Maternal and Perinatal Deaths

Review
 Outline:
• Community – Review of suspected Maternal deaths
• Facility – Review of suspected Maternal deaths
• Setting up MPDSR system at facility
• Data quality improvement
– Confidentiality: a Code of conduct
– Disclaimer pledge
– Committee discussion
• Summary Points
• Exercise on MDRF and PDRF
Community–Review of suspected Maternal and perinatal
deaths:
• Each completed verbal autopsy should be
reviewed by the rapid response team (RRT) of
the respective health center within one week
after Verbal autopsy report is received.

• The Health Center RRT should include

midwives, MCH nurses and other MCH
related health professionals.
Community–Review of suspected Maternal and perinatal
deaths cont. ….

• For every reviewed verbal autopsy an action

plan has to be developed for response based on the
identified modifiable factors
• Following the review of the verbal autopsy the
RRT will complete the case based reporting
format (maternal/Perinatal death reporting
format (MDRF/PDRF)
Facility –Review of suspected Maternal and perinatal deaths death

• Each completed FBAF should be reviewed by the

rapid response team (RRT) of the respective
health facility within one week.
• The health facility RRT should include midwives,
NICU Nurses, ESOs, GPs, Health officers,
obstetrician, pediatrician and other related
health professionals working in obstetrics or
neonatal care of that particular facility.
Facility –Review of suspected Maternal and perinatal deaths:

• For every reviewed FBMDA/FBPDA an

action plan has to be developed for response
based on the identified modifiable factors.
• Following the review of the FBMDA and
FBPDA, the health facility surveillance focal
person will complete the case based reporting
format (maternal/perinatal death reporting
format (MDRF/PDRF)
 Setting up MPDSR system at facility:

During the “Set Up” phase, facilities should:

– Raise awareness and provide training for all staff
– Schedule regular, routine facility reviews
– Appoint a MPDSR coordinator who relates well to
other staff, is supportive and respected
– Invite local experts to join committee from
backgrounds other than medical/midwifery
– Engage senior staff and managers
 Data quality improvement:
To improve the data quality for FBAF, MPDSR committee
members and data collectors have their great role
1. Role of data collector
– Ensuring data quality
– Maximizing data capture
– Summarizing cases for presentation at review

2. MPDSR Facility committee

Roles and responsibility
– Constructive discussion and taking key decisions
 Data quality improvement:
Data quality improves when...
• All members of staff understand the purpose of the data
collection
• There is good coordination across the facility departments for
collecting and synthesizing data
• Multiple sources are used (case notes, records from admission,
surgery theatre, mortuary etc.)
• Notes are legible
Once the process of data collection becomes routine, reporting
and quality often improve as staff realize their notes and records
will be looked at and used!
 Data quality improvement:

Data capture
• Include all sources of information if women/
neonate received care at multiple sites
• Every effort should be made to include
information from accompanying family members
• A summary of the chain of events should be
generated (description of events leading to the
death)
 Data quality improvement:
Reminder: Committee Roles
• Multi disciplinary to bring in different perspectives and ideas
• Preserves the anonymity of patients and staff (through non-
disclosure pledge)
• Maintains a “No Blame” culture
• Reports objectively on cases
• Identifies actions and provides required feedback to all concerned
• Coordinates with community reviews – essential to build a
complete picture
 Confidentiality: a Code of conduct :

