pregnancy comes with rising complications in canada
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while there are guidelines issued by healthcare professional organizations including family physicians, obstetricians and midwives, that recognize pregnancy risks and the importance of screening, there is also a significant mistrust of the healthcare system.
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we like to think that canada has one of the most modern medical systems in the world with advanced drug therapy, ai technology and highly-skilled health professionals. but even with these advantages, there’s a disturbing trend that canada has increasing rates of maternal health problems.
severe maternal morbidity (smm) refers to unexpected maternal outcomes related to pregnancy, labour, childbirth and the postpartum period resulting in severe illness, prolonged hospitalization, longterm disability or fatality. since maternal mortality in most high-income countries is low, smm is now recognized by many as the preferred indicator of the quality of maternity care.
in canada, the incidence of smm rose from 13.9 per 1,000 births in 2007 to 16.1 per 1,000 births in 2016. for every woman who dies as a result of pregnancy, 75 to 100 women experience severe complications, according to the society of obstetricians and gynaecologists of canada.
better monitoring of maternal health in canada could help women and their families
part of the mounting concern here is canada lags behind other developed countries with respect to monitoring maternal health and identifying preventable cases of mortality.
the fact is, having a baby can be complicated. you’re putting your body under stress as it changes to support a growing fetus and prepare for labour. changes to hair and nail texture from fluctuating hormones are common, along with leg cramps, swollen feet and ankles, larger and more tender breasts, and a slight rise in body temperature. as well, the respiratory rate rises to compensate for increased oxygen consumption and the entire cardiovascular system is readjusted as blood volume increases, more blood vessels grow and the pressure of the expanding uterus on large veins causes the blood to slow in its return to the heart. these are just some of the stressors.
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“what does make a pregnancy high risk, especially for maternal mortality? i don’t think we necessarily know the answer in an objective way. we know what we think,” says dr. michelle jacobson, an obstetrician gynecologist in toronto. she’s co-founder of coven women’s health virtual clinic launching this spring to support women with personalized obgyn-led care. “we think older moms who have more health risks and medical comorbidities are going to be at higher risk of maternal mortality.”
conditions like diabetes, high blood pressure and obesity that are more prevalent in older moms could be associated with more maternal mortality. there are also social and economic factors that impact immigrants who may have limited access to prenatal care, she says. “perhaps they’ve got medical problems that we don’t know as much about and things that we never would have considered in canada with a traditional canadian population. we have to learn those things and we may not even be aware of what to look for. so how do we know when people are having complications in pregnancy, and why it’s necessarily happening?”
older moms, changing demographics: ‘we don’t know if we don’t collect information’
for example, the u.k. and the u.s. both report that black women are three times more likely to die from a pregnancy-related cause than white women—something that could be happening in canada as well, “but we don’t have that,” dr. tunde byass, an obstetrics and gynecology specialist and past president of black physicians canada, told the canadian healthcare network about recording incidence of maternal mortality.
as the u.k and u.s. develop stronger policies to tackle maternal mortality, canada is being left behind. but that’s beginning to change with a goal to understand patient journeys surrounding smm and more fundamental issues of health systems access and quality of care.
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the u.k.’s maternal mortality ratio has declined over the last 15-plus years as a result of understanding contributing causes and addressing them, according to embrace-uk’s maternal, newborn and infant clinical outcome review programme in 2021. a 2024 paper in the journal of obstetrics and gynaecology canada noted that some canadian provinces routinely review and report maternal deaths, and occasional national reports aggregate provincial death registration and hospitalization data but these are incomplete.
“we’ve collected information in the same way over many, many years, but we haven’t until recently really started wanting to know more about the maternal mortality in our country, whereas other countries like the u.k., for example, have really put a lot of effort into collecting this evidence in an important way, canada hasn’t. but we’re starting to,” jacobson says. “so part of the problem is we don’t know if we don’t collect information.”
the society of obstetricians and gynaecologists of canada has been working to establish a confidential enquiry system similar to the u.k. system to identify underlying causes of maternal morbidity and mortality, specifically identifying those that are preventable. and leaders of the perinatal programs of four provinces (british columbia, alberta, ontario and nova scotia) developed a toolkit for maternal mortality review committees with the aim to capture and review all maternal deaths to one year post-delivery. experts say there’s a pressing need to determine contributing factors and opportunities for prevention.
“not all pregnancies are going to be uncomplicated and i think what we can do is we can prevent the progression of these complications into what we call severe morbidities and mortality. we can do this through a process of screening early on and early initiation of treatment, so even if the complications do happen, early recognition of these complications can prevent its progression into something more serious,” says dr. rohan d’souza, a maternal-fetal medicine physician at hamilton health sciences and associate professor in obstetrics and gynecology and the department of health research methods, evidence and impact at mcmaster university in hamilton, ont.
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“a person could be very healthy prior to a pregnancy but might have some risk factors that would put them at risk for an adverse event during pregnancy. so, recognizing the ones that might be at risk, for example, somebody who has got anemia, anemia is so common,” he says, adding that in the first few weeks of pregnancy, the blood is diluted even more, so symptoms of fatigue are exaggerated. “going to work, even taking a shower, you can get really exhausted and all of this can have mental health implications on a person when they’re feeling so rundown and they’re so exhausted.” anemia also puts women at risk for developing infections and could have an effect on the growth of the fetus. he also talks about the blood loss during childbirth which can impact women with anemia.
heart disease and anemia increase risk during pregnancy and childbirth
diagnosing anemia with a simple blood test during pregnancy screening would be treated with diet, then iron tablets if required or an iron infusion depending on how severe the symptoms.
another risk is heart disease related to the bowel or the heart valve that happens because of rheumatic fever in childhood that can have a detrimental effect on valves. d’souza says this is more prevalent among the immigrant refugee populations and first nations.
