MATERNAL DEATH REVIEW GUIDEBOOK
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MATERNAL DEATH REVIEW GUIDEBOOK
| P age 3
This handbook has been developed to assist nodal officers of the states and
districts in the implementation of Maternal Death Reviews (MDR), as per the
policy of Government of India. It contains a more in depth explanation of the
roles and responsibilities at different levels, how to conduct the trainings and
orientation sessions of stakeholders and a detailed guide for trainers and
interviewers who will conduct interviews with bereaved families in the
communities.
A few revisions have been made based on the recommendation of the
national core group on MDR to the questionnaires for both the community
based and facility based MDR, as well as the other formats. The modified
formats are included here.
All states will also receive a CD, in addition to this guidebook, which also
contains PowerPoint presentations from the National Orientation Workshop
in New Delhi December 10th and 11th 2010, as well as presentations that
should be used while training the community interviewers. It also includes a
role-play guide to be used during the same training.
MATERNAL DEATH REVIEW GUIDEBOOK
MDR Resource Persons
1. Dr Anjana Saxena, MoHFW
2. Dr Manisha Malothra, MOHFW
3. Dr Padmanaban, NHSRC
4. Mr Prasanth, K.S, NHSRC
5. Dr Sunanda Gupta, WHO
6. Dr Aboli Gore, UNICEF New Delhi
7. Dr Pavitra Mohan, UNICEF New Delhi
8. Ms Laila Lochting, UNICEF New Delhi
9. Dr Dilip Kumar Das, Burdwan Medical College, West Bengal
10. Dr Jayanti Pandian, Kilpauk medical College, Chennai
11. Dr Kaninika Mitra, UNICEF New Delhi
| Page 4
MATERNAL DEATH REVIEW GUIDEBOOK
| Page 5
Abbreviations
ACMO
ANC
ANM
AP
APGAR
APH
ASHA
AWW
BMO
BMNO
BPHN
CBMDR
CHC
CMO
CPD
CS
CVA
DH
DHS
DM
DNO
D&C
EDD
EmOC
FBMDR
FOGSI
FMDRC
FNO
GA
GDM
Gol
HFWTC
HMIS
ICDS
ICU
IEC
IMA
Additional Chief Medical Officer
Ante Natal Care
Auxiliary Nurse Midwife
Ante Partum
Activity Pulse Grimace Appearance Respiration
Ante Partum Haemorrhage
Accredited Social Health Activist
Anganwadi Worker
Block Medical Officer
Block Medical Nodal Officer
Block Public Health Nurse
Community Based Maternal Death Review
Community Health centre
Chief Medical Officer
Cephalo Pelvic Disproportion
Civil Surgeon
Cardio Vascular Accidents
District Hospital
District Health Society
District Magistrate
District Nodal Officer
Dilatation & Curettage
Expected date of Delivery
Emergency Obstetric Care
Facility Based Maternal death Review
Federation of Obstetric and Gynaecological Societies of India
Facility Maternal Death Review Commitee
Facility Nodal Officer
General Anaesthesia
Gestational Diabetes Mellitus
Government of India
Health & Family Welfare Training centre
Health Management Information System
Integrated Child Development Scheme
Intensive Care Unit
Information Education Communication
Indian Medical Association
MATERNAL DEATH REVIEW GUIDEBOOK
IP
IV
LHV
MAS
MBBS
MDR
MMR
MO I/c
MTP
MVA
N/A
NGO
NHSRC
NICU
NRHM
OB/GYN
OBC
OC
OT
PE
PET
PHC
PHN
PIH
POC
PP
PPH
PPROM
PROM
P&RD
QA
RCH-II
SC
SDH
SHC
SHS
SIHFW
SNO
ST
Intra partum
Intra Venous
Lady Health Visitor
Meconium Aspiration Syndrome
Bachelor of Medicine and Bachelor of Surgery
Maternal Death Review
Maternal Mortality ration
Medical Officer In-charge
Medical Termination of Pregnancy
Manual Vacuum Aspiration
Not Applicable
Non Governmental Organisation
National Health System resource center
Neonatal Intensive Care Unit
National Rural Health Mission
Obstetric & Gynaecology
Other Backward Class
Other Class
Operation Theatre
Pulmonary Embolism
Pre Eclamptic Toxaemia
Primary Health Centre
Public Health Nurse
Pregnancy Induced Hypertension
Product of Conception
Post partum
Post Partum Haemorrhage
Preterm Premature Rupture of Membranes
Premature Rupture of Membranes
Panchayat & Rural Development
Quality Assurance
Reproductive & Child Health phase II
Scheduled Caste
Sub District Hospital
Sub Health Centre
State Health Society
State Institute of Health & Family Welfare
State Nodal Officer
Scheduled Tribe
[Page 6
MATERNAL DEATH REVIEW GUIDEBOOK
(Page 7
CONTENTS
1. MATERNAL DEATH REVIEW GUIDELINES
10
1.1 Background Information.............................
10
1.2 Community-Based MDR............................
12
1.3 Facility-Based MDR...................................
15
1.4 MDR at District Level................................
17
1.5 MDR at State Level...................................
22
1.6 MDR Orientation/Training.........................
25
1.7 Training Schedule and Proposed Agendas ...
26
1.8 Data Analysis.............................................
33
1.9 Monitoring and Supervision.......................
34
2. COMMUNITY BASED MDR TOOLS.............
38
2.1 Interviewer Reference Manual...................
38
Informed Consent Form.......................
60
2.2 Manual for Trainers of Interviewers
61
3.1 FBMDR REFERENCE MANUAL
76
3.1 FBMDR Reference Manual....
76
3.2 Cause of Death Classification.
80
4. MDR FORMATS.................................................................................
85
Annexure 1: Facility Based Maternal Death Review Form.....................
86
Annexure 2: Verbal Autopsy Questionnaire...........................................
95
Annexure 3: MDR Case summary.........................................................
108
Annexure 4: MDR Line Listing Form for All Cases of Maternal Deaths
111
Annexure 5:Block Level MDR Register for All Women’s Death (15-49 years)
112
Annexure 6: Format for Primary Informer.......................................................
113
MATERNAL DEATH REVIEW GUIDEBOOK
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MATERNAL DEATH REVIEW GUIDEBOOK
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1. MATERNAL DEATH
REVIEW GUIDELINES
■
1.1 Background Information
1.2 Community-Based MDR
I if
1.3 Facility-Based MDR
^3
1.4 MDR at District Level
1.5 MDR at State Level
1.6 MDR Orientation/Training
1.7 Training Schedule and Proposed Agendas
1.8 Data Analysis
1.9 Monitoring and Supervision
z
MATERNAL DEATH REVIEW GUIDEBOOK
| Page 10
1. MATERNAL DEATH REVIEW
GUIDELINES
1.1 Background Information
Each year in India, roughly 28 million women experience pregnancy and 26
million have a live birth. Of these, an estimated 67,000 maternal deaths and
one million newborn deaths occur each year. In addition, millions more
women and newborns suffer pregnancy and birth related ill-health. Thus,
pregnancy-related mortality and morbidity continues to have a huge impact
on the lives of Indian women and their newborns.
The maternal mortality ratio is the number of women who die from any cause
related to or aggravated by pregnancy or its management (excluding
accidental or incidental causes) during pregnancy and childbirth or within 42
days of termination of pregnancy, irrespective of the duration and site of the
pregnancy, per 100,000 live births.
Maternal Mortality Ratio (MMR) in India has shown an appreciable decline
from 398/100,000 live births in the year 1997-98 to 301/100,000 live births
in the year 2001-03 to 254/100,000 live births in the year 2004-06 as per the
latest RGI-SRS survey report, released in April 2009. However, to accelerate
the pace of decline of MMR in order to achieve the NRHM and MDG Goal of
less than 100 per 100,000 live births, there is a need to give impetus to
implementation of the technical strategies and interventions for maternal
health. Levels of maternal mortality vary greatly across the regions, due to
variation in underlying access to emergency obstetric care, antenatal care,
anemia rates among women, education levels of women, and other factors.
About two-thirds of maternal deaths occur in a handful of states - Bihar and
MATERNAL DEATH REVIEW GUIDEBOOK
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Jharkhand, Orissa, Madhya Pradesh and Chhattisgarh, Rajasthan, Uttar
Pradesh and Uttarakhand and in Assam, all these states being among the 18
high focus states under NRHM.
Maternal Death Review (MDR) as a strategy has been spelt out clearly in the
RCH - II National Programme Implementation Plan document. It is an
important strategy to improve the quality of obstetric care and reduce
maternal mortality and morbidity. The importance of MDR lies in the fact that
it provides detailed information on various factors at facility, district,
community, regional and national level that are needed to be addressed to
reduce maternal deaths. Analysis of these deaths can identify the delays that
contribute to maternal deaths at various levels and the information used to
adopt measures to fill the gaps in service. MDR has been conducted as an
established intervention for the last few years by some states like Tamil
Nadu, Kerala and West Bengal.
Different approaches to investigation of
maternal deaths
• Community based maternal death review(Verbal autopsy)
• Facility based maternal deaths review
• Confidential enquiries into maternal deaths
• Surveys of severe morbidity(near miss)
• Clinical audit
Government of India has decided to take up Community based maternal
death review (CBMDR) and the Facility based maternal death review
(FBMDR) which would help in identifying the gaps in the existing health care
delivery systems, prioritize and plan for intervention strategies and to
reconfigure health services.
Guideline for Maternal Death Review (MDR)
Government of India has decided to take up Community based maternal
death review [CBMDR] and the Facility based maternal death review
(FBMDR) which would help in identifying the gaps in the existing health care
delivery systems, prioritize and plan for intervention strategies and to
reconfigure health services.
MATERNAL DEATH REVIEW GUIDEBOOK
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e 12
The objectives of the guidelines are:
1. To establish operational mechanisms/modalities for undertaking MDR at
selected institutions and in community level.
2. To disseminate information on data collection tools, data/information
flow, analysis.
3. To develop systems for review and remedial follow up actions.
1.2 Community-Based MDR
Community based MDR using a verbal autopsy format is a method of finding
out the medical causes of death and ascertaining the personal, family or
community factors that may have contributed to the deaths. The verbal
autopsy consists of interviewing people who are knowledgeable about the
events leading to the death such as family members, neighbors and
traditional birth attendants.
Community based reviews must be taken up for all deaths that occurred
in the specified geographical area, irrespective of the place of death, be
it at home, facility or in transit.
Steps of community-based MDR
Notification
The ASHA/AWW/ANM will notify all women
deaths in the age group of 15 to 49 years
from her area by telephone to the BMO
within 24 hour. The local panchayats and
other relevant persons/ groups may also be
encouraged to inform the BMO about
women's deaths in their area.
The ASHA/AWW/ANM will
notify all women deaths in
the age group of 15 to 49
years from her area by
telephone to the BMO
within 24 hour.
The ASHA/AWW/ANM will fill up the format for primary informer (Annex 6)
for all women's deaths (age 15-49) and send the format to the BMO within 24
hours. Format for primary informer gives information whether the death is a
suspected maternal death or a non maternal death.
MATERNAL DEATH REVIEW GUIDEBOOK
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13
Line listing of maternal deaths should be submitted to the BMO by the ASHA,
using annex 4, by the 5th of every month. In case no death has occurred
during the month, the ASHA has to submit a nil report.
The ASHA/AWW/ANM should also ensure the availability of the respondents
during the visit of the investigation team
Investigation
Investigation of the maternal deaths will be done using Verbal Autopsy
Format (annex 2]. In section 11 of the format, narration on the various
events which led to the death of the mother, should be explained in detail.
Block Medical Nodal Officer
The Block Medical Nodal Officer [BMNO] is the MO in
charge of the Block PHC. The BMNO is overall
responsible for the MD review process at the block and
will act as a supervisor for the investigation team.
Responsibilities:
The BMNO is overall
responsible for the MD
review process at the
block and will act as a
supervisor for the
investigation team.
• Appoint the ANM/LHV to visit the family of the deceased to verify
whether or not it is a maternal or non- maternal death, after receiving
annex 6 from the notifier.
BMO must report
• Report all suspected maternal deaths to the district
suspected maternal
DNO based on the report from the primary
deaths to the state
informant (by phone and by sending Format for
nodal officer by
telephone within
Primary Informer (Annex 6])
24 hours.
• Report suspected maternal deaths to the state nodal
officer by telephone within 24 hours
• Maintain registers of all women deaths (15-49 yrs) (Annex - 5) &
maternal deaths (Annex 4)
• Assigns interview team to investigate and fills the first page of the Format
for Verbal Autopsy (Annex 2). The cause of the death in Page 1 of Annex 2 can be filled based on the findings after the investigation is completed
.
It is desirable that the BMO should be part of the investigation team. In his
absence, he may nominate another medical officer from the block PHC to
be a part of the team.
MATERNAL DEATH REVIEW GUIDEBOOK
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• Scrutinize filled up forms to ensure the form is complete and filled
•
•
•
.
correctly.
Prepare Case summary (Annex 3] for all the maternal deaths in
consultation with the team which investigated and send it to the DNO
along with the filled in investigation format (Annex 2), within a month of
the date of notification. See box on Cause of Death on page 48 of the
Interviewer Reference Manual.
Conduct monthly meetings to review the whole process and take
corrective actions at his level. Reporting system should be reviewed even
if there are no cases in his block.
The BMO would pay Rs. 50/- to the primary informant (only ASHA and
AWW is eligible) and Rs 100/- per person for conducting the investigation
in the field (subject to a maximum of 3 persons)
Investigators
The investigators could be the Block Medical Officer (BMO]/ other Medical
Officers (MO), Lady Health Visitor(LHV), Block Public Health Nurse (BPHN),
Sector Health Nurse, Health supervisor, Nurse tutor or Auxiliary Nurse
Midwife (ANM). The investigating team should ideally comprise of 3 persons;
one for conducting the interview, one for recording and the other to co
ordinate the process. The investigators must be properly trained to
communicate with bereaved families.
Responsibilities:
• To investigate the maternal death using the format for Verbal Autopsy
[Annex 2] within 3 weeks of notification.
. Make sure all relevant information is captured during interview. If not, a
follow up interview may be required. If needed, with another respondent.
• Assist the BMO in preparation of Case summary (Annex 3)
• Hand over the filled up Format for Verbal Autopsy (Annex 2) to the BMO
for onward transmission to the District Nodal Officer (DNO) who will
prepare a compiled Line Listing for Maternal Deaths (Annex 4) of all
maternal deaths from all blocks.
MATERNAL DEATH REVIEW GUIDEBOOK
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1.3 Facility-Based MDR
Facility Based Maternal Deaths Reviews will be taken up for all Government
teaching hospitals, referral hospitals and other hospitals (District, Sub
district, CHCs) where more than 500 deliveries are conducted in a year.
Steps of Facility-based MDR
Notification
All Maternal deaths occurring in the hospital, including abortions and ectopic
gestation related deaths, in pregnant women or within 42 days after
termination of pregnancy irrespective of duration or site of pregnancy should
be informed immediately by the Medical officer who has treated the mother
and was on duty at the time of occurrence of death to the Facility Nodal
officer (FNO)
The FNO of the hospital should inform the maternal death to the District
Nodal Officer (DNO) and state nodal officer by telephone within 24 hours of
the occurrence of death. The Nodal officer of the hospital should complete the
primary informant format Annex 6 and send it to the DNO within 24hrs of the
occurrence of maternal death
Investigation
Any maternal death which occurred in the hospital should be immediately
investigated within 24hrs by the Medical officer who had treated the mother
and was on duty at the time of occurrence of death using the Facility Based
Maternal Death Review (FBMDR) Format [Annex 1] The form would be
submitted under the guidance and approval of the FNO. The FBMDR format
should be filled in triplicate, one copy would be retained by
All pregnant and
the FNO, one would be sent by the FNO to the DNO within
postpartum
24hrs and the other to the Facility Maternal Death Review
women that were
(MDR) committee of the Hospital.
treated, and died,
All medical officers in the facility must be aware about the
MDR program and oriented on the use of the FBR form. All
pregnant and postpartum women that were treated, and
died, in other departments than the OB/GYN department,
must also be reported and investigated.
in other
departments than
the OB/GYN
department, must
also be reported
and investigated.
MATERNAL DEATH REVIEW GUIDEBOOK
Facility Nodal Officer (FNO)
• Inform the District Nodal officer and state nodal officer
on the occurrence of maternal death in the hospital
within 24hours.
• Send the primary informant format (Annex 6) duly
filled to the District Nodal officer within 24 hours
| P age 16
FNO must inform
the District Nodal
officer and state
nodal officer on
the occurrence of
maternal death in
the hospital
within 24 hours.
• To review the FBMDR format filled by the medical
officer and approve it.
