Fly on the Wall: Improving maternal health outcomes in Canada

Welcoming a child into the world is a joyous and thrilling experience for many parents, but two McMaster University faculty members who are leading the global conversation around health outcomes related to pregnancy and childbirth say more needs to be done to address needless deaths and injuries connected with childbirth in Canada, regardless of how uncommon they are.

Jon Barrett, a professor and chair of the Department of Obstetrics and Gynecology, and Rohan D’Souza, an associate professor with the department and Canada Research Chair in Maternal Health, have taken their learnings at McMaster to several countries to improve childbirth outcomes. The pair was part of a team recently invited by the Government of Guyana along to help establish infrastructure for reducing deaths and critical illness during pregnancy, childbirth and postpartum.

We spoke with Barrett and D’Souza about maternal health in Canada, and what can be done to make improvements.

What is the difference between mortality and morbidity?

Barrett: Mortality refers to the death of a birthing parent during pregnancy, childbirth or the postpartum period, which has been variably defined as within six weeks to within a year of childbirth.

The trouble is that people think parents rarely die in childbirth, and while it is uncommon, it happens more than people think. In Canada, it is estimated that the maternal mortality ratio is between eight and 11 per 100 000 live births. Although comparable to other high-income countries, this might be an underestimate. There are countries in the world, especially low-income countries that have a much higher maternal mortality ratio than we do in Canada, estimated at around 430 per 100 000 live births.

D’Souza: For every person that dies during pregnancy, childbirth or postpartum, approximately 85-100 nearly die. These individuals are said to have experienced a ‘near miss’ event, which means that if they had not received timely medical intervention, they would have died.

Still more individuals experience serious complications in pregnancy that result severe illness, prolonged hospitalization, or long-term disability. They are said to have experienced a severe maternal morbidity (SMM).

In a nutshell, while mortality refers to death, morbidity refers to serious complications that result in serious consequences to the physical, mental, social, and functional health and wellbeing thereby compromising the quality of life of the pregnant person and their families.

How big of a problem is maternal health in Canada?

D’Souza: National vital statistics generated by most countries are limited. In Canada, we rely on epidemiological administrative data. Based on these data, we estimate that the maternal mortality ratio is somewhere between eight to 11 per 100 000 live births, while 1.6 per cent of all Canadians experience SMM. Although these numbers are disturbingly high, they may be underestimates.

We’re generally talking about young, healthy people who want to start a family. And if 1.6 per cent of them are ending up with prolonged hospitalization or long-term disability, then we have a problem. Mortality is lower, but severe maternal morbidity is quite high. It is a problem when we talk to governments as they still see these numbers as small.

Further, in Canada, as in the United States, United Kingdom and several high-income countries, the majority of people that experience either mortality or SMM belong to Indigenous, Black and other racialized/ minoritized communities. There are a number of reasons responsible for these disparities, including access to care, discrimination and systemic racism.

Barrett: In Canada, many people experience these near-miss situations. We’re drawing attention to the voice of the people that are either dying or are becoming sick.

When you have young people getting so sick that it affects their quality of life forever from a factor that you know, you can prevent, it’s beyond a numbers game.

One of the most common causes of death in Canada is bleeding to death during childbirth. So, in our modern society, young, healthy pregnant people bleed to death. We’re not asking for new machinery or drugs, I’m just saying, let us do what many other countries have done.

D’Souza: I do believe it’s an equity issue. Women’s health is often not prioritized. That’s the problem with our society.

What can be done in Canada to improve these health outcomes?

Barrett: We need confidential enquiries into maternal mortality. This involves reviewing a death using a comprehensive methodology that can determine what the avoidable factors are so that when a similar situation occurs, it isn’t missed.

It’s the same process that we’re trying to start with morbidity. The benefit of morbidity is these things happen much more often with less devastating consequences. So, you can learn these lessons before they result in a mortality.

But this type of review hasn’t been nationalized in Canada like it has been in other countries like the United Kingdom and I think it hasn’t been done because there hasn’t been the political will to do it.

D’Souza: I couldn’t agree more. Reviewing all cases of mortality and SMM in a confidential and respectful way, to understand the reasons behind the delays in accessing care or receiving a timely diagnosis and treatment is critical. These allow the development of targeted initiatives to address the problem. However, these reviews require information on these serious events to be shared in a respectful and de-identified manner across institutional and provincial boundaries. That has been a problem in Canada for various legal, political, and cultural reasons.

There’s also an issue about postpartum care in Canada. We don’t really have a formalized system of caring for our people after a pregnancy; so, we offer exceptionally good care while people are pregnant, but the last visit is scheduled for about six weeks postpartum, and then there is no scheduled visit.

If they need help beyond this period for pregnancy-related complications, those that have family doctors may be able to access care, but the vast majority of those at risk for these complications either do not seek care or end up in emergency departments that are not specialized in providing nuanced care for these individuals.

What do you want Canadians to take away from this conversation?

Barrett: You’re living in a country which is generally well-resourced. Chances are you’re going to have a wonderful healthy pregnancy and a wonderful baby. There’s a small chance that things will go wrong and you could become very sick. Very few people die, but there’s always a small chance. I don’t want you to think of that happening to you because the chances are not common, but it’s common enough for you to know that it might happen. What I want you to do, just in case it does happen, is to help us set up a system so that we can learn from it and make sure it doesn’t happen again to somebody else.

D’Souza: Pregnancy related mortality and morbidity have devastating consequences on families and many of these events are avoidable. Fortunately, communities and governments are becoming more aware of the importance of addressing the issue of morbidity and mortality. However, we need the support of individuals, communities, institutions and governments to address challenges with sharing of data to make the proposed review systems possible. Several initiatives are currently underway and I am convinced that we will be able to bring maternal morbidity and mortality rates in Canada down before long, so that every pregnancy can be as joyous as possible.