Perceived Stress, Quality of Life and Pregnancy Outcomes Among Women with Hypertensive Disorders of Pregnancy (HDP) And Role of Midwives in It: A Systematic Review

Hypertensive disorders during pregnancy are one of the leading causes of maternal & newborn death across the world. Many of the hypertensive antenatal women often end of with admission to ICU due to severe pre-eclampsia and eclampsia, or delivering dead babies of term pregnancy, even if live baby delivered, they mostly admitted to NICU due to respiratory distress and prematurity. Hence, they need continuous educational intervention and follow up by healthcare personnel. And a midwife is the right person for this. Midwives play an important role in encouraging pregnant mothers to adhere to treatment through various education and follow up resulting in safe pregnancy outcome among these mothers. But in Indian scenario in many places the role of midwives are often ignored while managing pregnancy complications. Therefore, current paper aimed to explore the expanded role of midwives in identifying the affected quality of life and its impact on pregnancy outcome among women with HDPs. The empirical research papers of various countries were searched through the electronic databases like Pro-Quest, Embase, Research Gate, Science direct, PUBMED, MEDLINE, CINAHL-EBSCO, web of science, Google Scholar etc and the references were also searched of those primary articles. A total of 15 out of 275 studies including both RCTs, Systematic & narrative review papers were analysed. In this paper 4 relevant points were analyzed, like-perceived stress, quality of life (QOL), pregnancy outcomes and role of midwife in GHTN management in rural India. The research papers on pregnancy outcomes as well as stress and QOL secondary to gestational outcome were plenty, but very less studies were retrieved on role of midwives. Mother’s with GHTN has more stress regarding the fetal wellbeing which ultimately affects the quality of life. Interventional studies revealed reduction in stress and improved perinatal outcome secondary to some integrated midwifery management approach. More research on addressing quality of life and exploring the stressors and interventional programs by midwifes are recommended to bring solution to this problem. The result of this review can be incorporated into nursing research to empower the women with gestational hypertension to have a positive pregnancy experience.


