Background: over half a million women die each year from pregnancy related causes signifying thatrncomplications of pregnancy and childbirth are the leading cause of death amongst women ofrnreproductive ages. Hypertensive disorders of pregnancy are the second direct cause of maternal deathrnonly next to hemorrhage which accounts 14% of all maternal mortality globally and 16 % in subSaharanrnAfricanrncountries.rnrnInrnEthiopiarn11%rnofrnallrnmaternalrndeathsrnandrn16%rnofrndirectrnmaternalrndeathsrnrnarernrndue to this obstetric complication. There is paucity of study looking into the pattern andrndistribution, the risk factors and the maternal and perinatal outcomes of hypertensive disorders ofrnpregnancy. Moreover, little is known why hypertensive disorders of pregnancy are not early detectedrnand managed to prevent the serious consequences of the disorders. rnObjective: the aim of this study was to assess hypertensive disorders of pregnancy and its effect onrnbirth outcomes rnMethods: The study was conducted in public hospitals of Tigray, Ethiopia. Cross-sectional, matchedrncase control, cohort and descriptive qualitative designs were applied for objectives one, two, threernand four respectively. For the retrospective record review, all records of women diagnosed withrnhypotensive disorders of pregnancy from September 2012 to August 2017 (with calculated samplernsize of 746) were considered while for the case control study a total of 330 (cases=110 andrncontrols=220) matched by parity were included. In addition, a total of 374 (exposed/withrnhypertensive disorders=187, non-exposed/without hypertensive disorders=187) were included in thernfollow up study. In the qualitative study, for documenting barriers, health professionals, health carernleaders and women with a history of hypertensive disorder of pregnancy were included. Cases werernpregnant women attending maternal health services with a diagnosis of hypertensive disorders ofrnpregnancy by an obstetrician while controls were pregnant women attending maternal health servicesrnwithout hypertensive disorders of pregnancy. In the cohort study, exposed group were womenrndiagnosed with any of the hypertensive disorders of pregnancy after 20 weeks of gestation by anrnobstetrician while non-exposed group were women free from any of the hypertensive disorders ofrnpregnancy. Case-control incidence density sampling was used to identify cases and controls. For therncohort study, women diagnosed with hypertensive disorders of pregnancy with their nonhypertensivernrnpairs were enrolled after 20 weeks of gestation and followed until the first 7 daysrnpostpartum. In both designs (case-control and cohort) the sample size was distributed to eachrnselected hospitals according to the case load. For the qualitative study, a total of 22 in-depthrninterviews were conducted and the sample size was guided by the level of information saturation rnData entry for the quantitative study was done into Epi-Info software and it was analysed usingrnSTATA 14 software. Descriptive statistics was computed and data were summarized in frequencies,rnproportions and means. Binary logistic regression was used to calibrate the association of differentrnvariables with the dependent variable for the quantitative study. For the case control studyrnconditional logistic regression model was applied and Odds ratio was generated. Besides, relativernrisk was generated from a binary logistric regression for the cohort study. P-value less than 0.05 werernconsidered significant in all analysis. For the qualitative study, recorded data were transcribedrnverbatim and translated to English. The transcript was exported to Atlas ti.7 software for qualitativerndata analysis which was followed by developing a categorization scheme to reduce the data andrnmake it more manageable. Transcripts were read for several times and the primary codes werernextracted. Then, the related codes were put in one group/category. Finally, based on similarity andrncontent, the subcategories were used to make the main categories or themes. Thus, thematic contentrnanalysis was used to generate the main themes of the study. The overall findings were presentedrnusing figures, tables and texts. Ethical clearance was obtained from Institutional Review Board (IRB)rnof Addis Ababa University College of Health Sciences. Cooperation letter was written from thernRegional Health Bureau and permission was requested from study facilities. Individual writtenrninformed consent was also sought from respondents at the time of data collection. rnResults: A total of 45,329 mothers were admitted to deliver in the selected public hospitals of Tigrayrnduring the five years study period (September 2012 to August 2017). Out of the total deliveries, 1347rn(3%) women were diagnosed for one of the hypertensive disorders of pregnancy. The overallrnmagnitude showed an increasing trend over the review period ranging from 1. 4% in 2013 to 4% inrn2017 which gives average percentage increase of 31% per annum.The change over the five yearsrnperiod was checked for its significance using chi-square trend analysis and it was found to bernsignificant (Xrn2rn= 153, pâ‰¤0.001). rnMultivariable analysis on the relationship between hypertensive disorders of pregnancy and differentrncovariates revealed that rural residence (AOR = 3.7, 95% CI; 1.9, 7.1), less amount of fruitsrnconsumption (OR =5.1, 95% CI;2.4, 11.15), being overweight (pre-pregnancy BMI>25 Kg/m2)rn(AOR= 5.5 95% CI; 1.12, 27.6), gestational diabetes mellitus (AOR = 5.4, 95%CI; 1.1, 27.0) andrnmultiple pregnancy (AOR= 4.2 95%CI; 1.3, 13.3) were independent predictors of hypertensiverndisorders of pregnancy. rnMoreover, the study showed higher risk of having pregnancies complicated by maternal and perinatalrnadverse outcomes. Thirty six (20.2%) of hypertensive women and 19(10.7%) of normotensivernwomen undergone cesarean section delivery. Preterm birth (RR=1.8; 95%CI, 1.5, 2.2), stillbirthrn(RR=1.6; 95%CI, 1.3, 2.02), low birth weight (RR=1.9; 95%CI, 1.6, 2.3), early neonatal deathrn(RR=1.7; 95%CI, 1.3, 2.3), perinatal death (aRR=2.6, 95%CI; 1.2, 5.7) and cesarean sectionrndelivery(RR=1.7; 95%CI, 1.02, 2.9) were significantly higher among women with hypertensiverndisorders of pregnancy rnFurthermore, the qualitative study showed that knowledge deficit and traditional believes towardsrnhypertensive disorders of pregnancy, delayed referral and provision of incomplete pre-referralrntreatments in the lower level health care facilities, failure to implement antenatal follow up as per thernrecommendation; scarcity and interruption in the supply of resources; and lack of mentorshiprnprograms to make professionals competent were claimed for the late detection and management ofrnhypertensive disorders of pregnancy. rnConclusion: Hypertensive disorder of pregnancy in Tigray is found to be 3% and it showed anrnincreasing trend. Rural residence, less fruit consumption, multiple pregnancy, presence of gestationalrndiabetes mellitus and pre-pregnancy overweight were identified as independent risk factors in therncurrent study. Besides, women with hypertensive disorders in pregnancy were at significantly higherrnrisk of having pregnancies complicated by maternal and perinatal adverse outcomes. A significantrnrisk of cesarean section delivery, preterm birth, perinatal death, stillbirth and low birth weightrndelivery were reported among women with hypertensive disorders of pregnancy. rnMoreover, poor awareness of mothers and community misconceptions towards hypertensiverndisorders of pregnancy, multiple referrals before reaching the final functional health care facility, lessrnfocus on the quality of antenatal care, scarcity of resources and limited capacity building programsrnwere reported as barriers for early detection and management of hypertensive disorders of pregnancy. rnTherefore, health care managers and administrators at different level of the health care system shouldrngive due emphasis to hypertensive disorders of pregnancy as it is one of the top causes of maternalrnand perinatal mortality and its magnitude is increasing from time to time. rnHealth institutions should have strong strategies of screening, counselling, follow-up and referralrnlinkage of mothers in the antenatal clinic and maternity wards by availing necessary materials andrndesigning strong supportive supervision/ mentorship programs.