Atluri et al. BMC Pregnancy and Childbirth (2023) 23:42 BMC Pregnancy and Childbirth https://doi.org/10.1186/s12884-023-05363-5 RESEARCH Open Access Benefits and barriers of home blood pressure monitoring in pregnancy: perspectives of obstetric doctors from a Ghanaian tertiary hospital Namratha Atluri1, Titus K. Beyuo2*, Samuel A. Oppong2, Sarah D. Compton3, Cheryl A. Moyer3 and Emma R. Lawrence3 Abstract Background Delayed diagnosis of preeclampsia contributes to maternal morbidity and mortality. Patient-performed home blood pressure monitoring facilitates more frequent monitoring and earlier diagnosis. However, challenges may exist to implementation in low- and middle income-countries. Methods This cross-sectional mixed methods study evaluated obstetric doctors’ perspectives on the benefits of and barriers to the implementation of home blood pressure monitoring among pregnant women in Ghana. Participants were doctors providing obstetric care at Korle Bu Teaching Hospital. Electronic surveys were completed by 75 par- ticipants (response rate 49.3%), consisting of demographics and questions on attitudes and perceived benefits and challenges of home BP monitoring. Semi-structured interviews were completed by 22 participants to expand on their perspectives. Results Quantitative and qualitative results converged to highlight that the current state of blood pressure monitor- ing among pregnant women in Ghana is inadequate. The majority agreed that delayed diagnosis of preeclampsia leads to poor health outcomes in their patients (90.6%, n = 68) and earlier detection would improve outcomes (98.7%, n = 74). Key qualitative benefits to the adoption of home blood pressure monitoring were patient empowerment and trust of diagnosis, more quantity and quality of blood pressure data, and improvement in systems-level efficiency. The most significant barriers were the cost of monitors, lack of a communication system to convey abnormal values, and low health literacy. Overall, doctors felt that most barriers could be overcome with patient education and counseling, and that benefits far outweighed barriers. The majority of doctors (81.3%, n = 61), would use home BP data to inform their clinical decisions and 89% (n = 67) would take immediate action based on elevated home BP values. 91% (n = 68) would recommend home BP monitoring to their pregnant patients. Conclusion Obstetric doctors in Ghana strongly support the implementation of home blood pressure monitoring, would use values to inform their clinical management, and believe it would improve patient outcomes. Addressing the most significant barriers, including cost of blood pressure monitors, lack of a communication system to convey abnormal values, and need for patient education, is essential for successful implementation. *Correspondence: Titus K. Beyuo drbeyuo@gmail.com Full list of author information is available at the end of the article © The Author(s) 2023. 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The Creative Commons Public Domain Dedication waiver (http://c reat iveco mmons. org/ publi cdoma in/z ero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Atluri et al. BMC Pregnancy and Childbirth (2023) 23:42 Page 2 of 11 Keywords Preeclampsia, Eclampsia, LMIC, Sub-Saharan Africa, Home monitoring, Patient monitoring, Provider perspective, High blood pressure in pregnancy, Hypertensive disorders of pregnancy Introduction Materials and methods Hypertensive disorders of pregnancy (HDP) are seri- Setting ous complications of pregnancy that contribute to poor This mixed methods study was conducted at the Korle Bu maternal and neonatal outcomes [1, 2]. HDP exist along Teaching Hospital (KBTH), Ghana’s largest tertiary care a spectrum spanning from gestational hypertension hospital. The Department of Obstetrics and Gynaecology (blood pressures > 140/90 diagnosed after 20 weeks (OBGYN) at KBTH runs a six-floor maternity unit with gestation), preeclampsia without severe features (ges- 275 inpatient beds, and manages approximately 10,000 tational hypertension plus proteinuria), preeclamp- deliveries annually. 15% of deliveries are complicated by sia with severe features (preeclampsia plus symptoms, HDP, which is the leading cause of maternal mortality at blood pressures > 160/ 100, or laboratory derange- KBTH [22]. ments), and eclampsia (preeclampsia with severe fea- tures plus seizures). Most HDP-related deaths can be prevented by early detection and timely medical inter- Participants ventions [2–4]. However, many barriers to adequate Participants were doctors who provide obstetric care, obstetric care exist in low-middle-income countries including antenatal care, intrapartum care, and postpar- (LMICs), and strikingly, 99% of maternal deaths from tum care, at KBTH. Inclusion criteria were doctors who HDP occur in LMICs [5–8]. Poor antenatal clinic provide care to obstetric patients, whose primary site of attendance, long intervals between routine visits, and clinical work is KBTH, and who have experience diag- the low rates of preeclampsia diagnosed prior to the nosing and managing patients with HDP. There were no onset of eclamptic seizures suggest a need for improved exclusion criteria. At KBTH, obstetric care is provided by models of blood pressure (BP) monitoring in such low- three groups of doctors: (1) house officers (doctors who resource settings [2, 4, 9–12]. recently graduated from medical school and are rotat- Home BP monitoring, which involves patients meas- ing through core clinical services including OBGYN), uring their own BPs outside of a clinical setting, has (2) OBGYN residents (doctors who have completed their been