Mothers are suffering injury, death during childbirth in Canada. Here's why it still happens
Samantha Hemmings stood in the operating room entrance, watching her sister Sophia on the table.
“Help me, please,” she recalls her sister saying. “I can’t breathe.”
In the spring of 2009, Sophia went into cardiac arrest while undergoing a caesarean section. She suffered an anoxic brain injury: for crucial minutes, her brain was deprived of oxygen.
Her baby boy lived. But today, Sophia cannot speak, cannot walk, cannot turn herself in bed. Her mother is her primary caregiver and has been trying to teach her to communicate by pointing to pictures.
Samantha, one year Sophia’s junior, blames herself. She had always been the one to stick up for the sister who used to braid her hair. “My dad always said, ‘You defend your sister, you look after your sister’ … So I feel responsible,” she says.
Sophia’s family has spent years arguing that those providing her medical care bear some liability for her injury. They argue the factors making her vulnerable, including her obesity, were not adequately taken into account. In February, they argued their case before the Supreme Court of Canada .
“Everything went wrong with her case. She was let down by the system in so many ways,” says her family’s lawyer, Amani Oakley. “It’s just hard to fathom.”
Lawyers for two doctors and the hospital that provided Sophia’s care argue the chain of events could not have reasonably been foreseen. There is no legal causal link, they say, between their clients’ actions and Sophia’s brain injury. The court will decide.
Sophia’s experience may seem extreme. But stories like hers raise broader questions about maternal injury and death. An Investigative Journalism Bureau analysis has found Ontario health-care providers are often failing to learn from the childbirth deaths and injuries of mothers and babies.
A review of a decade of Ontario coroner’s reports shows the same observations cropping up again and again. Medical practitioners aren’t sharing vital information; patients aren’t being adequately monitored; and strained resources are undermining life-saving care. These circumstances can set the stage for tragedy.
Between 2012 and 2022 alone, Ontario’s Office of the Chief Coroner’s Obstetric and Perinatal Death Review Committee made 458 recommendations, detailing a range of medical mishaps and missed opportunities behind 50 maternal deaths, 85 neonatal deaths and 25 stillbirths during that period.
And reporting of such repeated problems goes back even further.
A devastating bleed
Kim Le’s babies were born. Then cold overcame her. Then the shakes.
At first, clinicians tried to tell her this was normal. “But then it was very clear that I was losing a lot of blood,” she told the IJB.
In the wake of a Caesarean section to deliver her twin boys, Le began to bleed, and didn’t stop for what felt like an eternity.
An emergency transfusion saved her life, but the trauma impacted her heart, lungs, liver and kidneys. She was in Mount Sinai Hospital’s cardiac ward for a week, struggling even to walk to the washroom.
Le was lucky: she was at a leading hospital in the biggest city in the country. Had she been somewhere less well-equipped for such an emergency, she said, “I probably would have died.”
The IJB identified 17 coroner’s recommendations relating to hemorrhages in the decade ending in 2022. At least five recommendations arising from deaths in 2021 and 2022 called for standardized procedures in dealing with births involving excess bleeding.
But the problem goes back much further. For instance, 30 years ago, in 1996, an Ontario woman bled to death after giving birth, with deep lacerations in her vagina. The coroner’s jury examining her death made note of the need for timely intervention and “timely identification of estimates of blood loss.”
In 2010, an Ontario woman bled to death after giving birth. The coroner’s committee reminded care providers of the importance of assessing blood loss from postpartum hemorrhage.
In 2014, an Ontario woman bled to death giving birth after years of trying to conceive.
“Care providers poorly estimate blood loss and consistently underestimate the loss of a large volume of blood,” the coroner’s committee noted in response to her death.
The women’s home communities were not included in the reports.
Over a 20-year period from 2002 to 2022, 46 Ontario women bled to death after childbirth, comprising 27 per cent of pregnancy-related deaths during that period, according to a study published last year in the Journal of Obstetrics and Gynaecology of Canada.
Problems may arise from a failure to follow practices that have been shown to work, McMaster University obstetrician and researcher Rohan D’Souza said, or there may be a delay in diagnosis. And sometimes people go into childbirth in less than ideal circumstances: for instance, maybe their hemoglobin or iron levels are not optimal.
“Postpartum hemorrhage in itself is not always preventable … but death and serious complications from postpartum hemorrhage are always preventable,” D’Souza said.
Le recovered. But years after that harrowing time in hospital, she wonders if her care providers should have noticed something sooner. Earlier awareness of her preeclampsia, a pregnancy complication characterized by new-onset high blood pressure, for example, which clinicians thought could have begun post-delivery, might have dissuaded them from attempting a vaginal birth before switching to a C-section.
“I do think that maybe someone should have caught something.”
A lethal wait
In many cases, the IJB review found, tragedy can strike when care providers are strapped for resources.
Forty-one recommendations between 2012 and 2022 related to clinical resources or the transfer of patients either between sites or between care providers.
“Obstetrical care providers should acknowledge the risk that distance to suitably resourced facilities adds to a pregnancy,” reads a 2021 recommendation following a stillbirth in which the mother arrived at the closest hospital in premature labour. The hospital had no obstetrical services.
