Our study explores the patient perspective of knowledge and counseling on preeclampsia/eclampsia in an urban LMIC setting. Although 74% of women recognized having a complication during their pregnancy, one-third of women reported receiving no counseling from a provider regarding their condition. The biggest gap in counseling appears to be counseling on causes of the condition, with more than two-thirds of participants reporting no counseling on causes. Even when women reported being counseled, a large proportion reported understanding less than half of the information provided. Seventy-three percent of participants reported not knowing what to do to prevent or improve their condition in future pregnancies. Out of 22 possible points on the knowledge assessment, the average knowledge score was 13. Our multivariate analysis demonstrated that after controlling for age, parity, and number of antenatal visits, a higher knowledge score was predicted by a higher level of education and an increased amount of direct provider counseling.
Consistent with findings from studies of pregnant women in the United States [16], elsewhere in Ghana [17], and in other LMICs [21,22,23], our study demonstrates a low level of knowledge about preeclampsia/eclampsia. In the United States, 57% of participants reported being counseled on signs and symptoms of preeclampsia/eclampsia [16], compared to only 49% in our Ghanaian population. Importantly, our study population consisted of women with a recent clinical diagnosis of preeclampsia or eclampsia undergoing inpatient management of this complication of pregnancy. It is especially imperative for this particular population to have an adequate level of knowledge and understanding, as the condition has directly impacted their just completed pregnancies, may continue to impact their health in the postpartum period, and is more likely to recur in their future pregnancies. Our study demonstrated a significant relationship between provider counseling on preeclampsia and participants’ knowledge score. This key relationship has not been extensively explored, but agrees with findings from the United States [16, 18]. Education level was also a significant predictor of knowledge score, which is concordant with other studies performed in Ghana [17] and the United States [18]. Other studies demonstrated that higher literacy, multiparity, and a history of preeclampsia in a prior pregnancy were predictive of knowledge scores [18]. These relationships were significant in our bivariate analysis, but were no longer significant in our adjusted final model.
In 2016, updated World Health Organization (WHO) guidelines increased the number of recommended antenatal visits from four to eight, with the goal of better preventing and managing pregnancy-related or concurrent disease and providing health education [25]. Of note, our study demonstrated that the number of attended antenatal visits did not correlate with a higher PEKS score. While direct provider counseling increased a participant’s PEKS score, more frequent antenatal visits did not. This finding suggests that while increasing the frequency of antenatal visits may be important for many reasons, addressing systemic barriers to effective patient-provider communication, education, and counseling is important to see meaningful change in patient knowledge. Regarding ANC attendance and patient knowledge, our study fills a gap in the literature, as there are few studies that examine women’s knowledge of preeclampsia and its correlation to the number of antenatal care visits, especially when examined as a continuous variable in linear regression. Within sub-Saharan Africa, studies show that patient education level is linked to increased knowledge regarding preeclampsia [17] and birth preparedness and complication readiness [26]. One study concluded that ANC attendance increased participant knowledge of obstetric danger signs during pregnancy and childbirth by approximately 2.5 times; however, this study treated ANC attendance as a binary yes/no variable, preventing the examination of a dose-response relationship between the number of ANC visits and knowledge. Additionally, this study demonstrated that most participants were only able to identify vaginal bleeding as an obstetric warning sign, while less than half were able to identify any of the symptoms of preeclampsia as an obstetric warning sign [27]. This finding is consistent with another study that demonstrated less than one-third of participants could identify preeclampsia-specific warning signs [26]. This suggests that current ANC practices may not provide education and counseling that is comprehensive of all dangerous pregnancy-related complications. Addressing this problem requires a multidisciplinary approach and patients may benefit from other WHO-recommended methods of antenatal education such as group antenatal visits and community-based education [25].
Our study fills an important gap in the literature by exploring multiple predictors of patient knowledge, evaluating patient comprehension of provider counseling, and assessing the role of counseling in patient knowledge of preeclampsia in a LMIC setting. Strengths of the study include being embedded within a larger randomized controlled trial, which allowed our study population to consist entirely of women whose recent pregnancies were complicated by preeclampsia or eclampsia. To our knowledge, this is the first study of its kind to assess knowledge in this key targeted population. Participant knowledge of preeclampsia was assessed using a previously validated objective assessment created by the Preeclampsia Foundation [16], modified to the local context after extensive pilot testing. Although performed at a single site, the Korle Bu Teaching Hospital provides care for a wide range of attendants and referral patients from Ghana’s capital city of Accra, as well as surrounding peri-urban and rural areas—supporting generalizability across Ghana. Diversity of participants is reflected in the range of age, language, education level, and number of ANC visits represented by our sample.
Limitations include challenges with language and translation, particularly because there is no direct Twi/Akan translation of “preeclampsia” or “eclampsia.” A pilot period, with feedback from patients and healthcare providers, was utilized to standardize translation of English questions into Twi/Akan. However, nuanced differences in translation may persist, causing bias between participants who completed the survey in English versus in Twi/Akan. Survey questions were verbally presented by a research assistant in the participant’s language of choice to minimize limitations with literacy. Interviews were completed in an inpatient hospital setting, with potential for participants to be hesitant to respond negatively about counseling from their healthcare providers. However, research assistants had no role in patient care and the informed consent process outlined standards of confidentiality and anonymity. Additional limitations include recall bias, where participants with higher health literacy and more knowledge about preeclampsia may recall that more provider counseling was performed. Recall bias was minimized by not disclosing correct responses to the knowledge questions until the entire survey was complete. Additionally, recall bias could have unequally affected patients diagnosed with eclampsia, especially regarding provider counseling during antenatal and pre-delivery care. Lastly, additional studies are required to assess retention of knowledge over time and changes in knowledge after a patient’s outpatient postpartum visit.