Hindawi
Journal of Pregnancy
Volume 2023, Article ID 4194443, 12 pages
https://doi.org/10.1155/2023/4194443
Research Article
Prevalence, Awareness, and Control of Hypertensive Disorders
amongst Pregnant Women Seeking Healthcare in Ghana
Pauline Boachie-Ansah ,1 Berko Panyin Anto ,1 Afia Frimpomaa Asare Marfo ,1
Edward Tieru Dassah ,2,3 Constance Caroline Cobbold ,4 and Morrison Asiamah 5
1Department of Pharmacy Practice, Faculty of Pharmacy and Pharmaceutical Sciences, Kwame Nkrumah University of Science
and Technology, Kumasi, Ghana
2Department of Population and Family Reproductive Health, School of Public Health, Kwame Nkrumah University of Science
and Technology, Kumasi, Ghana
3Department of Obstetrics and Gynaecology, Komfo Anokye Teaching Hospital, Kumasi, Ghana
4Department of Pharmacotherapeutics and Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences,
University of Cape Coast, Ghana
5Department of Electron Microscopy and Histopathology, Noguchi Memorial Institute for Medical Research, University of Ghana,
Legon, Accra, Ghana
Correspondence should be addressed to Pauline Boachie-Ansah; paulineboachie.ansah@gmail.com
Received 15 March 2023; Revised 29 August 2023; Accepted 30 August 2023; Published 12 September 2023
Academic Editor: Süleyman Cemil Oğlak
Copyright © 2023 Pauline Boachie-Ansah et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Hypertensive disorders in pregnancy (HDPs) are no longer seen as “transitory diseases cured by delivery.” It accounts for up to
50% of maternal deaths. Information concerning HDPs is less in developing countries like Ghana. This study was conducted to
find out the prevalence, awareness, risk factors, control, and the birth outcomes of HDPs. This was a retrospective cohort
study conducted among pregnant women seeking care in selected health facilities in the Ashanti Region. Data on
demographics, HDPs, and its associated birth outcomes were collected. Logistic regression models were used to examine the
association of the independent variables with HDPs. The burden of HDPs was 37.2% among the 500 mothers enrolled with
chronic hypertension superimposed with preeclampsia accounting for 17.6%, chronic hypertension, 10.2%, and preeclampsia
6.8% whilst gestational hypertension was 2.6%. It was observed that 44% (220) of the mothers had excellent knowledge on
HDPs. Oral nifedipine and methyldopa were frequently used for HDP management, and it resulted in a significant reduction
in HDP burden from 37.2% to 26.6%. Factors that influenced the increased risk of HDPs were grand multigravida
(AOR = 4 53; CI = 1 42–14.42), family history of hypertension (AOR = 3 61; CI = 1 89–6.90), and the consumption of herbal
preparations (AOR = 2 92; CI = 1 15–7.41) and alcohol (AOR = 4 10; CI = 1 34-12.62) during pregnancy. HDPs increased the
risk of preterm delivery (AOR = 2 66; CI = 1 29–5.89), stillbirth (AOR = 12 47; CI = 2 72–57.24), and undergoing caesarean
section (AOR = 1 70; CI = 1 10–2.61) amongst mothers during delivery. The burden of HDPs is high amongst pregnant
mothers seeking care in selected facilities. There is the need for intensified campaign on HDPs in the Ashanti Region of Ghana.
1. Background eclampsia-eclampsia, gestational hypertension, and chronic
hypertension-superimposed preeclampsia are the four cate-
Hypertensive disorders in pregnancy (HDPs) are the leading gories of hypertensive disorders in pregnancy [3]. In Ghana,
cause of maternal mortality [1]. It contributes to 14% and it is estimated that the maternal mortality rate is 319 deaths
16% maternal mortality worldwide and in Sub-Saharan per 100,000 live births [4]. This is about 4.3 times higher
Africa (SSA), respectively [2]. Chronic hypertension, pre- than the UN recommended rate. One of commonest cause
2 Journal of Pregnancy
of direct maternal death identified was severe preeclampsia/ tion in the region and the large coverage of patients they
eclampsia which accounted for 23% of all direct maternal cater for.
deaths and 16% of all maternal deaths in 2011 [5].
Factors such as educational level, age, higher parity, 2.2. Sample and Sampling. This study included pregnant
occupation, family of HDPs, gravida, complications of preg- women above the ages of 18 years who had been admitted
nancy, and others such as healthcare systems and social, cul- for delivery and those who had delivered at the hospital dur-
tural, and economic factors are seen to be associated with ing the period of the study. Pregnant women who were on
HDPs [6]. Studies have shown that a woman’s knowledge admission for other reasons besides delivery were excluded.
about her condition can influence early health seeking At a significance level of 5%, the Yamane method was
behaviour and compliance to treatment which would result used to determine the sample size [13]. The estimated num-
in early diagnosis and prevent pregnancy complication ber of live births in the Ashanti Region in 2010 was 122878
including death [7]. Lack of knowledge on HDPs could lead [14]. If the number of live births equals the number of preg-
to misconceptions which may include interpretation of nant women for the year, a sample size of 440 pregnant
warning signs as normal occurrence during pregnancy or women would be sufficient. Considering nonresponse rate,
as “spiritual attacks” [8]. Although maternal serum AQP9 a minimum of about 500 pregnant women were recruited.