successfully implemented in many high-income house officers training and are now undergoing specialty countries (HICs) with demonstrated patient accuracy training in OBGYN), and (3) OBGYN consultants (doc- and adherence [13–15]. Existing evidence suggests tors who have completed specialty training in OBGYN) that benefits to home BP monitoring include reduced known in other settings as “attendings”. healthcare resource use and high patient and clinician satisfaction [14–17]. Studies in non-pregnant patients with chronic hypertension demonstrate improvement Recruitment in blood pressure control with home blood pressure Survey participants were identified using KBTH’s monitoring [18, 19]. While home BP monitoring in OBGYN departmental roster which lists all doctors cur- pregnancy has not yet been proven to improve clinical rently providing obstetric care at KBTH. The survey outcomes [20, 21], it still may be of particular benefit in was administered electronically by posting the survey LMIC settings that have a high prevalence of HDP and link to three WhatsApp groups at KBTH: (1) group for barriers to providing regular, in-person care. However, house officers rotating on OBGYN (2) group for OBGYN challenges to implementation may exist. residents (3) group for OBGYN attendings. At KBTH, This study aims to understand the feasibility of home WhatsApp groups are used for workplace communica- BP monitoring among pregnant patients in urban tion, coordination of departmental events, and research. Ghana, as perceived by obstetric doctors. Since doctors In total, there were 152 members in these groups, which can identify challenges from multiple levels (patient, was consistent with the department rosters. Seventy-five clinical, and system-level) and because doctor buy-in is surveys were completed with a response rate of 49.3% essential to the successful implementation of any clini- (Table 1). cal intervention, this study intended to evaluate doctor Interview participants were identified using KBTH’s perspectives on benefits and barriers to home BP moni- OBGYN departmental roster and the guidance of a toring among pregnant women in Ghana. local research team member. Purposive sampling was employed to identify obstetric providers with meaning- ful experience managing patients with HDP and ensure A tluri et al. BMC Pregnancy and Childbirth (2023) 23:42 Page 3 of 11 Table 1 Demographics of survey and interview participants Characteristic Survey participants (n = 75) Frequency Interview participants (proportion) (n = 22) Frequency (proportion) Clinical role House Officer 23 (30.7%) 4 (18.2%) Junior Resident in 17 (22.7%) 6 (27.3%) Obstetrics/Gynaecology 25 (33.3%) 8 (36.4%) Senior Resident in 10 (13.3%) 4 (18.2%) Obstetrics/Gynaecology Consultant (“attending”) in Obstetrics/Gynaecology Gender Male 54 (73.0%) 18 (81.8%) Female 20 (27.0%) 4 (18.2%) Other/ Prefer Not To Respond 0 (0%) 0 (0%) Years in practice as a doctor < 1 21 (28.0%) 4 (18.2%) 1—5 5 (6.7%) 2 (9.1%) 6—10 19 (25.3%) 8 (36.4%) 11—20 25 (33.3%) 7 (31.8%) > 20 5 (6.7%) 1 (4.5%) Average patients with preeclampsia managed weekly 0—5 20 (27.0%) 5 (22.7.0%) 6—10 40 (54.1%) 8 (36.4%) 11—15 8 (10.8%) 4 (18.2%) 16—20 3 (4.1%) 5 (22.7%) > 20 3 (4.1%) 0 (0.0%) Average patients with eclampsia managed monthly 0 7 (9.3%) 3 (13.6%) 1 28 (37.3%) 7 (31.8%) 2 12 (16.0%) 7 (31.8%) 3 11 (14.7%) 5 (22.7%) 4 4 (5.3%) 0 (0.0%) 5 or higher 13 (17.3%) 0 (0.0%) diversity of clinical roles. For each interview, transcrip- anchored in grounded theory, a qualitative approach for tion and review was conducted in an ongoing manner, collecting and analyzing data without imposing previ- and the final number of participants was determined by ously constructed theoretical frameworks. This approach thematic saturation of data. A total of 22 participants (4 was used to capture participants’ perspectives without house officers, 6 junior residents, 8 senior residents, and assuming they would conform to the researchers’ ideas 4 consultants) were interviewed (Table 1). about home blood pressure monitoring. Qualitative trustworthiness was established based on the credibility Design of the participants as obstetric providers. Our mixed methods study consisted of surveys and semi- structured interviews. Given the absence of validated Procedures scales to evaluate barriers and benefits of home BP moni- An electronic survey was developed in RedCAP, an toring, our survey questions were newly developed for online program for secure survey development and data this research. Survey questions were based on the local management. The survey link was electronically distrib- expertise of our authors as practicing OBGYNs, and were uted to WhatsApp groups as detailed earlier and survey piloted for clarity and content prior to finalization and responses were entered by participants electronically. administration. Our semi-structured interview guide was Survey questions were in English, the language used for Atluri et al. BMC Pregnancy and Childbirth (2023) 23:42 Page 4 of 11 medical education in Ghana. Surveys were organized employed an incremental and iterative process to review into 4 sections and consisted of closed-ended questions the transcripts together and collectively develop a code- with categorical response options (Supplemental file 1). book consisting of stabilized keyword-phrases. The tran- The first section asked demographic questions about the scripts were then coded using the codebook. Finally, the participant, their clinical role, and their clinical expe- coded transcripts were thematically analyzed using the rience with preeclampsia and eclampsia. The second Attride-Sterling Framework