The first blood clot was about the size of an avocado.

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Beatrice Mikkola, 30 years old, was exhausted. She had just arrived home from the hospital, having survived a postpartum hemorrhage while giving birth to her first child. She was trying to care for a newborn. And she was passing blood clots from her vagina.

At first, her health providers told her this was normal. Then, about a month after her delivery, she bled through her pants and several maxi pads. She got dizzy. “Your body just goes, like, ‘Whoosh.’ I was like, ‘There’s something wrong.’ ”

The Calgary resident went to the ER at her midwife’s direction but when the doctor couldn’t do an ultrasound with the device available, she was sent home.

“If he says I’m fine, I’m sure I’m fine,” she remembers thinking.

She went home. And kept passing clots.

Mikkola’s birth story is one of many the Investigative Journalism Bureau (IJB) reviewed as it examined maternal and neonatal morbidity and mortality across Canada.

The IJB found Canadian women are dying preventable pregnancy-related deaths and experiencing other adverse effects in childbirth. And Canada is bad at tracking maternal deaths. In fact, while data show a doubling in the maternal mortality rate for the decade ending in 2024, many experts think that reflects improvements in record-keeping rather than a dramatic rise in deaths.

Deaths during pregnancy, childbirth or following childbirth remain rare, but the IJB investigation shows health providers are missing opportunities to improve childbirth outcomes.

Canada is behind high-income European countries in tackling the “big three” leading causes of maternal morbidity and mortality: post-partum hemorrhage, hypertension and sepsis, says McMaster University obstetrician and researcher Rohan D’Souza.

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“The deaths from these causes are completely preventable,” he says. “It’s about access. It’s about equity.”

For Mikkola, it was about health providers not seeing what was in front of them.

“I was trying so hard to advocate for myself and be like, ‘I don’t think this is normal.’ And then just got the runaround,” she recalls. “I was told that everything I was experiencing was normal until they realized, ‘Oh f—, this is not.’ ”

At seven weeks postpartum and still passing clots the size of apricots, Mikkola got in to see a radiologist at the ultrasound appointment her midwife had booked in response to the bleeding. The radiologist came to talk to her.

“There’s something in there. I don’t know what it is,” Mikkola remembers the radiologist saying.

She went back to the ER at the radiologist’s urging but was sent home again because the hospital lacked the staff for a swift surgery.

Two days later, she was back. Then, what she was told would be a routine procedure to remove tissue from the uterus stretched on far longer than promised.

More than two months after Mikkola first told doctors something didn’t feel right with her body, and after multiple ER visits, they found a four-centimetre piece of placenta lodged in her cervix. The only reason she hadn’t gone septic, they told her, was because it was still connected to her uterus.

Clinicians usually examine a placenta after birth to ensure nothing is missing, although that test is not perfect, said Ontario obstetrician Graeme Smith, who was not involved in Mikkola’s care.

Emerging from surgery healthy and feeling lucky, Mikkola thought this would be her last obstetric close call.

Are death rates really rising?

The rate of Canadians dying in childbirth appears to be rising — from about six per 100,000 live births in 2014 to about 12.6 in 2024, according to Statistics Canada. The actual number of deaths is relatively small — 46 in 2024 — but that’s a doubling from 23 in 2014.

However, there is dramatic variation in how provinces track these deaths, and the apparent increase may simply show an improvement in surveillance.

“The better you get at counting,” D’Souza said, “the worse the outcomes are going to seem.”

In 2024, Ontario’s rate was 18.79 per 100,000 and Quebec’s was 3.89, according to Statistics Canada. Six provinces and territories registered rates of zero that year.

“I think a lot of that has to do with surveillance issues,” said University of Toronto researcher Hilary Brown. “When you’re dealing with an outcome that is so rare, even a handful of missed cases or misclassified cases can make a really big difference for their rates.”

The IJB asked 10 provinces and three territories how they define, track and investigate maternal and neonatal deaths.

Most track them in some way but there are key differences. Some only include deaths in health facilities; others only during or immediately following childbirth, even though a 2026 study found complications often happen outside the birth itself — a period less scrutinized by health workers.

Ontario investigates maternal deaths that occur up to a year following birth. But what counts as a birth (does a miscarriage, for example?) and will first responders necessarily know a person who has died was pregnant months earlier?

Saskatchewan’s coroner “does not track maternal or neonatal deaths,” Kerri Ward-Davis, a spokesperson for the Ministry of Justice and Attorney General in Saskatchewan, said in an email, “as most maternal or neonatal deaths are deemed to be from natural causes.”

