Awareness of pregnancy induced hypertension among pregnant women in Tigray Regional State, Ethiopia

Introduction Pregnancy-induced hypertension is among the leading cause of maternal mortality in Tigray regional state, Ethiopia. However, there was no study in this study area about awareness of pregnancy induced hypertension among pregnant women. Therefore, the aim of this study was to assess awareness of pregnancy induced hypertension among pregnant women. Methods A cross-sectional study design was conducted on a total of 798 pregnant women attending antenatal care in general hospitals of Tigray Regional State. Data were collected from February to November 30, 2018. Binary logistic regression analysis was used to determine factors associated with poor awareness and p-values < 0.05 was considered as statistically significant. Results A total of 792 pregnant women were included in this study with a response rate of 99.2%. In this study, 41.8% of pregnant women were having poor awareness of pregnancy-induced hypertension. Primigravida, women with no formal education, women with the lowest wealth status and occupation of a housewife were significantly associated with poor awareness. Additionally, there was a significant difference in the mean score of awareness of pregnancy-induced hypertension between normotensive women and women with pregnancy-induced hypertension (Mean score difference (95% CI) = 1.90(1.35, 2.45), t = 6.75, df = 790, p < 0.001)). Conclusion A high proportion of pregnant women had poor awareness on pregnancy-induced hypertension. Health care providers should improve awareness of pregnant women about pregnancy-induced hypertension in antenatal care clinics and at a community level with a special focus of awareness on primigravida women, women with no formal education, women with lowest wealth status and housewives.


Introduction
Pregnancy-induced hypertension (PIH) is defined as new hypertension that appears at 20 weeks or more gestational age with or without proteinuria [1][2][3]. Hypertension during pregnancy is defined as a sustained systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg [4].
Globally, pregnancy-induced hypertension is a significant public health threat both in developed and developing countries contributing to high maternal and perinatal morbidity and mortality [5]. According to World Health Organization (WHO) systematic analysis, hypertensive disorders of pregnancy attributed to 14% of maternal mortality and it is the second leading cause of maternal death after hemorrhage in sub-Saharan Africa which accounts for 16.0% of maternal mortality [6]. Similarly, WHO review identified hypertensive disorders of pregnancy were annually responsible for about 25,000 maternal deaths in Africa, 22,000 maternal deaths in Asia, 3,800 maternal deaths in Latin America and the Caribbean and 150 maternal deaths in industrialized countries [7,8]. Studies conducted on the global impact of preeclampsia and eclampsia showed that preeclampsia was associated with higher rates of preterm delivery, small for gestational age babies, stillbirth and low birth weight [9]. Fetal morbidity and mortality increase substantially in women with preeclampsia and it is one of the leading causes of stillbirths and neonatal deaths [10,11].
The prevalence of pregnancy-induced hypertension in Ethiopia ranges from 2.2% up to 18.3% [12][13][14][15][16][17]. Hypertensive disorders of pregnancy are among the five leading causes of maternal deaths in Ethiopia which account for 19% of deaths [18]. There are improvement in antenatal care (ANC) services in the last decade, according to the Ethiopian demographic and health survey (EDHS) report in Ethiopia but still, only 75% of pregnant women had their blood pressure measured, and 66% had urinetested [19,20]. A study conducted in the current study area, Tigray regional state, Ethiopia revealed that pregnancy induced hypertension is among the three most common obstetric causes of maternal mortality [21]. Recent evidence suggests that the presence of complications related to hypertension disorder of pregnancy was the result of inadequate knowledge; negative attitude towards hypertension in pregnancy and lack of preventive practice [22]. In addition, studies showed that women with a good awareness of pregnancy induced hypertension were more likely to promptly report symptoms and seek health care [23,24]. Poor awareness of pregnant women is one of the potential factors for delay in seeking care and decision and a bottleneck for early diagnosis and management of critical illnesses. However, there was no evidence about the awareness of pregnant women regarding pregnancy induced hypertension in Tigray Regional State, Ethiopia. Therefore, the findings of this study would primarily contribute to the existing limited evidence in this area and also have a great significance for program coordinators and health care facilities to design and implement effective strategies for the prevention and early management of pregnancy-induced hypertension. In addition, the data will be used as a baseline for other researchers who want to investigate further studies in this area. Hence the aim of this study was to assess awareness of pregnancy induced hypertension among pregnant women in general hospitals of Tigray Region State, Ethiopia.

Methods
Study setting and design: this study was conducted in Tigray regional state. Tigray Regional State is the northernmost of the nine Pretest of the data collection instrument was conducted on 5% of the total sample size in two selected hospitals (Abiadi and Alamata hospitals) of Tigray Regional State which were not included in the study. An unclear idea, the time needed for the interview, other technical related problems on the data collection instrument was corrected based on the result of the pretest. Daily close supervision and spot checks of the filled-in questionnaire were done by the field supervisor deployed with the data collectors. The overall data collection process was coordinated and supervised by supervisors and the principal investigator. Data analysis and management: statistical analysis was done using SPSS version 21.0. Descriptive statistics frequencies and mean, standard deviation and the percentage were used to describe the study population. Independent t-tests were used to evaluate the difference in mean awareness scores of pregnancy induced hypertension between women with PIH and normotensive women.
Multivariable logistic regression analysis was used to determine factors associated with poor awareness by avoiding confounders. Variables significant at p-value < 0.05 in the univariate model were moving to a multivariable analysis model to identify independent factors. In the final model p-value < 0.05 was considered as statistically significant.
Model goodness of fit for logistic regression was assessed using the Hosmer-Lemeshow goodness of fit test.  (Table 4).

Discussion
The purpose of this study was to assess the level of awareness

Conclusion
In this study, a high proportion of pregnant women had poor awareness on pregnancy induced hypertension in general hospitals of  Pregnancy induced hypertension is among the top three leading causes of maternal mortality in Tigray Regional State, Ethiopia.

Competing interests
The authors declare no competing interests.

Acknowledgments
We would like to thank Pan African University of Life and earth sciences Institute, Pan African University, African Union for financial support to conduct this study and University of Ibadan for hosting our Ph.D. program in Reproductive Health Sciences. Our gratitude also goes to data collectors and supervisors for their diligence during data collection to obtaining the necessary information. Our special thanks also go to participants who generously shared their thoughts and feelings despite other commitments. Last but not least our particular thanks goes to Tigray regional health bureau, administrators of all hospitals included in this study for giving us the necessary information.