There were a total of 19,374 deliveries at MTRH between June 1, 2012 and May 31, 2014. There were 8,472 deliveries before and 10,902 deliveries after the introduction of free maternity services. The proportion of women diagnosed with a hypertensive disorder of pregnancy was higher in the year before free maternity care was introduced (12.8% vs 11.4%, p=0.0029). Overall, 60% of the charts belonging to women with a hypertensive disorder of pregnancy were available for data collection. Our analysis included 412 patients before, and 623 after the policy change. Please refer to Figure 1 for further details.
As shown in Table 1, demographic characteristics between groups. The mean patient age was 27.4 ±SD 6 and the median parity was 1. There was no significant difference in the proportion of adolescents (aged 10-19 as per the WHO) or women > 35 years of age who presented for care. Most women reported being married (80%) with the most commonly reported form of employment being work within the home (38%). There was no difference in distance traveled to hospital or in the referral rate from smaller, community facilities. There was no difference in the proportion of women with a history of chronic hypertension or diagnosis of preeclampsia or eclampsia in a previous pregnancy before and after the policy change.
Table 1: Background demographic and health characteristics
Demographic
|
Before (n=428)
|
After (n=623)
|
P value
|
Age (mean)
|
27.4 (SD 6.06)
|
27.4 (SD 6.06)
|
0.945
|
Age < 20
|
32 (7.5%)
|
38 (6.1%)
|
0.379
|
Age > 35
|
47 (11.0%)
|
67 (10.8%)
|
0.907
|
Parity
0
1-4
4+
|
216 (49.5%)
179 (41.1%)
41(9.4%)
|
311 (49.6%)
257 (41.0%)
59 (9.4%)
|
1.000
|
Distance from Hospital (km)
|
23.6 (SD 37.6)
|
25.6 (SD 37.1)
|
0.415
|
Referred from Periphery
|
154 (40.3%)
|
242 (42.6%)
|
0.481
|
GA (at presentation)
< 28 weeks
28-34
>34 weeks
|
17 (4.6%)
61 (16.4%)
293 (79.0%)
|
28 (5.3%)
107 (20.2%)
393 (74.5%)
|
0.619
0.151
0.118
|
Education
None
Primary
Secondary + Post-Secondary
Missing
|
2 (0.5%)
40 (9.2%)
148 (34%)
246 (56.4%)
|
3 (0.5%)
53 (8.5%)
230 (36.7%)
341 (54.3%)
|
0.744f
|
Marital status
Single
Married
Separated/Divorced
Missing
|
78 (17.8%)
351 (80.5%)
2 (0.5%)
5 (1.2%)
|
112 (17.9%)
505 (80.5%)
0 (0.0%)
10(1.6%)
|
0.425f
|
Medical History
cHTN
|
15(0.03%)
|
25(0.04%)
|
0.389
|
RHD
|
1 (0.0%%)
|
0 (0.0%)
|
0.230
|
Diabetes
|
1 (0.2%)
|
2 (0.3%)
|
1.000f
|
Renal
|
2 (0.5%)
|
0 (0.0%)
|
0.168f
|
Pulmonary
|
7 (1.6%)
|
6 (1.0%)
|
0.344
|
Neurologic
|
6 (1.4%)
|
3 (0.5%)
|
0.172f
|
HIV
|
17 (3.9%)
|
27 (4.3%)
|
0.743
|
History of
PET
Eclampsia
|
22 (9.4%)
4 (0.92%)
|
25 (7.3%)
2 (0.32%)
|
0.367
0.803f
|
All background characteristics included for evaluation were similar between groups.
cHTN = chronic hypertension, RHD = rheumatic heart disease, PET = preeclampsia
f Fisher’s exact
m Median test
* Denominator is women with parity > 0
As illustrated in Table 2, there was no change in the proportion of women delivering live births. In both groups, nearly all women delivered at MTRH (96%) (as opposed to a peripheral facility, before referral or in transit), 43% underwent induction of labor, delivered vaginally (64%) and to a singleton pregnancy (93%). After the policy change, there was a trend towards increased preterm delivery but this did not reach statistical significance. Of note, there was no change in the median time from admission to delivery (1 day).
