25 times more likely to die: The pregnancy condition targeting African women

Pre-eclampsia is a danger to pregnant women. It’s a complication characterised by high blood pressure and organ damage, arising during the second half of pregnancy, in labour or in the first week after delivery.

It plays a major role in about 16 per cent of the deaths of pregnant women in sub-Saharan Africa.

And it’s on the rise: between 2010 and 2018, the incidence of pre-eclampsia in Africa jumped by around 20 per cent.

Pre-eclampsia usually occurs in young mothers during a first pregnancy. Girls under the age of 18 years are most at risk. The probability that a 15-year-old girl will die from complications of pregnancy is one in 150 in developing countries, versus one in 3,800 in developed countries, according to the World Health Organisation.

Not only does pre-eclampsia pose a serious health threat to women, it also harms babies. It contributes to stillbirth, pre-term birth and low birth weight.

Yet we still do not know enough about pre-eclampsia. This gap has driven my research into the disease.

I conducted the first genetic case-control study on pre-eclampsia among African women in comparison to European women over a decade ago for my PhD research.

My work revealed that both African and European populations have a gene (KIR AA genotype) that increases the chance of pre-eclampsia. However, African women are at greater risk of pre-eclampsia than other racial groups. This is because they are more at risk of carrying a foetus with a C2-type HLA-C gene from the father. African populations have a higher frequency of this gene, which raises the likelihood of risky mother-foetus combinations.

An additional finding from my research is that genetic protection from pre-eclampsia works differently across populations – and African populations carry unique protective genes. However, even with these additional protections, African women are at greater risk of developing severe pre-eclampsia due to the other challenges, like access to healthcare and socio-economic constraints.

There’s inequality in the treatment of the condition too. In my experience, wealthier and better-educated African women often receive the necessary diagnosis and treatment. Poorer and less-educated African women too often do not.

Pre-eclampsia research, especially in Africa, requires a lot more funding, as does broader research related to the maternal health of African women.

Pre-eclampsia in Uganda

Around 287,000 women worldwide die during pregnancy and childbirth every year. Shockingly, 70 per cent of these are African women.

Most of these deaths are preventable. For example, around 10 per cent are the result of high blood pressure-related conditions during pregnancy.

Uganda’s Ministry of Health recorded in 2023 that out of 1,276 maternal deaths reported, 16 per cent were associated with high blood pressure.

Hospitals are being overwhelmed by patients with the illness. For example, Kawempe National Referral Hospital in Kampala receives around 150 patients with the condition every month. It has set up a special ward to treat them.

The maternal mortality rate (death due to complications from pregnancy or childbirth) in Uganda is 284 per 100,000 live births.

In Australia it is 2.94. The neonatal mortality rate (death during the first 28 completed days of life) is 19 per 1,000 live births in Uganda against 2.37 in Australia. Infant mortality (death before a child turns one) is 31 per 1,000 live births in Uganda versus 3.7 in Australia, according to the WHO’s Global Health Observatory.

This stark contrast highlights an enormous gap in care that the two countries’ pregnant mothers and babies receive.

Part of the problem in Uganda, as in many developing countries, is persistent challenges in healthcare infrastructure. There are shortages of healthcare workers, medical supplies and facilities, particularly in the rural areas.

Early detection key

As a clinician and researcher working at the centre of Uganda’s healthcare system, I witness mothers arriving at hospitals already in a critical condition, with limited options to treat the complications associated with pre-eclampsia. It is heart-breaking.

The condition is both preventable and treatable if caught early. My research focuses on identifying biological signs of the likelihood of complications during pregnancy, using data analysis informed by Artificial Intelligence.

These predictive biomarkers, as they are called, enable us to categorise patients based on their risk levels and identify those most likely to benefit from specific treatments or preventive measures.

The precise causes of pre-eclampsia are not certain, but factors beyond genetics are thought to be problems with the immune system and inadequate development of the placenta. But much of what researchers know comes from work done in high-income countries, often with a limited sample size of African women.

Consequently, the findings may not apply directly to the genetics of sub-Saharan African women. My research addresses this knowledge gap.

Building on my findings about genetic determinants, I am leading a research team at Makerere University to design interventions tailored to specific prevention and treatment strategies for African populations.

Raising awareness

Research alone is not enough. There is an urgent need to bridge the gap between research and practice.

During my fieldwork, I have witnessed first-hand how many Ugandan women are not aware of pre-eclampsia’s warning signs and miss out on vital prenatal care. These warning signs often include headache, disturbances with vision, upper pain in the right side of the abdomen and swelling of the legs.

But we can develop screening algorithms so that healthcare professionals can rapidly diagnose women at higher risk early in their pregnancy. Timely intervention, including specific treatment and plans for delivery, would reduce the risk of adverse outcomes for both mother and baby.

In my capacity as a national pre-eclampsia champion appointed by Uganda’s Ministry of Health, I am spearheading initiatives to raise awareness and improve access to maternal healthcare services.

Through community outreach programs and educational campaigns, we want to empower all women, rich and poor, with knowledge about the condition and encourage them to seek medical assistance at an early stage.

More resources must be allocated to genetics research to realise our goals of prevention, early detection, diagnosis and treatment of pre-eclampsia and its associated complications.

This investment will drive the development of predictive technology for precise diagnosis, and enable timely intervention for at-risk mothers.

Moreover, investigating the genetic roots of pre-eclampsia could lead to novel therapies that reduce the need for costly medical procedures or prolonged care for those affected.

This would reduce the strain on already overburdened African healthcare systems.

Annettee Nakimuli is an Associate Professor of Obstetrics and Gynaecology, Makerere University