Hypertensive disorders of pregnancy are an important cause of severe morbidity, long-term disability and death among both pregnant women and their babies, and account for approximately 14% of all maternal deaths worldwide. Improving care for women around the time of childbirth is a necessary step towards achievement of the health targets of the Sustainable Development Goals (SDGs). Efforts to prevent and reduce morbidity and mortality during pregnancy, childbirth and the postpartum period could also help address the profound inequities in maternal and perinatal health globally. To achieve these aims, healthcare providers, health managers, policymakers and other stakeholders need up-todate and evidence-based recommendations to inform clinical policies and practices.
In 2017, the Executive Guideline Steering Group (GSG) on the World Health Organization's (WHO) maternal and perinatal health recommendations prioritized the updating of the existing three WHO recommendations on the management of severe pre-eclampsia before term in response to important new evidence on these questions. These recommendations are a revalidation of the previous recommendations issued in 2011 in the WHO recommendations on prevention and treatment of pre-eclampsia and eclampsia.

# Target audience
The primary audience of these recommendations includes health professionals who are responsible for developing national and local health protocols (particularly those related to hypertensive disorders of pregnancy) and those directly providing care to pregnant women and their newborns, including midwives, nurses, general medical practitioners, obstetricians, managers of maternal and child health programmes, and relevant staff in ministries of health, in all settings.

# Guideline development methods
The updating of these recommendations was guided by standardized operating procedures in accordance with the process described in the WHO handbook for guideline development. The recommendations were initially developed using this process, namely:
(i) identification of the priority question and critical outcomes;
(ii) retrieval of evidence;
(iii) assessment and synthesis of evidence;
(iv) formulation of the recommendation; and
(v) planning for the dissemination, implementation, impact evaluation and updating of the recommendations.
The scientific evidence supporting these recommendations was synthesized using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.
The systematic review was used to prepare evidence profiles for the prioritized question.
WHO convened an online meeting on 2 May 2018 where an international group of experts -the Guideline Development Group (GDG) -reviewed and approved these recommendations.

# The recommendations
The GDG reviewed the balance between the desirable and undesirable effects and the overall certainty of supporting evidence, values and preferences of stakeholders, resource requirements and cost-effectiveness, acceptability, feasibility and equity. The GDG revalidated the WHO recommendations published in 2011 with minor revisions to the remarks and implementation considerations.
To ensure that the recommendations are correctly understood and applied in practice, guideline users should refer to the remarks, as well as to the evidence summary, if there is any doubt as to the basis for the recommendations and how best to implement them.
Table 1: WHO recommendations: policy of interventionist versus expectant management of severe preeclampsia before term.
Recommendations: 1. Induction of labour is recommended for women with severe pre-eclampsia at a gestational age when the fetus is not viable or unlikely to achieve viability within one or two weeks. (strong recommendation, very low certainty evidence)
- In women with severe pre-eclampsia, a viable fetus and before 34 weeks of gestation, a policy of expectant management is recommended, provided that uncontrolled maternal hypertension, increasing maternal organ dysfunction or fetal distress are absent and can be monitored.
(conditional recommendation, very low certainty evidence)
- In women with severe pre-eclampsia, a viable fetus and between 34 and 36 (plus 6 days) weeks of gestation, a policy of expectant management may be recommended, provided that uncontrolled maternal hypertension, increasing maternal organ dysfunction or fetal distress are absent and can be monitored. (conditional recommendation, very low certainty evidence)
- A policy of expectant management usually includes intra-hospital care with steroids for fetal lung maturation, magnesium sulfate (as necessary), antihypertensive drugs (as necessary), and close maternal and fetal monitoring to identify indications for delivery (e.g. uncontrolled hypertension, deterioration in the condition of the mother and the fetus, including organ dysfunction and fetal distress).
As part of expectant management, in-utero transfer to a tertiary-level centre with neonatal intensive care capacity should be considered. The decision on the route of delivery should be made on a caseby-case basis, taking into account, among other factors, gestational age, fetal and cervical status and urgency.
- The guideline development group considered that the gestational age threshold for using expectant management in very preterm fetuses depends on the fetal viability status and on the anticipated prolongation of gestation with expectant management. The guideline development group acknowledged that the gestational age threshold of fetal viability should be locally agreed. In establishing this threshold, the local context, the availability of resources, and the local newborn survival rates by gestational age should be considered. The average gain in terms of prolongation of gestation with expectant management ranges from 1 week to 2 weeks. Hence, fetuses at a gestational age 1-2 weeks below the fetal viability threshold may benefit from expectant management.
An estimated 303 000 women and adolescent girls died as a result of pregnancy and childbirthrelated 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 achievement of the health targets of the Sustainable Development Goals (SDGs). International human rights law includes fundamental commitments of 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.

