From 1994 to 1996 the Enquiries had a psychiatric assessor, Prof. Channi Kumar, followed by Dr Margaret Oates. Regional assessors followed in 2006-8. The importance of psychiatric illness was recognised by WHO in 2012 when suicide was categorised as Direct death. Suicide and substance abuse are the main causes. Most deaths are Late (> 42 days after birth) and under-reporting is a problem. All social classes are at risk of suicide but social deprivation increases the risk of death from substance misuse. Screening for mental health disorder is now standard practice at booking. Good communication between primary care and maternity services is essential. Red flag indicators of risk should lead to review by a senior clinician and possible referral to a mother and baby unit. Risk factors include failure to restart medication after pregnancy. Each area should have a clinician responsible for the perinatal mental health service. The 2009-13 Report recommended regional networks to coordinate care. Rapid referral may be needed and the 2017-19 Report identified a lack of clear pathways into care. Management of substance misuse needs integrated multidisciplinary specialist services.

In the eighteenth century medical schools and hospitals first appeared in Britain, and so did man-midwives. One of them, William Smellie, was later called 'the father of British midwifery'. In the nineteenth century the medical profession became organised, anaesthesia was discovered and the germ theory of infection was proved. The Obstetrical Society of London was formed in 1858. Midwives, however, were seen as incompetent 'Sarah Gamps'. This changed in 1902 when the Midwives Act transformed midwifery from a craft into a profession, after a long campaign led by a nurse, Zepherina Smith, and a doctor, Sir Francis Champneys, who became chairman of the Central Midwives Board. In the twentieth century the Ministry of Health was established and maternity homes were created. In 1929 the British College of Obstetrics and Gynaecologists was formed but most births took place at home, where a GP would be called if complications occurred. All this time the maternal mortality rate did not change. From 1830 until 1930 one mother died in every 250 births. What did change was the public mood, and demand for action steadily grew.

The contagiousness of childbed fever was first recognised by Alexander Gordon in Aberdeen in 1795. Epidemics occurred in cities, rural communities and lying-in hospitals. In the USA Oliver Wendell Holmes caused uproar by saying doctors were carriers of disease. In 1848 Semmelweis reduced the death rate in Vienna’s maternity hospital by introducing handwashing but was not recognised until later. In the 1870s panic took hold in England. Midwives were charged with homicide and the hospital death rate in London was 2.6%. In Europe Billroth described the streptococcus and Pasteur showed that it caused puerperal sepsis. In Britain Listerian asepsis transformed surgery and reduced the death rate in lying-in hospitals. In the 1930s Colebrook worked on aseptic maternity practice. In Germany Domagk discovered prontosil and in 1936 Colebrook demonstrated its life-saving effects. Fleming discovered penicillin and Florey and Chain turned it into an antibiotic. Maternal mortality fell rapidly. By 1982-4 antibiotics had abolished deaths from puerperal sepsis but by 2006-8 sepsis was again the leading cause of Direct death and the Reports emphasised the need for constant vigilance.

In South Africa in the 1990s Prof. Robert Pattinson asked the minister of health to establish a CEMD based on the UK model. The first Report appeared in 1998. During the AIDS epidemic the president and officials were denialists and tried to alter the Reports. The Enquiry developed a system to report 'great saves'. Politicians were supportive and maternal mortality fell to 97/100,000 in 2019. In India, Dr VP Paily is the coordinator of Kerala’s Confidential Review of Maternal Deaths. The KFOG was founded in 2002 and the Review began in 2003, stimulated by the WHO. The government authorised hospitals to give the KFOG anonymised records of maternal deaths. Quality standards were developed, helped by NICE International. In 2019 the maternal mortality rate was 28/100,000. In the USA Prof. Elliott Main is the medical director of the California Maternal Quality Care Collaborative (CMQCC), established when mortality rose in the 2000s. It produced toolkits to tackle the leading causes and in 2012 established the Maternal Data Center, combining social and hospital data. Severe maternal morbidity is scrutinised. Mortality fell and similar initiatives have spread across the USA.

In the 1990s half a million women died each year from pregnancy-related causes. In 1995 the United Nations set the goal of a 75% reduction by 2015. A 43% fall was achieved. In 2020 the maternal mortality rate for low-income countries was 462/100,000 births. For every death, another 30 women suffer severe complications. Saving lives need not be expensive. As Prof. Mahmoud Fathalla said at the Safe Motherhood Movement launch in 1987, 'mothers are dying because societies have yet to make the decision that their lives are worth saving'. He had been inspired by the UK Enquiries. In 2004 WHO published a toolkit, Beyond the Numbers, mostly written by the director of the UK CEMD. It described how local mortality reviews, hospital-based or community-based, and near-miss reviews can be carried out without the government support which is needed for a national Enquiry. The principles of the CEMD apply to those reviews. Their aim is not to find scapegoats but to identify problems and suggest solutions. Confidentiality is vital if people are to be frank about individual and systemic failures. A safety culture requires support at individual, institutional and political levels.