• Retain one copy of the FBR format with him/her, send one copy to the
Facility based Maternal Death Review Committee and the other to the
DNO within 24hrs of the maternal death.
• He/ She have to prepare a case summary and send it to the Facility based
Maternal Death Review Committee along with a copy of the case sheet.
• The case sheet should be numbered and have the patient name and
registration number on each page.
• Will keep a register of all maternal deaths in the facility; line listing of
maternal deaths (Annexure 4)
• Even if there is no death in a month, the facility should report that there
was no death in that month. (Nil death report]
• He/ She will be the nodal persons for organizing the FBMDR Committee at
the hospital
. He/ She will be attending the FBMDR Committee meeting at the District
level and also the Review conducted by the District Magistrate (DM].
Another senior officer may be nominated in his/her absence.
Facility Maternal Death Review Committee
(FMDRC)
Members of the FMDRC may be the following:
Teaching hospital:
. Superintendent of the Hospital/ Other Administrative Head of the
Institution
• Head Of Department (OBG dept]
• FNO (Obstetrician from the department]
MATERNAL DEATH REVIEW GUIDEBOOK
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• At least three members should be OBG specialists from the Dept
• One anaesthetist
• One blood bank MO
• Nursing representative
• One physician
District/Other hospitals:
• Hospital superintendent
• FNO (Obstetrician from the Dept]
• At least two obstetricians/MO in OBG department as members
•
One anaesthetist
• One blood bank MO
• Nursing representative
• One physician
FBMDR committee:
• The FNO fixes the monthly meeting in discussion with the Hospital
superintendent of the hospital
• Conducts monthly review meeting once in a month with the FBMDR
format and case summary.
• Suggests corrective measures and steps to be taken to improve quality of
care at the hospital
• Suggests steps to be taken at the District level and State level.
• Sends minutes of meeting to DNO along with the case summary prepared.
1.4 MDR at District Level
At district level there will be two review meetings, one under the chairmanship
of the CMO, second led by the District Magistrate.
District Maternal Death Review Committee
The Chief Medical Officer [CMO] is mainly responsible for the Maternal Death
Reviews at the District level. Both facility and community based reviews
would be taken up at this level
MATERNAL DEATH REVIEW GUIDEBOOK
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The District CMO should form a Maternal Death Review Committee.
Preferably, the District CMO can utilize existing quality assurance committee
of the district or a new committee could be formed at the district level for
MDR. The existing quality assurance committee or a newly formed committee
should have following members:•
CMO/CS (chairman]
• DNO (member secretary]
• ACMO
• Head of Department of Obstetrics & Gynaecology (teaching
hospital/district hospital]
• Anaesthetist
• Officer in charge of blood bank/blood storage centre
• Senior nurse nominated by the CMO/CS/DPHNO
. MO who had attended the case in the facility should be invited
The district level nodal officer convenes the meeting of the committee under
the chairmanship of CMO/CS/ACMO once every month and will put up for
review by committee all maternal death reports received in the last month.
Responsibilities of CMO
• Ensure the reception of all formats (facility and community] every month
• Review all the maternal deaths from both facility and community
• Hold monthly review meetings and recommend corrective measures.
• Select a few cases for review by the DM. Ensure participation of the family
members. Selection of cases for review by DM, based on specified criteria
(more deaths in one particular place, same type of deaths, unwanted
referrals) in consultation with DM
• Conduct quarterly review meetings with analyzed data and process
indicators identified.
• Find means of sharing the district level data from the verbal autopsy with
the communities to create awareness and initiate action at village level.
• Facilitate, through the DNO, the monthly review meeting with the District
Magistrate [DM), and send minutes of both meetings [District MDR
committee meeting and the meeting with DM) to state level.
• Facilitate the data entry and analysis at the district level [including HMIS).
MATERNAL DEATH REVIEW GUIDEBOOK
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• The minutes of the meeting will be recorded in a register. The corrective
measures will be grouped into 3 categories with time lines:
o Corrective measures at the community level
O
Corrective measures needed at the facility level
O
Corrective measures for which state support is needed
District Nodal Officer (DNO)
The nodal officer is responsible for taking up the entire review process and
follow up at the district level. The CMO has to provide necessary support to
the District Nodal Officer for taking up the process.
DNO must
Responsibilities
supervise MDR
• Supervise MDR implementation in the district - both
implementation in
at facility and community level.
the district - both
at facility and
• Receive notification of all suspected maternal deaths
community level.
from the BMO and maternal deaths from the nodal
officer of the hospital (by phone and by Annex 6]
• Receive investigation format and case summary of CBMDR from the
blocks and FBMDR from the hospitals.
• Create a combined Line-listing of Maternal deaths (Annex 4] based on the
case summary formats from both facility and community from all blocks
• Prepare a compiled case summary, when applicable
. Coordinate the District MDR committee meeting and the review meeting
with the district magistrate (DM)
• Arrange to bring two relatives of the deceased to attend the review
meeting with DM. Only relatives who were with the mother during the
treatment of complications may be invited for the meeting.
• Paying Rs. 200/- per person to the relative of the deceased person who
attends the DMs meeting, (subject to a maximum of 2 persons only)
. Ensure that the training of the block level interviewers and the BMO have
taken place
• Ensure availability of funds for payment of incentives
• Facilitate the printing of formats by the District Health Society (DHS)
(forms used at all levels) and ensure its availability at blocks and facilities.
MATERNAL DEATH REVIEW GUIDEBOOK
| P age 20
• Represent the district in state level review meetings
. Prepare the minutes of the District MDR committee meeting and the
meeting with the DM
• Follow up the recommendations/corrective actions at district, block and
facility level
. Orientation to the Medical Officers of the hospital on use of FBMDR
formats
MDR review meetings with the District Magistrate
All the Maternal Death Reports compiled by the District MDR Committee will
be put up to the District Magistrate, who will have the option of reviewing a
sample of these deaths, which will be representative of deaths occurring at
home, at facilities and in transit.
This committee should have the following members:
• Chair: District Magistrate
.
CMO
. DNO
• Facility based nodal officers
• FOGSI
• IMA
The close relatives/friends who were with the deceased mother during the
time would be invited for the meeting, as well as the service providers who
had attended on the case.
Process of the meeting
The relatives of the deceased will first narrate the events leading to the death
of the mother in front of the DM and the service providers who attended the
deceased mother. The case history of each of the selected maternal deaths
will be heard separately. After the deposition and getting clarifications from
the relatives they will be sent back. Then the various delay, the decision
making at the family, getting the transport and institutional delays would be
discussed in detail. The outcome of the meeting will be recorded as minutes
and corrective actions will be listed with time line to prevent similar delays
in future.
MATERNAL DEATH REVIEW GUIDEBOOK
I P a g e 21
Outcome
• To institute measures to prevent maternal deaths due to similar reasons
in the district in future
• To sensitize the service providers to improve their accountability
• To find out the system gaps including the facility level gaps to take
appropriate corrective measures with time-line
• To allocate funds from the district health society for the interventions
• Take necessary actions both with health and other allied departments
and review action taken
• Liaise with the state on the recommendation made by the District level
committees.
!
I? ffivtJiys
■
_________________
___________ _
Reporting death of women
(15-49 years) by ASHA/other
person to the Block PHC MO
Within 24 hours of
occurrence of
death by phone
Rs.50 per report
Reporting death of woman by
Block MO to the DNO
Within 24 hours of
occurrence of
death by phone
No incentive
Community based
investigation
Within 3 weeks of
occurrence of
death
Rs.100 per person to a
maximum of three
persons
Submission of report by
Block PHCMO/facility MDR
Nodal MO to DNO in the
prescribed form
Within 4 weeks of
occurrence of
death
No incentive
Reporting deaths of women
by Block MO/ Nodal Officer of
Facility to the DNO
Within 24 hours of
occurrence of
death by phone
No incentive
Conduct of facility based
review meetings and
preparation of district MDR
report for all deaths in district
by the District committee
(chaired by the CMO)
Every Month for
the deaths
reported in
previous month.
No incentive
Conduct of MDR meeting
chaired by District
Magistrate/Dist. Collector
Once in a month
Incentive of Rs.200
each for two persons
of the deceased family
■
.
-.
'
•
■ ■■
HSC untied
fund
HSC untied
fund
District
hospital RKS
fund
MATERNAL DEATH REVIEW GUIDEBOOK
| P a g e 22
1.5 MDR at State Level
The overall responsibility of the Maternal Death Review process lies with the
state. The key steps to be taken by the state are I) nomination of the state
nodal Officer (member of the Quality Assurance (QA) Cell/any other person),
II) formation of a state level taskforce.
_
_
State Nodal Officer (SNO)
Responsibilities
• Collect relevant data on maternal death from the district and carry out
detailed analysis
• Nominate the district level nodal officers
•
Facilitate the preparation of an annual maternal death report for the state
and organize a dissemination meeting to sensitize the various service
providers and managers. The annual report may contain typical maternal
death case studies which may be used during the training of medical and
paramedical functionaries.
State Level Taskforce (SLF)
The State level task force will be formed headed by Principal Secretary
Health and Family Welfare, Mission Director SHS, Senior Obstetrician of the
Medical College Hospital, IMA/F0GS1 and any other members nominated by
Government.
Responsibilities
• The State Level Task Force will meet once in 6 months under the
chairmanship of Principal Secretary Health and Family Welfare to review
data and minutes sent from district level, discuss the actions taken on the
minutes of the last state level meeting and make recommendations to
Government for policy and strategy formulations.
• Share operational issues /feedback with G01.
Annex 2 (Verbal
autopsy) within 3
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MATERNAL DEATH REVIEW GUIDEBOOK
[Pag e 24
Figure 2: FBMDR information flow
State Level Taskforce
District Magistrate
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MATERNAL DEATH REVIEW GUIDEBOOK
| P age 25
1.6 MDR Orientation/Training
Maternal Death Review being a new initiative in most of the states, the
personnel involved will need some orientation/training on the objectives of
MDR, the process, use of tools and monitoring & supervision. Community
based maternal death investigation will be conducted at the field level by
public health nurses, LHVs etc and they will need a structured training on
how to use the CB-MDR tool and interpret the data for developing the case
summary. Facility-based review [FB-MDR] will be conducted by medical
personnel and for them an orientation and a review of the FBMDR Review
format (Annex 1) is required. In addition, the non-health personnel and
stakeholders like the district administration, 1CDS, Panchayat functionaries
etc will also need to be sensitized on the issue because they will have an
important role in the implementation of the process and subsequent action.
The orientation/training for state, district and block level personnel may be
done in a cascade mode:
Training Cascade
Training in Delhi for State Level
Trainers
State level Sensitization
Meeting
District level
Sensitization
Meeting
Block Level
Orientation
State level
training CBMDR
CBMDR District level
training (ToT) for
MO's in the blocks
State level
training FBMDR
FBMDR District level
trainir|g for MO's of
the facilities
Block level training of
investigators
FBMDR sensitization
at the facility
MATERNAL DEATH REVIEW GUIDEBOOK
(Page 26
1.7 Training Schedule and Proposed Agendas
CB and FBMDR: Training at Delhi for state trainers
Venue
National level
Duration
2 days
Facilitators
National Core group members
Batch size
36-40
Participants
State RCH Officials
Training
materials
All formats (annexes) Case studies, Instructions/ Reference
manuals, Facilitators manuals, Guidebook on MDR, filled up formats
(if available)
Training
procedures
Power-point presentations on the background: maternal mortality
causes, current status, rationale of MDR, process of CB-MDR, roles
and responsibilities, data flow and analysis, monitoring &
supervision, review process;
•' r on filling up of the formats with help
Question by question training
of the reference manuals; interpreting the filled up questionnaire to
develop the case summaries. Best practices from other
states/districts. Development of stat plam
CB and FBMDR: State level sensitization meeting
Venue
State capital
Duration
1/2 day
Facilitators
State level trainers
Participants
State officers of Health, ICDS, P&RD, General Administration, Urban
Local Bodies and other related departments. Heads of state &
district level. Medical facilities selected for conducting FB-MDR,
divisional level officers
Training
materials
Training
procedures
Guidebook on MDR
Initial power-point presentations on the background: maternal
mortality-causes, current status, rationale of MDR, process of MDR,
roles and responsibilities, data flow and analysis, monitoring &
supervision, review process;
MATERNAL DEATH REVIEW GUIDEBOOK
| P age 27
CB and FBMDR: District level sensitization meeting
Venue
District level
Duration
1/2 day
Facilitators
DNO, CMO and ACMO
Participants
District officers of Health, ICDS, P&RD, General Administration,
Urban Local Bodies and other related Departments. Head of district
level Medical facilities. Panchayats.
Training
materials
Training
procedures
Guidebook on MDR
Initial power-point presentations on the background: maternal
mortality-causes, current status, rationale of MDR, process of MDR,
roles and responsibilities, data flow and analysis, monitoring &
supervision, review process;
Proposed agendas for sensitization meetings
(1/2 day)
1/2 day
20 min
Background MMR / causes/current status
30 min
Introduction to two types of maternal death review.
Need/purpose
60 min
____________________________
Community based MDR - operational steps
- Importance of early notification
- how to interview families
- Role of investigation team
- Role of block MO
- Reporting process____________
15 min
Committees at state and district level
15 min
Data analysis
15 min
Monitoring and supervision
=—=
MATERNAL DEATH REVIEW GUIDEBOOK
| P age 28
CBMDR: State level training to develop district level
trainers (ToT)
Venue
State capital
Duration
2 days
Facilitators
State level trainers
Batch size
24-30
Participants
Training
materials
District Nodal officer, Dy CMOs, ACMO, HFWTC faculties,
All formats (annexes) Case studies, Instructions/ Reference
manuals, Facilitators manuals, Guidebook on MDR, filled up
formats (if available)
Training
procedures
Power-point presentations on the background: maternal mortality
causes, current status, rationale of MDR, process of CB-MDR, roles
and responsibilities, data flow and analysis, monitoring &
supervision, review process;
■ ' ; on filling up of the formats with help
Question by question training
of the reference manuals; interpreting the filled up questionnaire
to develop the case summaries.________________________
CBMDR: District level training/ToT for Medical
Officers
Venue
District level
Duration
2 days
Facilitators
DNO, CMO, ACMO
Batch size
24-30
Participants
BMO, two additional Medical Officers from the block
Training
materials
Interview format for CB-MDR, Case studies. Instructions or
Reference manual, Facilitators manual, Guidebook on MDR
Training
procedures
Power-point presentations on the background: maternal mortality
causes, current status, rationale of MDR, process of CB-MDR, roles
and responsibilities, data flow and analysis, monitoring &
supervision, review process;
How to approach the household/sensitivity issues
Question by question training on filling up of the formats with help
of the reference manuals; interpreting the filled up questionnaire
to develop the case summaries.
MATERNAL DEATH REVIEW GUIDEBOOK
1 ag6n In for 2 days s ate/
| P a g e 29
st i t
training
Day 1
_______________
30 min
Introduction: The two types of Maternal Death Review
60 min
MDR - Operational steps
- Roles and responsibilities
- District level committees
- State level Taskforce ___________
15 min
The need for Community Based MDR
30 min
How to interview families
30 min
Sensitivity issues
60 min
Verbal Autopsy: Question by question
LUNCH______________________________
90 min
Group work. Practice interview sessions
60 min
Presentation of group work and discussions
30 min
Training cascade
DAY 2
15 min
30 min
60 min
120 min
Recap of day 1_______________________________
Evaluation/comparison of the verbal autopsy formats filled on Day 1
I n d i cato rs a n d a n a lysis
Preparation of state/district/block plans for MDR implementation
LUNCH
180 min
Presentation and feedback on state plans
CBMDR: Block level training of investigators
Venue
Block
Duration
2 days
Facilitators
ToT trained medical officers
Batch size
24-30
Participants
Members of the investigation team
Training materials
All formats (annexes) Case studies, Instructions/Reference manuals,
MATERNAL DEATH REVIEW GUIDEBOOK
| P a g e 30
Facilitators manuals, Guidebook, filled up formats (if available)
Training
procedures
Power-point presentations on the background: maternal mortality
causes, current status, rationale of MDR, process of CB-MDR, roles
and responsibilities, data flow and analysis, monitoring &
supervision, review process;
How to approach the household/sensitivity issues
Question by question training on filling up of the formats with help
of the reference manuals; interpreting the filled up questionnaire to
develop the case summaries.
