Life-threatening complications are often overlooked in the weeks after childbirth, researchers say
Paige Eaton wanted to be open-minded about planning the birth of her first child, so when she needed an emergency C-section, the Kitchener, Ontario resident felt somewhat unprepared.
Still, she never imagined the terrifying rollercoaster that was to come.
A few days after the birth of his son Archie in June 2023, Eaton developed severe pain, chills and a fever. She was again hospitalized and treated for cellulitis, a serious bacterial skin infection at the site of her C-section wound, which turned into a pelvic abscess, inflammation in her abdomen and uterus, and ultimately life-threatening sepsis.
The first-time mother was stunned, but could barely understand what was happening due to the pain caused by her infection. Cleaning the wound was painful, and Eaton remembers screaming when a health care worker gave her an injection to numb the area.
“Every time they touched it even a little bit, I felt extreme pain,” he said.
Eaton spent two weeks in the hospital, undergoing multiple treatments and constant IV antibiotics while breastfeeding her newborn around the clock. At one point, she even went into early septic shock, which required abdominal surgery, blood transfusion and a month-long recovery.
“It’s really hard to describe the pain of sepsis unless you’ve been through it. Basically all you can say is: It’s the worst pain you could ever imagine,” he told CBC News. “And the main thing is that you feel like you’re going to die.”
Despite the severity of her infection – and how close she may have been to death – Eaton’s experience in the weeks following her son’s birth will not be captured in typical data on severe maternal morbidity, a term covering a range of potentially-fatal complications associated with pregnancy and childbirth.
Severe cases are thought to occur at a rate of less than 18 out of every 1,000 deliveries in Canada. But this estimate is based specifically on labor and delivery, a relatively short period of time from the beginning of regular contractions to the expulsion of the placenta after childbirth.
New Canadian research shows that nearly a third of life-threatening complications women experience during that period occur during the early weeks after delivery – a time when mothers typically experience much less medical tracking and support than during pregnancy.
4 out of 10 cases in Ontario missed earlier
Nearly 30 per cent of cases of serious maternal morbidity, from sepsis to severe bleeding, occurred within the first six weeks after delivery, according to the findings, based on a cohort of more than one million births in Ontario between 2012 and 2021.
More than half of those serious cases were during labor and delivery, while another 16 percent occurred during the first pregnancy.
Overall, expanding the time period revealed that nearly four in 10 cases of serious pregnancy and delivery complications in Ontario were previously missed, the paper’s authors wrote. Published on Monday In Canadian Medical Association Journal (CMAJ).
Senior author Dr. Giulia Muraca told CBC News that maternity care in Canada remains “very strong,” with 97 per cent of pregnancies not affected by these types of serious health issues. Still, he stressed that every case matters.
“If we can better survey when and in whom these cases are occurring, we can do a better job of responding to those patterns and reducing the number of people experiencing these serious complications,” said Muraca, who is also a perinatal epidemiologist and an associate professor at McMaster University in Hamilton, Ontario.
An Ontario mother has been fighting for answers for more than two decades after a needle was left in her spine during delivery. After several failed investigations, Giovanna Ippolito worries that no one will be held accountable.
The research team said their findings support global efforts to redefine severe maternal mortality and perinatal mortality to include issues that occur before labor begins and in the weeks after someone is discharged.
The paper looked only at close calls, not fatal outcomes, but researchers also found in a recent analysis of coroner’s data in Ontario that most maternal deaths occur either during pregnancy – about 47 per cent – or postpartum – closer to 46 per cent – while less than eight per cent of deaths occur during labor and delivery.
The new CMAJ findings “highlight that focusing solely on the intrauterine period will not adequately help identify, prevent, or respond to serious maternal health problems and deaths,” the research team wrote.
As a result, “outpatient monitoring is essential to identify and prevent maternal sepsis,” including postpartum home monitoring – for metrics such as heart rate and blood pressure – for individuals at increased risk. Extended midwifery care or postpartum home visits by public health nurses could also fill the gaps, the researchers said.
Yet, in contrast, many postpartum patients within the hospital system are typically given a maximum of six-week checkups. Ontario also has limited access to primary and maternity care, leaving “many individuals unable to receive adequate postpartum care,” the study said.
A GTA family is demanding accountability and new hospital policies after a mother died in childbirth earlier this summer. As CBC’s Sarah McMillan reports, the family says staff at Mississauga’s Credit Valley Hospital didn’t act quickly enough to recognize and treat the sepsis.
New insights could help ‘prevent maternal deaths’
Jocelyn Cook, chief scientific officer of the Society of Obstetricians and Gynecologists of Canada, said the new findings help improve maternal health.
“It is important to understand severe maternal morbidity in this wayBecause many maternal deaths are preceded by episodes of serious morbidity,” C.ook said in a statement to CBC News, adding studies like this could help improve maternal health and prevent deaths.
Dr. Sarka Lisonkova, an associate professor in the department of obstetrics and gynecology at the University of British Columbia, who also researches pregnancy complications, praised the Ontario team for highlighting the broad time frame when major issues arise and said “continuity of care” is important.
Patients are ideally evaluated for potential risk factors for complications before discharge and followed up with their family physician or nurse, she said.
“But sometimes there are groups that miss such a scenario of good follow-up and monitoring… and sometimes we focus more on the child than the mother,” Lisonkova said.
Almost no one in a large part of Northern Ontario between Timmins and Thunder Bay is trained in obstetrics, forcing women to relocate for the final weeks of pregnancy. CBC’s Nick Purdon went there to find out what it’s like to navigate the ‘maternity ward desert.’
Some women are at greater risk
A variety of life-threatening health problems can occur before, during, and after delivery.
The long list includes severe blood loss or ruptured uterus, acute kidney failure, etc. sepsisand various heart conditions. Some patients develop surgical complications, or require mechanical ventilation or admission to the intensive care unit.
Others develop a spectrum of high blood pressure conditions known as preeclampsia, eclampsia and an emergency situation This is called HELLP syndrome, which involves a dangerous trifecta of red blood cell breakdown, increased liver enzymes and a low platelet count.
Some women may have a higher risk of developing these serious health problems.
The latest findings from Ontario support other studies that show an association between severe maternal morbidity and patients being black, having low socioeconomic status, having a high body mass index, using medications during pregnancy or having multiple pregnancies.
The CMAJ study found a strong association between having type I diabetes and serious health problems during pregnancy, delivery, and the first six weeks postpartum.
‘I missed you a lot’
Still, Eaton, the mother who suffered from sepsis just weeks after her son’s birth, said that in her case, she had a sudden medical crisis, even though she had received follow-up care from a midwife, advocacy from her husband and extended family, and was healthy before her shocking diagnosis.
Eaton also recalled her deteriorating condition, while her concerns were repeatedly dismissed, with her midwife suggesting that her initial fever was simply part of routine recovery, with hospital staff later downplaying the possibility of her symptoms worsening as sepsis took hold.
In the weeks that followed, the now 36-year-old required home care from a nurse for regular wound checks and dressing changes, and had to carry a backpack with her IV antibiotic setup and a vacuum pump device that gently sucked out the remaining fluid from her infection. He recalled that in the early months of his recovery, Eaton’s mental health deteriorated and he was not allowed to properly bond with his newborn son.
“I didn’t get a chance to bathe her for the first time. I missed a lot and it was a blur,” he said.
The ordeal left her with a jagged scar from the C-section and all the trauma that followed – a constant reminder to Eaton of her struggle with death.
“Every day I have to look at it,” she said.
