World Pre-eclampsia Day: are we moving in the right direction?

INTRODUCTION In 2026, the greatest challenge in pre-eclampsia is no longer making the diagnosis or managing the condition. It is whether Asia can deliver screening and prevention equitably across its nations. This year’s World Pre-eclampsia Day highlights an uncomfortable paradox in our region. We now possess in our armamentarium the tools to predict and to prevent preterm pre-eclampsia. Yet, in many underserved populations, we continue to see women who present late, convulse and die from this ancient malady. Our ability to save lives is divided not by knowledge, but by access to it. Although we are all aware that modern medicine often deepens the divide between health and healthcare, saving mothers’ lives by reducing the incidence of preterm pre-eclampsia may yet be that singular goal where Asian nations unite to bring novel and frugal innovation into the capillaries of society, in which women give birth to the future itself. Hypertensive disorders account for approximately 16% of maternal deaths globally, corresponding to about 42,000 deaths in 2023.[1,2] The World Health Organization (WHO) estimates that pre-eclampsia affects around 2.8% of live births in developing countries—approximately seven times higher than in developed countries, where the incidence is about 0.4%.[3] Maternal mortality from eclampsia is also substantially higher in developing settings, reaching up to 15% compared with up to 1.8% in developed countries.[4] Pre-eclampsia thus remains a leading cause of maternal and perinatal mortality and morbidity, with short- and long-term morbidity being most significant when the disease arises preterm.[2] It is associated with eclampsia, HELLP syndrome, pulmonary oedema, renal failure and subsequently cardiovascular disease. Neonates require prolonged intensive care and endure the long-term consequences of preterm birth. The tools to mitigate this impact already exist; structured screening, timely initiation of aspirin prophylaxis and increased antenatal surveillance can yield substantial benefit, as every additional week gained in utero enhances neonatal survival and long-term neurodevelopmental outcomes. FROM RISK-BASED SCREENING TO PRECISION PREVENTION Screening strategies have evolved considerably, shifting from traditional risk factor-based approaches to multivariable first-trimester models incorporating biomarkers such as placental growth factor (PlGF) and uterine artery Doppler indices. The ASPRE trial demonstrated that a Bayesian-based screening approach combined with aspirin prophylaxis significantly reduced the occurrence of preterm pre-eclampsia. This model can predict 90% of early pre-eclampsia cases at <32 weeks of gestation and 75% of preterm pre-eclampsia cases at <37 weeks of gestation.[5] This has been further demonstrated in Asian populations by the FORECAST study, which confirmed the feasibility and effectiveness of real-world implementation. Low-dose aspirin (150 mg) initiated before 16 weeks of gestation reduces the incidence of preterm pre-eclampsia by approximately 60% and is associated with improved neonatal outcomes.[6] Importantly, safety data from large meta-analyses show no significant increase in the risk of placental abruption, postpartum haemorrhage or mean blood loss.[7] Consequently, the International Federation of Gynaecology and Obstetrics recommends early initiation of low-dose aspirin (100–150 mg daily) in high-risk women.[8] Implementation studies in a few countries have reported high acceptability rates for first-trimester pre-eclampsia screening.[9,10] However, even in well-resourced tertiary settings, up to 12% of all eligible pregnant women fail to undergo appropriate screening for pre-eclampsia;[6] systemic barriers in healthcare delivery in lower-resourced countries lead to significantly poorer uptake rates for any pre-eclampsia screening during pregnancy. In many parts of Asia, pregnancy outcomes are still affected by late booking, inconsistent blood pressure measurement, limited ultrasound access and inadequate medical supplies. In these settings, a 150-mg aspirin protocol commenced before 16 weeks may be scientifically sound but operationally irrelevant if many women first present after 20 weeks, or not at all until it is too late. High-performing multiparametric prediction models developed in European or high-income Asian populations have shown excellent results,[11,12] but their impact is negligible if they cannot be implemented where the burden of disease is greatest. The risk is that pre-eclampsia becomes yet another condition for which effective prevention exists, but only for those who live near tertiary centres or can afford to reach them—the familiar triad of availability, affordability and accessibility. THE IMPLEMENTATION GAP: WHEN DEVELOPED MODELS FAIL TO REACH THE FRONTLINES Despite growing evidence of improved detection rates, first-trimester pre-eclampsia screening using multiparametric models is not widely implemented and not part of antenatal screening recommendations from many international bodies. Various barriers to implementation must be considered, including the immediate cost of equipment and training, the need for audit and quality control, and the expected benefit to the population.