Abstract
Introduction:
Hypertensive disorders of pregnancy (HDP) are a leading cause of maternal morbidity and mortality in the United States (US), yet national trends across demographic groups are not well characterized.
Methods:
This population-based retrospective study analyzed HDP-related maternal mortality from 1999 to 2023 using the Centers for Disease Control and Prevention, Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER). Age-adjusted mortality rates (AAMRs) were calculated using the 2000 US standard population, and trends were evaluated using Joinpoint regression to calculate Annual Percent Change (APC) and Average Annual Percent Change (AAPC) for different demographic groups.
Results:
From 1999 to 2023, 1,851 HDP-related deaths occurred. While the AAMR remained stable at 0.10 deaths per 100,000 people, Joinpoint analysis identified a significant upward trend (AAPC 0.89*). AAMR for Non-Hispanic (NH) Black females was 4–5 times higher than the rate for NH White females and increased throughout the study period. Meanwhile, AAMR for NH White women showed no statistically significant overall trend. Age-stratified analysis demonstrated declining mortality among women aged 25–34 (AAPC −1.24*) and a non-significant upward trend in mortality among women aged 35–44 (AAPC 0.24), with rates between the two groups converging from approximately 2018 onwards. Geographic analysis indicated the highest HDP-related mortality burden in the South census region and no significant changes in urban populations.
Discussion:
These findings emphasize persistent disparities and the need for equitable access to obstetric and cardiovascular care, as well as improved peri-and postpartum monitoring to reduce preventable maternal deaths. However, these findings should be interpreted in the context of limitations inherent to the use of a single database (CDC WONDER), which may be affected by incomplete reporting in death certificate data.
1 Introduction
Hypertensive disorders of pregnancy (HDP) affect between 5%–10% of pregnant women and are the leading cause of pregnancy-related death in the United States (US) (, ). HDPs are characterized by elevated blood pressure during pregnancy, either because of the pregnancy or due to pre-existing chronic hypertension. HDPs resulting from pregnancy include gestational hypertension, pre-eclampsia, eclampsia, and pre-existing hypertension complicating pregnancy. These conditions can lead to adverse effects for both the mother and fetus, including required labor induction, placental abruption, stroke, and death in the case of the mother. They can also result in premature birth and low birth weight in the case of the fetus (). The risk of these complications is reduced by early diagnosis and treatment before, during, and after pregnancy. Importantly, following pregnancy HDP are associated with an increased risk of developing chronic hypertension and future cardiovascular disease, highlighting their role as an early indicator of long-term maternal cardiovascular health (). The prevalence of HDP has increased in the US from 10.8% to 13.0% between 2017 and 2019, with a 25% increase over the past two decades (, ). HDPs disproportionately affect females of color, predominantly Non-Hispanic (NH) Black and American Indian/Alaska Native women, who are more likely to develop mild to severe pre-eclampsia or enter pregnancy with chronic hypertension. Additionally, these females experience the highest ratio of deaths per birth at 41 and 30 pregnancy-related deaths per 100,000 births, respectively, compared to NH White females with 13 deaths for every 100,000 births ().
Despite improvements in prenatal care, blood pressure monitoring, and antihypertensive therapy, rates of severe complications and death due to HDP continue to rise (, ). Existing literature has largely focused on hospital-based outcomes during delivery, highlighting the increasing burden of HDP in the US. However, these studies primarily capture inpatient data and therefore do not reflect population-level mortality trends or deaths occurring outside the hospital setting (, ). Because the risks of HDP persist beyond hospital discharge and into the postpartum period, hospital datasets may underestimate these deaths (, ). Thus, comprehensive population-based studies are needed to capture deaths throughout the postpartum period and to better characterize the disparities in HDP maternal deaths across race, age, and geography at a national level. Population-based mortality datasets, such as the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) database, capture deaths recorded on death certificates. This data may include deaths occurring during the postpartum period when HDP is listed as an underlying or contributing cause.
To address these gaps, this study analyzes temporal patterns in maternal mortality associated with HDP stratified by race, age, and geographic region in the US from 1999 to 2023. Insight into these trends is essential for informing targeted interventions and equitable health policies to reduce preventable maternal deaths nationwide.
