A generic qualitative research approach, which is exploratory, descriptive and contextual in nature (Creswell 2013:45; Polit & Beck 2017:12), was employed. This allowed the researcher to collect data in the natural setting to explore and describe the knowledge and attitudes of preeclampsia women towards SMBP. The constructivism paradigm was applied to construct knowledge through social interactions. The qualitative research design and constructivism paradigms complemented each other by relying upon the participants’ views and their understanding of the situation being studied (Creswell 2013:45) and acknowledging the impact of their past experiences. The participants developed subjective meanings of their own experiences and knowledge of the subject under study that led to the researchers generating individual perspectives of meanings into several categories or themes and ideas (Creswell 2013:46). The researchers worked collaboratively with participants and obtained data by asking open-ended questions to encourage them to explain their understanding of and views about the subject under discussion.

The study was conducted in Gauteng province, in one of the public hospitals in the Tshwane Health District region. The selected hospital’s antenatal clinic (ANC) renders healthcare services to high-risk pregnant women. The patients attending the ANC are referred from primary healthcare clinics and community health centres in the catchment areas.

The population was sampled from pregnant women diagnosed with preeclampsia, who voluntarily consented to participate in the study. A non-probability sampling approach was used. A total number of 14 patients attending ANC were sampled using the purposive sampling method. This sampling technique allowed the researcher to make specific choices about which patients possessed a wealth of information about their personal experience about the condition to include in the research sample (Bertram & Christiansen 2014:60; Gray, Grove & Sutherland 2017:345). During the data collection period, the researchers went to the clinic in the mornings and selected the files of patients diagnosed and treated for preeclampsia.

The files were checked to select patients who met the inclusion criteria for the study, which were patients aged 18 years and above, a patient diagnosed with preeclampsia and attending ANC. The study excluded hospitalised patients and those aged below 18 years.

The trustworthiness of the study was ensured using the components and criteria of Lincoln and Guba (1985). To ensure credibility, the researcher collected data and engaged with participants in the natural setting. Data were collected using semi-structured interviews and unstructured observations. Field notes were taken during interviews, and interviews were audio-recorded for the accuracy of information. Transferability was ensured using an interview guide to collect relevant data, and thick descriptions of the findings were presented. To ensure the reliability of data, verbatim transcriptions were conducted, and the services of an independent co-coder were used to analyse the data. The researchers avoided bias by maintaining transparency using the research trail, where the research process and activities were documented.

The researchers provided information to the patients who met the inclusion criteria. The overview of the study was explained, including the purpose, data collection procedure, voluntary participation and audio recording during interviews to allow participants to make an informed decision. Participants signed informed consent before participating in semi-structured interviews that were recorded. Participants were assured of confidentiality and anonymity. They were advised of their right not to answer questions they felt uncomfortable with, and they were free to withdraw at any time from the interview. Semi-structured interviews were conducted between 4 September 2018 and 10 September 2018, and data were collected from 14 participants. Data saturation was reached after 12 interviews; the researchers conducted two more interviews to confirm that no new information was attained. Three participants were interviewed per day and interviews lasted for 30 min – 40 min. An interview guide was used with open-ended questions, which allowed the participants to describe their knowledge and attitudes towards SMBP and the researchers to ask follow-up probing questions when more information was required. Box 1 displays the questions that were asked during the interviews.

After demographic information regarding age, number of pregnancy, gestational age, employment history and preeclampsia history, the interview guide questions (Box 1) were posed to all the participants.

The researcher received ethical clearance from the University of South Africa Research Ethics Committee. Approval to conduct the study was obtained from the Department of Health and the selected hospital in Tshwane. Participants were provided with detailed information about the study, and they voluntarily signed informed consent forms to participate in the study. Exclusion from the study was based on the set inclusion criteria. Participants’ information was kept private using codes for all interviews and the co-coder signed the confidential agreement. Participants were informed that they had the freedom to withdraw from the study at any time.

The age of participants ranged from 18 to 43 years. Four (28.6%) participants were at an advanced maternal age, which is a pregnancy that occurs at 35 years or older (Dekker, Niles & Breakey 2016:9) and 10 (75.4%) participants were aged between 19 and 34 years. The gravida results reflected that three (21.4%) of the participants were primigravidae (pregnant for the first time), whereas 11 (78.5%) were multiparous women (having been pregnant before). Eleven (11) participants have received education up to high school level, one achieved a tertiary qualification, and two never attended school. Seven (50.0%) of participants were employed, and the other seven (50.0%) were unemployed and depend on social grants for a living.

The main aim of the study was to explore and describe preeclampsia patients’ attitudes towards the self-monitoring of their BP. The findings of the complete research study reflected in four themes, and the relevant sub-themes are summarised in Table 1. The themes and sub-themes represented the knowledge and attitudes of preeclampsia patients towards SMBP that emerged during the data analysis of this study.

Knowledge of BP is of particular importance for preeclampsia patients. In the discussion during the interview, the participants reflected their limited understanding of BP in pregnancy, as well as its causes and management. The sub-themes that give insight into these themes are discussed below.

