Maternal and Perinatal Death Surveillance and Response:: Materials To Support Implementation

Maternal and Perinatal
Death Surveillance
and Response:
Materials to Support
Implementation
Maternal and perinatal death surveillance and response: materials to support implementation
Maternal and Perinatal Death
Surveillance and Response:
Materials to Support
Implementation
ISBN 978-92-4-003666-6 (electronic version)

ISBN 978-92-4-003667-3 (print version)
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Contents
Acknowledgements iv
Abbreviations v
Introduction to WHO Implementation Tools for Maternal and Perinatal Death
Surveillance and Response 1
Module 1: Definitions 5
Module 2: Getting started at the facility level 11
Step 1: Assess the current situation 11
Step 2: Set up a steering committee 11
Step 3: Determine operating procedures and tasks 12
Module 3: Identifying cases 15

Module 4: Collecting information 19
Module 5: Conducting joint maternal and perinatal death reviews 25
Module 6: Analysing and presenting information 31
Module 7: Recommending actions and implementing change 35
Module 8: Monitoring MPDSR implementation and improvements in quality of care 43
Module 9: MPDSR in humanitarian and fragile settings 47
Module 10: Overcoming the blame culture of MPDSR 51
List of resources 61
Annexes 65
Contents iii
Acknowledgements
MPDSR Materials to support Implementation reflect the participation of the World Health Organization
(WHO) and the MPDSR Technical Working Group, including representatives from the following agencies
(alphabetically): Asia and Oceania Federation of Obstetrics and Gynaecology (AOFOG), Centers for
Disease Control and Prevention (CDC), Clinton Health Access Initiative (CHAI), Department of Foreign,
Commonwealth & Development Office (FCDO), Evidence for Action (E4A), International Federation of
Gynecology and Obstetrics (FIGO), International Confederation of Midwives (ICM), International Council
of Nurses (ICN), Johns Hopkins Program for International Education in Gynecology and Obstetrics
(Jhpiego), Liverpool School of Tropical Medicine (LSTM), London School of Hygiene and Tropical
Medicine (LSHTM), MSD for Mothers, Options Consultancy Services Ltd, Save the Children, United
States Agency for International Development (USAID), MOMENTUM Country and Global Leadership
(MCGL), Maternal and Child Survival Program (MCSP), United Nations Children’s Fund (UNICEF), and
United Nations Population Fund (UNFPA).
The document was originally drafted by Kate Kerber, a WHO consultant. Substantial input was provided by
Matthews Mathai and Subhasri Balakrishnan (LSTM), Kathleen Hill and Kusum Thapa (MCGL/ Jhpiego),
Ank de Jong (ICM), Elaine Scudder (Save the Children), Endang Handzel and Florina Serbanescu (CDC),
Louise Hulton (E4A), Robyn Churchill (CHAI), Mary Kinney (University of Western Cape, South Africa),
Debra Jackson, Louise Day, Mary Mbuo (LSHTM) and Tedbabe Degefie Hailegebriel and Alex Manu
(UNICEF), Animesh Biswas and Michel Brun (UNFPA), Temitayo Erogbogbo (MSD for Mothers).
WHO officers responsible for the document are Allisyn Moran and Francesca Palestra. WHO staff
contributing to the document include Blerta Maliqi, Maurice Bucagu, Anayda Gerarda Portela, Frances
McConville, Doris Chou, Ann-Beth Moller, Bremen De Mucio, Nancy Kidula, Fatim Tall, Eric-Didier N’Dri,
Sandra Dao Ramatou Sawadogo Windsouri, Assumpta Muriithi, Triphonie Nkurunziza, Nino Berdzuli,
Anoma Jayathilaka Chandani, Jennifer Cresswell, Rajesh Metha and Neena Raina.
The draft of MPDSR Materials to support Implementation were tested in four countries to evaluate their
efficacy, effectiveness and userfriendliness.
WHO acknowledges the helpful feedback received from participants of the following healthcare facilities
at the pilot-testing sites:
• Sri Lanka: thanks to Kapila Jayaratne (National Program Manager FHB) and participants from a
Specialist Women’s Hospital, four Teaching Hospitals, three District General Hospitals, two Base
Hospitals and a Private sector Hospital.
• Zimbabwe: thanks to Stephen Munjanja, Sunhurai Mukwambu (Department of Obstetrics and
Gynaecology, Faculty of Medicine and Health Sciences, University of Zimbabwe) and participants
from United Bulawayo Hospitals, Mutare Provincial and Sally Mugabe Hospitals
• Burkina Faso: thanks to René Pare and participants from HD de Boromo, HD de Gourcy, HD de
Sindou, HD de Batié, HD de Do, HD de Léo, HD de Pouytenga, HD de Ouargaye, HD de Ziniaré,
CHUR de Ouahigouya.
• Côte d’Ivoire: thanks to Seydou Kone, Marie Laurette Agbre Yace and participants from CHR
Abengourou, HG Aboisso, CHU Bouaké, HG Anyama, CHR Gagnoa, CHR Guiglo, HG Ferkessedougou,
HG Soubre, CHR Yamoussoukro, HG Port-Bouët
Special thanks are due to the Department of Foreign, Commonwealth & Development Office (FCDO)
of the United Kingdom of Great Britain and Northern Ireland for resources and support during the
development of the document.
iv Maternal and perinatal death surveillance and response: materials to support implementation
Abbreviations
ANC �� Antenatal care
CLAP/WR �� Latin American Center for Perinatology/Women’s and Reproductive Health Unit
CL �� Community Liaison
CDC �� Centers for Disease Control and Prevention
CRVS �� Civil Registration and Vital Statistics
DHIS2 �� District Health Information System
HMIS �� Health Management Information System
ICD-MM �� The WHO application of ICD-10 to maternal deaths during pregnancy, childbirth
and puerperium
ICD-PM �� The WHO application of ICD-10 to deaths during the perinatal period
ICD �� International Classification of Diseases
KMC �� Kangaroo mother care
MCSP �� Maternal and Child Survival Program
MCA �� Department of Maternal, Newborn, Child, Adolescent Health & Ageing
MDR �� Maternal death review
MDSR �� Maternal death surveillance and response
MPDSR �� Maternal and perinatal death surveillance and response
MMR �� Maternal mortality ratio
MoH �� Ministry of Health
PDR �� Perinatal death review
PNC �� Postnatal care
QI �� Quality improvement
UNFPA �� United Nations Population Fund
UNICEF �� United Nations Children’s Fund
WHO �� World Health Organization
WRA �� Women of reproductive age
Abbreviations v
vi Maternal and perinatal death surveillance and response: materials to support implementation
Introduction to WHO
Implementation Tools for
Maternal and Perinatal Death
Surveillance and Response
The purpose of these implementation tools is to provide a roadmap for conducting Maternal and Perinatal
Death Surveillance and Response (MPDSR) in clinical and policy settings, as described in the two World
Health Organization (WHO) guides entitled Maternal death surveillance and response (MDSR): technical
guidance information for action to prevent maternal death (2013) and Making every baby count: audit and
review of stillbirths and neonatal deaths (2016).
These two guides provide approaches to respond to maternal and perinatal death cases to help end
preventable maternal deaths, stillbirths and newborn deaths. Bringing the death review process together
has the potential to promote successful partnerships at different levels that can lead to real change for
communities and nations.
MPDSR involves qualitative, in-depth investigations of the causes and circumstances surrounding
maternal and perinatal deaths. This process is an integral part of quality of care improvement efforts to
reduce maternal deaths, as well as preventable stillbirths and neonatal deaths.
The MPDSR process relies on the effective identification of reporting and assigning causes of deaths,
identifying actions that may contribute to the prevention of further deaths, assigning those actions to
particular groups or individuals, designating time frames for completion of those actions, and following
up to ensure that those actions have been taken.
Some readers may be familiar with the term “audit” when applied to deaths and mortality in the context
of MPDSR, while others are more familiar with the term “review”. In these implementation tools, both
terms are used interchangeably.
These MPDSR implementation tools are primarily focused on getting started at the district and health
facility level as a first step. Surveillance, identification, notification and review of community-based deaths
are important components of MPDSR and may involve a separate, but linked set processes.
What are the goals of the MPDSR process and this guide?
• To establish a framework to assess the burden of maternal deaths, stillbirths and neonatal deaths,
including trends in numbers and causes of death.
• To generate information about modifiable factors contributing to preventable death, and to use the
information to guide action in order to prevent similar deaths in the future.
• To promote confidentiality and a “blame free” culture
• To provide accountability for results and compel decision-makers to give the problem of maternal
deaths, stillbirths and neonatal deaths due attention and response.
• To provide examples of forms and guidance that can be adapted to the local context.
• To compile and link to tools, resources and the evidence base for MPDSR.
Introduction to WHO Implementation Tools for Maternal and Perinatal Death Surveillance and Response 1
Fig. 1. The MPDSR cycle
THE MPDSR CYCLE

Surveillance & Response
QoC Vital
Improvement Registration
Response Identify
action deaths
Review Report
deaths deaths
QoC MMR & PMR

Measurement Tracking
Who is this guide meant for?

This operational guide has a broad target audience, which may include:
• clinicians and all participants in clinical care for women and babies, and the maternal and perinatal
death review processes;
• public health officials and public health leadership;
• other stakeholders in maternal and perinatal death reduction, such as planners and managers,
in-service trainers, epidemiologists, demographers, policy-makers and professionals working with
vital registration systems.
How are maternal and perinatal death review linked?

In some countries, maternal and perinatal death review processes are already linked at regional or national
level, as well as in health facilities. In others, either maternal or perinatal death reviews may be taking
place, or both are taking place, but they exist as separate entities. This guide is available for facility-level
quality improvement teams, clinical leaders, health decision-makers and other stakeholders seeking to
combine and strengthen efforts in order to learn from each other and reduce duplicate processes. Such
efforts could include, for example, combined maternal and perinatal death review meetings within a
single quality improvement committee, joint strategies to identify deaths, collect information and report
data, or sharing meeting minutes and relevant action items between committees.
2 Maternal and perinatal death surveillance and response: materials to support implementation
Outline of modules
There are ten modules in this operational guide that detail the process for maternal and perinatal
death reviews. Each module links to available tools and resources, including: guidelines, forms, training
materials, videos, training presentations and case studies. These materials can be adapted for various
settings. Each available resource is mentioned at the end of each module. The majority of tools and
resources in this document relate to maternal and perinatal deaths at the facility level and community level.
Text boxes throughout the document provide illustrative examples in different contexts and additional
resources can be found in Module 7. Please note that tools included in this document are in bold font
while links to existing resources are underlined with hyperlinks to the document.
MODULE TITLE TRAINING TRAINING CASE SAMPLE OTHER

MATERIALS MATERIALS STUDIES FORMS TOOLS AND
(Maternal) (Perinatal) RESOURCES
1. Definitions
2. Getting started at the

facility level
3. Identifying cases
4. Collecting information
5. Conducting joint
maternal and perinatal
death reviews
6. Analysing and
presenting
information
7. Recommending
actions and
implementing change
8. Monitoring, evaluating
and refining
9. Humanitarian and
fragile settings
10. Overcoming the

blame culture of
MPDSR
Introduction to WHO Implementation Tools for Maternal and Perinatal Death Surveillance and Response 3
MODULE
Definitions
1
Module 1: Definitions
Inconsistent use of terminology contributes to confusion around maternal mortality, neonatal deaths
and stillbirths. The following definitions cover some of the key terms adopted in the MDSR technical
guidance and Making every baby count guides that are used in mortality audits. Please note the difference
in definitions for pregnancy-related deaths and maternal deaths. For MDSR, we use the maternal deaths.
Pregnancy-related death: definition

The death of a woman while pregnant or within 42 days of termination of
pregnancy, irrespective of the cause of death (obstetric and non-obstetric); this
definition includes unintentional/accidental and incidental causes. Standards and
reporting requirements related for maternal mortality. In: ICD-11 Reference guide,
Part 2 [website]. Geneva: World Health Organization; 2019, accessed 12 July 2019).
Pregnancy-
related death
Maternal death: definition

The death of a woman while pregnant or within 42 days of the 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.
Maternal Maternal death: presentation of data
death Maternal mortality is presented as a ratio per 100 000 live births in a given
time period.
Maternal causes of death
Cause of death coding is conducted according to the International Classification
of Diseases–10th revision (ICD-10). WHO has developed guidance specific to
maternal mortality, called The WHO application of ICD-10 to maternal deaths
during pregnancy, childbirth and puerperium: ICD-MM. ICD-MM is intended to
facilitate the consistent collection, analysis and interpretation of information
on maternal deaths. The ICD-MM document will be updated based on ICD-11.
Stillbirth: definition
The internationally comparable definition of stillbirth as defined by WHO is
death before birth, among fetuses that are, by order of priority, of at least 1000 g
birthweight, and/or at least 28 weeks gestation, and at least 35 cm long.1 Because
Stillbirth of the increased viability of babies born with lower gestational age in some
parts of the world, and due to differences in capacity in measurement, some
groups and individuals define stillbirths differently. For example, they may include
fetuses of a lower gestational age. The national definition should be used, where
relevant, and all stillbirths at 22 weeks and 28 weeks should be reported for
international comparisons.
See Figure 2.1 in Making every baby count: audit and review of stillbirths and neonatal deaths (2016).
1
Stillbirth: presentation of data
Stillbirths can be grouped into two major categories: (i) antepartum stillbirths,
which occur before the onset of labour, and (ii) intrapartum stillbirths, which occur
after the onset of labour. For intrapartum stillbirth diagnosis, it is a prerequisite to
have heard fetal heart sounds on admission. Intrapartum stillbirths largely reflect
the quality of care during labour, while antepartum stillbirths can be a useful
indicator of the quality of antenatal care services and fetal growth monitoring in
some settings, especially in low- and middle-income contexts. Assigning cause
of death to stillbirths is very difficult, even in high- income settings with strong
diagnostic capabilities. The timing of death is therefore a proxy, but should not
be used to assign a cause of death. About one-half of all stillbirths worldwide
occur in the intrapartum period, though the proportion can vary by level of
access to care.
In areas where no fetal heart monitoring is available, stillbirths may be
categorized as (i) “macerated” stillbirths or (ii) “fresh” stillbirths. Examination
of fetal remains can assist in determining whether the fetus died more than
12 hours prior to childbirth (macerated stillbirth) or less than 12 hours before
(fresh), though there is some potential for misclassification between these
categories. For example, in settings with major delays in access to care,
stillbirths may occur during labour, but not be delivered for days, by which time
they are classified as macerated. Conversely, some intrapartum stillbirths may be
due to infections or congenital causes. The extent of this misclassification may
be important to consider in perinatal death review, depending on the context.
The stillbirth rate is defined as the number of stillborn babies per 1000 total
births (total meaning both live and stillborn babies).
Neonatal death: definition

Death after birth and within the first 28 days of life.
Neonatal death: presentation of data
Neonatal The “early neonatal period” refers to the first seven days after birth (Days 1
death through 7 after birth). The “late neonatal period” refers to the remainder of that
first month of life (Days 8 through 28 after birth). In this document, Day 1 is
considered in clinical terms to be the first day of life, but is defined differently in
research settings.
Neonatal mortality is expressed as a rate per 1000 live births.
Perinatal mortality: definition

The number of fetal deaths of at least 28 weeks of gestation and/or 1000 g in
weight and newborn deaths (up to and including the first seven days after birth).
Perinatal Perinatal mortality: presentation of data

mortality Perinatal mortality is presented as a rate per 1000 total births (i.e. including
stillbirths and live births).
Stillbirth and neonatal causes of death
Cause of death coding is conducted according to the International
Classification of Diseases-10th revision (ICD-10). WHO has developed new
guidance specific to perinatal mortality, called The WHO application of ICD-10
Stillbirth to deaths during the perinatal period: ICD-PM. ICD-PM is a globally applicable
and neonatal system for classifying perinatal mortality that overcomes the barriers posed by
causes of numerous existing classification systems, which have used different approaches
death and restricted data comparability. Making every baby count uses ICD-PM for
classification in order to allow programmatic groupings of cases, and for
comparison across low-income, middle-income and high-income settings with
differing diagnostic capabilities.The ICD-PM document will be updated based
on ICD-11.
Modifiable factors
A modifiable factor is something that may have prevented the death if a different course of action had
been taken.
For example, a delay in administering oxytocin (uterotonic), or not having blood products available,
could be a contributing or modifiable factor in a maternal death due to postpartum haemorrhage that
occurred at a health facility.
In the case of a neonatal death, a modifiable factor could be if the birth attendant did not provide vigorous
stimulation to the baby immediately after birth, or did not proceed to bag and mask ventilation, if vigorous
stimulation failed to resuscitate the baby.
Modifiable factors can be described as delays in care (1st – a delay in a decision to seek care, 2nd – a delay
in reaching care, or 3rd – a delay in receiving adequate care), and in levels of system failure (for example
family- or patient-related/personal, administration-related, provider-related). A root-cause analysis can
help to identify all the problems that led to or contributed to the system failure and the resulting stillbirth
or neonatal death under review.
Information Systems
A functional MPDSR process involves local data collection and review, linked to existing information
systems. Examples of these include:
Health Management Information System (HMIS)

An HMIS is a data collection system designed to support reporting, planning, management and decision-
making in health facilities and organizations. Data are collected using standardized tools at the health facility,
before being aggregated at different levels of the health system and used in health-related decision-making.
District Health Information System (DHIS2)

DHIS2 is a free and open source health information management software platform used by governments
and organizations around the world. DHIS2 is used to aggregate, validate, analyse, manage and present
information at subnational and national levels. The platform is available in eight different languages, and
offers mobile features as well as web-based and offline support. DHIS2 also offers a number of mobile
solutions where clients can use their mobile phones to register cases and events, conduct surveys and
collect aggregate data.
Civil Registration and Vital Statistics (CRVS)
A well functioning CRVS system registers all births and deaths, issues birth and death certificates, and
compiles and disseminates vital statistics, including cause of death information. Health facility reporting
provides a good starting point for ensuring that births and deaths are reported to CRVS. Some countries
have a CRVS office located within major hospitals, where both births and deaths can be registered.
However, in other settings, especially where rates of maternal deaths, neonatal deaths and stillbirths
remain high, the CRVS does not capture all births and deaths, or assign a cause of death. Many births
remain unregistered, and most stillbirths and half of all neonatal deaths neither receive a birth certificate
nor are counted as part of official statistics.
Relevant tools, forms and guidance

• MDSR technical guide glossary (page 66)
• The WHO application of ICD-10 to maternal deaths during pregnancy, childbirth and puerperium:
ICD-MM
• WHO application of ICD-10 to deaths during the perinatal period: ICD-PM
• Standards and reporting requirements related for maternal mortality. In: ICD-11 Reference guide,
Part 2 [website]. Geneva: World Health Organization; 2019
• Maternal and Child Survival Program (MCSP) MDSR workshop facilitator guide, Day 3, Session 2
• UNICEF Skill building on perinatal death reviews guide and presentation, Day 1, Session 4
• WHO and UNICEF Analysis and use of health facility data guidance for RMNCAH programme
managers
• DHIS2 website
• CRVS website
MODULE
Getting started at
2
the facility level
Module 2: Getting started at
the facility level
Step 1: Assess the current situation
Prior to implementation of MPDSR, conduct an assessment of the current situation of maternal death
review, perinatal death review, and other quality improvement initiatives taking place, noting the level
of implementation (e.g. facility, district, regional or national level). This could include mapping existing
data collection, identifying potential meeting resources and other related committees (such as quality
improvement), and clarification of regulations and legal protection. The mapping tool, which is to be
used as a checklist, will help you to identify the current mortality audit and quality improvement systems
and resources already in use in your facility or district. This checklist does not specify which items are
essential before starting the MPDSR process because this will vary by context, but it provides a framework
to assist in mapping what data sources exist, and where the gaps might be.
Step 2: Set up a steering committee

