Back

Spotlight 2/5

Follow-up on women’s health and obstetrical/gynecological care

Over the last two years, Patient Ombudsman has been monitoring trends in complaints related to obstetrical and gynecological care. These complaints include issues such as prenatal and postnatal care, pregnancy complications and miscarriages, sexual assaults, cancer care and delays in diagnosis, as well as poor communication and insensitivity when accessing care.

Illustration of two speech bubbles, each with different people inside them. Top: Pregnant woman looking down with one hand on her belly and the other over her face, with a medical professional touching her arm. Bottom: Mother holding and looking down at her baby with a smile.

In 2024/25, Patient Ombudsman identified 168 complaints related to obstetrical and gynecological care, a 29% increase from what we saw last year.

The majority of the complaints were about health care organizations within our jurisdiction (87%); the two sectors with the highest percentage were public hospitals (70%) and community surgical and diagnostic centres (15%). Similarly, we saw a small portion of non-jurisdictional complaints (13%), the majority of which were about primary care (7%) specialist care (2%) and other (4%).

Patient experience

A family doctor referred a patient to an ultrasound/imaging clinic for both an abdominal and pelvic ultrasound. Following the procedures, only the report for the abdominal ultrasound was sent to the family doctor. After both the family doctor and the patient followed up with the clinic, they were told that the patient had not undergone the pelvic portion of the exam.

After several weeks of additional follow-up, the ultrasound clinic found the pelvic ultrasound report and said it would provide it within a week. Two weeks later, the family doctor received the result, which noted nothing abnormal. Because of the inconsistent process and communication, the family doctor made a referral to another site to re-do the test, which ultimately found issues that required more testing.

What we did

The Early Resolution Specialist worked with the clinic to address the concerns within Patient Ombudsman’s mandate; concerns related to the competency of health care providers working in the clinic were referred to the appropriate regulatory colleges.

After reviewing the situation with Patient Ombudsman, the clinic changed how images are presented to the radiologist to ensure they reviewed all scans that had been requisitioned. In addition, the clinic offered an apology for the delay communicating results and made efforts to improve communication processes going forward. The clinic also ensured staff were trained in receiving, managing and escalating patients’ concerns.

Many complaints related to difficulties getting appropriate or timely care during pregnancy and birth. In some cases, patients left their local hospitals to travel to other hospitals further away in search of better care, including patients who left the emergency department for pregnancy complications because they felt they weren’t being heard, their concerns were minimized or not fully acknowledged. For some of these patients, this led to delays receiving care, misdiagnoses that resulted in further complications, or even pregnancy loss. Many complaints also raised concern about lack of adequate attention and support during and after childbirth, including being discharged prematurely or without follow-up care. These gaps in care highlight the need to improve patient-centred and trauma-informed care for patients who are pregnant and giving birth.

In addition to these challenges, many patients found it difficult to access diagnostic testing and reported excessive wait times for crucial tests such as ultrasounds and mammograms and having to navigate complex booking and referral processes. Many patients also faced delays getting test results, which played a role in them missing opportunities to treat their condition early and making their treatment more complicated in the end.

Recent research has highlighted that women’s health care experiences have been marked by a lack of empathy and, in some severe instances, have caused major health complications or severe emotional distress.¹ In addition to this, one survey of student doctors found only half of medical residents practiced trauma-informed care.²

Patient experience

The complainant gave birth by caesarean section at a large teaching hospital and experienced serious post-operative complications. The complainant reported that the resident physicians didn’t listen to her when she described the symptoms she was experiencing after the surgery and as a result didn’t recognize what was happening until further complications occurred. The complainant noted a lack of coordination between the care team and that she received conflicting messages and inconsistent information.

What we did

While Patient Ombudsman’s jurisdiction does not allow us to examine the conduct or competence of regulated health professionals, including medical residents, we were able to review the hospital’s process in responding to the complaint, and internal processes related to incidents involving quality of care and safety. In addition to speaking with both the complainant and the hospital’s Director of Patient Relations, the Early Resolution Specialist reviewed records provided by both.

The records indicated that a thorough review was carried out by the hospital that included the chief of obstetrics and gynecology. The review led to an organization-wide change to their procedures related to caesarean sections. The hospital now assigns a resident to serve as a point person to improve the coordination of care and communication for complex patients. The Early Resolution Specialist concluded that the hospital had responded appropriately after the incident, had shared the results of its review with the complainant and had made process improvements to reduce the likelihood of similar future events.

Through our resolution process, some health care organizations have provided additional training and education to staff, improved their appointment scheduling, and reduced wait times. We have also seen organizations embed trauma-informed approaches into their complaints process. The importance of trauma-informed approaches has been identified as a key way of providing patient-centred and compassionate care, and can improve outcomes for patients and their families if applied at an organizational level.³

Often complaints include concerns that fall outside of our jurisdiction. For example, if a patient has a complaint about a hospital experience that includes concerns about a doctor’s decision around care, we refer that part of the complaint to a regulatory college. For the remaining part of the complaint, we work to ensure a fair resolution for patients and their families.

References

¹ Diaz-Tello, F. (2016, June 01). Invisible wounds: obstetric violence in the United States. Reproductive Health Matters, 24(47), 56–64. https://doi.org/10.1016/j.rhm.2016.04.004
² Stokes, L., Burgess, A., & Burcher, P. (2025, April 30). Survey of OB/GYN Residents Knowledge and Practice of Trauma Informed Care. AJOB Empirical Bioethics, 1–7. https://doi.org/10.1080/23294515.2025.2497757
³ Grossman, S., Cooper, Z., Buxton, H., Hendrickson, S., Lewis-O’Connor, A., Stevens, J., Wong, L.Y., & Bonne, S. (2021, December 20). Trauma-informed care: recognizing and resisting re-traumatization in health care. Trauma Surgery & Acute Care Open, 6(1), e000815. https://doi.org/10.1136/tsaco-2021-000815