PLOS ONE NORFADILAH BT ABDULLAH SANI

ADMW 1/2020 (K) - 0023

RESEARCH ARTICLE

Prevalence and determinants of hypertensive

disorders of pregnancy in Ethiopia: A
systematic review and meta-analysis
Endalamaw Tesfa ID1,2*, Endalkachew Nibret2,3, Solomon Tebeje Gizaw4,
Yohannes Zenebe2,5, Zewdie Mekonnen1,2,4, Sefealem Assefa1,2, Mulatu Melese6,
Netsanet Fentahun7, Abaineh Munshea2,3
1 Department of Biochemistry, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar,
Ethiopia, 2 Biotechnology Research Institute, Bahir Dar University, Bahir Dar, Ethiopia, 3 Department of
a1111111111
Biology, College of Science, Bahir Dar University, Bahir Dar, Ethiopia, 4 Department of Biochemistry, College
a1111111111 of Health Science, Addis Ababa University, Addis Ababa, Ethiopia, 5 Department of Medical Laboratory
a1111111111 Science, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia, 6 Amhara
a1111111111 Public Health Institute (APHI), Bahir Dar, Ethiopia, 7 Department of Nutrition and Dietetics, College of
a1111111111 Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia

* endalamaw2009@gmail.com, endalamaw.tesfa@bdu.et

OPEN ACCESS Abstract

Citation: Tesfa E, Nibret E, Gizaw ST, Zenebe Y,
Mekonnen Z, Assefa S, et al. (2020) Prevalence
and determinants of hypertensive disorders of Introduction
pregnancy in Ethiopia: A systematic review and
Hypertensive disorder of pregnancy is the second commonest causes of maternal death
meta-analysis. PLoS ONE 15(9): e0239048. https://
doi.org/10.1371/journal.pone.0239048 globally. Different public health studies were conducted on hypertensive disorder of preg-
nancy which presented inconsistent result. Therefore, this systematic review and meta-
Editor: Frank T. Spradley, University of Mississippi
Medical Center, UNITED STATES analysis was commenced to summarize the findings conducted in several parts of the coun-
try and to generate the nationwide representative data on the prevalence and risk factors of
Received: June 18, 2020
hypertensive disorder of pregnancy in Ethiopia.
Accepted: August 30, 2020

Published: September 16, 2020 Methods and materials

Copyright: © 2020 Tesfa et al. This is an open Electronic databases such as PubMed, Scopus, Google Scholar, Hinari, and African Jour-
access article distributed under the terms of the
Creative Commons Attribution License, which
nals Online were searched for studies published in English up to March, 2020. Joanna
permits unrestricted use, distribution, and Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument and New-
reproduction in any medium, provided the original castle-Ottawa Scale were used for data extraction and quality assessment of the included
author and source are credited.
studies. The meta- regression analysis was computed at 95% CI to present the pooled prev-
Data Availability Statement: All relevant data are alence and risk factors of hypertensive disorder of pregnancy.
within the manuscript and its Supporting
Information files.
Results
Funding: The authors received no specific funding
for this work. Thirty four studies were included in this systematic review and meta-analysis. The pooled
prevalence of hypertensive disorder of pregnancy and preeclampsia in Ethiopia were 6.82%
Competing interests: The authors have declared
that no competing interests exist. (95% CI (5.90, 7.74)) and 4.74% (95% CI (3.99, 5.49)) respectively. Maternal age �35
years (Adjusted Odds Ratio (AOR): 2.91 (95% CI: 1.60, 5.26)), twin pregnancy (AOR: 3.04
Abbreviations: ANC, Antenatal care; BMI, Body
mass index; CI, Confidence interval; DM, Diabetes (95% CI: 1.89, 4.87)), previous history of preeclampsia (AOR: 5.36 (95% CI: 3.37, 8.53)),
mellitus; HDP, Hypertensive disorders of family history of hypertension (AOR: 4.01 (95% CI: 2.65, 6.07)), family history of diabetes

PLOS ONE | https://doi.org/10.1371/journal.pone.0239048 September 16, 2020 1 / 21

PLOS ONE Prevalence and determinants of hypertensive disorders of pregnancy in Ethiopia

pregnancy; HTN, Hypertension; JBI-MAStARI, mellitus (AOR: 3.07 (95% CI: 1.66, 7.70)), body mass index �25 (AOR: 3.92 (95% CI: 1.82,
Joanna Briggs Institute Meta-Analysis of Statistics 8.42)), alcohol consumption (AOR: 1.77 (95% CI: 1.11, 2.83)), urinary tract infection (AOR:
Assessment and Review Instrument; NOS,
Newcastle-Ottawa Scale; OR, Odds ratio; SNNPR,
4.57 (95% CI: 3.47, 6.02)), lack of nutritional counseling during antenatal period (AOR: 4.87
South Nations and Nationalities Peoples’ region; U. (95% CI: 3.36, 7.06)), lack of fruits (AOR: 3.49 (95% CI: 2.29, 5.30)), and vegetables con-
S.A, United states of America; UTI, Urinary tract sumption (AOR: 2.94 (95% CI: 2.01, 4.31)) were the risk factors of hypertensive disorder of
infection.
pregnancy in Ethiopia.

Conclusions
The pooled prevalence of hypertensive disorder of pregnancy is relatively higher compared
with the previous reports. Maternal age �35 years, twin pregnancy, previous history of pre-
eclampsia, family history of hypertension, family history of diabetes mellitus, body mass
index �25, alcohol consumption, urinary tract infection, lack of fruits and vegetables during
pregnancy were risk factors of hypertensive disorder of pregnancy. The governments and
stakeholders should work to strengthen the antenatal care practice to include the possible
risk factors of hypertensive disorders of pregnancy.

1. Introduction
Hypertensive disorders of pregnancy (HDP) include; preeclampsia, gestational hypertension,
chronic hypertension, and chronic hypertension with superimposed preeclampsia [1]. HDP
affects 5 to 10% of pregnant women worldwide and, resulted poor maternal and prenatal out-
come [1, 2]. It is the second common cause of maternal death worldwide. HDP accounted
about 76, 000 maternal and 500, 000 prenatal deaths globally per year [3]. According to World
Health Organization (WHO) report in 2019, 295 000 maternal deaths was recorded globally
due to pregnancy and child birth related causes in 2017. The risk of maternal death is 40 times
higher in the least developed countries compared with European counties. Sub-Saharan Afri-
can and Southern Asian countries accounted about 66% and 20% of the global maternal death,
respectively [4].
Ethiopia is one of the highest estimated number of maternal deaths observed in the world
that accounts about 4.8% (14, 000) of the global share in 2017 [4]. Based on the Ethiopian
demographic health survey (EDHS) report in 2016, pregnancy related maternal deaths were
412 from 100, 000 live births [5]. In Ethiopia, nationwide cohort studies were not conducted
that indicate the incidence and risk factors of HDP. However, different public health studies
involving varied study design have been conducted on HDP and reported inconsistent results
on the prevalence 1.2% [6] to 19.1% [7] and risk factors of HDP [8, 9].
Researchers identified different risk factors for HDP [9, 10]. Factors like; advanced mater-
nal age, twin pregnancy, being primigravida, previous history of preeclampsia, family history
of hypertension (HTN), family history of diabetes mellitus (DM) [11], being overweight or
obesity or body mass index (BMI) �25 [9, 11], urinary tract infection (UTI) [12], alcohol con-
sumption [13], lack of fruits and vegetables [14] during pregnancy increase the risk of HDP. In
Ethiopia, only one systematic review and meta-analysis was published by Berhe and his col-
leges and reported 6.07% of HDP prevalence [15] which is lower than the prevalence of HDP
in Africa which was 10% [16]. The previous review was including 17 (13 cross-sectional and 4
case-control) studies for the estimation of prevalence of HDP in Ethiopia. There is no pub-
lished systematic review and Meta-analysis study that shows the risk factors of HDP in

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PLOS ONE Prevalence and determinants of hypertensive disorders of pregnancy in Ethiopia

Ethiopia. Therefore, the current systematic review and meta-analysis was planned to assess the
risk factors of HDP in Ethiopia. In addition, this review was planned to estimate the prevalence
of HDP in Ethiopia by including more articles published since the previous review up-to
March, 2020.

