Use of multiple micronutrient supplementation integrated into routine antenatal care: A discussion of research priorities.

Optimal maternal nutrition, including adequate intake and status of essential micronutrients, is important for the health of women and developing infants. Currently, the World Health Organization (WHO) Antenatal care recommendations for a positive pregnancy experience recommend daily iron and folic acid (IFA) supplementation as the standard of care. The use of multiple micronutrient supplements (MMSs) is recommended in the context of rigorous research as more evidence was needed regarding the impact of switching from IFA supplements to MMS, including evaluation of critical clinical maternal and perinatal outcomes, acceptability, feasibility, sustainability, equity and cost-effectiveness. WHO convened a technical consultation of key stakeholders to discuss research priorities with the objective of providing guidance and clarity to donors, implementers and researchers about this recommendation. The overarching principles of the research agenda include the use of clinical indicators and impact measures that are applicable across studies and settings and the inclusion of outcomes that are important to women. Future studies should consider using standardized protocols based on current best practices to measure critical outcomes such as gestational age (GA) and birthweight (BW) in studies. As GA and BW are influenced by multiple factors, more research is needed to understand the biological impact pathways, and how initiation and considerations for timing of MMS influence these outcomes. A set of core clinical indicators was agreed upon during the technical consultation. For implementation research, the Evidence-to-Decision framework was used as a resource for discussing components of implementation research. The implementation research questions, key indicators and performance measures will depend on country-specific context and bottlenecks that require further research and improved solutions to enable the successful implementation of iron-containing supplements.

Non-communicable diseases and maternal health: a scoping review.

BACKGROUND: Non-communicable diseases [NCDs] are leading causes of ill health among women of reproductive age and an increasingly important cause of maternal morbidity and mortality worldwide. Reliable data on NCDs is necessary for accurate measurement and response. However, inconsistent definitions of NCDs make reliable data collection challenging. We aimed to map the current global literature to understand how NCDs are defined, operationalized and discussed during pregnancy, childbirth and the postnatal period.  METHODS: For this scoping review, we conducted a comprehensive global literature search for NCDs and maternal health covering the years 2000 to 2020 in eleven electronic databases, five regional WHO databases and an exhaustive grey literature search without language restrictions. We used a charting approach to synthesize and interpret the data.  RESULTS: Only seven of the 172 included sources defined NCDs. NCDs are often defined as chronic but with varying temporality. There is a broad spectrum of conditions that is included under NCDs including pregnancy-specific conditions and infectious diseases. The most commonly included conditions are hypertension, diabetes, epilepsy, asthma, mental health conditions and malignancy. Most publications are from academic institutions in high-income countries [HICs] and focus on the pre-conception period and pregnancy. Publications from HICs discuss NCDs in the context of pre-conception care, medications, contraception, health disparities and quality of care. In contrast, publications focused on low- and middle-income countries discuss NCDs in the context of NCD prevention. They take a life cycle approach and advocate for integration of NCD and maternal health services. CONCLUSION: Standardising the definition and improving the articulation of care for NCDs in the maternal health setting would help to improve data collection and facilitate monitoring. It would inform the development of improved care for NCDs at the intersection with maternal health as well as through a woman's life course. Such an approach could lead to significant policy and programmatic changes with the potential corresponding impact on resource allocation.

Seasonal variation in geographical access to maternal health services in regions of southern Mozambique.

