IPM Take
Maternal age is routinely treated as a biological risk factor. This study suggests that the biology does not unfold in the same social context for everyone.
Across 1.88 million California births, Black women had higher rates of hypertensive disorders of pregnancy, chronic hypertension and non-optimal prepregnancy cardiovascular health than White women. More importantly, those disparities widened with age, and higher education or private insurance did not consistently close them.
Among college-educated Black women, each five-year increase in age was associated with a 27% higher risk of hypertensive disorders of pregnancy, compared with a 23% increase among White women with a high-school education or less. For chronic hypertension, privately insured Black women had a 74% increase in risk per five years of age, compared with 64% among publicly insured White women.
The lesson is uncomfortable but important: socioeconomic advantage alone cannot be assumed to neutralise maternal cardiovascular inequality.
Pregnancy care that treats age as a universal biological variable may therefore miss the cumulative social conditions that shape how risk develops long before pregnancy begins.
Executive Summary
The JAMA Cardiology study analysed 1,880,400 births in California between 2007 and 2019, including live births and stillbirths from at least 20 weeks’ gestation among non-Hispanic Black and non-Hispanic White women. The mean maternal age was 29.9 years.
Researchers examined hypertensive disorders of pregnancy, including chronic hypertension, gestational hypertension, pre-eclampsia and eclampsia, together with measures of cardiovascular health before and during pregnancy. Socioeconomic status was assessed using maternal education and insurance type.
Overall, hypertensive disorders of pregnancy occurred in 14.2% of births among Black women versus 9.2% among White women. Chronic hypertension occurred in 4.7% versus 2.2%, while non-optimal prepregnancy cardiovascular health was present in 60.9% versus 45.2%, respectively.
Across socioeconomic categories, age-related increases in adverse outcomes were steeper among Black women. The greatest increases were generally seen among Black women experiencing greater socioeconomic disadvantage, but higher socioeconomic status did not eliminate the disparity.
The analysis was cross-sectional and based on administrative and vital-statistics data. It therefore cannot demonstrate that structural racism, socioeconomic disadvantage or chronic stress directly caused the observed risk differences. The authors interpret the findings through the concept of weathering, in which cumulative exposure to social adversity may contribute to earlier deterioration in health across the life course.
Why it matters
- HTA bodies: Maternal cardiovascular interventions may produce different value across populations if baseline risk and cumulative exposure differ substantially. Equity considerations should therefore examine who enters pregnancy at elevated risk, not simply whether an intervention performs similarly after complications appear.
- Payers: Pregnancy may be too late to begin prevention for some high-risk populations. Coverage models that focus narrowly on prenatal episodes risk missing opportunities for blood-pressure control, metabolic prevention and cardiovascular follow-up before conception and between pregnancies.
- Industry / innovation partners: Maternal cardiovascular trials and digital-risk tools need populations broad enough to test whether prediction and treatment effects differ across age, race and socioeconomic context. Algorithms trained on average risk could reproduce existing inequalities if they ignore these interactions.
The phrase “advanced maternal age” makes cardiovascular risk sound straightforward.
Get older, risk rises.
But the new California analysis suggests that this apparently simple biological relationship is shaped by social context in ways that conventional obstetric risk categories do not fully capture.
Researchers analysed statewide birth-hospitalisation records spanning more than a decade and found that Black women experienced higher prevalences of multiple adverse cardiovascular and hypertensive outcomes than White women. The differences were already visible before pregnancy in measures such as chronic hypertension, diabetes, BMI and smoking, and remained visible during pregnancy.
The more striking finding was what happened as maternal age increased.
For hypertensive disorders of pregnancy, every five-year increase in age was associated with larger relative increases in risk among Black women than among White women in comparable socioeconomic groups. The pattern held whether socioeconomic status was measured through education or insurance coverage.
This matters because healthcare frequently treats education, insurance and income as though they should automatically protect against racial health disparities.
The data suggest otherwise.
College-educated Black women still experienced age-related increases in hypertensive pregnancy risk that were comparable with or greater than those seen among White women with lower educational attainment. Privately insured Black women similarly showed steeper age-related increases in chronic hypertension than publicly insured White women.
Socioeconomic advantage did not erase the gradient
The study authors place the findings within the framework of weathering.
The concept proposes that repeated exposure to social and structural stressors can accumulate biologically over time, potentially producing earlier deterioration in cardiovascular and metabolic health among marginalised populations.
That interpretation is plausible, but it needs to be kept separate from what the study actually proves.
The dataset contained information on age, race, education, insurance and pregnancy-related clinical outcomes. It did not directly measure discrimination, neighbourhood conditions, chronic stress, environmental exposures or cumulative access to healthcare. Because the design was observational and cross-sectional, it cannot establish that any one of those factors caused the widening disparities.
What it does show is that age, race and socioeconomic status interact in ways that simple risk categories can obscure.
That has direct implications for prevention.
Current maternal care often intensifies once a woman becomes pregnant or once hypertension appears. Yet the study’s prepregnancy findings suggest that cardiovascular inequality may already be well established before conception.
Earlier identification of hypertension, obesity, diabetes and other cardiometabolic risk factors could therefore be particularly important for populations entering pregnancy with higher baseline risk. The authors specifically point toward preconception cardiovascular-health promotion, counselling and monitoring as areas for earlier intervention.
Pregnancy should not be the first cardiovascular checkpoint
Pregnancy is increasingly recognised as a window into long-term cardiovascular health.
Hypertensive disorders of pregnancy are associated with elevated future cardiovascular risk, making pregnancy both a clinical event and a potential early warning signal.
But this study pushes the timeline further backwards.
If disparities are already widening with age before and during pregnancy, then preventing maternal cardiovascular complications cannot remain solely the responsibility of obstetric care.
Primary care, preventive cardiology, reproductive health and public-health systems all become part of the pathway.
That is also where the policy question becomes harder.
It is easier to tell an individual patient to lose weight, control blood pressure or attend prenatal appointments than to address the social conditions that may shape cardiovascular risk over decades.
The study does not prove which structural interventions would reduce these disparities. It does, however, make one assumption increasingly difficult to defend: that equal clinical recommendations automatically create equal cardiovascular opportunity.
Precision maternal care may eventually require something broader than more accurate risk scores.
It may require recognising that the same age does not necessarily represent the same accumulated risk.
