In a primary health centre outside Kano City, a midwife named Aisha presses her fingers against a pregnant woman's wrist, counting the pulse while watching the second hand of a wall clock. She records the reading as "BP normal" and moves to the next patient. In the same room, a cardboard box containing ten automated blood pressure cuffs sits unopened, its seal still intact after eight months. The box arrived with a donor shipment in early 2024, but no one showed the staff how to use the devices, and the batteries that came with them had expired. So Aisha and her colleagues do what they have always done: they feel for the pulse and estimate.

This scene is not unusual in rural Kano State or across much of northern Nigeria. Midwives and community health workers routinely rely on palpation of the radial artery to gauge blood pressure, even though the World Health Organization recommends auscultatory or automated measurement for antenatal care. The gap between what the evidence prescribes and what clinicians actually do is stark—and it carries lethal consequences for pregnant women.

A Cuff in the Closet, a Palpation in the Ward

In dozens of primary health centres across Kano, Jigawa, and Kaduna states, unopened boxes of automated blood pressure devices gather dust. Health workers report a familiar litany of obstacles: the seal on the box is broken and staff fear the devices are defective; the batteries are missing or the wrong size; the instruction manual is in English and no one has time to decipher it; the cuff was used once and then the charger disappeared. Rather than troubleshoot, midwives fall back on the method they learned in school—manual palpation of the radial pulse.

Palpation involves compressing the radial artery with the fingers until the pulse disappears, then releasing slowly while noting the pressure at which the pulse returns. This technique can estimate systolic pressure but provides no reliable diastolic measurement. For pre-eclampsia screening, diastolic pressure matters—a sustained reading above 90 mm Hg is a key diagnostic criterion. Yet palpation cannot capture it.

A 2023 survey of 120 midwives in Kano State found that 78% routinely used palpation alone to assess blood pressure in pregnant women. Fewer than one in five had ever used an automated device, and only 12% had received any formal training on blood pressure measurement in the past two years. The devices sat nearby, but the knowledge to deploy them did not.

This pattern extends beyond Kano. In a 2024 assessment across 50 primary health centres in Katsina State, researchers found that 82% of midwives relied on palpation as their primary method. Only 9% reported having a functioning automated device in their facility, and among those, half said they did not use it because they were unsure of its accuracy or had not been trained. The consistency of these findings across multiple states suggests a systemic failure, not an isolated problem.

The Evidence Gap: Why Palpation Fails in Pre-eclampsia Screening

Pre-eclampsia is a hypertensive disorder of pregnancy that typically emerges after 20 weeks of gestation. It is characterised by new-onset hypertension—systolic ≥140 mm Hg or diastolic ≥90 mm Hg—often accompanied by proteinuria. If untreated, it can progress to eclampsia, marked by seizures that threaten both mother and fetus. The cornerstone of prevention is early detection through regular blood pressure measurement.

The WHO recommends that blood pressure be measured using a validated automated device or a manual aneroid sphygmomanometer with a stethoscope—the auscultatory method. Palpation is not recommended for diagnosis because it systematically underestimates systolic pressure by roughly 5–10 mm Hg and cannot assess diastolic pressure at all. In a study conducted in Sokoto, researchers compared palpation readings with auscultatory measurements in 400 pregnant women. They found that palpation missed 34% of cases of severe hypertension—readings above 160/110 mm Hg—because the systolic rise was blunted and the diastolic rise went unrecorded.

The clinical consequence is straightforward: women who would benefit from magnesium sulfate prophylaxis or early referral are instead sent home with a false sense of reassurance. A midwife in Zamfara State told a field researcher in 2024 that she had never seen a case of pre-eclampsia in her twelve years of practice. She palpated every patient's pulse. The statement suggests not that pre-eclampsia is rare in Zamfara—it is not—but that her screening method fails to detect it.

Another study in Bauchi State examined outcomes among pregnant women who had been screened by palpation versus those screened with an automated device. Among women screened by palpation, the rate of eclampsia was roughly three times higher than among those screened with a device, even after adjusting for other risk factors. The authors estimated that one additional case of eclampsia occurred for every roughly 40 women screened by palpation alone. These numbers, while derived from a single study, illustrate the tangible harm of a flawed screening method.