# Pre-eclampsia and eclampsia
Hypertensive disorders of pregnancy are an important cause of severe morbidity, longterm disability and death among both mothers and their babies. Worldwide, they account for approximately 14% of all maternal deaths (6). Pre-eclampsia stands out among the hypertensive disorders for its impact on maternal and neonatal health. It is one of the leading causes of maternal and perinatal mortality and morbidity worldwide. However, the pathogenesis of pre-eclampsia is only partially understood, and it is related to disturbances in placentation at the beginning of pregnancy, followed by generalized inflammation and progressive endothelial damage. There are other uncertainties too: the diagnosis, screening and management of pre-eclampsia remains controversial, as does the classification of its severity.
The 11th revision of the International Classification of Diseases (ICD-11) describes pre-eclampsia as a condition characterized by systolic blood pressure greater than 140 mmHg, and/ or diastolic greater or equal to 90 mmHg on two occasions 4 hours or more apart, in the presence of either proteinuria or other new onset maternal organ dysfunction characterized by one thrombocytopenia, elevated serum creatinine or liver transaminases, or neurological conditions or fetal growth restriction (7). Although patho-physiological changes (e.g. inadequate placentation) exist from the very early stages of the pregnancy, hypertension and proteinuria usually become apparent in the second half of pregnancy and are present in 2-8% of all pregnancies overall.
Obesity, chronic hypertension and diabetes are among the risk factors for pre-eclampsia, which also include nulliparity, adolescent pregnancy and conditions leading to hyperplacentation and large placentas (e.g. twin pregnancy). Preeclampsia is usually classified as mild or severe.
In most settings, pre-eclampsia is classified as severe when any of the following conditions is present: severe hypertension, heavy proteinuria or substantial maternal organ dysfunction. Early onset (before 32-34 weeks of pregnancy) of pre-eclampsia and fetal morbidity are used as independent criteria to classify pre-eclampsia as severe in some parts of the world. Maternal deaths can occur in severe cases, but the progression from mild to severe can be rapid, unexpected and occasionally fulminant. The only definitive treatment for pre-eclampsia is termination of pregnancy or delivery of the fetus and placenta, though some women with preeclampsia also present a transient aggravation of the disease in the postpartum period. Management of women with pre-eclampsia aims at minimizing further pregnancy-related complications, avoiding unnecessary prematurity and maximizing maternal and infant survival.
In 2011, the World Health Organization (WHO) published 22 recommendations for the prevention and treatment of pre-eclampsia and eclampsia, including three recommendations on the management of severe pre-eclampsia before term (8). These recommendations were developed according to the WHO guideline development standards, including synthesis of available research evidence, use of the 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 (9). 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 three existing WHO recommendations on the management of severe pre-eclampsia before term in response to new, potentially important evidence on the subject.
The primary goal of these recommendations is to improve the quality of care and outcomes for pregnant women, particularly related to the treatment of hypertensive disorders of pregnancy. These recommendations provide a foundation for the sustainable implementation of the intervention globally.

# Target audience
The primary audience includes health professionals 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 and implementing partners 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:
- In women with severe pre-eclampsia before term (P), does interventionist care (I) compared to expectant management (C), improve maternal or perinatal outcomes (O)?

