What is Severe Maternal Morbidity?
Severe maternal morbidity (SMM) refers to serious complications during pregnancy, labour, childbirth or the postpartum period that result in severe illness, prolonged hospitalization, long-term disability, and high-case fatality. SMM occurs in about 1.6% of deliveries in Canada. Examples of SMM include cardiac arrest, stroke, sepsis, severe preeclampsia, massive hemorrhage and failure of major organs such as the heart, lungs, liver and kidneys. In Canada, massive postpartum hemorrhage, severe pre-eclampsia, and sepsis are the leading causes of SMM. In addition to long-term health outcomes and risk of premature death, pregnant individuals who have had SMM have a higher incidence of mental health implications, face challenges engaging with their newborn, and may experience SMM again in a subsequent pregnancy. SMM places substantial economic and social burdens on a family’s well-being.
Aren’t hospitals already reviewing and monitoring for SMM?
Yes, but not consistently, and most hospitals focus on making changes at the local level only. When a SMM or maternal death happens, a team of hospital experts typically reviews the event at a morbidity and mortality rounds to determine if and how a future SMM can be prevented in their own setting only. Results and recommendations from these local hospital SMM reviews are not shared ‘between’ hospitals – consequently, they are not able to learn from one another. CanOSS will help to enhance the quality of local reviews, and facilitate the sharing of anonymized, aggregated reports and recommendations between hospitals. Some national databases like the Canadian Institute of Health Information (CIHI) or the Better Outcomes Registry & Network (BORN) Ontario collect only some of the numbers behind SMM, but not the reasons why SMM occurs, how best to treat them, or how to prevent them.
What is CanOSS?
CanOSS is the Canadian Obstetric Survey System. Many other high-, middle- and low-income countries have Obstetric Survey Systems that have been successful in identifying and reducing SMMs. Much like a public health surveillance system, it is a quality improvement program that will collect and review de-identified data on condition-specific in-hospital SMM topics (e.g. eclampsia) during pregnancy, the birthing period, and after childbirth from hospitals within each province and across the country. CanOSS seeks to reduce the rate of SMM by identifying modifiable system- and community-level factors to improve practice and patient outcomes, while centering a just culture. The focus is not to point blame at individuals. The CanOSS process will include an interprofessional and multidisciplinary review of SMM events and contributing factors to develop recommendations for practice, policy, and education. CanOSS will first be piloted at hospitals across Ontario, and then across Canada. Click here to learn more about CanOSS.
How will CanOSS collect and store data?
CanOSS will support hospitals to develop or update their SMM review process. Each hospital will enter their SMM review data into a secure, confidential, online survey database stored at McMaster University’ Faculty of Health Sciences that has a lot of international and national experience with gathering and storing data in a manner compliant with all regulations. Expert assessors will review SMM cases without knowing the hospitals where it happened, in a confidential, professional, and non-judgemental way. CanOSS will work with partners to ensure that the recommendations are implemented and strive to look at a SMM topic again in the future to see whether the implementation of these recommendations has been successful to reduce SMM and what further work remains to improve the healthcare system.
Is CanOSS like a research study?
While CanOSS uses many of the same methods used in research, such as online data collection and analysis techniques, it is actually a “quality improvement” program that uses hospital data to improve the quality of care at hospitals. CanOSS follows the same strict rules as research studies do on how it collects and stores anonymized data, and produces and shares recommendations on how to improve hospital quality of care.
How does CanOSS work?
The CanOSS process is illustrated in this figure. First, a SMM topic is selected based on regional, provincial, and national priorities. Then clinical experts are consulted to provide a clear definition of the topic and to specify the inclusion and exclusion criteria i.e. what cases will be studied and what will not.. Hospitals identify local cases of the SMM from their patient files, gather specific data, and review the case by a group of local clinicians. CanOSS will support these local reviews by ensuring that the local teams are truly multidisciplinary and that the process follows a no-blame culture, aimed at learning. De-identified data are then entered online into the CanOSS database. A team of expert assessors reviews all of the SMM cases across the province or country, and looks for systemic causes without judgement or blame. A multidisciplinary group then reviews the assessors’ review of all cases, and provides recommendations on how to reduce the rate of SMM through maternity healthcare providers, hospitals, government, policymakers, and communities.
