Prevalence of pre-eclampsia and associated factors among women attending antenatal care services in Felege-Hiwot referral hospital, Bahir Dar city, Northwest Ethiopia

Preeclampsia, also called pregnancy-induced hypertension is a pregnancy-specific hypertensive disorder usually occurs after 20 weeks of gestation and affects both the mother and the fetus. preeclampsia is one of the driving causes of maternal and perinatal horribleness and mortality. Institution based cross-sectional study was conducted from March 1st up to 30th 2017. Study participants was recruited by using systematic random sampling technique. A pre-tested questionnaire was used for data collection. The data were checked for its completeness and consistency each day and the collected data was coded and entered into Epi Data version 3.1 and analyzed by using Statistical package for social science version 23. The logistic regression assumption was checked and fitted at P >0.05. Abstract Introduction: Preeclampsia, also called pregnancy-induced hypertension is a pregnancy-specific hypertensive disorder usually occurs after 20 weeks of gestation and affects both the mother and the fetus. preeclampsia is one of the driving causes of maternal and perinatal horribleness and mortality. Objective: To assess the prevalence of preeclampsia and associated factors among women attending antenatal care service at Felge Hiwot Referral Hospital, Bahir Dar, Ethiopia, 2017. Methods: Institution based cross-sectional study was conducted from March 1 st up to 30 th 2017. Study participants was recruited by using systematic random sampling technique. A pre-tested questionnaire was used for data collection. The data were checked for its completeness and consistency each day and the collected data was coded and entered into Epi Data version 3.1 and analyzed by using Statistical package for social science version 23. The logistic regression assumption was checked and fitted at P >0.05. Result: The prevalence of preeclampsia was found to be 13.0 % (95%CI: 8.3,17.6). Factors that had a statistically significant association with preeclampsia were women having a family history of hypertension [AOR=4.61(1.06, 20.07)], Gestational diabetes mellitus [AOR=11.41(1.40, 92.83)], using traditional medicine during pregnancy [AOR= 26.29(3.68, 187.84)]. Conclusion: the result indicated that the prevalence of preeclampsia in this hospital was higher than similar studies conducted in Ethiopia. Preventable and risk factors Having a family history of Diabetes Mellitus, Gestational Diabetes Miletus and taking traditional medicines during pregnancy were statistically associated with preeclampsia.


Introduction
Preeclampsia, also called pregnancy-induced hypertension is a pregnancy-specific hypertensive disorder usually occurs after 20 weeks of gestation and affects both the mother and the fetus. preeclampsia is one of the driving causes of maternal and perinatal horribleness and mortality.

Objective
To assess the prevalence of preeclampsia and associated factors among women attending antenatal care service at Felge Hiwot Referral Hospital, Bahir Dar, Ethiopia, 2017.

Methods
Institution based cross-sectional study was conducted from March 1st up to 30th 2017. Study participants was recruited by using systematic random sampling technique. A pre-tested questionnaire was used for data collection. The data were checked for its completeness and consistency each day and the collected data was coded and entered into Epi Data version 3.1 and analyzed by using Statistical package for social science version 23. The logistic regression assumption was checked and fitted at P >0.05.