Proposed agenda for CBMDR investigation team
(2 days)
DAY 1
30 min
Maternal mortality — causes /current status
30 min
The importance of community based MDR
90 min
CB- MDR operational steps
- Formats
- Roles and responsibilities
- Information flow
- District/state level committees
30 min
Monitoring and Supervision
LUNCH
15 min
Data Analysis
______
45 min
The interview: Ethical aspects and informed consent
45 min
Approach to the household and respondents
DAY 2
15 min
Recap of day 1________________
60 min
Role play-communication and sensitivity issues
15 min
Discussions about the role plays
30 min
Conducting the interview
LUNCH_________ __________________________________
60 min
60 min
60 min
90 min
Group practice module 1
Group practice module 2
________
Group practice module 3
Group practice complete questionnaire and case summary
MATERNAL DEATH REVIEW GUIDEBOOK
| P a g e 31
CBMDR: Block level orientation
Venue
Block level
Duration
1/2 day
Facilitators
Block MO and the Block level investigation team
Participants
Block level functionaries of Health, ICDS, P&RD. General
Administration and other related Departments. Local NGOs.
The 'notifiers' ANM, ASHA, AWW
Training
materials
Training
procedures
Guidebook on MDR, case studies
Discuss MDR, rationale and processes. Emphasize on the
importance of timely reporting of all suspected maternal deaths
Discuss how to report a women's death, work on filling up the
required formats and how to identify a suspected maternal death
Remarks
This sensitization may be done at the block Health & FW Samity
meeting as well
FBMDR: State level training (ToT)
Venue
State capital
Duration
Idays
Facilitators
State level trainers identified by the state RCH officers (minimum 3
obstetrician)
Batch size
24-30
Participants
Facility Nodal officer, Dy CMOs, ACMO, nursing tutors
Training
materials
All formats (annexes) Case studies, Instructions/ Reference
manuals, Facilitators manuals, Guidebook on MDR, filled up formats
(if available)
Training
procedures
Power-point presentations on the background: maternal mortality
causes, current status, rationale of MDR, process of FB-MDR, roles
and responsibilities, data flow and analysis, monitoring &
supervision, review process;
•' r on filling up of the formats with help
Question by question training
of the reference manuals; interpreting the filled up questionnaire to
develop the case summaries.
MATERNAL DEATH REVIEW GUIDEBOOK
| P a g c 32
State level training on FBMDR
1 day
_______
20 min
Background MMR / causes/current status
30 min
Introduction to two types of maternal death review.
N eed/purpose______________ ________________
60 min
Facility Based MDR- Process
- Role of the Nodal Officer
- Role of facility Maternal death committee
- Role of the CM0,DN0 &DM
_________
60 min
Investigate maternal deaths using FBDR format
30 min
Cause of death - definitions___________________
45 min
Group work- case studies
45 min
Presentation of group work and discussions
FBMDR: Facility level training
Venue
Facility level
Duration
1 day
Facilitators
Facility Nodal officer
Participants
Staff that will take part in the MDR nodal committee at facility
level, i.e. medical superintendent, OB-GYN etc
Training
materials
Topics
Interview format for FB-MDR, Case studies, FB-MDR reference
manual, Guidebook on MDR
Power-point presentations on the background: maternal mortality
causes, current status, rationale of MDR, process of FB-MDR, roles
and responsibilities, data flow and analysis, monitoring &
supervision, review process;
How to use the FB-MDR review format. Cause of death definitions.
Non-punitive process
—
I k ** g
MATERNAL DEATH REVIEW GUIDEBOOK
33
District Level Training on FBMDR for Medical
Officers at the facility
1 day
20 min
Background MMR / causes/current status
30 min
Introduction to two types of maternal death review.
Need/purpose______________________________
60 min
Facility Based MDR- Process
-Role of the Nodal Officer
- Role of facility Maternal death committee
- Role of the CM0,DN0 &DM
60 min
Investigate maternal deaths using FBDR format
30 min
Cause of death - definitions___________________
45 min
Group work- case studies
45 min
Presentation of group work and discussions
__________
FBMDR: Facility level sensitization workshop
Venue
Facility level
Duration
l/2day
Facilitators
Facility Nodal officer
Participants
Other medical and paramedical staff of the facility
Training
materials
Guidebook on MDR
Topics
Power-point presentations on the background: maternal mortality
causes, current status, rationale of MDR, process of FB-MDR, roles
and responsibilities, data flow and analysis, monitoring &
supervision, review process; Non-punitive process
1.8 Data Analysis
The case summaries of maternal deaths (both CBMDR & FBMDR) will be
reviewed at district and block level by the designated officials and action will
have to be taken accordingly. In addition, there is a need for in-depth analysis
of the filled up formats to identify the trends in different factors associated
MATERNAL DEATH REVIEW GUIDEBOOK
| P a g e 34
with maternal deaths. This will help in guiding policy issues related to
maternal health and also capture any change over time and comparison
between different geographical areas and population groups. The analyzed
data may also be used to design communication strategies and develop IEC
materials for awareness generation and behavior change for reducing
maternal deaths.
For the in-depth analysis of data, states may take support from experts from
Medical Colleges, Universities and other specialized agencies at state and/or
district level. Selected indicators are to be entered in HM1S, and separate
software may also be developed for data entry and analysis.
Use of analyzed data
The analyzed data will be used for developing the Annual Maternal Death
Report for the state. The report will be disseminated to all stakeholders
annually and used for state level measures for systems improvement and
community action. At district level, the analyzed data should also be shared
with stakeholders including community for programmatic improvement and
community action.
Community awareness and action
Sharing analysed data on maternal deaths is a good way to raise awareness
about the issue with the local communities. Through discussions on the
contributory factors and the three delays leading to women's deaths, it
may stimulate a will to act among the community. Presentation of the data
can also be done using street theatre etc. Experience has shown that
creative discussions with the communities, using data from the maternal
deaths in the district, may lead to increased knowledge and action to
improve birth preparedness and complication readiness at local level.
1.9 Monitoring and Supervision
MDR being a new initiative, it will need close monitoring and supervision of
the process to identify the problems that need to be addressed on a priority
basis for its effective implementation and ultimate impact.
MATERNAL DEATH REVIEW GUIDEBOOK
| P age 35
The BMO will ensure timely reporting and investigation through regular
feedback to the notifiers and investigating team. He/she will be responsible
for scrutiny of the filled up formats and provide handholding support to the
block investigation team to improve quality of investigation. The BMO as a
supervisor of the block team will also participate in the field level
investigation himself/herself.
The district nodal officer/CMO will monitor the process indicators of the
district and give feedback to the blocks. He/she will also give feedback on the
quality of investigation through scrutiny of filled up formats and case
summaries (samples] and provide support to the block level investigation
teams and BMOs, as well as FNO's in the facilities to improve the MDR
process. The entity in charge of data entry may also give feedback on the
quality of investigation through scrutiny of filled up formats. The CMO and
will also follow up with the blocks/ health facilities on implementation of the
response plans.
The state nodal officer will also follow up with the districts/Medical Colleges
on implementation of the response plans. He will also monitor the process
indicators of all the districts. The process indicators will be used to assess the
completeness of reporting, timeliness and quality of investigation, regularity
of review meetings and development of response plans.
CB-MDR process indicators
1. Proportion of maternal deaths investigated in the district
a. Reported vs. expected/estimated
b. Investigated vs. reported
FBMDR process indicators
1. Proportion of institutions that conducted FBMDR meetings
[Ex: If there are 5 identified facilities in the district, 5 meetings should be
conducted every month. Even when there is no death, meetings should be held
to discuss quality issues and action taken since previous meetings]
2. Percentage of maternal deaths notified within 24 hours
3. Proportion of maternal deaths investigated
MATERNAL DEATH REVIEW GUIDEBOOK
| P age 36
4. Proportion of minor gaps resolved.
[Ex: Anything which can be resolved at the facility level is classifies as minor]
5. Proportion of major gaps on which action is initiated (proposals submitted)
6. Proportion of major gaps on which action taken (proposals approved and
process begun)
District level process indicators
1. Proportion of MDR meetings conducted by the DM
2. Proportion of cases reviewed vs. cases investigated
3. Proportion of maternal deaths notified vs. estimated.
'^1
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MATERNAL DEATH REVIEW GUIDEBOOK
| P age 37
i||
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2. COMMUNITY
BASED MDR TOOLS
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MATERNAL DEATH REVIEW GUIDEBOOK
(Page 38
2. COMMUNITY BASED
MDR TOOLS
2.1 Interviewer Reference Manual
The purpose of this reference manual is to provide the block MO and other s
who will interview women using the verbal autopsy questionnaire (MO, LHV,
BPHN, graduate nurse, ANM etc] with the information they need to conduct
systematic, reliable and valid interviews for investigating maternal deaths.
The manual describes the roles and responsibilities of MDR interviewers, and
provides a question-by-question guide to the verbal autopsy questionnaire
for women of reproductive age.
Interviewers are to use this manual as a reference guide during their training
and, as needed, in the course of their work as MDR interviewers.
Informed consent
All potential respondents have the right to determine for themselves whether
or not they will participate in the interview. All respondents must be at least
18 years old, to help ensure that they are capable of making this decision.
Part of the job as an interviewer is to administer informed consent to all
potential respondents. This means that you must fully inform them about the
MDR and the interview process before asking any questions; and that after
learning all the facts they consent to be interviewed. Respondentfs] must
fully understand the purpose and expected duration of the interview, the
risks and benefits of being interviewed, and their right to not answer any or
all questions. All these and other facts are described in a "consent form,”
MATERNAL DEATH REVIEW GUIDEBOOK
| P a g e 39
which you must read and explain to the respondent(s) before conducting the
interview. Each respondent must make their mark on the consent form,
which you will then sign to testify that the person consented to be
interviewed. Complete a separate consent form for each respondent. The
consent form is in Annex 1
Confidentiality
It is critical that all information obtained from the MDR interviews remains
strictly confidential. You are not permitted to discuss the findings from an
interview, gossip about it, or show your records to anyone other than your
supervisor. Make all entries on the questionnaires yourself. Do not leave your
verbal autopsy forms lying around where unauthorized persons may have
access to them.
Maintaining confidentiality is an ethical responsibility that we all share. It is
necessary to protect the respondents from any repercussions that might
occur as a result of the information they have provided. It is also necessary to
maintain the trust of the community and assure that people will be willing to
talk openly to us about the maternal deaths.
Falsification of data
Your job as an interviewer will not always be easy. There may be times when
you have to visit a household more than once to meet with the best
respondent. The interview will often take one hour or longer to complete.
Many of the questions seek sensitive information that may appear to reflect
badly on care provided to women by their families and sometimes by the
health system. All these conditions can lead to temptations to falsify data in
order to quickly complete the interview and not record painful facts.
However, you must never falsify your work. The whole purpose of the MDR
project is to collect and share information with the community that can be
used to prevent maternal deaths. This will be possible only if the information
collected is truthful. It is your responsibility to assure that you maintain this
standard. You should work as an interviewer only if you are certain you can
accomplish this.
MATERNAL DEATH REVIEW GUIDEBOOK
| P a g e 40
Approach to the household and selecting the
respondent(s)
The interview is best conducted with the one or a few persons who were
with the woman during her fatal illness and death. However, when
approaching a household in a rural village you are likely to be met by a crowd
of interested persons. Once inside the yard or the house several neighbours
and family members who know little about the woman’s illness may want to
participate in the interview or just observe. You must manage this situation
effectively and sensitively in order to ensure that you interview the most
knowledgeable person(s) and that the others are not offended.
Consider working with a local respected person (e.g., schoolteacher, village
leader) to pre-arrange the meeting and/or to accompany the interview team
to the household.
In order to have respondent’s cooperation and obtain complete and accurate
data, you must first gain the trust and confidence of the household. You can
do this by making a good impression and conducting yourself in a
professional, but also friendly manner.
Understand the project
If you are knowledgeable about the project and your responsibilities
respondents will be more likely to trust you and participate. You should be
able to answer any questions that household members may ask about the
purpose of the project and how the information they share will be used.
Emphasize the confidentiality of the information
You must assure participants that their responses will be held in strictest
confidence. No information will ever be released to anyone outside the
project in a way that reveals who provided the information.
If a household member or respondent hesitates to cooperate because of
confidentiality concerns, you should fully explain how confidentiality will be
maintained. Explain that no names will ever be revealed and that the
information from all interviews will be combined in a report for district and
national use.
MATERNAL DEATH REVIEW GUIDEBOOK
| P age 41
Introducing yourself at the household
This is a very sensitive time for the family so it is important that you be polite
and sensitive when introducing yourself. Be sure to state the purpose and
confidential nature of the interview—these are key elements to gaining the
family's cooperation. An example is provided below:
My name is [say your name]. / am a nurse/
in the-------- center, and an
interviewer with for MDR. I have been informed that a woman in your household
died. I am very sorry to hear this. Please accept my sympathy. In order to
improve health care in our district, we are collecting information on recent deaths
of women in this area. I would like to talk to the person in your house who took
care of [say the woman’s name] during her illness before death. I assure you that
any information you or your family provide will be kept confidential.
How to select the best respondent
The respondent is the main person that will provide information about the
deceased. S/he should be the one who was with the woman during her
illness. Usually, the woman’s husband, mother, sister or mother-in-law is the
preferred respondent for a maternal death. In some cases more than one
person will have taken care of the woman or been present during different
stages of the illness. For example, the woman’s mother may have attended
the birth at home, while the woman’s husband may have accompanied her to
the hospital after the birth. All respondents must be at least 18 years of age.
What to do if the potential respondent(s) is away or lives elsewhere
If the person(s) who appearfs) to be the best respondent is not available
when you first visit the household, try to make an appointment to return
when they will be at home. If no one is at home when you visit the house try
to ask a neighbour when you might be able to find family members at home.
Then leave a message indicating that you plan to return at this time. In either
case, make a note of this return date in your notebook.
Sometimes the best respondent(s) may have moved to another village. In this
case, you should discuss the situation with your supervisor, who will decide if
you should travel to the other village or if help needs to be sought from the
MDR team in another block.
How to handle multiple respondents
As discussed above, there may be instances when you need more than one
respondent to get the full story of the woman's illness. If you interview these
MATERNAL DEATH REVIEW GUIDEBOOK
I P a g e 42
persons together it should be clear as to who is the respondent for which
stage of the illness. More than one person answering the same question can
lead to confusion and greatly lengthen the interview.
Some persons who were not with the woman during her illness may insist on
attending the interview or even on being the respondent. For example the
woman's husband or mother might not let the sister talk to you alone, even if
she took care of the woman during the illness. Or, the respondent may have
children to care for who distract her attention from the interview. Lastly,
having a visitor at the household can attract many other unwanted people to
observe the interview. In these cases it is important to stress to the
respondent the importance of confidentiality and privacy. You can try.
• Suggest moving to a different location
• Ask some of the bystanders to leave and come back once the interview is
finished.
• Reschedule a time to come back and finish the interview
Communication and sensitivity issues
Effective communication with the respondent is of key importance in
obtaining high quality information. As an interviewer, you will interact with
bereaved relatives of women who have recently died. In addition to
mastering basic communication techniques, you need to be sensitive to the
emotions of these bereaved persons and know how to handle difficult
situations that might arise during the interview.
How to approach the respondent
Always have a positive approach. Do not use phrases such as: Are you too
busy?” or "Can you spare an hour?” Such questions invite refusal before you
start. Instead, begin by restating condolences for the death and say:' I would
like to ask you a few questions." or “I would like to talk with you for a few
minutes.” Just as when approaching the household, state the purpose of the
interview and its importance for helping the community; and stress the
confidential nature of the interview.
MATERNAL DEATH REVIEW GUIDEBOOK
| P a g e 43
However, if a respondent insists that s/he does not wish to talk to you, do not
argue. Instead, ask her/him for another day or time when s/he would be
available to participate in the interview. Answer any questions the
respondent asks frankly and to the best of your knowledge.
Basic communication techniques
Sit at the same level as the respondent(s) and maintain eye contact
Always look at the respondent when administering the interview. Remember,
this is a difficult time for the respondent and they must feel comfortable with
you in order to complete the interview.
Build rapport with the respondent(s)
Try to build rapport with the respondent(s) before discussing the case of the
deceased. For example, if culturally appropriate, you may ask the respondent
what work s/he does, or ask about her/his family.
Encourage speech, listen actively, do not rush, nod your head
These are ways of showing the respondent that you are interested in what
s/he is saying, and will encourage her/him to continue.
Be non-judgmental
Some of the respondent's answers may lead you to feel that s/he contributed
to the woman’s death, for example, by not taking her for health care quickly
enough. However, you must not transmit this message in any way because it
will discourage the respondent from providing truthful answers. The success
of the project depends on all of us taking this non-blaming approach. The
idea is for us and the community to learn what we can do together to prevent
maternal deaths. This can only be accomplished by working together without
blaming individuals for the deaths.
Language problems
If you encounter any language difficulties, for example, if you anticipate that a
respondent speaks a different dialect than you do, talk to your supervisor
beforehand.