Since 2022, Quebec’s Coroners Act has required anyone discovering the death of a pregnant person or a person within 42 days of childbirth to immediately notify a coroner or a peace officer — but the province is still determining how to study and disseminate this information, spokesperson Jake Lamotta Granato said in an email.

The data gaps pose a significant public health problem.

“We do not have an ability in Canada to learn the lessons of our errors in a systemic, national way,” said McMaster University obstetrician Jon Barrett. Same goes for adverse events — unwanted outcomes that may be no one’s fault, but from which clinicians can learn.

In provinces that do track and investigate maternal and neonatal mortality and morbidity, a few trends emerge. Repeated recommendations about steps as basic as monitoring and documentation are going unheeded; and resource constraints are hurting women and their babies as people in dire medical straits are transferred between practitioners and between health-care sites.

Variations in tracking pose problems; so do breakdowns in how improvements are implemented. Canada could learn from other industries’ practices of preventing adverse events, Barrett said. As an example, “whenever there’s an aircraft accident, there’s a systemic way of learning what happens so that we can prevent another one.”

Tracking is improving, D’Souza said. For instance, Ontario death certificates have a box to check: Was this person pregnant? But recording remains imperfect.

***

Surveillance aside, the University of Toronto’s Brown said another reason more things may go wrong during pregnancy and following birth may be tied to who is getting pregnant: older people with higher rates of obesity or chronic conditions such as diabetes, cardiovascular disease or kidney disease.

We do not have an ability in Canada to learn the lessons of our errors in a systemic, national way

McMaster University obstetrician Jon Barrett

In some ways this is good news: people are having children when previously they might not have dared. But this can pose new health challenges.

There’s a need to cut through health-care siloes, Brown said, so a pregnant person’s obstetrician is talking to their rheumatologist or cardiologist, so everyone knows what the birth plan is and what is needed to execute it.

Part of the problem relates to access to care, D’Souza said: people aren’t getting care early so they get diagnosed late, and treated late, for potentially complicating or even life-threatening conditions. If they lack resources when they are giving birth, that limits responses to life-threatening complications. They may not be adequately or swiftly diagnosed with a condition such as life-threatening heart failure or a pregnancy-related blood clot.

Marginalized women and babies face added perils: lack of finances, education, immigration status or linguistic facility can mean problems aren’t caught and addressed early. Someone without health coverage or primary care may lack prenatal care at 13 weeks; someone in a remote area may lack obstetric staff at 39.

Studies over the past decade have found living in a rural area, having less money or education or being Black can put mothers and babies at higher risk.

Overall, Barrett said, there is an “acute” lack of resources in women’s health. Some labour and delivery units do not have enough nurses. Some units are closing.

“Resources tend to go towards cancer and towards orthopedics. And I’m not saying that those things aren’t needed. But women’s health is often relegated.”

And, he implores, we should be examining close calls: illness and injury as well as death. He points to an initiative he and D’Souza are working on to zero in on pregnancy-related complications.

“It’s just not done in maternal health because, I’m afraid to say, women’s health is not prioritized. I always say, ‘If men were having babies, this would have been done long ago.’ ”

After a baby is born, much attention is paid to the tiny new human, said doctor and researcher Sarka Lisonkova. The human who just gave birth is also in need of care, she said, and health providers must keep an eagle eye out for everything from sepsis to depression.

A second birthing scare

Just over four years later and almost five weeks since she’d given birth to her third child, Mikkola was at an appointment with her daughter when she started to bleed.

She soaked through two overnight pads and passed clots the size of large cherries.

Her midwife gave her a requisition for an urgent ultrasound but the clinic told her it had to come from her doctor. On the phone as she was trying to negotiate an appointment, the bleeding recommenced and she rushed to the emergency department where she sat for 10 hours, breastfeeding in a miasma of coughing from those around her, until she got an appointment for the next day.

The verdict, again: a piece of placenta lodged in her cervix.

Mikkola is now recovering from surgery. All things considered, she is doing OK.

But she wonders, as she told the IJB before her youngest was born, what would have happened if she hadn’t been in a position to advocate so vocally.

“I worry for women that don’t have the exposure, education and network that I do.”

— With additional reporting from Jenna McConnell and Annushka Agarwal.

The Investigative Journalism Bureau (IJB) at the University of Toronto’s Dalla Lana School of Public Health is a collaborative investigative newsroom supported by Postmedia that partners with academics, researchers and journalists while training the next generation of investigative reporters.

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