# Persons affected by the recommendations
The population affected by the recommendations includes pregnant women in low-, middleor high-income settings, particularly those who experience severe pre-eclampsia during pregnancy.
The recommendations were first developed using standardized operating procedures in accordance with the process described in the WHO handbook for guideline development (10). In summary, the process included:
(i) identification of the priority question and critical outcomes;
(ii) retrieval of evidence;
(iii) assessment and synthesis of evidence;
(iv) formulation of the recommendations; and
(v) planning for the dissemination, implementation, impact evaluation and updating of the recommendations.
The three WHO recommendations on the management of severe pre-eclampsia before term were identified by the Executive GSG as a high priority for updating in response to new, potentially important evidence on this question. Six main groups were involved in this process, with their specific roles described in the following sections.

# Contributors to the guideline

# Executive Guideline Steering Group (Executive GSG)
The Executive GSG is an independent panel of 14 external experts and relevant stakeholders from the six WHO regions: African Region, Region of the Americas, South-East Asia Region, European Region, Eastern Mediterranean Region, and Western Pacific Region. The Executive GSG advises WHO on the prioritization of new and existing questions in maternal and perinatal health for recommendation development or updating (11).

# WHO Steering Group
The WHO Steering Group, comprising WHO staff members from the Department of Reproductive Health and Research (RHR) and the Department of Maternal, Newborn, Child and Adolescent Health (MCA) managed the updating process. The Group drafted the key recommendation questions in PICO format, identified the systematic review team and guideline methodologist, as well as the guideline development and external review groups. In addition, the WHO Steering Group supervised the syntheses and retrieval of evidence, organized the Guideline Development Group meeting, drafted and finalized the guideline document, and managed the guideline dissemination, implementation and impact assessment. The members of the WHO Steering Group are listed in Annex 1.

# Guideline Development Group
The From the MPH-GDG pool, 16 external experts and relevant stakeholders were invited to constitute the Guideline Development Group (GDG) for updating these recommendations. Those selected were a diverse group with expertise in research, guideline development methods, and clinical policy and programmes relating to maternal and perinatal health.
The GDG members for these recommendations were also selected in a way that ensured geographic representation and gender balance and there were no important conflicts of interest. The Group appraised the evidence that was used to inform the recommendations, advised on the interpretation of this evidence, formulated the final recommendations based on the draft prepared by the Steering Group, and reviewed and approved the final document. The members of this Group are listed in Annex 1.

# External Review Group
This Group included eight technical experts with interest and expertise in the provision of evidence-based obstetric care. None of its members declared a conflict of interest. The Group reviewed the final document to identify any errors of fact and commented on the clarity of the language, contextual issues and implications for implementation. The Group ensured that the decision-making processes had considered and incorporated contextual values and preferences of potential users of the recommendations, healthcare professionals and policy makers. They did not change the recommendations that was formulated by the GDG. The members of the External Review Group are listed in Annex 1.

# Systematic review team and guideline methodologists
A Cochrane systematic review on this question was updated, supported by the Cochrane Pregnancy and Childbirth Group. The WHO Steering Group reviewed and provided input into the protocol and worked closely with the Cochrane Pregnancy and Childbirth Group to appraise the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.
Representatives of the Cochrane Pregnancy and Childbirth Group attended the GDG meeting to provide an overview of the available evidence and GRADE tables and to respond to technical queries from the GDG.

# External partners and observers

# Identification of critical outcomes
The critical and important outcomes were aligned with the prioritized outcomes from the WHO recommendations on prevention and treatment of pre-eclampsia and eclampsia (8). These outcomes were initially identified through a search of key sources of relevant, published, systematic reviews and a prioritization of outcomes by the 2011 GDG panel. All outcomes were included in the scope of this document for evidence searching, retrieval, grading and formulation of the recommendations. The list of outcomes is provided in Annex 2.