A steering committee at the facility level organizes and oversees the review process, including implementing
and following up on action points. The facility steering committee has the following responsibilities:
• collects information on all pregnancies, births and deaths
• reviews deaths that are reported to the facility
• establishes medical causes of death
• determines if the death is a confirmed maternal death, stillbirth or neonatal death
• determines contributing, modifiable factors related to the deaths
• assesses quality of medical care
• provides recommendations for immediate and medium-term actions
• follows up on actions taken
• produces summary report and disseminates results.
While every member of the health service is responsible for implementing recommendations, the steering
committee is responsible for following up on implementation of the recommendations in order to
improve quality of care. The primary purpose of MPDSR is action, and without the support of key
stakeholders, recommendations cannot be turned into meaningful change.
In order to avoid duplication of activities, one overarching team for quality improvement (QI) is
recommended. At a minimum, MPDSR and QI meetings should be open to respective team members,
with shared information including data, meeting action plans and reports. Where feasible, harmonized
processes, and alignment of formal structures and reporting mechanisms will enable maximum benefit
to be drawn from both these programmes. Please refer to Module 7 for further insights on quality of
care (QoC) and MPDSR. The QI team can designate a specific steering committee for MPDSR if human
resources allow. Given the challenges of coordinating meeting schedules across a large, high-volume
tertiary or referral facility, separate obstetric and perinatal death review meetings may be held, with an
MPDSR steering committee overseeing them both. A smaller steering committee for oversight and
accountability can oversee two working subcommittees – one covering maternal deaths and the other
covering perinatal deaths. Expertise for maternal death reviews should include obstetrics, midwifery,

anaesthesiology, medicine and pathology. Other experts involved in particular cases under review may
be relevant, for example mental health experts, infectious disease specialists, emergency department
representatives. For perinatal deaths, key members include obstetricians, paediatricians/neonatologists,
midwives and neonatal nurses. Key managers and community liaisons should be part of the review
process and may be permanent steering committee members if available. Larger committees may be
considered when reviews involve several facilities, or at a regional or provincial level. In smaller facilities
where human resources may be more limited, the committee will consist of the staff members who are
available, and may represent a more generalist quorum. A small steering committee with a committed
membership can still be a successful one.
Other departments that do not have a standing representative on the steering committee or in review
meetings could still receive information related to the timing and outcomes of the meetings (e.g. a copy
of the meeting minutes). If facility administrators are not part of the steering committee, they should
receive meeting reports and may have a standing invitation to attend meetings, in order to ensure that
recommendations requiring higher levels of influence are seen and acted upon. Depending on the
circumstances, a community health or public health liaison, or someone representing peripheral or
primary health facilities, may also serve on the steering committee. Depending on the hospital structure,
there might be other possibilities for membership without direct clinical involvement, for example, patient
attendants or support staff.
More information on the organizational structures of district, regional and national level steering
committees can be found in Module 5.
Step 3: Determine operating procedures and tasks

A terms of reference document should be established for the steering committee, either by the local
health authority, the facility administrators, or the quality improvement team. This will determine the
composition of the steering committee, how often it will meet, and how often it will engage the wider
team of practitioners, facility staff and relevant policy- makers. Again, the steering committee might be
merged with an existing maternal or perinatal death review committee, or a separate audit team with
overlapping membership.
A formal terms of reference for the steering committee should include the authority and accountability to:
• organize and call meetings;
• identify and collect information on maternal deaths, stillbirths and neonatal deaths occurring
throughout the facility;
• organize meetings on a regular, recurring basis where deaths are to be reviewed;
• adhere to a specified meeting code of practice that upholds anonymity, confidentiality, beneficence
and autonomy for both patients and staff members;
• promote confidentiality and a blame culture free environment;
• make recommendations for action aimed at reducing the number of preventable deaths and following
up on implementation of the actions;
• produce a summary report about the data trends and the deaths investigated, ensuring anonymity, and
circulate this within the facility, the provincial health department, and among relevant stakeholders.
The frequency of meetings will depend on the burden of deaths at the facility (and in the district or region),
and how many deaths are reviewed at each meeting. Mortality review meetings, where the basic overview
of number of births and deaths is presented, can take place as regularly as every morning. However, a
larger periodic review meeting is necessary for the detailed review of select cases. “Zero reporting”, and
meeting even in the case of no deaths in a given time period, is recommended for reviewing trends in
overall data, and following up on action plans. Committees often aim to meet ad hoc as soon as possible
(within a week) of a maternal death, with a standing meeting at monthly or quarterly intervals to review
deaths in more detail. Typically in higher mortality settings, perinatal deaths are reviewed at the routine
meetings and not on an ad hoc basis after each death occurs. Depending on the burden of deaths, and
staff availability, steering committees may choose to have a shorter weekly meeting (45–60 minutes),
or more detailed 2–4 hour meetings less frequently. Steering committees should decide on an initial
schedule, and be open to adjusting it if the need arises. A sample information flow chart is available and
will be explained in Module 7. Moreover please refer to the MPDSR review meeting minutes template.
Relevant tools, forms and additional resources

• Situation mapping tool (Annex 1)
• Sample terms of reference for review committee (Annex 2)
• Sample meeting code of practice (Annex 3)
• Sample information flow chart (Annex 4)
• MPDSR integrated review meeting minutes and action items form (Annex 5)
• MDSR technical guide chapter: Development of an MDSR implementation plan
• MDSR technical guide: Committee worksheet (MDSR A6)
• Making every baby count guide: Meeting code of practice
• Making every baby count guide: Meeting minutes and action items form
• UNICEF Skill building on perinatal death reviews guide and presentation, Day 1, Session 6; and 7
• Video clip: Setting up a review committee.

MODULE
Identifying cases
3
Module 3: Identifying cases
What is the purpose?
To identify every pregnancy and birth, maternal death, stillbirth and neonatal death, even if only a selection
of events is eligible for review.
How is it done?
The following questions can assist in the selection of sources to investigate and use in the review process:
• Where are deaths likely to occur in the facility?
• What kinds of records exist (e.g. antenatal registers, labour and birth registers, postnatal registers,
registers from neonatal intensive care or special care baby units, emergency or operating theatre
records, discharge logs with status of patient, paediatric registers)?
• Are the records paper-based or electronic?
• Are all the records housed in one location, or are they dispersed?
The first step in identifying maternal deaths is to assess all deaths in women of reproductive age (WRA)
and identify those that occurred while a woman was pregnant or within 42 days of the end of a pregnancy
(suspected maternal death). Any death of WRA in a health facility should trigger a death review, with a
committee meeting taking place as soon as possible.
While many maternal and perinatal deaths will occur in the labour and postnatal ward, deaths that occur
elsewhere in the facility are still important, and are less likely to be captured and reviewed through MDPSR
processes. A death review that focuses on neonatal deaths should attempt to identify all the neonatal
deaths, whether in the postnatal ward or the special care baby unit, or after readmission to the pediatric
or general inpatient ward, or at the outpatient clinic. As the numbers of perinatal and neonatal deaths can
be high, especially in large volume facilities, it may be necessary to assign a health provider to record and
capture these deaths if feasible. This will assist in identifying patterns in missed opportunities for quality
care across the facility, and present an occasion to engage with quality improvement personnel or teams.
Once all the locations where the data might be found have been identified, a plan for systematically
reviewing these sources for potential maternal and perinatal deaths should be created by the steering
committee, including a schedule for contacting various departments and checking all relevant registers.
See the Where to Look tool for a systematic approach to identifying deaths.
Deaths can also occur in the community. There are different data sources available to identify community-
based deaths such as homes, mortuary, funeral parlor, police post, children’s hospital and others). Please
see box below about how to identify community-based deaths.

Importance of community death notification and classification of Maternal and
Perinatal Deaths
Identification and notification of community-based deaths is a key component of the MPDSR
system. In some contexts, deaths occurring in the community or on the way to a health
facility comprise the majority of deaths and are difficult to capture without a functional
system. Identification and notification of all deaths (those in the facility and community) will
provide more complete data on maternal and perinatal deaths, and allow an opportunity to
document the factors contributing to those deaths for a more complete response. Suspected
maternal deaths in the community may be reported by community health workers (CHW),
traditional birth attendants, or other community leaders; verbal autopsies should then be
performed to determine the probable cause of death. Deaths occurring in health facilities
should be identified and notified to the appropriate authorities within 24 hours, and deaths in
communities within 48 hours.
Fig.2. Community networking for capturing community deaths
Elected
member Community
Religious Group/
leader Support
Group
Pharmacists/
Traditional medicine
healer shopkeeper
Field level
health
worker
Elderly Person/ Neighbour
Village Leader
Teacher Caretaker of
graveyard
Traditional
NGO Worker/ Birth
Volunteer Attendant
What is the outcome?
The systematic collection of data on all births and deaths and the types of events in the various places
where events occur.

• Where to Look tool for identifying facility maternal and perinatal deaths (Annex 7)
• MDSR technical guide chapter: Identification and notification of maternal deaths
• MDSR technical guide appendix 7: Community identification for suspected maternal deaths, page 114
• Ayele B, Gebretnsae H, Hadgu T, Negash D, G/silassie F, Alemu T, et al. Maternal and perinatal death
surveillance and response in Ethiopia: Achievements, challenges and prospects. Biswas A, editor.
PLoS One [Internet]. 2019 Oct 11;14(10):e0223540. Available from: http://dx.plos.org/10.1371/journal.
pone.0223540

MODULE
Collecting
4
information
Module 4: Collecting information

To collect a sufficient amount of data to contribute to a meaningful understanding of events, particularly
data elements that will contribute to MPDSR and the formulation of solutions.
How is it done?
In order to ensure timely and thorough completion of files for meeting preparation, as well as planning
for turnover and sustainability, at least two people should be designated to be in charge of collecting
data and preparing cases for discussion in advance of the MPDSR meeting. It is likely that this process
of data collection and case preparation will be done separately for maternal and perinatal events.
A short written summary of each death under review is usually prepared for the review committee
presentation. This summary uses data from all sources and although concise, it includes all relevant
information, both medical and nonmedical, as well as standard demographic data. The case summary
may begin with some common defined variables, such as the mother’s age, ethnicity, education and
parity, and the gestational age at death, if applicable. A narrative describing the events that led to the death
usually follows this information. Case summaries should present objective and de-identified information.
Even if the identities of the patient and health-care workers are obvious in a smaller facility, this principle
should be adhered to insofar as possible. All staff should be advised that thorough history-taking and
adequate patient notes are essential to providing good quality and continuity of care.
When MPDSR is just getting started, senior members of the steering committee might lead this process.
As the process becomes more established, the role could be transferred to, for example, a well trained
data clerk, or a midwife or physician. The specific tasks and responsibilities should be outlined in the job
description of the person responsible in order to create a sustainable practice institutionalized within
specific roles, rather than allowing the task to rest with certain individuals who may leave the service
without a contingency plan. Training for this role could include practice exercises with an emphasis on
completing forms legibly and reviewing forms for completeness. The use of structured paper-based or
electronic forms will require less skill and discretion on the part of the data collector compared with an
unstructured workbook.
There are three new practical resources to build health worker skills to implement MPDSR processes
in low-resource settings. The first is the MDSR Capacity-Building Materials developed by the USAID-
funded Maternal and Child Survival Project (MCSP), which are designed to build the capacity of district
managers and facility health workers to strengthen MDSR processes in their local setting. The second are
capacity-building materials on perinatal death surveillance and response developed by UNICEF. The third
is a virtual Public Health course on MPDSR, developed by the Latin American Center for Perinatology/
Women’s and Reproductive Health Unit (CLAP/WR). Additionally an MPDSR Training of Trainers resource
package has been developed by MOMENTUM Country and Global Leadership (MCGL) in collaboration
with other partners, building on the above capacity building resources to support implementation included
in this document.

Maternal deaths
As described in Module 2, reports of all probable maternal deaths should be collected by the
steering committee. Data from multiple sources, including patient records, are verified and
compared. For example, data may initially be extracted from the obstetrics & gynaecology
admission and discharge register, and complemented with information from the labour and
childbirth ward register and theatre or minor surgery record books. Case notes, patient records
including referral notes, postoperative notes and laboratory results, when available, can also
be valuable sources of information. This can be compared against HMIS and local CRVS
information, if available. Deaths occurring in the community that have been notified to the
facility or district should also be reviewed.
The simplest approach is a review based on a single facility, which only collects data from
the site where the death occurred. However, if a woman who died received care at any other
facility, the additional records should also ideally be abstracted. Although more difficult to
obtain, additional information from the woman’s family is potentially valuable. The data
collected should include a summary of the chain of events that led to the maternal death,
using corroborated information from all available sources.
A number of sample forms exist, including the summary form for maternal deaths in facility
from the MDSR technical guide and the new MPDSR – Facility monthly summary form.
Perinatal deaths
Once identified, information on all events, i.e. births and deaths, should be documented and tallied using
consistent criteria and definitions linked to national systems such as HMIS and CRVS. A set of suggested
minimum set of perinatal indicators to be collected for each birth and death is available. These include
key data elements such as date of birth and death and birthweight. Many facilities will already be compiling
these indicators within the health information system, and this list is provided only as a guide to ensure
that the most basic pieces of data are collected. In some settings, it may be feasible to capture and track
additional information relating to the health and sociodemographic status of the mother, together with
more information on the type of care that she and her baby received.
Facility-wide data and trends may also be regularly reviewed at perinatal death review (PDR) meetings.
These data can be collected through a tool such as the MPDSR – Facility monthly summary form. The
instructions accompanying this form include a list of questions to consider in attempting to ensure the
complete capture of all births and deaths in your facility.
The stillbirth and neonatal death review form is the main source of information for the perinatal death
review. The steering committee may choose to complete this form for each death, or just for the cases
that the committee intends to review during the meetings. The form contains additional information that
can prove valuable to understand the case, cause of death and underlying contributing modifiable factors.
Although it is more efficient for a designated individual or small group to complete the whole form for
each case before the MPDSR meeting, these sections may also be discussed and completed during the
meeting itself, until the designated individuals are comfortable with completing the process independently.
At the outset, it may be particularly helpful to complete the section on critical delays and modifiable
factors as a group.
There are several general principles to keep in mind when completing these forms.
The first principle is to avoid assumptions: if any information is missing, such as the results of a standard
test, this should be marked “unknown,” not assumed or left blank.
The second principle is to consider the source. With gestational age, for example, it is important to note the
source of that information (e.g. mother’s estimate of last menstrual period, early or late ultrasound, etc.)
The third principle is that some information found in charts and registers may be contradictory. It is
important to highlight these contradictions in the review process, and to correct or resolve them to the
extent possible before reporting the relevant data to higher levels of the health system.
Selecting cases for review

To identify the levels and determinants of maternal mortality and emphasize the message
that no maternal death is acceptable, all maternal deaths must be reviewed. In facilities where
maternal deaths are relatively few in number (or where there has been no death over a period
of review), the committee may also want to consider reviewing near-miss cases.
For perinatal deaths, which are more frequent events than maternal events, the situation may
be different. In smaller facilities, it may be possible to review each death, but in larger hospitals
with a higher caseload, a sample might be reviewed. Basic data are collected on all events,
but the steering committee may elect to review only specific cases. Depending on the facility’s
staffing levels and workload, an in-depth review of 2–3 cases per meeting may be considered,
although new committees might want to start with just 1–2 cases per meeting, and focus on
the quality of the review.
More time is usually required to review term intrapartum stillbirths and early neonatal deaths,
especially in cases of no malformations and average weight. The number of cases that can be
reviewed in one session will vary by case mix and familiarity of the review team with the process.
There are different approaches that can be used in order to select a subset of cases. The
easiest method is to select deaths randomly, e.g. every fifth death. As teams gain more
experience, this approach may be modified. For example, it may be decided to review cases
that might be more easily prevented, such as term neonatal deaths and intrapartum stillbirths,
since these may be more likely to lead to actionable changes to the care provided, referral
procedures, or community practices.
Please see box below on how to collect information about community-based deaths.
Community verbal autopsy

Community-based maternal death reviews (or verbal autopsies) are a method for determining
the medical causes of death and ascertaining the personal, family or community factors
that may have contributed to deaths in women who died outside of a health facility. This
information can be combined with data from facility-based death reviews. Verbal autopsies
can be sensitive, so it is important to take these aspects into consideration when planning
the verbal autopsy and the team that will collect the information. Suspected maternal deaths
in the community are usually reported by community health workers or other community
representatives to the appropriate authority ideally within 48 hours.

A basic set of information captured on every event that occurs in settings with limited capacity for data
collection and analysis, and a more detailed set of information where capacity allows, and for the deaths
that will be reviewed in greater detail.

• MPDSR – Facility monthly summary form and instructions to complete it (Annex 8 and 9)
• Maternal death case review form and instructions to complete it (Annex 10 and 11)
• Stillbirth and neonatal death review form and instructions to complete it (Annex 12 and 13)
• Minimum perinatal data set (Annex 14)
• MDSR technical guide appendix: Types of facility information to collect (A3)
• MDSR technical guide (Appendix 4) Draft of community autopsy tool for maternal deaths, page 73
• Making every baby count guide: Stillbirth and neonatal death review form, page 71
• Making every baby count guide: Births and deaths summary form, page 82
• Making every baby count guide: Minimum set of perinatal indicators, page 87
• Making every baby count guide: Approaches for classifying modifiable factors, page 92. Video on audit
and neonatal deaths
• Virtual Public Health Campus on Surveillance and Response in the case of maternal and perinatal
death (MPDSR)
• MPDSR Training of Trainers package
MODULE
Conducting joint
5
maternal and
perinatal death
reviews
Module 5: Conducting joint
maternal and perinatal death
reviews
Integrating processes for maternal and perinatal death reviews and coordinating activities where feasible,
without losing speciality-specific detail.
How is it done?
It is important that the processes for maternal and perinatal death review are coordinated and linked,
rather that operating in parallel. In some settings, the implementation of either maternal or perinatal
death review may be more advanced. If a supportive health policy framework already exists for either
maternal or perinatal death review, this will help to facilitate the process of moving towards an integrated
MPDSR system. It may be possible to integrate the process of reviewing both maternal and perinatal
deaths within these platforms.
If maternal mortality and morbidity review meetings already exist at a health-care facility, with all maternal
deaths being reviewed at every meeting, multidisciplinary teams may consider reviewing, at a minimum,
a selection of intrapartum stillbirths and first-day neonatal deaths. If only a subset of all stillbirths and
neonatal death cases is being discussed at review meetings, key details should still be recorded for
each patient, in line with the minimum perinatal dataset. Given the higher numbers of stillbirths and
neonatal deaths than maternal deaths, it might make sense to institutionalize separate but linked perinatal
meetings once the review process has been established, especially in large facilities. If MPDSR exists at
various levels of the health system, information should be systematically shared.
Step 1: Plan and prepare for review meetings

The steering committee should agree on a meeting code of practice, or a similar document that
participants will sign, promising to work as collaboratively and constructively as possible. Participants
need to be assured that the sole purpose of the review process is to save future lives and improve the
quality of the health services, and not to find fault or discipline providers. Legal counsel should not be
involved at any stage of the review process, due to the possibility that this might hinder true reporting of
numbers and causes of deaths. Remember, the focus of the review needs to be on improving the system,
not blaming individuals, whether they be health professionals, the patient, family members, or others.
(Please see Module 10 for additional information.)
In order to ensure timely and thorough completion of files for meeting preparation, as well as planning
for turnover and sustainability, at least two people should be designated to be in charge of collecting
data and preparing cases for discussion in advance of the death review meeting. This could be anyone,
such as a data clerk, midwife or physician. However, the task should be outlined in the job description
of the person responsible, in order to create a sustainable practice institutionalized within specific roles,
rather than assigned to certain individuals.

