Planned early birth for pregnant women with high blood pressure cuts maternal complications by nearly half and reduces the risk of stillbirth, without increasing the likelihood of Caesarean section, according to a recent Cochrane review.
Hypertensive disorders of pregnancy, which include pre-eclampsia, gestational hypertension and chronic hypertension, are the second leading cause of maternal death globally. For women with pre-eclampsia, early birth remains the only definitive treatment, as the condition is driven by the placenta and will only resolve once it is delivered.
This review, led by King’s College London, pooled data from six randomised controlled trials involving 3 491 women, comparing planned early birth after 34 weeks to watchful waiting. The trials included women with one or more types of hypertensive disorder and took place across a range of settings, including the Netherlands, UK, US, India and Zambia.
Benefits for mother and baby
The findings show high-certainty evidence that serious maternal complications were nearly halved in women who had a planned early birth compared with those managed with watchful waiting.
Planned early birth may also have reduced the risk of stillbirth by approximately 75%, though this should be interpreted with caution. The finding is based on moderate-certainty evidence, and the reduction was driven by a single trial conducted in India and Zambia, where stillbirth rates are higher. There were no stillbirths recorded in the high-income country trials.
Reassuringly, planned early birth also likely results in no increase in neonatal unit admission, though this finding is also based on moderate-certainty evidence.
Importantly, the maternal benefit held across both high- and low-income settings, suggesting that early birth reduces complications even when women are already receiving appropriate monitoring and care.
“These findings give clinicians and women clearer guidance about the timing of birth when high blood pressure develops in pregnancy,” said Professor Catherine Cluver, senior author of the review and researcher at Stellenbosch University and Tygerberg Hospital. “For women with pre-eclampsia in particular, the evidence supports offering planned early birth from 34 weeks, and no later than 37 weeks.”
“Judging when to offer birth is the question we battle with clinically every day,” said Dr Alice Beardmore-Gray, lead author of the review and obstetrician at King’s College London.
The authors added that in two of the trials included, more than half of the women allocated to watchful waiting ended up needing emergency birth before 37 weeks, typically just three to five days later than women allocated to planned early birth, and often experiencing more complications.
“A common misconception is that by waiting longer, mum and baby are gaining more time, but often what you are doing is just delaying an inevitable emergency birth, when both may be in a worse condition,” said Beardmore-Gray.
No increased risk of C-section
The review found high-certainty evidence of no increased risk of Caesarean section associated with planned early birth. This is a finding the authors consider particularly important for clinical counselling and women’s decision-making.
“That is the first question anyone asks when you offer them an early induction: won’t it increase my risk of a C-section?” said Beardmore-Gray. “Being able to clearly answer no is a really important piece of information to give women when counselling them about the timing of their birth.”
The authors advise that the timing of birth should take into account the woman’s preferences and the severity of her condition. These findings are consistent with and reinforce current international guidelines, which recommend that all women with pre-eclampsia should be offered planned early birth no later than 37 weeks.
Women with gestational hypertension or chronic hypertension without severe features may choose to continue with careful monitoring, with planned early birth considered from 39 weeks onwards.
Further research is needed on longer-term outcomes for infants born late preterm and on the long-term cardiovascular health of mothers affected by hypertensive disorders of pregnancy.
Study details
Planned early birth versus expectant management for hypertensive disorders from 34 weeks’ gestation to term
Alice Beardmore-Gray, Christa Rohwer, Cristina Fernandez Turienzo, Catherine Cluver.
Published in Cochrane Library on 21 May 2026
Abstract
Rationale
Hypertensive disorders in pregnancy are significant contributors to maternal and perinatal morbidity and mortality. They include chronic hypertension, gestational hypertension and pre‐eclampsia. Definitive management of these disorders is planned early birth. The alternative is expectant management with close monitoring, if severe complications are not present. There are benefits and risks associated with both policies, so it is important to establish the safest option.
Objectives
To assess the benefits and risks of planned early birth versus expectant management in pregnant women with hypertensive disorders, from 34 weeks’ gestation onwards.
Search methods
An Information Specialist within the Cochrane Central Executive Team searched CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov and WHO ICTRP. The searches were run from 1 January 2016 to 16 January 2026 with no language restrictions. Reference lists of retrieved studies were also searched.
