Pre-eclampsia in Aotearoa New Zealand: elevating clinical vigilance and equity—a viewpoint

Pre-eclampsia is a leading global cause of maternal and perinatal morbidity and mortality. In Aotearoa New Zealand, pre-eclampsia, along with other hypertensive disorders of pregnancy such as white coat hypertension, gestational hypertension and chronic hypertension, continues to represent a significant public health challenge, with Māori and Pacific whānau disproportionately affected.¹ Despite universal access to antenatal care through a publicly funded health system, persistent inequities in both the incidence and outcomes of hypertensive disorders in pregnancy highlight ongoing systemic barriers and the urgent need for targeted, equity-focussed interventions. In recognition of its impact, the month of May is designated as Pre-eclampsia awareness month, providing a platform to increase awareness, promote early detection and advocate for improved maternal health outcomes.

Pre-eclampsia, defined as new-onset hypertension after 20 weeks gestation accompanied by one or more signs of new-onset organ involvement, is a complex multisystem disorder with an unclear aetiology. Pathophysiological mechanisms include impaired placentation, systemic inflammation and widespread endothelial dysfunction.² It can arise suddenly and progress rapidly, often in women with no prior risk factors. While routine antenatal care offers an essential safety net for identifying early signs, Māori and Pacific women continue to experience systemic barriers to accessing consistent, high-quality care. These barriers include geographic isolation, experiences of institutional racism, lower rates of continuity of care and reduced access to culturally safe services.³ Data from Health New Zealand – Te Whatu Ora consistently demonstrate higher rates of severe pre-eclampsia, preterm delivery and perinatal complications among wāhine Māori and Pacific compared with Pākehā women, even after adjusting for socio-economic status.⁴

Risk stratification models currently used in antenatal care can under-represent those most affected by inequity. While maternal history, comorbidities such as diabetes and hypertension and lifestyle factors are considered, these frameworks often fail to account for structural determinants of health. Consequently, many Māori and Pacific women may not be appropriately identified as high risk, despite facing compounding disadvantages that exacerbate vulnerability to hypertensive disorders.³

Culturally responsive models of maternity care are essential to improving outcomes.⁵ Kaupapa Māori maternity services, continuity of midwifery care and co-designed interventions with Pacific communities have shown promise in enhancing trust, engagement and clinical outcomes. Yet the scale and availability of such models remain limited. Health inequities are perpetuated when care pathways are designed without partnership and when services are not adequately resourced to reflect Te Ao Māori or Pacific worldviews.⁶

The cornerstone of pre-eclampsia management remains early identification and timely delivery. Surveillance tools such as blood pressure monitoring, urinalysis, serum creatinine, liver enzymes and platelet counts are standard. Advanced diagnostic measures—like angiogenic biomarkers (e.g., soluble fms-like tyrosine kinase 1: placental growth factor, sFlt-1: PlGF ratio)—offer more predictive value but are not equitably accessible across all districts.^7,8 Likewise, digital health tools, including home blood pressure monitors and telehealth platforms, are increasingly used in urban centres, but digital inequity presents a barrier in remote and under-served communities. This could be minimised by incorporating technology with Māori health values.⁹

Management must be multidisciplinary and equity-focussed with people at the centre. Mild cases may be managed with antihypertensives and close monitoring, but severe pre-eclampsia often requires urgent delivery. The use of corticosteroids for foetal lung maturity and magnesium sulphate for seizure prophylaxis is well established.⁸ However, access to secondary-level and tertiary-level care can be delayed for patients in rural regions, where transport, referral and coordination barriers further amplify risk for Māori and Pacific mothers.³

In 2021, Health New Zealand – Te Whatu Ora outlined national priorities for reducing maternal health inequities. However, implementation has been inconsistent, and accountability mechanisms remain limited. Investment in equity must go beyond rhetoric to include dedicated funding for Māori- and Pacific-led services, systemic anti-racism training across the maternity workforce and research into the lived experiences of under-served populations.^3,4 Prevention also plays a vital role. Low-dose aspirin, administered from early pregnancy in high-risk individuals, has been shown to significantly reduce the incidence of preterm pre-eclampsia and improve outcomes.¹⁰ Yet, uptake remains uneven, with lower prescribing rates in clinics serving Māori and Pacific populations. This reflects a broader failure to integrate population health equity into routine obstetric practice.

Pre-eclampsia awareness month should not merely be a calendar observance but a call to action—both clinically and structurally. Awareness alone cannot resolve inequity; it must be coupled with cultural humility, data-driven investment and systemic change. As a clinical community, we must commit not only to reducing the burden of pre-eclampsia but to transforming the conditions that make it deadlier for some and more survivable for others. At the individual clinician level, success hinges on vigilance and screening, training with updated knowledge and guidelines, personalised care and meticulous documentation keeping principles of equity in mind. In a nation that aspires to equity in health, no mother should suffer preventable harm due to an unequal system. Let us recommit to ensure that pre-eclampsia and other hypertensive disorders of pregnancy are not only managed better, but understood through the lens of justice, partnership and respect for the aspirations of all whānau.