Prevalence and Demographic Distributions of Pre-Eclampsia among Pregnant Women at Ho Teaching Hospital ()
1. Introduction
Pre-eclampsia remains a major clinical challenge in contemporary obstetric practice due to its associated burden of high maternal and perinatal adversities [1] . It is multi-factorial and forms an integral part of the continuum of hypertensive disorders in pregnancy [HDP] [2] . They are common medical conditions in pregnancy and responsible for approximately 14% of maternal deaths globally [3] .
In Ghana, the maternal mortality ratio remains excessively high, and hypertensive disorders in pregnancy are responsible for about 9% of maternal deaths. However, recent clinical studies in Ghana have indicated that HDP is the leading cause of maternal deaths in major tertiary institutions with similar findings reported in other African countries [1] . Pre-eclampsia is a four-arm of eclampsia, a pregnancy-specific syndrome characterized by a new onset of hypertension and significant protein in urine with or without edema occurring at 20 weeks of gestation. It is associated with high maternal mortality and morbidity as well as the risk of fetal perinatal death, preterm birth, intrauterine growth restriction, placenta abruption, oligohydramnios, and other pathology [4] . However, it is mostly asymptomatic and difficult to predict in the early stages of pregnancy. As a result, most cases are not detected early and seen at health facilities leading to severe eclampsia (high blood pressure in pregnancy with or without protein in urine). Pre-eclampsia is the second leading cause of maternal death and it has been associated with maternal morbidity and adverse perinatal outcomes globally though there is no known treatment except the delivery of the placenta [4] [5] .
According to the World Health Organization (WHO), its incidence is seven times higher in developing countries (2.8% of live births) than in developed countries (0.4%) [6] . In the United States of America, pre-eclampsia is believed to be responsible for 15% of premature deliveries and 17.6% of maternal deaths [7] . Despite its impact on maternal and child health, efforts to predict and prevent pre-eclampsia have been disappointing and remain one of the poorly understood obstetric complications with adverse effects on maternal and child health [8] . Its prevalence is still significant, especially in developing countries including Ghana, and yet a major threat to maternal and neonatal health. Hence, this study aimed to assess the prevalence, demography distribution, and associated risk factors of pre-eclampsia among pregnant women living in the Ho municipality.
2. Methods
2.1. Ethical Statement and Study Area
A hospital-based retrospective study with a quantitative approach was utilized to assess the prevalence and social demographic factors associated with pre-eclampsia using past medical information of pregnant women at the Ho Teaching Hospital. The University of Health and Allied Sciences ethical committee approved the study protocol (UHAS-RECA.12[177]20-21).
2.2. Subjects and Study Period
This study used the Hospital Administration and Management System (HAMS) to retrieve records of all pregnant women who reported at the Ho Teaching Hospital from January 2018 to December 2020 and were 18 years old or above. All pregnant women who were diagnosed with pre-eclampsia within this period were included in the study. The study excluded all pregnant women who had a history of hypertension before they became pregnant. The study was conducted for two months.
2.3. Data Collections and Tools
Data was collected using a checklist (Supplementary 1) that assessed the socio-demographic variables including; patient age, marital status, weight, height, residence, occupation, religion, educational level, and parity. The maternal age of the patient was classified into three categories (18 - 25, 25 - 35, and ≥35 years), marital status was dichotomized into married and unmarried, maternal educational level was grouped into primary, secondary, and tertiary levels, and maternal body mass index (BMI) as maternal weight in kilograms divided by maternal height in meters square and obstetric related factors grouped as gravidity, parity, gestational age.
2.4. Measurements
This measured the rate of the occurrences of pre-eclampsia among pregnant women at the Ho Teaching Hospital; The complications associated with pre-eclampsia; Demographic distributions of pre-eclampsia cases in the Volta Region and the socio-demographic determinant of pre-eclampsia in the Volta Region.
2.5. Statistical Analysis and Sample Size
This study included all pregnant women who reported at Ho Teaching Hospital from January 2018 to December 2020. The study retrieved data on 5609 pregnant women. The complete data in Microsoft Excel was exported to Statistical Package for Social Science (SPSS) version 22.01 (IBM Corporation, Armonk, NY, USA) which was used for data entry and analysis. Mean and SD were computed for quantitative variables such as age, weight, gestational age, and BMI. Descriptive analysis was done to evaluate the distribution of variables and statistical findings were reported as numbers, percentages, and frequencies. Binary analysis was done to determine the potential demographic associated with pre-eclampsia. The association between independent and dependent variables was measured and tested using chi-square and a P-value of ≤0.05 was considered significant.
