The Social Determinants of Preeclampsia and Eclampsia

  • Author / Creator
    Fellus, Saphire
  • Evidence has been accumulating in recent years showing that social factors have a determining influence on the health of populations. Specifically, in the field of cardiovascular health research, a growing body of evidence has shown robust associations between the social determinants of health (SDOH) and adverse outcomes. A similar pattern of relationship is demonstrated between socioeconomic inequalities and outcome disparities in maternal and neonatal health epidemiology. Within this context, the current study pulls together these areas of research to shed light onto their intersection area with preeclampsia—a hypertensive disease of pregnancy that is responsible for much of maternal and fetal morbidity and mortality worldwide, as well as for future cardiovascular risks for both mother and child.

    To answer the overarching question of how the SDOH are associated with preeclampsia, this research bifurcated into two branches comprising: a systematic review and meta-analysis (SRMA), and a population-based analysis of a Pregnancy Birth Cohort in Alberta. For the SRMA, searches were conducted to identify relevant literature in health sciences databases. The PROGRESS-Plus framework, which offers a structured list of a wide breadth of relevant determinants, was used to guide the search. Observational studies that reported measures of association (odds ratio, prevalence, or hazard ratio) between the outcome of interest (preeclampsia or eclampsia) and a SDOH were included. Quality assessment of studies was completed by two independent assessors using adapted versions of the Newcastle-Ottawa Scale. Included studies were described using narrative analysis and visualized using forest plots. Heterogeneity of studies according to SDOH groups was explored using subgroup analyses. Pooling of included studies’ effect measures was planned for methodologically-homogeneous studies using the DerSimonian and Laird method of the random-effects inverse-variance approach.
    The initial database search yielded 2,453 records, of which 220 were eligible for full-text screening, and 52 publications were included in the systematic review. Social determinants as well as preeclampsia outcome were operationalized differently within the field and between studies, limiting the comparability. Overall, the studies showed a clear positive relationship between preeclampsia and Black race, Native-American race, education, socioeconomic status, and marital status. This review indicates that there is likely an association of certain SDOH with preeclampsia.

    The Alberta study of SDOH and their relationship to preeclampsia was conducted using a 2005-2014 retrospective pregnancy and birth cohort established by Alberta Health administrative, de-identified health records. The primary objective was to assess the relationship between SDOH (maternal ethnicity, immigrant status, marital status, urban/rural residence, and social and material deprivation) and preeclampsia. The secondary objective was to assess if maternal and neonatal outcomes were different among high versus low socioeconomic status women with preeclampsia. Data from deliveries of women aged 15-49, who were residents of Alberta at the time of delivery, and who had a live singleton delivery with gestational age longer than 22 weeks were included. Frequencies and percentages of each independent variable, stratified by preeclampsia outcome, were reported with their p-values. Odds ratios (OR) and 95% confidence intervals (CI) were computed in a univariate analysis for each variable; next we examined the association after adjusting for age and parity; and finally after adjusting for pre-existing disease. The generalized estimated equation (GEE) approach was used to account for multiple data points per woman present in the cohort. Potential confounders included in the multivariable model were age, parity, pre-existing hypertension or cardiovascular disease, gestational diabetes mellitus, and prior diagnosis of diabetes mellitus. A final cohort of 473,143 singleton deliveries were included, with an overall preeclampsia prevalence of 1.46%.

    Adjusting for age, parity, and pre-existing clinical risk factors, the SDOH that were positively associated with preeclampsia were rural residence (aOR 1.40, 95% CI 1.32-1.48), marital status (aOR 1.15, 95% CI 1.09-1.22), Filipino ethnicity (aOR 1.52 95% CI 1.35-1.72), and material deprivation (Quintile 5: aOR 1.22, 95% CI 1.12-1.33) compared to their low-risk groups. Women of Chinese ethnicity, South Asian ethnicity, as well as women who were immigrants had significantly reduced odds of preeclampsia compared to the general population. Our study informs clinical practitioners of specific at-risk groups and the need for targeted interventions to alleviate inequalities in maternal and fetal health outcomes.

  • Subjects / Keywords
  • Graduation date
    Spring 2021
  • Type of Item
  • Degree
    Master of Science
  • DOI
  • License
    This thesis is made available by the University of Alberta Libraries with permission of the copyright owner solely for non-commercial purposes. This thesis, or any portion thereof, may not otherwise be copied or reproduced without the written consent of the copyright owner, except to the extent permitted by Canadian copyright law.