Why this Unity Health researcher says pregnancy is a ‘crystal ball’ for future health

In a developed country with universal healthcare, why is the maternal mortality rate increasing? The Society of Obstetricians and Gynecologists of Canada cites that since the 1990s, the country’s maternal mortality rate has increased from 5.1 to 11.9 per 100,000 live births.

Dr. Joel Ray is an Obstetrical Medicine Internist at St. Michael’s Hospital and a Scientist at the Li Ka Shing Knowledge Institute and SickKids Research Institute. Ray has published over 375 studies and won numerous grants to investigate maternal health outcomes and maternal mortality. His research career is focused on understanding the factors that contribute to negative maternal and newborn health outcomes, and disseminating evidence to prevent the untimely deaths of parents and newborns.

We spoke with Ray about his latest research, why he’s passionate about studying maternal health outcomes and mortality, and why he says pregnancy can be a ‘crystal ball’ that tells us about a woman’s future health trajectory.

You recently published a paper in Heart that explored the association between women with a history of preeclampsia, a condition that causes elevated blood pressure during pregnancy, and the severity of future coronary artery disease. The study is unique in that it used data from invasive coronary angiographies, a diagnostic tool that uses a catheter to see restrictions of blood flow to the heart. Why was this important to investigate?

We know there’s a fair number of studies that have shown some women who have preeclampsia have early-onset heart disease. Either the heart muscle starts to fail, or the woman develops symptoms of angina chest pain from poor flow through the heart’s arteries. In the context of those prior studies, we only really know that they developed angina chest pain, or had a heart attack or heart failure. We haven’t had a detailed objective assessment of the degree of obstruction or narrowing of those coronary arteries – and that led to this study, which is the first of its kind to detail the nature of obstructive coronary artery disease.

The study showed that prior preeclampsia was associated with a doubling of the risk of obstructive coronary artery stenosis, and a near tripling of that risk following preeclampsia with preterm birth or stillbirth. How might these findings affect medical practice or policy?

Luckily, there is growing awareness of what happens in a woman’s pregnancy as a predictor of that woman’s future health within the next one to two decades – essentially, before her child even reaches age 10 or 20 years. Pregnancy can be seen as a crystal ball, and while the cliché is that pregnancy can be seen as the ‘canary in the coal mine’, it can offer a forecasting of her future health trajectory as it relates to cardio-metabolic health.

Taking advantage of that crystal ball approach, and altering not only what happens in the pregnancy, but also what happens within months after the pregnancy, could help a woman to avert a harmful trajectory of negative health decline, and instead, could enable the improvement in her health state, to offset future health risks.

A lot of interventions for cardiovascular risk reduction and prevention can get very expensive if they’re medication-focused. In truth, lifestyle modification – particularly weight reduction over time, not suddenly, but gradually – remains one of the hallmarks of long-term risk reduction, for anyone at whatever age. If blood pressure, blood sugar or lipid values do not come under control, then there exist relatively inexpensive medications to help control each.

You have investigated gestational diabetes as well as preeclampsia and a heightened risk of premature cardiovascular disease. You recently received a CIHR grant to explore pre-pregnancy diabetes and adverse outcomes, as well as autism spectrum disorder and high blood sugar during pregnancy. Why is pregnancy and maternal health outcomes an area of interest for you?

I’ve always been a serious advocate for the healthy outcome of a woman in pregnancy, and the same for child, both in the womb and after birth. I see it as a sort of a very holy unity that they share – so both have to have a healthy outcome. I’ve always had a love for obstetrics and pediatrics, not just adult medicine, and that enabled me to create that interest and passion, and work with great people in those fields.

We can use the fetus to look at the health of the mom, and the mom to look at the health of the fetus. Not only do things matter in the bond they hold during the pregnancy – when the baby is inside the mother – but also, it’s a symbiosis that has to be considered after the birth is complete. It’s the idea of taking the pregnancy and expanding it beyond the pregnancy itself. Even after birth, the memory of pregnancy is still materially relevant to health of mother and child, to a degree.

An international report by the World Health Organization (WHO), UNICEF and others estimates Canada’s maternal mortality rate to be up to 60 per cent higher than what is reported by StatsCan. What is your reaction to that?

We probably are undercounting maternal deaths to a degree. Maternal deaths that happen after birth outside of hospital may not be reported as having been related to a pregnancy that could have ended 60 or 90 days earlier. A good proportion of maternal deaths occur outside hospital, some of them from preventable things like overdose or self-harm, for example.

As some maternal deaths may occur outside of hospital, and not connected to a pregnancy, they can be missed. I’m not sure it’s up to 60 per cent off the mark, but there’s probably some clear-cut disconnect. People conceptualize a maternal death as occurring in pregnancy, around time of birth, or soon after birth, but they are rarely connected to a miscarriage or induced abortion, so those pregnancy deaths may be missed as well.

Interest in how women die and why they die prematurely, especially in and around pregnancy, remains strong, since it’s such a catastrophic and untimely event. While much of my collaborative work is about the health of women and their babies, I also focus on the health of young adults and adolescents who are failing to meet their health needs and life goals. When a 95-year-old person dies, we say ‘it’s sad, but they lived a long, good life.’ When a 34-year-old person dies, you can only say that it’s not only tragic, but also almost always preventable. That too is the spirit of what drives my work, and I think that premature death in the adolescent and young adult is both unrealized or not talked enough about, so it sits under the radar.

By Jennifer Stranges

This interview has been edited and condensed.