Anaesthetic contribution to maternal mortality.

The Confidential Enquiries into Maternal Deaths in England and Wales are unique in British medicine in that they appraise systematically the results of medical work. The original enquiry was started in 1928, but was completely revised in 1952, since when there have been 10 reports covering a period of 30 years. Each maternal death is reviewed carefully to ascertain if additional or different action might have given the mother a better prospect of survival. The difficulties in collecting accurate information retrospectively in this type of report are well known, as is their examination from an elitist standpoint. It is a feature, however, that each successive one is more complete than its predecessor, because of the free participation of all those who have been concerned with the mother's care and who realize the importance of the enquiries. This is particularly true for anaesthesia, practitioners of which are much concerned with anaesthetic mortality and wish to pinpoint those areas where improvements can be made. Another unique feature is the "retrieval rate", which is almost 100%. Thus the causes of virtually all anaesthetic deaths from 1952 to 1981 are known.