Exploring the Role of the Pharmacist in the Prevention and Management of Hypertensive Disorders in Pregnancy in Ashanti Region, Ghana
Background Maternal health is of great importance to public health because of the risk of harm it poses to both the mother and the unborn child . Most women are often plagued with a number of complications during pregnancy. If these complications are not managed properly, they could result in a high rate of maternal mortality . Most of these deaths have been found to be associated with hypertensive disorders in pregnancy (HDPs) with a mortality ratio of 780 per 100,000 live births . HDPs are a leading cause of poor maternal and birth outcomes , contributing to nearly a quarter of maternal deaths . Globally, about 10% of pregnant mothers are affected by HDPs. However, in Ghana, there is evidence of persistent increase in HDP burden. Adu‐Bonsaffoh et al. reported that about 21.4% of pregnant women have HDPs , while Boachie‐Ansah et al. reported that about 37.2% of mothers have HDP , accounting for nearly a quarter of maternal mortalities in the country . There is evidence that most of the maternal deaths associated with HDPs could be avoided if women received timely and effective care according to evidence‐based standards . Policies recommend a collaborative approach towards the management of HDPs, which requires pharmaceutical care since antihypertensives and anticonvulsants (mainly magnesium sulphate) are the treatments of choice for uncontrolled blood pressure (BP) and the prevention and management of eclampsia . Thus, the services of the pharmacist are immense at maximizing the benefits of drug therapy during management and improving the health outcomes of HDPs. The concept of pharmaceutical care requires the pharmacist to be even more active and patient‐oriented in providing care. This paradigm has led to the introduction of pharmacist‐led interventions in patient management, where pharmacists are involved in patient follow‐ups, drug adherence assessment, adverse event soliciting, drug information and education, patient counseling, monitoring drug administration, and drug modifications [ , , , ]. To satisfy the modern role of pharmacist in provision of pharmaceutical care, Ghana remodeled the training of pharmacists and introduced the Doctor of Pharmacy program in 2012 . Therefore, the pharmacist is expected to play an active role in the management of HDPs among mothers in Ghana. Despite evidence of pharmacists improving quality of patients’ management, there is a paucity of data on the role of pharmacist‐led interventions in the management of HDPs in Ghana. Considering the high burden of HDP in Ghana , it was imperative to conduct this study to determine if pharmacist‐led interventions could improve antihypertensive medication adherence, knowledge on HDPs, and BP control, especially through Pharmacists’ recommendations in a pre‐ and post‐ interventional study . This could also serve as a newly identified source of training for Pharm D students and postgraduate clinical pharmacy students during their advanced pharmacy practice experience (APPE) in the country. 