2 Methods
The CDC WONDER database was used to identify maternal deaths from HDP occurring within the US (). Specifically, the “Multiple Cause of Death” option within CDC WONDER was used, allowing identification of HDP listed as either an underlying or contributing cause of death. The Multiple Cause-of-Death Public Use Record and the CDC WONDER database were analyzed to determine HDP as an underlying or contributing cause of death on nationwide death certificate records. This database was previously used to study patterns of pregnancy-related death in the US, where HDP represented one of several cause-specific groups evaluated in the analysis (). HDP-related mortality was identified using the International Classification of Diseases, 10th Revision, Clinical Modification codes O10-O16 in women aged 25–44, as this age range corresponds to when pregnancy most likely occurs, and aligns with the average US maternal age of 29.6 years (). Deaths were identified based on ICD-10 codes for HDP listed as an underlying or contributing cause of death, regardless of timing relative to delivery. The study was exempt from institutional review board approval, as the CDC WONDER database contains anonymized, publicly available data.
Data regarding HDP-related deaths and population sizes was extracted from the database from 1999 to 2023. Data on demographic and regional groups was collected, including race/ethnicity, age, urban-rural classification, and region. Racial/ethnic groups were defined as NH White, NH Black or African American, NH American Indian or Alaska Native, NH Asian or Pacific Islander, and Hispanic or Latino people as identified on death certificates. However, only NH White and NH Black or African Americans were included in the analysis, as mortality counts for the other racial/ethnic groups were frequently suppressed or classified as unreliable in CDC WONDER, preventing stable annual rate estimates (). Age groups were defined as 25 to 34 and 35 to 44 years of age to focus on women of reproductive age, defined as those aged 15–44 (). Within this broader reproductive age range, women aged 25–44 account for most births in the US, making these age groups particularly relevant for analysis of pregnancy-related outcomes (, ). For urban-rural classifications, the National Center for Health Statistics Urban-Rural Classification Scheme was used to divide the population into urban (including metropolitan areas with population >50,000) and rural (non-metropolitan areas with population <50,000). Trends could not be determined for urban populated zones after 2020 due to changes in geographic coding standards, and for rural populated zones from 1999 to 2023 due to unreliable data within the study parameters (). Regions were classified into Northeast, Midwest, South, and West according to the Census Bureau definitions (). Due to data suppression, annual mortality from 1999 to 2023 could not be reliably evaluated for the Northeast, Midwest, and West census regions (). To address data suppression in subgroup analyses, mortality data for groups with high yearly suppression were extracted using aggregated multi-year intervals (1999–2020 and 2021–2023) rather than single-year data.
HDP-related crude and age-adjusted mortality rates were calculated. Age-adjusted mortality rate (AAMR), defined as the number of deaths per 100,000 people, was standardized using the 2,000 United States standard population (, ). Population-based rates were used rather than rates per 100,000 live births for two reasons. First, CDC WONDER calculates age-adjusted mortality rates using U.S. Census Bureau July 1 resident population estimates as the denominator for all non-infant age groups; live births are only available as a denominator when querying infant mortality (i.e., deaths under 1 year of age) and cannot be selected for adult age groups. Second, ICD-10 codes O10–O16 capture HDP-related deaths occurring across the antepartum period, delivery, and puerperium, including deaths in pregnancies not resulting in a live birth. A live births denominator would therefore exclude a portion of the at-risk population and introduce systematic underestimation of mortality burden. Use of total female population as the denominator is consistent with population-level mortality surveillance studies using CDC WONDER for obstetric conditions. Numerator (death counts) and denominator (female population estimates) by year are reported. The Joinpoint Regression Program (Joinpoint version 5.4.0 available from the National Cancer Institute, Bethesda, Maryland) was used to determine trends in mortality within the study period (). Annual percentage change (APC) and average annual percent change (AAPC) with 95% confidence intervals (CIs) for the AAMRs were calculated for the line segments linking a Joinpoint using the Monte Carlo permutation test (–). APCs and AAPCs were considered increasing or decreasing if the slope describing the change in mortality over the time interval was significantly different from zero using a two-tailed t-test. Statistical significance was set at p ≤ 0.05. Asterisks, “*”, were used to denote significance.
