Objective: Study was carried out to know about awareness of HDsP in rural women of reproductive age.

Material & methods: Community based observational, cross sectional study was conducted in 140 villages in a remote, forestry, hilly region. Randomly included 2500 women of ≥20 to ≤45 years were interviewed over one year. Overall 58.6% had little bit awareness of some aspects of HDsP, complications, however of these 1465 women, only 463were aware that women who had high blood pressure during pregnancy could have headache, giddiness, 320 were aware that high BP was a disorder which occurred, during pregnancy, 577 said for diagnosis of HDsP, blood, urine examination were needed, remaining 28 women who said they were aware, actually did not seem to be aware of anything. There was no difference with age, parity, but level of education had significant impact on numbers with awareness. Of 1465 women 1334, were aware about dangers, 630 convulsions with hypertension, 278 said that HDsP were associated with pain in abdomen, vaginal bleeding, and 208 said possibility of respiratory arrest. Overall 66 didn’t know anything, other than it was a disorder. Out of 1465 women, 1166 were aware that HDsP could result in serious complications in baby. There was no difference with age, parity, but literacy did affect significantly. Of 1465 women with awareness, only890 said that HDsP were preventable, 294 through good antenatal care, 241 by proper control of BP during pregnancy, 197 with rest, plenty of fluid, low salt, other measures, remaining 158 did not say anything about prevention. Various variables did affect numbers, more elders, literate were aware.

Conclusion: Many women did not know about HDsP. Those who knew also many did not know about associated complications, impact on baby, prevention possibilities. If women did not know about disease they cannot be expected to know about timely care, future possibilities, need of follow up and action needed in future life. Health systems need to respond.

Keywords: hypertensive disorders, pregnancy, awareness, impact, prevention

Women with preexisting hypertension or those who get hypertensive disorders during pregnancy (HDsP) are known to have higher risk of adverse pregnancy outcome. Braunthal et al.,¹ from United States opined that HDsP, which included, preexisting hypertension, gestational hypertension, preeclampsia, and eclampsia, affected around 5-22% of pregnancies globally. Numbers are more in developing countries. Also there is quite a lot of evidence that any form of hypertension in pregnancy affects mother as well as the baby’s health during pregnancy, birth and their future life too. Also there is significant maternal and perinatal morbidity and mortality due to HDsP, more in low and middle income countries (LMIC). Acanthi et al.,² reported that increasing trends of severe pre-eclampsia in the USA, may be because of advance age at pregnancy. Dines et al.,³ also reported that HDsP were increasing as major causes of maternal morbidity and mortality in the USA. Singh et al.,⁴ reported that HDsP were increasing in the rural areas of Assam, India, but the awareness of disorders was quite low, necessitating studies and action in this regard. HDsP are persisting problems, actually increasing too, around the world. So it is essential that women who are the one who get the disorder, know about the disorder and possibilities of prevention. There are scarce reported studies, especially rural community based.

Community based study was carried out to know about awareness of HDsP in women of reproductive age in a rural remote region.

After taking institute’s ethics committee’s approval, information about awareness of women and their perceptions regarding HDsP was collected by using a predesigned tool, with some questions for yes or no answers and others for short answers. After informed consent, women of reproductive age were interviewed in their own villages at mutually convenient places. Information was recorded on the hard tool. No one was given to fill.

Study setting: Community based study in 140 villages around the village with health facility (study center) in a remote, forestry and hilly region.

Study design: Observational cross sectional study.

Study period: One year.

Inclusion criteria: Randomly women of ≥20 to ≤45 years residing in the study villages, willing to be part of the study and in a position to answer relevant questions in the tool were enrolled as study participants.

Exclusion criteria: Those <20 years or >45 years, not willing to give responses were planned to be excluded. However no one with inclusion criteria had to be excluded.

Sample size: The sample size was calculated using a free online statistical calculator with 95% confidence, and 2% absolute precision, rounded to2500, study subjects, minimum 15 from each village, using a random number table to attain more than the desired sample size as some villages were small others little bigger.

Of the total 2500 women interviewed, many were 30-39 years old, illiterate, laborer by occupation, and belonged to low economic class, many had one to two children. Of 2500 participants, who were interviewed, 1465 (58.6%) had little bit of awareness of some aspects of HDsP and resultant complications. However of these 1465 women, only 463 (31.6%) were aware that women who had high blood pressure during pregnancy could have headache and giddiness, 320 (21.8%) were aware that high blood pressure was a disorder which occurred during pregnancy, 577 (39.4 %) said for diagnosis of HDsP blood and urine examination. were needed and remaining 28 women who had said they were aware of HDsP actually did not seem to be aware of anything. There was no difference with age, but level of education had significant impact on numbers with awareness (P value<0.01). Less homemakers were aware compared to shopkeepers etc. (P value <0.05). Also more women of upper class were aware compared to low economic class, however upper class women were very less. Parity did not change the numbers Table one depicts information about women who had awareness of HDsP with modes of diagnosis in relation to various variables (Table 1). Out of 2500 study subjects, only 1334(91%of 1465 who had awareness of HDsP) were aware about the dangers of HDsP during pregnancy, 630 (47.2%of those who were aware) were aware that convulsions could occur with hypertension, 278 (20.8%) said that HDsP were associated with pain in abdomen and vaginal bleeding, 208 (15.6%) did talk of possibility of respiratory arrest. Overall 66(4.5) didn’t know anything, other than it was a disorder during pregnancy. Out of 1465 women, 1166 (79.45%) were aware that HDsP could result in serious complications in the baby. There was no difference with age and parity, but literacy did affect the numbers significantly (p value<0.01). However there were few graduate/ postgraduate studied women. More laborers were aware than others, probably because while working together, they shared information (P value<0.05). Table II depicts the awareness of dangers in HDsP (Table 2).