Methods 2.1 Study Design This is a quasi‐experimental study where health outcomes of participants were assessed before a pharmacist‐led intervention serving as baseline, and these health outcomes were measured again after the intervention to serve as comparator. The intervention was an adapted Findings, Assessment, Recommendations and Monitoring (FARM) pharmaceutical care model provided fortnightly to study participants till delivery. Knowledge on HDPs, adherence to antihypertensives, and BP were assessed before and after the intervention. 2.2 Study Setting It was conducted at the KNUST hospital. This is the main university hospital, which attends to staff and students of the university as well as the general public, especially those in the surrounding communities. It is an 800‐bed capacity hospital located within the main university campus, which is in the Oforikrom municipality. The hospital renders general and specialist services and has various units, including medical, surgical, children's, obstetrics and gynecology, dental, eye, and pharmacy units. It is the first referral (district) hospital within the municipality. The hospital attends to 7181 pregnant cases in a year. An average of 29 women with HDPs are seen at the maternity clinic in a month. There were pharmacists and doctors of pharmacy house officers who are well‐trained to offer pharmaceutical care to participants. 2.3 Sample and Sampling All pregnant women who were at least 18 years old, had estimated gestational ages of not less than 16 weeks, had intentions to have subsequent antenatal care and delivery at KNUST hospital, had moderate to high risk of developing HDPs, could receive calls and text messages by phone or through the phone of a proxy, and those who gave consent to participate in the study were eligible for inclusion into the study. Women were considered to be at moderate to high risk of developing HDPs if they had a history of HDPs in a previous pregnancy, were hypertensive before the index pregnancy (chronic hypertension), or recorded a BP above 130/90 mmHg on the day of enrollment at the antenatal clinic (for the index pregnancy). Pregnant women with co‐morbid conditions (such as diabetes mellitus, chronic kidney disease) and those who were not comfortable with follow‐up calls, text messages, and interactions were excluded. Using Yamane's formula at a significance level of 5% , an estimated sample size of 100 pregnant women was adequate. Out of the 100 women recruited, eight were lost to follow‐up. Participants were randomly selected. Participants who presented to the antenatal clinic were informed about the purpose and the benefits of the study, and those who were interested in participating and fell in the inclusion criteria were made to pick from a bowl of shuffled papers with “Yes” or “No” written on them. Participants who picked yes were enrolled in the study and were each assigned to a pharmacist. 2.4 Development and Pre‐Testing of Data Collection Tools A research team comprising one physician, two clinical pharmacists, four Pharm D house officers, five research assistants, and three midwives was formed. As part of quality assurance measures, they had a series of meetings for 4 days before the start of the study. The orientation covered patient counseling, management of hypertension in pregnancy, skills in high BP control, ethical considerations, the objectives, and the protocol for the study. Standard operating procedures were also developed. Each member had a specific role to play. The data collection tools were developed after reviewing several literatures, guidelines and interacting with staff at the maternity unit of the hospital. Pre‐testing of the tools was done at the Manhyia Government Hospital, a district hospital in a different municipality within the Ashanti region. Tools such as a sphygmomanometer were calibrated, and the pharmacist, nurses, and other research team members were trained on how to administer these tools. The quality of the data was assessed weekly. Information was collected on pharmacist‐led interventions and the birth outcomes. The level of knowledge was assessed as an 18‐item composite variable. The reliability of the construct of the composite variable (level of knowledge) was assessed using Cronbach's alpha test. Cronbach's alpha for the 18 items was 0.73, indicating a reliable composite variable. For a correct response, a score of 1 was assigned and a score of 0 for a wrong response, giving possible maximum and minimum scores 18 and 0, respectively, for a respondent. If a participant scored less than 5, the level of knowledge was graded as poor, scores between 5 and 9 were considered satisfactory, 10 to 14 as good and 15 to 18 as excellent. A 10‐item self‐report