Background: Hypertensive disorders of pregnancy (HDsP) affect 5 to 22% of pregnancies worldwide. Despite extensive global research, etiology, management, prevention remains elusive. When prevention is not possible, early diagnosis can save mothers and babies despite disorders, but rural women especially in developing countries lack awareness, health services, resources too, so suffer much more.

Objectives: Community-based study was carried out to know about burden, effects of HDsP amongst rural women of remote hilly regions.

Material Methods: After the base institute’s ethics committee’s approval, prospective study was carried out in 100 villages. Information about HDsP was collected from women’s antenatal records by a research assistant. However, blood pressure was measured by the research assistant also. If BP was high, diagnosis of HDsP was at referral, study centre. Detailed workup of many could not be done, so this wasn’t part of study.

Results: Of 3713 women who delivered during study period of over 2 years, 455 (12.3%) had HDsP. Overall 280 (7.6%) had moderate gestational hypertension (GH)/preeclampsia (PE), 129 (3.5%) severe, 46 (1.2%) eclampsia and 3258 (87.7%) were normotensive. Of 1133 women aged 15-19 years, 159 (14%) had HDsP, of 207 of 30-34 yrs 8.2%. Of 1241 almost illiterate (some had gone to school for one or 2 years) 179 (14.4%) had HDsP, 109 (8.8%) moderate, 49 (3.9%) severe disease and 21(1.7%) had eclampsia. Of 113 (3.0%) women who were postgraduate educated, 4 (3.5%) had HDsP. Of 853 Unskilled workers, 96 (11.3%) had HDsP, of 2301 Homemakers, 321 (14.0%) had HDsP, of 1384 Primigravida, 189 (13.7%) had HDsP, of 868 with 3 or more births, 75 (8.6%) had HDsP, significant difference between primi and multigravida. One-third of maternal deaths during the study period were due to Eclampsia and 62(42.17) perinatal deaths out of total 147 perinatal deaths were in women with HDsP.

Conclusion: HDsP were common in rural, tribal women of remote villages. They lead to a lot of maternal, perinatal loss. However many gaps were identified which need a lot of research.

• Rural women

• Hypertensive disorders of pregnancy

• Variables

• Maternal

• Perinatal Outcome

Chhabra S, Chhabda N, Afreen S, Rathod M (2024) Community Based Study of Hypertensive Disorders during Pregnancy in Rural Tribal Women of a Low Resource Region. Med J Obstet Gynecol 12(1): 1184.

Despite extensive global research, the etiology, prevention and management of hypertensive disorders of pregnancy (HDsP) remain elusive. Cunningham et al. [1], reported that HDsP complicated 5-10% of pregnancies and was the leading cause of maternal, fetal and neonatal morbidity and mortality globally. Others have reported that worldwide, HDsP affected around 5 to 22% of pregnancies. Some women develop severe complications and their babies also get affected, more in developing countries [2]. Mothers with HDsP can develop single organ or multiorgan failure, usually kidney, liver and heart which lead to severe morbidity and mortality. Sometimes diagnosis is delayed because of after admission in an emergency with organ failure, increasing the fatality due to HDsP [3]. If not prevented, at least early diagnosis and appropriate treatment of HDsP must be tried which can improve mothers’ and babies’ outcomes. Most studies are health facility-based. Community-based information is scarce, especially about rural, tribal women with low resources.

Present community-based study was carried out to know the burden and effects of HDsP in rural, tribal women who live in extreme poverty.

The study was conducted after obtaining the base institute’s ethics committee approval. The research assistant collected information in the villages through the predesigned tool, prospectively, mostly from the records of women. However, blood pressure was measured by the research assistant also. If BP was high, diagnosis of HDsP was made at referral. But a detailed workup of many could not be done, so is not of the present analysis.

Study setting

Community-based study was conducted in rural tribal communities of remote, forestry and hilly region in 100 villages near the village with health facility.

Study Type

Analytical cross-sectional study.

Study period

Almost two years

Study sample

Study sample was not calculated because all the births during the study period were included except for occasional migrations.

Inclusion criteria

Pregnant women of 15-39 years who delivered. The plan was to include women of 15 to 45 years but the eldest was 39 years old.

