Knowledge and Awareness of Pregnancy-Related Hypertension and Utilization of Exercises as its Preventive Strategies

Survey of Pregnant Women in Enugu State, Nigeria

Abstract

Introduction: 

Pregnancy-related hypertension (PRH) is the leading cause of maternal and fetal morbidity and mortality. Knowledge and prevention strategy of PRH among pregnant women is imperative to promote favourable outcomes. This study examined the knowledge and awareness of PRH, including exercises as a preventive strategy and factors related to it, among pregnant women in Enugu, Nigeria.

Materials and Methods: 

The study utilized a cross-sectional design. A structured questionnaire guided the collection of data from a sample of 296 women aged 18 years and above in multiple centres across the state.

Results: 

68.6% of respondents know PRH, while 52.36% know antenatal exercises as a preventive strategy for PRH. The level of education and maternal age were factors significantly associated with knowledge of PRH and exercises as a preventive strategy, respectively.

Conclusion: 

The study concluded that knowledge of PRH is high, while the knowledge and use of exercises to prevent the condition is average among expectant mothers.

INTRODUCTION

Among the common pathophysiological conditions of pregnancy is pregnancy-related hypertension (PRH), which manifests as a combination of raised blood pressure of systolic blood pressure ≥140 or diastolic blood pressure ≥90 mmHg or both.[¹] The description can occur as chronic, gestational, preeclampsia or eclampsia depending on the gestational period, the tendency for postpartum resolution, presence of proteinuria or seizure activities.[²] Preeclampsia and eclampsia are the most common PRH associated with adverse maternal and fetal effects.[¹]

Globally, PRH is a significant public health threat, occurring mainly in developing countries, accounting for 14% of maternal mortality worldwide and 16% in Sub-Saharan Africa.[³] The negative impacts of maternal death have been widely documented, such as disintegration in family bonding, decreased household productivity and income.[⁴⁵] Preserving maternal health is one of the critical components of the World Health Organization's Millennium Development Goals. This advocacy for safe motherhood is a sine qua non to reducing maternal morbidity and mortality, achievable through activities like “quality care offer” during the antenatal, perinatal, postnatal period and most importantly, creating awareness during these periods.

Knowledge plays an essential role in decreasing the risk or threat of diseases. It is essential to understand disease conditions so that rational decisions and appropriate health-seeking behaviours can be achieved.[⁵]

Poor knowledge of PRH, negative attitude and lack of preventive practices by pregnant women saddled with customary and cultural beliefs have been linked to a high maternal mortality rate.[⁴⁶⁷] Furthermore, Al Ebrahimy et al.[⁸] suggested that 50% of complications of PRH can be prevented with patient education and counseling, implying that knowledge is proportional to prevention. Studies[¹⁷⁸] have found poor awareness of pregnancy-induced hypertension (PIH) and correlated it with low-level maternal literacy. Conversely, Nigerian studies in the South-west and South-south reported a high awareness/knowledge of PRH, attributing it to urban places of residence, higher formal and antenatal education. However, studies are scarcely visible on the knowledge/awareness and associated factors of PRH in other parts of Nigeria.

Hypertension screening is inexpensive and straightforward. Although effective prevention methods of PRH are limited, physical activities have been documented to play a role in its control.[⁹¹⁰] Exercises have been reported to attenuate the increase in blood pressure and the loss of parasympathetic tone associated with pregnancy, thereby improving both maternal and fetal optimal outcomes generally.[¹¹] The effectiveness of exercise as a means of preventing and or managing PRH is also well documented. Equally, the association between antenatal exercises and a significantly lower incidence of hypertensive disorders/gestational hypertension has been reported.[¹⁰¹²] Similarly, Barakat et al.[¹³] sounded a note of warning that non-exercising pregnant women have a three times higher chance of developing hypertension than their exercising counterparts. However, exercise as a preventive strategy for PRH in Nigeria is not common knowledge because literature seems silent on it. Sufficient advocacy beyond creating awareness is imperative to promote antenatal exercise as a preventive strategy of PRH.

Given the Nigerian situation on PRH, it became imperative to determine the knowledge and awareness of PRH and awareness of utilizing exercises as both a preventive and management strategy among pregnant women in Enugu city, Nigeria.

