Prevention and management of Pre-eclampsia related maternal mortality During ANC in the Buea Health District.

doi:10.21203/rs.3.rs-5319592/v1

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Prevention and management of Pre-eclampsia related maternal mortality During ANC in the Buea Health District.

https://doi.org/10.21203/rs.3.rs-5319592/v1

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The study highlights the significant issue of maternal mortality in Cameroon, where 12–13 women die daily from pregnancy-related causes, despite a global decline in maternal mortality rates. The research aimed to determine the prevalence of preeclampsia, a major factor in maternal mortality, and evaluate the effectiveness of antenatal care (ANC) practices in reducing its impact.

Methods: A cross-sectional study was conducted, reviewing records from 2017–2021 in the BHD. The study used a simple random sampling technique to select facilities and pregnant women attending ANC. A sample of 200 women was assessed for their knowledge of ANC and factors hindering positive ANC practices. The study also measured the prevalence and management of preeclampsia among these women. Data were analyzed using SPSS Version 23.

Results: Out of 4,707 records reviewed, the prevalence of preeclampsia was 4.97% (234 cases). Knowledge of ANC was high, with 84% of women understanding its importance. Significant associations were found between ANC knowledge and factors such as religion (X²=12.029, p = 0.007), education level (X²=10.641, p = 0.031), and income (X²=8.061, p = 0.045). Other socio-demographic factors showed no significant association. Multivariate analysis indicated that ANC is effective in managing preeclampsia, with 95.3% of women successfully managed during ANC. Logistic regression analysis identified long distance to facilities (40%), financial limitations (36.5%), and long waiting times (37.5%) as barriers to ANC attendance.

Conclusion: The prevalence of preeclampsia among women attending ANC in the BHD is high. Most women have adequate knowledge of ANC, which is crucial for managing preeclampsia. Effective ANC utilization is essential, but factors like trust in healthcare, distance to facilities, and financial constraints significantly affect ANC attendance and frequency. Addressing these barriers could improve maternal health outcomes in Cameroon.

Pre-eclampsia

Pregnant women

Antenatal clinic

Management

Prevention Maternal mortality.

To improve maternal health, barriers that limit access to quality maternal health services must be identified and addressed at all health system levels. According to World Health Organization (WHO) (2019), maternal mortality referred to as the death of a woman during pregnancy, delivery, or within 48 days of childbirth, accounts for about 830 deaths every day worldwide [1]. This indicates that maternal mortality is unacceptably high. Maternal mortality claims the lives of many women in Sub-Saharan Africa (SSA), often from factors that could have been prevented, but wasn’t due to weak health systems. It is worth noting that in 2015, roughly 303 000 women died during and following pregnancy and childbirth. Almost all those deaths occurred in low-resource settings, and most could have been prevented. It has been reported that, in SSA, several countries halved their levels of maternal mortality since 1990. In other regions, including Asia and North Africa, even greater headway was made. Between 1990 and 2015, the global maternity ratio (the number of maternal deaths per 100 000 live births) declined by only 2.3% per year. However, increased rates of accelerated decline in maternal mortality were observed from 2000 onwards [2]. Pre-eclampsia, also known as EPH (Edema proteinuria hypertension) - gestosis, is a pregnancy specific syndrome. It affects 3–5% of pregnant women and is characterized by edema, high blood pressure, and proteinuria. Moreover, in women with preeclampsia dysfunction of many organs, such as kidney and liver, may be diagnosed, and in some cases, fetal growth restriction is observed. Pre-eclampsia, when left untreated, can lead to death. In low-income countries, this disorder is one of the main causes of maternal and child mortality [4].

In Cameroon despite a global decline (by 44%) in maternal mortality rates reported, as in many other sub-Saharan African countries, there is a high burden of maternal mortality. Cameroon has seen a rise in maternal mortality with 782 maternal deaths/100,000 live births occurring between 2004 and 2011 [3]. Maternal mortality due to preeclampsia has been recorded at about 24.3% of the general maternal mortality burden [6]. Pregnant or postpartum women with hypertensive disorders of pregnancy have an increased risk of maternal mortality, cesarean section, preterm delivery, perinatal mortality, and low birth weight newborns [5]. Preeclampsia usually begins after 20 weeks of pregnancy in women whose blood pressure had been normal. Rarely, preeclampsia develops after the delivery of a baby, a condition known as postpartum preeclampsia [7]. Furthermore, it has been reported that each day in Cameroon, there are 12–13 cases of maternal mortality. This shows that Cameroon is among the countries with high maternal mortality levels in Sub-Saharan Africa, representing an enormous burden for the health of conception till the onset of labor. This is particularly important so that, the mother should give birth safely to a healthy baby at full term. This care, traditionally involves continuous and proper clinical assessment of the mother and fetus, to obtain the best possible outcome for both mother and offspring. ANC coverage is an indicator of access and use of health care services during pregnancy. The antenatal period presents opportunities for reaching pregnant women with interventions that are vital to their health and wellbeing and that of their fetuses and neonates [7]. ANC is very important in monitoring and detecting early warning signs of preeclampsia from nausea, upper belly pain, vomiting, and blood pressure and urine tests for proteins. This goes along to emphasize the need for follow up on the 2016 Sustainable Development Goals (SDGs), stating the need for countries to consolidate and increase advances, and to expand their agendas to go beyond survival, with a view to maximizing the health and potential of their populations through all possible means especially with Women’s and children’s health. Skilled care before, during and after childbirth can save the lives of women and newborn babies [1].