In the 1900s infant mortality was appalling, and it was the highest in the working class in the north of England. A national association for its prevention was formed and official enquiries were initiated. Concern about maternal mortality began during the Great War. In 1919 George Newman, head of the new Ministry of Health, appointed an all-female team to investigate, headed by Janet Campbell. In 1923 she made wide-ranging recommendations on training, clinical practice and provision of maternity beds. Every maternal death was to be investigated by the local medical officer of health. Pressure for parliamentary action came from the Queen and other leading women who had had difficult labours. An enquiry had taken place in Scotland and in 1928 an English national enquiry was organised. Case reports were collated by Arnold Walker and Joe Wrigley, obstetricians known for their common sense. Its 1932 Report covered 5,805 deaths and recommended that enquiries should continue. At the same time Dr Andrew Topping, medical officer in Rochdale, involved local communities in improving maternity care. Rochdale’s maternal mortality rate, the highest in England, was halved within two years.

Social factors affecting pregnancy include poverty, deprivation, ethnicity and refugee status. Drug and alcohol misuse, poor nutrition and obesity also have harmful effects. Reports in the 1930s included information on social circumstances of the women who died but early CEMD Reports contained virtually none. In 1977 the Labour government commissioned an enquiry by Sir Douglas Black into social determinants of health but in 1980 the Black Report was all but suppressed by the new Conservative government. In the 1990s further reports appeared at a time when the future of the CEMD was in doubt because of its focus on clinical care. In 1994-6 the scope of the Enquiries broadened. The Reports stopped blaming women and focussed on barriers to accessing care. Shockingly the Enquiries revealed that mortality rates were much higher in deprived areas and among ethnic minorities, particularly Black women.The data stimulated a raft of well-meaning NHS initiatives but the lofty policy declarations remained disconnected from reality. In 2016-18 three quarters of women who died had pre-existing medical or mental health conditions and 90% were in some measure socially vulnerable.

Obstetric anaesthesia dates from 1853, when John Snow gave chloroform to Queen Victoria. Spinal anaesthesia was described in 1898 but became common only in the 1990s. Nitrous oxide and oxygen ('gas and air') became widely used in the 1960s. The 1930 Report on Maternal Mortality recommended that the same person should not act as anaesthetist and obstetrician. The anatomical and physiological changes of pregnancy increase the risks. In the 1952-4 CEMD Report anaesthesia was involved in nearly 1 in 20 deaths: a major factor was inhalation of stomach contents. The next Report advised tracheal intubation to reduce this risk. The need for an experienced anaesthetist became obvious and in 1969 the Obstetric Anaesthetists’ Association was formed. The 1973-5 Report recognised that anaesthetists require skilled help and later Reports recommended practice drills. In the 1980s there was a move towards regional anaesthesia, first as epidural and in the 1990s spinal anaesthesia. Both require considerable expertise. Improvements in staffing, training and equipment continued, and in the year 2000 anaesthesia was 5 times safer than in 1983 and 38 times safer than in 1963.

In 1952-4 the caesarean section rate was under 2% and many women died of complications of vaginal birth. The Report listed 190 deaths in an appendix under various causes including 'contracted pelvis', once common due to rickets. Pelvic measurement was part of antenatal care. In doubtful cases 'trial of labour' often ended in forceps delivery. A 10% fetal loss rate was considered acceptable. Home births could end in forceps delivery by GPs who had no postgraduate training and relied on their student experience. In the 1955-7 Report, 33 women died after forceps delivery at home or in a maternity home. In the 1960s 'prolonged labour' (> 24 hours) was blamed on 'inco-ordinate uterine action'. In 1969 in Dublin Kieran O’Driscoll introduced 'active management' for first-time mothers in hospital, showing that normal labour could safely be achieved with an intravenous oxytocin 'drip'. Early CEMD Reports criticised GPs but in the 1960s their comments became more constructive. The BMJ ran a series of articles, 'Obstetrics for GPs', written by leading obstetricians. By the late 1970s only 2% of births were home deliveries and the Reports no longer discussed place of birth.