for qualitative analysis, con- section focused on attitudes about the impact and man- sisting of a framework of basic, organizing, and global agement of preeclampsia, consisting of 5 statements with themes [24]. Likert scale responses (strongly agree to strongly disa- gree). The third section asked about the implementation Results of home BP monitoring, including anticipated patient Quantitative and qualitative results converged to high- ability and accuracy, provider attitudes toward trust and light that the current state of BP monitoring among preg- use of home BP values and perspectives on feasibility and nant women in Ghana is inadequate. Doctors perceived overall recommendation of use. This section included 14 several patient-level, clinical-level, and systems-level statements with Likert scale responses (strongly agree to benefits to the adoption of home BP monitoring but also strongly disagree). The final section focused on antici- emphasized key challenges to implementation that must pated barriers to home BP monitoring and asked partici- be recognized and addressed. Overall, doctors felt that pants to indicate the relative importance of six barriers most barriers could be overcome with patient education on a scale from 1 (minimum barrier) to 5 (maximal bar- and counseling and that benefits far outweighed barriers rier). This list of barriers was determined by the authors (Fig. 1). based on their pre-study hypotheses and informed by local experience in Ghana. Current state of BP monitoring among pregnant women A semi-structured interview tool asked about pro- in Ghana is inadequate viders’ experiences, attitudes, and perceived benefits In surveys, the vast majority of doctors agreed that and challenges to implementing home blood pressure maternal morbidity and mortality from preeclampsia is monitoring among their pregnant patients in Ghana preventable (98.7%, n = 74), delayed diagnosis of preec- (Supplemental file 2). Interviews were conducted by an lampsia leads to poor health outcomes amongst their American female medical student who received train- patients (90.6%, n = 68), and early detection of preec- ing on qualitative interviewing techniques and cultural lampsia would reduce poor health outcomes (98.7%, humility. Interviews were conducted in English, face-to- n = 74). In interviews, many doctors identified issues face, from January 27th to February 17th, 2022 in various with the current quality and frequency of BP monitoring quiet spaces within the KBTH compound. They lasted performed among pregnant women that inevitably leads approximately 20–40  min. Ethical approval was granted to delayed detection and poor outcomes. In-hospital from KBTH (KBTH-STC 00098/2021) and University of BP measurements are of poor quality due to a variety of Michigan (HUM00200589). Written informed consent reasons, including the use of ill-calibrated/ unvalidated was obtained from all participants. No incentive was machines, inappropriate cuff size (usually only one stand- offered for participation. ard cuff size is available for all patients), and improper technique. Inadequate frequency of BP monitoring is also Analysis a problem, with long intervals between scheduled ante- A convergent mixed-methods design was used for analy- natal clinic visits, especially when compounded by poor sis; quantitative and qualitative data were first analyzed antenatal clinic attendance by patients at baseline. separately and then merged for comparison [23]. Stata (Version 16.0 StataCorp. 2019) was used for analysis of “So it means that when you come [for antenatal survey data. Demographic data was summarized using care], the next time you’re coming is a month later. frequencies and proportions. Descriptive analysis was So, within that time, what are you doing? Who is conducted for survey responses, consisting of frequen- monitoring your BP and all that? So if anything hap- cies and proportions for Likert scale responses and mean pens within that period, you don’t know. Or no one and standard deviation for the barriers scale responses. will know.” ID 13, Male Junior Resident Interviews were audio-recorded and transcribed verba- Survey data suggested that while 63% (n = 46) of par- tim in English. Transcripts were uploaded into NVivo ticipants were aware that high-risk pregnant patients in 12.0 for qualitative coding. Transcripts were indepen- many countries monitor their BPs at home, only 21.7% dently reviewed by two researchers who each developed (n = 16) have experienced their own patients in Ghana a preliminary set of codes. Then, the two researchers engaging in home BP monitoring. Most pregnant women A tluri et al. BMC Pregnancy and Childbirth (2023) 23:42 Page 5 of 11 Fig. 1 Benefits of Home Blood Pressure Monitoring Outweigh the Barriers in Ghana do not have BP monitors at home and are a blood pressure monitor. Then they can do it them- not aware they could have elevated BPs if they have no selves.” ID 1, Male Senior Resident symptoms. “Most people don’t have BP machines at home. And Doctors perceived significant benefits to home BP they just live life on a day-to-day basis. Unless you monitoring have symptoms, you don’t really go to the hospital. Doctors anticipated many benefits to wider-scale imple- You don’t see the need to check your blood pressure.” mentation of home BP monitoring (Table 2), with clinical ID 16, Female House Officer benefits perceived as the most important. Despite the low utilization of home BP monitoring, In interviews, doctors unanimously described how the several doctors have still had positive experiences with ability to gain a greater quantity and quality of BP data the small