This study will help to find out the prevalence of maternal mortality due to preeclampsia/eclampsia in the Buea health district and how this prevalence can be reduced through active and participative ANC servicing from all stakeholders concerned to ensure better healthcare for the woman, child, household and community at large. This study will also help improve if not create policies that will foster the care of pregnant woman and also facilitate caregiving at all possible levels in the community.

Study area

The study took place in the Buea Health district. Buea is the administrative capital of the Southwest Region of Cameroon. The town is located on the Eastern slopes of Mount Cameroon and lies between latitudes 40 12´N and longitudes 90 12´ E with a total surface area of 870 km2 and an elevation of 3,000 feet (900 meters) above sea level [7]. Buea Health District which is made up of 7 Health Areas namely: Bokwaongo, Bova, Buea road, Buea Town, Molyko, Muea and Tole (as seen in Fig. 1) with a total of 31 Health Facilities [15]. Its mountainous topography gives allowance for miniature hills and valleys that contribute to the varying temperatures and diverse vegetation [14]. The 3 health facilities chosen for the study were PMI (Buea Road Integrated Health Center), Mount Mary and Bebetta Memorial Clinic located at 4 o08'55.0''N 9 o14'13.3''E, 4 o10'08.4''N 9o16'43.2''E respectively. The study constituted women of child bearing age who have given birth, lost a baby or gotten pregnant at some time of their lives and especially those who were pregnant at the time of the study in the selected health facilities in the BHD. The minimum sample size was 185 based on Cochran’s formula [86] for cross-sectional studies by

n = Z ² (p) (1-p)/e², where n = sample size, e = level of precision, and p = estimated proportion of population.

This sample size was rounded up to the nearest hundred to give n = 200. Redistributing this sample to the health facilities, sample proportionate was used to size, records serving as source of facility’s mean number of woman (Table 1):

(Number of women from records of Facility/ 𝐭𝐨𝐭𝐚𝐥 𝐧𝐮𝐦𝐛𝐞𝐫 𝐟𝐫𝐨𝐦 𝐚𝐥𝐥 𝟑 𝐟𝐚𝐜𝐢𝐥𝐢𝐭𝐢𝐞𝐬) 𝑿 𝟏𝟎𝟎 = 𝒑𝒆𝒓𝒄𝒆𝒏𝒕𝒂𝒈𝒆 𝒑𝒆𝒓 𝒇𝒂𝒄𝒊𝒍𝒊𝒕𝒚

Sampling Techniques

In the cross-sectional survey, a stratified simple random sampling technique was used. Health centers which provide ANC services within the Buea Health District were listed, and divided into 3 strata; public, private, and faith-based. Three centers were chosen using simple random sampling (the traditional balloting method), taking one center from each stratum and the selected facilities included: Buea Road Integrated Health Center-Public, Bebetta Memorial Clinic, checkpoint-Private and Mount Mary Hospital- Faith-based. Pregnant women attending ANC at these centers were selected using simple random sampling technique and those who gave their consent were administered questionnaires to test on the factors that affect/determine their ANC attendance. For retrospective data collection to determine the prevalence of preeclampsia, data was collected from the selected health facility records whereby all cases of preeclampsia within the chosen study period (5 years) was gotten and a prevalence value done as a percentage of all the women who attended ANC within the same study period. Inclusion criteria included: women who were undertaking ANC and women with recorded information in ANC registers but not necessarily undertaking ANC at the time of study. Women who took ill and did not give their consent could not participate in the study. The questionnaire and data extraction form were pretested at the Molyko integrated Health Center to ensure that the language was easy to understand, the objectives SMART and the variables were easy to identify and attain but also capable of acquiring the desired information from the study population.

Data Collection

Data was collected using two formats for prevalence and factors affecting ANC attendance. Firstly, using a data extraction form to record the findings from the various sources of information (Patient’s hospital file and registers), and secondly using self-administered paper questionnaires. The Data extraction form was made of three parts; general information containing socio-demography, investigations to be carried out from the registers and finally the outcome of the pregnancy, containing complications, diagnosis, intervention and effect on the woman, pregnancy or child. The second portion of the study utilized the questionnaire which was adapted from a previous study carried out in Malaysia [13]. The questionnaire was divided into 3 sections. The first section having questions on socio-demography, the second contained questions on knowledge on the aim and effectiveness of ANC in pregnancy, while the third section contained questions on factors limiting women’s attendance of ANC. Validity of the questionnaire was measured by piloting the questionnaire on a fewer number of women, to ensure the clarity of questions and that participants were able to respond to the questions on the questionnaire.

