve 1 race or ethnic group exclusively (k = 65).
       Participant self-report21 (32.3%)
       Existing records17 (26.2%)
       Not stated9 (13.8%)
       Other
      One study85 assessed participant ethnicity based on father’s birthplace (no rationale provided).
      1 (1.5%)
      Stated purpose of use or reason for collection
      Among studies that reported on race and/or ethnicity of participants and did not involve 1 race or ethnic group exclusively (k = 65).
       Demographic variable19 (29.2%)
       Sociodemographic variable5 (7.7%)
       Confounder or adjustment variable16 (24.6%)
       Not stated3 (4.6%)
       Other
      One study each described race or ethnicity variables as “baseline factors”102 and information of “intrinsic interest.”85
      2 (3.1%)
      Stated method of use in analysis
      Among studies that included race and/or ethnicity in at least 1 inferential analysis (apart from descriptive analyses) (k = 27). Note that some studies may have used more than 1 term; thus, the total is more than 27.
       Risk factor1 (3.7%)
       Confounder8 (29.6%)
       Interaction term2 (7.4%)
       Covariate6 (22.2%)
       Control for2 (7.4%)
       Adjust for16 (59.3%)
       Unclear5 (18.5%)
      Reported and discussed results
      Among studies that included race and/or ethnicity in at least 1 inferential analysis (apart from descriptive analyses) (k = 27). Note that some studies may have used more than 1 term; thus, the total is more than 27.
       Reported significant findings14 (51.9%)
       Discussed findings10 (37.0%)
       Called for further research5 (18.5%)
       Not stated6 (22.2%)
      Among studies that reported on race and/or ethnicity of participants and did not involve 1 race or ethnic group exclusively (k = 65).
      One study
      • Funai E.F.
      • Friedlander Y.
      • Paltiel O.
      • et al.
      Long-term mortality after preeclampsia.
      assessed participant ethnicity based on father’s birthplace (no rationale provided).
      One study each described race or ethnicity variables as “baseline factors”
      • Hovsepian D.A.
      • Sriram N.
      • Kamel H.
      • Fink M.E.
      • Navi B.B.
      Acute cerebrovascular disease occurring after hospital discharge for labor and delivery.
      and information of “intrinsic interest.”
      • Funai E.F.
      • Friedlander Y.
      • Paltiel O.
      • et al.
      Long-term mortality after preeclampsia.
      § Among studies that included race and/or ethnicity in at least 1 inferential analysis (apart from descriptive analyses) (k = 27). Note that some studies may have used more than 1 term; thus, the total is more than 27.
      Nearly one-third of included studies reported that participant race and/or ethnicity was assessed through participant self-report (eg, through questionnaires), whereas just over one quarter (k = 17) were assigned to a racial and/or ethnic category based on the use of existing records (eg, clinical registries). Twenty-nine percent of studies (k = 19) referred to race and/or ethnicity as demographic variables, whereas only 5
      • Andolf E.G.
      • Sydsjö G.C.
      • Bladh M.K.
      • Berg G.
      • Sharma S.
      Hypertensive disorders in pregnancy and later dementia: a Swedish National Register Study.
      ,
      • 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.
      ,
      • Kestenbaum B.
      • Seliger S.L.
      • Easterling T.R.
      • et al.
      Cardiovascular and thromboembolic events following hypertensive pregnancy.
      ,
      • Honigberg M.C.
      • Zekavat S.M.
      • Aragam K.
      • et al.
      Long-term cardiovascular risk in women with hypertension during pregnancy.
      ,
      • Malek A.M.
      • Wilson D.A.
      • Turan T.N.
      • Mateus J.
      • Lackland D.T.
      • Hunt K.J.
      Maternal coronary heart disease, stroke, and mortality within 1, 3, and 5 years of delivery among women with hypertensive disorders of pregnancy and pre-pregnancy hypertension.