2. Methods and materials

2.1. Study design and search strategy
A systematic review and Meta-analysis of published and unpublished studies were conducted
to assess the prevalence and risk factors of HDP in Ethiopia. We searched the following data-
bases: Scopus, PubMed, Hinari, Google Scholar and African Journals Online (AJOL). The
search was done by using the following Medical Subject Headings (MeSH) search terms; "Prev-
alence", "Risk Factors", "Hypertension", "Pregnancy", "Pregnancy induced hypertension", "Pre-
Eclampsia" AND "Ethiopia" through using string term "AND" and "OR". A combination of
MeSH terms and free terms were used for the searching strategy to conduct this systematic
review and meta-analysis (S5 File). All published and unpublished studies up-to March, 2020
in Ethiopia were retrieved to be assessed for eligibility of inclusion in this review. Preferred
Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was utilized
to conduct this review [17].

2.2. Eligibility criteria

Inclusion and exclusion criteria;
1. Studies with cross-sectional, case-control and cohort designs were included.
2. Articles that report prevalence or risk factors of HDP in Ethiopia were included.
3. Published and unpublished articles written in English were included
4. Studies reporting HDP as an outcome variable were included.
5. Studies conducted in the community or in the health institution levels were included.
6. Conference papers, editorial notes and systematic reviews and meta-analyses were excluded
from the study.

2.3. Study selection and screening

All citations identified by our search strategy were exported to EndNote -X9- and duplicate
articles were removed. And then the titles and abstracts of the identified articles were screened
by two independent reviewers, and eligible studies were included for further review. The full
texts of selected articles were retrieved and read thoroughly to ascertain the suitability prior to
data extraction. In case of disagreement between the two reviewers, discussion has been held
to reach consensus and the third reviewer was consulted. The search process was presented in
PRISMA flow chart that clearly shows the studies that were included and excluded with sound
reasons of exclusion (Fig 1) [17].

2.4. Definition of outcome interest

The primary outcome of this study was the prevalence of HDP. HDP includes; preeclampsia,
gestational hypertension, chronic hypertension, chronic hypertension with superimposed pre-
eclampsia and eclampsia.

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PLOS ONE Prevalence and determinants of hypertensive disorders of pregnancy in Ethiopia

Fig 1. Flow diagram shows the included studies for the systematic review and meta-analysis on the prevalence and determinants of
hypertensive disorders of pregnancy in Ethiopia.
https://doi.org/10.1371/journal.pone.0239048.g001

• Hypertension: Systolic blood pressure �140mmHg and/or diastolic �90mmHg that is mea-
sured at least two times within four hours interval.
• Proteinuria: urinary protein excretion of �300mg /24-h urine sample or �1+ on qualitative
dipstick examination or a total protein: creatinine ratio �30 mg/ mmol (or �0.3 when both
are measured in mg/dL).
• Gestational hypertension: hypertension diagnosed after 20 weeks of gestation.
• Preeclampsia: gestational hypertension plus proteinuria.

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PLOS ONE Prevalence and determinants of hypertensive disorders of pregnancy in Ethiopia

• Chronic hypertension: hypertension occurs before pregnancy or diagnosed before 20 weeks

of gestation for the first time.
• Chronic hypertension with superimposed preeclampsia: Occurrence of proteinuria in
women with chronic hypertension before 20 weeks of gestation.
• Eclampsia: Seizures in women with hypertension that cannot be attributed to other causes
[18].
The secondary outcomes of the current review were risk factors of HDP in Ethiopia (such
as age, gravidity, previous history of preeclampsia, family history of hypertension and DM,
BMI, nutritional counseling, alcohol drinking, UTI, eating of fruits and vegetables).

2.5. Quality assessment

For case-control and cohort studies, we used Newcastle-Ottawa Scale (NOS) to assess the qual-
ity of the included studies while for cross sectional studies the modified version of NOS was
used to assess the quality of the studies for inclusion [19]. The NOS included 3 categorical cri-
teria with a maximum score of 9 points. The quality of each study was rated using the following
scoring algorithms: �7 points was considered as “Good quality”, 3 to 6 points was considered
as “Fair quality”, and �3 point was considered as “Poor quality” (S2 File). Accordingly, in
order to improve the validity of this systematic review result, we only included primary studies
with fair to good quality [19].

2.6. Data extraction process

The data extraction was done using a tool developed by the 2014 Joanna Briggs Institute
Reviewers’ Manual data extraction form [20]. The abstract and full-text were reviewed by the
two independent reviewers. Data extraction includes: author’s name, publication year, study
period, study design (cross-sectional, case–control and cohort), sample size, study area
(region), age, gravidity, twin pregnancy, previous history of hypertensive disorders of preg-
nancy, family history of hypertension, family history of DM, obtaining nutritional counseling
during antenatal period, BMI, consumption of alcohol, UTI, eating of fruits and vegetables
and the prevalence of HDP were extracted from each article.

2.7. Result synthesis and statistical analysis

The data were entered into Microsoft Excel and the meta-analysis was conducted using Stata
14 software. Forest plots were used to show the prevalence and risk factors of HDP in Ethiopia
at 95% CI. Subgroup analysis was done by the region (Amhara, Oromia, SNNPR, Addis
Ababa, Tigray and Somali) and year of study (1991 to 2010, 2011 to 2014 and 2016 to 2020).
Risk factors like; advanced maternal age, twin pregnancy, primigravidity, previous history of
preeclampsia, family history of hypertension, family history of DM, BMI �25, alcohol con-
sumption, UTI, eating of fruits and vegetables were assessed for their association with HDP at
95% CI.

2.8. Heterogeneity and publication bias

Statistical heterogeneity was estimated by using Cochrane Q, I2 statistic and P-value. If I2 sta-
tistic value < 25%, 25–50%, and �50% was used to declare the heterogeneity test as low,
medium and high heterogeneity. In this review, random effect model was used for analysis. To
cope with the reasons of heterogeneity subgroup analysis and sensitivity test were performed

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PLOS ONE Prevalence and determinants of hypertensive disorders of pregnancy in Ethiopia

(S4 File) [21]. In addition, publication bias was assessed by using funnel plot asymmetry test
and Newcastle-Ottawa quality assessment Scale.

3. Results
3.1. Characteristics of the included studies
A total of 2270 articles were retrieved through electronic search by using different search
terms of which 1245 article were eligible for title and abstract assessment after removal of 1025
duplicate records. Out of 1245 articles screened for eligibility 1152 records were excluded by
their title and abstract assessment. A total of 93 articles were undergo full- text assessment for
eligibility, 59 studies were excluded due to different reasons (51 articles didn’t full fill the inclu-
sion criteria, 4 articles were done on different population, 2 articles were repeated publications
and 2 were review articles).
In this review a total of 34 studies were included. Twenty of them were cross-sectional, thir-
teen studies were case-control and one study was cohort. Published and unpublished studies
done in Ethiopia up- to March, 2020 were included. Most regions of Ethiopia were represented
in this systematic review and meta- analysis. Eleven studies were conducted in Amhara region,
eight studies from Addis Ababa city, five studies from Oromia region, four studies were from
Tigray region, four studies were from South Nations and Nationalities Peoples’ region
(SNNPR), one study from Somali region and one was a nation based study. In the included
studies the smallest sample size was 129 [22] and the maximum was 174, 561 [6]. Overall, this
systematic review and meta- analysis included a total of 320,942 pregnant women in Ethiopia
(Table 1).

