Maternal deaths in Australia 2021–2023

Maternal deaths are rare in Australia but do still occur. Understanding why helps inform maternity service policy and practice.

All maternal deaths require structured professional scrutiny to identify possible substandard care and ineffective provision of health care and community support. Analysis of contributory factors to maternal deaths suggests that up to one-third may be avoidable (CCOPMM 2025; Farquhar et al. 2011; Humphrey 2016). 

Confidential inquiries are conducted into maternal deaths in all Australian states and territories. Deaths of women during pregnancy or within 42 days of the end of pregnancy are reviewed by health professionals to determine the likely cause and whether the pregnancy contributed to the death. State and territory health authorities and other responsible jurisdictional bodies receive clinical data on the women who died from patient administrative and clinical records, as well as from the state and territory maternal mortality committees where death reviews are undertaken (see Technical notes for further detail).

Reporting of maternal deaths in Australia commenced for the 1964–1966 triennium (NHMRC 1966) and now documents 56 years of continuous maternal mortality monitoring in Australia. This is the 20th published report on maternal deaths in Australia and the 8th in the AIHW maternal deaths series.

What is included in this report? 

In Australia, more than 886,000 women gave birth during the triennium from 1 January 2021 and 31 December 2023. This report focuses on the 59 maternal deaths that occurred during this period, and presents key trends in maternal mortality, maternal and clinical characteristics of the women who died and information on causes of death.

Due to the rarity of maternal deaths in Australia, small variations in the number in a single year can lead to large fluctuations in the MMR, making it difficult to interpret the trend in maternal mortality over time using single year rates. Using a ‘triennia’ approach (aggregating three years of data) allows for more detailed and robust analyses. 

Though maternal deaths in Australia have been reviewed since 1964, this report only includes deaths from 1973 onwards, when comparable definitions were introduced.

This report aims to:

• provide an overview of maternal mortality in Australia 
• provide an evidence base to help inform policy development 
• provide information to health and community service providers that might be used to prevent avoidable deaths
• inform national processes for the classification of maternal deaths, providing a basis for consensus in the review of maternal deaths by state and territory maternal mortality review committees.

Maternal mortality ratio

In this report the incidence of maternal death is expressed as the maternal mortality ratio (MMR). The MMR is calculated using direct, indirect and maternal deaths not further classified, and expressed per 100,000 women giving birth. Coincidental deaths and deaths awaiting classification are not included in the MMR. Please see Technical notes for information on data sources and methodology used in this report.

What are maternal deaths?

All deaths that occur during pregnancy or within 42 days of the end of a pregnancy are reviewed by health professionals to determine the likely cause and whether the pregnancy contributed to the death. Following review, deaths are classified as maternal (direct, indirect or not further classified; WHO 2019), coincidental, or awaiting classification (unclassified).

Maternal deaths

Maternal death is the death of a woman while pregnant or within 42 days of the end of pregnancy, irrespective of the duration and outcome of the pregnancy. The death may be from any cause related to or aggravated by the pregnancy or the associated care received but not from accidental or incidental causes. Maternal deaths are divided into 3 categories:

• Direct maternal deaths are those resulting from complications of pregnancy or birth and/or the associated clinical care;
• Indirect maternal deaths are those resulting from diseases or conditions that were not due to a direct obstetric cause, but were aggravated by the pregnancy or birth; and
• Maternal deaths not further classified are those considered to be related to the pregnancy or its management but could not be further classified as either ‘direct’ or ‘indirect’.

Coincidental deaths

Coincidental deaths are defined as those that are reported to have occurred during pregnancy or within 42 days of the end of pregnancy, but are considered to be causally unrelated to pregnancy. Unlike direct and indirect maternal deaths, coincidental deaths are excluded from analysis and maternal mortality ratio (MMR) calculations. These are outside the scope of this report.

Awaiting classification (unclassified)

Unclassified deaths are deaths that have not yet been classified as either a maternal death or coincidental. These deaths are not included in reporting of maternal deaths. However, the classification will be updated once the jurisdictional maternal mortality review committee has reviewed the death.

Late maternal deaths

It is also important to note that deaths do occur beyond the 6-week postpartum period. Deaths that occur 43–365 days after the end of pregnancy are known as ‘late maternal deaths’. Currently, while AIHW has information on some late maternal deaths and is exploring ways to further report on these deaths, there are no consistent nationwide data available on late maternal deaths. As such, they are not included in this report.