number of patients who do monitor their BPs would likely lead to improved health outcomes. Doc- outside of the hospital, either by using their own moni- tors noted that the greater quantity of readings obtained tor at home or by visiting a nearby pharmacy daily. They with home BP monitoring, as opposed to a singular value noted many advantages, including cost and convenience, obtained at in-person ANC visits, would enable them to patients using their own monitor at home versus visit- to see trends throughout pregnancy and adjust medica- ing a pharmacy. tions as necessary. Since patients are comfortable in their home environment without the stresses of a busy hos- “So they may have to walk to a pharmacy shop and pital, home BP monitoring was also thought to be less get their blood pressures checked. But then, if they affected by “white coat hypertension” (the idea that being have to do this several times a day, it becomes a bit around providers can make patients anxious and thus of an inconvenience. And of course, it has finan- elevate their BP) and more representative of a patient’s cial implications because they have to pay for their true clinical status. The notion of improved health out- blood pressures to be monitored. So it’s easier if they comes centered on the widely held belief that home BP have the education and they have the means to get monitoring would allow for earlier detection of newly Atluri et al. BMC Pregnancy and Childbirth (2023) 23:42 Page 6 of 11 Table 2 Anticipated benefits of home BP monitoring Benefit categories Benefits Representative quotation Patient Benefits Empowerment “So she owns her health. She understands, she asks questions. It’s more of a joint care, multidisciplinary approach. We have the patient as one of the clini- cians.” ID 17, Female Senior Resident Trust of diagnosis “When [patients] start home BP monitoring early, they realize that it’s not the doctor saying it…you know this is something I didn’t have and I can see myself that [BP] is going up…As against me springing a diagnosis on you.” ID 4, Female Consultant Clinical Benefits More quantity and quality of data “I think [home monitoring] would create a better overall picture of the patient’s response rather than that snapshot that you get when they come to you once every 4 weeks.” ID 22, Male Consultant Earlier detection and improved management “If the high risk people are monitoring at home,…we are going to pick most of the diagnoses early, it will help us put in interventions early, and we are definitely going to achieve better outcomes.” ID 12, Male Junior Resident Systemic Benefits Reduced healthcare expenditure "So [home monitoring] will probably help reduce the costs for the facility and for the patient. It will help us catch late cases earlier. It will reduce the time and then probably the manpower you put into managing those adverse cases.” ID 13, Male Junior Resident Public health promotion “Other members of the family are going to go ahead and check their blood pressures. And they could have essential hypertension that could be picked up and they could seek care. So giving it to one person will save the whole family.” ID 10, Male House Officer elevated BPs. While the overall detection of preeclampsia battery life. However, doctors felt that the cost of pro- may increase, potentially leading to more patients at the viding home BP monitors to patients is well justified, hospital to care for, doctors viewed this positively. They and it would be less expensive to provide a BP monitor expected home BP monitoring to lead to a reduction in for home use than admit a patient to the hospital sim- the progression to eclampsia and incidence of compli- ply for blood pressure monitoring. cations, enabling them to provide better care to fewer acutely ill patients. “It’s the whole cost and benefit analysis. If you can Other benefits often described by doctors included provide pregnant women with a device that could patient-level benefits of empowerment, increased prevent her from coming to the hospital and be involvement in their own healthcare, and improved admitted, and then the cost of reporting to the hos- acceptance of their diagnosis when new elevated BPs are pital, the admission, daily bed charges...in the long detected. System-level benefits included reduced health- run you realize it’s actually cheaper to actually care resource expenditure due to earlier diagnosis and provide a device.” ID 17, Female Senior Resident prevention of complications and collateral public health The second main systems-level barrier doctors high- benefits to family members who may also start checking lighted was the lack of an efficient system for patient- their BPs (Table 2). provider communication (Table  3; Fig.  2). Currently, a central triage phone system does not exist for patients Doctors acknowledged key barriers to home BP to communicate abnormal home BP values or other monitoring concerns. Instead, they either call their doctor’s per- The most important systems-level barrier, and the single sonal phone number or come into the hospital for most significant barrier overall, was the ability of patients assessment. Doctors identify the limitations in this to afford and access home BP monitors (Table 3; Fig. 2). current approach, which depends on the 24 − 7 avail- Doctors felt most patients would be unable to pur- ability of individual physicians, or long transport times chase a monitor unless it were well-subsidized or to a healthcare facility. Doctors viewed not having a free. Additionally, doctors worried about the qual- protocol with clear next steps for patients when they ity of monitors that patients