Maternal risk beyond delivery and across populations

Two research articles in CMAJ examine gaps in how maternal risk is captured and how it varies across populations in Canada. One study shows that extending surveillance beyond delivery reveals a higher burden of severe maternal morbidity, particularly in the postpartum period. A second examines obstetric trauma, identifying differences across racial and immigration groups and pointing to structural and sociocultural factors that shape risk during delivery.

Dr. Giulia Muraca, an obstetrician-gynecologist at McMaster University and principal investigator on the first study, explains that extending surveillance beyond delivery increases estimated rates of severe maternal morbidity from 1.7% to 2.7%, representing nearly 10 000 affected pregnancies annually in Canada. Maya Rajasingham, a perinatal epidemiologist at McMaster and co-author, notes that 29% of these events occur postpartum, with sepsis emerging as a key contributor. Muraca adds that postpartum sepsis rates are substantially higher than previously reported, with most cases occurring in the first week after discharge. She also identifies acute appendicitis as the most frequent severe maternal morbidity in the antepartum period, a finding that remains underexplored in the Canadian literature. The findings suggest current surveillance windows underestimate the true burden of maternal morbidity.

In a second CMAJ study on obstetric trauma, Muraca again serves as principal investigator alongside Irina Oltean, a PhD candidate at McMaster and co-author. The study finds that obstetric trauma affects 5.5% of vaginal births, with substantial variation across racial groups. Oltean reports higher rates among Asian patients and lower rates among Black patients compared with White patients, even after adjusting for clinical factors. Among immigrants, risk declines with increasing time in Canada. The authors suggest this pattern reflects differences in communication, access to care, and familiarity with the health system rather than biological factors.

For clinicians, these studies suggest the need to expand the window of concern beyond delivery and to account for how social and structural factors shape risk across populations.

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Transcript

0:00

Dr. Blair Bigham I'm Blair Bigham. Dr. Mojola Omole I'm Mojola Omole. This is the CMAJ podcast. Dr. Blair Bigham Jola, we are talking about a very specific population of people today, one that is top of mind and maybe a little bit scary for clinicians because nobody ever wants anything to go wrong when you're taking care of someone who is labouring. Dr. Mojola Omole So this episode pairs two connecting studies, both out of Ontario, but looking at the gaps in how we understand care of pregnant people in Canada. The first one looks at the severe maternal morbidity, life-threatening complications of pregnancy and asks whether, have we been measuring it correctly? Because we do have low mortality when it comes to birthing people in Canada. Dr. Blair Bigham But morbidity is a bit different. And they've actually pushed that all the way out to six weeks postpartum. And they found some pretty interesting stuff. Dr. Mojola Omole That to me was actually made it really interesting of what you then capture when you push it out to six weeks. Dr. Blair Bigham Yeah, because like, I never remember that people don't actually see their obstetrician until six weeks after they deliver. And in the middle, it's up to family docs, emerg docs, like everybody else to kind of pick up on these complications. Super relevant. Dr. Mojola Omole And I also think that we think of the fourth trimester. No one really talks about the fourth trimester because... I've never heard of the fourth trimester. But here's the thing. And I think part of that is the sexism that lives in birthing is that once there's no longer a baby, well, you know, off to the side, whatever problems you have is not a big deal. But the fourth trimester is actually when they're picking up some of these morbidities. Dr. Blair Bigham We're also going to take a look at a second study that looks at the risk of obstetric trauma during childbirth itself and has found some interesting data on race and immigration status and how that contributes to the risk. So let's get into it and chat with the authors.

​Dr. Blair Bigham: 0:20

Dr. Giulia Muraca and Maya Rajasingham are the coauthors of the study on severe maternal morbidity. Dr. Muraca is an associate professor of obstetrics and gynecology at McMaster University and principal investigator of the Muraca Perinatal Epidemiology Research Lab. Maya Rajasingham is a perinatal epidemiologist and research coordinator for the SERENE Project, also at McMaster. Giulia, Maya, thank you so much for joining us.

Dr. Giulia Muraca: 0:23

Thank you for having us.

Maya Rajasingham: 0:25

Thank you.

Dr. Blair Bigham: 0:27

Let's set the stage here. What exactly is severe maternal morbidity?

