Maternal mortality appears to be on the rise in Canada, but as previously reported by Medscape News Canada, the lack of a comprehensive surveillance system makes it impossible to know exactly what is going on, let alone improve the situation. Nevertheless, the increasing numbers may raise alarm bells, given that the usual reasons for high maternal mortality in the developed world — lack of access to care resulting from abortion laws and economic restrictions — do not apply in Canada. Other systemwide issues may contribute to the problem, and Canadian experts in maternal health are proposing solutions.

Looking Beyond the Delivery Room

Canadian experts who spoke with Medscape News Canada emphasized that it is tempting to focus on the delivery room when addressing maternal mortality, but maternal mortality actually reflects maternal care overall. “According to the World Health Organization, the maternal mortality ratio is the number one marker of maternal healthcare quality,” said Elisabeth Codsi, MD, an obstetrician-gynecologist at CHU Sainte-Justine and a clinical associate professor of obstetrics and gynecology at the Université de Montréal, Montreal. “It should be the primary marker used to verify the quality of the healthcare that’s given to our pregnant population.” Codsi has been lobbying the Quebec provincial government for years to improve surveillance of maternal mortality.

“Many maternal deaths are considered potentially preventable, especially with earlier recognition, coordinated care, [and] access to better supports,” said Giulia Muraca, PhD, a perinatal epidemiologist and associate professor of obstetrics and gynecology and health research methods at McMaster University in Hamilton, Ontario. “When we think about prevention, we have to go beyond what happens in that delivery room and include identifying cardiovascular risk, ensuring access to postpartum mental health care, addressing substance use disorders, [and] improving continuity of care.…We need to start approaching this as a whole-system issue, not just a childbirth issue, and the solutions have to follow that framework. We have to hold our governments accountable and our health systems accountable to do that.”

Isabelle Malhamé, MD, an obstetric internist and clinician scientist at the CHU Sainte-Justine and an associate professor at Université de Montréal, agreed. “The increased mortality in the year postpartum is a reflection of how poorly adapted our healthcare system is to look after women with complex needs in the postpartum period,” she said.

Prioritizing Women’s Health

Zooming out even further, the experts agreed that the rise in maternal mortality reflects a lack of prioritization of women’s health in general. Some of the problems are logistic. A woman with an infant or young children may put her own health needs aside if accessing care for herself requires her to find childcare so that she can travel long distances to sit for an unpredictable amount of time in a waiting room.

The siloing of medicine is another issue. Codsi pointed out that her physician colleagues in nonobstetric specialities often do not feel confident treating patients with medical conditions that lie within their area of expertise if those patients happen to be pregnant or in the postpartum period. They are simply not trained for it. Medical schools teach obstetric care separately from the other specialties, and most drugs are not tested in pregnant populations. But many chronic conditions can worsen dramatically during pregnancy and postpartum if not managed appropriately.

The issue is particularly troublesome in psychiatry because many psychiatrists are uncomfortable prescribing medication for mental illness to pregnant women. Many also lack the expertise to recognize when postpartum depression requires treatment, dismissing it as a normal adaptation to motherhood when, in fact, lack of treatment may put new mothers at an increased risk for self-harm or even suicide.

Data and Collaboration

Better data could enable solutions. Every province and territory should have guidelines on surveillance of maternal mortality and morbidity, said Codsi. Protocols must be established to ensure that every physician reports these deaths, that a confidential inquiry always takes place, and that the findings are published so they are publicly available and actionable.

Collaboration is the key. “We can learn a lot from the various types of pregnancy care delivery models, be it the biomedical [model], the midwifery model, or the family medicine practice,” said Malhamé. “It does not need to be siloed.…Improving equitable access to respectful, equity-informed, trauma- and violence-informed maternity care isreducing maternal mortality.”

Collaborative efforts with the potential to enact real change are in the works. They include the GEM Hub, a national knowledge mobilization hub addressing pregnancy-related near-miss events and deaths. “The burden of [maternal] morbidity and mortality does not affect the population equally,” said Malhamé. “There are populations that have been historically marginalized in the healthcare system who experience more of these events, so the solutions need to be codeveloped in partnership with individuals from communities who are most affected by them.…[GEM Hub] is a unique model where, across the country, we’re coming together to build new care protocols, resources, and processes that have been cocreated with individuals who are affected by the issues.”

The GEM Hub forms part of the Pan-Canadian Women’s Health Coalition and is funded by the Canadian Institutes of Health Research. So far, they have developed clinical tools to support the implementation of patient-centered maternal early warning system protocols designed to facilitate prompt responses to medical emergencies in pregnancy. They are also building capacity for local, facility-based severe maternal morbidity reviews to better understand how to improve care in the future. The coalition also is launching a large-scale, community-led research priority-setting initiative. This work is guided by a multisectoral Advisory Sharing Council, mostly comprising people with lived experience of pregnancy (or patient partners). Town halls that are open to the public are hosted regularly to promote dialogue and foster public accountability.

But sustainable change needs to come from above, said Malhamé. None of these initiatives will fulfill their potential unless stakeholder support and research funding can be sustained over the long term. That means national and provincial government must start prioritizing women’s health now.

Codsi, Muraca, and Malhamé reported having no relevant financial relationships.