What Ontario's Maternal Death Reviews Reveal About Canada's Missed Opportunities for Preventing Maternal Mortality

To analyze maternal mortality review recommendations made by Ontario's Obstetrics and Perinatal Death Review Committee in Ontario between 2008 and 2023 to identify themes and opportunities to act on them to improve outcomes.

This retrospective content analysis included 162 maternal deaths reviewed by the Ontario Obstetrics and Perinatal Death Review Committee, generating 192 recommendations. Each recommendation was categorized by cause of death and thematically coded into 5 domains: education, clinical protocols, system-level gaps, practice issues, and patient-related factors.

Hemorrhage and infection were the leading causes of maternal death (40% combined), typically occurring within 72 hours postpartum. The most common themes across all causes were educational needs (59%) followed protocol gaps (29%), system issues (9%), and 3% were patient-focused. Several recommendations aligned with international strategies that have successfully reduced maternal deaths from thromboembolism, sepsis, and hypertensive disorders in the United Kingdom and United States. However, Canada lacks a national mechanism for implementing or tracking such recommendations, limiting impact and accountability.

Ontario's maternal mortality review findings mirror international data and reinforce that many maternal deaths remain preventable. Canada must act on existing recommendations without waiting for national infrastructure to be fully established. Adopting evidence-based care bundles, improving surveillance, and embedding maternal safety into health system priorities are urgent and feasible next steps toward ending preventable maternal deaths.