# Evidence identification and retrieval
A Cochrane systematic review was updated by the Cochrane Pregnancy and Childbirth Group (12). This systematic review was the primary source of evidence for these recommendations.
Randomized controlled trials (RCT) relevant to the key question were screened by the review authors, and data on relevant outcomes and comparisons were fed into Review Manager (RevMan) software. The RevMan file was retrieved from the Cochrane Pregnancy and Childbirth Group and customized to reflect the key comparisons and outcomes (those that were not relevant to the recommendations were excluded).
Then the RevMan file was exported to GRADE profiler software (GRADEpro) and GRADE criteria were used to critically appraise the retrieved scientific evidence.
Finally, evidence profiles (in the form of GRADE tables) were prepared for comparisons of interest, including the assessment and judgements for each outcome and the estimated risks.

# Certainty assessment and grading of the evidence
The certainty assessment of the body of evidence for each outcome was performed using the GRADE approach (13). Using the GRADE approach, the certainty of evidence for each outcome was rated as 'high', 'moderate', 'low' or 'very low' based on a set of established criteria. The final rating of certainty of evidence was dependent on the factors briefly described below.

# Study design limitations:
The risk of bias was first examined at the level of individual study and then across studies contributing to the outcome. For randomized trials, certainty was first rated as 'high' and then downgraded by one ('moderate') or two ('low') levels, depending on the minimum criteria met by the majority of the studies contributing to the outcome.

# Inconsistency of the results:
The similarity in the results for a given outcome was assessed by exploring the magnitude of differences in the direction and size of effects observed in different studies. The certainty of evidence was not downgraded when the direction of the findings were similar and confidence limits overlapped, whereas it was downgraded when the results were in different directions and confidence limits showed minimal or no overlap.
Indirectness: The certainty of evidence was downgraded when there were serious or very serious concerns regarding the directness of the evidence, that is, whether there were important differences between the research reported and the context for which the recommendations were being prepared. Such differences were related, for instance, to populations, interventions, comparisons or outcomes of interest.
Imprecision: This assessed the degree of uncertainty around the estimate of effect. As this is often a function of sample size and number of events, studies with relatively few participants or events, and thus wide confidence intervals around effect estimates, were downgraded for imprecision.

# Publication bias:
The certainty rating could also be affected by perceived or statistical evidence of bias to underestimate or overestimate the effect of an intervention as a result of selective publication based on study results. Downgrading evidence by one level was considered where there was strong suspicion of publication bias.
Certainty of evidence assessments are defined according to the GRADE approach:
- High certainty: We are very confident that the true effect lies close to that of the estimate of the effect

# Formulation of recommendations
The WHO Steering Group used the evidence profiles to summarise evidence on effects on the pre-specified outcomes. The evidence summary and corresponding GRADE tables, other related documents for assessment of values and preferences, resource requirements and costeffectiveness, acceptability, feasibility and equity were provided in advance to meeting participants, who were invited to submit their comments electronically in advance of the meeting.
The GDG members and other participants were then invited to attend an online GDG meeting (see Annex 1 for the list of participants) organized by the Steering Group on 2 May 2018. During the meeting, the GDG members reviewed and discussed the balance between the desirable and undesirable effects of the intervention and the overall certainty of supporting evidence, values and preferences of stakeholders, resource requirements and cost-effectiveness, acceptability, feasibility and equity, before finalizing the recommendations and remarks.

# Declaration of interests by external contributors
According to WHO regulations, all experts must declare their relevant interests prior to participation in WHO guideline development processes and meetings. All GDG members were therefore required to complete a standard WHO Declaration of Interest (DOI) form before engaging in the guideline development process and before participating in the guideline-related meeting. The WHO Steering Group reviewed each declaration before finalizing the experts' invitations to participate. Where any conflict of interest was declared, the Steering Group determined whether such conflicts were serious enough to affect the expert's objective judgement of the guideline and recommendation development process. To ensure consistency, the Steering Group applied the criteria for assessing the severity of conflict of interests in the WHO Handbook for Guideline Development to all participating experts. All findings from the DOI statements received were managed in accordance with the WHO DOI guidelines on a case-by-case basis and communicated to the experts. Where a conflict of interest was not considered significant enough to pose any risk to the guideline development process or reduce its credibility, the experts were only required to openly declare such conflicts of interest at the beginning of the GDG meeting, and no further actions were taken.
Annex 3 shows a summary of the DOI statements, and how the conflicts of interest declared by participating experts were managed by the Steering Group.