The issue of resources came up in recommendations every year from 2013 through 2021.
In July, 2017, an expectant Ontario mother noticed her baby was moving less than usual. She was nine days overdue, and her induction at an unnamed hospital — originally scheduled for that morning — had been delayed because the hospital was full.
She arrived at 11:30 a.m. but staff didn’t deliver her baby via C-section until seven hours later. They found a womb thick with fetal stool, which had entered the baby’s airway. Medical staff attempted to resuscitate the baby and transferred her to the Neonatal Intensive Care Unit.
She died at two days old.
A year later, investigators concluded that “Caesarean section should have been performed much earlier” given that fetal heart-rate tracing had been abnormal for several hours. While the report doesn’t say whether this decision was connected to resource shortages at the hospital, it notes that “the issue of available beds in active obstetrical units is province-wide.”
It isn’t feasible to have high-complexity obstetric capability in every hospital and birthing centre, nor does it make sense to only perform births in centres with high-complexity capacity, D’Souza said. So clinicians need to know when to transfer care to another medical centre or another medical practitioner.
“That is what is not happening.”
An obstetric hotline could help. So could better education about what a pregnancy complication looks like.
“You’ve got to have sufficient experience to say ‘This tiredness that this person is seeing is more than just pregnancy.’ And how does one get there when they see five pregnant people a year?” D’Souza said.
“Or if somebody says, ‘My legs are swollen’ and people say ‘Well, swollen legs are actually quite common in pregnancy.’ And so they’re not thinking about a blood clot.
“If you don’t know what you don’t know, it’s difficult to diagnose.”
A failure to communicate
Sophia’s family’s case went before Canada’s highest court in February after the family’s initial court victory was partially overturned by an appeals court in 2024. Her lawyers argued that those providing her care were negligent, in part because they failed to communicate and document the risks of her pregnancy. This, the lawyers say, contributed to disaster.
They argue, among other things, that the first obstetrician Sophia saw should have documented and communicated to Sophia and other clinicians the risks facing people who are obese. These include, according to the trial judge, cardiac arrest and difficult or failed labour.
They argue a lack of crucial paperwork should have prompted the nurse who answered when Sophia called the hospital months later, after vomiting repeatedly, to bring Sophia into hospital or instruct her to see her doctor.
“This case, like many of the cases we do, involves a significant amount of discussion on documentation,” said lawyer Daniela Pacheco, who acted for the family before the Supreme Court.
A lawyer for two doctors named in the case, and a lawyer for the Scarborough Health Network, declined to be interviewed. They said in court submissions there has been no legal causation established between their actions and Sophia’s injury; that the injury was not a reasonably foreseeable result of their actions. Lawyers for the anesthesiologist argued there is no evidence that Sophia would have avoided injury if their clients had acted differently.
Failed communication, inadequate monitoring and lack of documentation accounted for 136 of the 458 recommendations the IJB reviewed. Sixty-nine recommendations specifically mention improving documentation, often surrounding medical records.
Jocelynn Cook, chief scientific officer with the Society of Obstetricians and Gynaecologists of Canada, said that following up on test results, documentation, and communication are “huge areas where, if they don’t happen, it can have bad outcomes.”
“It’s really established in the medical literature, for sure, that these are our big issues.”
If coroner’s committee chair Dr. Louise McNaughton-Filion could impart a single message, she would tell clinicians, “Everybody should talk to each other.” And part of that crucial communication, she said, is adequate documentation — tricky but especially vital during an emergency.
In 2012, after a baby died at barely 12 hours old from a hemorrhage between its skull and its scalp, the coroner’s committee noted the bleed had not been considered, the baby not adequately monitored and documentation from the obstetrician was inadequate to help those who took over the baby’s care.
In 2016, a 32-year-old woman died of pulmonary arterial hypertension two days after giving birth. The coroner’s report noted that “erratic” postpartum vital signs were not flagged to the physician team.
The following year, a 37-year-old woman, a recent immigrant, died of complications of lacerations to her pregnant uterus and bladder. No blood pressure readings were noted and the coroner’s report mentioned inadequate physician documentation at multiple levels.
Almost 17 years after Sophia’s cardiac arrest during surgery, Rosalie Brown is still her daughter’s primary caregiver. Where Sophia cannot express her desires, her mother tries to guess whether she is hungry or thirsty, cold or warm.
“There’s a limited amount of things that you can do for her and it makes you sad … You pass her room every day and it comes over you: When are things going to change so that she can have a better life?”
Brown is also caring for her now-16-year-old grandchild.
“My grandson feels the pain even harder … He locks himself away in the room and sometimes he will cry and cry and cry.”
Oakley says working on Sophia’s case has been revelatory.
“The amount of work I did opened my eyes to the extreme danger that is inherent in pregnancy, and I don’t think most people understand that,” Oakley said.
“It’s a nine-month-long event. And negligence at any point during that nine months can have catastrophic outcomes.”
NEXT: Canada is terrible at tracking maternal mortality rates
The Investigative Journalism Bureau (IJB) at the University of Toronto’s Dalla Lana School of Public Health is a collaborative investigative newsroom supported by Postmedia that partners with academics, researchers and journalists while training the next generation of investigative reporters.
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