tool was used to measure patients’ adherence to their antihypertensive medications. This 10‐item composite variable was developed by the authors after careful consideration of several articles [ , , , ]. The variables included in assessing adherence considered whether the participant missed any dose, whether the participant was able to remember their prescribed regimen, and whether there were efforts to immediately administer their medication after unintended misses. A response identified as appropriate towards adherence was assigned a score of “1,” and a response against adherence was assigned a score of “0.” The highest score of “10” indicates adherence, and the lowest score of “0” indicates non‐adherence. The score was categorized into three: patients who obtained a score of 8 were highly adherent, those with a score of 6–8 were moderately adherent, and a score < 6 indicated low adherence. Adherence was measured at the beginning and after 6 months of follow‐up. The dependent variable, HDPs was diagnosed and classified in accordance to the National Standard Treatment Guidelines 2017 and American College of Obstetricians and Gynaecologist classifications of HDPs . Additionally, HDPs was measured as a binary outcome. Women with a BP above 140/90 mmHg beyond 20 weeks’ gestation with or without history of hypertension or evidence of organ damage diagnosed by a doctor were considered as having HDPs and coded as 1, and those without evidence of HDPs were given a code of 0. 2.5 Data Collection Participants were assessed at baseline on the day of enrollment using a semi‐structured questionnaire, with a fortnightly follow‐up assessment till delivery. Appropriate interventions were rolled‐out during the follow‐up visits using an adapted FARM pharmaceutical care model. The key components of the model are finding patient specific risk factors and medication‐related problems, addressing risk factors, and resolving actual medication issues to prevent complications and possible medication‐related issues. Under the FARM model, the pharmaceutical care issues identified were obtained, solutions provided and outcomes were collected and summarized in Table . At baseline, participants’ socio‐demographic characteristics, knowledge, awareness, preventive practices of HDPs and adherence to medications were assessed using a 10‐item adherence tool prior to the administration of the interventions. 2.6 Intervention The elements considered important prior to the introduction of the intervention was if Pharmacist‐led interventions could improve antihypertensive medication adherence, knowledge on HDPs, BP control and reduce the risk of complications amongst those with moderate to high risk of developing HDPs. After obtaining the baseline measurements, the pharmacist followed‐up with all participants and provided them with education and pharmaceutical care. Adapted FARM pharmaceutical care was provided by a pharmacist and comprised; education and counseling on risk factors and lifestyle modification in line with the needs of the patient, drug therapy issues, medication administration reminders and monitoring for signs of HDPs, through the use of the mobile phone (via calls and text messages), face‐to‐face meet up with the patient at the ANC and also through the use of designed patient information leaflets (PILs). To ensure confidentiality, the pharmacist interacted with patients individually in private rooms every two weeks till delivery. Dates were agreed on with the mothers for follow‐ups, usually at the clinic or through phone calls. Outcomes such as BP control, increase in awareness of HDPs, medication administration adherence, other pharmaceutical care issues and birth outcomes were assessed during the interactions. Final assessment was made after delivery using the same questionnaire administered at baseline to assess the improvement in participants’ knowledge of HDPs, adherence to the antihypertensives and to monitor their controlled BP. 2.7 Data Analysis Data was coded into excel and exported into Stata version 15 (Stata Corp, Texas, USA) for statistical analysis. Descriptive statistics were provided for summarizing the background characteristics of participants, medications for treatment, birth outcomes and reported side effects. These were expressed as frequencies, percentages or bar charts. Differences in pre‐ and post‐intervention median scores were compared using the Wilcoxon signed‐rank test. p < 0.05 was considered statistically significant. 2.8 Ethics Approval The Committee on Human Research, Publications and Ethics, KNUST (CHRPE/AP/053/21), and the Research Board of KNUST Hospital (UH/51/Vol.1) approved the study. All study procedures were conducted in accordance with the Declaration of Helsinki. 

