Global incidence and risk factors of pregnancy-related stroke: a systematic review and meta-analysis of over 270 million women

Abstract

Objective: Stroke is a leading cause of death and disability worldwide, with its prevalence increasing due to risk factors such as hypertension, diabetes, and hyperlipidemia. Pregnancy-related stroke (PRS), a severe pregnancy complication, particularly during the postpartum period, has shown rising incidence rates, occurring at 30 per 100,000 pregnancies, three times higher than in the general young adult population. This study systematically reviews and analyzes global and regional data regarding the incidence and risk factors of PRS. Methods: Comprehensive searches of PubMed/MEDLINE, Scopus, EMBASE, and Web of Science databases were performed until December 20, 2024. Studies reporting any type of stroke occurring during pregnancy (from the time of confirmation to one year postpartum) were included. Study quality was evaluated using the Joanna Briggs Institute (JBI) checklist, and data analysis was conducted with STATA version 17. A random-effects meta-analysis was employed to calculate pooled incidence rates per 100,000 pregnancies, with 95% confidence intervals (CIs). Heterogeneity was assessed using Cochran’s Q test and quantified with the I² statistic. Risk factors for PRS were also evaluated using univariate regression. Results: A total of 33 studies involving 270,136,827 pregnant women from 10 countries met inclusion criteria. The global cumulative incidence of PRS was 25.38 (95% CI: 21.02–30.63) per 100,000 pregnancies. Regional analysis revealed the highest incidence in the South-East Asia region (66.31; 95% CI: 44.22–99.42) and the lowest in the European region (12.88; 95% CI: 7.73–21.46). Based on 22 included studies, the pooled maternal mortality rate due to PRS was estimated at 1.55 per 100,000 pregnancies (95% CI: 1.04–2.32). Risk factors significantly associated with PRS included migraine, dyslipidemia, alcohol use, tobacco smoking, sickle cell disorders, coagulopathy, cardiovascular diseases, preeclampsia/eclampsia/gestational hypertension, and postpartum hemorrhage. Conclusion: PRS, with a global incidence of 25.38 per 100,000 pregnancies, remains a critical health concern, particularly in regions with limited resources. However, a lack of data from many countries limits a comprehensive global understanding. The identification of key risk factors, such as preeclampsia, cardiovascular disorders, and postpartum hemorrhage, highlights the need for targeted preventive strategies. Improved data collection, early detection, and timely intervention are essential to reducing the burden of PRS worldwide. Trial registration: The PROSPERO registration code is CRD420251152299.