concentrations have been found to be associated with From this figure, 105 (21%), 125 (25%), 120 (24%), and
early-onset preeclampsia [9], the cause of HDPs remains 150 (30%) mothers were recruited from the Ejisu District
unclear, and treatment remains symptomatic with the pri- Hospital, KNUST Hospital, Kumasi South Hospital, and
mary objective being the safety of the mother. Over the KATH, respectively. Employing quota, sample size for each
years, HDPs have being controlled with regular blood pres- facility was determined using the documented average
sure monitoring, use of approved pharmacotherapeutics, monthly delivery at each hospital.
and other nonpharmacological preventive measures. Consented participants were screened for eligibility. Par-
Target 3.1 of the Sustainable Development Goals (SDG) ticipants who were eligible for this study were numbered and
as set by the United Nations is aimed at reducing the mater- randomly sampled using an online number generator. Par-
nal mortality ratio to 70 per 100,000 live births by 2030 [10]. ticipants whose numbers were generated were included in
However, the burden of hypertension has been increas- the study.
ing over the past few decades in SSA, and a large percentage
of the population with hypertension remains untreated, inef- 2.3. Development and Validation of Questionnaire. The
fectively treated, or even undiagnosed [11]. Furthermore, questionnaire was developed after reviewing several litera-
this study is important because much research has studied tures to ensure that the items capture a meaningful construct
the prevalence, awareness, and control of hypertension to have causality to the outcome of interest. The question-
among the general population; however, there is a need for naire was piloted within a selected hospital. To assess the
studies focused on pregnant women as the effect of HDPs reliability of the construct of composite variables such as
include risk of harm not only to the mother but also to the the level of knowledge, a Cronbach alpha test was con-
unborn child. HDPs are no longer seen as “transitory dis- ducted. For the Cronbach alpha test for level of knowledge,
eases cured by delivery,” but as windows into the woman’s the score was 0.73 which indicates that the composite vari-
future health that needs integrated care, coordinating treat- able is reliable. Information was collected on their socio-
ment to identify risk factors and correct them [12]. This demographic characteristics, factors influencing their risk
study is aimed at identifying the prevalence, risks awareness, of hypertensive disorders in pregnancy, level of awareness,
control, and the birth outcomes of HDPs among pregnant management of the disorders, and the birth outcomes.
women in some selected health facilities in the Ashanti The level of knowledge was assessed as an 18-item com-
Region of Ghana. posite variable. For a correct response a code of 1 was
assigned, and for a wrong response, a code of 0 was assigned.
Therefore, a participant can score a maximum of 18 and a
2. Methods minimum of 0. Where a participant scores less than 5, and
then, the participant has poor level of knowledge, scoring
2.1. Study Design and Site. This was a retrospective cohort between 5 and 9 was considered satisfactory level of knowl-
study, which employed a well-structured, pretested, close- edge, and 10 to 14 was considered good level of knowledge.
response questionnaire to obtain data from pregnant women A participant is considered to have an excellent level of
who were seeking care at four hospitals in the Ashanti knowledge on HDPs if the participant scores 15 to 18.
Region. The Ashanti Region is the second most populous Code of 1 was assigned to participants who had HDPs
region in Ghana (GSS 2019) with over 100 hospitals, both and 0 to participants who did not have evidence of HDPs.
private and public hospitals. The study sites included the Thus, the dependent variable hypertensive disorder in preg-
Ejisu Government Hospital (Ejisu Municipal), Kwame nancy was measured as a binary outcome.
Nkrumah University of Science and Technology (KNUST)
Hospital (Oforikrom Municipal), Kumasi South Hospital 2.4. Data Collection. A research team comprising medical
(Asokwa Municipal), and the Komfo Anokye Teaching officers, pharmacists, pharmacy house officers, research sci-
Hospital (KATH) (Kumasi Metropolis, Bantama sub-metro entists, and midwives was formed and oriented through
district). These facilities were chosen because of their loca- series of meetings on the procedures and the objectives of
Journal of Pregnancy 3
the study. Each member had a specific role to play. The team dents, 314 (62.8%) had no hypertension throughout their
was grouped into four smaller groups for each hospital. All pregnancy while 186 (37.2%) were with HDPs. Fifty-one
consenting women who had delivered had their antenatal (27.4%) were chronic hypertensive, chronic hypertension
record booklets reviewed retrospectively from 16 week gesta- superimposed with preeclampsia was 88 (17.6%), preeclamp-
tion to the point of delivery by a member of the research sia was 34 (6.8%), and gestational hypertension was 13
team and underwent a confidential face-to-face interview (2.6%) (Figure 1).