Maya Rajasingham: 0:29

So severe maternal morbidity, or SMM, is a composite of pregnancy-related complications that can occur at any point from conception all the way up until six weeks postpartum. So some examples that I can list for you are things like severe hemorrhage or sepsis, and these conditions have been selected to be a part of our SMM composite because of the fact that they're associated with things like prolonged hospital stays, long-term disability, or death. The reason why SMM is of interest to researchers is because of the rarity of maternal death, which up until recently has been used as the traditional surveillance metric for maternal care in Canada or maternal health. So with the fact that it is rare in places like Canada, we've switched over to severe maternal morbidity as our alternative metric to monitor maternity care.

Dr. Blair Bigham: 0:32

Got it. When I think about maternal morbidity, I think about things that happen in the hours or maybe days after delivery. How do you track something that happens two weeks, four weeks, six weeks later? I assume most of these women have been discharged home. How do you know if they end up somewhere else for care?

Dr. Giulia Muraca: 0:35

So your question is a really good one, which is how do we do this in the period of time that doesn't involve that birth episode or that, you know, that labour and birth encounter? And so what we do is we just expand or we broaden our ascertainment window to look at what admissions and because we accessed administrative data through ICS, we could also look at outpatient records and we can look at emergency department records to see whether we have any diagnoses or any procedure codes that relate to these complications during that window. And so it's very easy to just expand that window and say, OK, if we look not just during that labour and delivery episode, but also, for example, in our analysis, we looked in that six weeks postpartum and we can say, OK, now during these six weeks, how many people experience these severe complications?

Dr. Blair Bigham: 0:37

So you're looking at events that happen across the health care system, not just people who bounce back to a hospital. And when you look at that huge sort of data set and you expand your window up to six weeks, what did you see? Maya, how about you take that one?

Maya Rajasingham: 0:39

So previously, I guess one thing that we haven't said is previous estimates of SMM are approximately 1.7 percent. In our study, when we looked at the entire period at risk, we found the rate of SMM to be 2.7 percent. And then we found of those events, 16 percent of those occurred during pregnancy, 55 percent in that labour and delivery event, and then 29 percent occurred postpartum.

Dr. Blair Bigham: 0:41

So was this revelatory, this like 29 percent bit?

Maya Rajasingham: 0:43

For the postpartum period? Yeah, I think definitely because if we were only looking at those intrapartum events that previous studies have been finding, we would have missed that window corresponding to the 29 percent of events occurring postpartum, as well as the 16 percent of events that were occurring antepartum.

Dr. Giulia Muraca: 0:45

Sometimes it's difficult to conceive of what's the big deal. We're looking at a difference between 2.7 percent and 1.7 percent. So we're already, we're looking at a minority of pregnancies, and that's true. We're not saying that maternity care is failing. Of course, the large majority of pregnancies are safe, and we don't want people to think that pregnancy is unsafe in Canada. Our maternity care is very strong. But when we look at the difference between like 3 percent of pregnancies or nearly 3 percent of pregnancies being affected by these complications, that translates to nearly 10,000 people in Canada each year. And identifying each of these cases is really important because these events can be life threatening. And if we catch them, then we have an opportunity to prevent them.

Dr. Blair Bigham: 0:49

When I was a resident, one of my favourite attendings just before I graduated said, bluntly, he's like, I'll sign off on you becoming an attending as long as you promise me one thing, and that's that no one will ever die from a complication of pregnancy under your care. So I totally resonate with that. I'm also very interested in sepsis as an ICU doctor, as an emergency doctor. So maybe we can talk about sepsis specifically for a minute. What did the numbers look like in terms of women presenting in the first six weeks postpartum with sepsis?

Dr. Giulia Muraca: 0:52

I'm so glad that you mentioned talking about sepsis in that way. You want to kind of do a deep dive because it was certainly one of the most important findings of this project. So our previous estimates of obstetric sepsis were about one per thousand. And so now when we extend this period into just those six weeks postpartum, we're seeing rates six times that. So we see six per thousand when we add that postpartum period. And most of these cases are occurring in that first week following delivery.

Dr. Blair Bigham: 0:55

And so after they go home, is this something that family doctors and midwives and emergency doctors should specifically raise their level of alert over?

Dr. Giulia Muraca: 0:57

100 percent. So what we see is they're discharged, and this is within that first week. Many of these cases are coming back. So Maya already mentioned 29 percent of all SMM cases occurring in the postpartum. Half of those are sepsis. And when I say what we thought before was one per thousand, and now we're seeing it's actually six per thousand. It's over 85 percent of cases of sepsis that we were not capturing in our surveillance and we were not accounting for. And of course, you know, why your supervisor said this to you and why sepsis is something that is on the forefront of your mind is because we know sepsis is preventable. And we see these tragic cases like we did in Ontario just a few months ago of these young people dying of something like obstetric sepsis. When we know if we could instill those protocols for the maternal early warning signs and we had, we could convey the need for that very high index of suspicion, then we wouldn't have to deal with these tragedies.