# Decision-making during the Guideline Development Group meeting
During the meeting, the GDG reviewed and discussed the evidence summary and sought clarification. In addition to evaluating the balance between the desirable and undesirable effects of the intervention and the overall certainty of the evidence, the GDG applied additional criteria based on the GRADE evidence-todecision framework to determine the direction and strength of the recommendations. These criteria included stakeholders' values, resource implications, acceptability, feasibility and equity.
Considerations were based on the experience and opinions of members of the GDG and supported by evidence from a literature search where available. Evidence-to-decision tables were used to describe and synthesize these considerations.
Decisions were made based on consensus defined as the agreement by three quarters or more of the participants. None of the GDG members expressed opposition to the recommendations.
Table 1: WHO recommendation: policy of interventionist versus expectant management of severe pre-eclampsia before term.
Recommendations: 1. Induction of labour is recommended for women with severe pre-eclampsia at a gestational age when the fetus is not viable or unlikely to achieve viability within one or two weeks. (strong recommendation, very low certainty evidence)
- In women with severe pre-eclampsia, a viable fetus and before 34 weeks of gestation, a policy of expectant management is recommended, provided that uncontrolled maternal hypertension, increasing maternal organ dysfunction or fetal distress are absent and can be monitored. (conditional recommendation, very low certainty evidence)
- In women with severe pre-eclampsia, a viable fetus and between 34 and 36 (plus 6 days) weeks of gestation, a policy of expectant management may be recommended, provided that uncontrolled maternal hypertension, increasing maternal organ dysfunction or fetal distress are absent and can be monitored. (conditional recommendation, very low certainty evidence)
- A policy of expectant management usually includes intra-hospital care with steroids for fetal lung maturation, magnesium sulfate (as necessary), antihypertensive drugs (as necessary), and close maternal and fetal monitoring to identify indications for delivery (e.g. uncontrolled hypertension, deterioration in the condition of the mother and the fetus, including organ dysfunction and fetal distress). As part of expectant management, in-utero transfer to a tertiary-level centre with neonatal intensive care capacity should be considered. The decision on the route of delivery should be made on a case-by-case basis, taking into account, among other factors, gestational age, fetal and cervical status and urgency.
- The guideline development group considered that the gestational age threshold for using expectant management in very preterm fetuses depends on the fetal viability status and on the anticipated prolongation of gestation with expectant management. The guideline development group acknowledged that the gestational age threshold of fetal viability should be locally agreed. In establishing this threshold, the local context, the availability of resources, and the local newborn survival rates by gestational age should be considered. The average gain in terms of prolongation of gestation with expectant management ranges from 1 week to 2 weeks. Hence, fetuses at a gestational age 1-2 weeks below the fetal viability threshold may benefit from expectant management.

# Document preparation
Prior to the online meeting, the WHO Steering Group prepared a draft version of the GRADE evidence profiles, evidence summary and other documents relevant to the deliberation of the GDG. The draft documents were made available to the participants of the meeting two weeks before the meeting for their comments. During the meeting, these documents were modified in line with the participants' deliberations and remarks. Following the meeting, members of the WHO Steering Group drafted a recommendation document to accurately reflect the deliberations and decisions of the participants. The draft document was sent electronically to GDG members and the External Review Group for final review and approval.

# Peer review
Following review and approval by GDG members and the External Review Group, the final document was sent to eight external independent experts who were not involved in the guideline panel for peer review. The WHO Steering Group evaluated the inputs of the peer reviewers for inclusion in this document. After the meeting and external peer review, the modifications made by the WHO Steering Group to the document consisted only of correcting factual errors and improving language to address any lack of clarity.

