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Indirect deaths have outnumbered direct deaths in the UK since 1994–1996 (Table 2.4). In that triennium, birth and death registrations were linked by the ONS, leading to better ascertainment.

Table 2.4 The rise in indirect deaths: maternal deaths notified to the CEMD, 1991–2018

	1991–1993	1994–1996	1997–1999	2000–2002	2003–2005	2006–2008	2009–2011	2010–2012	2016–2018
Direct	129	134	106	106	132	107	83	78	92*
Indirect	100	134	136	155	163	154	170	165	125
Total	229	268	242	261	295	261	253	243	217

^* Suicides are included in the classification of direct maternal deaths after a change in World Health Organization guidance.

From 2000–2002 onwards, CEMACH regional managers were involved in collecting data and this improved ascertainment further. Better identification of cases, however, is only one reason for the rise in indirect deaths, the other being a rise in risk factors such as smoking, obesity and older age at childbearing.