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See commentary page 491
Secular Trends in the Rates of Preeclampsia,
Eclampsia, and Gestational Hypertension,
United States, 1987–2004
Anne B. Wallis1, Audrey F. Saftlas2, Jason Hsia3 and Hani K. Atrash4
Background
Few studies have reported on population-level incidence of
or trends in the hypertensive disorders of pregnancy, and none
report on data through 2004. We describe population trends in
the incidence rates of preeclampsia, eclampsia, and gestational
hypertension in the United States for 1987–2004.
Methods
We analyzed public-use data from the National Hospital Discharge
Survey (NHDS), which has been conducted by the Centers for
Disease Control and Prevention, National Center for Health
Statistics since 1965. We calculated crude and age-adjusted
incidence rates and estimated the risk associated with available
demographic variables using Cox regression modeling.
Results
Rates of preeclampsia and gestational hypertension increased
significantly (by 25 and 184%, respectively) over the study
Preeclampsia is a dangerous, multisystem complication of
human pregnancy and a leading cause of fetal and maternal
morbidity and mortality worldwide. This hypertensive disorder
of pregnancy is characterized by sustained de novo hyperten-
sion and proteinuria after 20 weeks of gestation. The mater-
nal syndrome is associated with pitting edema, particularly of
the hands, face, and feet, abnormal clotting, and endothelial
abnormalities, as well as liver and renal dysfunction. With pro-
gression of preeclampsia to eclampsia or occurrence of HELLP
(Hemolysis, Elevated Liver enzymes, Low Platelets) syndrome,
the risk of maternal death increases. The fetal syndrome can be
manifested as preterm delivery, growth restriction, placental
abruption, fetal distress, and in some cases, death, especially
1Department of Community and Behavioral Health, College of Public Health,
University of Iowa, Iowa City, Iowa, USA; 2Department of Epidemiology,
College of Public Health, University of Iowa, Iowa City, Iowa, USA; 3Division of
Reproductive Health, National Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA;
4Office of the Director, National Center on Birth Defects and Developmental
Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
Correspondence: Anne B. Wallis (anne-wallis@uiowa.edu)
Received 27 November 2007; first decision 23 December 2007; accepted 26 January
2008; advance online publication 13 March 2008. doi:10.1038/ajh.2008.20
© 2008 American Journal of Hypertension, Ltd.
AMERICAN JOURNAL OF HYPERTENSION | VOLUME 21 NUMBER 5 | 521-526 | may 2008 521
articles
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period; in contrast, the rate of eclampsia decreased by 22%
(nonsignificant). Women under the age of 20 were at significantly
greater risk for all three outcomes. Women in the south of the
country were at significantly greater risk for preeclampsia and
gestational hypertension when compared to those in the
Northeast.
Conclusions
The increase in gestational hypertension may be exaggerated
because of the revised clinical guidelines published in the 1990s;
these same revisions would likely have reduced diagnoses of
preeclampsia. Therefore, our observation of a small but consistent
increase in preeclampsia is a conservative indication of a true
population-level change.
Am J Hypertens 2008; 21:521-526 © 2008 American Journal of Hypertension, Ltd.
with onset of preeclampsia before 34 weeks of gestation. It is
important to note that preeclampsia is the underlying cause of
about one-quarter of all medically indicated preterm deliveries
in the United States.1 Because preeclampsia is a multisystem
disorder that can progress rapidly, it requires prompt interven-
tion that may include observation in a tertiary care setting and
induction of delivery, which is the only known cure for this
condition.2–4
Epidemiologic research suggests that preeclampsia has a
multifactorial etiology that includes an immunogenetic com-
ponent.5 Established risk factors include nulliparity, family
history of preeclampsia–eclampsia, preeclampsia in a previ-
ous pregnancy, obesity, increased insulin resistance, hyperlipi-
demia, increased trophoblastic mass (i.e., multiple gestation,
molar pregnancy), and change of sexual partner between
pregnancies.5 Protective factors include a prior completed
pregnancy and a terminated pregnancy for women conceiving
again with the same partner.6
In a previous publication, our group summarized nation-
ally representative data on the incidence of preeclampsia and
eclampsia from 1979 through 1986.7 A subsequent publica-
tion by Zhang et al. provided an update from the years 1988
through 1997.8 There is now a pressing need to update these
articles
reports so as to track changing rates and observe trends that
may be related to population-level increases in pre-pregnancy
obesity,9,10 diabetes,11 maternal age,12 and multiple births12
or changing social and economic conditions that may affect
access to health care.
In this article, we present trends in incidence rates and
selected demographic risk factors during 1987–2004 so as to
provide continuity with our earlier publication and enable
observation of long-term trends. Knowledge of these trends at
the population level should improve understanding of mater-
nal risk, encourage preconception and interconception coun-
seling, and increase appropriate monitoring and treatment,
particularly for high-risk women.
Methods
Definitions. Gestational hypertension is defined as sustained
high blood pressures of 140 mm Hg systolic or 90 mm Hg dia-
