{"paper_id":"95118e4a-9153-4444-bb8e-8e5163b44d6f","body_text":"1 Prevalence, associated factors, and \n2 pharmacotherapy of hypertensive \n3 disorders among parturients in Bono \n4 Region of Ghana: An analytical cross-\n5 sectional study\n6\n7\n8 Authors: Francis Fordjour 1, #a, 2, #b ¶*, Edward Tieru Dassah3 ¶, Jonathan Boakye -Yiadom4&, \n9 Kwadwo Addai-Darko5&, Bernard Okyere5&, Kwame Ohene Buabeng2, #b, 6, #a ¶\n10\n11 Authors’ affiliations: \n12\n13 1 Department of Pharmaceutical Sciences, Faculty of Applied Science, Sunyani Technical \n14 University, Sunyani, Bono Region, Ghana.\n15 2 Department of Pharmacy Practice, Faculty of Pharmacy and Pharmaceutical Sciences, Kwame \n16 Nkrumah University of Science and Technology (KNUST), Kumasi, Ashanti Region, Ghana.\n17 3 Department of Population, Family and Reproductive Health, School of Public Health, Kwame \n18 Nkrumah University of Science and Technology (KNUST), Kumasi, Ashanti Region, Ghana. \n19 4 Department of Epidemiology and Biostatistics, School of Public Health, Kwame Nkrumah \n20 University of Science and Technology (KNUST), Kumasi, Ashanti Region, Ghana. \n21 5 Department of Obstetrics and Gynecology, Sunyani Teaching Hospital, Sunyani, Bono Region, \n22 Ghana.\n23 6 School of Pharmacy, University of Health and Allied Sciences, Ho, Volta Region, Ghana.\n24\n25 * Corresponding author\n26 E-mail: fransfordcudjoe@yahoo.co.uk (FF)\n27 ORCID ID: 0000-0002-7651-162X   \n28 ¶ These authors contributed equally to this work\n29 &These authors also contributed equally \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\n30 Abstract\n31 Background: The burden of hypertensive disorders among parturients in remote locations of \n32 Ghana remains understudied, considering existing data. We investigated the prevalence, associated \n33 factors, and treatment guideline’s adherence for maternal hypertensive disorders among parturients \n34 in a peripheral region.\n35 Method: In an analytical cross-sectional study, data of all parturients with hypertensive disorders \n36 were extracted from labor registers of nine public hospitals in the Bono Region of Ghana from \n37 January to December 2021. Additionally, guidelines for administering magnesium sulfate and \n38 antihypertensives to these patients were examined. Chi-square and multivariable binomial \n39 regression analyses were used to explore associations between independent and dependent \n40 variables. P ≤ 0.05 was considered statistically significant. \n41 Results: Hypertensive pregnancies were 711 out of 16,206 deliveries, with a prevalence of 4.4%. \n42 Non-severe pre-eclampsia (30.5%) and gestational hypertension (28.0%) were the most frequent \n43 disorders. Eclampsia (6.2%) and superimposed pre-eclampsia (1.7%) were less frequent. Maternal \n44 age, 15-25 years (cOR = 2.43; 95% CI = 1.57-3.75; p < 0.001), unemployment (cOR = 2.14; 95% \n45 CI = 1.29-3.53; p = 0.001), primigravida (cOR = 2.88; 95% CI = 1.80-4.62; p < 0.001), and \n46 primiparity (cOR = 2.39; 95% CI = 1.44-3.96; p < 0.001) were significantly associated with pre-\n47 eclampsia/eclampsia. After adjustment for confounders, primiparity remained a borderline \n48 significant predictor (aOR = 1.83; 95% CI= 0.97-3.46; p = 0.05).  Oral nifedipine (30mg) and \n49 intravenous hydralazine were the primary medications for pregnant hypertensives. Magnesium \n50 sulfate was universally administered by the Pritchard procedure, but product concentrations \n51 supplied by pharmacists for intramuscular application varied minimally. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \n\n52 Conclusion: The prevalence of hypertensive disorders among parturients was 4.4%. Young \n53 parturient age, unemployment, primigravida, and primiparity were the predictors. Magnesium \n54 sulfate protocols for managing pre-eclampsia/eclampsia cases followed a standard regimen. \n55 Standardizing the concentration of magnesium sulfate solutions for pre-eclampsia/eclampsia could \n56 optimize intramuscular dosing under the Pritchard regimen, improving treatment consistency.\n57 Introduction\n58 Hypertensive disorders in pregnancy (HDPs) continue to hinder the course of many pregnancies \n59 resulting in abrupt interventions, complications and mortalities with a potential of undermining \n60 target 3.1 of the Sustainable Development Goals (SDG) (1). The spectrum of HDPs, which varies \n61 from chronic, gestational, pre-eclampsia/eclampsia and superimposed pre-eclampsia, impact \n62 women health worldwide and have had significant repercussions for low-income nations (2,3)   \n63 These disorders have become topical recently due to the rise in cases that have been documented \n64 and the unfavorable consequences they have in certain nations (4,5). The incidence of HDPs has \n65 increased by 10.92% globally over the last three decades, having risen from 16.30 million in 1990 \n66 to 18.08 million in 2019 (4).