Elsevier

American Heart Journal

Volume 254, December 2022, Pages 35-47
American Heart Journal

Review Articles
Black-White disparity in severe cardiovascular maternal morbidity: A systematic review and meta-analysis

https://doi.org/10.1016/j.ahj.2022.07.009Get rights and content

ABSTRACT

Background

To synthesize existing evidence on Black-White disparities in the prevalence of severe cardiovascular maternal morbidity.

Methods

We searched MEDLINE, EMBASE, and CINAHL for observational studies published before July 31, 2021 that compared the risk of severe cardiovascular maternal morbidity between Black and White women. The outcome was severe cardiovascular maternal morbidity, including acute myocardial infarction, peripartum cardiomyopathy, and stroke during pregnancy, delivery, or postpartum. We extracted relevant information including adjusted and unadjusted effect estimates. We used random-effects models to estimate the pooled association between race and severe cardiovascular maternal morbidity, presented as odds ratios with 95% confidence intervals for the comparison of Black women relative to White women.

Results

We included 18 studies that met the eligibility criteria for systematic review and meta-analysis. All studies were conducted in the United States and included a total of 7,656,876 Black women and 26,412,600 White women. Compared with White women, Black women had an increased risk of any severe cardiovascular maternal morbidity (adjusted odds ratio, 1.90; 95% confidence interval, 1.54-2.33). Black women were at risk of acute myocardial infarction (adjusted odds ratio, 1.38; 95% confidence interval, 1.14-1.68), peripartum cardiomyopathy (adjusted odds ratio, 1.71; 95% confidence interval, 1.51-1.94), and stroke (adjusted odds ratio, 2.13; 95% confidence interval, 1.39-3.26).

Conclusions

Black women have a considerably higher risk of severe cardiovascular maternal morbidity than White women, including acute myocardial infarction, peripartum cardiomyopathy, and stroke. Reducing inequality in adverse cardiovascular outcomes of pregnancy between Black and White women should be prioritized.

Section snippets

Background

Racial disparities in severe cardiovascular maternal morbidity are poorly understood.1,2 Despite improvements in peripartum care, rates of severe morbidity due to cardiac conditions and cerebrovascular accidents in Black women are persistently elevated in comparison to White women.1,2 Maternal cardiovascular complications, including cardiac arrest, stroke, and cardiomyopathy, are top causes of morbidity and mortality,3 especially in Black women.4 A number of studies have shown that Black women

Methods

This systematic review was registered in PROSPERO, the International Prospective Register of Systematic Reviews (registration no. CRD42021256486). The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (Supplemental Table 1).6

This study was funded by the Heart and Stroke Foundation of Canada and Fonds de recherche de Québec-Santé. The authors are solely responsible for the design and conduct of this study, all study analyses, the drafting and

Study selection

We identified 4,752 articles in the literature search and removed 1,291 duplicates (Figure 1). We screened the titles and abstracts of the remaining 3,461 articles for eligibility. We conducted a full text review of 30 articles and found a total of 18 articles that met inclusion criteria. Among included studies, 12 had low risk of bias11-15,17-20,22,24,25 and 6 had moderate risk of bias.8,16,21,26-28 The overall quality of studies was good (median 8 stars, range 4-9 stars) (Supplemental Table

Principal findings

This systematic review and meta-analysis of 18 studies, involving a total of 7.6 million Black and 26.4 million White women, indicates that Black women have nearly double the risk of severe cardiovascular maternal morbidity than White women. Black women have a higher risk of acute myocardial infarction, peripartum cardiomyopathy, and stroke in pregnancy. Disparity between Black and White women was present after adjustment for maternal age, medical comorbidity, socioeconomic status, and other

Author contributions

All the authors have made a significant contribution to this manuscript as follows: UVU conceptualization, methodology, and original drafting of manuscript; XL: second reviewer for studies, result interpretation, manuscript review and editing; SQ: result interpretation, manuscript review; JHP: manuscript review and editing; ND: data curation, manuscript review and editing; NA conceptualization, interpretation of analyses and revising manuscript and editing, and supervision. All the authors have

Funding

This study was funded by the Heart and Stroke Foundation of Canada (G-22-0031974). UV Ukah (302972) and N Auger (296785) were supported by the Fonds de recherche de Québec-Santé. The funders had no involvement in the study design, collection, analysis, and interpretation of data, writing the report, or in the decision to submit article for publication.

Conflict of interest

None.

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    Declarations of interest: none.

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