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Bereaved respondents and sensitivity issues
Persons who are mourning the death of a loved might have several emotional
responses that could interfere with the interview. These might include the
following, some of which are discussed below:
• Becoming sad or upset
• Getting offended or angry
• Being wary or suspicious of the entire interview or certain questions
• Not wanting to answer certain questions for unstated reasons
Sadness, tearfulness
First, be sure to express your sympathy and condolences for the respondent s
loss before starting the interview. It may also help respondents to know that
the health program and community will use the MDR data to help improve
care for other women. If a respondent begins to cry or have great difficulty in
answering questions because s/he is overcome with emotion, you should
pause and offer a tissue for tears. Acknowledge how difficult it must be to
answer the questions, give the respondent time to regain their composure,
and ask if s/he can continue at this time. If the respondent chooses not to
continue, attempt to reschedule the interview.
Anger
A respondent may be angry at the health program if s/he feels that an
individual health worker or the health program in some way contributed to
the death. The respondent might direct this anger at you if s/he sees you as a
representative of the health program. Another possibility is that a
respondent may blame a relative or neighbor for the woman’s death if, for
example, s/he feels that this person did not provide help that was needed.
This anger could also come out during the interview. If this happens, let the
person express their anger. Then, again express your condolences for their
loss and acknowledge that you understand that they blame the particular
person or the health program. (Never state that you agree with them, just
that you understand that this is their feeling.) Last, again explain that the
purpose of the interviews is to learn more about the problems that lead to
maternal deaths and to help the community work together to overcome these
problems.
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Not wanting to answer certain questions
There could be several reasons that a respondent does not want to answer
certain questions. A question may rekindle painful memories; it may ask
about a topic that is particularly sensitive for the respondent; the respondent
may feel that they personally did not do enough to help the woman and that
the answer to the question would reflect badly on them, etc. Whatever the
reason, you must never demand or even ask a respondent to answer a
question that they have told you they do not want to answer. As stated in the
informed consent statement, respondents' participation is totally voluntary
and they have the right to refuse to answer any or all questions. It should not
be a problem for the interview if a respondent refuses to answer only a few
questions. However, many refusals will compromise the quality of the
interview. You should make a note about any reasons you think might be
leading to the respondent’s reluctance and discuss such cases with your
supervisor.
Conducting the interview
Materials you will need
Interviewers will be provided the materials listed below to help them
perform their duties. Make sure that you secure them in a safe place in your
home when you are not working to prevent loss, damage, or any
unauthorized person seeing information that is recorded on the MDR forms.
• Interviewer identification card (be sure to wear it where it can be seen]
• This manual, Maternal Death Review Interviewer s Reference Manual
• Blank maternal death verbal autopsy formats
• Consent form
• Pencils or pens for writing, and erasers
• Bag for carrying forms and other materials.
General instructions for the verbal autopsy
questionnaire
1. The first page of the questionnaire, except probable cause of death, will be filled
out by the block MO that assigns you the interview.
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2. The questionnaire has 3 modules that should be filled up according to the type
of death, however module 1 must be filled for all.
Antenatal deaths:
Module 1 and 2 (section 6 and 11)
Abortion deaths:
Module 1 and 2 (section 7 and 11)
Death during delivery:
Module 1 and 3 (section 8,10 and 11)
Postnatal deaths:
Module 1 and 3 (section 9,10, and 11)
3. Ask the questions slowly and clearly so the respondent understands. Allow the
respondent to think about the question before recording their answer. Note that
respondents may tend to give answers that they think will please the
interviewer. Do not show any surprise, approval or disapproval of the
respondent’s answer by the tone of your voice or facial expression.
4. If the respondent doesn’t know the answer to a question or looks uncomfortable
with the question, you can try “probing” to get an answer. This means asking
other questions similar to the subject material to try and help the respondent
remember certain events. For example, if the respondent cannot remember who
assisted the woman with the birth in the home, you might try “probing” by
asking: “Who was in the room at the time of delivery?” Use your judgment when
probing. Remember, this is a very sensitive time for the respondent and we do
not want to upset them further.
5. Allow the respondent to narrate the events leading to the death of the mother in
their own words. Keep prompting until the respondent says there was nothing
more to say.
6. If you make a mistake when marking your answers do not erase the
information. Instead, cross it out neatly with one line so the original entry can
still be read, and then mark the correct answer. Write your initials next to the
correction, so anyone who later examines the completed format will know who
made any changes in the answers. Corrections can be made only by the
designated interviewer.
Question-by-Question instructions
Front page: Available background information (to be filled out before
the interview)
Page 1 should be completed when you receive the format from your
supervisor. It provides background information that was gathered by the
death notifies which you should use to help locate the correct household
where a suspected maternal death occurred. However, the last question;
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probable cause of death, is not always clear and can be filled out by the
investigators after the interview.
Name of the state
Write name
Name of the district
Write name
Name of the block
Write name
Name of the PHC
Write the name of the PHC to which the mother belongs.
Name of the SC
Write the name of the Sub- center to which the mother belongs.
Name of pregnant woman/mother
Knowing the woman’s name will help you locate the correct household for
the interview and to communicate about the woman with the people you
meet at the household
Name of husband/other (father, mother)
If there is no information about the husband, the name of the head of
household can be noted here.
Date of woman's death
The day, month and year should be recorded. This can also help you locate
the correct household and ensure that you conduct the interview about the
correct woman.
Name and designation of the investigators
Full name and designation of the interviewer team (interviewer and
recorder). Please write the task (interviewer or recorder) in brackets next to
the name. >
Date of investigation
Date of the interview. If it is necessary to return a second time, write the
second date here as well.
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Probable cause of death
The MO may not have the information to answer this before the interview, so
it should be filled by the investigators after the interview. Please add also
underlying causes, in addition to medical causes - if known.
Cause of Death
Symptoms
_____________
Bleeding in antenatal period
APH
Bleeding after delivery or postnatal period
PPH
Convulsions in antenatal period
Eclampsia
Infection , fever and foul smelling
discharge after delivery
____
Puerperal sepsis
Woman not delivered after 18 hours after
Prolonged labour
onset of labour
________
Sudden cessation of labour pains, woman
Ruptured uterus
in shock
Woman develops fever and becomes
unconsciousness after induced abortion
Septic abortion
Any other cause
Other (specify)
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MODULE 1
1. Background information 2. Family history 3. Infant survival 4.
Availability of health facilities, services and transport 5. Current pregnancy
INSTRUCTION: Introduce yourself and the purpose ofyour visit Say that we
are trying to improve the care of women and children. Ask to speak to the
person(s) who knows the most about the circumstances of the woman's death.
This might be her sister, mother, mother-in-law or other person. In some cases
you may need to speak with more than one person to learn about different
stages of the illness. Ifsomeone you need to speak with is not available, arrange
a time to return when s/he will be home. Read the consent form to the
respondent(s) and ask for her/his participation. Each respondent must consent
to be interviewed.
Use the name of the woman who has died, when you are asking questions about
her in the interview. E.g. How old was/--- / when she died?
1. Background information
1.1 Resident /visitor death
Write 'Resident’ if the woman who died is a resident of the village/area
where she died. If she is usually residing outside, she is classified as a visitor
For example, if she was staying in her mother house during the delivery, she
can be classified as a visitor
1.2 Type of death
Ask the respondent whether the woman died after having an abortion, before
the labour started, during labour or after. If this is not yet clear, you can wait
to tick an answer until it becomes clearer later in the interview.
1.3 Place of death
Tick the right answer. If this answer is not written, please specify in othei s
1.4 Specify the name and place of the institution or village where death
occurred. Write down name of the facility and/or village where she died.
1.5
Onset of fatal illness
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MATERNAL DEATH REVIEW GUIDEBOOK
Try to find out when the women sickness that led to her death actually
started. Write down day/month/year and the time of day. If time of day is not
accurately known, write down an estimated time.
1.6
Admission in final institution (if applicable)
Final institution means the health facility in which she finally died. If she did
not die in a health facility, this question can be skipped. Write day/month
/year and time of day of the admission.
1.7
Death
Write day/month/year of death and the time of day.
1.8
Gravida
How many times has she been pregnant? Include this pregnancy, non- live
births and abortions as well. Tick the appropriate answer.
1.9 Para
Para means the number of live births that the woman has had previously.
Multiple births, i.e. twins, are considered as one para. Tick the appropriate
answer.
1.10 Abortions
Has the woman previously lost any pregnancies due to either spontaneous or
induced abortion? Spontaneous abortion is defined as < 20 weeks gestation.
1.11 Previous stillbirths
Did the woman previously experience any stillbirth? Stillbirth is defined as >
20 weeks gestation. Tick the appropriate answer.
1.12 Living children
How many living children did the women have (previous to the last
pregnancy)? Tick the appropriate answer.
1.13 Week of pregnancy (if applicable)
If the woman died after abortion, an antenatal death, or during delivery, try
to estimate the week of pregnancy she was in when she died. If respondents
know the expected date of delivery (EDD), this can help estimate number of
weeks.
Weeks
1-4
5-8
9-13
14-17
17-21
22-26
27-30
31- 35
36-40
Month
1
2
3
4
5
6
7
8
9
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1.14 Age at death
Even if the respondent does not know the woman's exact age it can help to
know her approximate age. Please estimate if not known exactly. Record the
exact or estimated age in completed, years.
2.0 Family history
2.1 Age at marriage
Tick the right answer.
2.2 Religion
Tick the correct answer. If, others, please specify.
2.3 Community
Tick the correct answer (SC= Scheduled caste, ST = Scheduled tribe, OBC Other backward class, OC = Other class )
2.4 Occupation
This means the occupation of the deceased mother. What was the main/daily
work of the woman? Tick the most appropriate answer. If there is none of the
ones mentioned, note than her occupation in others
2.5 Education
Please tick the correct answer according to how many years in school the
deceased women have completed.
3.0 Infant survival
3.1 Infant
At the time of the interview, is the newborn baby alive or dead? If dead,
please indicate whether it was a stillbirth or a newborn death. If the mother
died an antenatal death or abortion related death, please write N/A (not
applicable).
4.0 Availability of health facilities services and
transport
4.1 Name and location of the nearest government / private facility
providing Emergency Obstetric Care Services
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This information you can fill in before the interview, without asking the
respondents. Considering the village where the women lived, write the name
of nearest facility that provides Emergency Obstetric Care Services [EmOC]
EmOc Facility: A facility that can provide the 9 signal functions of comprehensive
emergency obstetric care:
1) Administer parenteral antibiotics (2) Administer uterotonic drugs (3) Administer
parenteral anticonvulsants for preeclampsia and eclampsia 4) Manually remove the
placenta (5) Remove retained products 6) Perform assisted vaginal delivery (7) Perform
basic neonatal resuscitation (8) Perform surgery (9) Perform blood transfusion
4.2 Distance of this facility from the residence
These questions you can also fill in without asking the respondents. Estimate
how many kilometres it is from the village to the above mentioned facility.
4.3
Number of institutions visited before death (in the order of visits)
Ask the respondents if they visited any formal health facilities (sub- center
and upwards) before she died. If there is more than one, list the name of the
institutions from the first to last. If she did not go to any, write 0 (zero)
4.4. Reasons given by providers for the referral
If the woman were referred to another facility, ask the respondents if the
health staff explained why she had to be referred. Tick the appropriate
answer, if’others’ please specify.
If the woman was not referred, tick 'Not applicable'
5.0 Current pregnancy
5.1 AN Care
Ask if the woman had any ANC check up during her pregnancy. Tick the
correct answer.
5.2
If yes, Place of Antenatal checkup
Please tick the appropriate answer. If she went to different places, you can
tick more than one. If she did not have any ANC check- up, write N/A for non
applicable. If‘other’, please specify/
5.3 Number of antenatal check ups
Please tick the correct answer.
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MODULE II
This module is only to be filled out if there was an abortion related death or
antenatal death - as stated in question 1.2. 6.1 to 6.5 is for antenatal death
only and 6.6 to 6.18 is for abortion deaths only
6 .0 Deaths during the antenatal period
6.1 Did the mother have any problem during antenatal period?
Ask the respondents if the woman had any problems relating to pregnancy or
been feeling ill during the antenatal period. If she had problems or was
feeling ill, tick yes. If she did not have any problems and was feeling well, tick
no. If the respondent is not sure, tick not known.
6.2 If yes, was she referred anytime during her antenatal period?
If the above answer was yes, meaning she had problems or was feeling ill
during the antenatal period, ask if a health worker referred her to a health
facility during the same period. Tick the correct answer. If the answer above
is no or not known, write N/A for not applicable.
6.3 What was the symptom for which she sought care?
Here is a list of symptoms, please tick the appropriate one(s) Ask the
question as an open question -but if they do not respond, you can prompt
carefully by asking about the listed symptoms. After they have answered,
kindly ask: 'anything else?’
6.4 If YES, did she attend any hospital?
This question is linked to 6.2. If yes, the woman was referred, please answer
if she attended the any formal facility after being referred. If she was not
referred, write N/A for not applicable.
6.5 In case of not seeking care from the hospital is it due to:
If the answer is yes or don’t know to 6.4, please write N/A for not applicable.
If the answer to the previous question 6.4 is no, please continue with this
question and tick the appropriate answer. If 'others' please specify in writing.
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7. 0 Abortion deaths
7.1 Did she die while having an abortion or within 6 weeks after having
an abortion?
An abortion is either spontaneous < 20 weeks gestation or induced. Please
tick the appropriate answer
7.2 If during an abortion, was the abortion spontaneous or induced,
including MTP?
if the onset of abortion is spontaneous, tick spontaneous. Induced abortion
also include induced by self or other unskilled person. Please tick the
appropriate answer.
MTP means both surgically through Vacuum Aspiration and medically using medicines.
7.3 If the abortion was induced, how was it induced?
Please tick the appropriate answer. If possible, please specify whether it was
MTP. If the abortion was not induced, tick 'not applicable’.
7.4 If the abortion was induced, where did she have the abortion?
Please tick the appropriate answer. If appropriate answer does not fit any
category, please specify outside the column, i.e. if the abortion took place at a
quack. If the abortion was not induced, tick' not applicable’.
7.5 If the abortion was induced, who performed the abortion?
Please tick the appropriate answer. If the abortion was not induced, tick ‘not
applicable’. If 'other ', please specify in writing.
7.6 If induced, what made family seek care?
This question means the reason for why she went to ‘induce’ the abortion.
Did she initially start bleeding, or did she have the abortion because she
wanted to terminate? Tick the appropriate answer. If the abortion was not
induced, tick ‘not applicable’
7.7 If the abortion was spontaneous, where was the abortion completed?
Please tick the appropriate answer. If other, please specify (e.g. informal
providers, quacks)
If the abortion was not spontaneous, tick 'not applicable
7.8 How many weeks of pregnancy completed at the time of abortion
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Write down weeks in completed weeks (same as in 1.13)
7.9 Whether she had any of these symptoms after abortion?
Ask the respondent whether she has any of the listed symptoms after the
abortion. Tick the appropriate one (s) If she did not have any symptoms, tick
'none'
7.10 After developing complications following abortion, did she seek
care?
Please tick the appropriate answer. If other, please specify, e.g. if she
developed complications while she was still in the facility that performed the
abortion
7.11 If yes, whom/where did she seek care?
This question is only applicable if answer to 7.10 is yes. Tick the appropriate
answer. If others, please specify. If she did not seek care, tick 'not applicable
7.12 In case of not seeking appropriate care, is it due to..
If the answer is yes or don’t know to 7.10, please write N/A for not
applicable. If the answer to the previous question 6.10 is no, please continue
with this question and tick the appropriate answer. If‘others’ please specify
in writing.
7.13 Date of spontaneous abortion/ date of termination of pregnancy
Write the day/month/ year of abortion.
7.14 Date of death
Repeat answer from 1.7
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MODULE-III
This module is only to be filled for deaths that occurred during delivery, and
postnatal deaths. Section 8 is for deaths during labor and delivery only, and
section 9 is for postnatal deaths only. Section 10 and 11 will be filled up by
both delivery and postnatal deaths.
8.0 Intranatal services
8.1 Place of delivery
Please tick the appropriate answer. If it is 'other' please specify in writing.
8.2 Admission (not applicable for home delivery and transit)
Write the day/month /year she was admitted in the facility where she
delivered. If she did not deliver in a facility, please tick 'not applicable’.
8.3 Delivery
Write day/month/year and the time of day when the baby was born. Tick
'Not applicable' if mother dies in labour, but before the baby is born.
8.4 Time interval between onset of pain and delivery (in hours)
Write down the time difference between start of labor pain and birth of baby.
Tick 'Not applicable’ if mother dies in labour, but before the baby is born.