Introduction
Gestational hypertension is still an unsolved problem in many developing countries including India affecting about 7-8 % all pregnancies.Global picture being 12%.This usually appears in the second nline at: le o b ila Ava -951 -half of the pregnancy and mostly disappears after the baby is born.But it is not the same case for all mothers.Various factors which increase the risk of gestational hypertension are: multi-fetal pregnancy, presence of diabetes, excessive weight gain during pregnancy and advanced age of mother. 1 According to "International Society for the Study of Hypertension in Pregnancy" (ISSHP) hypertension in pregnancy can be classified as chronic HTN, gestational hypertension (GHTN), pre-eclampsia (PE)/ superimposed on chronic hypertension or white coat hypertension.ISSHP in 2014 defined that any new onset of hypertension with systolic BP ≥140 mmHg and/ or diastolic BP ≥90 mmHg beyond 20 weeks in patients without any previous record of high BP should be considered as gestational hypertension.2It is the second in the triad as leading cause to maternal mortality after Obstetrics haemorrhage and sepsis.3A study conducted on 4,314 pregnant women to establish a relation between psychological stress and chronic hypertension revealed that life time stress, perceives stress increase the risk of preeclampsia by 20-fold.This study finding supports the importance of prevention, screening and tress management among those women.4   In continuation to the above study, another group of researchers also suggested that perceived maternal prenatal stress contributes to various adverse pregnancy outcomes including hypertensive disorders if pregnancy.This study usages perceived stress scale on 4161 women.This study also highlights that perceived stress can cause complications years after delivery also.5 Many-times the distress is more among pregnant women with hypertensive disorders when compared to other obstetric complications.The reason could be the sudden change in the maternal and fetal health status and the development of the risk factors for both of them.This is said by Leeners B and group while studying on connection between psychological distress and pregnancy hypertension on 738 women.6   Furthermore, there are various risk factors are responsible for progression of gestational hypertension to preeclampsia-eclampsia. However healthy nulliparous women can also be the pray for pre-eclampsia.
Though not clear the emerging data suggest that the genetic origin is responsible for development of pre-eclampsia.7An Indian study on incidence and factors affecting gestational hypertension found that the incidence was 7.4% and presence of high LDL level in blood was associated with severity like preeclampsia and LBW babies during delivery.8 Apart from the problem of perceived stress, the quality of life and quality of sleep is also affected among high-risk pregnancies like pregnancy hypertension.As per a study conducted on women with gestational hypertension and diabetes, the result showed the the prevalence of sleep disturbance as 96.4%.hence the study raised the concern regarding the need of training by midwives to improve the sleep quality as well as quality of life.9 A comparative study between the normotensive and hypertensive women conducted to see the effect of hypertension on quality of life.Same study undertook on 194 hypertensive antenatal mothers and 195 normotensive mothers and quality of life was assessed.The result revealed that the hypertensive women got low score on quality of life i.e 17.63.This may be concluded that hypertensive pregnancy highly interferes with quality of life of mothers.10 Further a prospective observational study conducted on 112 mothers with pregnancy-related hypertension revealed that the most occuring disorders were preeclampsia/ PE (n=28; 25.23%) and eclampsia (n=48; 43.24%).The study also resulted, common factors associated with maternal complications are placental abruption and PPH (n=31; 27.6%).Similarly, The common risks associated to fetal complications were meconium aspiration syndrome, followed by preterm birth, IUGR, and LBW as well.Therefore, the study emphasized on efforts to made at both level of community and hospital to raise awareness regarding hypertensive disorder of pregnancy (HDP) and reduce its associated morbidity and mortality.This also adds the importance of midwives in management.11 Additionally the optimum treatment of such pregnant mothers is not possible due to shortage of specialists like obstetricians, anaesthetists, paediatricians and skilled nurses in the remote areas.12There are many treatment protocols and preventive measures available but as far as the success rate of any treatment option is concerned no individual therapy is found hundred percent effective.Hence more steps for preventing gestational hypertension and its progress to pre-eclampsia/eclampsia, among general antenatal population should be taken.The important pillars of such approaches include, close antenatal monitoring of pregnancy and timely delivery to prevent subsequent morbidity and mortality.Therefore, the purpose of this paper is to review extensively about the possibility of integrated management by skilled midwives in rural India for the prevention of complications secondary to gestational HTN and to ensure a safe child birth.

Etiopathogenesis of Gestational Hypertension
(Fig- 1 Showing the etiopathogenesis of gestational hypertension)

Materials And Methods
This narrative review is based on the analysis of similar articles published in last 5 years i.e 2017-2021.This paper includes both original and review studies from various countries focusing on subjects like perceived stress, quality of life, pregnancy outcome and midwife's role in pregnancy hypertension.The databases searched are pub-med, science direct, research gate, CINAHL-EBSCO, web of science, google scholar and med-line.The mesh-terms for search were 'gestational Hypertension/GHTN', 'pregnancy induced hypertension', 'pregnancy outcome', 'role of midwife', 'educational interventions', 'perceived stress', 'quality of life' in combination with 'randomized control trials', 'narrative reviews', 'systematic reviews.The references of primary articles were searched and analyzed.Three relevant points were identified for analysis like-perceived stress in HDPs, quality of life of women with HDPs, It's effect on pregnancy outcome (Table 1) and role of midwife in GHTN management in rural India.Total 15 studies included (Fig- 2).Abundant studies were found on perceived stress, quality of life and pregnancy outcome but a very little got regarding midwives' role in managing HDPs.

Inclusion criteria
1. Research studies directly related to perceive stress, quality of life, pregnancy outcome and midwife's role in pregnancy hypertension.

Results and Discussion
A total of 475 articles were found from search engines like pub-med (196) No significant difference was found between the two groups in terms of psychological stress.High BMI found to be the only risk factor for hypertension in pregnancy (OR = 1.13; 95% CI: 1.04-1.23,p = .003).confirmatory trial 63 evidence is pending.The study also suggested that most of the antihypertensives drugs were found safe for use when breastfeeding is on.
Table 2 depicts the study summary of role of midwives in gestational hypertension management.

