At a glance
- Analysis of commercial and Medicaid claims data and published literature suggests that in the United States alone, preeclampsia affects an estimated 325,000 births annually, contributes to severe maternal morbidity, is associated with 1,000 to 2,200 stillbirths, and is linked to over $28 billion in costs over the lifetime of women who develop preeclampsia every year and their children.
- Unlike many other costly medical conditions, costs of preeclampsia are highly concentrated and likely addressable. While lifetime costs account for a substantial majority of the total economic burden, approximately one-third of costs are incurred around delivery and the first year postpartum and are largely driven by maternal hospitalization and neonatal intensive care.
- Despite preeclampsia’s large burden and unmet need, the solution is often delivering the baby, even when they are not full term. Delivery is the definitive intervention when maternal or fetal risks outweigh the benefits of continuing pregnancy. Improvements in health access and care using existing tools, as well the development of new, effective disease-modifying therapies, could improve maternal and neonatal outcomes and reduce healthcare costs.
Preeclampsia is a multisystem pregnancy disorder that takes a heavy toll on women’s health in the United States and around the world.1 It is associated with new-onset hypertension after 20 weeks’ gestation, the presence of excess protein in the urine, and/or maternal organ or placental dysfunction. It can lead to severe complications, including death, for mothers and babies—especially for mothers in low- and middle-income countries and Black women in the United States.2 Its effects can also last long after pregnancy: Women who have had preeclampsia and their children face higher long-term health risks, particularly of heart and metabolic conditions. Several studies have estimated that women with a history of preeclampsia experience a two to four times increased risk of cardiovascular disease.3
Preeclampsia has generally been reported to affect between 5 and 8 percent of pregnancies in the United States annually. A new analysis from the McKinsey Health Institute conducted in collaboration with the Gates Foundation has found that preeclampsia affects approximately one in 11 live births a year, or 325,000 of 3.6 million annual births.4
Every year, according to our analysis of commercial and Medicaid claims, preeclampsia’s disease burden drives more than $28 billion in lifetime economic burden for women who develop preeclampsia in the United States and for their children.5 While these estimates are focused on the impact of preeclampsia on women and their children, the true burden is likely greater, as preeclampsia also affects partners, caregivers, and families more broadly. Approximately 29 percent ($8 billion) of costs are medical costs incurred by the healthcare system within a year of delivery. The remaining costs include an estimated $16 billion to $18 billion of long-term medical costs associated with increased risk of chronic maternal and child health conditions and approximately $2 billion to $3 billion in societal costs. The healthcare and economic burden is particularly concentrated among women with early-onset preeclampsia (diagnosed earlier than 34 weeks into pregnancy). Early-onset disease makes up approximately 20 percent of preeclampsia cases, but it accounts for about 77 percent of estimated short-term medical costs among affected births within one year of admission for delivery.6
Despite these human and economic costs, there is currently no approved disease-modifying therapy for preeclampsia. As outlined in the World Health Organization’s Global roadmap for hypertensive disorders of pregnancy from 2026 to 2035, the development of preeclampsia therapeutics has not been sufficient to address the need, with only a handful of candidates in active clinical development.7 Barriers to development of therapeutics include concerns about liability for maternal and fetal safety during trials, relatively untested regulatory pathways for novel mechanisms, and lack of coordination across researchers, innovators, and policy-makers.8 The development of new therapeutics that prevent or slow disease progression, alongside improvements in risk identification, antenatal management, and postpartum follow-up, could improve maternal and neonatal outcomes and reduce the burden associated with the condition.
This analysis complements MHI’s recent CARE for Women report, which highlighted gaps in care delivery for pregnancy and cardiovascular disease, including hypertensive disorders. It also builds on MHI’s 2025 report Blueprint to close the women’s health gap, which found that closing the gap on treatment for maternal hypertensive disorders represents potential estimated gains of 0.85 million annual disability-adjusted life years (DALYs).
This paper focuses on opportunities for innovators and investors to generate new approaches to preeclampsia prevention and treatment, based on the human and economic burden of preeclampsia. While it outlines some opportunities to improve care delivery with existing interventions, this is not a primary focus of the paper.
Prevalence and effects of preeclampsia
MHI analysis of US commercial and Medicaid claims found that approximately 9 percent of pregnancy episodes preceding live births met the study definition of preeclampsia, corresponding to roughly 325,000 births annually when applied to the US birth population.9 (For more, see sidebar, “Methodology.”) Preeclampsia is associated with maternal mortality and serious maternal complications, including acute kidney injury, HELLP syndrome, stroke, and placental abruption, and it increases the risks of fetal growth restriction, medically indicated preterm delivery, and stillbirth.10
This report focuses on preeclampsia in the United States specifically, because of the availability of claims data, but preeclampsia is a worldwide issue.11 Preeclampsia and resulting eclampsia are a leading cause of maternal morbidity and maternal mortality globally (hypertensive disorders cause an estimated 42,000 maternal deaths12 and 500,000 infant deaths annually13) and is one of the top six causes of maternal mortality in the United States.14 In the United States alone, preeclampsia leads to 1,000 to 2,200 stillbirths every year.15
In any country, established risk factors for preeclampsia include type 1 or type 2 diabetes, previous hypertension, obesity, family history of preeclampsia (including partner’s genetics and family history),16 prior preeclampsia, first pregnancy, and extremes of maternal age.17 In the United States, the prevalence of some of these risk factors has increased substantially: From 2010 to 2021, rates of chronic hypertension increased from 1.2 percent to 2.7 percent, rates of pregestational diabetes increased from 0.7 percent to 1.1 percent, rates of women having their first child at age 35 or older increased from 14.7 percent to 20.1 percent, and rates of obesity increased from 22.5 percent to 30.5 percent.18
For this analysis, preeclampsia is grouped into three timing-based categories: early-onset, late-onset, and postpartum preeclampsia (Exhibit 1).