      referred to these constructs as sociodemographic variables. The authors of 4 studies
      • Carleton H.
      • Forsythe A.
      • Flores R.
      Remote prognosis of preeclampsia in women 25 years old and younger.
      ,
      • Gaugler-Senden I.P.
      • Berends A.L.
      • de Groot C.J.
      • Steegers E.A.
      Severe, very early onset preeclampsia: subsequent pregnancies and future parental cardiovascular health.
      ,
      • Melchiorre K.
      • Sutherland G.R.
      • Liberati M.
      • Thilaganathan B.
      Preeclampsia is associated with persistent postpartum cardiovascular impairment.
      ,
      • Srinivas S.K.
      • Sammel M.D.
      • Bastek J.
      • et al.
      Evaluating the association between all components of the metabolic syndrome and pre-eclampsia.
      reported matching study participants based on race, and another
      • Ditisheim A.
      • Wuerzner G.
      • Ponte B.
      • et al.
      Prevalence of hypertensive phenotypes after preeclampsia: a prospective cohort study.
      reported limiting at least 1 secondary analysis to white participants with no explanation for this restriction. One 2010 study
      • Mongraw-Chaffin M.L.
      • Cirillo P.M.
      • Cohn B.A.
      Preeclampsia and cardiovascular disease death: prospective evidence from the child health and development studies cohort.
      presented unadjusted CVD death rates by maternal race.
      Among studies that included race and/or ethnicity in at least 1 statistical analysis (k = 27), most (59%) reported that these variables were adjusted for in statistical models. Only 2 studies
      • Cirillo P.M.
      • Cohn B.A.
      Pregnancy complications and cardiovascular disease death: 50-year follow-up of the Child Health and Development Studies pregnancy cohort.
      ,
      • Malek A.M.
      • Wilson D.A.
      • Turan T.N.
      • Mateus J.
      • Lackland D.T.
      • Hunt K.J.
      Maternal coronary heart disease, stroke, and mortality within 1, 3, and 5 years of delivery among women with hypertensive disorders of pregnancy and pre-pregnancy hypertension.
      reported the inclusion of data on race and/or ethnicity as part of an interaction term. The authors of a recently published study
      • Malek A.M.
      • Wilson D.A.
      • Turan T.N.
      • Mateus J.
      • Lackland D.T.
      • Hunt K.J.
      Maternal coronary heart disease, stroke, and mortality within 1, 3, and 5 years of delivery among women with hypertensive disorders of pregnancy and pre-pregnancy hypertension.
      reported excluding participants of other race/ethnicity from analysis because of low numbers. More than half of these studies (approximately 52%) reported significant findings related to race and/or ethnicity, but only 10 discussed them in detail. Five studies
      • Honigberg M.C.
      • Riise H.K.R.
      • Daltveit A.K.
      • et al.
      Heart failure in women with hypertensive disorders of pregnancy: insights from the Cardiovascular Disease in Norway Project.
      ,
      • Honigberg M.C.
      • Zekavat S.M.
      • Aragam K.
      • et al.
      Long-term cardiovascular risk in women with hypertension during pregnancy.
      ,
      • Markovitz A.R.
      • Stuart J.J.
      • Horn J.
      • et al.
      Does pregnancy complication history improve cardiovascular disease risk prediction? Findings from the HUNT study in Norway.
      ,
      • Parikh N.I.
      • Norberg M.
      • Ingelsson E.
      • et al.
      Association of pregnancy complications and characteristics with future risk of elevated blood pressure.
      ,
      • Valdés G.
      • Quezada F.
      • Marchant E.
      • et al.
      Association of remote hypertension in pregnancy with coronary artery disease: a case-control study.
      , called for further research to address knowledge gaps related to the generalizability of findings to more diverse populations.

