|Year : 2021 | Volume
| Issue : 2 | Page : 105-112
Prevalence of hypertensive disorders of pregnancy in India: A systematic review and meta-analysis
Manisha Dhinwa, Kanchan Gawande, Nishu Jha, M Anjali, Ajeet Singh Bhadoria, Smita Sinha
Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
|Date of Submission||25-Sep-2020|
|Date of Decision||27-Mar-2021|
|Date of Acceptance||27-Mar-2021|
|Date of Web Publication||30-Aug-2021|
Dr. Ajeet Singh Bhadoria
All India Institute of Medical Sciences, Rishikesh, Uttarakhand
Source of Support: None, Conflict of Interest: None
Background: Pregnancy-induced hypertension is one of the major health problems leading to maternal mortality. Globally, one woman dies every 7 min due to hypertensive disorders of pregnancy (HDOP). Pre-eclampsia and eclampsia contribute majority of maternal, perinatal morbidity and mortality. The objective of this meta-analysis was to estimate the pooled prevalence of pregnancy-induced hypertension in India. Methods: A systematic search was done through PubMed, Google Scholar, MEDLINE, EMBASE and Scopus for studies conducted on HDOP. All studies that met inclusion criteria published till January 2020 were included and analysed. The analysis was done using STATA 20.0 software (STATA Version 20.0 is sufficient). The pooled prevalence of hypertension in pregnancy was estimated using both mixed-effects and random-effects models. Results: A total of 18 studies with 92,220 study participants (pregnant women) were included in this review. The estimated overall pooled prevalence of HDOP in India was found to be 11% (95% confidence interval, 5%–17%). Most of the included studies were cross sectional and from the southern zone of India. Conclusions: The overall pooled estimate shows high prevalence, i.e., 1 out of 11 women suffers from pregnancy-induced hypertension. High prevalence of hypertension in the study population demands the attention of policymakers and healthcare professionals. Better implementation of early screening of hypertension during pregnancy should be undertaken.
Keywords: Eclampsia, hypertensive disorder, India, pre-eclampsia, pregnancy
|How to cite this article:|
Dhinwa M, Gawande K, Jha N, Anjali M, Bhadoria AS, Sinha S. Prevalence of hypertensive disorders of pregnancy in India: A systematic review and meta-analysis. J Med Evid 2021;2:105-12
|How to cite this URL:|
Dhinwa M, Gawande K, Jha N, Anjali M, Bhadoria AS, Sinha S. Prevalence of hypertensive disorders of pregnancy in India: A systematic review and meta-analysis. J Med Evid [serial online] 2021 [cited 2021 Sep 25];2:105-12. Available from: http://www.journaljme.org/text.asp?2021/2/2/105/324955
| Introduction|| |
Pregnancy is a crucial period for both mother and foetus. Around 15% of pregnant women are expected to suffer from life-threatening complications either during pregnancy, at delivery or in post-partum period., Hypertensive disorders of pregnancy (HDOP) are the significant contributors to these complications. Globally, it is estimated that almost 10% of pregnancies are complicated by hypertension., Blood pressure (BP) ≥140/90 mmHg, taken after a period of rest, on two occasions or ≥160/110 mmHg on one occasion in a previously normotensive woman is labelled as pregnancy-induced hypertension.,
The American College of Obstetricians and Gynaecologists has classified pregnancy-induced hypertension (PIH) into four groups of disorders:,,
- Gestational hypertension, where resting BP is 140/90 mmHg or higher after the 20th week of gestation
- Chronic hypertension that exists before pregnancy or begins in the first 20 weeks of gestation
- Pre-eclampsia (raised BP and oedema or proteinuria)/eclampsia (pre-eclampsia and seizures)
- Pre-eclampsia superimposed on chronic hypertension.
HDOP are a global concern. Globally, 5%–8% of all pregnant women are affected by pregnancy-induced hypertensive disorders., Amongst all, pre-eclampsia and eclampsia are the major cause of maternal and perinatal morbidity and mortality. Pre-eclampsia presenting with hypertension and proteinuria affects 5%–7% of all pregnancies., The common causes for PIH are pregnancy at young age (<20 years), primigravida, twin pregnancy, history of diabetes or pre-existing hypertension and previous history of PIH. PIH has a greater impact on both mother and newborn health leading to many complications such as premature delivery, intrauterine growth retardation, abruptio placentae and intrauterine death, as well as maternal morbidity and mortality.,,
A study conducted in Ethiopia, a developing country, shows that the prevalence of hypertension amongst pregnant women ranges from 1.8% to 16.7%. Around 40,000 women, mainly from developing countries, die each year due to either pre-eclampsia or eclampsia, with only pre-eclampsia accounting for 40%–60% of maternal deaths.,, A prospective population-level analysis done in Mozambique, Nigeria, Pakistan and India found the prevalence of hypertension disorder as 10.9%. 10.2%, 9.3% and 10.3%, respectively.
