Pre-eclampsia remains a major cause of maternal and perinatal harm, with risks spanning clinical care, social conditions, workplace exposures and access to antenatal services. A 2026 article in BJOG, linked to the PRECISE Network, sets out a prevention framework that brings these risks together. It integrates 35 social and clinical determinants associated with pre-eclampsia, 31 of them potentially modifiable. Metabolic, cardiovascular, environmental and healthcare access factors sit within a single structure, giving healthcare leaders a clearer view of prevention points before and during pregnancy.
Integrated Determinants of Risk
The framework identifies clinical determinants with definite or probable associations and moderate or high-quality evidence. High body mass index is central, including obesity and overweight, alongside type 2 diabetes mellitus, obstructive sleep apnoea, chronic hypertension, elevated blood pressure in early pregnancy and stage 1 hypertension at booking. Antiphospholipid syndrome, prior pre-eclampsia, prior stillbirth, family history of pre-eclampsia in a mother or sister, fetal trisomy 13 and infection in current pregnancy are also included.
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Several indirect clinical relationships connect these risks. High body mass index is linked with type 2 diabetes, obstructive sleep apnoea and hypertension. Obstructive sleep apnoea is also linked with type 2 diabetes. Smoking has an inverse association with pre-eclampsia in the evidence grading, but this requires cautious interpretation because methodological artefacts, misclassification and inappropriate adjustment may affect that relationship. Smoking is also associated with altered placental development and higher oxidative stress, so the inverse pattern does not translate into a protective clinical message.
Social factors include work stress, occupational exposure to whole-body vibration, prolonged bending, lack of antenatal care, distance to a health facility, heat exposure in early pregnancy, ultraviolet B exposure and micronutrient supplementation. Calcium and/or vitamin D supplementation and ultraviolet B exposure are identified as protective factors, while the remaining social determinants act as risk factors.
Modifiable Pathways for Prevention
Most determinants in the framework are potentially modifiable. Clinical factors considered modifiable include high body mass index, obstructive sleep apnoea, type 2 diabetes, high blood pressure, smoking, antiphospholipid syndrome and infection. Non-modifiable clinical factors include prior stillbirth, prior pre-eclampsia, family history of pre-eclampsia and fetal trisomy 13. All social determinants included in the framework are considered modifiable.
The strongest modifiable clinical pathways centre on body mass index, either directly or through type 2 diabetes and chronic hypertension or high blood pressure. These relationships point to metabolic and cardiovascular pathways in pre-eclampsia. Maternal risk factors can combine, particularly in late-onset pre-eclampsia, which accounts for at least 70% of cases. Evidence cited within the framework also connects obesity with pre-eclampsia more strongly in subgroups with chronic hypertension, prior pre-eclampsia, diabetes, kidney disease or autoimmune conditions.
Antenatal care is a key factor within social pathways. Maternal stress is associated with fewer antenatal care visits, while high antenatal care attendance is associated with increased calcium supplementation. Early and consistent healthcare engagement during pregnancy supports preventive measures, detection of risk factors and access to treatment. Micronutrient supplementation is probably protective, although certainty is affected by heterogeneity between sources of evidence and by unaccounted factors such as water calcium and ultraviolet B exposure.
Clinical Care and System Action
The framework links pre-eclampsia prevention with both individual care pathways and wider system conditions. Management of cardiovascular and metabolic risks sits alongside access to quality antenatal services, especially when chronic hypertension, high blood pressure, diabetes, elevated body mass index or infection are present. Improved screening can also support prevention and earlier detection for women with non-modifiable risk factors, including prior stillbirth, previous pre-eclampsia, family history and fetal trisomy 13.
Workplace and environmental determinants broaden the prevention agenda beyond traditional clinical risk assessment. Work stress, whole-body vibration, prolonged bending, distance to a health facility and heat exposure in early pregnancy sit within the same evidence-based structure as clinical determinants. Occupational protection, accessible antenatal care and support for women facing stress or barriers to attendance are therefore part of the prevention landscape defined by the framework.
No strong indirect associations between clinical and social domains are identified with definite or probable strength and moderate or high-quality evidence. Several possible links remain, including work stress with type 2 diabetes, work stress with higher body mass index, work stress with smoking in pregnancy, smoking with fewer antenatal visits and overweight with late antenatal booking. These gaps reflect the fragmentation of evidence across disciplines and the frequent separation of clinical and social factors in pre-eclampsia research.
The framework places pre-eclampsia risk within an integrated structure that combines clinical, social, environmental and healthcare access determinants. Its emphasis on modifiable factors supports prevention strategies across maternity care, public health and policy. Body mass index, hypertension, diabetes, infection, antenatal care attendance, occupational exposures and environmental conditions all form part of a connected prevention agenda. Non-modifiable risks remain important for screening and early detection. The overall structure supports more targeted prevention planning while recognising the multifactorial nature of pre-eclampsia.
Source: BJOG: An International Journal of Obstetrics & Gynaecology
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References:
Woo Kinshella ML, Bone JN, Elawad T et al. (2026) Integrating Social and Clinical Determinants of Pre-Eclampsia: A Hierarchical Systematic Review and Conceptual Framework for Prevention. BJOG: An International Journal of Obstetrics & Gynaecology: 1–11.