- Early-onset preeclampsia, occurring before 34 weeks of gestation,19 is often linked to problems with how the placenta develops. In a healthy pregnancy, the blood vessels supplying the placenta widen to provide enough blood, nutrients, and oxygen to support the growing baby. In early-onset preeclampsia, this process may not happen normally. Emerging scientific research points to several biological mechanisms, including abnormal trophoblast invasion and reduced development of uterine spiral arteries.20 Early-onset preeclampsia can have serious consequences for both mother and baby. For the mother, it can lead to problems with major organs, a serious complication known as HELLP syndrome, or early separation of the placenta from the womb. For the baby, reduced blood flow through the placenta can restrict growth and require early delivery for the baby.21 Babies born very prematurely are more likely to require care in a neonatal intensive care unit.
- Late-onset preeclampsia develops later in pregnancy and is more common in women with certain risk factors, including long-term high blood pressure, a higher body weight, older maternal age, and first pregnancies.22 Compared with early-onset preeclampsia, it is more often linked to the mother’s underlying heart, blood vessel, and metabolic health, although both early- and late-onset preeclampsia share many of the same biological features.23 Late-onset preeclampsia can increase the risk of complications around the time of delivery and is also linked to an increased risk of heart and kidney problems later in life.24 Because it develops later in pregnancy, delivery can often take place at or near full term, which reduces some of the risks to the baby associated with being born prematurely.
- Postpartum preeclampsia presents after delivery and is generally defined as new-onset preeclampsia from 48 hours through six weeks postpartum. Most delayed presentations occur within the first seven to ten days of delivery.25 Given that symptoms often develop after hospital discharge, postpartum preeclampsia is often undiagnosed until the condition becomes severe, increasing the risk of stroke, seizures, and brain injury. Postpartum preeclampsia may occur de novo after a pregnancy without hypertension or following antepartum hypertensive disease. Its pathophysiology is not fully understood.26
Early-onset preeclampsia represents a fifth of cases but has the highest rates of newborn and maternal intensive care stays and emergency visits.
1Numbers are % of commercial claims data set (n = 140,778).
2Outcomes are weighted based on the payer mix in pregnancy (40% Medicaid, 60% commercial).
3Neonatal intensive care unit (NICU) admit rate.
4Maternal emergency department (ED) visits.
5Maternal intensive care unit (ICU) admit rate.
The effects of preeclampsia also reach far beyond pregnancy, shaping a woman’s heart health for the rest of her life. Studies on cardiovascular risk find that preeclampsia is associated with a fourfold increase in risk of heart failure and a doubling of the risk of coronary heart disease, stroke, and mortality due to cardiovascular disease. Preeclampsia is also associated with an increased risk of chronic hypertension, venous thromboembolism, and other conditions.27 This research points to the importance of preeclampsia as not only an acute pregnancy complication but also an important marker of lifelong health risk.
Preeclampsia outcomes vary substantially across racial groups in the United States. Preeclampsia treatment experience and intensity of care utilization differ by race, socioeconomic, and geographical factors. Notably, Black women are approximately 1.6 times more likely than white women to develop preeclampsia, and they experience higher rates of severe complications and pregnancy-related deaths.28 The disparity may be even larger for early-onset disease: In one California cohort, the prevalence of preeclampsia with delivery before 32 weeks was approximately three times as high among Black women as among White women (0.41 percent versus 0.13 percent).29 Existing research indicates important contributions from social determinants of health, structural inequities, differential exposure to racism and chronic stress, and variation in access to and quality of care.30
The experience and intensity of care among women with preeclampsia also differs according to type of insurance. Around 41 percent of pregnancies are covered by Medicaid, and around 52 percent are covered by private insurance (with the remaining 7 percent using self-pay or other types of coverage).31 One US study further found that for women with hypertensive disorders of pregnancy specifically, 54 percent are covered by Medicaid, 44 percent are covered by private insurance, and 2 percent by other types of coverage.32 In our analysis of deliveries covered by Medicaid versus commercial insurance, the average gestational age for women with early-onset preeclampsia was similar to women with commercial insurance (estimated 33-34 weeks), but Medicaid members with preeclampsia had approximately 3.3 to 3.5 times the emergency department utilization and four to seven times the intensive care unit (ICU) utilization of commercially insured patients. Within the Medicaid population analyzed, Black women with preeclampsia had higher observed rates of cesarean delivery, emergency department utilization, and neonatal intensive care unit (NICU) admission than other Medicaid members with preeclampsia.33 These differences are observational and may reflect variation in baseline health, social determinants of health, access to care, care delivery, and other factors.34
Geographic disparities are also evident in terms of experience and utilization of care. In our analysis, among Medicaid members with preeclampsia, women living in rural areas had higher ICU utilization than their urban counterparts, including approximately 16 percent higher rates among women with early-onset preeclampsia and 14 percent higher rates among women with postpartum preeclampsia.35 These differences may reflect variation in disease severity, referral patterns, access to care, care delivery, and other contextual factors; the claims data do not establish the mechanisms underlying the observed geographic differences.