8.5 Who conducted the delivery- if at home or in institution (Not
applicable for transit delivery)
This question includes both private and public health facilities. Tick the one
that attended her at the time. Please tick the appropriate answer. If 'other',
please specify.
8.6 Type of delivery
Please tick the appropriate answer . Tick ‘Not applicable’ if mother dies in
labour, but before the baby is born.
8.7 Outcome of the delivery
Please tick the appropriate answer. If multiple births, write down how many
alive/dead. Tick 'Not applicable’ if mother dies in labour, but before the baby
is born.
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8.8 During the process of labor/delivery did the mother have any
problems?
Please see the possible answers and tick the appropriate one. If there are not
any of the mentioned alternatives, please specify elaborately in 'others'. If she
did not have any problems, write No.
8.9 Did she seek treatment, if yes by whom and what was the treatment
given by the ANM/Nurse/LHV/ / MO/others? (Give details)
If the woman was having problems during the delivery (8.8), please write
here a small narrative on what happened - did she seek treatment? Who
treated her? Was any treatment given?
If she did not seek care, or respondent does not know, please note it as well.
8.10 Was she referred?
If answer to 8.9 is no, question 8.10 - 8.17 is not applicable. Skip to section 9.
If answer to 8.9 is yes, please tick the appropriate answer.
8.11 Did she attend the referral centre?
If answer to 8.10 is no or not known, question 8.11 - 8.17 is not applicable.
Skip to section 9. If answer to 8.10 is yes, please tick the appropriate answer.
8.12 In case of non compliance of referrals state the reasons
If answer to 8.11 is no, she did not attend the referral centre- please ask why
and tick the appropriate answer. If'other', please specify.
If answer to 8.11 is yes, tick ‘not applicable'.
8.13 Was there delay in:
If answer to 8.11 is yes - she did go to the place she was referred, ask if there
was delay (it took quite some time) in any of the alternatives listed in
questionnaire. ‘Decision making’ means if it took time to decide to seek help.
Please tick the appropriate answer(s). If any ‘other’ delays, please specify.
8.14 Any information given to the relatives about the nature of
complication from the hospital
If the woman went to a health facility, ask if the persons who accompanied
her received any information about her condition from the health staff.
Please tick the appropriate answer
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8.15 If yes, describe
If they did receive information, please write a small narrative on what
information they got. If the answer to 8.14 is no, please tick 'not applicable
8.16 Was there any delay in initiating treatment?
Ask if the woman had to wait for some time in the facility before they started
the treatment. Tick the appropriate answer.
8.17 If yes, describe
If the answer to question 8.16 is yes, please write a small narrative on what
happened. What caused the delay? No staff, they had to pay the first etc. If
the answer to question 8.16 is no, please tick 'not applicable'
9. 0 Postnatal period
9.1 No. of Postnatal checkups
Ask how many times she was seen by a health staff after the delivery - either
at home or if she returned to the facility. Please tick the appropriate answer.
9.2. Did the mother had any problem following delivery
Ask if the mother had any problems during the delivery and/or the
immediate period after. Please tick the appropriate answer.
9.3 Onset of the problem.
Write day/month/year and time of day when she got the illness that lead to
her death. Please tick the appropriate answer.
9.4 Specific problems during the postnatal period
Ask the question as an open question -but if they do not respond, you can
prompt carefully by asking about the listed symptoms. After they have
answered, kindly ask: 'anything else?’
Please tick the appropriate answer. If 'other ', please specify. If she did not
have any specific problems, write No and skip question 9.5 - 9-9.
9.5 Did she seek treatment?
Please tick the appropriate answer.
9.6 If yes, by whom
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Please tick the appropriate answer. If‘otherplease specify. If she did not
seek treatment, please tick ‘not applicable’.
9.7 What was the treatment given (give details)
Please write a short narrative about what the healthcare provider (formal/
informal) did to help the woman. If she did not seek treatment, please write
N/A for not applicable.
9.8 Was she referred?
Please tick the appropriate answer. Tick 'Not applicable' if she had not sought
care in the first place (question 9.4 or 9.5 is no)
9.9 Did she attend the referral center?
If answer to 9.7 is yes, please tick appropriate answer. Tick ‘Not applicable’ if
she had not sought care in the first place (question 9.4 or 9.5 is no)
9.10 In case of non compliance of referrals state the reasons
If the answer to question 9.9 is no, please ask the respondent why she did not
go. Please tick the appropriate answer. If 'other ', please specify in writing.
If the answer to question 9.8 is no, please tick ‘not applicable’
10. Reported cause of death
10.1 Did a doctor/nurse at the health facility tell you the cause of death?
Please tick the appropriate answer
10.2 If yes, what was the cause of death.
If the answer to question 10.1 is no, nobody was told the cause of death,
please write N/A for not applicable.
11. Open history
Read: Thank you for answering the many questions that I've asked. Would you
like to tell me about the illness in your own words? Also, is there anything else
about her illness that I did not ask and you would like to tell me about?
After the respondent(s) finishes, ask: Is there anything else? Write the
respondent's exact words. After s/he has finished, read it back and ask
her to correct any errors in what you wrote.
THANK RESPONDENT(S) FOR THEIR COOPERATION
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Informed Consent Form
Interview about a maternal death
Instructions to Interviewer: Please ask the respondent to acknowledge her/his
consent to be interviewed by checking the response below. The interviewer
should sign and put date below. If the respondent does not consent to the
interview, thank her/him for their time and terminate the conversation.
Purpose of the interview: We are talking to people in the community to learn why some
women die while they are pregnant or during or soon after giving birth. At the same time,
we are learning about the reasons that some babies die during the pregnancy or soon after
the birth.
What will happen during the interview: 1 will ask you questions about your
relative/neighbor/friend who recently died. 1 will ask about her background, her
pregnancy history and events during her most recent pregnancy. I may also some questions
about her baby from this pregnancy. Some questions have a choice of possible answers and
others are open-ended.
Time required: Your interview will take approximately one hour.
Risks: It is possible that some questions could make you feel uncomfortable by talking
about bad experiences.
Benefits: There are no direct benefits, however, your participation will help up improve
maternal and newborn care for women and babies.
Confidentiality: All information you provide will be kept confidential. Your responses will
be assigned a code number and your name will not be used in any way.
Voluntary Participation: Your participation is strictly voluntary. Refusal to participate will
not affect whether or not you receive subsequent services. You may discontinue
participation at any time.
Contact: If you have any questions or concerns, please contact.
Doyon agree to participate in this interview?
Interviewer
Date
Respondent’s relationship to woman
□ YES
□
NO
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2.2 Manual for Trainers of Interviewers
SESSION PLAN
Title
Sessions
Duration
Session 1
Ethical Aspects and Informed Consent
45 min
Session 2
Approach to the household and respondents
45 min
Session 3
Role play-communication and sensitive issues
60 min
Session 4
Conducting the Interview
30 min
Session 5
Group practice module 1
60 min
Session 6
Group practice module 2
60 min
Session 7
Group practice module 3
60 min
Session 8
Group practice complete questionnaire
90 min
SESSION 1: ETHICAL ASPECTS AND INFORMED CONSENT
Purpose: This session ensures that the participants understand the importance of
conducting MDR in an ethical manner and how to accomplish this.
Objectives: After completing this session, participants will be able to:
1.
Define three key principles of human subjects research ethics;
2.
Know how to administer informed consent;
3.
Understand why they must keep the MDR data confidential
Duration: 45 minutes
Needed provide materials: PowerPoint presentation on Ethical Aspects of MDR;
informed consent form (Appendix A of the Interviewer's Reference Manual)
GETTING STARTED
Inform the participants: This session will consist of a slide presentation,
discussion and looking over the informed consent form. You should review
the consent form on your own this evening.
Slide Presentation: Ethical Aspects of Maternal Death Review
Slide 1 (title slide): Explain: There are two reasons why it is so important
that we all conduct MDR in an ethical manner. First, we are trying to help the
community, so of course it's the right thing to do to treat people decently.
Second, acting in this manner will help us gain the community's trust so that
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people will be more likely to share information with us. This is the only way
we can learn the true stories of what happened to the women during their
fatal illnesses, and so be able to help prevent further deaths.
Slide 2: Explain: All persons who are conducting interviews must be trained
in how to maintain the required ethical standards and how to ensure
informed consent from the interviewee. That means everyone in this room
who will be an interviewer or supervisor. Later in this session, we will
discuss what informed consent means and how you will administer this.
Slide 3: Explain: There are three key ethical principles that govern all
research activities. The words ‘ethical principles’ are underlined to remind
you that the three points on this slide are the principles. After we discuss the
principles, we will discuss how we maintain the principles. But remember
that the three points on this slide are the principles that must be maintained.
The first principle is:
1. Justice, which means that the burdens and benefits must be distributed fairly.
For example, if there are two maternal deaths and you can only interview one,
then you have to find a fair way to decide which one to interview.
2. Respect for individuals’ autonomy, meaning that everyone has the right to
decide for him or herself if they will participate; and that children and other
persons with diminished autonomy must be protected. Therefore, we will only
interview people who are over 18 years old.
3. Beneficence, which means that we must do our best to maximize the benefits of
our work and minimize the risks.
Slide 4: Explain: We do certain things to maintain these principles. The first
principle, justice, is maintained by equitable and factual recruitment of the
respondents. This means that we can’t make any false promises, such as that
you will pay them money to answer the questions. The second principle,
autonomy, is maintained by informed consent. This means that before you
can interview anyone, you must tell them all about the interview and then
they must consent to be interviewed. We will discuss this more fully in a
moment. The third principle, beneficence, is maintained by everyone on the
MDR team taking responsibility for their actions. Now let's discuss each of
these in more detail.
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Slide 5: Explain: Remember, equitable and fair conduct to the respondents
maintains the principle of justice. You don't need to memorize the points on
this slide because they are included in the informed consent statement that
you will read to potential respondents. But you do need to understand them.
To be fair to someone when asking them for an interview, you must clearly
describe the purpose of the study. You must invite them to participate, which
means it is their choice. You can’t make any false promises or threaten them
in any way if they decide not to participate. And you have to tell them about
the interview itself, for example, about how long it will last.
Slides 6 and 7: Explain: Informed consent maintains the principle of
autonomy. Only by being fully informed about the study can someone decide
if they want to participate. You will administer informed consent just before
doing the interview. Everything on these two slides is part of the statement
that you will read to potential respondents. (Read the items on the slides.)
Ask participants and discuss: Notice that the only risk to a respondent is the
discomfort he or she may feel when talking about the death of their family
member. However, can you think of any other risks that might happen if we
don't maintain the confidentiality of the information that respondents share
with us?
Write: all responses on flip-chart paper. Discuss that breaching
confidentiality could lead to a risk for the respondent. For example, the
woman’s in-laws might share some information about the care they provided
during her illness that they would not want her parents to know.
ACTIVITY: Read through the informed consent form
The trainees (interviewers and supervisors) take turns reading aloud
sections of the informed consent form. The trainers answer any questions.
Remind the participants to review the form this evening on their own.
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SESSION 2: APPROACH TO THE HOUSEHOLD AND RESPONDENTS
Purpose: This session marks the transition to actually conducting the
interview. It provides ways to approach a household where an interview is
to be conducted and to identify and approach the best respondent(s). it
also discusses communication and sensitivity issues
Objectives: After completing this session the participants should be able to:
1. List the MDR interview sequence in the correct order;
2. State three helpful methods for approaching a household; and
3. Identify the best respondent(s) for a maternal death inquiry.
4. Identify some sensitive ways to deal with possible reactions;
Duration: 45 minutes
Needed provided materials: PowerPoint presentation on Approach to the
Household and Respondents
Inform the participants: This session will consist of a slide presentation and
discussion.
ACTIVITY: Slide Presentation: Approach the Household and
Identify the Respondent(s)
Slide 1 (title slide): Explain: In this presentation we will make the transition
to conducting the interview. While we won't actually look at the
questionnaire until tomorrow, the steps and methods that we will discuss
now are critical to the success of the interview. The first presentation is on
how to approach the household and identify the best respondents. The next
presentation is on communication methods and being sensitive to bereaved
respondents.
Slide 2: Explain: The interview sequence consists of the four steps you see on
this slide: 1) Approach the household, 2) Identify the best respondent or
respondents, 3) Obtain informed consent, and 4) Conduct the interview.
Slide 3: Explain: When your supervisor assigns a maternal death to you for
interview, he or she will give you a blank MDR questionnaire except for page
1, which will be filled with locating information provided by the death
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notifier. Use this information to locate the household where the deceased
woman stayed during her illness. Consider seeking the help of the ASHA or a
local respected person, such as a village leader or schoolteacher, to pre
arrange the meeting and perhaps accompany you and introduce you to the
family. This is more likely to result in a cordial reception and successful
interview than showing up without any warning.
Slide 3: Continue: Your arrival at the household may create a lot of interest
and so there may be many observers. You should seek a quiet place with as
much privacy as possible to be alone with the family. If a local person from
the village accompanies you to the household, you should ask for their help
with this.
Slide 4: Explain: You must quickly gain the family's trust and cooperation if
you hope to conduct a successful interview. You should dress professionally
and carry an ID badge that shows you are part of the MDR project. Be polite
and sensitive to the family's recent loss. State the purpose of your visit and
the confidential nature of any information the family provides. Also be
prepared to answer any questions the family may ask about the project.
Chapter 5 of the interviewer's reference manual includes an example of how
to introduce yourself:
My name is [sayyour name], I am a nurse/in the
center, and an
interviewer with the MDR project. I have been informed that a woman in
your household died. I am very sorry to hear this. Please accept my
sympathy. In order to improve health care in our district, we are collecting
information on recent deaths of women in this area. I would like to talk to
the person in your house who took care of [say the woman’s name] during
her illness before death. I assure you that any information you or your
family provide will be kept confidential.
Slide 5: Explain: Once the introductions are over, say that you want to speak
to the person who knows the most about the woman’s fatal illness. We want
only first-hand information, so this should be the person who was with her
during the illness. For a woman who has died a maternal death, the best
respondent will often be her husband, mother, mother-in-law or another
close female relative. If necessary, set an appointment and return to conduct
the interview. Sometimes the respondent may live in another location. If this
happens you should discuss this with your supervisor and decide what to do.
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Slide 6: Explain: In some cases you may need to interview more than one
respondent to get first-hand information about the entire illness. For
example, the woman's mother-in-law may have been with her during her
labor and delivery at home; and her husband may have accompanied her to
the hospital after the delivery. Try to ensure that only one person serves as
the respondent for each illness stage. It can get confusing if two or more
people try to tell you about the same stage of the illness. If two people were
actually with the woman during the same illness stage and both insist on
answering the same question, then they must agree between themselves on
the answer. It is not possible to record two answers for the same question.
Slide 6: Continue: You may also face the situation where a person who was
not with the woman during her illness insists on being the respondent. For
example, the woman’s husband may not let her sister answer any questions
even though she was the one who stayed with her during the illness. Try to
explain to the person the importance of gaining first-hand information in
order to prevent further maternal deaths. Other times, a neighbor or other
person who doesn't know about the illness may want to participate. In such
cases, ask the person to leave or reschedule the interview for another time.
Slide 7: Explain: After identifying the best respondent, read the informed
consent form exactly as it appears and ask the person if they agree to be
interviewed. If they do, have them make their mark on the form and then you
sign and date the form to show that you witnessed the signing. If there is
more than one respondent, then complete a separate form for each person,
listing who they are, for example, 'husband,’ at the top of the form. Last, you
conduct the interview, which we will begin tomorrow.
Slide 8: ACTIVITY: Re-arrange the tasks
Ask the trainees to re-arrange the tasks in the correct order:
1. Obtain locating information from supervisor
2. Conduct the interview
3. Identify the best respondent(s)
4.
Obtain informed consent
5. Introduce yourself to the household
Thank respondents for their participation. Correct order: 1, 5, 3, 4, 2, 6
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Slide 9: Explain: We all need to keep in mind that the MDR interview is about
a very painful experience, and this can affect the respondent's ability to
answer the questions. We can help the respondent complete the interview by
being sensitive to their needs. Good communication with the respondent and
being sensitive to his or her recent loss are both essential to the success of
the interview. Even if we use a technically perfect questionnaire, we are
unlikely to obtain useful information if we don’t first establish good
communication with the respondent and put them at ease. Being sensitive to
their situation will help them discuss painful memories, continue with the
interview and do their best to answer our questions thoughtfully.
Slide 10: Explain: Good communication starts with your approach to the
household, before you even identify the respondent. You can set the tone for
a good interview by dressing and acting professionally, building trust,
ensuring confidentiality and stressing the importance of the information.
Once speaking with a potential respondent, don't demand when the
interview must take place. Instead, arrange a time and place that is good for
the respondent. Remember, their participation is voluntary.