(where possible) in vernacular or English using a pretested
structured questionnaire. The questionnaire was used to col- 3.4. Antihypertensives Prescribed and Blood Pressure Control
lect data on demographic, socioeconomic characteristics, among Women with HDPs. All women diagnosed of HDPs
patient-related factors, and knowledge on hypertension received at least one antihypertensive. Oral nifedipine
related disorders in pregnancy (HDPs). Antenatal record (43.3%, n = 81) and oral methyldopa (43.1%, n = 80) were
books were reviewed for the outcome and mode of preg- often prescribed, 7.6% (n = 14) of respondents received IV
nancy, blood pressure control during the gestational period, magnesium sulphate, 4.7% (n = 09) were on injection, and
antenatal quality indices, and any diagnosis of HDPs. The hydralazine and tab prazosin were 1.3%. The parenteral
mode of deliveries was recorded in patients’ records by phy- medications were prescribed during pregnancy for those
sicians or the midwives. who recorded high blood pressure or were at risk of develop-
Women who had been admitted for delivery but had not ing eclampsia (Figure 2).
delivered were recruited after delivery and then interviewed.
The participants were allowed to withdraw from the study at 3.5. Effect of Intervention on the Blood Pressure Control of
any time if they wish to do so and reasons for withdrawal Respondents. The mean blood pressure of patients with
documented. HDPs was 137/93mmHg at 16 week gestation. However, at
the time of delivery, the mean blood pressure was 137/
2.5. Data Analysis. Data was entered in Excel and cross- 89mmHg. The reduction in blood pressure due to medicine
checked, cleaned, and exported to Stata version 14 for the treatment was not statistically significant. However, there
analysis. There were no missing data due to the use of inter- was a significant reduction in the proportion of mothers
viewer administered questionnaire and a check on women who had hypertensive disorders from 37.2% to 26.6%
medical records. A univariate analysis employing the Pear- (Table 3).
son’s Chi square test and simple logistic regression analysis
was carried out to assess the factors associated with HDPs. 3.6. Factors Influencing Hypertensive Disorders in Pregnancy.
Multiple logistic regression analysis was considered to assess From the findings, mothers who had education at the junior
the association between independent variables that proved high school level were 68% less likely to have HDPs
to be statistically significant under the univariate analysis. compared to mothers who had no education (AOR = 0 27;
The results obtained from the multivariable analysis were CI = 0 10–0.68). Grand multigravida mothers were 4.5 times
expressed as odds ratio with their respective 95% confidence more likely to have HDPs compared to primigravid mothers
intervals (CIs) and p values. Statistically significant was con- (AOR = 4 53; CI = 1 42–14.42). Additionally, mothers with
sidered at a p < 0 05. family history of hypertension were 4.3 times more likely
to have HDPs (AOR = 3 61; CI = 1 89–6.90). Herbal con-
3. Results sumption during pregnancy was associated with an increased
risk of HDPs (AOR = 2 92; CI = 1 15–7.41), and also, mothers
3.1. Sociodemographic Characteristics of Respondents. A total
who consumed alcohol were more likely to have HDPs
of 500 pregnant women participated in this study. A fifth of
(AOR = 4 10; CI = 1 34-12.62) (Table 4).
the participants were aged 18 to 24 years, 174 (34.8%) aged
between 25 and 29 years, and a quarter were aged 30 to 34
3.7. Association between Hypertensive Disorders and
years. Respondents were more likely to be educated (420;
Obstetric Outcomes. Tables 5–7 present the findings on the
84.0%), married (378; 75.5%), Christian (394; 82.8%), man-
association between hypertensive disorders in pregnancy
aging their own private businesses (320; 64.8%), prefer to
and various obstetric outcomes. Mothers with HDPs were
receive antenatal care (ANC) in a health facility located in
2.66 times more likely to have preterm birth compared to
an urban area (270; 54.0%), and have some knowledge on
mothers who were not diagnosed of HDPs (AOR = 2 66;
HDPs (429; 85.80%) (Table 1). CI = 1 29–5.89). The health facility, alcohol consumption
3.2. Medical Characteristics of Respondents. Women attend- status, and family history of HDPs did not influence the risk
ing the health facilities were more likely to be multigravida of preterm delivery (Table 5).
(329; 66.06%), with no history of miscarriage (400; 80.16%) Similarly, mothers who are diagnosed of HDPs have 70%
nor caesarean section (318; 63.60%), and do not have his- increased chance of experiencing caesarean section mode of
tory of chronic condition (420; 85.80%), nor HDPs (337; delivery compared to mothers who were not diagnosed of
67.54%). Most of them, 342 (68.67%), had their first ante- HDPs (AOR = 1 70; CI = 1 10–2.61). Mothers who con-
natal visit in their first trimester (Table 2). sumed alcohol were 2.37 times more likely to experience cae-
sarean section compared to mothers who did not consume
3.3. Prevalence of Hypertensive Disorders in Pregnancy alcohol (AOR = 4 21; CI = 2 37–7.49). Mothers who had
(HDPs). The results indicated that, out of the 500 respon- family history of hypertension were 1.61 times more likely
4 Journal of Pregnancy
Table 1: Sociodemographic characteristics of study respondents.