3.2. Prevalence of HDP in Ethiopia

A wider difference in the prevalence of HDP was observed in the studies included in this sys-
tematic review and meta-analysis. A lower prevalence (1.2%) of HDP was reported in the
nation based study [6] and the higher prevalence (19.1%) of HDP was observed in the study
conducted in Somali region [7] The overall pooled prevalence of HDP in Ethiopia was 6.82%
(95% CI: (5.90%, 7.74%)) and summarized in Fig 2. Twenty two articles are included for the
estimation of the pooled prevalence of HDP. Out of twenty two articles twenty articles were
further utilized for the assessment of pooled prevalence of preeclampsia 4.74% (3.99%, 5.49%)
at 95% CI.

3.3. Subgroup analysis of HDP prevalence in Ethiopia

The subgroup analysis of HDP prevalence by region showed the highest pooled prevalence
9.88% (5.12, 14.64)) at 95% CI in Amhara region followed by 9.29% (1.01, 17.56) at 95% CI
SNNPR region. The lowest prevalence 4.02% (1.95, 6.08) at 95% CI of HDP was observed in
Tigray region. The subgroup analysis of HDP by the year of study had shown the highest
pooled prevalence 7.82 (6.68, 8.96) at 95% CI in the studies conducted from 2016 to 2020. This
indicates that the current trend of HDP has increased compared with the studies conducted
from 2006 to 2015 (Table 2).

3.4. Risk factors of hypertensive disorders of pregnancy in Ethiopia

In this systematic review and meta- analysis different risk factors like; age, gravidity, previous
history of preeclampsia, twin pregnancy, family history of hypertension, family history of DM,
BMI, alcohol consumption, urinary tract infection, obtaining nutritional counseling during

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PLOS ONE Prevalence and determinants of hypertensive disorders of pregnancy in Ethiopia

Table 1. Summary of research articles included in the systematic review and meta-analysis of HDP in Ethiopia (N = 34).
No Authors Publication Year Study Site Study Design Sample Size Prevalence of HDP (% SE Quality
(Region) CI) assessment
1 Hinkosa et al., 2020 [9] 2020 Oromia Case Control 597 3.57 [2.08, 5.06] 0.759 7 points
2 Walle & Azagew, 2019 [23] 2019 Amhara Cross 422 16.8 [13.23, 20.37] 1.820 7 points
-Sectional
3 Belay and Wudad, 2019 [22] 2019 Oromia Cross- 129 12.4 [6.71, 18.09] 2.902 7 points
Sectional
4 Gudeta and Regassa, 2019 [24] 2019 SNNPR Cross- 422 7.9 [5.33, 10.47] 1.313 5 points
Sectional
5 Legesse et al., 2019 [25] 2019 Tigray Cross- 8, 502 5.08 [4.61, 5.55] 0.238 4 points
Sectional
6 Mekonnen et al., 2018 [7] 2018 Somali Cross- 408 19.1 [15.29, 22.91] 1.946 6 points
Sectional
7 Gudeta et al., 2018 [26] 2018 Oromia Cross- 356 10.3 [7.14, 13.46] 1.611 5 points
Sectional
8 Kahsay et al., 2018 [27] 2018 Tigray Cross- 45, 329 2.98 [2.94, 3.26] 0.081 4 points
Sectional
9 Wodajo and Reddy, 2016 [28] 2016 Amhara Cross- 320 8.8 [5.70, 11.90] 1.584 7 points
Sectional
10 Wagnew et al., 2016 [29] 2016 Addis Ababa Cross- 42,963 4.2 [4.01, 4.39] 0.097 6 points
Sectional
11 Shegaze et al., 2016 [30] 2016 SNNPR Cross- 422 18.25 [14.57, 21.94] 1.880 7 points
Sectional
12 Terefe et al., 2015 [31] 2015 Amhara Cross- 8, 626 3.9 [3.49, 4.31] 0.208 5 points
Sectional
13 Tessema et al., 2015 [32] 2015 Amhara Cross- 490 8.4 [5.94, 10.86] 1.253 5 points
Sectional
14 Vata et al.,2015 [33] 2015 SNNPR Cross- 7,702 2.23 [1.90, 2.56] 0.168 5 points
Sectional
15 Seyom et al., 2015 [34] 2015 Oromia Cross- 5, 415 2.4 [1.99, 2.81] 0.208 6 points
Sectional
16 Selamawit and Sisay, 2015 [35] 2015 Addis Ababa Cross- 3,488 7.2 [6.34, 8.06] 0.438 4 points
Sectional
17 Mariamawit and Shiferaw, 2014 2014 Addis Ababa Cross- 3,351 7.8 [6.89, 8.71] 0.463 4 points
[36] Sectional
18 Wolde et al., 2011 [37] 2011 Oromia Cross- 1, 863 8.48 [7.22, 9.75] 0.645 5 points
Sectional
19 Gaym et al., 2011 [6] 2011 Nation Based Cross 174, 561 1.2 [1.15, 1.25] 0.026 4 points
-Sectional
20 Teklu and Gaym, 2006 [38] 2006 Addis Ababa Cohort 3, 424 5.3 [4.55, 6.05] 0.383 4 points
21 Mekbebe and Ketsela, 1991 [39] 1991 Addis Ababa Cross- 6, 766 5.14 [4.61, 5.67] 0.268 5 points
Sectional
22 Hailu and Kebede, 1991 [40] 1991 Amhara Cross- 567 12.2 [9.51, 14.89] 1.374 6 points
Sectional
23 Mekie et al., 2020 [41] 2020 Amhara Case Control 330 --- --- 7 points
24 Fantahun and Berhane, 2019 [42] 2019 Amhara Case Control 291 --- --- 5 points
25 Girum et al., 2018 [43] 2018 Addis Ababa Case Control 243 --- --- 7 points
26 Kahsay et al., 2018 [44] 2018 Tigray Case Control 330 --- --- 6 points
27 Grum et al., 2017 [13] 2017 Addis Ababa Case Control 291 --- --- 7 points
28 Temesgen, 2017 [45] 2017 Amhara Case Control 470 --- --- 5 points
29 Mohammed et al., 2017 [46] 2017 Addis Ababa Case Control 261 --- --- 7 points
30 Aklilu et al., 2016 [47] 2016 Amhara Case Control 831 --- --- 4 points
31 Ayele et al., 2016 [8] 2016 SNNPR Case Control 466 --- --- 5 points
(Continued )

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PLOS ONE Prevalence and determinants of hypertensive disorders of pregnancy in Ethiopia

Table 1. (Continued)