Step 2: Conduct integrated review meetings
A skilled, independent and accepted chairperson is needed to guide the discussion. While the tendency
is to designate a senior clinician, such as a doctor, it is important to consider nurses and midwives for
the role, and to involve them in the process.
At least one participant needs to be assigned to taking notes or meeting minutes, as well as to filling out all
forms as the review proceeds. This role should have at least one backup for leave coverage, and for long-
term sustainability. To maximize meeting time for discussion of recommendations and actions, forms
should be completed in advance and not during the meeting. The minute-keeping participant should
record (at least): any statistics discussed, cases discussed (including causes of death and modifiable
factors identified), and action plans for implementing recommended solutions. A number of tools
exist to support this process, including the meeting minutes and action items form, or the sample
committee worksheet.
Step 3: Finalize forms and flow of information

The steering committee should establish a data flow chart, which can be used to assign responsibility
to named people along the path of data collection. A sample information flow chart is included in the
appendices. Forms for gathering and organizing information are included in this operational guide, along
with steps for completion.
Step 4: Prepare meeting reports

A summary report can be useful to document data trends, and as a mechanism to follow through on
recommendations. The scope of the report may vary, depending on the audience, frequency and approach.
Examples of different types of meeting reports are given below. The steering committee should decide
on the frequency with which this report will be compiled, by whom, and the content to be included. The
frequency of a summary report might range from quarterly at health facility or district level, to annually
or every other year at national level. This does not need to be an exhaustive report, but a summary of
key trends in outcomes and actions. It is a good opportunity to highlight positive outcomes and success
stories. A sample report outline is available as an annex.
Examples of different types of meeting and summary reports
Single facility death review report, or compilation of key actions from meeting minutes
Audience: internal document, copied and distributed to all staff.
Objective: to share findings and recommendations, focusing on positive recommendations,
rather than placing blame. This is particularly important if the MPDSR process only involves a
single facility, and there is no routine district or national level reporting.
District-level, or other grouping of facilities report
Audience: all facilities involved in conducting death reviews and submitted data, other facilities
in the area not conducting reviews, decision-makers at various levels.
Objective: to provide a broader picture of trends in births and deaths, potentially including
community surveillance data and linking to HMIS and CRVS, and distribution of deaths by
place and level of facility. The report can highlight recommendations and follow-up on actions
outside the jurisdiction of a single facility.
National-level report
Audience: usually national and high-level, and widely distributed to all stakeholders. This may
include ministries or departments outside health, such as education or infrastructure, as well
as the general public and media.
Objective: a comprehensive report focusing on accountability, detailing local, regional and
national efforts to track trends and identify and address gaps in care, with more general
recommendations and efforts requiring interministerial collaboration.
Reviews of ‘near-miss’ maternal and perinatal deaths

MPDSR can potentially be expanded to include reviews of near-miss cases, where the patient
survived but nearly did not, such as in cases of severe obstetric haemorrhage or eclampsia
for the mother, or asphyxia or severe infection for the baby. This process can add more depth
to data collection, and better inform quality improvement strategies. It is described in other
resources, including Beyond the Numbers: Reviewing maternal deaths and complications to
make pregnancy safer (2004), and the WHO near-miss approach for maternal health.

A phased approach to an integrated, multidisciplinary review process for maternal and perinatal deaths.
MPDSR is an ongoing set of activities and not a one-off event. Some of the essential factors for the
sustainability of this process include:
• designating and supporting MPDSR coordinators, either as a stand-alone role or integrated into
existing responsibilities at facility, district and national levels;
• promoting a no-blame culture through mentoring and open communication, and a meeting code
of practice;
• institutionalizing multidisciplinary review through regular meetings, clear membership of committees,
and follow-up on recommendations;

• strengthening the health workforce by including MPDSR in pre-service and in-service training and by
implementing clinical outreach visits and supervision across different levels of care;
• strengthening accountability at all levels;
• improving communication and networking between health system levels, facilities and different
role players.
Ideas for expanding maternal and perinatal mortality audit

Is the review committee confined to a single team or unit?
• Consider expanding to include multidisciplinary membership.
Are maternal deaths few and far between?
• Great! Consider incorporating regular maternal near-miss reviews.
Is the idea of reviewing all perinatal deaths overwhelming?
Consider:
• capturing and reviewing only high-level quantitative indicators for all perinatal deaths;
• adding qualitative reviews of those cases directly related to obstetric care, e.g. intrapartum
stillbirths.
Is the review committee ready to take on more perinatal death reviews?
Consider:
• introducing reviews of more cases and a wider range of causes of death;
• monitoring more quantitative data trends (e.g. causes in different gestational age or weight
categories).
Please see box below to know how to engage the community in participating in review of facility-based
deaths.
Community Participation in Review of Facility-Based Deaths

Engaging community members in the review of deaths occurring in health facilities is
an important component of the MPDSR process. This allows community members an
opportunity to participate in the discussion, share views, and ensure their voices are heard.
There are several ways community members can participate in the review of facility-based
deaths such as: 1) expanding Steering Committees to include community members such as
religious leaders; and 2) conducting forums on quality of care with community members to
incorporate into SMART recommendations. Engaging communities and ensuring multiple
perspectives for each death can reduce blame on health care providers and create a trusting
environment for maternal and perinatal health.
• Sample integrated MPDSR report outline for a single facility (Annex 6)
• MPDSR monitoring framework (Annex 15)
• MDSR technical guide committee worksheet
• UNICEF Skill building on perinatal death reviews guide and presentation, Day 1, Session 6 and 7

MODULE
Analysing and
6
presenting
information
Module 6: Analysing and
presenting information
To use quantitative and qualitative data to identify patterns and trends in a way that illuminates
potential solutions.
How is it done?
MPDSR is not primarily a process to produce data, but there are a number of informative analyses that
can be undertaken by the steering committee lead, or designated staff, and presented at scheduled
meetings, as well as posted publicly within the wards or units involved.
Analyses conducted at the facility level will have different functions and corresponding responses from
those at district and national levels. All facilities should know their facility-specific number of maternal
and perinatal deaths, and each should be able to calculate indicators for the facility and report on the
causes of deaths and related background characteristics captured in the minimum perinatal dataset.
Health facilities with a large volume of deliveries (500 or more annually) should also be able to perform
descriptive analyses of facility-based maternal and perinatal deaths.
The analysis process should avoid making assumptions about the data. Missing and contradictory
information should be summarized, noted and reported to the group. This can be frustrating as there
may be gaps in the summary, but this missing information should be treated as an important data point
in its own right, representing a lack of complete reporting.
The steering committee may want to select a few indicators to focus on and follow over time, to see
if outcomes improve after implementing recommendations from a mortality review. The numbers
contributing to the in-facility numerator and denominator of the indicator can be compared with data
extracted from HMIS, DHIS2 and/or CRVS. The review team should remain open to considering all
possible problems and factors revealed by the data.
For both maternal and perinatal deaths, data should be presented to the review committee in a qualitative
fashion that describes the course of pregnancy and includes descriptions of where and how care was
provided. Essential interventions that took place or were missed, at all levels, should be described,
together with any problems that may have contributed to the death. The primary and final cause of death
should be detailed, as well as the modifiable factors that contributed to it.
The combined quantitative and qualitative analysis will allow identification of patterns and trends of
problems, both nonmedical and medical, which lead to deaths. Indicator tallies over time are simple and
quick to prepare, but more precise information could be obtained by geographically mapping key details
related to specific indicators. For example, if a number of women presenting with obstructed labour come
from a specific area, there may be an issue related to transport or another concern affecting access to the
hospital. Mapping cases may be time-consuming for the steering committee, but it can provide more
information about the population’s care-seeking behaviour, existing social and health services, and the
natural environment.
Finally, electronic programmes can be designed to run analyses and produce standardized tables, graphs
and maps, which may enhance the use and reporting of data. For example the South African Perinatal
Problem Identification Programme is an open-source software for capturing and analysing perinatal
deaths and modifiable factors.

Reliable indicators and trends over time, including tables, graphs and other visual displays, which can
be cross-referenced with other information systems such as HMIS, DHIS2, CRVS.

• MDSR technical guide chapter: Data aggregation and interpretation
• MDSR technical guide chapter: Analysis
• MDSR technical guide appendix: Steps to completing the committee worksheet (A6)
• Making every baby count guide: Sample calculations for reporting, page 99
• MPDSR Action Tracker tool, Options Consultancy Services ltd
• Open-source software: the South African Perinatal Problem Identification Programme
MODULE
Recommending
7
actions and
implementing
change
Module 7: Recommending
actions and implementing
change
To use data to reach consensus on priorities and inform actionable recommendations.
How is it done?
The main purpose of the MPDSR meeting is to identify solutions to gaps in the management of the
case(s) under consideration. One of the most challenging parts of the review process is the formulation of
appropriate recommendations, but this step is critical. Findings from death reviews can lead to immediate
actions to prevent similar deaths, especially those at health facilities, by identifying gaps that should be
addressed at the point of care; other recommendations might require the action of other, more distal
stakeholders. With the correct processes in place for sharing information, deaths that have a modifiable
factor linked to the community or the referral pathway may also lead to actions, even though this may
be outside the sphere of control of the review committee. There is no need to wait for aggregated data
over time, or from multiple facilities, to begin implementing actions.
The meeting chairperson should lead a discussion of the chain of events related to the case, reflecting
on the modifiable factors, and any changes in trends from meeting to meeting. The committee should
examine the reliability of the information available; the adherence to clinical standards and guidelines
in the provision of care, where available; and the quality of the monitoring of the patient’s condition.
The group should attempt to reach consensus on appropriate, evidence-based strategies required to
address the main gaps in care that have come to light. Involving the Quality of Care focal point or team
in developing recommendations and actions will maximize the opportunity to ensure that responses
are addressed through a quality improvement cycle process. Minuted notes with recommendations,
suggested actions, and identification of the person responsible for implementing and/or tracking each
should be compiled (see meeting minutes and action plan).

Facilitating linkages between quality improvement processes and MPDSR
Effectively conducted death reviews generate high-quality information on leading local causes of
death and important common contributors to those deaths. This information can help to inform
prioritization of quality improvement interventions likely to produce real impact. It can also
promote understanding of common contributors and promising changes to systems or service
delivery that will overcome identified gaps. Quality improvement processes prioritize measurable
time-bound objectives based on local disease burden, equity and management gaps.
A common feature of MPDSR is inadequate systematic monitoring of implementation of the audit
cycle’s response element, and analysis of whether implemented responses are yielding desired
effects. Integrating MPDSR within broader quality improvement efforts has the potential to link
responses to a more systematic monitoring and analysis process at facility and subnational level.
MPDSR recommendations might receive increased support for follow-up if they were incorporated
into broader quality improvement efforts at facility or district level.
The structures that support quality improvement processes and MPDSR will look different
across settings and levels, but aligning these, and at least formalizing information sharing and
communication, is more likely to result in impactful changes arising from MPDSR activities.
Fig. 3. Possible alignment of QoC/QI for MNCH and MPDSR across health system levels
Subnational level (province/district)

National policies, strategies, and structures
QoC working group/

MPDSR committee
commitee
Facility level (province/district)
MPDSR
Larger QoC committee
committee
facility or team Public
or team
and
private
Smaller Combined QoC and MPDSR sector
facility committee or team
Review committees will be able to determine from the results of their own analysis which mixture
of strategies will be best suited to their circumstances, including their access to resources. However,
solutions should always be SMART: specific, measurable, appropriate, relevant and time-bound (see Box
below). Responsibility for tracking the progress of each solution should be assigned to specific individuals.
Even if the designated person is not solely responsible for making the change, assigning implementation
and monitoring tasks to individuals reduces the likelihood of failure to follow through with action.
Developing SMART recommendations
Is the recommendation SPECIFIC?
Does it clearly articulate what needs to be done to address the problems, causes?
Is the recommendation MEASUREABLE?
Can it be monitored on a monthly or annual basis?
Is the recommendation APPROPRIATE?
Is it feasible to implement at the health facility level? If not, then it should be recommended
for other levels of the health system, with a designated person responsible to follow up.
Is the recommendation RELEVANT?
Does it address a specific problem, factor, cause or subcause?
Is the recommendation TIME-BOUND?
Does it include a specific time period, as well as who is responsible?
Example of a maternal death review, recommendations, and actions that led to

change
Case summary: A 23-year-old woman was admitted to hospital at 12 weeks’ gestation in
general poor health. She had blood pressure of 49/25 mmHg, tachycardia (120 beats/min)
and body temperature of 36.6 °C. She said she was given some herbs by a woman in the
village to insert into her vagina to try to end the pregnancy, since she was unmarried. She was
put on isotonic solution while further assessments were completed. Her haemoglobin was
6 grams/dL. Ultrasound revealed echogenic content suggestive of product of conception with
free fluid in the uterus and pelvic cavity. She was taken to the theatre where an evacuation of
the uterus was performed. Foul smelling products of conception were removed. She was put
on IV fluids and antibiotics. Despite aggressive hydration therapy including blood products, by
central venous catheterization, she had persistent bradycardia and hypotension. The woman
died after five hours, despite all efforts.
Modifiable factors identified:
Patient-related: The patient accessed potential harmful care in the community and used herbs
that she was told would end her pregnancy.
SMART RECOMMENDATION: Community Liaison (CL) together with Dr X (both in
attendance at the review meeting) to request facility administrator (absent, with regrets) to
follow up with district health management team about establishing a series of community
engagement sessions led by CL and Dr X regarding traditional medicines, and the danger of
this herb in particular for pregnancy termination. Due to the potentially sensitive nature of this
conversation, CL will engage key community representatives and faith leaders. CL will report
back on progress to the MPDSR Committee at the next meeting.
ACTION TAKEN: Within the following quarter, after receiving approval and token funding
support from the district health management team, six engagement sessions were hosted by
CL and Dr X with women’s groups, faith-based leaders and traditional healers.
Provider-related: The guidelines for management of incomplete septic abortion were not
followed.

SMART RECOMMENDATION: Nurse in-charge to organize refresher training on management
of incomplete septic abortion by next quarter, to be attended by all relevant staff in women’s
ward, maternity unit and theatre staff. Hospital administration to ensure that postpartum
haemorrhage guidelines are available and visible on the ward, and to all staff involved in
emergency obstetric care.
ACTION TAKEN: In-service training on management of incomplete septic abortion was made
mandatory for all maternity staff; booklets with management guidelines were made available to
all staff; posters on management of incomplete septic abortion were placed in all labour wards
and staff areas; maternal sepsis deaths were tracked and a decrease noted.
Administrator-related: The maternity nursing staff is overloaded and not supported by a
doctor, particularly on weekend mornings, when this admission occurred.
SMART RECOMMENDATION: Doctor X (in attendance at the review meeting) to request
facility administrator (absent, with regrets) to ensure that nursing staff complement is full,
including coverage on weekends, by the end of next quarter.
Example of a perinatal death review, recommendations, and actions that led to change
Case summary: 21-year-old gravida 2, para 1. At 20 weeks’ gestation she started antenatal care
(ANC) at the nearby antenatal care clinic. No abnormalities were found. She attended the
second visit at 28 weeks, and at 32 weeks she attended the ANC clinic again. At the gestational
age of 33 weeks her membranes ruptured and she started leaking amniotic fluid of normal
colour at 09:00, but there were no contractions. She realized that the baby was still quite small
to be born. When her husband came home from work at 16:00 she informed him, and the
next day he arranged transport and took her to the general hospital. At the hospital she was
admitted to the maternity unit with a diagnosis of threatened premature labour and put on
complete bed rest. Monitoring was infrequent. The draining of liquor diminished, but became
lightly meconium stained on the second day. After four days she had slight contractions. She
was prescribed a salbutamol intravenous infusion of 10 mg/1 litre normal saline, but despite
this she went into labour the next day. During admission, her vital signs and the fetal heart
rate were only recorded 12-hourly, and fetal heart rate monitoring during labour was scarce.
On the day she went into labour a temperature of 38 0C was recorded in the morning. At 15:00
she gave birth to a premature male infant weighing 1800 g, with an Apgar score of 4 after 1
minute, and 7 after 5 minutes. The cord was clamped after 3 minutes, the baby was wiped dry
and wrapped in a cloth, received 1 mg Vitamin K1 intramuscularly, and was placed beside the
mother. After the mother received 10 U oxytocin, the placenta was delivered by controlled cord
traction. The newborn was unable to suck and was put on 3-hourly nasogastric tube feedings
of expressed breast milk and received ampicillin 100 mg BD and gentamycin 5 mg OD. The
baby had chest indrawing, was breathing more rapidly than normal, and was also grunting.
Unfortunately, the maternity had run out of oxygen cylinders, so oxygen could not be given.
At night the baby stopped breathing. There was no oxygen or bag and mask available. In
additional, no one on the staff had been trained in resuscitation with bag and mask.
Patient-related: The patient showed up late for antenatal care in the second trimester and
had a very poor follow-up. The gestational age may not have been accurate, as ultrasound for
gestational age dating was not performed. By consequence, either the estimated gestational
age of 33 weeks at birth may have been much lower – and the patient should have received
corticosteroid treatment – or the baby was growth restricted and hence more susceptible to
asphyxia during labour, and this was not picked up during the antenatal care visits.
Provider-related: The guidelines for monitoring antenatal inpatients were not followed.
ACTION TAKEN: Incharge released a circular to staff stating the importance of 4-hourly
monitoring of vital signs, contractions and fetal heart rate for all antenatal patients.
Provider-related: Patient charting was not completed adequately, including vital signs and fetal
heart rate.
SMART RECOMMENDATION: Incharge to conduct in-service training on patient charting and
mentorship around completion, by the end of the month. Committee to assess patient chart
completion rates at the next review meeting.
ACTION TAKEN: In-service training on why these data are important, and incharge introduced
random record spot checks; patient chart quality tracked by committee and increase in
completion rates noted.
Provider-related: No use of bag and mask for resuscitation.
SMART RECOMMENDATION: Paediatrician X to lead a series of lunchtime resuscitation
trainings for all staff to attend, by the end of next month. Maternity incharge and Special
Care Unit incharge to follow up on availability of neonatal bag and mask in the childbirth and
postnatal units, and report back at the next review meeting.
ACTION TAKEN: Neonatal bag and masks were relocated from locked cabinets to designated
areas, and in-service neonatal resuscitation training provided for all staff; number of babies
resuscitated with bag and mask was tracked and an increase noted.
Administrator-related: No oxygen.
SMART RECOMMENDATION: Hospital administrator to review supply management process
in relation to oxygen supplies and referrals, and report back by the next meeting.
ACTION TAKEN: Review of supply management process to designate emergency procedures
for procurement of essential supplies, including oxygen and pulse oximetry, and a policy
introduced for referral when, in extenuating circumstances, oxygen is unavailable.
Administrator-related: No immediate skin-to-skin policy or Kangaroo mother care (KMC) unit
in the facility.
SMART RECOMMENDATION: Department head to issue a circular within two weeks to
maternity staff regarding adoption of immediate skin-to-skin care for all babies after childbirth.
Paediatrician Y and Maternity Nurse B to develop a plan for a KMC unit within the next six
months and report back on progress at subsequent meetings.
ACTION TAKEN: Immediate adoption of standard to use skin-to-skin care straight after
childbirth, and plan in place to start a new KMC unit.

