Introduction

Hypertensive disorders in pregnancy (HDP) are one of the main causes of maternal and fetal morbidity and mortality ¹, especially in low- and middle-income countries ². They affect approximately 10 % of all pregnancies and represent 14 % of all maternal deaths, which is why they are still an important public health problem globally ³. In Latin America and the Caribbean, HDP represents 25.7 % of all maternal deaths ⁴ and, in 2021, they were the leading direct cause of maternal death in Colombia, with 14.6 % ⁵.

Studies conducted in different parts of the world have sought to establish the exact etiology of HDP; however, it is still unknown ³ and, therefore, both their prediction and prevention represent a major challenge ⁶. In this sense, at the international ^6-9 and national ¹⁰ levels, guides for the clinical practice targeted at HDP prevention, detection, and treatment have been issued. Among the preventive measures, calcium supplementation is established as the indication with the highest level of evidence and recommendation degree ^9,10. However, although more evidence is required to make recommendations related to diet, exercise, rest ⁷, restriction in the consumption of salt, alcohol and cigarettes, and workload or stress reduction ⁹, they are self-care behaviors that continue to be important in pregnant women and their family nucleus.

The literature suggests that a large part of the complications related to HDP are the result of low knowledge levels, negative attitudes, and lack of sensitization among pregnant women towards the disease and health behaviors ¹¹. In the face of this problem, a theoretical proposal such as the Theory of Planned Behavior (TPB) has been useful to understand, predict, and explain human behavior. According to the theory, behavior is determined by intention, which in turn is influenced by three determinants ¹². The first one is attitude, which reflects the favorable or unfavorable assessment level towards a given behavior. The second one is subjective norms, which refer to the pressure exerted by significant people on the subject who approve or disapprove of a given behavior. Finally, there is perceived behavioral control, defined as the personal ability to control the factors that ease or hinder performing a given behavior ^12,13.

The TPB proposes that to predict the intention, it is indispensable to establish people’s salient beliefs about the behavior of interest; in other words, those that a person mentions more frequently and which are considered determinants of their actions. Theoreticians distinguish three types of salient beliefs: 1) Behavioral, which influence attitudes, 2) Normative, which precede subjective norms, and 3) Control, which constitute the grounds of behavioral control ¹².

In the context of caring for pregnant women, studies ^14-20 following the TPB approach have sought behavioral goals targeted at promoting health and preventing complications during pregnancy. However, research focused on establishing pregnant women’s beliefs towards self-care behaviors when facing HDP in the light of the TPB is still incipient in Colombia and Latin America. It is for that reason that it is fundamental to identify the beliefs preceding the determinant of behavioral intention in pregnant women. In addition, specifying the salient beliefs constitutes the first phase of the theoretical framework for the elaboration of measuring instruments and for planning interventions targeted at motivating the acquisition of health behaviors ²¹. Consequently, the objective of the current study was to identify the salient beliefs in the intention for self-care behaviors when facing hypertensive disorders in pregnant women.

Materials and Methods

Discussion

The TPB sets forth that human behaviors are reasoned or planned actions, as they are consistent with a person’s beliefs ²⁶. In this sense, it can be asserted that it is through behavioral beliefs that people weigh the consequences of future actions in terms of their favorable or unfavorable nature ²¹.

The behavioral beliefs related to physical exercises stand out as the ones with the greatest advantage in improving mothers’ and babies’ health during pregnancy. Although this result is coherent, there is a limited perception of the benefits of physical exercises on blood pressure control, a finding that can be related not only to causal unawareness of these disorders in the obstetric population ²⁷ but also to women’s disinformation and lack of knowledge by the health personnel in terms of the effects of physical exercises during pregnancy, which results in not providing this type of recommendation and in few pregnant women benefiting from this behavior ²⁸. Physical exercises have been considered an important non-pharmacological strategy to reduce the risk of suffering HDP ²⁷. The findings of a systematic review and meta-analysis showed the beneficial effect of aerobic, strength and flexibility exercises (OR = 0.50; 95 %CI: 0.33-0.75; p = 0.001) or yoga (OR = 0.28; 95 %CI: 0.13-0.58; p = 0.001) in preventing or reducing the risk of developing HDP (29). Currently, the recommendations proposed by the American College of Obstetricians and Gynecologists (ACOG) suggest that, whether during pregnancy or in the postpartum period, all women should practice moderate-intensity physical exercises for at least thirty minutes a day and five or more days in the week ³⁰. Among the negative behavioral beliefs, most of the participants state no disadvantages regarding physical exercises during pregnancy; such practice generates sensations of tiredness, pain and abdominal discomforts only for some women, in addition to the use of improper strength and positions. In this sense, the ACOG describes that physical exercises contribute to reducing body, back and sciatic pain in pregnant women. In addition, it recommends motivating women undergoing uneventful pregnancies to perform aerobic and strength exercises before, during and after pregnancy ³⁰.

