ABSTRACT
Maternal mortality has been one of the key problems in public health over the decades. This is because about 585,500 women lose their lives annually through maternal mortality. According to the World Health Organization, more than 14% of the world's deaths among pregnant women are attributed to hypertension-related to pregnancy. This predicament hinders the efforts in reaching sustainable development goal three (3) which seeks to end preventable deaths of new- borns and children under five years of age. The aim of this study was to assess the risk factors of hypertension during pregnancy in the Ikeja Metropolis. An analytical cross-sectional study was conducted among 424 pregnant women randomly sampled in three hospitals within the Ikeja Metropolis. A structured questionnaire was used to collect data on socio-demographic, factors associated with elevated blood pressure and prevelance of Hypertension Induced Preganancy among pregnant women. Data was analysed in SPSS version 21. Bivariate logistic regression and multivariate logistic regression were used to determine associations and strength of associations, respectively, at a significant threshold of P < 0.05. In all 67 (15.7%) pregnant women were diagnosed with hypertension. The results further detailed that some of the pontential factors associated with hypertension include age (x2 = 11.62, p = 0.009) , occupation (x2 = 12.61, p = 0.027), family history of hypertension (x2 = 42.85, p < 0.001) and history of smoking .In a multivariate logistic regression, only history of smoking ( aOR = 3.97, CI = 1.4-11.1, p = 0.009) was statistically associated with hypertension. Pregnancy-Induced Hypertension is becoming increasingly recognized as a highly complex multisystem disorder with numerous contributing factors. Nigeria Health Service should implement public education policy across all health facilities on the risk factors of Hypertension During Pregnancy to women before pregnancy to reduce the rate of HDP.
CHAPTER ONE INTRODUCTION
This chapter presents a background development establishing the purpose of the study. It also establishes the problem that led to the need for the study, research questions and objectives, study’s relevance and potential impact on maternal health in Nigeria. It presents the scope, content and significance of this study. The summary of the methodological approach used to examine the research problem is described as well as the operationalized definition of key concepts.
1.1 Background of this Study
Maternal mortality has been one of the key problems in public health over the decades. This is because about 585,500 women lose their lives annually through maternal mortality (Ahenkorah, 2017). Out of this number, 98% occur in less-developed countries such as Nigeria (Ahenkorah, 2017; Owiredu et al., 2012). Various factors such as pregnancy complications and unsafe abortions have been named as origins of maternal deaths (WHO, 1994 cited by Owiredu et al., 2012). One other major cause of this increased mortality rate is hypertension associated with pregnancy. According to the World Health Organization, more than 14% of the world's deaths among pregnant women are attributed to hypertension-related to pregnancy (Say et al., 2014). Hypertensive disorders of pregnancy (HDP) (Meazaw et al., 2020; Antwi et al., 2016) includes pregnancy-induced hypertension (PIH), pre-eclampsia, eclampsia and the Haemolysis-Elevated- Liver Enzymes-Low Platelets (HELLP) syndrome. Out of the total deaths among pregnant women recorded in Latin-American and the Caribbean, more than 25.7% were caused by hypertension related to pregnancy. Additionally, the canker accounts for more than 9.1% of maternal deaths in Asia and Africa. In sub-Saharan Africa, it contributed to 16% of maternal deaths (Khan et al., 2006). Currently, the higher risk of maternal death due to pregnancy-related hypertension is approximately 300 times higher in developing countries than in developing countries (Gashe, & Ayele, 2018).
According to Saudan et al. (1998 cited by Owiredu et al., 2012), hypertension is the commonest medical complication associated with pregnancy. It is also the major cause of maternal and perinatal morbidity and mortality (Meazaw et al., 2020; Antwi et al., 2016). This occurs in 3% to 10% of all pregnancies. In Nigeria, the prevalence of hypertension during pregnancies is one of the topmost five leading causes of maternal and neonatal deaths (Der, 2013). Also, Osei-Nketiah, (2001) found that hypertensive pregnancy was among the four major risk factors associated with forty per cent (40%) of maternal deaths in Nigeria. Thus, HDP accounts for nine per cent (9%) of maternal deaths (Owiredu et al., 2012).