Please see the box below about Community Participation in monitoring MPDSR SMART recommendation.
Community Participation in monitoring MPDSR Responses

Community members can be engaged in the process of monitoring the implementation of
recommended actions in partnership with health providers and health managers as well as
other relevant stakeholders. Effective monitoring process rely on well demarcated roles and
responsibilities for any recommendations arising from the MPDSR process (Bandali et al.,
2019) For instance community members can hold joint meetings where they review progress
made on various recommendations. This can also be an opportunity to celebrate successes
as well as identify barriers to implementation. This process requires on-going dialogue and
partnership among stakeholders.

Documentation of the main problems, root causes and factors, specific actions to address these causes
and factors, identification of responsible persons, and a time frame for implementation.

• MDSR technical guide chapter: Response
• MDSR technical guide chapter: Dissemination of results
• MDSR technical guide appendix: Implementation planning tool (A8)
• Making every baby count guide: approaches for classifying modifiable factors, meeting minutes and
action plan and fishbone diagram, page 102
• Knowledge Brief: Implementation of Maternal and Perinatal Death Surveillance and Response as part of
the Quality of Care efforts for Maternal and Newborn Health: Considerations for synergy and alignment
• Bandali, S., Thomas, C., Wamalwa, P., Mahendra, S., Kaimenyi, P., Warfa, O., & Fulton, N. (2019).
Strengthening the “p” in Maternal and Perinatal Death Surveillance and Response in Bungoma county,
Kenya: Implications for scale-up. BMC Health Services Research, 19(1), 1–10. https://doi.org/10.1186/
s12913-019-4431-4
• Marston, C., Hinton, R., Kean, S., Baral, S., Ahuja, A., Costello, A., & Portela, A. (2016). Community
participation for transformative action on women’s, children’s and adolescents’ health. Bulletin of the
World Health Organization, 94(5), 376–382. https://doi.org/10.2471/BLT.15.168492
• Melberg, A., Mirkuzie, A. H., Sisay, T. A., Sisay, M. M., & Moland, K. M. (2019). “Maternal deaths should
simply be 0”: Politicization of maternal death reporting and review processes in Ethiopia. In Health
Policy and Planning (Vol. 34, Issue 7). https://doi.org/10.1093/heapol/czz075
• Renedo, A., Komporozos-Athanasiou, A., & Marston, C. (2018). Experience as Evidence: The Dialogic
Construction of Health Professional Knowledge through Patient Involvement. Sociology, 52(4),
778–795. https://doi.org/10.1177/0038038516682457
• WHO. (2017). WHO community engagement framework for quality, people-centred and resilient
health services.
MODULE
Monitoring
8
MPDSR
implementation
and improvements
in quality of care
Module 8: Monitoring
MPDSR implementation and
improvements in quality of care
What is the purpose of monitoring the MPDSR system?
Once an MPDSR system has been established, it is essential to maintain and supervise the system by
monitoring.
• To document the implementation of MPDSR system including solutions recommended by MPDSR
steering committees;
• To deliver improvements to the quality of care provided.
How is it done?
Monitoring should be conducted in two areas:
• assessment of how well the MPDSR system it is functioning and whether the recommendations are
being enacted; and
• assessment of the maternal and perinatal health indicators to monitor changes.
Monitoring the MPDSR system

A monitoring system should assess the following elements:
• whether the recommendations for action have been implemented
• whether the recommendations are being implemented on a proposed timeline
• whether the recommendations are achieving the desired results
• where any problems may lie if the desired results are not being achieved
Analyzing indicators and examining trends can provide a quick snapshot of whether the MPDSR system
are improving quality of care and outcomes and can suggest areas that need further improvement or
where more efforts are needed. Users of the MPDSR system may be more motivated to provide the
needed data and enact recommendations if they periodically receive feedback linked to the data, such
as long-term trends showing a reduction in the rate of intrapartum stillbirths over a five-year period.
This monitoring is done by continuously collecting and reporting information on output and outcome
indicators such as:
• the number and percentage of maternal and perinatal deaths that were notified and reviewed
(outcome indicator)
• the number and percentage of recommendations that were implemented (outcome indicator)
• information on how many steering committee meetings were completed (output indicator)
• completeness of MPDSR reporting (output indicator)
• whether recommendations were properly formatted and feasible to implement (ouptput indicators)

In addition to monitoring how the MPDSR system itself is working, it is necessary to monitor the health
outcomes and trends in the area to see whether maternal and perinatal deaths especially at district/
regional and national levels. These are measured using impact indicators such as the following:
• number of maternal and perinatal deaths, by cause of death
• maternal mortality ratio
• perinatal mortality rate
Monitoring the MPDSR system may be carried out at health facility, district/regional, and national levels
and the approach will vary depending on the particular circumstances in each facility and organizational
level.
There are also a set of common/core indicators that should be monitored and reported by all countries
to track global progress in MPDSR implementation. These indicators include:
• institutional maternal mortality ratio
• institutional perinatal mortality ratio
• number of maternal and perinatal deaths, by cause of death
• maternal and perinatal deaths notified and reviewed
• MPDSR steering committee meetings
• completion of annual reports
• MPDSR recommendations implemented
Details on how to conduct MPDSR monitoring can be found in Annex 15, MPDSR monitoring framework;
a list of common/core indicators is in Annex 16; there is a catalogue of monitoring indicators to be used
at the global, national and district levels in Annex 17.
Evaluating the MPDSR system

In addition to monitoring, it may sometimes be necessary to conduct a more detailed evaluation to assess
whether the system could function more efficiently and effectively. This may be needed if the routine
monitoring indicators demonstrate that:
• one or more of the steps in the MPDSR process is not reaching expected results
• the indicators demonstrate that health outcomes are not improving despite actions being taken
• maternal and/or perinatal mortality ratios/rates are not decreasing
While it is important to look at reductions in in-facility mortality rates, trends in these rates are not always
the best illustration of improvements in care. This is because there are many factors that influence the
mortality rate/ratio at a single facility and numbers might be small making estimates unstable. It may
also be useful to conduct an evaluation looking at improvements in the community, the health system, or
society in general (e.g. female education), and changes in the types of delays or modifiable factors that are
being identified. A more detailed evaluation can also be used to assess whether the system can function
more efficiently. Tools have been developed that can be used to help health-care managers, implementing
partners and stakeholders to periodically assess structures and activities that support MPDSR.

Appropriate, evidence-based performance measures and key functions of MPDSR tracked at each level
of the health system.
• Common measures for monitoring MPDSR across countries (Annex 16)
• Indicator catalogue for monitoring MPDSR at health facility, district/regional and national levels
(Annex 17)
• MDSR technical guide chapter: Monitoring and evaluation of the MDSR system
• MCSP tools for assessing MPDSR processes in facilities and subnational level

MODULE
MPDSR in
9
humanitarian and
fragile settings
Module 9: MPDSR in
humanitarian and fragile settings
To capture and strengthen information on maternal and perinatal deaths, as well as provide information
on interventions to improve the quality of care in humanitarian and fragile settings.
How is it done?
The process of collecting information on numbers and causes of deaths is essential for developing
interventions to prevent similar future deaths, particularly in humanitarian settings, where the health
system is strained and needs may be constantly shifting within the affected population.
In humanitarian and fragile settings, mortality surveillance is crucial, however health systems are often
constrained and there is a paucity of data from these settings. MPDSR can be used to collect and monitor
information on deaths, but it is essential to adapt it depending on the type of humanitarian and fragile
setting.
In October 2019, WHO, UNICEF, UNHCR, UNFPA, CDC and Save the Children convened an expert
meeting bringing together key stakeholders from MPDSR, humanitarian, and development sectors. The
group developed a series of recommendations for implementation of MPDSR in these settings.
Different scenarios in humanitarian and fragile settings have been identified:
Acute phase of humanitarian settings MPDSR should NOT be implemented. Tracking deaths
is crucial, and the focus should be on rapid surveillance,
Definition: first 6 months post counting deaths, and establishing critical health services.
disruption
A landscape analysis should be done to determine
what health systems and infrastructure remain to count
the deaths.
Stabilized phase of humanitarian Once lifesaving health services are in place, implementing
settings a MPDSR system should be considered, but the focus
should first be on strengthening health systems, and quality
of care. Once a system is established, it is essential to
institute both death surveillance and quality death reviews.
When establishing a MPDSR system, focus should first be
on health facilities, and then expand to surveillance and
response of community-based deaths.

Refugee humanitarian settings MPDSR could be implemented to strengthen the general
mortality surveillance system, quality of care and referral
networks, in line with the above considerations. A
collaboration among actors is a key component, especially
with the host government. Community engagement
and sensitization are fundamental to increase access.
MPDSR should be integrated in the national health
systems and supported by local outreach services.
MPDSR documentation of the host government should
be used where available to enable integrated information
management. Where not available, alternative standardized
forms such as the UNHCR standard Maternal Death
Review forms could be considered.
Considerations:
1. MPDSR cannot be applied uniformly in all phases of the humanitarian settings – any mortality
surveillance system must be contextualized.
2. MPDSR should be flexible, simple, cost effective, and easy to implement.
3. Strengthening of health systems is crucial. Quality of MPDSR depends on the quality of the care and
a strong functional health system. Good management and supportive supervision are needed for a
robust health system.
4. Coding system needs to be simplified. Staff should be well trained in data management/analysis.
5. MPDSR should be implemented in stages, in partnership with the host government, camp
management, other stakeholders, and organizations operating at the situation.
6. A MPDSR system is only successful if recommendations can be implemented. Therefore, focus in
humanitarian settings should be on the response. If resources allow, MPDSR may then be used as
a complementary component to strengthen the response.

Greater accountability and improved quality of care for women and newborns in humanitarian and fragile
settings.

• Blanche Greene-Cramer et al. Systematic Identification of Facility-Based Stillbirths and Neonatal Deaths
Through the Piloted Use of an Adapted RAPID Tool in Liberia and Nepal. Plos One 2019
• Andrew T. Boyd et al. Use of Rapid Ascertainment Process for Institutional Deaths (RAPID) to identify
pregnancy-related deaths in tertiary-care obstetric hospitals in three departments in Haiti. BMC, 2017
• UNHCR. Maternal Death Review Form and Guide, 2020.
• Tappis, H., Ramadan, M., Vargas, J. et al. Neonatal mortality burden and trends in UNHCR refugee
camps, 2006–2017: a retrospective analysis. BMC Public Health 21, 390 (2021)
MODULE
Overcoming the
10
blame culture of
MPDSR
Module 10: Overcoming the
blame culture of MPDSR
What is the purpose of this module?
The purpose is to provide a basic framework for understanding and overcoming the “No Name, No
Blame and No Shame” culture for Maternal and Perinatal Death Surveillance and Response (MPDSR),
to highlight key strategies for addressing blame, and to identify key resources relating to blame culture.
How is it done?
Understanding the blame culture
The concept of “No Name, No Blame and No Shame” is considered essential for successful
implementation of MPDSR. It relates to basic ethical principles that need to be maintained in order for
the process to work effectively. These principles include confidentiality, anonymity and respect. Failure
to implement MPDSR in a “No Name, No Blame and No Shame” environment can result in a variety of
consequences. When confidentiality and anonymity are breached, such as when the names of health-care
workers and patients involved in cases are shared, this can lead to demoralization and demotivation of
health-care workers. The lack of anonymity can lead to punishment of the health-care workers concerned
– including with litigation, imprisonment and even violence from the community. When health workers
fear these consequences, the situation can lead to a lack of transparency – such as misclassification,
or underreporting of deaths, or unnecessary referrals. It can also result in reviews not being conducted
properly in order to collectively avoid blame. Health-facility staff may fear punitive action towards their
facility from higher levels of health-system management – such as less support or reduced allocations
to the facility. A blame culture may lead to weakening of health systems and of community trust in the
health-care system.
The organizational climate and culture of MPDSR, including elements of blame, were key implementation
factors identified in a recent scoping review on MPDSR in low- and middle-income countries.1 The
findings from the review highlighted the complexity of blame, including different reasons for it and the
different forms it takes. The review also found that lessons on blame and the implementation climate
have changed little in the past two decades, indicating the need for this module to help strengthen “No
Name, No Blame and No Shame” MPDSR.
Understanding “No Name, No Blame and No Shame” MPDSR requires consideration of factors at the
multiple levels of the health system, as originally proposed by Lewis (2014),2 namely:
1. A supportive policy and political environment (macro level) whereby national policies are needed
to initiate and support implementation, including guidelines as well as legal and other protective
frameworks. Political priority for maternal and newborn survival and health also facilitates a more
supportive policy process, with corresponding investment in the resources required to deliver
quality services.
2. The organizational culture (meso level) whereby the institutional work environment/climate
influences implementation. For example, a proactive ethos that promotes learning as a critical part
of quality improvement can shape a health facility’s organizational culture. Lewis calls this supportive
institutional behaviour.2

3. The individual responsibility for, and ownership of, the process (micro level) whereby health workers
embrace life-long learning and positive attitudes towards behaviour change in order to improve their
practice.2 The success of MPDSR is in part reliant on the commitment of staff towards conducting
the audit themselves, accepting open discussion with peers to improve maternal and perinatal health,
taking forward the actions recommended and being willing to “self-correct”.3–5
At the meso and micro levels, reasons why a “name, blame and shame culture” may exist include the
lack of clarity around the process when first implemented,3,6,7 defensiveness and other issues concerning
record-keeping, the existing organizational culture (e.g. staff hierarchies), and the quality of leadership
and facilitation of review meetings.1 The most common issues at a micro level relate to persons feeling
threatened during the review meetings and fearing legal action or punitive repercussions.1 The lack
of management, communication and coordination across teams (including non-functioning teams),
and health worker emotional fatigue and burnout due to the disrespect health workers face can further
contribute to a culture of blame. The negative influence of professional hierarchies between health cadres
can silence the more junior staff and especially nurse-midwives,8,9 and may even result in demotivating
personnel from participating in MPDSR in some contexts. Structural hierarchies may also constrain the
process when management or senior team members do not buy into or engage in the process, thus
preventing more junior staff from taking actions forward. Community awareness and engagement, when
appropriate, also strengthens collective ownership and responsibility, and improves quality of care. 10
Regular feedback of results to communities and the subnational level also ensures accountability and
promotes sustainability.1,8
At the macro level, a strong MPDSR legal framework can reduce perceived fear among health workers.7,11,12
National political commitment and government ownership can result in increased pressure to implement
MPDSR as countries aim to meet global and regional commitments and development goals.8,13,14 Research
describes the fear of litigation as both a positive influence on MPDSR implementation as a form of
accountability,15–18 as well as a negative influence that leads to a rise in avoidable medical interventions.19
Strategies to minimize the blame culture

“No Name, No Blame and No Shame” MPDSR functions well in settings with a culture of accountability,
learning and improvement. A culture of trust is nurtured by strong leadership and continuous re-assurance
of a “blame-free culture”.6,8,20,21 Open and enabling environments, which encourage active participation
of all participants during meetings, are reported to improve implementation.22–24
This module highlights for consideration 10 key strategies to minimize fear and blame. These
strategies have been identified in the literature and through experiential evidence. Annex 1 provides
more information about each of these strategies, as well as related resources where more information
and country experiences can be found.
10 key strategies:
1. Ensure that policy and planning for MPDSR includes national guidelines that explain how to conduct
“No Name, No Blame and No Shame” MPDSR, as well as policies for death notification requirements
and legal protection for individual staff and health departments. MPDSR implementation tools that
describe national guidelines and policies need to be made available at all levels of the health system.
Legal frameworks may draw distinctions between the MPDSR process and appropriate disciplinary
action to ensure that the information generated as part of the MPDSR process will not be used for
litigation purposes. Find out more from the experience in Kenya (Smith et al., 2017).25
2. Ensure national prioritization of the prevention of maternal and perinatal deaths, leading to positive
promotion and use of MPDSR. Global, regional and national commitments to mortality reduction,
including mortality targets in national health plans, can result in national authorities putting more
pressure on the health system to deliver outcomes. This additional pressure may lead health workers
to fear the occurrence of a death and can compromise accurate reporting and individual willingness to
participate in the audit process. Efforts must be made to consider the political context of implementing
MPDSR and strategies should be put in place to protect heath workers. Political priority for maternal
and newborn health can also lead to increased funding for improving health outcomes, benefitting
the response and actions identified through MPDSR. Find out more from the experience in Ethiopia
(Melberg et al., 2019; Tura et al., 2020).26,27
3. Harmonize MPDSR in routine monitoring systems to support standardization of the process and
strengthen accountability. Harmonizing or integrating MPDSR with routine monitoring systems
enables data to be used in real-time to assess issues and avoid blame. Additionally, aligning the
different processes of data capture strengthens accountability measures, promotes quality data
capture and use, and reduces workload. Learn more from the experience in Bangladesh (Biswas,
2017)28 and India (Purandare et al., 2014).29
4. Create and advocate for an enabling environment for implementation of MPDSR with “No Name,
No Blame and No Shame”, including an overall organizational culture of learning, accountability
and transparency. An enabling environment requires adequate human and material resources across
the health system and functional coordinating mechanisms. Open and enabling environments
encourage active participation of all participants during meetings and improves implementation.
Quality improvement strategies, including data quality assessments, foster a system of data use
for decision-making. Promoting MPDSR as a learning experience and ensuring anonymity mitigate
blame. Reviewing success stories as well as adverse outcomes can also build team morale. Find out
more from the experience in South Africa (Belizan et al., 2011)20 and Senegal (Dumont et al., 2009).30
5. Strengthen leadership within all participating professional groups at all levels and ensure engagement
with the MPDSR focal point on how to facilitate meetings and mentor others. A good chairperson of a
review meeting is someone who is able to steer the conversation in a direction that is blame-free and
productive. Leadership also includes participation of senior staff in meetings and in the data analysis
in order to guide priorities and actions. Champions or engaged leaders are highly motivated persons
who also serve as mentors and in supportive supervisory roles. Find out more from the experience
in South Africa (Rhoda et al., 2014)31 and Malawi (Bakker et al., 2011).16
6. Nurture team relationships among those who participate in the audit through continuous
engagement, a teamwork approach, support from hospital management, and through deliberate
efforts and strategies such as mentorship. In contexts where a teamwork approach to implementing
MPDSR is adopted, there is consensus, inclusiveness, monitoring of staff performance, delegation
of responsibility and continuity of the MPDSR implementation processes. Strong communication,
involvement and support from hospital management also strengthen team relationships for MPDSR.
Find out more from the experience in Ghana (Dartey, 2012)24 and India (Purandare et al., 2014).29
7. Ensure that audit meetings take place regularly with a multidisciplinary group of staff. Holding
regular meetings is an important element of integrating MPDSR into routine practice. The more
frequently people attend review meetings, the more practice they have, the less blame is experienced
and the more embedded the process becomes. Participation in the MPDSR process of all cadres
of health workers involved in the care of women and newborns, including junior and senior team
members, creates ownership of the process by staff, reduces hierarchies and blame, and enhances
the analysis of information. Provision of organizational incentives such as refreshments, extra training
or financial motivations may strengthen overall implementation efforts. Box 1 contains some guiding
principles for conducting review meetings. Find out more from the experience in Rwanda (Tayebwa
et al., 2020)32 and Zimbabwe (MCSP, 2017).17
8. Put in place a code of conduct or “audit charter” with clear rules on the purpose of meetings, expected
behaviour during meetings and the confidentiality of meetings. Official codes of conduct or audit
charters may minimize acrimony and prevent (or reduce) blame and recriminations. In some settings,
a code of conduct would be a signed or verbally agreed non-disclosure confidentiality agreement (See
Box 2 for examples). Find out more from the experience in Burkina Faso (Richard et al., 2009; Congo
et al., 2017)33,34 and Ghana (Dartey, 2012).24