3 Results
From 1999 to 2023, there were 1,851 deaths related to HDP in the US. While death rates fluctuated between 0.05 and 0.10 from 1999 to 2006, they stabilized at approximately 0.10* (95% CI 0.08 to 0.13) from 2007 through the remainder of the study period, with minor year-to-year variation not apparent due to rounding to two decimal places, as reported by the CDC WONDER database (Figure 1, Supplementary Table S1). Although absolute values appear numerically small and relatively stable, this reflects the rarity of HDP-related mortality at the population level. Overall, both the AAPC and APC were 0.89* (95% CI 0.03 to 1.93). The Joinpoint analysis did not identify any statistically significant Joinpoints between 1999 and 2023, indicating a single, continuous temporal trend. Consequently, the APC and AAPC are the same, reflecting a statistically significant increase over the study period overall. The steady upward trend suggests a persistent rise in HDP-related mortality over time without evidence of meaningful inflection points (Figure 1).
Figure 1
3.1 Race stratified results
There were 803 HDP-related deaths among the NH Black or African American population and 676 deaths among the NH White population throughout the study period. The NH Black or African American population had the highest AAMR, ranging from 0.15* (95% CI 0.09 to 0.22) in 2007 to 0.29* (95% CI 0.19 to 0.37) in 2023, with an APC and AAPC of 1.52* (95% CI 0.30 to 2.88). The NH White population had an overall lower and more consistent AAMR throughout the study period, of 0.05* (95% CI 0.03 to 0.07) (Figure 2). Due to relatively low event counts, year-to-year estimates for this group were subject to greater variability, and multiple years were suppressed per CDC WONDER privacy rules, which may limit the stability and interpretability of temporal trend analyses. Rates initially rose between 1999 and 2020 (APC 3.57*, 95% CI 1.46 to 10.09), followed by a sharp decline from 2020 to 2023 (APC −23.13*, 95% CI −38.36 to −0.56). Across the entire study period, the overall trend for NH White individuals was not statistically significant (AAPC −0.22, 95% CI, −2.81 to 2.90) (Supplementary Figure S2). Years with unreliable data were removed from the analysis (Supplementary Table S2).
Figure 2
Although yearly trends could not be determined for the NH American Indian or Alaska Native, NH Asian or Pacific Islander, and Hispanic or Latino populations due to unreliable data, we were able to estimate mortality burden using aggregated multi-year data extracted directly from the database for these groups. From 1999 to 2023, excluding the years with suppressed data, there were 328 HDP-related deaths among Hispanic or Latino individuals, 51 among Asian or Pacific Islander Individuals, and 13 among American Indian or Alaska Native individuals (Supplementary Table S6).
3.2 Age-group stratified results
Across the study period, 1,058 deaths were recorded for individuals aged 25–34, and 793 deaths among those aged 35–44. The AAMR for individuals aged 25–34 declined throughout the period from 0.12* (95% CI 0.09 to 0.16) in 1999 to 0.11* (95% CI 0.08 to 0.11) in 2023 with an APC and AAPC of −1.24* (95% CI −1.97 to −0.44).
In contrast, the AAMR for those aged 35–44 increased throughout the period from 0.07* (95% CI 0.05 to 0.10) in 1999 to 0.10* (95% CI 0.08 to 0.14) in 2021 (APC 2.09*, 95% CI 0.82 to 15.49). This was followed by a nonsignificant decline from 2021 to 2023 (APC −17.94, 95% CI −33.74 to 1.82) (Supplementary Figure S3). Across the full study period, the AAPC for individuals aged 35–44 was 0.24 (95% CI −1.52 to 2.67). These diverging trends resulted in a convergence of crude mortality rate between the two age groups from approximately 2018 onward (Figure 3). Years with unreliable data were removed from the analysis (Supplementary Table S3).
Figure 3
3.3 Census region results
There were 904 deaths due to HDP in the South census region between 1999 and 2023. The AAMR increased from 0.10 in 1999 and peaked at 0.20 in 2019 before declining to 0.09 in 2023(Figure 4, Supplementary Table S4). The AAPC was −0.04 (95% CI −2.58 to 5.66) with an APC of 3.39 (95% CI −1.68 to 40.11) from 1999 to 2021 and −31.00 (95% CI −51.82 to 3.68) from 2021 to 2023. Neither segment nor the overall trend reached statistical significance (Supplementary Figure S4).