\n67 Given that almost a third of affected women nearly die, particularly in nations with limited \n68 resources, this rising trend is extremely concerning and unnecessarily causes panic among \n69 parturients and medical personnel (6). Hypertensive disorders of pregnancy together with \n70 hemorrhage, sepsis, and unsafe abortions are major contributors to the maternal death ratio in low-\n71 income countries (7,8), surpassing the SDGs' estimate by more than six-fold (1). \n72 According to World Health Organization (WHO) data (9), Ghana still has a high maternal \n73 mortality ratio (263/100,000), and the country's rising HDP burden adds to these deaths (10). \n74 Studies available on the subject almost a decade ago suggest that the incidence of HDPs in Ghana's \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \n\n75 Upper West and Greater Accra regions is less than 10% (11). However, the prevalence was high \n76 when explored in 2019 and 2017 at the Komfo Anokye Teaching Hospital (KATH) in Kumasi, \n77 Ghana, and the Korle-Bu Teaching Hospital (KBTH) in Accra respectively (12,13). In Ghana, it \n78 is reported that over a third of women with HDPs experience ‘near-death’ episodes; the ratio of \n79 these incidents to death is approximately 12:1 (14). Despite the negative impact, it appears that the \n80 majority of research looking for HDPs in Ghana concentrate on tertiary hospitals, with little \n81 information published from lower-tier facilities, particularly those located in the rural and smaller \n82 administrative regions. There is a need to close this information gap because it is argued that the \n83 unavailability of published statistics on HDPs in smaller regions significantly affects regional and \n84 global estimations which may mislead policies (15). \n85 Many maternal deaths, including those caused by HDPs in sub-Saharan Africa, are listed by the \n86 WHO as avoidable, implicating care plans offered to maternal hypertensives in the sub-region (8). \n87 The essential ideas that underpin the management of HDPs worldwide include early antenatal \n88 screening for case identification, antihypertensive therapy, the administration of anticonvulsants, \n89 and timely baby delivery. However, the way these concepts are applied may vary based on the \n90 resources, patient characteristics, and skill set that are available in a given geographical area. \n91 Inconsistencies were found in post-implementation studies involving the administration of \n92 magnesium sulfate (MgSO 4) to women who were eclamptic. Some nations lacked the necessary \n93 skills to safely administer the product, while others had difficulties with product accessibility. \n94 Furthermore, some institutions lacked treatment-guided protocols for MgSO 4 application, which \n95 hindered the safe use of the anticonvulsant in nations that have high rates of HDPs (16,17). Ghana's \n96 standard treatment guideline (STG) incorporates all of the fundamental HDP management \n97 principles; nevertheless, there aren't many post-implementation studies assessing these in \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \n\n98 healthcare institutions. In this study, we reviewed practice guidelines on the use of MgSO 4 and \n99 antihypertensives for HDPs as well as the prevalence and factors associated with these disorders \n100 among parturients in the Bono Region. \n101 Materials and method\n102 Study design and setting\n103 An analytical cross-sectional study design was employed in which obstetric records, particularly \n104 labor registers, and institutional treatment protocols for HDPs were monitored retrospectively for \n105 data in nine public hospitals of the region.  The Sunyani Municipal, Sunyani SDA, Bono Regional, \n106 Berekum Holy Family, Dormaa Presbyterian, Drobo St. Mary’s Catholic, Sampa Government, \n107 Tain District, and the Wenchi Methodist Hospitals were the purposefully chosen research facilities. \n108 These hospitals were selected because they provided important obstetric services in eight of the \n109 region's twelve administrative districts and were the most established and resourced facilities. \n110 Health facilities in four districts were at the time of data collection not included due to their status \n111 as health centers which could not fully manage HDPs. The nine hospitals had a maternal bed \n112 capacity of 384 and conducted about 1800 deliveries annually.\n113 The Bono Region is located on Ghana's middle belt zone, sharing an international boundary to the \n114 west with the Republic of Cote d'Ivoire and to the north and south with Ghana's Savannah and \n115 Ashanti regions, respectively. With a population of roughly 1,208,649, the region occupies an area \n116 of 11,113 km2 (18). Its residents are primarily famers and traders.\n117\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \n\n118 Study population and Sample\n119 All pregnant women who were registered and delivered at the public hospitals in Bono Region of \n120 Ghana between 3 rd January 2021, and 31 st December 2021, were considered. Overall, 16,206 \n121 deliveries were conducted within the period of which 711 women presented with various HDPs. \n122 All 711 parturients diagnosed with HDPs during the study period were included in the study. \n123 Women with incomplete records during the review were excluded.\n124\n125 Data collection\n126 Data of parturients was extracted from the labor registers of the hospitals using a designed \n127 template. Women’s age, level of education, occupation, parity, gestational ages at labor, and the \n128 kind of HDP identified were among the information collected. Additionally, each hospital's \n129 institutional guideline for treating the spectrum of HDPs was reviewed, and with informed consent, \n130 the heads of the various labor wards filled questionnaire on the use of anti-HDP drugs. The \n131 questionnaire was about antihypertensive and anticonvulsant medication availability and their \n132 usage for treating HDPs, particularly pre-eclampsia/eclampsia. It required the names of all \n133 medicines, their dosage forms, pharmaceutical strengths, and how they were administered. \n134 Importantly, requests were made for institutional MgSO4 protocols and administration procedures \n135 including loading and maintenance doses, and their concentrations when given intravenously (IV) \n136 or intramuscularly (IM). Further, unit leaders answered questions on serum concentration \n137 monitoring of MgSO 4, adverse effects and toxicity monitoring in both open and closed-ended \n138 questions.