All questionnaires were verified/checked for proper filling. Those with incomplete data were excluded. Data was collected and coded using a well-designed data collection form and was entered into a data entry template developed in EPI info version 7.0, exported to Microsoft excel and imported into the statistical package for social sciences (SPSS) version 23.0 for analysis. Participant information was coded and kept confidential all through the research period and thereafter. Descriptive statistics (with measures of frequency, central tendency, dispersion and position) was used to describe the variables and inferential statistics was used to establish associations between socio-demographic factors and major independent variables (knowledge of pregnant women on the importance of ANC). Five questions were used to assess for knowledge on the importance of ANC, having ≥ 18 points on 25 was considered adequate knowledge. The prevalence of preeclampsia was calculated from retrospective studies. Trends were gotten from retrospective datasets, alongside a measure of the effectiveness of ANC in the prevention and management of preeclampsia. Factors affecting women’s attendance of ANC was gotten from the questionnaires and factors independently associated to it determined using a logistic regression model. P < 0.05 was considered significant. Data was displayed on charts, graphs and, tables.

Table 1

Population proportionate to size of facilities in the study
Facility	Percentage (%)	Total sample size	Number of women per facility.
PMI: 585/1300	45	200	90
Mount Mary:455/1300	35	200	70
Bebetta:260/1300	20	200	40

Socio-demographic characteristics of participants

For the retrospective study, 4,707 female participants were sampled from the hospital registers with 234 participants selected as they met the desired characteristics of the study i.e., Preeclampsia. The highest participants were within age groups of 28–32 years, with 82(35.0%) participants while the age group with lowest participants was ≤ 22 years with 30 (12.8%). Married women constituted the majority of the retrospective study with 155 (66.2%) of the total participants, while cohabitating participants were the lowest with 10 (4.3%) of the participants as indicated by marital status. A summary of this retrospective demographic data is represented accordingly, (Table 2).

Table 2

**Socio-demographic characteristics of the retrospective cross-sectional study participants**
Variable	Characteristics	Number examined N (%)
Age groups (Years) Total	≤ 22 23–27 28–32 ≥ 33 4	30(12.8) 70(29.9) 82(35.0) 52(22.2) 234(100)
Marital status Total	Single Married Cohabitation 3	69(29.5) 155(66.2) 10(4.3) 234(100)

Socio-demographic characteristics of cross-sectional study participants

With regards to the data collected from respondents’ questionnaires in the cross-sectional study, there was a 100% response rate from the 200 women sampled. Data revealed that the age group with the highest participants was 23–27 years with 73(36.5%) of the total participants while the age group with the lowest number of participants was ≤ 22 with 35 participants, representing 17.5% of the sample population. Most participants were Christians 184(92.0%) while 4(2.0%) indicated they belonged to other non-conventional religious groups. Of the 200 participants, more than half, 106(53.0%) participants were married while 13(6.5%) participants were cohabitating. For the educational level, 88(44.0%) of the participants were persons with university level of education while 3(1.5%) had no formal educational background. Tole health area had the least participants in the study represented by 1(0.5%) while Buea Town health area had 45(22.5%) of the participants, representing the highest portion of women in the study. Regarding occupation 72(36.0%) participants were business owners while the least group 10(5%) was made of farmers. Among the study participants, majority 124(62.0%) had ≤ 1 children while those with ≥ 4 represented the least number 11(5.5%) of the participants. More than half 122(61.0%) of the participants have incomes between 20.000 and 90.000 while only 17(8.5%) of the participants have salaries ≥ 200.000, (Table 3).

Table 3

Socio-demographic characteristics for cross-sectional study participants (n = 200)
Variable	Characteristics	Frequency N (%)
Age Group (Years)	≤ 22 23–27 28–32 ≥ 33	35(17.5) 73(36.5) 55(27.5) 37(18.5)
Religion	Christian Muslim African Traditional Beliefs Others	184(92.0) 6(3.0) 6(3.0) 4(2.0)
Marital status	Single Married Cohabitation	81(40.5) 106(53.0) 13(6.5)
Educational level	No formal education Primary Secondary High School University Education	3(1.5) 19(9.5) 43(21.5) 47(23.5) 88(44.0)
Location	Buea Town Bokwoango Bova Molyko Muea Tole Buea Road Others	45(22.5) 23(11.5) 16(8.0) 44(22.0) 19(9.5) 1(0.5) 25(12.5) 27(13.5)
Occupation	Civil Servant Farmer Private sector Business person Others	29(14.5) 10(5.0) 52(26.0) 72(36.0) 37(18.5)
Transportation to Health facility	Walking Car Motorcycle	10(5.0) 186(93.) 4(2.0)
Monthly Income	≤ 10.000 20.000–90.000 100.000-190.000 ≥ 200.000	18(9.0) 122(61.0) 43(21.5) 17(8.5)
Number of children	≤ 1 2–3 ≥ 4	124(62.0) 65(32.5) 11(5.5)

Prevalence of Preeclampsia amongst pregnant women in the Buea Health District (2017–2021)

In this study, of the 5year range of files examined for a total of 4,707 women, the prevalence of preeclampsia was 4.97% that is 234 women, (Fig. 2). For the educational level, 88(44.0%) of the participants were persons with university level of education while 3(1.5%) had no formal educational background.Tole health area had the least participants in the study represented by 1(0.5%) while Buea Town health area had 45(22.5%) of the participants, representing the highest portion of women in the study.

