Preconception contributors to severe maternal morbidity in black and white women

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ABSTRACT Adverse pregnancy outcomes (APO), including hypertensive disorders of pregnancy, preterm birth, and gestational diabetes, are associated with short- and long-term cardiovascular risk in mothers. The urgency of these associations is amplified by an `unexplained epidemic' of increased CVD risk among young adult women (age 35 to 55) (ref; Vaccarino, Circulation 2019). These CVD trends coincide with unexplained increases in severe maternal morbidity (SMM) and mortality in the U.S, the dominant cause being cardiovascular in nature. (Creanga 2017) Further complicating these trends of deteriorating cardiovascular health in young adult women are profound and persistent race disparities, with black women having rates of CVD and severe maternal morbidity 2 to 3 times higher than white women (Peterson 2019). Social determinants of health including stress, discrimination and access to care are also known contributors to CVD risk and SMM, but to date these have not been studied in a comprehensive and synergistic fashion to understand precursors and contributors to racial disparities in SMM. Our on-going NHLBI-funded study, Shared antecedents to preterm birth and CVD in women (R21HL145419), is uniquely poised to disentangle these questions. It also provides a unique opportunity to expand research on the leading causes of maternal mortality and severe maternal morbidity in order to strengthen evidence-based care and prevention strategies and improve maternal health. The CARDIA study has conducted up to 9 in-person exams among 2,787 women (50% Black), of whom 1,362 delivered 2,389 births from baseline and up to the year 30 follow-up exam (1985-2015). There are extensive longitudinal data on blood pressure, lipids, glycemia, cardiac structure, adiposity, lifestyle, metabolic diseases, and subclinical atherosclerosis. Uniquely, these exams include longitudinal data on stress, social determinants of health and discrimination. We propose to assemble these features to study 900 CARDIA women from both before and after pregnancies. We hypothesize that cardiometabolic, inflammatory and social stressors prior to pregnancy converge and contribute to racial disparities in severe maternal morbidity and premature CVD. Assessing pre-conception bio-behavioral markers will provide novel insights into the pathophysiology of pregnancy-associated morbidity as well as identify modalities to mitigate CVD in women of reproductive age.