By examining disparities in LDA prescription/recommendation and utilization among populations at risk, this review aims to inform interventions improving maternal health outcomes and addressing the disproportionate burden of preeclampsia on Black women. Fifteen studies from the systematic review evaluated physician adherence to the 2014 USPSTF guideline or 2021 update recommending daily LDA for preeclampsia prevention in pregnant patients, as well as racial/ethnic disparities in prophylaxis recommendations [9, 10].

Therefore, this review has shown that Black women are prescribed LDA for preeclampsia prevention at rates similar to women from other racial/ethnic populations when risk factors are present, but Black patients’ rates of adherence are consistently lower. This finding is in line with a recent study by Vinogradov et al. that identified multiple obstacles to pregnant patients’ adherence, including insufficient knowledge about aspirin’s benefits, concerns about necessity and safety, access issues, social influences, as well as lack of habit formation [31]. These barriers are even more noticeable in marginalized populations, including Black women. It is important to mention that these factors are exacerbated by systemic issues such as distrust of the healthcare system and poor physician-patient communication. Similarly, a report from SMFM highlighted that nonadherence often stems from inconsistent counseling, mixed physician messaging, and logistical barriers, despite the low cost of LDA treatment [32].

It is also important to mention purposeful avoidance of LDA usage by some pregnant women. Some patients are cautious about taking LDA as prescribed or recommended due to potential risks of increased bleeding, and consequently, cerebrovascular accidents. However, a recent study by Cloud et al. notes that caution in aspirin use should only be exercised in older individuals who are prone to head trauma due to falls [33]. Young women of reproductive age are generally not included in this high-risk category.

The potential harm of any prescription drug is at the forefront of the minds of many expectant mothers, and even the most harmless and well-studied medications can raise concerns when the health of the future child is at stake. A recent public and scientific discussion about a potential link between the use of acetaminophen (Tylenol) during pregnancy and an increased risk of autism spectrum disorder (ASD) in children is one of the examples of such discourse. The overwhelming consensus among major medical and health organizations including ACOG, the Food and Drug Administration (FDA), and the World Health Organization (WHO), is that no established causal link between maternal acetaminophen usage during pregnancy and ASD in offspring [34, 35]. However, these statements are sometimes still not enough to convince a worried parent. A similar, though less widespread, hesitancy exists with respect to LDA usage in pregnancy and its link to ASD or attention deficit/hyperactivity disorder in offspring. Reassuringly, a recent study that came out in 2025 by Rodriguez-Sibaja et al. demonstrated no increased risk of maternal, fetal, or neonatal adverse events associated with LDA use during pregnancy [36]. This evidence reinforces current guideline recommendations and further confirms the need to address misconceptions that may contribute to intentional LDA nonadherence.

Moreover, we found that the reported prescription/recommendation rates of LDA in Black women vary across studies. Several studies suggest that the prescription/recommendation rates of LDA among Black women were lower than White women, even when the risk factors were present. In contrast, a few studies suggest equal or even higher prescription/recommendation rates of LDA among Black women, even though the adherence rates in these populations were statistically lower compared to White women.

Overall, the average LDA adherence rate among high-risk populations was about 70%. This important finding suggests that over one out of four pregnant women who are prescribed or recommended LDA do not use it consistently, despite strong guideline recommendations. It was also discovered that the LDA adherence rates among Black patients were consistently lower than among White patients, even though prescription/recommendation rates were similar. Prescription uptake itself was more comparable, with average rates in the 70–80% range across groups when risk factors were present. However, patient follow-through after prescription appears to be the most significant challenge.

To our knowledge, no previous studies have comprehensively examined LDA prescription/recommendation and adherence patterns in high-risk pregnancies by race/ethnicity, specifically comparing pre- and post-2014 USPSTF guideline adoption periods. This remains a critical gap in literature, and we aim to address this gap in our study. The literature highlights the underrepresentation of Black women in clinical trials, which limits the generalizability of data and emphasizes the need for research on implementation and adherence within this population. The study by Mendoza et al. determined that over 92% of participants in a recent large aspirin trial were White, explicitly stating that this lack of racial/ethnic diversity limits the applicability of results to Black women, who have a higher incidence of preeclampsia [37]. When analyzing the 2014 USPSTF guidelines for adoption, it appears that adherence had not improved significantly, highlighting a persistent gap in implementation. Some studies also reported that Black women were more likely to discontinue aspirin prematurely compared to White women, often citing inconsistent guidance from healthcare clinicians and the overall lack of understanding of the importance of LDA.