Table 2: Admission and delivery outcomes among women with live births
|
Before (n=437)
|
After (n=626)
|
P value
|
Live births
|
394 (90.2%)
|
551 (88.0%)
|
0.274
|
Stillbirths
|
43 (9.8%)
|
75 (12%)
|
0.391
|
GA (at delivery) mean
< 28 weeks
28-34 weeks
>34 weeks
|
4 (1.2%)
43 (13.0%)
280 (84.9%)
|
6 (1.3%)
77 (16.5%)
467 (80.9%)
|
0.928
0.179
0.153
|
Median Interval time from admission to delivery, range (days)
|
1 (0 - 32)
Mean = 2.1 ± 4.6
|
1 (0 - 46)
Mean = 2.2 ± 4.6
|
0.240
0.754
|
Location of delivery
MTRH
Hospital (other then MTRH)
Home/Transit)
|
367 (96.8%)
8 (2.1%)
4 (1.1%)
|
518 (95.9 %)
18 (3.3%)
5 (5.3%)
|
0.578f
|
Type of delivery
Induction
SVD
Assisted VD
CS
Not recorded
|
166 (42.2%)
239 (63.1%)
6 (1.6%)
134 (35.3%)
0 (0.0%)
|
245(44.7%)
347 (64.1%)
8 (1.5%)
182 (33.6%)
4 (0.7%)
|
0.493
0.218f
|
Type of Fetuses delivered
Singleton
Twins
Triplets
|
364 (92.9%)
27 (6.9%)
0 (0.0%)
|
520 (94.5%)
28(5.1%)
1 (1.2%)
|
0.566f
|
Birth weight
|
2750.9 (700-4350)
Mean 2652 ± 702.7
|
2685.6 (270-4850)
Mean 2568 ± 769.6
|
0.03
0.096
|
Maternal median and range laboratory values during admission
Hemoglobin (mg/dl)
Platelets
ALT (IU)
AST(IU)
Creatinine (mg/dL)
|
13.3 (3.0 – 17.1)
201.5 (13-640)
14.3 (0.4-2,362)
25.7 (10.1-3,112.8)
58 (4.4-873)
|
11.6 (3.2-19.6)
186 (6-618)
15.2 (1.9-1,399.5)
27.2 (6.0-3,977.4)
66 (1.4-1,669)
|
0.369m
0.034 m
0.102 m
0.403 m
<0.001 m
|
Maternal median and range BP recorded during admission
Systolic (mmHg)
Diastolic (mmHg)
|
148.5 (109.5-221)
95 (39.5-160)
|
150 (119.5-205)
98 (48.5 – 160)
|
0.017 m
<0.001m
|
*due to facility record-keeping standards, detailed delivery information about stillbirth cases was not uniformly available and therefore these cases were not included for analysis here (see Table 5).
SVD = spontaneous vaginal delivery, assisted VD = assisted vaginal delivery (with Kiwi vacuum), CS = cesarean section
f Fisher’s exact
m Median test
Scope of Hypertensive Disorders
Table 3 outlines the distribution of hypertensive disorders between groups. Among those women diagnosed with a hypertensive disorder of pregnancy, there was an upward trend in the proportion of women diagnosed with eclampsia and HELLP after policy change, although this did not reach statistical significance. There was a statistically significant increase in the proportion of women diagnosed with gestational hypertension (4.1% vs 8.1%, p=0.009) after the policy change.
