Educational Disadvantage as a Social Determinant of Health and Its Impact on Maternal Cardiovascular Outcomes in the Fourth Trimester: A Retrospective Propensity-Matched Cohort Study (2008–2023)

Background: Education and literacy are key components of the social determinants of health (SDOH) that may influence maternal cardiovascular health, particularly during the vulnerable postpartum period. This study evaluates the association between education/literacy-related SDOH and adverse cardiovascular and maternal outcomes in reproductive-age females following delivery. Methods: Using data from the TriNetX US Collaborative Network, a retrospective cohort study was conducted among females aged 15–60 years with delivery or postpartum encounters from 2008 to 2023. Two cohorts were identified: Cohort 1 (n=3,033) included individuals with a diagnosis of education/literacy-related SDOH (ICD-10 Z55), and Cohort 2 (n=1,876,884) included patients without any SDOH exposure. Propensity score matching produced two comparable cohorts of 2,981 patients each. Outcomes were assessed within 5 years following the index event. Results: No significant differences were found in all-cause mortality, ischemic stroke, or major adverse cardiovascular and cerebrovascular events (MACCE). However, individuals in the SDOH group had a significantly higher incidence of cardiac arrest (0.3% vs. 0.0%, p=0.002), end-stage heart failure (0.3% vs. 0.0%, p=0.002), and acute myocardial infarction (HR=3.94, p=0.021). Conversely, the incidence of postpartum eclampsia was lower in the SDOH cohort (0.3% vs. 0.8%, p=0.016). Kaplan-Meier analyses revealed lower survival probabilities in the SDOH group for several endpoints, despite most outcome differences not reaching statistical significance. Conclusions: Education and literacy-related SDOH are associated with increased risk of severe cardiovascular outcomes—including cardiac arrest and end-stage heart failure—among postpartum women. These findings underscore the importance of addressing educational inequities as part of comprehensive maternal cardiovascular risk reduction strategies.