Over 2 years, 3713 women delivered  455 (12.3%) of them had HDsP, 280 (7.5%) moderate, 129 (3.5%) severe HDsP and 46 (1.2%) had eclampsia. Of 1133(30.5%) women of 15-19yrs, 159 (14%) had HDsP, 96 (8.5%) moderate, 44 (3.9%) severe disease, and 19 (1.7%) had eclampsia. Of 313 women of 30-39 yrs, 23 (7.3%) had HDsP, statistically significant difference, between adolescents and adults, 15 (4.8%) moderate, 7 (2.2%) severe and one (0.3%) had eclampsia. Of 1241 (33.4%) almost illiterate (some had gone to school for one or 2 years) women, 179 (14.4%) had HDsP, 109 (8.8%) moderate, 49 (3.9%) severe disease, and 21(1.7%) had eclampsia. Of 113 (3.0%) women who were postgraduate educated, 4 (3.5%) had HDsP, statistically significant difference between illiterate and Postgraduate educated women (P-value 0.0001), 2 (1.8%) had moderate, 2 (1.8%) severe disease, no one had eclampsia. Of 2301 Homemakers, 321 (14%) had HDsP, 184 (8.0%) moderate, 102 (4.4%) severe disease and 35 (1.5%) had eclampsia. Of 853 Labourer women, 96 (11.3%) had HDsP, 66(7.7%) moderate, 21 (2.5%) severe disease and 9 (1.1%) had eclampsia. Of 559 (15.0%) women who did other works (skilled, semi-skilled, small businesses), 38 (18.6%) had HDsP, 30 (15.7%) moderate, 6 (0.9%) severe disease, and 2 (0.6%) had eclampsia, statistically significant difference between homemakers other working women (P- value <0.0001). Of 2330 economically low class women, 326 (14.0%) had HDsP, 199 (8.5%) moderate, 92 (3.9%) severe disease, and 35 (1.5%) had eclampsia. Of the 315 (8.4%) women of middle and middle- upper class, 39 (19.0%) had HDsP, 33 (17.0%) had moderate, 5 (2.3%) severe disease, and one (0.5%) had eclampsia. Of 1384 primigravida, 189 (13.7%) had HDsP, 118 (8.5%) had moderate,53 (3.8%) severe disease and 18 (1.3%) had eclampsia. Of the166 women with 4 or more births, 7 (4.2%) had HDsP, statistically significant difference between primi and multi gravida (P-value 0.0001), 3 (1.8%) moderate, 3 (1.8%) severe disease and one had(0.6%) eclampsia (Table 1).

Table 1: Hypertensive Disorders in Rural Tribal Pregnant Women

Of 3258 (87.7% of 3713) normotensive women, 32 (1.0%) had early preterm (EPT) (<34 weeks) births, 92 (2.8%) late preterm births (LPT) (>34 to <37 weeks) and 3134 (96.2%) had term births. Of 32 (1.0%) EPT 21(0.7%) had vaginal births (VB), [2 intrauterine fetal death (IUFD), one neonatal death (NND) 6 SBs (intra partum deaths) and 12 live babies] and remaining 13 had cesarean births (CB) [2 SBs, 10 live babies with one NND, no IUFD]. Among 92 LPT births, 71 had VB, [ 2 NND, 3 IUFD, 10 SBs and 56 live babies] and 21 had CB, [one NND, one IUFD, 7 SBs and 12 live babies]. Among 3134 term births, 3010 (97.0%) had VB, [5 IUFDs, 127 SBs, 2879 live babies, no NND] and 122 had CB, [3 IUFD, 20 SBs, 99 live babies and no NND]. Of 455 women with HDsP, 280 had moderate disease and of them 12 (4.2 %) had EPT, 56 LPT and 212 (75.71% %) had term births, Of 12 EPT births 11 had VBs, [2 IUFD, one had NND, no SB, 6 and 3 live babies] and remaining 2 (0.7%) had CB[2 live babies]. Among 56 LPT births 45 (16.1%) had VB, [1 IUFD, 41 live babies, had one NND and 2 had SBs] and 8 (14.28%) had CB [one IUFD, 7 live births and no SB or NND]. Of 129 (3.5%) women with severe HDsP, 10 (7.8%) had EPT, 31 (24.0%) LPT and 88 (68.0%) term births. Of 46 (1.2%) women with eclampsia, 18 (39.1%) had EPT, 13 (28.3%) had LPT and 15 (32.0%) term births (Table 2).

