A New Model for Improving Quality of Hypertension’s Determinant Factors in Pregnancy
Yusrawati Yusrawati2
Adang Bachtiar3
Masrul Muchtar2
Mudjiran Mudjiran4
Hema Malini5
Defrin Defrin2
Authors Info & Affiliations
Abstract
Background
Hypertension in pregnancy should be detected earlier to prevent possible complications of pregnancy such as preeclampsia. Pregnancy hypertension could transform into preeclampsia if unmonitored and untreated, it can even be bad for eclampsia.
Purpose
This research aims to identify the determinant factors of hypertension during pregnancy and to develop a suitable model to prevent hypertension in the future.
Methods
The research was developed using a mixed method with an embedded design approach. This study has adopted the ADDIE concept including Analysis, Design, Development, Implementation, and Evaluation steps. Purposive sampling based on knowledge proportion has designated 164 pregnant women as key participants. Qualitative analysis was applied through in-depth interviews. Quantitative analysis was conducted with SEM-PLS.
Results
The determinant variable components of late detection of hypertension in pregnancy are knowledge and understanding, self-efficacy, intentions, and attitudes of pregnant women. Other variables are also considered as psychosocial support of husband/family and midwives, antenatal care, and service facilities.
Conclusion
The data shows that the MEGA model is proven to be effective in evaluating the determinant factors of hypertension in pregnancy.
1. INTRODUCTION
In 2020, about 800 women per day passed away from pregnancy- and childbirth-related avoidable causes. In low- and lower-middle-income countries, maternal fatalities accounted for about 95% of all deaths in 2020 [1]. In 2021, the Ministry of Health reported the number of maternal deaths of 7,389 in Indonesia. Based on the causes, the majority of maternal deaths in 2021 were related to COVID-19 with 2,982 cases, 1,330 cases of bleeding, and 1,077 cases of hypertension in pregnancy. Cases of preeclampsia in North Sumatra Province contributed to 23.7% of maternal deaths, especially in Deli Serdang Regency of 21.1% [2]. Several efforts by the Indonesian Government to reduce Maternal Mortality Rate (MMR) include the “Safe Motherhood Initiative” which focuses on the concept of death prevention by providing antenatal care [3], deliveries performed by health personnel, family planning, and managing complications [2]. Currently in Indonesia, Mother & Child Health Book, and Health Score-card are used together to determine the risk level of pregnancy in mothers. Because it is only used by doctors and midwives during antenatal visits, so there is no involvement of pregnant women in knowing whether their pregnancy is classified as at risk and experiencing complications of hypertension in pregnancy. The participation of pregnant women, families, communities, and health workers is crucial to success as an effort to prevent delays in detection [4]. A recent study has developed a prediction model using a combination of biomarkers that had good discriminatory performance for hypertension in pregnancy [5]. A recent study discovered that the majority of high-risk pregnancies in rural areas—nearly one-fifth of all pregnancies—were caused by maternal age and pregnancy-induced hypertension. High-risk pregnancies were independently correlated with parity and socioeconomic level [6,7]. A limitation of the safe motherhood program is the challenge of accessing healthcare services in various regions of Indonesia, attributable to geographical constraints and the unequal distribution of healthcare personnel. Furthermore, comprehensive and consistent antenatal care fails to encompass all areas of Indonesia, resulting in unmet targets for antenatal visits. Consequently, prioritizing the implementation of early detection for pregnancy hypertension becomes imperative [8]. The proposed model can be applied in the public health service centers as primary care for the prevention of complications of pregnancy hypertension. Hence, this study focuses on the improvement of determinant factors that empower pregnant women to know the risk factors for the occurrence of hypertension in pregnancy, recognize the early signs of hypertension in pregnancy, and efforts to increase antenatal visits so that mothers' pregnancies are maintained with standard antenatal services [9,10].