9. Promote individual awareness of roles, responsibilities and competence to complete tasks through
on-the-job capacity-development linked to implementing “No Name, No Blame and No Shame”
MPDSR. The staff engaged in MPDSR must be aware of their role in implementing the “No Name,
No Blame and No Shame” process, and must understand the purpose of the process. The hierarchical
nature of meetings may demotivate personnel from participating in the process in some contexts.
Lack of personal accountability for an honest process can also lead to responsibility being shifted to
other staff, resulting in blame and shame experiences. Find out more from the experience in Tanzania
(Armstrong et al., 2014),35 Morocco (Muffler et al., 2007)36 and South Africa (Belizan et al., 2011).20
10. Engage communities in awareness about reporting and participation in MPDSR verbal and social
autopsies. Building community awareness and community sensitization around the MPDSR process
may reduce blame and create an enabling environment for implementation of MDSPR at community
level (Box 3). Find out more from the experience in Bangladesh (Biswas et al., 2016; Biswas et al.,
2015).37,38
A framework for promoting a positive implementation culture for MPDSR

To help implement a “No Name, No Blame and No Shame” culture of MPDSR, this module presents an
adapted framework for understanding the MPDSR cultural environment which includes many elements of
the health system. This framework was adapted from the original framework of the cultural environment
of maternal death and near-miss reviews presented by Lewis (2014),2 further investigated,39,40 and vetted
by experts working on MPDSR.
Figure 4 provides a visual of the framework for promoting a positive implementation culture for MPDSR.
As shown, addressing blame requires action at all levels of the health system. The 10 strategies can be
implemented at various levels and thus surround the three health-system levels. The framework shows
that issues of blame and shame cut across the three levels and that the strategies are interlinked.
Fig. 4. Framework for promoting a positive implementation culture for MPDSR
Individual
awareness and
competence
Community
Leadership engagement and
awareness
Individual
responsibility &
ownership
Code of conduct
of the process National policy
and planning
(Micro level)
MPDSR
Organizational Supportive policy
culture and political National
Regular meetings
(Meso level) environment prioritization
(Macro level)
MPDSR
Team in routine
relationships monitoring
system
Enabling
environment
Future research needs to go beyond identifying blame as a barrier to understanding how to create
a culture of accountability, learning and improvement which can be achieved through strengthening
leadership, improving teamwork and communication, and driving motivation while considering context.
Key research gaps include understanding individual perspectives on overcoming barriers to creating a
culture of accountability, learning and improvement.
The purpose of reviewing a maternal or perinatal death is to give value to that life and
collectively learn from the experience, and NOT to blame individuals or institutions.

The outcome of implementing the strategies presented in this module is the creation of an environment
where health-care professionals feel confident in conducting MPDSR with a “No Name, No Blame and
No Shame” approach. A positive implementation culture for MPDSR will contribute to the reduction of
preventable maternal and perinatal deaths by improving the quality of care and reducing barriers to care.
Acknowledgements
This module was prepared by the MPDSR Technical Working Group’s subgroup assigned to further
understand the blame culture. The content was drawn from a scoping review of MPDSR implementation
factors in low- and middle-income countries, which identified 42 studies that described the implementation
climate and culture of MPDSR, including aspects of blame. We thank the authors of the scoping review
published in Health Policy and Planning (Kinney et al 2021) for extracting data from the 42 studies
identified as describing the implementation climate and culture of MPDSR and allowing us to use that
information to inform this module. The following persons contributed to the content of the module:
Mary Kinney, Louise Tina Day, Debra Jackson, Animesh Biswas, Mary Mbuo, Patricia Doherty, Ank de
Jonge, Nathalie Roos, Alex Manu, Francesca Palestra, Loveday Penn-Kekana and Sylvia Alford.

Example of principles of facility-based case review meetings to ensure no blame
Key principles:
• Meetings should be multidisciplinary and interactive. They should not be didactic. This is
best achieved with participants sitting in a circle.
• Meetings should be held on a regular basis and during protected time reserved for staff
attendance.
• Administrators and others who can act on the recommendations should be present.
Example meeting agenda:

1. Read and agree code of conduct.
2. Re-evaluate the recommendations of previous sessions and provide a short follow-up of
actions decided at the last meeting. Identify any further action required.
3. Present the clinical summary of case(s).
4. Conduct a systematic case review, using a common template and with reference to any
clinical guidelines or standards available.
5. Prepare a case analysis and local recommendations.
6. Plan for implementation.
7. Prepare a case analysis and a report to be sent to the overall steering committee for the
wider review programme, if one exists.
8. Provide feedback on general findings and recommendations to staff who could not attend
and to hospital administrators.
Source: Lewis G. Emerging lessons from the FIGO LOGIC initiative on maternal death and near-
miss reviews. Int J Gynaecol Obstet. 2014;127(Suppl 1):S17–20.
Examples of audit charter or non-disclosure agreements
A) Generic example
Non-disclosure confidenitality 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 analysed here, and will not disclose the names
of any individuals involved, including family members or health-care providers.
B) Example from Burkina Faso
Audit charter for the maternity unit of the district hospital Secteur 30
The medical audit consists in a systematic and critical analysis of the quality of care by
comparison to defined standards (norms and care protocols). It enables the members of a
team to discuss and question or improve certain practices. The audit must never be used to
sanction a member of staff. Its purpose is to propose recommendations and actions aimed at
avoiding in future the deficiencies or errors observed.
We, staff of the maternity of the hospital Secteur 30, promise to respect the rules of good
practice that follow:
1. To arrive on time for audit sessions.
2. To respect the statements and ideas of everyone.
3. To respect the confidentiality of the team discussions. Information and problems raised
during the audit must not be communicated outside the team (friends, relatives, colleagues
in other health departments, etc.).
4. To participate actively in the discussions.
5. To accept discussion and debate among participants without verbal violence.
6. To refrain from hiding or falsifying information that could be useful in understanding the
case being audited.
7. To try as much as possible (because it is not easy) to accept questioning of one’s own actions.
Staff of the maternity department, Ouagadougou, 25 February 2004

Source: Richard F, Oue´draogo C, Zongo V, Ouattara F, Zongo S, Grue´nais M, De Brouwere V.
The difficulty of questioning clinical practice: experience of facility-based case reviews in
Ouagadougou, Burkina Faso. BJOG. 2009;116:38–44.

Engaging the community to prevent blame
Community awareness, sensitization and engagement around the MPDSR process can reduce
blame and improve implementation. The blame culture at the community level can work in
many ways. Health care workers may be blamed by women, their families and the community
after a death; likewise women, their families or even communities may be blamed for deaths
related to delaying care.26,41 Promoting a collaborative partnership approach to the MPDSR
process can be established by facilitating dialogue between community members, health care
providers and managers to build trust and form learning communities. Successful community
consultation and engagement on the response portion of MPDSR has shown to improve
implementation of actions in some settings.8,15,42,43 Breaking down barriers associated with
blame is especially important to strengthen community engagement around data collection of
deaths in the community.7,44,45 In addition, those implementing MPDSR need to acknowledge
and accommodate for the strong emotions associated with death, such as grief and anger.
As such, the actors (both community and health care providers) need to be empathetic in
validating and carefully managing these emotions by providing support to the bereaved
families, such as psychosocial support relevant to the context.

• Ten strategies for promoting a “No Name, No Blame and No Shame” culture and key resources with
more information (Annex 18)
References
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response in low- and middle-income countries: a scoping review of implementation factors. Health policy and
planning 2021; 36(6): 955–973.
2. Lewis G. The cultural environment behind successful maternal death and morbidity reviews. Bjog 2014; 121
Suppl 4: 24–31.
3. van Hamersveld KT, den Bakker E, Nyamtema AS, et al. Barriers to conducting effective obstetric audit in Ifakara:
a qualitative assessment in an under-resourced setting in Tanzania. Trop Med Int Health 2012; 17(5): 652–7.
4. Pattinson RC, Say L, Makin JD, Bastos MH. Critical incident audit and feedback to improve perinatal and maternal
mortality and morbidity. Cochrane Database Syst Rev 2005; (4): CD002961.
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effective clinical audit. Qual Health Care 2000; 9(1): 23–36.
6. du Châtelet A, Zamboni K, Fornah F, Yilla M, Nam S. Barriers and enablers to the implementation of Maternal
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7. Agaro C, Beyeza-Kashesya J, Waiswa P, et al. The conduct of maternal and perinatal death reviews in Oyam
District, Uganda: a descriptive cross-sectional study. BMC Womens Health 2016; 16: 38.
8. Kerber KJ, Mathai M, Lewis G, et al. Counting every stillbirth and neonatal death through mortality audit to
improve quality of care for every pregnant woman and her baby. BMC Pregnancy Childbirth 2015; 15 Suppl 2: S9.
9. de Kok B, Imamura M, Kanguru L, Owolabi O, Okonofua F, Hussein J. Achieving accountability through maternal
death reviews in Nigeria: a process analysis. Health policy and planning 2017.
10. Martin Hilber A, Blake C, Bohle LF, Bandali S, Agbon E, Hulton L. Strengthening accountability for improved
maternal and newborn health: A mapping of studies in Sub-Saharan Africa. Int J Gynaecol Obstet 2016; 135(3):
345–57.
11. Koblinsky M, Kaptiningsih A, Fitriyani. Indonesia: Reducing maternal & perinatal deaths through MPDSR –
mapping the possibilities: Draft report for USAID prepared by Management Systems International, 2017.
12. WHO. Study on the implementation of maternal death review in five countries in the South-East Asia Region
of the World Health Organization. New Dehli, India: World Health Organization for South-East Asia, 2014.
13. Bandali S, Thomas C, Hukin E, et al. Maternal Death Surveillance and Response Systems in driving accountability
and influencing change. Int J Gynaecol Obstet 2016; 135(3): 365–71.
14. WHO. Summary report on the regional meeting on maternal death surveillance and response, Rabat, Morocco,
7–9 October 2013. Rabat, Morocco: World Health Organization Regional Office for the Eastern Mediterranean,
2013.
15. Abebe B, Busza J, Hadush A, et al. ‘We identify, discuss, act and promise to prevent similar deaths’: a qualitative
study of Ethiopia’s Maternal Death Surveillance and Response system. BMJ global health 2017; 2(2): e000199.
16. Bakker W, van den Akker T, Mwagomba B, Khukulu R, van Elteren M, van Roosmalen J. Health workers’
perceptions of obstetric critical incident audit in Thyolo District, Malawi. Trop Med Int Health 2011; 16(10):
1243–50.
17. MCSP. Assessment of Maternal and Perinatal Death Surveillance and Response Implementation in Zimbabwe.
Washington, DC: Maternal Child Survival Program, 2017.
18. Melberg A, Teklemariam L, Moland KM, Aasen HS, Sisay MM. Juridification of maternal deaths in Ethiopia:
a study of the Maternal and Perinatal Death Surveillance and Response (MPDSR) system. Health policy and
planning 2020; 35(8): 900–5.
19. Betran AP, Temmerman M, Kingdon C, et al. Interventions to reduce unnecessary caesarean sections in healthy
women and babies. Lancet 2018; 392(10155): 1358–68.
20. Belizan M, Bergh AM, Cilliers C, Pattinson RC, Voce A, Synergy G. Stages of change: A qualitative study on the
implementation of a perinatal audit programme in South Africa. BMC Health Serv Res 2011; 11: 243.
21. Grellier R, Shome P. FIGO Saving mothers and newborn project: Summary evaluation: Options, 2011.
22. MCSP. Assessment of Maternal and Perinatal Death Surveillance and Response Implementation in Nigeria.
Washington, DC: Maternal Child Survival Program, 2017.
23. Kinney MV, Ajayi G, de Graft-Johnson J, et al. “It might be a statistic to me, but every death matters.”: An
assessment of facility-level maternal and perinatal death surveillance and response systems in four sub-Saharan
African countries. PloS one 2020; 15(12): e0243722.
24. Dartey AF. The role of midwives in the implementation of maternal death review (MDR) in health facilities in
Ashanti region, Ghana. Cape Town: University of the Western Cape; 2012.
25. Smith H, Ameh C, Godia P, et al. Implementing Maternal Death Surveillance and Response in Kenya: Incremental
Progress and Lessons Learned. Global health, science and practice 2017; 5(3): 345–54.
26. Melberg A, Mirkuzie AH, Sisay TA, Sisay MM, Moland KM. ‘Maternal deaths should simply be 0’: politicization
of maternal death reporting and review processes in Ethiopia. Health policy and planning 2019; 34(7): 492–8.
27. Tura AK, Fage SG, Ibrahim AM, et al. Beyond No Blame: Practical Challenges of Conducting Maternal and
Perinatal Death Reviews in Eastern Ethiopia. Global health, science and practice 2020; 8(2): 150–4.
28. Biswas A. Shifting paradigm of maternal and perinatal death review system in Bangladesh: A real time approach
to address sustainable developmental goal 3 by 2030. F1000Res 2017; 6: 1120.
29. Purandare C, Bhardwaj A, Malhotra M, Bhushan H, Shah PK. Every death counts: electronic tracking systems
for maternal death review in India. Int J Gynaecol Obstet 2014; 127 Suppl 1: S35–9.
30. Dumont A, Tourigny C, Fournier P. Improving obstetric care in low-resource settings: implementation of facility-
based maternal death reviews in five pilot hospitals in Senegal. Hum Resour Health 2009; 7: 61.