Table 3: Distribution of Hypertensive Disorders (as previously defined – see Background)
Hypertensive disorders
|
Before (n =360)
|
After(n= 529)
|
P value
|
gHTN
|
18 (4.1%)
|
51 (8.1%)
|
0.009
|
PET
|
199 (45.6%)
|
266 (42.4%)
|
0.298
|
Severe PET
|
95 (21.8%)
|
114 (18.2%)
|
0.146
|
Eclampsia
|
33 (7.6%)
|
63 (10.1%)
|
0.165
|
HELLP
|
15 (3.4%)
|
35 (5.6%)
|
0.105
|
gHTN = gestational hypertension, PET = preeclampsia
After policy change, there was a statistically significant decrease in the number of women with a hypertensive disorder of pregnancy who presented to hospital for concerns specific to labor and delivery (labor pains and/or suspected rupture of membranes) (54.4% vs 45.6%, p=0.015 and 11.7% vs 6.5%, p=0.005, respectively), as illustrated in Table 4. It should be noted that many women presented with more than one complaint both before and after the policy change.
Table 4: Chief Complaint(s) at Presentation to MTRH
Chief Complaint(s) at Presentation of Women Diagnosed with Hypertensive Disorder of Pregnancy
|
Before (n=436)
|
After (n=627)
|
P value
|
Lower abdominal pains/Labor
|
237 (54.4%)
|
286 (45.6%)
|
0.015
|
Drainage of liquor/SROM
|
51 (11.7%)
|
41 (6.5%)
|
0.005
|
Headache
|
131 (30.0%)
|
216 (34.5%)
|
0.314
|
Swelling/Edema
|
123 (28.3%)
|
177 (28.3%)
|
0.965
|
Epigastric/RUQ pain
|
71 (16.3%)
|
82 (13.1%)
|
0.121
|
Decreased Fetal movement
|
44 (10.1%)
|
62 (9.9%)
|
0.659
|
Visual changes
|
43 (9.9%)
|
56 (8.9%)
|
0.817
|
Nausea +/- vomiting
|
20 (4.6%)
|
34 (5.4%)
|
0.799
|
SROM = spontaneous rupture of membranes
Adverse Outcomes
Among those women diagnosed with hypertensive disorders, there was no difference in the proportion who developed obstetric or medical complications, including severe postpartum hemorrhage, disseminated intravascular coagulopathy (DIC), renal failure requiring dialysis, pulmonary edema, or stroke between the groups. Of major concern, there was a statistically significant increase in the proportion of women dying as a result of their condition (1.2% vs 3.03%, p= 0.042) after policy change.
There was a significantly higher incidence of preterm births between 28-34 weeks when stillbirths were included in the analysis (13.5% vs 21.6%, p=0.003) after policy change. There were also more neonates with Apgar scores less than 7 at 1 minute (23% vs 29%, p = 0.048). There was a trend towards higher admission rates to the NBU, stillbirths, and neonatal deaths after policy change, although these differences did not reach statistical significance. There was no difference in fetal/neonatal adverse outcomes among women with multiple gestation (data not shown). Please refer to Table 5 for full details of maternal and neonatal outcomes.
Table 5: Significant Maternal and Neonatal Outcomes in Women with Hypertensive Disorders of Pregnancy
Severe Maternal Outcomes
|
N = 436
|
N = 627
|
P value
|
Death
|
5 (1.15%)
|
19 (3.03%)
|
0.042
|
Postpartum Hemorrhage*
|
58 (13.3%)
|
76 (12.1%)
|
0.568
|
Placental abruption
|
10 (2.3%)
|
6 (1.0%)
|
0.078
|
Intensive Care Unit admission
|
8 (1.8%)
|
8 (1.3%)
|
