Challenges and Prospects in Managing Hypertensive Disorders of Pregnancy in Sub-Saharan Africa: A Narrative Review

Abstract

Background

Hypertensive disorders of pregnancy (HDP) are the leading cause of maternal mortality in sub-Saharan Africa (SSA), accounting for 70% of the global maternal death burden. Despite international guidelines, the management of these conditions, particularly preeclampsia, is hindered by significant structural, clinical, and sociocultural challenges in low-income countries. This narrative review critically analyzes the challenges in the prevention, diagnosis, and management of HDP in resource-constrained settings in SSA, and identifies contextually appropriate solutions to improve maternal outcomes.

Methods

A literature search of studies published between 2014 and 2024 was conducted using the PubMed, Scopus, Google Scholar, and African Journal Online databases. This review synthesizes evidence from qualitative, quantitative, and mixed-method studies and systematic reviews focusing on the epidemiological, organizational, and community dimensions of care for hypertensive disorders across SSA countries. Studies were selected on the basis of their relevance to HDP care challenges and innovations in SSA. The Scale for the Assessment of Narrative Review Articles (SANRA) guided the rigor and reporting of this review, with six core criteria systematically applied: justification of article selection, comprehensive literature search, quality assessment, evidence synthesis, transparent reporting, and methodological transparency.

Results

Key challenges identified included fragmented health systems, poor adherence to clinical protocols, shortages of essential medicines and equipment, inadequate healthcare worker training, delayed care-seeking due to low health literacy and cultural beliefs, and insufficient epidemiological data. Promising strategies include strengthening antenatal care and screening, maternal education, task-sharing with community health workers, providing targeted training for healthcare workers, implementing simplified protocols, utilizing task sharing with community health workers, and enhancing interdisciplinary coordination.

Conclusion

Reducing maternal mortality due to HDP in SSA requires an integrated approach that combines strengthening health systems, community engagement, targeted training, and context-adapted guidelines. Sustained investment in local research, data sharing, and policy reform is essential for achieving sustainable improvements in maternal health care.

Introduction

Hypertensive disorders of pregnancy (HDP), including pre-eclampsia, are among the most common medical complications of pregnancy,^1,2 affecting 5–10% of pregnancies globally.^3,4 Globally, HDP is the second leading cause of maternal mortality² contributing to 25% of maternal deaths.^5,6 In some settings, HDP is a significant cause of adverse neonatal outcomes including preterm birth and intrauterine growth restriction.^1,7–9 However, in sub-Saharan Africa (SSA), they are the leading cause of maternal death, accounting for a disproportionate share of the global burden.^6,9–11 This disparity underscores HDP as a critical public health challenge, with profound implications for maternal and neonatal survival in the region.

Preeclampsia represents the most frequent type of HDP and can become severe and complicated without adequate and early management, leading to various signs of multiorgan failure associated with poor maternal and fetal prognosis.^9,10,12 In SSA, the burden is compounded by biological susceptibility among women of African descent, with emerging evidence implicating genetic factors beyond biological and genetic predispositions, particularly among this population.^10,13

Modifiable risk factors further amplify this vulnerability; primiparity, adolescent pregnancy, chronic hypertension, obesity, anemia, and inadequate antenatal care have all been consistently associated with increased HDP risk across the region.^14–16

Despite the wealth of accumulated evidence, significant unresolved issues remain concerning the effective translation and practical application of knowledge.^17–19 High death rates in this area are due to social and cultural factors, problems in the healthcare system, and personal risks.^1,20–22 Several studies have investigated these issues. Discussions often focus on issues such as slow access to healthcare, lack of medicines, and broken systems separately.^14,15,18,19 This approach overlooks how these issues are connected and does not suggest combined solutions for areas with limited resources.^4,16,23 Another major problem is that policymakers do not have sufficient practical advice on how well different solutions work, where they can be used, and how they work.^16,24,25 Insufficient research on the efficacy of these solutions across various regions of SSA necessitates the development and implementation of community-based strategies that enhance health systems through judicious use of local resources.^26–28

To create a comprehensive understanding that can guide contextually relevant policy and practice, these gaps underscore the necessity of narrative synthesis that incorporates various evidence types, qualitative insights, quantitative findings, and programmatic experiences.

