Special Report on Maternal Mortality and Severe Morbidity in Canada Enhanced Surveillance: The Path to Prevention

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Table of Contents

Foreword

Contributors

Introduction

Methods

• Provincial/Territorial-Level Maternal Death Review Activities Determined
• List of Deaths Constructed from National Databases
• Individual Case-Level Data Obtained from Provincial/Territorial Death Review Committees or Coroners/Medical Examiners
• Expert Review and Analysis of Maternal Deaths
• Occurrence of Severe Maternal Morbidity

Key Findings

• Current Provincial/Territorial Maternal Death Review Activities
• Maternal Deaths in Canada (excluding Quebec), 1997-2000
• Direct Maternal Deaths in Canada (excluding Quebec), 1997-2000
• Indirect Maternal Deaths in Canada (excluding Quebec), 1997-2000
• Incidental Deaths in Canada (excluding Quebec), 1997-2000
• Severe Maternal Morbidity in Canada (excluding Manitoba, Quebec and Nova Scotia), 1991-1992 to 2000-2001

Discussion

• Current Provincial/Territorial Maternal Death Review Activities
• Maternal Mortality in Canada
• Severe Maternal Morbidity in Canada
• Strengths and Limitations

Key Recommendations to Enhance Surveillance of Maternal Mortality and Severe Maternal Morbidity in Canada

References

Appendix A: Maternal Death Data Collection Tool

Appendix B: Diagnostic and Procedure Codes Used in the Analysis of Severe Maternal Morbidity

Appendix C: List of Acronyms

Foreword

Canada's maternal mortality ratio is among the lowest in the world, yet even in a country that considers its health care system integral to its national identity, women continue to die during or shortly following a pregnancy. This Special Report on Maternal Mortality and Severe Morbidity in Canada - Enhanced Surveillance: The Path to Prevention from the Maternal Health Study Group of the Canadian Perinatal Surveillance System (CPSS) reminds us of this tragic and frequently avoidable reality. It identifies some shortcomings in our national, provincial and territorial continuous quality improvement efforts in comparison with benchmark international peers, and provides a series of recommendations for providers and leaders of maternity care in Canada to consider and implement.

The principles of multidisciplinary confidential case reviews, developed most notably in the United Kingdom, are applied to the Canadian scene, and the study of severe maternal morbidity "near misses" is introduced and encouraged. The rigorous analysis of our maternal deaths from 1997 to 2000 identified pulmonary embolism and pre-eclampsia/pregnancy-induced hypertension (direct), cardiovascular (indirect), and motor vehicle collisions (incidental) as leading causes. Are there not opportunities for us to further reduce or eliminate these tragedies? When even devastating events become infrequent or rare, they can become lost in overall descriptive statistics. Higher frequency of undesirable outcomes in specific disadvantaged minorities can be overlooked.

This report is a significant and welcome contribution. It presents us with important challenges. I look forward to our response, and the continuing surveillance of maternal mortality and other important perinatal health outcomes by CPSS in future reports as a measure of our efforts.

Thank you on behalf of care providers and, most of all, the women and their families we serve.

David Young, MD, MSc, FRCSC
President
Society of Obstetricians and Gynaecologists of Canada

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