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Public health
Original research
Prevalence of non-communicable diseases and risk factors of pre-eclampsia/eclampsia in four local government areas in Nigeria: a cross-sectional study
  1. Ayoposi Ogboye1,
  2. Jonas Kofi Akpakli1,
  3. Amira Iwuala1,
  4. Imo Etuk1,
  5. Kendra Njoku1,
  6. Stodia Jackson1,
  7. Ugo Okoli2,
  8. Kathleen Hill2,
  9. Victoria Omoera3,
  10. Folashade Oludara4,
  11. Iniobong Ekong4,
  12. Nneka Mobisson1
  1. 1mDoc Healthcare, Lagos, Nigeria
  2. 2Jhpiego Corporation, Abuja, Nigeria
  3. 3Lagos State Government Ministry of Health, Ikeja, Lagos, Nigeria
  4. 4Federal Capital Territory Health & Human Services Secretariat, Abuja, Nigeria
  1. Correspondence to Ayoposi Ogboye; ayoposi.ogboye{at}mymdoc.com

Abstract

Objectives To assess the prevalence of non-communicable diseases (NCDs) and risk factors associated with pre-eclampsia and eclampsia (PE/E) in women of reproductive age (WRA) in Nigeria.

Design A cross-sectional survey was administered to the entire study population. In the point-of-care testing, physical and biochemical measurements were taken in a subset of the participants.

Setting The study was conducted in the Ikorodu and Alimosho local government areas (LGAs) in Lagos and the Abuja Municipal Area Council and Bwari LGAs in the Federal Capital Territory.

Participants Systematic random sampling was used to randomly select and recruit 639 WRA (aged 18–49 years) between May 2019 and June 2019.

Outcome measures Prevalence of select NCDs (hypertension or raised blood pressure, diabetes or raised blood sugar levels, anaemia, truncal obesity and overweight/obesity) and risk factors associated with PE/E (physical activity, fruit and vegetable consumption, alcohol consumption and smoking).

Results The prevalence of raised blood pressure measured among the WRA was 36.0% (95% CI 31.3% to 40.9%). Approximately 10% (95% CI 7.2% to 13.4%) of participants had raised blood sugar levels. About 19.0% (95% CI 15.3% to 23.2%) of the women had moderate or severe anaemia. Excluding WRA who were pregnant, 51.9% (95% CI 45.7% to 58.0%) of the women were either overweight or obese based on their body mass index. Approximately 58.8% (95% CI 53.8% to 63.6%) of WRA surveyed reported three to five risk factors for developing NCDs and PE/E in future pregnancies.

Conclusions The study identified a high prevalence of NCDs and associated PE/E risk factors in surveyed women, signifying the importance of early detection and intervention for modifiable NCD and associated PE/E risk factors in WRA. Further research is necessary to assess the national prevalence of NCDs.

  • Noncommunicable disease
  • prevalence
  • risk
  • women of reproductive age
  • Nigeria
  • hypertension
  • diabetes
  • obesity
  • Africa
  • maternal health
  • pregnancy
  • eclampsia

Data availability statement

Data are available upon reasonable request. The data that support the findings of this study are available on request from the corresponding author AO.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi-org.ezproxy.u-pec.fr/10.1136/bmjopen-2023-071652

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    STRENGTHS AND LIMITATIONS OF THIS STUDY

    • The inclusion of participant-reported behavioural risk factors and self-reported personal and family history related to prioritised non-communicable diseases and associated pre-eclampsia and eclampsia risk factors.

    • The study was aligned with the STEPS survey. Since Nigeria has yet to conduct a nationwide STEPS survey, these results can be used as a benchmark for future surveys.

    • The study used the Open Data Kit tool for more efficient survey administration and used the only Food and Drug Administration-approved rapid point-of-care test for diabetes diagnosis, the Afinion AS100 analyser, to conduct HbA1c testing.

    • The study limitations include the small subsample groups (eg, women with diabetes) that preclude reliable analysis of linked behavioural risk factors.

    • The women could not respond accurately to all the questions for reasons including that certain questions were deemed sensitive due to cultural norms and stigma and many of the respondents were incognisant about their health status and household incomes.