2. METHODS
This research used a mixed method with an embedded design approach, which means that qualitative and quantitative data were collected simultaneously. A qualitative method was employed via in-depth interviews to identify existing problems and to assess the needs, thus determinant factors of delay in the detection of hypertension could be recognized. The quantitative method has been used to test the validity and reliability of data obtained by questionnaires. Simple random sampling was applied where the participants were midwives, midwives’ coordinators, and pregnant women. Inclusion criteria are pregnant women in trimesters I, II, and III and having spouses. The sample size was 164 people selected by considering the protocol of Lemeshow, 1997 [11]. All participants were then classified by sociodemographic background of age, education, occupation, parity, gestational age, economic level, history of hypertension, obesity, and exercise. This research was conducted in rural areas, so there is no classification between urban and rural. In-depth interviews were conducted at the community health center. This study chose married women because married women are the focus of antenatal care and these women want to have children and are obliged to maintain a healthy pregnancy without complications. Data from randomly selected respondents was obtained from the results of anamnesis that the respondent had a history of hypertension before pregnancy, there was no connection between hypertension in menopausal women and the research sample. Respondents were taken from 164 married women in the working areas of the Deli Tua, Talun Kenas, and Biru-biru health centers by randomly drawing numbers. This model was designed entirely by the author based on literature, hypothesis testing results and expert discussions. Training in this research was carried out four times for 1 month. The participants were interviewed to examine the determinant factors of hypertension risk such as their level of knowledge, self-efficacy, attitude, family support, midwife support, antenatal care, and healthcare family. The determinant factors were measured by ordinal scales. After checking the questionnaire's fulfillment, the data entry was done by using EpiData Entry 3.1. We also used SPSS ver.24 to analyze the statistical data. Data obtained were tested by univariate, bivariate, and multivariate analyses with confidence level 95% and alpha 5% on both sides. The establishment of a new model in this research has surpassed the five steps of the ADDIE method; analysis, design, development, implementation, and evaluation [12]. The feasibility study of the MEGA-model was based on assessment criteria on the quality of the developed module, including; Introduction, Presentation, Closing, Glossarium. The feasibility study of module construction has involved the module experts, midwife coordinators, and midwives. The effectiveness of MEGA-model was evaluated by the quality improvement of determinant factors before and after implementation (p < 0.05). This research was conducted from June to October 2022 in Deli Serdang Regency, Province of North Sumatra, Indonesia. The experimental method was approved by the Ethics Committee of the Faculty of Medicine, Andalas University, under approval number 817/UN.16.2/KEP-FK/2022.
3. RESULTS
3.1. Step 1. Analysis
The social background of hypertension in pregnancy can be seen in the sociodemographic data presented in Table 1. All risk factors showed a significant correlation with hypertension in pregnancy (sig. < 0.05).
| No | Risk Factors | f | % | Sig. |
|---|---|---|---|---|
| 1 | Age | - | - | 0.011 |
| - | ≥ 20 and ≤ 35 | 72 | 43.9 | - |
| <20 and >35 | 92 | 56.1 | - | |
| 2 | Education | - | - | 0.002 |
| - | High (College/Univ) | 73 | 54.5 | - |
| Low (Elementary-Mid School) | 91 | 55.5 | - | |
| 3 | Occupation | - | - | 0.007 |
| - | Working | 76 | 46.3 | - |
| No Work | 88 | 53.7 | - | |
| 4 | Parity | - | - | 0.004 |
| - | Primipara | 53 | 32.3 | - |
| Multigravida | 111 | 67.7 | - | |
| 5 | Gestational Age | - | - | 0.013 |
| - | Trimester I | 75 | 45.7 | - |
| Trimesters II and III | 89 | 54,3 | - | |
| 6 | Economic level | - | - | 0.008 |
| - | Low | 75 | 48.2 | - |
| Adequate | 89 | 54.3 | - | |
| 7 | History of Hypertension | - | - | 0.007 |
| - | Yes | 79 | 48.2 | - |
| No | 85 | 51.8 | - | |
| 8 | History of Hypertension in Family | - | - | 0.002 |
| - | Yes | 67 | 40.9 | - |
| No | 97 | 59.1 | - | |
| 9 | Obesity | - | - | 0.004 |
| - | Yes | 30 | 18.3 | - |
| No | 134 | 81.7 | - | |
| 10 | Sport/Exercise | - | - | 0.007 |
| - | Not Active | 72 | 43.9 | - |
| Active | 92 | 56.1 | - |
| No. | Determinant Factors | f | % | Sig. |
|---|---|---|---|---|
| 1 | Knowledge | - | - | 0.001 |
| - | Good | 63 | 38.4 | - |
| Not Good | 101 | 61.6 | - | |
| 2 | Self-efficacy | - | - | 0.002 |
| - | Good | 78 | 47.6 | - |
| Not Good | 86 | 52.4 | - | |
| 3 | Attitude | - | - | 0.001 |
| - | Positive | 74 | 45.1 | - |
| Negative | 90 | 54.9 | - | |
| 4 | Family Supports | - | - | 0.001 |
| - | Good | 79 | 48.2 | - |
| Not Good | 85 | 51.8 | - | |
| 5 | Midwives Support | - | - | 0.001 |
| - | Good | 90 | 54.9 | - |
| Not Good | 74 | 45.1 | - | |
| 6 | ANC (Antenatal Care) | - | - | 0.001 |
| - | Good | 92 | 56.0 | - |
| Not Good | 72 | 44.0 | - | |
| 7 | Healthcare Facility | - | - | 0.001 |
| - | Good | 81 | 49.4 | - |
| Not Good | 83 | 50.6 | - |
Furthermore, the data showed several factors that influence the determinant factors of hypertension in pregnancy as presented in Table 2. All determinant factors showed a significant correlation with early detection of hypertension in pregnancy (sig. < 0.05).