This narrative review addresses these gaps by providing a critical synthesis of the interconnected challenges impeding effective HDP prevention, diagnosis, and management in SSA, with the following specific aims to:

1. Critically synthesize the current evidence on the interconnected barriers to HDP prevention, diagnosis, and management in resource-constrained SSA.

2. Identify contextually appropriate multilevel strategies spanning health systems, community engagement, workforce training, and policy reform to improve maternal and perinatal outcomes.

3. Highlight scalable innovations and prospects for intervention, emphasizing integrated and sustainable approaches tailored to low-resource settings.

The subsequent discussion examines these challenges in depth, from systemic and logistical constraints to healthcare workforce limitations and sociocultural factors, before presenting corresponding solutions organized around the same thematic framework, ensuring clear linkages between problems and prospects. By integrating diverse evidence types, this narrative approach generates a holistic understanding to inform policymakers, practitioners, and researchers working toward equitable maternal healthcare in the region, advancing the Sustainable Development Goals (SDGs) for maternal health (SDG 3), quality education (SDG 4), and gender equality (SDG 5).²⁴

Methods of the Narrative Review

Literature Search Strategy

We applied the Scale for the Assessment of Narrative Review Articles (SANRA) criteria to guide the development and reporting of this review.²⁹ This checklist enhances the reliability of a narrative review by emphasizing transparency and systematic approaches, thereby improving the quality of the synthesized evidence.²⁹ SANRA’s six core criteria of SANRA were specifically applied: justification of article selection, comprehensive literature search, quality assessment, evidence synthesis, transparent reporting, and methodological transparency. This framework helped define explicit inclusion criteria, guided the multi-database search strategy, facilitated critical appraisal of studies for methodological quality and contextual relevance, enabled thematic synthesis of diverse evidence types, and ensured the transparent presentation of findings with clear source attribution.²⁹

We conducted a systematic search of peer-reviewed literature published between 2014 and 2024. The databases used for this search included PubMed/MEDLINE, Scopus, and the African Journal Online (AJOL). A combination of Medical Subject Headings MeSH terms and keywords relevant to hypertensive disorders during pregnancy and SSA were employed.

The search focused on identifying key evidence, including guidelines, seminal trials, systematic reviews, and qualitative studies, that addressed care challenges and innovations. In addition, grey literature from major health organizations was reviewed. Articles were selected based on their relevance to the critical analysis objectives of the review, prioritizing high-impact and context-specific studies (Table 1). This strategy is aimed at conceptual saturation and representativeness, rather than exhaustive retrieval.

Table 1.

Summary Table of Challenges and Prospects for the Management of Hypertensive Disorders in Pregnancy in Sub-Saharan Africa