MATERIALS AND METHODS

Study area

This study was carried out in Enugu city, the capital of Enugu State in south-eastern Nigeria. Two out of three local government areas in Enugu city, Enugu North, and Enugu South were involved in this study. According to the last national population census, Enugu North had a population of 242,140, while Enugu South had 198,032.[¹⁴] Enugu North has three tertiary, 41 secondary and 44 primary health facilities, while Enugu South has one tertiary, 39 secondary and 27 primary health facilities.[¹⁵]

Study design and location

This work is a cross-sectional study of pregnant women in Enugu State, Nigeria. Two major government health care facilities and a private hospital in Enugu North and Enugu South were used for the study.

Eligibility criteria

Inclusion criteria

Every pregnant woman greater than or equal to 18 years attending antenatal care in the selected hospitals was included during the study, July 1^st–5^th, 2019.

Exclusion criteria

Pregnant women on admission in the selected hospitals were excluded during the study.

Sample size determination

Sample size of 296 was derived for the study using Taro Yamane's formular.

N = N/1 + N (e)², where

n = Sample size, N = Whole population, and e = Sample error of 0.05.

N = 1150 (population attending antenatal care per week in the 3 hospitals)

n = 1150/1 + 1150 (0.05)² = 1150/1 + 2.875, =1150/3.875 = 296.8

Sampling technique

All pregnant mothers attending antenatal care in the selected three hospitals from July 1–5, 2019, constitute the study population. The hospitals were conveniently selected.

Study instrument

A self-structured questionnaire divided into two sections (A and B) was used for the study. Section A, containing information on age, sociodemographic data and maternal characteristics, was used to elicit information on variables such as religion, occupation, educational level, marital status, number of pregnancies, number of birth, number of children, and inception of current antenatal care. Section B contains eight questions used to assess their knowledge and awareness of PRH, utilizing exercises as a preventive and management measure against PRH.

Data collection procedure

Four physiotherapists collected the data. The participants got an explanation of the study's purpose, and the questionnaires were administered to those who agreed to participate.

Data analysis

Descriptive statistics of frequencies, mean and percentages were used to describe the study population. Independent Chi-square tests were used to evaluate awareness and knowledge of exercises as prevention for PRH and factors associated with PRH among respondents. Statistical Package for Social Sciences (SPSS) for windows version 21.0 (IBM Corp., Armonk, New York, USA) was used for the analysis with P < 0.05 statistical significance.

Ethical consideration

Ethical clearance was obtained from the three hospitals, and informed consent was obtained from the respondents.

RESULTS

The respondents' mean age is 27.98 ± 4.51. The sociodemographic statistics of the respondents and maternal characteristics are presented in Table 1. The majority of the respondents were Christians (97.30%), had secondary education (45.61%), were married (91.25%), and were into business (40.6%). 49.3% have been pregnant 2–4 times, 49% are nulliparous, 50.5% do not have children, while 50.7% started antenatal care at 4–6 months. Awareness of PRH is presented in [Table 2]. The majority (68.6%) knew about PRH, and their source of information on PRH was from antenatal and postnatal clinics (45.32%). [Table 3] presents knowledge and utilization of antenatal exercises as preventive and management strategies for PRH. 52.36% of the respondents knew antenatal exercises as preventive and management strategies for PRH. Of this population, 12.84% were diagnosed with hypertension, and greater than half (52.63%) received exercise prescriptions, mostly from nurses (44.44%). The majority (88.24%) of respondents who received exercise prescriptions complied and reported good outcomes. Factors associated with knowledge of PRH are presented in Table 4. A significant association existed only between the level of education and PRH (P = 0.030). Factors associated with knowledge of exercises as a prevention strategy for PRH are presented in [Table 5]. A significant association existed between maternal age and knowledge of exercises as prevention for PRH (P = 0.030).

Table 1: Age, sociodemographic, and maternal characteristics of respondents

Table 2: Awareness of pregnancy-related hypertension among respondents

Table 3: Knowledge and utilization of antenatal exercises as preventive strategy and management of pregnancy-related hypertension

Table 4: Age and demographic variables associated with knowledge of pregnancy-related hypertension among respondents

Table 5: Factors associated with knowledge of exercises as prevention for pregnancy-related hypertension

DISCUSSION

This study aimed to answer the following clinical questions. What is the level of awareness of expectant mothers in Enugu city on PRH? What is their understanding of the knowledge and utilization of antenatal exercises as both preventive and management strategies for PRH, including their compliance levels? What demographic variables are associated with it?

This study showed that 68.6% of the respondents know about PRH. This value is lower when compared to previous studies in Ekiti State, South-west and Cross River State, South-south Nigeria, which reported values of 82.0%.[⁴⁵] This may be due to cultural differences as Enugu is primarily populated by the Igbo tribe, mainly traders who have little time to check or understand PRH. In addition, a common prevailing religious belief that a pregnant woman could be under “spiritual attack” may deter knowledge of PRH or fuel its ignorance.

