Among 59,180 married women of reproductive age, we identified 5,314 women with a pregnancy outcome within one year prior to the survey (Figure 1). Of these, 622 women were excluded from the analysis: 87 (2%) were misclassified and no pregnancy information was collected, and 535 (10%) could not be located. It is common in this population for women to relocate to their natal home to give birth and return to their marital home several months later. A total of 4,692 women were included in the analysis (Figure 1). Approximately 46% (2,163 out of 4,692) of respondents reported previously having been screened for diabetes, compared to nearly all having been previously screened for hypertension (97%). Of those screened, 3% (75 out of 2,163) reported previous diagnoses of diabetes, and 10% (434 out of 4,552) reported previous diagnoses of hypertension (Figure 1).
Most recently pregnant women (78%) were under 30 years of age, and 35% had recently completed their first pregnancy (Table 1). We observed a prominent generational difference in educational status among the women surveyed: 72% of women over 40 years of age reported primary school completion or lower, while 89% of women under 20 years of age reported secondary school completion or higher.
Table 1. Socio-economic and health history characteristics of the study population
Characteristic
|
All women
|
|
N = 4,692 n(%)
|
Age (Years)
|
|
<20
|
925 (20%)
|
20–29
|
2,707 (58%)
|
30–39
|
1,021 (22%)
|
40–49
|
39 (1%)
|
Education (Completed)
|
|
None
|
202 (4%)
|
Primary
|
873 (19%)
|
Secondary
|
2,406 (51%)
|
Post-Secondary
|
1,211 (26%)
|
Household Wealth Quintile
|
|
Lowest
|
909 (19%)
|
Second
|
921 (20%)
|
Middle
|
949 (20%)
|
Fourth
|
981 (21%)
|
Highest
|
932 (20%)
|
Gravidity (the total number of lifetime pregnancies)
|
|
1
|
1,651 (35%)
|
2–4
|
2,765 (59%)
|
5+
|
276 (6%)
|
Characteristics associated with diabetes and hypertension screening
In crude and adjusted analyses, young women and women with no education had the lowest odds of ever having been screened for diabetes compared to other groups (Table 2). After adjusting for age, education, wealth, and gravidity, primigravid or multigravida (5+) women below the fourth wealth quintile had significantly lower odds of ever having been screened for diabetes compared to wealthier women and women reporting a lifetime total of 2–4 pregnancies (Table 2).
All women over 40 years of age reported having previously been screened for hypertension at least once in their lives. Women who had completed post-secondary education were two-fold more likely to report having been previously screened for hypertension (OR 2.21, 95% CI 1.02, 4.81), and this association strengthened after controlling for age, wealth, and gravidity (aOR 2.46, 95% CI 1.06, 5.70) (Table 1). Among the respondents, 3% (140 of 4,692) reported having never been screened for hypertension; 41% (57 out of 140) were primigravida. Overall, having never been screened was associated with having very little interaction with the health care system during pregnancy; 46% (65 out of 140) reported either receiving no antenatal care or having an ultrasound as their only antenatal care during pregnancy.
Diabetes and hypertension diagnoses
While higher educational attainment and increased wealth were associated with an increased likelihood of ever having been screened for diabetes (Table 3), these characteristics were not associated with higher odds of reporting a diagnosis of diabetes in adjusted analyses (Table 3). Membership in the highest wealth quintile (aOR 1.70, 95% CI 1.18, 2.44) was the only statistically significant socio-economic factor associated with increased risk for hypertension in fully adjusted analyses.