Study Design This is a quasi‐experimental study where health outcomes of participants were assessed before a pharmacist‐led intervention serving as baseline, and these health outcomes were measured again after the intervention to serve as comparator. The intervention was an adapted Findings, Assessment, Recommendations and Monitoring (FARM) pharmaceutical care model provided fortnightly to study participants till delivery. Knowledge on HDPs, adherence to antihypertensives, and BP were assessed before and after the intervention. 

Study Setting It was conducted at the KNUST hospital. This is the main university hospital, which attends to staff and students of the university as well as the general public, especially those in the surrounding communities. It is an 800‐bed capacity hospital located within the main university campus, which is in the Oforikrom municipality. The hospital renders general and specialist services and has various units, including medical, surgical, children's, obstetrics and gynecology, dental, eye, and pharmacy units. It is the first referral (district) hospital within the municipality. The hospital attends to 7181 pregnant cases in a year. An average of 29 women with HDPs are seen at the maternity clinic in a month. There were pharmacists and doctors of pharmacy house officers who are well‐trained to offer pharmaceutical care to participants. 

Sample and Sampling All pregnant women who were at least 18 years old, had estimated gestational ages of not less than 16 weeks, had intentions to have subsequent antenatal care and delivery at KNUST hospital, had moderate to high risk of developing HDPs, could receive calls and text messages by phone or through the phone of a proxy, and those who gave consent to participate in the study were eligible for inclusion into the study. Women were considered to be at moderate to high risk of developing HDPs if they had a history of HDPs in a previous pregnancy, were hypertensive before the index pregnancy (chronic hypertension), or recorded a BP above 130/90 mmHg on the day of enrollment at the antenatal clinic (for the index pregnancy). Pregnant women with co‐morbid conditions (such as diabetes mellitus, chronic kidney disease) and those who were not comfortable with follow‐up calls, text messages, and interactions were excluded. Using Yamane's formula at a significance level of 5% , an estimated sample size of 100 pregnant women was adequate. Out of the 100 women recruited, eight were lost to follow‐up. Participants were randomly selected. Participants who presented to the antenatal clinic were informed about the purpose and the benefits of the study, and those who were interested in participating and fell in the inclusion criteria were made to pick from a bowl of shuffled papers with “Yes” or “No” written on them. Participants who picked yes were enrolled in the study and were each assigned to a pharmacist. 

Development and Pre‐Testing of Data Collection Tools A research team comprising one physician, two clinical pharmacists, four Pharm D house officers, five research assistants, and three midwives was formed. As part of quality assurance measures, they had a series of meetings for 4 days before the start of the study. The orientation covered patient counseling, management of hypertension in pregnancy, skills in high BP control, ethical considerations, the objectives, and the protocol for the study. Standard operating procedures were also developed. Each member had a specific role to play. The data collection tools were developed after reviewing several literatures, guidelines and interacting with staff at the maternity unit of the hospital. Pre‐testing of the tools was done at the Manhyia Government Hospital, a district hospital in a different municipality within the Ashanti region. Tools such as a sphygmomanometer were calibrated, and the pharmacist, nurses, and other research team members were trained on how to administer these tools. The quality of the data was assessed weekly. Information was collected on pharmacist‐led interventions and the birth outcomes. The level of knowledge was assessed as an 18‐item composite variable. The reliability of the construct of the composite variable (level of knowledge) was assessed using Cronbach's alpha test. Cronbach's alpha for the 18 items was 0.73, indicating a reliable composite variable. For a correct response, a score of 1 was assigned and a score of 0 for a wrong response, giving possible maximum and minimum scores 18 and 0, respectively, for a respondent. If a participant scored less than 5, the level of knowledge was graded as poor, scores between 5 and 9 were considered satisfactory, 10 to 14 as good and 15 to 18 as excellent. A 10‐item self‐report tool was used to measure patients’ adherence to their antihypertensive medications. This 10‐item composite variable was developed by the authors after careful consideration of several articles [ , , , ]. The variables included in assessing adherence considered whether the participant missed any dose, whether the participant was able to remember their prescribed regimen, and whether there were efforts to immediately administer their medication after unintended misses. A response identified as appropriate towards adherence was assigned a score of “1,” and a response against adherence was assigned a score of “0.” The highest score of “10” indicates adherence, and the lowest score of “0” indicates non‐adherence. The score was categorized into three: patients who obtained a score of 8 were highly adherent, those with a score of 6–8 were moderately adherent, and a score < 6 indicated low adherence. Adherence was measured at the beginning and after 6 months of follow‐up. The dependent variable, HDPs was diagnosed and classified in accordance to the National Standard Treatment Guidelines 2017 and American College of Obstetricians and Gynaecologist classifications of HDPs . Additionally, HDPs was measured as a binary outcome. Women with a BP above 140/90 mmHg beyond 20 weeks’ gestation with or without history of hypertension or evidence of organ damage diagnosed by a doctor were considered as having HDPs and coded as 1, and those without evidence of HDPs were given a code of 0. 

Data Collection Participants were assessed at baseline on the day of enrollment using a semi‐structured questionnaire, with a fortnightly follow‐up assessment till delivery. Appropriate interventions were rolled‐out during the follow‐up visits using an adapted FARM pharmaceutical care model. The key components of the model are finding patient specific risk factors and medication‐related problems, addressing risk factors, and resolving actual medication issues to prevent complications and possible medication‐related issues. Under the FARM model, the pharmaceutical care issues identified were obtained, solutions provided and outcomes were collected and summarized in Table . At baseline, participants’ socio‐demographic characteristics, knowledge, awareness, preventive practices of HDPs and adherence to medications were assessed using a 10‐item adherence tool prior to the administration of the interventions. 

