Maternal harm or death

All maternal deaths and serious harm must be reported within 28 days to the Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM).

Please note: We no longer accept notifications by email or fax. Please use our new online forms below.

What do you have to report?

All maternal deaths

• The death of a woman during pregnancy or childbirth.
• The death of a woman within 42 days of the birth or termination of the pregnancy irrespective of the cause of death.
• The death of a woman within one year of the birth or termination of the pregnancy when the death is from direct or indirect causes.

Severe acute maternal morbidity (SAMM)

• Women who were pregnant or had given birth in the past 42 days, who were admitted to an adult intensive care unit. 
• Women who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of birth or termination of pregnancy.

1. Notify us

Access our online reporting form for:

• Maternal death 
• Severe Acute Maternal Morbidity (SAMM)

Please refer to the relevant preview below of the questions you will be required to answer to complete a death or SAMM notification form. Please make sure you have all the information available before starting the form. The form does not save when partially completed, so needs to be finished once started.

• Preview of Maternal death notification form
• Preview of Severe Acute Maternal Morbidity (SAMM) notification form

2. Review the death

Health services must review every maternal death that occurs in their hospital, as well as deaths elsewhere when the patient was predominately treated at one of their hospitals.

The extent of a death review depends on the type of death, and if it was expected or unexpected.

All internal reviews should be submitted to CCOPMM as part of step 3.

3. Submit your review

Within 1-3 days of completing a death or SAMM notification you will receive a response from CCOPMM that includes access to a SharePoint folder to upload documents and reviews to. The documents required to complete a CCOPMM report are specified in the following checklists:

• Maternal death report checklist
• Severe Acute Maternal Morbidity (SAMM) report checklist

4. CCOPMM case review

Once all the information is in, CCOPMM reviews all deaths to determine:

• if the harm or death was avoidable
• any contributing factors, including potential deficiencies in clinical care or system-wide faults
• (if death) classification 
• any recommendations for improvement
• preventable factors, for example smoking in pregnancy, maternal age, family violence, and other social and demographic factors.

Maternal deaths are generally classified in one of three principal categories:

• Direct maternal death: The death is considered to be due to a complication of the pregnancy itself, for example, haemorrhage from placenta praevia.
• Indirect maternal death: The death is considered to be due to a pre-existing condition aggravated by the physiological changes of pregnancy, for example, heart disease or diabetes.
• Incidental death: The death is considered unrelated to pregnancy, for example, a motor vehicle accident.

What do we use this information for?

We report annually to share the lessons and improvements from maternal harm and deaths in Victoria.

Why do we collect information on SAMM?

SAMM is an important safety and quality indicator for maternity care. SAMM cases are more common than maternal deaths. 

By investigating these cases, CCOPMM can significantly improve how poor care or system factors are identified.

Your information is confidential

The confidentiality of information provided to CCOPMM is strictly protected under the Public Health and Wellbeing Act 2008. CCOPMM members cannot share any documents or information to a third party.