Objective
The purpose of this study is to examine hypertension and cholesterol screening, knowledge of heart attack symptoms, and cardiovascular disease (CVD) risk factors among women with a history of gestational hypertension.
Study Design
We used weighted 2008 National Health Interview Survey data to examine health indicators and modifiable CVD risk factors and to estimate prevalence and adjusted odds ratios for recommended CVD screening and knowledge of heart attack symptoms by hypertension history among 11,970 adult women.
Results
Among women with gestational hypertension only (n = 301), 93% received the recommended screening for hypertension; 75% received screening for dyslipidemia, and 40% correctly identified 5 of 5 heart attack symptoms. The odds of CVD screenings and knowledge did not differ between women with a history of gestational hypertension and those with no hypertension. However, women with gestational hypertension had higher rates of obesity (43%), CVD (18%), and diabetes mellitus (13%), compared with women without a history of hypertension (21%, 8%, and 3%, respectively).
Conclusion
A history of gestational hypertension is a neglected CVD risk marker.
Hypertension is one of the most common pregnancy complications; it affects 6-8% of pregnancies and accounts for 16% of maternal deaths in the United States. Hypertensive disorders during pregnancy cause significant maternal, fetal, and neonatal morbidity and death, which includes preterm delivery, small-for-gestational-age infants, and infant death. In addition to immediate health risks to the mother and fetus, even when hypertension resolves after delivery, the woman remains at heightened risk for subsequent hypertension, diabetes mellitus, and cardiovascular disease (CVD), which is the leading cause of death among women.
Given their increased risk for CVD, women with a history of gestational hypertension should be informed about their future risk for CVD and counseled about their need for primary prevention through CVD screening, which includes blood pressure and cholesterol measurements and lifestyle modifications. Additionally, being knowledgeable of heart attack symptoms increases the chances that a woman will recognize when she is having a heart attack and will seek care right away, which hopefully will improve her chances of survival and limit complications. Women’s interactions with the health care system, particularly during the postpartum period and as they age, provide important opportunities for health care providers to communicate this information. Yet, despite a robust literature that establishes an association between hypertension during pregnancy and subsequent CVD, we found only 1 study that assessed CVD screening rates beyond the postpartum period among women with preeclampsia (gestational hypertension accompanied by proteinuria). In that study, which had a mean follow-up time of nearly 3 years, researchers reported that 26 of 35 Dutch women (75%) with a history of preeclampsia had had their blood pressure checked within a year after pregnancy. We are not aware of similar studies that have been conducted in the United States. The primary objective of our study was to estimate rates of adherence to hypertension and cholesterol screening recommendations and knowledge of heart attack symptoms among US women with a history of gestational hypertension and compare them with rates among US women with and without history of other hypertension. We also estimated the prevalence of chronic disease conditions and modifiable CVD risk factors in these 3 populations.
Materials and Methods
We analyzed 2008 data from the National Health Interview Survey (NHIS), an annual survey of civilian, noninstitutionalized adults that uses a multistage sampling method and computer-assisted personal interviewing. The total household response rate was 84.9%. Sample weights were used to adjust for design, ratio, nonresponse, and poststratification; the data are representative of US residents who are ≥20 years old.
In 2008, 11,988 women participated in the NHIS, of whom 18 women lacked information on hypertension history (HTN), which left 11,970 women in our final sample. When weighted, these women represented 112,194,000 women in the United States.
Variables of interest were HTN, blood pressure and cholesterol screening, and knowledge of heart attack symptoms. In 2008, for the first time, an NHIS adult heart disease supplement queried female respondents about their history of pregnancy-related hypertension. They were asked whether they had “ever been told by a doctor or other health professional that they had hypertension, also called high blood pressure.” If they answered affirmatively, they were asked whether this was only during pregnancy. We categorized self-reported HTN into 3 discrete levels: no history of hypertension (non-HTN), gestational hypertension only (gestational-HTN), and self-reported history of hypertension (ever-HTN). The gestational-HTN category included women with a history of preeclampsia and gestational-HTN, which is a nonspecific diagnosis that is used when hypertension occurs only during pregnancy and in the absence of proteinuria. The ever-HTN category included women who may or may not have had hypertension during pregnancy who reported that their hypertension was not “only during pregnancy.”
