Pre-eclampsia/eclampsia is a serious condition that complicates 5%–10% of pregnancies globally [1] and, together with other hypertensive diseases of pregnancy, is responsible for approximately 14% of maternal deaths every year [2]. Because treatment requires early and careful monitoring of the pregnancy, the negative impact of these diseases is felt more in low-income countries where health-system factors often cause delay in reaching appropriate care [3]. In Nigeria, which has the second highest number of maternal deaths in the world [4], the prevalence of eclampsia/pre-eclampsia is reported at 163 per 10 000 deliveries [5]. One facility-based study [6] attributed 46.1% of maternal deaths to pre-eclampsia and eclampsia in Jigawa state in Northern Nigeria, where there is a high prevalence of early marriage (young age is a risk factor for pre-eclampsia) [7].
Although there is little understanding of what causes pre-eclampsia/eclampsia, there is an effective treatment for this condition. In 1994, WHO recommended magnesium sulfate as the standard treatment for pre-eclampsia and eclampsia, and within 2 years, it was placed on WHO’s Essential Medicines List. Treatment of pre-eclampsia with magnesium sulfate has been shown to significantly lower the risk of eclampsia (by 58%) and the risk of mortality (by 45%) [8–10].
Despite its known efficacy, this inexpensive drug is often underused, partly because the diffusion of an innovation takes time, but also because it requires a strong and effective referral system, often a challenge in under-resourced health systems. Although the treatment of eclampsia seems simple—introduce magnesium sulfate into the woman’s blood stream and deliver the fetus as soon as possible—doing so in time and correctly is complicated and involves many steps and many players [11–14].
The substantial contribution of pre-eclampsia/eclampsia to maternal mortality in Nigeria—along with the promise of magnesium sulfate as a solution—caught the attention of the John D. and Catherine T. MacArthur Foundation in 2005, when a program officer overheard a conversation between two Nigerian doctors who were lamenting the failure of a piece of equipment in their hospital laboratory that was used in the manufacture of magnesium sulfate. Without it, one was saying to the other, they would have no supply of the drug to treat pre-eclampsia/eclampsia and no way to save women’s lives.

In 2007, the MacArthur Foundation began funding a series of grants to expand the use of magnesium sulfate for pre-eclampsia/eclampsia in Nigeria. The impact of this work on maternal mortality was significant: the case fatality rate due to eclampsia dropped from 20.9% to 2.3%, and the findings encouraged the government to scale up the intervention to other states [15]. In 2014, the Foundation commissioned a process evaluation of this work to help to determine what factors facilitated uptake and expansion of magnesium sulfate services, the challenges encountered while implementing the projects, and existing opportunities for future scaling up of the services across the country. The present paper reports on the findings of that process evaluation.