Records collected from the 3 facilities involved indicated that the trends in prevalence of preeclampsia were not directly proportional to size though some institutions with large populations actually had high incidences of preeclampsia. The case of PMI with 1,206(25.62%) participants observed had 14.3% (173participants) prevalence vs. Mount Mary with 3,106(65.98%) participants had 58(18.7%) participants who turned out positive with preeclampsia (Table 4). The yearly trends amongst facilities involved were irregular (Fig. 3) with a great increase observed across all facilities in 2021. Considering the observed trend, it was noticed that there is a general increase across the years on the incidence of preeclampsia across all facilities involved in the study (Fig. 4, 5, 6).

Knowledge of pregnant women on the importance of ANC

From a Likert scale of 3 responses; Yes, No and No idea, a tally of 33points was generated with a minimum score of 24 considered as the threshold for adequate knowledge. As such participants with scores < 24 was considered to have inadequate knowledge while those with scores of ≥ 24 was considered to have adequate knowledge on ANC. Findings showed most; 189(94.5%) of the participants had adequate knowledge on ANC, (Fig. 7 ).

Knowledge of participants with respect to sociodemographic factors

Age group was seen to be significantly associated (X2 = 15.306, p = 0.018) with knowledge on ANC. Religion (X2 = 47.521, p < 0.001), marital status (X2 = 11.663, p = 0.020), educational level (X2 = 32.148, p < 0.001), location (X2 = 24.287, p = 0.042), and number of children (X2 = 25.799, p < 0.001) were all significantly associated with knowledge on ANC while the other socio- demographic factors had no significant association with women’s’ knowledge on ANC, (Table 4).

Knowledge on importance of ANC

A 5 response Likert scale was used to test for the level of knowledge on the importance of ANC by pregnant women and responses gotten were graded as such from the 5 questions asked: <18; inadequate knowledge, ≥ 18; adequate knowledge. It was observed (Fig. 8) that 169(84.5%) participants had adequate knowledge while 31(15.5%) had inadequate knowledge on the importance of ANC. This was tested with questions like “Antenatal care schools you on complications (danger signs) that should warn you of problems with the pregnancy”, And others like “Early antenatal booking reduces the risk of preeclampsia”.

Table 4

a: Association of demographic factors with participant’s knowledge on ANC (n = 200).
Variable	Characteristics	Frequency (n)	Adequate knowledge (%)	Inadequate knowledge (%)	X² Value	P value at 95% CI
Age Group (Years)	≤ 22	35	30(85.7)	5(14.3)	15.306	0.018
Age Group (Years)	23–27	73	72(98.6)	1(1.4)
	28–32	55	51(92.7)	4(7.3)
	≥ 33	37	34(91.9)	3(8.1)
Religion	Christian	184	174(94.6)	10(5.4)	47.521	< 0.001
	Muslim	6	6(100.0)	0
	African Traditional Beliefs	6	3(50.0)	3(50.0)
	Others	4	4(100.0)	0
Marital status	Single	81	72(88.9)	9(11.1)	11.663	0.020
	Married	106	103(97.2)	3(2.8)
	Cohabitation	13	12(92.3)	1(7.7)
Educational level	No formal education	3	3(100)	0	32.148	< 0.001
	Primary	19	13(68.4)	6(31.6)
	Secondary	43	40(93.0)	3(7.0)
	High School	47	44(93.6)	3(6.4)
	University Education	88	87(98.9)	1(1.1)

Table 4

b: Association of demographic factors with participant’s knowledge on ANC (n = 200)
Variable	Characteristics	Frequency (n)	Adequate knowledge (%)	Inadequate knowledge (%)	X² Value	P value at 95% CI
Location	Buea Town	45	44(97.8)	1(2.2)	24.287	0.042
	Bokwoango	23	22(95.7)	1(4.3)
	Bova	16	14(87.5)	2(12.5)
	Molyko	44	43(97.7)	1(2.3)
	Muea	19	16(84.2)	3(15.8)
	Tole	1	1(100.0)	0
	Buea Road	25	21(84.0)	4(16.0)
	Others	27	26(96.3)	1(3.7)
Occupation	Civil Servant	29	29(100.0)	0	9.292	0.318
	Farmer	10	10(100.0)	0
	Private sector	52	50(96.2)	2(3.8)
	Business person	72	63(87.5)	9(12.5)
	Others	37	35(94.6)	2(5.4)
Monthly Income	≤ 10.000	18	15(83.3)	3(16.7)	8.394	0.211
Monthly Income	20.000–90.000	122	112(91.8)	10(8.2)
	100.000-190.000	43	43(100.0)	0
	≥ 200.000	17	17(100.0)	0
Number of children	≤ 1	124	117(94.4)	7(5.6)	25.799	< 0.001
Number of children	2–3	65	63(96.9)	2(3.1)
	≥ 4	11	7(63.6)	4(36.4)

Knowledge on importance with respect to Socio-demographic factors.

