Assessment of Cardiovascular Risk Factors During Pregnancy: A Multicenter Study in West Africa, Dakar, Senegal ()
1. Introduction
Non-communicable diseases (NCDs) are the leading cause of mortality worldwide, accounting for nearly 70% of global deaths, according to the World Health Organization [1]. Pregnancy induces significant physiological changes that increase cardiac load and can reveal or worsen pre-existing cardiovascular conditions. Major risk factors include hypertension, gestational diabetes, obesity, family history of cardiovascular diseases, and socio-behavioral aspects like smoking, excessive alcohol consumption, physical inactivity, and urban-related environmental and socio-economic conditions [2] [3].
Evaluating cardiovascular risk factors during pregnancy is crucial for ensuring maternal and fetal health. Hypertension and strokes have significant incidence during pregnancy. Pregnant women are more likely to develop cardiovascular complications, endangering their health and that of their children. Gestational hypertension and preeclampsia are serious complications requiring close monitoring due to their potential impacts on maternal and fetal health. Moreover, pregnant women with gestational diabetes are at increased risk of developing cardiovascular diseases later in life, necessitating early screening and rigorous monitoring strategies [4]-[6].
A multidisciplinary approach involving obstetricians, cardiologists, endocrinologists, and nutritionists can improve maternal and perinatal outcomes. Proactively identifying and managing these risks can prevent severe complications and ensure optimal pregnancy outcomes [7]. Cardiovascular diseases are the most frequent cause of pregnancy-related maternal mortality in the United States, with a 25% increase in hospital admissions for pregnant women with cardiovascular diseases between 2003 and 2012. Large cohort studies report cardiac complication rates of 10% to 15%, with 4% being severe or life-threatening [8] [9]. Cardiovascular contributions to severe maternal morbidity, including cardiac arrest, arrhythmia, and acute myocardial infarction, are increasing, likely due to the demographic changes in the pregnant population, which includes a greater number of women of advanced maternal age and a higher prevalence of cardiometabolic diseases and structural heart diseases [10].
In Senegal, NCDs are a major public health concern, with a mortality rate attributed to them estimated at 34%, and cardiovascular diseases accounting for 10% of deaths [11] [12]. Rapid urbanization in Senegal, along with air pollution, stress, and limited access to balanced nutrition, is associated with socio-environmental changes that can affect pregnant women’s health and exacerbate cardiovascular risks. However, research on the frequency and determinants of cardiovascular diseases during pregnancy in Senegal remains limited [13].
This study aims to evaluate the frequency of cardiovascular risk factors in pregnant women in Senegal, identify socio-behavioral and socio-economic determinants associated with these risk factors, and assess their implications for maternal and fetal health. A better understanding of these aspects through the evaluation of cardiovascular risk factors during pregnancy is not only a medical necessity but also a major preventive approach for the long-term health of pregnant women and their children in Senegal.
2. Methodology
This was a descriptive, analytical cross-sectional study with prospective data collection conducted over three months (April 10 to July 10, 2023). The study included pregnant women aged 15 and older from the public maternity wards of Dalal Jamm, Pikine, and Abass NDAO hospitals in Dakar, Senegal. The recruitment was conducted during prenatal consultation visits. All women who expressed a desire to participate in the study were enrolled. A pre-test was conducted on pregnant women who were not selected to participate in the survey. The shortcomings of the data collection tools were identified and corrected. The data collection was carried out by us in a designated area to ensure confidentiality.
We studied sociodemographic aspects, cardiovascular risk factors, clinical and paraclinical data. We also collected information on previous and current pregnancies, such as a history of eclampsia, preeclampsia, gestational diabetes, number of pregnancies, parity, miscarriages, date of last menstrual period, end of pregnancy, number of prenatal consultations, and the number of fetuses during the current pregnancy. Blood pressure was measured in all pregnant women while seated for at least 15 minutes, with an empty bladder, and without the consumption of coffee or other stimulants. Three (03) measurements were taken at a minimum interval between each. These parameters were collected using a questionnaire and recorded on a data collection sheet.
This study was conducted in collaboration with the concerned hospitals, with approval from the heads of the maternity centers, who signed the confidentiality agreement. An information note was prepared for the patients, summarizing the survey and made available to each pregnant woman. The two-page information letter included the title, objectives, target population, duration, number of patients to include, advantages and disadvantages of the survey, and contact details of the survey coordinators. Written consent was obtained from participants; those who refused to participate were excluded, which did not affect their care and follow-up. All patients were informed about the confidentiality of the study.
Blood pressure was measured in all pregnant women while seated for at least 15 minutes, with an empty bladder, without coffee or other stimulants. Three measurements were taken at minimum intervals.
Data analysis was performed using Epi Info version 7 and R Studio version 4. In the descriptive analysis, qualitative variables were described in counts and percentages, and quantitative variables in means with standard deviation, extremes, and median. In the bivariate analysis, binary logistic regression was used. All variables with a p-value ≤ 0.05 were included in the modeling of poor prognosis using an ascending modeling approach. Adjusted odds ratios (OR) with 95% confidence intervals were calculated for each variable in the final model. The Hosmer-Lemeshow test was used to assess the model’s goodness-of-fit.