    Introduction

    Chronic diseases and associated risk factors in women of reproductive age (WRA) before, during and after pregnancy increase the risk of maternal and perinatal mortality and morbidity and can have long-lasting effects on the mother and child.1 According to the WHO, non-communicable diseases (NCDs) represent the biggest threat to women’s health worldwide, increasingly impacting women in low-income and middle-income countries (LMICs) in their most productive years.2

    NCDs account for almost 65% of women’s deaths around the globe, with 75% of these deaths occurring in LMICs. This is primarily due to cardiovascular diseases (CVDs), diabetes, preventable cancers and chronic respiratory diseases.3 With an estimated ratio of 512 maternal deaths per 100 000 live births, Nigeria has one of the highest mortality ratios globally and it is estimated that 10% of pregnancies in Nigeria are complicated by hypertension (HTN).4–6 Although population-level information on the causes of maternal death in Nigeria is sparse, evidence suggests that Nigeria is experiencing an obstetric transition in which the proportion of maternal deaths due to indirect causes (eg, chronic HTN) is increasing as women continue to die of direct causes (eg, postpartum haemorrhage, eclampsia). Important risk factors for indirect causes of maternal mortality that are also linked to an elevated risk of pre-eclampsia/eclampsia (PE/E) include high blood pressure, obesity, anaemia and diabetes. Globally, it is estimated that indirect causes (including NCDs and infectious diseases) contribute to nearly one-third of all maternal deaths.7 Women diagnosed with gestational HTN, diabetes mellitus and PE/E face a higher future risk of CVD and complications in future pregnancies.7

    Even with this immense burden, the country’s data on chronic disease prevalence and associated risk factors are limited. Nigeria has never conducted a national STEPS survey, a standardised surveillance approach devised by the WHO to collect, analyse and disseminate data on key NCD risk factors.

    This research paper presents the findings of a prevalence study of NCDs and PE/E risk factors in WRA within four local government areas (LGAs) in two states in Nigeria. The study was part of a larger maternal health project to reduce risk factors for PE/E among WRA: the Reducing Indirect Causes of Maternal Mortality and Morbidity (RICOM3) Project. The RICOM3 Project was created to reduce the high burden of maternal morbidity and mortality that affects WRA by expanding the implementation of an integrated Quality of Care framework in 40 healthcare facilities in Lagos state and the Federal Capital Territory (FCT) of Nigeria. This study’s findings will help inform interventions to improve maternal health outcomes in Nigeria.

    Methods

    Study design

    A descriptive cross-sectional study that used mixed methods was conducted to assess the prevalence of selected NCDs and associated PE/E risk factors among WRA (18–49 years old) in four Nigerian LGAs from May 2019 to June 2019. Data were collected during face-to-face interviews using a mobile-based survey tool Open Data Kit (ODK). A supplementary survey was administered, and physical and biochemical measurements for NCDs and associated PE/E risk factors were taken in a subset of 400 women. The Patient Health Questionnaire-2 (PHQ-2), comprising the first two questions of the Patient Health Questionnaire-9, was used to screen the women for depression. Women with positive scores (>+3) were referred for evaluation. Further details on the mobile survey and the point-of-care (POC) testing are included in figure 1. Qualitative methods included photovoice and case studies with women in the community. The results of the qualitative photovoice and case studies with the women are presented in a separate publication.8

    Figure 1
    Figure 1

    Process flow for conducting the mobile survey and point-of-care testing.

    Sample size and selection

    Purposive sampling was used to select periurban and urban LGAs in Lagos and FCT. Systematic random sampling was used for the mobile survey and POC testing based on available resources, time constraints and logistic requirements.

    Based on population estimates for FCT and Lagos, it was assumed that the target population (WRA 18–49 years) accounted for approximately 44% of the female population for each LGA. Based on these assumptions, the minimum required sample size was calculated to be approximately 150 respondents per LGA. Participating women were grouped into three cohorts: never pregnant, pregnant, previously pregnant at least once.

    Potential study participants were screened for eligibility based on the following selection criteria: age (18–49 years), residence and consent to participate. Eligible women were oriented to the study and signed consent forms before the interview if they agreed to participate in the study. Women who participated in the mobile survey were asked whether they were interested in the POC testing, and after they consented to testing, they were enrolled until 400 women were reached.

    Data collectors canvassed various locations, such as markets, estates, streets, schools, tertiary educational institutions, salons, supermarkets, etc, to identify survey respondents.

    Study sites

    The four LGAs were selected from the FCT and Lagos state. In the FCT, the two LGAs were Abuja Municipal Area Council (AMAC) and Bwari. In Lagos state, the two LGAs were Ikorodu and Alimosho. The location of LGAs within the states is shown in figures 2 and 3. The two states, Lagos and FCT, were selected based on several criteria, including ensuring one state in the north and south of the country, respectively. In addition, the two states selected were required to have both urban and periurban areas and existing programmes or health plans to address NCDs (for the larger project). Urban areas include cities, towns and other similarly densely populated areas, while periurban areas are not well defined but exist between rural and urban areas; they are areas which are not fully urban nor completely rural.9 10

    Figure 2
    Figure 2

    Map of Abuja showing the location of Abuja Municipal Area Council (urban) and Bwari (periurban).

