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Confidential Enquiry into Maternal and Child Health

Improving the health of mothers, babies and children

Overview Maternal and Perinatal Health
Maternal & Perinatal Mortality Surveillance
Saving Mothers' Lives
Obesity in Pregnancy
Near term Intrapartum death & Neonatal Encephalopathy
Diabetes in Pregnancy
CEMACH/UCL Diabetes Project
Local clinical audits

Child Health
New Child Health Enquiry Topic
Child Death Review
Confidential Enquiry into Head Injury in Children

Maternal & Perinatal Mortality Surveillance


Maternal and perinatal mortality surveillance is an integral part of CEMACH’s national enquiry programme. CEMACH is continuing the work of the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) in carrying out surveillance of perinatal mortality in England, Wales and Northern Ireland.  From 2007 (report due 2009) CEMACH will be including maternal mortality in its annual surveillance reports.

In respect of perinatal deaths the annual report will include stillbirths (i.e. in utero deaths from 24 weeks gestation) and each live birth resulting in a neonatal death (up to 28 days of life). The annual report will also include quantitative data on deaths of women while pregnant or within 42 days of the end of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.  The cases we review for the triennial report "Saving Mothers' Lives" include a wider range of maternal deaths than will be monitored in our annual report.

In addition to reporting on mortality trends with focused reports on specific issues, CEMACH will make available reports to Strategic Health Authorities (SHA’s), neonatal networks and Trusts comparing their mortality rates over time and with other SHA’s, PCT’s neonatal networks and Trusts.

CEMACH collects information from every hospital on all perinatal deaths using a specific notification form, the Perinatal Death Notification (PDN) in England, Wales and Northern Ireland.

Continuing and developing the enquiry’s perinatal mortality surveillance enables us to:

  • Monitor changes in the rates, causes and risk factors associated with perinatal mortality
  • Identify topics where it may be beneficial to carry out further more detailed studies
  • Provide cases for detailed study in a full confidential enquiry and data for other studies
  • Assist hospital Trusts, neonatal networks, Strategic Health Authorities and Primary Care Trusts monitor their mortality rates.

CEMACH’s first perinatal mortality surveillance report covered the years 2000-2003. In the surveillance report for 2004, CEMACH expanded this to provide an analysis of emerging issues and for the first time  compared each NHS Trust’s crude mortality rates to the national average using a “funnel chart”, which allowed for the identification of “outliers”. This benchmarking of hospitals using crude analysis is a first step in the development of an informed comparison of NHS Trust-level perinatal mortality rates.

The 2005 and 2006 reports describe more fully:

  • Perinatal mortality by neonatal networks
  • Term intrapartum deaths
  • Perinatal deaths and deliveries occurring at home including planned home births.

All the reports related to Maternal & Perinatal Mortality published to date are available to download from the publications page.

For further information on this work please contact Shona Golightly on 020 7486 1191.




Important: LSCB responsibilities and collection of data for neonatal deaths (less than 28 days)

CEMACH continue to collect data on all neonatal deaths (up to 28 days). The standard CEMACH 2009 Perinatal Death Notification form below should continue to be completed as normal.  For information regarding additional reporting requirements of child deaths in your area, please contact your LSCB.

Publications Information

Mortality Surveillance 2006 Reports

Trust specific reports relating to 2006 data are now available. Please contact your CEMACH Regional manager for more information. 

Data Collection Forms and other useful documents

Extended Wigglesworth Classification
Fetal & Neonatal Classification
Obstetric (Aberdeen) Classification
2008 Perinatal death notifications form (All regions)
2009 Perinatal Death Notification Form (Main)
2009 Perinatal Death Notification Form (North East)
2009 Perinatal Death Notification Form (Northern Ireland)