Investigations
All maternal deaths require structured professional scrutiny to:
- determine the likely cause and whether the pregnancy contributed to the death
- identify possible substandard care and ineffective provision of health care and community support.
Confidential inquiries are conducted into maternal deaths in all Australian states and territories. These investigations include autopsy, assessment of complicating and pre-existing conditions in pregnancy, and assessment of potential contributing factors.
Incidence of autopsy
Cause of death was confirmed by autopsy in over two-thirds of maternal deaths (66%, 39 deaths) (Figure 4.6). Autopsy was not performed for 19 deaths (32%).
This autopsy rate of 66% in 2021–2023 is a decrease from the preceding triennium:
- 75% of maternal deaths had cause of death confirmed by autopsy in 2018–2020
- 70% of maternal deaths had cause of death confirmed by autopsy in 2015–2017.
We and the National Maternal and Perinatal Mortality Clinical Expert Group (NMPMCEG) continue to advocate for autopsy in all cases of maternal death, as clinical appearances are not always confirmed by autopsy findings. We will continue to monitor these proportions over time.
Figure 4.6: Maternal deaths, by performance of autopsy and type of death, Australia, 2021–2023
| Maternal deaths classification | Performed | Not performed | Not stated |
|---|---|---|---|
| Direct | 64 | 32 | 4 |
| Indirect | 67.6 | 32.4 | 0 |
| Total | 66.1 | 32.2 | 1.7 |
Note: Total maternal deaths includes maternal deaths classified as direct, indirect, and those not further classified. In 2021–2023 there were no maternal deaths not further classified. Does not include coincidental deaths, deaths awaiting classification, and late maternal deaths (deaths occurring from 43–365 days postpartum).
Source:
AIHW analysis of the National Maternal Mortality Data Collection.
Health conditions complicating pregnancy
Of the 59 maternal deaths in 2021–2023, 53 had information provided around complicating conditions. Of these 53 mothers, 36 (68%) had one or more pre-existing health conditions, and 42 (79%) had new health conditions, or significant exacerbations of existing complicating conditions, that arose during pregnancy. Pre-existing health conditions and complicating conditions arising during pregnancy do not necessarily have a causative role in the death.
Pre-existing health conditions
The most common pre-existing conditions recorded amongst mothers who died were mental health conditions (15 mothers), respiratory disease (11 mothers) and cardiovascular disease (7 mothers). See table 4.2 for a complete list of pre-existing health conditions complicating pregnancy for this period.
| Pre-existing health conditions complicating pregnancy(a) | Maternal deaths |
|---|---|
| Mental health conditions | 15 |
| No specific pre-existing health condition recorded | 12 |
| Respiratory disease | 11 |
| Cardiovascular disease | 7 |
| Hypertension | 6 |
| Diabetes mellitus | 4 |
| Epilepsy | 3 |
| Renal disease | 3 |
| Malignancy | 1 |
| Thromboembolic disease | 1 |
| Pulmonary hypertension | 0 |
(a) More than 1 condition can be identified per pregnancy.
New or significantly exacerbated health conditions
The most common health conditions that were new or significantly exacerbated in pregnancy were gestational diabetes (9 mothers), mental health conditions (7 mothers) and postpartum haemorrhage (6 mothers). See table 4.3 for a complete list of complicating conditions for this period.
| New or significantly exacerbated health conditions arising during pregnancy(a) | Maternal deaths |
|---|---|
| Gestational diabetes | 9 |
| Mental health conditions | 7 |
| Postpartum haemorrhage | 6 |
| Pre-eclampsia | 5 |
| Multiple pregnancy | 3 |
| Placenta accreta/percreta | 2 |
| Amniotic fluid embolism | 2 |
| Gestational hypertension | 2 |
| Placenta praevia | 2 |
| Miscarriage | 2 |
| Ectopic pregnancy | 1 |
| Molar pregnancy | 0 |
(a) More than 1 condition can be identified per pregnancy.
Contributing factors in maternal deaths
State and territory maternal mortality review committees (STMMCs) assess the circumstances surrounding a maternal death to establish whether systemic factors might have contributed to the death. Contributing factors identified might not have directly caused the death or influenced the outcome.
A maternal mortality committee finding that there were contributing factors does not imply negligence. A review of contributing factors seeks to identify lessons that can be learned to improve future outcomes through potential upgrades to health services, support processes and medical care.
Contributing factors are grouped into the 3 main categories:
- professional care (such as inadequate numbers and/or seniority of staff, failure or delay in emergency response, failure to offer and/or follow recommended best practice)
- delayed, or lack of, access to care (such as geographical isolation from appropriate services, socioeconomic situation affecting access to appropriate care)
- mother/family/social situation (such as infrequent or late attendance at or absence of antenatal care, substance abuse, family violence, socioeconomic deprivation, language barriers).
Of the 59 maternal deaths in 2021–2023, 47 were reviewed for contributing factors. STMMCs identified 36 contributing factors relating to 25 deaths – in 8 of these cases more than one factor was identified (see supplementary table 24 – Data tables: Maternal deaths in Australia, 2021–2023). The majority of the 36 contributing factors related to:
- professional care of the woman (36%, 13 deaths)
- the woman/her family/social situation (31%, 11 deaths), and
- access to care (14%, 5 deaths).
STMMCs also provide information on whether the sub-optimal care factors identified by the state/territory perinatal mortality review committee had relevance to the outcome (maternal death). Of the 25 deaths where at least one contributing factor was identified, 40% of contributing factors were identified as significant (likely to have contributed to the death), 52% as possibly having contributed to the death, and 8% as unlikely to have contributed to the death or relevance was not stated.
Impact of COVID-19
The period 2021–2023 spans a period that saw fluctuating health system and community restrictions due to the COVID-19 pandemic. While there were no deaths recorded with a cause of death of COVID-19 in this period, there were 3 deaths where COVID-19 was recorded as a pre-existing or complicating condition during pregnancy.
Additionally, there were a small number of deaths where measures to limit the spread of COVID-19, such as stay at home orders and COVID-19 screening requirements and associated clinical management and transition to telehealth services, were listed as contributing factors.
For more detail about the impact of COVID-19 pandemic on mothers and babies, see Maternal and perinatal outcomes during the COVID-19 pandemic 2020-2021.