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The Perinatal and Maternal Mortality Review Committee (PMMRC) has established a working group to investigate maternal deaths with a view to reducing the numbers of deaths.


  • Dr Sarah Wadsworth (Chair), obstetrician, Counties Manukau District Health Board (DHB) 
  • Dr Sue Belgrave, obstetrician and gynaecologist, Waitemata DHB
  • Dr Eileen Bass, physician, Hutt Valley DHB 
  • Dr Rose Elder, obstetrician and gynaecologist, Capital & Coast DHB 
  • Dr Lesley Dixon, midwife, Christchurch 
  • Dr Anne Hart, anaesthetist, Counties Manukau Health
  • Beatrice Leatham, midwife, Auckland
  • Dr Liz MacDonald, perinatal psychiatrist, Canterbury DHB 
  • Dr Catherine Marnoch, physician, Waitemata DHB 
  • Jo McMullan, midwife, Capital & Coast DHB 
  • Mr John Tait (chair, PMMRC)
  • Dr Susan Tutty, general practitioner and GP Liaison Women's Health Counties Manukau DHB
  • Dr Kate White, pathologist, MidCentral DHB
  • Karen Whiterod, Clinical Nurse Specialist, Mental Health and Addiction Service, MidCentral Health

Definitions of maternal death

Maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy (miscarriage, termination or birth), irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes (World Health Organisation).

The cause of maternal death is sub-classified into the following categories based on The WHO Application of ICD-10 to Deaths during Pregnancy, Childbirth and Puerperium: ICD MM (WHO 2012).

  • Direct maternal deaths: those resulting from obstetric complications of the pregnant state (pregnancy, labour or puerperium), from interventions, omissions, incorrect treatment or from a chain of events resulting from the above. In the 12th report (2018), the PMMRC adopted the WHO revision to include deaths by suicide with direct maternal deaths. This was then applied retrospectively to data from previous years.
  • Indirect maternal deaths: those resulting from previous existing disease or disease that developed during pregnancy and was not due to direct obstetric causes but that was aggravated by the physiologic effects of pregnancy.
  • Unknown/Undetermined (or Unclassifiable) maternal deaths: deaths during pregnancy, childbirth and the puerperium where the underlying cause is unknown or was not determined.
  • Coincidental maternal deaths: deaths from unrelated causes that happen to occur in pregnancy or the puerperium.

Review and reporting

Maternal deaths are reviewed nationally by the MMRWG. The MMRWG has developed a data collection tool for maternal deaths. All completed reporting forms, along with relevant clinical information and reports from DHBs, Coronial Services and any other relevant investigative processes, are reviewed by designated members of the MMRWG, who present a summary of each case to the working group. The MMRWG then discusses each case in detail, including assessing the presence of contributory factors and potential avoidability.
Maternal deaths are reported annually in the Maternal Mortality Chapter of the PMMRC Annual Report.

Terms of reference


Related Resources

Last updated: 13th November, 2021