Gendered racial microaggressions found to raise blood pressure after childbirth

Gender-based racism through microaggressions may be linked to higher blood pressure postpartum and beyond, according to new research published today in Hypertension, a peer-reviewed journal of the American Heart Association.

People who recently gave birth can be at an elevated risk of developing high blood pressure, or postpartum hypertension. Although rare, this can sometimes be life-threatening and may be associated with developing heart disease later in life, and the risk is elevated in people that had any pregnancy-related high blood pressure issue such as preeclampsia.

In the current study, the authors examined the potential association between high blood pressure and gender-based racial microaggressions - subtle unintentional slights, such as being told to calm down - experienced while receiving health care services during pregnancy and delivery.

It is well-known that Black, Hispanic and South Asian women experience microaggressions during health care. It is not as well known whether these microaggressions may have an association with higher blood pressure."

Teresa Janevic, Ph.D., M.P.H., lead study author, associate professor of epidemiology at Columbia University Mailman School of Public Health, New York

Researchers used the Gendered Racial Microaggressions Scale (GRMS), adapted into a 26-item, four-factor scale, to ask 373 Asian, Black and Hispanic study participants delivering at four hospitals in Philadelphia and New York City how frequently they experienced gendered racial microaggressions. The participants were asked to check their blood pressure at home for three months after birth using text-based monitoring. They also estimated community-level structural racism with the Structural Racism Effect Index, a publicly available national index.

The analysis found:

• More than one-third of participants reported experiencing at least one gendered racial microaggression during their obstetrical care.
• Participants who experienced one or more gendered racial microaggressions had three-month average systolic and diastolic blood pressure, or top and bottom numbers, that were 2.12 mm Hg and 1.43 mm Hg higher than participants who did not report microaggressions.
• The highest three-month average blood pressures came from participants who experienced microaggressions and lived in areas with high levels of structural racism, while the lowest average blood pressures were observed in participants who lived in areas with low levels of structural racism and who didn't report experiencing microaggressions. Between these two groups, there was an average top number blood pressure difference of 7.55 mm Hg and average bottom number blood pressure difference of 6.03 mm Hg.

"It's surprising the associations were strongest in the later postpartum period between 12 days and three months after delivery. This is an emerging critical period for preventing high blood pressure," Janevic said. "Our findings provide further evidence that health care professionals and policies should focus more intensely on improving maternal health care equity. We need high blood pressure monitoring and interventions to extend further into the period after birth when blood pressure may continue to be sensitive to social drivers of health as well as racial microaggressions."

Future research is needed to explore how experiencing racism influences blood pressure, to understand the potential health effects on infants and to identify the best interventions to improve postpartum health, Janevic noted.

"This work serves as a reminder of the long-term impact that racism can have on one's overall health. The magnitude of these types of physiologic changes may become cumulative over time and lead to the inequities we see in many health outcomes," said senior study author Lisa Levine, M.D., M.S.C.E., the Michael T. Mennuti, M.D., Associate Professor in Reproductive Health, director of the Pregnancy and Heart Disease Program and chief of the Maternal Fetal Medicine Division at the University of Pennsylvania Perelman School of Medicine.

The study had limitations, including that researchers did not know the participants' blood pressure trends before pregnancy, meaning they did not know how much of the data collected reflects those pre-pregnancy trends. Additionally, the researchers did not collect other health information that could influence blood pressure, such as diet; and, because this study was conducted in only two large cities, the findings may not be generalizable to more rural settings. The authors also noted that future research is needed to link postpartum blood pressure trends to midlife heart health.

"The synergistic effects of experiencing gendered racial microaggressions and high levels of place-based structural racism were profound, resulting in a nearly 8mmHg higher systolic blood pressure. For many people, this can make the difference between needing blood pressure lowering medications or not," said Natalie A. Cameron, M.D, M.P.H., an internal medicine specialist and instructor in preventive medicine at Northwestern University's Feinberg School of Medicine, who was not involved in the study. Cameron is also a member of the Association's Council on Epidemiology and Prevention and Council on Lifestyle and Cardiometabolic Health.

"These results emphasize that hypertension management needs to extend beyond prescription medications," she said. "Future work is needed to design interventions that reduce gendered racial microaggressions in the health care setting and investigate their effects on postpartum blood pressure."

Study design, background and details:

• The study included 373 patients who delivered live babies at four maternity hospitals located in Philadelphia and Queens, New York, between March and October 2022.
• Study participants ranged from 16 to 46 years old; approximately 43% were 20-29 years old. 40% of participants self-identified as Hispanic (39); 38.6% as Black (144); 10.5% as Asian (149); and 11% selected "Other" (41).
• The survey used a validated 26-item, four-factor model that asked patients to report how frequently they experienced gendered racial microaggressions (0 = never to 5= once a week or more). Examples of items included "I have been disrespected," "Someone told me to calm down," and "Someone accused me of being angry when speaking assertively."
• 37.5% of participants reported experiencing at least one gendered racial microaggression during their obstetrical care.
• Participants were given validated blood pressure monitors and asked through text messaging to record their blood pressure twice a day for the first 10 days after being discharged following delivery and then twice a week from days 11 to 90.
• Participants were compensated up to $100 in gift cards for completing all research activities within the 90-day study period.