• Local data collectors and involved health care

workers are the only staff who see the names of
deceased
• Knowledge contained within review committees
• All individuals (including committee members)
who access identifying data sign a non-disclosure
confidentiality agreement (kept on record)
 Disclaimer pledge :
(Non-disclosure confidentiality agreement)
We, the members of the ---- review committee, agree
to maintain anonymity and confidentiality for all the
cases discussed at this meeting, held on [DATE]. We
pledge not to talk to anyone outside this meeting
about details of the events analyzed here, and will
not disclose the names of any individuals involved,
including family members or health care providers.
 Committee discussion:
Five key decisions
1. Cause of death
2. Death classification Direct/indirect/incidental
3. Relevant delays
4. Preventability Lessons learnt are applied to
prevent further deaths
5. Actions
 Summary Points:
• Quality of notes and records are vital to the success
of facility based reviews
• Data must be obtained from all relevant sources
(departments where woman treated, other health
services she attended, family members)
• The whole team should review cases and contribute
to taking the key 5 decisions
 MPDSR Case based reporting(MDRFs and PDRFs)
• The Health facility RRT ( including
MCH experts) meet to discuss on
the case
Attention should be given to the
• The committee agrees on the Completeness of MDRF and
major delays involved PDRFs
• The RRT decides on any local
actions needed to prevent further
similar deaths
• The surveillance focal person is Completed forms should be
sent timely within 48 hrs
responsible for completing the
from level to level
MDRF and PDRF (case based
reporting format) and sending it
up the system
• A UNIQUE ID is also given to
MDRF/PDRFS
 Maternal death reporting forms(MDRF)
Annex 6: Maternal Death Reporting Format (MDRF)
Includes five sections (To
(To be
be filled
I.I. Reporting
filled in
in 55 copies
Reporting Facility
copies by
Facility Information
Information
by the
the Health
Health Centre/hospital.
Centre/hospital. Send
Send the
the rest
rest of
of copies
copies to
to the
the next
next level
level by
by keeping
keeping one
one copy)
copy)

Reporting
Reporting Health
Health Facility
Facility name
name & & type
type (H.C/Clinic
(H.C/Clinic Hosp):
Hosp): Region:Region: ________
________ Zone Zone :: _____________
_____________ Woreda:Woreda: _____________
_____________

• Reporting Health facility

__________________________________
__________________________________ Date
Date ofof Reporting
Reporting DD/MM/YYYY
DD/MM/YYYY ____/____/_____
____/____/_____
This MDRF
This MDRF is is extracted
extracted from
from 1. 1. Verbal
Verbal autopsy
autopsy (VA)
(VA) 2. 2. Facility
Facility based
based maternal
maternal death
death abstraction
abstraction form
form (FBAF)
(FBAF)
II. Deceased
II. Deceased Information
Information
Deceased
Deceased ID(code):
ID(code): Date
Date of
of Death
Death DD/MM/YYY
DD/MM/YYY Age
Age atat death:
death: ___
___ Years
Years

information ________________________________ ____/____/_____

________________________________
Residence of
Residence of deceased
deceased Urban
Urban
Rural
Rural
____/____/_____
Region___________ Zone_____________
Region___________
Woreda___________
Woreda___________
Zone_____________ Kebele _____________
Kebele _____________

Place of
Place of Death
Death 1. At
1. At home
home 2. At
2. At health
health post
post 3. At
3. At health
health centre
centre 4. At
4. At Hospital
Hospital

• Deceased information Marital

Marital status
Religion:
status
5. On
5.
1.
On transit
transit from
1. Single
Single
Religion: _________________________________
_________________________________
from home
2.
home to
2. Married
Married
to health
health facility
facility 6.
3.
3. Divorced
Divorced
6. On
On transit
transit from
from health
4.
health facility
4. Widowed
Widowed
facility to

Ethnicity :________________________________
Ethnicity :________________________________
to health
health facility
facility

Level of
Level of Education
Education 1. No
1. No Formal
Formal education
education 2. No
2. No formal
formal education,
education, butbut can
can read
read and
and write
write 3. Elementary
3. Elementary school
school

• Antenatal Care (ANC),

4.
4. High
High school
school 5.
5. College
College andand above
above 6.
6. II do
do not
not know
know
Gravidity _______________
Gravidity _______________ Parity__________________
Parity__________________
Timing of
Timing of death
death in
in relation
relation toto pregnancy
pregnancy 1= Antepartum
1= Antepartum 2= 2= Intra-partum
Intra-partum 3= Postpartum
3= Postpartum
st
st nd
nd rd
rd th
th th th th
th
IfIf the
the deaths
deaths occur
occur in
in post-partum/post-abortion,
post-partum/post-abortion, timingtiming ofof 1.
1. 11 2424 hr.
hr. 2.
2. 22 and
and 33 dayday 3. 3. 44 -7-7 day day 4.4. 88 -42
-42 day
day

Delivery and Postnatal death?

