Reducing maternal mortality: reaudit of recommendations in reports of confidential inquiries into maternal deaths

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Abstract
The development of clinical audit over the past 10 yearshas led to questioning of the role of the triennial reports of the confidential inquiries into maternal deaths. Recently, the maternal death rate has been 6-7 per 100 000 maternities, with the proportion of deaths attributed to substandard care remaining around 40%.To investigate the uptake of the recommendations of the confidential inquiries into maternal deaths Hibbard and Milner audited the facilities in consultant maternity units in the United Kingdom in 1993, including the availability of clinical guidelines for two major maternal complications, eclampsia and haemorrhage.1This audit followed the publication of Maternal Mortality— the Way Forward 2 and was published around the time the Royal College of Obstetricians and Gynaecologists produced Deriving Standards from the Maternal Mortality Report3 and the Department of …