Religion was significantly associated with knowledge on the importance of ANC, having a chi-square(X²) value of 12.029 and a p-value of 0.007, together with educational level (X 2 = 10.641 p = 0.031), and income (X 2 = 8.061, p = 0.045) while the other socio-demographic had no significant association (p > 0.05) with women’s’ knowledge on the importance of ANC, (Table 5).

Effectiveness of ANC in the prevention and management of preeclampsia during pregnancy.

A total of 223 (95.3%) of the 234 diagnosed cases of preeclampsia were observed to have been properly managed at the 3 health institutions over the time of the study (2017–2021), leaving a total of 11(4.7%) cases that resulted in eclampsia (Table 6).

Table 5

a: Association of demographic factors with participant’s knowledge on importance of ANC (n = 200)
Variable	Characteristics	Frequency (n)	Adequate knowledge (%)	Inadequate knowledge (%)	X² Value	P value at 95% CI
Age Group (Years)	≤ 22	35	28(80.0)	7(20.0)	1.147	0.766
Age Group (Years)	23–27	73	64(87.7)	9(12.3)
	28–32	55	46(83.6)	9(16.4)
	≥ 33	37	31(83.8)	6(16.2)
Religion	Christian	184	160(87.0)	24(13.0)	12.029	0.007
	Muslim	6	3(50.0)	3(50.0)
	African Traditional Beliefs	6	3(50.0)	3(50.0)
	Others	4	3(75.0)	1(25.0)
Marital status	Single	81	66(81.5)	15(18.5)	0.989	0.610
	Married	106	92(86.8)	14(13.20
	Cohabitation	13	11(84.6)	2(15.4)
Educational level	No formal education	3	3(100)	0	10.641	0.031
Educational level	Primary	19	15(78.9)	4(21.1)
	Secondary	43	34(79.1)	9(20.9)
	High School	47	35(74.5)	12(25.5)
	University Education	88	82(93.2)	6(6.8)
Location	Buea Town	45	41(91.1)	4(8.9)	5.666	0.579
	Bokwoango	23	17(73.9)	6(26.1)
	Bova	16	14(87.5)	2(12.5)
	Molyko	44	35(79.5)	9(20.5)
	Muea	19	15(78.9)	4(21.1)
	Tole	1	1(100)	0
	Buea Road	25	22(88.0)	3(12.0)
	Others	27	24(88.9)	3(11.1)

Table 5

b: Association of demographic factors with participant’s knowledge on importance of ANC (n = 200)
Variable	Characteristics	Frequency (n)	Adequate Knowledge (%)	Inadequate Knowledge (%)	X² Value	P value at 95% CI
Occupation	Civil Servant	29	26(89.7)	3(10.3)	7.624	0.106
	Farmer	10	10(100)	0
	Private sector	52	39(75.0)	13(25.0)
	Business person	72	60(83.3)	12(16.7)
	Others	37	34(91.9)	3(8.1)
Transportation to Health facility	Walking	10	9(90)	1(10)	1.021	0.600
	Car	186	156(83.9)	30(16.1)
	Motorcycle	4	4(100)	0
Monthly Income	≤ 10.000	18	18(100)	0	8.061	0.045
Monthly Income	20.000–90.000	122	98(80.3)	24(19.7)
	100.000-190.000	43	36(83.7)	7(16.3)
	≥ 200.000	17	17(100)	0
Number of children	≤ 1	124	105(84.7)	19(15.3)	1.303	0.521
Number of children	2–3	65	56(86.2)	9(13.8)
	≥ 4	11	8(72.7)	3(27.3)

Table 6

Management of Preeclampsia at ANC facilities
Variable	Number examined (N)	Preeclampsia N (%)	ManagedN (%)	Resulted in Eclampsia N (%)
Examined (N)	4,707	234(4.97)	223(95.3)	11(4.7)

Results indicate that most cases of preeclampsia were seen from women who started ANC during the 2nd trimester, 166(70.9%) cases in total of the 234 observed. This also indicated that women who started ANC early (1st trimester) had fewer cases of preeclampsia [51(21.8%)]. Pregnancy outcome was also monitored to ascertain what became of the women with or without preeclampsia and it was noticed 204(87.2%) of the women were lost to follow-up with just a single case (0.4%) referred (Table 7).

