Short- and intermediate-terms health outcomes following Hypertensive Disorders in Pregnancy in Nigeria

Chapter 1 introduces the thesis. Chapter 2 evaluates knowledge and skills of antenatal care providers and the capacity of the health system to detect and manage HDP in Nigeria. All domains of quality except provider interpersonal skills scored below 55%. The lowest overall scores were observed in provider knowledge (49.9%) and provider technical skill (47.7%). PHCs performed significantly worse than hospitals in all elements of quality except for provider interpersonal skills. Provider knowledge was significantly associated with their designations. Chapter 3 assessed level of compliance to guidelines in postpartum management HDP across tertiary hospitals. In general, level of adherence is poor. Institutionalization of guidelines linked to the entire continuum of maternity care is recommended. Chapter 4 assessed the prevalence of persistent hypertension up to one year in women with HDP and determined associated risk factors. Among women diagnosed with gestational hypertension and pre-eclampsia/eclampsia, 22.3% (95% CI; 8.3 – 36.3) and 62.1% (95% CI; 52.5 – 71.9), respectively, had persistent hypertension at 6 months and this remained similar at one year 22.3% (95% CI; 5.6 – 54.4) and 61.2% (95% CI; 40.6 – 77.8), respectively). Maternal age and body mass index were significant risk factors for persistent hypertension at one year after delivery [aORs = 1.07/year (95% CI; 1.02 -1.13) and 1.06/kg/m2 (95% CI; 1.01-1.10)], respectively. Chapter 5 studied the association of metabolic syndrome with history of HDP. The prevalence of metabolic syndrome among those with HDPs were 17.4% (71 of 407), 8.7% (23 of 263), 4.7% (11 of 232) and 6.1% (17 of 278), at delivery, nine weeks, six months and one year postpartum, respectively. The incidence rate for metabolic syndrome in HDP versus normotensive at one year were, respectively, 57.5/1000 persons’ year (95%CI; 35.8 – 92.6). and 16.9/1000 persons’ years (95%CI; 2.4-118.3), with incidence rate ratio of 3.4/1000 person’s years. Only parity significantly predicted the presence of metabolic syndrome for women with HDP at one year in the multivariable logistic analysis. Chapter 6 reported association between previous HDP and chronic kidney diseases (decreased eGFR < 60mL/min/1.73m2 lasting for ≥ three months). Within 24 hours of delivery, nine weeks and six months postpartum, women with HDPs were more likely to have a decreased eGFR compared to their normotensive counterparts (12%, 5.7%, 4.3% versus 0%, 2% and 2.4% respectively). The prevalence of CKD in HDPs at six months and one year postpartum was 6.1% and 7.6%, respectively, and zero in the normotensive cohort. Only maternal age independently predicted occurrence of CKD at six months postpartum. Chapter 7 explored survivor perceptions of pre-eclampsia and eclampsia in Nigeria through the health belief model. It was found that many of the beliefs, attitudes, knowledge and behaviors of women are consistent across the country, with some variation between the north and south. Women’s perceived susceptibility and threat of health complications during pregnancy and childbirth, including pre-eclampsia and eclampsia, influence care-seeking behaviors. Chapter 8 recommends a primary health care model for managing pre-eclampsia and eclampsia that should be adopted and scaled up, which displays the linkages and opportunities to prevent and treat PE/E in a simplified way; however, there are numerous interlinking factors, angles, and critical points to consider including leadership, policies and protocols; relevant medicines and commodities, ongoing capacity building strategies at lower levels and understanding what women and their communities want for safe pregnancies. Conclusion All stakeholders should be educated that effects of HDPs are beyond during pregnancy and childbirth but potentially life-long. To accelerate research around HDPs in LMICs, a collaboration between local/international NGOs and academic research institutions is highly recommended.