Hypertensive disorders of pregnancy and its effect on birth outcomes among mothers in public hospitals of Tigray, North Ethiopia.

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Addis Abeba University


Background: over half a million women die each year from pregnancy related causes signifying that complications of pregnancy and childbirth are the leading cause of death amongst women of reproductive ages. Hypertensive disorders of pregnancy are the second direct cause of maternal death only next to hemorrhage which accounts 14% of all maternal mortality globally and 16 % in subSaharan African countries. In Ethiopia 11% of all maternal deaths and 16% of direct maternal deaths are due to this obstetric complication. There is paucity of study looking into the pattern and distribution, the risk factors and the maternal and perinatal outcomes of hypertensive disorders of pregnancy. Moreover, little is known why hypertensive disorders of pregnancy are not early detected and managed to prevent the serious consequences of the disorders. Objective: the aim of this study was to assess hypertensive disorders of pregnancy and its effect on birth outcomes Methods: The study was conducted in public hospitals of Tigray, Ethiopia. Cross-sectional, matched case control, cohort and descriptive qualitative designs were applied for objectives one, two, three and four respectively. For the retrospective record review, all records of women diagnosed with hypotensive disorders of pregnancy from September 2012 to August 2017 (with calculated sample size of 746) were considered while for the case control study a total of 330 (cases=110 and controls=220) matched by parity were included. In addition, a total of 374 (exposed/with hypertensive disorders=187, non-exposed/without hypertensive disorders=187) were included in the follow up study. In the qualitative study, for documenting barriers, health professionals, health care leaders and women with a history of hypertensive disorder of pregnancy were included. Cases were pregnant women attending maternal health services with a diagnosis of hypertensive disorders of pregnancy by an obstetrician while controls were pregnant women attending maternal health services without hypertensive disorders of pregnancy. In the cohort study, exposed group were women diagnosed with any of the hypertensive disorders of pregnancy after 20 weeks of gestation by an obstetrician while non-exposed group were women free from any of the hypertensive disorders of pregnancy. Case-control incidence density sampling was used to identify cases and controls. For the cohort study, women diagnosed with hypertensive disorders of pregnancy with their nonhypertensive pairs were enrolled after 20 weeks of gestation and followed until the first 7 days postpartum. In both designs (case-control and cohort) the sample size was distributed to each selected hospitals according to the case load. For the qualitative study, a total of 22 in-depth interviews were conducted and the sample size was guided by the level of information saturation Data entry for the quantitative study was done into Epi-Info software and it was analysed using STATA 14 software. Descriptive statistics was computed and data were summarized in frequencies, proportions and means. Binary logistic regression was used to calibrate the association of different variables with the dependent variable for the quantitative study. For the case control study conditional logistic regression model was applied and Odds ratio was generated. Besides, relative risk was generated from a binary logistric regression for the cohort study. P-value less than 0.05 were considered significant in all analysis. For the qualitative study, recorded data were transcribed verbatim and translated to English. The transcript was exported to Atlas ti.7 software for qualitative data analysis which was followed by developing a categorization scheme to reduce the data and make it more manageable. Transcripts were read for several times and the primary codes were extracted. Then, the related codes were put in one group/category. Finally, based on similarity and content, the subcategories were used to make the main categories or themes. Thus, thematic content analysis was used to generate the main themes of the study. The overall findings were presented using figures, tables and texts. Ethical clearance was obtained from Institutional Review Board (IRB) of Addis Ababa University College of Health Sciences. Cooperation letter was written from the Regional Health Bureau and permission was requested from study facilities. Individual written informed consent was also sought from respondents at the time of data collection. Results: A total of 45,329 mothers were admitted to deliver in the selected public hospitals of Tigray during the five years study period (September 2012 to August 2017). Out of the total deliveries, 1347 (3%) women were diagnosed for one of the hypertensive disorders of pregnancy. The overall magnitude showed an increasing trend over the review period ranging from 1. 4% in 2013 to 4% in 2017 which gives average percentage increase of 31% per annum.The change over the five years period was checked for its significance using chi-square trend analysis and it was found to be significant (X 2 = 153, p≤0.001). Multivariable analysis on the relationship between hypertensive disorders of pregnancy and different covariates revealed that rural residence (AOR = 3.7, 95% CI; 1.9, 7.1), less amount of fruits consumption (OR =5.1, 95% CI;2.4, 11.15), being overweight (pre-pregnancy BMI>25 Kg/m2) (AOR= 5.5 95% CI; 1.12, 27.6), gestational diabetes mellitus (AOR = 5.4, 95%CI; 1.1, 27.0) and multiple pregnancy (AOR= 4.2 95%CI; 1.3, 13.3) were independent predictors of hypertensive disorders of pregnancy. Moreover, the study showed higher risk of having pregnancies complicated by maternal and perinatal adverse outcomes. Thirty six (20.2%) of hypertensive women and 19(10.7%) of normotensive women undergone cesarean section delivery. Preterm birth (RR=1.8; 95%CI, 1.5, 2.2), stillbirth (RR=1.6; 95%CI, 1.3, 2.02), low birth weight (RR=1.9; 95%CI, 1.6, 2.3), early neonatal death (RR=1.7; 95%CI, 1.3, 2.3), perinatal death (aRR=2.6, 95%CI; 1.2, 5.7) and cesarean section delivery(RR=1.7; 95%CI, 1.02, 2.9) were significantly higher among women with hypertensive disorders of pregnancy Furthermore, the qualitative study showed that knowledge deficit and traditional believes towards hypertensive disorders of pregnancy, delayed referral and provision of incomplete pre-referral treatments in the lower level health care facilities, failure to implement antenatal follow up as per the recommendation; scarcity and interruption in the supply of resources; and lack of mentorship programs to make professionals competent were claimed for the late detection and management of hypertensive disorders of pregnancy. Conclusion: Hypertensive disorder of pregnancy in Tigray is found to be 3% and it showed an increasing trend. Rural residence, less fruit consumption, multiple pregnancy, presence of gestational diabetes mellitus and pre-pregnancy overweight were identified as independent risk factors in the current study. Besides, women with hypertensive disorders in pregnancy were at significantly higher risk of having pregnancies complicated by maternal and perinatal adverse outcomes. A significant risk of cesarean section delivery, preterm birth, perinatal death, stillbirth and low birth weight delivery were reported among women with hypertensive disorders of pregnancy. Moreover, poor awareness of mothers and community misconceptions towards hypertensive disorders of pregnancy, multiple referrals before reaching the final functional health care facility, less focus on the quality of antenatal care, scarcity of resources and limited capacity building programs were reported as barriers for early detection and management of hypertensive disorders of pregnancy. Therefore, health care managers and administrators at different level of the health care system should give due emphasis to hypertensive disorders of pregnancy as it is one of the top causes of maternal and perinatal mortality and its magnitude is increasing from time to time. Health institutions should have strong strategies of screening, counselling, follow-up and referral linkage of mothers in the antenatal clinic and maternity wards by availing necessary materials and designing strong supportive supervision/ mentorship programs.



Hypertensive disorders,pregnancy ,mothers