Table 2. Association between diabetes and hypertension screening and selected background characteristics using logistic regression
Total number screened/not screened
|
|
Diabetes
|
|
Hypertension
|
|
2,163/2,529
|
|
4,552/140
|
|
%^
|
Crude
|
Adjusted
|
%^
|
Crude
|
Adjusted
|
|
|
OR
|
95% CI
|
aOR
|
95% CI
|
|
OR
|
95% CI
|
aOR
|
95% CI
|
Age (Years)
|
|
|
|
|
|
|
|
|
|
|
< 20
|
38
|
Ref
|
|
Ref
|
|
96
|
Ref
|
|
Ref
|
|
20–29
|
46
|
1.39*
|
(1.19, 1.62)
|
1.23*
|
(1.03, 1.47)
|
97
|
1.71*
|
(1.14, 2.55)
|
1.49
|
(0.92, 2.42)
|
30–39
|
52
|
1.79*
|
(1.49, 2.15)
|
1.80*
|
(1.44, 2.27)
|
97
|
1.32
|
(0.82, 2.11)
|
1.33
|
(0.70, 2.51)
|
40–49
|
59
|
2.33*
|
(1.21, 4.47)
|
2.93*
|
(1.44, 5.92)
|
100
|
--
|
--
|
--
|
--
|
Education (Completed)
|
|
|
|
|
|
|
|
|
|
|
None
|
32
|
Ref
|
|
Ref
|
|
95
|
Ref
|
|
Ref
|
|
Primary
|
41
|
1.53*
|
(1.10, 2.11)
|
1.71*
|
(1.23, 2.39)
|
96
|
1.15
|
(0.54, 2.44)
|
1.24
|
(0.58, 2.64)
|
Secondary
|
44
|
1.72*
|
(1.27, 2.34)
|
2.15*
|
(1.56, 2.97)
|
97
|
1.51
|
(0.74, 3.07)
|
1.79
|
(0.85, 3.74)
|
Post-Secondary
|
55
|
2.66*
|
(1.94, 3.66)
|
3.27*
|
(2.32, 4.60)
|
98
|
2.21*
|
(1.02, 4.81)
|
2.46*
|
(1.06, 5.70)
|
Household Wealth Quintile
|
|
|
|
|
|
|
|
|
|
|
Lowest
|
40
|
Ref
|
|
Ref
|
|
97
|
Ref
|
|
Ref
|
|
Second
|
44
|
1.15
|
(0.95, 1.38)
|
1.16
|
(0.96, 1.33)
|
97
|
0.91
|
(0.54, 1.54)
|
0.92
|
(0.54, 1.56)
|
Middle
|
44
|
1.15
|
(0.95, 1.38)
|
1.10
|
(0.91, 1.33)
|
96
|
0.80
|
(0.48, 1.33)
|
0.74
|
(0.44, 1.24)
|
Fourth
|
48
|
1.37*
|
(1.15, 1.65)
|
1.26*
|
(1.04, 1.52)
|
97
|
1.08
|
(0.63, 1.86)
|
0.97
|
(0.56, 1.69)
|
Highest
|
54
|
1.75*
|
(1.45, 2.10)
|
1.38*
|
(1.14, 1.69)
|
98
|
1.33
|
(0.74, 2.37)
|
1.04
|
(0.57, 1.91)
|
Gravidity
|
|
|
|
|
|
|
|
|
|
|
1
|
43
|
Ref
|
|
Ref
|
|
96
|
Ref
|
|
Ref
|
|
2–4
|
48
|
1.22*
|
(1.08, 1.38)
|
1.20*
|
(1.03, 1.40)
|
97
|
1.34
|
(0.94, 1.90)
|
1.32
|
(0.83, 2.09)
|
5+
|
48
|
1.24*
|
(0.96, 1.60)
|
1.16
|
(0.86, 1.57)
|
96
|
0.86
|
(0.45, 1.67)
|
0.93
|
(0.41, 2.10)
|
Adjusted model includes age, education, wealth, and gravidity.
*Denotes significance at the p < 0.05 level
^Percent screened out of the total number of women in the category.