      Reporting of participant race and ethnicity

      As shown in Table 2, 61 studies (49%) did not report on participant race and/or ethnicity. Among those that did (k = 45), the highest number of race and/or ethnic groups reported in a single study was 7, which was noted in 2 studies published in 2018
      • Miller E.C.
      • Boehme A.K.
      • Chung N.T.
      • et al.
      Aspirin reduces long-term stroke risk in women with prior hypertensive disorders of pregnancy.
      and 2020.
      • Wu P.
      • Chew-Graham C.A.
      • Maas A.H.
      • et al.
      temporal changes in hypertensive disorders of pregnancy and impact on cardiovascular and obstetric outcomes.
      Two other recently published studies
      • Arnaout R.
      • Nah G.
      • Marcus G.
      • et al.
      Pregnancy complications and premature cardiovascular events among 1.6 million California pregnancies.
      ,
      • Kumar N.R.
      • Grobman W.A.
      • Barry O.
      • Clement A.C.
      • Lancki N.
      • Yee L.M.
      Evaluating the maternal and perinatal sequelae of severe gestational hypertension.
      reported that participants belonged to 1 of 6 different race and/or ethnic groups, and 7 studies
      • Black M.H.
      • Zhou H.
      • Sacks D.A.
      • Dublin S.
      • Lawrence J.M.
      • Harrison T.N.
      • et al.
      Hypertensive disorders first identified in pregnancy increase risk for incident prehypertension and hypertension in the year after delivery.
      ,
      • Cirillo P.M.
      • Cohn B.A.
      Pregnancy complications and cardiovascular disease death: 50-year follow-up of the Child Health and Development Studies pregnancy cohort.
      ,
      • Funai E.F.
      • Friedlander Y.
      • Paltiel O.
      • et al.
      Long-term mortality after preeclampsia.
      ,
      • Haas D.M.
      • Parker C.B.
      • Marsh D.J.
      • Grobman W.A.
      • et al.
      Association of adverse pregnancy outcomes with hypertension 2 to 7 years postpartum.
      ,
      • Leon L.J.
      • McCarthy F.P.
      • Direk K.
      • et al.
      Preeclampsia and cardiovascular disease in a large UK pregnancy cohort of linked electronic health records: a CALIBER study.
      ,
      • Mongraw-Chaffin M.L.
      • Cirillo P.M.
      • Cohn B.A.
      Preeclampsia and cardiovascular disease death: prospective evidence from the child health and development studies cohort.
      ,
      • Stuart J.J.
      • Tanz L.J.
      • Missmer S.A.
      • et al.
      Hypertensive disorders of pregnancy and maternal cardiovascular disease risk factor development: an observational cohort study.
      reported that participants belonged to 1 of 5 different race and/or ethnic groups, 5 of which
      • Black M.H.
      • Zhou H.
      • Sacks D.A.
      • Dublin S.
      • Lawrence J.M.
      • Harrison T.N.
      • et al.
      Hypertensive disorders first identified in pregnancy increase risk for incident prehypertension and hypertension in the year after delivery.
      ,
      • Cirillo P.M.
      • Cohn B.A.
      Pregnancy complications and cardiovascular disease death: 50-year follow-up of the Child Health and Development Studies pregnancy cohort.
      ,
      • Haas D.M.
      • Parker C.B.
      • Marsh D.J.
      • Grobman W.A.
      • et al.
      Association of adverse pregnancy outcomes with hypertension 2 to 7 years postpartum.
      ,
      • Leon L.J.
      • McCarthy F.P.
      • Direk K.
      • et al.
      Preeclampsia and cardiovascular disease in a large UK pregnancy cohort of linked electronic health records: a CALIBER study.
      ,
      • Stuart J.J.
      • Tanz L.J.
      • Missmer S.A.
      • et al.
      Hypertensive disorders of pregnancy and maternal cardiovascular disease risk factor development: an observational cohort study.
      were published in 2015 or later. The median/mean number of race and/or ethnic categories reported generally increased over time.
      Table 2Number of categories of race or ethnicity reported in included studies
      k = 124 included studies; however, this summary table excludes k = 18 studies in which authors reported that all participants were of the same race or ethnicity.
      Publication yearTotal nNo. of studiesNo. of race and/or ethnic categories reported
      Median categoriesMean categoriesMinimum, maximum categories
      1970s-2001122N/A
      2002-200524.54.54, 5
      2006-2009411.31, 2
      2010-2013532.81, 5
      2014-2017122.52.61, 5
      2018-20212133.51, 7
      Did not report on race and/or ethnicity61
      TOTAL106
      k = 124 included studies; however, this summary table excludes k = 18 studies in which authors reported that all participants were of the same race or ethnicity.
      The range of race and ethnicity groups reported on by studies was extensive, with the highest proportion of studies reporting participants of white race (Table 3). Several studies (k = 22) reported that participant race or ethnicity was unknown, missing, unspecified, or other, and several different terms were used to describe the same construct (eg, Caucasian, white, non-Hispanic white, European descent). Only 3 studies
      • Black M.H.
      • Zhou H.
      • Sacks D.A.
      • Dublin S.
      • Lawrence J.M.
      • Harrison T.N.
      • et al.
      Hypertensive disorders first identified in pregnancy increase risk for incident prehypertension and hypertension in the year after delivery.
      ,
      • Cirillo P.M.
      • Cohn B.A.
      Pregnancy complications and cardiovascular disease death: 50-year follow-up of the Child Health and Development Studies pregnancy cohort.
      ,
      • Miller E.C.
      • Boehme A.K.
      • Chung N.T.
      • et al.
      Aspirin reduces long-term stroke risk in women with prior hypertensive disorders of pregnancy.
      reported if participants identified as multiracial, mixed, or multiple race.
      Table 3Race and ethnicity categories reported on by authors of included studies
      Categorized using the Canadian Institute for Health Information’s Proposed Standards for Race-Based and Indigenous Identity Data Collection and Health Reporting in Canada13 as a guide.
      AsianBlackHispanic or LatinoIndigenousMiddle EasternWhiteUnknown or missingOther terms
      Korean (k = 1)

