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Year : 2020  |  Volume : 4  |  Issue : 3  |  Page : 103-108

Management of gestational hypertension disorders in Saudi Arabia by primary care nurses

1 Department of Reproductive Endocrine and Infertility Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
2 Department of Nursing, College of Applied Sciences, Al Maarefa University, Riyadh, Saudi Arabia
3 Department of Health Administration, Brooks College of Health, University of North Florida, Jacksonville, Florida, USA
4 Department of Maternity and Child Health Care Nursing, College of Nursing, King Saud University, Riyadh, Saudi Arabia

Date of Submission21-Jul-2020
Date of Decision22-Aug-2020
Date of Acceptance14-Sep-2020
Date of Web Publication30-Sep-2020

Correspondence Address:
Nazik M A. Zakari
Department of Nursing Administration, College of Applied Sciences, Al Maarefa University, P O Box 71666, Riyadh 11597
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sccj.sccj_32_20

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Objective: Failure of health-care providers to have sufficient knowledge and prevention measures of gestational hypertension leads to an increased rate of complications during pregnancy that may lead to the loss of the fetus. The study aims to determine the level of the nurses' knowledge working in primary health-care (PHC) centers regarding gestational hypertension disorders in Riyadh city. Subjects and Methods: A descriptive correlational, nonexperimental study design was conducted at 6 PHC centers using a self-administered questionnaire for nurses (n = 257). Results: Nurses had inadequate knowledge about the essential key items of gestational hypertension disorders. Almost half of the nurses (44%) lacked knowledge about how to assess the fetal condition in case of gestational hypertension, and 57.98% of the sample had difficulty in identifying the signs and symptoms of mild preeclampsia. The majority of the sample (70.42%) had unsatisfactory knowledge about essential drugs for the treatment of preeclampsia; 54.08% of the nurses experienced insufficient knowledge about their role before the administration of magnesium sulfate drugs. In addition, study results show that there was a lack of knowledge on the appropriate management of preeclampsia among the majority study participants (98.83%) with a total knowledge mean score (19.09, 63.63%). Conclusion: Primary care nurses lacked the needed knowledge to identify and provide preventive care to women experiencing gestational hypertension. Furthermore, there was a lack of knowledge in regard to identifying the complications of preeclampsia. The nurses are accountable for the quality of maternity care, and a maternity training program must be considered.

Keywords: Antenatal care, hypertensive disorders, nurses' knowledge, preeclampsia, primary health care

How to cite this article:
Alrowaili MM, A. Zakari NM, Hamadi HY, Moawed S. Management of gestational hypertension disorders in Saudi Arabia by primary care nurses. Saudi Crit Care J 2020;4:103-8

How to cite this URL:
Alrowaili MM, A. Zakari NM, Hamadi HY, Moawed S. Management of gestational hypertension disorders in Saudi Arabia by primary care nurses. Saudi Crit Care J [serial online] 2020 [cited 2022 Dec 8];4:103-8. Available from: https://www.sccj-sa.org/text.asp?2020/4/3/103/296838

In 2017, globally, about 295,000 unborn neonates died due to preventable medical problems that can be addressed during fetal development. Appropriate management of maternal and prenatal care could have avoided almost 95% of these deaths.[1] Likewise, preeclampsia and eclampsia are one of the most common problems to blame for almost 75% of all maternal fatalities. Preeclampsia is a pregnancy complication that is attributed to high blood pressure. Typically, preeclampsia can present as early as 20 weeks of pregnancy among women who have normal blood pressure readings earlier during pregnancy and before pregnancy. Eclampsia is a severe complication of preeclampsia where high blood pressure results in severe symptoms such as seizures. It is estimated that 830 pregnant women die daily in poor-resource environments. The risk of dying during childbirth is 33 times more likely for mothers-to-be living in a developing country than those living in an industrialized country.[2]