CVD screening and knowledge questions included time since last blood pressure and cholesterol screening and knowledge about 5 specific heart attack symptoms. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommended hypertension screening every 2 years for healthy individuals. We created a binary outcome: blood pressure checked within the past 2 years by a doctor, nurse, or other health professional (yes/no). The National Cholesterol Education Program Adult Treatment Panel III recommended that all adults ≥20 years old have their cholesterol checked every 5 years; accordingly, we constructed a binary variable that indicated time lapse of <5 years since blood cholesterol was last checked by a doctor, nurse, or other health professional (yes/no). Accurate knowledge about heart attack symptoms was defined as correct identification of all of the following 5 symptoms of a heart attack: pain or discomfort in the jaw, neck, or back; feeling weak, lightheaded, or faint; chest pain or discomfort; pain or discomfort in the arms or shoulder; and shortness of breath.
We adjusted for numerous potential confounders based on the literature review and included demographic characteristics, health insurance, modifiable risk factors, and health indicators. Demographic characteristics that were examined included age, race/ethnicity, income, and education. Because of a large number of cases with missing income data, an additional category was created for unknown income (n = 959; 8.0%). Three binary measures of health insurance coverage were constructed to indicate uninsured, publicly funded, and private health insurance. Uninsured included persons with no coverage and limited private plans that covered only 1 type of service (eg, accidents or dental). Publicly funded insurance included Medicaid, Medicare, State Children’s Health Insurance Program, Indian Health Service coverage, or military insurance.
We examined the following modifiable risk factors: obesity, smoking, physical activity, and alcohol use. Obesity was based on the National Institutes of Health body mass index formula and defined as (≥30 kg/m 2 ). Because of a large number of cases with missing information about body mass index, an additional category was created to adjust for unknown body mass index (n = 667; 5.6%). Women who reported having ever smoked 100 cigarettes during their lifetime and who said that they currently smoke every day or some days were coded as smokers. Based on the 2008 Physical Activity Guidelines for Americans , we classified women as physically inactive if they reported no leisure time physical activity (such as exercise, sports, and physically active hobbies). Women who reported some physical activity but <150 minutes per week of moderate activity or <75 minutes of vigorous activity or an equivalent combination were coded as insufficiently active. Those women who reported any combination of moderate or vigorous activity totaling ≥150 minutes per week (after the vigorous minutes were doubled) were coded as physically active.
In accordance with the American College of Cardiology Foundation/American Heart Association 2009 performance measures for primary prevention of CVD in adults, we categorized alcohol use as a risk factor if women reported drinking >1 alcoholic beverage per occasion on the days when they consumed alcohol during the last year.
Health indicators included poor/fair respondent-reported health status (vs good, very good, or excellent), history of CVD (yes/no), and history of diabetes mellitus (yes/no). Women were considered to have a history of CVD if they reported ever being told by a doctor or health professional that they had coronary heart disease, angina, a heart attack or stroke, or any kind of heart condition or heart disease. Women were considered to have a history of diabetes mellitus if they reported ever being told by a doctor or health professional that they had diabetes mellitus or sugar diabetes, but not if they were told they were borderline diabetic.
We estimated the prevalence of modifiable risk factors and health indicators by self-reported hypertensive history. Pearson χ 2 tests were conducted to assess differences in the distributions. We used multivariable logistic regression to adjust for potential confounders and to determine whether gestational hypertension was associated with adherence to screening recommendations and knowledge of heart attack symptoms. Observations with missing data were excluded from the logistic regression models. Unweighted sample sizes and weighted prevalence estimates are presented in the Tables 1 and 2 . Stata software (version 10.1; Stata Corporation, College Station, TX) was used to adjust for the complex survey design and to carry out all analyses with weighted data. Studies that use deidentified, publicly available data do not require Centers for Disease Control institutional review board approval.
