By Khadijah Alibhai
In Ethiopia, 412 women die per 100,000 live births. Most of these deaths are preventable, and 19 percent of them are from hypertensive disorders of pregnancy, including pre-eclampsia and eclampsia (PE/E). Typically, pre-eclampsia is detectable during early antenatal care with regular blood pressure checks and tests for abnormal amounts of protein in urine. When necessary, it can be managed with administration of antihypertensive drugs, or when necessary magnesium sulphate, an anticonvulsant drug.
Some of the most common risk factors for pre-eclampsia are anemia, chronic hypertension, and overweight/obesity – all of which can be a direct consequence of malnutrition. In a retrospective study of anemia in pregnant women, researchers found that women with severe anemia were 3.6 times more likely to develop PE compared to women with no anemia. Research focusing on survivors of severe acute malnutrition found that malnutrition during infancy and childhood puts people at greater risk of hypertension in adulthood. And in addition to increased risk of hypertension, another study showed that malnutrition beginning at an early age increases the likelihood of adult overweight/obesity. While these studies are limited by their specific locations and relatively small cohorts, a recent Ending Eclampsia study in Ethiopia found that women are very aware of the impacts malnutrition, hypertension, and anemia can have on a pregnancy.
Our study aimed to reduce gaps in information about how pregnant women interact with the health system to get the care they need. We partnered with the Federal Ministry of Health to learn more about the barriers and opportunities for PE/E care in the Ethiopian context. We wanted to know about cultural norms during pregnancy and awareness of pregnancy-related complications among women, husbands, and mothers-in-law. To find out, researchers conducted a series of focus group discussion (FGDs), comprised of married men and women, aged 18 years or older with children, in rural and peri-urban communities in the Southern Nations and Nationalities Region (SNNPR) of Ethiopia.
The FGDs revealed that health extension workers have been successful in educating their communities, and consequently, respondents appeared to be extremely aware of one main challenge: the difficulties women face when trying to maintain a healthy diet during pregnancy. Despite awareness of the importance of nutrition, they reported financial difficulties and purchasing power, rather than a lack of availability of nutritious food, as barriers to maintaining healthy diets. As one participant explained:
“Even when the hen lays an egg, [a pregnant woman] wouldn’t eat it…She will take it to the market to sell so that she can earn money to purchase salt and gasoline. This is how balanced diet is difficult to maintain.”
As this respondent points out, despite the pregnant women knowing it would be healthy for her to eat an egg, she does not eat it because her family needs to sell it for money. The quote above reflects awareness of the barriers beyond nutrition education that impact accessibility to proper diet.
Poor diet was associated with pregnancy-related complications and negative outcomes during delivery, and respondents even recommended consuming a low-caffeine, low-salt diet to manage hypertension in pregnancy. Another FGD participant explained:
“In order to give birth to a healthy and normal baby, we need to have a good nutrition system, but if we are hurt inside and don’t eat properly, we could deliver a baby who is under weight.”
The results of our FGDs, though not representative of the whole country, show not only the impact community health workers can have on populations, but could also be useful in deciding the best ways to spread awareness about the causes, prevention, and treatment of PE/E. Furthermore, these data point toward a number of additional obstacles and the need to investigate and implement interventions that eliminate the barriers preventing women and girls from accessing quality maternal and newborn health services and healthy birth outcomes. While nutrition education on a community level is trending upward, it is evident that barriers to effecting change lie in economic growth/stability and capacity building further up the chain.
 Ali, A. A., Rayis, D. A., Abdallah, T. M., Elbashir, M. I., & Adam, I. (2011). Severe anaemia is associated with a higher risk for preeclampsia and poor perinatal outcomes in Kassala hospital, eastern Sudan. BMC Research Notes, 4, 311. http://doi.org/10.1186/1756-0500-4-311
 Tennant, I. A., Barnett, A.T., Thompson, D. S., Kips, J., Boyne, M. S., Chung, E. E., Chung, A. P., Osmond, C., M. A., Hanson, M. A., Gluckman, P. D., Segers, P., Kennedy Cruickshank, J., and Forrester, T.E. (2014), Impaired Cardiovascular Structure and Function in Adult Survivors of Severe Acute Malnutrition. Hypertension, DOI: 10.1161/HYPERTENSIONAHA.114.03230
 Sawaya, A. L., Sesso, R. , Florêncio, T. M., Fernandes, M. T. and Martins, P. A. (2005), Association between chronic undernutrition and hypertension. Maternal & Child Nutrition, 1: 155-163. doi:10.1111/j.1740-8709.2005.00033.x
 Sripad, P., Ismail, H., Dempsey, A., Kirk, K., Warren, C., (2018). Exploring barriers and opportunities for pre-eclampsia and eclampsia prevention and management in Ethiopia. Ending Eclampsia, Population Council.