3. Results
3.1. Socio-Demographic Profile of Pre-Eclampsia Cases
5609 data on pregnant women were recorded at the Ho Teaching Hospital from January 2018 to December 2020. The mean age of the respondents was 28.89. The data showed that 314 respondents out of the 5609 pregnant women were diagnosed with pre-eclampsia, 27.7% of the pre-eclampsia cases were within the age group of 18 - 24 years old, 25.5% of them were within 25 - 29 years old, 26.1% were within the age group of 30 - 34 years old, whereas 4.8% of them were over 40 years old. The data also showed that 93% of the pre-eclampsia cases were Christian, whereas 7% of them were Muslims. The results showed that 67.5% of patients diagnosed with pre-eclampsia were married and 32.5% of them were not married. Regarding their level of education, the data showed that 38.9% of the pre-eclampsia patients had Junior High School education, whereas 4.5% had no education (Table 1).
3.2. Prevalence of Pre-Eclampsia in Ho Municipality
We investigated the prevalence rate of pre-eclampsia in Ho Municipality from 2018 to 2020. The data showed a prevalence rate of 5.6% for 5609 pregnant women recorded. We also determined the yearly prevalence rate of pre-eclampsia and observed a rate of 4.6% in 2018 for 1950 pregnant women recorded, 5.6% in 2019 for 1809 pregnant women recorded, and 6.6% in 2020 for 1850 pregnant women recorded (Table 2).
3.3. Pre-Eclampsia Complications
The occurrence of complications associated with pre-eclampsia from the study recorded that 70.4% of the pre-eclampsia patients suffered from preterm delivery, 19.7% of them had intrauterine fetal death, 2.9% had their conditions progressed to eclampsia, 1.6% of them developed HELLP syndrome and 5.4% of them resulted in maternal deaths (Table 3).
3.4. The Occurrence of Pre-Eclampsia Cases within the Volta Region
We examined the distribution of pre-eclampsia cases within the Volta region from 2018 to 2020 the cases recorded at the Ho Teaching Hospital. The data
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Table 1. Socio-demographic characteristics of pre-eclampsia cases.
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Table 2. Prevalence of pre-eclampsia from 2018 to 2020.
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Table 3. Distribution of pre-eclampsia complications among 314 pregnant women
showed that 47 (15%) of the pre-eclampsia cases were from Kpetoe, 26 (8.3%) were from Peki, 24 (7.6) were from Hohoe, 22 (7%) were from Adaklu and 19 (6.1%) were from Adidome whilst Ho recorded the highest of 37.3% (Table 4).
3.5. Associations between the Occurrence of Pre-Eclampsia and Its Demographic Distributions within the Volta Region
The binary analysis from Table 5 and Table 6 indicates the association between demographic factors and pre-eclampsia among pregnant women diagnosed with pre-eclampsia at Ho Teaching Hospital within the said period. There was no significant association between age, BMI, marital status, religion, address, and gravidity (P-value ≥ 0.05). However, there was a significant association between parity, level of education, and occupation with a P-value of 0.004, 0.00, and 0.003 respectively (Table 5 and Table 6). The study observed that 117 of the women who were diagnosed with pre-eclampsia came from Ho, followed by 47 from Kpetoe (Table 6). The study also observed a yearly increase in the incidents of pre-eclampsia in certain areas of the Volta Region (Table 6).
4. Discussion
4.1. Prevalence of Pre-Eclampsia
The prevalence of pre-eclampsia throughout the study was 5.6% which is higher compared to other studies reported in Norway [9] , and Germany [10] with 3% and 2.3%, respectively. Our study fell below the estimated prevalence rate of 6.55% - 7.03% pre-eclampsia in a study conducted in Ghana [11] . A further study conducted at the Korle-Bu Teaching Hospital [12] supports Ahenkorah’s estimated range with a prevalence rate of 7.03% in pre-eclampsia. This is a clear indication of how medical performance improved during the years as practitioners showed interest in understanding and reducing the complications of pregnancy, especially pre-eclampsia. The high rate of prevalence at the Korle-Bu Teaching Hospital could also be due to the high patient attendance since it is one of the largest referral centers in Ghana. However, this prevalence was also lower compared to studies conducted in Ethiopia and Nigeria with a prevalence rate of 12.4% and 16% respectively [13] [14] . Over the study period, there was a slight increase in the prevalence from; 4.6% in 2018 to 5.6% in 2019 and 6.6% in 2020. The factors responsible for this slight increase are not clear in this study.
