Measuring Maternal Mortality in Canada: An Update on the Establishment of a Confidential Enquiry System for Preventing Maternal Deaths #savingmoms #savingbabies

J Obstet Gynaecol Can. 2019 Dec;41(12):1768-1771. doi: 10.1016/j.jogc.2019.07.018. Epub 2019 Oct 4.


A reduction in maternal mortality has traditionally been used as a critical measure of progress in improving maternal health, and the maternal mortality ratio is one of the main indicators of a country's status in the area. In Canada, maternal mortality is infrequent yet devastating. In many cases, there were no interventions that could have saved the mother's life, but in others, there were opportunities for prevention. There is absolute consensus that the upper limit for a preventable maternal death is zero. The World Health Organization's 2010 report indicated a rise in Canada's maternal mortality and prompted the Society of Obstetricians and Gynaecologists of Canada to work with partners to review national maternal mortality surveillance. Since then, efforts have begun and stalled. We are now in the fortunate position to work with experts and provincial leaders to implement a national system of confidential enquiry into maternal deaths and severe maternal morbidity in Canada. Canada's existing data do not tell the true story of maternal deaths; we cannot learn from each death and its circumstance to identify measures for prevention in the future. Dedicated leaders have been working hard to leverage their collective expertise. Recommendations for definitions, processes, knowledge translation tools, and programs that raise awareness about maternal mortality in Canada have been developed and are being piloted. It is anticipated that, with the appropriate support and appropriate leadership, Canada will have the foundation of a national confidential enquiry system into maternal deaths very soon. This is an update on progress.

Keywords: CONFIDENTIAL enquiry; MATERNAL mortality; PREGNANCY; PREVENTION of maternal death.

MeSH terms

  • Female
  • Humans
  • Maternal Death / prevention & control*
  • Maternal Mortality*
  • Quality of Health Care / organization & administration*