Without HDPs With HDPs Total
Variable
n (%) n (%) n (%)
Age
18–24 74 (23.57) 25 (13.44) 99 (19.80)
25–29 110 (35.03) 64 (34.41) 174 (34.8)
30–34 76 (24.20) 47 (25.27) 123 (24.6)
35–39 47 (14.97) 31 (16.67) 78 (15.6)
40–44 7 (2.23) 19 (10.22) 26 (5.20)
Educational background
No education 51 (16.24) 29 (15.60) 80 (16.06)
Primary 23 (7.32) 7 (3.76) 30 (6.02)
JHS 81 (25.80) 26 (13.99) 107 (21.49)
SHS 83 (26.43) 46 (24.73) 129 (25.90)
Tertiary 76 (23.57) 78 (41.93) 154 (30.52)
Marital status
Single 75 (23.89) 44 (23.66) 119 (23.90)
Married 236 (75.16) 140 (77.27) 376 (75.50)
Divorced 1 (0.32) 2 (1.08) 3 (0.60)
Religion
Christian 246 (78.34) 163 (87.63) 394 (82.80)
Moslem 39 (12.42) 15 (8.06) 54 (10.93)
Others 24 (7.64) 7 (3.76) 31 (6.28)
Occupation
Gov. employee 61 (19.43) 55 (29.57) 116 (23.08)
Housewife 38 (12.10) 22 (11.83) 60 (12.15)
Private business 209 (66.56) 109 (58.60) 320 (64.77)
Setting of facility receiving ANC
Periurban 205 (65.28) 25 (13.44) 230 (46)
Urban 109 (34.71) 161 (86.56) 270 (54)
Knowledge
Poor 63 (20.06) 6 (3.28) 69 (13.88)
Satisfactory 123 (39.17) 8 (4.37) 131 (26.36)
Good 40 (12.74) 38 (20.77) 78 (15.69)
Excellent 88 (28.03) 131 (71.58) 219 (44.06)
to undergo caesarean section during delivery (AOR = 1 61; pital in Ghana in 2017, the burden of HDPs was found
CI = 1 06–2.46) (Table 6). 21.4% which is about two times the global burden [16]. With
In addition to the birth outcomes of the study, it was a national maternal mortality of 776 in 2020 [17], it was esti-
realized that mothers who were diagnosed of HDPs were mated that up to 388 maternal deaths in Ghana were caused
12.47 times more likely to have stillbirth during delivery by hypertensive disorders.
compared to mothers who were not diagnosed of HDPs The burden of HDPs in this study was 37.2%, and 62.8%
(AOR = 12 47; CI = 2 72–57.24). Other predictors such as of the participants had no HDPs, which is comparable to a
maternal age, anxiety over pregnancy, history of chronic study by Awuah et al. [18], in which the burden of HDPs
medical condition, and consumption of alcohol did not was 39.25% and the proportion of women without HDPs
influence the risk of stillbirth amongst mothers (Table 7). was 60.7%. Although the sample size was less compared to
this study, the prevalence of gestational hypertension and
4. Discussion preeclampsia were high compared to chronic hypertension
in pregnancy. Awuah recorded 52% and 33% for preeclamp-
Hypertensive disorders in pregnancy (HDPs) have been sia and gestational hypertension, respectively, against 6.8%
established to be a leading cause of maternal deaths, and 2.6% in this study. Another study which was conducted
accounting for about 26.4% to 50% of all maternal deaths in a tertiary hospital in the Ashanti Region also recorded a
in the country [15]. In a study conducted in a teaching hos- prevalence of 32.4% and 48.8% for gestational hypertension
Journal of Pregnancy 5
Table 2: Medical characteristics of study respondents.
Without HDPs With HDPs Total
Variable
n (%) n (%) n (%)
Gravida
Primigravida 96 (30.67) 37 (20.00) 133 (26.71)
Multigravida 204 (65.18) 125 (67.57) 329 (66.06)
Grand multigravida 13 (4.15) 23 (12.43) 36 (7.23)
Miscarriage
No 260 (82.80) 140 (75.68) 400 (80.16)
Yes 54 (17.20) 45 (24.32) 99 (19.84)
Had caesarean section
No 219 (69.75) 99 (53.23) 318 (63.60)
Yes 95 (30.25) 87 (46.77) 182 (36.40)
Anxious of pregnancy
No 239 (76.11) 105 (56.76) 344 (68.94)
Yes 75 (23.96) 80 (43.24) 155 (31.06)
Alcohol consumption
No 297 (95.19) 128 (69.19) 425 (85.51)
Yes 15 (4.81) 57 (30.81) 72 (14.49)
History of chronic condition
No 279 (90.29) 144 (78.26) 423 (85.80)
Yes 30 (9.71) 40 (21.74) 70 (14.20)
Family history of HDPs
No 236 (75.40) 101 (54.30) 337 (67.54)
Yes 77 (24.60) 85 (45.70) 162 (32.46)
First antenatal visit
First trimester 194 (61.98) 148 (80.00) 342 (68.67)
Second trimester 106 (33.87) 31 (16.76) 137 (27.51)
Third trimester 13 (4.15) 6 (3.24) 19 (3.82)
Number of ANC visit
1–3 times 112 (36.01) 149 (80.11) 261 (52.52)
4–6 times 95 (30.55) 25 (13.44) 120 (24.14)
Above 7 times 104 (33.44) 12 (6.45) 116 (23.34)
and preeclampsia, respectively [19]. A systematic review of concern because it has been a major cause of maternal and
HDPs in Ethiopia pooled a national prevalence of 6.07 with prenatal morbidity and mortality.