\n139\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \n\n140 Ethical Approval\n141 Permission to obtain data from the institutions in the Bono Region was granted by the Bono \n142 Regional Health Directorate, and ethical approval was sought and obtained from the Committee \n143 on Human Research Publication and Ethics of KNUST (Ref: CHRPE/AP/119/20). Authors had no \n144 access to the identities of individual participants whose data were collected, and informed consent \n145 was obtained from labor ward in-charges/doctors where questionnaires required completion.\n146 Data analysis\n147 The data was analyzed using Stata 17.0 (Stata Corporation, Texas, USA). Categorical variables \n148 were compared using Chi-square (𝜒2) or Fisher’s exact tests, as appropriate. Binomial regression \n149 with a log-link function was used to estimate crude and adjusted odds with 95% confidence \n150 intervals (CIs) for factors associated with hypertensive disorders in pregnancy (HDPs). The dataset \n151 that supports the findings of this study has been attached under the supporting information section \n152 as S1 file_Dataset.xlsx. Missing data was excluded, and results with p-values ≤ 0.05 were \n153 considered statistically significant.\n154\n155 Diagnoses of HDPs according to the standard treatment guideline of \n156 Ghana\n157 According to Ghana's STG, a pregnant woman has a hypertensive disorder when her blood \n158 pressure (BP) is ≥ 140/90 mmHg on two or more occasions, spaced at least five minutes apart, \n159 using an appropriate BP monitoring device (19). The diagnoses of gestational hypertension, \n160 chronic hypertension, pre-eclampsia with or without severe features, superposed pre-eclampsia \n161 and eclampsia may be made based on the timing of the onset of the hypertensive BP relative to the \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \n\n162 gestational age, time to conception, the patient's signs and symptoms, and any biochemical \n163 assessment suggesting an organ dysfunction. Gestational hypertension is new onset, occurring \n164 after mid-gestation without proteinuria or classical signs and symptoms; chronic hypertension is \n165 similarly symptomless, carried into pregnancy or identified in the first 20 weeks of gestation, \n166 unassociated with proteinuria, and persists after labor. A non-severe and severe forms exist in pre-\n167 eclampsia. Usually, it begins during mid-gestation with a fresh onset of hypertension (SBP ≥ \n168 140/DBP ≥ 90 mmHg) and mild proteinuria. It becomes severe if there are neurological signs and \n169 symptoms, massive proteinuria, elevated BP (SBP > 160/DBP ≥ 110 mmHg), or biomarkers \n170 related to target organ injury. Women with chronic hypertension are diagnosed with superimposed \n171 pre-eclampsia if their features align with pre-eclampsia while eclampsia is diagnosed if a pre-\n172 eclamptic woman experiences seizures without other identifiable reasons (19). It is highlighted \n173 that screening for soluble fm-like tyrosine kinase-1 (sFlt-1) and placental growth factors (PlGF) is \n174 also accessible for diagnosing HDPs in advance settings but non-existent in the region at the time \n175 of data collection.\n176\n177 Pharmacotherapy of HDPs per the guidelines of Ghana\n178 Under Ghanaian treatment policy, methyldopa and sustained release/retarded nifedipine are \n179 prescribed for mild hypertensive cases in pregnancy (BP 140/90-159/109 mmHg). The \n180 recommended treatments for severe maternal hypertension are IV hydralazine, and labetalol. To \n181 abort seizures or prevent same, MgSO4 by the Pritchard approach is recommended. This protocol \n182 administers the drug in two phases: an IV loading and IM maintenance doses. During loading, 14g \n183 of the anticonvulsant is administered as 4g IV in a 20% MgSO 4 solution at first, with 2 doses of \n184 5g IM in a 50% solution into each buttock (10g). Subsequently, series of 5g IM doses of a 50% \n185 solution are injected into alternate buttocks every four hours to initiate the maintenance phase. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \n\n186 This begins four hours after the loading dose has been initiated and continuously administered for \n187 24 hours for preventive therapies or 24 hours after the last fit (19).\n188\n189 Results\n190 Level of care of the Health Facilities involved in the study \n191 Primary care level health services were provided by eight of the nine hospitals in rural and semi-\n192 urban communities of the region. The ninth establishment was a regional hospital that provided \n193 specialist services and doubled as the referral center for the Bono Region of Ghana. \n194\n195 Parturients’ sociodemographic and obstetric data \n196 Table 1 presents the sociodemographic data of parturients. The age range was 15-46 years and the \n197 mean age was 30.9789 (±6.80541). Those aged 26-34 years made up the largest proportion \n198 (43.9%). The majority were those who attained basic education (61.7%), working in informal \n199 occupations (68.0%), multigravida (51.9%), and multiparous women (53.0%).