Abortion Policy Restrictiveness and Hypertensive Disorders of Pregnancy in the United States: A Multilevel Analysis

BACKGROUND: While prior research has highlighted the consequences of restrictive reproductive policies on access to care and maternal morbidity, there is limited attention on the potential impact on hypertensive disorders of pregnancy (HDP), a leading contributor to maternal morbidity and mortality. This study examined whether cumulative state-level abortion policy restrictiveness is associated with the odds of HDP among women aged 15-44 in the United States. METHODS: Data from the 2018 and 2021 National Vital Statistics System were linked with state-level abortion laws compiled by the LawAtlas Abortion Law Project. A composite abortion policy index was created using 12 restrictive legal indicators, scored and grouped into tertiles representing low, moderate, and high restrictiveness. The primary outcome was HDP, including gestational hypertension, preeclampsia, and eclampsia. Generalized linear mixed models were used to estimate adjusted odds ratios (aORs) for individual-level and state-level covariates. RESULTS: = 0.036), but this association was not observed in 2021. High restrictiveness was not significantly associated with HDP in either year. Strong, consistent predictors of HDP included adolescent and advanced maternal age, preexisting diabetes, obesity, and racial disparities, particularly among Black and Hispanic women. CONCLUSIONS: This study found no consistent link between abortion policy restrictiveness and HDP, with individual-level clinical, demographic, and social factors serving as the strongest predictors. Ongoing monitoring is needed to understand how shifting reproductive health policies intersect with structural inequities to shape maternal outcomes in the United States.