**3. Primary health care implications on maternal care**

Primary health care (PHC) is a whole of society approach to the well-being of persons that targets optimal health standards while warranting standardised quality and unbiased caretaking into consideration the individuals needs in the context of the prevention of illness such as pre-eclampsia and promotion of health, furthermore, interventions of the PHC across the developing countries expected to save approximately 60 millions of lives and possible upsurge the life expectancy by 3.7 years by the year 2030 [14].

The global health community endorsed an obligation to appoint PHC as a keystone to endeavour the sustainable development goals (SDGs) by the year 2030 [15]. However, with the achieved decrease in maternal mortality between 1990 and 2015 by 44 and 49% correspondingly. Hypertensive disorders in pregnancy (HDPs) pre-eclampsia included remain the cause of death accounting for 11 and 16% of maternal deaths and stillbirth amongst gravid women globally, respectively [15]. The aspects of classification, diagnosis and management of HDPs remains a disparity globally, therefore, leading to lack of consensus that hinders the aptitude not only to study the immediate rates of adverse effects of perinatal outcomes for the classified HDPs but also the long-term effects on the maternal and newborn's health that survived the condition [16].

A study to assess the quality of antenatal care (ANC) to detect and treat HDPs pre-eclampsia included in two-tier Nigerian establishments shown that PHC accomplished significantly worse than tertiary institutions in all elements of quality of care in assessment, diagnosis and treatment of HDPs, further substantiated that to provide optimal standard care PHC must seek to regenerate ANC programs through training to reduce disparity in quality of care [17]. A meta-analysis and systematic review of 34 studies in Etopia shown that the prevalence of HDPs and pre-eclampsia in Etopia were 6.82 and 4.74%. Showing that the prevalence of such conditions is relatively higher compared previously therefore further encouraging stakeholders and government to reinforce ANC practice to include identification of risk factors of HDPs at early ANC visits [17].

Approximately 78% of maternal deaths in South Africa at the secondary and tertiary level of care HDP emergencies such as pre-eclampsia emerged from PHC facilities and district hospitals. Moreover, such deaths were due to preventable factors at community health centres accounting for 60% of cases of maternal deaths as a result of the poor assessment, faults in diagnosing, delayed or no referrals to a higher level of care as well as non-adherence to treatment protocols and inadequate monitoring [18]. As a result of such maternal mortalities resulting from preventable factors, South Africa implemented a mobile health initiative such as mom connect to improve foetal-maternal well-being at home by targeted communications to pregnant with all kinds of disorders pre-eclampsia included and breastfeeding women via messages with the provision of information reflecting on their gestational age or postpartum period twice weekly [8].

#### **4. Pre-eclampsia pathophysiology and implications**

Pregnancy results in physiological adaptation in all the body system, however the failure of such adaptation could lead to a number of illnesses within the gravidas, such as pregnancy-induced by hypertension resulting from the failure of the trophoblast to invade the spiral arteries causing vasoconstriction and damage to the endothelial layer such as the impact on gravidas causes impact and compromise placental foetal unit likely to lead to negative perinatal outcomes [4]. Pre-eclampsia has multifaceted pathophysiology, abnormal placentation being the most primary cause [19]. The pathogenesis of pre-eclampsia progresses in 2 stages; being abnormal placentation in the first trimester and maternal syndrome in the second and third trimester characterised by the antiangiogenic factors. A non-conclusive number of theories has been proposed for placental dysfunction; being oxidative stress, abnormal natural killer cells, genetic and environmental factors [20]. The progressive stages are as follows;

Stage 1: Abnormal placentation

In normal placentation implantation, cytothrophoblasts invade the maternal spiral arteries, to form a maternal-foetal crossing point for nutrition and other functions. However, during pre-eclampsia development, there's a failure of the cytothrophoblast to migrate into the spiral arteries. This leads to incomplete spiral artery remodelling causing spiral artery narrowing causing oxidative stress and placenta ischemia [19, 20]. The placental ischemia will result in foetal complications such as intrauterine growth restrictions (IUGR) and intrauterine death (IUD). The oxidative stress due to decreased oxygen tension results in maternal peripheral endothelial cells dysfunction causing systemic inflammatory response leading to second stage namely; maternal syndrome [19–21].

Stage 2: Maternal syndrome

The effects of stage result in decreased blood flow to the maternal organs leading to multi-organs failure in the maternal systems. The biological assessment will then indicate vasospasm, coagulation cascade activation and decreased plasma levels [21]. As a result of the endothelial cell dysfunction, a hepatic system will be affected contributing to haemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome, neurological system impairment (cerebral endothelial damage) causing neurological disorders [19]. Moreover, the endothelial dysfunction results in renal system impairment, i.e. acute kidney failure and proteinuria [22]. Lastly, the endothelial dysfunction promotes microangiopathic haemolytic anaemia and


**Figure 2.** *pre-eclampsia risk factors [21].* hyperpermability linked with low albumin levels causing pulmonary and peripheral oedema [19]. Pre-eclampsia is associated with the number of risk factors as outlined in the table below (**Figure 2**) [21].