# Recommendations and supporting evidence
The following section outlines the recommendations and the corresponding narrative summary of evidence for the prioritized question. The evidence-to-decision table, summarizing the balance between the desirable and undesirable effects and the overall certainty of the supporting evidence, values and preferences of stakeholders, resource requirements, cost-effectiveness, acceptability, feasibility and equity that were considered in determining the strength and direction of the recommendations, is included in the evidence-todecision framework (Annex 4).
The following recommendations were adopted by the GDG. Evidence on the effectiveness of the intervention was derived from one systematic review and was summarized in GRADE tables (Annex 5). The certainty of the supporting evidence was rated as 'very low' for most critical outcomes. To ensure that the recommendations are correctly understood and appropriately implemented in practice, additional 'remarks' reflecting the summary of the discussion by GDG are included under the recommendations.

# Dissemination and implementation of the recommendations
The dissemination and implementation of these recommendations is to be considered by all stakeholders and organizations involved in the provision of care for pregnant women at the international, national and local levels. There is a vital need to increase access and strengthen the capacity of health facilities to provide high quality services to all women giving birth. It is therefore crucial that these recommendations are translated into antenatal and intrapartum care packages and programmes at country and health-facility levels (where appropriate).

# Recommendation dissemination and evaluation
A shorter document containing the recommendations, remarks, implementation considerations and research priorities will be formulated for public dissemination. This document will have annexes (also made publicly available) containing all the information in this document, including methods, evidence-todecision frameworks and GRADE tables.
The recommendations will be disseminated through WHO regional and country offices, ministries of health, professional organizations, WHO collaborating centres, other United Nations agencies and nongovernmental organizations, among others. These recommendations will be also available on the WHO website and in the WHO Reproductive Health Library. Updated recommendations are also routinely disseminated during meetings or scientific conferences attended by relevant WHO staff.
The recommendations document will be translated into the six UN languages and disseminated through the WHO regional offices. Technical assistance will be provided to any WHO regional office willing to translate the full recommendations into any of the six UN languages.

# Implementation considerations
- The successful introduction of these recommendations into national programmes and healthcare services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. The adaptation and implementation processes may include the development or revision of existing national guidelines or protocols;
- The recommendations should be adapted into a locally appropriate document that can meet the specific needs of each country and health service. Any changes should be made in an explicit and transparent manner;
- A set of interventions should be established to ensure that an enabling environment is created for the use of the recommendations (including, for example, the availability of antihypertensive drugs), and that the behaviour of the healthcare provider changes towards the use of this evidence-based practice;
- In this process, the role of local professional societies is important and an allinclusive and participatory process should be encouraged;
- Healthcare providers should discuss with women the risks, benefits and treatment options in the management of severe preeclampsia, to facilitate informed consent and shared decision-making (19);
- Other WHO resources (such as the clinical handbook Managing Complications of Pregnancy and Childbirth) provide further guidance on applying these recommendations in clinical settings (19).

# Research implications
The GDG identified important knowledge gaps that need to be addressed through primary research, which may have an impact on these recommendations. The following areas were identified as high priorities for further research:
- Relative effectiveness of available drugs for severe acute hypertension, including effects on the fetus and newborn;
- Further research to understand the relative importance that women with preeclampsia during pregnancy place on treatment options and health outcomes, and their preferences; and
- Evaluating communication interventions and tools (such as visual aids) to assist women with pre-eclampsia to make informed decisions.

# Applicability issues
Anticipated impact on the organization of care and resources
Implementing these evidence-based recommendations will require resources to ensure implementation is done safely, including staff time for monitoring of women undergoing induction of labour. The GDG noted that updating training curricula and providing training would increase impact and facilitate implementation. Standardization of care by including recommendations into existing maternity care packages and protocols could encourage healthcare provider behaviour change.