Table 2: Pregnancy outcome with Hypertensive Disorders

Of 3258 (87.7% of 3713) normotensive women 3211(98.5%) had term births and 47 (1.5%) had preterm births. Among 3211 term births of 1521 (46.6%) AGA babies, 8 (0.2) had IUFD, 34 (1.0%) SBs and 1479 (45.4%) live babies, no NND and of 1690 (51.8%) SGA had 5 (0.2%) IUFD occurred 20 (0.6%) SBs, and 1664 (51.1%) live babies, one NND. Among 47 (1.4%) preterm births of 33 (1.0%) AGA babies 2 (0.1%) IUFD, 8 (0.2%) SBs 22 (0.7%) live babies (0.03%) NND and of 14(0.4%) SGA babies one (0.03%) had IUFD, 4 (0.1%) SBs and 8 (0.25%) live babies, one (0.03%) NND. Of 280 (7.5% of 3713) women with moderate HDsP 238 (85.0%) had term births and 42(15.0%) had preterm births. Among 238 term births of 119 (42.0%) AGA babies, 4(1.4%) had IUFD 5 (1 .8%) SBs, 108 (38.6%) live babies 2 (0.7%) NND and of 119 (42.0%). SGA babies 3 (1.1%) had IUFD, 4 (1.4%) SBs and 112 (40.0%) live births, no NND. Among 42 (15. %) preterm births, of 33 (11.7%) AGA babies 2 (0.7%) had IUFD, 2 (0.7%) SBs, 28 (10.0%) live babies one (0.4%) NND and of 9 (3.2%) SGA babies 1 (0.4%) IUFD no SB and 6 (2.14%) live births, 2 (0.7%) NND. Of 129 (3.5% of 3713) women who had severe HDsP, 99 (76.7%) had term births and 30 (23.2%) preterm births. Among 99 term births, of 53 (53.53 %) AGA babies, 4 (3.1%) had IUFD, 6(4.7%) SBs, 42 (32.6%) live babies, one (0.8%) NND occurred.

Of 46 (35.6%) SGA babies, 2 (1.6%) had IUFD, 3(2.3%) SBs, 39 (30.2%) live babies, and one (1.6%) NND occurred. Among 30  (23.3%) preterm births of 23 (17.8%) AGA babies, one (0.8%) IUFD, (0.8%) SBs and 19 (14.7%) live babies and 2(1.6%) NND of (5.4%) SGA babies there was no IUFD, 1(0.8%) SB and 6 (4.6%) live births, no NND. Of 46 (1.2% of 3713) women with Eclampsia 20 (43.7%) had term births and 26 (56.5%) had preterm births. Among 20 term births, 7 (15.2%) had AGA babies, one (2.2%) IUFD, 1(2.2%) SB occurred, 4 (8.7%) live babies, one (2.2%. Of 13 (28.2%)  SGA  babies, 1 (2.2%) had IUFD, 2 (4.3%) SBs and (17.4%) live babies, 2(4.3%) NND. Among 26 (56.5%) preterm births, of 10 (21.7%) AGA babies, there was no IUFD, 1(2.2%) SB and 7(15.2%) live births and 2(4.3%) NNDs and of 16 (34.7%) SGA there was no IUFD, 1(2.2%) SBand 14 (30.4%) live babies, 1 (2.2%) NND (Table 3).

Table 3: Hypertensive Disorders and Neonatal Outcome

*IUFD:-intrauterine Fetal Death; *NND:- Neonatal Death

HDsP contributed to 42.17 % perinatal deaths. Amongst 455 HDsP, 12(4.3%) amongst EPT, 56 (20.0%) amongst LPT of 280 women with moderate HDsP cases and 10 (7.8%) EPT, 31(24.0%) LPT of 129 cases with 18(59.0%) EPT, 13(28.0%) LPT. Of 46 women with eclampsia and 1.2% of normotensive 32(1.0%) of EPT and 92(2.8%) of LPT. Overall 147 perinatal deaths occurred amongst 3713 births, (3.95%). There were 13.62% perinatal deaths amongst cases of HDsP (62 of 455). HDsP contributed to 42.17% perinatal deaths.

There were 10 maternal deaths amongst 3713 cases. Of them, 3 (0.1%) were cases of eclampsia, HDsP contributed to one-third of maternal deaths.

Maternal, perinatal morbidity and mortality associated with HDsP are the most difficult to prevent and continue to be a research agenda because of the persisting gaps in knowledge. Mehta [4], from India reported that nearly one in 14 pregnant women in rural areas had HDsP. Chauhan [5], from Chhattisgarh, India reported that among tribal women HDsP were higher and maximum cases were of 20-25 years and primigravida. Oliveira [6], reported that hypertension among the indigenous village population was similar to the prevalence in Brazilians, but may have a more negative effect in disadvantaged populations. Identifying high-risk women early and modifying their risk was desirable which seems a dream for rural women who get even basic care with difficulty. Early diagnosis and treatment through regular and quality antenatal care are key factors for the prevention of severe HDsP and their complications. However, for rural women quality antenatal care is also difficult. Hurrell et al. [7], from the UK reported that Placental growth factor (PlGF) based testing is increasingly being implemented in clinical practice in several countries. Guy et al. [8], from the UK reported that early screening is not feasible in public healthcare settings in place with limited resources.

A significant reduction in the rate of preterm preeclampsia and nearly total compliance of aspirin use has been reported [9]. This as of now is not possible in remote villages. Lean et al. [10], also reported that HDsP and fetal growth restriction increased a mother’s risk of cardiovascular disease (CVD) in later life. Giorgione et al. [11], also reported that women with a history of HDsP were at increased long-term risk of cardiovascular disease.

