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

• Published in: PLoS medicine Vol. 16; no. 4; p. e1002783
• Main Authors: Magee, Laura A., Sharma, Sumedha, Nathan, Hannah L., Adetoro, Olalekan O., Bellad, Mrutynjaya B., Goudar, Shivaprasad, Macuacua, Salécio E., Mallapur, Ashalata, Qureshi, Rahat, Sevene, Esperança, Sotunsa, John, Valá, Anifa, Lee, Tang, Payne, Beth A., Vidler, Marianne, Shennan, Andrew H., Bhutta, Zulfiqar A., von Dadelszen, Peter
• Format: Journal Article
• Language: English
• Published: United States Public Library of Science 12.04.2019; Public Library of Science (PLoS)
• Subjects: Adult; Analysis; Blood pressure; Care and treatment; Children & youth; Childrens health; Clinical trials; Complications; Cross-Sectional Studies; Developed countries; Diagnosis; Eclampsia; Female; Gestation; Gestational age; Gestational hypertension; Gynecology; Health care facilities; Higher education; Hospitals; Humans; Hypertension; Hypertension - epidemiology; Hypertension, Pregnancy-Induced - epidemiology; Incidence; India - epidemiology; Industrialized countries; Life sciences; Low income groups; Maternal mortality; Medical personnel; Medical personnel training; Medicine; Medicine and Health Sciences; Mozambique - epidemiology; Nigeria - epidemiology; Obstetrics; Pakistan - epidemiology; Pakistani foreign relations; People and Places; Polls & surveys; Pre-eclampsia; Pre-Eclampsia - epidemiology; Preeclampsia; Pregnancy; Pregnancy complications; Pregnancy Complications - epidemiology; Pregnant women; Prenatal Care; Primaries; Proteinuria; Risk factors; Secondary analysis; Supervision; Women; Womens health; Workers; Young Adult; Mozambique; Pakistan; Nigeria; India; Canada; United Kingdom > UK; Toronto Ontario Canada; Vancouver British Columbia Canada; Karachi Pakistan
• ISSN: 1549-1676; 1549-1277; 1549-1676
• DOI: 10.1371/journal.pmed.1002783

Most 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. CLIP-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%). Pregnancy 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. This study is a secondary analysis of a clinical trial - ClinicalTrials.gov registration number NCT01911494.