Maternal Mortality Secondary to Maternal Sepsis in Ontario: A Call-to-Action.

Maternal sepsis remains a leading and rising cause of preventable maternal mortality in Ontario and globally. The Maternal and Perinatal Death Review Committee (MPDRC) investigates maternal deaths and issues recommendations; however, it remains unclear if these have been widely adopted. This review analyzes maternal deaths due to sepsis in Ontario from 2019 to 2022, as assessed by the Obstetric and Perinatal Death Review Committee, to identify recurring clinical themes and consolidate recommendations. Maternal sepsis cases were reviewed to extract common clinical features, pathogens, systemic barriers, and population-specific vulnerabilities. Themes were synthesized to inform revised clinical and policy recommendations. Key findings included delayed recognition of atypical sepsis presentations, frequent involvement of Group A Streptococcus, and systemic delays in multidisciplinary involvement. Vulnerable populations-such as patients with substance use disorders and those in remote areas-faced disproportionate risk due to biological, social, and structural factors. Ongoing review of maternal mortality cases is essential to improving clinical care administration and to inform policies. This review found that existing early warning systems were inconsistently applied, and accountability for MPDRC recommendations remains limited.