The rural tribal woman who struggle for survival for themselves and their babies, neither have a system of having records for their future nor are aware. Despite the seriousness of the maternal and fetal consequences of HDsP, developing effective screening modalities, reliable diagnostic tests of possible, effective therapy or amelioration of the postpartum maternal cardiovascular legacy are still challenges. Studies revealed that 10-15% of maternal mortality in developing countries was due to HDsP [12]. In the present community-based study in remote rural regions HDPs contributed to around one-third of maternal deaths. HDsP are also reported to affect babies adversely causing preterm births, intrauterine growth retardation, reduced birth weight, SBs and higher perinatal mortality [13]. In the present study, HDsP contributed too many perinatal deaths, 42.17% % of all perinatal deaths. In a study [14], the proportion of HDsP almost doubled from 603 to 1196 per 10,000 delivery hospitalisations, representing an average annual percent change of 3.8% over the study period. More alarmingly, in the same period, risk factors for HDsP increased from 9.6% to 24.6%, which appears to account for part of the increase in the incidence of HDsP. Incidences of acute renal failure and acute liver injury increased, comparable to the incidences in non-hypertensive pregnancies.

In the present study, there were 10 maternal deaths amongst 3713 cases. Of them 3 were cases of eclampsia, HDsP contributed to almost one-third of maternal deaths. Overall 147 perinatal deaths occurred amongst 3713 births, (3.95%). There were 13.62% perinatal deaths amongst cases of HDsP (62 of 455). HDsP contributed to 42.17% perinatal mortality. As at present hypertensive disorders of pregnancy can’t be completely prevented, at least early diagnosis and appropriate treatment of HDsP must be tried which can improve mothers’ and babies’ healthy survival.

The authors are grateful to Indian Council of Medical Research New Delhi India for funds but were only for community work. We are grateful to communities for cooperation.

1. Cunningham F, Leveno K, Dashe J. Williams Obstetrics Chapter 40 Preeclampsia Syndrome, 26e. McGraw Hill Professional, 2022
2. Poon LC, Nguyen-Hoang L, Smith GN, Bergman L, O’Brien P, Hod M, et al. Hypertensive disorders of pregnancy and long-term cardiovascular health: FIGO Best Practice Advice. Int J Gynecol Obstet. 2023; 160: 22- 34.
3. Nour NM. An introduction to maternal mortality. Rev Obstet Gynecol. 2008; 1: 77.
4. Mehta B, Kumar V, Chawla S, Sachdeva S, Mahopatra D. Hypertension in pregnancy: a community-based study. Indian J Community Med. 2015; 40: 273.
5. Chauhan P, Sinha T, Shrivastava P, Chauhan VK. A study of hypertensive disorders in pregnancy among tribal women at tertiary level care in bastar Chhattisgarh. Int J Biol Med Res. 2014; 5: 4075- 4083.
6. Oliveira GF, Oliveira TR, Ikejiri AT, Andraus MP, Galvao TF, Silva MT, et al. Prevalence of hypertension and associated factors in an indigenous community of central Brazil: a population-based study. PloS one. 2014; 9: e86278.
7. Hurrell A, Beardmore-Gray A, Duhig K, Webster L, Chappell L, Shennan A. Placental Growth Factor in Suspected Preterm Pre-eclampsia: A Review of the Evidence and Practicalities of Implementation. BJOG. 2020; 127.
8. Guy GP, Leslie K, Diaz Gomez D, Forenc K, Buck E, Khalil A, et al. Implementation of routine first trimester combined screening for pre-eclampsia: a clinical effectiveness study. BJOG. 2021; 128: 149-156.
9. Young BC, Thadhani R, Karumanchi SA. Aspirin to Prevent Preterm Preeclampsia. Hypertension. 2020; 75: 941-942.
10. Lean S. The placental prophecy: predicting future maternal CVD. BJOG. 2020; 22.
11. Giorgione V, Ridder A, Kalafat E, Khalil A, Thilaganathan B. Incidence of postpartum hypertension within 2 years of a pregnancy complicated by preeclampsia: a systematic review and meta-analysis. BJOG. 2020; 128: 495-503
12. Maternal Mortality Rates in the United States, 2022.
13. Minopoli M, Noël L, Meroni A, Mascherpa M, Frick A, Basky Thilaganathan. Adverse pregnancy outcomes in women at increased risk of preterm pre-eclampsia on first-trimester combined screening. BJOG. 2023; 131: 81-87.
14. Rocha de Moura, Margotto PR, Nascimento Costa K, Carvalho GarbiNovaes MR. Hypertension induced by pregnancy and neonatal outcome: Results from a retrospective cohort study in preterm under 34 weeks. Laganà AS, editor. PLOS ONE. 2021; 16: e0255783