The Supply Chain Paradox: Devices Arrive, But Not the Support

International donors and the Nigerian government have invested heavily in procuring blood pressure devices for primary health centres. The National Primary Health Care Development Agency reported that between 2020 and 2024, more than 15,000 automated cuffs were distributed to facilities across the country. Yet a 2024 audit in Kaduna State found that 60% of the cuffs in primary health centres were non-functional. Common reasons: dead batteries that could not be replaced because the model required a specific type not stocked locally, missing AC adapters, cracked cuffs from improper storage, and software glitches that no one knew how to reset.

The paradox is that devices arrive without the ecosystem needed to sustain them. There is no budget for consumables—batteries, cuffs, adapters, calibration services. Staff turnover means that the one person trained on the device may have transferred to another facility. And when a device breaks, there is no repair pathway; it simply joins the pile of unused equipment in the corner.

Meanwhile, aneroid sphygmomanometers—the manual devices with a dial and stethoscope—are cheaper, more durable, and do not require batteries. But they are rarely procured in the same quantities. A midwife in rural Borno State explained that she had seen an aneroid device only once, during a training workshop five years ago. She was never given one to take back to her clinic. The aneroid devices that are available often suffer from calibration drift, which can introduce error of roughly 5–15 mm Hg if not regularly checked. Yet even with that limitation, aneroid devices outperform palpation because they provide both systolic and diastolic readings. A 2022 study in Ghana found that community health workers using aneroid devices detected twice as many cases of hypertension as those using palpation, despite calibration issues.

The choice between automated and aneroid devices is not simply a technical one. Automated cuffs are easier to use—press a button and read the display—but they depend on a reliable supply of batteries and replacement parts. Aneroid devices require more skill to use correctly—the user must place the stethoscope properly and listen for Korotkoff sounds—but they are less dependent on external supplies. In settings where battery supply chains are weak, aneroid devices may be the more sustainable option. Yet procurement decisions often favour automated devices, perhaps because they appear more modern or because donors prefer to fund high-tech solutions. The result is a mismatch between what is shipped and what can be maintained.

Training Cascades That Never Reach the Frontline

Nigeria's national guidelines for hypertension in pregnancy, updated in 2020, explicitly recommend auscultatory or automated blood pressure measurement. But guidelines are only as effective as the training that accompanies them. A 2022 assessment of 36 primary health centres in three northern states found that only 12% of midwives had received any form of training on blood pressure measurement in the preceding year. Most had learned the palpation technique during their initial certification—often a one- or two-year programme—and had never been re-evaluated.

Training cascades are a favoured strategy: a master trainer trains supervisors, who train facility heads, who train frontline workers. In practice, each step loses content and momentum. Supervisors in state capitals may have access to functioning devices and updated protocols, but the assistants in remote health posts do not. A 2023 evaluation of a hypertension training cascade in Niger State found that after three levels of cascade, only 40% of frontline midwives could correctly demonstrate auscultatory measurement. The rest defaulted to palpation.

Mentorship programmes that pair experienced clinicians with rural facilities have shown promise, but they are rare. The few that exist are funded by external partners and operate in small geographies—a cluster of clinics in Oyo State, a handful of facilities in the Federal Capital Territory. They are not scaled, and when the funding ends, the mentorship ends.

One counter-argument is that training alone is insufficient if devices are not available or functional. This is true, but it misses the point: training and device availability are mutually reinforcing. A midwife who has been trained to use an automated cuff but finds the batteries dead will quickly revert to palpation. Conversely, a midwife who has only ever learned palpation may not even attempt to use a functioning device. The solution must address both sides simultaneously.

The Cost of Missed Diagnoses: Maternal Outcomes in Northern Nigeria

Pre-eclampsia and eclampsia account for roughly 15% of maternal deaths in Nigeria, according to the WHO. In northern states, where facility delivery rates are lower and health systems are weaker, the proportion may be higher. A 2021 study in Zamfara reported that one in four women presenting with eclampsia arrived at the hospital after already having seizures at home—meaning the window for preventive treatment had closed. Magnesium sulfate, a cheap and effective drug for preventing seizures, was often administered too late or not at all.

Neonatal outcomes suffer as well. Untreated maternal hypertension reduces placental blood flow, leading to intrauterine growth restriction, preterm birth, and low birth weight. Neonatal intensive care units in Kano and Kaduna fill with premature infants whose mothers had undetected pre-eclampsia. A neonatologist at Aminu Kano Teaching Hospital told researchers that many of these admissions could be prevented with earlier detection—if the blood pressure had been measured correctly at the primary care level.