No Authors Publication Year Study Site Study Design Sample Size Prevalence of HDP (% SE Quality
(Region) CI) assessment
32 Tesfay et al., 2016 [48] 2016 Tigray Case Control 400 --- --- 5 points
33 Endeshaw et al., 2016 [49] 2016 Amhara Case Control 453 --- --- 7 points
34 Endeshaw et al., 2015 [14] 2015 Amhara Case Control 453 --- --- 7 points
https://doi.org/10.1371/journal.pone.0239048.t001

antenatal care (ANC) period, fruits and vegetables consumption were evaluated for their asso-
ciation with hypertensive disorders of pregnancy.
3.4.1. Association between maternal age and HDP. In this sub-categorical analysis, thir-
teen studies were included for the assessment of age as a risk factor for HDP [9, 13, 22–24, 30,
32, 42, 44–46, 48, 50]. Seven studies had shown statistical significant association between
increased maternal age with HDP [9, 22, 23, 30, 32, 44, 49]. Whereas, two studies [13, 45] had
shown lower risk of HDP as maternal age increases whereas four studies [24, 42, 46, 48]
reported non-significant difference between younger and older mothers. The pooled meta-
regression analysis showed that there is statistical significant association in the occurrence of
HDP in the maternal age �35 years compared with the maternal age <35 years with the odds
of 2.91 (95% CI: 1.60, 5.26) (Fig 3).
3.4.2. Association between gravidity and HDP. In this sub-categorical analysis, twelve
studies were included for the assessment gravidity as a risk factor for HDP [7–9, 13, 28, 42, 43,
45–49]. Five of the included studies had shown statistical significant association with primigra-
vida and HDP [9, 28, 42, 43, 47]. Whereas, four studies [8, 13, 45, 49] showed lower risk of
HDP among primigravida women and three studies [7, 46, 48] showed non-significant differ-
ence. The pooled meta-regression analysis showed that there is no statistical significant differ-
ence in the occurrence of hypertensive disorders of pregnancy in the primigravida and
multigravida women, OR = 1.27 (95% CI: 0.78, 2.41) (Fig 3).
3.4.3. Association between twin pregnancy and HDP. In this sub-categorical analysis,
eleven studies were included for the assessment of twin pregnancy as a risk factor for HDP [9,
13, 22, 23, 28, 30, 41, 44, 46, 47, 49]. Eight of the included studies had shown statistical signifi-
cant association among twin pregnancy and HDP [9, 13, 22, 23, 41, 44, 47, 49]. Although, two
studies [30, 46] showed a lower risk of HDP among twin pregnancy, another one study [28]
showed non-significant difference between the groups. The pooled meta-regression analysis
showed that there is a statistical significant association between the occurrence of HDP and
twin pregnancy, the odds being 3.04 (95% CI: 1.89, 4.87) times higher than that of singleton
pregnancy (Fig 4).
3.4.4. Association between Previous history of preeclampsia and HDP. In this sub-cate-
gorical analysis, fourteen studies were included for the assessment of previous history of pre-
eclampsia as a risk factor for HDP [7–9, 13, 23, 28, 30, 32, 42, 43, 45–48]. Thirteen of the
included studies had shown a statistical significant association between previous history of pre-
eclampsia and HDP [7–9, 13, 23, 28, 32, 42, 43, 45–48]. However, one study showed a lower
risk of HDP among previous history of preeclampsia or HDP [30]. The pooled meta-regres-
sion analysis showed that there is a statistical significant association in the occurrence of HDP
and previous history of preeclampsia with the odds of 5.36 (95% CI: 3.37, 8.53) (Fig 4).
3.4.5. Association between family history of hypertension and HDP. In this sub-cate-
gorical analysis, fifteen studies were included for the assessment of family history of hyperten-
sion (HTN) as a risk factor for HDP [7, 9, 13, 23, 26, 28, 30, 32, 41, 42, 44–47, 49]. Thirteen of
the included studies had shown statistical significant association of family history of HTN with

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PLOS ONE Prevalence and determinants of hypertensive disorders of pregnancy in Ethiopia

Fig 2. Forest plot of the pooled prevalence of HDP in Ethiopia.

https://doi.org/10.1371/journal.pone.0239048.g002

HDP [7, 9, 13, 23, 26, 30, 32, 41, 44–47, 49]. Whereas, two studies [28, 42] showed lower risk
and non-significant association with the women having family history of HTN and HDP. The
pooled meta-regression analysis had shown statistical significant association between HDP
and family history of hypertension with the odds of 4.01 (95% CI: 2.65, 6.07) compared to the
women with no family history of hypertension (Fig 5).

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PLOS ONE Prevalence and determinants of hypertensive disorders of pregnancy in Ethiopia

Table 2. Subgroup analysis of HDP by region and year of study in Ethiopia.

Subgroup No of studies Pooled prevalence (95% CI) Heterogeneity test (I2) P-value
Amhara 5 9.88 (5.12, 14.64) 96.1% <0.001
SNNPR 3 9.29 (1.01, 17.56) 97.8% <0.001
Oromia 5 6.91 (3.51, 10.31) 96.4% <0.001
Addis Ababa 5 6.00 (4.65, 7.35) 96.7% <0.001
Tigray 2 4.02 (1.95, 6.08) 98.6% <0.001
Somali 1 19.10 (15.29, 22.91) -- --
Nation based 1 1.20 (1.15, 1.25) -- --
Total pooled 22 6.82 (5.90, 7.74) 99.2% <0.001
2016–2020 11 7.82 (6.68, 8.96) 97.3% <0.001
2006–2015 8 5.09 (3.62, 6.57) 99.1% <0.001
1990–2005 3 6.81 (4.89, 8.73) 92.1% <0.001
Total pooled 22 6.82 (5.90, 7.74) 99.2% <0.001
https://doi.org/10.1371/journal.pone.0239048.t002

3.4.6. Association between family history of DM and HDP. In this sub-categorical anal-
ysis, eleven studies were included for the assessment of family history of diabetes mellitus as a
risk factor for HDP [9, 22, 28, 30, 32, 42, 44–47, 49]. Seven of the included studies showed a
statistically significant association of family history of diabetes mellitus with HDP [9, 22, 28,
32, 44, 47, 49]. While, one study [42] showed lower risk of HDP among pregnant women hav-
ing family history of diabetes mellitus and three studies did not show significant association
with HDP [30, 45, 46]. The pooled meta-regression analysis showed that there is a statistical
significant association between the occurrence of HDP and women having family history of
DM, with the odds of 3.07 (95% CI: 1.66, 5.70) (Fig 5).
3.4.7. Association of BMI, nutritional counseling, UTI alcohol consumption, fruits and
vegetables ingestion with HDP. In this sub-category analysis obtaining nutritional counsel-
ing during antenatal period, consumption of fruits and vegetables reduce the risk of HDP.
Lack of nutritional counseling during ANC period, lack of fruits and vegetables consumption
during pregnancy increase the risk of HDP with the odds of 4.87 (95% CI: 3.36, 7.06), 3.49
(95% CI: 2.29, 5.30) and 2.94 (95%: 2.01, 4.31) time, respectively. Similarly, BMI of �25kg/m2,
alcohol consumption and presence of UTI during pregnancy increased the risk of HDP with
the odds of 3.92 (95% CI: 1.82, 8.42), 1.77 (95% CI: 1.11, 2.83) and 4.57 (95% CI: 3.47, 6.02)
times, respectively compared with the women whose BMI< 25, and women having no history
of alcohol consumption and UTI during pregnancy (Figs 6 and 7).

3.5. Risk of publication bias

The results of this systematic review and meta-analysis were heterogeneous. To understand
the cause of heterogeneity publication bias was assessed. The funnel plot figure shows the pres-
ence of possible publication bias (S3 File). This bias might be due to missing of unpublished
articles in the country. The other causes might be due to the inclusion of articles with different
methodology and different outcome of interest for the assessment of risk factors of HDP. Sub-
group analysis and sensitivity test were done to further explore the causes of heterogeneity (S4
and S6 Files).

