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h To establish operational mechanisms/
modalities for undertaking MDR at selected
institutions and in community level
h To disseminate information on data collection
tools, data/information flow, analysis

h To develop systems for review and remedial


follow up actions
ÿ
 

h „mplementation of MDR should be supported


by a State Govt Order
h Notification of Maternal Deaths
h ÷ 
 
 



h 
 
 



h ‘ll health functionaries have a role in MDR
h District Collector ( DM) to conduct review
meeting with the relatives of the deceased and
service providers
h No punitive action against service providers


  ÿ



 




[ State Task Force
[ State Nodal Officer
[   

[ District Nodal Officer


- ÷ 

- Facility Nodal Officer


[ lock: lock Nodal Officer ( MOH)
- lock „nvestigation Team
[ Notifier of deaths
- 


! "÷ 

[ Members: Principal Secretary - Health and Family Welfare,
Mission Director SHS, Senior Obstetrician/s of the Medical
College Hospital, „M‘ FOGS„ and any other members
nominated by Government

[ STF will 

 
 #  $ to discuss the actions
taken on the minutes of the last meeting and make
recommendations to Government for policy and strategy
formulations

[ very year an    


 

%  for the state
will be prepared and a dissemination meeting will be
organized to sensitize the various service providers and
managers
- 
|  

[ „dentification of District Nodal officers


[ Organizes analysis of data collected from the
districts and feed back to the district
[ Organizes state level sensitization workshops
[ Convene state task force meeting
[ Facilitate preparation of annual maternal death
report and dissemination meeting
   



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  (

Facility ased Maternal Death Review:
Steps-Process
h ÷   of facility level committee & identification of
facility nodal officer (co-nodal officer) for each facility
h |   of maternal deaths by MO on duty within
24 hours to FNO ( 
.#)
FNO to inform district and state nodal officer within 24
hours telephonically and through ‘nnex 6
h +
(  within 24 hours using prescribed format
( 
./) by MO/Faculty/ ‘CMOH (for facilities other
than MCH) & sending to FNO
h 
%  
   ( 
.0) by FNO and
sending copy of filled up format, summary and case
sheet to facility MDR committee and DNO
F MDR: Steps-Process«

h   
( 
of maternal deaths in the facility
± line listing of maternal deaths ( 
.$1)
h 

 by the F MDR committee headed
by the Hospital superintendent/MSVP and sending
minutes to DNO
h Remedial measures
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m -& -&
 "
 Notify all deaths of women between
15-49 years within 24 hours to block PHC MO ± telephone
and in the primary informer format ( 
.#)
m "
  
 Notify to district and state nodal
officer within 24 hours of receipt of information and send
the details in format ( 
.#)
+
( 
m ‘ll suspected maternal deaths to be investigated by a team
of 3 members ( PHN/PHN, ‘NM, LHV etc) with µverbal
autopsy¶ format ( 
.4) within 3 weeks
m 
%  
  ( 
.0) by MOH and
sending to DNO along with filled up format ( 
.4)
$-
% $  
533
[ MOH to   
( 
of all deaths of women in the
reproductive age group ( 
.6) and line listing of all
confirmed maternal deaths ( 
.1) at block PHC
- ‘SH‘/‘NM also maintain line listing of maternal deaths
(‘nnex 4)
[ Feedback sharing with service providers at monthly
meeting

[   

 DNO to


÷  
     
  
7%
%



  
8
     
 (of all
maternal deaths  
.1)
2|+!, - !|  !&+
 
÷ 
Line listing of maternal deaths,
-& -
submitted to lock MO PHC by
‘SH‘ ( monthly)
!

%    
2|+!, 
 
 

41 "
&
Deploys investigation team ( PHN/
" ‘NMPHN/Nurse to visit the deceased
& woman¶s house and conduct verbal
!

%     autopsy
 ÿ |  -|
41  

% 
     
  Case summary sheet for every maternal

  death and format sent to the DNO

2 relatives of the   





 "

  
+-!+! deceased attend   
    

  ( 



!3
 9 -3&
-


 
 

%  




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 9  

 





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-! !
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m    
 





 
&
‘ll maternal deaths reported in the month ± both F MDR
and C MDR

m) 
    
 



‘ll 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
   
 




 %
5
[ To institute measures to prevent maternal deaths due to
similar reasons in future
[ To sensitize service providers to improve accountability
[ To find out the system gaps to take appropriate corrective
measures with time-line
[ To allocate funds from the district health society for the
interventions
[ To monitor the implementation of the corrective measures
- at the community level
- at the facility level
- requiring state support
Maternal Death Review Process
0

 ÿ$0
4

-|  ÿ$4

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/

| |
/
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÷ 

÷/ ÷4 ÷0


  / 4 0

 
Orientation Training

 



 

[ National level: Sensitization and Training


[ State level: Sensitization and Training
[ District level: Sensitization and Training
[ Facility level: Orientation
[ lock level: Sensitization