    Figure 3
    Figure 3

    Map of Lagos showing the location of Alimosho (urban) and Ikorodu (periurban).

    The interviews were conducted in various locations in the LGAs, such as markets, streets, schools, tertiary educational institutions, salons, churches, mosques and supermarkets, to ensure optimal representation of the population. Data supervisors worked with designated staff from the LGA secretariat, the local community and traditional leaders to select several widespread representative locations across the four LGAs to use as sites for the mobile survey and POC testing.

    Personnel and training

    Eighteen people comprising 10 mobile surveyors and 8 testers with clinical and biochemical testing experience were recruited and distributed across Lagos and the FCT as data collectors. They participated in the 2-day training on administering e-questionnaires that had been uploaded onto the ODK collect application and downloaded onto Android mobile phones. They participated in the 2-day training on the ODK collect application, e-survey administration, global positioning system (GPS) coordinate identification, informed consent procedures, and safe and accurate physical and biochemical measurements collection.

    Study measures and collection methods

    Mobile survey

    The questions for the mobile survey were adapted primarily from validated instruments, including WHO STEP surveys, Demographic and Health Survey, the Nord-Trøndelag Health Study-HUNT2 and HUNT3.11–13 The survey is presented in online supplemental file 1.

    Data collection was carried out using Android devices pre-populated with the survey items. Survey teams consisted of one surveyor and two medical personnel (testers). The survey team members were fluent in English and the local languages (Hausa, Yoruba and Igbo). A unique ID, automatically generated during the mobile survey, was assigned to each respondent to link the mobile survey tool to the POC data for analysis.

    The mobile survey included a consent page and the respondents’ GPS coordinates. Question domains for the mobile survey included: participant’s demographic information; pregnancy status and history; family or personal history of diabetes, anaemia or raised blood pressure; health services utilisation and history of health screening (breast, cervical cancer and mental health); physical activity; lifestyle habits including fruit and vegetable consumption, alcohol consumption and smoking.

    Lastly, given this study was part of a larger project on maternal health, survey questions addressed technology use such as phone and SIM card ownership, access to WhatsApp and social media, data spending, use of mobile money and bank account ownership. For reporting on household income, a rate of 357.14 naira to US$1 was used.

    Measurements

    Baseline demographic and health information through the ODK tool was obtained for all women before anthropometric and biochemical (POC) testing in a subset of women. Data gathered included a personal history of HTN, anaemia and diabetes; physical measurements of weight, height, waist circumference, body mass index (BMI) and blood pressure. BMI readings were taken for pregnant women but excluded from the analysis. Height was measured in centimetres (cm) using a portable Seca 217 mobile stadiometer; weight was measured in kilograms (kg) using a portable mechanical scale; waist circumference was measured using a standard tape measure; blood pressure measurements were taken three times using Omron M2 and M3 blood pressure monitors and recorded.

    The mean for all three readings was used for the analysis. The Omron M2 and M3 were chosen as they are validated by the British and Irish Hypertension Society with their ability to accommodate a larger cuff size.

    Biochemical measurements of capillary blood samples were tested for both haemoglobin and glycosylated haemoglobin (HbA1c): haemoglobin measurements were taken using the DiaSpect Haemoglobin Analyser, while HbA1c tests were conducted using the Afinion AS100 analyser. The assay is the first and only rapid POC test cleared by the US Food and Drug Administration (FDA) to aid healthcare professionals in diagnosing diabetes.

    Data analysis

    The mobile survey and POC data were imported from MS Excel into Stata V.15.1 (College Station, Texas, USA). These two datasets were linked using respondents’ unique IDs. The common variables in both datasets, such as age, state, LGA, pregnancy status, etc, were checked for data consistency. The difference between the groups was tested using Χ2 tests with the statistical significance level set at p<0.05. Results were presented in tables as frequencies, percentages and a 95% CI.

    Patient and public involvement

    The women involved in this study were not involved in the design, conduct or reporting of the prevalence study but have been part of the dissemination of the results and were involved in the design of interventions that stemmed from the results seen in the prevalence study.

