Pregnancy Induced Hypertension and Associated Factors among Pregnant Women Receiving
Antenatal Care Service at Jimma Town Public
Health Facilities, South West Ethiopia
Tesfaye Abera Gudeta1, Tefera Belachew Lema2 and Sena Belina Kitila2
1Department of nursing, Mizan Tepi University, Ethiopia
2Department of Population and Family health, Jimma University, Ethiopia
3Department of Nursing and Midwifery, Jimma University, Ethiopia
Submission: April 24, 2018; Published: July 17, 2018
*Corresponding author: Tesfaye Abera Gudeta, Department of nursing, Mizan Tepi University, Ethiopia, Email: firstname.lastname@example.org
How to cite this article: Tesfaye A G, Tefera B L, Sena B K. Pregnancy Induced Hypertension and Associated Factors among Pregnant Women Receiving
Antenatal Care Service at Jimma Town Public Health Facilities, South West Ethiopia. J Gynecol Women’s Health. 2018: 10(3): 555792.
Background: Hypertensive disorders of pregnancy are a major health burden in the obstetric population as it is one of the leading causes of maternal and perinatal morbidity and mortality. World Health Organization estimates that at least one woman dies every seven minutes from complications of hypertensive disorders of pregnancy.
Objective:To assess prevalence of pregnancy induced hypertension and associated factors among pregnant women receiving antenatal care service at Jimma town public health facilities, Southwest Ethiopia.
Methods:Health facility based cross-sectional study was carried out from March 01-30, 2015. The study was used the total sample size of 356 pregnant women who were proportionally allocated to the hospitals and health centers. Then the study participants were systematically selected from each health facility. The data was collected using pre-tested structured questionnaireadaptedfrom validated questionnaire, content validity was checked by experts and reliability of the scaled tools were tested by cronbach’s alpha test( 0.70). Prior to analysis data was entered and checked using Epi data and exported in to Statistical Package for Social Sciences (SPSS) version 20.00. Bivariate analysis was carried out between the dependent and independent to identify variables candidate for multivariable logistic regression. Multivariable logistic regression analysis was made to obtain odds ratio and the confidence interval of statistical associations between pregnancy induced hypertension and its associated factors.
Result:Prevalence of pregnancy induced hypertension was 10.3% and among mothers had pregnancy induced hypertension, preeclampsia 23(63.9%) was the most common type. This study also showed that rural residence (Adjusted Odds Ratio (AOR)=5.310, 95%CI=1.518-18.574), positive family history of chronic hypertension (AOR=9.90, 95%CI=2.31-42.44), Positive family history of pregnancy induced hypertension (AOR=9.13(2.33-35.78)), kidney diseases (AOR=3.97, 95%CI=1.36-11.56) and psychological stress (AOR=5.79, 95%CI=1.66-20.25) were statistically significant association with pregnancy induced hypertensi
Conclusion:According to this study, the prevalence of pregnancy induced hypertension was high. Address, family history of chronic hypertension, family history of pregnancy induced hypertension, kidney diseases, psychological stress during pregnancy were the factors contributing pregnancy induced hypertension.
Keywords: Pregnancy induced hypertension; Pregnancy; Antenatal care service; Women
Hypertension in pregnancy is defined as a systolic blood pressure ≥140 or diastolic blood pressure ≥90 mmHg or both.
Both systolic and diastolic blood pressure elevations are
important in the identification of Hypertension Disorder of Pregnancy (HDP) .
Pregnancy Induced Hypertension (PIH) is hypertension in
pregnancy that occurs after 20 weeks of gestation in a woman
with previously normal blood pressure. The general classification
of PIH during pregnancy are Gestational hypertension (without
proteinúria), pre-eclampsia (with proteinúria), and eclampsia
(pre-eclampsia with convulsions)  and there are three
primary characteristics of pregnancy induced hypertension
conditions; high blood pressure (a blood pressure reading
higher than 140/90mmHg or a significant increase in one or
both pressures), protein in the urine, abnormal edema . PIH
is a global problem and the most common medical problem
requiring special attention in the intrapartum period [4,5].
The PIH is usually diagnosed in late pregnancy by the
presence of hypertension with proteinuria and /or edema.
Clinical, biophysical, and biochemical tests have been proposed
for prediction or early detection of PIH. Despite the fact that
diagnostic criteria, the clinical manifestation of the disease,
the management and the prognosis are clear and homogenous,
the prevalence of maternal and fetal complications still differ
considerably among studies .