Figure 4
When deaths were aggregated across the full study period, HDP-related maternal mortality burden was observed across all census regions, with 904 deaths in the South, 323 in the West, 303 in the Midwest, and 283 in the Northeast from 1999 to 2023 (Supplementary Table S7).
3.4 Urban-Rural classification results
There were 1,383 deaths due to HDP in urban population zones between 1999 and 2020. While the AAMR was 0.10 in both 1999 and 2020, rates fluctuated between 0.05 and 0.10 from 1999 to 2006 before stabilizing at 0.10 for the remainder of the study period Overall, the AAMR did not change significantly across the study period, with an AAPC and APC of 0.68 (95% CI −0.37 to 1.95) (Figure 5, Supplementary Table S5).
Figure 5
4 Discussion
This study highlights that HDP-related maternal mortality has increased over the past two decades, with a consistent upward trend extending through 2023, providing updated insight into recent national trends not fully captured in prior analyses. The use of CDC WONDER enables a comprehensive, longitudinal assessment of maternal mortality patterns across the US, which may not be captured in smaller or institution-specific datasets. These findings add to the existing literature by demonstrating that these trends have remained consistent over time, rather than solely updating prior estimates. Importantly, the absence of significant inflection points suggests that this increase has occurred as a continuous and persistent trend rather than being driven by discrete temporal shifts, suggesting that advances in prenatal monitoring and therapeutic options have not resulted in measurable reductions in HDP-related mortality at the population level (, ). In this context, the identification of sustained increases in HDP-related mortality when outcomes were examined by race and age underscores the persistent inequities that continue to shape maternal health outcomes in the US.
NH Black individuals consistently experienced substantially higher and increasing HDP mortality rates compared to NH White individuals. In contrast, mortality among NH White individuals showed no statistically significant overall change, though rates rose between 1999 and 2020 before declining sharply. Previous studies demonstrate that NH Black women are more likely to have their symptoms dismissed, receive inadequate or delayed management of hypertension, and deliver in hospitals with fewer resources and worse maternal outcomes (, ). Thus, structural racism, unequal access to quality obstetric care, and delayed recognition and treatment of hypertensive disease in pregnancy may contribute to the disproportionate mortality burden faced by NH Black individuals in this study (, ). Although yearly analysis could not be completed for Hispanic or Latino, NH American Indian or Alaska Native, and NH Asian or Pacific Islander individuals due to insufficient data, aggregate mortality counts across the study period demonstrate a persistent mortality impact of HDP-related maternal deaths in these populations. Thus, the absence of yearly specific mortality estimates reflects the dataset and does not demonstrate an absence of risk. Underrepresentation of these groups in national analyses may contribute to delayed recognition of disparities and inadequate prevention efforts ().
Age-stratified analysis demonstrated shifting patterns in HDP-related mortality, with mortality among individuals aged 25–34 declining and mortality among individuals aged 35–44 increasing, exceeding that of the former age group by the end of the study period. This trend observed in our study may reflect a documented shift in the demographic profile of pregnant women, where delaying pregnancy results in a greater proportion of pregnancies in women older than age 35 (). Advanced maternal age (AMA) itself contributes to increased HDP-related morbidity and mortality through age-related endothelial dysfunction, increased systemic inflammation, and a higher prevalence of hypertension, diabetes, and obesity (–). Thus, the observed increase in HDP-related mortality among individuals aged 35–44 likely reflects both the increasing proportion of pregnancies occurring at an older maternal age as well as the associated age-related physiological risks. Together, these risks underscore the importance of optimizing cardiovascular health prior to contraception and enhancing monitoring throughout pregnancy and the postpartum period, especially for women who are pregnant later in life.
Regional analysis of patients within the South census region showed that HDP-related mortality has gradually increased over time. Chronic hypertension during pregnancy more than doubled in the U.S. from 1.8% to 3.7% between 2008 and 2021, with the highest rates in the South, where HDP affects about 8.9% of pregnancies (, ). This regional disparity observed in our study may reflect higher rates of obesity, diabetes, and chronic hypertension, along with limited prenatal and obstetric care access in the South as compared to other regions (). Declining early prenatal care and widespread maternity care deserts in the South further delay HDP detection and contribute to rising maternal mortality (, ). While statistically significant temporal trends were only observed in the South census region, aggregated analyses demonstrated cumulative HDP-related mortality across all U.S. census regions. The presence of a mortality burden in the Northeast, Midwest, and West highlights that HDP-related maternal death is a national issue, even in regions where annual case counts are insufficient to support trend analyses (). Thus, prevention strategies and resource allocation should not be limited to regions with statistically detectable trends.