There is a marked difference in the value from this study compared to reported values in studies done in some African countries such as Ghana and Ethiopia. A miserly 11.4% of pregnant women in Ghana had adequate knowledge of preeclampsia,[¹⁶] while 58% had ever heard of PIH,[¹] and only 28.8% had good knowledge of preeclampsia[¹⁷] in Ethiopia.

There are variations in documented values in India. The report has it that 63.6% had average knowledge, and 22.7% had good knowledge;[¹⁸] 55% had average knowledge, and 14% had good knowledge[¹⁹] of PIH. Conversely, 70.7% of insufficient knowledge of gestational hypertension was also reported.[²⁰] Although the study used a different nomenclature to qualify the condition, this nomenclature variation may have contributed to its low value.

A lowly 20.70% good knowledge of PIH was documented in Iraq.[⁸] Iraq is recovering from several wars and turmoil, which may negatively have impacted the values obtained.

The major source of information about PRH in this study was health facilities. This finding is similar to other Nigerian studies[⁴⁵] as well as the study in Ethiopia[¹] but incongruent with,[⁸²¹] whose principal source of information was friends and relatives.

This study showed that 52.36% of the respondents know antenatal exercises as a preventive strategy for PRH. From this group, 12.84% were diagnosed with hypertension and greater than half received exercise prescriptions, mostly from nurses. In addition, the majority of the respondents who received exercise prescriptions complied and reported good outcomes. This finding aligns with,[²¹] who reported a positive association between physical activities during pregnancy and reduced gestational hypertensive syndrome.

The level of education is associated with knowledge of PRH. This finding is hardly surprising and is supported by many studies, which concur that awareness of PRH is directly proportional to the level of education.[^{116171819202223}] However, Al Ebrahimy et al.[⁸] found no correlation between educational level and knowledge of PRH. It should be pointed out that having a greater level of education makes it easier for anyone to cast off ignorance, furnish understanding, reduce delay in seeking out solutions, in this case, health-related solutions like regular antenatal visits and exercise, as well as increased possibility of compliance to established protocol.

Maternal age did not show association with awareness of PRH. This result corroborates with the findings of Aswathy et al[¹⁸] & Anita[¹⁹] Nevertheless, a report of a statistically significant association between age and awareness of PRH has been documented.[⁸¹⁷²⁰]

In addition, this study found no association between occupation and awareness of PRH. This result agrees with Al Ebrahimy et al[⁸], Mekie et al[¹⁷] & Aswathy et al[¹⁸] but is at Variance with Berhe et al[¹] & Anita[¹⁹] which reported an association. Similarly, a marital status held no association with awareness of PRH, Which is in line with Fondjo et al.[¹⁶]

The maternal characteristics of the respondents held no association with awareness of PRH. Results from previous studies on this are conflicting and highly variable. Parity was associated with PRH,[¹⁹] but Aswathy et al[¹⁸] reported parity held no association, while many pregnancies showed an association.[¹] The association has been reported with being primiparous[²³] while first pregnancy lacks association.[¹⁶] The inception of antenatal at first trimester was associated,[¹⁷] but the association on family size was inconclusive.[²³]

Maternal age is associated with knowledge of exercises as prevention for PRH. The positive correlation between knowledge of exercise and preventing PRH with maternal age may be related to knowledge being refined with increasing age, as the experiential knowledge and a desire, perhaps, to ensure favourable outcomes take precedence. Although exercise as a deterrent to PRH seems to increase with maternal age, literature is scarcely visible on demographic variables associated with it.

CONCLUSION

This study showed that the level of awareness of PRH among expectant mothers in Enugu city is well above average. The knowledge and utilization of exercise as a preventive and management strategy is just average. Compliance and positive outcomes following exercises were rated high also. Again, this study seems to highlight the back seat taken by physiotherapists concerning antenatal exercises and exercise prescription for expectant mothers.

Limitation

Its urban setting may have limited the study as the results may not be applicable in a rural setting. Furthermore, the questionnaire design may have lacked specificity concerning the degree of knowledge levels about PRH, exercise prescription, type of exercises and augmentation with drug therapy, and factors impeding compliance.

Recommendation

This study recommends a similar study, inclusive of the missing data mentioned, in a rural setting as the way forward.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgment

We would like to acknowledge the respondents.