The worldwide phenomenon of teenage pregnancy among 13–9-year-olds is complicated by obstetric conditions. Among the top three causes of maternal mortality, hypertension is the third in South Africa. Quality maternal care is assured by obstetric practitioners (OPs) implementing guidelines specific for management of hypertension in pregnancy.
The objective of this study was to investigate implementation of maternal guidelines for hypertension in pregnancy among teenagers.
As a retrospective quantitative research design was used, 173 maternal records of pregnant teenagers from 13 to 19 years were sampled from six district hospitals and Community Health Centres (CHCs) between 01 January 2017 and 31 December 2019 to undergo systematic random sampling. A pretested structured checklist was used to record data from sampled maternal records. Statistical Package for Social Sciences (SPSS) version 26 was used for data analysis, and results were presented using simple descriptive statistics.
Research results indicated that teenagers who suffered from hypertension intrapartum and postpartum did not receive maternal care according to the guidelines for maternity care in South Africa. Blood pressure was not measured of six (3.47%) intrapartum and five (2.9%) postpartum teenagers. Seventeen (9.8%) hypertensive postpartum teenagers received their antihypertensives.
Public health institutions (PHIs) compromised provision of quality maternal care among teenagers, evidenced by incomplete intrapartum and postpartum assessment, diagnosis and management of hypertensive disorders in pregnancy (HDP).
This study contributed to facilitating adherence to guidelines improving healthcare of teenagers in government facilities.
Teenage pregnancy, that of a pregnant woman aged 13–19 years, affects all countries (Sanchez & Favara
Butalia, Audibert and Cote (
To minimise complications associated with HDP among teenagers for obstetric practitioners (OPs) to apply their knowledge and experience when implementing obstetric guidelines for assessment, diagnosis and management (Peres, Mariana & Cairrao
Guidelines of HDP apply to adults and teenagers to guide assessment, diagnosis and management, thus improving quality maternal care during pregnancy, labour and puerperium. Obstetric practitioners need to assess the risks of hypertension when a teenager experiences labour pains and after delivery of the foetus. The parameters to be assessed include measuring blood pressure (BP), assessing and grading oedema, testing urine using dipsticks and so forth (South Africa
A nonexperimental retrospective quantitative study was conducted in order to determine the quality of the maternal care rendered on the basis of assessment and diagnosis of hypertensive disorders among intrapartum and postpartum teenagers. The documented maternal care in the maternal records was used by the researcher to justify type of care rendered on the basis of the Guidelines for Maternity Care in South Africa (
The researcher conducted this study in a natural setting in KwaZulu-Natal, consisting of a CHC and six district hospitals in a rural district. These public health institutions (PHIs) render various healthcare services, including antepartum, intrapartum and postpartum care. The district consisted of urban, semi-urban and deep rural areas regulated by traditional tribal authorities.
The study population were maternal records between 01 January 2017 and 31 December 2019 for teenagers who were living with HDP and treated for HDP during pregnancy, labour and puerperium. Maternal records of teenagers aged 13–19 years indicated those who were living with HDP from January 2017 and December 2019 for their inclusion in this study. To retrieve these records, a list with admission numbers from admission and discharge registers of teenagers diagnosed with HDP was used by the administrative personnel.
The researcher used the sampling frame comprising admission numbers between 01 January 2017 and 31 December 2019 to start a systematic random sampling process (Polit & Beck
The researcher developed a new structured checklist using the Guidelines for Maternity Care in South Africa (
The quantitative recorded data were analysed using descriptive statistics. According to Patten and Newhart (
Ethical clearance to conduct this study was obtained from the University of South Africa Health Studies Higher Degrees Ethics Review Committee (ref. no. HSHDC/994/2020). The Department of Health in KwaZulu-Natal, district managers and selected public health institutional managers officially permitted this study. Codes were used instead of real names of institutions and maternal records to maintain confidentiality and anonymity. The signing of a confidentiality agreement form between the statistician and the researcher strengthened confidentiality in this study. The PHIs reserved small spaces dedicated for the researcher to record data on site.
The admission numbers of teenagers extracted from the admission and discharge registers kept in labour wards were used to form a comprehensive list, which was submitted to the administration clerks for retrieval of maternal records. The signing of a borrowing register by the researcher while receiving and returning maternal records to administrative personnel prevented loss of these files after use, and 11–48 maternal records were recorded per day.
Validity means the accuracy of the data collection instrument to measure what was supposed to be measured (Polit & Beck
Reliability refers to the degree of dependability of a data collection instrument to yield similar results when repeatedly used by other researchers on the same population (Polit & Beck
The implementation of the maternal guidelines for hypertension in pregnancy was assessed from 173 maternal records of teenagers who suffered from hypertensive disorders during intrapartum and postpartum periods.
Biographic features of the sample.