stolic with onset after the 20th week of gestation in women
with no history of chronic hypertension and where evidence
of proteinuria is absent. Chronic hypertension is diagnosed if
hypertension is present before the 20th week of gestation or
when blood pressure does not return to normal by 12 weeks
postpartum.2,13
Current criteria for a diagnosis of preeclampsia require the
presence of de novo hypertension and proteinuria with onset
after the 20th week of gestation.2,13 Eclampsia is the presence
of seizures in a woman with preeclampsia when the seizures
cannot be attributed to other causes.2,13
Data source. We obtained data for this study from the National
Hospital Discharge Survey (NHDS) public-use data set. This
annual survey, which has been conducted by the National
Center for Health Statistics since 1965, uses a nationally rep-
resentative sample of discharge records drawn from a prob-
ability sample of ~400 non-Federal, short-stay hospitals in all
50 states and the District of Columbia (military, veteran, and
institutional hospitals are excluded). The NHDS was rede-
signed in 1988 to provide geographic sampling comparable
to other National Center for Health Statistics surveys.14 The
redesign ensured inclusion of all hospitals with at least 1,000
beds and 40,000 or more discharges annually. The sampled dis-
charge records are weighted to represent the total number of
discharges from non-Federal short-stay hospitals in the United
States. Estimates based on fewer than 30 records are consid-
ered to be statistically unreliable.14
Discharge diagnoses from the NHDS are coded according
to the International Classification of Diseases, 9th Revision,
Clinical Modification (ICD-9-CM). Up to seven discharge
diagnoses and four operative procedures are abstracted from
the face sheet of each hospital record sampled. Additional data
items collected include the patient’s date of birth, sex, race,
marital status, expected source of payment for hospitalization,
and geographic region of residence. It should be noted that the
ICD-9-CM codes are assigned by the individual sampled hospi-
tals according to their own procedures. NHDS data are subject
to computerized edits and manual review, including validity
522 MAY 2008 | VOLUME 21 NUMBER 5 | AMERICAN JOURNAL OF HYPERTENSION
US Secular Trends in Hypertensive Disorders of Pregnancy
and range checks for non-medical variables and consistency
checks for dates and ICD-9-CM codes. The National Center for
Health Statistics reports high accuracy of discharge diagnostic
categories in comparison with hospital census reports.14
Study population. The study population included all NHDS-
sampled discharges for delivery admissions among women
who delivered one or more live or stillborn infants between
1987 and 2004. Hospital admissions for which a delivery
occurred were identified by the ICD-9-CM code V27. In 2004,
the NHDS represented ~4.1 million hospitalizations for deliv-
ery with an average length of stay of 2.6 days.15
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Analytical methods. Crude and age-adjusted incidence rates
were calculated as cases per 1,000 deliveries for gestational
hypertension (ICD-9-CM 642.3), mild or unspecified preec-
lampsia (ICD-9-CM 642.4), severe preeclampsia (ICD-9-CM
642.5), and eclampsia (ICD-9-CM 642.6). For the analysis,
mild or unspecified preeclampsia and severe preeclampsia
were combined into a single variable (preeclampsia). Direct
standardization was conducted to adjust incidence rates for the
effects of maternal age using the 1995 US natality population,
which represents the mid-point of the 18-year study period.
Weighted linear regression was used to test for linear trend
in the crude and age-adjusted rates of all preeclampsia (ICD-
9-CM 642.4 and 642.5) and gestational hypertension (ICD-
9-CM 642.3) over the period, 1987–2004. Because eclampsia is
a relatively rare complication of pregnancy, we calculated aver-
age annual age-adjusted rates for two 9-year time periods so as
to ensure statistical stability of these estimates.
In addition to diagnoses and operative procedures, the
NHDS public-use data set includes patient’s date of birth, sex,
marital status, expected source of payment, and geographic
region of residence. Although race and marital status are
of great interest, we were not able to use them in our analy-
sis because of the large proportion (>50%) of “unknown” and
“other” responses in the NHDS data set. Rate ratios were cal-
culated to estimate the risk of all gestational hypertension,
preeclampsia, and eclampsia associated with maternal age
and geographic region of the sampled hospitals. Rate ratios
for preeclampsia and gestational hypertension were calcu-
lated on the basis of five age categories (i.e., <20, 20–24, 25–29,
30–34, 35+); for eclampsia, sample size limitations restricted
the analysis to just two age categories (i.e., <20, ≥20). In cal-
culating rates, we used Cox regression modeling to simultane-
ously adjust for maternal age and geographic region.16 Because
of concerns about confidentiality, the NHDS public-use data
set does not include the sampling stage variables. Therefore, in
order to take into account the complex sampling design of the
NHDS, we assumed, on the basis of previous empirical results,
that the estimated variance under NHDS is twice as large as
that under simple random sampling.17
Protection of human subjects. This study used de-identified
public-use data that did not involve human subjects; therefore,
institutional review board approval was not required.
US Secular Trends in Hypertensive Disorders of Pregnancy articles