subgroup analysis by region showing a higher prevalence of Knowledge of an individual on a particular health condi-
HDPs [20]. This confirms the high prevalence of HDPs in tion influences the health seeking behaviour of individual
the region, and the needs for better strategies for prevention [22]. Thus, knowledge on HDPs has been assessed as efforts
to improve pregnancy outcomes are required in the mater- at preventing HDP burden. It is evident from this study that
nity care centers. almost half (44%) of the women have excellent knowledge of
The disparity of the disease burden among the various HDPs. This is very encouraging. Having more knowledge
studies could be attributed to a lack of consensus on the would mean that the mother would be informed on the
diagnostic criteria of the various hypertensive disorders. causes, risk factors, signs, symptoms, and possibly treatment
This is because the health facilities in this study all use treat- options for HDPs. Considering the negative effect of these
ment protocols similar to the national standard treatment disorders on both maternal and neonatal outcomes coupled
guidelines [21] for management of HDPs. However, the with the associated economic cost of management, an
blood pressure level to start treatment depends on the facil- increase in knowledge would go a long way to decrease the
ity, prescriber on duty, and other patient-related factors [16]. burden of the disorders, improve treatment compliance,
It would be appropriate to address these discrepancies so and overall reduce maternal and neonatal morbidities and
that accurate prevalence can be recorded and tackled well. mortalities associated with the disorders. It is expected that
Despite the above explanation, Ghana has often recorded as the knowledge of an individual increases, the risk of con-
a high burden of HDPs, and this should be of national health tracting that disease reduces.
6 Journal of Pregnancy
pressure at 16 week gestation resulted in a decrease of the
proportion of mothers who had high blood pressure at the
time of delivery. It is also worth noting that as part of man-
Chronic HPT agement, some proportion of mothers delivered preterm as
10.2% part of efforts to avert adverse birth complications. Thus,
at time of delivery, these mothers would be hypertensive.
Chronic HPT
superimposed with Hence, although there was a drop, the proportion of mothers
pre-eclampsia who were hypertensive at delivery was significantly higher
17.6%
and of public health concern.
The level of education influenced the risk of being hyper-
Normotensive
62.8% Pre-eclampsia tensive in pregnancy such that mothers who had junior high
6.8% school education were 68% less likely to develop HDPs com-
pared to the likelihood of mothers without any formal edu-
cation developing HDPs. This finding is consistent with
Gestational HPT the findings of Abalos et al. [26] where evidence obtained
2.6%
established that education was a risk factor for hypertensive
disorders. This may be that as an individual that is educated,
there is an increased chance of been informed on the risk
Figure 1: Proportion of various types of HDPs amongst study factors and prevention of HDPs. So that, they may take nec-
respondents. essary measures to prevent the risk of developing HDPs.
However, there was no statistical significance association
Oral nifedipine and oral methyldopa, at different doses, between the odds of mothers who had no formal education
were the drugs often prescribed. This finding is similar to developing HDPs compared to the odds of mothers who
the findings of Kumar et al. where it was observed that both had other levels of education developing HDPs. Under the
nifedipine and methyldopa are the most prescribed antihy- bivariate analysis, mothers with tertiary education were
pertensives in pregnancy [23]. Nifedipine is a calcium chan- 1.85 times more likely to develop HDPs compared to
nel blocker which is effective at reducing blood pressure mothers who had no formal education. However, after
without uteroplacental blood flow nor slowing foetal heart adjusting for known confounders, this association dimin-
rate [24]. While methyldopa is preferred because it is a cen- ished with no statistical significance. This indicates that the
trally acting α-agonist that decreases sympathetic outflow to observed association maybe an anomaly, and, as such, it is
decrease BP, it has a very long duration of action and the inconclusive to suggest that education status influences the
best safety profile amongst the antihypertensive drugs used risk of HDPs in this study.
