Dr. Giulia Muraca, PhD, is a perinatal epidemiologist and an Associate Professor in the Departments of Obstetrics and Gynecology and Health Research Methods, Evidence & Impact at McMaster University.
When Canadians think about maternal death, they often imagine a catastrophic emergency in the delivery room: a severe hemorrhage, a life-threatening infection, or a dangerous spike in blood pressure that unfolds during childbirth.
These tragedies do happen. They remain among the most devastating outcomes in medicine and continue to deserve our attention. Preventing them is why I’ve dedicated my career to perinatal epidemiology – the study of health events that occur related to reproduction and pregnancy.
Recent reporting by the Investigative Journalism Bureau and the creation of a public maternal death tracker have brought much-needed visibility to these deaths and the families they affect.
But one of the challenges in understanding maternal mortality is deciding which deaths count.
Traditionally, maternal mortality refers to deaths that occur during pregnancy or within 42 days after its end and are directly or indirectly related to pregnancy. This definition remains essential; it captures many of the most feared complications of pregnancy and childbirth, allows us to track trends over time, and facilitates comparisons across jurisdictions.
Yet our current definition draws an arbitrary boundary six weeks after birth: health consequences of pregnancy can occur after this narrow postpartum window.
While many people recover fully after childbirth, others continue to experience physical and mental health challenges for months or years. Increasingly, researchers and clinicians are recognizing that some of the most serious threats to maternal health may occur well beyond the traditional postpartum period.
This raises difficult questions, because pregnancy can reveal underlying health vulnerabilities, worsen existing conditions, and alter health trajectories in ways that extend far beyond childbirth. There is a legitimate debate to be had about what deaths are related to maternal factors, and what deaths could have been prevented because of maternal care interventions.
How should we think about a death from suicide? Or an unintended overdose linked to postpartum depression? Or a cardiovascular death following a pregnancy complicated by severe hypertension? All of these can happen months or years after labour, outside the six week window.
Depending on the circumstances, these deaths may not meet the formal definition of a maternal death. Nor should we assume that pregnancy was their sole cause. Many individuals who die from mental health conditions, substance use disorders, or chronic disease have longstanding risk factors that predate pregnancy.
Yet it is equally difficult to conclude that pregnancy, childbirth, postpartum recovery, and the systems of care surrounding them played no role.
Consider a person with a pre-existing mental health condition who experiences worsening depression after childbirth and dies by suicide several months later. Pregnancy may not be viewed as the direct cause of death. However, the physiologic, psychological, and social changes associated with pregnancy and the postpartum period may have contributed to a chain of events that culminated in tragedy. Similar questions arise for substance use disorders, cardiovascular disease, and other chronic conditions that may be exacerbated by the demands of pregnancy and the transition to parenthood.
Rather than focusing exclusively on whether these deaths satisfy a particular definition, a more useful question may be whether they represent missed opportunities for prevention during pregnancy and the year that follows, a holistic approach used in many other areas of medicine and public health.
The postpartum period remains one of the least developed components of maternal health care. Many individuals experience a dramatic transition from frequent prenatal visits to relatively limited follow-up after birth, a period marked by sleep deprivation, mental health challenges, chronic disease management, financial stress, and difficulties accessing ongoing care.
We must learn from every death that may have been influenced by pregnancy because it may reveal opportunities to save lives.
But we cannot learn about what we do not count.