Results
The crude average annual incidence rates (cases per 1,000
deliveries) of preeclampsia and gestational hypertension over
the 18-year study period were 27.4 and 21.3, respectively (data
for individual years are shown in Table 1); for eclampsia, the
rate was 0.92.
The rate of preeclampsia and gestational hyperten-
sion increased significantly over the 18-year study period
(Figure  1). The age-adjusted rate (per 1,000 deliveries) of
preeclampsia rose by 24.6% from 23.6 in 1987–1988 to 29.4
in 2003–2004. Over the same time period, the rate of gesta-
tional hypertension nearly tripled from 10.7 to 30.6. In con-
trast, the age-adjusted rate of eclampsia decreased by 22.0%
try, while women delivering in the west are at the lowest risk.
During the second 9-year time period of the study, the risk of
preeclampsia is lower in each of the geographic areas relative
to the northeast.
Women <20 years of age are at significantly increased risk of
gestational hypertension. Women ≥35 years of age were also at
increased risk, although this rate ratio was not statistically sig-
nificant. In all sub-categories of maternal age and geographic
area, the rates of gestational hypertension increased uniformly
over time (Table 2).
35.0

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30.0

from an average annual rate of 1.04 during 1987–1995, to

25.0
0.82 during 1996–2004. These two rates did not differ statisti-

Incidence per 1,000

cally, but the NHDS is not powered to detect modest changes 20.0
in the occurrence of rare conditions.
Shown in Table 2 are the number of weighted cases, crude 15.0

incidence rates, and relative risk estimates of preeclampsia, ges-

10.0
tational hypertension, and eclampsia associated with maternal
age and geographic region, each adjusted for the effects of the 5.0
other variable. When compared to women ages 30–34, the risk
of preeclampsia is consistently and significantly higher among 0.0
1987–88 1989–90 1991–92 1993–94 1995–96 1997–98 1999–00 2001–02 2003–04
women <25 years of age and highest among women <20 years Gestational hypertension (642.3) Preeclampsia (642.4–5)
of age; the risk among women of ages ≥35 is slightly higher
and comparable to that of women in the 20–24-year age group. Figure 1 | Age-adjusted incidence per 1,000 deliveries for women with
Regional analyses show that the risk of preeclampsia is signifi- gestational hypertension (b = 0.0024; P < 0.0001) or preeclampsia (b = 0.0009;
cantly higher for women delivering in the south of the coun- P = 0.009) for 2-year periods, 1987–2004.