      Japanese (k = 4)

      Taiwanese (k = 2)

      Asian (k = 9)
      One study116 included persons of South Asian descent (Indian, Pakistani, Bangladeshi) and persons classified as other Asian into a single Asian category.


      Asian or Pacific Islander (k = 5)
      Black (k = 13)
      One study116 included persons classified as black Caribbean, black African, and black other into a single Black category.


      African American (k = 7)

      Non-Hispanic black (k = 5)

      Black/African American (k = 1)

      Afro-Caribbean (k = 1)

      African (k = 1)
      Hispanic (k = 16)

      Hispanic/Latino
      One study141 reported Hispanic/Latin, which was also included in this category.
      (k = 2)

      Northeastern Brazilian(k = 1)

      Latina (k = 1)
      American Indian (k = 1)

      Aboriginality (k = 1)

      Native American (k = 3)

      American Indian/Alaskan (k = 1)
      Iranian (k = 1)

      Turkish origin (k = 1)

      Moroccan origin (k = 1)

      Father’s birthplace: Other West Asia (k = 1)

      Father’s birthplace: Israel (k = 1)
      White or white origin (k = 16)

      Caucasian or Caucasian origin (k = 10)

      Non-Hispanic white (k = 8)

      Finnish (k = 2)

      Norwegian ethnicity (k = 1)

      Norwegian (k = 1)

      European (k = 2)

      Europe (k = 1)

      White European (k = 1)

      White Northern European (k = 1)

      European continental ancestry (k = 1)

      Nordic (k = 1)
      Unknown (k = 4)

      Declined (k = 1)

      Missing (k = 1)
      Father’s birthplace: North Africa (k = 1)

      Father’s birthplace: Europe or elsewhere (k = 1)

      Non-white (k = 1)

      Non-black (k = 1)

      Non-Nordic (k = 1)

      Non-Hispanic (k = 2)

      Other (k = 16)
      One study116 included participants classified as Chinese, mixed, and other into a single Other category.


      Other or unspecified (k = 1)

      Other/multiple (k = 1)

      Multi-racial/other (k = 1)

      Other/mixed (k = 1)
      Categorized using the Canadian Institute for Health Information’s Proposed Standards for Race-Based and Indigenous Identity Data Collection and Health Reporting in Canada
      as a guide.
      One study
      • Leon L.J.
      • McCarthy F.P.
      • Direk K.
      • et al.
      Preeclampsia and cardiovascular disease in a large UK pregnancy cohort of linked electronic health records: a CALIBER study.
      included persons classified as black Caribbean, black African, and black other into a single Black category.
      One study
      • Quesada O.
      • Park K.
      • Wei J.
      • et al.
      Left ventricular mass and myocardial scarring in women with hypertensive disorders of pregnancy.
      reported Hispanic/Latin, which was also included in this category.
      § One study
      • Leon L.J.
      • McCarthy F.P.
      • Direk K.
      • et al.
      Preeclampsia and cardiovascular disease in a large UK pregnancy cohort of linked electronic health records: a CALIBER study.
      included persons of South Asian descent (Indian, Pakistani, Bangladeshi) and persons classified as other Asian into a single Asian category.
      One study
      • Leon L.J.
      • McCarthy F.P.
      • Direk K.
      • et al.
      Preeclampsia and cardiovascular disease in a large UK pregnancy cohort of linked electronic health records: a CALIBER study.
      included participants classified as Chinese, mixed, and other into a single Other category.