For all its prevalence and seriousness, preeclampsia still has no approved treatment that reverses or meaningfully changes the disease once it has developed. Management of individuals at increased risk of preeclampsia includes low-dose aspirin, though uptake remains limited. Management along the disease course includes but is not limited to close maternal and fetal surveillance, treatment of severe hypertension with antihypertensive medications, magnesium sulfate for seizure prophylaxis when indicated, and appropriately timed delivery.36 Therapeutic candidates in preclinical and clinical development include therapies that target sFLT-1s37 (a protein produced largely by the placenta) and those that dilate blood vessels and reduce blood pressure,38 but substantial unmet need remains for disease-modifying treatments and for continued research into the incompletely understood mechanisms underlying preeclampsia.
The human and economic costs of preeclampsia
Beyond its substantial mortality and morbidity burden, preeclampsia is associated with billions of dollars of healthcare and societal costs (Exhibit 2). The analysis in this report builds upon existing literature that has established preeclampsia’s substantial economic burden, particularly 12 months postpartum.39 Previous studies have found that care for babies is a major driver of those costs, especially for babies born earlier in pregnancy, and that preeclampsia is associated with poorer outcomes for mothers and newborns, including higher risk of preterm birth and long-term health conditions.40
Building upon this evidence, our analysis sizes preeclampsia’s economic burden beyond the direct medical costs incurred one year post delivery by also capturing its potential lifetime medical and societal costs. Using commercial and Medicaid claims data, medical costs are assessed across early-onset, late-onset, and postpartum preeclampsia by applying propensity score matching on pre-pregnancy risk factors to estimate incremental medical costs associated with preeclampsia relative to matched pregnancies without preeclampsia (for more, see Appendix: Approach to analysis and methodology). The analysis then extends beyond claims-based medical costs one year post-delivery to model potential long-term medical and societal costs associated with preeclampsia for both mother and child.
Together, these estimates give a broad picture of the lifetime economic costs of women who develop preeclampsia each year in the United States. They are also conservative. Our claims-based costs include only care linked to a preeclampsia diagnosis code, and our long-term and societal costs include only conditions and effects with quantified evidence in the published research. In addition, studies of long-term medical effects also often follow women and children for limited periods, so true lifetime costs are likely higher.
Preeclampsia costs do not end with discharge, but include substantial long-term medical and societal costs.
Note: Segments are drawn at the midpoint of each range; components may not sum to totals, because of rounding.
1Costs are weighted based on the payer mix in pregnancy (40% Medicaid, 60% commercial).
Lifetime medical and societal costs reach $28 billion or more per year
Preeclampsia drives an estimated $28 billion in lifetime medical and societal costs for women who develop preeclampsia every year in the United States, including $8 billion within a year of admission for delivery.
An estimated 29 percent of total economic burden is direct medical costs incurred from pregnancy through the first year after delivery. Of those short-term medical costs, maternal inpatient care is associated with 41 percent, and NICU care with 34 percent across commercial and Medicaid populations, largely driven by early-onset preeclampsia cases.41
Starting January 1, 2027, the American Medical Association Current Procedural Terminology (CPT) is replacing the bundled global obstetric package with fee-for-service billing, which will involve separate codes for prenatal visits, labor and delivery, and postpartum care instead of one lump payment.42 This may result in higher medical costs associated with pregnancy episodes overall, once codes are adopted by payers. (Commercial payers and state Medicaid programs may set their own adoption timelines.) While major medical cost drivers associated with preeclampsia (ICU and NICU costs) typically fall outside what is covered in maternity bundles already, these changes may have an impact on approaches to managing the costs associated with preeclampsia.
As part of the overall burden of preeclampsia, the analysis estimates approximately $16 billion to $18 billion in incremental long-term medical costs for women who had preeclampsia, reflecting the higher incidence of cardiovascular disease, including hypertension; ischemic heart disease; stroke; venous thromboembolism;43 metabolic conditions for women with preeclampsia, including diabetes and chronic kidney disease; and other long-term health conditions, including postpartum depression and dementia.44 Cardiovascular disease and chronic kidney disease account for the largest share—an estimated $7 billion to $8 billion for cardiovascular disease and $1.5 billion to $2.5 billion for chronic kidney disease—in incremental lifetime costs associated with women affected by preeclampsia every year.45
The long-term cost impact also includes modeled incremental healthcare costs associated with selected neurodevelopmental outcomes (e.g., autism, ADHD, cerebral palsy, and schizophrenia), which have been reported to occur more frequently in children born from pregnancies complicated by preeclampsia.46 Our analysis likely underestimates long-term child-related costs because of the limited quantification of the impacts of long-term health outcomes for neonates. Research has linked preeclampsia to other health problems for babies not included here, including respiratory and cardiovascular disease, physical disabilities, and infection.47 Modeled long-term costs are highest for early-onset preeclampsia, consistent with the greater long-term cardiovascular and kidney disease risks reported in this population.48 In addition, estimates exclude the costs of preeclampsia associated with future pregnancies.