4. Discussion
This review was conducted to determine the pooled prevalence and risk factors of hypertensive
disorders of pregnancy in Ethiopia. In this meta- analysis the pooled prevalence of all forms of

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PLOS ONE Prevalence and determinants of hypertensive disorders of pregnancy in Ethiopia

Fig 3. Forest plot of odds ratio for the association of maternal age and gravidity with HDP in Ethiopia.
https://doi.org/10.1371/journal.pone.0239048.g003

HDP and preeclampsia were 6.82% (95% CI: (5.90%, 7.74%)) and 4.74% (95% CI (3.99, 5.49))
respectively. This is slightly higher to the previous meta- analysis report done by Berhe and his
colleagues which was 6.07% (95% CI: 4.83%, 7.31%) [15]. This result found in the range of the
global prevalence of HDP which is 5.2–8.2% (51). However, in this review the pooled preva-
lence of HDP was relatively lower than the meta-analysis done in Africa [16]. This discrepancy
might be due to the number of included studies and study setting. Additionally, in this review
there are retrospective cross-sectional studies that might under report the prevalence of HDP

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PLOS ONE Prevalence and determinants of hypertensive disorders of pregnancy in Ethiopia

Fig 4. Forest plot of odds ratio for the association of twin pregnancy and previous history of preeclampsia and HDP in Ethiopia.
https://doi.org/10.1371/journal.pone.0239048.g004

due to poor secondary data storage system [27]. In this meta-analysis the pooled prevalence of
preeclampsia was 4.74% (95% CI: 3.99%, 5.49%) that is found in the range of the global report
and slightly lower than the meta- analysis finding in African continent level [16, 51]. In the
subgroup analysis, higher prevalence of HDP was observed in Amhara region and articles pub-
lished from 2016–2020 with the prevalence of 9.88% (5.12, 14.64)) and 7.82 (6.68, 8.96), respec-
tively (p-value <0.001) (S6 File). This difference might be due to different methodology and
different outcome of interest for the assessment of risk factors of HDP in Ethiopia.
In this review, different risk factors were assessed with their association to HDP in Ethiopia.
Age is an important predictor for HDP and assessed for its association with HDP by classifying

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PLOS ONE Prevalence and determinants of hypertensive disorders of pregnancy in Ethiopia

Fig 5. Forest plot of odds ratio for the association of family history of DM and HDP in Ethiopia.
https://doi.org/10.1371/journal.pone.0239048.g005

maternal age �35 and maternal age <35 years. Maternal age of �35 years is almost three times
more likely to develop HDP compared with the maternal age <35 years and the association
were statistically significant. Similar findings were reported in the studies conducted in Kenya,
Asian, China, Latin American and Caribbean women among older maternal age group with
HDP compared with maternal age <35 years [11, 52–54].
The frequency of gravidity as a risk factor for HDP was assessed in this systematic review
and meta-analysis. The odds of developing HDP in primigravida were 1.27 times compared
with multigravida pregnant women. There was not statistical significant difference in the
occurrence of HDP between primigravida and multigravida pregnant women in Ethiopia,

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PLOS ONE Prevalence and determinants of hypertensive disorders of pregnancy in Ethiopia

Fig 6. Forest plot of odds ratio for the association of BMI, nutritional counseling, fruits and vegetables consumption with HDP in
Ethiopia.
https://doi.org/10.1371/journal.pone.0239048.g006

although studies conducted in Kenya, China and Latin America had shown than women in
primigravida were 2.1, 1.5 and 2.38 times more likely of developing HDP compared to multi-
gravida pregnant women, respectively [11, 53, 54]. This difference might be attributed to the
heterogeneity of the articles included in this review in respect to a particular variable. In this
regard, without considering one article published by Ayele et al. (2016) in the analysis the odds
of primigravidity to be associated with HDP 1.5 times compared to multigravidity and was sta-
tistically significant [8].
In this meta-analysis, twin pregnancy increased the risk of developing HDP three times
more compared to singleton pregnancy and the association was statistically significant. This is
similar with the studies conducted in China multiple pregnancy where they have shown a
3.68-fold higher risk of HDP compared with singleton pregnancy [55]. Similar report was
observed in other multicenter trials were the odds of developing preeclampsia were 2.62 times
higher compared with singleton pregnancy [56]. Multiple pregnancy causes an increased pla-
cental mass or placental hypoxia that possibly leads to the secretion of placental circulating
antiangiogenic factors like;- soluble fms-like tyrosine kinase 1(sFlt1) and soluble endoglin

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PLOS ONE Prevalence and determinants of hypertensive disorders of pregnancy in Ethiopia

Fig 7. Forest plot of odds ratio for the association of alcohol consumption and UTI with HDP in Ethiopia.
https://doi.org/10.1371/journal.pone.0239048.g007

(sEng) which antagonize the placental growth factors and vascular endothelial growth factors
results in hypertension, protein and maternal syndromes [57].
Previous history of preeclampsia is an important risk factor for HDP. In this meta-analysis,
women having previous history of preeclampsia were shown to develop HDP and the likeli-
hood of its occurrence could be increased by five times as compared with HDP in those
women having no previous history of preeclampsia and the association was statistically signifi-
cant. Supporting evidence of our current finding was reported in the study conducted in
China [11]. Similarly, family history of HTN could also increase the risk of developing HDP by
four- fold compared with women having no family history of HTN. Likewise, the women hav-
ing family history of DM had an increased risk of developing HDP by three-fold compared to
women having no family history of DM. Thus, family history of HTN and family history of
DM have shown statistical significant association with HDP. This report is consistent with the
studies conducted in Swedish medical center, China and US hospitals [55, 58, 59].
Obesity is one of an important predictor for HDP or preeclampsia. In the current meta-
analysis, women having BMI �25 had 3.9 times more risk of developing HDP compared with
the women having BMI< 25 and the association was statistically significant. Supporting evi-
dence has been found in the systematic review and meta- analysis conducted by Wang and his
colleagues [60]. The exact mechanism how obesity and overweight are associated with HDP or
preeclampsia is not well elucidated but obesity and overweight associated with hyperinsulin-
ism, insulin resistance and maternal systemic inflammation. This is one of the proposed

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PLOS ONE Prevalence and determinants of hypertensive disorders of pregnancy in Ethiopia

mechanisms of endothelial dysfunction, hypertension, proteinuria and multi-organ damage

that occur in HDP and preeclampsia [61].
In this review, women obtained nutritional counseling during antenatal period, women
consuming fruits and vegetables had lower risk of developing HDP compared with their
counter- parts and the association is statistically significant. Similar report was observed in the
prospective cohort study done by Timmermans and his colleagues [62]. Experimental studies
in animal model proved that higher fiber and lower fat diet improve fetal development and
growth through improving the antioxidant defense mechanisms that is one of the proposed
pathways in the pathogenesis of HDP or preeclampsia [63]. Similar report also observed in the
studies conducted in U.S.A on pregnant women in which taking higher dietary fiber was
shown lower risk of preeclampsia [64].
Drinking of alcohol during the second and third trimesters of pregnancy increases the risk
of preterm birth and results in different adverse consequences on the fetal development [65].
In the current review, alcohol consumption during pregnancy had shown the odds of develop-
ing HDP to be 1.77 times more compared with the women did not drink alcohol (p<0.05).
The same evidence has been reported in China and Japan [55, 66]. Similarly, UTI increases the
risk of developing HDP by 4.55 times more compared with those women who did not have
history of UTI and the association was statistically significant. Similar results were reported by
Easter et al. (2016) and Yan et al. (2018) [12, 67].