Analysis of HDP-related mortality in urban population zones showed no significant change during the study period. Although patients in urban areas continue to experience the burden of hypertensive disorders of pregnancy, increased access to healthcare may have helped prevent further increases in maternal mortality, as urban zones are more likely to have higher concentrations of hospitals, specialty clinics, medical practitioners, and specialists (). Disparities in access to obstetric care experienced by patients in rural zones increase the need to assess the burden of HDP ().
These findings are consistent with prior studies using hospitalization and delivery-based datasets. An analysis of the National Inpatient Sample (NIS) demonstrated increasing rates of HDP-related maternal mortality and persistent disparities with reported mortality rates of approximately 14.2 deaths per 100,000 live births, with significantly higher rates among NH Black compared to NH White women (). In the present study, HDP-related mortality remained at 0.10 per 100,000 population between 1999 and 2023, with a statistically significant upward trend detected by Joinpoint analysis. While absolute rates appear smaller than those reported in studies using live birth denominators, this difference is expected due to the use of population-based rates in this analysis.
Together, these results suggest a potential role for incorporating predictive markers, such as microalbuminuria, elevated systolic blood pressure, and increased serum uric acid levels, into risk stratification efforts, as they are associated with progression to more severe hypertensive disease, such as preeclampsia (). Integration of these markers alongside demographic and clinical risk factors may help improve early identification of high-risk patients and address persistent disparities present in HDP-related outcomes.
4.1 Limitations
This study is limited by the reporting thresholds of the CDC WONDER database, which deems mortality rates as unreliable when the death count is less than twenty individuals that meet the specific search criteria, due to increased standard error (). Additionally, mortality count is suppressed for privacy when fewer than ten deaths occur within a subgroup during a given period (). As a result, analysis for certain racial and ethnic groups (NH American Indian or Alaska Native, NH Asian or Pacific Islander, and Hispanic or Latino populations), regions (Northeast, Midwest, West), and rural populations could not be performed due to an insufficient number of HDP-related maternal deaths by year within these populations. Thus, year-to-year comparisons across all demographic groups could not be made, and population trends may underestimate disparities in underrepresented groups. To address this limitation, aggregated mortality counts across the study period were examined to contextualize HDP-related deaths in populations with suppressed annual estimates and characterize the cumulative burden. While aggregation reduces data suppression and improves completeness, it limits temporal resolution and prevents assessment of yearly trends within these subgroups. Additionally, as this is a descriptive analysis, these findings represent associations and do not allow for direct evaluation of underlying mechanisms.
5 Conclusion
Overall, HDP poses a threat to maternal health in the US. Despite advancements in prenatal screening and increased maternal health education, HDP-related mortality is still a prevalent issue in the US that disproportionately affects disadvantaged patient populations, reflecting systemic inequities and disparities in access to healthcare. Increasing efforts to expand data collection relating to maternal health, particularly for underrepresented racial groups and rural populations, are essential to understand the impact of access, resources, policy, and prevention efforts on maternal health. This will ultimately help to reduce mortality from HDP nationwide.
Statements
Data availability statement
The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author/s.
Ethics statement
Ethical approval was not required for the study involving humans in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was not required from the participants or the participants' legal guardians/next of kin in accordance with the national legislation and the institutional requirements.
Author contributions
MF: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing. MA: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing. KH: Data curation, Supervision, Writing – review & editing. OF: Supervision, Writing – review & editing. AT: Supervision, Writing – review & editing.
Funding
The author(s) declared that financial support was not received for this work and/or its publication.
Acknowledgments
The authors acknowledge the Centers for Disease Control and Prevention (CDC) for providing publicly accessible data through the CDC WONDER database. No external funding was received for this study.
Conflict of interest
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Generative AI statement
The author(s) declared that generative AI was used in the creation of this manuscript. Generative artificial intelligence tools were used solely for language editing, formatting assistance, and improving clarity and organization of the manuscript. All data analysis, interpretation, and scientific conclusions were conducted and verified by the authors, who take full responsibility for the content.
Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/frph.2026.1816821/full#supplementary-material
References
1.
Centers for Disease Control and Prevention (CDC). High blood pressure during pregnancy [Internet] (2024). Available online at:https://www.cdc.gov/high-blood-pressure/about/high-blood-pressure-during-pregnancy.html (Accessed October 15, 2025).
2.
FordND. Hypertensive disorders in pregnancy and mortality at delivery hospitalization—united States, 2017–2019. MMWR Morb Mortal Wkly Rep. (2022) 71(17):585–91. 10.15585/mmwr.mm7117a1
3.
XuJLiTWangYLiXMiaoZWeiLet alThe association between hypertensive disorders in pregnancy and the risk of developing chronic hypertension. Front Cardiovasc Med. (2022) 9:897771. 10.3389/fcvm.2022.897771
4.
PetersenEEDavisNLGoodmanDCoxSSyversonCSeedKet alRacial/ethnic disparities in pregnancy-related deaths—united States, 2007–2016. MMWR Morb Mortal Wkly Rep. (2019) 68(35):762–5. 10.15585/mmwr.mm6835a3
5.
RadparvarAAVaniKFioriKGuptaSChavezPFisherMet alHypertensive disorders of pregnancy. JACC Adv. (2024) 3(3):100864. 10.1016/j.jacadv.2024.100864
6.
AnanthCVBrandtJSHillJGrahamHLGroverSSchusterMet alHistorical and recent changes in maternal mortality due to hypertensive disorders in the United States, 1979 to 2018. Hypertension. (2021) 78(5):1414–22. 10.1161/HYPERTENSIONAHA.121.17661
7.
CallaghanWMCreangaAAKuklinaEV. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol. (2012) 120(5):1029–36. 10.1097/AOG.0b013e31826d60c5
8.
BatemanBTBansilPHernandez-DiazSMhyreJMCallaghanWMKuklinaEV. Prevalence, trends, and outcomes of chronic hypertension: a nationwide sample of delivery admissions. Am J Obstet Gynecol. (2012) 206(2):134.e1–8. 10.1016/j.ajog.2011.10.878
9.
Murray HorwitzMERodriguezMIDissanayakeMCarmichaelSLSnowdenJM. Postpartum health risks among women with hypertensive disorders of pregnancy, California 2008–2012. J Hypertens. (2021) 39(5):1009–17. 10.1097/HJH.0000000000002711
10.
Centers for Disease Control and Prevention (CDC). CDC WONDER [Internet]. Available online at:https://wonder.cdc.gov/ (Accessed September 22, 2025).
11.
ChenYShielsMSUribe-LeitzTMolinaRLLawrenceWRFreedmanNDet alPregnancy-related deaths in the US, 2018–2022. JAMA Netw Open. (2025) 8(4):e254325. 10.1001/jamanetworkopen.2025.4325
12.
BrownAHamiltonBKissinDMartinJ. Trends in mean age of mothers in the United States, 2016 to 2023. Natl Vital Stat Rep. (2025) 74(9):1–6. 10.15620/cdc/174598
13.
World Health Organization. Women of reproductive age (15–49 years) population (thousands) [Internet] (2025). Available online at:https://www.who.int/data/gho/indicator-metadata-registry/imr-details/women-of-reproductive-age-(15-49-years)-population-(thousands) (Accessed December 10, 2025).
14.
March of Dimes. Percentage of births by maternal age: United States, 2020–2022 average [Internet]. Available online at:https://www.marchofdimes.org/peristats/data (Accessed December 10, 2025).
15.
National Center for Health Statistics. Vital and health statistics. Series 2, No. 166 [Internet] (2014).
16.
Centers for Disease Control and Prevention (CDC). Principles of epidemiology: lesson 3, section 3 [Internet] (2023). Available online at:https://archive.cdc.gov/www_cdc_gov/csels/dsepd/ss1978/lesson3/section3.html (Accessed September 22, 2025).
17.
AndersonRRosenbergH. Vital statistics. Lancet. (1901) 158(4062):47–8. 10.1016/S0140-6736(01)55060-6
18.
Centers for Disease Control and Prevention (CDC). Joinpoint trend analysis software—Health, United States [Internet] (2023). Available online at:https://www.cdc.gov/nchs/hus/sources-definitions/joinpoint.htm (Accessed September 22, 2025).