Eligibility criteria
We included randomised controlled trials comparing planned early birth (by induction of labour or by Caesarean section) with expectant management for women with hypertensive disorders from 34 weeks’ gestation. Cluster‐randomised trials would have been eligible for inclusion in this review, but we found none.
Studies using a quasi‐randomised design were not eligible for inclusion in this review. Studies using a cross‐over design were not eligible for inclusion, because they are not a suitable study design for investigating hypertensive disorders in pregnancy.
Outcomes
The prespecified critical outcomes (based upon a core outcome set agreed via Delphi consensus) were (1) a composite outcome of maternal mortality and morbidity; (2) a composite outcome of perinatal mortality and morbidity; (3) maternal death; (4) foetal death; (5) neonatal death.
The prespecified important maternal outcomes were: Caesarean section, maternal admission to a high dependency unit, eclampsia, pulmonary oedema, severe renal impairment, and HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome. The prespecified important perinatal outcome was neonatal unit admission. Additional maternal and perinatal outcomes were also analysed in accordance with the review protocol, including maternal quality of life measures and health resource use.
Risk of bias
Two review authors independently assessed risk of bias using the Cochrane Risk of Bias 2 (RoB 2) tool. The Cochrane trustworthiness screening tool was applied to all eligible studies at full‐text review stage.
Synthesis methods
Two review authors independently assessed eligibility and risk of bias. Two review authors independently extracted data using a prespecified data extraction form. Data were checked for accuracy. Statistical analysis was carried out in RevMan using a random‐effects meta‐analysis. We assessed the certainty of evidence using GRADE.
Included studies
We included six studies involving 3491 women. All six studies were randomised controlled trials evaluating planned early birth compared with expectant management. Planned early birth was evaluated at between 34 and 37 weeks in four studies, between 36 and 38 weeks in one study and between 36 and 41 weeks in one study. One study took place in low‐ and middle‐income countries, while five took place in high‐income countries. Three studies included only women with pre‐eclampsia, two studies included women with a mixture of hypertensive disorders in pregnancy and one study included only women with chronic hypertension.
Synthesis of results
Planned early birth reduces the risk of maternal mortality and morbidity compared to expectant management (RR 0.54, 95% CI 0.37 to 0.77; I² = 0%; 6 studies, 3491 participants; high‐certainty evidence). There was no increased risk of Caesarean section associated with planned early birth (RR 0.94, 95% CI 0.83 to 1.06; I² = 25%; 6 studies, 3539 participants; high‐certainty evidence).
Planned early birth likely results in a large reduction in the risk of stillbirth (foetal death) (RR 0.25, 95% CI 0.07 to 0.87; I² not applicable; 5 studies, 3 407 participants; moderate‐certainty evidence), but probably results in little to no difference in rates of neonatal unit admission (RR 1.11, 95% CI 0.90 to 1.37; I² = 41%; 6 studies, 3 560 participants; moderate‐certainty evidence).
Planned early birth may result in little to no difference in maternal death (RR 0.33, 95% CI 0.05 to 2.10; I² = 0%; 6 studies, 3491 participants; low‐certainty evidence) or neonatal death (RR 1.40, 95% CI 0.45 to 4.35; I² not applicable; five studies, 3407 participants; low‐certainty evidence).
The evidence is very uncertain about the effect of planned early birth on composite perinatal mortality and morbidity due to high variation between the trials (RR 1.06, 95% CI 0.75 to 1.51; I² = 83%; 6 studies, 3576 participants; very low‐certainty evidence).
Five of the six trials included in this analysis were at low risk of bias. We graded the evidence as high, moderate, low, or very low certainty based upon GRADE criteria. Where we downgraded the evidence, it was typically due to higher levels of heterogeneity or due to imprecision, whereby the confidence interval crossed the line of both appreciable benefit and harm or the number of events was low.
Authors’ conclusions
For women with hypertensive disorders of pregnancy beyond 34 weeks’ gestation, planned early birth is associated with a lower risk of maternal complications, and probably a reduced risk of foetal death (stillbirth), with no increased risk of Caesarean section and probably no clear differences in the rate of neonatal unit admission or short‐term neonatal morbidity.
It is important that the timing of delivery takes into account the woman’s preferences, the type of hypertensive disorder and the presence or absence of severe features.
Further information is needed to establish the longer‐term infant outcomes associated with late preterm birth and longer‐term maternal cardiovascular health.
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