      Participant race and ethnicity by HDP diagnosis

      A total of 2,871,907 women with a history of any HDP (or HDP deliveries) were categorized into a race or ethnic group by study authors. More than 1.5 million participants (53%) were described as white, Caucasian, non-Hispanic white, or European (including Finnish, Norweigan, and Dutch)—2.8 times more participants than the next highest represented race or ethnic group, Hispanic or Latino (n = 544,957) (Figure 3). Nearly 110,000 participants with a history of HDP were classified as other, unknown or unspecified race or ethnicity, representing 4% of the total. Just over 400 participants were described as African and 35 women with HDP in included studies were Iranian.
      Figure thumbnail gr3
      Figure 3People graph illustrating the total number of women with a history of any hypertensive disorder of pregnancy in included studies by reported race or ethnicity group.

      Other sociodemographic variables

      Although the primary focus of this review was on the reporting of race and/or ethnicity, we also noted other sociodemographic variables reported on by authors of included studies (see Supplemental Table S6). Briefly, just over half of included studies (k = 68) reported on at least 1 sociodemographic variable other than race and ethnicity, such as participant marital status, socioeconomic status, religious affiliation, and type of health insurance. Of these, most authors (74%) also explicitly reported having included 1 or more of those factors as an adjustment variable or covariate in at least 1 statistical model. These types of sociodemographic varibles varied widely across studies, both in terms of how they were defined, breadth of variables reported, and in terms of the combination of variables that were incorporated into statistical models.
      The most commonly reported sociodemographic variables reported by authors were participant education and marital status. Measures of socioeconomic status and social class varied most widely, ranging from factors such as annual family income,
      • Mongraw-Chaffin M.L.
      • Cirillo P.M.
      • Cohn B.A.
      Preeclampsia and cardiovascular disease death: prospective evidence from the child health and development studies cohort.
      employment information (ie, job title or category),
      • Bhattacharya S.
      • Prescott G.J.
      • Iversen L.
      • Campbell D.M.
      • Smith W.C.
      • Hannaford P.C.
      Hypertensive disorders of pregnancy and future health and mortality: a record linkage study.
      ,
      • Männistö T.
      • Mendola P.
      • Vääräsmäki M.
      • et al.
      Elevated blood pressure in pregnancy and subsequent chronic disease risk.
      ,
      • Wikström A.K.
      • Haglund B.
      • Olovsson M.
      • Lindeberg S.N.
      The risk of maternal ischaemic heart disease after gestational hypertensive disease.
      to composite variables that derived an overall score for each participant using previously established methods (eg, the Index of Relative Socio-Economic Advantage and Disvantage
      • Arnott C.
      • Nelson M.
      • Alfaro Ramirez M.
      • et al.
      Maternal cardiovascular risk after hypertensive disorder of pregnancy.
      and Nam-Powers socioeconomic scores
      • Theilen L.H.
      • Fraser A.
      • Hollingshaus M.S.
      • et al.
      All-cause and cause-specific mortality after hypertensive disease of pregnancy.
      ,
      • Theilen L.H.
      • Meeks H.
      • Fraser A.
      • Esplin M.S.
      • Smith K.R.
      • Varner M.W.
      Long-term mortality risk and life expectancy following recurrent hypertensive disease of pregnancy.
      ). These scores combined information about a variety of factors such as car ownership, neighbourhood-level social class and overcrowding, and highest level of education and occupation, among other factors.
      • Auger N.
      • Fraser W.D.
      • Schnitzer M.
      • Leduc L.
      • Healy-Profitós J.
      • Paradis G.
      Recurrent pre-eclampsia and subsequent cardiovascular risk.
      ,
      • Smith G.C.
      • Pell J.P.
      • Walsh D.
      Pregnancy complications and maternal risk of ischaemic heart disease: a retrospective cohort study of 129,290 births.
      Two studies published in 1997
      • Hannaford P.
      • Ferry S.
      • Hirsch S.
      Cardiovascular sequelae of toxaemia of pregnancy.
      and 2005
      • Funai E.F.
      • Friedlander Y.
      • Paltiel O.
      • et al.
      Long-term mortality after preeclampsia.
      used husband’s occupation as a measure of participant social class but provided no rationale for doing so (eg, participants may not have been employed outside the home, and the tools used to assess social class did not account for this kind of work).
      Only 25 (20%) studies reported on participant sociodemographic information in addition to race and/or ethnicitiy; however, none investigated how the additional sociodemographic variables they collected (eg, education, marital status, income, rural vs urban setting, insurance payer) may have had synergistic or antagonistic effects with race and/or ethnicity to influence participants’ risk of CVD.