	Author(s)	Year	Country/Region	Type of Study	Target Hypertensive Disease	Challenges Identified	Proposed Solutions	SANRA Score	Quality Level
1.	Nakimuli et al9	2025	Uganda	National assessment	Severe preeclampsia	Variability in emergency care, regional inequalities	Harmonisation of practices, strengthening hospital capacity	10/12	High
2.	Muhindo et al22	2025	Uganda	Qualitative study	Preeclampsia, eclampsia	Delayed access to care, sociocultural barriers	Community awareness, close monitoring	12/12	High
3.	Bune et al30	2024	Ethiopia	Case-control study	Gestational hypertension, preeclampsia	Delayed diagnosis, lack of follow-up	Targeted screening, strengthening primary care	11/12	High
4.	Namagembe et al21	2024	Uganda	Qualitative study	Preeclampsia	Lack of coordination, overburdened services, absence of clear protocols	Strengthening clinical leadership, clarifying roles, improving interprofessional communication.	12/12	High
5.	Escobar andet al4	2024	LMICs	Scope review	Hypertensive disorders	Fragmentation of care, inequalities in access	Integrated care models, digital tools	12/12	High
6.	Koiwah Koi-Larbi et al16	2024	Ghana (regional symposium)	Scientific conference report	Hypertensive disorders	Poor interdisciplinary collaboration, low use of evidence	Collaborative research, data sharing, shared decision-making	12/12	High
7.	Sium et al31	2024	Ethiopia	Mixed study	Severe preeclampsia	Poor pre-referral management, delays in transfer	Standardisation of care prior to transfer, targeted training for providers.	10/12	High
8.	Ngwira et al32	2024	Malawi	Qualitative study	Preeclampsia	Lack of resources, provider stress, differing perceptions	Patient-provider dialogue, resource strengthening	9/12	High
9.	Atluri et al20	2023	Ghana	Qualitative study	Preeclampsia	Lack of equipment, provider overload	Clinical algorithms, obstetric simulation	12/12	High
10.	Jikamo et al24	2023	SSA	Systematic review	Preeclampsia	Limited epidemiological data	Enhanced surveillance	12/12	High
11.	Byiringiro et al25	2023	SSA	Systematic review	Gestational hypertension	Lack of training, absence of guidelines	Continuing education, local adaptation of recommendations	12/12	High
12.	Tanya Robbins et al33	2023	Rural Ethiopia	Qualitative study	Preeclampsia	Staff shortages, lack of clear protocols, overload	Systemic approach, strengthening hospital staff	12/12	High
13.	Adu-Bonsaffoh et al15	2022	Ghana	Multicentre qualitative study	Preeclampsia and eclampsia	Logistical barriers, lack of coordination, absence of clear guidelines	Development of simplified local protocols, skills building and involvement of general practitioners	8/12	Moderate
14.	Confidence et al34	2022	Uganda	Qualitative study	Severe preeclampsia	Difficulties in adhering to national guidelines	Clinical supervision, continuing education	11/12	High
15.	Von Dadelszen et al23	2021	LMICs (SSA)	Review/PRE-EMPT programme	Preeclampsia	Lack of standardised protocols, poor access to specialist care	Integrated care models, triage tools, provider training	11/12	High
16.	Sevene et al28	2021	Mozambique	Feasibility study	Preeclampsia	Delays in access, lack of qualified personnel	Task-sharing with community agents, emergency protocols	10/12	High
17.	Warren et al27	2020	Multi-Country	Commentary	Preeclampsia, eclampsia	Poor integration into primary care	Adoption of a community-based care model	9/12	High
18.	Meazaw andet al1	2020	Multi-country SSA	Systematic review and meta-analysis	Hypertensive disorders of pregnancy	Limited access to care, late diagnosis, lack of data	Strengthening prenatal care, community surveillance	11/12	High
19.	Gemechu andet al6	2020	SSA	Systematic review	Preeclampsia and eclampsia	Poor obstetric coverage, high mortality	Training of providers, improvement of protocols	10/12	High
20.	Tura et al35	2020	Ethiopia	Comparative study	Severe hypertensive disorders	Low sensitivity of WHO criteria, underestimation of severe cases	Adaptation of near-miss criteria to the African context	10/12	High
21.	Rawlins et al18	2018	6 African countries	Observational study	Preeclampsia and eclampsia	Low use of magnesium sulphate, lack of protocols	Training of midwives, standardisation of care	12/12	High
22.	Adoyi et al14	2016	Nigeria	Assessment of facility preparedness	Preeclampsia, eclampsia	Poor facility preparedness, lack of resources	Quality audits, capacity building	12/12	High
23.	Muchiri et al17	2016	Kenya	Clinical audit	Preeclampsia, eclampsia	Non-compliance with national guidelines	Monitoring practices, strengthening protocols	12/12	High
24.	Vogel et al19	2016	DRC, Ethiopia, Myanmar, Laos	Multicentre qualitative study (GREAT Network)	Maternal health (including PE/E)	Barriers to implementation of WHO guidelines	Contextual adaptation, local prioritisation, stakeholder engagement	12/12	High
25.	Goldenberg et al26	2015	SSA	Critical review	Preeclampsia and eclampsia	Delayed treatment, maternal mortality	Community interventions, access to magnesium sulphate	8/12	Moderate
26.	Elongi et al36	2011	DRC (Kinshasa)	Cross-sectional study	Preeclampsia	Seasonal influence on prevalence	Seasonally adapted epidemiological surveillance	11/12	High

Abbreviations: WHO, World Health Organization; SSA, Sub-Saharan Africa; LMICs, Low- and Middle-Income Countries; HTN, Hypertension; DRC, Democratic Republic of the Congo; SANRA, Scale for the Assessment of Narrative Review Articles.