| Variable | No hypertension (n = 7915) | Gestational hypertension (n = 301) | Ever hypertension (n = 3754) |
|---|---|---|---|
| Demographics and insurance, % b | |||
| Age, y | |||
| 20-44 | 58.1 | 59.4 | 15.3 |
| 45-64 | 32.7 | 18.3 | 43.2 |
| ≥65 | 9.2 | 22.3 | 41.5 |
| Race/ethnicity | |||
| White, non-Hispanic | 68.8 | 64.8 | 70.7 |
| Black, non-Hispanic | 11.0 | 16.9 | 15.7 |
| Hispanic | 13.8 | 14.8 | 9.2 |
| Other | 6.4 | 3.6 | 4.4 |
| Annual family income | |||
| $0-34,999 | 27.6 | 40.1 | 41.1 |
| $35,000-49,999 | 14.0 | 8.9 | 15.6 |
| $50,000-74,999 | 17.4 | 16.1 | 15.8 |
| $75,000-99,999 | 11.7 | 11.1 | 7.9 |
| ≥$100,000 | 21.3 | 16.6 | 10.8 |
| Unknown | 8.0 | 7.3 | 8.9 |
| Education (highest level) | |||
| <12th grade | 9.9 | 16.3 | 18.0 |
| 12th grade, GED, or high school graduate | 26.1 | 31.6 | 36.8 |
| Some college | 64.1 | 52.1 | 45.3 |
| Health insurance c | |||
| Private | 69.3 | 59.5 | 60.8 |
| Public d | 13.2 | 27.9 | 29.4 |
| Uninsured e | 17.5 | 12.6 | 9.9 |
| Outcome variables, % b | |||
| Time since blood pressure checked, y | |||
| <1 | 76.1 | 82.2 | 92.8 |
| 1-2 | 13.7 | 11.0 | 4.1 |
| ≥2 | 8.3 | 6.5 | 2.9 |
| Never | 1.9 | 0.3 | 0.2 |
| Time since cholesterol checked, y | |||
| <1 | 40.2 | 46.8 | 74.0 |
| 1-2 | 27.4 | 24.3 | 16.9 |
| >2-4 | 4.3 | 4.3 | 2.0 |
| 5+ | 4.4 | 6.6 | 2.3 |
| Never | 23.8 | 18.1 | 4.8 |
| Heart attack symptoms correctly identified f | |||
| Pain or discomfort in the jaw, neck, or back | 51.2 | 52.5 | 61.9 |
| Feeling weak, lightheaded, or faint g | 65.5 | 61.9 | 66.5 |
| Chest pain or discomfort g | 83.4 | 82.9 | 84.9 |
| Pain or discomfort in the arms or shoulder | 78.8 | 79.0 | 82.0 |
| Shortness of breath | 77.9 | 79.7 | 80.5 |
| Correctly identified all 5 symptoms | 41.4 | 39.7 | 49.5 |
a 2008 National Health Interview Survey; n = 11,970 women; unweighted sample sizes and weighted percentages are presented;
b Percent totals may not sum to 100 because of missing data and rounding; χ 2 , P < .05 except as noted;
c Persons with >1 type of insurance were assigned to the first appropriate category in the hierarchy of coverage comprehensiveness;
d Includes Medicaid, Medicare, State Children’s Health Insurance Program, Indian Health Service coverage, and military insurance;
e Includes persons with no coverage and private plans that paid for only one type of service (eg, accidents or dental);
f Respondents were asked, “Which would you say are the symptoms that someone may be having a heart attack?”;
g Differences between groups are not statistically significant.