BACKGROUND: Geographic proximity to health facilities is a known determinant of access to maternal care. Methods of quantifying geographical access to care have largely ignored the impact of precipitation and flooding. Further, travel has largely been imagined as unimodal where one transport mode is used for entire journeys to seek care. This study proposes a new approach for modeling potential spatio-temporal access by evaluating the impact of precipitation and floods on access to maternal health services using multiple transport modes, in southern Mozambique. METHODS: A facility assessment was used to classify 56 health centres. GPS coordinates of the health facilities were acquired from the Ministry of Health while roads were digitized and classified from high-resolution satellite images. Data on the geographic distribution of populations of women of reproductive age, pregnancies and births within the preceding 12 months, and transport options available to pregnant women were collected from a household census. Daily precipitation and flood data were used to model the impact of severe weather on access for a 17-month timeline. Travel times to the nearest health facilities were calculated using the closest facility tool in ArcGIS software. RESULTS: Forty-six and 87 percent of pregnant women lived within a 1-h of the nearest primary care centre using walking or public transport modes respectively. The populations within these catchments dropped by 9 and 5% respectively at the peak of the wet season. For journeys that would have commenced with walking to primary facilities, 64% of women lived within 2 h of life-saving care, while for those that began journeys with public transport, the same 2-hour catchment would have contained 95% of the women population. The population of women within two hours of life-saving care dropped by 9% for secondary facilities and 18% for tertiary facilities during the wet season. CONCLUSIONS: Seasonal variation in access to maternal care should not be imagined through a dichotomous and static lens of wet and dry seasons, as access continually fluctuates in both. This new approach for modelling spatio-temporal access allows for the GIS output to be utilized not only for health services planning, but also to aid near real time community-level delivery of maternal health services.

Constructing maternal morbidity - towards a standard tool to measure and monitor maternal health beyond mortality.

BACKGROUND: Maternal morbidity is a complex entity and its presentation and severity are on a spectrum. This paper describes the conceptualization and development of a definition for maternal morbidity, and the framework for its measurement: the maternal morbidity matrix, which is the foundation for measuring maternal morbidity, thus, the assessment tool. DISCUSSION: We define maternal morbidity and associated disability as "any health condition attributed to and/or complicating pregnancy and childbirth that has a negative impact on the woman's wellbeing and/or functioning." A matrix of 121 conditions was generated through expert meetings, review of the International Classification of Diseases and related health problems (ICD-10), literature reviews, applying the definition of maternal morbidity and a cut-off of >0.1% prevalence. This matrix has three dimensions: identified morbidity category, reported functioning impact and maternal history. The identification criteria for morbidity include 58 symptoms, 29 signs, 44 investigations and 35 management strategies; these criteria are aimed at recognizing the medical condition, or the functional impact/disability component that will capture the negative impact experienced by the woman. The maternal morbidity matrix is a practical framework for assessing maternal morbidity beyond near-miss. In light of the emerging attention to Universal Health Coverage (UHC) as part of the post-2015 Sustainable Development Goals (SDGs) planning, a definition and standard identification criteria are essential to measuring its extent and impact.

Community perspectives on the determinants of maternal health in rural southern Mozambique: a qualitative study.

BACKGROUND: Mozambique has one of the highest rates of maternal mortality in sub-Saharan Africa. The main influences on maternal health encompass social, economic, political, environmental and cultural determinants of health. To effectively address maternal mortality in the post-2015 agenda, interventions need to consider the determinants of health so that their delivery is not limited to the health sector. The objective of this exploratory qualitative study was to identify key community groups' perspectives on the perceived determinants of maternal health in rural areas of southern Mozambique. METHODS: Eleven focus group discussions were conducted with women of reproductive age, pregnant women, matrons, male partners, community leaders and health workers. Participants were recruited using sampling techniques of convenience and snow balling. Focus groups had an average of nine participants each. The heads of 12 administrative posts were also interviewed to understand the local context. Data were coded and analysed thematically using NVivo software. RESULTS: A broad range of political, economic, socio-cultural and environmental determinants of maternal health were identified by community representatives. It was perceived that the civil war has resulted in local unemployment and poverty that had a number of downstream effects including lack of funds for accessing medical care and transport, and influence on socio-cultural determinants, particularly gender relations that disadvantaged women. Socio-cultural determinants included intimate partner violence toward women, and strained relationships with in-laws and co-spouses. Social relationships were complex as there were both negative and positive impacts on maternal health. Environmental determinants included natural disasters and poor access to roads and transport exacerbated by the wet season and subsequent flooding. CONCLUSIONS: In rural southern Mozambique, community perceptions of the determinants of maternal health included political, economic, socio-cultural and environmental factors. These determinants were closely linked with one another and highlight the importance of including the local history, context, culture and geography in the design of maternal health programs.

