In South Africa in the 1990s Prof. Robert Pattinson asked the minister of health to establish a CEMD based on the UK model. The first Report appeared in 1998. During the AIDS epidemic the president and officials were denialists and tried to alter the Reports. The Enquiry developed a system to report 'great saves'. Politicians were supportive and maternal mortality fell to 97/100,000 in 2019. In India, Dr VP Paily is the coordinator of Kerala’s Confidential Review of Maternal Deaths. The KFOG was founded in 2002 and the Review began in 2003, stimulated by the WHO. The government authorised hospitals to give the KFOG anonymised records of maternal deaths. Quality standards were developed, helped by NICE International. In 2019 the maternal mortality rate was 28/100,000. In the USA Prof. Elliott Main is the medical director of the California Maternal Quality Care Collaborative (CMQCC), established when mortality rose in the 2000s. It produced toolkits to tackle the leading causes and in 2012 established the Maternal Data Center, combining social and hospital data. Severe maternal morbidity is scrutinised. Mortality fell and similar initiatives have spread across the USA.

In 2012 the Enquiry moved to the National Perinatal Epidemiology Unit (NPEU) as part of MBRRACE-UK. CEMD Reports became annual and included near-misses. Life-threatening complications are 100 times commoner than death in pregnancy. In 2005 the NPEU had established a surveillance system through which all obstetric units notify uncommon complications. This facilitated a Confidential Enquiry into Maternal Morbidity, which identified an increase in severe haemorrhage due to abnormal placentation, and inadequate treatment of breast cancer due to withholding drugs in pregnancy. Positive trends included better long-term results of treating psychosis. The Enquiries’ work was hampered by NHS bureaucracy, the need for recommendations to be cost-neutral and a media embargo – even though the CEMD had shown that public information is vital for improving safety. Recently the CEMD revealed an increase in deaths from sudden death in epilepsy (SUDEP) due to withdrawal of medication in pregnancy, and continuing disparity in mortality rates between ethnic groups in the UK. Structural biases in the maternity care system persist, as shown by Black Lives Matter movement and the COVID emergency.

This chapter examines the risks of pregnancy for women over 40 and the strategies to optimize the management of pregnancy, labour and puerperium in this age group. In the UK, antenatal care is not usually any different at less than 40 years unless there are other confounding factors. Women at advanced age booking for pregnancy should have a thorough risk assessment to ascertain risk of hypertensive diseases of pregnancy and those at higher risk should be started on 75 mcg aspirin from 12 weeks till until 36 weeks Increased surveillance for GDM is not recommended in the UK based on age alone. However, it should be noted that AMA is associated with an increased background incidence of diabetes and it is our practice to offer a mini glucose tolerance test. Risk of venous thromboembolism should be assessed at booking and at each encounter. Serial growth scans with doppler studies are to be performed starting from 26-28 weeks of gestation in women more than 40 years. Induction of labour is recommended between 39 to 40 weeks when maternal age is more than 40 years. There is insufficient evidence to comment on the possible effect on perinatal mortality and rates of operative delivery from this intervention and this should be mentioned when counselling for induction of labour.