Although evidence shows that hypertension during pregnancy has no definite cause, some studies have focused on risk factors across the globe, and common risk factors during pregnancy have been identified (Wolde et al. 2011). Available literature reveals that risk factors of hypertensive pregnancies include socio-demographic, personal and lifestyle characteristics of pregnant women. In Nigeria, several studies including Owiredu et al. (2012) concluded that HDP risk factors include family history, contraceptives usage, and use of condoms during coitus, change of partners. Also, Deborah van Middendorp et al. (2013) found that women in urban settings were at increased danger of developing maternal hypertension than women in rural areas. Larry Jones et al. (2017) added maternal age, unemployment and marital status, food with high fats, family history of pregnancy hypertension and history of preterm delivery were the main factors linked to HDP. Additionally, Owiredu et al. (2012) added obesity, age, use of contraceptives as well as patients' family history as the causes of HDP in urban areas (Owiredu et al., 2012).
The American College of Obstetricians and Gynaecologists (ACOG) define “hypertension in pregnancy as systolic blood pressure greater than or equal to 140 mmHg and/or diastolic blood pressure greater than or equal to 90 mmHg in two occasions at least 6 h apart after the fifth month of gestation for pregnancy-induced hypertension or before pregnancy/before 20 weeks of gestation for chronic hypertension” (ACOG, 2013). HDP represents a group of disorders associated with high blood pressure during pregnancy, proteinuria and in some cases convulsions (Lowe et al., 2014). One significant finding of pregnancy-related to pregnancy is that HDP can advance to an adverse stage of maternal hypertension known as eclampsia (Wallis et al., 2013). Wallis et al. (2013) reiterate that eclampsia can affect foetal development which can intensify the risk of heart and brain diseases, cause preterm birth, etc.
The psychosocial well-being of pregnant women is also an issue of concern (Omidvar et al., 2018). It has a key effect on pregnancy outcomes (Woods et al, 2010), a significant pace toward improving women's health and birth outcomes (Lapp, 2000). Social and psychological factors such as stigma, discrimination, anxiety, depression and quality of life are related to healthy behaviours in pregnant women (Omidvar et al., 2018). Existing literature has revealed that patients' awareness about their state affects their compliance with treatment which improves complications accompanying the disease. In Nigeria, one of the hurdles in combating hypertension during pregnancies is the delay in visiting health facilities after discovering its symptoms as well as limited knowledge of risk factors associated with it (Fondjo et al., 2019). Out of 5,247 deaths reported by Der et al. (2013) among women between the ages of 15 and 49, 12.1% (634) are from pregnancy-related complications. Also, 79.5% of these deaths are related to obstetric causes including HDP. The main conclusion was the late start of ante-natal care and community-based studies to look into maternal associated complications and death.
This study would be conducted in the Northern Nigerian population, assessing risk factors associated with hypertension during pregnancy in 3 hospitals in the Ikeja Metropolis of Nigeria.
1.2 Problem Statement
Hypertensive disorders are a worldwide public health concern in both advanced and third world countries (NICE, 2010; Fondjo et al., 2019). It has contributed to about 16% of maternal deaths in sub-Saharan African countries, Nigeria inclusive (Say et al., 2014). Early detection of pregnancy-related complications can reduce the number of levels of preventable causes of maternal deaths. However, one of the major hurdles in combating hypertension during pregnancy in Nigeria is; reporting of women to healthcare centres, and the lack of awareness of risk factors (Fondjo et al., 2019). This predicament hinders the efforts in reaching sustainable development goal three (3.1) seeks to “end preventable deaths of new-borns and children under five years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births and under-five mortality to at least as low as 25 per 1000 live births”.