3.2. Step 2. Design
The early detection model for hypertension in pregnancy was designed by using a questionnaire instrument that involved 7 variables exogen of determinant factors and 1 variable endogen of early detection of hypertension in pregnancy. The results of the convergent validity test show that all exogenous (X) and endogenous (Y) variable indicators have an R-count validity value greater than the outer loading value (0.7), meaning that all variables are valid. The reliability test showed that Cronbach’s alpha > 0.6, which means all variables are reliable. The results of the Smart-PLS analysis showed that the structural model path coefficients of sociodemographic early detection, sociodemographic empowerments, and empowerments early detection had estimated coefficients of 0.450, 0.984, and 0.564, respectively. Results of the R-square analysis also showed that the variables of early detection and empowerment had R-squares of 0.987 and 0.981, respectively. The goodness-of-fit analysis showed that the total adjusted R-square was 1.950, indicating a high category of the combined performance of the outer and inner models.
3.3. Step 3. Development
The incorporation of moderating variables is intended to enhance the efficacy of early detection, thereby mitigating the complications associated with hypertension. The moderating variable employed in the model development pertains to the empowerment of pregnant women. Expert consultation endeavors aim to ascertain the appropriate applications aligned with a predetermined model. Through consensus and collaborative decision-making, it was determined that the implementation of the early detection model in this study would entail a structured module centered around midwives, who serve as agents in empowering pregnant women throughout their pregnancies via an educational model and self-assessment. This module assumes a critical role as a valuable tool, facilitating the enhancement of early detection outcomes for both midwives and pregnant women. The module is then named as “MEGA-model”. Instead of the author’s name, the MEGA-model stands for Module of Education Given at Antenatal Care. The chosen phrase represents a brief concept of a module that was developed to educate pregnant women during antenatal care and represents the inventor’s name.
| No. | Module’s Assessment Criteria | Results | |||
|---|---|---|---|---|---|
| Module Expert | Midwife Coord Expert | Midwife Expert | |||
| 1 | Introduction | 82 | 79 | 80 | |
| 2 | Presentation | 75 | 74 | 75 | |
| 3 | Closing | 80 | 82 | 83 | |
| 4 | Glossarium | 77 | 75 | 81 | |
| - | Average | 78.5 | 77.5 | 79.75 | |
| - | Summary: | This module deserves to be a followed up. | This module needs to be more systematic so that it’s easier to understand | This module has improved education for pregnant women so they can prevent complications of hypertension from an early age | |
| No. | Variables | Mean | Sig-p | |
|---|---|---|---|---|
| Pre | Post | |||
| 1 | Knowledge | 33.11 ± 5.62 | 38.76 ± 7.55 | 0.001 |
| 2 | Self-efficacy | 18.01 ± 3.52 | 21.15 ± 4.99 | 0.001 |
| 3 | Attitude | 18.40 ± 3.60 | 20.96 ± 4.91 | 0.001 |
| 4 | Family supports | 24.90 ± 3.90 | 27.73 ± 4.45 | 0.001 |
| 5 | Midwives support | 25.14 ± 3.74 | 27.04 ± 3.82 | 0.001 |
| 6 | Antenatal care | 25.90 ± 3.97 | 28.46 ± 4.50 | 0.001 |
| 7 | Healthcare facility | 33.11 ± 5.62 | 38.76 ± 7.55 | 0.001 |
The development of an early detection model was carried out with reinforcing factors in the form of empowering pregnant women, including educating pregnant women and improving lifestyles, as described in Fig. (1).
Based on the results of quantitative data analysis with moderating tests using the Smart-PLS program, qualitative analysis with expert consultation, and model feasibility tests according to experts and consensus as shown in Table 3.
3.4. Step 4. Implementation
Prior to implementing the model, a pretest questionnaire was administered to a sample of 164 pregnant women, who served as respondents. The empowerment session spanned a single day and encom- passed comprehensive explanations regarding the MEGA-model for the early detection of hypertension in pregnancy. Subsequent to the completion of the training, participants were once again presented with a questionnaire to assess potential improvements in knowledge, understanding, self-efficacy, intentions, and attitudes among pregnant women. Additionally, the questionnaire sought to evaluate the extent of utilization of various support systems, including husband/family psychosocial support, midwife support, quality antenatal care, and healthcare facilities, all aimed at preventing delayed detection of early gestational hypertension.
3.5. Step 5. Evaluation
Following the empowerment of pregnant women by midwives, notable improvements were observed in various social indicators, including enhanced knowledge and understanding among pregnant women, increased self-efficacy, positive shifts in intentions and attitudes, heightened utilization of husband's support, greater utilization of midwife support, increased utilization of antenatal services, and improved utilization of health facilities. These findings were substantiated through a comprehensive analysis of the pretest and posttest models, yielding the effectiveness of MEGA-model as represented in Table 4.