Each facility had varying degrees of management across the years with PMI having the most managed cases: 170 representing 98.3% of their total diagnosed cases and Mount Mary having the most cases that progressed to eclampsia; 8 representing 13.8% of their total diagnosed cases, (Table 8). Graphical representation shown in Fig. 10.

Table 7

General observation of Preeclampsia during 1st to 3rd trimesters and their outcomes (n = 234)
Variable	Characteristics	Number examined N (%)
Gestational Age at first ANC (Trimesters)	1st	51(21.8)
Gestational Age at first ANC (Trimesters)	2nd	166(70.9)
	3rd.	17(7.3)
Pregnancy Outcome	Completed pregnancy	29(12.4)
	Loss to follow up	204(87.2)
	Referred	1(0.4)

Table 8

Management Results of Preeclampsia per health institution (2017–2021) in BHD
Health institution	Number examined N (%)	Preeclampsia N (%)	Successfully managed N (%)	Resulted in Eclampsia N (%)
PMI	1,206	173(14.2)	170(98.3)	3(1.7)
Mount Mary	3,106	58(1.9)	50(86.2)	8(13.8)
Bebetta	395	3(0.8)	3(100.0)	0
	4,707	234(4.97)	223(95.3)	11(4.7)

Factors limiting ANC attendance

Considering the various factors laid down as challenges that limit access to ANC care, long distance to the facility was seen to be significantly associated with ANC attendance (p = 0.032), together with financial limitations (p = 0.002), biased treatment from hospital staff (p0.05) with ANC attendance, (Table 9).

Reasons why women choose particular ANC centers

Among the study participants, almost half indicated that they preferred the particular ANC sites they visited because of the trust they had in the services provided 49.5%( p0.05). These reasons were listed in Table 10.

Table 9

Association of Factors limiting ANC attendance with use of ANC in the BHD (n = 200)
FACTOR	RESPONSE	FREQUENCY N (%)	P value at 95% CI	Confidence Interval
		FREQUENCY N (%)	P value at 95% CI	Lower Bound	Upper Bound
Long Distance from facility	No	120(60.0)	0.032	0.007	0.165
Long Distance from facility	Yes	80(40.0)
Financial limitations	No	127(63.5)	0.002	0.046	0.201
	Yes	73(36.5)
Biased treatment from hospital staff	No	170(85.0)	< 0.001	0.203	0.424
	Yes	30(15.0)
No time to come to the hospital	No	164(82.0)	0.120	-0.017	0.143
No time to come to the hospital	Yes	36(18.0)
Long waiting time at the hospital	No	125(62.5)	0.002	0.059	0.247
	Yes	75(37.5)
No privacy	No	176(88.0)	< 0.001	0.146	0.383
	Yes	24(12.0)
No Security	No	187(93.5)	0.074	-0.015	0.323
	Yes	13(6.5)
Limited female staff	No	193(96.5)	0.261	-0.104	0.382
	Yes	7(3.5)
Little or no knowledge on the need for ANC	No	169(84.5)	0.780	-0.086	0.114
Little or no knowledge on the need for ANC	Yes	31(15.5)
Family resistance	No	185(92.5)	0.195	-0.053	0.258
	Yes	15(7.5)
Community restrictions	No	194(97.0)	0.439	-0.321	0.140
	Yes	6(3.0)
No specialized staff Gynecologist	No	181(90.5)	0.005	0.069	0.375
No specialized staff Gynecologist	Yes	19(9.5)

Table 10

Reason why women choose particular ANC centers (n = 200)
FACTOR	RESPONSE	FREQUENCY N (%)	P value at 95% CI
Location close to home	No	153(76.5)	0.007
	Yes	47(23.5)
Low cost	No	128(64.0)	0.005
	Yes	72(36.0)
Trust in providers/ High quality care	No	101(50.5)	< 0.001
Trust in providers/ High quality care	Yes	99(49.5)
Availability of drugs	No	183(91.5)	0.192
	Yes	17(8.5)
Availability of female staff	No	179(89.5)	0.462
Availability of female staff	Yes	21(10.5)
Recommendation/ Referral	No	138(69.0)	0.051
Recommendation/ Referral	Yes	62(31.0)
Availability of specialized staff	No	164(82.0)	0.782
Availability of specialized staff	Yes	36(18.0)

Prevalence of Preeclampsia amongst pregnant women in the Buea Health District

The present study estimated the prevalence of preeclampsia with biochemical variables like albumin concentration and blood pressure during pregnancy. The overall prevalence of preeclampsia was 4.97% among pregnant women in the BHD. Comparatively, this prevalence is considerably lower than that reported from studies conducted in settings in other places like Bangladesh and Ethiopia [8,17]. The prevalence of preeclampsia in the present study is higher compared with the global average, which is around 2% [8].

