Most maternal deaths can be averted with known, effective interventions but countries require information about which women are dying and why, and what can been done to prevent such deaths in future. This paper describes the introduction of two approaches to reviewing maternal deaths and severe obstetric complications in 12 countries in transition in the WHO European Region - national-level confidential enquiries into maternal deaths and facility-based near-miss case reviews. Initially, two regional meetings involving stakeholders from 12 countries were held in 2004-2005, followed by national meetings in seven of the countries. The Republic of Moldova was the first to pilot the review process, preceded by a technical workshop to make detailed plans, provide training in how to facilitate and carry out a review, finalise clinical guidelines against which the findings of the confidential enquiry and near-miss case review could be judged, and a range of other preparatory work. To date, near-miss case reviews have been carried out in the three main referral hospitals in Moldova, and a national committee appointed by the Ministry of Health to conduct the confidential enquiry has met twice. Several other countries have begun a similar process, but progress may remain slow due to continuing fears of punitive actions against health professionals who have a mother or baby die in their care.