| Blood pressure screening within previous 2 y (n = 11,450) | Cholesterol screening within previous 5 y (n = 10,986) | Knowledge about heart attack symptoms (n = 11,600) | ||||
|---|---|---|---|---|---|---|
| Variables | Adjusted odds ratio | 95% CI a | Adjusted odds ratio | 95% CI a | Adjusted odds ratio | 95% CI a |
| Health indicators | ||||||
| Hypertension | ||||||
| Ever | 2.5 | 1.8–3.4 | 2.4 | 2.0–3.0 | 1.2 | 1.1–1.4 |
| Gestational only | 1.3 | 0.8–2.2 | 1.0 | 0.7–1.5 | 1.0 | 0.7–1.3 |
| None | Referent | Referent | Referent | |||
| Cardiovascular disease | ||||||
| Yes | 1.6 | 1.1–2.2 | 1.5 | 1.2–1.9 | 1.5 | 1.3–1.7 |
| No | Referent | Referent | Referent | |||
| Diabetes mellitus | ||||||
| Yes | 2.3 | 1.3–4.0 | 2.4 | 1.5–3.7 | 1.1 | 0.9–1.4 |
| No | Referent | Referent | Referent | |||
| Respondent-reported health status | ||||||
| Poor/fair | Referent | Referent | Referent | |||
| Good | 0.8 | 0.6–1.1 | 0.9 | 0.7–1.1 | 1.1 | 0.9–1.3 |
| Very good | 0.6 | 0.4–0.8 | 0.7 | 0.6–0.9 | 1.1 | 0.9–1.3 |
| Excellent | 0.5 | 0.3–0.7 | 0.7 | 0.5–0.9 | 1.1 | 0.9–1.3 |
| Demographics and insurance | ||||||
| Age, y | ||||||
| 20-44 | Referent | Referent | Referent | |||
| 45-64 | 1.0 | 0.8–1.2 | 3.6 | 3.1–4.3 | 1.6 | 1.4–1.7 |
| ≥65 | 1.2 | 0.9–1.7 | 6.1 | 4.7–7.8 | 1.4 | 1.2–1.6 |
| Race/ethnicity | ||||||
| White, non-Hispanic | Referent | Referent | Referent | |||
| Black, non-Hispanic | 1.1 | 0.9–1.4 | 1.3 | 1.1–1.6 | 0.6 | 0.5–0.6 |
| Hispanic | 0.6 | 0.5–0.8 | 1.6 | 1.3–1.9 | 0.5 | 0.4–0.5 |
| Other | 0.6 | 0.4–0.8 | 1.1 | 0.8–1.5 | 0.5 | 0.4–0.6 |
| Annual family income | ||||||
| $0-34,999 | Referent | Referent | Referent | |||
| $35,000-49,999 | 0.9 | 0.7–1.2 | 1.4 | 1.1–1.7 | 1.0 | 0.9–1.2 |
| $50,000-74,999 | 1.2 | 0.9–1.6 | 1.5 | 1.2–1.9 | 1.3 | 1.1–1.6 |
| $75,000-99,999 | 1.1 | 0.8–1.6 | 2.0 | 1.5–2.6 | 1.4 | 1.2–1.7 |
| ≥$100,000 | 1.7 | 1.2–2.4 | 2.2 | 1.7–2.8 | 1.4 | 1.2–1.7 |
| Unknown | 1.0 | 0.7–1.4 | 1.3 | 1.0–1.8 | 1.4 | 1.1–1.7 |
| Education | ||||||
| <12th grade | Referent | Referent | Referent | |||
| 12th grade, GED, or high school graduate | 0.7 | 0.6–1.0 | 1.1 | 0.9–1.4 | 1.3 | 1.0–1.5 |
| Some college | 1.1 | 0.9–1.5 | 1.5 | 1.2–1.8 | 1.7 | 1.5–2.0 |
| Health insurance | ||||||
| Private | 3.6 | 2.9–4.4 | 2.3 | 1.9–2.7 | 1.2 | 1.0–1.4 |
| Public b | 3.0 | 2.3–3.9 | 2.0 | 1.6–2.4 | 1.1 | 0.9–1.3 |
| Uninsured c | Referent | Referent | Referent | |||
| Modifiable risk factors | ||||||
| Body mass index | ||||||
| Underweight/normal | Referent | Referent | Referent | |||
| Overweight | 1.0 | 0.8–1.3 | 1.4 | 1.2–1.6 | 1.1 | 1.0–1.2 |
| Obese | 1.2 | 1.0–1.5 | 1.4 | 1.2–1.6 | 1.3 | 1.1–1.4 |
| Unknown | 0.8 | 0.5–1.2 | 1.1 | 0.8–1.5 | 1.0 | 0.8–1.3 |
| Current smoking | ||||||
| No | Referent | Referent | Referent | |||
| Yes | 0.7 | 0.5–0.9 | 0.7 | 0.6–0.9 | 1.1 | 1.0–1.3 |
| Physical activity d | ||||||
| Active | Referent | Referent | Referent | |||
| Insufficiently active | 1.0 | 0.5–0.8 | 1.0 | 0.8–1.2 | 1.1 | 0.9–1.2 |
| Inactive | 0.7 | 0.5–0.9 | 0.7 | 0.6–0.9 | 0.8 | 0.7–0.9 |
| Alcohol use | ||||||
| 0-1 drink per occasion e | Referent | Referent | Referent | |||
| ≥2 drinks per occasion | 1.2 | 1.0–1.5 | 0.9 | 0.8–1.1 | 0.9 | 0.8–1.0 |
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