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Int J Gynaecol Obstet. 1989 Sep;30(1):41-5.

The role of confidential enquiries in the reduction of maternal mortality and alternatives to this approach.

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  • 1Division of Family Health, World Health Organization, Geneva Switzerland.


The aim of confidential enquiries into maternal deaths is to identify weaknesses in the maternal health care system with a view to remedying them. The method of confidential enquiry is explained using the British system as an example. The reasons why this apparently useful practice is not more widely adopted can in some countries include fears of litigation or lack of trust in confidentiality. Alternative approaches to maternal death audit are discussed.


The main objective of confidential inquires into maternal deaths that happen over a period of time is to show weaknesses of the maternal health care system. The best known system has been the one in England and Wales. Started in 1952, 10 triennial reports have been issued. The most recent of these is for 1979-81. 3 central assessors are appointed by the Department of Health and Social Security (DHSS) not only in obstetrics, but also in anesthesia and pathology. These have counterparts in the 15 health regions of the country. The District Medical Officer starts the inquiry by sending a questionnaire to all those who were concerned with the woman's care. When these persons have completed the forms, they are sent to the regional obstetric assessor, who involves the assessors in anesthesia and pathology when appropriate. These are then sent to the DHSS assessors who review all the facts and make the final analysis of the factors that led to the death. Strict confidentiality is observed. These inquiries are also made in countries other than the United Kingdom. More countries are not doing these inquiries because of 1) a loss of interest in maternal mortality as it becomes "rare;" and 2) a lack of confidence in confidentiality. An alternative approach to confidential inquiry into maternal mortality is peer review, or a maternal death audit. If done properly it can improve teaching and clinical management. However, 2 characteristics detract from its usefulness: 1) important elements of a patient's history will often be missing; 2) it can't be expected to exert much good influence except indirectly through improved teaching. Another alternative is a form of research in which an attempt is made to identify all maternal deaths by examining the cause of all deaths of women of reproductive age, discarding those not maternal, and further studying the maternal deaths. These community level studies can be expensive. Another approach directly examines the system itself. The aim is to discover to what extent the services meet the needs in maternal health care of the population and whether the norms and standards laid down are complied with; in other words, to compare what actually exists with what is supposed to exist. An important part of this kind of evaluation is to explore the perspective of the consumers themselves.

[PubMed - indexed for MEDLINE]
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