LA Magee, Pvon Dadelszen, W Stones, M Mathai

Hypertensive disorders complicate 5–10% of pregnancies worldwide, with limited data suggesting an upward trend in incidence most likely related to increasing maternal weight and sedentary lifestyle (Chapter 4). With few differences, all international societies define the hypertensive disorders of pregnancy as chronic hypertension, gestational hypertension and pre-eclampsia (Chapter 3). Although women with pre-eclampsia have the greatest risk of maternal and perinatal complications, what constitutes pre-eclampsia is controversial, and diagnostic distinctions are often blurred. As such, it is important to view all women with a hypertensive disorder of pregnancy and their babies as being at increased risk of mortality and morbidity, and act accordingly.

Pre-eclampsia remains one of the top five causes of maternal and perinatal mortality worldwide. Our best estimate is that pre-eclampsia claims the lives of more than 70,000 women per year and more than 500,000 of their fetuses and newborns; this is equivalent to the loss of 1600 lives per day1. More than 99% of these losses occur in low- and middle-income countries (LMICs), particularly those on the Indian subcontinent and sub-Saharan Africa2. For every woman who dies, it is estimated that another 20 suffer a life-altering morbidity3,4.

Given that maternal (and perinatal) deaths and sequelae result primarily from delays in triage, transport and treatment, it would seem important for the global community to turn its attention to community-based care1. A community-focused approach could include community engagement and use of innovative technologies, like smartphone applications could be used to support community-based health workers. In addition, however, care at facility must be of high quality in order for outcomes to be improved, a point that has been highlighted by the move towards encouraging more facility births and concerns about the quality of care received there. In the World Health Organization Multicountry Survey on Maternal and Newborn Health (WHOMCS) that covered 357 health facilities in 29 countries, high coverage of essential interventions was not associated with reduced maternal mortality5. As such, attention must also be focused on strengthening provision of evidence-based comprehensive emergency obstetric care (CEmOC)6, conducting maternal death and near-miss morbidity surveillance and response (www.who.int/mdsr), and performing large-scale effectiveness evaluations, with the district as the unit of design and analysis and the clear message that there is local ownership, by women, communities, care providers and government7.

Knowledge is power, and the impact that evidence-based knowledge can have on practice and policy is highlighted by the WHO IMPAC (Integrated Management of Pregnancy and Childbirth) guidance documents (2000) (who.int/preadolescence/topics/maternal/impac/en/). These were among the first WHO documents to recommend MgSO4 for eclampsia prevention and treatment. The information was adopted in national guidelines in many African and Asian countries, and formed the core of EmOC training packages, as well as led to policy changes in countries on use of MgSO4 as reflected in national medicines lists.

In the 1980s, it was noted that the dramatic decline in maternal mortality over the prior 50 years in Britain was related to the standard of maternity care, even in the face of ongoing social deprivation:

“In obstetrics the difference between a careful doctor (or midwife) and a careless one can be very large indeed. The introduction, therefore, of an ordinary standard of good obstetric practice, not necessarily at the level of the hospital specialist, can be expected to have a profoundly beneficial effect in societies that still suffer high maternal mortality.”

Irvine Loudon, British Med J 19868