[13] The problem, therefore, is no longer scientific. It is moral, operational and political. The question for Asia is not whether these tools work, but for whom, under what conditions and at what cost. An excessive fascination with cutting-edge prediction can distract from the quieter, but more transformative work of strengthening primary antenatal care, ensuring universal blood pressure measurement and urine testing, and embedding simple aspirin eligibility criteria into routine workflows. A genuinely equitable strategy for Asia must, therefore, extend across the full continuum of care. Preconception lifestyle-based interventions, along with identification and optimisation of medical conditions such as chronic hypertension, diabetes mellitus, kidney disease and obesity, through non-communicable disease programmes and robust preconception care, are crucial.[14] During pregnancy, every woman should have access to the fundamentals: accurate blood pressure measurement, urine testing, symptom review and, where indicated, low-dose aspirin with calcium supplementation in populations with low calcium intake. Around birth, meticulous monitoring and early warning systems, escalation pathways, magnesium sulfate protocols, antihypertensive treatment and referral systems must be standardised, taught and closely monitored. After pregnancy, a history of pre-eclampsia should not be archived as an obstetric footnote. It should be treated as a cardiovascular red flag requiring structured long-term follow-up in primary care. TECHNOLOGY TO ADDRESS WIDENING INEQUITIES Remote blood pressure monitoring offers genuine promise, particularly for geographically dispersed populations and urban women for whom repeated antenatal visits are difficult. When paired with community health workers, teleconsultation pathways and clear escalation thresholds may help redistribute care more intelligently. But when confined to isolated pilot projects in academic centres, technology risks becoming another elegant proof of concept with little public health consequence. Machine learning carries the same danger—elegance without equity. These models refine risk prediction, but if they are trained on datasets that exclude rural, uninsured or socially marginalised populations, they will inevitably reproduce the inequities already embedded within those systems. Asia must not merely adopt these technologies; it must shape them with local data and deploy them with explicit concern for those most at risk of being left behind. What, then, would meaningful progress look like by the next World Pre-eclampsia Day? At the system level, ministries and professional bodies would treat pre-eclampsia prevention as a core quality indicator, tracking early antenatal booking, aspirin coverage among eligible women and timely treatment of severe hypertension with the same discipline often applied to institutional delivery rates or caesarean section metrics. At the institutional level, hospitals would align protocols with operational realities, selecting screening strategies appropriate to their laboratory and workforce capacities, training nurses and midwives in simplified risk assessment, and building referral pathways that minimise delays for women with suspected severe disease. At the clinical level, providers would normalise discussions about long-term cardiovascular risk after pre-eclampsia and ensure that this history is handed over to primary care. SIMPLICITY OVER SOPHISTICATION: DELIVERING WHAT WORKS On this World Pre-eclampsia Day, Asia must resist the temptation to confuse complexity with progress. The region does not need the most elaborate prediction model. It needs the simplest, most effective package that can be delivered reliably to every woman, regardless of income, geography or postcode. That means choosing scalable strategies over glamorous but fragile ones, investing in frontline antenatal and postpartum care, and reserving advanced tools for contexts in which they genuinely add value. The science of pre-eclampsia has advanced significantly. The more important test now is whether we apply that science justly across all nations and ensure consistent care through various strategies proposed by Asian centres.[15,16] For Asia, equitable delivery of screening and prevention should not be seen as an optional extra. It is the central challenge, and the profession will be judged by whether it has the wisdom, will and moral courage to meet it. Financial support and sponsorship Nil. Conflicts of interest Choolani M is a member of the SMJ Editorial Board and was thus not involved in the peer review and publication decisions of this article.