Limited information about high blood pressure in pregnancy: The majority of the participants indicated that during their attendance in the healthcare facility, they did not receive any information about BP in pregnancy. In contrast, a few participants admitted having received limited information about preeclampsia from the doctor and other healthcare workers such as nurses. Little knowledge was expressed by the following quotes:

A few participants indicated hearing about the condition from healthcare practitioners during a consultation and said that:

Knowledge of the causes, effects and management of high blood pressure during pregnancy: The majority of the participants understood the general causes of high BP as associated with dietary lifestyles and psychological problems such as stress. To control high BP, participants believed in eating healthy, exercising and taking prescribed medication. This understanding is depicted by the following quotes:

Most of the participants had basic insight into how to manage high BP. They focused on diet, exercise and taking prescribed medication. They discussed the management of hypertension in pregnancy as follows:

Knowing how to manage high BP does not mean that patients are compliant with it; some patients acknowledged that they do not take their medication as they are supposed to, do not eat healthy foods and do not exercise.

All the participants were aware of the effects or complications of uncontrolled high BP in pregnancy, and they reported their knowledge of the effects on/complications for both the mother and the baby as follows:

Based on the discussion about their knowledge of high BP in pregnancy, a few participants portrayed limited knowledge about high BP in pregnancy that they received from healthcare workers such as doctors and nurses. In contrast, the majority reported having never received such information. This suggests that healthcare practitioners working in ANCs do not provide pregnant women with the necessary information about hypertension in pregnancy.

The majority of participants showed interest and openness to SMBP at home; however, a few acknowledged challenges. The participants’ views are discussed in the relevant sub-themes below.

Willingness to self-monitoring of blood pressure at home: The majority of the participants admitted that SMBP at home is a good thing to do and more acceptable than more frequent clinic visits. Some also stated that it is still essential to check BP at home to get to know what is happening with the baby:

The majority of participants support SMBP because they believed that the home environment is private and relaxed. Participants were of the view that checking BP would make them aware of the high readings and thus, it would encourage them to seek medical help from the doctor or the clinic. Few participants indicated that monitoring at home would also help to reduce the frequent number of antenatal visits at the clinic, especially for those who attend the clinic only to check their BP.

Reluctance to self-monitoring of blood pressure at home: Few of the participants were reluctant and uncomfortable to do self-monitoring at home as they fear mistakes because they are unfamiliar with the machine. They were worried about inaccurate measurements and mentioned that it is better to go to the clinic because they can question the health professionals about their condition and clear their doubts. Participants do not feel safe to monitor at home because they believe anything wrong could happen to the mother and baby at home, so it is better to be monitored at the hospital and the clinic. These fears are supported by the following statements made by the participants:

The information above has depicted the willingness of participants to SMBP at home; although some reluctance was also noted on account of the fear of making mistakes because of unfamiliarity with the BP measuring machine.

Successful monitoring of BP at home requires preeclampsia patients to have access to or own the digital BP machine.

Affordability and availability to buy the blood pressure measuring machine : Preeclampsia patients will need to have an affordable BP machine to be able to check BP at home. The socio-economic status of the participants may make it difficult for them to acquire a reliable BP machine. Participants expressed themselves as follows:

Lack of self-confidence and knowledg e on the use of the blood pressure machine: Few of the participants were concerned about not knowing how to use the machine. They were also afraid that the device might show inaccurate measurements and put their health at risk:

Though the majority of participants showed openness to SMBP, owning the BP measuring machine is inconceivable because participants cannot afford to buy for themselves. Lack of confidence amongst few participants to use the BP machine as well as insufficient knowledge on the subject of SMBP was notable.

The SMBP at home may bring changes in the lives of patients and healthcare facilities.

Early identification of abnormalities and seeking medical attent ion urgently: The majority of the participants believed that SMBP pressure would make them aware of the high readings, allowing them to seek medical assistance on time. The value of monitoring BP at home was expressed as follows:

The majority of the participants believed that SMBP at home would be useful in recognising abnormal BP readings; they would then rush to the clinic or hospital to seek urgent medical care. This was expressed as follows:

Safety of the mother and the unborn baby: The majority of the participants believed that SMBP at home will keep them and their unborn babies safer because they will immediately notice if it is high and will report it to the healthcare providers:

The study incorporated pregnant women of a variety of ages, parity, social conditions, literacy and past experiences including those with a preeclampsia history and other pregnancy-related illness. The evidence obtained will help in addressing the knowledge gaps regarding preeclampsia and the challenges that could inhibit patients from SMBP. It would empower pregnant women in caring for themselves, thus reducing the need for frequent visits to the ANC for BP check-ups. Health facilities will have to deal with fewer attendees, in compliance with the caronavirus disease 2019 (COVID-19) guidelines. This study provides empirical evidence of the limited knowledge based on lack of health education in ANC and could thus enhance the development of health policies and health education strategies in ANCs. Participants were all Africans, only one participant obtained a post-school qualification, as such the findings may not be representative of the broader population of women with higher education levels. Qualitative research was used, and participants were purposively sampled. The study was conducted in just one public health facility in Gauteng province, in South Africa. The findings, therefore, cannot be generalised to all the pregnant women with preeclampsia in private health facilities or those in other provinces and countries.

Self-monitoring of BP was well received and accepted by preeclampsia pregnant women who participated in the study. It is therefore recommended that the Department of Health introduces the use of BP machines for preeclampsia patients. Due to the unaffordability and unavailability of the BP machine, it is recommended that hospitals and clinics rendering ANC provide patients with preeclampsia and those who are at high risk, with reliable and affordable BP equipment to do self-monitoring at home. Healthcare institutions and practitioners, especially midwifery specialists, should provide health education programmes that will be monitored and measured for compliance to ensure that quality outcomes can be accurately reported.

Future studies on SMBP should be conducted using different designs, including more facilities and patients in public and public institutions in South Africa to explore the feasibility, attitudes of preeclampsia patients in other provinces as well as in the private sectors.