may buy with regards to detect home BP elevations as a potential challenge to calibration, validation, and appropriate cuff sizes. They the utility of home BP monitoring. However, doctors also expressed concerns about future maintenance and also believed that with proper planning and training of A tluri et al. BMC Pregnancy and Childbirth (2023) 23:42 Page 7 of 11 Table 3 Potential barriers to home BP monitoring Barrier categories Barriers Representative qualitative quotation Patient Barriers Health literacy “I think the number one barrier is when they’ve not been properly educated. If they don’t understand. Once they have the understand- ing, I believe they will use it. So the next thing will be working on their understanding. So lots of counseling.” ID 21, Male Consultant Agency to make and act upon healthcare decisions “Here is a case that a lady comes, she’s told about everything. But the husband doesn’t come. The husband doesn’t see the need to come and listen to what we say. Meanwhile, he is the provider. Yes, so if you say, okay, let’s get a [BP monitor],….[he] tells you that I don’t have the money to buy the [BP monitor] or I won’t do it. He’s taking the major decision here.” ID 9, Male Senior Resident Willingness to perform regular BP monitoring “Every woman wants to have a safe delivery and to have their babies. So, if they understand the complications of the disease, they will be motivated.” ID 11, Male Senior Resident Ability to use BP monitor “If they have been taught well…I think our patients are smart enough to do it and it should be accurate.” ID 6, Male Senior Resident Clinical Barriers Provider comfort with home management “If something goes wrong, we will be held responsible. Because you allowed her to go home and now she has had a stroke. So I think from healthcare workers, that may be the resistance to allowing more women to monitor their blood pressures at home. If some- thing goes wrong, who is going to be held responsible?” ID 4, Female Consultant Provider trust in home BP values “Most patients who understand what is wrong with them, will not lie…I think that is the bottomline. By and large I think most people will not give false readings.” ID 14, Male Junior Resident Systemic Barriers Cost of BP monitors “When it comes to our care, cost is literally a big barrier. You know most patients cannot afford [a BP monitor].” ID 19, Male Senior Resident Quality of BP monitors “You have to check to see the cuff size, whether it tallies. Whether the machine is working well or not. Use it on another person to be really sure that hey this machine is good. It’s not just that the values are high, the machine is actually appropriate for the person.” ID 5, Male Junior Resident Provider-patient communication of abnormal BP values “I think [there should be] systems in place so that when BPs are elevated…that the [patient] can call and complain to somebody that this is the BP I checked and these are the symptoms I am feel- ing and all of that. And if they need for the person to [come to the hospital], then the person reports.” ID 8, Male Junior Resident staff, such a protocol and communication system can n = 45), and could accurately monitor BPs at home be developed. (48%, n = 36). Doctors expanded that patients who may While systemic barriers were viewed as most impor- not truly appreciate the risks of preeclampsia may not tant, doctors did report several patient-level barriers adhere to home BP monitoring as recommended (not (Table  3; Fig.  2). Interviewed doctors reported con- regularly measure blood pressures or report dishon- cerns about patients’ sufficient health literacy to recog- est values). Importantly, all doctors during interviews nize elevated BP values and agency to take action when who mentioned these potential patient-level challenges elevated values are detected. Consistent with inter- also stated that they can be overcome with proper views, surveys showed that only half of participants counseling, focused education by ancillary health staff felt patients know about the risks and complications during antenatal visits, and additional public health of preeclampsia (44%, n = 33), could follow the recom- initiatives. Notably, interviewed doctors did not view mended schedule for monitoring BPs at home (61%, patient willingness to use BP monitors to be significant barriers for the majority of their patients, with surveys Atluri et al. BMC Pregnancy and Childbirth (2023) 23:42 Page 8 of 11 Fig. 2 Magnitude of Barriers to Implementation of Home Blood Pressure Monitoring showing 77% (n = 58) of participants believing patients into place, they perceived it would be feasible and is the would be interested in monitoring BPs at home. way forward for improving the diagnosis and manage- Clinical barriers were overall less important and ment of preeclampsia in Ghana. included provider discomfort managing patients at home “So I think this should be the way to go…Helping due to concern for poor outcomes occurring at home and [patients] get a monitor, teaching them how to check subsequent blame from colleagues, as well as potential it properly, and then telling them or educating them distrust of patient-measured home blood pressure values on what to do when they get abnormal figures. This (Table  3). Similar to patient-level barriers, doctors felt will help.” ID 12, Male Junior Resident that these could be overcome with patient education and counseling. Surveys demonstrated that 81.3% (n = 61) of partici- pants would use home BP data to inform their clinical Doctors believed home BP monitoring would be feasible decisions and 89% (n = 67) would take immediate action and impactful