  Introduction Top

Prior research has identified a strong correlation between gestational hypertension, also known as pregnancy-induced hypertension (PIH), and maternal mortality. Globally, approximately 10% of maternal mortality rate is due to PIH. In fact, PIH disorders cause 30,000 deaths per year among women.[3] Preeclampsia can influence both the pregnant woman and the fetus. Markedly, the development of preeclampsia can lead to acute kidney injury, liver damage and dysfunction, hemorrhagic stroke, ischemic acute respiratory distress syndrome, preterm labor, and cesarean section. Furthermore, an elevation in blood pressure can cause placental abruption and preterm delivery. Fetal health problems include fetal growth restriction and possibly fetal and prenatal death.[4] In Saudi Arabia, the incidence of preeclampsia is approximately 5.37 per 10,000 women.

Indeed, nurses are accountable for the quality of maternity services provided to women. Therefore, acquiring sufficient knowledge among nurses is essential to the provision of adequate and safe nursing care in pregnancy and childbirth throughout all circumstances. Furthermore, as indicated by studies, insufficient knowledge of hypertensive disorders of pregnancy among nurses has been identified. Contributing to this is the lack of programs designed for training on management and prevention of such disorders, including the early identification of risk factors and lifestyle modifications being necessary components to prevent PIH disorders.[5],[6] The knowledge of symptoms and alarm signs related to hypertensive disorders of pregnancy was very limited, if not absent, among pregnant women. Early detection provides the opportunity for follow-up management and/or treatment, and this may reduce complications of PIH disorders.[7] Consequently, informing pregnant women of the common symptoms of PIH is critical to the delivery of care and the health of the unborn child. This, however, needs to be done by knowledgeable and well-educated health-care providers such as nurses.

Antenatal model of care is common primary and secondary prevention of health problems. To scale back increasing maternal mortality rates, women with hypertensive disorders throughout gestation should be educated on the critical medical information about their disease from their health-care providers. Inadequate knowledge of nurses and lack of preventive practice within a primary care setting will result in an increased incidence of pregnancy complications associated with PIH disorders.[8] The maternal death rate might be decreased if women are equipped with adequate information and good attitudes about the need to attend antenatal clinics, use good health services, and adhere to the preventive practice.[9] Nurses are consequently accountable for the effectiveness and efficiency of maternity services provided for women during pregnancy to decrease both the maternal and infant mortality rates.[10] Therefore, this study explored the level of knowledge and skills of primary care nurses in the treatment of PIH disorders in primary health-care (PHC) centers.

  Subjects and Methods Top

A quantitative descriptive cross-sectional research design was selected in this research. This study was conducted at 6 PHC centers, selected purposefully, as these centers serve the largest population and have an adequate number of nurses in Riyadh city. Purposive nonprobability sampling technique was carried out of nurses working from the six selected centers. Study inclusion criteria were all nurses working at government-owned PHC centers in Riyadh with a minimum of 1-year experience. Nurses with personal history of hypertension were excluded from the study to reduce prior self-knowledge bias, and nurses holding a master's degree were also excluded due to insufficient sampling frame.

The total sample size consisted of 257 female nurses working in PHC centers in Riyadh city. Data collection for this study was conducted using a three-part English paper-based self-administered questionnaire created by the researcher. Part I contained questions relating to the sociodemographic data of the study sample. Sentence should say: Part II contained 14 multiple-choice questions relating to nurses' knowledge on PIH disorders. The questions asked nurses about the definition, causes, signs and symptoms, risk factors, predisposing factors which included diseases, side effects of hypertension, complications on of the mother and fetus, and warning signs of PIH. Finally, part III focused on knowledge of the nurses about the management of hypertensive disorders (preeclampsia) and included 16 multiple-choice questions related to knowledge of maternity nursing care, including monitoring of the mother and fetus, mother's health education, the use of guidelines in the management of the hypertensive disorder, and provided treatment as prescribed. To determine the knowledge level, all 30 items (total of parts II and III) related to the knowledge score needed to be answered by the participants. The score was assigned according to the correctness of the answer, 0 for wrong or incomplete answers and 1 for the correct answer. These three levels were high knowledge level (score aggregation ranges from 66.67% to 100%), moderate knowledge level (score aggregation ranges from 33.4% to 66.6%), and low knowledge level (score aggregation ranges from 0 to 33.3%).