during pregnancy [25]. Currently methyldopa has no associ- It was also realized that high number of pregnancies
ated congenital anomaly. The prescribed medications are greatly influenced the risk of HDPs (Table 4). Though sev-
accepted for the management of hypertensive disorders in eral studies, such as Sengodan and Sreeprathi [27], have
pregnancy because of their low risk of adverse complications established that primigravid mothers were at risk of HDPs,
in pregnancy. All the prescribed drugs are in line with the the findings from this study corroborate the evidence by
stated guidelines. Cho et al. [28] that mothers with multiple gestation have
The mean blood pressure of pregnant women at 16 week an increased risk of hypertensive disorders in pregnancy,
gestation was 119.7/76.9mmHg, which is considered nor- particularly preeclampsia. However, it has been established
mal. However, this average is confounded by several factors that up to about 61.2% of hypertensive disorders do not
such as the gestational stage and the baseline blood pressure resolve after delivery [29]. When these hypertensions do
at the start of the pregnancy. At around the fifth week of ges- not resolve before a woman gets pregnant again, it is consid-
tation, there is an expansion of the blood volume which ered as chronic hypertension in pregnancy and thus
causes a drop in the blood pressure of the mother. At this increases the cumulative burden of hypertensive disorders
critical stage, hypertensive mothers may appear to have a amongst mothers with multigravidity.
normal blood pressure [24]. This may have accounted for Genetics has been explained to influence the risk of
the normotensive mean blood pressure of mothers at that chronic disease in several populations. The evidence of this
gestational age. At the point of delivery, it was realized that study suggests that mothers who have family history of
the mean BP of the mothers was 121.8/77mmHg which HDPs were at 3.6 times increased risk of developing HDPs
saw a significant increase of the mean diastolic pressure of compared to women who have no family history of hyper-
the mothers. Even though, the mean blood pressures of the tensive disorders. This is in sync with the systematic review
mothers were still within the normotensive regions. This by Tesfa et al. [30] which confirmed that family history of
increase in the mean diastolic pressure may be normaliza- hypertension increased the risk of hypertensive disorders
tion of the BP after the initial drop of the blood pressure. in pregnancy by fourfolds. Since family members share some
Again, from the results obtained, it was realized that genetic make-up and some lifestyle or habits [31], there is an
there was a significant decrease in the proportion of mothers increased likelihood that they may share similar risk of a
who had high blood pressure by 10.4% (Table 1). This particular disease burden [32]. This explains why mothers
indicates that management of mothers who had high blood with family history of hypertensive disorders are at an
Journal of Pregnancy 7
50
45 43.3% 43.1%
40
35
30
25
20
15
10 7.6%
4.7%
5 1.3%
0
Oral nifedipine Hydralazine Tab methyldopa IV mag. sulphate Tab prazosin
Figure 2: Medicines used to manage HDPs in the selected health facilities.
Table 3: Effect of antihypertensive therapy on BP control among women with HDPs.
Variable At 16 weeks At delivery Difference (95% CI)
Mean systolic BP 137 60mmHg ± 2 11 137 24mmHg ± 1 89 0.36mmHg (-5.19–5.91)
Mean diastolic BP 93 24mmHg ± 1 81 89 02mmHg ± 1 46 4.22mmhg (0.39–8.05)
Prop. with high BP 37 2% ± 0 022 26 8% ± 0 020 10.4% (4.7%-16.14%)
increased risk of HDPs. It is therefore recommended that in increases the risk of hypertension in normotensive individ-
diagnosing a mother of HDPs, the risk profile should con- uals [36]. From this study, alcohol consumers were 3.5 times
sider the history of hypertension in the family. This would more likely to experience HDPs compared to nonalcohol
help in early diagnosing and management of hypertensive consumers. Alcohol has a biphasic effect on blood pressure.
disorders. In less than 12 hours after consumption, alcohol reduces
The use of complementary and alternative medicine blood pressure, and subsequently, after 12 hours, alcohol
(CAM) is predominant in Ghana, and it is recognized by tends to increase blood pressure. It is believed to influence
the health system [33]. Nonetheless, the role of CAM in the blood pressure through the renin-angiotensin-aldosterone
management of HDPs is scarce [34]. Evidence from this system by increasing the concentration and activity of renin
study found that mothers who used herbal medicines were in blood [37]. An increase in renin is associated with an
2.9 times more likely to have HDPs. Some studies have increase in a potent vasoconstrictor called angiotensin II,
reported the beneficial use of CAM in pregnancy and how responsible for the rise in blood pressure. Additionally, alcohol
it has improved on blood pressure levels and also on various is believed to reduce the baroreceptor sensitivity thus affecting
obstetric outcomes [35]. blood pressure regulation at the long term [37]. It is advised
This study’s finding does not imply that the use of herbal that mothers must be counseled during ANC visits to strictly
medicines negatively increases blood pressure. This is avoid alcohol intake during pregnancy.
because the study is methodologically limited to the use of The aetiology of these HDPs, however, is not known
herbal medicines. It did not assess the type of herbal medi- [38]. It is therefore recommended that to effectively reduce
cine used, how the herbal medicines were used, and whether the incidence of HDPs, pregnant women should be coun-
it was prescribed or was appropriate for use. However, this seled on the risk factors of these conditions and screened
finding reveals a very critical issue of the appropriate use for during their antenatal care visits to prevent the adverse
of herbal medicines in pregnancy. Herbal medicines are effects of its complications.
