Skip to main content

Table 6 MDSR Maternal death reporting form. This is the form used to report maternal death information in the MDSR system after review

From: Causes of maternal deaths and delays in care: comparison between routine maternal death surveillance and response system and an obstetrician expert panel in Tanzania

1. Name of Reporting Health

Facility __________________

2. Facility unique

ID number

(YYYY/Number)

________________

3. Address of the deceased

Ward

______________

 

Division ____________________

District

______________

  

Region

______________

Deceased Information

4. Date of Death (DD/MM/YYYY)

____/____/_____

5. Age at death: ___ Years

6. Gravidity ________

7. Parity __________

8. Marital status (circle what applies. Only one response allowed)

 

1. Married

 

4. Cohabiting

 

2. Single

 

5. Separated

 

3.Widowed

 

6. Divorced

9. Level of education (circle whatapplies)

1. None

 

4. Higher education

2. Primary

 

5. Unknown

 

3.Secondary

  

10. Occupation

_________________________

11. Admission at the health facility

Date (DD/MM/YY)

__________________

Time

______________

Antenatal Care (ANC)

12. Attended ANC?

1. Yes

2. No

3. Not known

13. Where was the ANC done?

1. Dispensary

4. Other (specify) _________

 

2. Health centre

5. Had not attended yet

 

3. Hospital

 

14. Number of ANC visits

 

Not applicable (Had not attended yet)

15. Basic package of services

provided on ANC (Circle what applies)

Syphilis screening

1. Yes 2. No. 3. Unknown

Hgb,

1. Yes 2. No 3. Unknown

HIV status

1. Yes 2. No 3. Unknown

Blood group

1. Yes 2. No 3. Unknown

BP measurement during the follow up

1. Yes 2. No 3. Unknown

 

Urinalysis

1. Yes 2. No 3. Unknown

Fe/FoL supplementation

1. Yes 2. No 3. Unknown

TT immunization

1. Yes 2. No 3. Unknown

16. Diagnosis on admission (circlewhat is appropriate)

1.Normal labour

10. Ectopic pregnancy

2. Eclampsia

11. Previous C/S scar

3. Hypertensive disorders without eclampsia

4. Nursing mother

12. Violence

5. HIV/AIDS

13. Obstructed labour

6. Antepartum haemorrhage

14. Severe malaria

7. Postpartum haemorrhage

15. Ruptured uterus

8. Incomplete abortion

16. Anaemia

9.Sepsis

17. IUFD

 

18. Others (Specify) … … …

17. Name and Place of Delivery/abortion (circle what applies)

1. Hospital

5. Delivery before arrival

2. Health centre

6. Home

3. Dispensary

7. Not applicable (in case undelivered

4. Maternity home

 

18. Date of death (DD/MM/YYY)

______________________

18 b. Place of Death (circle what applies)

1. at home

4. at Hospital

2. at dispensary

5.on transit to facility

3. at health centre

6. Other specify

19. Duration from onset of complication to time of death

 

20. When did death occur?

_________(hours/days)

1. Before Intervention

2. During intervention

21. Timing in relation to pregnancy

1 = Antepartum

2 = Intrapartum

3 = Postpartum

Delivery and related information

22. Mode of delivery

1. Spontaneous vertex delivery

6.Laparotomy/Hysterotomy

2. Emergency C/S

7. Other … … ………………… … ..

3. Elective C/S

8. Not applicable (had not delivered yet)

4. Vacuum extraction

 

5. Breech delivery

 

23. Delivery attendant

1. Nurse/midwife

6. Assistant Clinical officer

2. Medical Officer

7. Traditional birth attendant

3. Obstetrician

8. Other______________________

4. AMO

9. Not applicable (had not delivered)

5. Clinical officer

 

24. In case of caesarean section/laparotomy/Hysterotomy (fill in or circle what applies)

1. Indication of surgery _____________________________________________

2. Duration of surgery: a. 1 h or less b. More than 1 h

3. Type of anaesthesia used: a. General b. Spinal c. Not recorded

4. Time from decision to performing surgery …… .hrs … … ...mins

5. Not a C-section/laparotomy

25 Pregnancy outcome (circle what applies)

1.Live baby

2. Fresh still birth

3. Macerated stillbirth

4. Ectopic

5. Abortion

 

26. Was a post mortem done?

1 = Yes

2 = No

What was the diagnosis?

Cause of death

27. Direct cause (Circle what applies. Only one choice allowed)

• O0 Ectopic pregnancy

• O14.1 Severe pre eclampsia

• O15 Eclampsia

• O85 Puerperal sepsis

• O64 Obstructed labour-Malposition/Malpresentation

• O65 Obstructed labour-Maternal pelvic abnormality

• O66 Obstructed labour-Other causes

• O44.1 Placenta praevia

• O45.0 Abrutpio placentae

• O71 PPH- Trauma

• O72 PPH- Non traumatic

• O08 Abortion

• O74 Anaesthetic complication

• O88 Embolism

28. Indirect cause

• O99.0 Anaemia

• O98.6 Malaria

• O98.7 HIV and AIDS

• O93.3 Cardiomyopathy

• T65 Herbal intoxication

• O24 Diabetes Mellitus

• O98.0 TB

• Others Specify...............

29. Other causes

• O95 Unspecified or unknown cause of death

30. Underlying medical conditions that could have contributed to the death

______________________________________________

______________________________________________

31. Contributory factors and non-medical causes of death (Tick all that apply)

Delay 1

Traditional practices

Lack of decision to go to health facility

Family poverty

Unwillingness to seek medical help

Failure of recognition of the problem

Delayed referral from home

Delay in starting antenatal care

 

Delay 2

Delayed arrival to referred facility

Lack of transportation

Lack of roads

No facility within reasonable distance

Lack of money for transport

 

Delay 3

Sub optimal antenatal care

Delayed arrival to next facility from another facility on referral

Delayed or lacking supplies and equipment (specify) _______________________

Delayed management after admission

Human error or mismanagement (specify) ____________________________

Inadequate skills of provider (specify) _______________________________

Others

(specify)

___________________________________________________________________

32. Could this death have been avoided?

Yes

No

Comment_________________________________________________ __________________________________________

33. List the avoidable factors, missed opportunities or substandard care – why did this happen?

 

34. Summarize the case

 
Back to article page

BMC Health Services Research

ISSN: 1472-6963

Contact us