Variables | Frequency ( |
Percentage |
---|---|---|
Community health centre - 1 | 20 | 11.60 |
District hospital - 2 | 13 | 7.50 |
District hospital - 3 | 26 | 15.00 |
District hospital - 4 | 11 | 6.40 |
District hospital - 5 | 30 | 17.30 |
District hospital - 6 | 25 | 14.50 |
District hospital - 7 | 48 | 27.70 |
13 | 1 | 0.58 |
14–15 | 14 | 8.09 |
16–17 | 48 | 27.75 |
18–19 | 110 | 63.58 |
Primigravida | 160 | 92.49 |
Multigravida (Gravida 2) | 13 | 7.51 |
No foetal loss | 167 | 96.53 |
Foetal loss through miscarriage | 6 | 3.47 |
The severity of HDP depends on intrapartum and postpartum assessment findings from various body systems. In this study, intrapartum and postpartum assessments were focused on cardiovascular and urinary systems. These assessments measured BP, assessment and grading of oedema and urinalysis tests.
Intrapartum and postpartum assessment of hypertension among teenagers.
Assessment | Frequency ( |
% |
---|---|---|
Measuring blood pressure | ||
Not measured | 6 | 3.47 |
70–139/50–105 | 117 | 67.63 |
140–224/70–134 | 46 | 26.59 |
Rechecked | 4 | 2.31 |
Urinalysis test | ||
Not performed | 52 | 30.10 |
No proteinuria | 109 | 63.00 |
Proteinuria ≥ 1+ | 12 | 6.90 |
Assessment of oedema | ||
Not assessed | 170 | 98.27 |
Assessed and graded | 3 | 1.73 |
Measuring blood pressure | ||
Not measured | 5 | 2.90 |
90–139/40–96 | 151 | 87.30 |
140–159/80–100 | 15 | 8.70 |
170–174/110–114 | 2 | 1.10 |
Urinalysis test | ||
Not carried out | 172 | 99.40 |
No proteinuria | 1 | 0.60 |
Assessment of oedema | ||
Not assessed | 172 | 99.40 |
Assessed and graded | 1 | 0.60 |
The heart pumps blood at a normal pressure, and this pressure can be estimated and called the BP. This study found that the blood pressure was not measured in 6 (3.47%) of the teenagers.
To detect diseases of the urinary system, the urine needs to be tested using various tests such as urinalysis. The urinalysis test results showed no proteinuria in 63.03% (
Swelling in the body manifests a disease that needs specific management. Out of 173 teenagers who experienced labour pains and were admitted in PHIs, only 1.73% (
In this study, the values of BP were grouped into four strata, with the first stratum consisting of teenagers whose BP was not measured; the second stratum consisted of teenagers who had a normal BP; the third stratum (
The study found 0.58% (
Out of 173 teenagers who delivered in the PHIs, only 0.6% (
Hypertensive disorders in pregnancy require therapeutic treatment intrapartum and postpartum to prevent maternal–foetal–neonatal complications. This study was focused on the management of HDP during labour and after delivery, as the determinant of the mode of delivery and maternal and neonatal condition after delivery, which might affect the duration of hospital stay postpartum.
Intrapartum and postpartum care and complications.
Intrapartum | Frequency ( |
% |
---|---|---|
BBA | 3 | 1.73 |
Unsure of dates | 4 | 2.31 |
Miscarriage | 3 | 1.73 |
≥ 28–36 weeks | 22 | 12.72 |
37–42 weeks | 141 | 81.50 |
Received intrapartum | 22 | 12.72 |
Not received intrapartum | 151 | 87.28 |
Received postpartum | 17 | 9.80 |
Not received postpartum | 156 | 90.20 |
NVD with episiotomy cut | 105 | 60.69 |
NVD without episiotomy cut | 25 | 14.45 |
Caesarean section | 43 | 24.86 |
Alive | 168 | 97.11 |
Demised after birth | 5 | 2.89 |
3/10 – 0/10 | 5 | 2.89 |
6/10 – 10/10 | 2 | 1.16 |
7/10 – 10/10 | 13 | 7.51 |
8/10 – 10/10 | 153 | 88.44 |
No complications | 152 | 87.86 |
New onset of HDP | 2 | 1.15 |
Eclampsia | 1 | 0.58 |
Retained placenta | 1 | 0.58 |
PPH | 2 | 1.15 |
Vaginal tears | 14 | 8.10 |
Anaemia | 1 | 0.58 |
No complications | 172 | 99.42 |
Neonatal jaundice | 1 | 0.58 |
< 6 hours | 1 | 0.58 |
≥ 6 h ≤ 2 days | 115 | 66.50 |
3–5 days | 56 | 32.40 |
Not recorded | 1 | 0.58 |
HDP, hypertensive disorders in pregnancy; NVD, normal vaginal delivery; BBA, birth before arrival; PPH, postpartum haemorrhage.