Intervention The elements considered important prior to the introduction of the intervention was if Pharmacist‐led interventions could improve antihypertensive medication adherence, knowledge on HDPs, BP control and reduce the risk of complications amongst those with moderate to high risk of developing HDPs. After obtaining the baseline measurements, the pharmacist followed‐up with all participants and provided them with education and pharmaceutical care. Adapted FARM pharmaceutical care was provided by a pharmacist and comprised; education and counseling on risk factors and lifestyle modification in line with the needs of the patient, drug therapy issues, medication administration reminders and monitoring for signs of HDPs, through the use of the mobile phone (via calls and text messages), face‐to‐face meet up with the patient at the ANC and also through the use of designed patient information leaflets (PILs). To ensure confidentiality, the pharmacist interacted with patients individually in private rooms every two weeks till delivery. Dates were agreed on with the mothers for follow‐ups, usually at the clinic or through phone calls. Outcomes such as BP control, increase in awareness of HDPs, medication administration adherence, other pharmaceutical care issues and birth outcomes were assessed during the interactions. Final assessment was made after delivery using the same questionnaire administered at baseline to assess the improvement in participants’ knowledge of HDPs, adherence to the antihypertensives and to monitor their controlled BP. 

Data Analysis Data was coded into excel and exported into Stata version 15 (Stata Corp, Texas, USA) for statistical analysis. Descriptive statistics were provided for summarizing the background characteristics of participants, medications for treatment, birth outcomes and reported side effects. These were expressed as frequencies, percentages or bar charts. Differences in pre‐ and post‐intervention median scores were compared using the Wilcoxon signed‐rank test. p < 0.05 was considered statistically significant. 

Ethics Approval The Committee on Human Research, Publications and Ethics, KNUST (CHRPE/AP/053/21), and the Research Board of KNUST Hospital (UH/51/Vol.1) approved the study. All study procedures were conducted in accordance with the Declaration of Helsinki. 

Results 3.1 Socio‐Demographic Characteristics of Participants A total of 100 participants were enrolled but 8 were lost to follow‐up. Hence data for 92 participants were analyzed. The socio‐demographic characteristics are shown in Table . The ages ranged from 20 to 44 years, with a mean of 35.7years (± 1.2). Majority of the participants (60.9%) were in their late 30s (35–39 years). Most (63%) participants were Asantes, more than half (55.4%) had attained basic education, about a fifth tertiary education and less than 5% had had no formal education. Majority were married (83.2%), Christians (78.9%), in private employment (7.5%) and resided in urban areas (91.3%). 3.2 Obstetric History of Participants Majority of the women in this interventional study were multigravida (73.6%), and multiparity (65.2%). Thirty percent (30%) of the women had family history of hypertension, about a fifth (19.6), had history of HDPs while a tenth (10.9%) of the mothers monitored their BP at home (Table ). 3.3 End of Study Outcome Measures The pharmacist‐led interventions had significant effects on BP control, identification and resolution of pharmaceutical care problems, adherence to medication and level of knowledge on preventive lifestyle measures for HDPs among pregnant women. The outcomes are shown in results that follows below. 3.4 Identification and Resolution of PC Issues as an Outcome of Study Table summarizes outcomes of the pharmaceutical issues identified and resolved during the study. The key care issues were knowledge on HDPs, issues with medication side effects and adherence, use of unprescribed medicines, BP recordings, and other pregnancy‐related issues. 3.5 Effect of Intervention on BP Control, Level of Knowledge, and Medication Adherence The proportion of mothers who had HDPs decreased by nearly a tenth at the end of the intervention, however, this decrease was not statistically significant (9.8%, 95% CI: 23.8%–4.2%; p = 0.17), Table . Medication adherences were assessed on 45 of the respondents who were put on antihypertensives. The proportion of mothers who were adherent increased (5 vs. 8; p < 0.001). The median knowledge score of the participants on HDPs improved significantly after the intervention (11 vs. 17; p < 0.001). 3.6 Trend in Participant Adherence to Medication Similarly, the post‐intervention median adherence score was significantly higher than the baseline median adherence score (5 vs. 9; p < 0.001), Table . The adherence before and during the follow up period are shown in Figure . Overall, adherence to medication therapy increased significantly by 68.9% (95% CI, 53.9%–83.8%; p < 0.001), with the peak adherence (88.9%) occurring around 28 weeks’ gestation. 3.7 Obstetric Outcomes Measures On obstetric outcomes, about 91% of these women at risk of developing HDPs delivered vaginally, and all but two of all the deliveries resulted in live birth (97.8%) (Table ). 