To confirm content validity, the questionnaire was sent to an expert reviewer committee (n = 6), who have thorough experience in research (2 professors, 2 assistant professors, and 2 obstetricians). Each reviewer recorded both criticisms and suggestions for improvement on a separate form provided for this purpose. Furthermore, the test–retest method was used to measure instrument reliability. Previously, a pilot study was conducted to confirm the reliability of the instrument, to check the accuracy and clarity of words and questions, etc., The questionnaire Cronbach's alpha coefficient was 0.87.

The pilot study was conducted to determine the feasibility before performing the main study and to improve the quality and efficiency of the main study if needed. Those nurses (20 nurses) were excluded. The main study proceeded without any modification to the study design.[11] Furthermore, the internal consistency of the study instrument was assessed. The reliability of the instrument showed a Cronbach's alpha value of (0.87) on a total of 30 items.

Ethical considerations were emphasized. The general director of PHC centers at the Ministry of Health in Riyadh guaranteed the permissions to carry out the study. The ethical approval of the Director of Academic Affairs and Research Center at Riyadh was received before starting the data collection phase.

Nurses working in the PHC center were informed about the purpose of the study. They were also informed that participation in the study was voluntary and they could withdraw from the study at any time. The consent form was signed by the participant. Anonymity and confidentiality of data collection were also assured.

Data collection was completed over a 4-month period, however, only 5 days per week were allocated over that 4-month period. Data were collected from participants via a self-administered questionnaire. To fill out the questionnaire sheet, each participant required 15–20 min. A statistical software package (SPSS-24) (IBM Corp, Armonk, NY) was used for data entry and statistical analysis. Quality control was completed through the coding and data entry processes. The sample was presented using descriptive statistics. Frequencies, percentages, means, and standard deviations were used. A t-test (t), one-way ANOVA (F), and P = 0.05 level of significance were employed in the analysis of the data to determine the relationship between nurses' characteristics and knowledge of PIH disorders.

  Results Top

The distribution of respondents according to their sociodemographic characteristics is shown in [Table 1] where about two-thirds of the nurses were in the age category of 30 years or more. The majority of the nurses (98.44%) were Saudi, and about two-thirds of them held a nursing diploma. More than half of the sample (50%) had more than 6 years of working experience in the field of primary health. A total of 152 nurses (59%) attended training courses in care for preeclampsia mothers. Two-thirds of the nurses (65.37%) answered correctly regarding the definition of PIH, and only 96 nurses (37%) knew the different risk factors for developing preeclampsia [Table 2]. Regarding the causes of PIH, more than half of the nurses (57.98%) gave the correct answer. The majority of the nurses (93.77%) knew the contributing factors which may worsen PIH.
Table 1: Distribution of respondents according to their sociodemographic characteristics

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Table 2: Distribution of respondents according to their correct knowledge about hypertensive disorder during pregnancy (n=257)

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Although the results showed that 64.59% of the study sample were able to identify which women were liable for primary induced hypertension, 113 nurses (44%) answered incorrectly about the signs of severe preeclampsia. Furthermore, 108 (42.02%) and 32 (12.45%) of the study sample had knowledge about the impacts of preeclampsia on both the pregnant women and the fetus. The result shows that 107 nurses (44%) had inadequate knowledge about the most common complications of eclampsia.