How exactly will CanOSS reduce SMM?
By collecting data on why SMM is occurring and not just how many SMMs are occurring, CanOSS will use experts to determine what things contribute to SMM, such as if medical guidelines were followed; if hospital staffing, medical transport, or available services were issues; if more in-service hospital education and training might have helped; and if the patient’s race, economic situation, access to care, housing, language, ethnicity, family, or community situation contributed to a SMM. CanOSS holds a no-blame, no-shame culture, centered in supporting evidence-based practice and learning health systems. Up to 50% of SMMs may be prevented if these systemic issues can be identified and addressed. By finding out the factors that lead to SMM, changes can be made in hospital wards and communities across the country that can help make a difference to many families.
Recommendations by the CanOSS team will need to be adapted to local settings. CanOSS will support local regional and site champions to develop an implementation and evaluation plan. The Hub is a sister process to CanOSS that is being developed to determine how recommendations can be translated into practice at the hospital and community level, with more information coming soon.
How will hospitals and patients benefit from CanOSS?
By understanding ‘why’ and not just ‘what’ SMMs are happening, using a systematic review system with expert assessors, hospitals can determine the root causes of SMM in their area, share their lessons learned with other hospitals facing similar SMMs, and come up with solutions that address any problems identified in the system.
SMM have a profound impact on people and their families, affecting their ability to return to work, ability or desire to have another baby, and can result in divorce and broken relationships, and high rates of hospital and emergency visits. Communities, healthcare systems, the workforce, and subsequent generations are all significantly affected by severe maternal morbidity.
Pregnant people benefit the most from CanOSS, with a lower risk of getting an SMM during pregnancy, birth, and post-partum, and the assurance that they are getting the best care possible should a problem arise. People who have had a severe maternal morbidity want to ensure that their experience helps change things for all others after them.
Where is CanOSS happening now?
The goal is to develop CanOSS nationwide. We have surveyed the 289 birthing hospitals in Canada to understand if they already had a SMM review system, and how it works. More than 60% responded and 75% answered that they were willing to share anonymized SMM data with a central reporting system like CanOSS to help reduce SMM. CanOSS will first be piloted in Ontario. We are currently studying the existing SMM review system among the 89 birthing hospitals in Ontario. This pilot will first examine massive maternal hemorrhage during and after pregnancy and birth. Soon after, CanOSS will launch a Canada-wide study looking at cardiac complications in pregnancy. Many different kinds of SMM will be examined through the CanOSS network each year, depending on data obtained through epidemiologic studies as well as regional and national priorities.
Who is involved in CanOSS?
CanOSS is led by a team of researchers from McMaster and McGIll University. CanOSS has partnered thus far with the Society of Obstetricians and Gynaecologists of Canada (SOGC), the Provincial Council for Maternal and Child Health (PCMCH) in Ontario, the Better Outcomes and Registry Network (BORN) Ontario, the Public Health Agency of Canada (PHAC), the Canadian Association of Midwives (CAM), the Canadian Association of Perinatal and Women’s Health Nurses (CAPWHN), the Maternal and Perinatal Death Review Committee (MPDRC) with the Ontario Office of the Chief Coroner, the Canadian Neonatal Network (CNN), McMaster University, McGill University, “The Hub”, Hamilton Health Sciences (HHS), the Juravinski Research Institute (JRI), the Canadian Institutes of Health Research Institute of Gender and Health (CIHR-IGH), the Heart and Stroke Foundation of Canada, and the Brain Canada Foundation, as well as numerous hospitals across Canada and Ontario.
Where can I get more information about SMM and CanOSS?