The cost burden varies across preeclampsia cohorts
The total $28 billion total medical and societal cost burden varies across preeclampsia cohorts, reflecting differences in cost per woman and prevalence.
Early-onset preeclampsia accounts for approximately 40 percent of total costs ($11.1 billion), driven by higher acute maternal and neonatal costs for NICU and ICU, as well as greater long-term risk of cardiovascular disease,49 chronic kidney disease, and other cardiometabolic conditions (Exhibit 3).50 Late-onset preeclampsia has a lower cost per case but represents approximately 64 percent of preeclampsia cases in the United States,51 resulting in approximately 45 percent of total costs. Postpartum preeclampsia accounts for approximately 12 percent of costs, driven by its relatively small patient population size (approximately 52,000 women) compared with early- and late-onset preeclampsia. Within the total medical and societal costs, approximately 70 percent of costs ($20 billion) are maternal-related costs, with the remaining 30 percent resulting from neonatal costs ($8 billion).
Late-onset preeclampsia comprises nearly half of the $28 billion in total costs, with early-onset and postpartum cases adding the rest.
lifetime costs,
by type of
preeclampsia,1
$ billion
Note: All values are approximate.
1Costs are weighted based on the payer mix in pregnancy (40% Medicaid, 60% commercial).
While we sized the $28 billion in medical and societal costs using US national averages, the cost burden of preeclampsia may disproportionately impact geographies where barriers to care can amplify adverse outcomes (for example, earlier gestational age and higher rates of maternal pregnancy complications).52
Our primary analysis may not capture the full economic burden associated with preeclampsia cohorts. Diagnostic criteria for preeclampsia differ internationally. For example, in the United Kingdom, the National Institute for Health and Care Excellence (NICE) includes uteroplacental dysfunction, such as fetal growth restriction, as a diagnostic feature when it occurs with new-onset hypertension, whereas fetal growth restriction alone is not part of the American College of Obstetricians and Gynecologists (ACOG) diagnostic criteria for preeclampsia.53 In our analysis of claims data, we found approximately 1 percent of births that lacked a coded preeclampsia diagnosis but met prespecified criteria for medically indicated preterm delivery and had placental dysfunction and fetal growth restriction (indicators of preeclampsia). Incremental medical spending each year driven by this cohort within a year of admission for delivery was estimated at approximately $1.2 billion, representing incremental spend of these births over deliveries without complications from preeclampsia. Because we are not fully confident that these births represent undiagnosed preeclampsia, these costs are not included in the primary estimate of the economic burden of diagnosed preeclampsia.
Costs per case are highest for early-onset preeclampsia
An average delivery with preeclampsia costs the healthcare system approximately $25,000 in the first year postpartum. Early-onset preeclampsia is associated with an estimated $94,000 in incremental costs per delivery, compared with pregnancies not involving preeclampsia. Late-onset preeclampsia has an incremental cost of $6,000, and postpartum $11,800 (Exhibit 4).
Early-onset preeclampsia adds an estimated $94,000 in costs per delivery within 1 year of discharge, compared with pregnancies with no preeclampsia.
Note: Figures may not sum to totals, because of rounding.
1Costs are weighted based on the payer mix in pregnancy (40% Medicaid, 60% commercial).
For early-onset preeclampsia, medical costs incurred between pregnancy and hospital discharge of mothers and their children reflect high maternal inpatient utilization and neonatal intensive care. NICU costs often relate to medically necessary early deliveries, and maternal ICU use often reflects mothers facing life-threatening complications. Almost half of infants in the early-onset cohort were delivered before 33 weeks’ gestation. (ACOG defines full-term as 39 weeks to 40 weeks and six days.) Our findings align with existing research linking preeclampsia and preterm birth, with one study reporting an 80-fold higher risk of preterm birth among women with severe preeclampsia.54
Short-term preeclampsia medical costs are highly concentrated in a small subset of pregnancies
Ten percent of preeclampsia pregnancies account for approximately half of costs.
High-cost episodes are substantially more common among pregnancies complicated by preeclampsia than among other pregnancies. These births are approximately 3.5 times more likely to incur costs of $50,000 to $100,000. Each birth associated with early-onset preeclampsia costs the healthcare system an average of $144,000 within a year of delivery (Exhibit 5). Two percent of births complicated by early-onset preeclampsia cost the healthcare system more than $500,000 within a year of a delivery.
Short-term medical costs related to preeclampsia are highly concentrated in a subset of pregnancies.
Note: Figures may not sum to 100%, because of rounding.
1Pregnancy-related costs are identified by limiting to claims with relevant pregnancy-related medical follow-ups and complication diagnoses; excludes pharmacy costs.