Dr. Blair Bigham: 1:02

You found something else in your data set along with this really interesting incidence of sepsis. You also found a fair amount of appendicitis.

Dr. Giulia Muraca: 1:04

This is incredibly surprising. And this is something we haven't seen written about in the literature very much at all. Even in general, there's not a ton out there, especially in the Canadian context about acute appendicitis in pregnancy. And so even when we're looking at how often does this occur, we're not really sure how often this occurs. And so, yes, we did find in that antepartum period that acute appendicitis was the most frequent severe maternal morbidity we observed. But we have to be careful about that because, as I say, we don't know much about it. We don't really know, is this happening at the same rate as it's happening in the non-pregnant population? This is a study that Maya and our colleagues at our lab are looking at right now to understand, is this something that's occurring more frequently? Or is this just something that because these acute appendicitis cases are happening among pregnant people, we're seeing longer lengths of stay or we're seeing more perforations? Maybe it's just because acute appendicitis is more complex in a pregnant person. Certainly, as pregnancy advances, you can imagine how much more difficult it would be to use all the modalities we have to detect and to treat acute appendicitis.

Dr. Blair Bigham: 1:09

In pregnancy, it's something that emergency doctors are always focused on. The textbook tells us to get an MRI to diagnose it, but that's almost always unfeasible.

Dr. Giulia Muraca: 1:11

Correct. And so imagine all the ways that we have, the imaging that we're supposed to use, even knowing, is this person presenting with a higher white count? Well, people in pregnancy have higher white counts in general. So all of our metrics for saying, all right, this person is certainly going to be diagnosed with acute appendicitis, they just take longer. They're just a bit more complex. And again, just like sepsis, we know with acute appendicitis, these are one of the conditions where timing matters a great deal. And so we're trying to better understand what those high rates of acute appendicitis antepartum mean, whether this is happening in pregnant people more often, whether outcomes are different, and if they are, why?

Dr. Blair Bigham: 1:15

I could talk to you about this all day, but we got to keep going on our line here because there's so much interesting stuff on this topic, and we're about to bring in another guest on another paper. But before we do that, I just want to ask, in your study, did you find any data about abuse towards women in the postpartum period, any intimate partner violence?

Maya Rajasingham: 1:17

One thing that we did look at was experience of assault in the two years prior to pregnancy. But we did measure this in a very specific way. So this wasn't something that was based off of self-reports. We looked at if there was a hospital or an emergency department visit or someone presented, and there was a suspicion of assault. So we did look at it in a very particular manner, and we did find that this was one characteristic that was associated with SMM in all three of our periods. So in the pregnancy period, during labour and delivery, as well as postpartum.

Dr. Giulia Muraca: 1:20

I have something to add here, Blair, and it's too important for me to not include, which is that obviously one of the things we really learned in this paper was that looking at the postpartum is life-saving, it's critical, and that maternity care doesn't begin and end in the delivery room. And one of the things we're learning is that the postpartum period is often where both physical and mental health needs become visible. So making sure people have access to that follow-up care and support during that time, we know is important, but this underscores very, very important. And one of the things that makes this project and this paper really special is that this work was done in partnership with people who've experienced these pregnancy complications themselves, and their insights helped shape the research questions, they helped interpret the findings, and how we really think about solutions. The work is much stronger in our view because of this partnership. And so we're doing a lot of qualitative research where we're trying to understand the experience of people who have these complications, who've survived these complications, and their interactions with the healthcare system, so that we can best support them, their care providers, and their partners. And their care providers is really important because we're interested in studying things like moral injury and trauma among the people who provide care for people who experience these events.

Dr. Blair Bigham: 1:24

Absolutely. Giulia, thank you for that. And Maya, congratulations on this very enlightening research. That's being published. I'm definitely going to keep an eye out for sepsis. I'm going to keep an eye out for now appendicitis. And certainly abuse far beyond sort of what I might typically think of as that period of vulnerability. Now, Giulia, let's change focus here because you're also principal investigator on a second study, one that looks at obstetric trauma, which is looking at injuries that women face during the birthing process itself, different from maternal morbidity that we've just spoken about. So let me bring in Irina Oltean. She's a PhD candidate with you, Giulia, the Perinatal Epidemiology Research Lab at McMaster, and co-author on this next study, which was also striking. So let's jump into this second conversation. Irina, when you look at obstetric trauma that people face during birthing, what did you find?