Approach the respondent in a similar manner as you approach the
household. Be positive, express condolences for their loss, state the purpose
of the interview and assure them that the information they provide will be
kept confidential. Answer any questions the person has and try to allay their
concerns about the interview. Even though the informed consent form will
cover many of the same issues, it can help build trust if you express these
things informally during your introductions. Also be prepared to deal with
possible unpleasant emotional reactions of the respondent. We'll discuss this
more in a few moments.
Slide 11: Explain: There are a few basic communication methods you can use
to help ensure a good interview. Build rapport with the respondent before
you start the interview by chatting a bit about a subject other than the
woman’s death. For example, you might ask the respondent about what type
of work he does. Always sit at the same level as the respondent and maintain
eye contact. Encourage the respondent to speak freely. Pay close attention to
what he says, don’t rush, and be sensitive to his or her needs. Above all, never
be judgmental about what the respondent tells you. He may already feel
guilty or ashamed that he did not properly care for the woman during her
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illness. If he senses that you are judging him, he is unlikely to tell you
anything further that may reflect badly on himself.
Slide 12: Explain: Many of the questions you will be asking may be difficult
for the respondent to answer. They may feel uncomfortable or get upset
when you ask certain questions. If a respondent becomes tearful then wait
until she regains her composure. Express your sympathy and offer a tissue to
wipe her tears. Then ask if she feels alright to continue the interview at that
time. If not, then ask to schedule a time when you can return to complete the
interview.
Respondents may feel angry about the woman's death. For example, they
might feel that a health center did not provide proper care, or they may think
that a relative or neighbor did not do enough to help them take the woman to
the hospital. You should express your understanding of their anger, but never
say you agree with them. It might also help to again explain that the purpose
of MDR is not to determine who is to blame for a death, but to help the
community work together to prevent similar deaths from happening again.
Slide 13: Explain: Some people may be suspicious of why you want to
interview them. This could be expressed as anger or they may just refuse to
participate. It might calm these persons to approach them with the help of a
local leader or other respected person, or by explaining the purpose of MDR.
However, you will also have to learn to accept that not everyone will consent
to be interviewed.
Most people will consent to be interviewed, but occasionally someone may
not want to answer a particular question. It might be that this question raises
painful memories or perhaps feelings of guilt or shame. You must never
demand or push a respondent to answer a question she does not want to
answer. Remember, consent is an ongoing process. We are trying to work
with people to find out how their loved one died and prevent unnecessary
deaths in the future. However, do let your supervisor know if a respondent
refused to answer several questions. This could affect the quality of the
interview.
Ask participants and discuss: Why is it important that you be sensitive when
conducting the interview? Would anyone like to share a personal
experience of loss, and how you think you might have responded to an
interview about the loss?
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Allow participants to answer and share personal experiences if they
wish. Ask participants and discuss: What are some possible impacts of
mourning on the interview?
Record all answers on a flip chart: Possible answers may include:
• Respondents may not feel comfortable answering certain questions;
• Respondents may get angry or offended when asked questions;
•
Respondents may get sad and upset; and
• Respondents may be suspicious of the entire interview.
Ask participants and discuss: What are some ways you can help
respondents feel more comfortable about answering the questions in
the interview?
Record all answers on a flip chart: Possible answers may include:
•
Be patient;
• Be non-judgmental;
• Sit at the same level as the respondent;
• Maintain eye contact;
• Nod your head, encourage speech, listen actively, do not rush; and
• Allow the respondent to speak freely even if he strays slightly from the
interview.
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SESSION 3: SMALL GROUP ROLE PLAYS OF COMMUNICATION
AND SENSITIVITY ISSUES
Purpose: This session provides an occasion for the trainees to practice
methods of approaching the household and sensitively communicating with
respondents.
Objectives: After completing this session the participants should be able to:
1. Have a more practical understanding of how to approach the household and
identify and communicate with the best respondent(s); and
2. Be prepared to sensitively deal with several emotional responses of the
respondents.
Duration: 1 hour
Needed provided materials: Interviewer's Role Play Guide (Appendix D in
the Interviewer's Reference Manual) and Trainer's Role Play Guide
(Appendix C in this manual)
ACTIVITY: Small-group role-plays of interview situations
Instructions: The Interviewer's and Trainer’s Role Play Guides provide
several examples of problem situations that MDR interviewers may
encounter in the field. In addition to presenting the same scenarios as the
interviewer's guide, the trainer's guide discusses each situation and provides
hints for overcoming the problems. It also offers suggestions for utilizing the
scenarios as a training tool, including how to organize the session and assist
the interviewers to solve problems on their own. This will serve them well in
their work. The following instructions supplement the information provided
in the trainer's guide. Use them together to gain the full benefit of this
session.
Divide the participants into four groups of four to six persons each. Assign
two of the eight scenarios in the role play guides to each group. Divide the
scenarios among the groups according to topic, so that each group enacts two
different situations. (Scenarios 1-5 focus on approaching the household and
selecting the best respondent; scenario 6 is on being sensitive to
respondents; and scenarios 7-8 deal with problems that might occur during
the interview.) Allow the small groups 10 to 15 minutes to discuss and enact
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each situation amongst themselves. Reconvene the entire group after half an
hour. Each small group should act out one of their two role plays to the whole
group, followed by feedback and dialogue. The actors and observers of each
role play should comment on problems and solutions they noted, as well as
their own emotional responses to the situations and those that they observed
in the others.
SESSION 4: CONDUCTING THE INTERVIEW____________________
Purpose: This session provides an overview of the Suspected Maternal
Death Format and general instructions for how to complete the format.
Objectives: After completing this session the participants should be able to:
1. Understand general instructions for completing the format;
2. Know how to correct mistakes made in filling the format; and
3. Know which questions to skip.
Duration: 30 minutes
Needed provided materials: MDR Interviewer's Reference Manual
Instructions: The trainees must read through the ‘General Instructions for
completing the Verbal Autopsy questionnaire’ in the Interviewer’s Reference
Manual. Discuss and resolve any issues that require clarification, it provides
the foundation for conducting the entire interview, so it is essential that
every participant understands every point raised by the instructions. The
trainers must ensure that this is so.
Hint to the trainers: The general instructions provides ideas and examples
of how to deal with general questionnaire issues, such as how to record the
response "Don't know,” how to correct mistaken entries and how to skip
certain questions. The trainees may have many inquiries about the interview
format. However, the specific issues raised by each question will be dealt
with in the following sessions.
Also, some trainees may not have prior experience with a standardized
format that needs to be filled in so precisely. Explain to them that the
responses may be computerized, and that the answers must be clear to the
data entry personnel.
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SESSIONS 6- 9: GROUP PRACTICE OF MODULE 1- 3 AND THE
COMPLETE QUESTIONNAIRE
Purpose: These sessions provide an opportunity to practice using the
Maternal Verbal Autopsy questionnaire and solidify what was learned
yesterday.
Objectives: After completing these sessions the participants should be able
to:
1. Be able to fully conduct an interview using the Maternal Death review
questionnaire
Duration:
1 hour for each module, and 1, 5 hours for the complete
questionnaire.
Needed provided materials: Verbal Autopsy questionnaire for investigation
of maternal deaths
Instructions: Over the next 4 sessions the trainees take turns practicing the
three different modules and then the entire maternal death interview.
Plenary discussions help solidify what is learned through the practice.
It is essential that every participant be competent in conducting the
interview. Today, the trainers’ main role is to serve as facilitators during the
practice sessions. Each trainer/facilitator should work with two groups of
three trainees per group. Observe the trainees in action as they practice the
interview. Do not interrupt them if you see an error being made; instead, wait
until they have completed the interview section(s) they are working on, and
then offer helpful observations, clarifications and corrections if necessary.
Even if the trainees appear to be doing very well, give them an opportunity to
ask questions.
Practice of the modules: The trainees should work in groups of three. Just as
during an actual interview, one person should serve as the interviewer and
another as the recorder. The third person serves as the respondent. Take
about 20 minutes to complete one module; then switch roles so that a second
trainee gets a turn as the interviewer and another as the recorder, again
taking about 20 minutes to complete one module.
For each interview, the interviewer should begin by introducing him or
herself to the household. Since we are working in small groups at this time,
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pretend that the person who answered the door turns out to be the best
respondent and interview this person.
Plenary discussion of practice interviews: After each module, there should
be a plenary discussion. Begin with the two groups of three trainees each
who worked with one trainer/facilitator. Allow each trainee to give his/her
comments and observations about the process in their group, any problems
encountered and solutions to the problems. Each person should also
comment on how it felt to be the interviewer, the recorder and the
respondent. Then the trainer/facilitator for the two groups should make
his/her observations. Repeat this process for each pair of trainee groups.
Group practice of an entire maternal death interview: There is insufficient
time for each person to complete an entire interview, so the time is best
spent with one person in each group conducting the interview, one being the
recorder and a third the respondent. If there are more than three persons in a
group, the others can observe and critique. Trainees who will be supervisors
in the project might better serve as observers for this session, to practice in
this role.
Annex A: Practice interview situations
Scenario 1 - Postpartum haemorrhage
A 28-year-old woman, gravida 6, para 5, delivered at home with the help of
an untrained dai. Her labour lasted 14 hours with difficult pushing for more
than 2 hours. The baby was large and had difficulty breathing at birth. The
woman had some bleeding during the birth, which continued after delivery of
the placenta. After 1 hour the husband became concerned and decided to
seek help. Many difficulties were experienced in finding a vehicle and the
woman died on the way to the hospital.
Scenario 2 - Post-abortion sepsis
A 21-year-old woman, gravida 4, para 3, had an abortion performed by a
quack who inserted a traditional root in her vagina. One day after the
abortion the woman had fever and chills. The next day she noticed a foul
smelling vaginal discharge and had pain in her abdomen. She became more ill
over the next days, with increased fever and sweats. She sought care from a
neighbour who was knowledgeable about traditional medicines. He treated
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her with an application of leaves to her abdomen and hot tea. She became
sicker over the next day and went to see the ANM at her local health
subcenter. The ANM referred her to hospital but the woman did not go
because of a lack of money for transportation and treatment, but went to
receive another traditional medicine. However, her illness worsened. She
became incoherent and then unconscious for 1 day, after which she died at
home.
Scenario 3 - Ante partum haemorrhage
A 25-year-old woman, gravida 3, para 2, had light vaginal bleeding early in
her pregnancy that stopped by the third month. The bleeding recurred in the
sixth month, occurring periodically and becoming heavier with each episode.
She sought care from her ANM for several of these episodes. During the last
episode, in the eighth month of pregnancy, the woman had heavy bleeding
and felt faint and cold. She sought care from the ANM, who referred her to the
hospital. Her husband was away so she had trouble getting money to go to
the hospital. Once she got the money, she went to the nearest CHC, which
took more than 1 hour to reach. The doctor at the CHC said she needed a
transfusion and referred her to the district hospital. It took her another hour
to reach the district hospital. When she arrived she was already unconscious
and she died soon after.
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3.1 FBMDR REFERENCE
MANUAL
3.1 FBMDR Reference Manual
Instructions for filling up the Facility Based
Maternal Death Review format
Process offilling and submission of the FBR format
This form would be filled by the Medical officer (MO) who had treated the
mother and was on duty at the time of the maternal death. The form would
be submitted after incorporating the suggestions and approval of the nodal
officer designated for that hospital. The format has to be prepared in
triplicate. One copy of the FBR format would be retained by the institution,
one copy would be sent for review by the Maternal Death Review (MDR)
committee of the hospital and the other would be sent to the District Nodal
Officer with 24hrs of the occurrence of death.
Guideline for filling up the FBR format:
Page -1
Note: Read the notes carefully and follow accordingly
Mark with an X or V, or fill the boxes as required
Please fill the relevant areas only. For example if death was due to septic
abortion do not fill questions related to AN, intranatal and post natal
components.
The box for “office use only” will be filled by the District Nodal Officer only.
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The Medical officer has to start filling from 'General Information' onwards.
General information on this page includes details of the Nodal officer and
address of the deceased women and the institution.
Page -2
Appropriate boxes have to be filled or ticked as required.
III.2. In Reasons for admission/diagnosis at admission:
• APH refers to abruption placenta or placenta previa
• Abortion- specify the type - spontaneous, induced, septic etc
• Previous Csection refers to caesarean section
•
CPD refers to Cephalo pelvic disproportion.
• Medical condition refers to systemic problems like cardio vascular
problems, diabetes, jaundice, renal problems and other conditions like
Tuberculosis, asthma etc
III. 4. Diagnosis when died:
• Post operative complications include surgical complications, anaesthesia
complications and complications due to blood transfusion.
• Abortion specify - spontaneous, induced with/without bleeding, septic
abortion etc
• Medical condition refers to systemic problems like cardio vascular
problems, diabetes, jaundice, renal problems and other conditions like
Tuberculosis, asthma etc
Page -3
III.7. Answer this question only if the patient had come to the hospital with a
complication. E.g. Severe haemorrhage at the time of admission.
III.8. Answer this question only if the patient had been admitted for a normal
process and later developed complications. For eg. She was admitted for
normal delivery, but she developed post partum haemorrhage following
delivery.
III. 10.a Mention the centre which had referred her
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III. 11. The mother might have visited more than one centre since the onset of
the problem/labour before coming to this centre. Tick for all the centres
visited. More than one box can be ticked.
IV. l.b. Illegal abortion refers to abortion done by unqualified persons or
quacks
IV.2. Others refer to unapproved/ unacceptable procedures like introducing
sticks of plant etc
Page -4
IV.6. Give detailed information on how the mother developed complications
(due to abortion) and how it was managed.
V.l.b. SC refers to Health Sub centre & MO refers to Medical Officer, other
specialist refers to doctors who have a diploma/ Degree in specialties other
than Obstetrics, e.g. ENT surgeon
V.l.c. GDM refers to Gestational Diabetes Mellitus & Grand Multi refers to 5th
pregnancy or above
Page-5
V.4. Additional information on AN complication ....
All events that happened during the AN period should be recorded. Narration
of the patient/ their attenders, reports, complications during the AN period
and treatment given should be given in detail.
VI.2. PROM refers to Premature rupture of membranes, PPROM refers to
Preterm Premature rupture of membranes and IP sepsis refers to
Intrapartum sepsis
Page-6
VI. 6. Phases of labour
•
Latent phase - The phase of labour when irregular and painful
contractions start and continue to build up both in intensity and
frequency.
• Active Phase - The active phase of labour is the second part of the first
stage, during which the cervix dilates from 0 to 10 cm.
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• Second stage - starts from full dilatation of the cervix to the delivery of
the baby
• Third stage - delivery of placenta
• Fourth stage - up to two hours following delivery of placenta
VI. 7.a. CVA refers to cerebro vascular accidents & PE refers to Pulmonary
embolism
VI.7.b. others refers to conditions like urinary tract infections,
thrombophlebitis etc.
VI.9. Intervention done, which is not the list may be included in the last row
in the appropriate columns.
VI.10. All information on the complications during delivery and puerperium
should be stated. All interventions done and medication given should be
mentioned in detail
Page- 7
VII.4. Still birth refers to death of a fetus having birth weight >500 g (or
gestation 22 weeks or crown heel length 25 cm] or more.
VII.4. NICU refers to Neonatal intensive care unit
VII. 4.b. MAS refers to Meconium aspiration syndrome. Preterm refers to
Gestational age of less than 37 completed weeks (i.e. less than 259 days]
VII.5. Provide details of the status of the newborn and complications if any
and its management
VII Cause of Maternal Death: Guide to define the Direct, Indirect & Non
obstetric cause of death is given in detail in this manual in a separate chapter.
Page-8
IX- Tick appropriate boxes, if information is not know, tick ‘Not known'
X. Detailed information on avoidable factors both prior to admission /
subsequent to it can be discussed including sub standard care in the hospital.
MATERNAL DEATH REVIEW GUIDEBOOK
| P a g e 80
Page-9
XI.1. If autopsy was done, mention the gross findings and the detailed
autopsy report can be send the Facility based maternal death review
committee later.
XII. A summary of cause of death and the events leading to it, specifying the
date and time of each complication and steps taken and treatment provided.
On completion of the format the medical officer should submit the format to
the nodal officer, who would review for the completeness of the information
and approve submission of the report duly signed.
3.2 Cause of Death Classification
Direct obstetric deaths
Maternal deaths resulting from obstetric
complications of the pregnant state
(pregnancy, labour, and the puerperium),
from interventions, omissions or incorrect
treatment, or from a chain of events
resulting from any of the above.
A classification of dual causes of
maternal death are more useful. It
allows for two of causes: an essential
level and a specific level. The essential
level identifies a minimum list of causes
that can be identified in all settings,
whatever the level of sophistication of
the cause of death reporting. The list of
specific causes improves the degree of
detail achieved.