made up of several constituents, and the safety of their use Some studies have established that HDPs influence the
should be ascertained. Currently, there is paucity of infor- birth outcomes at delivery. From this study, mothers who
mation on the use of herbal medicine in the management had HDPs were 2.66 times more likely to have preterm babies.
of hypertensive disorders, particularly in pregnancy. More This finding is consistent with a study by Xiong et al. [39],
research evidence would be needed to understand why preg- where it was realized that HDPs increased the risk of stillbirth
nant women in selected health facilities use these medicines, by twelvefolds. Hypertension is known as the leading cause of
its constituents, and appropriateness for use in hypertensive stillbirth by affecting the development of the placenta by
disorders. restricting nutrient and oxygen flow to the foetus. Also, it
Alcohol consumption is known to influence hyperten- increases the risk of abnormal bleeding between the placenta
sive disorders in adults. Several studies have propounded and uterine walls leading to placenta abruption [40]. All these
that alcohol consumption, particularly heavy consumption, causes foetal distress and subsequently death. Thus, it is
(%)
8 Journal of Pregnancy
Table 4: Factors influencing risk of hypertensive disorders of pregnancy.
Variable Category Frequency (%) COR 95% CI AOR 95% CI
18–24 99 (19.8) Ref Ref
25–29 147 (34.8) 1.72 1.00–2.98 1.82 0.82–4.06
Age 30–34 123 (24.6) 1.83 1.02–3.27 1.38 0.57–3.32
35–39 78 (15.8) 1.95 1.03–3.71 1.21 0.45–3.23
40-44 26 (5.2) 8.03 3.02–21.36 1.71 0.43–6.92
Periurban 230 (46.0) Ref Ref
Residence
Urban 270 (54.0) 7.53 2.27–24.91 1.95 0.46–8.34
No education 80 (16.0) Ref Ref
Primary school 30 (6.0) 0.54 0.20–1.40 0.74 0.19–2.95
Educational status Junior high school 107 (21.4) 0.56 0.30–1.06 0.27 0.10–0.68
Senior high school 129 (25.8) 0.97 0.55–1.74 0.44 0.19–1.02
Tertiary 154 (30.8) 1.85 1.06–3.23 0.53 0.20–1.43
Gov. employee 116 (23.2) Ref Ref
Occupation Housewife 66 (12.0) 0.64 0.34–1.22 1.83 0.60–5.61
Private Business 318 (63.6) 0.58 0.38–0.89 2.14 0.89–5.12
Had caesarean section Yes 182 (36.4) 2.03 1.39–2.95 1.44 0.72–2.88
Anxious of pregnancy Yes 155 (31.0) 2.13 1.64–3.59 1.24 0.61–2.55
History chronic condition Yes 70 (14.0) 2.58 1.54–4.32 2.66 1.21–5.82
Primigravida 133 (26.6) Ref Ref
Gravida Multigravida 329 (65.8) 1.59 1.02–2.47 1.34 0.70–2.53
Grand multigravida 38 (7.6) 4.59 2.11–10.00 4.53 1.42–14.42
History of HDPs Yes 160 (32.0) 2.58 1.54–4.32 3.61 1.89–6.90 ∗
First trimester 342 (68.4) Ref Ref
First antenatal visit Second trimester 137 (27.4) 0.38 0.24–0.60 0.60 0.21–1.72
Third trimester 21 (4.2) 0.60 0.22–1.63 2.44 0.32–18.90
1–3 times 261 (52.2) Ref Ref
Number of antenatal care visit 4–6 times 120 (24.0) 0.20 0.12–0.33 0.81 0.35–1.89
Above 7 times 119 (23.8) 0.09 0.05–0.17 0.26 0.10–0.67
Less than ȼ400 79 (15.8) Ref Ref
ȼ400–ȼ799 194 (38.8) 0.73 0.39–1.39 0.67 0.27–1.67
Average monthly salary
ȼ800–ȼ1200 128 (25.6) 3.03 1.62–5.70 1.52 0.57–4.04
More than ȼ1200 99 (19.8) 8.45 4.26–16.76 4.51 1.48–13.76
Herbal medication consumption Yes 257 (51.4) 9.17 5.86–14.35 2.92 1.15–7.41 ∗
Alcohol consumption Yes 72 (14.4) 8.82 4.81–16.15 3.53 1.42–8.78 ∗
Health professionals 443 (88.6) Ref Ref
Family & friends 15 (15.0) 0.54 0.14–2.01 0.79 0.15–4.12
Source of information
Media 25 (5.0) 2.06 0.75–5.65 2.92 0.72–11.89
Others 17 (3.4) 0.11 0.01–0.82 0.33 0.03–3.20
Monitoring of blood No 20 (16.0) Ref Ref
Yes 436 (87.2) 5.75 1.32–25.10 2.19 0.24–19.81
Pressure during ANC
Not sure 44 (8.8) 3.30 0.66–16.61 10.38 0.92–117.11
Adjusted for all other variables shown. ∗Statistically significant. COR = crude odds ratio. CI = confidence interval. AOR = adjusted odds ratio. The entries in
boldface are significant and must bear the symbol “∗” as shown in the table.