    Measurement of NCDs and associated PE/E risk factors

    BMI was calculated as weight (kg) divided by height in metres squared (m2). Overweight was defined as a BMI between 25.0 and 29.9 kg/m2, while obesity was defined as a BMI ≥30 kg/m2. Truncal obesity was defined as a waist circumference >88 cm.14 For never-pregnant and previously pregnant women, anaemia (moderate or severe) was defined as a haemoglobin level of less than 110 g/L and for pregnant women, anaemia was defined as a haemoglobin value of less than 100 g/L. An HbA1c value of >5.7 was considered an elevated blood glucose level.15 An HbA1c value >6.4 was classified as diabetes.15 HTN was classified based on Nigeria’s national guidelines that specify a systolic blood pressure of ≥140 mm Hg or a diastolic blood pressure of ≥90 mm Hg.16 To further understand the prevalence of elevated blood pressure as a precursor for HTN, the 2017 American Cardiology College (ACC)/American Heart Association (AHA) guidelines were used, which classified elevated blood pressure as a systolic blood pressure of 120–129 mm Hg and a diastolic blood pressure of <80 mm Hg.17 The research team felt that it was important to use the newer AHA guidelines to classify HTN in anticipation of the adoption of this classification system in Nigeria and consideration of the relatively young age of study participants (age 15–49 years).

    Results

    Characteristics of the study population

    We exceeded our recruitment target for the mobile survey of 150 women per LGA. A total of 639 (94.39%) women out of the 677 randomly selected participated in the mobile survey, while 400 (100%) participated in the POC testing. The general characteristics and demographic data of the women surveyed are presented in online supplemental file 2. Most women (42.6%) were aged between 20 and 29 years. A majority (67.6%) of the women were married. Most women (72%) reported a monthly household income below 75 000 naira (US$210), and 57.8% reported completing secondary school education. About 91.2% lacked health insurance, 52.4% were self-employed and 76.4% had a bank account. Most of the participants were either Yoruba (43.5%) or Igbo (22.2%), followed by Gwari (5.3%), Hausa (3.6%), Idoma (3.6%), Igala (2.8%) and Ibibio (1.6%). The others (17.4%) included Ebira, Esan, Ham, Isoko, etc.

    Table 1 shows a summary of the pregnancy status and the total number of births of surveyed women; the full table is presented in online supplemental file 3. Most women who participated in the study were either pregnant (32.4%) or had previously been pregnant (34.9%), while 32.7% of the women had never been pregnant (table 1). Pregnant and previously pregnant women had an average of 3.39 pregnancies and 2.5 live births.

    View this table:
    Table 1

    Pregnancy status, total pregnancies and live births of the participants

    Online supplemental file 4 represents the behavioural, physical and biochemical characteristics of the study population which include the nine risk factors that are described in the Methods section.

    Behavioural risk factors

    Prevalence of tobacco and alcohol use

    The prevalence of women across the LGAs who reported current tobacco use was also low, with no self-reported current smokers in AMAC and Alimosho and 1% of women self-reporting tobacco use in the periurban areas of Bwari and Ikorodu. Alcohol consumption is more prevalent than tobacco use as across all LGAs, less than one out of five women reported current alcohol consumption (19.7% of women in AMAC, 16% in Bwari, 15.5% in Alimosho and 17.3% of women in Ikorodu).

    Prevalence of women who eat less than five servings of fruits and vegetables per day

    Only 28.8% of the women reported eating at least five servings of fruits and vegetables per day. In every LGA, most women reported eating less than five servings of fruits and vegetables per day, including 69.1% of women in AMAC, 67.3% of women in Bwari, 74.5% of women in Alimosho and 73.4% of women in Ikorodu.

    Prevalence of women who reported less than 5 days a week of moderate-intensity or less than 3 days of vigorous-intensity physical activity

    About two-thirds of respondents reported low levels of moderate or vigorous-intensity physical activity, with 63% of women in AMAC, 62% of women in Bwari, 67% of women in Alimosho and 58% of women in Ikorodu reporting less than 5 days of moderate-intensity exercise per week or less than 3 days of vigorous-intensity physical activity.

    Risk of depression

    Based on a PHQ-2 score of 3 or greater, one-fifth to one-third of surveyed women in Ikorodu, AMAC and Alimosho were at risk of depression, including 21.4% of women in Ikorodu, 27% in AMAC and 29.8% in Alimosho. In Bwari, 9.8% of women were at risk of depression.

    Family history of NCDs

    The most reported conditions in the family histories were HTN and diabetes. An estimated one in five respondents reported a family history of HTN. Diabetes was less frequently reported, with 10.0% of respondents in Bwari reporting a family history of diabetes compared with 25.7% of respondents in Ikorodu.

    History of cancer screening

    Our findings show low breast and cervical cancer screening in WRA. Eighty-six per cent of women in both AMAC and Bwari, 78% of those in Alimosho and 75% of women in Ikorodu had not had a breast examination conducted by a health worker. Similarly, 94% of women in both AMAC and Bwari, 95% of the women in Alimosho and 88% of those in Ikorodu had not been screened for cervical cancer.