death?
III. Antenatal
III. Antenatal Care
Attended
Attended ANC? ANC?
Care (ANC),
(ANC), Delivery
Delivery and
and Postnatal
Postnatal care
1.
1. Yes
Yes
care (PNC)
(PNC) // Post
2.
2. No
No
Post abortion
abortion care(PAC)
3.
3. Not
care(PAC)
Not known
known
IfIf yes,
yes, where
where is
is the
the ANC? 1.
1. Health
Health post
post 2. 2. Health
Health centre
centre 3.3. Hospital
Hospital 4.
4. Other
Other (specify)
(specify) _________

care (PNC) / Post

ANC? _________
IfIf yes
yes for
for ANC,
ANC, number
number ofof visits?
visits? _________________
_________________
IfIf yes,
yes, GA
GA in
in months
months atat the
the first
first ANC
ANC visit
visit _________________
_________________
IfIf delivered,
delivered, Mode
Mode of of delivery?
delivery? 1. Vaginal
1. Vaginal delivery
delivery
2.
2. Abdominal
Abdominal operated
operated delivery
delivery (CS
(CS or
or hysterectomy)

abortion care(PAC)
hysterectomy)
Place
Place of of delivery
delivery or
or Abortion?
Abortion? 11 Home
Home 2.
2. On
On transit
transit 3. 3. H/post
H/post 4.
4. H/center
H/center 5. 5. Hospital
Hospital 6.
6. Clinic
Clinic
Date
Date of of delivery
delivery /Abortion
/Abortion Date __________________
Date __________________
IfIf itit was
was delivery/Abortion,
delivery/Abortion, who
who assisted
assisted 1. Family/
1. Family/ 2. TBA
2. TBA elderly
elderly 3. HEWs
3. HEWs 4. HCWs
4. HCWs
the
the delivery/Abortion?
delivery/Abortion?

• Causes of death
Attended
Attended PNC/PAC?PNC/PAC? 1.
1. Yes
Yes 2.
2. No
No 3.
3. Not
Not known
known 4.
4. Not
Not applicable
applicable
IfIf yes
yes for
for PNC/PAC,
PNC/PAC, number
number of
of visits?
visits? _________________
_________________
IV.
IV. Cause
Cause of
of death
death
Direct
Direct obstetric
obstetric 1=
1= haemorrhage
haemorrhage 2=
2= obstructed
obstructed labour
labour 3=
3= HDP
HDP 4=abortion
4=abortion 5=
5= sepsis
sepsis 6.
6. Others
Others __________
__________

• Contributory factors
Indirect
Indirect obstetric
obstetric 1=anaemia
1=anaemia 2=
2= malaria
malaria 3=
3= HIV
HIV 4=
4= TB
TB 5.
5. Others
Others _______________________
_______________________
IfIf delivered,
delivered, what
what was
was the
the outcome?
outcome? 1.
1. Live
Live birth
birth 2.
2. Stillbirth
Stillbirth
Is
Is the
the death
death preventable?
preventable? 1=
1= Yes
Yes 2=
2= No
No
V.
V. Contributory
Contributory factors
factors (Thick
(Thick all
all that
that apply)
apply)
Traditional
Traditional practices
practices Lack of
Lack of decision
decision to
to go
go to
to health
health facility
facility Family
Family poverty
poverty Delayed
Delayed referral
referral from
from home
home
Delay
Delay 11 Failure of
Failure of recognition
recognition of
of the
the problem
problem
Delay
Delay 22 Delayed arrival
Delayed arrival to
to referred
referred facility
facility Lack of
Lack of transportation
transportation Lack
Lack of
of roads
roads No
No facility
facility within
within reasonable
reasonable distance
distance
Lack of
Lack of money
money for
for transport
transport

Delay
Delay 33 Delayed
Delayed arrival
arrival to
to next
next facility
facility from
from another
another facility
facility on
on referral
referral
Delayed or
Delayed or lacking
lacking supplies
supplies and
and equipment(specify)_____________________________
equipment(specify)_____________________________
Delayed management
Delayed management after
after admission
admission Human error
Human error or
or mismanagement
mismanagement
Reported
Reported by: ______________________ Signature:
by: ______________________ Signature: _______________
_______________ Seal Seal
 Perinatal death reporting forms(PDRF)
Reporting
Reporting Facility
Facility Information
Information
Reporting
Reporting Health
Health Facility
Facility name
name &type(H.C/Cl./Hosp):_____________________________
&type(H.C/Cl./Hosp):_____________________________ Woreda:
Woreda: __________________
__________________

Includes six sections Zone :_________________

Zone :_________________
This PDRF is extracted from
This PDRF is extracted from :
Deceased
Deceased Information
Deceased
Information
:
Region:
Region: ___________________
1. VA
1. VA
___________________
2. Facility
Date
Date of
based
of Reporting
Reporting DD/MM/YYYY
Perinatal death
DD/MM/YYYY ____/____/_____
abstraction
____/____/_____
form
2. Facility based Perinatal death abstraction form

