LEARNING FROM ADVERSE OUTCOMES: A SYSTEM FOR IDENTIFICATION AND ASSESSMENT OF SEVERE MATERNAL MORBIDITY

Traditionally, the maternal mortality ratio has been used as a measure of the quality of maternity care and review of individual cases of maternal death has provided information for professional learning in order to improve patient care. In the United Kingdom, this process of multidisciplinary review has been carried out for over 50 years in the form of the Confidential Enquiry into Maternal Deaths (CEMD). The Confidential Enquiry is well respected internationally and has been used as a model for confidential enquiries in other countries, such as South Africa.