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![Public Health Agency of Canada](/web/20061214073628im_/http://www.phac-aspc.gc.ca/gfx_common/pphb.gif)
[Health Surveillance and
Epidemiology Division]
Special Report on Maternal Mortality and Severe Morbidity in Canada
Enhanced Surveillance: The Path to Prevention
PDF
Version (2.58
MG)
Table of Contents
- 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
- 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
- Current Provincial/Territorial Maternal Death Review Activities
- Maternal Mortality in Canada
- Severe Maternal Morbidity in Canada
- Strengths and Limitations
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
PDF
Version (2.58
MG)
[Health Surveillance and
Epidemiology Division]
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