Maternal death
The death of a woman while
pregnant or within 42 days of
termination of pregnancy,
irrespective of the duration
and site of the pregnancy,
from any cause related to or
aggravated by the pregnancy
or its management but not
from accidental or incidental
causes (WHO).
Maternal Mortality
Ratio (MMR)
The Maternal Mortality Ratio
is the number of maternal
deaths per 100,000 live births
per year (WHO).
Examples: Antepartum haemorrhage following placenta praevia, Postpartum
haemorrhage following prolonged labour, PPH following cervical tear, eclampsia,
sepsis following prior foetal death (WHO).
MATERNAL DEATH REVIEW GUIDEBOOK
| Page 81
Indirect obstetric deaths
Maternal deaths resulting from previous existing disease or disease that
developed during pregnancy and that was not due to direct obstetric causes
but was aggravated by the physiological effects of pregnancy.
Indirect maternal deaths are relatively few in number. The classification
should list the causes of importance according to the local epidemiology of
diseases. The diseases representing relatively large proportions should be
listed as such rather than hidden in a broader category.
Examples: Heart diseases, Hepatitis, malaria, TB, AIDS, tetanus [WHO].
Non-obstetric causes
Death of pregnant woman resulting from accidental or incidental causes.
(Examples: Accident, assault, suicide, snake bite, burns).
A. Direct Obstetric Causes
(i) Ante partum Haemorrhage
(After 20 weeks of pregnancy)
I. Early Pregnancy death (EPD)
1. APH due to placenta praevia.
(First 20 weeks of
pregnancy)
(i)Abortions
1. Spontaneous abortion and
haemorrhage
2. Spontaneous abortion and sepsis
3. Spontaneous abortion and trauma
4. Induced abortion and haemorrhage
5. Induced abortion and sepsis
6. Induced abortion and trauma
2. APH due to abruptio placenta
3. APH due to indeterminate causes.
(ii) Obstructed labour/ rupture
uterus
1. Antepartum rupture
2. Postpartum rupture
3. Scar rupture
4. Rupture uterus attributed to
oxytocin
7. Ectopic pregnancy
5. Rupture uterus attributed to
misoprostol
8. Molar pregnancy
(iii) Post partum
II.Late pregnancy deaths
Haemorrhage (PPH).
MATERNAL DEATH REVIEW GUIDEBOOK
| P a g e 82
(a)Primary PPH (birth to 24 hours
of delivery)
(iv) Hypertensive disorders of
1. PPH following uterine atony due to
hydramnios
1. 34.Severe Pre eclampsia
2. PPH following uterine atony due to
twins
3. PPH following uterine atony due to
prolonged or obstructed labour
4. PPH following uterine atony due to
multiparity
5. PPH following retained membranes
or placental bits
pregnancy
2. 35. Eclampsia.
3. 36.Chronic hypertension with
superimposed PIH
4. 37.HELLP syndrome
5. 38.CVA
(v) Sepsis related to
pregnancy and child
6. PPH following retained placenta
with normal placentation
7. PPH following retained placenta
with abnormal placentation
(acreta/increta/percreta)
8. Traumatic PPH following tears in
cervix /vagina / perineum
9. PPH following placenta praevia
birth
1. Chorioamnionitis.
2. Puerperal Sepsis following normal
delivery
3. Puerperal Sepsis following
caesarean section
4. Peritonitis
10. PPH following abruptio placenta
11. DIG
12. PPH following inversion of uterus.
13. PPH following prior foetal death
14. PPH due to undetermined cause
(b) Secondary PPH (abnormal or
excessive bleeding which occurs
between 24 hours and 6 weeks
postpartum)
(vi) Complications of anaesthesia
1. Complications following general
anaesthesia
2. Complications following spinal
anaesthesia
3. Complications following epidural
anaesthesia
4. Complications following local
anaesthesia
1. 31.Secondary PPH due to retained
placental tissue
(vi) Surgical complications
2. 32. Secondary PPH due to sepsis
5. Surgical complications following
caesarean section
3. 33. Secondary PPH due to
undetermined causes.
6.
Surgical complications following
emergency hysterectomy
MATERNAL DEATH REVIEW GUIDEBOOK
7.
Surgical complications following
puerperal sterilization
8.
Surgical complications following
sterilization after MTP*
(vii) Transfusion reactions
1. Transfusion reactions
(Page 83
1. Anaemia complicating pregnancy
(iii) Endocrine disorders
1. Diabetes mellitus
2. Thyroid disease
3. Other endocrine conditions
2. Reactions following IV fluid
administration
(iv) Infectious diseases
(viii) Sudden deaths (others)
2. Maternal tetanus.
1. Pulmonary Embolism
3. HIV/AIDS
2. Amniotic Fluid Embolism
4. Malaria
3. Sudden death due to undetermined
5. Typhoid
cause
(ix) Other conditions
1. Peripartum cardiomyopathy
Suicide due to puerperal psychosis.
1. Meningitis / encephalitis.
6. Tuberculosis
7. Tuberculosis and HIV
8. H1N1( swine flu)
9. Other infections
2. Any other direct cause- specify
(v) Liver disorders
B. Indirect Obstetric Causes
1. Jaundice due to hepatitis viruses
(i) Heart diseases
complicating pregnancy
1. Congenital Heart Disease
2. Rheumatic Heart Disease
3. Complications following valve
replacement
4. Chronic hypertension (existing
before 20 weeks & pregnancy)
2. Jaundice due to noninfectious
cause
3. Hepatic encephalopathy
(vi) Renal conditions
1. Acute renal failure due to non
obstetric cause
2. Chronic renal failure due to non
obstetric causes
5. Myocardial infarction
(vii) Other conditions
6. Dilated cardiomyopathy
1. Bronchial Asthma
7. Undiagnosed heart disease
2. Epilepsy
(ii) Anaemia
3. Intracranial Space occupying lesion
4. Cancer
MATERNAL DEATH REVIEW GUIDEBOOK
(Page 84
5. Haematological causes
4. Injury due to Road Traffic Accident
6. Other causes-specify
5. Injury due to other accidents
IH. Non- Obstetric Causes
or
incidental
(accidental
causes)
1. Non obstetric surgical cause
(appendicitis, pancreatitis, bowel
obstruction, ovarian torsion etc.)
2. Injury due to burns
3. Injury due to assault
6. Electric shock
7. Snake Bite
8. Suicide
9. Any other specify
Note:* included here because death is
due to complications of sterilization
but not due to abortion.
MATERNAL DEATH REVIEW GUIDEBOOK
| P a g e 85
^3®
4. MDR FORMATS
[Modified version December 2010]
Annex 1. FBMDR Format
Annex 2. Verbal Autopsy Questionnaire
I
Annex 3. MDR Case Summary
Annex 4. MDR Line Listing Cases of
Maternal Deaths
Annex 5. Block Level MDR Register for All
Women's Death (15-49 years)
f
Annex 6. Format for Primary Informer
MATERNAL D E A T H REVIEW GUIDEBOOK
| P a g e 86
Annexure 1: Facility Based Maternal Death
Review Form
Annexure 1
For official use only
CONFIDENTIAL
Facility Based Maternal Death Review Form
1. NOTE: This form must be completed for all deaths occurring in the
hospital, including abortions and ectopic gestation related deaths, in
pregnant women or within 42 days after termination of pregnancy
irrespective of duration or site of pregnancy
2. Mark with an (X)/ )/ fill where applicable
3. Attach a copy of the case records to this form
4. Complete the form in triplicate within 24 hours of a maternal death. The
original remains at the institution where the death occurred and one
copy would be sent to the District Nodal Officer and the other to the
Facility Maternal Death Committee by the Facility Nodal officer.
For Office Use Only:
FB -MDR
TNO:
Year
Name, Designation & Address of the District Nodal Officer:
I.
General Information:
Name, Designation and Address of the nodal officer of the Hospital:
Name, Age and Address of Deceased Woman:
Name and Address of Facility where death occurred:
District:
State:
MATERNAL DEATH REVIEW GUIDEBOOK
(Page 87
II. DETAILS OF DECEASED
1.Inpatient Number:
2.Name:
4. Obstetric formula
3. Age( years) :
Abortions □□ No. Living children □□
Para
Gravida
Day
Yr
Month
min
Hrs
□□
□□
5.Date and time of admission:
Day
min
Hrs
Yr
Month
□□ □□ □□
6. Date & time of delivery:
Day Month Yr
min
Hrs
□□
□□ □□
7. Date & time of death:
Days
Hrs
□□
8. Delivery/abortion-death interval :
III. DETAILS OF ADMISSION AT INSTITUTION WHERE DEATH OCCURRED
OR FROM WHERE IT WAS REPORTED (tick where appropriate)
1. Type of facility where died:
Sub District Hospital
District Hospital
Referral hospital
Medical College/ Tertiary
Hospital
2. Reasons for admission /Diagnosis at admission:
Normal
delivery
Previous
C section
Abortion
(Specify type)
Ectopic
pregnancy
Vesicular
Mole
Anaemia
Diabetes
PET/
Eclampsia
Multiple
pregnancy
APH
Hydramnios
CPD
Abnormal
presentation
PPH
Medical
conditions
Others
3. Period of admission:
AN before
Antenatal
Intrapartu
20 weeks
> 20
m
weeks
Post
Partum/Natal up
to 24hrs
Post natal
24hrs-1
week
Post natal 1
week to 42 days
4. Diagnosis when died:
Obstructed
labour/
Rupture Uterus
Sepsis
PPH
Abortion
(specify)
Ectopic
pregnancy
Vesicular
Mole
Anaemia
(failure)
Diabetes
Eclampsia
APH
Inversion of
uterus
Post operative
complication
Pulmonary
embolism
CVA
Medical
condition
Others
| Page 88
MATERNAL DEATH REVIEW GUIDEBOOK
5. Period of gestation, Intranatal, postnatal- at time of death:
Antenatal
before 20
weeks
Post Partum
/Post natal
Intrapartum
Antenatal after 20
weeks
6.Outcome of pregnancy:
! Ectopic
Live birth
Undelivered
Still birth
Abortion
7. Duration from onset of complication to admission :
IZZlHrs
mins
8. Duration from admission to onset of complication : □□ Hrs □□ mins
9. Condition on Admission: Stable
Semi conscious responds to verbal
commandsD Semi conscious responds to painful stimuli
Unconscious
10. Was she Referred from another centre? Yes CNo
Don’t know
10.a. If yes, Type of facility from which referred:
PHC ’ 24x7 PHC
SDH/Rural Hospital/ CHC
Private Hospital
District Hospital
Private clinic
Others
11. Other centres visited before coming to the present institution
PHC
24x7 PHC
SDH/Rural Hospital/ CHC
District Hospital
Private Hospital
Private clinic
IV.ABORTION (to be filled if applicable)
1. Was the abortion
1.a. If spontaneous,
Spontaneous^
l.a.i. Was it? Complete
IncompleteD
Induced
MVA
l.a.ii. mention mode of termination? Medical abortion
1.b. If induced, was it
Legal
Illegal
2. What was the procedure adopted? Medical abortion
Extra Amniotic Installation
Hysterotomy
3. Post Abortal Period Uneventful
D&C
MVA
D&C
Others
Sepsis
Haemorrhage
others
Others
MATERNAL DEATH REVIEW GUIDEBOOK
|Page 89
3.a. If Sepsis, Method of management
IV fluids
Yes
Non
Parenteral Antibiotics
Yes
NoD
Metronidazole
Yes
NoD
Surgical Interventions
Yes
No
Blood/Blood products transfused
Yes
No
Days Hrs
4. Time taken to initiate treatment since onset of the problem
□□
5. Was the termination procedure done in more than one centre
YesD
NoD
6.Additional information on complications including Management:
V. ANTENATAL CARE
1 .Did she receive ANC?
No
YesD
V.1 .a. If no, reason: Lack of awareness
Lack of accessibility
Lack of fundsn Lack of attendeeD Family problems
V.1 .b. If Yes, Type of Care Provider (mark all):
MO CHC
Obstetrician SDH
College/Tertiary Hosp
MBBS/other specialist
Others
SC ANM
Obstetrician DH
MO PHCQ
Obstetrician
Private Hosp □-Specify- Obstetrician
Nurse
V.1 .c. If yes, was she told that she has risk factors?
Don’t know
No. of Visits:
Don’t know
YesLZI
No
| P age 90
MATERNAL DEATH REVIEW GUIDEBOOK
V.1 .c.i.lf yes, what was the risk factor identified ?
Previous
C section
Multiple
pregnancy
Abortion
Short
stature
APH
hydramnios
Vesicular
Mole
Abnormal
presentation
Ectopic
pregnancy
Big baby
Diabetes/G
DM
Medical
conditions
Anaemia
Grand
multi
PET
Others
Specify
2. Was she admitted with a complication / developed a complication during
the AN period YesD
No
2. a. If yes, what was the complication?
Bleeding
Preterm
labour
Surgical
conditions
Eclampsia
Preterm
labor
Leaking
memebranes
Ectopic
pregnancy
Vesicular
Mole
Anaemia
(with/without failure)
Anaemia
(with/without failure)
Heart Disease
(with/without failure)
Other Medical
conditions
Others
Specify
3. Time taken to initiate treatment since the onset of the Problem:
DHrs
Mins
3.a. At the first point of contact
□Hrs
3.b.At the present Institution
□□ Mins
□Hrs
□□ Mins
4. Additional information on AN complications including medication if any:
VI. DELIVERY, PUERPERIUM AND NEONATAL INFORMATION
1. Did she have labour pains? YesD
No
1 .a.If Yes, was a partograph used in the referred centre? YesD
know
1 .a.i. Was partograph used in the present centre? YesD
No
No
Don’t
MATERNAL DEATH REVIEW GUIDEBOOK
| Page 91
2. Complications during labour:
PROM
PPROM
IP
sepsis
3. Duration of labour:
Eclampsia
Inversion
of Uterus
Obstructed
labour/
Rupture
Uterus
Others
Specify
□□hrs □□mins
4. Mode of Delivery
Undelivered
SpontaneousVaginal
(with/without episitomy)
Caesarean section
Vacuum/forceps
S.Time taken to initiate treatment since the onset of the Problem:Hrs
DMins
6. In which phase of labor did she die?
Latent
phase
Second
stage
Active
phase
Third
stage
>24hrs after
birth
Fourth
stage
7. Postnatal period: - Uneventful / Eventful
7.a. If eventful , specify
PPH Sepsis
CVA Anaemia
/PE
Eclampsia
Post
partum
Psychosis
8. Blood /Blood products given : YesQ
Post op
complication
Medical
conditions
No
8.a. If yes number of units transfused :
8.b. Was there any transfusion reactions: YesD
NoO, If yes , specify
9. INTERVENTIONS (Tick appropriate box),Specify other in the last row provided
Early pregnancy
Evacuation
Transfusion
Laprotomy
Hysterectomy
Intrapartum
Postpartum
Anaesthesia/
ICU
Transfusion
Instrumental del.
Removal of
retained POC
Anaesthesia -GA
Version
Caesarean
section
Laprotomy
Spinal
Hysterectomy
Transfusion
Local
Hysterectomy
Epidural
Antenatal
Other
surgeries
Transfusion
Hysterotomy
Manual removal
of placenta
ICU monitoring
Othe
rs
MATERNAL DEATH REVIEW GUIDEBOOK
| P a g e 92
10. Additional information on labour delivery and puerperium, including
management
VII .Details of Baby:
I.Baby
Birth weight (g)
/10
2. APGAR Score (5 mins)
3. Needed resuscitation Y/ N
3.a. If yes, who gave Early resuscitation?
Obstetrician
Paediatrician
4. Outcome of Delivery:
MBBS doctor/
other
specialist
Still born
Alive
4.a. If stillborn, was it....
Fresh
4 b If the baby is alive, is it
NormalD
4.c Birth - death interval:
days
Staff Nurse
Others
(specify)
Born alive and died
Macerated
NICU
hrsOD
4 d If died, mention probable cause:
Birth
Asphxia
Sepsis Aspiration
including
MAS
Congenital
Anomalies
Preterm
5. Additional information on baby status( in box below)
Respiratory
distress
Others
MATERNAL DEATH REVIEW GUIDEBOOK
VIII.
| P a g e 93
CAUSE OF MATERNAL DEATH :
a. Probable direct obstetric (underlying) cause of death: Specify:
b. Indirect Obstetric Cause of death: Specify
c. Final Diagnosis (including Non Obstetric causes)
IX.
IN YOUR OPINION WERE ANY OF THESE FACTORS PRESENT?
