Maternal Care of Rural Tribal Women in Context to Hypertensive Disorders of Pregnancy: A Cross-Sectional Study

Background: Hypertensive Disorders of Pregnancy (HDsP) are major causes of maternal, perinatal morbidity, mortality worldwide. Community-based observational cross-sectional study was conducted to know about maternity care at rural, remote health facilities in context of HDsP.

Methodology: Study was conducted in women between ≥20 to ≤49 years in 140 villages around village with health facility. Face-to-face interviews of women regarding pregnancy care, care providers, work-ups, complications during pregnancy and post-birth periods, birth place in context of HDsP were conducted using predesigned tool by research assistant over one year.

Results: Of 2000 women interviewed, majority (61.2%) were 20-29 years, illiterate (38.9%), agricultural laborers (44.8%), belonging to lower economic class (46.9%), 44.8% had many births. Majority (40.3%) who had antenatal checkups started their check-ups from 20 weeks onwards with an average of four visits. Of all, 84.6% got checkups and investigations done by community health workers/nurse-midwives, doctor or both. Of these only 15.4% got their blood pressure checked and 28.2% hemoglobin during pregnancy. Total 68.6% talked of developing disorders during pregnancy with anemia being most common (39.4%), followed by anemia and HDsP (28.6%), and HDsP alone (21.1%). It was observed that majority of less educated women, laborers, belonging to lower economic class didn’t go for regular antenatal check-ups, did not get investigations had disorders during pregnancy and most of them delivered at home.

Conclusion: There was significant impact of socio-demographic features and health care providers on type, contents of antenatal care received in context of HDsP, did not have even basic blood pressure checked.

Hypertensive disorders of Pregnancy (HDsP) result in major complications during pregnancy, birth, post-birth and are leading causes of maternal, perinatal morbidity and mortality worldwide [1,2]. HDsP are an umbrella which includes preexisting hypertension, gestational hypertension, preeclampsia, and eclampsia, most common being gestational hypertension, diagnosed after 20 weeks of pregnancy. It has been estimated that HDsP complicate around 5 to 10% of pregnancies globally [3], more in developing countries [4]. There is abundant evidence that any form of hypertension in pregnancy places women at increased risk of adverse outcome [5,6]. In addition to many problems in the mothers because of high blood pressure and single or multi organ dysfunction or failure, HDsP also lead to preterm births, fetal growth restriction, low birth weight and perinatal deaths [7,8]. HDsP are usually diagnosed in the course of regular prenatal care, which must include surveillance of blood pressure, weight and urine protein check. Quality antenatal care (ANC), one of the key care packages required to reduce global maternal and perinatal mortality and morbidity, quite a lot of which is due to HDsP, is essential for early diagnosis of HDsP [9]. Hence, it becomes essential to address this issue especially in rural, remote areas with limited heath facilities.

Objective: Community-based study was carried out to know about maternity care in rural remote health facilities in context of HDsP.

After institute’s ethics committee’s approval and informed written consent from the participants, the information was collected about pregnancy care in context of HDsP by interviews using a predesigned tool with some questions for yes or no answers and others short answers. After consent women were interviewed in villages at mutually convenient places. Information was recorded on the hard tool then and there. No one was given tool to fill.

Study setting: Community based study was carried out in 140 villages around the village with health facility in rural tribal communities of remote, forestry and hilly region. 

Study Design: Observational cross-sectional study.

Study period: One year.

Inclusion criteria: All women of ≥20 to ≤49 years of age residing in the 140 villages around the village with health facility (study center) with their last delivery within previous year and those willing to undergo a personal interview were randomly enrolled as study participants.

Exclusion criteria: Those <20>49 years, unmarried, with no child birth, not willing to give responses, or not comfortable were excluded. 

Sample size: The sample size was calculated as 2000 with a 95% confidence, 2

Of the total 2000 women interviewed, the majority (61.2%) were 20-29 years of age, illiterate (38.9%), agricultural laborer (44.8%), belonging to lower economic class (46.9%) and had three to four previous births (44.8%). Of the 2000 women interviewed, 1580(79.0%) revealed that they had regular antenatal care with the majority (40.3%) from 20 weeks onwards. Most of the women had four antenatal visits (42.9%) to the hospital. It was found that 80.9% of women of 30-39 years of age, well-educated (89.2%), agricultural laborers, belonging to lower middle class and with many births had regular antenatal checkups. Table 1 depicts the relation of socio-demographic features with the antenatal care received in the immediate previous pregnancy within a year (Table 1).

Table 1: Relation of Sociodemographic features with the Antenatal care in Last Pregnancy.

*Small Scale, Food, Shoes Making, Bamboo Items Industry, Welding Workshop, Brick Furnace.