Importantly, fetal growth restriction (FGR)—which can be a clinical manifestation of placental dysfunction—is associated with a greater likelihood of a high-cost preeclamptic pregnancy. Approximately 22 percent of all preeclamptic births that cost over $100,000 were complicated by FGR, and the average cost of a preeclamptic pregnancy with FGR is $145,000.55
Preeclampsia imposes societal costs of up to, or approximately, $2.5 billion a year
Beyond medical costs, preeclampsia imposes up to an additional $2.5 billion in annual societal costs over the lifetimes of women who develop preeclampsia.
Women who have had preeclampsia may experience wage penalties, given long-term health conditions associated with preeclampsia such as cardiovascular disease56 and the short-term burden and impacts of perinatal mood and anxiety disorders (PMAD).57 This burden also extends to children and families: Children whose mothers had preeclampsia may earn less as adults because of the lasting effects of being born preterm (Exhibit 6).58 Preeclampsia is also associated with an estimated 1,000 to 2,200 stillbirths annually, with those tragedies causing profound consequences on family well-being and quality of life.59 This analysis sizes the economic burden of child mortality by quantifying lost lifetime earnings associated with stillbirths.
Preeclampsia imposes $2.5 billion in societal costs over the lifetimes of women who develop preeclampsia every year.
Note: Figures may not sum to totals, because of rounding. Additional societal costs, such as quality of life, family and partner relationships, and additional childcare burden, are not quantified.
Yet these statistics still do not fully capture the full societal burden of preeclampsia. It can reduce quality of life through trauma and PTSD resulting from the preeclampsia episode, decrease a woman’s ability to return to work and provide for her family, and create additional caregiver burdens for families of children with preeclampsia-attributable conditions.
Improving diagnosis, management, and treatment of preeclampsia
Major gaps remain in how preeclampsia is prevented, managed, and treated, starting with knowing which women will develop it and when it will occur (Exhibit 7). As we outline in MHI’s recent CARE for Women report, these gaps illustrate a broader challenge in women’s healthcare: Clinical outcomes not only depend on the availability of effective interventions but also on whether women receive that care in a timely manner.60 Recognizing the urgency of addressing these gaps, the World Health Organization (WHO) outlined a global call to action for hypertensive disorders of pregnancy to emphasize the need for coordinated efforts to advance research and innovation, expand access to health products and care, and elevate preeclampsia as a global healthcare priority.61 Building upon this agenda, our analysis highlights that there is not only meaningful opportunity for new innovations but also for broader use of existing tools that have already been proven effective at diagnosing and preventing preeclampsia.
Major gaps remain across the prevention, management, and treatment of preeclampsia, including identifying women who will develop the disease.
Note: Figures may not sum to 100%, because of rounding.
1Prevalence estimates assume ~325,000 women experience preeclampsia annually, based on preeclampsia affecting about 9% of pregnancies (commercial claims data) and ~3.6 million women who are pregnant each year. Cohort-specific estimates apply the observed prevalence of each subtype among women with preeclampsia: early-onset (20%), late-onset (64%), and postpartum (16%).
2The presence of one of the following conditions indicates severe preeclampsia: severe blood pressure elevation, symptoms of central nervous system dysfunction, hepatic abnormality, thrombocytopenia, kidney function impairment, pulmonary edema; “Preeclampsia: Clinical features and diagnosis,” UpToDate, Aug 11, 2026.
Preeclampsia prevention
Preeclampsia is diagnosed after 20 weeks’ gestation on the basis of new-onset hypertension together with proteinuria and/or other evidence of maternal organ dysfunction.62 Earlier in pregnancy, clinical risk factors are used to identify women at increased risk who may benefit from preventive strategies such as low-dose aspirin.63 However, risk-based prediction remains limited and is not highly accurate, and there is a need for genetic and/or proteomic markers that more accurately determine risk.
In our analysis of commercial claims data, more than half of women who subsequently developed preeclampsia did not meet the American College of Obstetricians and Gynecologists (ACOG) clinical risk criteria used to classify women as high risk.64 Similarly, a large Danish cohort found that ACOG risk-factor criteria identified 60.5 percent of women who subsequently developed preterm preeclampsia,65 while a Canadian study found that the ACOG checklist accurately predicted preeclampsia in 43.6 percent of women.66
Low-dose aspirin is the current standard preventive therapy for women at increased risk of preeclampsia, but its population-level effectiveness depends in part on accurately identifying women who are most likely to benefit. Earlier systematic reviews based largely on conventional clinical risk-factor approaches reported absolute reductions in preeclampsia risk of approximately 2 to 5 percent, depending on baseline risk.67 By contrast, a UK trial that used first-trimester multi-marker screening to identify women at high risk of preterm preeclampsia and found that aspirin 150 mg initiated at 11 to 14 weeks reduced preterm preeclampsia from 4.3 percent to 1.6 percent.68 These findings suggest that improved risk stratification may increase the effectiveness of preventive therapy by better identifying women with aspirin-responsive disease.
