ABSTRACT
This chapter outlines the results of a recent Malaysian investigation into maternal mortality through a system of clinical audits that were anonymous and non-punitive. The Confidential Enquiry into Maternal Deaths (CEMD) evaluates all maternal deaths including those that occur in the private sector and at home. All deaths, including fortuitous deaths of noncitizens, are studied. This is important as there can be important lessons to learn in every death. The initial use of the term substandard care in the CEMD was changed to remediable factors to ensure a more positive attitude toward the caregivers. There has been improvement in the reporting systems of maternal deaths. This contrasts positively with figures reported in 1991, when CEMD data showed a doubling of maternal mortality rate (MMR) as compared with that reported by Department of Statistics, Malaysia. The CEMD system is not anonymized at the health district or state level. However, the report is anonymized when it is sent to the national level.