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Table 4. Distribution of pre-eclampsia cases within the Volta Region from 2018 to 2020.
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Table 5. Associations between pre-eclampsia and demographic distributions.
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Table 6. Pre-eclampsia and demographic distributions.
The difference between our findings and those of previous studies could also be due to the variations in the socio-demographic characteristics of pregnant women. Fondjo et al. [15] , stipulated that advanced age and age below 18 years of pregnant women are significantly predisposed to developing pre-eclampsia. Thus, the low prevalence rate observed in this study can be attributed to the fact that ages below 18 years were excluded from the sample and the highest rate of attendants were within the age group of 18 to 24 as well as few women above 45 years.
4.2. Complications of Pre-Eclampsia
Pregnant women who had pre-eclampsia in this study were identified with complications including; preterm delivery, intrauterine fetal death (IUFD), eclampsia, and HELLP syndrome. When poorly managed pre-eclampsia could progress into eclampsia which is characterized by seizures, in addition to exhibiting the symptoms of pre-eclampsia [16] . The low recordings of pregnant women diagnosed with eclampsia could be the fact that medical personnel at the Ho Teaching Hospital put maximum effort into caring for pregnant women diagnosed with pre-eclampsia to prevent the progress of the condition into complications. Consistent with the findings of this study, Duley [17] , reported that up to about 20% of preterm deliveries are a result of pre-eclampsia and have been documented to result in high neonatal mortalities and prolonged neonatal morbidities. According to Jeyabalan [18] , pre-eclampsia does not only result in neonatal mortalities, but accounts for up to about 9% of maternal deaths in sub-Saharan Africa, and Asia. Consequently, adequate management of pre-eclampsia is the best means of preventing complications. It is noteworthy that although there have been several advances in medical science, the only known cure for pre-eclampsia is the delivery of the fetus and the placenta [18] .
4.3. Demographic Distribution and Association with Pre-Eclampsia
The study identified a statistically significant association between parity and severity of Pre-eclampsia (P = 0.04) which is inconsistent with findings from a study conducted in Kenya, that nulliparous and primiparous women were at an increased risk of developing pre-eclampsia, compared to multiparous women [16] . Grum et al. [19] , also reported an association between parity and the development of pre-eclampsia among pregnant women. Also, level of education had an association with pre-eclampsia (p = 0.00). A study conducted by Fondjo et al., 2019 reported that pregnant women who had poor knowledge of pre-eclampsia stood at risk of being diagnosed with pre-eclampsia with the progress of their pregnancy.
In our study, women who completed their education at the junior high school level indicated an increased rise in pre-eclampsia than those who attained a higher educational level. The increased risk of pre-eclampsia among women with low education levels could be because, in Ho, people with low income are more likely to practice poor lifestyle practices including lack of physical exercise and poor eating habits that could lead to overweight or obesity which increases the risk of developing pre-eclampsia. On the other hand, the increased risk of pre-eclampsia among women with low education could be attributed to low maternal age, as women with reduced or less education achievement are more likely to have their children at an early maternal age. Similarly, a study conducted in Uganda has reported higher education to be protective against pre-eclampsia [20] . This study also found occupations associated with pre-eclampsia (P = 0.003) with the majority of the pregnant women being traders. Jeyabalan [18] , in his study, indicated that increasing BMI is associated with an increased risk of developing pre-eclampsia in pregnancy which conflicts with our study findings. The differences could be due to the study designs that were utilized. A retrospective cross-sectional study was used in our research as Jeyabalan, 2013 utilized the case-control method which offered the opportunity to identify risk factors.
5. Conclusion
The prevalence of pre-eclampsia was found to be rather low in this study, compared to rates that have been documented by some previous Ghanaian studies, and in other parts of Africa. However, the study showed a rising trend in the incidence of pre-eclampsia over the years. Parity, level of education, and occupation were found to be associated with developing pre-eclampsia, whereas the remaining demographic characteristics showed no associations.
6. Study Limitations
The limitation of the study was the small sample size analyzed due to problems with the retrieval of patients’ records and information. Also, the study design used in this study was a retrospective cross-sectional study, limiting the chances of identifying risk factors associated with pre-eclampsia. This study was conducted in a tertiary healthcare facility and the findings cannot be generalized in other healthcare settings. Further, because hospital records were used in collating data on pregnant women, some pertinent information could not be identified. In addition, pregnant women below 18 years of age were not included in this study, although past studies have reported pre-eclampsia among girls below 18 years of age.