A study conducted in southern India showed prevalence of various HDOP which were gestational hypertension (47.4%), pre-eclampsia (32.6%), chronic hypertension (8.2%) and pre-eclampsia superimposed on chronic hypertension (11.8%). A study conducted in western India shows that the overall prevalence of HDOP was 7.8%. A northern region study found the prevalence of hypertension in pregnancy as 6.9%. This higher prevalence in developing countries including India, may be due to problems of poverty, malnutrition and poor obstetric facilities, etc. These studies are inconsistent and inconclusive to show the national magnitude. The country-level estimate is essential to design evidence-based interventions. Therefore, this systematic review and meta-analysis was designed to estimate the pooled prevalence of HDOP in India.
| Methods|| |
Data source and search strategy
To identify eligible studies on prevalence of HDOP in India, we implemented a comprehensive computerised search of electronic databases (MEDLINE, EMBASE, Scopus and Cochrane Library) published till January 2020, using variant Medical Subject Headings (MeSH) and free-text (Text) terms. The search terms/MeSH words utilised were as follows: Pregnancy Induced Hypertension, preeclampsia, eclampsia, High blood pressure, complications in pregnancy, ante natal period, India and prevalence, along with alternate combined use of Boolean operators (AND, OR and NOT). We also hand-searched the reference lists of eligible studies for further studies that might have been missed.
Inclusion and exclusion criteria
Studies conducted to measure the prevalence of HDOP in India were included in the review. The review used the standard definition for classification of HDOP (American College of Obstetrics and Gynaecology).,, The included studies should have reported the prevalence of various HDOP as per definition by the American College of Obstetrics and Gynaecology. We excluded studies reporting complication of pregnancy other than hypertension. Studies were also excluded if they provided composite prevalence of all complications during pregnancy rather than individual finding.
Types of studies
We included original articles which may be cross sectional, prospective observational (in which the baseline prevalence of PIH is taken), All India Survey, etc.
Identifying eligible studies
Titles and abstracts of the remaining citations were screened independently by all authors for any potential study on HDOP. Full texts of the identified potentially eligible studies were thoroughly screened and independently assessed by all the authors. The qualities of the extracted studies were independently assessed by each author. Discrepancies in data extraction were discussed and resolved.
Data from eligible studies were extracted into a data extraction excel file using a pre-defined list of variables. Our outcome of interest was the weighted pooled prevalence of HDOP in India. We extracted the following data on the baseline characteristics of the eligible research reports – author names, study year, year of publication, study area, study design, study population/sample size, number of women with hypertensive disorders and prevalence of HDOP.
Meta-bias and heterogeneity
The existence of heterogeneity was assessed using I2 and its corresponding P value. A value of 25%, 50% and 75% was used to declare the heterogeneity test as low, medium and high heterogeneity. Egger's regression asymmetry test was used to assess the statistical significance of publication bias.
Quality assessment of included studies
Methodological quality assessment was done using 'Mirza and Jenkins Checklist'. Critical appraisal was done by two reviewers independently. The study inclusion criteria, statistical tests performed in each selected study, were discussed amongst authors and were found appropriate.
Quantitative synthesis: Meta-analysis
Meta-analysis of the extracted data was done to estimate the weighted pooled prevalence of HDOP, and the corresponding 95% confidence interval (CI) was calculated. An overall pooled prevalence was generated using a random-effects model. Heterogeneity measures were also calculated using the inconsistency index, I2. Subgroup analysis was done for number of women with HDOP as per study zones. All meta-analyses were performed using the STATA ver. 20.
| Results|| |
Search of eligible studies
Out of 2903 records identified through database, 18 studies,,,,,,,,,,,,,,,,, were found eligible reporting the prevalence of HDOP [Figure 1].
Scope of reviewed studies
[Table 1] shows the prevalence of HDOP in India by study zone, publication year and study design. Amongst the 18 studies, 7 studies were from southern zone of India,,,,,,, 3 from northern zone,,, 2 from western zone,, 4 studies from central zone,,, and 2 are All India Survey, ranging by the year between 2006 and 2020. Seventy-two per cent of studies were published after the year 2015. Twelve studies were of cross-sectional study designs,,,,,,,,,,,, followed by three prospective observational studies,, and three retrospective studies.,,
|Table 1: Prevalence of hypertensive disorders of pregnancy in India by study zone, publication year and study design|
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Findings of the review
[Figure 2] and [Figure 3] show that for the 18 studies, the weighted pooled prevalence of HDOP in India was estimated at 11% (95% CI, 5–17). Heterogeneity amongst included studies was found as high (I2 = 99.86%), which was statistically significant (P = 0.00). One of the studies showed the highest prevalence of HDOP (39%) compared to the others. By removing this study and performing sensitivity analysis, the pooled prevalence was found to be 9% (95% CI, 7–10) with 94.32% heterogeneity (P = 0.00), which is consistent with the overall prevalence of HDOP in India.