The generalisability of much-published research on this issue is problematic. This is because many studies have indicated several risk factors of which findings were not conclusive (Kahsay, 2018; Der, 2013). There have been reports of discrepancies between populaces and ethno- geographic groups. Albeit, the link between hypertension related to pregnancy and maternal mortality and morbidity is established, what is not yet clear is the dearth of proof of the level of risk in literature (Meazaw, 2020). Additionally, there are geographical variations in the occurrence and frequency of HDP in the sub-Saharan region (WHO, 1988; Antwi et al., 2016). In assessing the geographical disparities in the occurrence of the disease, Antwi et al. (2016), established that the recorded disparities are caused by urbanisation and lifestyle changes. This was also confirmed by the Nigeria Maternal Health Review undertaken in the year 2007 which found that HDP was more common in highly urbanised areas (GSS, 2007). Another study undertaken at the Komfo Anokye Teaching Hospital in Nigeria established that hypertension- related to pregnancy was the leading cause of maternal mortality recorded by the institution (Lee et al., 2012).
Over the past years Antwi et al., (2016) has emphasised the need for further scientific enquiry may be required to corroborate or refute existing research findings. There is enough evidence for the call for studies into risk factors of pregnancy and related complications such as HDP to help reduce preventable maternal mortality, more importantly; there is currently limited study that evaluates risk factors of hypertension during pregnancy in Northern Nigeria. According to Antwi et al., (2016), no study was identified to have documented the experiences of pregnant women diagnosed with HDP. Woods et al. (2010) posit that psychological issues have not regularly been measured in everyday obstetric practice.
There have been several epidemiological studies that have looked into the relationship between maternal demographic variables and the risk of hypertensive disorders during pregnancy (HDP). There have been reports of discrepancies between populaces and ethno-geographic groups. Albeit, the link between hypertension related to pregnancy and maternal mortality and morbidity is established, what is not yet clear is the dearth of proof of the level of risk in literature (Meazaw, 2020). Additionally, there are geographical variations in the occurrence and frequency of HDP in the sub-Saharan region (WHO, 1988; Antwi et al., 2016).
Although there exist some studies in the local setting, this study seeks to address the local variation in HDP prevalence and understand its psychological and social impact of it on those diagnosed. This study assessed five potential risk factors including prenatal bonding, marriage status, social support, socioeconomic status, stress and intimate partner violence (Woods et al., 2010; Mathibe-Neke and Masitenyane, 2018) and their association with HDP among pregnant women in three public hospitals of Ikeja Metropolis.
1.3 Research Questions
1. What is the prevalence of elevated blood pressure among pregnant women in the Ikeja Metropolis?
2. What are the risk factors associated with elevated blood pressure among pregnant women in the Ikeja metropolis?
1.4 Research Objectives
1.4.1 Main Objective
This study was designed to assess the risk factors of hypertension during pregnancy in the Ikeja Metropolis.
1.4.2 Specific Objectives
1. To assess the prevalence of elevated blood pressure among pregnant women.
2. To determine the risk factors associated with elevated blood pressure among pregnant women.
1.5 Significance of this Study
The findings of this study would be useful in terms of helping clinicians to identify the risk of HDP among pregnant women.
Also, the findings from this study add to the body of research and scholarly works and generate further interest in the research field to improve the situation of hypertension during pregnancy in Ikeja Metropolis and Nigeria as a whole.
1.6 Study Scope
This study would be undertaken geographically in the Ikeja Metropolis. The metropolis is home to about 233,252 people according to the 2010 population and housing census. The metropolis is highly urbanised with 80.08% of the population living in urban areas compared to 19.1% in rural localities. Specifically, the study would be conducted in the three main hospitals in the metropolis i.e., University of Lagos Teaching Hospital, West and the Central Hospitals which largely serve the population in Ikeja.
The study population would be pregnant women who seek antenatal services at the University of Lagos Teaching, Central and West hospitals. The sample size for this study would be 424 anticipating a 10% non-response rate.
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