Socio‐Demographic Characteristics of Participants A total of 100 participants were enrolled but 8 were lost to follow‐up. Hence data for 92 participants were analyzed. The socio‐demographic characteristics are shown in Table . The ages ranged from 20 to 44 years, with a mean of 35.7years (± 1.2). Majority of the participants (60.9%) were in their late 30s (35–39 years). Most (63%) participants were Asantes, more than half (55.4%) had attained basic education, about a fifth tertiary education and less than 5% had had no formal education. Majority were married (83.2%), Christians (78.9%), in private employment (7.5%) and resided in urban areas (91.3%). 

Obstetric History of Participants Majority of the women in this interventional study were multigravida (73.6%), and multiparity (65.2%). Thirty percent (30%) of the women had family history of hypertension, about a fifth (19.6), had history of HDPs while a tenth (10.9%) of the mothers monitored their BP at home (Table ). 

End of Study Outcome Measures The pharmacist‐led interventions had significant effects on BP control, identification and resolution of pharmaceutical care problems, adherence to medication and level of knowledge on preventive lifestyle measures for HDPs among pregnant women. The outcomes are shown in results that follows below. 

Identification and Resolution of PC Issues as an Outcome of Study Table summarizes outcomes of the pharmaceutical issues identified and resolved during the study. The key care issues were knowledge on HDPs, issues with medication side effects and adherence, use of unprescribed medicines, BP recordings, and other pregnancy‐related issues. 

Effect of Intervention on BP Control, Level of Knowledge, and Medication Adherence The proportion of mothers who had HDPs decreased by nearly a tenth at the end of the intervention, however, this decrease was not statistically significant (9.8%, 95% CI: 23.8%–4.2%; p = 0.17), Table . Medication adherences were assessed on 45 of the respondents who were put on antihypertensives. The proportion of mothers who were adherent increased (5 vs. 8; p < 0.001). The median knowledge score of the participants on HDPs improved significantly after the intervention (11 vs. 17; p < 0.001). 

Trend in Participant Adherence to Medication Similarly, the post‐intervention median adherence score was significantly higher than the baseline median adherence score (5 vs. 9; p < 0.001), Table . The adherence before and during the follow up period are shown in Figure . Overall, adherence to medication therapy increased significantly by 68.9% (95% CI, 53.9%–83.8%; p < 0.001), with the peak adherence (88.9%) occurring around 28 weeks’ gestation. 

Obstetric Outcomes Measures On obstetric outcomes, about 91% of these women at risk of developing HDPs delivered vaginally, and all but two of all the deliveries resulted in live birth (97.8%) (Table ). 