Out of 1465 women, 890 (60.75%) said that hypertension was preventable, 294 (33%) said it could be prevented through good antenatal care, 241 said (27.1 %) by proper control of blood pressure during pregnancy and 197 (22.1%) with adequate rest, plenty of fluid, low salt intake and other measures. The remaining 158 (17.8%) did not say anything about prevention of hypertension during pregnancy. Various variables did affect the numbers, more elders were aware (p value<0.05) and educated too (p value<0.05), however such cases were less. Numbers of upper class women were also small, though there was significant difference (p value<0.) Table III depicts awareness about the mode of prevention of HDsP (Table 3).

Information about awareness of women, especially rural in context of HDsP, is lacking. There are hardly any community based studies. In the study conducted in South Ethiopia, Ayele et al.,⁵ suggested that for investigating the determinants of HDsP for evidence based public health interventions, in local context special emphasis was needed for the mothers who had preexisting chronic medical illnesses, age beyond best for reproduction and prim gravida for early recognition and readiness for timely appropriate management of HDsP. The present community based study was conducted with 2500 reproductive age rural women between >/ 20 to <45 years of age to know their awareness about hypertension during pregnancy and awareness of its effects on mother and baby. It revealed that around 42% did not know anything about HDsP. Of those who had some awareness also, 69% did not know about symptom and 78% women did not know that high blood pressure was a disorder during pregnancy. Olaoye et al.,⁶ did a study to know about the knowledge, perceptions and management of HDsP among health providers in a maternity hospital of Nigeria and reported gaps in the awareness of causes, diagnoses, and treatment of HDsP. It may be attributable to lack of training and absence of written guidelines for management of HDsP. In the present study, it was found that only 58.6% women had some awareness of HDsP and little information about associated events during pregnancy. Out of these 58 % women also 20% did not know that there were dangers associated with HDsP. Savage et al., ⁷ did a community based study which aimed at assessment of knowledge of women living in Tanzania, comparing respondent’s subgroups with different demographic characteristics which revealed that for provision of potential life-saving information to communities, community health centers and educational programs were essential. In the present study very few participants knew about the serious complications like convulsions and serious impact on mother and baby. Espinoza et al.,⁸ opined that while a variety of risk factors have been associated with increased probability of HDsP, most cases of HDsP occurred in healthy women with no obvious risk factors. Women’s awareness of at least hypertension, proteinuria, swelling of the face or hands and a weight gain is essential. Affected women are likely to experience headaches, dizziness, irritability, shortness of breath, a decrease in urine output, upper abdominal pain, and nausea or vomiting. Changes may develop in vision including flashing lights, increased sensitivity to light (photophobia), blurring of vision, or temporary blindness. In the present study out of 2500 women, 1166 (46.6%) were aware that HDPs could result in serious complications in the baby. Gebremedhin et al.,⁹ did a population based study in Australia to know about association between inter pregnancy interval and HDsP and reported that the risk of preeclampsia increased at longer IPIs compared to 18 months for mothers 35 years or older and to a lesser extent for mothers of 30 to 34 years. Compared to18 months, the risk of preeclampsia was lower at 12 months of IPI for mothers younger than 20 years, but not for mothers 35 years or older. Such things should be known to health providers as well as women for timely recognition and further action. In the present study out of 2500 participants, 1465 had some awareness about HDsP, 463 (31.6%) were aware that hypertension in pregnancy was associated with headache and giddiness, only 320 (21.8%) knew about high blood pressure as a disease during pregnancy, 577 (39.4 %) talked about importance of blood and urine examination. Remaining 28women who said they knew could not tell anything. A study¹⁰ conducted in rural Karnataka, India with focus groups facilitated by local researchers with clinical and research expertise revealed terminologies exist in the local language to describe convulsions and hypertension, but there were no terms that were specific to pregnancy. Community participants perceived stress, tension and poor diet to be precipitants of hypertension in pregnancy. Seizures in pregnancy were thought to be brought on by anemia, poor medical adherence, lack of tetanus toxoid immunization, and exposure in pregnancy to fire or water. Sweating, fatigue, dizziness-unsteadiness, swelling, and irritability were perceived to be signs of hypertension, which was recognized to have the potential to lead to eclampsia or death. Home remedies, such as the smell of onion, placing an iron object in the hands, or squeezing the fingers and toes, were all used regularly to treat seizures prior to accessing facility-based care although transport was not delayed. HDsP are not well-known. Hypertension and seizures are perceived as conditions that may occur during or outside pregnancy. Improving community knowledge about, and modifying attitudes towards, hypertension in pregnancy and its complications (including eclampsia) has the