System
Personal/Family
Example
Delay in woman seeking help
Refusal of treatment
Refusal of admission in previous
facility______________________
Logistical Problems Lack of transport from home to
health care facility____________
Lack of transport between
health care facilities
Health service - Health
service communication
breakdown__________________
Facilities
Lack of facilities, equipment
or consumables
Lack of blood
Lack of OT availability
Health
personnel
problems
Lack of human resources
Lack of Anesthetist
Lack of Obstetricians
Lack of expertise, training
or education
¥
N
Not known
MATERNAL DEAT H REVIEW GUIDEBOOK
| P a g e 94
X. Information on avoidable factors, missed opportunities & substandard
care
XI. AUTOPSY:
performed
Performed
Not
1 .If performed please report the gross findings and send the detailed report
later
XII.CASE SUMMARY (please supply a short summary of the events surrounding the death)
Form filled by the MO on duty
Signature & Name
Designation
Nodal Officer of the Hospital:
Signature & Name
Address of the Institution
Stamp & Date :
MATERNAL DEATH REVIEW GUIDEBOOK
| P a g e 95
Annexure 2: Verbal Autopsy Questionnaire
FOR INVESTIGATION OF MATERNAL DEATHS
NAME OF THE STATE
NAME OF THE DISTRICT
NAME OF THE BLOCK
NAME OF THE PHC
NAME OF THE SHC
NAME OF THE VILLAGE
NAME OF THE PREGNANT WOMAN/
MOTHER
NAME OF HUSBAND/OTHER
(FATHER/MOTHER)
DATE OF DEATH
NAME & DESIGNATION OF THE
INVESTIGATOR(S)
NAME & DESIGNATION OF THE
INVESTIGATOR(S)
DATE OF INVESTIGATION
PROBABLE CAUSE OF DEATH
MATERNAL DEATH REVIEW GUIDEBOOK
MODULES
Page No. 1 - 3
MODULE-I
Should
be
used
for
collection
of
general
information for all maternal deaths irrespective of
whether deaths occurred during antenatal or
intranatal or postnatal period or due to abortion.
MODULE - II
Page No. 3 - 4
Should be used for the deaths occurring during
the antenatal period including abortion
MODULE - III
Page No. 4-6
Should be used for the deaths occurring during
delivery or postnatal period
| P a g e 96
MATERNAL DEATH REVIEW GUIDEBOOK
(Page 97
General Instructions
1. The verbal autopsy is a technique whereby family members, relatives,
neighbors or other informants and care providers are interviewed to
elicit information on the events leading to the death of the mother
during pregnancy/ abortion/ delivery / after delivery in their own
words to identify the medical and non medical (including socio
economic) factors for the cause of death of the mother.
2. It is preferable to give advance information about the purpose of visit
to the relatives of the deceased who were with the mother from the
onset of complications till the death, and obtain their consent.
3. CONFIDENTIALTITY: After the formal introduction to the respondents,
the investigating official should give assurance that the information will
be kept confidential.
4. Throughout the interview, the interviewer should be very polite and
sensitive questions should be avoided.
5. Make all the respondents seated comfortably and explain to them that
the information that they are going to provide will prevent death of
mothers in future.
6. Allow the respondents to narrate the events leading to the death of
the mother in their own words. Keep prompting until the respondent
says there was nothing more to say.
7. Wherever needed, the investigating official should encourage the
respondents to bring out all information related to the event.
8. Please also write information in a narrative form
9. NEUTRALITY AND IMPARTIALITY: The interviewer should not be
influenced by the information provided by the field health
functionaries, doctors or by the information available in the mother
care register, case sheets etc.
MATERNAL DEATH REVIEW GUIDEBOOK
| P a g e 98
MODULE-I
Contains general information, information about previous pregnancies wherever
applicable. It should be used for all the maternal deaths irrespective whether occurred
during antenatal, delivery or postnatal period including abortion)
I. BACKGROUND INFORMATION
Kindly ( V )tick the correct answer for each question
1.1
1.2
Resident / Visitor death
Type of death
Abortion
Delivery
Antenatal
Post natal
death
Sub
Health
Home
Centre
1.3
Place of death
CMC
PHC
Medical college
Dist.
Hosp.
Hosp.
Sub Dist. Hosp.
Pvt. Hosp.
Others
Transit/ on the way
(specify)
Specify the name and place of the
1.4
institution or village where death
occurred
1.5
1.6
Onset of fatal illness
Admission in final institution (if
applicable)
Date
/
/
Time
Date
/
/
Time
/
/
Time
1.7
Death
Date
1.8
Gravida
1
2
3
4
>5
0
1
2
3
>4
1.9
Para (number of previous live
births)
1.10
Abortions (induced or spontaneous)
0
1
2
3
>4
1.11
Previous stillbirths
0
1
2
3
>4
1.12
Living children
0
1
2
3
4
1.13
1.14
Week of pregnancy
<16
17-28
>29
If applicable
weeks
weeks
weeks
Age at death
>5
MATERNAL DEATH REVIEW GUIDEBOOK
| Page 100
3. INFANT SURVIVAL
Infant
3.1
Alive
Newborn
Stillbirth
death
Not
applicable
4. AVAILABILITY OF HEALTH FACILITIES, SERVICES AND TRANSPORT
(4.1& 4.2 to be filled by the investigator before the interview)
Name and location of the
4.1
nearest government/ private
facility providing Emergency
Obstetric Care Services
4.2
4.3
4.4
Distance of this facility from the
residence
Number of institutions visited
before death (in the order of
visits)
Reasons given by providers for
the referral
No
explanati
on given
Lack of
blood
Lack of
staff
Others
(specify)
Not
applicabl
e
5. CURRENT PREGNANCY
(To be filled from the information given by the respondents)
5.1
5.2
AN Care
If yes, Place of Antenatal
checkup
YES
NO
Sub Health
Centre
PNC/CMC
Govt. Hosp.
Pvt. Hospital
VHND
Govt. & Pvt.
hospital_____
Don't know
Not applicable
Don't
know
Other
(specify)
5.3
Number of antenatal
check ups
Nil
1
2-3
4 and
above
Not known
MATERNAL DEATH REVIEW GUIDEBOOK
| Pag c 101
MODULE -II
6. DEATHS DURING THE ANTENATAL PERIOD
This module is to be filled for the maternal deaths that occurred during the antenatal
period including deaths due to abortion. In addition to module II, module I also should
be filled for all maternal deaths
6.1
6.2
Did the mother have
any problem during the
antenatal period?
If yes, was she referred
anytime during her
antenatal period?
Not known
No
Yes
YES
NO
Don't know
Not
applicable
•
•
•
•
6.3
•
•
What was the
symptom for which she
sought care ?
•
•
•
•
6.4
6.5
If YES, did she attend
any hospital?
In case of not seeking
care from the hospital
is it due to
Head ache
Edema
Anemia
High blood
pressure
Bleeding p/v
No foetal
movements
Fits
Sudden
excruciating
pain
High fever
with rigor
Others
(specify)
YES
NO
Don't know
Not
applicable
Severity of the
complications not
known_________
No attender
available
Institution
far away
No money
Lack of
transport
beliefs and customs
Others
(specify)
Not applicable
IajH'UO
\7-L+-S5
P'O
| Page 102
MATERNAL DEATH REVIEW GUIDEBOOK
7. ABORTION DEATHS
7.1
Did she die while
Yes
Don't know
No
having an abortion
or within 6 weeks
after having an
abortion?
7.2
If during an
Induced
Spontaneous
Don't
know
abortion, was it
spontaneous or
induced, including
MTP?
7.3
If the abortion was
induced, how was it
induced?
Oral
medicine
Traditional
lnstrum-
Don't
Not
vaginal
entation
know
applica
ble
herbal
application
7.4
If the abortion was
Home
induced, where did
she have the
abortion?
7.5
Don't
know
Government
hospital
(specify
level)
clinic
Nurse
Doctor
Don't
know
7.6
Ayush
Traditional
doctor
practitioner
If induced, what
Bleeding started
made family seek
spontaneously
care?
7.7
If the abortion was
Home
spontaneous,
Where was the
abortion
completed?
Not
applicable
Others
(specify)
performed the
abortion?
Not
applicable
Other
(specify)
If the abortion was
induced, who
Private
Governm
ent
hospital
(specify
level)
Not
applicable
Wanted to
terminate the
pregnancy
Private
clinic
Other (please
Specify)
Not applicable
Don't know
MATERNAL DEATH REVIEW GUIDEBOOK
7.8
7.9
7.10
7.11
7.12
7.13
7.14
How many weeks
of pregnancy
completed at the
time of abortion
Whether she had
any of these
symptoms after
abortion?________
After developing
complications
following abortion,
did she seek care?
If yes,
whom/where did
she seek care?
In case of not
seeking
appropriate care, is
it due to..
Date of
spontaneous
abortion/ date of
termination of
pregnancy______
Date of death
High
fever
Foul
smelling
discharge
Yes
No
Governm
ent
hospital
(specify
level)
Private
Bleeding
| Page 103
Shock
None
Other
(specify)
Don't
know
Quack
Don't know
clinic/ce
nter
Other
(specify)_________
Beliefs and
customs
Not
applicable__
Severity of
complications
not known
No attender
available
Not
applicable
Institution far away
Others,
Please specify
Date
/
/
Date
I
!
No money
Lack of transport
MATERNAL DEATH REVIEW GUIDEBOOK
| Page 104
MODULE - III
(First section (8) to be used for the deaths occurring during delivery. Second section (9) is
for women who died in the postnatal period. For these deaths, Module I should also be
filled)
8. INTRANATAL SERVICES
8.1
Place of delivery
Home
Sub centre
CHC
PHC
Medical
Dist. Hosp.
College______
8.2
8.3
Admission
(not applicable for
home delivery and
transit)
Sub dist. Hosp.
Pvt. Hosp.
Transit
Other
(specify)
Date
/
Not applicable
Delivery
Date
8.4
8.5
8.6
Time
/
Time interval between
onset of pain and
delivery (in hours)
Who conducted the
delivery- if at home or
in institution (Not
applicable for transit
delivery)____________
Type of delivery
/
/
Time
Not applicable
Not applicable
Hours
ANM
Staff Nurse /
M. Asst.
Doctor
Dai
Quack
Not applicable
Other (specify)
Normal
Assisted
Unattended
Caesarean
8.7
8.8
Outcome of the
delivery
During the process of
labour/delivery did the
mother have any
problems?
Live birth
Still birth
Multiple births
Not applicable
Prolonged labour
(Primi>12hrs/
Subsequent deliveries >8
hrs)__________________
Severe bleeding/ bleeding
with clots- (one
saree/inskirt soaked
=500ml)
Labour pain which
disappeared suddenly
Inversion of the uterus
Retained placenta
Convulsions
Severe breathlessness
/cyanosis/ edema
Unconsciousness
High fever
Other
(specify)
Not
applicable
MATERNAL DEATH REVIEW GUIDEBOOK
| Page 105
8.9
Did she seek treatment, if yes by whom and what was the treatment given by the ANM/Nurse/LHV/ /
MO/others? (give details)
8.10
Was she referred?
8.11
8.12
Did she attend the referral
centre?
In case of non compliance
of referrals state the
reasons
YES
NO
Not known
Not applicable
YES
NO
Not known
Not applicable
Intensity of complications
not known
Institution far away
No attender available
No money
beliefs & customs
Lack of transport
Not applicable
Others
(specify)
8.13
Was there delay in
Decision making
Mobilizing funds
Arranging transport
Not applicable
Others (specify)
8.14
8.15
8.16
8.17
Any information given to
the relatives about the
nature of complication
from the hospital______
If yes describe
Was there any delay in
initiating treatment
If yes, describe
No
Yes
Not applicable
Not
applicable
Yes
Not
applicable
No
Not applicable
MATERNAL DEATH REVIEW GUIDEBOOK
| Page 106
9. POST NATAL PERIOD
9.1
9.2
9.3
9.4
No. of Postnatal
checkups
Did the mother had any
problem following
delivery_____________
Onset of the problem
Specific problem during
PN period
Nil
1
>4
Don't know
YES
NO
2-3
Not known
Date
/
/
Severe bleeding
Sudden chest
pain & collapse
Bleeding from
multiple sites
Time
:_______
Severe fever and foul
smelling discharge
Unconsciousness/
visual disturbance
Severe leg pain,
swelling
Abnormal
behavior
Severe anemia
Don't know
Other (specify)
9.5
Did she seek treatment
Yes
No
9.6
If yes, by whom
ANM
Nurse
Not
applicable
LHV
MO
Others
(specify)
9.7
What was the
Not applicable
treatment given (give
details)
9.8
9.9
9.10
Was she referred?
Yes
No
Not known
Not applicable
Did she attend the
Yes
No
referral center?
Not known
Not applicable
In case of non
Intensity of
complications
not known
No attender
available
Beliefs &
customs_____
compliance of referrals
state the reasons
Not applicable
Institution far
away
No money
Lack of transport
Others (specify)
MATERNAL DEATH REVIEW GUIDEBOOK
| Page 107
10: Reported cause of death
10.1
Did the doctor or nurse at the health
facility tell you the cause of death?
Yes
No
Don't know
10.2
If yes, what was the cause of death?
11.Open history (Narrative format) (exp 1 ore)
■
■
■
■
■
■
■
■
Name and address of the facilities she went - decisions and time taken for action
How long did it take to make the arrangements to go from first centre to higher centers and why
those referrals were made and how much time was spend at each facility and time spend at each
facility before referrals were made and difficulties faced throughout the process
Transportation method used
Transportation cost? (at each stage of referral)
Travel time - at each stage
Care received at each facility?
Total money spend by family
How did the family arrange the money?
MATERNAL DEATH REVIEW GUIDEBOOK
| P a g e 108
Annexure 3: MDR Case summary
To be filled by the medical officer and the investigation team for each maternal death
Name of the Block
PHC/District
OR
Name of facility
Particulars of the
deceased
Religion
Age
Name:
Caste:
Address
(where she was residing
when illness/labour
began)
Place, date and time
of death
Timing of Death
Obstetric History
Investigation
Pregnancy
Gravida
Date of 1st
visit
During or
within 6 weeks
of abortion
Para
Date of 2nd
visit
In labour or during
delivery
Abortions
Spontaneous
Within 1
week after
delivery
Infant outcome
Induced
Name and contact details of main respondents
7- 42 days after
delivery
MATERNAL DEATH REVIEW GUIDEBOOK
1. Delay in Seeking Care
Unawareness of danger signs
Illiteracy & Ignorance
Delay in decision making
No birth preparedness
Beliefs and customs
Non availability of health care professional
Any other/specify
2. Delay in reaching first level health facility
Delay in getting transport
Delay in mobilizing funds
Not reaching appropriate facility in time
Difficult terrain
Any other/specify
3. Delay in receiving adequate care in facility
Delay in initiating treatment
Substandard care in hospital
Lack of blood, equipment & drugs
Lack of adequate funds
Any other/specify
Fill in appropriate cause of Delay 1
Fill in appropriate cause of Delay 2
Fill in appropriate cause of Delay 3
| Page 109
MATERNAL DEATH REVIEW GUIDEBOOK
| Page 110
Probable direct obstetric cause of death:
Indirect obstetric cause of death:
Contributory causes of death
Initiatives suggested:
Name and designation of investigation team
Signatures and Name of Block Medical Officer (with stamp)
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MATERNAL DEATH REVIEW GUIDEBOOK
| Page 112
Annexure 5:Block Level MDR Register for All Women’s Death
(15-49 years)
Name of Block PHC
District
Month
Name of Ag
Sr.N
decease
e
o
d
Date
of
deat
h
Add res
s
(Fill in one register for every month)
Block
____ S ta te_______________
Year______________
Name/
Cause of death
Husband’
(tick
V)
designatio
s name
n of
Primary
Materna Non
informant
materna
1
(Annex 6)
I
Signature & Date of MO I/C of the Block PHC:
Date of field
investigatio
n
If died
due to
materna
1 causes,
specify
reasons
Actio
n
taken
MATERNAL DEATH REVIEW GUIDEBOOK
Annexure 6: Format for Primary Informer
All Women's Death (15-49) Information Report
(Maternal deaths alone to be reported from Facilities)
1. Name of State
2? Name of District
3? Name of Block
4? Name of village/
Description of location
5. Name of the deceased woman
6? Name of husband
7? Age of the woman
8? Date and time of death
9? Place of death
Home
Health Facility
Others
10 When did death occur
a)During pregnancy
b) During delivery
c) Within 42 days after delivery
n
□
□
□
□
d)During abortion or within 6
weeks after abortion
If either a, b, c, d, =yes: suspected maternal death
If either a, b, c, d, =no; non- maternal deaths
Name of reporting person
Signature of reporting person:
Designation:
Date:
YES
NO
□
□
□
□
I Page 113
I
Maternal Health Division
Ministry of Health and Family Welfare
Government of India
Nirman Bhawan
New Delhi
- Media
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