“they don’t know that they have a heart condition and then pregnancy happens. and within the first six weeks of pregnancy, so much changes that the demand on the heart is so great that they could experience serious complications quite early on.”
d’souza was one of the authors of the paper, mortality following childbirth in ontario: a 20-year analysis of temporal trends and causes, published in november 2024, that found for individuals who died after 2012, 20 per cent did not have a first-trimester visit with a clinician. “even in a publicly funded system access to care is an issue, especially for uninsured newcomers or in rural, remote and northern areas,” the authors write.
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while there are guidelines issued by healthcare professional organizations including family physicians, obstetricians and midwives, that recognize pregnancy risks and the importance of screening, there is also a significant mistrust of the healthcare system, d’souza explains. women need care all the way through their pregnancy and postpartum to be screened for risks that change throughout the patient journey.
how do you build trust in healthcare and find out what the barriers are to good maternal care?
“national vital statistics and epidemiologic data are very good at telling us what the problem is. they’re very good at telling us that there is a rising number of people, a higher proportion of people, who are conceiving now have blood pressure or diabetes,” he says, adding that data also shows that certain ethnic groups are at a higher risk for having adverse events. “but what they’re not able to tell us is why? so that results in a lot of speculation.”
he’s the co-lead of the canadian obstetric survey system (canoss), a national initiative to deep dive into all the serious maternal adverse events that have happened with an attempt to understanding the root cause analysis. “it is a very time-consuming process of not making assumptions but going down to each of those cases and following people up.” the collaborative team is not out to point blame or stir fodder for litigation, but understand root causes that are putting maternal health at risk.
“if you know if there was an error or an omission and it was stopped or addressed at some point, it wouldn’t progress into the next when something bad happens. so, it’s often that something is not recognized and then a cascade of events begins, and sometimes things might not be directly contributing but are responsible for that event.”
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the goal is to make targeted recommendations and see them put into action. d’souza emphasizes that the approach will help clinicians and healthcare professionals learn from contextual evidence that’s been generated in their own province in their own region, and it will help researchers focus on topics that are of interest to communities and to clinicians.
“it is important for us to reclaim trust within the health system and i think all of our clinical and research work needs to be directed toward family-centred and community-centred care.”
training simulation sessions in hospitals promote problem-solving and teamwork
understanding the maternal patient experience and being prepared to navigate complications are central to the work of healthcare providers in the field. dr. susan ellis, chief of obstetrics and gynecology at st. joseph’s healthcare hamilton and associate professor at mcmaster university, says one of her biggest passions is working on simulation and interprofessional teamwork and communication—and how this emphasis can reduce adverse outcomes.
“we’re actually doing simulations in terms of obstetrical emergencies which we then will do with our authentic teams in the authentic environments in order to identify the latent safety threats so that we’re then able to identify our gaps, implement procedures to ensure that we don’t have the gaps, and then run the simulation again and make sure we’re running it successfully,” she says. however, even if everything runs like a well-oiled machine, you can still have severe morbidity for moms because there is always a range of things that aren’t within your control.
after simulation training, improvement strategies are reviewed with input from the team to mitigate future risk.
“we know that everybody has showed up to work today to do the very best job that they can. we know that everybody wants to do the best for every patient. so you need to start with that culture framework and be able to help to identify these gaps and build trust.”
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a sample simulation exercise could look like this: a non-english speaking patient comes to the emergency room who is in active labour, but not able to express what’s going on. she is triaged and is imminently delivering. she isn’t able to be transferred to the delivery room because the baby is coming so quickly.
as ellis points out, “how do you get the people there that you need to get there? how do you provide the safest environment that you can for the patient? what translation services can you reach out to? how do you ensure both maternal and baby care?”
this patient went on to have a postpartum hemorrhage, which is severe or excessive bleeding after childbirth and potentially life-threatening condition. one of the latent safety threats identified was that the delivery team didn’t have all of the drugs that would normally be available in the labour and delivery rooms.
as a result, ellis and her team designed an emergency room postpartum hemorrhage kit in case of this scenario. st. joseph’s also has a mental health focus on maternal care and a substance use disorder program.
she’s positive about moving maternal care forward and making change to support all canadians, commending the work of canoss and the society of obstetricians and gynaecologists of canada.
“as an obstetrician, having been practicing in canada for a very long time, we are really pushing this work forward in a way that i am very proud to be a part of. and we’re broadening it, we’re saying, ‘ok, what about health equity? what about gaps due to access and care? what about racialized minorities? what is different about our indigenous population? what is access of care? if you have to be moved from your community, what are your supports?’”
ellis also notes the importance of engaging patients and having open discussions with patients and their families about their experiences, which happens regularly at st. joseph’s, making sure their voices are heard.
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“will we ever have a world with zero maternal morbidity and mortality? i really don’t think so. can we do better? yes. can we share so that we all understand how we can do better? absolutely.”
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