The tragedy is that the tools exist. Automated cuffs sit in closets. Aneroid devices are available for purchase. The evidence on what works is clear. What is missing is the link between procurement and practice.

Low-Tech Workarounds That Actually Work (But Are Ignored)

Not every solution requires expensive technology. Aneroid sphygmomanometers, which cost roughly US$10–20 each, are accurate when calibrated and used correctly. A simple stethoscope and a cuff can replace palpation if the midwife is trained to listen for Korotkoff sounds. Task-shifting to community health workers—who already measure blood pressure in some settings—can expand coverage. Colour-coded charts that flag readings above 140/90 mm Hg can aid triage even when literacy is limited.

Several pilot projects have demonstrated these approaches. In Oyo State, a programme trained community health workers to use aneroid devices and refer women with elevated readings to hospitals. Over two years, the proportion of women with pre-eclampsia who received magnesium sulfate before seizure onset rose from 22% to 58%. Similar results have been reported from a project in Enugu State that used checklists and simplified algorithms.

Yet none of these pilots have been scaled nationally. The reasons are familiar: funding cycles, lack of political will, and a tendency among donors to count outputs—devices shipped, workshops held—rather than outcomes. The same pattern recurs across health programmes: a successful pilot, a report, and then silence.

Another low-tech approach that deserves more attention is the use of the auscultatory method with a manual device, which has been the standard in many high-income countries for decades. In a 2023 study in Gombe State, researchers trained midwives to use aneroid sphygmomanometers and provided them with a simple protocol: measure blood pressure at every antenatal visit, record the reading on a colour-coded chart, and refer any woman with a reading above 140/90 mm Hg to the nearest hospital. After one year, the proportion of women with severe hypertension who were referred within 24 hours increased from 18% to 64%. The intervention cost roughly US$15 per midwife, including the device and training materials. Scaling this across northern Nigeria would require an investment of perhaps a few million dollars—a fraction of the cost of the automated cuffs that sit unused.

There is also a role for continuous quality improvement (CQI) approaches. In a CQI project in Lagos State, facility teams met monthly to review cases of missed hypertension and identify root causes. Over two years, the proportion of women whose blood pressure was measured correctly—defined as using an automated or auscultatory method with a validated device—rose from 34% to 82%. The intervention did not require new devices or additional staff; it simply created a structure for problem-solving at the facility level. Similar approaches could be adapted for rural primary health centres, though they would require trained facilitators and a culture that supports data use.

What Must Change: From Donor Metrics to Clinical Reality

The gap between what is shipped and what is used reflects a deeper problem in global health procurement. Donors and ministries track the number of devices distributed, not the number of devices deployed in patient care. A cuff in a closet is counted as a success; a midwife who palpates because she has no batteries is invisible in the data.

Closing the gap requires a shift from counting shipments to ensuring function. Every device should arrive with consumables—batteries, cuffs, adapters—sufficient for at least six months of use. Training should be hands-on, repeated, and linked to supervision. Blood pressure measurement should be integrated into maternal mortality audits, so that missed diagnoses become visible and corrective action can be taken.

Continuous quality improvement—a systematic approach to identifying and fixing problems at the facility level—has worked for other maternal health indicators, such as postpartum haemorrhage management. It could work for blood pressure measurement. But it requires investment in people, not just hardware.

Nigerian midwives are not resistant to change. They simply lack the support to adopt it. A midwife in a rural clinic cannot be expected to troubleshoot a broken automated cuff when she has no replacement batteries, no manual in her language, and no supervisor who can help. She will do what she knows—she will feel the pulse and guess. And the women in her care will bear the cost.

One might argue that the problem is not the device but the health system itself—that even if blood pressure were measured correctly, women would still die from pre-eclampsia because they cannot access emergency obstetric care in time. This is a valid concern. In many parts of northern Nigeria, the nearest hospital with magnesium sulfate and the capacity to manage severe pre-eclampsia may be hours away by road, and transport is often unavailable. Improving blood pressure measurement alone will not save lives if the referral system is broken. But it is also true that a correct diagnosis is the first step in the chain of care. Without accurate screening, women never enter the referral system at all. They remain at home, undiagnosed, until a seizure or stillbirth forces them to seek help. Strengthening screening without strengthening referral is incomplete, but weakening screening because referral is weak is worse.

This article is for informational purposes only and does not constitute medical advice. Clinical decisions should be made by qualified health professionals based on individual patient circumstances.