[Table 3] shows that 114 nurses (45%) had poor knowledge about monitoring the fetal well-being and mother's preeclampsia with the use of a Doppler or electronic fetal monitor. Regarding nursing duties before the administration of the magnesium sulfate (MgSO4) drug, 139 nurses (54.08%) illustrated a lack of knowledge. While 162 nurses (63.04%) were aware of the existence of standardized guidelines for the management of preeclampsia, 180 nurses (70%) mentioned that these guidelines were not followed when managing severe preeclampsia in their institutions.
Table 3: Distribution of respondents according to their correct answer about the management of preeclampsia patients (n=257)

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The total score of knowledge about the management of preeclampsia was detected from 20 to 30 degrees (66.67% and more) described as a high level of total knowledge; a score from 10 to 20 degrees (33.33%–66.67%) was described as a moderate level of total knowledge, while a score equal to 10 or less (33.33% and less) was described as a poor level of total knowledge. The data in [Table 4] show the deficiency of 254 nurses (98.83%) from poor to moderate level of total knowledge about the management of preeclampsia with a moderate mean score (19.09, 63.63%).
Table 4: The total level of knowledge about the management of preeclampsia patients for respondents (n=257)

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[Table 5] shows that no statistically significant differences regarding nationality and training aspects were observed. [Table 6] demonstrates that there were statistically significant differences at the 0.01 level between the nurses concerning the level of education categories in their knowledge about the management of preeclampsia patients (F = 6.644, P = 0.002), specifically in the level of education groups “bachelor degree in nursing” (mean = 2.38) and “diploma in nursing” (mean = 2.20). Moreover, there were no statistically significant differences between the nurses concerning the number of years of experience in PHC categories in their knowledge about the management of preeclampsia patients. Furthermore, there were no statistically significant differences between the nurses concerning age categories in their knowledge about the management of preeclampsia patients.
Table 5: Differences in respondents' knowledge and management of patients with preeclampsia by nationality and training

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Table 6: One-way ANOVA analysis according to age, level of education, and years of experience in primary health care for respondents toward their general knowledge, knowledge about hypertensive disorder during pregnancy

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  Discussion Top

In PHC settings, the first points of contact for expectant mothers tend to be nurses, who also administer the majority of the prenatal services rendered. For some expectant mothers, these services may include hypertension management. PIH conditions, such as preeclampsia, are very complex and often multifaceted.[12] As a result, it is important that nurses possess the necessary knowledge and training on the recognition and management of this disease in order to properly care for both the mother and fetus. Our findings suggest that primary care nurses lack the necessary knowledge to provide comprehensive prenatal care services as it relates to the identification, treatment, and management of PIH. These services include conducting fetal hypertension assessments, recognizing the signs and symptoms of mild preeclampsia and its consequences, and nurses' role in the administration of MgSO4 to treat preeclampsia, as well as the monitorization of potential toxicity due to the overadministration of MgSO4. These findings suggest that nurses have inadequate knowledge for early detection and treatment methodology to facilitate positive care outcomes. In congruence with our findings, nurses in Saudi Arabia were found to have subpar knowledge and only “satisfactory” ratings as it relates to assessments on PIH. Likewise, a Ugandan study assessing nurses' knowledge of PIH via the number of satisfactory answers on their pre- and postquestionnaires found that nurses' knowledge significantly improved once educational interventions were implemented.[13]

Similar findings have been discovered outside the realm of a primary care setting. Researchers have conducted hospital-led educational programs to assess their impact on nurses' knowledge of pregnancy risk factors leading to PIH. The researchers found that more than half of the nurses provided incorrect responses on the pretest as it related to the identification of high-risk pregnancies, which was attributed to an insufficient overview of the subject during their nursing education or the need for continuous training.[14]

A common risk factor for PIH is obesity – women who are obese prepregnancy and women who experience a large weight gain during pregnancy are four and two times more likely to develop hypertension during their pregnancies, respectively.[15] As diet and exercise management are the foremost option in combatting obesity-driven hypertension in pregnant women, we also assessed nurses' knowledge of this management option. Ultimately, we found that nurses in our sample size scored poorly on an assessment testing their knowledge of diet and weight management guidelines for hypertensive pregnant women, suggesting that more education/training for nurses is required on this topic. Similarly, 96.7% of the nurses in Saudi Arabia were found to score significantly poorly (mean: 9 out of 20) on an assessment testing their knowledge on the impact of a diet and weight management program on their pregnancy-induced management. Nurses' knowledge on the positive impacts of diet and exercise and how they communicate it to patients (in a nonjudgmental, encouraging way) has the potential to develop a positive impact on not only the patient's health but also the child's.[16] More educational content and training on nutritional guidelines and the importance of diet, exercise, and a balanced healthy lifestyle on hypertension management is required among nurses.