19.
AlhusenJLBowerKMEpsteinESharpsP. Racial discrimination and adverse birth outcomes: an integrative review. J Midwifery Women’s Health. (2016) 61(6):707–20. 10.1111/jmwh.12490
20.
National Cancer Institute. Joinpoint regression program [Internet]. Available online at:https://surveillance.cancer.gov/joinpoint/ (Accessed September 22, 2025).
21.
HowellEAZeitlinJ. Quality of care and disparities in obstetrics. Obstet Gynecol Clin North Am. (2017) 44(1):13–25. 10.1016/j.ogc.2016.10.002
22.
FleszarLGBryantASJohnsonCOBlackerBFAravkinABaumannMet alTrends in state-level maternal mortality by racial and ethnic group in the United States. JAMA. (2023) 330(1):52–61. 10.1001/jama.2023.9043
23.
MartinJHamiltonBOstermanM. Births in the United States, 2024. NCHS Data Brief. (2025) 535:1–8. 10.15620/cdc/174613
24.
LopianMLigumskyLKManyA. A balancing act: navigating hypertensive disorders of pregnancy at very advanced maternal age, from preconception to postpartum. J Clin Med. (2023) 12(14):4701. 10.3390/jcm12144701
25.
LeonardSASiadatSMainEKHuybrechtsKFEl-SayedYYHlatkyMAet alChronic hypertension during pregnancy: prevalence and treatment in the United States, 2008–2021. Hypertension. (2024) 81(8):1716–23. 10.1161/HYPERTENSIONAHA.124.22731
26.
MooreMDMazzoniSEWingateMSBronsteinJM. Characterizing hypertensive disorders of pregnancy among medicaid recipients in a non-expansion state. J Womens Health. (2022) 31(2):261–9. 10.1089/jwh.2020.8741
27.
American College of Obstetricians and Gynecologists' Committee on Obstetric Practice, Society for Maternal-Fetal Medicine. Pregnancy at age 35 years or older. Obstet Gynecol. (2022) 140(2):348–66. 10.1097/AOG.0000000000004873
28.
March of Dimes. Maternity care deserts report [Internet] (2024). Available online at:https://www.marchofdimes.org/maternity-care-deserts-report (Accessed December 10, 2025).
29.
HawkinsSSHarperSBaumCFKaufmanJS. Associations between state-level changes in reproductive health services and indicators of severe maternal morbidity. JAMA Pediatr. (2023) 177(1):93–5. 10.1001/jamapediatrics.2022.4136
30.
DohertyP. Rural and urban healthcare: challenges, disparities, and solutions. J Community Public Health Nurs. (2025) 11:616. 10.4172/2471-9846.1000616
31.
WaldmanHZimmermanA. Maternal health in rural America [Internet]. National Rural Health Association (2024). Available online at:https://www.ruralhealth.us/nationalruralhealth/media/documents/advocacy/white%20paper/maternal-health-in-rural-america-white-paper-final.pdf (Accessed December 15, 2025).
32.
NguyenHHNguyenLTTranPHNguyenKTTranAVTranSKet alPredictive value of microalbuminuria, systolic blood pressure, and Serum uric acid levels for preeclampsia/severe preeclampsia in gestational hypertensive patients. Clin Exp Obstet Gynecol. (2024) 51(12):259. 10.31083/j.ceog5112259
Summary
Keywords
age-adjusted mortality rate, CDC WONDER, health disparities, hypertensive disorders of pregnancy, maternal mortality
Citation
Anderson M, Fries M, Haase K, Foley OA and Tauseef A (2026) Hypertensive disorders of pregnancy (HDP) mortality in the United States: a CDC WONDER population analysis, 1999–2023. Front. Reprod. Health 8:1816821. doi: 10.3389/frph.2026.1816821
Received
24 February 2026
Revised
24 April 2026
Accepted
04 May 2026
Published
20 May 2026
Volume
8 - 2026
Edited by
Astawus Alemayehu, Haramaya University, Ethiopia
Reviewed by
Yixiao Wang, Southeast University, China
Yulin Zou, University Medical Center Göttingen, Germany
Updates
Copyright
© 2026 Anderson, Fries, Haase, Foley and Tauseef.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Meghan Fries meghanfries@creighton.edu
Disclaimer
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.