Initiated in 1952, the British Confidential Enquiries into Maternal Deaths have been setting the standard for other such endeavours for nearly half a century.1 The triennial reports of these inquiries make compelling reading, and the latest report, the second to combine the whole of the United Kingdom, is no exception.2 While the intricacies of defining and measuring maternal mortality and, more importantly, of drawing valid inferences are well recognised,3 there are several causes for concern.

Firstly, the inquiry found evidence of substandard care in half (49%) of the 238 maternal deaths in the 1988-90 triennium, irrespective of whether they were direct (due to obstetric complications of or interventions during pregnancy) or indirect (due to unrelated disease aggravated by the physiological effects of pregnancy). Hypertensive disorders were the leading cause of death, accounting for 18.6% of direct maternal deaths. Yet, substandard care was identified in 88% of these cases. Following closely, each accounting for 15% to 17% of direct maternal deaths, are pulmonary embolism; deaths in early …