Journal of Pregnancy 9
Table 5: Predictors of risk of preterm delivery.
Variable Category COR 95% CI AOR 95% CI
Periurban Ref Ref
Setting of ANC facility
Urban 1.90 1.06–3.39 1.09 0.52–2.26
Not hypertensive Ref Ref
Hypertensive status
Hypertensive 3.15 1.79–5.55 2.66 1.29–5.89 ∗
Not consumer Ref Ref
Alcohol consumption
Consumer 2.13 1.10–4.13 1.27 0.61–2.62
No history Ref Ref
Family history of HDPs
History 2.02 1.16–3.52 1.63 0.91–2.92
Adjusted for all other variables shown. ∗Statistically significant. COR = crude odds ratio. CI = confidence interval. AOR = adjusted odds ratio.
Table 6: Predictors of caesarean section.
Variable Category COR 95% CI AOR 95% CI
Not hypertensive ref ref
Hypertensive status
Hypertensive 2.59 1.76–3.81 1.70 1.10–2.61 ∗
Not consumer ref ref
Alcohol consumption
Consumer 5.49 3.19–9.45 4.21 2.37–7.49 ∗
No history ref ref
Family history of HDPs
History 1.89 1.28–2.80 1.61 1.06–2.46 ∗
Adjusted for all other variables shown. ∗Statistically significant. COR = crude odds ratio. CI = confidence interval. AOR = adjusted odds ratio.
Table 7: Predictors of stillbirth.
Variable Category COR 95% CI AOR 95% CI
18–24 Ref Ref
25–29 1.15 0.28–4.70 0.82 0.19–3.58
Age 30–34 1.64 0.40–6.73 0.94 0.20–4.34
35–39 1.73 0.38–7.97 1.04 0.21–5.16
40–44 7.62 1.69–34.39 2.37 0.46–12.19
No Ref Ref
History of C/S
Yes 3.10 1.33–7.24 1.25 0.34–4.55
No Ref Ref
Anxious of pregnancy
Yes 3.31 1.43–7.62 1.04 0.26–4.17
No Ref Ref
History of chronic condition
Yes 2.87 1.14–7.26 1.72 0.62–4.77
Not hypertensive Ref Ref
Hypertensive status
Hypertensive 20.86 4.85–89.81 12.47 2.72–57.24 ∗
Not consumer Ref Ref
Alcohol consumption
Consumer 5.70 2.44–13.30 2.02 0.58–7.12
Adjusted for all other variables shown. ∗Statistically significant. COR = crude odds ratio. CI = confidence interval. AOR = adjusted odds ratio.
critical to deliver the baby before term to avert foetal distress associated with an increased risk of caesarean section
and possibly foetal wastage. amongst mothers during delivery. Considering this evidence,
Another evidence from this study reveals that hyperten- it is recommended that health professionals in charge of
sive mothers were 1.70 times more likely to undergo caesar- antenatal care critically monitor hypertensive mothers dur-
ean section. This finding is consistent with the findings of ing care and to pragmatically help to control their blood
Roberts et al. [41], where it was realized that HDPs were pressure to normotensive status before delivery.
10 Journal of Pregnancy
5. Conclusion and Recommendations Consent
The overall prevalence of HDPs was 37.2% with chronic Informed consents were sought from all pregnant women
hypertension superimposed with preeclampsia having the before enrolment in the study. Participants were assured of
highest prevalence of 17.6%. Lack of formal education, fam- their right to be informed about the findings of the study.
ily history, multigravida, consumption of alcohol, and herbal
preparation were identified as factors that could influence Conflicts of Interest
the risk of HDPs. The use oral nifedipine and methyldopa
considerably reduced the proportion of mothers with high The authors of this study have no competing interests.
blood pressure. The selected mothers with HDPs were likely
to undergo caesarean sections, experience stillbirth, or have
preterm babies. The burden of HDPs is high amongst preg- Authors’ Contributions
nant women seeking care in selected facilities. There is the Conception, design, acquisition, and analysis of data were
need for intensified campaign on HDPs in the Ashanti conducted by PBA, BPA, AFAM, ETD, CCC, and MA.
Region of Ghana. PBA, BPA, AFAM, and ETD drafted and revised the manu-
Considering the increasing risk of HDPs in the Ashanti script. Revising and approval of final manuscript to be
region, its increased adverse association to obstetric out- published were conducted by PBA, BPA, and AFAM.
comes such as stillbirth, preterm, and caesarean section,
there is the need to investigate the cost impact of HDPs on
the mother and the household. Additionally, the quality of Acknowledgments
life of mothers diagnosed with HDPs and the impact of
HDPs on the risk of prenatal and postnatal depression The authors acknowledged the GNPC Foundation, research
should be assessed further. team, and all participants of the study. Authors received
local scholarship from the GNPC Foundation, Ghana
(GNPC/FDN/C4/KNUST/18).
6. Strength and Limitations
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