Prevention of Maternal Mortality in Canada

Context

The maternal mortality ratio is a key performance indicator of the strength and quality of health care. Since the 1990s, maternal mortality has increased from 5.1 to 11.9 per 100, 000 live births in Canada1,2. However, monitoring maternal deaths, and particularly identifying cases of preventable death, has been difficult and inconsistent across the country, and we know that the numbers are probably under-estimated and under-reported.

The SOGC has been working toward developing a systematic approach for measuring, understanding and ultimately preventing maternal morbidity and mortality in Canada. Our mission is to increase awareness of the issues surrounding pregnancy-related deaths and to promote change among individuals, healthcare systems, and communities to reduce the number of those deaths.

Statistics

Identifying women at higher risk for severe maternal morbidity and maternal death is not easy. There have been significant shifts in the demographics of child-bearing population in Canada and factors such as advanced maternal age; prevalence of significant medical co-morbidities (i.e., increased rates of obesity; diabetes; mental health; and substance use); a growing refugee and immigrant population with different risks and susceptibilities; are all leading to a new set of contributing causes of maternal mortality that the existing system was not designed to measure and is unequipped to analyze. Emerging knowledge also underscores the critical importance in understanding the causes of maternal deaths, the circumstances, and the complexities that surround them.

Recent data from the United States (US) show that over 60% of pregnancy-related maternal deaths were preventable3. Evidence from the US suggests that there is a direct relationship between the probability of a woman dying during childbirth or in the 42 days following pregnancy termination and the number of risk factors and/or morbidities that are present. The UK has very successfully shown that, by understanding factors that contribute to maternal mortality, programs can be developed that address specific education, training, system and policies that prevent future cases on maternal mortality. As a result, the UK’s maternal mortality ratio has declined steadily over the past 15 years4.

Why does Canada need a Confidential Enquiry System into maternal deaths?

A Canadian Confidential Enquiry System into maternal deaths will improve Canada’s maternal death statistics, and more importantly generate system and practice information required to understand how deaths might be prevented in the future, inform provincial/territorial and national networks for improvement in maternal mortality and severe morbidity, and identify trends and emerging issues.

Identifying every single maternal death is a critical factor to improving Canada’s surveillance programs – if deaths are not identified as “maternal”, they will not be picked up by existing federal and provincial/territorial surveillance systems. More complete ascertainment, by implementing a confidential enquiry component to maternal death reviews, will provide accurate prevalence and allow us to determine trends, to identify priorities for recommendations and to report on the effectiveness of interventions. Identifying factors that could contribute to prevention will ultimately not only save pregnant/post-partum women, but it will also mitigate maternal morbidities and improve perinatal outcomes.

Advocates and experts across Canada have been working together to gather momentum and support for a Canadian Confidential Enquiry System into maternal deaths. You can see some of the activities at the links below:

Canada’s Maternal Mortality Review Committee Toolkit

Provinces and territories have a critical role to play in leading the implementation of maternal mortality review processes. Leaders of the Perinatal Programs of four provinces (British Columbia, Alberta, Ontario and Nova Scotia) developed a Toolkit for Maternal Mortality Review Committees (MMRCs) with the ultimate goals of capturing and reviewing all maternal deaths to one year post-delivery, identifying contributory factors and opportunities for prevention. The ultimate goal is to eliminate all future preventable deaths in Canada.

The MMRC Toolkit consists of materials that are standardized enough to provide useful templates for maternal mortality review, but flexible enough for each jurisdiction or committee to adapt them for their own environments. Those who are new to maternal mortality review will have the materials, tools and resources that they need to be able to initiate a process.

Canada’s MMRC Toolkit promotes best practices in maternal mortality review. It provides guidance related to gathering resources, tools, and provides support for establishing a review committee. In addition, it provides best practices for both establishing an MMRC as well as reviewing maternal deaths and providing recommendations toward prevention. The toolkit also contains materials to be used to raise awareness of the critical role MMRCs play in eliminating preventable maternal deaths, and to review severe maternal morbidities. 

The importance of Maternal Mortality Review Committees

MMRCs are multidisciplinary committees, often at the regional, provincial or territorial level, that perform comprehensive reviews of deaths among women who die during pregnancy or in the post-partum period (most often up to 42 days after the end of the pregnancy). They include representatives from public health, obstetrics and gynecology, maternal-fetal medicine, anesthesiology, nursing, midwifery, forensic pathology, mental and behavioral health, and community-based organizations.