Despite guideline recommendations, uptake of low-dose aspirin for preeclampsia prevention remains limited, with one large-scale electronic health record (EHR) study finding that only 8 percent of pregnancies at high risk of preeclampsia received aspirin.69 Several factors may contribute to the limited uptake in aspirin in the prevention of preeclampsia, including lack of recommendations from providers, women’s reluctance in taking medication during pregnancy, and limited medication adherence.70
Early-onset preeclampsia. No single test can reliably predict which women will develop early-onset preeclampsia, although multivariable risk stratification approaches have improved prediction. The Fetal Medicine Foundation first-trimester algorithm combines maternal characteristics with mean arterial pressure, uterine artery Doppler, and placental biomarkers to estimate the risk of preterm preeclampsia. In the ASPRE screening population, this approach identified approximately 77 percent of preterm preeclampsia cases at a screen-positive rate of about 10 percent.71 Other tools address a different clinical need: The FDA-cleared Roche Elecsys sFlt-1/PlGF ratio is intended to support short-term risk stratification among hospitalized pregnant women with hypertensive disorders of pregnancy, identifying those at higher or lower risk of progression to preeclampsia with severe features within two weeks.72 These approaches have not been adopted uniformly in routine prenatal care, as clinical guidelines, including those from ACOG, advise against their use, due to the limited evidence of clinical efficacy.73
A major area for innovation in early-onset preeclampsia is the development of therapies that modify underlying disease-driving pathways. Current management can stabilize maternal and fetal condition and, where appropriate, allow expectant management. However, delivery remains the definitive intervention when maternal or fetal risks outweigh the benefits of continuing pregnancy. A disease-modifying therapy could potentially slow disease progression, reduce severe maternal complications, and safely prolong pregnancy, thereby reducing neonatal morbidity associated with very preterm delivery. Excess sFlt-1 is an important mediator of the angiogenic imbalance and endothelial dysfunction characteristic of preeclampsia, making the sFlt-1 pathway an attractive therapeutic target. However, the regulatory pathway for such disease-modifying therapies remains relatively untested, reflecting the early stage of the field.
Late-onset and postpartum preeclampsia. A major unmet need in late-onset and postpartum preeclampsia is improved prediction, diagnosis, and clinical management. Once women are diagnosed with late-onset preeclampsia, management focuses on maternal and fetal surveillance, treatment of severe hypertension and other complications, and appropriately timed delivery. Although late-onset disease occurs closer to term than early-onset preeclampsia, it can still progress rapidly and lead to severe maternal complications, including HELLP syndrome, eclampsia, and stroke, and increase the risk of long-term health conditions.74 Improved tools to identify women at risk before disease becomes clinically apparent or to detect early deterioration after diagnosis could create a larger window for monitoring and intervention. Potential approaches include improved biomarker-based risk stratification. One study suggests that the use of placental growth factor (PIGF) testing can decrease time of preeclampsia diagnosis from approximately four days to two while also reducing severe maternal health outcomes.75 However, no single biomarker currently provides sufficient sensitivity and specificity for routine prediction of late-onset preeclampsia.76 Earlier recognition could support more timely escalation of care and delivery when maternal or fetal risks warrant it.
Similarly, postpartum preeclampsia presents an important challenge because new or worsening hypertension may develop after hospital discharge. ACOG recommends blood pressure evaluation no later than seven to ten days postpartum for women with hypertensive disorders of pregnancy and within 72 hours for women with severe hypertension. However, follow-up and blood pressure monitoring is inconsistent.77 In one large single-center cohort of women eligible for postpartum hypertension monitoring in the United States, only 11.8 percent of those who did not participate in a remote monitoring program had a blood pressure recorded within ten days of delivery, compared with 97.7 percent of women enrolled in the program.78 Limited monitoring means that postpartum preeclampsia that could be addressed with outpatient care and/or oral medication if identified earlier can necessitate inpatient admission, requiring separation between women and their newborns during the postpartum period.
Current follow-up recommendations primarily target women with recognized hypertensive disorders during pregnancy and may therefore miss women who are normotensive before discharge but subsequently develop de novo postpartum hypertension or preeclampsia. Broader use of postpartum blood pressure surveillance, including home or remote blood pressure monitoring, is a relatively low-cost opportunity to facilitate earlier identification and more timely escalation of care. Postpartum follow-up also provides an opportunity to address the elevated long-term cardiovascular risk associated with a history of preeclampsia.
Emerging opportunities exist in using biomarkers to predict development of postpartum preeclampsia and innovate on post-delivery medications; early-stage research is investigating the use of aspirin during postpartum to prevent preeclampsia.79 However, realizing these opportunities would require a deeper scientific understanding of the biological causes of the condition.
Potential therapeutics. Given the concentration of medical costs and severe maternal and neonatal outcomes in early-onset preeclampsia, disease-modifying therapies in this population could have particularly substantial clinical and economic impact (Exhibit 8):
Disease-modifying therapies for preeclampsia could have substantial clinical and economic impact.
Note: Totals are the theoretical maximum, assuming a therapy eliminated all modeled incremental costs in the target population; they are not expected savings. Per-woman costs divide the costs of preeclampsia among high-risk women by all women treated (~1.5 million high-risk pregnancies, or 43% of pregnancies).
1All preventable short-term costs are measured from pregnancy to discharge.