    Physical risk factors

    Prevalence of overweight or obesity

    There was a high prevalence of overweight and obesity across all the LGAs. In FCT, 55.6% of the women in AMAC and 50.7% in Bwari were either overweight or obese with a BMI >25 kg/m2. In Lagos, 41.8% and 59.7% of women in Alimosho and Ikorodu, respectively, were overweight or obese. The prevalence of overweight/obesity differs across the LGAs being highest (59.7%) in Ikorodu (a periurban area) followed by AMAC (an urban area). However, there was no significant difference between the prevalence in urban and periurban areas.

    A total of 22.4% of women in Alimosho and 34.3% of the women in Ikorodu were obese with a BMI >30 kg/m2, while 23.8% of women in AMAC and 29.6% of women in Bwari were obese.

    Prevalence of truncal obesity

    There was a statistically significant difference in the prevalence of truncal obesity across the four LGAs, with 41.3% of the respondents in AMAC, 57.7% in Bwari, 43.3% in Alimosho and 62.7% in Ikorodu (p<0.05). There was also a statistically significant difference in the prevalence of truncal obesity between the urban and periurban areas, with the prevalence in periurban areas (62.7% in Ikorodu and 57.7% in Bwari) higher than the prevalence in the urban areas (43.3% in Alimosho and 41.3% in AMAC) (p<0.05).

    Prevalence of HTN or elevated blood pressure

    Across the four LGAs, approximately two-thirds of the 400 women who had a blood pressure measurement (64%) had a normal blood pressure value based on 2018 ACC/AHA criteria (<120 systolic or <80 diastolic). Nearly 1 in 10 women (9.3%) of the 400 women with a measured blood pressure had HTN based on Nigeria national guidelines of systolic blood pressure >140 or diastolic blood pressure >90, ranging from 8% in Ikorodu and Bwari to 9% in AMAC to 12% in Alimosho. Based on ACC/AHA blood pressure classification guidelines, 33% of women in AMAC, 30% in Bwari, 42% in Alimosho and 39% of women in Ikorodu had elevated blood pressure or stage I or stage II HTN. However, only 5.9%, 2.6%, 7.5% and 12.7% of women in AMAC, Bwari, Alimosho and Ikorodu, respectively, reported ever being told by a healthcare professional that they had elevated blood pressure or HTN.

    Proportion of women reporting a family or personal history of PE/E (excluding never pregnant women)

    The proportion of women across the four LGAs who reported a family history of PE/E (0–2.6%) was lower than the proportion of women who reported a personal history of PE/E, ranging from 1.5% of women in Bwari to 20.9% in Ikorodu. Several respondents (7.2%) did not know if there was a family history of PE/E.

    Biochemical risk factors

    Prevalence of diabetes or raised blood glucose (pre-diabetes)

    Women who lived in periurban settings had a higher prevalence of raised blood glucose or diabetes than their urban counterparts. Seven per cent of women in AMAC and 8.0% of women in Alimosho to 11.0% of women in Bwari and 12.0% of the women in Ikorodu had a diagnosis of diabetes based on an HbA1c level of higher than 5.7. Seven per cent of surveyed women were diagnosed with raised blood glucose (pre-diabetes) based on an HbA1c level of 5.7–6.4. The proportion of women reporting a prior diagnosis of diabetes by a healthcare professional, however, was only 1–3% across all LGAs. The percentage of women who reported having had their blood glucose measured previously by a doctor or health worker was highest in the periurban LGA, Ikorodu (68.2%), and lowest in the urban area, AMAC (27.6%). A total of 50.3% of the women in Alimosho and 33.3% of the women in Bwari also reported that their blood glucose had been measured by a doctor or health worker. Of the women who reported a prior blood glucose measurement at any time, 59.4% of respondents in AMAC, 63.9% in Bwari, 70% of respondents in Alimosho and 74.2% of those in Ikorodu reported having this measurement taken while pregnant.

    Prevalence of anaemia

    Across the four LGAs, nearly one-fifth of women (19.5%) of the 400 women tested for anaemia had moderate or severe anaemia. A higher proportion of women were measured to have any degree of anaemia (mild, moderate or severe), including 59% in Alimosho, 54% in Ikorodu, 43% in AMAC and 37% in Bwari (p<0.05). However, only 1.5% of 400 women tested for anaemia reported ever being diagnosed with anaemia, while 26% of respondents reported ever having had a test for anaemia.