Table 1 | Weighted number of cases and crude incidence rates, gestational hypertension and preeclampsia, 1987–2004
Diagnosis 1987 1988 1989 1990 1991 1992
Gestational hypertension (ICD-9-CM 642.3)
  No. of cases 41,249 40,671 57,484 60,005 64,958 64,374
  Rate (95% CI) 10.5 (8.2, 12.9) 10.8 (8.0, 13.5) 14.6 (11.3, 17.9) 14.9 (12.0, 17.9) 16.3 (13.1, 19.6) 16.5 (13.3, 19.6)
Preeclampsia (ICD-9-CM 642.4–5)
  No. of cases 98,017 83,046 109,846 93,168 99,446 87,263
  Rate (95% CI) 25.1 (21.5, 28.6) 21.9 (18.2, 25.7) 27.9 (23.1, 32.6) 23.2 (19.3, 27.0) 25.0 (20.7, 29.3) 22.3 (18.6, 25.9)
Diagnosis 1993 1994 1995 1996 1997 1998
Gestational hypertension (ICD-9-CM 642.3)
  No. of cases 79,380 81,864 68,184 86,902 85,985 83,698
  Rate (95% CI) 19.8 (16.0, 23.5) 21.0 (17.3, 24.7) 18.1 (14.8, 21.4) 22.7 (18.8, 26.6) 22.6 (18.9, 26.3) 20.9 (17.3, 24.5)
Preeclampsia (ICD-9-CM 642.4–5)
  No. of cases 91,931 100,936 108,689 111,551 117,770 125,262
  Rate (95% CI) 22.9 (18.7, 27.1) 25.9 (21.9, 29.9) 28.9 (24.4, 33.3) 29.0 (24.6, 33.5) 30.9 (26.4, 35.4) 31.2 (26.0, 36.5)
Diagnosis 1999 2000 2001 2002 2003 2004
Gestational hypertension (ICD-9-CM 642.3)
  No. of cases 100,586 119,338 105,522 110,123 125,630 122,667
  Rate (95% CI) 26.4 (21.9, 30.9) 31.9 (27.2, 36.6) 27.5 (23.2, 31.7) 27.9 (23.3, 32.4) 31.2 (26.0, 36.5) 29.7 (25.4, 33.9)
Preeclampsia (ICD-9-CM 642.4–5)
  No. of cases 119,221 104,437 117,248 115,924 106,282 132,800
  Rate (95% CI) 31.2 (26.6, 35.8) 27.9 (23.8, 32.1) 30.5 (26.1, 35.0) 29.3 (24.8, 33.9) 26.4 (22.3, 30.6) 32.1 (27.6, 36.6)

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articles US Secular Trends in Hypertensive Disorders of Pregnancy

Table 2 | Weighted number of cases, rates, and rate ratios for gestational hypertension, preeclampsia, and eclampsia, 1987–2004
Time Period
1987–1995 1996–2004
Demographic variables No. of cases Rate Rate ratio (95% CI) No. of cases Rate Rate ratio (95% CI)
Preeclampsia (ICD-9-CM 642.4–5)
 Age group (years)
   <20 167,883 37.1 1.65 (1.47, 1.86) 175,270 41.8 1.73 (1.57, 1.90)
   20–24 232,811 25.5 1.15 (1.03, 1.28) 274,537 31.5 1.31 (1.20, 1.42)
   25–29 221,740 20.9 0.95 (0.85, 1.06) 267,442 28.2 1.18 (1.08, 1.28)
   30–34 82,862 24.7 1.00 (referent) 138,560 29.8 1.00 (referent)

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   35+ 166,560 21.9 1.14 (0.99, 1.31) 193,443 23.9 1.26 (1.14, 1.38)
  Region
   Northeast 139,765 22.5 1.00 (referent) 162,564 29.3 1.00 (referent)
   Midwest 194,318 25.2 1.10 (0.99, 1.23) 205,475 28.9 0.97 (0.89, 1.06)
   South 357,793 28.2 1.20 (1.09, 1.33) 470,230 34.1 1.12 (1.03, 1.21)
   West 179,980 20.9 0.91 (0.81, 1.02) 210,983 24.3 0.81 (0.74, 0.89)
Gestational hypertension (ICD-9-CM 642.3)
 Age group (years)
   <20 83,269 18.4 1.18 (1.02, 1.38) 124,441 29.7 1.14 (1.02, 1.28)
   20–24 136,054 14.9 0.97 (0.84, 1.10) 217,765 25.0 0.97 (0.88, 1.06)
   25–29 163,841 15.4 1.00 (0.88, 1.14) 260,918 27.5 1.07 (0.98, 1.17)
   30–34 57,681 17.2 1.00 (referent) 130,368 28.1 1.00 (referent)
   35+ 117,374 15.4 1.11 (0.95, 1.30) 206,959 25.5 1.10 (1.00, 1.22)
  Region
   Northeast 104,287 16.8 1.00 (referent) 144,025 26.0 1.00 (referent)
   Midwest 100,512 13.0 0.78 (0.68, 0.89) 178,458 25.1 0.97 (0.88, 1.06)
   South 214,576 16.9 1.00 (0.89, 1.13) 411,014 29.8 1.15 (1.05, 1.26)
   West 138,844 16.1 0.96 (0.84, 1.10) 206,954 23.9 0.92 (0.83, 1.02)
Eclampsia (ICD-9-CM 642.6)
 Age group (years)
   <20 10,633 2.40 2.64 (1.76, 3.95) 6,358 1.50 2.17 (1.45, 3.25)
   ≥20 25,811 0.80 1.00 (referent) 21,973 0.70 1.00 (referent)
  Region
   Northeast 5,191 0.80 1.00 (referent) 6,425 1.20 1.00 (referent)
   Midwest 6,415 0.80 0.97 (0.54, 1.72) 4,956 0.70 0.59 (0.34, 1.04)
   South 18,886 1.50 1.63 (0.96, 2.78) 11,800 0.90 0.70 (0.41, 1.17)
   West 5,952 0.70 0.85 (0.44, 1.45) 5,150 0.60 0.50 (0.28, 0.88)