5. Strength and limitation

Strength
This systematic review and meta-analysis showed the national pooled image on the risk factors
of hypertensive disorders of pregnancy in Ethiopia. In addition, it produced an updated data
on the prevalence of hypertensive disorders of pregnancy in Ethiopia via including more arti-
cles from the previously published reviews.

Limitation
The search strategy may miss unpublished articles; publication bias likely high. In addition,
high statistical heterogeneity was observed in this review because the inclusion of articles with
different methodology and different outcome of interest for the assessment of risk factors of
HDP. The included studies lack consistency to include more articles for a particular variable of
risk factor that leads to small study effect. These together reduce the quality of the generated
evidence.

6. Conclusion
The pooled prevalence of hypertensive disorders of pregnancy was found to relatively higher
than what was reported previously in Ethiopia. In the subgroup analysis, the highest preva-
lence was observed in Amhara region and in the studies conducted between 2016 to 2020.
Maternal age �35 years, twin pregnancy, previous history of preeclampsia, family history of
hypertension, family history of diabetes mellitus, body mass index �25, alcohol consumption
and urinary tract infection during pregnancy were significantly increased the risk of develop-
ing hypertensive disorders of pregnancy. Conversely, pregnant women obtaining nutritional
counseling during antenatal period, fruit and vegetable consumption during pregnancy signif-
icantly reduce the risk of developing hypertensive disorders of pregnancy. During patient diag-
nosis and management clinicians will conduct detail patient evaluation to identify the risk
factors of hypertensive disorders of pregnancy and to develop better treatment protocol. The

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PLOS ONE Prevalence and determinants of hypertensive disorders of pregnancy in Ethiopia

governments and stakeholders should work to broaden and strengthen the antenatal care prac-
tice by involving all possible risk factors of hypertensive disorders of pregnancy in the ANC
follow up guidelines. Additionally, large-scale prospective cohort studies should be needed to
identify risk factors of hypertensive disorders of pregnancy in Ethiopia.

Supporting information
S1 Checklist. PRISMA check list of the review.
(DOC)
S1 File. Table of data extraction document.
(XLSX)
S2 File. Table of quality assessment.
(XLSX)
S3 File. Table of funnel plot.
(DOCX)
S4 File. Table of sensitivity test.
(DOCX)
S5 File. Search strategy.
(DOCX)
S6 File. Fig of subgroup analysis by region and year of study.
(DOCX)

Author Contributions
Conceptualization: Endalamaw Tesfa.
Data curation: Endalamaw Tesfa, Endalkachew Nibret.
Formal analysis: Endalamaw Tesfa, Solomon Tebeje Gizaw, Netsanet Fentahun.
Investigation: Zewdie Mekonnen, Sefealem Assefa.
Methodology: Endalamaw Tesfa.
Software: Endalamaw Tesfa, Netsanet Fentahun.
Supervision: Solomon Tebeje Gizaw, Yohannes Zenebe, Mulatu Melese, Abaineh Munshea.
Validation: Yohannes Zenebe, Zewdie Mekonnen, Sefealem Assefa, Mulatu Melese, Abaineh
Munshea.
Writing – original draft: Endalamaw Tesfa, Endalkachew Nibret, Solomon Tebeje Gizaw,
Yohannes Zenebe, Zewdie Mekonnen, Sefealem Assefa, Mulatu Melese, Netsanet Fentahun,
Abaineh Munshea.
Writing – review & editing: Endalamaw Tesfa, Endalkachew Nibret, Solomon Tebeje Gizaw,
Yohannes Zenebe, Zewdie Mekonnen, Sefealem Assefa, Mulatu Melese, Netsanet Fentahun,
Abaineh Munshea.

References
1. Hutcheon JA, Lisonkova S, Joseph KS. Epidemiology of pre-eclampsia and the other hypertensive dis-
orders of pregnancy. Best practice & research Clinical obstetrics & gynaecology. 2011; 25(4):391–403.

PLOS ONE | https://doi.org/10.1371/journal.pone.0239048 September 16, 2020 17 / 21

PLOS ONE Prevalence and determinants of hypertensive disorders of pregnancy in Ethiopia

2. Sánchez-Aranguren LC, Prada CE, Riaño-Medina CE, Lopez M. Endothelial dysfunction and pre-
eclampsia: role of oxidative stress. Frontiers in physiology. 2014; 5:1–11. https://doi.org/10.3389/fphys.
2014.00001 PMID: 24478714
3. Salam RA, Das JK, Ali A, Bhaumik S, Lassi ZS. Diagnosis and management of preeclampsia in commu-
nity settings in low and middle-income countries. J Family Med Prim Care. 2015; 4(4):501–6. https://doi.
org/10.4103/2249-4863.174265 PMID: 26985406
4. WHO U, UNFPA, World Bank Group and the United Nations Population Division. Trends in Maternal
Mortality 2000 to 2017. 2019.
5. CSA. demographic and health survey 2016: key indicators report. Report. 2016; 363:249–51.
6. Gaym A, Bailey P, Pearson L, Admasu K, Gebrehiwot Y, Ethiopian National Em ONCAT. Disease bur-
den due to pre-eclampsia/eclampsia and the Ethiopian health system’s response. International journal
of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and
Obstetrics. 2011; 115(1):112–6.
7. Mekonen L, Shiferaw Z, Wubshet Ea, Haile S. Pregnancy Induced Hypertension and Associated Fac-
tors among Pregnant Women in Karamara Hospital, Jijiga, Eastern Ethiopia, 2015. Journal of Preg-
nancy and Child Health. 2018; 5(3).
8. Ayele G, Lemma S, Agedew E. Factors Associated with Hypertension during Pregnancy in Derashie
Woreda South Ethiopia, Case Control. Quality in Primary Care. 2016; 24(5):207–13.
9. Hinkosa L, Tamene A, Gebeyehu N. Risk factors associated with hypertensive disorders in pregnancy
in Nekemte referral hospital, from July 2015 to June 2017, Ethiopia: case-control study. BMC Preg-
nancy Childbirth. 2020; 20(16):1–9.
10. Galaviz-Hernandez C, Sosa-Macias M, Teran E, Garcia-Ortiz JE, Lazalde-Ramos BP. Paternal Deter-
minants in Preeclampsia. Front Physiol. 2018; 9:1870. https://doi.org/10.3389/fphys.2018.01870 PMID:
30666213
11. Ye C, Ruan Y, Zou L, Li G, Li C, Chen Y, et al. The 2011 Survey on Hypertensive Disorders of Preg-
nancy (HDP) in China: Prevalence, Risk Factors, Complications, Pregnancy and Perinatal Outcomes.
PloS one. 2011; 9(6):1–9.
12. Yan L, Jin Y, Hang H, Yan B. The association between urinary tract infection during pregnancy and pre-
eclampsia: A meta-analysis. Medicine (Baltimore). 2018; 97(36):e12192.
13. Grum T, Seifu A, Abay M, Angesom T, Tsegay L. Determinants of pre-eclampsia/Eclampsia among
women attending delivery Services in Selected Public Hospitals of Addis Ababa, Ethiopia: a case con-
trol study. BMC Pregnancy Childbirth. 2017; 17(1):307. https://doi.org/10.1186/s12884-017-1507-1
PMID: 28915802
14. Endeshaw M, Abebe F, Bedimo M, Asart A. Diet and Pre-eclampsia: A Prospective Multicentre Case-
Control Study in Ethiopia. Midwifery. 2015; 31(6):617–24. https://doi.org/10.1016/j.midw.2015.03.003
PMID: 25862389
15. Berhe AK, Kassa GM, Fekadu GA, Muche AA. Prevalence of hypertensive disorders of pregnancy in
Ethiopia: a systemic review and meta-analysis. BMC Pregnancy Childbirth. 2018; 18(1):34. https://doi.
org/10.1186/s12884-018-1667-7 PMID: 29347927
16. Noubiap JJ, Bigna JJ, Nyaga UF, Jingi AM, Kaze AD, Nansseu JR, et al. The burden of hypertensive
disorders of pregnancy in Africa: A systematic review and meta-analysis. Journal of clinical hyperten-
sion (Greenwich, Conn). 2019; 21(4):479–88.
17. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-
analyses: the PRISMA statement. PLoS Med. 2009; 6(7):e1000097. https://doi.org/10.1371/journal.
pmed.1000097 PMID: 19621072
18. Chaiworapongsa T, Chaemsaithong P, Yeo L, Romero R. Pre-eclampsia part 1: current understanding
of its pathophysiology. Nature reviews Nephrology. 2014; 10(8):466–80. https://doi.org/10.1038/
nrneph.2014.102 PMID: 25003615
19. Hartling L, Milne A, Hamm MP, Vandermeer B, Ansari M, Tsertsvadze A, et al. Testing the Newcastle
Ottawa Scale showed low reliability between individual reviewers. Journal of clinical epidemiology.
2013; 66(9):982–93. https://doi.org/10.1016/j.jclinepi.2013.03.003 PMID: 23683848
20. Institute JB. Joanna Briggs Institute Reviewers’ Manual: 2014 edition / Supplement. Joanna Briggs
Institute. 2014.
21. Higgins J, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ (Clin-
ical research ed). 2003; 327:557–60.
22. Belay AS, Wudad T. Prevalence and associated factors of pre-eclampsia among pregnant women
attending anti-natal care at Mettu Karl referal hospital, Ethiopia: cross-sectional study. Clinical hyperten-
sion. 2019; 25:14. https://doi.org/10.1186/s40885-019-0120-1 PMID: 31304042