    Prevalence of WRA with multiple NCD and PE/E risk factors

    In determining the risk of NCD and PE/E in surveyed WRA, the prevalence of women with multiple physical, behavioural and biochemical NCD and PE/E risk factors was examined, as summarised in table 2. The full table is presented in online supplemental file 5. Most women (58.8%) had three to five risk factors, with 54% in AMAC, 60% in Bwari, 63% in Alimosho and 58% in Ikorodu reporting so.

    View this table:
    Table 2

    Prevalence of combined NCD and PE/E risk factors by location

    Discussion

    This study sheds important light on the prevalence of NCDs and associated PE/E risk factors among surveyed WRA in four LGAs in two states of Nigeria. In a country where PE/E is a leading cause of preventable maternal and perinatal mortality and morbidity, the proportion of surveyed women with NCD-related PE/E risk factors, including elevated blood pressure (36.0%), moderate or severe anaemia (19.0%), diabetes/pre-diabetes (9.6%) and obesity (51.9%), is of concern. Apart from truncal obesity (p<0.05), there was no statistically significant difference in the prevalence of women with NCDs and their risk factors between those living in periurban versus urban areas. The data highlight that many WRA suffer from or are at high risk of NCDs.

    Of concern, most women identified to have NCD risk factors had no prior knowledge of their status or risk. Less than 14% of women identified with diabetes or pre-diabetes and less than 23% of women identified with elevated blood pressure reported to have ever been informed by a healthcare provider that they had elevated blood glucose or blood pressure. This finding is surprising given that approximately 87% of the respondents had a minimum of secondary school education and 29% had a university degree. In a comparable study in Lagos Mainland LGA that assessed women’s knowledge of NCDs including diabetes and high blood pressure, 82.6% showed awareness; however, 99.1% of participants had poor knowledge of preventive healthcare services for these NCDs.18 The low screening for cancer underscores the need for more screening and presents a missed opportunity in women’s health to prevent cervical cancer and encourage the early diagnosis of breast cancer.

    Except for the Ikorodu LGA, the largest percentage of respondents was in the 20–29 years age group. In Ikorodu, the participants were older, with nearly half of the respondents in the 35–49 years age group, which may help explain the higher NCD and associated PE/E risk among participating women in Lagos compared with FCT.

    People with low incomes face more significant financial barriers to accessing healthcare services.19 Most respondents (72.2%) reported monthly household incomes between 0 and 75 000 naira (US$210) in each of the four LGAs, with more than 40% of respondents in each LGA reporting an income of 0–30 000 naira (US$83), with most lacking health insurance. In most LGAs, less than 10% of respondents had insurance, with Bwari (14.4%) being the only exception. Across all four LGAs, 36–43% of women frequented clinics or healthcare providers, yet only 9%, collectively, had health insurance. This may be related to the high proportion of women who were not employed by the private or public sector (75.1%). This insurance coverage is comparable with the 7.9% seen in low-income countries but lower than the 27.3% seen in lower middle-income countries in a 2022 review.20 Given the preventive health needs of WRA, especially those with NCDs, this low insurance coverage (although higher than the national average) is concerning.

    Many women reported a family history of NCDs, especially HTN and diabetes. This was highest in the periurban area of Ikorodu, where 33.1% reported a family history of HTN and 25.7% reported a family history of diabetes. A family history of HTN or diabetes is a known risk factor for developing essential HTN and diabetes (and other chronic diseases), and it is important that maternal, NCD and primary healthcare programmes incorporate knowledge about family history as one mechanism to raise awareness and knowledge about NCDs and associated maternal health risk factors among WRA.

    A notable study finding is the proportion of women identified with HTN (9.3%) applying national Nigeria guidelines (systolic blood pressure >140 or diastolic blood pressure >90 mm Hg) and the high proportion of women (36%) identified with elevated blood pressure applying 2017 ACC/AHA guidelines (systolic blood pressure >120 or diastolic blood pressure >80 mm Hg).16 17 A systematic review found that studies conducted using the Nigerian HTN classification recorded the prevalence of elevated blood pressure in the range of 10–47.3% in women of all ages, similar to our study findings.21 Providers in Nigeria define HTN using the 140/90 mm Hg cut-off, which the WHO also uses. This classification is equivalent to stage 2 HTN by ACC/AHA guidelines. When this study was conducted, there were discussions in the global health community about adopting the ACC/AHA guidelines. However, at the time of this report, the WHO and Nigerian HTN guidelines do not reflect this change. Several studies have associated ‘stage 1’ HTN based on ACC/AHA classification (systolic blood pressure 120–129 or diastolic blood pressure 80–90) with an excess of adverse maternal and perinatal outcomes (ie, pre-eclampsia, preterm birth and gestational diabetes).22 Given the increased risk of premature CVD and indirect causes of maternal mortality and morbidity associated with HTN (including stroke due to uncontrolled severe HTN in pregnancy), our study findings highlight the vital importance of prevention, early detection and management of HTN and associated modifiable risk factors (eg, physical activity, obesity) in WRA.