Result
The prevalence of preeclampsia was found to be 13

Introduction
Severe pre-eclampsia commonly occurs during the second trimester or third trimester of gestation, which is characterized by blood pressure, elevated than 160/110 mmHg, proteinuria greater than 5g per 24 hrs., visual disturbances, epigastric pain or more specifically right upper quadrant pain (1, 2).
The factors that have been postulated to influence the risk of pre-eclampsia in various studies include diabetes and gestational diabetes, obesity, multiple pregnancy, personal and family history of pre-ec lampsia, chronic infections, urinary tract infection, first pregnancy and older maternal age or younger than 20 years age, renal disease and autoimmune disorder, the prolonged interval between pregnancies and the history of abortion and maternal diet (3).
In the world, Pre-eclampsia influences a considerable public ill health, a tributary to maternal and perinatal dreariness and mortality. Its impact accounts between 5 to 10 percent of pregnancies (4). There is approximately one maternal death due to pre-eclampsia-eclampsia per 100,000 live birth with a case-fatality rate of 6.4 deaths per 10,000 cases (5,6).
In developing countries, the impact of the condition, however, is thought to be more severe and with the prevalence of between 1.8% and 16.7% which is significantly higher than 2%, the maternal and infant mortality and morbidity (7).
The world health organization estimated the incidence of pre-eclampsia to be seven times higher in developing countries than in developed countries (8).
In Africa, preeclampsia occurs in 10% of pregnancy, which is significantly higher than the global average of 2 percent (9).
The Ethiopian national emergency obstetric and newborn care showed that eclampsia contributed for the complication of approximately 1% of all deliveries and 5% of all pregnancies moreover, it had contributed to 16% of direct maternal mortality and 10% of all maternal mortality and morbidity (10).
This study was provided a clear picture of risk factors by depicting their association with eclampsia. It also can be used as baseline information for other researchers who could conduct further study on a similar issue.

Study Area, Period and Design
The study was conducted at FHRH, which is one of the top ten governmental hospitals in Ethiopia, it's situated in Bahir Dar city, which is the capital city of Amhara National Regional State. It is found 565 km away from Addis Ababa, the Capital city of Ethiopia. Currently, the Hospital is giving services for more than 5 up to 7 million people per year in the western part of the region as a referral hospital.
The present capacity of the hospital has more than 350 beds of which 55 are currently allocated for the department of Obstetrics and Gynecology, about 3,521 mothers attend in antenatal care each year, and the hospital has 61 medical doctors among those 19 senior specialized doctors, 17 medical residents, 25 General practitioners, from Gynecology and Obstetrics ward; 2 gynecologist, 33 midwives and 6 medical doctors, 3 ANC classroom. (11). The study was conducted from March 1 st up to 30 th /2017 G.C using an institutional based cross-sectional study design.

Sample Size Determination
The sample size was determined using a single population proportion formula with an assumption of 95% confidence interval, 4% margin of error and the proportion of preeclampsia among ANC attendant mothers was 8.4% (12). Therefore; the final sample size for this study was 193

Sampling Procedure
Study participants were selected by using a systematic random sampling technique by considering a list of ANCs follows up as a sampling frame. Pregnant women's gestational age was measured based on their recall of the last menstrual period.
Ultrasound estimation for gestational age was also considered when women fail to remember the last menstrual period.
Inclusion criteria: Among ANC attending women, those with SBP > 140mmHg and DBP >90mm Hg on two separate readings taken at least four hours apart with previously normal blood pressure and when proteinuria is greater than or equal to 300 mg per 24-hour urine collection or dipstick reading of 1+ were included in the study.
Exclusion Criteria: Women who were unable to speak due to severe illness at the time of data collection and women with known hypertension and renal disease were excluded from the study. Proteinuria: Protein in the urine, which is greater than or equal to 300 mg per 24hours or Dipstick reading 1 + .

Patient and Public Involvement statement
The data were collected using a structured questionnaire and a sphygmomanometer.
Four clinical nurses and one BSC midwifery supervisor were involved in the data collection process. Therapeutic records were likewise looked into for some clinical and laboratory results including proteinuria. Each participant was allowed to take rest for ten minutes before measuring her blood pressure. Blood pressure readings were taken while the woman was seated in the upright position using a mercury sphygmomanometer apparatus which covers two-thirds of the upper arm. The measurement was taken from the participant's right hand. The cuff was inflated at a rate of 2-3 mmHg per second. Systolic blood pressure was taken upon hearing the first sound, and diastolic blood pressure was taken up on the 4th (muffled) Korotkoff sound. Those pregnant women with abnormal findings were checked again and again and then have undergone another BP measurement after 4-6 hours in order to confirm the diagnosis. For the sake of assuring whether the mercury sphygmomanometer apparatus was functioning correctly, the data collectors checked it by measuring the blood pressure of other data collectors. When a pregnant woman was found to have severe preeclampsia (BP of 160/110 mmHg), she was sent for immediate re-checkup and medical advice. Data regarding proteinuria and other clinical information was accessed from the women's medical record books. Proteinuria was assessed using a urine dipstick, which is a routine investigation for all pregnant women.