31. Rhoda NR, Greenfield D, Muller M, et al. Experiences with perinatal death reviews in South Africa--the Perinatal
Problem Identification Programme: scaling up from programme to province to country. Bjog 2014; 121 Suppl 4:
160–6.
32. Tayebwa E, Sayinzoga F, Umunyana J, et al. Assessing Implementation of Maternal and Perinatal Death Surveillance
and Response in Rwanda. International journal of environmental research and public health 2020; 17(12).
33. Richard F, Ouedraogo C, Zongo V, et al. The difficulty of questioning clinical practice: experience of facility-based
case reviews in Ouagadougou, Burkina Faso. Bjog 2009; 116(1): 38–44.
34. Congo B, Sanon D, Millogo T, et al. Inadequate programming, insufficient communication and non-compliance
with the basic principles of maternal death audits in health districts in Burkina Faso: a qualitative study. Reprod
Health 2017; 14(1): 121.
35. Armstrong CE, Lange IL, Magoma M, Ferla C, Filippi V, Ronsmans C. Strengths and weaknesses in the
implementation of maternal and perinatal death reviews in Tanzania: perceptions, processes and practice.
Trop Med Int Health 2014; 19(9): 1087–95.
36. Muffler N, Trabelssi Mel H, De Brouwere V. Scaling up clinical audits of obstetric cases in Morocco. Trop Med
Int Health 2007; 12(10): 1248–57.
37. Biswas A, Rahman F, Eriksson C, Halim A, Dalal K. Facility Death Review of Maternal and Neonatal Deaths in
Bangladesh. PloS one 2015; 10(11): e0141902.
38. Biswas A, Halim MA, Dalal K, Rahman F. Exploration of social factors associated to maternal deaths due to
haemorrhage and convulsions: Analysis of 28 social autopsies in rural Bangladesh. BMC Health Serv Res 2016;
16(1): 659.
39. George A, al. e. Lenses and levels: the why, what and how of measuring health system drivers of women’s,
children’s and adolescents’ health with a governance focus. BMJ global health 2019 4(Suppl 4).
40. Kinney MV, Walugembe DR, Wanduru P, Waiswa P, George AS. Implementation of maternal and perinatal death
reviews: a scoping review protocol. BMJ open 2019; 9(11): e031328.
41. E4A. 2012. Maternal death surveillance and response systems: overcoming legal challenges and creating an
enabling environment. MDSR Action Network. Presented during ‘Interactive MDSR Resource Room’ at XXFIGO
World Congress of Gynecology and Obstetrics, Rome, Italy, 7-12 October 2012.
42. Hofman JJ, Mohammed H. Experiences with facility-based maternal death reviews in northern Nigeria. Int J
Gynaecol Obstet 2014; 126(2): 111–4.
43. Kongnyuy EJ, Leigh B, van den Broek N. Effect of audit and feedback on the availability, utilisation and quality
of emergency obstetric care in three districts in Malawi. Women and birth : journal of the Australian College of
Midwives 2008; 21(4): 149–55.
44. Kerber KJ, Mathai M, Lewis G, et al. Counting every stillbirth and neonatal death to improve quality of care for
every pregnant woman and her baby. BMC Preg Childbirth 2015; 15(Suppl 2)(S9).
45. Mogobe KD, Tshiamo W, Bowelo M. Monitoring maternity mortality in Botswana. Reprod Health Matters 2007;
15(30): 163–71.
List of resources
Links provided where available.
Module 1
• MDSR technical guide glossary (page 66)
• The WHO application of ICD-10 to maternal deaths during pregnancy, childbirth and puerperium:
ICD-MM
• WHO application of ICD-10 to deaths during the perinatal period: ICD-PM
• Standards and reporting requirements related for maternal mortality. In: ICD-11 Reference guide,
Part 2 [website]. Geneva: World Health Organization; 2019
• WHO and UNICEF Analysis and use of health facility data guidance for RMNCAH programme
managers
• DHIS2 website
• CRVS website
Module 2
• Situation mapping tool (Annex 1)
• Sample terms of reference for review committee (Annex 2)
• Sample meeting code of practice (Annex 3)
• MDSR technical guide chapter: Development of an MDSR implementation plan
• MDSR technical guide: Committee worksheet (MDSR A6)
• UNICEF Skill building on perinatal death reviews guide and presentation, Day 1, Session 6; and 7
• Video clip: Setting up a review committee.
Module 3
• Where to Look tool for identifying facility maternal and perinatal deaths (Annex 7)
• MDSR technical guide appendix 7: Community identification for suspected maternal deaths, page 114
• Ayele B, Gebretnsae H, Hadgu T, Negash D, G/silassie F, Alemu T, et al. Maternal and perinatal death
surveillance and response in Ethiopia: Achievements, challenges and prospects. Biswas A, editor.
PLoS One [Internet]. 2019 Oct 11;14(10):e0223540. Available from: http://dx.plos.org/10.1371/journal.
pone.0223540
Module 4
• Maternal death case review form and instructions to complete it (Annex 10 and 11)
• Stillbirth and neonatal death review form and instructions to complete it (Annex 12 and 13)
• Minimum perinatal data set (Annex 14)
• MDSR technical guide appendix: Types of facility information to collect (A3)
• MDSR technical guide (Appendix 4) Draft of community autopsy tool for maternal deaths, page 73
• Making every baby count guide: Stillbirth and neonatal death review form, page 71
• Making every baby count guide: Births and deaths summary form, page 82
• Making every baby count guide: Minimum set of perinatal indicators, page 87
• Making every baby count guide: Approaches for classifying modifiable factors, page 92. Video on audit
and neonatal deaths
• Virtual Public Health Campus on Surveillance and Response in the case of maternal and perinatal
death (MPDSR)
• MPDSR Training of Trainers package
Module 5
• Sample integrated MPDSR report outline for a single facility (Annex 6)
• MDSR technical guide committee worksheet
• UNICEF Skill building on perinatal death reviews guide and presentation, Day 1, Session 6 and 7
Module 6
• MDSR technical guide chapter: Data aggregation and interpretation
• MDSR technical guide chapter: Analysis
• MDSR technical guide appendix: Steps to completing the committee worksheet (A6)
• Making every baby count guide: Sample calculations for reporting, page 99
• MPDSR Action Tracker tool, Options Consultancy Services ltd
• Open-source software: the South African Perinatal Problem Identification Programme
Module 7
• MDSR technical guide chapter: Response
• MDSR technical guide chapter: Dissemination of results
• MDSR technical guide appendix: Implementation planning tool (A8)
• Making every baby count guide: approaches for classifying modifiable factors, meeting minutes and
action plan and fishbone diagram, page 102
• Knowledge Brief: Implementation of Maternal and Perinatal Death Surveillance and Response as part of
the Quality of Care efforts for Maternal and Newborn Health: Considerations for synergy and alignment
• Bandali, S., Thomas, C., Wamalwa, P., Mahendra, S., Kaimenyi, P., Warfa, O., & Fulton, N. (2019).
Strengthening the “p” in Maternal and Perinatal Death Surveillance and Response in Bungoma county,
Kenya: Implications for scale-up. BMC Health Services Research, 19(1), 1–10. https://doi.org/10.1186/
s12913-019-4431-4
• Marston, C., Hinton, R., Kean, S., Baral, S., Ahuja, A., Costello, A., & Portela, A. (2016). Community
participation for transformative action on women’s, children’s and adolescents’ health. Bulletin of the
World Health Organization, 94(5), 376–382. https://doi.org/10.2471/BLT.15.168492
• Melberg, A., Mirkuzie, A. H., Sisay, T. A., Sisay, M. M., & Moland, K. M. (2019). “Maternal deaths should
simply be 0”: Politicization of maternal death reporting and review processes in Ethiopia. In Health
Policy and Planning (Vol. 34, Issue 7). https://doi.org/10.1093/heapol/czz075
• Renedo, A., Komporozos-Athanasiou, A., & Marston, C. (2018). Experience as Evidence: The Dialogic
Construction of Health Professional Knowledge through Patient Involvement. Sociology, 52(4),
778–795. https://doi.org/10.1177/0038038516682457
• WHO. (2017). WHO community engagement framework for quality, people-centred and resilient
health services.
Module 8
• Common measures for monitoring MPDSR across countries (Annex 16)
• Indicator catalogue for monitoring MPDSR at health facility, district/regional and national levels
(Annex 17)
• MDSR technical guide chapter: Monitoring and evaluation of the MDSR system
• MCSP tools for assessing MPDSR processes in facilities and subnational level
Module 9
• Blanche Greene-Cramer et al. Systematic Identification of Facility-Based Stillbirths and Neonatal Deaths
Through the Piloted Use of an Adapted RAPID Tool in Liberia and Nepal. Plos One 2019
• Andrew T. Boyd et al. Use of Rapid Ascertainment Process for Institutional Deaths (RAPID) to identify
pregnancy-related deaths in tertiary-care obstetric hospitals in three departments in Haiti. BMC, 2017
• UNHCR. Maternal Death Review Form and Guide, 2020.
• Tappis, H., Ramadan, M., Vargas, J. et al. Neonatal mortality burden and trends in UNHCR refugee
camps, 2006–2017: a retrospective analysis. BMC Public Health 21, 390 (2021)
Module 10
• Ten strategies for promoting a “No Name, No Blame and No Shame” culture and key resources with
more information (Annex 18)
Annexes
Annexes
Annex 1: Situation mapping tool 67
Annex 2: Sample terms of reference for review committee 68
Annex 3: Sample meeting code of practice 69
Annex 4: Sample information flow chart 70
Annex 5: MPDSR integrated review meeting minutes and action items form 71
Annex 6: Sample integrated MPDSR report outline for a single facility 74
Annex 7: Where to Look tool: to identify maternal and perinatal deaths 77
Annex 8: MPDSR – Facility monthly summary form 78
Annex 9: Instructions for MPDSR – Facility monthly summary form 80
Annex 10: Maternal death case review form 82
Annex 11: Instructions for completing the Maternal death case review form 87
Annex 12: Stillbirth and neonatal death case review form 94
Annex 13: Instructions for completing the stillbirth and neonatal death case review form 97
Annex 14: Minimum perinatal data set 103
Annex 15: MPDSR monitoring framework 104
Annex 16: Common/Core measures for monitoring MPDSR across countries 108
Annex 17: Indicator catalogue for monitoring MPDSR at health facility, district/regional
and national levels 109
Annex 18. Ten strategies for promoting a “No Name, No Blame and No Shame” culture and key
resources with more information 124
Annex 1: Situation mapping tool
Before undertaking MPDSR, complete this tool to assess the current landscape of relating to mortality audit and
quality improvement systems in your facility or district.
Unsure
Main person or
Yes
No
Item position responsible Description
Committees or teams
Quality improvement
Maternal death review (frequency of meeting,
availability of registers and minutes)
Perinatal death review (frequency of meeting,
availability of registers and minutes)
Other (e.g. child, near-miss)
Documentation (available at level of review)
Death certification
Maternal death notification
If yes, time period for notification:
Perinatal death notification
If yes, time period for notification:
Perinatal death certificate
Birth certificate
Paper-based birth register
Electronic birth register
Paper-based postnatal register
Electronic postnatal register
Maternal death review forms
Perinatal death review forms
Births and deaths captured in HMIS
Births and deaths notified to civil authority
Burial permits
Other forms, [FILL IN]
Community surveillance
Community outreach from facility
Community birth register
Maternal death data collection
Stillbirth data collection
Neonatal death data collection
Verbal autopsy tools
Social autopsy tools
Other resources
Legal protection for staff
Confidentiality agreements
[FILL IN]
[FILL IN]
[FILL IN]
Annexes 67
Annex 2: Sample terms of reference for review committee
Purpose
Reducing maternal and perinatal deaths is a priority for this health facility, in accordance with local,
national and global goals. Recognizing that the primary aim of MPDSR is action that results in improved
quality of care, the purpose of the MPDSR review committee is to coordinate an effective review of
maternal deaths, stillbirths and neonatal deaths, and to oversee implementation of the recommendations
arising from these reviews.
Authority
The committee may decide or advise on appropriate corrective and other actions, which may be required
to reduce mortality and improve quality of care.
Membership
Describe the core, ad hoc and other members of the MPDSR review committee. Stress the importance
of multidisciplinary membership.
Duties & Responsibilities

• coordinate meetings at a specified frequency;
• ensure that all relevant health information and data are made available for such meetings;
• monitor trends in births and deaths, and other relevant data;
• ensure that actions arising from recommendations are implemented and communicated;
• work collaboratively with other quality improvement mechanisms and other key partners within
the facility;
• promote a no-blame environment for mortality review;
• consider the relevance of MPDSR activities to other levels of the health system and share findings
as mandated;
• ensure attendance of key stakeholders;
• ensure confidentiality;
• coordinate the creation and dissemination of summary reports as required.
Procedural Issues
Describe decisions made in regards to:
• frequency of meetings
• meeting roles (e.g. chairperson, secretary)
• quorum
• adherence to a meeting code of conduct
• completion and distribution of meeting minutes (maximum 3 working days).
Review
The terms of reference and committee processes will be reviewed every year, or sooner should the
need arise.
Annex 3: Sample meeting code of practice
(Adapted from Making every baby count audit and review of stillbirths and neonatal deaths. Annex 6,
page 98 (WHO, 2016)).
Code of practice
To show respect for the babies and families we are responsible for looking after, we, the staff of
________________________ [name of facility], agree to respect the rules of good conduct during meetings
where cases of deaths that have occurred in our facility are reviewed We understand and appreciate that
the results of these meetings will not result in punitive measures. The rules of our stillbirth and neonatal
mortality audit meetings include:
• arrive on time to the audit meetings;
• participate actively in discussions;
• respect everyone’s ideas and ways of expressing them;
• accept discussion and disagreement without resorting to verbal abuse;
• respect the confidentiality of the discussions that take place during the meetings;
• agree not to hide useful information or falsify information that could provide insight into the case(s)
under review; and
• try as much as possible (recognizing that it is not easy) to accept that your own actions can be questioned
Signed: _______________________________________________ Date: ________________________
Signed: _______________________________________________ Date: ________________________
Signed: _______________________________________________ Date: ________________________
Signed: _______________________________________________ Date: ________________________
Signed: _______________________________________________ Date: ________________________
Signed: _______________________________________________ Date: ________________________
Annexes 69
Annex 4: Sample information flow chart
FIGURE 6.2. Example of data flow in a mortality audit system for stillbirths and neonatal deaths
The MPDSR committee should establish a data flow chart,

which can be used to assign responsibility to named Raw data collected and entered
See Annex 3 for the Minimum
people along the path of data collection. into facility birth and death
Perinatal Dataset capture form
register and/or HMIS system
Data from facility registers and patient charts can be
transferred to maternal or perinatal case information
forms in preparation for mortality review meetings.
In addition, the information for a given time period can be
summarized in a single Seeform.
Annex 1 for the case Transfer of data from the register
information
These pieces of information formuse of the MPDSR
are for the to the case information form
committee and should not be shared outside the review
committee unless there is clear written agreement on the
use and dissemination of the information.
Meeting minutes and reports that come out of the
meetings can be shared, and
See Annex also
7 for howbetocollated
generateand linked Case information form transferred
back to other information systems,
summary including the Health
statistics to database (if electronic system)
Management Information System (HMIS), as well as Civil
Registration and Vital Statistics (CRVS).
Cases for given time period

See Annex 2 for a case summary form
collated into summary form
Mortality audit systems allow discussion

See Annex 8 for the sample minute of information and potentially
meetings and follow-up form changes to the causes of death
and modifiable factors assigned
Codes edited on the electronic

system (if applicable)
Data collated and sent to district/

regional/or national coordinator
Source: adapted from Rhoda et al , 2015 (41)
64 MAKING EVERY BABY COUNT: AUDIT AND REVIEW OF STILLBIRTHS AND NEONATAL DEATHS
Annex 5: MPDSR integrated review meeting minutes
and action items form
Institution: ___________________________________________________________________________
Date of meeting: ____________________ Start time: ______________ End time: ______________
Meeting chairperson: __________________________________________________________________
Period of time under review (e.g. week, month): ____________________________________________
Statistics for the above time period:
Number of women booked / registered: Number of births: Number of live births:
Number of preterm births (<37 weeks): Preterm birth rate (divide number by total
births and multiply by 100):
%
Number of low birth weight babies <2500g: Low birth weight rate (divide number by
live births and multiply by 100):
%
Number of caesarean sections: Caesarean section rate (divide number by
total births and multiply by 100):
%
Number of complicated deliveries Complication rate (divide number by total
(breech, multiple, vacuum, forceps, etc): births and multiply by 100):
%
Number of maternal deaths: Maternal mortality ratio (divide number
by live births and multiply by 100,000):
Number of stillbirths: Stillbirth rate (divide number by births and

multiply by 1000):
Number of intrapartum stillbirths Proportion of intrapartum stillbirths

(fetal heart sounds heard on admission): (divide number by total number of
stillbirths and multiply by 100):
%
Number of neonatal deaths aged 0–6 days: Early neonatal mortality rate (divide
number by live births and multiply
by 1000):
Number of neonatal deaths aged 0–28 days: Neonatal mortality rate (divide number by
live births and multiply by 1000):
Main causes of maternal deaths:

1. __________________________________________________________________________________
2. __________________________________________________________________________________
3. __________________________________________________________________________________
Annexes 71
Main causes of stillbirths:
1. __________________________________________________________________________________
2. __________________________________________________________________________________
3. __________________________________________________________________________________
Main causes of early neonatal deaths:

1. __________________________________________________________________________________
2. __________________________________________________________________________________
3. __________________________________________________________________________________

1. __________________________________________________________________________________
2. __________________________________________________________________________________
3. __________________________________________________________________________________
Action plans
Modifiable Specific actions to Follow-up

factor address modifiable Responsible Time (this section to be completed
identified factor person frame at the next meeting)
Add rows as needed

Date of next meeting: __________________________________________________________________
Date minutes ratified: _________________________________________________________________
Proposed by: ______________________________ Seconded by: ____________________________
Chairperson’s signature: _______________________________________________________________
Steps for minute taking at MPDSR meetings:
1. Use this form to capture the minutes, which should be accompanied by the code of practice declaration
signed before each meeting and the attendance register signed at the end of each meeting.
2. The meeting chairperson is responsible for ensuring that the minutes are taken, and that the meeting
minutes and action form is completed at the end of the meeting. Do not leave the filling out of the
form for a later time. For the minutes to be a functional document, the completion needs to be part
of the meeting process.
3. The statistics can be filled in on the form during preparations in advance of the meeting. If more
extensive statistics are presented at the meeting, it is optional to attach a copy of the presentation
as an addendum to the minutes.
4. Enter a short (e.g. single line) summary about each case presented. For example: “Case No. 13390,
35 y-o with postpartum haemorrhage due to uterine atony”, or “Case No. 45368, intrapartum
stillbirth 2.5 kg, ruptured uterus”. It is not necessary to include a full case report. If requested, case
presentations can be attached as an addendum to the minutes.
5. The chairperson should allocate at least 5 minutes at the end of the meeting to summarize the key
problems that have been identified during the meeting, based on the presentation of statistics or
the cases discussed, or both. Based on these problems, action plans can be drawn up, as outlined in
the table on the second page of the form. The task list should be clearly allocated and agreed upon
at the meeting.
6. At the end of the meeting, the chairperson should ensure that the minutes form is fully complete,
either on paper or electronically. Only the follow-up section of the table should be left blank.
7. Within 72 hours of the meeting, paper-based minutes should be typed up and stored electronically.
This should not be a long task if the format of the template is adhered to.
8. The typed minutes should be verified by the chairperson, and then circulated as draft minutes by email
to all members on the attendance list for the meeting, as well as to other interested stakeholders and
anyone with responsibility for one of the tasks in the action plan. Distribution of the draft minutes
should be completed within a week of the date of the meeting.
9. At the subsequent MPDSR meeting, the chairperson should allocate some time for reviewing the
draft minutes of the previous meeting, preferably at the start. If a task has not been completed, this
should be noted in the follow-up column and the task can be carried over into the action plans table
for the current meeting. Once the follow-up column from the minutes of the previous meeting has
been filled in, those final minutes can be ratified, with a proposer and a seconder.
10. The meeting can then proceed with new statistics and/or case presentations.
Annexes 73
Annex 6: Sample integrated MPDSR report outline for a single
facility
Background
• If the report is to be distributed outside the health facility, include background information on the facility,
such as the level of care, management structure, number of beds and annual number of deliveries.
• Include details of the timing and types of event covered by the death review.
• Describe the set-up of the committee, the frequency of review meetings, people and departments
involved, and the process of review.
• Identify the period under review, and report publication date.
• Include information on the team compiling the report, and a point of contact.
Findings
Summary of pregnancies and births
• Describe current results and differences from the previous review period.
Number
Pregnancies booked or registered
Deliveries
Live births
Maternal deaths
Induced abortions (harmonized to local laws)
Stillbirths (according to local definition)
Early neonatal deaths (0–6 days)
Late neonatal deaths (7–28 days)
Maternal deaths
• Describe the number and causes of death.
ICD-MM grouping Number
Direct Group 1
Group 2
Group 3
Group 4
Group 5
Group 6
Indirect Group 7
Unspecified Group 8
Coincidental Group 91
Total maternal deaths should only be the sum of groups 1 to 8 and NOT include deaths in group 9. Deaths in group 9 are
1
pregnancy-related deaths but not maternal deaths.
Include ICD-MM reference sheet for more information on group classification, or use locally accepted
cause of death categories
Stillbirths and neonatal deaths

• Describe the number and causes of death.
Births by weight Antepartum Intrapartum Stillbirth, Early Late

stillbirth stillbirth unknown neonatal neonatal
timing death death
< 1000g
1000–1499 g
1500–1999 g
2000–2499 g
2500 g+
Weight unknown
Gestational age Antepartum Intrapartum Stillbirth, Early Late

timing death death
Extreme preterm < 27+6
Very preterm 28+0−31+6
Moderate to late preterm
32+0−36+6
Term 37+0−41+6
Post-term > 42+0
Gestational age unknown
Type of childbirth Antepartum Intrapartum Stillbirth, Early Late

timing death death
Cephalic vaginal
Assisted (forceps, vacuum,
breech, destructive procedures)
Caesarean section
Unknown
Antepartum stillbirths M1 M2 M3 M4 M5 other unknown

a. congenital
b. antepartum complications
c. intrapartum complications
d. complications of prematurity
e. infection
f. other
g. unknown/unspecified
Annexes 75
Intrapartum stillbirths M1 M2 M3 M4 M5 other unknown
a. congenital
e. infection
f. other
Neonatal deaths M1 M2 M3 M4 M5 other unknown
a. congenital
e. infection
f. other
Include ICD-PM reference sheet for more information on group classification
Background characteristics
• Include specific background characteristics based on local epidemiology (e.g. syphilis, HIV status),
or information relevant to the facility (e.g. where the deaths occurred, referral status, neighbourhood
of patient).
Maternal Maternal Antepartum Intrapartum Stillbirth, Early Late

age death stillbirth stillbirth unknown neonatal neonatal
timing death death
< 18y
18–19y
20–34y
> 35y
Unknown
Modifiable factors
• description and trends in modifiable factors.
• actions taken to address identified modifiable factors.
Recommendations and plans for action