Overall, of 2000 women, 1692(84.6%) had their blood pressure and investigations done during pregnancy, either by a nurse, community health worker (CHW), or doctor or all.  Of the 1692 women, 522 (30.8%) had checkup done by Nurse or CHW, 470 (27.8%) were seen by a doctor and the remaining 700 (41.4%) got it done by both nurse and doctor. Of all 1692 women, only 260(15.4%) had their blood pressure checked during pregnancy, 477(28.2%) got their hemoglobin checked and 543(32.1%) urine examination. A detailed of relationship of various socio-demographic features with the healthcare personnel providing the antenatal care is depicted in table 2 (Table 2).

Table 2: Relationship of sociodemographic features with Service providers, work up in last pregnancy.

It was observed that less educated, laborer, and those belonging to lower economic class had minimum number of antenatal visits and didn’t get their blood pressure or routine investigations done during pregnancy, neither when examined by nurse/CHW nor by doctors. Most of them had infrequent visits to CHW/nurse-midwives, with few visiting both doctors and CHW/nurse midwives. Of 2000 women, 1372 (68.6%) developed some disorder in their last pregnancy, anemia being the most common disorder (39.4%), followed by anemia with HDsP (28.6%), HDsP alone (21.1%) and other disorders like preterm prelabor rupture of membranes, preterm labor pains, etc. (10.9%). It was found that the complications were more in women who were less educated or illiterate, laborer by occupation, belonged to lower middle or low economic classes and had many births (P3-P4). Table 3 depicts the relation of various socio-demographic features with the disorders developed in last pregnancy (Table 3).

Table 3: Relationship of sociodemographic features with the Disorders developed in last pregnancy.

Of 1372 women, 541 who had anemia in their previous pregnancy, 13.9percentage delivered at home, 55.6percentage at Subcenter (SC)/Primary Health center (PHC) and the remaining 30.5percentage delivered at District Hospital (DH)/ Subdistrict Hospital (SDH). Of 393 women who had anemia as well as HDsP, 24.7percentage delivered at home, 39.9percentage at SC/ PHC and the remaining 35.4percentage delivered at DH/ SDH. Of 289 women who had HDsP, 22.8percentage delivered at home, 39.1percentage at SC/ PHC and the remaining 38.1percentage delivered at DH/SDH. Similarly of 149 women who had other disorders during their last pregnancy, 28.9percentage delivered at home, 30.2percentage at SC/ PHC and the remaining 40.9percentage delivered at DH/ SDH. It was revealed that the majority of women who delivered at home were less educated or illiterate, agricultural laborer by occupation, and belonged to lower economic class. Furthermore, majority of illiterate (42.4percentage), laborers (61.5percentage), belonging to lower economic class (45.5percentage) and 53.6percentage who had previous multiple births delivered at SC/PHC even when diagnosed with HDsP, instead of DH/Tertiary care center. Table 4A and 4B depict the relationship between sociodemographic features of women who developed complications in their last pregnancy with the place of delivery (Table 4A and 4B). It was revealed that the majority of women who were less educated, laborer or homemakers and had previous multiple births delivered at home even in presence of disorders including, anemia, HDsP or both.

Table 4-A: Disorders in last pregnancy and place of birth.

SC - Sub Center, PHC - Primary Health Center, SDH - Sub Districts Hospital, DH - District Hospital, HDsP - Hypertensive Disorder During Pregnancy.

Table 4-B: Disorders in last pregnancy and place of birth.

Overall, 628 (31.4percentage) women who developed no complications in their last pregnancy when asked about the place of delivery revealed that the majority (60.8percentage) delivered at home followed by SC/PHC (29.0percentage), and only 10.2percentage delivered at DH/SDH. Furthermore, it was found that the majority of women that had birth at home were illiterate, homemakers, and belonged to lower economic classes. Table 4B depicts the relationship between sociodemographic features of women who had no complications in their last pregnancy with the place of delivery (Table 4B).

Many women with mild gestational hypertension or even preeclampsia does not feel ill, and the condition is often first detected through high blood pressure with or without protein in urine as part of antenatal care. Other than hypertension and proteinuria, symptoms, of HDsP include facial or hand edema, increase in weight due to fluid retention. A study from Norway revealed that 10-20% of women with severe preeclampsia develop life-threatening complications like HELLP (Hemolysis elevated liver enzymes, and low platelets) syndrome, retinal or cerebral hemorrhage, pulmonary oedema, or maternal death [11]. HDsP can also affect the fetus, due to impairment of blood and oxygen flow resulting in increased risk of fetal growth restriction, intrauterine fetal death or stillbirth and neonatal death [12]. Women who have had preeclampsia have approximately twice the lifetime risk of heart disease and stroke than do women in the general population over the years [13-16]. Researchers suggested that preeclampsia, heart disease, and stroke may share common risk factors [17,18]. HDsP are more likely to occur in first pregnancy, but subsequent pregnancies, are not immune, particularly in women with other disorders. The early recognition of symptoms and signs of HDsP can prevent severity and further all such complications. For diagnosis and information regarding disorders during pregnancy, it is essential that women get quality care during pregnancy and birth.