Table 3. Association between diabetes and hypertension diagnoses and selected background characteristics using logistic regression
Total number diagnosed/not diagnosed
|
Diabetes
|
Hypertension
|
75/2,140
|
434/4,552
|
|
%^
|
Crude
|
Adjusted
|
%^
|
Crude
|
Adjusted
|
|
|
OR
|
95% CI
|
aOR
|
95% CI
|
|
OR
|
95% CI
|
aOR
|
95% CI
|
Age (Years)
|
|
|
|
|
|
|
|
|
|
|
< 20
|
0.6
|
Ref
|
|
Ref
|
|
5.4
|
Ref
|
|
Ref
|
|
20–29
|
2.7
|
4.90*
|
(1.17,20.51)
|
3.79
|
(0.84,17.02)
|
8.2
|
1.56*
|
(1.13,2.15)
|
1.44*
|
(1.01,2.08)
|
30–39
|
7.3
|
13.77*
|
(3.30,57.41)
|
8.19*
|
(1.74,38.48)
|
16.4
|
3.42*
|
(2.45,4.79)
|
3.02*
|
(2.00,4.56)
|
40–49
|
0.0
|
-
|
--
|
-
|
--
|
20.5
|
4.50*
|
(1.97,10.33)
|
3.37*
|
(1.36,8.31)
|
Education (Completed)
|
|
|
|
|
|
|
|
|
|
|
None
|
7.8
|
Ref
|
|
Ref
|
|
12.4
|
Ref
|
|
Ref
|
|
Primary
|
4.4
|
0.55
|
(0.19,1.55)
|
0.67
|
(0.23,1.92)
|
10.2
|
0.80
|
(0.50,1.30)
|
0.94
|
(0.58,1.55)
|
Secondary
|
3.6
|
0.45
|
(0.17,1.78)
|
0.69
|
(0.26,1.89)
|
8.9
|
0.68
|
(0.44,1.08)
|
0.99
|
(0.62,1.60)
|
Post-Secondary
|
2.2
|
0.27
|
(0.17,1.18)
|
0.44
|
(0.14,1.38)
|
9.9
|
0.77
|
(0.48,1.23)
|
1.08
|
(0.65,1.82)
|
Household Wealth Quintile
|
|
|
|
|
|
|
|
|
|
|
Lowest
|
3.8
|
Ref
|
|
Ref
|
|
7.7
|
Ref
|
|
Ref
|
|
Second
|
3.5
|
0.91
|
(0.43,1.93)
|
0.96
|
(0.45,2.07)
|
9.7
|
1.28
|
(0.92,1.78)
|
1.35
|
(0.96,1.89)
|
Middle
|
2.9
|
0.75
|
(0.34,1.65)
|
0.83
|
(0.37,1.83)
|
8.7
|
1.15
|
(0.82,1.61)
|
1.22
|
(0.86,1.71)
|
Fourth
|
2.7
|
0.71
|
(0.33,1.53)
|
0.91
|
(0.41,2.01)
|
8.9
|
1.17
|
(0.84,1.63)
|
1.26
|
(0.89,1.77)
|
Highest
|
4.4
|
1.15
|
(0.58,2.28)
|
1.51
|
(0.72,3.17)
|
12.6
|
1.73*
|
(1.26,2.37)
|
1.73*
|
(1.24,2.43)
|
Gravidity
|
|
|
|
|
|
|
|
|
|
|
1
|
1.3
|
Ref
|
|
Ref
|
|
7.0
|
Ref
|
|
Ref
|
|
2–4
|
4.2
|
3.36*
|
(1.65,6.85)
|
1.66
|
(0.74,3.69)
|
10.1
|
1.49*
|
(1.19,1.88)
|
1.09
|
(0.82,1.44)
|
5+
|
8.3
|
6.99*
|
(2.84,17.23)
|
2.40
|
(0.84,6.91)
|
18.5
|
3.00*
|
(2.08,4.32)
|
1.56
|
(0.99,2.44)
|
Adjusted model includes age, education, wealth, and gravidity.
^Percent diagnosed out of total number of women ever screened in the category.
* denotes significance at the p<0.05 level
In the fully adjusted analyses, a higher age was significantly associated with higher odds of diagnoses of both hypertension and diabetes compared to a lower age of < 20 years. Women 30–39 years of age had significantly higher odds of hypertension (aOR 3.02, 95% CI 2.00, 4.56) and diabetes (aOR 8.19, 95% CI 1.74, 38.48) diagnoses compared to women under 20 years of age (Table 3). Among the 39 recently pregnant women over 40 years of age (Table 1), 23 (59%) had ever been screened for diabetes, and none reported a history of diabetes diagnosis. Women over 40 years of age had the highest odds of hypertension diagnosis (aOR 3.37, 95% CI 1.36, 8.31) compared to women under 20 years of age. The number of total lifetime pregnancies was not associated with higher odds of hypertension or diabetes diagnoses in the adjusted analyses (Table 3).
Antenatal care services among women with diabetes and hypertension
Among women with reported diabetes diagnoses, 53% (40 out of 75) occurred before and 47% (35 out of 75) occurred during or after the index pregnancy (Table 4). Women with any diabetes diagnosis were more likely to have four or more antenatal care contacts compared to women who were never diagnosed (48% vs. 36%, p = 0.04). Women with any diabetes diagnosis were significantly more likely to report having blood tests during antenatal care compared to women who were never diagnosed (83% vs. 66%, p < 0.01) (Table 4). A greater proportion of women with any diabetes diagnosis reported receiving calcium and iron folate supplements, any urine test, and having their weight and blood pressure measured compared to women who have never been diagnosed, but these differences were not statistically significant (Table 4). Among women with any diabetes diagnosis, 17% (13 out of 75) received all seven measured elements of antenatal care, including 15% (8 out of 53) of women diagnosed with diabetes prior to the index pregnancy.