    Our study found that the prevalence of women with HbA1c levels that correlate with pre-diabetes was 7.4%, more than twofold higher than that of a comparative study in Kenya, which recorded a pre-diabetes prevalence of 3.1%.23 This higher prevalence is mirrored in that of diabetes, where the prevalence in our study was 2.3%, almost double the prevalence of 1.3% found in Kenyan WRA.24

    Our study found that 48.2% of the women had anaemia, slightly lower than the prevalence reported by the WHO in 2019 (55.1%).25 Pregnant women, however, had a 55.3% prevalence of anaemia which was more than was seen in a review by Ugwu and Uneke done in 2020, which showed that the prevalence of anaemia in pregnant Nigerian women was between 25% and 45.6%.26 Importantly, nearly one-fifth of women in the study (19.5%) had moderate or severe anaemia (based on a haemoglobin level of 70 g/L or lower) which is a risk factor for multiple maternal and perinatal complications, including preterm birth and postpartum haemorrhage, shock, maternal death, fetal growth restriction and stillbirth.27

    Our findings show that over half of the women in the study (51.9%) were either overweight or obese, with an overweight prevalence of 24.3% and an obesity prevalence of 27.6%. We also saw that BMI rose with age across all LGAs. Other studies differ in their findings on the prevalence of overweight or obesity among women. In 2018, Tagbo et al found an overweight and obesity prevalence among Nigerian women of 18.1% and 9.9%, respectively.28 In comparison, in 2006, Wahab et al found more similar figures to this study, with a 62% prevalence of overweight and a 29.8% prevalence of obesity in Katsina state, Nigeria.29

    We saw a 51.9% prevalence of truncal obesity in the women in this study, similar to the prevalence of 43.8% found in women in Plateau state, Nigeria.30

    This study found that only 29.6% of women engaged in adequate moderate physical activity, while only 20.5% engaged in sufficient vigorous physical activity. A previous survey of Nigerian women found that 55.8% of women engaged in less than 150 min of moderate-intensity aerobic exercise and less than 75 min of vigorous-intensity aerobic exercise during the week.31

    Our results show that 22.1% of the women were at increased risk of depression based on the PHQ-2. Further screening via the PHQ-9 or similar instruments would be required to establish a definite diagnosis of depression.32 With that in mind, this was comparable with the 28.9% prevalence of depression seen in a study carried out on non-pregnant WRA in a rural area of Oyo state, Nigeria.33 This was also consistent with another survey of pregnant women in Ogun state, Nigeria, which found a 24.5% prevalence of depression.34 These findings speak to the importance of incorporating screening and care for depression as part of primary healthcare and maternal health services to address the silent burden of depression and perinatal mental health disorders.35

    A small percentage of women (17.1%) reported that they were current alcohol drinkers at the time of the study, and much fewer (0.5%) said they currently smoked. While there may be a risk of under-reporting as smoking is a social stigma in Nigeria, these results correspond with those of a study of smoking prevalence in 42 LMICs which saw 0.7% of pregnant women and 1.1% of non-pregnant women report that they smoked.36 Approximately 71.2% of the women in the study eat less than the recommended five servings of fruits and vegetables per day.

    This study shows that not only are the physical, behavioural and biochemical risk factors for NCDs prevalent in WRA in Nigeria, but many women also possess multiple risk factors. Only 2.3% of the women in the study reported no risk factors, while 33% reported between one and two risk factors. Alarmingly, most women (58.8%) reported three to five risk factors for NCDs and associated PE/E risk factors.

    Our findings show low screening for breast and cervical cancer in WRA. A total of 80.8% of women had not had a breast examination conducted by a health worker, while 92.6% had not been screened for cervical cancer. The low screening for cancer underscores the need for more screening and presents a missed opportunity in women’s health to prevent cervical cancer and encourage the early diagnosis of breast cancer.

    Strengths and limitations of the study

    The study’s strengths include the prevalence of NCDs and associated PE/E risk factors among WRA in four LGAs representing urban and periurban areas in two states in Nigeria. Another strength is the inclusion of participant-reported behavioural risk factors and self-reported personal and family history related to prioritised NCDs and associated PE/E risk factors. Second, the study was aligned with the STEPS survey. Since Nigeria has yet to conduct a nationwide STEPS survey, these results can be used as a benchmark for future surveys. Lastly, the study used the ODK tool for more efficient survey administration and the use of the only FDA-approved rapid POC test for diabetes diagnosis, the Afinion AS100 analyser, to conduct HbA1c testing.