2Lifetime long-term costs from preeclampsia, including costs of cardiovascular disease, diabetes, postpartum depression, chronic kidney disease, future pregnancy complications, and dementia for the mother, and autism, ADHD, cerebral palsy, and schizophrenia for the child.
-
Disease-modifying therapy. A disease-modifying therapy for established early-onset preeclampsia could act through several pathways, including growing and maintaining healthy blood vessels (by reducing excess anti-angiogenic signaling or restoring maternal vascular and endothelial function) or improving blood flow to the placenta (uteroplacental perfusion). Based on commercial and Medicaid analysis of claims data, approximately $6.1 billion in short-term medical costs are associated with early-onset preeclampsia, while literature-based analysis estimates an additional $4.6 billion in long-term medical costs, for a total modeled cost burden of approximately $10.7 billion. This represents a theoretical maximum addressable cost burden under the assumption that an intervention eliminated all modeled incremental costs in the target population; it should not be interpreted as the expected savings from a therapy. Assuming 50 percent efficacy of a disease-modifying therapy, up to $5.4 billion of the economic burden could be avoided. In particular, long-term costs associated with preeclampsia may not be entirely avoidable through disease-modifying therapy, given underlying risk factors or genetic susceptibility of developing preeclampsia linked to other risk factors.80
Given the biological heterogeneity of preeclampsia, therapeutic benefits may differ across patient subgroups and disease-driving pathways. Investigational approaches currently in clinical development include Comanche Biopharma’s CBP-4888, an siRNA designed to reduce excess placental sFlt-1 production,81 and DiaMedica’s DM199, a recombinant human tissue kallikrein-1 being evaluated for its potential effects on maternal vascular function and uteroplacental perfusion.82
To be attractive to payers and providers, a successful therapy would need to demonstrate meaningful improvement in maternal and/or neonatal outcomes. Relevant maternal outcomes could include reductions in severe hypertension, eclampsia, placental abruption, pulmonary edema, and other major maternal complications. Neonatal benefit would be expected principally through safe prolongation of pregnancy and reduction in morbidity associated with very preterm birth. Any prolongation of gestation would need to occur without increasing maternal or fetal risk. Importantly, even a modest reduction in high-cost preterm births could generate substantial cost savings for payers.
A preventive therapeutic for women at high risk of developing preeclampsia could also improve outcomes and offset medical costs.
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Preventive therapy. Based on our claims analysis, risk stratification approaches identify approximately 1.5 million births annually as being at elevated risk of preeclampsia, representing approximately 43 percent of pregnancies. Among women in this high-risk population who subsequently develop preeclampsia, our analysis estimates approximately $3.5 billion in short-term medical costs, while literature-based analysis estimates an additional $7.2 billion in long-term medical costs, for a total modeled cost burden of approximately $10.7 billion.
A successful preventive therapy could potentially reduce a portion of this burden, although the magnitude of benefit would depend on the accuracy of risk stratification, treatment efficacy, adherence, and the proportion of preeclampsia that is preventable through the targeted pathway. A preventive treatment also may not address the entire burden of long-term costs, given underlying risk factors or susceptibility to long-term conditions such as cardiovascular disease.83
Preventive therapies that support healthy placentation or modify other early disease-driving pathways could complement improved approaches to identifying women at risk. However, preventive treatments in pregnancy would face a particularly high safety threshold and would need to demonstrate benefit beyond existing low-cost preventive strategies such as aspirin. Their clinical and economic value would also depend on sufficiently accurate risk stratification to avoid exposing large numbers of women who would not otherwise develop preeclampsia to unnecessary treatment.
Call to action
Innovators and investors have substantial opportunities to create new approaches to preeclampsia prevention and treatment, and the decisions of payers and philanthropists can support these advances. In the meantime, providers and health systems already can take steps to improve access to and provision of high-quality care.
Potential role of innovators and investors. Innovators can address unmet need through the development of therapeutics and diagnostic tools that improve maternal and neonatal outcomes while potentially reducing costs for payers and society. In particular, a disease-modifying drug that can show measurable impacts to both maternal and neonatal outcomes could address a portion of the approximately $10.7 billion in medical costs associated with early-onset preeclampsia. Much of this value could come from reducing costly neonatal complications. Pregnancy-to-one-year discharge costs average approximately $144,000 per infant born following a pregnancy complicated by early-onset preeclampsia, creating substantial potential savings if a therapy can safely prolong gestation and reduce neonatal morbidity. Innovators could consider how successful development of these therapies means overcoming additional barriers associated with bringing a preeclampsia drug to market, including incomplete understanding of disease mechanisms, regulatory requirements, and the particularly high maternal and fetal safety considerations associated with treatment during pregnancy.
Innovators and investors may also need to consider the payer mix of preeclampsia. With Medicaid covering approximately 41 percent of US births,84 innovators may need to demonstrate compelling clinical benefits and economic value across both Medicaid and commercial populations. Considerations related to the Medicaid Drug Rebate Program, ensuring access through Preferred Drug Lists, and that clinical trials adequately represent the Medicaid population are therefore likely to be important components of a product’s market access and launch strategy. Innovators can also engage payers and regulators early in the therapeutic development process to better understand the evidence required for coverage and reimbursement to prevent approval and manufacturing delays while working toward developing payment models that could improve affordability and accessibility of preeclampsia therapeutics.
