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Perinatal Care in Canada

Beverley Chalmers, DSc (Med) (University of Toronto), PhD; and Shi Wu Wen, MB, PhD (Health Canada)

Health Issue

Canada's standard of perinatal care ranks among the highest in the world, but there is still room for improvement, both in terms of regional differences in care across the country and global comparisons of approaches to care in Canada and elsewhere. This chapter makes use of data obtained through the Canadian Perinatal Surveillance System (CPSS) to examine morbidity and mortality among mothers and infants as well as the implications for perinatal care for the increasing proportion of older women giving birth, and the use of infertility treatments.

Key Findings

Maternal mortality rates in Canada dropped to 4.4 per 100,000 live births in 1993-1997 and are among the lowest in the world. The most common causes of death during pregnancy are hypertensive disorders, pulmonary embolism, hemorrhage, and ectopic pregnancy. Life-threatening conditions during pregnancy include amniotic fluid embolism, obstetric pulmonary embolism, eclampsia, septic shock, anesthesia complications, cerebrovascular disorders, and hemorrhage. National data on amniotic embolism indicate that this is a rare event (5.6 per 100,000 deliveries) but carries a high case-fatality rate (approximately 80%). Rates of maternal readmission after Caesarean birth have increased from 3.2 per 100 Caesarean sections in 1990 to 3.9 in 1997, compared with a stable rate of 2.5 per 100 for readmission after normal vaginal delivery. This may signal a potential future concern as rates of Caesarean section are increasing (from 15.3 per 100 hospital deliveries in 1994 to 19.1 in 1997). Rates of maternal readmission after Caesarean birth are being exacerbated as postpartum stays in hospital become shorter.

The live birth rate among teenaged mothers aged 10.14 and 15.19 has declined, from 0.29 per 1,000 in 1981 to 0.22 in 1997, and from 25.8 per 1,000 in 1981 to 19.9 in 1997 respectively. The total induced abortion rate in 1997 was 16.8 per 1,000 women, an increase from 14.6 in 1990. These figures are likely to be significantly underreported, however, and should be interpreted with caution. The past two decades have also seen a steady increase in the proportion of births to older women, who are more at risk of the complications of pregnancy and of preterm birth (among women over age 34, 8.8 preterm births per 1,000 total births in 2000, the highest rate of all age groups).

Although the infant mortality rate in Canada is among the lowest in the world (5.3 to 8.8 per 1,000 live births between 1990 and 2000) there are unacceptable disparities between subpopulations. Low-income groups show a risk of infant deaths 1.6 times higher than that of high income groups. In Aboriginal populations, rates of stillbirth and perinatal mortality are double (among registered Indians) and 2.5 times (among Inuit groups) the Canadian average. Rates of preterm birth increased in Canada between 1981 and 2000 (6.4 to 7.5 per 100 deliveries), possibly because of increases in multiple births and obstetric interventions. The increasing rate of multiple births, partially related to increasing use of infertility treatments, has accelerated recently and is of concern. Multiple births carry a higher risk of complications and are associated with an increased risk of preterm birth: in 2000, 51.5% of twin pregnancies and 97.7% of triplet or higher pregnancies resulted in preterm births. The costs to the health care system in terms of neonatal intensive care, prolonged hospital stay, and medication use are likely to be high.

Data Gaps and Recommendations

The authors identified the following data gaps and made the following recommendations:

• Data contributing to CPSS surveillance needs to be collected in a more timely and uniform manner across provinces and territories. Furthermore, events occurring outside of hospitals are not necessarily captured.
• Economic indicators should be part of CPSS surveillance of perinatal health, so that unnecessary or excessive use of certain (possibly costly) practices can be assessed.
• The CPSS should provide an evaluation of how well Canada fares in relation to international standards of perinatal care.

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