Barriers and facilitators to health care seeking behaviours in pregnancy in rural communities of southern Mozambique.

BACKGROUND: In countries, such as Mozambique, where maternal mortality remains high, the greatest contribution of mortality comes from the poor and vulnerable communities, who frequently reside in remote and rural areas with limited access to health care services. This study aimed to understand women's health care seeking practices during pregnancy, taking into account the underlying social, cultural and structural barriers to accessing timely appropriate care in Maputo and Gaza Provinces, southern Mozambique. METHODS: This ethnographic study collected data through in-depth interviews and focus group discussions with women of reproductive age, including pregnant women, as well as household-level decision makers (partners, mothers and mothers-in-law), traditional healers, matrons, and primary health care providers. Data was analysed thematically using NVivo 10. RESULTS: Antenatal care was sought at the heath facility for the purpose of opening the antenatal record. Women without antenatal cards feared mistreatment during labour. Antenatal care was also sought to resolve discomforts, such as headaches, flu-like symptoms, body pain and backache. However, partners and husbands considered lower abdominal pain as the only symptom requiring care and discouraged women from revealing their pregnancy early in gestation. Health care providers for pregnant women often included those at the health facility, matrons, elders, traditional birth attendants, and community health workers. Although seeking care from traditional healers was discouraged during the antenatal period, they did provide services during pregnancy and after delivery. Besides household-level decision-makers, matrons, community health workers, and neighbours were key actors in the referral of pregnant women. The decision-making process may be delayed and particularly complex if an emergency occurs in their absence. Limited access to transport and money makes the decision-making process to seek care at the health facility even more complex. CONCLUSIONS: Women do seek antenatal care at health facilities, despite the presence of other health care providers in the community. There are important factors that prevent timely care-seeking for obstetric emergencies and delivery. Unfamiliarity with warning signs, especially among partners, discouragement from revealing pregnancy early in gestation, complex and untimely decision-making processes, fear of mistreatment by health-care providers, lack of transport and financial constraints were the most commonly cited barriers. Women of reproductive age would benefit from community saving schemes for transport and medication, which in turn would improve their birth preparedness and emergency readiness; in addition, pregnancy follow-up should include key family members, and community-based health care providers should encourage prompt referrals to health facilities, when appropriate. TRIAL REGISTRATION: NCT01911494.

Magnesium sulphate for the management of preeclampsia and eclampsia in low and middle income countries: a systematic review of tested dosing regimens.

OBJECTIVE: To review systematically the magnesium sulphate (MgSO4) dosing regimens tested in low and middle income countries (LMICs) for women with preeclampsia (prevention) and/or eclampsia (treatment). DATA SOURCES: We searched Medline, EMBASE, IPA, CINAHL, CDSR, and CENTRAL databases for relevant English language publications. STUDY SELECTION: Our search yielded 753 publications, of which 26 (10 randomized controlled trials and 16 observational studies) evaluated MgSO4 for preeclampsia and/or eclampsia in World Bank-classified LMICs. DATA EXTRACTION: Independent, by two authors. DATA SYNTHESIS: Twenty-five studies were conducted in hospital settings and one in the community. Rates of eclampsia were usually < 5% (median 3.0%, range 0.0% to 26.5%) even when MgSO4 was administered for eclampsia. When dosage varied from the standard Pritchard or Zuspan regimens, almost all (n = 22) reduced the dose or duration of treatment, most commonly because of concerns about maternal safety, cost, or resource availability. Four trials of a loading dose only (4 g IV + 10 g IM) versus loading plus maintenance dosing of 5 g/4 hr IM found no difference in eclampsia recurrence (RR 1.64; 95% CI 0.48 to 5.65, n = 396). One study documented less eclampsia recurrence associated with community administration of a MgSO4 loading dose before referral to a care facility versus treatment in a care facility (RR 0.23; 95% CI 0.11 to 0.49, n = 265). CONCLUSION: Use of MgSO4 for eclampsia treatment and prevention has been well-studied in LMICs, but concern remains about potential toxicity. Further studies are needed to identify the minimum effective dosage of MgSO4 for management of preeclampsia and eclampsia and whether MgSO4 loading can be safely administered in the community.