MMRCs have the critical task of determining whether individual maternal deaths were preventable and recommending specific and feasible actions to prevent future deaths. Objective and standardized reviews of all maternal deaths, and the implementation of recommendations for prevention, have had a positive impact on maternal health and outcomes around the world. Although maternal deaths are rare, the information from each case can contribute important information to prevent additional deaths, and all such deaths must be reviewed in a thorough and timely manner. Thus, each province and territory should have, at the minimum, an annual review of all deaths. Some jurisdictions may have committees for specific institutions or regions as well, depending on the volume of deaths that require review.

Public health surveillance of maternal deaths through MMRCs offers opportunities to explore the circumstances around every maternal death. The goals of MMRCs are to identify the factors contributing to maternal deaths and implement recommendations to help prevent future deaths. Historically, MMRCs have relied on data from administrative, medical, coroner, and law enforcement records. Typically, trained abstractors review the records and synthesize their findings into a narrative, which committee members then review to identify contributing factors, determine whether the death was preventable, and formulate recommendations to prevent future deaths.

To read more information about existing MMRCs in Canada, please click the links below:

An Overview of Canada’s Toolkit for Confidential Enquiry

This overview can be used to provide context for the importance of Maternal Mortality Review in Canada and the critical role of the MMRCs.

An Overview of Canada’s Toolkit for Confidential Enquiry (PDF) 

Maternal Mortality Review Committees Guide

This guide is for members of a MMRC, to help them maximize their committee’s effectiveness and impact, and contribute important information to maternal health in the Canadian context, by establishing and consistently following comprehensive and sound formal processes. The review of maternal deaths is not about assigning blame but about learning how to improve care and circumstances to prevent future occurrences. The process is distinct from, but not a substitute for, hospital peer review committees, root-cause analysis, or complaint investigations.

This guide is intended to share suggestions and best practices that will help MMRCs establish processes for standardized case review and reporting. The guide is structured in the general order of steps a committee might take in conducting an actual review committee meeting. Committees may choose to do things differently, depending on resources, committee composition, and scope.

Maternal Mortality Review Committees Guide (PDF)

Maternal Mortality Review Committee Forms for Reviewers

A comprehensive Maternal Mortality Review Process requires notes from a thorough abstraction that are compiled into a comprehensive Case Narrative for presentation to the committee. After all data and information is gathered, it can be used to populate the forms. The templates will help committee members to write a case narrative that can be easily printed for presentation to the committee.

The following forms are available:

To download all forms, please click the link here: Maternal Mortality Review Committee Forms for Reviewers (PDF) 

Interview Guide for Confidential Enquiry into Maternal Deaths

Most MMRCs do not have access to the perceptions, experiences, and accounts of families, health care professionals, and others who can provide an understanding regarding the circumstances of a maternal death. However, these accounts, when obtained through established confidential enquiry methods, can provide multi-faceted perspectives on the woman’s care experiences before and surrounding her death and, in this way, informant interviews are the foundation of the added value that a confidential enquiry provides to the maternal mortality review process and can provide rich contextual information to complement existing records so that factors contributing to the death can be comprehensively assessed and effective recommendations can be made for prevention. This guide provides detailed information about how to conduct interviews related to a maternal death.

Interview Guide for Confidential Enquiry into Maternal Deaths (PDF)

Abstractor Document Checklist

This checklist was designed to provide an overview of the documents and information obtained by the Abstractor.

Abstractor Document Checklist (PDF)

Minimum Dataset

This minimum dataset identifies indicators that should be captured to inform a comprehensive review of maternal mortality/severe maternal morbidity/perinatal mortality, including suggested data sources and definitions. It also suggests which indicators may be important to report on provincially or nationally. Existing data systems may or may not currently capture this information and will have to determine the process that works best for them.

Minimum Dataset (PDF)

Maternal Mortality Review Committee Orientation Slides

These slides can be used to orient stakeholders, partners and MMRC members to the importance of the review process, and the goals and functions of the MMRCs. Specific information can be inserted related to statistics, processes or anything else that users feel is important.

Maternal Mortality Review Committee Orientation Slides (PPT)

Maternal Death Surveillance and Response Technical Guidance (World Health Organization)

The World Health Organization published information for action to prevent maternal death in their Maternal Death Surveillance and Response Technical Guidance.

Maternal death surveillance and response (MDSR) builds on the principles of public health surveillance, promotes routine identification and timely notification of maternal deaths and is a form of continuous surveillance linking health information system and quality improvement processes from local to national level. It helps in quantification and determination of causes and avoidability of maternal deaths. MDSR emphasizes the link between information and response and will contribute to strengthening vital registration and better counting of maternal deaths, and provide better information for action and monitoring improvements in maternal health.