The diagnosis of any patient with hypertension is a complex and ongoing process as it requires the proper identification, management, and subsequent as-needed modifications to treat it. As nurses are primarily charged with the management of hypertension, their lack of comprehensive knowledge and training may hinder their ability to effectively manage their patients' hypertension or negatively impact the clinical outcomes of the mother and child. In our analysis, we found that 70% of our sample possessed inadequate knowledge of clinical protocols or guidelines to manage PIH care. This may, in part, be due to nurses' lack of clinical exposure, training, and access to hypertensive pregnancy cases. Two-thirds of the nurses in our sample held a nursing diploma, but they may require additional basic training or continuous refresher courses on hypertension. Although 50% of the nurses had 6 years or more of primary care fieldwork experience, they may not have had the necessary exposure to patients requiring prenatal care or PIH management. This lack of exposure/access has limited their knowledge on the various clinical care requirements for PIH. In particular, a lack of training on PIH has been shown to negatively impact nurses' knowledge on the subject matter, suggesting that continuous training is required for nurses caring for pregnant women.[17]

Our study highlights the importance of providing continuous education, training, and exposure to primary care nurses on common and evolving medical conditions such as hypertension. Furthermore, it is crucial that these continuing education opportunities be provided with clearly defined objectives and goals and are conducted under proper supervision in the relevant medical setting. Previous research has found that the implementation of educational programs improved nurse-midwives' knowledge on PIH.[18] Recently, guidelines for entry into the nursing field have been adjusted to require, at minimum, a baccalaureate degree. As such, recruiting bachelor of nursing students into the PHC setting would be beneficial in combatting this knowledgeability gap as these students have been exposed to more comprehensive care management content and have extended training provided either during their studies or internships. This may be especially beneficial in facilitating the development of a robust workforce, as medical personnel often exchange information while on duty. For example, approximately 66% of the midwife nurses in an Indian study reported that their knowledge source on pregnancy-related hypertensive disorders stems from their fellow health-care coworkers.[19] Further opportunities to remedy gaps in nurses' knowledge on medical issues can be found by providing incentives to postgraduate students to further their education, develop and teach more comprehensive curriculums in the bachelor program, and/or instituting a suitable program to extend nurses' education within the health-care centers they work for.

The knowledge of symptoms and warning signs related to hypertensive disorders of pregnancy was found to be very limited, if not absent, among nurses. Since early detection provides the opportunity for follow-up management and/or treatment, it may also reduce complications of PIH disorders.[1] Nurses should be knowledgeable and highly skillful in providing nursing care according to an individual woman's needs and problems in order to save her life. It is important to conduct training programs for nurses and highlight the need to provide an assessment of nursing practice at PHC centers, training to address the identified knowledge gaps, and to develop patient-centered education modules.

  Conclusion Top

The lack of knowledge of symptoms related to hypertensive disorders in pregnancy could endanger a woman's health or the health of their baby(ies).[8] To provide an inclusive nursing care management of PIH, assessing the attitudes of health professionals including nurses is exceedingly essential. The study has identified three key recommendations; the first is that nurses must encourage the attendance of continuing education sessions in the form of workshops, conferences, training programs, and reviewing updated nursing care related to PIH. The second is to establish a nursing library with recent scientific books and periodicals in the Arabic language to help nurses be able to explain medical information to patients who primarily speak Arabic. The third is to develop protocols for evaluating all educational programs delivered by hospitals and PHC units in Riyadh city and using the results in updating the programs and implementing new developments.


The authors are thankful to Al-Maarefa University, Riyadh, for providing facilities to carry out the work.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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