Discussion The role of the pharmacist in recent years has been the delivery of patient‐oriented drug therapy with the aim of improving the patient's overall quality of life . As such the concept of pharmaceutical care has caused a paradigm from compounding of drugs to being more involved in the management of patients’ condition. As part of a team‐based care model, pharmacists are increasingly involved in interdisciplinary efforts to enhance patient outcomes . This study sought to explore the role of pharmacist‐led interventions within a team‐based care framework in the management of HDPs among women at risk who are seeking obstetric care at the university hospital. As part of team‐based care, pharmacists offered interventions including monitoring of BP, resolving drug therapy issues (including intolerable side effects, interactions and contraindications), medication administration reminders, hypertensive disorder signs monitoring, health education, and counseling on preventive lifestyle modifications in line with the needs of the patient during follow‐ups. ANC attendance was duly encouraged, and the pregnancy outcomes were also monitored. This confirmed previous studies which concluded that pharmacists monitored BP readings from their patients, informed them of their target BP measurements, emphasized the necessity to maintain their medications even after reaching their target BP ranges, and referred patients to their doctors as needed. These monitoring, interventions, and collaboration with patients and doctors were thought to critically enhance patient hypertension control . Additionally, it was discovered that better BP control was related to patients' understanding of their BP goal values . Mothers who received treatment for HDPs, showed higher rate of reporting side effects, and this is because of the consistent Pharmacist follow ups and education on expected side effects of medicines. It is therefore evident that follow up could increase the rate of reporting of adverse events and should be encouraged considering the country is plagued with the issue of under‐reporting of adverse events . However, the reported side effects were not severe but of common occurrence as reported in reference materials and they were resolved. This role of the pharmacist was seen to be relevant at reducing the effects of adverse medicine reactions, increase medication compliance and also promote safety of both mother and child, which would subsequently lead to improved hypertensive status of the mothers. In addition, the outcomes of this study's interventions helped to increase awareness on the importance of the supportive role of the pharmacist at antenatal care, reduced complications, and hospitalization, promoted better outcome of pregnancy and overall patient satisfaction. The BP monitoring was based on the JNC 8 classification for hypertension, ACOG practice guidelines 222, and the Ghana standard treatment guidelines 2017 . The prevalence of HDPs was estimated as 66.3% and 56.5% at baseline and post intervention, respectively. Thus, the effect size of the impact of the pharmaceutical intervention was estimated at reducing HDPs by 9.8%. Although the estimated impact of pharmacist‐led interventions was not statistically significant, this finding is at variance with scientific suggestions that pharmacist interventions are potent at achieving BP control . As evidence from the analysis revealed that the pharmaceutical intervention could reduce the burden by as huge as 23.8%. This impact size estimate may be due to the delayed timing of the intervention. The intervention started at week 16 gestation where most mothers begin to develop hypertensive disorders. Delayed care is often associated with poor outcomes. Second, the sample size of the interventional study was small which made the study less powered and as such increased the risk of type two error. This accounts for the wide confidence interval obtained for this study. The Pharmacist‐led team‐based intervention increased the level of adherence by over fourfold (Figure ). This increase is considered statistically significant and higher than the50% adherence to medication as reported by the WHO and several studies . This finding also confirms a clinical trial conducted by Erku et al. , which realized that pharmacist interventions increased medication adherence by over six folds. Additionally, the level of adherence to antihypertensive medications was sustained above 80% amongst mothers with HDPs until delivery. This was as a result of continuous administration of the pharmaceutical counseling and reminder interventions bimonthly. Most pharmaceutical interventions on behavioral changes such as medication adherence are short term and their effects dissipates when the intervention ceases, continuous administration of the pharmacist intervention, particularly for the management of chronic health conditions is recommended . It is therefore obvious that the role of the pharmacist at providing continuous medication counseling could improve medication adherence because the pharmacist has been identified as been skilled at reinforcing patient's attitude with medications . This would in turn improve treatment outcomes, reduce hospitalization, morbidity, mortality, and treatment costs. The counseling role of the pharmacist is of great importance at influencing the awareness of the patient to drug related information and lifestyle modifications to disease prevention. Previous studies have shown that patient education and counseling improves patient knowledge on HDPs as well as regular monitoring of BP and attendance at antenatal clinic . In this study, after receiving the clinical pharmacist's education on HDPs, lifestyle modification, and medication adherence, the women's knowledge on HDPs increased by a third and their practices towards management of HDPs improved. Similarly, results from a previous study had also reported that the clinical pharmacist's education on knowledge of PIH among pregnant women about their disease, lifestyle modification, and pharmacotherapy achieved an optimal outcome of therapy. This process helped provide insight for the management of HDPs with the help of PILs and other patient education inputs . This finding supports existing scientific evidence that pharmacist counseling improves knowledge, attitude, and practices of patients . Therefore, it may be timely to include the pharmacist as part of the antenatal care services of the mother and to explore a collaborative approach among health care professionals during the management of patients with hypertensive disorders. The burden of stillbirth among the high‐risk group of HDPs in this study was 2.17% after pharmacist's intervention. This prevalence though of public health importance, is reduced compared to the study findings. Amongst participants with HDPs, the burden of stillbirth could rise to about 17% as witnessed in the study conducted by Raghuraman et al. Another study conducted in Ghana revealed that 6.8% of mothers with HDPs had stillbirths . Therefore, the observed reduction in the burden of stillbirth in this study is likely attributed to the effect of the Pharmacist's intervention. Additionally, several studies have established that HDPs increase the risk of complications such as placenta abruption, previa, restricted fetal growth, preterm delivery, and caesarean section. For this study it was realized that 6.52% underwent caesarean section. This could even be higher amongst mothers with HDPs as evidence suggests that their risk of undergoing caesarean section could be increased by 1.7 folds . Some studies reported a burden of about 26% which indicates that about a quarter of mothers with HDPs undergo caesarean section . Therefore, there is a decreased cases of caesarean section among the mothers. The introduction of the pharmacist's intervention led to early HDPs management and its associated reduction in poor birth outcomes. 4.1 Scalability and Sustainability of Intervention The pharmacist‐led intervention has the potential to be scaled across all level of the health care system. This is because the members of this team‐based approach are already recruited at all levels of the health care system. Additionally, this intervention does not require specialized skills to execute. It employs a collaborative approach with the pharmacist having a profound duty to follow up on patients. This intervention is a cost‐effective approach and does not require additional resources to execute. Since most duties are part of the routine activities of the professionals, patients are expected to pay their usual healthcare bills with some portions of the income invested into the pharmacists’ follow‐up plan. 