      Discussion

      In this review, we examined the use of race, ethnicity, and national origin in observational studies assessing CVD morbidity and mortality in women with a history of HDP. Overall, we found limited and heterogeneous reporting of race and ethnicity information across included studies. Despite evidence of substantial racial and ethnic differences in the prevalence estimates for HDP, which range from less than 3% for Chinese and Vietnamese women to 8.9% for Indigenous American women and nearly 10% for non-Hispanic black women,
      • Singh G.K.
      • Siahpush M.
      • Liu L.
      • Allender M.
      racial/ethnic, nativity, and sociodemographic disparities in maternal hypertension in the United States, 2014-2015.
      we found that white participants were heavily overrepresented in the literature. Continents such as Africa, where the burden of HDP is high,
      • Noubiap J.J.
      • Bigna J.J.
      • Nyaga U.F.
      • et al.
      The burden of hypertensive disorders of pregnancy in Africa: a systematic review and meta-analysis.
      exceeding 20% of all pregnancies in Botswana alone,
      • Johnson K.M.
      • Zash R.
      • Haviland M.J.
      • et al.
      Hypertensive disease in pregnancy in Botswana: prevalence and impact on perinatal outcomes.
      were also poorly represented. Despite the burden of HDP being higher across several racial and ethnic minority groups, almost no studies examined race and/or ethnicity differences in the association between HDP and CVD outcomes.