In 2012 the Enquiry moved to the National Perinatal Epidemiology Unit (NPEU) as part of MBRRACE-UK. CEMD Reports became annual and included near-misses. Life-threatening complications are 100 times commoner than death in pregnancy. In 2005 the NPEU had established a surveillance system through which all obstetric units notify uncommon complications. This facilitated a Confidential Enquiry into Maternal Morbidity, which identified an increase in severe haemorrhage due to abnormal placentation, and inadequate treatment of breast cancer due to withholding drugs in pregnancy. Positive trends included better long-term results of treating psychosis. The Enquiries’ work was hampered by NHS bureaucracy, the need for recommendations to be cost-neutral and a media embargo – even though the CEMD had shown that public information is vital for improving safety. Recently the CEMD revealed an increase in deaths from sudden death in epilepsy (SUDEP) due to withdrawal of medication in pregnancy, and continuing disparity in mortality rates between ethnic groups in the UK. Structural biases in the maternity care system persist, as shown by Black Lives Matter movement and the COVID emergency.

Lying in after giving birth has a long tradition but carries a risk of thrombosis. Blood clots form in leg veins and may embolise to the lungs, causing death. Early CEMD Reports did not recognise the benefits of early ambulation but divided thromboembolism deaths into three groups – during pregnancy, after vaginal delivery and after caesarean section. The Reports identified risk factors including age, obesity and caesarean section, and found that warning symptoms were being ignored. Shorter hospital stay reduced the number of deaths after vaginal birth. Caesarean section rates rose and an Enquiry into Perioperative Deaths (modelled on the CEMD) revealed the risk factors for post-operative thromboembolism. An 1995 an RCOG report advised on preventive measures including anticoagulants, previously avoided lest they cause bleeding. A sharp fall in deaths after caesarean section followed in 1997-9. By then thromboembolism was the leading Direct cause of maternal death and the benefits of guidelines had become clear. In 2004 the RCOG published a guideline on thromboprophylaxis in pregnancy and in 2006-8 thomboembolism fell to third place among causes of Direct death.

During World War II maternal mortality fell. In the USA deaths were investigated by local committees and in 1949 the RCOG decided Britain should do the same. Its president, Eardley Holland, had worked with George Godber of the Ministry of Health during the war and they set up an Enquiry covering England and Wales. After each death a local obstetrician sent information to a regional assessor, who could request further comments. Assessors' reports, which included no names, were collated by two national obstetric assessors. A team of five authors, including an anaesthetist, compiled a triennial report which anyone could buy. In each case a 'primary avoidable factor' was identified. Deaths were grouped by cause. The Ministry was anxious about the Report’s frankness but its publication in 1957 met with wide approval and no complaints about anonymity. The recommendations were disseminated in medical journals. Government committees recommended wideer availability of hospital birth. The Reports became UK-wide in 1985. New chapters discussed psychiatric illness, social exclusion and ethnicity, showing the need for Enquiries to continue despite the low overall mortality rate.

Indirect deaths result from diseases made worse by pregnancy. Their importance increased as reporting improved. In 1991 Michael de Swiet became the medical assessor to the Enquiries. Initially heart disease was the main concern. Rheumatic heart disease may follow streptococcal rheumatic fever. Women can live with it but pregnancy puts a strain on the heart and death may occur during childbirth. In 1952-4 the deaths from heart disease included 37 women giving birth at home. The disease diminished due to penicillin and better social conditions. Women with congenital heart disease were warned against pregnancy but cardiac surgery reduced the risk and obstetricians learned to work with cardiologists. The pattern of disease changed due to smoking and obesity, and myocardial infarction became the main cause of cardiac death. After 1997-9 Indirect deaths outnumbered Direct deaths. Reports highlighted the inadequate management of epilepsy, with poor communication between maternity carers and neurologists, particularly for women in deprived circumstances. The Enquiries’ findings helped to create a new specialty and the Obstetric Medicine Society now runs its own training programme.

In the nineteenth century abortion was widely available in Britain but abortionists risked life imprisonment. In 1927 The Lancet suggested that doctors should be allowed to act in good faith and in 1929 abortion to save a woman’s life became legal. Calls for change grew and the Abortion Law Reform Association was formed in 1936. In 1937 an investigation found that abortion caused 14% of all puerperal deaths. In 1938 a leading gynaecologist, Aleck Bourne, was acquitted after performing an abortion on a 14-year-old rape victim. In 1939 a committee recommended that grounds should include serious risk to health. War changed Parliament’s priorities and in 1952-4 abortion was the third commonest cause of maternal death: 80% of the women were married with children. Abortion was the leading cause in the 1960s, and, in 1967, after many failed attempts, Parliament passed the Abortion Act sponsored by David Steel, a young Liberal MP. The number of legal abortions rose to equal pre-1967 estimates and levelled off. By 1979 deaths from abortion – including those classed as spontaneous – had almost disappeared. Medical opinion was still split and NHS provision remained patchy for years.