|Figure 2: Forest plot displaying pooled prevalence of hypertensive disorders of pregnancy in India|
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|Figure 3: Forest plot displaying pooled prevalence of hypertensive disorders of pregnancy in India after sensitivity analysis|
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Meta-bias in prevalence of pregnancy-induced hypertensive disorders
[Figure 4] and [Figure 5] show the funnel plot examining small-study effects on the pooled prevalence of HDOP before and after sensitivity analysis. The Egger's regression test value (P = 0.649) indicates no evidence of publication bias.
|Figure 4: Funnel plot for prevalence of hypertensive disorders of pregnancy in India|
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|Figure 5: Funnel plot for prevalence of hypertensive disorders of pregnancy in India after sensitivity analysis|
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[Figure 6]a, [Figure 6]b, [Figure 6]c, [Figure 6]d, [Figure 6]e shows that the weighted pooled prevalence of gestational hypertension, pre-eclampsia–eclampsia, eclampsia, pre-eclampsia superimposed on chronic hypertension and chronic hypertension in India was estimated at 5% (95% CI, 4%–6%), 3% (95% CI, 2%–4%), 1% (95% CI, 1%–2%), 1% (95% CI, 0%–1%) and 1% (95% CI, 0%–1%), respectively. Heterogeneity amongst included studies was found high for all types of HDOP, which was statistically significant (P = 0.00).
[Figure 7]a, [Figure 7]b, [Figure 7]c, [Figure 7]d, [Figure 7]e shows the funnel plots examining small-study effects on the prevalence of different types of hypertensive disorders: gestational hypertension, pre-eclampsia–eclampsia, eclampsia, pre-eclampsia superimposed on chronic hypertension and chronic hypertension in India. There is no evidence of publication bias in studies associated with the different subtypes except that of eclampsia (Egger's regression test value, P = 0.045).
|Figure 7: (a) Funnel plots displaying publication bias related to gestational hypertension. (b) Funnel plots displaying publication bias related to pre-eclampsia–eclampsia. (c) Funnel plots displaying publication bias related to eclampsia. (d) Funnel plots displaying publication bias related to pre-eclampsia superimposed on chronic hypertension. (e) Funnel plots displaying publication bias related to chronic hypertension|
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| Discussion|| |
Hypertension is a common complication during pregnancy in developed as well as in developing countries. In developing countries, the problem may be more severe due to sociocultural and economic factors. In Southeast Asia region, the mortality amongst reproductive age group women from HDOP was 11.35%. In India, 18.35% of maternal morbidity and 0.96% of maternal mortality are attributed to HDOP.
The present meta-analysis shows the pooled prevalence of HDOP in India as 9% (95% CI, 8%–10%), which was found significantly higher than the global prevalence. However, it was comparable with the survey conducted in China. The global variation may be due to difference in sociocultural practices, availability, accessibility and utilisation of antenatal services.
The regional variation in the prevalence was observed, with highest in northern zone and lowest in eastern zone of India. This variation in the prevalence may be due to difference in availability and utilisation of antenatal care (ANC) services, lifestyle, dietary factor or physical activity. The subgroup analysis by publication year shows no major changes in the prevalence of HDOP over 2006–2020. These results are consistent with the NFHS-4 analysis report which shows that only 21% of pregnant women in India utilised full ANC services. This utilisation was lowest in eastern state (Nagaland 2.36%) and highest in southern region (Lakshadweep – 65.88% and Kerala – 61.16%) and western region (Goa – 63.38%). Illiteracy and belonging to socially disadvantaged groups (SC/ST/OBC) are reported as contributory factors for this less utilisation of ANC services. Even after WHO recommendation of eight ANC visits during antenatal period, more than half of the pregnant women did not receive even minimum four ANC visits in India.
The pooled prevalence of pre-eclampsia–eclampsia and chronic hypertension in this meta-analysis was estimated as 4% (3%–6%) and 0% (0%–1%). The results were consistent with a multicounty survey reporting the prevalence of pre-eclampsia–eclampsia and chronic hypertension as 2.44% and 0.29%, respectively. A WHO secondary analysis conducted in low and middle countries also shows the prevalence of pre-eclampsia as 4%.
The current review does not show an association of gravid level of pregnant women and presence or development of HDOP. Similar results were found in the study conducted in China, a survey conducted in low- and middle-income countries and a case–control study conducted in Columbia.
An extensive search strategy was employed to retrieve all eligible studies. PRISMA guideline was followed during the review process. This review reports the pooled estimate of HDOP, their variation according to region, year and types of HDOP. It does not report on factors associated with development of various HDOP. Hence, further wide-scale studies and reviews are needed to fill this gap.
Because of few studies included in this meta-analysis, the conclusions may not reflect the reality in general population. The significant heterogeneity amongst the included studies is another limitation.
| Conclusions|| |
This meta-analysis identified prevalence as 1 out of 11 pregnant women suffering from hypertensive disorders in India. Pre-eclampsia and eclampsia were reported as the main type of hypertensive disorders amongst pregnant women. Government and other stakeholders should give due attention to early screening and treatment of HDOP. Community-based approaches to diagnose and treat the problem are recommended. Furthermore, further national-level studies and reviews are recommended to find associating factors for development of HDOP amongst pregnant women.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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