Objectif : Procéder à une analyse systématique des schémas posologiques de sulfate de magnésium (MgSO4) mis à l'essai dans des pays à revenu faible ou intermédiaire (PRFI) chez des femmes présentant une prééclampsie (prévention) et/ou une éclampsie (traitement). Sources de données : Nous avons mené des recherches dans les bases de données Medline, EMBASE, IPA, CINAHL, CDSR et CENTRAL afin d'en tirer les publications anglophones pertinentes. Sélection des études : Notre recherche nous a menés à 753 publications, dont 26 (10 essais comparatifs randomisés et 16 études observationnelles) ont évalué l'utilisation de MgSO4 dans des cas de prééclampsie et/ou d'éclampsie au sein de PRFI identifiés par la Banque mondiale. Extraction de données : Indépendante, menée par deux auteurs. Synthèse des données : Vingt-cinq études ont été menées en milieu hospitalier et une étude l'a été en milieu communautaire. Les taux d'éclampsie étaient habituellement inférieurs à 5 % (médiane : 3,0 %, plage : 0,0 % - 26,5 %) même lorsque du MgSO4 était administré pour contrer l'éclampsie. Lorsque les posologies utilisées s'éloignaient des posologies standard Pritchard ou Zuspan, pratiquement chacune d'entre elles (n = 22) réduisait la dose de MgSO4 ou la durée du traitement, la raison la plus couramment citée étant la présence de préoccupations au sujet de la sûreté maternelle, des coûts ou de la disponibilité des ressources. Quatre essais ayant comparé le seul recours à une dose de mise en charge (4 g IV + 10 g IM) au recours à une dose de mise en charge et à une dose d'entretien de 5 g/4 h IM n'ont constaté aucune différence en matière de récurrence de l'éclampsie (RR, 1,64; IC à 95 %, 0,48 - 5,65, n = 396). Une étude a constaté une récurrence moindre de l'éclampsie associée à l'administration d'une dose de mise en charge de MgSO4 en milieu communautaire avant l'orientation vers un établissement de soins, par comparaison avec l'administration d'un tel traitement au sein d'un établissement de soins (RR, 0,23; IC à 95 %, 0,11 - 0,49, n = 265). Conclusion : Bien que l'utilisation de MgSO4 aux fins de la prévention et de la prise en charge de l'éclampsie ait bien été étudiée au sein des PRFI, des préoccupations subsistent quant à sa toxicité potentielle. La tenue d'autres études s'avère requise pour identifier la posologie minimale efficace de MgSO4 pour la prise en charge de la prééclampsie et de l'éclampsie, ainsi que pour déterminer si une dose de mise en charge de MgSO4 peut être administrée en toute sûreté en milieu communautaire.

Addressing Racial Disparities in the Hypertensive Disorders in Pregnancy: A Plan for Action from the Preeclampsia Foundation's Racial Disparities Task Force.

Hypertensive disorders of pregnancy (HDP) are among the leading causes of maternal mortality in the United States, with Black women and birthing people disproportionately having higher HDP-related deaths and morbidity. In 2020, the Preeclampsia Foundation formed a national Racial Disparities Task Force (RDTF) to identify key recommendations to address issues of racial disparities related to HDP. Recommendations are centered around the Foundation's three pillars: Community, Healthcare Practice, and Research. Healthcare practices include adequate treatment of chronic hypertension in Black women and birthing people, re-branding low-dose aspirin to prenatal aspirin to facilitate uptake, and innovative models of care that especially focus on postpartum follow-up. A research agenda that examines the influence of social and structural determinants of health (ssDOH) on HDP care, access, and outcomes is essential to addressing disparities. One specific area that requires attention is the development of metrics to evaluate the quality of obstetrical care as it relates to racial disparities in Black women and birthing people with HDP. The recommendations generated by the Preeclampsia Foundation's RDTF highlight the strategic priorities and are a call to action that requires listening to the voices and experiences of Black women and birthing people, engaging their communities, and multi-sectoral collaboration to improve healthcare practices and drive needed research.

