Let’s not be smug: Canada has much work to do in caring for pregnant women

Just days after the overturning of Roe vs. Wade in the United States, in Canada protesters have gathered in front of U.S. consulate buildings, politicians have reassured their constituents of their reproductive rights and citizens have posted expressions of support for Americans seeking abortions across the border.

But while Canada is not on the verge of criminalizing medically safe procedures that protect women’s lives, we cannot be smug when we compare ourselves to our southern neighbors.

The experiences in our health-care system of miscarriage – the most frequent complication of early pregnancy, affecting one in five pregnancies – suggest reproductive health is, at best, off the radar of Canadian health policy decision-makers and, at worst, intentionally neglected.

The majority of pregnancy losses occur in the first trimester when many women in Canada do not yet have an obstetrical care provider. As comprehensive maternity care by family physicians has decreased over time, few patients know to contact their family physicians who are skilled to provide an assessment when bleeding or pain arise in early pregnancy, and patients are often told by telehealth providers to go to their nearest emergency department.

In a Canadian research study in 2021, patients with symptoms of miscarriage described emergency departments as the only place where they knew to access urgent care, even when minimal bleeding or pain were present.

Thus, it is not surprising that a study of all pregnant women in Ontario found four in five women sought care in an emergency department when experiencing a miscarriage, and nearly 40 per cent of pregnant women visited an emergency-department during or shortly after pregnancy. Both statistics are much higher than peer countries.

In Ontario, four in five women sought care in an emergency department when experiencing a miscarriage.

And while the emergency department may be the safest and most expeditious location for a pregnant woman with vaginal bleeding or abdominal pain to receive care, the patient experience of an early pregnancy loss in the emergency department is often appalling.

Ontario’s pregnant patients have longer than average waits to see doctors in the emergency department, often sitting in chairs in non-private locations, and frequently describe being made to feel as though they are “wasting the emergency-department providers’ time” given space constraints and relative stability compared to sicker patients.

Pregnant patients also report being given little to no information by emergency providers of the need for physical or psychological follow-up care or where to seek care if unexpected symptoms were to occur, which results in a common assumption that the situation is “over” once they leave the emergency visit.

Yet, some pregnant patients describe going home only to unexpectedly pass a recognizable fetus into the toilet amidst enormous amounts of bleeding and pain.

These research interviews occurred before the pandemic, when emergency departments were not as crowded, understaffed or at the epicentre of health-care system collapse as they are today.

And, unlike other specialty services that pivoted to virtual care, that model is of limited use for first assessments of patients with vaginal bleeding or pain. Patients in early pregnancy with complications require a physical examination by a health-care provider, blood work and ultrasound imaging.

The Canadian experience of pregnancy loss according to pre-pandemic research was horrible and most likely has gotten worse.

In short, the Canadian experience of pregnancy loss according to pre-pandemic research was horrible and most likely has gotten worse.

Beyond the graphic and overwhelmingly negative patient experiences, research suggests the safety of patients with symptoms of early pregnancy loss in Canada is also compromised. A survey of emergency departments in Ontario found that 60 per cent of hospitals do not have access to outpatient early pregnancy clinical services and are reliant on emergency departments to provide ongoing follow-up for those experiencing complications of early pregnancy.

For women with a possible ectopic pregnancy, a potentially life-threatening condition if undetected, the lack of specialized follow-up puts patients at higher risk of rupture and bleeding to death.

In 2019, Health Quality Ontario introduced a quality standard for early pregnancy complications and loss that was informed by an advisory committee of patients with lived experience and health-care professionals. The introduction to the standard states that the emergency department is not the optimal patient-centred setting for this care due to long wait times, lack of privacy, inability to provide follow-up care and sometimes a lack of staff with specialized training in caring for these patients.

To achieve better outcomes, Health Quality Ontario standards define eight care and system-related recommendations. Three years on, little if any improvements have been made toward achieving these standards.

In peer countries like the United Kingdom, patients with symptoms of early pregnancy loss bypass the emergency department altogether and are seen without referral at an early pregnancy assessment clinic. One of the Health Quality Ontario standards states all patients with symptoms of pregnancy loss should have access to such early pregnancy assessment services, at least in the form of follow-up after an emergency department visit.

Even prior to the pandemic, the limited number of early pregnancy assessment clinics in Ontario could not accommodate all referrals from their own emergency departments, let alone others. And, for the foreseeable future, an alternative to the emergency department as the first point of care is unlikely for this patient population. As it stands, early pregnancy assessment services are a pipedream for many, especially rural Canadians.

For decades, Canada has done little to demonstrate its commitment to protecting the physical and psychological health of miscarrying women. At a time when there is impetus to preserve reproductive rights globally, in Canada there must be an emphasis on patient-centred approaches to education, policies and models of care for the most frequent complication of early pregnancy.