Women <20 years of age had a 2.6-fold higher risk of eclamp-
sia than older women during the first time period of the study,
and a slightly lower risk during the second time period. In our
regional analysis, the risk of eclampsia was higher in the south
than in the northeast (reference) during the first time period.
The risk for women whose deliveries took place in the mid-
west was comparable to the risk for women in the northeast,
whereas the risk was lowest for those in the west. During the
second time period, the risk in all three regions had decreased
to levels more comparable to or lower than those observed in
the northeast (Table 2).
Discussion
Our analysis indicates that important population-level changes
in the rates of preeclampsia, eclampsia, and gestational hyper-
tension occurred during the 18-year period ending in 2004.
The rates of both preeclampsia and gestational hypertension
increased significantly. In contrast, the ­eclampsia rate showed
a nonsignificant decrease of 22% over the same time period.
This study is important because few others have reported
incidence rates based on population-level data, and none
reflect the results of analysis carried out through 2004, the lat-
est year for which NHDS data are available. The NHDS data

524 MAY 2008 | VOLUME 21 NUMBER 5 | AMERICAN JOURNAL OF HYPERTENSION

US Secular Trends in Hypertensive Disorders of Pregnancy
set is remarkable for its depth in terms of national represen-
tation of US short-stay hospitals and its breadth in providing
annual data on hospital discharges since 1965. The incidence
rates we report for preeclampsia are similar to those reported
from other population-based studies in the United States,
Canada, and western Europe, range from 2 to 5%.7,8,11,18–21
Rates as low as 1.1% and as high as 7.5% have been reported
from regional,22 clinical,23 and multicenter trials;24,25 however,
the generalizability of these data is limited by the selective rep-
resentation of hospitals and study populations.25,26
It is interesting to note that our data indicate higher rates of
eclampsia than those reported from population-based stud-
ies in Canada, the United Kingdom, and western Europe,
with lowest rates (per 1,000 deliveries) ranging from 0.24 in
Finland and 0.27 in Nova Scotia to 0.44 in Sweden, and 0.66 in
Scotland.27–32 Any possible explanations for these differences
in international data are speculative because of the very low
incidence of this condition, but may include: international and
temporal variation in definitions and classification of hyper-
tensive disorders of pregnancy;4,33 the possibility of greater
misclassification of preeclampsia as eclampsia in the sampled
US hospitals;34 racial and ethnic differences among the popu-
lations (e.g., larger proportion of black women in the US and
UK populations); and the presence of universal health care
outside the United States, which may provide greater opportu-
nity for earlier detection and treatment of preeclampsia.
Despite the acknowledged strengths of the NHDS sample
and our analytical methods, our conclusions may be con-
strained by certain limitations of the data set. Recent valida-
tion studies of hospital discharge diagnoses of obstetrical
health conditions conducted in the United States and Europe
indicate moderate to high validity for all diagnoses of preec-
lampsia and gestational hypertension.35–37 A recent study of
the Danish registry data reviewed the hospital charts of 3,039
deliveries and reported a positive predictive value of 74.4% for
all preeclampsia diagnoses.35–37 Another recent study reported
the potential for under-reporting of deliveries with severe
complications if estimates are identified only by the maternal
delivery code (V27); the authors recommend an enhanced
algorithm for improving estimates.37 Because NHDS is based
on discharges (not individuals), we were restricted to using
only the V27 code to identify cases, in order to minimize the
probability of counting a single mother more than once.
A limitation of the NHDS data that is particularly relevant to
reproductive health research is the high proportion of missing
information on the variables “maternal race” and “marital sta-
tus”, making them insufficient for valid analysis. In addition,
the NHDS does not collect data on parity, reproductive history,
and other established risk factors for preeclampsia, including
pre-pregnancy body mass index, family history of preeclamp-
sia, and health behaviors such as smoking. The NHDS is also
limited by its sample size, which may not permit detection of
modest and yet important changes in the occurrence of rarer
outcomes, such as eclampsia.14
We should also note that in 1996, and again in 2002,
the American College of Obstetricians and Gynecologists