Scalability and Sustainability of Intervention The pharmacist‐led intervention has the potential to be scaled across all level of the health care system. This is because the members of this team‐based approach are already recruited at all levels of the health care system. Additionally, this intervention does not require specialized skills to execute. It employs a collaborative approach with the pharmacist having a profound duty to follow up on patients. This intervention is a cost‐effective approach and does not require additional resources to execute. Since most duties are part of the routine activities of the professionals, patients are expected to pay their usual healthcare bills with some portions of the income invested into the pharmacists’ follow‐up plan. 

Conclusion The pharmacist‐led interventions increased medication adherence, increased the level of awareness on HDPs preventive measures among HDP mothers through education and continuous counseling, addressed issues on medication therapy issues and controlled the BP. The role of the pharmacist is imperative for the management of HDPs. 

Conception, design, acquisition, and analysis of data: Pauline Boachie‐Ansah, Berko Panyin Anto, Afia Frimpomaa Asare Marfo, Edward Tieru Dassah, Morrison Asiamah, Kwaku Gyamfi Oppong, and Nana Ofori Adomako. Drafting of manuscript and revising it: Pauline Boachie‐Ansah, Berko Panyin Anto, Afia Frimpomaa Asare Marfo, Morrison Asiamah, Edward Tieru Dassah, and Ivan Eduku Mozu. Revising and approval of final manuscript to be published: Pauline Boachie‐Ansah, Afia Frimpomaa Asare Marfo, Ivan Eduku Mozu, and Edward Tieru Dassah. 

The Committee on Human Research, Publications and Ethics, KNUST (CHRPE/AP/053/21) and the Research Board of KNUST Hospital (UH/51/Vol.1) approved the study. 

Informed consent was obtained from all pregnant women before enrollment in the study. Participants were assured of their right to be informed about the findings of the study. 

The authors of this study have no competing interests. 