Pharmacotherapy for preeclampsia in low and middle income countries: an analysis of essential medicines lists.

OBJECTIVE: To determine the prevalence of drugs for comprehensive management of preeclampsia in national essential medicine lists (EMLs) in low and middle income countries (LMICs) METHODS: We collected EMLs from the 144 LMICs identified by the World Bank through broad-based Internet searches and in collaboration with the World Health Organization. We identified therapies for hypertension, eclampsia, preeclampsia complications (e.g., pulmonary edema, thrombosis), preterm birth, and labour induction contained in the EMLs. RESULTS: In 91 EMLs obtained from 144 LMICs, the most commonly listed parenteral antihypertensive therapies were verapamil (63.7%), hydralazine (61.5%), sodium nitroprusside (48.3%), and propranolol (39.6%). The most prevalent oral antihypertensive therapies were nifedipine (95.6%), methyldopa (93.4%), propranolol (90.1%), and atenolol (87.9%). For eclampsia/preeclampsia, magnesium sulphate was present in 84.6% of EMLs and calcium gluconate in 85.7%. For pulmonary edema, most EMLs (94.5%) listed oral furosemide, for thrombosis 92.3% listed heparin, for acceleration of fetal pulmonary maturity 90.1% listed parenteral dexamethasone, and for labour induction 97.8% listed oxytocin or a prostanoid (usually misoprostol, 40.7%). CONCLUSION: EMLs of LMICs provide comprehensive coverage of preeclampsia pharmacotherapy. These EMLs may be used as advocacy tools to ensure the availability of these therapies within each country.

Preeclampsia in low and middle income countries-health services lessons learned from the PRE-EMPT (PRE-Eclampsia-Eclampsia Monitoring, Prevention and Treatment) project.

The hypertensive disorders of pregnancy, in particular preeclampsia, matter because adverse events occur in women with preeclampsia and, to a lesser extent, in women with the other hypertensive disorders. These adverse events are maternal, perinatal, and neonatal and can alter the life trajectory of each individual, should that life not be ended by complications. In this review we discuss a number of priorities and dilemmas that we perceive to be facing health services in low and middle income countries as they try to prioritize interventions to reduce the health burden related to preeclampsia. These priorities and dilemmas relate to calcium for preeclampsia prevention, risk stratification, antihypertensive and magnesium sulphate therapy, and mobile health. Significant progress has been and is being made to reduce the impact of preeclampsia in low and middle income countries, but it remains a priority focus as we attempt to achieve Millennium Development Goal 5.

Global and regional estimates of maternal near miss: a systematic review, meta-analysis and experiences with application.

INTRODUCTION: Maternal near miss (MNM) is a useful means to examine quality of obstetric care. Since the introduction of the WHO MNM criteria in 2011, it has been tested and validated, and is being used globally. We sought to systematically review all available studies using the WHO MNM criteria to develop global and regional estimates of MNM frequency and examine its application across settings. METHODS: We conducted a systematic review by implementing a comprehensive literature search from 2011 to 2018 in six databases with no language restrictions. The predefined data collection tool included sections on study characteristics, frequency of near-miss cases and study quality. Meta-analysis was performed by regional groupings. Reported adaptations, modifications and remarks about application were extracted. RESULTS: 7292 articles were screened by title and abstract, and 264 articles were retrieved for full text review for the meta-analysis. An additional 230 articles were screened for experiences with application of the WHO MNM criteria. Sixty studies with near-miss data from 56 countries were included in the meta-analysis. The pooled global near-miss estimate was 1.4% (95% CI 0.4% to 2.5%) with regional variation in MNM frequency. Of the 20 studies that made adaptations to the criteria, 19 were from low-resource settings where lab-based criteria were adapted due to resource limitations. CONCLUSIONS: The WHO MNM criteria have enabled the comparison of global and sub-national estimates of MNM frequency. There has been good uptake in low-resource countries but contextual adaptations are necessary.