As a study conducted in Latin American and Caribbean,
Pakistan, New York, and Sri lanka identified the following risk
factors for developing pregnancy induced hypertension: null
parity, multiple pregnancies, history of chronic hypertension,
gestational diabetes, fetal malformation and obesity ,
extreme maternal age (less than 20 or over 40 years), history
of PIH in previous pregnancies, preexisting diseases like renal
disease, diabetes mellitus, cardiac disease, unrecognized chronic
hypertension, positive family history of PIH which shows genetic
susceptibility, psychological stress ,alcohol use, rheumatic
arthritis, very underweight and overweight, and low level of
socioeconomic status are the risk factors for PIH [5,8-10].
According to a population based study in South Africa the
incidence of hypertensive disorders of pregnancy was 12%
and hypertension disorder of pregnancy was the commonest
cause of maternal death which contributed 20.7% of maternal
deaths . Similarly Ethiopian Demographic Health survey
(EDHS) 2011 reported, maternal mortality ratio is 676 deaths
per 100,000 live births and pregnancy induced hypertension
the second leading cause of maternal death . A review study
conducted on the causes of maternal mortality in Ethiopia
showed that, the proportion of maternal mortality in Ethiopia
due to hypertensive disorders between 1980 and 2012 is in
increased trend from 4%-29% .
Pregnancy induced hypertension is leading causes of
pregnancy associated morbidity and it is most frequent cited
cause of maternal death . Despite the fact that hypertensive
disorders in pregnancy is leading causes of maternal morbidity
and mortality during pregnancy but little is known about the
current magnitude and associated factors among pregnant
women in Ethiopia and specifically in Jimma. This study
therefore aims to fill this gap by assessing the current status
and factors associated with hypertensive disorders in pregnancy
among pregnant women attending antenatal service in Jimma
town, south west Ethiopia, through health facility based cross
sectional study. It is hoped that the results of the study will
provide valuable information for the design of possible programs
The study was conducted in Jimma town public health
facilities from March 01-30/2015.The town is located 357
kilometers to southwest of Addis Ababa.The total population
projection of 2014/15 Jimma town was 184925. The town has
one referral hospital, one district hospital, four health centers
and 47 private clinics. The total reproductive age groups and
targets of pregnant women of Jimma town was 40692, 6834
The study was conducted in all public health facilities found
in Jimma town namely; Jimma University Specialized Hospital,
Shenen Gibe Hospital, Jimma Health Center, Higher-2-Health
Center, Mendera Kochi Health Center and Bacho Bore Health
All pregnant women attending antenatal care service at
Jimma town public health facilities during the study period were
considered as source of population and all sampled pregnant
women attending antenatal care service at Jimma town public
health facilities during the study period were considered study
All pregnant women attending antenatal care service with
gestational age greater than 20 weeks were included in the study
whereas pregnant women gestational age less than 20 weeks
and those of critically ill and unable to communicate after full
course of treatment were excluded from the study.
The samples ize was calculated by using a single population
proportion sample size calculation formula, then the final
sample size was 356. The source of population was taken from
twelve months report of pregnant women attending antenatal
care service at all public health facilities of Jimma town. Then
the average was taken, which was 2072 pregnant women
monthly. The total sample size was allocated proportionally to
the different care giving public health facilities found in Jimma
town according to the number of pregnant women attending
antenatal care service in the respective health facilities .Then
the study participants were systematically selected from each
health facilities.The first pregnant woman was selected based on
lottery method and the rest were selected every six interval.
In this study, pregnancy induced hypertension was
operationalized as if the blood pressure of pregnant women
receiving antenatal care service is 140/90mmHg after 20 weeks
of gestation, measured two times six hours apart by trained
data collectors and with or without proteinuria. Pregnancy
induced hypertension includes gestational hypertension, preeclampsia,
and eclampsia, superimposed preeclampsia on
chronic hypertension, andPsychologicalstress operationalized as
psychological stress measurement items of 9 questions score of
single woman greater than that of the mean score was considered
as psychologically stressed.
The data was collected using pre-tested structured
questionnaire adapted and customized from validated
questionnaire [15-17]. Questionnaires were first adapted in
English then translate to Afan Oromo and Amharic by expert and
translated back to English to see consistency of the question.