However, the prevalence ranges from 1.8 to 16.7% in developing countries. It was observed that there were variations in proportion of preeclampsia across the years studied with 2021 having the most diagnosed cases of preeclampsia, summing up to 168(71.79%) of the total 234 cases. Most of these cases were seen to arise during the 2nd trimester of pregnancy with 166(70.9%) of the total positive cases seen here. BHD has a high prevalence of preeclampsia 234(4.97%) for women attending ANC compared to the global average of 2% indicated by previous studies [18].

There was no association seen between age and preeclampsia as seen in other studies [19]. A systematic review showed that, women aged ≥ 35 were more likely to develop pre-eclampsia than younger women. Similar findings were observed in studies carried out in Ethiopia, and some 24 low- and middle-income countries selected by WHO [10,19]. The increasing risk of preeclampsia in older mothers could be related to the abnormally high lipid profile, high-density lipid cholesterol, and higher risk of vascular damage in this age group compared to younger women [19, 20].

This result 55 stands to be contrasted though by former studies carried out in Cameroon [21]. Blood pressures could not be easily separated and compared to prevalence unlike other studies which indicated significantly higher blood pressures in the first trimester for women who later developed preeclampsia [9].

Knowledge of pregnant women on the importance of ANC

Women in this study were seen to have adequate knowledge on ANC and its importance as opposed to the expected hypothesis. They were aware of the various tests to be done, frequency of ANC attendance, when and why ANC should be done and also the various danger signs to take note of during pregnancy. Findings showed that religion and income were major factors that contributed to women’s knowledge/perspective on the importance of ANC as shown by some studies in Ghana, Kenya, Malawi and, Uganda. [12, 22, 23].

This also influenced their usage of ANC services, as indicated by other studies [12]. Educational level has been noticed to greatly influence the level of knowledge on ANC and also its attendance as was noticed in this study and many others [24]. A great proportion of those with accurate knowledge on ANC were between younger women of child bearing age (23-27years) who were found to have greater knowledge on the importance of ANC than women who were ≥ 33 years of age. This indicator proved to be a key indicator in the prevalence of preeclampsia in the study region as suggested by other studies which state that women who had fewer visits to the doctor during their pregnancy period had about 6.8 times higher odds of being preeclampsia than women who did occasionally or regularly [8, 25, 26] and also greatly contributed to the maternal mortality 56 burden.

Unlike in other areas, the issue of antenatal cards could not be added as a factor for late ANC start as that is not a major limiting factor to giving birth at the concerned facilities [22]. The data also suggest that a woman’s level of education plays an important social role; secondary or tertiary education enables women to approach health staff on relatively equal terms, to pose questions and, potentially, to seek care with lesser concern about any possible reprimands [23].

Marital status played an important role in the level of knowledge as 97.2% of the married women had adequate knowledge. Women’s marital status has often been associated with higher levels of formal ANC [24]. Married women tend to visit the ANC centers early while younger unmarried women hid their pregnancies and delayed ANC to avoid the potential social implications of pregnancy: exclusion from school, expulsion from their natal home, partner abandonment, stigmatization and gossip [27]. There was a relation between number of children and awareness of ANC importance which showed that multigravida was less aware than their primigravida counterparts as seen in other but this could also be associated to the age and educational level of the multigravida as they were older and had lower educational levels. This is in contrast to findings from Emeh’s “Antenatal care and determinants of obstetric danger signs awareness of immediate postpartum women in the Buea regional Hospital” in 2021 [28]. This study goes along with a study conducted in urban areas of Pakistan which found that women having knowledge about ANC are more likely to utilize ANC services [29].

Assessing the effectiveness of ANC in the prevention and management of Pre-eclampsia in BHD

Management of preeclampsia in the BHD for women attending ANC has been observed to be very effective as the recovery rate was noticed to be high with 223 (95.3%) of the participants recovered. A recent review by Sibai supported expectant management in selected cases of severe PE presenting before 34 weeks [30]. At the ANC centers, care givers monitor blood pressure 57 and albuminuria; the major indicators of preeclampsia and also conditions such as severe headaches, blurred vision or other visual disturbance, severe pain in your abdomen, or severe shortness of breath and handle with immediate effect [4, 7,11].

Severe conditions of PE prompted the initiation of inpatient management with bed rest and administration of antihypertensive drugs like methyldopa, labetalol and beta blockers (except atenolol); the main drugs for which there is some evidence of benefit for preeclampsia prevention, and its use is recommended by professional societies for pregnancies at risk [31,32], and pravastatin endorsed as tactics to manage preeclampsia [33]. This management is only possible after proper monitoring is done upon antenatal servicing and the proper diagnosis made. Pregnancies complicated by severe preeclampsia have significantly high maternal and perinatal morbidity and mortality [34] but none of such cases was observed in this study.

