Date on Master's Thesis/Doctoral Dissertation


Document Type

Doctoral Dissertation

Degree Name

Ph. D.


Epidemiology and Population Health

Degree Program

Public Health Sciences

Committee Chair

Wallis, Anne

Committee Co-Chair (if applicable)

Baumgartner, Richard

Committee Member

Baumgartner, Richard

Committee Member

Taylor, Kira

Committee Member

Kong, Maiying

Committee Member

Coates, Tawana Marie

Author's Keywords

preeclampsia; hypertensive disorders; eclampsia; gestational hypertension


Background: Hypertension remains one of the most prevalent medical issues in pregnancy. It contributes considerably to maternal and fetal morbidity and mortality, making it one of the most significant public health problems. Although various epidemiological studies have been conducted over the past decades to assess the disease incidence and key risk factors associated with hypertensive disorders of pregnancy, current incidence rates and trends are lacking. This is a novel and significant study because there are no current population-based incidence estimates of hypertensive disorders of pregnancy and their subtypes and very few studies with the power to explore a wide range of risk factors. Objective: The purpose of this dissertation is to provide the most current national trend incidence rates of gestational hypertension, preeclampsia, and eclampsia in the United States from 2016 to 2018, as well as to investigate the associated risk factors in women with hypertensive disorders of pregnancy. Design: Serial cross-sectional secondary analysis Setting: The Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP), which was drawn from all 48 States participating in HCUP, covering more than 97% of the U.S. population. The NIS represents a stratified sample of approximately 20% of discharges from community hospitals in the United States, excluding rehabilitation and long-term acute care hospitals. Participants: 11,097,776 deliveries of US women aged 15–45 years between 2016 and 2018. Methods: The descriptive patient and hospital characteristics of the study cohort, which included all women who had one or more live or stillbirths between 2016 and 2018, were given in counts and percentages. The incidence of gestational hypertension, preeclampsia, and eclampsia was reported in crude rates per 1000 delivery hospitalizations. The risks of gestational hypertension, preeclampsia, and eclampsia among US pregnant women aged 15–45 years were assessed using univariate and multivariable regression models that were adjusted for previously known covariates. Primary outcome measures: Gestational hypertension, preeclampsia, and eclampsia. Results:The incidence rate of hypertensive disorders of pregnancy is 54.6 per 1,000 deliveries for gestational hypertension, 48.9 per 1,000 deliveries for preeclampsia, and 0.8 per 1,000 deliveries for eclampsia. During the three-year study period, preeclampsia and gestational hypertension rates continued to rise while eclampsia rates declined. The incidence rate of gestational hypertension increased by 13.2% per year and that of preeclampsia by 9.0% per year, while the incidence rate of eclampsia decreased by 16.3% per year on average. Hospitalizations with gestational hypertension disorder were associated with higher risk among younger age groups (age 15–19), and older age groups (age 40–45) compared to 30-34 years-old, white race, women living in the south, the poorest area, women delivered in urban teaching hospitals, women with private insurance, and women with preexisting conditions including gestational diabetes and non-gestational diabetes, obesity, anemia, and hypothyroidism. The risk ratio of gestational hypertension was significantly lower in women with a history of smoking, thrombophilia, and renal disease, after adjusting for other covariates. On the other hand, preeclampsia was linked to a higher risk in younger and older age groups, Black race, women residing in the south and poorest areas, those who gave birth in teaching hospitals in urban areas, and those who had preexisting conditions like gestational diabetes and non-gestational diabetes, multiple pregnancy, obesity, systemic lupus erythematosus, antiphospholipid syndrome, anemia, hypothyroidism, and renal disease. The risk ratio of preeclampsia was significantly lower in women with a history of smoking and thrombophilia. Further, eclampsia was more likely to occur in younger age groups Conclusion: This work provides, to the best of the author’s knowledge, the most recent large-scale population-based studies that have estimated the incidence of the main types of hypertensive disorders in pregnancy and investigated the risk factors associated with those conditions on a larger scale. The risk of gestational hypertension, preeclampsia, and eclampsia increased among US women from 1979 to 2018. Additional efforts are needed to monitor and revise trends, as well as construct a risk-based model that could aid in early detection.