7. Recommendation
Further studies should be conducted to identify the risk factors associated with pre-eclampsia among this population. This is important to channel educational interventions in the right direction. In addition, the diagnosis of pre-eclampsia was determined by written reports in hospital records. It is unclear the means of diagnosis of pre-eclampsia, offers the possibilities of missed diagnosis and misdiagnosis. Consequent studies should endeavor to evaluate all markers for diagnosis for onward inclusion into the sample. Again, because of the challenge of paucity of data, hospital personnel should be encouraged to collate detailed information about patients before they are attended to at the facility. This would allow for more objective policies to be formulated, and directed towards achieving specific goals. In addition, it is pertinent for all females of reproductive age to be included in future studies, as opposed to this study where only females above 18 years of age were utilized.
Declarations
Ethics Approval and Consent to Participate
The University of Health and Allied Sciences ethical committee approved the study protocol (UHAS-REC A.12[177]20-21). Written informed consent was obtained from each recruited parturient after providing them with adequate explanations regarding the aims of this study.
Consent to Publish
Not applicable.
Availability of Data and Materials
The datasets generated and/or analyzed during the current study are not publicly available due to patient confidentiality but are available from the corresponding author on reasonable request.
Competing Interests
Authors declare that they have no competing interests.
Authors’ Contributions
NA and SK conceived and designed the study. SK was responsible for the supervision and coordination of this study. NA, JAK, CAA, JK, and SK conducted the data collection. NA and SK led the data analysis with inputs from JAK, JAK, and CAA. JAK wrote the first draft of the manuscript, and then NA, JAK, CAA, JK, and SK contributed to revising and reviewing the manuscript. All authors read and approved the final manuscript before submission.
Acknowledgements
We thank the Chief Executive Officer (CEO) of the Ho Teaching Hospital and the staff of the Department of Obstetrics and Gynecology, at Ho Teaching Hospital for making available all the necessary materials needed for this study.
Data Collection Tool
Prevalence and demographic distributions of pre-eclampsia among pregnant women at Ho Teaching Hospital.
This research data collection tool was to assess the prevalence and demographic distributions of pre-eclampsia among pregnant women at the Ho Teaching Hospital.
1) Patient Age...…………………………….
2) Ethnicity
A) Ewe
B) Akan
C) Ga
D) Fante
E) Others………………………………
3) Area of resident………………………………….
4) Name of town…………………………………..
5) District/Municipality……………………………
6) BMI
A) Body weight....................................
B) Body Height.....................................
7) Religion
A) Muslim
B) Orthodox
C) Catholic
D) Protestant
8) Occupation
A) Housewife
B) Government employee
C) Private employee
D) Student
9) Educational Status
A) No formal education
B) Read and write
C) Primary
D) Secondary and above
10) Income Level
A) In-debt
B) Just meets life expenses
C) Insufficient
11) Parity……………………………
A) Primiparous
B) Multiparous
12) Gravida
A) Primi
B) Second
C) Third
D) More than a third………….
13) Birth Spacing in years
A) <2 yrs
B) >2 yrs
14) History of Abortion
A) No
B) Yes
15) Was pregnancy planned
A) Yes
B) No
16) History of stillbirth
A) No
B) Yes
17) Gestational age in weeks
A) <37
B) 37 - 42
C) >42
18) Multiplicity of gestation
A) Single
B) Twin
19) Number of ANC visits..........
20) Pre-eclampsia…………..
A) Yes
B) No
21) Chronic Hypertension
A) Yes
B) No
22) Previous history of Hypertension
A) Yes
B) No
23) Family history of Hypertension
A) Yes
B) No
24) Gestational diabetes mellitus
A) Yes
B) No
25) Previous history of Gestational diabetes mellitus
A) Yes
B) No
26) Family history of diabetes
A) Yes
B) No
27) Drinks alcohol during the current pregnancy
A) Yes
B) No
28) Drinks coffee during the current pregnancy
A) Yes
B) No
29) Performs physical exercise during current pregnancy
A) Yes
B) No
30) Uses traditional medicine
A) Yes
B) No
31) Convulsions during previous and current pregnancy
A) Yes
B) No
32) Mode of delivery of pregnancy
A) Normal vaginal delivery
B) Caesarean section