\n200\n201\n202\n203\n204\n205\n206\n207\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \n\n208\n209\n210\n211\n212 Table 1. Sociodemographic data of women involved in the study\nVariable Number of women (n=711)\nn(%)\nAge group (years)\n  15-25 151 (21.2)\n  26-34 312 (43.9)\n  35-46 248 (34.9)\nEducational level\n  Basic 439 (61.7)\n  Secondary 124 (17.4)\n  Post-secondary/tertiary 148 (20.8)\nOccupation\n  Unemployed 89(12.5)\n  Informal employment 483(68.0)\n  Formal employment 139(19.5)\nGravida\n  Primigravida 135 (19.0)\n  Multigravida 369 (51.9)\n  Grand multigravida 207 (29.1)\nParity\n  Primiparous 248 (34.9)\n  Multiparous 377 (53.0)\n  Grand multiparous 86 (12.1)\nGestational age at delivery\n  First trimester 8 (1.1)\n  Second trimester 18 (2.5)\n  Third trimester 685 (96.3)\n213\n214\n215 Types of hypertensive disorders diagnosed among parturients\n216 A sum of 16,206 deliveries were conducted in the nine hospitals: 711 were diagnosed with HDPs. \n217 A prevalence of 4.4% was observed. From Fig 1, the commonest HDP among the parturients was \n218 pre-eclampsia. This occurred without severe features in 30.5% of the subjects but in 21.0%, it was \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \n\n219 associated with severe features. Gestational hypertension was found among 28.0%, whereas 6.2% \n220 developed eclampsia.\n221\n222\n223\n224 Fig 1. Patients’ diagnoses\n225\n226 Maternal demographic data compared with diagnoses\n227 Table 2 summarizes the distribution of HDPs across parturients’ demographic variables. Chronic \n228 hypertension was conspicuous among women aged 35-46 years (53.3%), basic education attainers \n229 (60.0%) and multiparous women (62.2%). Gestational hypertension was prevalent among women \n230 aged 26-34 years (45.2%), the least educated (65.8%) and multiparous as well (58.8%). Pre-\n231 eclamptic disorders (non-severe, severe, and superimposed) were seen mostly in middle-aged \n232 women (46.8%) between 26-34 years, those with low literacy (59.0%), multigravida (54.2%) and \n233 multiparous (52.1%). The majority of eclamptics (68.2%) were in the 15-25 age group, the least \n234 educated (70.5%), and primiparous (77.3%) who had delivered for the first time.\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \n\n235    Table 2. A comparison of hypertensive disorders with maternal sociodemographic characteristics \nVariable\nChronic \nhypertension\n(n=90)\nn(%)\nGestational \nhypertension\n(n=199)\nn(%)\nPre-eclampsia\n(n=378)\nn(%)\nEclampsia\n(n=44)\nn(%)\nAge\n  15-25 5 (5.6) 37 (18.6) 79 (20.9) 30 (68.2)\n  26-34 37 (41.1) 90 (45.2) 177 (46.8) 8 (18.2)\n  35-46 48 (53.3) 72 (36.2) 122 (32.3) 6 (13.6)\nEducational level\n  Basic 54 (60.0) 131 (65.8) 223 (59.0) 31 (70.5)\n  Secondary 19 (21.1) 25 (12.6) 70 (18.5) 10 (22.7)\n  Post-secondary/tertiary 17 (18.9) 43 (21.6) 85 (22.5) 3 (6.8)\nOccupation\n  Unemployed 2 (2.2) 21 (10.6) 47 (12.4) 19 (43.2)\n  Employed 88 (97.8) 178 (89.4) 331 (87.6) 25 (56.8)\nGravida\n  Primigravida 5 (5.6) 30 (15.1) 74 (19.6) 26 (59.1)\n  Multigravida 45 (50.0) 105 (52.8) 205 (54.2) 14 (31.8)\n  Grand multigravida 40 (44.4) 64 (32.2) 99 (26.2) 4 (9.1)\nParity\n  Primiparous 16 (17.8) 57 (28.6) 141 (37.3) 34 (77.3)\n  Multiparous 56 (62.2) 117 (58.8) 197 (52.1) 7 (15.9)\n  Grand multiparous 18 (20.0) 25 (12.6) 40 (10.6) 3 (6.8)\nGestational age\n  First trimester 7 (7.8) 1 (0.5) 0 (0.0) 0 (0.0)\n  Second trimester 7 (7.8) 2 (1.0) 7 (1.9) 2 (4.5)\n  Third trimester 76 (84.4) 196 (98.5) 371 (98.1) 42 (95.5)\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \n\n237 Factors associated with hypertensive disorders during pregnancy\n238 The associations between parturients’ characteristics and hypertensive disorders are presented in \n239 Table 3. Age was significantly associated with hypertensive disorders during pregnancy (p<0.001). \n240 Younger women aged 15-25 years (25.8%), were observed more frequently with pre-\n241 eclampsia/eclampsia, whereas older women aged 35-46 years (41.5%), were more common in the \n242 chronic/gestational hypertension group. Maternal employment status also showed a significant \n243 association (p=0.002). A higher proportion of the unemployed (15.6%) were in the pre-\n244 eclampsia/eclampsia category, while those in employment (92.0%) dominated in the \n245 chronic/gestational hypertension group. Gravidity and parity were strongly associated with \n246 hypertensive disorders (p<0.001). Primigravida (23.7%) or primiparous women (41.5%), were \n247 more linked to pre-eclampsia/eclampsia. In contrast, grand multigravida women (36.0%) and \n248 multiparous women (59.9%) were more represented in the chronic/gestational hypertension group. \n249 However, the educational status of a parturient did not significantly impact the type of a \n250 hypertensive disorder (p = 0.411).