3. Results
In our observational study, we enrolled 222 pregnant women admitted for consultations at maternity wards, representing 28% of total admissions in the three gynecological units (Figure 1). The average age was 29.18 years, ranging from 15 to 47 years, with 20% aged 27 - 31 (Figure 2). Most participants (90%) lived in Dakar suburbs, and 74.20% had no financial coverage for medical care.
Figure 1. Distribution of the study population by hospitals.
Among the pregnant women, 84% worked in the informal sector, exposing them to higher risk factors (p = 0.043). Additionally, 18% (41/222) had no formal education (Table 1). Significant differences were observed for those without schooling (p = 0.37) and those with primary education (p = 0.047). Most participants (97%) were married (p = 0.057).
Figure 2. Distribution of the study population by age group (n = 222).
Table 1. Distribution of the study population by education level (n = 222).
Level of education |
Number |
Percentage (%) |
p value |
None |
41 |
18% |
0.037 |
Primary |
53 |
24% |
0.047 |
Secondary |
77 |
35% |
0.072 |
University |
40 |
18% |
0.12 |
Not specified |
11 |
5% |
- |
Consultation data revealed that only 10% had seen a gynecologist outside recommended prenatal visits (p = 0.071). Of the participants, 30.63% were in their first confirmed pregnancy, while 42.79% had at least three pregnancies (Figure 3). In our study, 34% were nulliparous, and 3.15% were grand multiparous (at least five viable births) (Figure 4). Additionally, 21% had experienced at least one miscarriage. Bivariate analysis showed a p-value of 0.047 for women with more than three pregnancies and 0.051 for those with more than three gestations (parity). Among the study population, 51% (113/22) had a pregnancy duration between 31 and 40 weeks of amenorrhea (p = 0.053) (Figure 5). The average number of prenatal visits was 3.5, with about 40% having more than four visits (Figure 6). Compared to those with risk factors, the p-value was 0.059. Additionally, 29.28% had at least four prenatal visits. During our study, 88% had a singleton pregnancy, 4% had twin pregnancies, and 8% were unaware of their status.
The study of cardiovascular risk factors revealed that hypertension (HTN) was present in 17% of pregnant women. Among hypertensive women, 51% developed hypertension before 20 weeks of amenorrhea (p = 0.043). HTN was more frequent in patients beyond 24 weeks of amenorrhea, with none observed before 13 weeks. Women over 30 were more prone to HTN, with a frequency of 17% (p = 0.043). The number of hypertensive patients seemed to increase with pregnancy term, confirmed by Fisher’s test (p = 0.019).
Figure 3. Distribution of the study population by number of pregnancies (n = 222).
Figure 4. Distribution of the study population by parity (n = 222).
Figure 5. Distribution of the study population by pregnancy duration (n = 222).
Figure 6. Distribution of the study population by number of prenatal visits (n = 222).
Other identified risk factors included diabetes (4%), with an average blood glucose of 0.85 g/ml, and 4% with fasting hyperglycemia (p = 0.72). Smoking was noted in 2% (p = 0.57), with no alcohol consumption reported before or during pregnancy. Average daily fruit consumption was 5.45 servings and vegetables 5.81 servings. However, 67.65% of patients consuming a lot of salt had HTN, while almost none consuming very little salt had HTN, showing statistical significance (p < 0.001). Additionally, 25% of those consuming vegetable oils had HTN, whereas none consuming olive oil developed HTN (p = 0.002) (Table 2).
Table 2. Summary of the cardiovascular risk factors during pregnancy.
Risk Factor |
Prevalence (%) |
Associated Factors |
Statistical Significance |
Hypertension |
17% |
More common in women > 30 years old, advanced pregnancy terms |
p = 0.043 |
Diabetes |
4% |
Average blood glucose: 0.85 g/ml higher in older age groups |
p = 0.72 |
Smoking |
2% |
Low prevalence, no significant
alcohol consumption reported |
p = 0.57 |
High salt consumption |
67.65% of hypertension cases |
Strong correlation with
hypertension |
p < 0.001 |
Type of oil consumption |
25% hypertension with vegetable oil; none with olive oil |
Diet impacts prenatal hypertension risks |
p = 0.002 |
4. Discussion
During our study, we encountered various challenges, primarily due to the non-receptivity of the women surveyed. Most refused to answer our questions. This is linked to mystical beliefs, as some pregnant women prefer not to disclose the number of pregnancies and living children. This reluctance may also be due to shyness.
The study parameters included public hospitals in the outskirts of the capital, primarily serving pregnant women from low- and middle-income groups. Thus, the results cannot be extrapolated to pregnant women from higher socio-economic groups due to differences in psychosocial factors and living standards.
This observational study of pregnant women reveals significant trends and risk factors in prenatal consultations at three gynecological units. The 28% incidence rate, representing 222 women over three months, indicates a high demand for prenatal services. This is significantly higher than an American study where 130 pregnant women completed their baseline visit on average over three months, totaling 783 over 18 months [14]. This variation suggests that prenatal consultation frequency depends on the country’s development level.