Table 4. Timing of diagnoses of diabetes or hypertension and antenatal care services
|
Diabetes
|
P-value
|
Hypertension
|
P-value
|
Ever diagnosed
|
No
|
Yes
|
|
No
|
Yes
|
|
|
4,617
|
75
|
|
4,258
|
434
|
|
|
n(%)
|
n(%)
|
|
n(%)
|
n(%)
|
|
Timing of diagnosis
|
|
|
|
|
|
|
Before pregnancy
|
|
40 (53)
|
|
|
158 (36)
|
|
During pregnancy
|
|
29 (38)
|
|
|
195 (45)
|
|
After pregnancy
|
|
6 (8)
|
|
|
81 (19)
|
|
|
|
|
|
|
|
|
Number of antenatal care contacts
|
|
|
0.04*
|
|
|
<0.01*
|
None
|
535 (12)
|
6 (8)
|
|
502 (12)
|
39 (9)
|
|
< 4
|
2,427 (53)
|
33 (44)
|
|
2,257 (53)
|
203 (47)
|
|
4–8
|
1,507 (33)
|
30 (40)
|
|
1,360 (32)
|
177 (41)
|
|
9+
|
148 (3)
|
6 (8)
|
|
139 (3)
|
15 (3)
|
|
|
|
|
|
|
|
|
Elements of antenatal care
|
|
|
|
|
|
|
Weight Taken
|
3,486 (76)
|
63 (84)
|
0.09
|
3,206 (75)
|
343 (79)
|
0.08
|
Blood Pressure Taken
|
3,648 (79)
|
65 (87)
|
0.11
|
3,343 (79)
|
370 (85)
|
<0.01*
|
Any Urine Test
|
2,857 (62)
|
51 (68)
|
0.28
|
2,599 (61)
|
309 (71)
|
<0.01*
|
Any Blood Test
|
3,070 (66)
|
62 (83)
|
<0.01*
|
2,814 (66)
|
318 (73)
|
<0.01*
|
Tetanus Toxoid Vaccine
|
2,092 (45)
|
27 (36)
|
0.27
|
1,946 (46)
|
173 (40)
|
0.05
|
Any Iron Folate Supplement
|
3,202 (69)
|
55 (73)
|
0.75
|
2,944 (69)
|
313 (72)
|
0.42
|
Calcium Supplement
|
3,107 (67)
|
54 (72)
|
0.68
|
2,863 (67)
|
298 (69)
|
0.29
|
Received all seven measured elements of care
|
1051 (23)
|
13 (17)
|
0.27
|
97 (22)
|
97 (22)
|
0.86
|
The p-value compares women ever diagnosed to women never diagnosed with the disease.
* denotes significance at the p < 0.05 level
Among women with reported hypertension diagnoses, 36% (158 out of 434) occurred before and 64% (276 out of 434) occurred during or after the index pregnancy (Table 4). Women with any hypertension diagnosis were more likely to have four or more antenatal care contacts compared to women who have never been diagnosed (44% vs. 35%, p < 0.01). Women with any hypertension diagnosis were significantly more likely to receive calcium supplements and tetanus toxoid vaccination, report having their weight and blood pressure measured, and have any blood test during pregnancy compared to women who have never been diagnosed (Table 4). Among women with any hypertension diagnosis, 22% (97 out of 434) received all seven measured elements of antenatal care, including 15% (28 out of 158) of women diagnosed with hypertension prior to the index pregnancy.
Among the respondents, 8% of diabetes and 19% of hypertension diagnoses occurred after delivery, indicating that the disease may not have been identified through routine antenatal care in pregnancy. Despite more antenatal contacts during pregnancy, after adjusting for age, education, wealth, and the total number of lifetime pregnancies, women with any diagnosis of diabetes (aOR 0.87, 95% CI 0.47, 1.60) or hypertension (aOR 1.05, 95% CI 0.82, 1.34) were no more likely to receive all seven measured elements of antenatal care services at least once in their pregnancy compared to never diagnosed women.