Predicting pre-eclampsia with a survey to estimate sub-optimal health status (SHSQ-25)

Article: Integration of suboptimal health status evaluation as a criterion for prediction of preeclampsia is strongly recommended for healthcare management in pregnancy: a prospective cohort study in a Ghanaian population


EPMA Journal volume 10, pages 211–226(2019)
doi: 10.1007/s13167-019-00183-0


Enoch Odame Anto 1 2 , Peter Roberts 1 , David Coall 1 , Cornelius Archer Turpin 3, Eric Adua 1 , Youxin Wang 4 , Wei Wang 1 4 5


1. School of Medical and Health Sciences, Edith Cowan University, Perth, WA, Australia
Enoch Odame Anto, Peter Roberts, David Coall, Eric Adua & Wei Wang
2. Department of Molecular Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
Enoch Odame Anto
3. Department of Obstetrics and Gynaecology, Komfo Anokye Teaching Hospital, Kumasi, Ghana
Cornelius Archer Turpin
4. Beijing Key Laboratory of Clinical Epidemiology, School of Public Health, Capital Medical University, Beijing, China
Youxin Wang & Wei Wang
5. School of Public Health, Taishan Medical University, Taian, China
Wei Wang


This work was supported by the Australia-China International Collaborative Grant (NHMRC-APP1112767-NSFC81561120) and Edith Cowan University (ECU)-Collaborative Enhancement Scheme Round 1 (G1003363). Enoch Odame Anto was supported by ECU-International Postgraduate Research Scholarship.


Sub-optimal health status could be used as a tool to identify pregnant women at risk of pre-eclampsia. Pre-eclampsia is a condition characterised by high blood pressure in mothers during pregnancy or just after birth. At present, it is not fully clear what causes pre-eclampsia, and it remains a potentially serious pregnancy complication.
It is important that conditions such as pre-eclampsia can be detected early or prevented to improve health outcomes for mother and baby. This research team hoped to better understand the qualitative and biological differences between pregnant women with normal blood pressure and pregnant women who then develop pre-eclampsia. The team used a questionnaire developed from public health research called the SHSQ-25 to categorise a sub-optimal health stage before pre-eclampsia sets in.


Normotensive pregnancy: Maintenance of a normal blood pressure during pregnancy
Pre-eclampsia: A serious condition that arises during or after pregnancy and is identified by high blood pressure in the mother, proteins in the urine and fluid retention
Sub-optimal health status (SHS): The state between good health and disease
Predictive prevention personalised medicine (PPPM): A new tool that can predict the occurrence of disease which helps establish opportunities for prevention and personalised treatment options
Primary healthcare: Range of health services available to individuals as provided by medical systems and the community
Health risk assessment: Designed to promote good health by measuring potential threats to an individual’s health, usually with a questionnaire.


Participants were pregnant women visiting the Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana, from June 2017 to December 2018 who provided informed consent to participate in the study.
593 pregnant women were surveyed as part of the SHSQ-25 that tests overall health from 5 areas: fatigue, cardiovascular, digestive, immune and mental health. The questions were asked in the native Ghanaian language and translated for the consultant OBGYN.
Participants rated their answers on a scale of 1-5, 1 meaning never and 5 meaning always. Their scores were tallied up. A score greater or equal to 19 signified high SHS (poor health) and less than 19 was optimal health status.
Other information about participants was also gathered relating to sociodemographic factors (education, occupation, marriage status), medical history and previous pregnancy issues. Physical determinants such as blood pressure, pre-pregnancy BMI, height and proteins in the urine were also measured. Normal blood pressure was classed as less than or equal to 120/80 mmHg.
Blood samples were taken from pregnant women to identify biochemical features such as triglycerides, cholesterol, glucose levels and minerals.
Women were followed up twice during pregnancy and at birth for changes and pre-eclampsia.


498 women (of the 593 to start with) returned for final assessment. About half of the group had high sub-optimal health status (SHS) and half had optimal health status. Of those who had high SHS, 62% went on to develop pre-eclampsia compared to 18% in pregnant women who had optimal health status.
At baseline, a greater proportion of pregnant women with normal blood pressure were employed, Akan by ethnicity, completed high school, were married and had no family history of high blood pressure. Of these women, those with high SHS had a significantly greater history of miscarriage and completed pregnancies, while a greater proportion had never given birth before compared to those with optimal health.
When comparing women with pre-eclampsia in those with high SHS to those with optimal health, the high SHS group had significantly reduced magnesium, calcium, protein and albumin levels and increased blood pressure, low-density lipoprotein (bad cholesterol) and liver damaging enzymes.
There was a positive link between pre-eclampsia and the five question topics of the survey: fatigue, cardiovascular system, digestive, immune and mental health status as well as SHS score.
When predicting pre-eclampsia and other acute pregnancy complications, the regression model revealed that SHS alone had greater odds, higher ability to correctly identify those with pre-eclampsia (sensitivity), higher ability to correctly identify those without pre-eclampsia (specificity), pre-eclampsia coexisting with intrauterine growth restriction and stillbirth compared to its grouping with mineral levels of magnesium and calcium.


SHSQ-25 can be used on its own to estimate the risk of a pregnant women developing pre-eclampsia.


Pre-eclampsia (high blood pressure) is a common issue that can arise during pregnancy and after birth. While there are known risk factors, sometimes pre-eclampsia does not present with clear symptoms.
Current treatments for pre-eclampsia involve medication use to manage the condition or delivery. There has been a shift to focus research on preventative strategies that could help protect women during pregnancy and prevent complications that are related to pre-eclampsia.

HRA Comment:

This research incorporates elements that are qualitative, in that is uses non-numerical data gathered from questionnaires and interviews to capture the more unique characteristics of people that affect their health. These can relate to aspects such as our relationships, economic stability, education, and physical environments. Qualitative research can help understand the complexities of the human condition and experiences which are not possible to replicate in animal studies. As such, qualitative research methods produce results that not only reflect human health more accurately, but also minimise the need for animal use.


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