Potential role of payers. Payers can support preeclampsia innovation by signaling their willingness to cover novel therapies and other interventions that improve outcomes and reduce avoidable healthcare utilization and costs. Even without direct partnerships with drug developers, payers can help create the conditions for therapeutic development. By sharing deidentified claims and outcomes data, they can quantify the full cost of preeclampsia, including NICU admissions, readmissions, and long-term maternal cardiovascular risk, which helps developers prioritize target populations and endpoints. Payers can also clarify the evidence they would expect from future disease-modifying therapies, such as clinically meaningful maternal and neonatal outcomes and effects on healthcare utilization.
Beyond informing development, payers could explore innovative financing and payment approaches, such as value-based or outcomes-based contracts, to improve the affordability and accessibility of new preeclampsia therapeutics once available.
Payers can also build the care infrastructure that new therapies will need at launch. This could include reimbursement for validated first-trimester risk stratification tests, access to remote blood pressure monitoring in the first seven to ten days postpartum,85 and use of extended postpartum coverage to track longer-term outcomes. In addition, payers can collaborate with providers, Medicaid agencies, and other stakeholders to identify pregnant members earlier in their pregnancy journeys and enroll them in care management programs that improve monitoring and enable earlier intervention.
Potential role of philanthropy and foundations. Philanthropic organizations play an important role as the key investment engine in funding early-stage, high-risk preeclampsia research and product development that may be underfunded by the private sector as a result of scientific, regulatory, and pregnancy-related liability risks. Major barriers to preeclampsia research include exclusion of pregnant women from trials, concerns about liabilities for maternal and fetal safety, and relatively untested regulatory pathways for novel mechanisms. Philanthropic organizations could consider helping to overcome these barriers by supporting and derisking early-stage clinical research into disease biology, identifying biomarkers for novel therapies, helping to validate clinically meaningful end points, and supporting development of diagnostics and novel therapeutics. By providing nondilutive funding, philanthropic organizations can accelerate financing by attracting venture capital and other sources of funding.
Beyond funding, philanthropic organizations could raise awareness of women’s lived experiences with preeclampsia and convene stakeholders to elevate preeclampsia as a maternal health priority. As highlighted in the WHO Global roadmap for hypertensive disorders of pregnancy, the lack of a compelling investment case for preeclampsia and inconsistencies within guidelines for preeclampsia remains a key barrier to progress.86 Philanthropic organizations play a critical role in addressing this gap by building the case for investment for financing and aligning regulatory bodies and key guideline developers to develop standardized policies in preeclampsia care. Moreover, they can strengthen health literacy to support consistent use of proven interventions (for example, blood pressure monitoring) and expand access to the standard of care.
Potential role of providers. Providers and health systems play an important role in addressing the care delivery gap of preeclampsia. In its recent CARE for Women report, the McKinsey Health Institute (MHI) identified opportunities throughout the postpartum journey to better address the long-term risk of cardiovascular disease (CVD), including routine CVD risk monitoring in postpartum, creating standardized and integrated reporting of CVD risk for prior preeclampsia for long-term risk management.
Obstetrics and primary care doctors can standardize adoption of prevention and management protocols. For example, protocols could include providing aspirin prophylaxis to all eligible women at high risk of developing preeclampsia and ensuring timely postpartum blood pressure assessment for women with hypertensive disorders of pregnancy, including within 72 hours for those with severe hypertension and within seven to ten days for all others. Given documented racial disparities in aspirin uptake, particularly among Black women,87 providers should engage in culturally responsive care to address barriers to equitable treatment.
Moreover, health systems and healthcare professionals, including labor and delivery nurses, pediatricians, doulas, and cardio-obstetrics, can also strengthen their postpartum surveillance and patient education by giving women clear guidance on the signs and symptoms of postpartum preeclampsia and when to seek urgent care. Healthcare providers should recognize preeclampsia as a condition with lifelong health implications and ensure that women with a history of preeclampsia receive long-term cardiovascular and metabolic risk assessment and care pathways.
While all providers can adopt more protocolized care pathways for preeclamptic patients, hospitals serving rural communities or populations with high Medicaid coverage can strengthen escalation and transfer pathways for women with severe preeclampsia who require higher-acuity or ICU-level care. Finally, providers can help advance innovation in preeclampsia care through participation in clinical trials, appropriate patient identification and recruitment, and integration of validated diagnostics and novel therapies into existing care pathways.
Preeclampsia is a major source of maternal and infant burden in the United States and globally, but unlike many costly conditions, preeclampsia presents in a more acute, time-bound period, and solutions to address the short- and long-term complications are within reach. A large portion of costs are concentrated within a relatively narrow window around delivery, so targeted innovation—including development of novel disease-modifying therapies—and broader use of existing tools could meaningfully shift outcomes. Closing the gap between unmet need and solution will require coordinated action across innovators and investors, philanthropic organizations, providers, and the broader ecosystem. These efforts represent a credible path to reducing burden on families and the entire healthcare system.
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