November 30, 2016

Community voices for fewer maternal deaths

By Charlotte Warren

The Lancet Maternal Health Series, published last month, calls for stronger appreciation of the voices and needs of women and their families, and emphasizes better incorporation of health providers’ views when defining maternal health priorities. Lynn Freedman’s piece says, “The engine will be the determination of people at the front-lines of health systems – patients, providers, and managers – to find or take the power to transform their own lived reality. Our job in global health is first to listen to them, and then to co-create the conditions at every level of the system that can make that locally driven transformation possible.”

Hypertensive disorders during pregnancy (HDP) cause 12% of maternal deaths globally, according to Graham and colleagues. In Nigeria, Bangladesh, and Pakistan, HDP makes up 30%, 20%, and 10% of maternal deaths, respectively. We know these deaths are preventable, and we also know that barriers at all levels of the health system allow them to continue.

The Ending Eclampsia project conducted three in-country landscape analyses that identified policy and health system barriers prohibiting women from accessing life-saving care. The analyses also honed in on the experiences of women who had pre-eclampsia and eclampsia (PE/E), their families, and their health providers. The findings support Freedman’s appeal.

Across seven states, only 15% of Nigerian health providers assessed pregnant women for risk factors during antenatal care (ANC) visits. Other than severe hypertension or proteinuria, only 9% knew edema, blurred vision, severe headaches, and convulsions are other symptoms of severe pre-eclampsia and eclampsia.

In Bangladesh, our assessments of facility and provider capacity showed the same heartbreaking results. Of Bangladeshi women who attended ANC visits at primary and secondary facilities, only 24% knew of PE/E danger signs after their consultation. Four percent and 13% understood that high blood pressure and convulsions, respectively, are associated with PE/E. Despite that, 92% of these same women said they were satisfied with their ANC experiences and planned to refer their friends to ANC.

Our researchers also conducted focus group discussions with men and women to assess their understanding of pregnancy- and childbirth-related complications. Overall, they believe symptoms of PE/E are normal experiences for pregnant women.

“These are women’s problems during pregnancy and after delivery. My mother also passed through these. So, I don’t want to interfere with women’s problems and step in. My mother and grandmother might be the right persons to decide.” Male FGD participant, Bangladesh

We asked them to name three major complications during pregnancy. The most common responses: Physical weakness, breech presentation, and bleeding before and after delivery. No mention of PE/E, even though it the second most common direct cause of maternal deaths in Bangladesh.

Considering these numbers, it is no surprise that so many women die from PE/E because it lives under the radar, undetected. These numbers show that better training and support are needed for health providers currently working at facilities, not just an increase in the number of providers at facilities. Community education and sensitization that raises awareness on quality ANC and danger signs of PE/E and explains that it is preventable and treatable, can empower decision makers to invest in their mothers’ and babies’ health. Community data like this, listening, and co-creation of interventions should inform national and state strategies. It could enhance the success of maternal and child health policies worldwide.

For the full landscape analysis reports from Nigeria and Bangladesh, visit the Resources section on The report from Pakistan will be available soon!



  • Graham, W et al. Diversity and divergence: The dynamic burden of poor maternal health. The Lancet Maternal Health Series, 2016.
  • Warren, C et al. Landscape Analysis of Pre-eclampsia/Eclampsia in Nigeria. Population Council, 2015.

Charlotte Warren is a senior associate at the Population Council’s Washington, DC office. A nurse by training, she serves as Director of the Ending Eclampsia project and has extensive experience in sub-Saharan Africa using implementation research to support ministries of health develop policies, implement best practices, and scale up programs for maternal and neonatal health, reproductive health, family planning, and primary health care.