\n251\n252\n253\n254\n255\n256\n257\n258\n259\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \n\n260\n261 Table 3. Parturients’ factors and their association with hypertensive disorders (n=711) \nVariable Chronic/gestational \nhypertension\nPre-eclampsia/ \neclampsia p-value\nAge <0.001\n  15-25 42 (14.5) 109 (25.8) \n  26-34 127 (43.9) 185 (43.8)\n  35-46 120 (41.5) 128 (30.3)\nEducational level 0.411\n  Basic 185 (64.0) 254 (60.2)\n  Secondary 44 (15.2) 80 (19.0)\n  Post-secondary/tertiary 60 (20.8) 88 (20.9)\nOccupation 0.002\n  Unemployed 23 (8.0) 66 (15.6)\n  Employed 266 (92.0) 356 (84.4)\nGravida <0.001\n  Primigravida 35 (12.1) 100 (23.7)\n  Multigravida 150 (51.9) 219 (51.9)\n  Grand multigravida 104 (36.0) 103 (24.4)\nParity <0.001\n  Primiparous 73 (25.3) 175 (41.5)\n  Multiparous 173 (59.9) 204 (48.3)\n  Grand multiparous 43 (14.9) 43 (10.2)\nTrimester of pregnancy 0.001*\n  First trimester 8 (2.8) 0 (0.0)\n  Second trimester 9 (3.1) 9 (2.1)\n  Third trimester 272 (94.1) 413 (97.9)\n262 Note: * (Fisher’s exact)\n263\n264 Parturients’ odds of developing a hypertensive disorder  \n265 Table 4 examines the odds of a parturient developing pre-eclampsia/eclampsia based on \n266 sociodemographic and obstetric factors. Early maternal age (15-25 years) was 2.43 times more \n267 related to pre-eclampsia/eclampsia (cOR = 2.43; 95% CI: 1.57-3.75 p = < 0.001) compared to \n268 older parturient age (35-46 years). Unemployed parturients were twice likely to have pre-\n269 eclampsia/eclampsia (cOR = 2.14; 95% CI=1.29-3.53; p = 0.001). Primigravidity elevated the odds \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \n\n270 to almost three times that of grand multi-gravida women (cOR =2.88; 95% CI: 1.80-4.62, p < \n271 0.001). Primiparity also doubled the odds (cOR = 2.39, 95% CI: 1.44 -3.96; p = <0.001) and after \n272 adjusting for potential confounders, primiparity remained a significant predictor though with a \n273 marginal significance level (aOR = 1.83; 95% CI: 0.97–3.46, p-value = 0.05). The educational \n274 level of a parturient did not significantly impact the odds of developing pre-eclampsia/eclampsia.\n275\nTable 4. Regression analysis of the association between maternal sociodemographic data with \npre-eclampsia/eclampsia \nVariable Pre-eclampsia\n/Eclampsia cOR 95% CI p-value aOR 95% CI p-value\nAge 0<0.001 0.37\n  15-25 109 (72.2) 2.43 1.57-3.75 1.51 0.84-2.72\n  26-34 185 (59.3) 1.36 0.97-1.91 1.14 0.78-1.67\n  35-46 128 (51.6) 1 1\nEducational level 0.40\n  Basic 254 (57.86) 1\n  Secondary 80 (64.52) 1.32 0.88-2.00\n  Post-\nsecondary/tertiary\n88 (59.46) 1.07 0.73-1.56\nOccupation 0.001\n  Unemployed 66 (74.16) 2.14 1.29-3.53\n  Employed 356 (57.23) 1\nGravida 0<0.001\n  Primigravida 100 (74.07) 2.88 1.80-4.62\n  Multigravida 219 (59.35) 1.47 1.04-2.07\n  Grand multigravida 103 (49.76) 1\nParity 0<0.001 0.05\n  Primiparous 175 (70.56) 2.39 1.44-3.96 1.83 0.97-3.46\n  Multiparous 204 (54.11) 1.17 0.73-1.88 1.09 0.66-1.80\n  Grand multiparous 43 (50.00) 1 1\nTrimester of \npregnancy\n0.38\n  Second trimester 9 (50.00) 1\n  Third trimester 413 (60.29) 0.65 0.25-1.68\naOR, adjusted odds ratio; cOR, crude odds ratio; CI, confidence interval; p, probability\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \n\n16\n277 Availability and use of antihypertensive medications for the \n278 pregnant women at the hospitals\n279 Methyldopa and the sustained-release nifedipine were the common oral antihypertensive \n280 medicines available in all facilities for HDPs. The sustained release oral nifedipine (30mg) was \n281 used by seven hospitals as first choice agent for HDPs, particularly pre-eclampsia. Intravenous \n282 hydralazine (20mg/ml) was available and used in all the hospitals for severe cases of pre-\n283 eclampsia. Four out of nine hospitals had IV labetalol (100mg/20ml) as an alternative (Table 5). \n284\n285 Table 5. Antihypertensive medicines available in the hospitals for managing hypertension \n286 in pregnancy  \nMedicines Number of hospitals that use \nthe agent (n=9)\nUsed as first choice \nagent (n=9)\nOrals\nMethyldopa 250mg 9 2\nNifedipine retard 20mg 5 0\nExtended release nifedipine 30mg 9 7\nOral Hydralazine 25mg 2 0\nOral Labetalol 50mg/100mg 0 0\nParenteral agents\nIV hydralazine (20mg/ml) 9 9\nIV labetalol(100mg/20ml) 4 0\n287 IV, intravenous\n288\n289 Usage of magnesium sulfate as anticonvulsant for pre-\n290 eclampsia/eclampsia\n291 All the nine hospitals had stocks of MgSO4 injectables for managing pre-eclampsia/eclampsia. The \n292 50% solution (10ml ampoule) was available in 8/9 facilities and protocols in the form of posters \n293 for administering same were conspicuous in all labor wards. The Pritchard regimen was the norm \n294 across facilities. Loading doses were unanimously 14g; injected as 4g IV followed by 10g IM. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \n\n17\n295 Maintenance doses were 5g IM, given four hourly apart. The 50% MgSO 4 solution was used for \n296 IM maintenance doses while IV doses were administered with a 20% solution. One hospital had \n297 in addition to the 50% protocol, another protocol that allowed a 20% solution to be used to inject \n298 5g IM doses. Per all protocols examined, MgSO4 prophylactic treatment was completed 24 hours \n299 after initiating the loading and administering a series of 6 IM maintenance doses. When the loading \n300 and maintenance doses are put together, each patient receives 44g of the salt within 24 hours. \n301 Testing renal function of patients at the point of initiating MgSO4 therapy was not always done in \n302 any of the hospitals. All facilities lacked the capacity to monitor serum concentrations of \n303 magnesium ions in women on treatment. Therapy monitoring was solely based on patient \n304 sign/symptoms such as knee jerk responses, respiratory rate and urine output. Seven out of the nine \n305 hospitals had usable calcium gluconate injectables to manage MgSO4 toxicities (Table 6).