based on elevated home BP values. In interviews, doctors After considering the benefits and barriers, most doc- explained they would use home BP values to adjust doses tors in interviews and surveys (90.7%, n = 68) stated they of antihypertensive medications, to differentiate between would recommend home BP monitoring to their preg- true hypertension and white coat hypertension, and nant patients (Fig.  3). With appropriate measures put most importantly, to recommend immediate in-person Fig. 3 Physician Views on Utility of Home Blood Pressure Monitoring A tluri et al. BMC Pregnancy and Childbirth (2023) 23:42 Page 9 of 11 assessment if a patient measured new or worsening BP Clinical and policy implications elevations at home. By describing the current challenges to routine BP monitoring in Ghana, this study emphasizes the need “If the BP is high, it is high. So if they come [in] or for home BP monitoring in low-resource settings. they call that they are checking their BPs and it is Home BP monitoring can augment current clinical high, then you have to act on it… It will affect the practice by identifying women with new or worsen- clinical management” ID 13, Male Junior Resident ing elevations of BP at home. Recognizing that false positive BP revelations are possible at home, elevated home values should be followed by subsequent clini- Discussion cal assessment by a healthcare provider. Together, this Principal findings approach will facilitate earlier diagnosis of HDPs and Obstetric doctors at a tertiary hospital in urban Ghana potential for earlier medical intervention at a health- hold very positive attitudes towards home BP monitor- care facility. Like other aspects of antenatal care, home ing in pregnancy. Doctors believe that the many ben- BP monitoring should be utilized at the discretion and efits of home BP monitoring far outweigh the challenges supervision of healthcare providers and health systems. to implementation. The primary benefits are improved There is value in wide-scale adoption of home BP moni- clinical outcomes, greater patient empowerment and toring for every pregnant patient, because even low involvement in their care, and more effective healthcare risk pregnancies can develop hypertensive disorders. resource utilization. The main barriers are the cost of In addition, there is value in early adoption (in 1st tri- BP monitors, lack of an efficient patient-provider com- mester) of home BP monitoring to establish baseline munication system, and patient health literacy. Doctors blood pressure values, identify chronic hypertension, emphasized that if the cost of the BP monitor could be distinguish between true and white coat hypertension, subsidized, then the majority of the other barriers could and establish patient routines. However, given varying be addressed with patient education and counseling. availability of resources and levels of feasibility, pro- tocols in different clinical settings should delineate Results in the context of what is known which populations (all pregnant women or only those Few studies have evaluated the utility of home BP moni- with risk factors for development of HDP) may benefit toring, particularly in pregnancy and in LMICs. Fur- the most from home blood pressure monitoring and at thermore, there is limited research globally focused on which time point in pregnancy (first trimester or later physician attitudes towards the implementation and second trimester) it should be initiated. clinical use of home BP monitoring. Similar to the find- We also highlight potential barriers to home BP mon- ings from this qualitative study, studies evaluating home itoring in LMIC settings, including lower patient health BP monitoring in non-pregnant patients in HIC settings literacy and numeracy. However, we conclude that also found patient education and counseling to be a key with appropriate education and training, all patients issue. Despite this barrier, patients and providers had could successfully partake in home BP monitoring. positive attitudes towards home BP monitoring with ben- Home monitoring programs targeting illiterate patients efits including convenience, patient empowerment, and should consider modifications such as assistance from trust in BP values [14, 18]. A pilot study in the United relatives, use of photographs for training, and use of Kingdom about home BP monitoring in pregnancy found color-coded results rather than objective BP values. patient-reported benefits that were similar to those When considering wide-scale implementation of home reported by our participants, including patient empow- BP monitoring, doctors identified potential future chal- erment and increased engagement in their own health- lenges, including increased patient loads in the hos- care, and that patient willingness and ability to adhere to pitals due to greater detection of BP elevations. Thus, home monitoring was high [15]. Consistent with clinical implementation approaches should anticipate these benefits reported by participants in our study, a system- potential issues and include appropriate evaluation atic review and meta-analysis of home BP monitoring in metrics. In particular, the cost of home BP monitors is pregnancy found a 70% reduction in antepartum hospi- an important and addressable barrier. Doctors believe tal admissions and a 50% lower rate of development of that providing home BP monitors to patients would be preeclampsia associated with use of home BP monitor- more economical than in-patient BP monitoring and ing [16]. However, recent large-scale RCTs among preg- suggested using that rationale to advocate for the cov- nant women in the