Prevention of maternal mortality: Canada’s toolkit for confidential enquiry


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The Society of Obstetricians and Gynaecologists of Canada (SOGC) has been working toward developing a foundation for preventing maternal and perinatal morbidity and mortality in Canada.  The mission is to increase awareness of the issues surrounding pregnancy-related death and to promote change among individuals, healthcare systems, and communities in order to reduce the number of deaths.

The maternal mortality ratio (MMR) is a critical measure of a nation’s health, and thus a key performance indicator of the strength and quality of health care. In Canada, maternal mortality is an infrequent yet often preventable event with devastating consequences to families and care providers. There have been reports of a rise in maternal mortality from the 1990s (5.1 to 11.9 per 100,000 live births).  Despite this concerning statistic, monitoring maternal deaths, and particularly identifying cases of preventable death, has been difficult and inconsistent in Canada. 

In Canada, maternal mortality-related data sources have traditionally been based on death registrations and hospitalization data, neither of which provides the clinical and social context required to identify intervention points for preventable maternal death.  Furthermore, these data sources consistently under-ascertain and misclassify maternal deaths, leading to an underestimation of Canada’s MMR. 

Since 2010, the Society of Obstetricians and Gynaecologists of Canada (SOGC) has been working with partners to review national maternal mortality surveillance programs. During the process, it became apparent that not all provinces/territories in Canada have established maternal mortality review committees, and on a national level there is no system to synthesize and report on maternal mortality. Jurisdictions all differ with respect to definitions, data collected, ascertainment and the maternal mortality review process.

Canadian provinces and territories have a critical role to play in the design and implementation of this system, as do coroners/medical examiners, vital statistics, and maternal mortality review committees.  The SOGC has been engaging with relevant federal and provincial leaders as well as multi-disciplinary clinical experts since 2016 to develop the foundation for the process and to draft standardized definitions and a common minimum dataset of indicators that can be rolled up to tell a national story about maternal deaths in Canada.  In addition, over the past year, leaders of the perinatal programs of four provinces (British Columbia, Alberta, Ontario and Nova Scotia) have been participating in a pilot project to develop a toolkit that includes policies and procedures, as well as standardized data/information fields, maternal mortality review best practice, reporting templates, tools, resources and knowledge translation materials that align with a confidential enquiry-type system, with the ultimate goal 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 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 context.  It is anticipated that 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 without a lot of difficulty, and with a lot of guidance from a very experienced group who are motivated and excited to provide leadership.  The toolkit has elements that are based on the United States’ MMRIA and the UK’s MBRRACE programs and includes the World Health Organization (WHO) Maternal Death Surveillance Response Technical Guidance, which is an excellent resource for all participating in Maternal mortality reviews.

The MMR Toolkit will be released in December 2020 and the SOGC will host webinars for coroners/medical examiners, clinicians, provinces/territories (including perinatal programs), researchers and policymakers to talk about the program, to share experiences and to start the process of regular sessions for engagement, networking and sharing experiences.

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 our 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.

The SOGC is also leading a research project to map the recommendations from the MPDRC that are relevant to the SOGC’s practice as well as to the level of evidence for the recommendations over the last five years in order to determine gaps in practice and evidence, required updates, or opportunities for focused educational/training initiatives.

The SOGC continues to also work nationally with the Canadian Perinatal Surveillance System for alignment and coordinated efforts for national reporting of severe maternal morbidity and mortality.  The SOGC is also partnering on several research projects related to measurement of maternal morbidity and mortality.