Considerng nutritional behaviors, reducing salt consumption contributes to preventing high blood pressure and diseases in the mother. Although, according to clinical practice guides, there is not enough evidence showing that reducing salt in the diet helps treat or prevent hypertension during pregnancy ^7-9, such restriction can be beneficial for normotensive pregnant women with metabolic disorders or obesity, or with a chronic hypertension diagnosis ³¹. The unfavorable beliefs towards this behavior are related to losing taste, appetite and preference for food. These findings are similar to those described by Sousa et al. ²¹, where it is highlighted that the changes in food palatability associated with salt usage in the preparation of meals represent negative aspects for reducing its consumption.

In the consumption of fruit, vegetables, legumes and meats, the contribution of vitamins and minerals assisting in the baby’s proper growth and development and the mother’s nutrition and health stands out. Several studies have found that eating fruit, vegetables and legumes is positively related to newborns’ size and weight ³². Likewise, food products of animal origin are iron, protein and vitamin sources that not only contribute to preventing maternal diseases but, due to their high nutritional value, also exert an influence on the baby’s development and protection ³³.

On the other hand, the participants included in this study did not describe the importance of eating fruit, vegetables and legumes on weight control during pregnancy. In this sense, it has been described that gestational weight gain higher than the recommended increases the risk of obstetric complications like hypertension. Therefore, proper prenatal control, adequate nutritional classification, sound indications from the health personnel and elaborating a diet are key strategies to attain a food regime in pregnant women that allows for avoiding excessive weight gain and reduces the risk of developing HDP ³⁴.

Likewise, the women included in this study consider that reducing the consumption of fats, flour and sugar would avoid diabetes, high blood pressure, and maternal overweight problems, in addition to promoting the baby’s healthy growth and development. These beliefs are in line with the scientific evidence, where it has been identified that maternal diets with high energy intake are associated with higher risks of hypertension, gestational diabetes, increased maternal weight, macrosomia, and C-sections ³⁵.

The favorable beliefs of calcium intake during pregnancy are related to the baby’s growth, development and well-being, as well as to its value as a nutritional supplement in mothers and babies alike, which prevents dental and bone decalcification in women. Although these findings are consistent with what is reported in the literature, the role of calcium in reducing HDP risk is unknown. A Cochrane review has concluded that there is enough evidence to prove that calcium supplementation (≥1 g/day) is significantly associated with a reduction in the risk of pre-eclampsia and other pregnancy hypertensive diseases, particularly in women on diets that are low in this mineral ³⁶.

Among the advantages of avoiding caffeinated drinks, alcohol, tobacco or cigarettes, beliefs such as preventing malformations and promoting the baby’s healthy growth and development stand out, as well as preserving the mother’s health and preventing high blood pressure. There is evidence that prenatal exposure to alcohol, tobacco and caffeine exerts adverse effects on the health of the pregnant woman, the fetus and the newborn ^37,38. Considering the development of HDP, a systematic review suggested an association between alcohol and pre-eclampsia, with a 13 % prevalence, although none of the studies included reported tobacco consumption as a risk factor ³⁹. Likewise, Kawanishi et al. ⁴⁰ showed that consuming 131 mg/day of caffeine, a value way below the amount recommended by the World Health Organization (300 mg/day), was associated with higher HDP risk (OR=1.35; 95 %CI: 1.99-1.52; p = 0.001).

Both sleep and the periods during pregnancy are mentioned as behaviors that favor relaxation and peace of mind in the mother and the baby. However, there is a lack of knowledge about the importance of sleep quality and pregnancy results. Some studies suggest that pregnant women are a population group at a higher risk of sleep disorders such as sleep apnea, restless leg syndrome and insomnia ⁴¹. In this sense, the findings by Sharma et al. ⁴² indicated that sleep insufficiency or fragmentation can predispose pregnant women to several adverse results, such as gestational hypertension and C-section deliveries.

Finally, in the behavioral beliefs, blood pressure control is mentioned as a behavior that allows monitoring the blood pressure values, controlling and following up on the mother’s and baby’s health and preventing complications during pregnancy. Although blood pressure monitoring plays no role in HDP prevention, it is in fact useful to determine alterations in the parameters considered normal and in early detection of HDP.

Regarding the normative beliefs, the findings emphasize that health personnel, mothers, husbands or partners and other family members are referents that might exert an influence on pregnant women’s motivation to perform a given self-care behavior when facing HDP. In this sense, Malta et al. ⁴³ describe that women are in frequent contact with physicians and nurses during their prenatal appointments. Therefore, these professionals, as providers of knowledge, practices and support, play a relevant role in promoting changes in health behaviors. In the family context, the evidence has shown that when partners, mothers and close family members are involved in the pregnancy, pregnant women are more likely to timely access prenatal care programs, avoid harmful behaviors for their health and develop self-care actions, all components that are associated with better results in maternal/perinatal health ^44,45.