Irina Oltean: 1:29

So first of all, I just want to set the stage and define obstetric trauma and how we defined it in our study.

Dr. Blair Bigham: 1:31

Sure, yeah, that would be great.

Irina Oltean: 1:33

Using the Canadian Institutes for Health Information definition. But so briefly, obstetric trauma is a severe injury to the perineum, cervix, or vagina during childbirth, including the surrounding pelvic structures, including pelvic joints or lacerations to ligaments of the uterus and other pelvic injuries such as pelvic hematoma. And what is really striking about this study is, first of all, we found that the rate of obstetric trauma is 5.5%, which corresponds to what we expect a reasonable range to be between 4% to 6%, which is very common obstetric condition. And what this translates to roughly is around 1 in 20 of all vaginal births experience obstetric trauma on average. And in light of that, we found that these rates actually vary substantially by people of different races, so much so that the rate of obstetric trauma was 7.5% in Asian parents and lower in Black parents at 3.3% compared with White parents at 5%. And so once we adjust for very important factors, including biological factors, obstetric and infant-related factors such as infant birth weight, mode of birth, episiotomy, labour induction, augmentation, we see that these rates continue to be high among Asian parents. So the rate is 1.5-fold higher in Asian parents compared with White parents, with 14% lower risk of obstetric trauma in Black parents compared with White parents.

Dr. Blair Bigham: 1:36

All of that was incredible background and like very top-level information for our listeners.

Irina Oltean: 1:38

Thank you.

Dr. Blair Bigham: 1:40

I want to ask about a really interesting finding that you had when you were looking at those racial disparities, and that was that the increased risk actually was augmented by how long they had been living in Canada. Tell me a little bit about what you found with that.

Irina Oltean: 1:42

Yeah, so that's a very interesting finding. I was shocked by that because I myself am a Romanian immigrant, so I'm very interested in this socio-demographic lens that we applied. So what we found actually is contrary to what you expect. So every year that an immigrant resides in Canada, they actually experience a decline in the rate of obstetric trauma. So specifically, we see quite a difference among Asian immigrants. So with every year that they spend in Canada, there is a relative 2% decrease in their rate of obstetric trauma. The reason why I say this is contrary to what we expect in doing some research behind this is we thought about how the healthy immigrant effect theory applies to this, and that basically suggests that immigrant health can be — they have a protective effect in health outcomes initially upon arrival in Canada, but that isn't sustained with increasing time in Canada. So what we see is actually contrary to that. We're seeing that their risk declines with increasing time in Canada, regardless of whether you're an Asian, Black, or another kind of immigrant.

Dr. Blair Bigham: 1:46

So across races, the longer any immigrant is in Canada, their risk becomes more towards the average and is less of an outlier. Is that fair to say?

Irina Oltean: 1:48

Yeah, and I agree with that. And actually, you do see, right, like if you look at the figure, Asian immigrants, when they — upon arrival in Canada — have a rate of obstetric trauma around 10 to 11%, and once they've been in Canada for about 35 years, that rate drops to around 5%, and that starts to look like what you see among white immigrants when they arrive in Canada.

Dr. Blair Bigham: 1:50

So they go from double the rate to the mean rate, but it takes 30, 35 years to achieve that. Giulia, what's behind that? What's the hypothesis here?

Dr. Giulia Muraca: 1:52

So what this could mean is fragmentation in prenatal care that we could conceive of happening in newcomers to Canada. Things like language barriers that could obviously be attenuated the longer you live in Canada, better understanding of the healthcare system, having better social nets that would allow you to understand that you can — I think there's a lot that could be culturally motivated here where you would potentially not have as much agency or understand your autonomy in our Canadian healthcare system. One of the things that we did in this project was we explored the role of language, and this was telling because when we did look at the language of people among Asian countries, we did see that people who spoke South Asian languages were the people with the highest rates of these injuries among people who identified as Asian, and we also saw some patterns in other immigrant groups. But when you start seeing that these increases in rates aren't distributed equally, it makes you think about things like language because imagine you're in the delivery room. Not understanding an instruction from a care provider to push or to not push can be a big difference in the way the outcome of birth might be with respect to a perineal tear. If you're going to have any tear versus a second-degree tear versus a fourth-degree tear, these could have implications. So the answer to your question is, what does this mean? We're not sure. What this means is that there's certainly heterogeneity in these racial groups that have been previously studied in kind of a one-dimensional way, and that we're seeing that these risks are highest among newcomers, and we have to do a better job of understanding what the barriers are to accessing the same equitable care that nonimmigrants and longer-term immigrants are accessing here.