United Kingdom did not demonstrate erage of home BP monitors by Ghana’s National Health earlier clinical diagnosis of elevated BPs associated with Insurance. home BP monitoring [20, 21]. Atluri et al. BMC Pregnancy and Childbirth (2023) 23:42 Page 10 of 11 Research implications Obstetric doctors would use patient-measured BP val- Amidst conflicting evidence regarding the efficacy of ues to make meaningful changes in clinical manage- home BP monitoring during pregnancy in HIC settings ment and believe home BP monitoring would improve [16, 20, 21], our study emphasizes the differences in the patient outcomes and healthcare system efficiency. current state of BP monitoring between HICs, which have high compliance with weekly visits in late third trimester, and LMIC settings like Ghana, which have AbbreviationsHDP H ypertensive disorders of pregnancy significant barriers to frequent in-person care and moni- LMICs low- and middle-income countries toring. Participants in our study anticipate that home BP BP B lood pressure monitoring would result in increased quantity and qual- HICs High-income countriesKBTH Korle Bu Teaching Hospital ity of BP values among high-risk pregnant women in the OBGYN Obstetrics and Gynaecology Ghanaian context. We also demonstrate that the ben- efits of home BP monitoring extend beyond the potential Supplementary Information for earlier diagnosis of elevated BPs, to other important The online version contains supplementary material available at https:// doi. benefits including patient empowerment and improved org/1 0.1 186/s 12884- 023- 05363-5. utilization of limited healthcare resources (i.e. reduced admissions simply for BP monitoring). Together, these Additional file: 1. findings highlight the significant potential impacts of Additional file: 2. home BP monitoring in low-resource areas and the criti- cal need for additional studies to be conducted in these Acknowledgements highest-risk settings. Not applicable. Authors’ contributions This study was conceptualized by NA, TKB and ERL. The study design was Strengths and limitations developed by NA, TKB, SAO, and CAM. Recruitment was completed by NA, With a diverse sample of different clinical roles and lev- ERL, and TKB, and data collection was conducted by NA, with input and els of experience, this mixed methods study provides key supervision from TKB, SAO CAM, and ERL. Analysis was conducted by SDC, ERL, and NA. The manuscript was primarily drafted by NA and ERL. All authors read, qualitative and quantitative data on an emerging, clini- edited, and approved the final manuscript. cally important, and understudied topic. Limitations do exist that may impact the interpretation and generaliz- Funding Research reported in this publication was supported by the Fogarty Inter- ability of the results. First, a single study site was selected national Center of the National Institutes of Health under Award Number to facilitate a qualitative design that was able to explore K01 TW012166 and a North Pacific Global Health Fellowship. The content is thorough and nuanced perspectives. Second, interviews solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Funding was also received by were performed within the hospital compound and the the NIH T-35 Short-Term Training Grant for Medical Students and the Univer- research team included the participants’ peer obstetrics sity of Michigan Woll Scholarship through Global REACH. Funding sources had colleague. Thus, participants could have been hesitant to no involvement in the research design, preparation of manuscript, or decision to submit. share challenges about the hospital setting or their own clinical practice. However, involvement of a local obstet- Availability of data and materials ric doctor in the research team was critical to develop- The datasets generated and/or analysed during the current study are not publicly available due to the data (qualitative interview transcripts) containing ing a comprehensive and culturally competent interview specific, personal, and detailed information about the participants, but are guide as well as a tailored sampling strategy. Moreover, available from the corresponding author on reasonable request. The impor- interviews were intentionally performed by an Ameri- tant and representative information are available in the quotations and tables available in the manuscript. can research team member to limit this concern. Surveys were conducted on an anonymous electronic platform, Declarations and survey data showed strong agreement with qualita- tive results. Third, midwives were not included as partici- Ethics approval and consent to participate pants. Given their critical role in obstetric care in Ghana Ethical approval was granted by the Institutional Review Boards at the Korle Bu Teaching Hospital (KBTH-STC 00098/2021) on September 24, 2021 and the and most LMICs, future research should address mid- University of Michigan (HUM00200589) on July 2, 2021. Electronic informed wives’ perspectives. consent was obtained from all survey participants and written informed con- sent was obtained for all interview participants. All methods were performed following the relevant guidelines and regulations of the ethical review boards Conclusion at the Korle Bu Teaching Hospital and the University of Michigan. Overall, obstetric doctors in Ghana strongly support Consent for publication the implementation of home BP monitoring in Ghana Not applicable. and believe it would be successful and impactful. A tluri et al. BMC Pregnancy and Childbirth (2023) 23:42 Page 11 of 11 Competing interests telemonitoring, for titration of antihypertensive medication (TASMINH4): The authors declare that they have no competing interests. an unmasked randomised controlled trial. Lancet. 