Critical Summary of the Challenges

The management of preeclampsia in SSA is hampered by interconnected constraints operating at the systemic, healthcare delivery, and community levels (Figure 1). These barriers do not exist in isolation, but reinforce one another, creating a cycle of delayed diagnosis, inadequate treatment, and preventable maternal deaths.

Figure 1.

Challenges in the Management of Hypertensive Disorders during Pregnancy in sub-Saharan Africa.

Systemic, Political and Logistical Challenges

Health policies and system failures represent fundamental obstacles to effective HDP management across SSA. A primary concern is poor adherence to established care protocols even when they exist. A lack of effective referral networks for at-risk and suspected patients is commonly observed.^{14,17,18,20,30,34}

In Kenya, despite the availability of standardized national guidelines, healthcare providers frequently do not observe them.¹⁷ In Uganda, skill shortages hinder protocol implementation, resulting in the delayed assessment of at-risk women.³⁴ As a result, the majority of at-risk women were not seen immediately upon admission to the hospital.¹⁴ A Nigerian study found that less than one-fifth of health facilities had appropriate preeclampsia management guidelines, particularly regarding magnesium sulfate (MgSO₄) availability or administration.¹⁸

These policy shortcomings are compounded by the structural and logistical deficits. Limited access to antenatal care, delayed diagnosis of preeclampsia, initiation of preventive measures such as low-dose aspirin,⁵ and the absent of patient triage compromise the appropriate assessment and management of suspected or confirmed cases.²³

Weak referral and transfer systems further exacerbate delays, particularly for patients identified in primary health centers requiring higher-level.²¹

In addition, geographical inaccessibility compounds organizational failures. In rural and isolated areas, physical distance to well-equipped facilities, combined with unrealizable and unaffordable transport, creates critical delays or a complete lack of access to intensive care.²¹ Even when essential medicines and equipment are available at the national level, inefficient supply chains, storage deficiencies, and distribution failures lead to stockouts at local facilities.¹⁵

Healthcare Challenges: Human and Material Resources

At the facility level, shortages of basic diagnostic tools (poor supplies for diagnosis), such as blood pressure-measuring devices (sphygmomanometers and stethoscopes), urine test strips for rapid proteinuria, and medications, including MgSO₄ and antihypertensive drugs, delay diagnosis and management.^14,19,37 Adoyi et al¹⁴ found that less than a third (31%) of Nigerian facilities had all the necessary equipment and supplies, and only 34% had MgSO₄ available in labor and maternity units.

Preventive interventions such as low-dose aspirin, calcium supplementation,³⁸ and vitamin D remain underutilized owing to cost, logistical constraints, inadequate, and provider training.³⁹

Parallel to material shortages is a critical human resource crisis: quantitative and qualitative deficiencies of healthcare personnel.^14,18,20,30 Insufficient knowledge of the prevention, diagnosis, and management of the available staff leads to the delayed recognition of preeclampsia.^14,18,20,30

Furthermore, a lack of mentoring and clinical supervision perpetuates poor protocol adherence.^17,34 These human and technical shortcomings reinforce each other, creating overwhelming workloads for the existing staff who manage referrals from under-ressourced facilities with limited technical capacity.^20,21,33 Quality preeclampsia care requires organizational change that creates a safe space for learning and improvement, patient-centered approaches, and provider support necessary for evidence-based practice.^15,20,21

Socio-Community and Patient-Related Challenges

Community-level factors profoundly influence care-seeking behaviors and treatment adherence. Generally, low literacy in the SSA population affects early detection and compliance with management recommendations, ultimately impacting maternal and fetal prognosis.²² This reflects a lack of sufficient information, often cited as the root cause of dependence, which may explain patients’ attitudes toward this recognized fatal disease.²⁰ This may lead to an underestimation of the medical complexity of pregnancy, thereby ignoring the increased risk of preeclampsia,²¹ which is also the cause of the stress experienced during pregnancy.³² However, this educational deficit²¹ may be the basis for a lack of awareness of the symptoms (headaches and facial swelling), thus delaying the seeking of care³² and sometimes a lack of understanding of the risks and non-adherence to treatment.²⁰ This may also be linked to a low socioeconomic status³² and cultural or religious beliefs.²⁰