Seven data collectors who were four diploma midwives and
three nurses in qualification and four supervisors who were BSc
nurses by qualification and who were fluent in speaking, writing
and reading AfanOromo and Amharic language were recruited
purposefully from their respective facilities to maintain the
quality of the data. Data were collected through direct interview
and supported by reviewing of medical record or reports for
pregnant women referred from different health facilities to
the study area for the purpose of taking blood pressure and
protein in urine at time of diagnosis. Pretested structured
questionnaire was used by trained data collectors. Blood
pressure measurements were taken in the sitting position after
the woman has rested at least 10 minutes by using a mercury
sphygmomanometer apparatus from non-dominant arm and for
referred women; BP and protein urea at time of diagnosis were
EPI data Statistical software version 3.1 and Statistical
Package for Social Sciences (SPSS) software version 20.0 were
used for data entry and analysis. After organizing and cleaning
the data, frequencies and percentages were calculated to all
variables that are related to the objectives of the study. Variables
with P-value of less than 0.25 in binary logistic regression
analysis were entered into the multivariable logistic regression.
Odds ratio with 95% confidence interval was used to examine
associations between dependent and independent variables. P.
value less than 0.05 was considered as statistically significant.
The quality of the data was assured by using validated
pretested questionnaires. Prior to the actual data collection;
content validity was checked by experts, pretest was done on 5%
of the total study eligible subjects.The questions used to measure
psychological stress adapted from validated questionnaire then
after modification of the questions the reliability of the questions
tested yielding cronbach’s alpha value of 0.70. Data collectors
were trained for one day intensively on the study instrument
and data collection procedure that includes the relevance of the
study, objective of the study, confidentiality of the information,
informed consent and interview technique. The data collectors
were worked under close supervision of the supervisors
to ensure adherence to correct data collection procedures,
supervisors and investigator checked the filled questionnaires at
the end of data collection every day for completeness. Moreover,
the data were carefully entered and cleaned before the beginning
of the analysis.
Written ethical clearance obtained from Jimma University,
college of health science of Institutional Review Board.
Permission was obtained from respective health institutions
and written consent (signed on the informed consent sheet)
was obtained from pregnant mother attending antenatal care
service after discussing the objective of the study. For pregnant
women were under 18 years old, the written informed consent
were taken from parent. The right of the respondents to refuse
answering for few or all of the questions were also be respected.
The letter of ethical approval was attached with manuscript.
A total of 351 pregnant women participated in the study,
272(77.5%) from antenatal clinics and the rest were from
pregnant women admitted to maternity wards. The mean age
of the respondents was 24.83 with SD±4.85, 119(33.9%) were
between age group of 25-29 years and 210(59.8%) were from
urban and the rest were from rural areas. Ethnicity of the study
subjects indicated that, 252(71.8%) were Oromo followed by
Amhara 42(12%). Majority of the study subjects, 242(68.9%)
were Muslims, 341(97.2%) were married, 158(45.0%) had
primary education, 257(73.2%) were housewives, 232(66.1%)
of them were in the middle income class and 143(40.7%) of
them had family size of 1-2 (Table 1).
The prevalence of PIH among pregnant women receiving
antenatal care services was 36(10.3%). The minimum, maximum
and mean systolic blood pressure were 80mmHg, 190mmHg
and 110.78mmHg with SD±17.10 respectively. The minimum,
maximum and mean diastolic blood pressures were 50mmHg,
140mmHg and 71.85mmHg with SD±13.04 respectively. The
result dipstick urine test, proteinuria ranges from negative to +++
.Out of the total of 36 pregnant women who had PIH, 11(30.6%)
were gestational hypertension, 23 (63.9%) were preeclampsia
and 2 (5.6%) were eclampsia.
From the total study participates, 264(75.2%) of pregnancies
were wanted and 210(59.8%) of pregnancy were multigravida.
Parity of the women showed that 178(50.7%) of women had 1-4
children and majority, 321(91.5%) had gestational age less than
37 weeks. Only 5(1.4%) of pregnant mothers receiving antenatal
care service had previous history of PIH and 26(7.4%) of the
women had multiple pregnancies (Table 2).
Medical and family histories of illness formed the
major predisposing factors, 5(1.4%) had history of chronic
hypertension and 41(11.7%) of them had family history of
chronic hypertension, 24(6.8%) of them had family history
of PIH commonly from women’s relatives, 88 (25.1%) of the
respondents had history of kidney diseases during current
pregnancy, 3(0.9%) had history of diabetic mellitus, 29(8.3%)
and 21(6.0%) had history of rheumatic arthritis and asthma
respectively (Table 3).
