An estimated 303 000 women and adolescent girls died as a result of pregnancy and childbirth-related complications in 2015, around 99% of which occurred in low-resource settings (1). Haemorrhage, hypertensive disorders and sepsis are responsible for more than half of all maternal deaths worldwide. Thus, improving the quality of maternal healthcare for women is a necessary step towards the achievement of the health targets of the Sustainable Development Goals (SDGs). International human rights law includes fundamental commitments by states to enable women and adolescent girls to survive pregnancy and childbirth as part of their enjoyment of sexual and reproductive health and rights and living a life of dignity (2). The World Health Organization (WHO) envisions a world where “every pregnant woman and newborn receives quality care throughout the pregnancy, childbirth and the postnatal period” (3).
There is evidence that effective interventions exist at reasonable cost for the prevention or treatment of virtually all life-threatening maternal complications (4). Almost two-thirds of the global maternal and neonatal disease burden could be alleviated through optimal adaptation and uptake of existing research findings (5). To provide good quality care, healthcare providers at all levels of maternal healthcare services (particularly in low and middle-income countries) need to have access to appropriate medications and training in relevant procedures. Healthcare providers, health managers, policymakers and other stakeholders also need up-to-date, evidence-based recommendations to inform clinical policies and practices in order to optimize quality of care and enable improved healthcare outcomes. Efforts to prevent and reduce morbidity and mortality in pregnancy and childbirth could reduce the profound inequities in maternal and perinatal health globally.
Hypertensive disorders of pregnancy are an important cause of severe morbidity, long- term disability and death among both mothers and their babies. Worldwide, they account for approximately 14% of all maternal deaths (6). In 2011, WHO published 22 recommendations for the prevention and treatment of pre-eclampsia and eclampsia, including two recommendations on the use and choice of antihypertensive drugs for the treatment of severe hypertension during pregnancy (7). These recommendations were developed according to the WHO guideline development standards, including synthesis of available research evidence, use of the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology, and formulation of recommendations by a guideline panel of international experts.
Rationale and objectives
In 2017, WHO established a new process for prioritizing and updating maternal and perinatal health recommendations whereby an Executive Guideline Steering Group (GSG) oversaw a systematic prioritization of maternal and perinatal health recommendations in most urgent need of updating (8). Recommendations were prioritized on the basis of changes or important, new uncertainties in the underlying evidence base on benefits, harms, values placed on outcomes, acceptability, feasibility, equity, resource use, cost-effectiveness or factors affecting implementation. The Executive GSG prioritized the updating of the existing WHO recommendations on antihypertensive drugs for severe hypertension during pregnancy in response to new, potentially important evidence.
The primary goal of these recommendations is to improve the quality of care and outcomes for pregnant women, particularly those related to the treatment of hypertensive disorders of pregnancy. These recommendations provide a foundation for the sustainable implementation of drug treatment for severe hypertension in pregnancy globally.
Target audience
The primary audience of these recommendations includes healthcare providers who are responsible for developing national and local health guidelines and protocols (particularly those related to hypertensive disorders of pregnancy) and those directly providing care to women during labour and childbirth, including midwives, nurses, general medical practitioners, obstetricians, managers of maternal and child health programmes and relevant staff in ministries of health, in all settings.
The recommendations will also be of interest to professional societies involved in the care of pregnant women, nongovernmental organizations concerned with promoting people-centred maternal care and implementers of maternal and child health programmes.
Scope of the recommendations
Framed using the Population (P), Intervention (I), Comparison (C), Outcome (O) (PICO) format, the question directing these recommendations was:
For women with severe hypertension in pregnancy (P), does treatment with one antihypertensive drug (I), compared with another (C), improve maternal and perinatal outcomes (O)?
Persons affected by the recommendations
The population affected by the recommendations includes pregnant women in low-, middle- or high- income settings, particularly those who experience severe hypertension during pregnancy.
