Ontario mom Taylor Mott has three children, the youngest just two months old.
When her first child was born, her daughter was admitted to a special care nursery. Despite the stressors that came with her delivery, Mott found that the early postpartum period was in some ways easier than with her second and third child.
“I had nurses and doctors all around me. I was able to ask quickly ‘Is this okay?’… I could say, for example, engorged breasts or breast-feeding and blood clots, ‘What’s normal and what’s not?’”
With her other two children, she found she often had to turn to the internet.
“You are exhausted, you are a new mom, you are just trying to survive… and here you are trying to manage your own health. You don’t have these check-ins, and without check-ins [your own health] gets pushed to the back burner. You prioritize the health of your baby.”
Following the birth of her third child, Taylor suffered a blood clot in her leg and other health complications, including significant postpartum anxiety. “I didn’t know who to reach out to to get the help that I needed. There were so many people in the picture, but no one was taking full responsibility.”
Mothers like Mott are getting lost in the cracks of Canada’s healthcare system.
“I feel like when you’re pregnant, you get an appointment every month/week. Then after [the] baby, you are kind of forgotten about and no one cares as much,” said one mom in a 2022 study. The study, which examines postpartum care in the Atlantic provinces, is one of the only such studies in Canada.
While three-quarters of women reported being satisfied with their care, many commented on difficulty accessing care, long gaps between care and inconsistent information when seeing multiple care providers.
The study also showed roughly 40 per cent of women did not have a follow-up appointment between weeks six and seven — a critical time period during which the Society of Obstetricians and Gynecologists of Canada (SOGC) recommends all mothers be seen.
Pregnant population changing
The lack of standardization of postpartum care is a concern to experts across the country, as is the dearth of data on maternal death and illness.
More than 500 Canadian women died from complications of pregnancy and childbirth between 2000 and 2023, a number widely considered an underestimate. The World Health Organization (WHO) suggests this number is closer to 800.
And maternal death is only one part of the picture. Many Canadian studies have shown that new mothers are getting sicker. A population-based study in the Journal of Obstetricians and Gynecologists of Canada found that the number of women who experienced severe illness postpartum increased 9 per cent between 2005 and 2015.
The rate of severe complications and illness may also be underreported. “It’s a hugely unknown area in Canada,” says Dr. Harrison Banner, Maternal Fetal Medicine (MFM) expert at London Health Sciences. “We aren’t actually tracking that data in any systematic way.”
One factor that may explain increased complications and illness is significant changes in the demographics of the pregnant population. Across Canada, 46 per cent of pregnant women are overweight or obese, up from 41 per cent in 2003, according to the Public Health Agency of Canada (PHAC). Twenty-seven per cent have chronic illness and 20 per cent of babies are born to women over the age of 35, up from 15 per cent in 2003.
Women over the age of 35 have a higher risk of preterm birth, gestational diabetes and high blood pressure, as well as higher rates of c-section delivery. High blood pressure in pregnancy is one of the leading causes of maternal death.
In addition, rates of postpartum depression and anxiety doubled over the course of the pandemic. In Canada, suicide is the fourth leading cause of maternal death.
Who’s the provider?
The WHO recommends postpartum care in the first 24 hours after birth, as well as contact with a healthcare provider between two to three days, one to two weeks, and six weeks post-birth.
In Canada, postpartum care varies greatly depending on the primary care provider.
Obstetricians usually see patients once at six weeks postpartum, in accordance with SOGC guidelines. These guidelines also suggest mothers should be seen in the first week after delivery, but for many, it is unclear who should be doing this visit.
Mott found this lack of clarity about who to see, as well as how to find help after the six-week period, a challenge in her recovery. “Even at two-and-a-half months postpartum, my body is still going through so much… [as well as] mental struggles.”
Dr. Diane Bedrossian, a family doctor in Toronto, tries to book time for both mom and baby during their first visits after delivery. But, she says, “many physicians do not have extra time in their busy clinics and as issues like hypertension and mental health concerns increase, it will be difficult to meet the needs of the postpartum population.”
The care women receive is also greatly affected by the province in which they reside.
National PHAC guidelines report that, across the country, 56 per cent of women are cared for by an obstetrician and 38 per cent by family physicians. But this shifts depending on the number of family physicians and midwives in the province.
Dr. Alicia Power is a family physician and maternity specialist in Victoria, BC. She says in British Columbia the majority of patients are seen by either a family doctor specialized in maternity care or a midwife. Obstetricians are involved in consultation for high-risk cases.
In the Atlantic provinces, 2-5 per cent of women are cared for by midwives, 4 per cent in Quebec, 20 per cent in Ontario, 8-10 per cent in the Prairies and 25 per cent in British Columbia.
Most Canadian midwifery associations recommend an average of six visits after delivery, which occur through a combination of home and clinic visits.
T.I.M.E.
Dr. Banner is part of a team of care providers who have developed a program called The Interprofessional Midwifery/Maternal-Fetal Medicine Expanded Program, or T.I.M.E. Its aim is to respond to the growing need for comprehensive postpartum care.
In the program, high-risk patients are seen by both maternal-fetal (MFM) specialists and midwives. This collaborative care allows for extra support at prenatal visits, access to the expertise of the MFM and six weeks of postpartum care by the midwifery team.
The T.I.M.E program receives specialized funding from the Ministry of Health in Ontario. Similar small-scale programs exist across Canada, including in Guelph and Vancouver. Many focus on high-risk populations, but healthcare providers would like to see these programs scaled up.
For Mott, who saw midwives in her first pregnancy and obstetricians in the second two, this type of collaborative care can provide the best of both worlds, offering an accessible and experienced team to address the disparities that so many new mothers experience.