Dr. Rohan D’Souza and Dr. Isabelle Malhamé are the co-principal investigators leading the development of CanOSS. You can find more information about CanOSS at https://canoss.ca/. You can read more about SMM in these medical articles:
- Government of Canada. Health outcomes: Reproductive health [Internet]. 2023 [cited 2023 Nov 29]. Available from: https://www150.statcan.gc.ca/n1/pub/82-570-x/2023001/section1-eng.htm#a2
- Dzakpasu S, Deb-Rinker P, Arbour L, Darling EK, Kramer MS, Liu S, et al. Severe Maternal Morbidity in Canada: Temporal Trends and Regional Variations, 2003-2016. J Obstet Gynaecol Can. 2019 Nov;41(11):1589-1598.e16. https://pubmed.ncbi.nlm.nih.gov/31060985/
- Ukah UV, Platt RW, Auger N, Lisonkova S, Ray JG, Malhamé I, et al. Risk of recurrent severe maternal morbidity: a population-based study. Am J Obstet Gynecol. 2023 Nov;229(5):545.e1-545.e11. https://pubmed.ncbi.nlm.nih.gov/37301530/
- Dzakpasu S, Deb-Rinker P, Arbour L, Darling EK, Kramer MS, Liu S, et al. Severe maternal morbidity surveillance: Monitoring pregnant women at high risk for prolonged hospitalisation and death. Paediatr Perinat Epidemiol. 2020;34(4):427–39. https://pubmed.ncbi.nlm.nih.gov/31407359/
- Ray JG, Park AL, Dzakpasu S, Dayan N, Deb-Rinker P, Luo W, et al. Prevalence of Severe Maternal Morbidity and Factors Associated With Maternal Mortality in Ontario, Canada. JAMA Netw Open. 2018 Nov 9;1(7):e184571. https://pubmed.ncbi.nlm.nih.gov/30646359/
- Geller SE, Koch AR, Garland CE, MacDonald EJ, Storey F, Lawton B. A global view of severe maternal morbidity: moving beyond maternal mortality. Reprod Health. 2018 Jun;15(S1):98. https://pubmed.ncbi.nlm.nih.gov/29945657/
- Diguisto C, Saucedo M, Kallianidis A, Bloemenkamp K, Bødker B, Buoncristiano M, et al. Maternal mortality in eight European countries with enhanced surveillance systems: descriptive population based study. BMJ. 2022 Nov 16;e070621. https://www.bmj.com/content/379/bmj-2022-070621
- Malhamé I, Knight M, D’Souza R. Initial Steps in Developing and Implementing a Canadian Obstetric Survey System (CanOSS) for Severe Maternal Morbidity. J Obstet Gynaecol Can. 2022 Jun;44(6):637–8. https://pubmed.ncbi.nlm.nih.gov/35691680/
- D’Souza R, Seymour RJ, Knight M, Dzakpasu S, Joseph KS, Thorne S, Ospina MB, Barrett J, Cook J, Fell DB, Scott H, Metcalfe A, van den Akker T, Lapinsky S, Skeith L, Murray-Davis B, Shah P, Forte M, Ashraf R, Chundamala J, Hutchinson SA, Chen KK, Malhamé I. Feasibility of establishing a Canadian Obstetric Survey System (CanOSS) for severe maternal morbidity: a study protocol. BMJ Open. 2022 Mar 23;12(3):e061093. doi: 10.1136/bmjopen-2022-061093. PMID: 35321901; PMCID: PMC8943762. https://pubmed.ncbi.nlm.nih.gov/35691680/
How can people get involved?
This work costs time and money. We receive grants from government and foundations to begin to design CanOSS, but not necessarily to continue it through into a permanent system. You can help by donating or by spreading the word about what CanOSS is trying to do. Dr. D’Souza’s FLOURISH (Family-Oriented and Service User Centered Research In Supporting Pregnancy Health) lab through McMaster University accepts online donations to support CanOSS staff to make pregnancies safer at: https://secureca.imodules.com/s/1439/17/giving/form.aspx?sid=1439&gid=1&pgid=770&cid=1618&dids=2753&bledit=1&appealcode=24T2
For more information or to get involved, email us at canoss@mcmaster.ca or visit https://canoss.ca/.
If you belong to a hospital, regional health network, or provincial/national organization and want to learn more about CanOSS, please contact a member of the CanOSS team at canoss@mcmaster.ca to arrange a meeting.