Nausea and vomiting in pregnancy is not always nausea and vomiting of pregnancy.

The majority of pregnant women experience nausea and vomiting during pregnancy. However, nausea and vomiting in pregnancy is not always nausea and vomiting of pregnancy (NVP). The differential diagnosis of nausea and vomiting in pregnancy can be extensive and the underlying cause can sometimes be difficult to diagnose. However, the timing or onset of the symptoms is important in differentiating NVP from other causes. A thorough history and physical examination, with appropriate investigations, should be carried out in symptomatic women.

Cerebral venous sinus thrombosis in a woman using the etonogestrel-ethinyl estradiol vaginal contraceptive ring: a case report.

BACKGROUND: The vaginal contraceptive ring is a hormonal contraceptive that releases etonogestrel and ethinyl estradiol. Cerebral venous sinus thrombosis (CVST) is a rare but serious complication of hormonal contraceptive use. CASE: We present a case of CVST in a 33-year-old nulligravid woman who was using a vaginal contraceptive ring. At the time of presentation, she had been using the ring for 18 months, having previously used oral contraceptives for 13 years. She had no additional risk factors for thrombosis apart from cigarette smoking. Despite vigorous management, the patient died from the effects of the CVST. CONCLUSION: The serious adverse effects of the vaginal contraceptive ring are not well known, although deep vein thrombosis, pulmonary embolism, and aortic thrombosis in association with use of the ring have been reported to Health Canada. Continuing post-market surveillance of thrombotic risk in users of the vaginal contraceptive ring is critical.

Hypertension Canada's 2020 Comprehensive Guidelines for the Prevention, Diagnosis, Risk Assessment, and Treatment of Hypertension in Adults and Children.

Hypertension Canada's 2020 guidelines for the prevention, diagnosis, risk assessment, and treatment of hypertension in adults and children provide comprehensive, evidence-based guidance for health care professionals and patients. Hypertension Canada develops the guidelines using rigourous methodology, carefully mitigating the risk of bias in our process. All draft recommendations undergo critical review by expert methodologists without conflict to ensure quality. Our guideline panel is diverse, including multiple health professional groups (nurses, pharmacy, academics, and physicians), and worked in concert with experts in primary care and implementation to ensure optimal usability. The 2020 guidelines include new guidance on the management of resistant hypertension and the management of hypertension in women planning pregnancy.

Place-specific factors associated with adverse maternal and perinatal outcomes in Southern Mozambique: a retrospective cohort study.

OBJECTIVES: To identify and measure the place-specific determinants that are associated with adverse maternal and perinatal outcomes in the southern region of Mozambique. DESIGN: Retrospective cohort study. Choice of variables informed by literature and Delphi consensus. SETTING: Study conducted during the baseline phase of a community level intervention for pre-eclampsia that was led by community health workers. PARTICIPANTS: A household census identified 50 493 households that were home to 80 483 women of reproductive age (age 12-49 years). Of these women, 14 617 had been pregnant in the 12 months prior to the census, of which 9172 (61.6%) had completed their pregnancies. PRIMARY AND SECONDARY OUTCOME MEASURES: A combined fetal, maternal and neonatal outcome was calculated for all women with completed pregnancies. RESULTS: A total of six variables were statistically significant (p≤0.05) in explaining the combined outcome. These included: geographic isolation, flood proneness, access to an improved latrine, average age of reproductive age woman, family support and fertility rates. The performance of the ordinary least squares model was an adjusted R2=0.69. Three of the variables (isolation, latrine score and family support) showed significant geographic variability in their effect on rates of adverse outcome. Accounting for this modest non-stationary effect through geographically weighted regression increased the adjusted R2 to 0.71. CONCLUSIONS: The community exploration was successful in identifying context-specific determinants of maternal health. The results highlight the need for designing targeted interventions that address the place-specific social determinants of maternal health in the study area. The geographic process of identifying and measuring these determinants, therefore, has implications for multisectoral collaboration. TRIAL REGISTRATION NUMBER: NCT01911494.