Maternal Death Surveillance and Response Technical Guidance

Perinatal Health Indicators

The Perinatal Health Indicators produced by the Public Health Agency of Canada's Canadian Perinatal Surveillance System present information on maternal, fetal and infant health in Canada based on data from the Canadian Institute for Health Information’s Discharge Abstract Database (CIHI-DAD), the Canadian Community Health Survey (CCHS), and Vital Statistics (birth, stillbirth and death databases). The PHI are grouped into four key health domains: Health Behaviours and Practices, Health Services, Maternal Outcomes, and Infant Outcomes.

https://health-infobase.canada.ca/phi/

The Better Outcomes Registry & Network (BORN)

The Better Outcomes Registry & Network (BORN) is Ontario's prescribed perinatal, newborn and child registry with the role of facilitating quality care for families across the province. BORN collects, interprets, shares and rigorously protects high-quality data essential to making Ontario the safest place in the world to have a baby.

https://www.bornontario.ca/en/index.aspx

Healthcare Insurance Reciprocal of Canada (HIROC)

The Healthcare Insurance Reciprocal of Canada (HIROC) is a non-profit insurance reciprocal owned and governed by over 700 health care organizations across Canada. It was started in the 1980s when health care organizations were unable to find reasonably priced insurance in the commercial marketplace. The reciprocal/cooperative model allows for pooling of data across multiple similar organizations, sharing of lessons learned, and collective pressure exerted by members to implement effective risk management programs that reduce injury. HIROC values research and innovative projects that drive healthcare safety.

HIROC publishes a number of evidence-based reports that provide important information related to obstetrics.

Obstetrics Services in Canada Advancing Quality and Strengthening Safety

Delivery in Focus: Strengthening obstetrical care in Canada (Summary Report) (2018) 

2020 Top Healthcare Risks Report

Maternal Mortality Review Cycle

 

References

  1. Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, et al. Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014 Sep 13;384(9947):980-1004. Erratum in: Lancet. 2014 Sep 13;384(9947):956.
  2. Public Health Agency of Canada, Perinatal Health Indicators for 2017: A report from the Canadian Perinatal Surveillance System. http://publications.gc.ca/collections/collection_2018/aspc-phac/HP7-1-2017-eng.pdf Accessed November 26, 2021.
  3. Maternal Mortality Review Information App. Building U.S. Capacity to Review and Prevent Maternal Deaths. Report from nine maternal mortality review committees: a view into their critical role. 2018 Retrieved 11/25/21 from https://www.cdcfoundation.org/sites/default/files/upload/pdf/MMRIAReport.pdf
  4. Maternal, Newborn and Infant Clinical Outcome Review Programme. MBRRACE-UK Saving Lives, Improving Mothers' Care – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2017-19. Marian Knight, Kathryn Bunch, Derek Tuffnell, Roshni Patel, Judy Shakespeare, Rohit Kotnis, Sara Kenyon, Jennifer J Kurinczuk (Eds.) 2021. https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2021/MBRRACE-UK_Maternal_Report_2021_-_FINAL_-_WEB_VERSION.pdf
  5. Nair M, Kurinczuk JJ, Brocklehurst P, Sellers S, Lewis G, Knight M. Factors associated with maternal death from direct pregnancy complications: a UK national case-control study. BJOG. 2015 Apr;122(5):653-62.
  6. Nair M, Knight M, Kurinczuk JJ. Risk factors and newborn outcomes associated with maternal deaths in the UK from 2009 to 2013: a national case-control study. BJOG. 2016 Sep;123(10):1654-62.
  7. Hwang SS, Diop H, Liu CL, Yu Q, Babakhanlou-Chase H, Cui X, Kotelchuck M. Maternal Substance Use Disorders and Infant Outcomes in the First Year of Life among Massachusetts Singletons, 2003-2010. J Pediatr. 2017 Dec;191:69-75.
  8. Metz TD, Rovner P, Hoffman MC, Allshouse AA, Beckwith KM, Binswanger IA. Maternal deaths from suicide and overdose in Colorado, 2004-2012. Obstet Gynecol. 2016 Dec;128(6):1233-1240.
  9. Schiff DM, Nielsen T, Terplan M, Hood M, Bernson D, Diop H, Bharel M, Wilens TE, LaRochelle M, Walley AY, Land T. Fatal and Nonfatal Overdose Among Pregnant and Postpartum Women in Massachusetts. Obstet Gynecol. 2018 Aug;132(2):466-474.