      Findings in light of previous research

      The methodologic issues related to the reporting and use of race and/or ethnicity identified in this review align with those reported in several published studies.
      • Ahdieh L.
      • Hahn R.A.
      Use of the terms ‘race’, ‘ethnicity’, and ‘national origins’: a review of articles in the American Journal of Public Health, 1980–1989.
      • Jones C.P.
      • LaVeist T.A.
      • Lillie-Blanton M.
      "Race" in the epidemiologic literature: an examination of the American Journal of Epidemiology, 1921-1990.
      • Williams D.R.
      The concept of race in Health Services Research: 1966 to 1990.
      • Bokor-Billmann T.
      • Langan E.A.
      • Billmann F.
      The reporting of race and/or ethnicity in the medical literature: a retrospective bibliometric analysis confirmed room for improvement.
      ,
      • Guerrero S.
      • López-Cortés A.
      • Indacochea A.
      • et al.
      Analysis of racial/ethnic representation in select basic and applied cancer research studies.
      ,
      • Braun L.
      • Wolfgang M.
      • Dickersin K.
      Defining race/ethnicity and explaining difference in research studies on lung function.
      The overrepresentation of white populations in health research has been frequently observed,
      • Williams D.R.
      The concept of race in Health Services Research: 1966 to 1990.
      ,
      • Bokor-Billmann T.
      • Langan E.A.
      • Billmann F.
      The reporting of race and/or ethnicity in the medical literature: a retrospective bibliometric analysis confirmed room for improvement.
      ,
      • Braun L.
      • Wolfgang M.
      • Dickersin K.
      Defining race/ethnicity and explaining difference in research studies on lung function.
      ,
      • Nazha B.
      • Mishra M.
      • Pentz R.
      • Owonikoko T.K.
      Enrollment of racial minorities in clinical trials: old problem assumes new urgency in the age of immunotherapy.
      ,
      • Berkowitz S.T.
      • Groth S.L.
      • Gangaputra S.
      • Patel S.
      Racial/ethnic disparities in ophthalmology clinical trials resulting in US Food and Drug Administration drug approvals from 2000 to 2020.
      and others
      • Valdiviezo C.
      • Garovic V.D.
      • Ouyang P.
      Preeclampsia and hypertensive disease in pregnancy: their contributions to cardiovascular risk.
      have noted it as a major limitation of studies examining cardiovascular risk in women with a history of HPD. Like others,
      • Bokor-Billmann T.
      • Langan E.A.
      • Billmann F.
      The reporting of race and/or ethnicity in the medical literature: a retrospective bibliometric analysis confirmed room for improvement.
      we found limited reporting of race and ethnicity information across included studies, and, when authors did report this information, several different terms were used to describe the same construct (eg, Caucasian, white, non-Hispanic white, European descent). Further, we identified only 1 study
      • Schokker S.A.
      • Van Oostwaard M.F.
      • Melman E.M.
      • et al.
      Cerebrovascular, cardiovascular and renal hypertensive disease after hypertensive disorders of pregnancy.
      whose authors reported classifying participants into a specific ethnic group based on an existing framework or prespecified criteria.
      In their 2020 review, Bokor-Billmann et al.
      • Bokor-Billmann T.
      • Langan E.A.
      • Billmann F.
      The reporting of race and/or ethnicity in the medical literature: a retrospective bibliometric analysis confirmed room for improvement.
      noted that a substantive portion of studies in general medicine, surgery, and oncology published between 2007 and 2018 reported non convenience race or ethnic groupings. Similarly, we found that across included studies, thousands of women with HDP were assigned to a category referred to as other to represent their race. In addition, we noted that only 3 studies
      • Black M.H.
      • Zhou H.
      • Sacks D.A.
      • Dublin S.
      • Lawrence J.M.
      • Harrison T.N.
      • et al.
      Hypertensive disorders first identified in pregnancy increase risk for incident prehypertension and hypertension in the year after delivery.
      ,
      • Cirillo P.M.
      • Cohn B.A.
      Pregnancy complications and cardiovascular disease death: 50-year follow-up of the Child Health and Development Studies pregnancy cohort.
      ,
      • Miller E.C.
      • Boehme A.K.
      • Chung N.T.
      • et al.
      Aspirin reduces long-term stroke risk in women with prior hypertensive disorders of pregnancy.
      included in this review reported any category that captured individuals who identify as multiracial. This finding is concerning given that individuals who identifiy as multiracial may experience inequalities in health that are different from those who identify with a single racial group.
      • Veenstra G.
      Black, white, black and white: mixed race and health in Canada.
      In the year 2000, the US Census started distinguishing Asian and Pacific Islander as 2 separate racial categories.
      • Zavala V.A.
      • Bracci P.M.
      • Carethers J.M.
      • et al.
      Cancer health disparities in racial/ethnic minorities in the United States.
      However, the authors of 5 studies,
      • Arnaout R.
      • Nah G.
      • Marcus G.
      • et al.
      Pregnancy complications and premature cardiovascular events among 1.6 million California pregnancies.
      ,
      • Black M.H.
      • Zhou H.
      • Sacks D.A.
      • Dublin S.
      • Lawrence J.M.
      • Harrison T.N.
      • et al.
      Hypertensive disorders first identified in pregnancy increase risk for incident prehypertension and hypertension in the year after delivery.
      ,
      • Miller E.C.
      • Boehme A.K.
      • Chung N.T.
      • et al.
      Aspirin reduces long-term stroke risk in women with prior hypertensive disorders of pregnancy.
      ,
      • 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.
      ,
      • Wu P.
      • Chew-Graham C.A.
      • Maas A.H.
      • et al.
      temporal changes in hypertensive disorders of pregnancy and impact on cardiovascular and obstetric outcomes.
      all of which were published in 2016 or later, still reported individuals as belonging to a combined Asian/Pacific Islander race. This finding points to the limitations of using registry and administrative data in epidemiologic studies, as researchers using these types of data cannot control how they are collected and may not be able to adapt their reporting of variables if data collection methods change over time.
      Previous reviews
      • Comstock R.D.
      • Castillo E.M.
      • Lindsay S.P.
      Four-year review of the use of race and ethnicity in epidemiologic and public health research.
      ,
      • Ahdieh L.
      • Hahn R.A.
      Use of the terms ‘race’, ‘ethnicity’, and ‘national origins’: a review of articles in the American Journal of Pub