Data Quality Management
The questionnaire was first prepared in English then translated to the local language (Amharic) and back-translated into English to maintain conceptual consistency. Data collectors and supervisors were trained on the objective of the study, interviewing technique, and other activities. The questionnaire was pretested for its completeness, consistency, and accuracy at Addis Alem Hospital in Bahir Dar City. Day to day supervision was made on how data were collected during the data collection and data collectors were informed to brief the respondents for any misunderstanding during the data collection.

Data Entry and analysis
Each datum was checked for its completeness, coded, cleaned and entered using

Discussion
Preeclampsia is a disorder of pregnancy characterized by high blood pressure and a significant amount of protein in the urine. It is one of the major causes of maternal mortality worldwide. This study endeavored to examine the prevalence and factors associated with preeclampsia on a sample of 193 pregnant women who had ANC follow up at Felege Hiwot Referral Hospital. According to this study, the prevalence of preeclampsia was found to be 13.0 % (95%CI: 8.3,17.6). This was in line with the study finding in Dessie referral hospital (8.4%) (12). However higher than the studies conducted in Dilla university referral hospital which were 2.2% [21]. respectively However this finding was lower than a study finding at Arba Minch town public health institutions 18.3% (13). The difference might be due to sampling size variation and study period.
In this study having a family history of hypertension, gestational DM and taking traditional medicine during pregnancy were significantly associated with preeclampsia were.
In the present study, those pregnant women with a family history of hypertension were about four points six times more likely to develop preeclampsia. This finding was supported by a study done in Pakistan (14), in Dessie referral hospital (12), in Arba Minch public health institution (13), and in Addis Ababa Selected Public hospitals (15). The reason might be the association of some cardiovascular disorders with the genetic inheritance that can expose for preeclampsia.
The odds of mothers who had gestational DM were about eleven points four times more likely to develop preeclampsia as compared to those who had no gestational DM. This finding was supported by a study done in low and middle-income countries(16) Those pregnant women who used traditional medicines during pregnancy were at high risk of developing preeclampsia as compared to their counterparts. This finding was also supported by a study done in Alexandria, USA use of herbal medicine among pregnant women were significant risk for the developing preeclampsia compare with those who couldn't use (7)and this finding was also in agreement with a study conducted in Nigeria on the use herbal medicine during pregnancy that showed users of traditional medicines during pregnancy were exposed to pregnancy-induced hypertension(17).

Strength and Limitations of the study
Due to its cross-sectional nature of the study, it is difficult to establish a causal relationship between the dependent and independent variables.
Being an institutional based study, it could be difficult to infer the finding of the study to the target population as all pregnant women may not attend their pregnancy in the hospital.
Since the current study was not triangulated with a qualitative method; it might not help to indepth explore on factors that contribute to the occurrence of preeclampsia.

Conclusion
The result indicated that the prevalence of preeclampsia in this hospital was higher than similar studies conducted in Ethiopia. Having a family history of hypertension, Gestational DM and using traditional medicines during pregnancy were statistically associated and preventable risk factors with preeclampsia. Identifying risk factors at early gestational age would be valuable for the prevention of occurrence, treatment, and prevention of complications of pre-eclampsia.

Ethics approval and consent to participate
Ethical approval was obtained from the GAMBY College of Medical Sciences,

Research and Publication Office and approval letter were obtained from Felege
Hiwot Referral Hospital. The purpose of the study was explained to the mothers and Verbal informed consent was obtained from them. Secrecy of data was kept up by removing any personal identifier from the questionnaires. The study participant information sheet was attached in the front page of the questionnaire and before the actual data collection process the participants were well informed and the data collection was on a voluntary basis.

Consent for publication
Written consent was obtained that the interview will be included in publications

Availability of data and material
The data can be accessed from the corresponding author through the following address fentahun143@gmail.com / / agumlt@yahoo.com.
The data will be accessed for research purposes.