Comparatively, management was noticed to have decreased across the years as the numbers of cases progressing to eclampsia have witnessed a rise compared to previous years (Fig. 11). Despite the improvement in health service coverage, expansion of health extension programs and improvement in antenatal care coverage and services in the Region, the prevalence of preeclampsia is still on the rise. This together with higher progression to eclampsia in some facilities was thought to be as a result of the lack of appropriate and prompt referrals, as these facilities aimed at managing severe cases of preeclampsia even when they were not so capable to do so. Socioeconomic status, having been referred, income level, religion, age group, level of education and distance to health facilities were identified as critical determinants of ANC attendance in the BHD. These factors upon influencing ANC attendance also had a role to play with the recovery 58 rate of PE as only those who attended ANC could be identified and thus managed if they came down with preeclampsia.

Factors limiting ANC attendance in the BHD

Data revealed that many factors influenced ANC attendance: long distances from the home to a health center, high direct and indirect costs of ANC, and long waiting time at the hospital. Even with the location of at least an ANC center within each health area in the Buea Health District, distance from a woman's home to the hospital was clearly indicated as a factor lowering ANC attendance, with 80(40%) persons answering yes to long distance from facility as a limiting factor.

Some other factors like biased treatment from hospital staff and no time to come to the hospital were also indicated but were later dismissed as their response rates represented less than 20% of the participant population. Generally, it was observed that of the many factors indicated, only about ¼ had any major impact on women’s attendance of ANC; 9 out of the 12 factors had below a 20% scoring “Yes” to the said factor as affecting their ANC attendance. In contrast to this, other factors pushed women to choose particular health facilities over others and included: trust in care provided, location closer to home, lower financial expenditures and referral from family, friends and colleagues. This tied with other studies that indicated that women easily assessed facilities close to their homes, especially if they trusted the care services provided at such institutions [12, 23, and 24,29].

Availability of specialized staff, availability of female staff, and availability of drugs were other factors mentioned which could affect a patient’s choice of choosing a facility. These findings align with a study [35] that emphasize the importance of trust and accessibility in ANC attendance.

The prevalence of preeclampsia was comparatively higher (4.97%) in the Buea health district. Most pregnant women (94.5%) had adequate knowledge on ANC and its importance. Proper antenatal care is an important part of prevention and management of PE, as seen in the study with a recovery rate of 95.3% of the pregnant women in the BHD. Participants who were recorded to have been properly managed/recovered from PE participated in antenatal care upon diagnosis and hence the recovery. The study informed that distance to facility, financial limitations and long waiting time at the facilities have measurable impacts on antenatal care utilization among women in the Buea Health District.

ANC

Antenatal Care

BHD

Buea Health District

EOPE

Early onset preeclampsia

EPH

Edema proteinuria hypertension

FGR

Fetal Growth Restriction

HELLP

Hemolysis,Elevated Liver Enzymes,Low Platelets Syndrome.

HDP

Hypertensive Disorders of Pregnancy

HIC

High-Income Country

ISSHP

International Society for the Study of Hypertension in Pregnancy

LMIC

Low and Middle-Income Countries

LOPE

Late onset preeclampsia

MCH

Maternal and Child Health

MMR

Maternal Mortality Ratio

Pre-eclampsia

SDG

Sustainable Development Goals

TBA

Traditional Birth Attendant

WHO

World Health Organization.

Ethics Approval and consent to participate

An ethical clearance was obtained upon submitting a research proposal at the Institutional Review Board, of the Faculty of Health Sciences (FHS), University of Buea. Administrative authorization was obtained from the Regional Delegation of Public Health to enable data collection. Authorization letters were obtained from Biaka University Institute of Buea and all the health facilities 3(PMI, Bebetta Memorial Clinic, and Mount Mary Hospital) concerned to be able to collect secondary data from their records and also to engage with their clients in the facilities. An informed consent was shown to participants which clearly explained the importance and impact of the research. Participants signed a written informed consent showing their participation is voluntary.

Consent for publication

Not applicable

Availability of data and materials

All datasets generated and analyzed in this study are presented in the paper. However, data is available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

The authors state that there were no commercial or financial relationships that may be considered as a potential conflict of interest during the research.

Authors' contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Acknowledgements

The authors appreciate the support and cooperation of the health personals in the health facilities used within the Buea health district. Special thanks to all the pregnant women that participated in this study.

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No competing interests reported.

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Prevention and management of Pre-eclampsia related maternal mortality During ANC in the Buea Health District.

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Abstract

Figures

Introduction

Materials and methods

Study area

Sampling Techniques

Data Collection

Results

Socio-demographic characteristics of participants

Socio-demographic characteristics of cross-sectional study participants

Prevalence of Preeclampsia amongst pregnant women in the Buea Health District (2017–2021)

Knowledge of pregnant women on the importance of ANC

Knowledge of participants with respect to sociodemographic factors

Knowledge on importance of ANC

Factors limiting ANC attendance

Reasons why women choose particular ANC centers

Discussion

Prevalence of Preeclampsia amongst pregnant women in the Buea Health District

Knowledge of pregnant women on the importance of ANC

Assessing the effectiveness of ANC in the prevention and management of Pre-eclampsia in BHD

Factors limiting ANC attendance in the BHD

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

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