    The study limitations include the small subsample groups (eg, women with diabetes) that preclude reliable analysis of linked behavioural risk factors. Second, certain questions were deemed sensitive due to cultural norms and stigma. For example, some women were reluctant to answer questions about their pregnancy status and whether they smoked. Third, many of the respondents were incognisant about their health status and household incomes and could not accurately respond to all the questions. Many respondents also saw questions about their household incomes as a security risk and refused to answer. Fourth, HbA1c was measured in all women, but while it is useful for assessing impaired glucose tolerance in the first trimester of pregnancy, it lacks the specificity and sensitivity of the oral glucose tolerance test and thus cannot be used in diagnosing gestational diabetes mellitus.37 As some pregnant women did not know their gestational age or were uncomfortable stating their gestational age, HbA1c levels for pregnant women must be interpreted cautiously. Fifth, respondents were more likely to share information about their health status during the POC testing than during the mobile survey, possibly leading to less accurate answers given during the mobile survey. Finally, the immobility of the Afinion B analyser setup, which required a power source (ie, a generator) and ice packs and ice, limited the number of sites where the POC testing occurred.

    Conclusion

    Although the study population represents only a small subset of the Nigerian population, the findings help fill some of the vast knowledge gaps on the prevalence of NCDs and associated maternal risk factors in WRA in Nigeria. The study shows that the prevalence of certain NCDs and risk factors of PE/E is high among WRA in urban and periurban areas across FCT and Lagos, Nigeria and that women were largely unaware of these risk factors due to insufficient screening, diagnosing, managing and counselling on lifestyle modifications from healthcare providers. There is a need to develop, disseminate and implement evidence-based guidelines for screening and managing NCDs (and their risk factors) in WRA throughout their life. One way to optimise this is by exploring new integrated, holistic, women-centred community-based care models. Equipping communities with the knowledge and skills so that WRA have personal agency for their health can help to lessen the burden on the health system in Nigeria.

    Data availability statement

    Data are available upon reasonable request. The data that support the findings of this study are available on request from the corresponding author AO.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants and was approved by the FCT and Lagos Research Ethics Committees, the National Health Research Ethics Committee of Nigeria and the Institutional Review Board of the School of Public Health, Johns Hopkins University, Baltimore (IRB no 00009452). Informed consent was obtained from all respondents.

    Acknowledgments

    We would like to thank the women who participated in the study. We extend our deepest thanks to the Federal Ministry of Health of Nigeria, Health, and Human Services in the Federal Capital Territory (FCT), Lagos State Ministry of Health and the local government and community leads who helped us navigate the different communities we visited. We would also like to thank the FCT and Lagos State Technical Advisory Group members, the members of the National Health Research Ethics Committee of Nigeria, the project states and the Johns Hopkins University Institutional Review Board, Jhpiego and MSD for Mothers. We are grateful for the efforts of the research and field team who worked tirelessly on this project to collect and bring these data to life: Dr Nneka Mobisson, Imo Etuk, Dr Kendra Njoku, Bosoye Olagbegi, Daniel Ejiofor, Jonas Kofi Akpakli, Dr Imuetinyan Okoh, Ifeoma Nehemiah, Maria Etuk, Eniola Adegbokan, Eniola Balogun, Gift Nwanne, Nikkev Marshall and the remaining surveyors and testers in FCT and Lagos.

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    Supplementary materials

    Footnotes

    • Contributors Guarantor—NM. Conceptualisation—NM, ImE, KN, UO and KH. Methodology—NM, ImE, KN and UO. Analysis—JKA. Writing (original draft preparation)—AO, JKA, AI, ImE and NM. Writing (review and editing)—AO, JKA, InE, SJ, NM, FO, VO, UO, ImE and KH. All authors have read and agreed on the published version of the manuscript.

    • Funding The research in this publication was supported by funding from MSD, through its MSD for Mothers Initiative. MSD for Mothers is an initiative of Merck & Co, Kenilworth, New Jersey, USA (grant number: N/A).

    • Disclaimer MSD had no role in the design, collection, analysis and interpretation of data, in writing of the manuscript or in the decision to submit the manuscript for publication. The content of this publication is solely the responsibility of the authors and does not represent the official views of MSD.

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    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

    • Provenance and peer review Not commissioned; externally peer reviewed.

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