In the present study it was observed that well educated and multiparous women had regular antenatal checkups in their previous pregnancies that too by trained health care professionals. Of 84.6% women who visited health providers for blood pressure and investigations during pregnancy, only 15.4% had their blood pressure checked during pregnancy, 28.2% got their hemoglobin checked and 32.1% urine examination. It was observed that women with antenatal complications were less educated or illiterate, laborers, belonged to lower middle or low economic classes and had multiple births (P3-P4), as they had minimum number of antenatal visits and majority didn’t have their blood pressure or routine investigations done during pregnancy even when doctors examined them. There was obvious lack of quality care during pregnancy, with many disorders during pregnancy including, anemia, HDsP, both and others. Furthermore, the majority of women with disorders who delivered at home had less education or were illiterate, agricultural laborer by occupation, and belonged to lower economic class.

Ayele et al (2016) opined that woman with first pregnancy with preexisting chronic medical illnesses should be given special emphasis for early diagnosis of HDsP and better management [20]. Gebremedh et al (2021) from Australia did a study to assess the association between inter pregnancy interval (IPI) and the risk of HDsP and revealed that the risk of preeclampsia was more with longer IPIs compared to 18 months for mothers more than 35 years of age [21]. During maternity care such things are crucial, that women and health providers need to know. Another study revealed that factors including lack of antenatal care or poor-quality care by untrained people, failure in early detection, and effective management of HDsP, delayed referrals from periphery, and lack of awareness about HDsP were the most common causes responsible for avoidable deaths due to HDsP [22]. In the present study also, it was observed that women who had antenatal complications like anemia, HDsP, or both were mostly less educated or illiterate women, laborers, those belonging to lower middle or low economic classes and multiparous (P3-P4).

Also, most women with HDsP, stops care after delivery, although studies have suggested that complications associated with HDsP continue in immediate postnatal period and over the years [23]. Poor quality care during pregnancy itself poses women at increased risk of these complications. Similar to present study, a study from Ghana revealed that poor quality antenatal care, lack of patient awareness, lack of medications and laboratory support, inadequate health professionals and their poor attitudes towards patient and improper documentation of records were the causes of delayed detection and management of HDsP [24]. Purohit et al did a study of utilization of antenatal care services in a remote, tribal and hilly district of Himachal Pradesh of India which revealed high utilization of ANC services by indigenous women, but it was accompanied by physical, psychological, and financial hardships [25].

A study regarding antenatal care facilities in rural India revealed that about three-fifths of women failed to receive basic antenatal care during their last pregnancy. It was also reported that the services received by these women predominantly included provision of tetanus toxoid vaccination and supply of iron and folic acid tablets. Very few pregnant women (13%) had their blood pressure checked and some blood investigations done, that too only once in their entire antenatal period. Furthermore, the study revealed that there was significant underutilization of nurses/midwives in the provision of antenatal services and doctors were often the lead providers. The average number of antenatal visits reported were only 2.4 and most visits were in the second trimester [26]. In the present study it was revealed that most of the women who developed complications in their pregnancy had no of very minimum antenatal visits many by CHW/nurse midwives. Other studies have also revealed that women who do not visit hospitals or health care workers for routine antenatal check-ups were at a higher risk of developing HDsP compared to women who received regular antenatal care and visited health facility during their pregnancies [27,28]. Furthermore, similar to the present study, it was observed that higher social and economic status was associated with increased chances of receiving antenatal care, blood pressure measurement, routine antenatal investigations but not physical examination, no abdominal examination [29,30]. Madaj et al did a multi-country study regarding availability of antenatal and postnatal care in low- and middle-income settings and revealed that though healthcare providers were available, but in the facilities needed for all essential components of ANC and PNC were lacking [31]. Hence, focused attention on contents is required, if disorders during pregnancy especially HDsP are to be prevented. Early diagnosis and treatment through regular antenatal checkups, routine investigations during pregnancy are key factors in prevention of HDsP and its complications.

In the present study it was found that most of the women who had antenatal checkups, started from in second trimester, with many visiting either CHW or nurse midwives with no physical antenatal examination. Of 84.6% women who visited health providers for blood pressure and investigations during pregnancy, only 15.4% had their blood pressure checked during pregnancy, 28.2% got their hemoglobin checked and 32.1% urine examination. Such things need more studies.  Furthermore, anemia was the most common complication reported by women in their last pregnancy followed by anemia with HDsP and HDsP alone it was also observed that many of women with complicated pregnancy delivered at home were less educated, laborers, and belonged to lower economic class and these women had no or minimum antenatal visits or investigations done by health care providers. Hence, regular and quality antenatal and postnatal care is must for all women and creating awareness regarding safe deliveries at hospitals is crucial for healthy maternal and perinatal outcome.

Ethics Approval

The present study was conducted after approval of the Ethical Committee of Mahatma Gandhi Institute of Medical Sciences, Sewagram.

Consent of Participants

The study was conducted after informed consent from the participants.