The Report on maternal deaths in Australia, 1994–961 was released in September 2001. It is the eleventh in a series of triennial reports that detail maternal deaths in a case summary format. The principal aim of the Report is to improve the quality and safety of healthcare during pregnancy and the puerperium through the education of obstetric practitioners.

The Report defines a "maternal death" as the death of a woman while pregnant or within 42 days of the pregnancy being delivered or terminated, and classifies maternal deaths occurring in Australia into three categories:

• Direct deaths, resulting from obstetric complications of the pregnant state;

• Indirect deaths, resulting from pre-existing disease or disease that developed during pregnancy and was not due to obstetric causes, but which may have been aggravated by the physiological effects of pregnancy; and

• Incidental deaths, due to condition(s) occurring in pregnancy, in cases where the pregnancy is unlikely to have contributed significantly to the death.

The current Report documents the first rise in the maternal death ratio in Australia since the 1988–1990 triennium — a rise from 10.9 deaths per 100 000 confinements in 1991–1993 (total number of deaths, 84) to 13.0 deaths per 100 000 confinements in 1994–1996 (total number of deaths, 100). Of particular concern is the finding that the rise in the number of deaths was almost exclusively in the "direct deaths" category (see Box). However, as the rise was non-significant in a statistical sense, we will not know, until the next two triennial maternal death reviews are completed, whether this represents the beginning of a new trend or just a statistical fluctuation in very rare events.

Although a high proportion of the direct deaths (22/46 [48%]) involved the presence of avoidable or preventable factors, the lack of uniform assessment of avoidable factors across all States and Territories, and the absence of any single factor that could account for the rise in deaths, suggests the apparent increase in avoidable factors should be interpreted with caution.

The disparity between Indigenous and non-Indigenous maternal mortality rates has previously been observed2 and remains an issue of concern. The Indigenous maternal mortality rate did decline, from 41.4 to 34.8 deaths per 100 000 confinements, between the 1991–1993 and 1994–1996 reviews. However, changes in ascertainment of Indigenous status over the past nine triennia make it difficult to determine whether there has been a consistent decline, particularly among direct Indigenous maternal deaths.

A number of factors may have contributed to the increase in deaths in the most recent triennium. In other countries,3 improved ascertainment of maternal deaths through the use of multiple data sources, including vital statistics and hospital morbidity collections, has resulted in the identification of more deaths. However, in the latest Australian Report, only three of the 12 deaths identified using additional data sources were direct deaths. The changing risk profile of women becoming pregnant may account for some of the increase in deaths. Many women are delaying child-bearing,4 leading to an older cohort of women being pregnant and at increased risk of maternal death.5 Furthermore, with advances in technology an increasing number of women who previously were unable to have children because of infertility or complex medical problems are now having children. Also to be considered is the largely unevaluated impact on maternal death rates of the implementation of multiple models of delivery of obstetric care as well as the larger structural changes in healthcare delivery. Both require further investigation.

Despite recent publicity to the contrary, the rise in maternal deaths does not appear to be attributable to the increasing caesarean section rate. The proportion of maternal deaths associated with caesarean section has remained higher than the proportion of all caesarean births over the past four triennia. However, despite rising caesarean section rates (18.4% of all births in 1991–1993 and 19.4% in 1994–1996), maternal deaths associated with caesarean section, excluding those on recently dead or moribund women, fell from 29.8% of deaths in 1991–1993 to 24.0% in 1994–1996. There are no data causally relating the rising caesearan section rate with the increase in the number of maternal deaths.

With a small number of deaths from a range of very different causes, it is difficult to draw meaningful conclusions about the impact of the many factors purported to relate to maternal death in Australia. Furthermore, without the availability of the 1997–1999 and probably the 2000–2002 results, it cannot be determined whether the increase in deaths represents a new trend or merely an aberration.

Overall, the risk of maternal death during pregnancy and the puerperium remains small. Although differences in definition and collection procedures make international comparisons difficult, Australia appears to compare well with other developed countries, having a similar adjusted maternal mortality ratio to Canada, and a lower ratio than New Zealand, the United States and the United Kingdom.6 With improved general health status and family planning and increased access to general and specialised healthcare, maternal mortality declined considerably in the 20th century. Nevertheless, life-threatening complications still occur, often unpredictably and relatively more often among Indigenous women. It is therefore important that we closely monitor and review all maternal deaths and develop a surveillance system for severe maternal morbidity to ensure the health and safety of all women during pregnancy and the puerperium. The inclusion of pregnancy tick-boxes on Australian death certificates and the use of a standardised national maternal death reporting form should facilitate more accurate reporting of maternal deaths in the future.