Spoiler alert: Remember when Lady Sybil died on Downton Abbey? That was eclampsia, the second-leading cause of all maternal deaths.

We’ve made a lot of progress since the 1920s, but 63,000 women still die from eclampsia every year. The good news is these deaths are entirely preventable.


On Downton Abbey, Lady Sybil died from eclampsia shortly after giving birth to her daughter.

Unlike postpartum hemorrhage, pre-eclampsia—a sudden increase in blood pressure after the 20th week of pregnancy, increased swelling and protein in urine—can be diagnosed during prenatal visits. If the condition becomes severe enough and begins to cause seizures, it has progressed to eclampsia. If pre-eclampsia is detected and appropriately managed before a woman progresses to convulsions, she should be able to give birth safely.

The risk of dying from eclampsia is 300 times higher for women in the developing world compared to women in the developed world. Magnesium sulfate is the most effective drug to prevent and treat the fatal seizures that can result from eclampsia.

How can eclampsia continue to be a leading cause of maternal death when we know how to manage it? One of the issues impacting women’s access to magnesium sulfate is health provider preference, and in some cases, bias. The World Health Organization (WHO) clearly recommends magnesium sulfate as the drug of choice to prevent eclampsia in women with severe pre-eclampsia and to treat women with eclampsia. However, in many countries, these recommendations may not be reflected in treatment guidelines, magnesium sulfate is not consistently available in facilities, and/or providers there may not be aware of the need to use magnesium sulfate.

In some cases, providers prefer to use another drug (diazepam) because there is a need to calculate and prepare the magnesium sulfate dosage. Although magnesium sulfate is the standard of care, providers often choose diazepam because it is readily accessible and less time-intensive to administer.

Some health providers also hesitate to use magnesium sulfate due to concerns about perceived side effects or a belief that magnesium sulfate should only be administered at higher-level facilities. Studies have shown that magnesium sulfate is a safe and effective treatment. Yet, relatively widespread concerns about adverse events persist among providers. Even in the rare cases of magnesium sulfate toxicity, there is an effective antidote.

Ultimately, these challenges matter because they prevent women from receiving the most effective drug to prevent and treat eclampsia.  Policies at the national level are not enough to assure that facilities have magnesium sulfate available and providers feel equipped to provide the drug.  Treatment guidelines as well as training curricula and materials need to reflect WHO recommendations on the use of magnesium sulfate. Additionally, provider concerns need to be addressed to ensure that providers are not only technically competent, but feel comfortable providing magnesium sulfate as the drug of choice for eclampsia.