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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