All of the respondents did not smoke cigarette, but 35(10%)
had family members particularly their husbands who smoke
cigarette (94.3%) and only 19(5.4%) of the women had any
alcoholic drink in the past two years. Out of the total study
participants, 308(87.7%) of the pregnant women used caffeine
(coffee & tea) drinks .Among the users, 263(85.4%) use coffee and
45(14.6%) use tea commonly. A greater proportion, 318(90.6%)
of the respondents had mid upper arm circumference ≥21cm.
More than half, 209(59.5%) of the respondents sleep 7-8 hours
per night, 52(14.8%) sleep 6 hours, 90(25.6%) sleep ≥9 hours
per night and 104(29.6) had a nap at day time. Only 31(8.8%) of
the women were involved in scheduled regular physical exercise
during their current pregnancy. Based on the nine items used to
assess psychological stress, 140(39.9%) of the pregnant women
had psychological stress. Only 27 (7.7%) did not get diversified
diet (Table 4).
Other*= Children, Relatives, any other person live with family members
Age, family size, gestational age, multiple pregnancy, positive
history of chronic hypertension, diversified diet and antenatal
care follow up before data collection periodwere found to have
significant association with pregnancy induced hypertension.
Family history of PIH, family history of chronic hypertension,
kidney disease, number of routine antenatal care follow up
and psychological stress had strong statistical association with
pregnancy PIH in binary logistic regression.
In multivariable logistic regression analysis, the factors
contributing pregnancy induced hypertension were identified:
Address, positive family history of chronic hypertension, positive
family history of pregnancy induced hypertension, kidney
diseases during current pregnancy and psychological stress
had statistically significant association with pregnancy induced
Pregnant women from a rural residence weremore likely to
report having PIH when compared to those of pregnant women
residing in urban areas (AOR=5.31, 95%CI=(1.52-18.57),
p=0.009), those who had family history of chronic hypertension
were 9.903 times more likely to develop PIH when compared
with pregnant women those who did not have family historyof
chronic hypertension (AOR=19.9 at 95% CI= (2.31-42.44),
p=0.002) and those pregnant women who had family history of
pregnancy induced hypertension weremore likely to developed
pregnancy induced hypertension than those did not have family
history of chronic hypertension(AOR=9.13 at95%CI= (2.33-
Findings of the study showed that those pregnant women
with kidney disease during current pregnancy were more likely
to developed PIH as compared to pregnant women with pregnant
did not have kidney disease during pregnancy (AOR=3.97
at 95%CI=(1.36-11.56),p=0.012) and being psychologically
stressed during pregnancy increases the like hood of PIH
by 5.79 times. (AOR= 5.79, 95%CI= (1.66-20.25, P=0.006)
when compared to those pregnant women who did not have
psychological stress during pregnancy (Table 5).
The above table shows variables the statistically significant variables in the multiple logistic regression analysis after adjusting variables candidate for multivariable logistic regression (Age of
women, address, occupational status, monthly income, family
size, gestational Age, multiple pregnancies, history of chronic
hypertension, family history of chronic hypertension, family
history of PIH, kidney diseases, alcohol intake, diversified diet,
sleep pattern, had a nap at day time, (Antenatal) ANC follow up,
non-routine ANC follow up, utilization of health facility for other
problem and Psychological stress)
Hypertensive disorders of pregnancy are an important
cause of severe morbidity, long-term disability and death among
mothers and their babies . In this study, the prevalence of
pregnancy PIH among pregnant women receiving antenatal
service was 36(10.3%).This reflects that the morbidity and
mortality of the mother and the fetus high due to this diseases
condition. If appropriate preventive measures are not taking
place, the risk of PIH among pregnant women might be ranked as
first cause of maternal mortality.This finding was slightly higher
than global prevalence of pregnancy induced hypertension
which ranges between 5-10%  and also systematic review
study conducted in Nigeria shows that the prevalence of PIH
ranges between 2% to 10% . In addition to the above studies,
the prevalence of PIH in this study was higher than the studies
conducted in Iran which was 9.8% , India 7.8% , Port
Elizabeth 6.69% , and Ethiopia (Tikur Anbessa hospital 5.3%
 and Jimma University specialized hospital 8.5% . The
possible explanation for this difference mightbe the difference in
study period, study design which most of them used longitudinal
study design, sample size and study area. In addition to this, the
gap might be due to current health policy of the country which
was focused on implementation of focused ANC and exempted
service for maternal care might be increases the health care
seeking behaviour of pregnant women which increases the detection of the case. On the other hand an increment of the
prevalence of PIH might be related to an increased burden of
non-communicable diseases in our country
On the other hand, the prevalence of PIH in this study was
lower than the studies conducted in Brazil  and South
Africa  which were 13.9% and 12% respectively. This gap
might be due to the differences in the study period, sample size,
geographical difference of the study areas and health seeking
behavior of the pregnant women in the area.