4. DISCUSSION
Based on our data, the majority of respondents have low education (Table 1). Insufficient educational attainment implies that pregnant women may have limited awareness and knowledge regarding the criticality of self-detection in pregnancy hypertension. In line with previous studies reported, the majority of pregnant women in Ethiopia initiate their ANC late [14]. Most of the complications of gestational hypertension are related to the lack of knowledge of pregnant women and the negative attitude of pregnant women toward early detection and lack of prevention practices [15,16]. Occupation exhibits a substantial correlation with early detection, wherein individuals in lower occupational strata are more prone to delayed initiation of gestational hypertension early detection. Empirical data on the association between employment and the risk of experiencing a high-risk pregnancy is scarce; however, existing evidence generally indicates that women are capable of handling work-related tasks effectively [17].
The significance of this study lies in its pioneering approach of empowering pregnant women as a moderating factor, influencing various social conditions, namely, the knowledge and understanding of pregnant women, self-efficacy, intentions and attitudes of pregnant women, husband/family psychosocial support, midwives' psychosocial support, access to and quality of antenatal care, as well as healthcare facilities [13].
Our research findings also demonstrate a notable correlation between parity and early detection, indicating that lower parity is associated with a higher likelihood of delayed initiation of gestational hypertension early detection. This finding was consistent with Behrens et al.'s (2017) claim that parity was a confounding factor in the connection between hypertensive diseases of pregnancy [18]. Moreover, gestational age exhibits a relationship with early detection, whereby lower gestational age is linked to a higher probability of delayed initiation of gestational hypertension early detection [19]. A previous study reported that older women (≥40 years old) had increased odds of mild preeclampsia, fetal distress, and poor fetal growth [20]. Strategic implementation related to the relationship between economic factors and early detection of pregnancy hypertension is important for pregnant women, realizing that economic factors greatly affect health conditions, especially during pregnancy [21]. Therefore, for pregnant women with unfavorable economic factors, it is advisable to limit their pregnancies [22].
Our study indicated that respondents who have a history of hypertension are more anticipative by emphasizing pregnancy checks so that they avoid the risk of severe preeclampsia [23]. The results of the data analysis showed that the majority of respondents who were late for early detection of pregnancy hypertension were respondents with a family history of family hypertension [24]. Pregnant women who are obese or who have the potential to get body fat should strategically apply strategies related to the association between obesity and early identification of prenatal hypertension to reduce the number of pregnancies and control their lifestyle, particularly concerning eating [25] and sports or exercise [26].
The MEGA model for early detection of gestational hypertension has a significant effect on preventing delays in the implementation of early detection of gestational hypertension. Before the development of the early detection model (pre), out of 164 research samples, there were 68 people (41.5%) who were late and 96 people (58.5%) did early detection of pregnancy hypertension. After developing the model by empowering pregnant women, out of 164 research samples, only 27 people (16.5%) were late and 137 people (83.5%) were not late for early detection of pregnancy hypertension. This means that there is an increase in the number of samples (pregnant women) who are not late for early detection of gestational hypertension. On the other hand, there was a decrease in the number of samples (pregnant women) who were late for early detection of gestational hypertension.
With the application of the MEGA model, pregnant women experience the benefits of empowering pregnant women such as education in increasing the understanding and knowledge of pregnant women about early detection of hypertension in pregnancy, lifestyle improvements, and antenatal services so that pregnant women recognize that empowering pregnant women has succeeded in increasing the delay of pregnant women early detection of gestational hypertension.
CONCLUSION
Based on the research results, we conclude that the design of the early detection model has a moderating factor in the form of empowering pregnant women, which includes education with counseling to increase knowledge and lifestyle improvement. The empowerment intervention in this study encompassed educational sessions highlighting the importance of early detection of pregnancy hypertension, lifestyle enhancement, and counseling regarding midwives' services.
LIST OF ABBREVIATIONS
| MEGA | = Module of Education Given at Antenatal Care |
| ADDIE | = Analysis, Design, Development, Implementation, and Evaluation. |
| SEM-PLS | = Structural Equation Model-Partial Least Square |
| MMR | = Maternal Mortality Rate |
| ANC | = Antenatal Care |
ETHICAL STATEMENT
The experimental method was approved by the Ethics Committee of the Faculty of Medicine, Andalas University, Ethical Approval No. 817/UN.16.2/KEP-FK/2022. All clinical investigations have been conducted according to the Declaration of Helsinki principles.
CONSENT FOR PUBLICATION
Informed consent was obtained from all participants in this study according to Ethical Approval No. 817/UN.16.2/KEP-FK/2022. All participants agreed to participate in this study and that the results will be published.