Perceived stress in HDPs
A Cross-sectional study carried out at south Brazil to determine the change in psychological factor and coping strategy in pregnant women having hypertension.Total 552 sample have recruited, having 343 mothers with hypertension.The exclusion criteria include the participants with co-morbidities.The study resulted a high score of depression, stress and anxiety among hypertensive group and worse among pre-eclamptic group. 13In continuation another study also conducted with the same aim at Canada to see the association of maternal anxiety and mood disorder among hypertensive group when compared to normotensive one.It recruited total 9,097,355 pregnant women.And the study resulted that mental health disorders incusing anxiety increases the risk of hypertension in pregnancy (adjusted odds ratio (aOR) 1.324, 95% CI 1.255-1.397)and its severity. 14Whereas an USA based case control study with secondary data on psychological distress and its association with development of HTN in pregnancy showed a opposite outcome, that no significant difference was seen in both hypertensive and normotensive group as far as the stress is concerned.There are very rare studies with such findings.This may be due to less sample size (29 in hypertensive group and 87 were healthy women) for drawing the conclusion. 15

Quality of life in HDPs
Quality of life is presumed to be low among the mothers with hypertensive disorders.For this, various studies conducted to establish an association between the pregnancy induced hypertension among antenatal mothers and the impact on quality of life.In every study the result revealed a low score of quality of life among hypertensive group when compared with a group without it.The questionnaires used are WHOQOL questions, Ferrans & Powers Quality of Life Index.The average score of QOL was 17.6. 16Mann-Whitney test done to compare between 2 groups and variability found in both age of the mother (PE 27.8±6.2x HG 23.0±6.6,p<0.01) and gestational age (PE 224±28.1 x HG 253.8±43.7,p<0.01). 18But one study showed no difference in quality-of-life score among hypertensive and normotensive group.The mean values between the two groups are equivalent; this can be explained because the PE pregnant women were hospitalized and receive multidisciplinary care. 17

Pregnancy outcome in HDPs
Gestational weight gain and adverse pregnancy outcome are interrelated.This is revealed when a study identified 14,369 women with chronic hypertension having more gestational weight gain.Those cases later developed preterm delivery, small-for-gestational age, preeclampsia large-for-gestational age including preeclampsia and cesarean delivery. 19In a observational study of London on pregnancy outcome among women with gestational hypertension shows total 49% of the sample have pregnancy complication and out of that 72% developed HDP including preeclampsia (25.8%). 20Mostly gestational hypertension results in adverse pregnancy outcome.Bone JN etal in 2021 conducted a multi-centric study on Community-Level Interventions for Pre-eclampsia (CLIP).The investigators took BP measurement of 103 679 samples across 3 trials.The result reveal that the antenatal mothers with stage 2 HTN developed severe maternal CNS symptoms and events of perinatal death including stillbirth as well. 21Additionally two numbers of study of India also coincides with the previous finding.One study based on cardiovascular risk to mother having pregnancy hypertension resulted that hypertensive pregnancy increases the prevalence of cardiovascular complication among them. 22Second study on relation between maternal hypertension and development of feto-maternal complication done at a nline at: le o b ila Ava -959 -tertiary care center of India, revealed that out of 5139 pregnancies, 338 (6.57%) had PIH, 40 (0.77%) had eclampsia.PIH shows more prevalence among primigravidas.Maternal complication was present in 6.5% cases.NICU admissions & LBW incidences are also increased. 23Lastly an Ethiopian study on influence of PIH on LBW babies shows that the prevalence of LBW babies among PIH mothers were 2 fold higher than those without it. 24