• Review completed and outstanding recommendations from previous reports.
• Highlight recommendations that are not being implemented, and those that have encountered delays,
and provide a revised plan for implementation or reassessment.
• Identify new recommendations and the plan to take action.
• Consider including a success story of a recommendation leading to sustained change in practice.
Annex 7: Where to Look tool: to identify maternal and
perinatal deaths
Maternal deaths
Daily check of logs from (to be defined locally):
• gynaecology ward (maternal deaths in early pregnancy due to abortion complications and maybe
extrauterine pregnancies);
• antenatal ward;
• obstetric ward;
• postnatal ward;
• adult or women’s ward;
• emergency department;
• intensive care units;
• surgery;
• operating theatre or anaesthesiology register;
• mortuary;
• outpatient clinic;
• community log (if available).
Note: Any death of a woman of reproductive age should trigger a review of her medical record to look for
evidence that she could have been pregnant, or within 42 days of the end of a pregnancy.
Stillbirth and neonatal deaths

Daily check of logs from:
• antenatal ward
• obstetric ward
• postnatal ward
• Special Care Baby Unit/NICU
• pediatric ward
• mortuary
• outpatient clinic
• community log (if available).
Annexes 77
Annex 8: MPDSR – Facility monthly summary form
SECTION 1: IDENTIFICATION
1.1 Data collected at (facility name):
1.2 Data for the month of:
1.3 District name:
1.4 Pregnancies, abortions, births, maternal, perinatal & neonatal deaths

Total Total
Total Total maternal Total Total neonatal
pregnancies live births deaths2 abortions stillbirths deaths
Total births Stillbirths (SB) Neonatal deaths

Births by weight (incl. deaths) Antepartum SB Intrapartum SB Unknown SB Early Late
< 1000 g
1000–1499 g
1500–1999 g
2000–2499 g
2500 g+
weight unknown
1.5 Multiple pregnancies ________ babies from ________ pregnancies
1.6 Born before arrival ________ total

1.7 Mode of childbirth CVD breech vacuum forceps caesarean
1.8 Gestational age term post-term ext. preterm very preterm mod. preterm
1.9 HIV status negative positive unknown
1.10 Syphilis serology negative positive unknown
1.11 Maternal age 20–34 y > 34 y 18–19 y < 18 y unknown
SECTION 2: CAUSES OF MATERNAL DEATH
Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8 Group 9

direct direct direct direct direct direct indirect unspecified coincidental
see ICD-MM reference sheet for more information on group classification
2
Total maternal deaths should only be the sum of groups 1 to 8 and NOT include deaths in group 9. Deaths in group 9 are pregnancy-related
deaths but not maternal deaths.
SECTION 3: CAUSE OF PERINATAL DEATH
3.1a Cause of death: antepartum stillbirths M1 M2 M3 M4 M5 other unknown
a. congenital
e. infection
f. other
3.1b Cause of death: intrapartum stillbirths M1 M2 M3 M4 M5 other unknown
a. congenital
e. infection
f. other
3.1c Cause of death: neonatal deaths M1 M2 M3 M4 M5 other unknown
a. congenital
e. infection
f. other
see ICD-MM and ICD-PM reference sheets for more information on group classification
CVD: cephalic vaginal childbirth
Annexes 79
Annex 9: Instructions for MPDSR – Facility monthly
summary form
Purpose of form: To assist a facility in its documentation of births and perinatal deaths.
Responsibility for completion: Once per month by the facility data clerk or statistics department. Additionally,
numbers generated on this form can be compared between months for qualitative trends. At every MPDSR
meeting, these data can be reviewed to identify similarities in cases reviewed with overall trends. This may
help to guide prioritization of actions or interventions recommended by the MPDSR Committee.
Section 1: Identification
1.1: Write facility name here.
1.2: Write the month and year for which these numbers were collected.
1.3: Write the name of the district of the facility.
1.4 Column 1: Total births: Write the total number of births in each of the categories, including both live
and stillbirths, and including any live births of neonates who later died. The internationally comparable
definition of stillbirth, as defined by WHO, is death before birth, among fetuses that are, by order of
priority, of at least 1000 g birthweight, and/or at least 28 weeks’ gestation, and at least 35 cm long.3
Column 2: Stillbirths: Write the total number of births in each category, as defined here:
• “Antepartum SB” (antepartum stillbirth) is the death of a fetus before the onset of labour.
– This can be determined by “macerated” appearance of the fetus upon childbirth, in combination
with absence of fetal heart sounds on admission.
○ Absence of fetal heart sounds on admission does not necessarily indicate an antepartum stillbirth,
as there may have been delays in reaching the facility during labour.
○ Presence of fetal heart sounds on admission of a labouring woman does exclude the possibility
of an antepartum stillbirth.
• “Intrapartum SB” (intrapartum stillbirth) is the death of a fetus who was alive at the onset of labour,
but who died before childbirth.
– This can be determined by the presence of fetal heart sounds (fetal heart tones) on admission or
prior to childbirth, or, by the appearance of a “fresh” stillbirth (intact skin and fetus on childbirth).
• “Unknown timing for SB” (stillbirth of unknown timing) is the category for those for whom it is not
possible to tell the timing of the stillbirth.
1.5: In the “pregnancies” box, write the total number of pregnancies of at least two fetuses (e.g. twins,
triplets)
In the “babies” box, write the total number of fetuses or neonates who resulted from these pregnancies.
Include those born alive, as well as those who were stillborn.
For example, suppose that in one month a hospital delivered 10 women who had pregnancies with more
than one fetus. Suppose that of these 10 women, 8 delivered live twins, 1 delivered stillborn twins, and 1
delivered live triplets. In this example, the “pregnancies” box would have the number 10, and the “babies”
box would have the number 21.
1.6: Enter the total number of deliveries that occurred before arrival to the facility.
3
See Figure 2.1 in Making every baby count: audit and review of stillbirths and neonatal deaths
1.7: Write in each box the total number of deliveries by CVD (cephalic vaginal childbirth), assisted,
caesarean, and unknown.
1.8: Write in each box the total number of:
• term deliveries: pregnancies of gestational age 37+0 weeks to 41+6 weeks;
• post-term deliveries: pregnancies of gestational age 42 weeks or greater (≥ 42+0);
• extremely preterm deliveries (“ext. preterm”): pregnancies of gestational age less than 28 weeks
(≤ 27+6) (lower limit may depend on setting; consider 23+0 weeks for inclusion on this form);
• very preterm deliveries: gestational age between 28+0 and 31+6 weeks;
• moderate to late preterm deliveries (“mod. preterm”): pregnancies of gestational age 32+0–36+6 weeks.
1.9: Record numbers of HIV-negative mothers, HIV-positive mothers, and mothers of unknown HIV
status served by the facility in the past month.
1.10: Record numbers of syphilis-negative mothers, syphilis-positive mothers, and mothers of unknown
syphilis status served by the facility in the past month.
1.11: Record numbers of mothers served by the facility in the past month within each of the age categories,
as well as those for whom age was unknown.
Section 2: Cause of maternal death

2: Record the numbers of maternal death by ICD-MM group. Use the ICD-MM reference sheet if needed.
Section 3: Cause of perinatal death

3.1a: Tally the number of causes of antepartum stillbirths in each of the listed categories in the past month
at this facility. If M1–M5 designations were used, total those. If M1–M5 designations were not used, enter
all in the “other” column provided. Tally any unknowns in the “unknown” column.
If a facility has stillbirths for which antepartum vs. intrapartum status is unknown, record these separately
to the right of the antepartum deaths list, along the same rows.
3.1b: Tally the number of causes of intrapartum stillbirths in each of the listed categories in the past
month at this facility. If M1–M5 designations were used, total those. If M1–M5 designations were not
used, enter all in the “other” column provided. Tally any unknowns in the “unknown” column.
3.1c: Tally the number of causes of neonatal deaths in each of the listed categories in the past month at
this facility. If M1–M5 designations were used, total those. If M1–M5 designations were not used, enter
all in the “other” column provided. Tally any unknowns in the “unknown” column.
Annexes 81
Annex 10: Maternal death case review form
1.1 ID # / Full name of mother: ___________________________________________________________________________________________________________

1.2 Facility name: _______________________________________________________________________________________________________________________
1.3 Type of care available: Comprehensive EmOC Basic EmOC first aid home delivery
1.4 District name: ______________________________________________________________________________________________________________________
1.5 Referred not referred referred in from: ____________________________________________________________
referred out to: ______________________________________________________________
SECTION 2: PREGNANCY AND ANTENATAL CARE

2.1 Obstetric history
Gavidity Parity Live births Stillbirths Spontaneous abortions Induced abortions
2.1a Previous cesareans none number: date of most recent c/s:
(and date of most recent) ___________________________ _____________________________________________
2.1b Previous pregnancy complications none number and date: description:
___________________________ _____________________________________________
2.2 Mother’s age: ____________________________ y
2.3 Mother’s education None Primary Secondary Higher
2.4 Marital status Single Married Widowed Divorced Separated Living in union
2.5 Contraception use just prior to pregnancy no yes If yes, what type (e.g. Pill, DMPA, Implant, IUD): _______________________
2.6 Type of pregnancy singleton twin higher multiple = unknown
2.7 Antenatal care number of visits 8+ 6–7 4–5 3 2 1 no visits unknown

2.8 Pre-existing medical conditions
2.8a Hypertension no yes unknown
2.8b Diabetes no yes unknown
2.8c Anaemia no yes unknown
2.8d Hepatitis no yes unknown
2.8e Heart Problem no yes unknown
2.8f Syphillis no yes unknown
2.8g Other _________________________________ no yes unknown
2.9 Antenatal risk factors
2.9a Hypertension no yes unknown
2.9b Proteinuria no yes unknown
2.9c Glycosuria no yes unknown
2.9d Anaemia no yes unknown
2.9e Urinary tract infection no yes unknown
2.9f Placenta previa no yes unknown
2.9g Malaria no yes not applicable unknown
2.9h Other _________________________________ no yes unknown
2.10 Antenatal hospitalization? no yes unknown
Describe: ___________________________________________________________________________
2.11 Antenatal medications? no yes unknown
List: ________________________________________________________________________________
2.12 Laboratory tests
2.12a Blood type and Rh no yes unknown
2.12b Hemocrit/hemoglobin no yes unknown
2.12c VDRL no yes unknown
2.12d Rubella no yes unknown
2.12e Urinalysis no yes unknown
2.12f Other _________________________________ no yes unknown
adjust as per local context
2.13 Malaria prophylaxis not needed IPT3+ IPT2 IPT1 not received unknown
2.14 Tetanus toxoid vaccination TT2+ TT2 TT1 not received unknown
2.15 HIV status HIV-negative HIV-positive not done unknown
2.15.1 HIV-positive action HAART other, specify: _____________________________
2.16 Tuberculosis status Tb positive action under treatment, specify no treatment
SECTION 3: PATHWAY BEFORE ADMISSION

3.1 Patient came on her own no yes
Referred or evacuated no yes
3.2 If referred/ evacuated: Referral center: ____________________________________________________
3.3 Reason for referral/evacuation: _________________________________________________________
3.4 Ambulance no yes If yes, medical (medicines and no yes
health personnel on board)?
3.5 Accompanying person? no yes If yes, specify: ___________________________________________________
3.6 Date and time of onset of symptoms: ____________________________________________________
3.7 Date and time of the referral/evacuation decision: __________________________________________
3.8 Date and time of departure from the referral center: ________________________________________
SECTION 4: ADMISSION
4.1 Vital signs
4.1a Heart rate no yes unknown Specify: ______________________________________
4.1b Systolic blood pressure no yes unknown Specify: ______________________________________
4.1c Diastolic blood pressure no yes unknown Specify: ______________________________________
4.1d Temp (Celsius) no yes unknown Specify: ______________________________________
4.1e Respiratory rate no yes unknown Specify: ______________________________________
4.1f Height no yes unknown Specify: ______________________________________
4.1g Weight no yes unknown Specify: ______________________________________
4.1h Other _________________________________ no yes unknown
4.2 Abdominal Examination
4.2a Fundal height no yes unknown
4.2b Fetal heart sounds on admission no yes unknown
4.2c Fetal presentation normal abnormal
4.3d Other _________________________________ no yes unknown
4.3 Pelvic Examination
4.3a Stage of labor not in labour in active labor second third
4.3b Pelvic abnormality no yes unknown
4.4 Admission complications
4.4a Premature rupture of membranes no yes unknown
4.4b Pre-eclampsia no yes unknown
4.4c Eclampsia no yes unknown
4.4d Abruption no yes unknown
4.4e Placenta Praevia no yes unknown
4.4f Premature labour no yes unknown
4.4g Fetal Demise no yes unknown
4.4h Pylonephritis no yes unknown
4.4i Sepsis no yes unknown
4.4j Malaria no yes not applicable unknown
4.4k Other _________________________________ no yes unknown
SECTION 5: LABOUR AND BIRTH

5.1 Mother’s LMP DD MM YYYY unknown
5.2 Date of birth DD MM YYYY
5.2.1. Time of birth _____________ : _____________ h
Annexes 83
5.3 Gestational age weeks unknown
5.3.1. Method of determination sure LMP dates unsure LMP dates
early ultrasound late ultrasound
5.4 Place of childbirth facility home road other, specify unknown
5.4.1 Attendant at childbirth midwife nurse doctor other, specify: _________________________________ no one unknown
5.5 Onset of labour spontaneous induced c/s before onset unknown
5.6 Fetal heart sound no yes unknown
5.7 Partograph used no yes unknown
5.8 Complications of labour and birth
5.8a Intrapartum hemorrhage no yes unknown
5.8b Intrapartum infection no yes unknown
5.8c Intrapartum pre-eclampsia/eclampsia no yes unknown
5.8d Obstructed labor no yes unknown
5.9 Mode of childbirth CVD vaginal breech internal podalic version breech extraction
5.10 Time between action decision and birth n/a < 30 mins 30–60 min > 60 mins unknown
5.11 Active management of third stage? no yes unknown
5.12 Retained placenta? no yes unknown
5.13 Postpartum hemorrhage no yes unknown
5.14 Postpartum infection no yes unknown
5.15 Postpartum pre-eclampsia/eclampsia no yes unknown
SECTION 6: NEONATE
6.1 Apgar score 1 min = _______________ 6 or more 5 or less
5 min = _______________ 6 or more 5 or less
6.2 Resuscitation not needed bag + mask not done Other, specify: __________________________________________
6.3 Sex of baby male female
6.4 Birth weight ____________________ g ≥ 2500 g 1500–2499 g 1000–1499 g < 1000 g
LBW VLBW ELBW
SECTION 7: INTERVENTIONS
7.1 Early pregnancy
Evacuation no yes unknown
Laparotomy no yes unknown
Hysterotomy no yes unknown
Transfusion no yes unknown
Other _________________________________ no yes unknown
7.2 Antepartum
Version no yes unknown
Labour induction no yes unknown
Magnesium Sulfate no yes unknown
Antibiotics no yes unknown
7.3 Intrapartum
Symphysiotomy no yes unknown
Hysterectomy no yes unknown
Destructive operations (e.g. craniotomy) no yes unknown
7.4 Postpartum
Evacuation no yes unknown
Laparotomy no yes unknown
Hysterotomy no yes unknown
Hysterectomy no yes unknown
Oxytocin no yes unknown
Misoprostol no yes unknown
7.5 Other interventions
General Anaesthesia no yes unknown
Epidural no yes unknown
Spinal no yes unknown
Local no yes unknown
ICU ventilation no yes unknown
Invasive monitoring no yes unknown
SECTION 8: DETAILS OF THE DEATH
8.1 Date of death DD MM YYYY
7.1.1 Time of death ______________ : ______________ h
8.2 Underlying cause of death (ICD MM): Group 1 Group 2 Group 3 Group 4 Group 5
_________________________________________ Group 6 Group 7 Group 8 Group 9
8.3 Contributory causes of death: ICDMM code not identified
8.4 Autopsy Not done Completed
SECTION 9: CRITICAL DELAYS AND MODIFIABLE FACTORS