Sociodemographically, the average age of participants was 29.18 years, with most aged 27 - 31 (20%), indicating a relatively young population. In contrast, Anita Nath in the USA found a younger average age of 23.6 ± 4.47 years with a mean gestational age of 16.7 ± 4.4 weeks, and 88.8% of participants were 28 or younger [14]. Most women resided in Dakar suburbs (90%), highlighting a crucial need for accessible medical services in these areas. The lack of financial coverage for 74.20% of patients is concerning, suggesting significant financial barriers to adequate medical care. Additionally, 84% of women working in the informal sector were most at risk (p = 0.043), highlighting socio-economic vulnerabilities affecting prenatal health. Education plays a crucial role, with 18% of patients having no formal education and significant differences for those with primary education (p = 0.047). In Anita Nath’s study, about 90% of respondents were housewives, and more than one-third had high school education, with 43.9% belonging to the lower-middle class and 50% receiving high social support from their families [14].
Regarding parity, Anita Nath found 46.4% of participants were nulliparous [14], while in our study, 34% of women were nulliparous, and 3.15% were grand multiparous, with 21% having at least one miscarriage. The high number of multiple pregnancies and miscarriages requires increased medical attention. Additionally, consultation rates outside prenatal appointments were low (10%, p = 0.071), indicating a potential lack of awareness or access to care.
Our study revealed a hypertension prevalence of 17%, more frequent in women over 30 (p = 0.043) and with advanced pregnancies (p = 0.019). Anita Nath found a prevalence of 13.9% [14], matching exactly the rate observed by Ganguly and Begum in a hospital-based study in Dhaka, Bangladesh [15]. Hypertension significantly contributes to up to 15% of pregnancy and postpartum complications [16]. Hypertensive disorders in pregnancy include pre-existing hypertension, gestational hypertension, preeclampsia, and eclampsia, with an estimated prevalence of 5% to 10% among women of reproductive age [17] [18]. These disorders are significant contributors to maternal and perinatal morbidity and mortality, accounting for 10% to 15% of maternal deaths in low- and middle-income countries [19] [20]. A multicentric study in four developing countries (India, Nigeria, Pakistan, and Mozambique) revealed that one in ten pregnant women had hypertension [21]. Dietary factors, such as salt and oil consumption, show significant correlations with hypertension, underscoring the importance of diet in managing prenatal risks.
In our study, diabetes prevalence was 4%, with an average blood glucose of 0.85 g/ml. However, according to an American study, 14.9 million women in the United States suffer from diabetes mellitus [22]. The prevalence of diabetes mellitus among women of reproductive age has been reported between 3.1% and 6.8%, with pregestational diabetes observed in 1% to 2% of all pregnancies [23] [24]. Although 90% of diabetes cases encountered during pregnancy are gestational, more than half of these women develop type 2 diabetes mellitus later in life. There are racial and ethnic disparities among women with pregestational diabetes [25], with higher rates found among Black women compared to women of other races [24].
5. Conclusions
Non-communicable diseases are the leading cause of mortality worldwide. The physiological changes induced by pregnancy can reveal or exacerbate pre-existing cardiovascular conditions. Growing urbanization in Senegal is associated with socio-environmental changes that affect pregnant women’s health and increase cardiovascular risks. However, research on the frequency and determinants of cardiovascular diseases during pregnancy in Senegal remains limited.
This study shows a high prevalence of hypertension (17%) among women over 30 and those with advanced pregnancies. Dietary factors, such as salt and vegetable oil consumption, show significant correlations with hypertension, highlighting the importance of diet in managing prenatal risks. The study underscores critical prenatal health needs and socio-economic challenges faced by pregnant women, emphasizing the need for targeted strategies to improve healthcare access and health education.
Evaluating cardiovascular risk factors during pregnancy is crucial for ensuring maternal and fetal health. A better understanding of these aspects is essential for a major preventive approach to improve the long-term health of pregnant women and their children in Senegal. Additionally, a multidisciplinary approach involving obstetricians, cardiologists, endocrinologists, and nutritionists can improve maternal and perinatal outcomes. By proactively identifying and managing these risks, severe complications can be prevented, ensuring optimal pregnancy outcomes.
Ethics Approval and Consent to Participate
This study was approved by the ethics committee of Cheikh Anta Diop University of Dakar. All patients included in the study signed a written informed consent.
Consent for Publication
Not Applicable.
Availability of Data and Materials
The data and materials of this study are available upon request and ready to be shared. For further information, please contact the corresponding author, Aliou Alassane NGAIDE.
Funding
The study did not receive any funding.
Authors and Contributors
Aliou Alassane Ngaïdé and Abdoul Kane designed the study protocol, participated in the data collection and writing of the draft manuscript.
Ngoné Diaba Gaye and Alassane Diouf oversaw the execution of the study, participated in data analysis and critically revised the manuscript for important intellectual content.
Zineb Zinia and Mouhamadou Bamba Ndiaye participated in study design and in data analysis.
Joseph Salvador Mingou participated in statistical analysis and interpretation of results.
Aknowledgements
Sincere thanks to Professor Abdoul Kane for his unwavering support, his foresight, and his exemplary management.