\n306\n307\n308\n309\n310\n311\n312\n313\n314\n315\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \n\n18\n316\n317 Table 6. Usage of MgSO4 to manage pre-eclampsia/eclampsia by hospitals in Bono Region\nMgSO4 Usage Facility (n=9)\nPresence of MgSO4 injectable at hospital\nYes 9\nType of stocks present at the time\n50% MgSO4 (10ml ampoule) 8\n20% MgSO4 (10ml ampoule) 1\nTreatment protocol pasted at labor ward\nYes 9\nType of treatment regimen\nLoading dose + maintenance doses 9\nComposition of loading dose\n4g IV + 10g IM 9\nConcentration of MgSO4 by IV route\n20% 9\n50% 0\nMaintenance doses\n5g IM 4 hourly 9\nConcentration of MgSO4 by IM route\n50% 8\n20% 1\nInjection site for IM doses\nButtocks 9\nCompletion of treatment regimen \nAfter 6 IM maintenance doses injected 4 hourly 9\nMaximum dose of MgSO4 administered to a patient\n44g 9\nRenal function test results seen before starting MgSO4\nAlways 0\nSometimes 9\nPatient monitoring\nSolely based on patient signs and symptoms 9\nSerum concentrations of Mg2+ 0\nAvailability of calcium gluconate to manage toxicity\nYes 7\nNo 0\nExpired 2\n318 IM, Intramuscular; IV, Intravenous; MgSO4, Magnesium sulfate\n319\n320\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \n\n19\n321 Discussion\n322 This study highlights the prevalence of hypertensive disorders among parturients in the Bono \n323 Region of Ghana and examines how these disorders were managed at service delivery points using \n324 antihypertensive and anticonvulsant medicines. The need for the study arose from the lack of \n325 published data on HDPs in the region, which made it challenging to quantify the burden and \n326 compare same with other smaller regions of Ghana. Additionally, several years after the adoption \n327 of WHO-recommended treatment guidelines by Ghana, there have been limited post-\n328 implementation studies evaluating the administration of MgSO 4 for pre-eclamptic/eclamptic \n329 patients. The study addresses these knowledge gaps.\n330 Our results indicate that the prevalence of HDPs in the Bono Region was 4.4%, a rate less than \n331 those reported in Zambia (6.7%), Ethiopia (6.82%), sub-Saharan Africa (8%), and Nigeria (25.8%)  \n332 (20–23). However, it was higher than Burkina Faso (1.4%) and Ghana's Upper West Region \n333 (3.2%) (11,24). The observed regional variations could be due to differences in study \n334 methodologies, environmental and socioeconomic factors. Unlike studies that collected data from \n335 antenatal clinics (ANCs) attendees, our study focused on data from women in labor, potentially \n336 influencing prevalence estimates. Hospital deliveries in most Ghanaian facilities usually rank \n337 lower than ANC attendance which may contribute to differences in findings (25,26). This may be \n338 due to factors such as transportation challenges, financial constraints, fear of cesarean section, and \n339 some negative perceptions of hospital staff attitudes which could contribute to home deliveries in \n340 rural settings, leading to an underestimation of HDP prevalence in hospitals (25,26). However, in \n341 Burkina Faso and the Upper West Region of Ghana, where the occurrences were lower than our \n342 data, it seems that the effects of attendance and social characteristics were more prominent (11,24).\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \n\n20\n343 Pre-eclampsia was the most prevalent HDP in this study, consistent with findings of Dassah et al. \n344 (2019) in Kumasi, Ghana (13). Among affected women, 30.5% had non-severe pre-eclampsia \n345 while one-fifth had pre-eclampsia with severe features. These rates exceed the prevalence (4.1%) \n346 estimated in a systematic review of sub-Saharan Africa indicating that our findings may reflect \n347 regional differences in healthcare access and resources (22). Previous researchers showed that \n348 HDPs were predicted by maternal age (27,28). Our multivariable regression analysis revealed a \n349 significant association between age and HDP. Younger parturients (15-25 years) were more prone, \n350 particularly to pre-eclampsia/eclampsia. Decreasing maternal age increased the odds, with over \n351 two-thirds of eclamptic cases occurring in this age group (see Table 2). This trend is supported by \n352 previous studies in Ghana and South Africa (29,30). The pathophysiological basis for this \n353 association remains unclear but may involve mothers' aberrant immune responses to paternally \n354 inherited fetal antigens during first pregnancies as hypothesized in earlier literature which could \n355 apply to younger women getting pregnant for the first time (31). Additionally, reduced ANC \n356 attendance among teenage mothers due to social stigma may lead to poor pregnancy monitoring, \n357 anemia, and inadequate preventive care, further increasing their risk (28). Contrarily, our \n358 advanced-aged parturients (≥ 35 years) were more aligned with chronic hypertension which was \n359 consistent with existing literature (20,32,33). This is conceivable, given that obesity, vascular \n360 calcification, stiffness, and loss of distensibility correlate with old age and greatly impact \n361 hypertension (34). \n362 The results of this study relates to previous authors who reported that parity plays a role in pre-\n363 eclampsia/eclampsia (28,35). While our crude odds ratio indicated a significant association \n364 between primigravidity and HDPs (p < 0.001), the adjusted odds showed significance for \n365 primiparity (p = 0.05). Known in literature, multigravidity has been associated with a more \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \n\n21\n366 regulated immune response and adaptation to repeated exposure to paternally inherited antigens as \n367 opposed to primigravid/primiparous women, who are first time encounters, less adapted and \n368 therefore prone to inflammatory response leading to pre-eclampsia (31). Whereas parity was a \n369 significant predictor, educational level did not show an association. Unlike some prior studies, our \n370 findings did not establish a significant relationship between HDPs and illiteracy after adjusting for \n371 other variables (27,28). The lack of variability in educational attainment among study participants \n372 may have limited the statistical power to detect such an association.\n373 Maternal hypertensives were primarily treated with the 30mg extended release nifedipine, 250mg \n374 methyldopa, and IV hydralazine (20 mg/ml). These agents were consistently available across all \n375 the nine hospitals. Among the available oral agents, nifedipine was the most commonly prescribed \n376 first-line treatment in seven out of nine hospitals, mirroring prescribing patterns observed at \n377 Tamale Teaching Hospital in Ghana (36). Its preference over methyldopa may be attributed to its \n378 faster onset of action (30-45 minutes vs. 1-1.5 hours for methyldopa) (37–39). Oral labetalol was \n379 rarely stocked, so its use for treatment was limited, likely due to cost and availability. Nifedipine’s \n380 use was in line with Ghana's treatment policy, but some evidence suggests that nifedipine may \n381 increase the risk of disease progression to pre-eclampsia when used in non-severe maternal \n382 hypertension, prompting WHO to advocate for alternative oral agent such as labetalol in non-\n383 severe hypertensive cases (40). \n384 Some recently revised guidelines and review publications appear to place IV hydralazine as second \n385 line agent for severe pre-eclampsia due to its  perceived unfavorable kinetics and side effects, but \n386 its utilization as first choice agent was evident in this study (41). The widespread usage was also \n387 observation in Nigerian (42). The high utilization of IV hydralazine, despite recent guidelines \n388 favoring IV labetalol may be driven by staff familiarity, affordability, and availability (43).\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \n\n22\n389 All study sites adhered to national and international guidelines recommending MgSO₄ for \n390 managing severe pre-eclampsia/eclampsia  (19,44). All hospitals had access to the product, along \n391 with its administration protocols. The Pritchard regimen was uniformly followed, likely due to its \n392 convenience and independence from infusion pumps, which are often scarce in resource-limited \n393 settings (19). Magnesium sulfate is administered to severe pre-eclamptic women not because they \n394 have Mg2+ deficiency, but rather to raise Mg2+ plasma concentrations to counteract Ca2+--induced \n395 muscle twitches, vasospasms, and glutamate-mediated neuronal excitement in eclamptic and \n396 severely pre-eclamptic women (45–47). Moreover, the goal is to hinder cholinergic transmission \n397 at the neuromuscular junction to stop or avoid convulsive episodes (46,47).\n398 Under Pritchard method, patients receive an initial loading dose of 14g MgSO₄ . This is \n399 implemented as 4g slow IV infusion using a 20% solution, which provides immediate \n400 anticonvulsant activity lasting about 30 minutes. This is followed by a 10g intramuscular (IM) \n401 injection using a 50% solution, extending the anticonvulsant effect for 3-4 hours. To maintain \n402 therapeutic levels, a 5g IM dose is injected into alternating gluteal muscles every 4 hours for up to \n403 24 hours (46,47). Eight hospitals stocked the 50% w/v MgSO₄ in 10 ml ampoules in compliance \n404 with WHO requirements (48). However, one hospital only had 20% w/v MgSO₄, presenting a \n405 significant clinical challenge. A 5g IM dose of 20% MgSO₄ requires 25 ml, exceeding the regular \n406 injection volume of 10 ml for gluteal muscles from a 50% solution (19,49). Some hospital \n407 pharmacists might have underestimated the health implication of substituting a 50% w/v MgSO₄  \n408 solution with a 20% for IM doses. Such an excess volume may cause pain, drug leakage, \n409 inflammation, and abscess formation (50,51). This issue, as highlighted by Babu et al. (2022) may \n410 contribute to poor patient compliance with IM maintenance therapy (52).\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \n\n23\n411 At the sites, severe pre-eclamptic/eclamptics received six IM maintenance doses based on the \n412 MgSO4 protocols evaluated. These amounted to cumulative doses of 44g MgSO 4 for each patient \n413 in 24 hours as opposed to 40g reported in some literature (53). Despite high adherence to the \n414 MgSO₄ guidelines, none of the hospitals had the capacity to monitor serum Mg²⁺ levels, relying \n415 instead on urine output, respiratory rate, and patellar reflexes, a practice that may be insufficient \n416 for preventing toxicity. Given the risk of accumulation in patients with impaired renal function, \n417 dose adjustments based on weight or alternative regimens like the Dhaka regimen or a 12-hour \n418 protocol proposed by Beyuo et al. ( 2022) may be safer options for facilities without laboratory \n419 capacity (54–56).