0.462
|
Disseminated intravascular coagulation
|
1 (0.23%)
|
7 (1.12%)
|
0.151f
|
Blood transfusion
|
45 (10.3%)
|
85 (13.6%)
|
0.113
|
Seizure/convulsion
|
33 (7.6%)
|
63 (10.05%)
|
0.165
|
Need for dialysis
|
4 (0.92%)
|
13 (2.07%)
|
0.139
|
VTE
|
5 (1.15%)
|
2 (0.32%)
|
0.130f
|
Myocardial Infarction
|
2 (0.5%)
|
1 (0.2%)
|
0.571f
|
Pulmonary Edema
|
3 (0.69%)
|
7 (1.1%)
|
0.539f
|
Stroke
|
3 (0.69%)
|
4 (0.64%)
|
1.000f
|
Platelets <50
|
9 (2.3%)
|
25 (4.5%)
|
0.073
|
Transaminitis (ALT or AST >70IU)
|
55 (14.2%)
|
102 (19.6%)
|
0.034
|
Total with an adverse maternal outcome
|
147(33.6%)
|
226(36.1%)
|
0.408
|
Neonatal Outcomes
|
|
|
|
Delivery at < 28 completed weeks
Delivery at 28-34 completed weeks
Delivery at 34-37 completed weeks
|
12 (3.5%)
46 (13.5%)
55 (16.2%)
|
13 (2.6%)
108 (21.6%)
91 (18.2%)
|
0.434
0.003
0.455
|
Low Birth Weight (<2.5kg)
|
141 (38.0%)
|
237 (42.8%)
|
0.148
|
NBU Admission
|
107 (26.4%)
|
189 (32.1%)
|
0.052
|
IUFD/Stillbirth
|
41 (10.1%)
|
70 (11.9%)
|
0.391
|
Neonatal Death
|
12 (5.2%)
|
28 (4.8%)
|
0.160
|
Total with adverse fetal/neonatal outcomes
|
224(55.2%)
|
353 (59.9%)
|
0.135
|
*Postpartum hemorrhage defined as >500mL after vaginal delivery and >1000mL after cesarean section
VTE = venous thromboembolism, IUFD = intra-uterine fetal demise
fFisher’s exact
Pharmacological Management
As demonstrated in Table 6, there was a statistically significant increase in the use of magnesium sulfate for seizure prophylaxis (77.3% vs 84.5%, p = 0.003), mostly among women with gHTN (20.2% vs 24%, p=0.020), after policy change. Of concern, there was a trend towards less use of magnesium sulfate among women with eclampsia and HELLP syndrome. There was no overall difference in the use of anti-hypertensives between groups. Less than 50% of women between 28-34 weeks received dexamethasone for fetal lung maturity in both groups.
Table 6: Pharmacological management of Hypertensive Disorders of Pregnancy
Medication
|
Before (n = 436)
|
After (n=627)
|
P value
|
Magnesium sulfate
|
337 (77.3%)
|
530 (84.5%)
|
0.003
|
gHTN
|
7 (30.4%)
|
24 (42.1%)
|
0.02
|
PET
|
147 (73.9%)
|
231 (86.8%)
|
0.298
|
Severe PET
|
81 (85.3%)
|
107 (93.9%)
|
0.146
|
Eclampsia
|
33 (100%)
|
58 (92.1%)
|
0.165
|
HELLP
|
14 (93.3%)
|
31 (88.6%)
|
0.105
|
|
Anti-Hypertensives
|
433 (99.3%)
|
618 (98.6%)
|
0.378f
|
Nifedipine (oral)
|
374 (85.8%)
|
563 (89.8%)
|
0.046
|
Labetalol (IV )
|
80 (18.4%)
|
142 (22.6%)
|
0.09
|
Hydralazine (IV and/or oral)
|
27 (6.2%)
|
26 (4.2%)
|
0.132
|
Methyldopa (oral)
|
24 (5.5%)
|
27 (4.3%)
|
0.369
|
Atenolol (oral)
|
13 (3.0%)
|
40 (6.4%)
|
0.012
|
Dexamethasone
|
|
|
|
< 28 weeks
|
4 (30.9%)
|
5 (29.4%)
|
0.929
|
28-34 weeks
|
24 (44.4%)
|
54 (48.2%)
|
0.645
|
34-37 weeks
|
13 (22.4%)
|
24 (34.8%)
|
0.008
|
> 37 weeks
|
11 (4.7%)
|
5 (1.7%)
|
0.045
|
Medications unrelated to the direct management of a patient’s hypertensive disorder were not included in the analysis. Only those patients receiving the correct dose have been included as having received a medication. Of note, oral labetalol is not used at MTRH.