These findings highlight discrepancy between issuing the guidelines, prescription practices, and patient adherence. According to our analysis, physicians are generally following the guideline recommendation in prescribing aspirin to eligible pregnant patients of all racial/ethnic backgrounds, including Black women. Low adherence rates across high-risk patient groups, and particularly lower rates among Black women, suggest that current interventions are insufficient and must go beyond simple counseling and prescribing to increase patient adherence. Patient-centered interventions, such as trust-building approaches, culturally tailored education materials, and focused counseling should be prioritized by clinicians. Structural support tools such as reminder systems, pharmacy access programs, and integration of aspirin adherence into routine prenatal care monitoring may also be required. These findings align with maternal health disparities research showing that systemic inequities, such as structural racism, lower access to high-quality care, implicit bias, and adverse social determinants of health, and not just individual patient factors drive differences in outcomes [38]. The disproportionately high rates of preeclampsia among Black women cannot be reduced without addressing the combined effects of mistrust, communication barriers, and underrepresentation in clinical evidence-based research.

There were several limitations noted related to this study. First, the included studies were heterogeneous in design, methodology, and patient population which limited our ability to conduct a formal meta-analysis and required us to rely on descriptive interpretation of the data. Second, reporting of race and ethnicity was inconsistent across the studies, with some authors combining groups or omitting data on patients of other racial/ethnic backgrounds. Third, this review relies on retrospective data and data from electronic health records in many studies, which may underestimate aspirin counseling or adherence due to incomplete documentation. Similarly, adherence measures were often based on data about prescription fills or self-report, both of which may not accurately reflect actual medication use and fall short due to recall bias. Fourth, because the studies included the span of pre- and post-2014 and 2021 USPSTF guideline adoption, temporal differences in physician practice and patient uptake could confound comparisons. Finally, women of Asian population were not included in this study. Due to data limitations, majority of the studies did not report data on Asian patients. Within the few studies that did, the results of LDA prescription/recommendation rates were similar in Asian patients as seen in White patients.

There are a few critical avenues for improvement in understanding LDA prescribing and adherence in racially and ethnically diverse pregnant populations. These avenues include conducting large-scale prospective studies that separate outcomes by race and ethnicity, developing standardized methods to measure adherence that go beyond prescription fill or self-report data, and identifying which factors most strongly predict continuous use of aspirin during pregnancy. A recent review has demonstrated that universal risk assessment tools, electronic health record prompts, and structured clinician education can improve prescribing practices, but future randomized implementation studies are necessary in larger, more diverse samples to better demonstrate longitudinal impacts on patient adherence and maternal health outcomes [39].

Furthermore, community-based studies that examined adherence behaviors and maternal outcomes in diverse settings have suggested that culturally tailored education and patient-centered counseling can improve medication uptake [40]. However, more research is needed to determine which social, demographic, or clinical factors most strongly predict sustained adherence to aspirin use across different racial/ethnic groups. Alternative approaches, such as including adherence monitoring into routine prenatal visits and using mobile health phone applications for reminders, have also demonstrated promise in improving consistent use of medications during pregnancy [41]. These community-based strategies can be further combined with health education modules to address mistrust, barriers to care, and current knowledge gaps.

Another approach to reducing racial/ethnic disparities in preeclampsia outcomes is to focus on comprehensive systems-level interventions. Integrated prenatal care models and multidisciplinary maternal health programs have demonstrated improvements in hypertension management and maternal outcomes, by expanding access, improving continuity of care, and strengthening physician–patient communication [42]. Adding LDA adherence monitoring within such models may further reduce racial/ethnic disparities. In addition, future research should evaluate biological and pharmacogenomic factors that may influence aspirin effectiveness across populations, given the higher baseline risk of preeclampsia among Black women.

Establishing standardized reporting frameworks for LDA prescribing and adherence rates, stratified by race and ethnicity, will also be essential to track progress and guide evidence-based policy updates. Since the completion of this review, several new studies on LDA use for preeclampsia prevention have been published in 2025. A recent paper published in October 2025 by Jaclyn Del Pozzo discussed the utilization of a universal LDA protocol for preeclampsia prevention with retrospective cohort studies pre- and post-USPSTF guidelines update in 2021 [43]. They found this implementation of universal LDA protocol in a high-risk, underserved population markedly improved LDA adherence and reduced severe preeclampsia without increasing hemorrhage risk. Another retrospective cohort study analyzing the LDA use before and after the 2021 USPSTF guideline update came out in May 2025, and they found overall rates of LDA use remain well below expected even with the updated guidelines emphasizing racial/ethnic inequities of preeclampsia [44].