Cultural and religious beliefs further shape health behaviors. In Uganda, midwives report that patients often misinterpret preeclampsia symptoms or do not consider them serious, viewing pregnancy as naturally requiring medical intervention only when severe symptoms appear. Some women prefer traditional healers over hospitals,^20,28 or settle for ill-equipped local facilities to manage preeclampsia.²¹ Fear of medical interventions, unfamiliar hospital environments, and stigma associated with pregnancy complications leads others to avoid or delay seeking care.^22,30

Beyond individual and family determinants, there may be a lack of awareness and education about the symptoms of preeclampsia, risks, and importance of prompt medical intervention. This can lead to delays in seeking care, particularly in communities where traditional beliefs may override modern medical advice.^{1,14,22,26,28}

Community leadership is an underutilized resource. Low-involvement community leaders, individuals in whom populations place their trust, contribute significantly to delayed recognition and response times.^22,28,30 These leaders, in whom the population places trust and guidance is perceived as necessary and inspiring, play a central role. Unfortunately, their limited knowledge of preeclampsia has created a critical gap in prevention, early detection, monitoring, and treatment.²⁸

Underlying these challenges are deeply entrenched gender inequalities characteristic of many patriarchal African societies. Women’s health and education are often deprioritized, resulting in low educational attainment, limited health knowledge, financial dependence on male partners, and reduced capacity to make informed health decisions.²⁰

Research and Data Gaps

Finally, SSA faces a fundamental research challenge: the scarcity of contextual data on prevalence, risk factors, and effective interventions for severence-based health policy development. Health systems lack robust data collection and sharing mechanisms, making it impossible to accurately assess disease burden, monitor patient outcomes, or measure intervention effectiveness. These dual shortcomings perpetuate a cycle in which the absence of local evidence and reliable data presents sustainable progress against preventable maternal mortality.¹⁶

Prospects for Improving Management

Addressing these interconnected challenges requires equally integrated multilevel responses. Given the complex realities documented across SSA, approaches must be holistic to achieve effective management and reduce the causes of maternal mortality from HDP. The following prospects correspond directly to the previously identified challenge domains, thus creating a coherent framework for action (Figure 2).

Figure 2.

Prospects for improving management of Hypertensive Disorders during Pregnancy in sub-Saharan Africa.

Addressing Systemic and Logistical Barriers Through Health Systems Strengthening

The persistence of unacceptable maternal mortality rates in SSA highlights the failure of such fragmented approaches. Comprehensive strategies for improving maternal health services that address primary, secondary, and tertiary prevention. This initially involved adapting the WHO near-miss criteria to local contexts and implementing them.^35,40 Antenatal care must become geographically and financially accessible, even in rural and disadvantaged areas, to enable early first-trimester consultations and timely identification of at-risk patients.³⁶

To address critical resource shortages, consistent availability of basic equipment, essential medicines, and qualified personnel must be ensured.⁴¹ This requires a strategic overhaul of public health policies, moving beyond one-off interventions toward a holistic vision that integrates the structural, financial, and collaborative dimensions. Such policy frameworks must rest on three interdependent pillars: strengthening the capacity of the system, eliminating financial barriers, and strategically mobilizing multisectoral partnerships.

Addressing Socio-Community Barriers Through Maternal Education and Community Awareness

Meazaw et al¹ identified low maternal education as a significant risk factor for HDP in SSA, suggesting that interventions should focus on improving women’s access to education and raising their awareness of potential risk factors. Jikamo et al²⁴ echoing the rationale, recommending awareness-raising, early screening, pharmacological treatment, and health promotion as part of routine antenatal care and community outreach.²⁴ Benjelloun et al²⁴ advocated the systematic integration of hypertension screening with antenatal consultations using simple and accessible tools.