Deceased ID(code):
ID(code): ______________________________________________________________
______________________________________________________________
Residence
Residence of
of deceased/parents
deceased/parents Region_________________________
Region_________________________ Zone________________________________
Zone________________________________

• Reporting Health facility

Urban
Urban Rural
Rural Woreda______________________________
Woreda______________________________ Kebele
Kebele ___________________________
___________________________
Date
Date and
and time
time ofof birth
birth DD/MM/YYYY
DD/MM/YYYY ___/____/____/
___/____/____/ Day Day ☐ Night ☐
☐ Night ☐ (hrs/min)____/____
(hrs/min)____/____
Vital status
Vital status of
of the
the newborn
newborn atat birth
birth 1.
1. Alive
Alive (live
(live birth)
birth) 2.
2. Dead
Dead (still
(still birth
birth
Date and time of death (Not applicable for stillborn)
Date and time of death (Not applicable for stillborn) DD/MM/YYYY
DD/MM/YYYY _____/______/______/
_____/______/______/ Day Day ☐ Night ☐
☐ Night ☐ (hrs/min)______/_______
(hrs/min)______/_______
Sex of the deceased
Sex of the deceased 1.
1. Male
Male 2.
2. Female
Female
Estimated gestational
Estimated gestational age
age at
at delivery
delivery inin weeks
weeks __________________
__________________ weeks weeks

information
Place of
Place of Death
Death 1. Home/
1. Home/ Relatives’
Relatives’ Home
Home 4.
4. Hospital
Hospital
2. Health
2. Health Post
Post 5. In
5. In Transit
Transit (estimated
(estimated Distance
Distance from
from the
the destination
destination in
in km:
km: _____)
_____)
3.
3. Health
Health Centre
Centre 6.
6. During
During referral
referral (from
(from facility
facility to
to facility
facility ))
General
General information
information of of the
the mother
mother
Is
Is the
the mother
mother of
of the
the deceased
deceased alive?
alive? ☐ No
Yes ☐
Yes No ☐☐

• Deceased information
Age of the mother_____________(years)
Age of the mother_____________(years) Parity_____________
Parity_____________ Number Number of of alive
alive children
children ______________
______________
Religion of
Religion of the
the mother
mother 1. Orthodox
1. Orthodox 2. Muslim
2. Muslim 3. Protestant
3. Protestant 4.Catholic
4.Catholic 5. Others
5. Others (specify)____________________
(specify)____________________
Educational status
Educational status 1.No formal Education
1.No formal Education 3.Elementary
3.Elementary school
school 5.
5. College
College and
and above
above
Of
Of the
the mother
mother 2.No
2.No formal
formal education,
education, but
but can
can read
read and
and write
write 4.
4. High
High school
school 6.
6. Unknown
Unknown
Occupation
Occupation of of 1.Pofessional
1.Pofessional 4.Manual
4.Manual Skilled
Skilled 7.
7. Unemployed
Unemployed
the
the mother
mother 2.Clerical
2.Clerical 5.
5. Manual
Manual Unskilled
Unskilled 8.
8. Others
Others (Specify)
(Specify) _________________
_________________

• General information of
3.Sales
3.Sales and
and Services
Services 6.
6. Agriculture
Agriculture
Obstetric History
Obstetric History ofof the
the mother
mother inin relation
relation to
to this
this deceased
deceased case
case

Number
Number of
of ANC
ANC visits
visits in
in relation
relation to
to the
the deceased
deceased case
case (( report
report “0”
“0” ifif no
no ANC
ANC visits
visits )) ___________________
___________________
Number of
Number of TT
TT vaccine
vaccine during
during the
the pregnancy
pregnancy of
of the
the deceased
deceased case:
case: 1.
1. No No TT
TT 2.
2. One
One TTTT 3.
3. Two
Two and
and above
above TT
TT
Mode
Mode of
of delivery
delivery of
of the
the deceased
deceased baby 1.
1. SVD
SVD 2.
2. Operative
Operative vaginal
vaginal delivery
delivery 3.
3. Forceps
Forceps 4.
4. Vacuum
Vacuum 5.
5. C/S

the mother
baby C/S

Status
Status of
of the
the baby
baby at
at birth
birth Still
Still birth ☐ live
birth ☐ born ☐
live born ☐ ifif alive
alive APGAR
APGAR score
score at
at 5th
5th minute
minute ______________________
______________________
Where was
Where was the
the deceased
deceased baby
baby born?
born? 1. Home
1. Home 2. 2. On
On transit
transit 3.
3. H/post
H/post 4.4. H/center
H/center 5.
5. Hospital
Hospital 6.Clinic
6.Clinic
Maternal
Maternal disease
disease or
or condition
condition identified
identified _________________________________________________________________________________
_________________________________________________________________________________

