The latest Confidential Enquiries into Maternal Deaths Report has raised concerns about access to care for some of the UK's most vulnerable pregnant women.
The report says 'it is clear that some women who died felt inhibited about seeking help', and 'the socially excluded, the very young and those from some minority ethnic groups did not always appear to have their specific concerns understood'.
It recommends that 'commissioners and trusts should provide those least likely to use services with the opportunity to gain acceptable professional and social support during their pregnancies'.
A total of 376 deaths were reported to the inquiry in 1994-96. The UK baseline maternal mortality rate is now 12.2 deaths per 100,000 maternities.
But the report says no general trends could be seen that could be attributed to individual trusts, geographical areas or changing patterns of maternal care.
Examples of substandard care include failure to identify cases of ectopic pregnancy, pre-eclampsia and pulmonary embolism.
The report called for the introduction of 'auditable standards' for maternity care, a call supported by the Royal College of Obstetricians and Gynaecologists last week.
The report also recommends routine 'sensitive inquiries' about domestic violence and more education on how to wear seat-belts during pregnancy.
Confidential Enquiries into Maternal Deaths Report. Stationery Office. www.the-stationery-office.co.uk