Dr. Blair Bigham: 1:56

Interesting. So your impression here in terms of credible explanations is that it's less about an anatomic or genetic or biologic variant and more around sociocultural realities that people face.

Dr. Giulia Muraca: 1:58

That's much more consistent with what we understand when we look at racial differences in any health outcome. So all of the hypotheses that hinge on biological differences are extremely weak. And we know that immigration status and immigration factors influence things like access to prenatal care, communications with providers, experiences of discrimination, and just differences in outcomes because of varying and mistrust in the healthcare system. So these factors can affect many different things in the labour and delivery room and many different decisions and many different kind of dynamics between patient and provider. Those are much more legitimate and plausible mechanisms to our group than any of the biological mechanisms that have been purported.

Dr. Blair Bigham: 2:01

Is there anything specific that you want to highlight from your results that go into a more discrete racial category? You had mentioned Asian and Black patients. Those are both pretty large categories. Is there anything top-level from your research that you think our listeners need to know about?

Dr. Giulia Muraca: 2:04

The first thing that I want to say, just to speak exactly what you raise about something discretely relevant to one racial group. So all of the previous research in westernized countries that look at these differences and look at differences between Black and white birthing people, there's a quite consistent finding that we see lower rates among Black individuals. And what this project really brings to light is that we cannot paint all of these individuals in one racial group with one brush. Now this seems very intuitive and of course many people and all the listeners will be saying, of course we wouldn't, but we do. We do expect when you, anyone who studied obstetric trauma knows that the literature says lower rates among Black individuals. But we see in our results that that is not true across the board. We see higher rates in Black individuals who are refugees and who are economic immigrants and lower rates among family immigrants and other type immigrants. So these things are not the same. There are a lot of different communities. There's a lot of different intersectional effects at play here. And it's really important not to assume that the risk for obstetric trauma is lower among a Black individual without understanding some of these other things. The second thing that I want to raise, which Irina explained what obstetric trauma was earlier, and she explained that the rate we found was 5.5%. And this is consistent with what we know about obstetric trauma, 4 to 6% of all vaginal deliveries is the usual kind of quote. But this is extremely common, OK. When we're talking about, these are severe events. And they're happening 5% of the time, let's say, among vaginal births. I really want listeners to remember how important it is that we recognize that these traumas have short-term, of course, but long-term effects on people's quality of lives. So when we think about using instruments that perhaps will increase our risk of obstetric trauma, or when we think about whether we have time to talk about consent when engaging in labour and delivery interventions that might increase the risk for obstetric trauma, it's incredibly important to remember that these are people who, for the rest of their lives, feel isolated and helpless and sexless and can't leave the house without a Ziploc bag with three changes of underwear, whose relationships fall apart, who can sometimes never have sex again. These are people who are marathon runners and are never able to run again, who can't feel connections with their babies. So the number one thing with this project and all of our projects on obstetric trauma is for us to remember that even though they happen often, and even though they happen in deliveries that don't involve surgeries, these are very severe outcomes that can affect people's long-term quality of life in ways that, in the delivery room, we could never conceive of.

Dr. Blair Bigham: 2:11

There's obviously a high prerogative to unpack this further. I wish we had more time. But what I can say is that this is remarkably enlightening, both from my frontline perspective and also just from the moral prerogative to deliver better and more equitable care. I want to thank all three of you for joining us today.

Dr. Giulia Muraca: 2:14

Thank you, Blair. Thanks for having us. Thanks for having us.