2018;391:949–59. 19. Fletcher BR, Hinton L, Hartmann-Boyce J, Roberts NW, Bobrovitz N, Author details McManus RJ. Self-monitoring blood pressure in hypertension, patient 1 University of Michigan Medical School, 1301 Catherine St, MI 48109 Ann and provider perspectives: a systematic review and thematic synthesis. Arbor, USA. 2 Department of Obstetrics and Gynaecology, University of Ghana Patient Educ Couns. 2016;99:210–9. Medical School, Korle Bu, Accra, P.O. Box 4236, Ghana. 3 Department of Obstet- 20. Tucker KL, Mort S, Yu L-M, Campbell H, Rivero-Arias O, Wilson HM, et al. rics and Gynecology, University of Michigan, 1500 E. Medical Center Dr, Effect of self-monitoring of blood pressure on diagnosis of Hypertension 48109 Ann Arbor, MI, USA. during higher-risk pregnancy: the BUMP 1 Randomized Clinical Trial. JAMA. 2022;327:1656–65. Received: 14 September 2022 Accepted: 9 January 2023 21. Chappell LC, Tucker KL, Galal U, Yu L-M, Campbell H, Rivero-Arias O, et al. Effect of self-monitoring of blood pressure on blood pressure control in pregnant individuals with chronic or gestational hypertension: the BUMP 2 Randomized Clinical Trial. JAMA. 2022;327:1666–78. 22. Adu-Bonsaffoh K, Oppong SA, Binlinla G, Obed SA. Maternal deaths References attributable to hypertensive disorders in a tertiary hospital in Ghana. Int J 1. Duley L. The global impact of pre-eclampsia and eclampsia. Semin Peri- Gynaecol Obstet. 2013;123:110–3. natol. 2009;33:130–7. 23. Fetters MD. The mixed methods Research Workbook: activities for Design- 2. WHO | WHO. recommendations for prevention and treatment of pre- ing, Implementing, and Publishing Projects. SAGE Publications Inc; 2020. eclampsia and eclampsia. 2020. 24. Attride-Stirling J. Thematic networks: an analytic tool for qualitative 3. Main EK, McCain CL, Morton CH, Holtby S, Lawton ES. Pregnancy-related research.Qualitative Research. 2001. mortality in California: causes, characteristics, and improvement opportu- nities. Obstet Gynecol. 2015;125:938–47. 4. Haelterman E, Qvist R, Barlow P, Alexander S. Social deprivation and Publisher’s Note poor access to care as risk factors for severe pre-eclampsia. Eur J Obstet Springer Nature remains neutral with regard to jurisdictional claims in pub- Gynecol Reprod Biol. 2003;111:25–32. lished maps and institutional affiliations. 5. von Dadelszen P, Magee LA. Preventing deaths due to the hyper- tensive disorders of pregnancy. Best Pract Res Clin Obstet Gynaecol. 2016;36:83–102. 6. Abalos E, Cuesta C, Grosso AL, Chou D, Say L. Global and regional esti- mates of preeclampsia and eclampsia: a systematic review. Eur J Obstet Gynecol Reprod Biol. 2013;170:1–7. 7. Ahmad Mahran H, Fares R, Elkhateeb M, Ibrahim H, Bahaa A, Sanad A, Gamal M, Zeeneldin. Eissa Khalifa and Ahmed Abdelghany. Risk factors and outcome of patients with eclampsia at a tertiary hospital in Egypt. BMC Pregnancy Childbirth. 2017. https:// doi. org/ 10. 1186/ s12884- 017- 1619-7. 8. Ronsmans C, Campbell O. Quantifying the fall in mortality associated with interventions related to hypertensive diseases of pregnancy. BMC Public Health. 2011;11(Suppl 3):8. 9. Alexander GR, Kotelchuck M. Assessing the role and effectiveness of pre- natal care: history, challenges, and directions for future research. Public Health Rep. 2001;116:306–16. 10. Chalmers B, Mangiaterra V, Porter R. WHO principles of perinatal care: the essential antenatal, perinatal, and postpartum care course. Birth. 2001;28:202–7. 11. Urassa DP, Carlstedt A, Nyström L, Massawe SN, Lindmark G. Eclampsia in Dar es Salaam, Tanzania -- incidence, outcome, and the role of antenatal care. Acta Obstet Gynecol Scand. 2006;85:571–8. 12. Cooray Shamil E, Sally, Mbbs TS. Samarasekera Sumudu, Whitehead Clare. Characterization of Symptoms Immediately Preceding Eclampsia. Obstet Gynecol. 13. Magee LA, von Dadelszen P, Chan S, Gafni A, Gruslin A, Helewa M, et al. Women’s views of their experiences in the CHIPS (control of hypertension in pregnancy study) pilot trial. Hypertens Pregnancy. 2007;26:371–87. 14. Tucker KL, Taylor KS, Crawford C, Hodgkinson JA, Bankhead C, Carver T, et al. Blood pressure self-monitoring in pregnancy: examining feasibility Ready to submit your research ? Choose BMC and benefit from: in a prospective cohort study. BMC Pregnancy Childbirth. 2017;17:442. 15. Hinton L, Tucker KL, Greenfield SM, Hodgkinson JA, Mackillop L, McCourt • fast, convenient online submission C, et al. Blood pressure self-monitoring in pregnancy (BuMP) feasibility study; a qualitative analysis of women’s experiences of self-monitoring. • thorough peer review by experienced rese archers in your field BMC Pregnancy Childbirth. 2017;17:427. • rapid publication on acceptance 16. Kalafat E, Benlioglu C, Thilaganathan B, Khalil A. Home blood pressure • support for research data, including large and complex data types monitoring in the antenatal and postpartum period: a systematic review meta-analysis. Pregnancy Hypertens. 2020;19:44–51. • gold Open Access which fosters wider collaboration and increased citations 17. Butler Tobah YS, LeBlanc A, Branda ME, Inselman JW, Morris MA, • maximum visibility for your research: over 100M website views per year Ridgeway JL, et al. Randomized comparison of a reduced-visit prenatal care model enhanced with remote monitoring. Am J Obstet Gynecol. At BMC, research is always in progress. 2019;221:638e1–8. 18. McManus RJ, Mant J, Franssen M, Nickless A, Schwartz C, Hodgkinson Learn more biomedcentral.com/submissions J, et al. Efficacy of self-monitored blood pressure, with or without