Abstract
A Confidential Enquiry into Maternal Deaths is an anonymous, multidisciplinary and systematic review of all cases of maternal mortality. This paper describes one such process implemented at national level in Moldova. Its aim was to conduct an in-depth review of the underlying causes and circumstances surrounding each mother's death to learn lessons to improve care in future. Its findings showed that deaths were predominantly due to direct obstetric causes, especially haemorrhage and sepsis, and adverse social determinants, particularly poverty and migration also played a decisive role in more than half of the cases. The final report identified potentially remediable actions and the key areas requiring interventions by the health sector, administrators and the community. Its recommendations have enabled the implementation of some solutions to help prevent future maternal deaths, including the development of evidence-based clinical guidelines.
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