The 24-hour urine collection: gold standard or historical practice?

OBJECTIVE: The objective of the study was to determine completeness of 24-hour urine collection in pregnancy. STUDY DESIGN: This was a retrospective laboratory/chart review of 24-hour urine collections at British Columbia Women's Hospital. Completeness was assessed by 24-hour urinary creatinine excretion (UcreatV): expected according to maternal weight for single collections and between-measurement difference for serial collections. RESULTS: For 198 randomly selected pregnant women with a hypertensive disorder (63% preeclampsia), 24-hour urine collections were frequently inaccurate (13-54%) on the basis of UcreatV of 97-220 micromol/kg per day (11.0-25.0 mg/kg per day) or 133-177 micromol/kg per day (15.1-20.1 mg/kg per day) of prepregnancy weight (respectively). Lean body weight resulted in more inaccurate collections (24-68%). The current weight was frequently unavailable (28%) and thus not used. For 161 women (81% proteinuric) with serial 24-hour urine levels, a median [interquartile range] of 11 [5-31] days apart, between-measurement difference in UcreatV was 14.4% [6.0-24.9]; 40 women (24.8%) had values 25% or greater, exceeding analytic and biologic variation. CONCLUSION: Twenty-four hour urine collection is frequently inaccurate and not a precise measure of proteinuria or creatinine clearance.

Hypertension Canada's 2018 Guidelines for the Management of Hypertension in Pregnancy.

We present Hypertension Canada's inaugural evidence-based Canadian recommendations for the management of hypertension in pregnancy. Hypertension in pregnancy is common, affecting approximately 7% of pregnancies in Canada, and requires effective management to reduce maternal, fetal, and newborn complications. Because of this importance, these guidelines were developed in partnership with the Society of Obstetricians and Gynaecologists of Canada with the main common objective of improving the management of women with hypertension in pregnancy. Guidelines for the diagnosis, assessment, prevention, and treatment of hypertension in adults and children are published separately. In this first Hypertension Canada guidelines for hypertension in pregnancy, 7 recommendations for the management of nonsevere and severe hypertension in pregnancy are presented. For nonsevere hypertension in pregnancy (systolic blood pressure 140-159 mm Hg and/or diastolic blood pressure 80-109 mm Hg), we provide guidance for the threshold for initiation of antihypertensive therapy, blood pressure targets, as well as first- and second-line antihypertensive medications. Severe hypertension (systolic blood pressure ≥ 160 mm Hg and/or diastolic blood pressure ≥ 110 mm Hg) requires urgent antihypertensive therapy to reduce maternal, fetal, and newborn adverse outcomes. The specific evidence and rationale underlying each of these guidelines are discussed.

A framework for healthcare interventions to address maternal morbidity.

The maternal health agenda is undergoing a paradigm shift from preventing maternal deaths to promoting women's health and wellness. A critical focus of this trajectory includes addressing maternal morbidity and the increasing burden of chronic and noncommunicable diseases (NCD) among pregnant women. The WHO convened the Maternal Morbidity Working Group (MMWG) to improve the scientific basis for defining, measuring, and monitoring maternal morbidity. Based on the MMWG's work, we propose paradigms for conceptualizing maternal health and related interventions, and call for greater integration between maternal health and NCD programs. This integration can be synergistic, given the links between chronic conditions, morbidity in pregnancy, and long-term health. Pregnancy should be viewed as a window of opportunity into the current and future health of women, and offers critical entry points for women who may otherwise not seek or have access to care for chronic conditions. Maternal health services should move beyond the focus on emergency obstetric care, to a broader approach that encompasses preventive and early interventions, and integration with existing services. Health systems need to respond by prioritizing funding for developing integrated health programs, and workforce strengthening. The MMWG's efforts have highlighted the changing landscape of maternal health, and the need to expand the narrow focus of maternal health, moving beyond surviving to thriving.