Dr. Blair Bigham: 2:16

Maya Rajasingham is a perinatal epidemiologist and research coordinator for the SERENE project at McMaster University. Irina Oltean is a PhD candidate at the Perinatal Epidemiology Research Lab, also at McMaster. Both are supervised by Dr. Giulia Muraca, an associate professor of obstetrics and gynecology at McMaster. Dr. Mojola Omole So, Blair, I'm going to start off as I'm a birthing person and I've birthed before. Dr. Blair Bigham You have birthed a baby before. Dr. Mojola Omole I have birthed. I am a birthing human. So for me, I think the two things that stood out are like, you know, my wheelhouse, appendicitis and sepsis. And for me, the sepsis one was mind-blowing that that far out you can have sepsis related to childbirth. Dr. Blair Bigham Yeah. Two weeks, three weeks, four weeks, up to six weeks. But well after you've left the hospital. And it just makes me wonder, like, what have I missed? Like, what am I not surveilling for when people come in? I would think, I don't know, I would think that postpartum people would come in early, right? You just had a baby. You're probably extra worried about your health, but maybe not. Dr. Mojola Omole Maybe they're busy taking care of their baby. Everything is awful in the postpartum. You got, like, I didn't even know you were supposed to have night sweats. I thought I had cancer. It was just night sweats from all the fluid retention. Like, everything is hurting. There are parts of you that are leaking that you didn't know could leak before. So, you know. So you kind of just think maybe some of these signs are normal. And then, like, you know, signs of sepsis are augmented also in the pregnant person and also postpartum. So, you know, you're tired. That fits in with everything that's happening to you. But I do think from the clinical perspective of being able to pick that up and maybe also just having better information for people who birth of, like, you know, what to look out for. We don't necessarily do enough in terms of that teaching of, like, you know, like I for me, I was very super cautious about having a PE. But maybe there are other things that we can also alert people about. Dr. Blair Bigham Yeah, I think this was very high yield for, like, hot tips for being on service and what to watch out for when someone comes in and says, by the way, four weeks ago. So I found this really, really helpful. Dr. Mojola Omole And for me, the last one was just the paradox, you know, regarding Black patients, which is in terms of obstetric trauma and how that differs from what we've seen in terms of maternal morbidity and mortality being higher in Black patients. I think my head when I was, you know, when I was listening and thinking about it is, well, could this be related to more of the mortality and morbidity due to systemic factors? So we're talking about preeclampsia, sepsis could be also, you know, within that, you know, PEs and all of those other things versus just because this was looking at obstetrics trauma itself. So maybe that's where that lies and where we see the difference. But I'm quite fascinated and being able to have more studies to see how we can, how both of those fit in together. Dr. Blair Bigham It's very interesting. And then regardless of the race, the immigrant status of somebody and the theory that it's a language barrier, an inability to follow or understand the instructions associated with labour might be contributing that, that seems like a pretty easy fix. But I wonder if there's more to it. Like, I think there is. Dr. Mojola Omole I don't know. Dr. Blair Bigham I think when somebody yells push, you might not need to speak English to know what they're talking about. Dr. Mojola Omole But there's nuances because it's not just pushing. You actually have to learn how to push correctly. Dr. Blair Bigham Yeah, no, totally, totally. You're right. I don't mean to oversimplify it. Dr. Mojola Omole Well, of course, you're a man. I'm just joking. But, you know, one of a colleague of mine that I worked with, she actually works at Toronto East in Toronto, Michael Garron Hospital. And this is something that actually is quite fascinating that she works on is just that language barrier and how it affects people during birthing. And I do think that it's just, it is a very chaotic, fast-paced environment. And, you know, not fully being able to interpret, especially if you're translating something in your head from English to your native language and then going back to answer it in English, things do get lost in translation. And I do think like in moments of high stress, we all revert to what's most comfortable to us. And maybe that makes it more challenging in terms of that. So being able to have more concordant care in terms of language, whether it's to have an interpreter, you know, or just being able to have that for people, I think will be very important because that does also explain part of that obstetric trauma that was happening. Dr. Blair Bigham Absolutely. I love how we've been able to have something so proximal to the obstetric trauma in the one study and then also look at the complications coming down the road in the other study. Really, really important information. Dr. Mojola Omole And I also think it's just important, though, that we're finally studying this, right? Often obstetrics and gynecology is wholly underfunded and understudied. So being able to actually have these brilliant people focus on it, to me, is also just the win. Dr. Blair Bigham Yeah. Kudos to Giuliana and her team, as well as the entire program that she runs there at McMaster. Great stuff. That's it for this episode of the CMAJ podcast. The links to both studies are going to be in our show notes. Please do us a favour and follow or subscribe wherever you get your podcasts. It really helps us spread the message. Or share, rate, review the podcast. Anything that affects the algorithm goes a long way. The podcast is produced for CMAJ by Neil Morrison at PodCraft Productions. Catherine Varner is deputy editor at CMAJ and our senior editor for the podcast. I'm Blair Bigham. Dr. Mojola Omole I'm Mojola Omole. Until next time, be well.