1. Pregnancy-induced hypertensive disorders and antihypertensives before and after a national economic collapse Védís Eiríksdóttir Unnur Valdimarsdóttir, Tinna Laufey Ásgeirsdóttir, Sigrún Helga Lund, Arna Hauksdóttir, Ragnheiður Bjarnadóttir, Sven Cnattingius, Helga Zoëga PharmacoEpiSLAM!

2. The 2008 Icelandic economic collapse Collapse of the 3 largest banks in the first week of October 2008 o ~ 85% of Iceland‘s financial system failed o Largest collapse in history, relative to the size of the economy o Increase in unemployment and household debts o Firms and individuals went insolvent

3. The first months following the collapse Range Rover = Game over The pot&pan revolution Demonstration Anger

4. Increased stress Shocks and stress during/before pregnancy can affect maternal health and birth outcomes –Loss of a close relative: ↓gestational length 1 ; ↓birth weight 2 ; ↑preeclampsia 3 –Job loss or job insecurity: ↓birth weight 4

5. Aims 1.To examine the potential change in the prevalence of pregnancy- induced hypertensive disorders following the 2008 Icelandic economic collapse. 2.To examine the potential change in the use of antihypertensive drugs during pregnancy following the economic collapse. 3.To assess whether potential changes in hypertensive disorders were due to changes in the aggregate economic climate in Iceland during that time.

6. Data sources and study population Birth Registry Mothers of 35,211 liveborn singletons >20 weeks pregnant Oct 2004 - Dec 2012 Medicines Registry Drug prescriptions for antihypertensives Statistic Iceland – economic indicators Unemployment rate Statistic Iceland – surrounding economic climate Gross domestic product (GDP Difficulties making ends meet (%) Balance of accounts Defaults on loans or rent

7. Prevalence over time

8. OR of beta-blockers and calcium channel blockers Regression models Pre-collapse periodPost-collapse year 1Post-collapse year 2Post-collapse year 3Post-collapse year 4 OR [95% CI] (A) Beta-blockers Crude 1.00 [ref.]1.64 [1.36-1.99]1.29 [1.04-1.60]1.12 [0.88-1.41]1.46 [1.17-1.82] Model I* 1.00 [ref.]1.43 [1.07-1.90]1.05 [0.72-1.52]0.87 [0.55-1.37]1.06 [0.62-1.80] Model II** 1.00 [ref.]1.49 [1.11-2.00]1.12 [0.76-1.64]0.91 [0.56-1.46]1.10 [0.64-1.89] Model III*** 1.00 [ref]1.05 [0.72-1.54]0.77 [0.49-1.20]0.67 [0.41-1.10]0.91 [0.53-1.55] (B) Calcium channel blockers Crude* 1.00 [ref.]1.68 [1.11-2.53]1.48 [0.95-2.29]2.30 [1.56-3.39]3.91 [2.77-5.52] Model I** 1.00 [ref.]0.67 [0.38-1.18]0.38 [0.18-0.81]0.40 [0.16-0.97]0.45 [0.16-1.31] Model II*** 1.00 [ref.]0.62 [0.35-1.11]0.36 [0.17-0.76]0.32 [0.13-0.79]0.39 [0.13-1.14] Model III****1.00 [ref.]1.07 [0.49-2.31]0.63 [0.25-1.62]0.60 [0.21-1.67]0.59 [0.19-1.81] *Adjusted for maternal age, gravidity and time in weeks [time-trend]. ** Simultaneously adjusted for maternal age, gravidity, time in weeks, sex, diabetes, pre-existing hypertension, relationship status, place of residence, employment status and citizenship. ***Adjusted for maternal age, gravidity, time in weeks and aggregate unemployment rate

9. Conclusions Transient increase of gestational hypertension and use of beta-blockers in the first and most severe year of the crisis. The aggregate economic climate at that time is a likely explanation for the observed pattern.

10. Ahhh! Thanks helgaz@hi.is

11. The literature Shocks and stress during/before pregnancy can affect maternal health and birth outcomes –Loss of a close relative: ↓gestational length 1 ; ↓birth weight 2 ; ↑preeclampsia 3 –Job loss or job insecurity: ↓birth weight 4 Macroeconomic recessions and birth outcomes –Some studies find an increase in adverse birth outcomes 5 –Other find no effect 6 –Yet another find decrease in adverse birth outcomes during recessions 7 No studies on pregnancy-induced hypertension in relation to recessions 1 Khashan et al. 2008; 2 Khashan et al. 2009; 3 Lázló et al. 2014; 4 Dooley and Prause 2005, Lindo 2011, Carlson 2015 5 Cruses at al. 2012, Catalano 1999, Margerison-Zilko 2011, 6 Joyce 1990; Joyce et al. 1993 7 Dehejia and Lleras-Muney 2004

12. OR of gest. hypertension and preeclampsia Regression models Pre-collapse periodPost-collapse year 1Post-collapse year 2Post-collapse year 3Post-collapse year 4 OR [95% CI] (A) Gestational hypertension Crude 1.00 [ref.]1.62 [1.37-1.93]1.29 [1.06-1.56]1.29 [1.06-1.57]1.28 [1.04-1.57] Model I* 1.00 [ref.]1.47 [1.13-1.91]1.11 [0.79-1.55]1.09 [0.72-1.63]1.02 [0.63-1.64] Model II** 1.00 [ref.]1.44 [1.11-1.87]1.08 [0.77-1.52]1.05 [0.69-1.58]0.99 [0.61-1.61] Model III*** 1.00 [ref.]1.04 [0.74-1.47]0.78 [0.52-1.17]0.81 [0.52-1.26]0.85 [0.52-1.38] (B) Preeclampsia Crude* 1.00 [ref.]0.78 [0.65-0.94]0.83 [0.69-1.00]0.89 [0.74-1.07]0.91 [0.75-1.11] Model I** 1.00 [ref.]0.86 [0.67-1.11]0.97 [0.72-1.31]1.09 [0.76-1.56]1.15 [0.76-1.74] Model II*** 1.00 [ref.]0.86 [0.66-1.10]0.97 [0.71-1.31]1.11 [0.77-1.59]1.12 [0.73-1.72] Model III****1.00 [ref.]0.88 [0.62-1.23]0.99 [0.67-1.45]1.11 [0.73-1.67]1.16 [0.75-1.79] *Adjusted for maternal age, gravidity and time in weeks [time-trend]. ** Simultaneously adjusted for maternal age, gravidity, time in weeks, sex, diabetes, pre-existing hypertension, relationship status, place of residence, employment status and citizenship. ***Adjusted for maternal age, gravidity, time in weeks and aggregate unemployment rate