This was a qualitative cross-sectional study which was conducted in health centres, in Blantyre district, in southern region of Malawi, between September and December, 2012. Data was collected using semi-structured interviews, focus group discussion, review of records and observation. Eleven (11) health centres and a referral hospital were included. 29 health workers, 4 patients and 2 guardians participated in the study. Malawi continues to experience high maternal deaths. Although, efforts are in place to reduce maternal deaths, there is need to explore how maternal cases are managed in health institutions.The study therefore sought;1. To assess how first level health care providers in Blantyre manage patients of pre-eclampsia and eclampsia before referral to the second or third level of care2. To assess barriers to proper management of patients with pre-eclampsia and eclampsia at the first level of care3. To obtain suggestions for the improvement of the management of patients with pre-eclampsia and eclampsia at the first level facility of careIn exploring how pre-eclampsia and eclampsia are managed at the first level of care, the data was collected from three sources: health workers at referral facility, health workers at the health centres and from patients with pre-eclampsia and eclampsia. The sources were identified based on their proximity to the referral hospital and within a single district.The study established that, despite a significant awareness of the prevalence of pre-eclampsia and eclampsia among pregnant women, health workers both at first level facility of care and at the referral facility had numerous challenges in the management of these complications. Some of the challenges were patients delay in reporting to health centres, inability to diagnose the condition due to lack of equipment and materials resources, inability to provide adequate care to patients due to understaffing, lack of or insufficient drugs; delays in transporting patients to referral facility due to poor transport system, skill decay due to infrequent occurrence of cases, lack of supervision and feedback from superiors on how the health centres are providing first level care to patients.The management of pre-eclampsia and eclampsia at the first level facility of care also varied between health centres as well as among individual health workers; indicating need for refresher courses to upgrade and synchronize the process of handling the patients. The study further established that patients do not have enough knowledge about pre-eclampsia and eclampsia, often culturally interpreted.In conclusion, management of pre-eclampsia and eclampsia at the first level facility of care continues to be challenging in Blantyre, Malawi. Application of knowledge by health workers is still weak. Most health workers in first level facilities face numerous problems in the management of pre-eclampsia and eclampsia.Therefore to improve management of patients with pre-eclampsia and eclampsia, knowledge and skills in identification and management of pre-eclampsia and eclampsia at the first level facilities need to be improved; health centres must be provided with all the necessary materials and drugs; referral cases must be transported to hospital without delay; supervision of pre-eclampsia and eclampsia at the first level facility of care must be strengthened. Feedback from the hospital is a necessary ingredient for ensuring that pre-eclampsia and eclampsia at the first level facility of care is improved. There is also need to strengthen education of patients during antenatal care on pre-eclampsia and eclampsia and not to rely on cultural beliefs. Increasing staffing in health centres would also help in improving the management of pre-eclampsia and eclampsia at that level.