PLOS ONE | https://doi.org/10.1371/journal.pone.0239048 September 16, 2020 18 / 21

PLOS ONE Prevalence and determinants of hypertensive disorders of pregnancy in Ethiopia

23. Walle TA, Azagew AW. Hypertensive disorder of pregnancy prevalence and associated factors among
pregnant women attending ante natal care at Gondar town health Institutions, North West Ethiopia
2017. Pregnancy hypertension. 2019; 16:79–84. https://doi.org/10.1016/j.preghy.2019.03.007 PMID:
31056163
24. Gudeta TA, Regassa TM. Pregnancy Induced Hypertension and Associated Factors among Women
Attending Delivery Service at Mizan-Tepi University Teaching Hospital, Tepi General Hospital and Geb-
retsadik Shawo Hospital, Southwest, Ethiopia. Ethiopian journal of health sciences. 2019; 29(1):831–
40. https://doi.org/10.4314/ejhs.v29i1.4 PMID: 30700950
25. Legesse AY, Yibrah. B, Mohammednur SA, Teka Hale a, Goba G. Prevalence and Determinants of
Maternal and Perinatal outcome of Preeclampsia ata a teritiary Hospital in Ethiopia. Ethiopian Journal
of Reproductive Health. 2019; 11(4):1–8.
26. Gudeta TA. Pregnancy Induced Hypertension and Associated Factors among Pregnant Women
Receiving Antenatal Care Service at Jimma Town Public Health Facilities, South West Ethiopia. Journal
of Gynecology and Womens Health. 2018; 10(4).
27. Kahsay HB, Gashe FE, Ayele WM. Patterns of Hypertensive Disorders of Pregnancy in Selected Hospi-
tals of Tigray, Ethiopia. Journal of Advances in Medicine and Medical Research. 2018; 27(12):1–14.
28. Wodajo S, Reddy S. Hypertensive Disorders of Pregnancy and Associated Factors among Admitted
Pregnant cases in Dessie Town Referral Hospital, Northeast Ethiopia, 2015. Med Res Chron. 2016; 3
(3):297–306.
29. Wagnew M, Dessalegn M, Worku A, Nyagero J. Trends of preeclampsia/eclampsia and maternal and
neonatal outcomes among women delivering in addis ababa selected government hospitals, Ethiopia: a
retrospective cross-sectional study. The Pan African medical journal. 2016; 25(Suppl 2):12. https://doi.
org/10.11604/pamj.supp.2016.25.2.9716 PMID: 28439336
30. Shegaze M, Markos Y, Estifaons W, Taye I. Magnitude and Associated Factors of Preeclampsia
Among Pregnant Women who Attend Antenatal Care Service in Public Health Institutions in Arba Minch
Town, Southern Ethiopia, 2016. Gynecology & Obstetrics. 2016; 6(12).
31. Terefe W, Getachew Y, Hiruye A, Derbew M, Haile Mariam D, Mammo D, et al. Patterns of hypertensive
disorders of pregnancy and associated factors in Debre Berhan Referral Hospital, North Shoa, Amhara
Region. Ethiop Med J. 2015; 2015:57–65.
32. Tessema GA, Tekeste A, Ayele TA. Preeclampsia and associated factors among pregnant women
attending antenatal care in Dessie referral hospital, Northeast Ethiopia: a hospital-based study. BMC
Pregnancy Childbirth. 2015; 15(1):73.
33. Vata PK, Chauhan NM, Nallathambi A, Hussein F. Assessment of prevalence of preeclampsia from
Dilla region of Ethiopia. BMC research notes. 2015; 8(1):816.
34. Seyom E, Abera M, Tesfaye M, Fentahun N. Maternal and fetal outcome of pregnancy related hyperten-
sion in Mettu Karl Referral Hospital, Ethiopia. J Ovarian Res. 2015; 8(1):10.
35. Wayima SD, Teklu S. Maternal and Perinatal outcomes of Pregnancy complicated by Preeclampsia
/Eclampsia at Zewditu Memorial Hospital. Unpublished 2015.
36. Asfaw M, Negash S. Severe Preeclampsia: Effect Of Timing Of Termination Of Pregnancy On Maternal
And Perinatal Outcome. Unpublished. 2014.
37. Wolde Z, Segni H, Woldie M. Hypertensive Disorders of Pregnancy in Jimma University Speciallized
Hospital. Ethiop J Health Sci. 2011; 21(3):147–54. PMID: 22434994
38. Teklu S, Gaym A. Prevalence and clinical correlates of the hypertensive disorders of pregnancy at Tikur
Anbessa Hospital, Addis Ababa, Ethiopia. Ethiop Med J. 2006; 44(1):17–26. PMID: 17447359
39. Mekbeb T, Ketsela K. Pre-eclampsia/eclampsia at Yekatit 12 Hospital, Addis Ababa, Ethiopia (1987–
1989). East Afr Med J. 1991; 68(11):893–9. PMID: 1800083
40. Hailu A, Kebede D. Determinants of Preeclampsia and Gestational Hypertension. EthiopJHealth Dev.
1991; 5(1):24–34.
41. Mekie M, Mekonnen W, Assegid M. Cohabitation duration, obstetric, behavioral and nutritional factors
predict preeclampsia among nulliparous women in West Amhara Zones of Ethiopia: Age matched case
control study. PloS one. 2020; 15(1):e0228127. https://doi.org/10.1371/journal.pone.0228127 PMID:
31986179
42. Fantahunegn T, Berhane K. Determinants of Preeclampsia among women attending Delivery Services
in Debre Berhan Referral Hospital, Debere Berhan, Ethiopia:(A case control studey). unpublished.
2019.
43. Grum T, Hintsa S, Hagos G. Dietary factors associated with preeclampsia or eclampsia among women
in delivery care services in Addis Ababa, Ethiopia: a case control study. BMC research notes. 2018; 11
(1):683. https://doi.org/10.1186/s13104-018-3793-8 PMID: 30285827

