Confidential Enquiry into Maternal Deaths (CEMD)
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Confidential Enquiry: BACKGROUND
Confidential enquires into maternal deaths are intended primarily to assess the levels, causes of and contributors to maternal mortality and to learn lessons to address these. A key feature of the method is confidentiality, which is maintained at all levels keeping the women, health care providers and institutions anonymous at all times. Very often, confidential enquiries involve active surveillance of pregnancy-related or maternal deaths.
Confidential enquiries make extensive efforts to identify all maternal deaths. If confidential enquiries are ongoing, they provide useful information on maternal mortality trends.
The United Kingdom has the longest history of confidential enquiry into maternal deaths, dating back to the 1950s. National enquiries, either continuous or undertaken at regular intervals, and sub-national enquiries have also been carried out in Australia, some states in the USA, and in some European countries. Confidential enquiries have been started in parts of Suriname, Malaysia, Israel, Indonesia and South Africa by adapting the United Kingdom methodology. Time-limited enquiries have also been carried out in Jamaica, the Netherlands and Egypt.
Another tool which modifies the traditional CEMD approach is called TRACE (Tracing Adverse and Favourable Events in Pregnancy Care). Developed by Immpact, TRACE differs from CEMD by including cases of severe obstetric morbidity (“near misses”) as well as maternal deaths, by examining favourable as well as adverse factors associated with obstetric care (useful for preserving morale in low-resource health facilities), and by assessing community factors which may have contributed to a maternal death. For more information on TRACE please see the Additional Resources section of this page.
Identification of death
Generally not applicable (only potential pregnancy-related or maternal deaths are reviewed) but may also use a RAMOS approach.
Ascertainment of maternal/pregnancy related status
Varied, and sometimes multiple, sources used to identify and record all potential pregnancy-related deaths.
Existing records for confidential enquiry can include:
Maternal deaths are usually ascertained by medical professionals (with or without diagnostic aids and/or autopsy) or by verbal autopsy.
Advantages:
- provides additional data on quality of care associated with maternal deaths
- often has medical diagnoses of cause of death
Limitations:
- requires complete death reporting and good cause of death data
- if multiple sources are used, duplicate deaths need to be avoided
- can be complex and time consuming to undertake, especially on a large scale
- data on community level risk factors often missed when medical records relied on
- method is essentially an observational case series and risk factors can only be quantified when contrasted with an appropriate comparison group
Measurement requirements:
- duplicate deaths need to be excluded
- sub-causes of maternal deaths must be coded and classified as maternal deaths
- data on births are needed to calculate MMR
- data on population of women aged 15-49 are needed to calculate MMRate
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Confidential Enquiry: GUIDELINES
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Confidential Enquiry: REFERENCES
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D'Ambruoso L, Achadi E, Adisasmita A; Izati Y; Makowiecka K, Hussein J. (2007) Assessing quality of care provided by Indonesian village midwives with a confidential enquiry. Midwifery. In press. |
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Drife, J (2006) Fifty years of the Confidential Enquiry in Maternal Deaths. British Journal of Hospital Medicine, Vol. 67(3): 121-5. |
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Drife, J (1999) Maternal mortality: lessons from the confidential enquiry. Hospital Medicine. 60(3)3: 156-7. |
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Hussein, J (2007) Improving the use of confidential enquiries into maternal deaths in developing countries. Bulletin of the World Health Organization, 85(1): 68-9. |
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Schuitemaker N, van Roosmalen J, Dekker G, van Dongen P, van Geijn H, Gravenhorst J.B (1998) Confidential enquiry into maternal deaths in the Netherlands: 1983-1992. European Journal of Obstetrics & Gynecology and Reproductive Biology, 79(1): 57-62. |
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Salanave B, Bouvier-Colle M-H, Varnoux N, Alexander S, Macfarlane A, The MOMS Group (1999) Classification Differences and Maternal Mortality: a European study. Int J Epidemiol; 28: 64-9 |
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Confidential Enquiry: ADDITIONAL RESOURCES
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Ministry of Health. Evaluation of implementation of the confidential enquiries into maternal deaths in the improvement of maternal health services. Kuala Lumpur, Ministry of Health, 1998. |
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