• Obstetric History of the

Perinatal
Perinatal Cause
Cause of
of death
death
Neonatal
Neonatal Cause
Cause of
of death
death 1.
1. Complications
Complications Prematurity
Prematurity 2.
2. 3.
3. Sepsis/pneumonia/meningitis
Sepsis/pneumonia/meningitis 4.
4. 5.
5. Lethal
Lethal congenital
congenital anomaly
anomaly
Asphyxia
Asphyxia Neonatal Tetanus
Neonatal Tetanus 6. Other
6. Other ______________
______________

Maternal
Maternal causes
causes of
of 1.
1. Obstructed
Obstructed labor
labor 3.
3. Preeclampsia/
Preeclampsia/ Eclampsia
Eclampsia 5.
5. Obstetric
Obstetric Sepsis
Sepsis

mother in relation to the

death
death 2. Ruptured
2. Ruptured Uterus
Uterus 4. APH
4. APH (Placenta
(Placenta previa
previa or
or abruption)
abruption) 6.Others_______________________
6.Others_______________________
st
Timing
Timing of
of the
the 1.
1. Antepartum
Antepartum stillbirth
stillbirth 3.
3. Still
Still birth
birth of
of un
un known
known time
time 5.
5. Death
Death Between
Between 11st day
day and
and 77 day
day
death
death 2.
2. Intrapartum
Intrapartum stillbirth
stillbirth 4.
4. Death
Death In In the
the first
first 24
24 after
after birth
birth 6.
6. Death
Death Between
Between 88 day
day and
and 28
28 days
days
Is the death preventable?
Is the death preventable? 1= Yes
1= Yes 2= No
2= No 3= Unknown
3= Unknown

deceased case
Contributory factors (Thick all that apply)
Contributory factors (Thick all that apply)
Delay
Delay in
in 1.
1. Family
Family poverty
poverty 5.
5. Had
Had no
no one
one to
to take
take care
care of
of other
other children
children
seeking
seeking care
care 2.
2. Did
Did not
not recognize
recognize thethe danger
danger signs
signs of
of newborn
newborn infants
infants 6.
6. Reliant
Reliant on
on traditional
traditional practice/medicine
practice/medicine
3.
3. Unaware
Unaware of of the
the warning
warning signs
signs of
of problems
problems during
during pregnancy
pregnancy 7.
7. Lack
Lack of decision to go to the health facility
of decision to go to the health facility
4.
4. Did
Did not
not know
know where
where to to go
go

• Perinatal Cause of death Delay

Delay in
health
in reaching
reaching to
health care
to aa
care facility
facility
1.
1.
2.
2.
Transport
Transport was
was not
Transport was
Transport
not available
was too
available
too expensive
expensive
3.
3.
4.
4.
5.
5.
.No
.No facility
facility within
Lack of
Lack of road
Others
within reasonable
road access
access
reasonable distance

Others _______________________
_______________________
distance

• Contributory factors
Delay
Delay in
in receiving
receiving care
care in
in aa 1.
1. Delayed
Delayed arrival
arrival to
to next
next facility
facility from
from another
another referring
referring 5.
5. Human
Human error
error or
or mismanagement’
mismanagement’ andand
health
health facility
facility facility
facility 6.
6. Delay
Delay in
in first
first evaluation
evaluation by
by care
care giver
giver after
after admission
admission
2.
2. Family lacked money for health
Family lacked money for health care care 7.
7. Lack of supplies or equipment,
Lack of supplies or equipment,
3.
3. delayed management
delayed management afterafter admission
admission specify___________________
specify___________________
4.
4. Fear to
Fear to be
be scolded
scolded oror shouted
shouted at at by
by the
the staff
staff
Exercise how to fill and review the
MDRF or PDRF