Author ORCID Identifier


Defense Date


Document Type


Degree Name

Doctor of Philosophy



First Advisor

Tilahun Adera, M.P.H, M.A., Ph.D.

Second Advisor

Juan Lu, Ph.D., M.P.H., M.D.

Third Advisor

Robert A. Perera, Ph.D.

Fourth Advisor

Edward H. Springel, M.D.


Background: Pregnancy induced hypertension (PIH) is the leading cause of maternal mortality and a major contributor to preterm birth and neonatal mortality. Literature suggests that several modifiable psychosocial and health behavioral factors may play significant roles in the development of PIH. However, interrelationships among these factors and their collective impact on PIH are not well understood.

Objectives: This study aims to: 1) Examine the relationship between pre-pregnancy physical activity and risk of PIH, 2) Determine the association between prepregnancy depression and PIH and the role of race/ethnicity in this association, 3) Evaluate the association between intimate partner violence (IPV) in women before and/or during pregnancy and PIH, and the role of utilization of prenatal care (PNC) as a mediator in this association.

Methods: This study utilized the national Pregnancy Risk Assessment Monitoring System survey data (years 2009-2015). The outcome variable PIH was defined as a dichotomized variable (Yes; No) utilizing a birth certificate variable data. Domain-adjusted multiple logistic regression, multiple logistic regression with stratification, and structural equation modeling analyses were used to investigate the study aims.

Results: No significant reduced risk of PIH was observed in women who were physically active prior to pregnancy compared to sedentary women. However, women with prepregnancy depression were more likely to have PIH compared to women without prepregnancy depression and this association was significant for non-Hispanic White women when stratified by race/ethnicity. Further, PNC utilization was a significant mediator in the association between IPV before and/or during pregnancy and PIH. However, IPV had no direct or total effect on PIH in this study.

Conclusions: Public health professionals and health care providers should be aware of the relationships between prepregnancy depression, race/ethnicity, IPV, and prenatal care utilization, and PIH, and utilize the information in risk profiling, screening, early detection and intervention in women at risk of PIH.


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