\n420 The study had some drawbacks. For example, part of the data was collected by observing drug \n421 protocols, drug shelves, and medicine trays. In addition, procedural data were gathered from \n422 physicians, labor/maternity unit heads, and pharmacists rather than by watching actual procedures \n423 being performed which might differ. Moreover, inaccurate records might have been captured in \n424 labor registers, which could impact the quality of the data collected. Again, the study did not \n425 include health centers, private clinics, or maternity homes since it was assumed that many HDP \n426 patients would be directed to major hospitals because such smaller facilities were unable to handle \n427 maternal complications or conduct caesarean surgeries when urgent deliveries were required. If \n428 some HDPs were managed without referral, this would have an effect on the statistics that this \n429 study projects. \n430 Conclusions\n431 The prevalence of HDP in the Bono Region of Ghana was 4.4%. Pre-eclampsia was the most \n432 common HDP. Young parturient age, unemployment, primigravida and primiparity were the \n433 predictors of pre-eclampsia/eclampsia. The extended-release oral nifedipine and IV hydralazine \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \n\n24\n434 were the main therapies for HDPs, especially for severe pre-eclamptic patients. Magnesium \n435 sulfate protocols for pre-eclampsia/eclampsia conformed to standard regimen. The supply of \n436 20% MgSO4 solutions for IM maintenance doses was inappropriate due to its larger injection \n437 volumes that may be harmful to patients. Standardizing the concentration of magnesium sulfate \n438 solutions for pre-eclampsia/eclampsia could optimize intramuscular dosing under Pritchard \n439 regimen, improving treatment consistency.\n440 Acknowledgments \n441 We appreciate the Bono Regional Health Directorate and the medical directors or administrators \n442 of all the hospitals for granting us permission to access hospital records for data. We also \n443 appreciate the cooperation of midwives, doctors and pharmacists in the hospitals for providing \n444 some information that was needed for this study.\n445\n446 References\n447 1. WHO. Acceleration towards the sustainable development goal targets for maternal health \n448 and child mortality. 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Davis Company. 2023. \n609 54. PubChem. Bethesda (MD): National mibrary of Medicine (US), national center for \n610 biotechnology information; 2004. PubChem compound summary for CID 24083, \n611 magnesium sulfate. [Cited 2024 Apr 20] [Internet]. Available from: \n612 https://pubchem.ncbi.nlm.nih.gov/compound/Magnesium-Sulfate\n613 55. Begum R, Begum A, Johanson R, Ali MN, Akhter S. A low dose (“Dhaka”) magnesium \n614 sulphate regime for eclampsia. Acta Obs Gynecol Scand. 2001;80(11):998–1002. \n615 doi:10.1034/j.1600-0412.2001.801105.x\n616 56. Beyuo TK, Lawrence ER, Kobernik EK OS. A novel 12-hour versus 24-hour magnesium \n617 sulfate regimen in the management of eclampsia and preeclampsia in Ghana (MOPEP \n618 Study): A randomized controlled trial. Int J Gynaecol Obs. 2022;159(2):495–504. \n619 doi:10.1002/ijgo.14181\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \n\n29\n620\n621 Supporting information\n622 S1 Fig. Patients’ diagnoses\n623 S1 Table. Sociodemographic data of women involved in the study\n624 S2 Table. A comparison of hypertensive disorders with maternal sociodemographic \n625 characteristics\n626 S3 Table. Parturients’ factors and their association with hypertensive disorders (n=711). \n627 Note: * (Fisher’s exact)\n628 S4 Table. Regression analysis of the association between maternal sociodemographic data \n629 with pre-eclampsia/eclampsia. aOR, adjusted odds ratio; cOR, crude odds ratio; CI, confidence \n630 interval; p, probability\n631 S5 Table. Antihypertensive medicines available in the hospitals for managing hypertension \n632 in pregnancy. IV, intravenous\n633 S6 Table. Usage of MgSO4 to manage pre-eclampsia/eclampsia by hospitals in Bono \n634 Region. IM, Intramuscular; IV, Intravenous; MgSO4, Magnesium sulfate\n635\n636\nS1_Fig.docx\n S1_Table.docx\n S2_Table.docx\n S3_Table.docx\n S4_Table.docx\n S5_Table.docx\n637\nS6_Table.docx\n S1 file_Dataset.xlsx\n638 Competing interest\n639 No conflict of interest is declared by authors\n640\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \n\n30\n641 Funding\n642 We received no funding from any source.\n643\n644 Data availability statement\n645 All relevant data are within the manuscript and its supporting information file attached\n646\n647 Authors’ contributions\n648 Conceptualization: Francis Fordjour, Edward Tieru Dassah and Kwame Ohene Buabeng\n649 Data curation: Francis Fordjour, Bernard Okyere, Kwadwo Addai-Darko\n650 Data analysis: Francis Fordjour, Jonathan Boakye-Yiadom and Edward Tieru Dassah\n651 Methodology: Francis Fordjour, Edward Tieru Dassah and Kwame Ohene Buabeng,\n652 Mentorship & supervision: Edward Tieru Dassah and Kwame Ohene Buabeng,\n653 Writing-original draft: Francis Fordjour, Bernard Okyere, Jonathan Boakye-Yiadom and \n654 Edward Tieru Dassah\n655 Writing-review & editing: Kwadwo Addai-Darko, Edward Tieru Dassah, and Kwame \n656 Ohene Buabeng\n657\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 20, 2025. ; https://doi.org/10.1101/2025.05.18.25327871doi: medRxiv preprint","source_license":"CC-BY-4.0","license_restricted":false}