In the control beliefs, it is evident that visiting other people, going out for a walk with their partner and taking their children to school are facilitating factors for physical exercises during pregnancy. These findings highlight that there is a dependent relationship between the participants and their social referents, which contributes to adopting health behaviors during pregnancy that might be able to promote optimum results in the mothers’ and babies’ health ⁴⁴.

At the nutritional level, preparing meals with low salt content and the habit of low consumption to prevent diseases in the mother and the baby are beliefs that ease the behavior. In fact, the mothers’ knowledge about the benefits of reducing salt consumption during pregnancy and the strategies to do so can help reduce its use ⁴⁶. Eating fruit, vegetables, legumes and meats can be favored by the support from friends and family members, by the partner buying them and by the habit and preference for their consumption. In this sense, the study by Hromi et al. ⁴⁷ showed that social, spouse and family support is the main source driving healthy eating behaviors, especially the consumption of fruit and vegetables. Likewise, Asiabar et al. ⁴⁸ reported that the partners are usually the financial support source in the family and, therefore, they play an important role in the food supply. In addition, it has been described that social support exerts a direct influence on pregnant women’s perceived self-efficacy, favoring access, preferences, knowledge and strategies required to increase consumption of this type of food products ⁴⁷.

On the other hand, the beliefs that contribute to reducing unhealthy nutritional behaviors during pregnancy emphasize the habit of avoiding fats, flours and sugars, aversion to meals, and lack of habit or preference for caffeinated drinks, alcohol or cigarettes, which are ways to promote the baby’s well-being and prevent health problems in the mother. These beliefs are consistent with the findings by Forbes et al. ⁴⁹, for whom the most common reasons for women to reduce or discard consumption of this type of food products include the baby’s health, concern about their own health, aversions, nausea and the intention to meet the dietary recommendations provided by the health professionals.

Regarding consumption of calcium supplements, the participants describe thinking about the baby’s well-being, provision by the health institution or purchasing power to buy them as the major facilitating factors. According to a study conducted in Bangladesh, calcium supplementation during pregnancy depends on factors such as maternal knowledge, support from the husband or partner, reminders by the household members to take it, early initiation and more prenatal visits, as well as the free provision by the health services ⁵⁰.

The control beliefs associated with sleep and rest are targeted at the habit of taking a previous shower, going to bed early and performing activities that favor sleep and rest. The activities described coincide with the findings by Hashmi et al. ⁵¹, who emphasize that strategies that improve sleep quality should be implemented during pregnancy, such as going to bed and getting up at the same time every day, taking a warm bath and performing non-stimulating activities such as knitting, reading a book, etc. Likewise, the participants describe beliefs that interfere with sleep duration and quality that are also identified in the literature, such as pollakiuria, discomforts caused by back pain, fetal movements and abdominal discomfort ⁵¹.

Finally, going to a nearby pharmacy, a family member or acquaintance measuring blood pressure and the low cost involved in the procedure are identified as beliefs that ease measuring it. The findings by Tucker et al. ⁵² describe that pregnant women feel satisfied with monitoring blood pressure either in the self-control or outpatient modality and, therefore, it is possible that the beliefs stated by the participants included in this study contribute positively to this behavior.

In terms of the implications for the Nursing practice, the findings set forth the need to strengthen pregnant women’s self-care knowledge and actions when facing HDP, through education in prenatal consultations or by developing health education interventions or programs that promote a positive attitude, involve greater social or family support and reinforce in pregnant women the acknowledgment and control over their own resources and abilities, as well as their motivation to develop health behaviors when facing HDP. In addition, identifying the salient beliefs will support the elaboration of instruments that allow assessing the attitudes, subjective norms and perceived behavioral control as key determinants in pregnant women’s intention towards self-care behaviors when facing HDP.

This study acknowledges the following as one of its limitations: the absence of more answers to the questions asked that would allow for a better understanding of the phenomenon, which may have been due to how the information was collected or to the participants’ refusal to provide more in-depth answers. Another limitation corresponds to the fact that the study was conducted in a single environment, which entails carrying out new research studies in different Colombian regions, acknowledging pregnant women’s cultural plurality, nutritional diversity and lifestyle habits, to expand, ratify or refute the findings of this study, as it deals with care behaviors during the prenatal stage that subjected to diverse influence from the pregnant women’s cultural and social contexts, thus precluding generalization of the findings.

Conclusion

The results of this study revealed pregnant women’s behavioral, normative and control salient beliefs towards the self-care behaviors related to HDP. In the behavioral beliefs, some advantages should be preserved, reinforced or modified in HDP risk prevention or control, as well as disadvantages that need to be corrected. On the other hand, health personnel, mothers, partners or husbands and other family members are referents that exert a strong influence on achieving the expected self-care behaviors. Finally, factors easing the behaviors were identified, as well as others that exert a negative influence, which can be negotiated or restructured to achieve health behaviors that strengthen maternal/perinatal health care when facing HDP risks.