Access to quality magnesium sulfate and implementation of guidelines can help reduce maternal deaths due to preeclampsia.
When a mother dies, the impact of her death reaches much further than the individual tragedy. It affects the life and health of the family, their economic situation, as well as their community. Many studies show just how devastating the loss of mothers is, especially in low and middle-income countries, where 99% of these deaths occur . A study in Ethiopia showed that 81% of newborns whose mother had died during or shortly after childbirth also died . Older surviving children (especially girls) suffered through high school drop-out rates to take over some of the mother’s role, poorer health, higher likelihood of early marriage and childbearing, and sometimes an unfavourable social status if the father takes on a new wife .
Between 1990 and 2015, the maternal mortality rate (MMR) worldwide dropped 44%, from 385 to 216 maternal deaths per 100’000 live births , but many countries are still far from the 2030 Sustainable Development Goals target of a global MMR of below 70. It was estimated that in 2015 303’000 women died in pregnancy, childbirth, or postpartum. Most of these deaths were preventable through effective care, implementation of guidelines, and access to quality lifesaving medicines.
Between 2003 – 2009, it is estimated that hypertensive disorders were the second cause of maternal mortality worldwide after haemorrhage, accounting for 14% of all deaths. Of these, only 1% happened in developed countries . Preeclampsia is a condition which can affect pregnant women from around the 20th week of gestation and up to 6 weeks postpartum, characterised by elevated blood pressure (hypertension) and protein in urine  .
In 2011 the WHO recommended the use of magnesium sulfate (MgSO4) for the prevention of eclampsia and treatment of severe pre-eclampsia (PE/E) .
Only quality assured magnesium sulfate, correctly transported and stored, and used by trained health workers will effectively prevent and treat PE/E. Women in many resource-poor settings are at risk of receiving drugs which are out of specification due to low quality ingredients, poor manufacturing, incorrect storage, expired or falsified products.
“What do I know about this vial? When it expires? I tell you, I know for how long I have it and if it turns yellow then for sure it’s not good anymore…. What does it do? It saves two lives. Of the mother, and of the baby…. [But] it may be plain water or poison.” Doctor referring to a vial of magnesium sulfate with no expiry date, brought by a former patient from a bordering country, in response to local shortages in Romania 
There are six WHO prequalified magnesium sulfate products , and three different preparations (2ml, 10ml and 20ml) stocked by UNFPA , yet many women in lower income countries have issues with access to quality life-saving drugs. Factors facilitating the presence of poor quality drugs can largely be grouped in three main categories: access-related, governance-related, and limited technical capacity (manufacturing, regulators, testing etc…) [8, p. 3].
MgSO4 is one of the 13 Life-Saving Commodities identified by the UN Commission on Life Saving Commodities as essential for maternal and child health. The UN Commission on Life Saving Commodities (UNCoLSC) follow-up report found high stockouts rates at national level of magnesium sulfate: 78% of facilities in the Democratic Republic of Congo, 74% in Kenya and 68% in Zambia . Inefficient budgeting and procurement practices for maternal health supplies are one of the main factors leading to stockouts which create increased demand for unofficial markets, where quality is not controlled. Open drug markets are also popular in countries where out of pocket expenditure on medicines is high, as patients will seek more affordable options.
In addition to availability challenges, the dosage of MgSO4 for treatment of PE/E requires careful calculation and patient monitoring for toxicity, so training of healthcare workers and availability of guidelines are key pieces of the puzzle, without which maternal death cannot be efficiently prevented. Interviews with hospitals in Pakistan found large variations in the doses of MgSO4 being administered. Healthcare workers and pharmacists lacked adequate dosage training in some teaching hospitals which prevented them from using this lifesaving medicine, especially as written protocols were often unavailable . Studies have demonstrated how development of evidence-based protocols for healthcare worker trainings in Nigeria, decreased the PE/E mortality rate by 80% in the facilities involved [13, p. 6].
99% of maternal deaths due to hypertensive disorders occur in developing countries. Magnesium sulfate is vital for treating PE/E, but access to quality-assured magnesium sulfate and lack of local implementation of guidelines and training in low resource settings pose large barriers to its safe and effective use.
On World Pre-Eclampsia Day we join the call for increased action across low and middle income countries on increasing access to magnesium sulfate and adequate training and guidelines to ensure that healthcare workers can effectively eliminate this cause of maternal deaths.
More information on World Preeclampsia Day here.
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 Population Council, “Increasing Access to Magnesium Sulphate in Nigeria Brief,” 2016. [Online]. Available: https://www.popcouncil.org/uploads/pdfs/2016RH_EndingEclampsia_MagnesiumSulphateNigeria.pdf. [Accessed 13 May 2019].
 Preeclampsia Foundation, “Postpartum Preeclampsia: Moms are Still at Risk After Delivery,” 02 October 2018. [Online]. Available: https://www.preeclampsia.org/stillatrisk. [Accessed 13 May 2019].
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 M. Bigdeli, S. Zafar, H. Assad and A. Ghaffar, “Health System Barriers to Access and Use of Magnesium Sulfate for Women with Severe Pre-Eclampsia and Eclampsia in Pakistan: Evidence for Policy and Practice,” PLoS ONE, vol. 8, no. 3, p. e59158, 2013.
 C. Warren, S. Ishaku and O. B. Ayodeji, “Landscaping analysis for pre-eclampsia and eclampsia in Nigeria,” Population Council, Abuja: Federal Capital Territory, 2015.