Role of midwives in HDPs management
Midwives play an important role in managing hypertensive mothers, especially counselling, compliance with the treatment and follow up.An UK based study observes a change in BP after home blood pressure monitoring.For this they have recruited trained midwives who gave training to mother how to measure BP at home.The aim was to avoid sudden complication and to act fast in case of emergency by identifying the warning signs.The result showed significantly lower BP among the intervention group. 25Another study on effect of exercise during pregnancy and risk of gestational hypertension done at Italy revealed lower BP among those who have done aerobic exercise for about 30-60 min two to seven times per week. 26Again a community level intervention of India recruited 14,783 pregnant women under 12 clusters and midwives to provide them mobile health (mHeath)-guided clinical assessment, initial treatment, and referral to facility.The result demonstrated that the treatment group suffered with less feto-maternal complication than control group including still birth. 27Similarly a study of Australia researched on impact of mind body intervention on PIH and pre-eclampsia.It included 2 relaxation exercise and 1 yoga seem to reduce both systolic and diastolic BP along with stress, one trial of guided imagery reduced significantly the mean arterial BP.Except for 3 acupuncture cases reported some adverse outcome.This implies that relaxation exercises to have positive effect when it is caried out under controlled condition with special focus on safety. 28A prenatal education program arranged in Turkey for women with gestational hypertension as an intervention.It is a quasiexperimental case control study carried out among 132 randomized sample.Here the treatment group received prenatal informative education on hypertension care through Roy's adaptation model.The result shows that less number of women in treatment group (11) developed pre-eclampsia in comparison to control group (37) and 44 subjects of intervention group had no pre-eclampsia. 29Additionally a simulation enhanced nursing mentoring program on preeclampsia and eclampsia care at Bihar, India also proved effective in preventing serious complications among women with GHTN.Here samples were 94 nurses. 30In a Scotland study on mobile health intervention was done to support rural midwifery practice in management of PIH.Here 18 numbers of midwives were taken as sample, where the focus was on difficulty in managing PIH and effectiveness of m-health application.Result shows that in difficult to reach areas the m-health application give continuous professional help. 31A Iranian study also conducted to see the success of a comprehensive home based care program for health promotion of mothers with preeclampsia.The result of this mixed method approach, showed that the designed and applied intervention is beneficial for the health of the mother including high risk pregnancies like PIH. 32 Lastly a UK based study did a narrative review to check the benefits of personalized care in the management of chronic HTN.The outcomes were improved by timed birth between 38 0/7 and 39 6/7 weeks based on observational literature and compliance with anti-hypertensive drug, which can be followed up by midwives.

Conclusion
This is an extensive narrative review, where the authors tried to bring light on the various factors affected by Gestational hypertension and roles of midwives in the same.It can be observed that, there are very limited studies on stress, quality of life and management by midwives.Through this review it is certain that hypertensive mothers develop stress and their quality of life also getting affected.But still there are controversial study results, which needs further investigation.Secondly, the cases which is included here were not independently carried out by midwives.Also no programs were implemented in this regard, rather most of them are in the planning stage.Hence this paper provides an insight to focus more into the development of a real time integrated program package which would work perinatally starting with the early identification, home based BP monitoring, carrying out physical activity and dietary management, safe delivery and postpartum follow up altogether.Moreover this should be carried out by the midwives as they are the primary caregivers at community level and also by doing so the duplication of work by obstetrician can be reduced as they can focus more on referred cases.

Table 1 : summary of study characteristics: perceived stress in HDPs
, SCOPUS (115), CINAHL (56), web of science (46), Research gate (62).Considering the exclusion criteria 205 duplicate articles were rejected, 122 based on title, 108 based on abstract.The retrived articles were 40 numbers.Next the retrieved articles were screened for eligibility and 19 full text article were removed based on inclusion criteria.Finally, 21 articles were included in this narrative review.The PRISMA flow of the selected article is presented in Figure 1.
Perceived stress, Quality of life and pregnancy outcomes among women with hypertensive disorders of pregnancy (HDP) and role of midwives in it: A Systematic Review Available online at: https://jazindia.com-954 -

Table 3 : summary of study characteristics: pregnancy outcomes in GHTN
Perceived stress, Quality of life and pregnancy outcomes among women with hypertensive disorders of pregnancy (HDP) and role of midwives in it: A Systematic Review

Table 1
depicts the study summary of pregnancy outcomes in gestational hypertension.