potential to address community-based delays in disease recognition and delays in treatment that contribute to maternal - perinatal morbidity and mortality. Advocacy and educational initiatives should be designed to target knowledge gaps and potentially harmful practices, and respond to cultural understandings of disease. In another study¹¹ participants were adult women with a history of preeclampsia and women with normal pregnancies were used as the comparison group. utilizing an online, self-administered questionnaire and findings revealed that more than half of the women with prior preeclampsia (55.4%) were not aware of hypertensive disorders that can occur during pregnancy before their diagnosis, and a similar percentage (45.2%) had not received information about the long-term health risks following their diagnosis, only 4.7% with a history of preeclampsia were aware of the risk of developing cardiovascular diseases. There were no statistically significant differences between the preeclampsia and the comparison group regarding their concerns about long-term health risks, frequency of health checks, perceptions of factors influencing cardiovascular disease development, and doctor communication about different health topics, except from hypertension or high blood pressure. This emphasized the importance of implementing public health programs aimed at promoting cardiovascular risk assessment and effective management, both for clinicians and women with experienced preeclampsia. Study by Khawaja et al.,¹² from Pakistan explored community perceptions, and traditional management practices about HDsP and reported that HDsP were not recognized as a group of disorders and there was no name in the local language to describe the disease. Women, however, knew that high blood pressure could develop during pregnancy. It was widely believed that stress and weakness caused high BP in pregnancy which lead to headache. Also perception of high BP was not based on measurement of BP, but on symptoms. Self- medication was often used for headache associated with high BP. Women were also aware that severe high BP could result in death. In the present study out of2500 study subjects, 1334 had some awareness about the dangers with HDsP, 630 (47.2%) knew that convulsions could occur, 278 (20.8%) said that HDsP were associated with pain in abdomen and vaginal bleeding, 208 (15.6) did talk about possibility of respiratory arrest, 66(4.5%) did not know anything about features of HDsP. Mrema et al.,¹³ reported that studies from developed countries revealed that high pre pregnancy body mass index (BMI),increased the risk of preeclampsia compared to those with normal BMI, overweight and obese women had a higher risk of HDsP globally but more in developing countries.. Melchiorre et al.,¹⁴ from UK reported that women who had HDsP were known to have higher cardiovascular morbidity and mortality later in life compared to those who had normotensive pregnancies. Several studies have revealed that women with preeclampsia are likely to have cardiovascular disorders in future life. Women who have had preeclampsia have approximately twice the lifetime risk of heart disease and stroke than do women in the general population. Although there is general agreement that women who suffered from HDsP should undertake early screening for cardiovascular risk in order to allow for appropriate preventive strategies the exact timing and modality of screening have not been standardized yet. It has been suggested that prevention should start as early as possible after delivery by making the women aware of their increased cardiovascular risk and encouraging weight control, take healthy diet, exercises and not to smoke which were well-established and use cost-effective preventive strategies. However for follow-up also awareness is essential. In the present study 42% did not know anything about the disorder and of those who knew also many did not know about symptoms and diagnosis .Of those who knew around 5% did not know that it could be dangerous for mother and baby .Almost two third women did not know anything about prevention. In the present study out of 2500, only 890 (35.6%) women were aware that severe HDsP were preventable , 294 (33%) said that they could be prevented through good antenatal care, 241 (27.1 %) by proper control of blood pressure during pregnancy and 197 (22.1%) with adequate rest, plenty of fluid, low salt intake and other measures. The remaining 158 (17.8%) did not know anything about prevention. Ayele et al.,⁵ also reported that around 15% of women who had gestational hypertension suffered from chronic hypertension in future life and, risk was greater with preterm HDsP and preterm births. HDsP could also affect the offspring’s adult health too. Researchers opined that preeclampsia, heart disease, and stroke may share common risk factors.

Many women did not know about HDsP. Those who were aware also, many did not know about associated complications, impact on the baby and prevention possibilities. If women did not know about disease, they cannot be expected to know about prevention, timely care, future possibilities, need of follow up and action needed in future life. Early recognition of symptoms and signs of HDsP is expected to prevent some complications. If women do not know about HDsP during pregnancy, they will not know about symptoms, signs and future effects. All this needs awareness of women.  Health systems need to respond.

Authors are grateful for financial assistance which was only for some honorarium to field assistant and to communities for all the cooperation.

None.

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