# Monitoring and evaluating guideline implementation
Implementation should be monitored at the health-service level as part of broader efforts to monitor and improve the quality of maternal and newborn care. For example, interrupted time series, clinical audits or criterion-based clinical audits can be used to obtain relevant data related to induction of labour. Clearly defined review criteria and indicators are needed and these could be associated with locally agreed targets. These could be aligned with the standards and indicators described in the WHO document Standards for improving quality of maternal and newborn care in health facilities (20).

# Updating the recommendations
The Executive GSG convenes annually to review WHO's current portfolio of maternal and perinatal health recommendations and to advise WHO on prioritization of new and existing questions for recommendation development and updating. Accordingly, these recommendations will be reviewed and prioritized by the Executive GSG. In the event that new evidence that could potentially impact the current evidence base is identified, the recommendations may be updated. If no new reports or information are identified, the recommendations may be revalidated.
Following publication and dissemination of the updated recommendations, any concerns about the validity of the recommendations will be promptly communicated to the guideline implementers, in addition to any plans to update the recommendations.
WHO welcomes suggestions regarding additional questions for inclusion in the updated recommendations. Please email your suggestions to mpa-info@who.int. The conflict was not considered serious enough to affect GDG membership or participation in the Technical Consultation excluded, because it was felt that the neonatal care provided was too poor due to limited resources in some units.
All of the women had severe pre-eclampsia. Their gestation period ranged from less than or equal to 34 weeks' (one trial), between 28 and 32 weeks' gestation (one trial), between 28 and 34 weeks' gestation (two trials) and between 28 and 33 weeks' gestation (two trials). In five trials, women had a 24-to 48-hour period during which they were given steroids to accelerate fetal lung maturity and if necessary magnesium sulfate to prevent seizures and antihypertensives to lower blood pressure. At the end of this period, if they continued to meet the eligibility criteria, they were then randomized. They were randomized either to an interventionist group, for immediate delivery by caesarean section or induction, or to an expectant management group, who were managed with hospitalisation and intensive maternal and fetal monitoring. Earlier delivery in the expectant group was implemented if either the maternal or fetal condition deteriorated, as determined by pre-specified criteria.

# Effects of interventions Maternal outcomes
Maternal death: Two studies reported on this outcome, and there were no maternal deaths in either study (two studies, 320 women; 0/159 vs 0/161; effect not estimable; low certainty evidence).
Eclampsia: It is uncertain whether interventionist care reduces eclampsia because the certainty of this evidence is very low.
HELLP syndrome: Low-certainty evidence from two studies suggests little or no clear difference between the interventionist and expectant care groups (two studies, 359 women; 22/179 vs 20/180; RR 1.09, 95% CI 0.62 to 1.91).
Pulmonary oedema: It is uncertain whether interventionist care reduces pulmonary oedema because the certainty of this evidence is very low.
Renal failure: It is uncertain whether interventionist care reduces renal failure because the certainty of this evidence is very low. There were no data reported for the prioritized maternal outcome: recurrent seizures.

# Infant outcomes

# Additional considerations
Evidence from a qualitative systematic review found that while women place a high value on a physiological labour and birth experience, they also acknowledge that birth can be unpredictable.
Even where an intervention (such as interventionist care) is needed or wanted, women usually wish to retain a sense of personal achievement and control by being involved in decision-making (14).
The GDG considered it likely that women in different settings with a pregnancy of viable gestational age would highly value perinatal morbidity and mortality outcomes.
What would be the impact of interventionist care on severe pre-eclampsia before term on health equity?

# Research evidence
No direct evidence identified.

# Additional considerations
In low to middle-income countries (LMICS), women who are poor, least educated, and residing in rural areas have lower health intervention coverage and worse health outcomes than the more advantaged women. In the 2015 WHO State of Inequalities Report, antenatal care coverage of at least four visits differed by at least 25% between the most and least educated, and the richest and poorest in half the LMICs studied (15). It is therefore likely that adverse consequences of hypertensive disorders of pregnancy are worse in women living in disadvantaged circumstances.