Abstract
INTRODUCTION: Hypertension is a leading contributor to maternal and cardiometabolic morbidity in Bangladesh. We developed and interpreted machine-learning (ML) models to predict hypertension and rank associated factors among married women with the goal of informing targeted screening and policy in low-resource settings. METHODS: We analyzed 4,253 married women from the nationally representative BDHS 2017-18 survey (hypertension prevalence: 23.1%). Twelve ML algorithms were trained under six class-balancing strategies with hyperparameters tuned via random search. Validation used a hold-out test set (80/20) and repeated stratified k-fold cross-validation; bootstrap confidence intervals were estimated for the selected model. Model performance was compared with parametric and non-parametric tests. To interpret results, SHAP was used to rank the top 20 predictors and visualize feature effects. Models quantify associations rather than causation. RESULTS: The Extra Trees classifier with SMOTE+ENN achieved the best discrimination (F1 = 0.94; AUC-PR = 0.95; ROC-AUC = 0.95). Compared with the original imbalanced training, minority-class detection improved substantially (Extra Trees F1 increased from 0.08 to 0.94; recall from 0.04 to 0.95) while accuracy and ROC-AUC remained relatively stable across samplers. Statistical testing favored SMOTE+ENN for recall, F1, G-mean and AUC-PR. SHAP identified age, parity, recent births, contraceptive use, spousal education and BMI as key predictors. Younger age (<35 years) and normal/underweight status were protective, while parity ≥2-3, husbands' age ≥ 40 years and overweight/obesity increased risk. CONCLUSIONS: An interpretable ensemble model built primarily on sociodemographic and behavioral variables supplemented by limited biometric markers (BMI, glucose) can accurately flag hypertensive risk among married women in Bangladesh. Findings support programmatic integration of risk scores into eRegistries, routine blood pressure checks in family planning and postpartum visits, husband-focused education/SMS interventions and prioritization of high-parity households in high-risk regions. External validation on BDHS-2022 is planned to assess generalizability.