Hypertensive disorders of pregnancy and its effect on birth outcomes among mothers in public hospitals of Tigray, North Ethiopia.
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Date
2019-05
Authors
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Addis Abeba University
Abstract
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.
Description
Keywords
Hypertensive disorders,pregnancy ,mothers