PLOS ONE | https://doi.org/10.1371/journal.pone.0239048 September 16, 2020 19 / 21

PLOS ONE Prevalence and determinants of hypertensive disorders of pregnancy in Ethiopia

44. Kahsay HB, Gashe FE, Ayele WM. Risk factors for hypertensive disorders of pregnancy among moth-
ers in Tigray region, Ethiopia: matched case-control study. BMC Pregnancy Childbirth. 2018; 18(1):482.
https://doi.org/10.1186/s12884-018-2106-5 PMID: 30522444
45. Temesgen MA. Factors Associated with Hypertensive Disorder of Pregnancy in Kombolcha. Clinics in
Mother and Child Health. 2017; 14(4).
46. Mohammed E, Agero G, Ali E. Preeclampsia risk factors among pregnant women attending in four Pub-
lic Health Facilities of Addis Ababa City. Ethiopian Journal of Reproductive Health (EJRH). 2017; 9
(1):1–16.
47. Aklilu A, Abeje G, Azage M, Asmer S. Does anemia risk for pre-eclampsia? A multicenter, Case control
study in Amhara region, Ethiopia. unpublished. 2019.
48. Tesfay Y, Berhe S, Aregay A. Risk factors of Pregnancy Related Hypertension among Women Attend-
ing Maternal Health Care Service in Selected Public Hospitals of Tigray, Ethiopia. International Journal
of DEVELOPMENT RESEARCH. 2016; 6(8):8904–11.
49. Endeshaw M, Abebe F, Bedimo M, Asrat A, Gebeyehu A, Keno A. Family history of hypertension
increases risk of preeclampsia in pregnant women: a case-control study. Universa Medicina. 2016; 35
(3).
50. Endeshaw M, Abebe F, Worku S, Menber L, Assress M, Assefa M. Obesity in young age is a risk factor
for preeclampsia: a facility based case-control study, northwest Ethiopia. BMC Pregnancy Childbirth.
2016; 16:237. https://doi.org/10.1186/s12884-016-1029-2 PMID: 27543276
51. Umesawa M, Kobashi G. Epidemiology of hypertensive disorders in pregnancy: prevalence, risk fac-
tors, predictors and prognosis. Hypertens Res. 2017; 40(3):213–20. https://doi.org/10.1038/hr.2016.
126 PMID: 27682655
52. Conde-Agudelo A, Belizán JM. Risk factors for pre-eclampsia in a large cohort of Latin American and
Caribbean women. BJOG: an international journal of obstetrics and gynaecology. 2000; 107(1):75–83.
53. Conde-Agudelo A, Belizh JM. Risk factors for pre-eclampsia in a large cohort of Latin American and
Caribbean women. BJOG: an international journal of obstetrics and gynaecology. 2000; 107(1):75–83.
54. Logan GG, Njoroge PK, Nyabola LO, Mweu MM. Determinants of preeclampsia and eclampsia among
women delivering in county hospitals in Nairobi, Kenya. F1000Research. 2020; 9.
55. Ye C, Ruan Y, Zou L, Li G, Li C, Chen Y, et al. The 2011 survey on hypertensive disorders of pregnancy
(HDP) in China: prevalence, risk factors, complications, pregnancy and perinatal outcomes. PloS one.
2014; 9(6):e100180. https://doi.org/10.1371/journal.pone.0100180 PMID: 24937406
56. Sibai BM, Hauth J, Caritis S, Lindheimer MD, MacPherson C, Klebanoff M, et al. Hypertensive disorders
in twin versus singleton gestations. National Institute of Child Health and Human Development Network
of Maternal-Fetal Medicine Units. Am J Obstet Gynecol. 2000; 182(4):938–42. https://doi.org/10.1016/
s0002-9378(00)70350-4 PMID: 10764477
57. Bdolah Y, Lam C, Rajakumar A, Shivalingappa V, Mutter W, Sachs BP, et al. Twin pregnancy and the
risk of preeclampsia: bigger placenta or relative ischemia? Am J Obstet Gynecol. 2008; 198(4):428 e1–
6.
58. Qiu C, Williams MA, Leisenring WM, Sorensen TK, Frederick IO, Dempsey JC, et al. Family history of
hypertension and type 2 diabetes in relation to preeclampsia risk. Hypertension. 2003; 41(3):408–13.
https://doi.org/10.1161/01.HYP.0000056996.25503.F5 PMID: 12623936
59. Zhang J, Troendle JF, Levine RJ. Risks of hypertensive disorders in the second pregnancy. Paediatric
and Perinatal Epidemiology. 2001; 15:226–31. https://doi.org/10.1046/j.1365-3016.2001.00347.x
PMID: 11489149
60. Wang Z, Wang P, Liu H, He X, Zhang J, Yan H, et al. Maternal adiposity as an independent risk factor
for pre-eclampsia: a meta-analysis of prospective cohort studies. Obes Rev. 2013; 14(6):508–21.
https://doi.org/10.1111/obr.12025 PMID: 23530552
61. Lopez-Jaramillo P, Barajas J, Rueda-Quijano SM, Lopez-Lopez C, Felix C. Obesity and Preeclampsia:
Common Pathophysiological Mechanisms. Front Physiol. 2018; 9:1838. https://doi.org/10.3389/fphys.
2018.01838 PMID: 30618843
62. Timmermans S, Steegers-Theunissen RP, Vujkovic M, Bakker R, den Breeijen H, Raat H, et al. Major
dietary patterns and blood pressure patterns during pregnancy: the Generation R Study. Am J Obstet
Gynecol. 2011; 205(4):337 e1–12.
63. Lin Y, Han XF, Fang ZF, Che LQ, Wu D, Wu XQ, et al. The beneficial effect of fiber supplementation in
high- or low-fat diets on fetal development and antioxidant defense capacity in the rat. Eur J Nutr. 2012;
51(1):19–27. https://doi.org/10.1007/s00394-011-0185-4 PMID: 21424688
64. Qiu C, Coughlin KB, Frederick IO, Sorensen TK, Williams MA. Dietary fiber intake in early pregnancy
and risk of subsequent preeclampsia. Am J Hypertens. 2008; 21(8):903–9. https://doi.org/10.1038/ajh.
2008.209 PMID: 18636070

PLOS ONE | https://doi.org/10.1371/journal.pone.0239048 September 16, 2020 20 / 21

PLOS ONE Prevalence and determinants of hypertensive disorders of pregnancy in Ethiopia

65. Sun SV, Manuck TA. Alcohol in pregnancy: not recommended at any gestational age. BJOG: an inter-
national journal of obstetrics and gynaecology. 2019; 126(12):1455.
66. Iwama N, Metoki H, Nishigori H, Mizuno S, Takahashi F, Tanaka K, et al. Association between alcohol
consumption during pregnancy and hypertensive disorders of pregnancy in Japan: the Japan Environ-
ment and Children’s Study. Hypertens Res. 2019; 42(1):85–94. https://doi.org/10.1038/s41440-018-
0124-3 PMID: 30401907
67. Easter SR, Cantonwine DE, Zera CA, Lim KH, Parry SI, McElrath TF. Urinary tract infection during preg-
nancy, angiogenic factor profiles, and risk of preeclampsia. Am J Obstet Gynecol. 2016; 214(3):387
e1–7.

PLOS ONE | https://doi.org/10.1371/journal.pone.0239048 September 16, 2020 21 / 21