Hypertensive Disorders in Pregnancy: A Comparative Analysis of Clinical Guidelines Across Six High‐Income Countries

BACKGROUND: Women in the United States (U.S.) experience higher maternal morbidity and mortality than other high-income countries, with hypertensive disorders of pregnancy (HDP) among the most common, preventable contributors. Despite evidence supporting pharmacologic intervention, American College of Obstetricians and Gynecologists (ACOG) guidelines prioritize surveillance over active HDP management. This study compared ACOG guidance for HDP prevention, diagnosis, management, and postpartum follow-up with recommendations from six high-income countries. METHODS: Document analysis compared national HDP guidelines from Australia and New Zealand, Canada, Japan, Trinidad and Tobago, and the United Kingdom with ACOG guidance, systematically coded across five domains: (1) first-trimester risk assessment, (2) preeclampsia prevention, (3) antihypertensive medication initiation thresholds, (4) postpartum monitoring, and (5) patient education. RESULTS: Divergences exist between ACOG and international guidelines across all domains. Most notably, ACOG recommends initiating antihypertensive medication at ≥ 160/110 mmHg for gestational hypertension, while international guidelines recommend initiation at ≥ 140/90 mmHg with specified targets. International guidelines also recommend calcium supplementation for low dietary intake, structured postpartum monitoring beyond 8 weeks, home-based monitoring, mental health screening, and education on long-term cardiovascular risk, elements underspecified in ACOG guidance. ACOG incorporates Black race and low income as independent aspirin prophylaxis risk criteria, though using race as a proxy for racism raises equity questions. No reviewed guideline explicitly defines midwifery roles in HDP management. DISCUSSION: Substantial divergences between ACOG and international guidelines suggest opportunities to strengthen U.S. HDP prevention and management. Recent trial evidence and persistent, inequitable maternal mortality support moving beyond voluntary recommendations toward accountability mechanisms driving consistent, evidence-based care.