Research Article: The incidence of pregnancy hypertension in India, Pakistan, Mozambique, and Nigeria: A prospective population-level analysis

Date Published: April 12, 2019

Publisher: Public Library of Science

Author(s): Laura A. Magee, Sumedha Sharma, Hannah L. Nathan, Olalekan O. Adetoro, Mrutynjaya B. Bellad, Shivaprasad Goudar, Salécio E. Macuacua, Ashalata Mallapur, Rahat Qureshi, Esperança Sevene, John Sotunsa, Anifa Valá, Tang Lee, Beth A. Payne, Marianne Vidler, Andrew H. Shennan, Zulfiqar A. Bhutta, Peter von Dadelszen, Jenny E Myers

Abstract: BackgroundMost pregnancy hypertension estimates in less-developed countries are from cross-sectional hospital surveys and are considered overestimates. We estimated population-based rates by standardised methods in 27 intervention clusters of the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials.Methods and findingsCLIP-eligible pregnant women identified in their homes or local primary health centres (2013–2017). Included here are women who had delivered by trial end and received a visit from a community health worker trained to provide supplementary hypertension-oriented care, including standardised blood pressure (BP) measurement. Hypertension (BP ≥ 140/90 mm Hg) was defined as chronic (first detected at <20 weeks gestation) or gestational (≥20 weeks); pre-eclampsia was gestational hypertension plus proteinuria or a pre-eclampsia-defining complication. A multi-level regression model compared hypertension rates and types between countries (p < 0.05 considered significant). In 28,420 pregnancies studied, women were usually young (median age 23–28 years), parous (53.7%–77.3%), with singletons (≥97.5%), and enrolled at a median gestational age of 10.4 (India) to 25.9 weeks (Mozambique). Basic education varied (22.8% in Pakistan to 57.9% in India). Pregnancy hypertension incidence was lower in Pakistan (9.3%) than India (10.3%), Mozambique (10.9%), or Nigeria (10.2%) (p = 0.001). Most hypertension was diastolic only (46.4% in India, 72.7% in Pakistan, 61.3% in Mozambique, and 63.3% in Nigeria). At first presentation with elevated BP, gestational hypertension was most common diagnosis (particularly in Mozambique [8.4%] versus India [6.9%], Pakistan [6.5%], and Nigeria [7.1%]; p < 0.001), followed by pre-eclampsia (India [3.8%], Nigeria [3.0%], Pakistan [2.4%], and Mozambique [2.3%]; p < 0.001) and chronic hypertension (especially in Mozambique [2.5%] and Nigeria [2.8%], compared with India [1.2%] and Pakistan [1.5%]; p < 0.001). Inclusion of additional diagnoses of hypertension and related complications, from household surveys or facility record review (unavailable in Nigeria), revealed higher hypertension incidence: 14.0% in India, 11.6% in Pakistan, and 16.8% in Mozambique; eclampsia was rare (<0.5%).ConclusionsPregnancy hypertension is common in less-developed settings. Most women in this study presented with gestational hypertension amenable to surveillance and timed delivery to improve outcomes.Trial registrationThis study is a secondary analysis of a clinical trial - registration number NCT01911494.

Partial Text: The United Nations Sustainable Development Goal (SDG) 3.1 aims to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030 [1]. The SDGs aim to maintain the momentum of the Millennium Development Goals, which catalysed a global reduction in maternal deaths from approximately 390,000 in 1990 to 275,000 in 2015 [1,2]. The burden of maternal mortality remains disproportionately borne by women in less-developed countries, particularly in sub-Saharan Africa (66%, 201,000 deaths) and southern Asia (22%, 66,000 deaths) [3].

This is a secondary, planned analysis of data collected in the 4 countries and 27 intervention clusters of the CLIP cluster randomised controlled trials (NCT01911494) [18], in India (N = 6, Karnataka State), Pakistan (N = 10, Sindh Province), Mozambique (N = 6, Maputo and Gaza Provinces), and Nigeria (N = 5, Ogun State). A STROBE checklist is provided (S2 Table).

Of the 44,794 pregnancies in CLIP intervention clusters, 12,211 (27.2%) did not receive at least 1 POM-guided visit, and 4,163 (9.3%) were not delivered by trial end, leaving 28,420 (63.4%) pregnancies for inclusion in this analysis (Fig 1).

In almost 30,000 pregnancies from 27 CLIP intervention clusters in sub-Saharan Africa and southern Asia, use of standardised BP measurement revealed an incidence of pregnancy hypertension of approximately 10%. The rate was slightly lower in Pakistan, but the difference was not explained by between-country differences in measurable baseline maternal and pregnancy characteristics.



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