AMERICAN JOURNAL OF HYPERTENSION | VOLUME 21 NUMBER 5 | mAY 2008 525
articles
adopted new clinical guidelines and terminology, respectively,
for classifying the hypertensive disorders of pregnancy.2,38
The American College of Obstetricians and Gynecologists’
1996 Technical Bulletin provided stricter and more specific
definitions of preeclampsia than those previously recom-
mended, requiring that cases meet criteria for hypertension
in the presence of proteinuria after the 20th week of gesta-
tion. In 2002, the American College of Obstetricians and
Gynecologists adopted the recommendations of the National
High Blood Pressure Education Program Working Group
on High Blood Pressure in Pregnancy to use the term “ges-
tational hypertension” rather than “transient hypertension of
pregnancy” for a patient with hypertension with no evidence
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of proteinuria; the latter term is now reserved for patients in
whom a definitive diagnosis is made by 12 weeks postpar-
tum. A logical consequence of the stricter 1996 criteria for a
diagnosis of preeclampsia would be a proportional increase in
diagnoses of gestational hypertension, some of which would
have previously met American College of Obstetricians and
Gynecologists criteria for preeclampsia, as observed in our
study. This change in diagnostic guidelines may also have
resulted in a decrease in diagnoses of preeclampsia; therefore,
the increase we report in preeclampsia is likely to represent a
true increase in the incidence of this condition.
What are the possible causes of the substantial increases we
found in rates of preeclampsia and gestational hypertension?
There are several plausible contributors, among them, popu-
lation-level increases in known risk factors for preeclampsia
such as pre-pregnancy overweight and obesity,9,10 diabetes,11
multiple births,12 and maternal age.12 Our analysis of the risk
of preeclampsia by geographic region suggests that risk is
highest among women residing in the south, possibly because
of the higher prevalence of obesity and the higher proportion
of women of black race in that region, neither of which could
be assessed because of limitations in the data set.39 An alterna-
tive explanation may be related to climatic differences across
US regions. Some studies have reported a higher incidence of
preeclampsia associated with conception during the spring
and summer months.40,41 Potential mechanisms include sea-
sonal variation in exposure to infections, dietary changes, and
alteration in vitamin D regulation and calcium ­metabolism
as a consequence of exposure to sunlight, which are, in turn,
associated with blood pressure levels.40,41 Year-round tem-
peratures and sunlight exposures in the southern latitudes
are higher when compared to temperate regions; the possibil-
ity exists that these climatic characteristics are related to the
observed higher incidence of preeclampsia in the south.
Though not statistically significant, the decreased rate of
eclampsia reported in this study is encouraging. This find-
ing may reflect better and earlier diagnosis of preeclampsia,
resulting in prompter treatment and prevention of eclamp-
sia. The reduction in risk for women under 20 may similarly
reflect increased clinical awareness of young maternal age as
a risk factor, and the decrease in teen birth rate that occurred
over the 18-year study period.42,43 Analysis of eclampsia risk
by geographic region indicates that regional differences that
 articles
were present in the first nine-year time period had dimin-
ished, thereby suggesting that prevention efforts have become
increasingly successful across the country. The reduction of
risk in the south is most notable.
The observed increases in the incidence of preeclampsia
and gestational hypertension represent important changes
in the burden of maternal morbidity at the population level,
raising both clinical and public health concerns. These study
findings should serve as an important call for clinicians to
heighten their awareness of the increased population-level
risk for hypertensive disease originating in pregnancy. An
increase in the risk for conditions as potentially dangerous
as preeclampsia and eclampsia underlines the importance of
regular reproductive health care during the preconception,
antenatal, and interconception periods. Continued epide-
miological research should focus on uncovering preventable
causes of preeclampsia, while public health practice and
policy must promote improved access to health care prior
to conception as well as during gestation and between preg-
nancies, and reduction of social and behavioral risk factors,
including overweight and obesity.
Disclosure: The authors declared no conflict of interest.
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