The Role of the Urban/Rural Divide and Socioeconomic Factors in the Incidence, Outcomes and Post-partum Care of Hypertensive Disorders of Pregnancy

PROJECT SUMMARY/ABSTRACT In this proposal, we will quantify disparities in incidence, short- and long-term outcomes, and barriers to post- partum care in women with hypertensive disorders of pregnancy (HDP) according to various demographic factors and socioeconomic (SES) status indicators. HDP includes a broad spectrum of subtypes associated

with varying degrees of morbidity. Incidence of HDP and its complications are higher in rural areas and socioeconomic status (SES) likely plays a moderating effect, but this has not been well-studied due to challenges in determining individual-level SES. Our overall goal is to develop targeted strategies to improve

the cardiovascular health of women after HDP. This proposal strongly aligns with Goal 1 of the 2019-2023 Trans-NIH Strategic Plan for Women's Health Research "Advancing Science for the Health of Women”, which aims to understand chronic conditions understudied among women and/or that disproportionately affect

populations of women who are understudied, underrepresented, and underreported in biomedical research – specifically, women in rural areas and women who have low SES. We will use a novel indicator of SES, the HOUsing-based Socioeconomic Status (HOUSES) index, which is an objective, scalable, standardized, and

individual-level SES measure that predicts multiple health outcomes. Our hypothesis is that SES may be an important modifier of risk, with low SES causing a multiplicative increase in HDP incidence and outcomes, regardless of place of residence.The following 3 aims are proposed to understand the intersection between

rural residence and SES in HDP. The first aim is to determine if SES is a significant moderator in the relationship between urban/rural status and the incidence of HDP and its subtypes. We will quantify the incidence of HDP subtypes in a 27-county region of the Upper Midwest, which has a large rural population,

using electronic health record data from 2000 to 2021 and test for interactions between urban/rural status and SES. The second aim is to determine if SES is a significant moderator in the association between urban/rural status and the risk of short and long-term complications of HDP. Using HDP cases identified in the first aim, we

will identify any cardiovascular and cardiometabolic diagnoses that develop after delivery and characterize acute care and post-partum visits in the first year after delivery. We will test for interaction between rural/urban status and SES and conduct a comprehensive cost analysis. The third aim will be to assess key barriers to

care for high-risk women with HDP complications through qualitative semi-structured interviews. We will interview 30 demographically diverse women with adverse outcomes after HDP using the Health Belief Model to understand barriers and facilitators of access to post-partum care. By combining the results of this

qualitative aim with the results from Aim 1 and 2, we can develop effective interventions that target high-risk populations in rural areas and improve the care of women with HDP in the reproductive era and beyond.