This study also revealed that factors associated with
pregnancy induced hypertension; residence, positive family
history of chronic hypertension, positive family history
of pregnancy induced hypertension, kidney diseases and
psychological stress are statistically significant association with
PIH. Pregnant women from a rural residence were five times
more likely to develop PIH when compared to those of pregnant
women residing in urban areas.
This finding was in line with the study conducted at
Jimma University Specialized Hospital which showed that
rural residents were more suffered with pregnancy induced
hypertension than urban dwellers  but inconsistent with
the comparative cross sectional study conducted in Ghana
showedthat pregnancy induced hypertension common among
urban than rural area (3.1% versus 0.4% ) . The discrepancy
might be due to the difference in the study area, health polices
of the country, lifestyle of urban women’s of Ghana and health
seeking behavior Ghana’s rural community.
According to this study, those womenwho havepositive
family history ofchronic hypertension and positive family history
of pregnancy induced hypertension had about ten and nine times
respectively greater odds of developing pregnancy induced
hypertension as compared to those whohaven’t it. This finding is
consistent with that of studies conducted in Pakistan , Ghana
 and New York  shows that family history of chronic
hypertension and family history of PIH had strong association
with PIH and also text book of current diagnosis and treatment
in obstetrics and gynecology support this finding . This might
have occurred due to genetic factors that contribute to the
physiologic predisposition of pregnancy induced hypertension.
As this study showed, having kidney disease during
pregnancy increases the likelihood of pregnancy induced
hypertension by 3.97 times. This finding is similar with the study
conducted in the United Kingdom  and Netherlands and New
York  which showed that preexisting renal disease had a
significant association with pregnancy induced hypertension
and other theories support that renal physiological function had
direct relationship with cardiovascular system .
According to this study, being psychologically stressed
during pregnancy increases the likelihood of pregnancy induced
hypertension by 5.79 times. This result was consistent with a
study conducted in New York  and also this finding is in lined
with a study conducted in Sri Lanka with a slight difference
. Stress activates the hypothalamus-pituitary-adrenal cortex
system (HPA), which in turn increases in levels of corticosteroids
and catecholamine. Stress also activates the sympathetic nervous
system and affects the immune system and increased levels of
corticotrophin-releasing hormone and increased sympathetic
activity which increases the risk of PIH .
This study identified the factors contributing pregnancy
induced hypertension, so all pregnant women having such risk
factors should supplemented with calcium, low dose of aspirin
to prevent it and early detection and treatment mandatory to
reduce the morbidity and mortality of women secondary to PIH.
This cross-sectional study has possible limitations that may arise
from pregnant women’sreadiness and ability to provide every
information about themselves and their family correctly based
on which PIH was measured and recall bias may be introduced
during data collection from the pregnant women as they were
However; measure has been taken to minimize these
limitations were using questions targeted information. The
others limitation of this study was few variables have small
observation which causes lower precision, so it was carefully
interpreted.Moreover, the use of pretested and validated
questionnaire, inclusion of all public health institutions found in
Jimma town and data collection from both in patient and ANC
unit were other strengths of this study.
The prevalence of pregnancy induced hypertension among
pregnant women receiving antennal care service was 36(10.3%).
Among pregnancy induced hypertension, preeclampsia was the
most common especially among those pregnant women admitted
to maternity ward. The rural residence, positive family history
of chronic hypertension, positive family history of pregnancy
induced hypertension, chronic renal diseases (kidney diseases)
and psychological stress during pregnancy were the associated
factors with pregnancy induced hypertension.
Written ethical approval was obtained from Jimma University,
college of health science of Institutional Review Board.
Permission was obtained from respective health institutions and
written consent was obtained from pregnant mother attending
antenatal care service after discussing the objective of the study.
And also we attached the ethical declaration letter at the annex
of this manuscript.
The budget of this study was funded by Jimma University and
the researchers of Jimma University and Mizan-Tepi University
participated on this study from proposal development, data
collection and analysis, and writing the manuscript.
We would like to express our deepest gratitude to Jimma
University, College of Public Health for financially supporting us.
Our appreciation also goes to our data collectors, supervisors,
Jimma town health facilities and study participants for their
valuable contribution in the realization of this study.