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Hypertensive disorders of pregnancy and the postpartum period (HDPP) are the second leading cause of maternal deaths worldwide^1,2 and account for 6.3% of all pregnancy-related deaths in the US.³ Black birthing people have the highest rates of pregnancy-related mortality in the US.⁴ The American College of Obstetricians and Gynecologists recommends management of severe blood pressure in pregnancy within 30 to 60 minutes of diagnosis to prevent complications such as stroke, myocardial ischemia, seizure, placental abruption, and maternal and neonatal mortality.⁵ Given the need for prompt intervention, the emergency department (ED) is a critical access point for treatment of HDPP. To our knowledge, there are no studies reporting national trends of ED use for HDPP. In this study, we assess US ED utilization and admission for HDPP.

This cross-sectional study was determined exempt from review and the requirement of informed consent by the University of Michigan institutional review board and followed the reporting guidelines. This was a longitudinal retrospective analysis of HDPP-related ED utilization from 2006 to 2020 using the Nationwide Emergency Department Sample (NEDS), managed by the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. Pregnant or postpartum people aged 15 to 50 years with a primary diagnosis of HDPP by International Classification of Diseases, Ninth Revision (ICD-9) or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes were included (eMethods in Supplement 1). The primary outcome was total annual ED visits for HDPP. Secondary outcomes included hospital admissions, and HDPP-related ED use by race and ethnicity. Characteristics including age, income quartile by zip code, payment method, hospital geographic region, and hospital teaching status were analyzed. Race and ethnicity data, abstracted from the NEDS database, were only available for 2019 to 2020. Race and ethnicity categories included Asian or Pacific Islander, non-Hispanic Black, Hispanic, American Indian or Alaska Native, non-Hispanic White, and other (defined as multiracial).

Considering the complex sample design, SAS survey sampling and analysis procedures were applied, including stratum, clusters, and weights into χ², t tests, and multivariable logistic regression. Statistical significance was defined as a 2-sided P < .05. SAS version 9.4 (SAS Institute) was used for analysis. Analysis occurred from August 2022 to February 2023.

Between 2006 and 2020, 656 711 HDPP-related ED encounters occurred. HDPP annual ED visits increased from 31 623 to 55 893 from 2006 to 2020 (P < .001) (Table 1). Admissions and admission rates for HDPP also increased over the study period from 17 338 admissions in 2006 (rate, 54.8%) to 43 563 admissions in 2020 (rate, 77.9%) (P < .001), in contrast with stable admission rates for all other primary diagnoses (2 823 749 or 35 177 059 admissions [8.0%] in 2006 to 2 796 555 of 33 402 798 admissions [8.4%] in 2020; P = .08).

Non-Hispanic Black, Hispanic, and Asian or Pacific Islander individuals were more likely to present to the ED for HDPP compared with all other diagnoses (non-Hispanic Black, 27 968 of 104 556 visits [26.7%] vs 17 942 147 of 70 664 334 visits [25.4%]; P = .007; Hispanic, 22 097 of 104 556 visits [21.1%] vs 12 405 817 of 70 664 334 visits [17.6%]; P < .001; and Asian or Pacific Islander, 4603 of 104 556 visits [4.4%] vs 1514913 of 70 664 334 visits [2.1%]; P < .001). Additionally, compared with non-Hispanic White individuals, non-Hispanic Black, Hispanic, and Asian or Pacific Islander individuals were more likely to be admitted for HDPP (Table 2).

In this cross-sectional study, US ED visits and admissions for HDPP increased significantly from 2006 to 2020. This finding may reflect a higher prevalence of disease or increased awareness for prompt assessment and treatment. However, the greater ED utilization for HDPP compared with all other diagnoses for non-Hispanic Black, Hispanic, and Asian or Pacific Islander individuals may imply limited access to timely outpatient care or barriers to uptake blood pressure monitoring programs. Furthermore, non-Hispanic Black, Hispanic, and Asian or Pacific Islander individuals were more likely to be admitted for HDPP than non-Hispanic White individuals, suggesting worse disease severity at presentation.

Study strengths include a nationally representative dataset with large sample and inclusion of recently added race and ethnicity data. Limitations include a visit-based dataset that may count individuals multiple times and use of diagnostic codes which shifted from ICD-9 to ICD-10 between 2015 and 2016. Racial differences in ED utilization for HDPP underscore the ongoing racial disparities in US maternal morbidity and mortality and highlight a critical need for accessible, culturally competent community-level interventions for all.

Accepted for Publication: July 16, 2024.

Published: September 13, 2024. doi:10.1001/jamanetworkopen.2024.33045

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2024 Townsel C et al. ÌÇÐÄvlog Open.

Corresponding Author: Erica E. Marsh, MD, MSCI, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan, University Hospital South, L4000, 1500 E Medical Center Dr, Ann Arbor, MI 48109 (marshee@med.umich.edu).

Author Contributions: Dr Marsh and Mr Jiang had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Townsel, Louis, Mitchell-Solomon, Marsh.

Acquisition, analysis, or interpretation of data: Townsel, Louis, Clark, Jiang, Caldwell, Marsh.

Drafting of the manuscript: Townsel, Louis.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Jiang.

Administrative, technical, or material support: Townsel, Clark, Caldwell.

Supervision: Marsh.

Conflict of Interest Disclosures: Dr Caldwell reported receiving grants from the Robert Wood Johnson Foundation, Blue Cross Blue Shield of Michigan Foundation, Genentech, Patient-Centered Outcomes Research Institute, and Power to Decide and personal fees from Deloitte, Cardea, Access Bridge, and Partners in Contraceptive Choice & Knowledge outside the submitted work. Dr Marsh reported receiving personal fees from Alnylam Consulting outside the submitted work. No other disclosures were reported.

Data Sharing Statement: See Supplement 2.