Strengthening Clinical Care Delivery Through Training, Protocols, and Leadership

Targeted Training and Clinical Supervision

Ensuring adequate and ongoing training of health personnel in preeclampsia screening and management for quality care.^{6,15,18,23,34} Continuing education programs, obstetric simulations, and regular clinical supervision significantly improves care quality.^{14,20,28,31,34}

Simplified Protocols and Digital Tools

Developing simple, context-appropriate referral and management protocols for preeclampsia diagnosis and screening is imperative.^4,15,17 Dissemination of these protocols, their availability in healthcare facilities, and their rigorous use by personnel must be prioritized. Clarifying professional roles and improving interprofessional communication are effective strategies for managing this disease. Mobile applications that guide therapeutic decisions offer particular promise in resource-limited settings.⁴

Clinical Leadership and Interdisciplinary Coordination

Recent evidence from Uganda and Ethiopia highlights the value of transformational approaches that focus on strengthening clinical leadership and improving interprofessional communication.^21,33 This strategy consolidates the care pyramid by facilitating synergy between actions and efficiency in patient management, thereby directly addressing the coordination failures identified earlier.

Overcoming Human Resource Constraints Through Task-Sharing and Community Engagement

Task-sharing with community health workers (CHWs) is a significant opportunity in SSA. Informing pregnant women and their communities about the importance of antenatal care and preeclampsia danger signs through awareness campaigns and community meetings can significantly increase attendance at consultations.^22,26–28 Task sharing for the initial screening and preliminary management of preeclampsia has proven to be feasible and acceptable in Mozambique and other settings.²⁸

Goldenberg et al,²⁶ Warren et al²⁷ and Sevene et al²⁸ also emphasized the role of CHWs in early detection, emergency management, and referral, demonstrating feasibility and effectiveness in low-resource context consultations.^22,26–28

Filling Research and Data Through Collaborative Research and Data Sharing

Robust local data form the foundation of evidence-based planning in healthcare. Koiwah Koi-Larbi et al¹⁶ reported the recommendations of the 5th Scientific Symposium on Preeclampsia in Ghana, which issued clear recommendations: strengthening local research, sharing data, and integrating results into clinical practice.

These actions enable a clear understanding of the problem and the development of appropriate solutions aligned with sustainable development goals to improve women’s reproductive health.

Creating and Consolidating Multi-Stakeholder Participation

Sustainable improvement requires the participation of all decision makers, including patients, community leaders, health professionals, and policymakers. Patient collaboration in screening and treatment adherence, vigilance from health professionals, and the implementation of policies that promote universal access to obstetric care by policymakers must align, ensuring that solutions are technically sound, socially acceptable, and politically feasible.

Conclusion

On the eve of 2030, the fight against maternal mortality remains a serious challenge in SSA despite most deaths being preventable While efforts to address postpartum hemorrhage continue, hypertensive disorders of pregnancy (HDP), particularly preeclampsia and eclampsia, are the leading causes of maternal death in the region, demanding urgent and focused attention.

These systemic challenges include poor referral mechanisms, inadequate drug supplies, healthcare service constraints caused by insufficient training and diagnostic resources, societal barriers such as gender disparity and limited health awareness, and notable deficiencies in contextual research and evidence.

These obstacles mutually strengthen each other, creating recurring patterns of delayed diagnosis, inadequate care, and preventable mortalities. Addressing this multifaceted challenge requires comprehensive and coordinated strategies rather than isolated efforts.

Three practical priorities were highlighted. First, ensuring the widespread availability of magnesium sulfate and blood pressure monitoring equipment across all healthcare tiers must be a governmental priority. These two measures alone could avert the majority of eclamptic seizures and facilitate early identification. Second, expansion of task delegation to community health workers for initial screening, basic management, and patient referral should be implemented regionally to directly address delays in seeking care and staffing gaps. Third, all maternity care centers should implement streamlined, locally appropriate treatment guidelines combined with routine hands-on training exercises to enhance healthcare providers’ compliance and competence.

These priorities are practical, cost effective, and expandable. Their execution requires political commitment; decision-makers must convert policy recommendations into financial commitments and supply chain systems, and the research community should assess the practical impact through implementation research. Most importantly, women and their communities must serve as collaborators through educational and empowerment initiatives.

Meeting Sustainable Development Goal 3.1, which aims to reduce maternal deaths to less than 70 per 100,000 live births, requires urgent action to address hypertensive disorders during pregnancy. The research is conclusive and effective interventions exist. What is now required is a shared resolution to implement them.

Funding Statement

There is no funding to report.

Data Sharing Statement

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

Author Contributions

All authors made a significant contribution to the work reported, whether in the conception, study design, and execution or in all these areas, took part in drafting, revising, or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors have no conflicts of interest in this work.