Normal labour starts spontaneously from 37 to 42 completed weeks’ gestation including limited interventions when a teenager delivers vaginally (Sellers
Antihypertensives prescribed intrapartum and postpartum normalise BP. This study found 22 (12.7%) teenagers received antihypertensives during labour, and others did not receive any treatment related to hypertension in pregnancy. Again, 17 (9.8%) received antihypertensives after delivery while the majority did not receive such treatment.
Delivery of teenagers commonly needs to be assisted with other means to be effective; otherwise, complications may occur. The majority of teenagers delivered vaginally with episiotomy cuts, but 25 (14.45%) gave birth without episiotomy cuts, and others were delivered by caesarean section.
Foetuses need to adjust in the extra-uterine environment, and effective or ineffective adjustment is mostly indicted by a scoring instrument. This study found five (2.89%) babies who demised after birth, while others survived. The findings also reveal that 153 (88.44%) had a normal Apgar score of 8/10 in 1 min and 10/10 in 10 min, and other babies had a varying degree of asphyxia neonatorum.
The HDP induced various complications, some preventable while others were manageable intrapartum and postpartum. The study found two (1.16%) teenagers who had developed hypertension during the fourth stage, two (1.16%) who developed postpartum haemorrhage (PPH) and less than 1% who had eclampsia, anaemia and retained placenta.
Other foetuses fail to adjust to the extra-uterine environment and develop complications. In this study, only one (0.58%) neonate had developed jaundice, which was treated with phototherapy, and others were without complications.
Teenagers need to stay in the facility after delivery to monitor their condition for the development of life-threatening complications. The results revealed that 115 (66.5%) teenagers were discharged after 6 h until the second day postpartum, 56 (32.4%) teenagers stayed for 3–5 days, and the others were discharged after less than 6 h.
The study focused on teenagers aged 13–19 years who became pregnant with their bodies still in the process of growth. To be pregnant at an early age increases the risks of developing conditions complicating pregnancy among teenagers. Such conditions include anaemia, HDP and infections (particularly sexually transmitted), leading to foetal loss. Risk of HDP increases three times higher among teenagers aged less than 15 years. According to Abebe et al. (
Obstetric practitioners assess intrapartum and postpartum teenagers for cardinal signs of HDP. These are hypertension, proteinuria and oedema. The Government of the Republic of South Africa standardised guidelines for routine assessment of these cardinal signs during labour and after delivery (Sellers
According to South Africa (
To help teenagers deliver, OPs cut episiotomies, assisting a premature foetal head in distending the vulva while preventing vaginal tearing and excessive moulding from the resistance of pelvic floor muscles against stretching. Cutting episiotomies can be contraindicated for other teenagers, particularly those who test human immunodeficiency virus (HIV)-positive during pregnancy or labour, minimising mother-to-child HIV transmission. Findings from this study revealed that the majority (60.69%,
Countries implement various guidelines recommending periods of stay in the health facility after delivery. During this period, OPs conduct assessments for early recognition of life-threatening conditions. In this study, 66.5% (
A rural district in KwaZulu-Natal province interested the researcher to focus the study on teenagers who presented themselves in PHIs for intrapartum and postpartum care. To implement principles of retrospective design, data were recorded in a structured checklist from maternal records of teenagers. Data were recorded in the absence of OPs, as the researcher is a midwifery specialist with understanding in obstetric-related data. The researcher presented results generalised to intrapartum and postpartum teenagers suffering from HDP and seven research sites included in this study. In future, further studies need to focus on OPs’ knowledge and experience in implementation of guidelines for hypertension in pregnancy among teenagers and explore perceptions and experiences of teenagers living with HDP.
The effective implementation of guidelines for hypertension in pregnancy depends on the academic knowledge and experience of OPs. The OPs need to undergo continuous professional development through formal education, workshops, and so forth on hypertension in pregnancy. The researcher recommends future research to focus on developing a midwifery clinical competency model as an effective strategy in the management of hypertensive disorders intrapartum and postpartum among teenagers.
The determinants of quality assurance include OPs and adequate material resources. Incomplete assessments from a lack of obstetric-required material cause OPs to fail in providing quality maternal care. This results in nonadherence to the 2016 Guidelines for Maternity Care in South Africa. Obstetric practitioners need to be excellent in maternal care through complete and relevant assessments, diagnoses and management of hypertension in pregnancy to reduce morbidity and mortality among future heroines of the South African nation.
The author would like to acknowledge Rev. Fr. Mlungisi Nhlanhla Patrick Mazibuko. He persuaded the researcher through prayers to complete the submitted manuscript.
The author declares that he has no financial or personal relationships that may have inappropriately influenced him in writing this article.
S.Z.B is the sole author of this article.
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
The authors confirm that the data supporting the findings of this study are available within the article.
The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of any affiliated agency of the author.