9.1 Critical delays delay 1 not identified 1. delay recognizing need for care: _________________________________________________
delay 2 not identified 2. delay seeking care: ____________________________________________________________
delay 3 not identified 3. delay receiving care: ___________________________________________________________
9.2 Modifiable factors
Family-related none identified Specify: _______________________________________________________________________
e.g. late/no antenatal care; cultural inhibition to seeking care; no knowledge
of danger signs; financial constraints; partner restricts care-seeking; use of
traditional/ herbal medicine; smoking / drug / alcohol abuse; attempted
termination; etc.
Administration-related none identified Specify: _______________________________________________________________________
e.g. neonatal facilities; theatre facilities; resuscitation equipment; blood
products; lack of training; insufficient staff numbers; anaesthetic delay; no
antenatal documentation; etc.
Provider-related none identified Specify: _______________________________________________________________________
e.g. partogram not used; action not taken; inappropriate action taken;
iatrogenic childbirth; delay in referral; inadequate monitoring; delay in calling
for assistance; inappropriate discharge; etc
Other ____________________ none identified Specify: _______________________________________________________________________
Annexes 85
Actions to address the critical delays and modifiable factors
Form completed by: ____________________________________________ Date: _____________________________________________________________
c/s: caesarean section; CVD: cephalic vaginal childbirth; ELBW: extremely low birthweight; EmOC: emergency obstetric care; HAART: highly active antiretroviral therapy;
HIV: human immunodeficiency virus; IPT: intermittent preventive treatment; LBW: low birthweight; LMP: last menstrual period; NVP: nevirapine prophylaxis; TT: tetanus toxoid;
VLWB: very low birthweight
Section 7: See ICD-MM reference sheet for more information on group classification
Annex 11: Instructions for completing the Maternal death case
review form
Purpose of form: To assist maternal death review meetings/ committees in reviewing a maternal death,
to provide information about the death, and to identify critical delays and modifiable factors that can be
targeted with interventions to prevent future deaths. The form is designed so that the ‘normal’ answers
appear on the left and the ‘abnormal’ answers appear on the right, making it easier to visually identify
problem areas. The accompanying reference form for maternal conditions according to ICD-MM should
be used alongside this form. The WHO application of ICD-10 should be used for more details (ICD-MM).
1.1: ID# / Full name of mother: Include all ID numbers that are standardly used by your health care facility.
If no standard ID numbers are used, write the mother’s name here.
1.2: Put the name of the facility where the maternal death took place. If it is being reviewed at a different
facility, add “reviewed at facility: ____” to clarify.
1.3: Type of care available: Circle the type of care available at the time the mother presented for care.
Type of care is defined according to the World Health Organization classification of basic emergency
obstetric and newborn care (BEmONC) and comprehensive emergency obstetric and newborn care
(CEmONC), from Monitoring emergency obstetric care: a handbook, 2009.
To classify care as “basic”, it must provide all of seven essential interventions:
1) administer parenteral antibiotics
2) administer uterotonic drugs (i.e. parenteral oxytocin)
3) administer parenteral anticonvulsants for pre-eclampsia and eclampsia (i.e. magnesium sulfate)
4) manually remove the placenta
5) remove retained products of conception (e.g. manual vacuum extraction, dilation and curettage)
6) perform assisted vaginal childbirth (e.g. vacuum extraction, forceps childbirth)
7) perform basic neonatal resuscitation (e.g. with bag and mask).
To classify care as “comprehensive”, it must provide the seven essential interventions listed above and
the following additional interventions:
1) perform surgery (i.e. caesarean section)
2) perform blood transfusion.
1.4: District name: Put the name of the district where the facility at which the mother delivered is located.
This may not be the district that the mother is from.
1.5: Circle “not referred” if the woman presented from home.
If the woman was referred from another hospital, health centre or clinic, write the name of that facility
on the line for “referred in from”.
If the woman was referred out to another hospital or other facility, put the name of that hospital or other
facility on the line for “referred out to”.
Annexes 87
Section 2: Pregnancy progress and care
2.1: Obstetric history: For “gravidity”, put the total number of pregnancies the mother had. Include the
pregnancy being discussed. Pregnancies with twins or other multiples are counted as one pregnancy.
For “parity”, put the total number of births the woman has had of babies of gestational age of 28 weeks.
Some countries consider babies of gestational age of 22 weeks, so please adopt based on your country’s
national definition. Include the pregnancy being discussed. Deliveries of twins or other multiples are
counted as one childbirth.
For “live births”, put the number of living children of the mother. If both are living, twins are counted as
two living children.
For “stillbirths”, put the number of deceased babies before birth, among fetuses that are, by order
of priority, of at least 1000 g birthweight, and/or at least 28 weeks gestation, and at least 35 cm long,
depending on the country’s national definition.
2.1a: Previous caesareans: Write the number of caesarean sections done, along with the dates if any.
2.1b: Previous pregnancy complications: write the number of pregnancy complications, the date when
they happened, and under “description”, write what happened.
2.2: Put the mother’s age in completed years. For example, a woman of 23 years and 10 months of age
would be entered as “23”.
2.3: Mother’s education: Specify the level of education of the mother, whether she has a primary or
secondary level of school or higher, or whether she received no education.
2.4: Marital status: Specify her marital status (single and never married, married, widowed, divorced,
separated but married, or living in union but not married and not single).
2.5: Contraception use just prior to pregnancy: Specify if the woman was using any family planning
method and, if so, which modern contraception method the woman was using.
2.6: Circle the type of pregnancy being discussed:
• “singleton” if a pregnancy with one fetus;
• “twin” if a pregnancy with two fetuses;
• “higher multiple” if greater than two fetuses. If greater than two fetuses, put the number of fetuses
next to the equals sign;
• “unknown” if the total number of fetuses is/was not known.
2.7: Circle the total number of antenatal care visits the mother had during this pregnancy.
2.8: Circle the pre-existing medical conditions that the woman had during this pregnancy.
• Circle “unknown” if there is no information on her receipt of treatments.
2.9: Circle the antenatal risk factors that the woman had during this pregnancy.
• Circle “unknown” if tests not done/or there is no information on her receipt of treatments.
2.10: Circle if the woman has had any antenatal hospitalization during this pregnancy. If “yes”, then provide
details of why, when and where (which facility), and what treatment/advice was provided.
2.11: What antenatal medications is the woman taking during this pregnancy?
2.12: Circle the status of the laboratory tests in the list carried out during this pregnancy.
2.13: Circle the number of intermittent prophylactic treatments (IPT) for malaria that the woman received
during her pregnancy.
• Circle “not needed” if malaria prophylaxis was not medically indicated due to lack of malaria in her
residence during pregnancy.
• Circle “IPT3+” if she received at least three treatments.
• Circle “IPT2” if she received only two treatments.
• Circle “IPT1” if she received only one treatment.
• Circle “not received” if she did not receive any IPT in an area where it is indicated.
2.14: Circle the number of tetanus toxoid (TT) doses that the woman received during her pregnancy, or
whether she was protected at birth (“PAB”) through vaccinations during childhood or during previous
pregnancies.
2.15: Indicate the mother’s HIV status.
• Circle “HIV negative” if the woman was tested and found to be negative.
• Circle “HIV positive” if the woman was tested and found to be positive, or was known to be positive
prior to pregnancy (and proceed to 2.71 below).
• Circle “not done” if no HIV testing was performed during pregnancy.
• Circle “unknown” if the HIV status and testing status are unknown.
2.15.1: If the woman was found to be HIV positive or known to be HIV positive prior to pregnancy,
indicate what action was taken:
• Circle “HAART” if the woman received highly active antiretroviral treatment during her pregnancy.
• Next to “other”, write if:
– any additional treatment was received for HIV or its complications
– no treatment was received
– treatment was received but the type is unknown.
Do not complete line 2.15.1 for any woman who was not known to be HIV positive.
2.16: Indicate the mother’s tuberculosis status.
• Circle “negative” if the woman was tested for TB and found to be negative.
• Circle “positive” if the mother was tested and found to be positive; specify the medication she
is taking.
• Circle “not done” if no testing was performed during pregnancy.
• Circle “unknown” if the status and testing status are unknown.
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Section 3: Pathway before admission
3.1: Enter all referral details and means of transportation.
Section 4: Details on admission

4.1: Enter the details of the “vital signs” on admission.
• Circle “no” if they were not measured.
• Circle “yes” if they were measured, and enter the details.
• Circle “unknown” if nothing is mentioned.
4.2: Enter the details of abdominal examination of the pregnant woman.

• Circle “yes” and provide the details of fundal height and fetal heart sounds if they were measured.
• If the fetal presentation is “abnormal”, please provide details.
4.3: Enter the details of pelvic examination of the pregnant woman.

• Circle the stage of labour she is in.
4.4: Enter the details if the woman had any complications on admission during this pregnancy.
Section 5: Labour and birth

5.1: Woman’s LMP: If there is an LMP in line with first trimester ultrasound, enter this here.
1) If there is no LMP in line with first trimester ultrasound, enter the estimated LMP according to
mother’s recollection.
2) Do not enter LMP based on third trimester ultrasound, or estimated by size at childbirth.
3) If there is no LMP by ultrasound or mother’s recollection, circle “unknown”.
5.2: Date of birth: Record the date or birth here, whether live or stillborn.
5.3: Gestational age. Enter in weeks and days at the time of birth (live or stillbirth), using the LMP. If
there is no gestational age calculated, circle “unknown”.
5.3.1: Method of determination: Circle the method by which this gestational age was calculated. This
should be the same method as was used to derive LMP. Additionally, circle “sure” or “unsure” LMP
dates based on mother’s certainty.
• If mother’s certainty is not stated, circle “sure”.
5.4: Circle the place of childbirth. If childbirth was at a facility, enter the facility’s name on this line.
5.4.1: Attendant at childbirth:
• Circle “midwife” if childbirth was attended by a trained midwife.
• Circle “doctor” if childbirth was attended by a physician.
• Circle “nurse” if childbirth was attended by a trained skilled birth attendant.
• Write in “other” if childbirth was attended by someone else.
• Circle “unknown” if childbirth attendant is not known.
5.5: Onset of labour: Circle if onset was spontaneous, induced or if baby was delivered by caesarean
section before onset of labour.
5.6: If fetal heart sounds (fetal heart tones) were auscultated on admission and were not present, circle
“no”. If fetal heart sounds (fetal heart tones) were auscultated on admission and were present, circle
“yes” and write what they were recorded as on admission. If fetal heart sounds were not auscultated on
admission, or if this information is not available, circle “unknown”.
5.7: Use of partograph: Circle whether or not a partograph was used during childbirth, or enter “unknown”
if this information is not available. If a partograph was used during childbirth, write any relevant additional
comments next to “yes”. For example, write “incomplete” if it was used for only a portion of childbirth
or does not include all standard information on a partograph.
5.8: Complications of labour and birth: Circle one of the options.
5.9: Mode of childbirth:
• Circle “CVD” (cephalic vaginal childbirth) if it was a normal vaginal childbirth with cephalic presentation.
• Circle “vaginal breech” if it was a spontaneous vaginal childbirth with breech presentation.
• Circle “breech extraction” if it was an assisted vaginal breech childbirth.
• Enter under “others” it was a vacuum or a forceps childbirth or other complications, e.g.
shoulder dystocia.
• “caesarean” if indicated, or
• Enter “unknown” if this information is not available.
5.10: Time between action decision and birth: If mode of childbirth was anything other than “CVD”, circle
the time from decision to proceed with this form of childbirth and the childbirth itself. If childbirth was
“CVD”, circle “not applicable”.
5.11 to 5.15: Circle any one of the options for the conditions or interventions.
Section 6: Neonate
6.1: Record the APGAR scores at 1 and at 5 minutes. Next to these, circle “6 or more” or “5 or less”, as
indicated by the score. If either of these scores is not available, circle “unknown” for that score.
6.2: Resuscitation of the neonate:
• Circle “not needed” if not indicated by APGAR scores or clinical state.
• Circle “bag + mask” if performed.
• Circle “none” if resuscitation was indicated but not performed.
• Circle “other” and record if the following forms of resuscitation were performed:
– Stimulation
– Suction
– Intubation
– CPR
– Other forms of resuscitation (record).
6.3: Sex of baby: circle “male”, “female” or “unknown” as indicated.

6.4: Birthweight: record the total birthweight and circle the appropriate category. The acronyms stand for:
• Low birthweight (LBW), <2500 g
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• Very low birthweight (VLBW), <1500 g
• Extremely low birthweight (ELBW), <1000 g.
Section 7: Interventions:
7.1: Early pregnancy: Provide details if interventions such as evacuation, laparotomy, hysterectomy or
transfusion were carried out. If there is no mention of any, circle “unknown”. If there was any other
intervention, specify.
7.2: Antepartum: Provide details if interventions such as version or induction of labour were done, and/
or if transfusion, magnesium sulphate and antibiotics were given during the antepartum period. In the
event of any other, provide details.
7.3: Intrapartum: Provide details if interventions such as symphysiotomy or hysterectomy were done, or if
destructive operation was done on the fetus; and/or if transfusion, antibiotics and magnesium sulphate
were given during the intrapartum period. In the event of any other, provide details.
7.4: Postpartum: Provide details if interventions such as evacuation, laparotomy, hysterotomy, hysterectomy
were carried out; and/or if transfusion, antibiotics and magnesium sulphate, oxytocin and misoprostol
were given during the postpartum period. In the event of any other, provide details.
7.5: Other interventions: Provide details if interventions such anaesthesia (general, spinal, epidural or
local) was used, if there was any invasive monitoring or intensive care was provided. In the event of any
other, provide details.
Section 8: Details of the death

8.1 and 8.1.1: Record the date and time of death.
8.2: Circle the type of death. Note that Groups 1–6 are grouped as direct causes of maternal death, Group
7 as indirect causes of maternal death, Group 8 where cause of maternal death is unspecified (not known
or determined), and Group 9 as pregnancy-related death during pregnancy, childbirth and puerperium
due to coincidental causes.
Enter the name of the main maternal condition found on the maternal conditions reference page according
to ICD-MM guidance. Please see the WHO application of ICD-10 to deaths during the maternal period:
(ICD-MM) for more detail.
8.3: Contributory causes of death: Identify the relevant cause of maternal death using the numbers
provided on the accompanying reference page, and according to ICD-MM guidance.
8.4: Mention if an autopsy was completed or not done.
Section 9: Critical delays and modifiable factors

9.1: Circle any delays in care that are recognized in review of the case.
Delay 1: Delay in the decision to seek care (for example, a woman may labour at home for too long
because she and/or her family are afraid to come for care, are concerned about the cost of care, or do
not recognize developing problems).
If a Delay 1 is present, circle “Delay 1” and describe the delay on this line. If no Delay 1 is identified, circle
“not identified”.
Delay 2: Delay in reaching care (for example, a labouring woman may not be able to find or afford suitable
transport to a care facility).
If a Delay 2 is present, circle “Delay 2” and describe the delay on this line. If no Delay 2 is identified, circle “not
identified”.
Delay 3: Delay in receiving adequate care (for example, a labouring woman may arrive at a hospital without any
clinicians available to provide care to her, or transfer between lower and higher-level facilities may take too long to
provide effective care and prevent death).
If a Delay 3 is present, circle “Delay 3” and describe the delay on this line. If no Delay 3 is identified, circle “not
identified”.
9.2: Modifiable factors: This section relates to modifiable factors in terms of levels of system failure. These may be
helpful to identify interventions aimed at preventing future deaths.
Family-level related: Did the family of the pregnant woman who died not understand when to seek care? Should
families in their community be recipients of any educational campaign, or resources to get them to care sooner?
If a family-level modifiable factor is present, circle “family related” and describe the factor(s) next to “specify”. If no
family-level modifiable factor can be identified, circle “none identified”.
Administration-level related: Was transfer between lower and higher-level facilities inhibited by administrative barriers?
Was there a stock-out of any needed drugs or equipment?
If an administration-level modifiable factor is present, circle “administration related” and describe the factor(s) next
to “specify”. If no administration-level modifiable factor can be identified, circle “none identified”.
Provider-level related: Was a provider unable to give timely and adequate care? Is there a need for training or additional
resources for provider use?
If a provider-level modifiable factor is present, circle “provider related” and describe the factor(s) next to “specify”. If
no provider-level modifiable factor can be identified, circle “none identified”.
Comments on critical delays and avoidable factors:

This section is the least structured part of the form, but potentially the most important.
Participants in the maternal death review should work together to highlight the critical delays and avoidable factors
that can be targeted by interventions. It is particularly helpful to ask the question: “What if we could not say that any
individual (either the family member or any provider) was at fault? What could actually be done to prevent a critical
delay or avoidable factor?”
Provide any comments that the group can generate to address these critical delays and avoidable factors, attaching
additional pages as needed.
Adding a contact name for “form completed by” with contact information can be very helpful to future people reviewing
the forms.
Add the date on which the review was completed next to “Date”.
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Annex 12: Stillbirth and neonatal death case review form
1.1 ID # / Full name mother: ________________________________________________
1.2 ID # / Full name baby: __________________________________________________
1.3 Facility name: _______________________________________________________________________________
1.4 Type of care available: comprehensive EmOC basic EmOC first aid home delivery
1.5 District name: ______________________________________________________________________________
1.6 Referred not referred referred in from: _________________________________
referred out to: __________________________________
SECTION 2: PREGNANCY PROGRESS AND CARE
2.1 Obstetric history
Gravidity Parity Live births Deaths Stillbirths Neonatal Abortions
deaths
2.1a Previous cesareans (and date of most recent) none number: ________ date of most recent c/s:_______
2.1b Previous pregnancy complications none number and date:______ description :________________
2.2 Mother’s age ________ y
2.3 Mother’s education None Primary Secondary University
2.4 Marital status Single Married Widowed Divorced Separated
2.5 Contraception use just prior to Yes No If yes, what type (e.g. Pill, DMPA, Implant,
pregnancy IUD):_________________________________
2.6 Type of pregnancy singleton twin higher multiple = ______ unknown
2.7 Antenatal care number of visits 8+ 6–7 4–5 3 2 1 no visits unknown
Adjust as per local context
2.8 Malaria prophylaxis
not needed IPT3+ IPT2 IPT1 not received unknown
2.9 Tetanus toxoid vaccination TT2+ or PAB TT2 TT1 not received unknown
2.10 HIV status HIV-negative HIV-positive not done unknown
2.10.1 HIV-positive action HAART other, specify
2.11 Syphilis test negative syphilis-positive not done unknown
SECTION 3: LABOUR AND BIRTH
3.1 Mother’s LMP DD MM YYYY unknown
3.2 Date of birth DD MM YYYY
3.2.1. Time of birth: _____ : ____ h
3.3 Gestational age weeks unknown
3.3.1 Method of determination sure LMP dates unsure LMP dates
first trimester ultrasound other ultrasound
3.4 Place of childbirth facility home road other, specify unknown
3.4.1 Attendant at midwife nurse doctor other, specify no one unknown
childbirth
3.5 Onset of labour spontaneous induced c/s before onset unknown
3.6 Fetal heart sounds on admission no yes unknown
3.7 Partograph used no yes
3.8 Mode of childbirth CVD breech caesarean other, specify unknown
3.9 Time between action decision and birth n/a < 30 mins 30–60 min > 60 mins unknown
3.10 Apgar score 5 min = 6 or more 5 or less unknown
10 min = 6 or more 5 or less unknown
3.11 Resuscitation not needed bag + mask not done other, specify: ______________ unknown
3.12 Sex of baby male female unknown
3.13 Birth weight g ≥ 2500 g 1500–2499 g 1000–1499 g < 1000 g unknown
LBW VLBW ELBW
SECTION 4: DETAILS OF THE DEATH
4.1 Date of death DD MM YYYY
4.1.1 Time of death: _____ : ____ h
4.2 Type of death (circle one) neonatal intrapartum antepartum stillbirth,
death stillbirth stillbirth unknown timing
Main maternal condition followed by the
corresponding number. Use the reference
4.3 Main maternal condition none identified page to write in corresponding number
below. Include more than one if applicable.
4.4 Cause of death (circle one) M1 M2 M3 M4 M5 other unknown
a. congenital
e. infection Tetanus Sepsis Pneumonia Meningitis
Syphilis Diarrhoea Other, specify if known:
_____________________
f. other, specify: _____________________________

SECTION 5: CRITICAL DELAYS AND MODIFIABLE FACTORS
5.1 Critical delays delay 1 not identified 1. delay recognizing need for care: ___________________
delay 2 not identified 2. delay seeking care: ______________________________
delay 3 not identified 3. delay receiving care: ____________________________
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5.2 Modifiable factors
Family-related none identified specify: _________________________________________
e.g. late/no antenatal care; cultural inhibition to seeking care;
no knowledge of danger signs; financial constraints; partner
restricts care-seeking; use of traditional/ herbal medicine;
smoking / drug / alcohol abuse; attempted termination; etc.
Administration-related none identified specify: _________________________________________
e.g. neonatal facilities; theatre facilities; resuscitation
equipment; blood products; lack of training; insufficient staff
numbers; anaesthetic delay; no antenatal documentation; etc.
Provider-related none identified specify: _________________________________________
e.g. partogram not used; action not taken; inappropriate
action taken; iatrogenic childbirth; delay in referral; inadequate
monitoring; delay in calling for assistance; inappropriate
discharge; etc
other none identified specify: _________________________________________
Actions to address the critical delays and modifiable factors
Form completed by: ________________________ Date: ___________________________________________

c/s: caesarean section; CVD: cephalic vaginal childbirth; ELBW: extremely low birthweight; EmOC: emergency obstetric care;
HAART: highly active antiretroviral therapy; HIV: human immunodeficiency virus; IPT: intermittent preventive treatment;
LBW: low birthweight; LMP: last menstrual period; NVP: nevirapine prophylaxis; TT: tetanus toxoid; VLWB: very low birthweight
Annex 13: Instructions for completing the stillbirth and
neonatal death case review form
Purpose of form: To assist perinatal death review meetings/committees in reviewing a perinatal death,
to provide information about the death, and to identify critical delays and modifiable factors that can be
targeted with interventions to prevent future deaths. The form is designed so that the “normal” answers
appear on the left and the “abnormal” answers appear on the right, making it easier to visually identify
problem areas. The accompanying reference forms for maternal conditions according to ICD-PM should be
used alongside this form. Please see the WHO application of ICD-10 to deaths during the perinatal period:
(ICD-PM) for more detail.
Time of completion: during the perinatal death review meeting. Parts of the form may be copied from the set
of minimum perinatal indicators in advance of the meeting, if this has been completed as a stand-alone form.
1.1: ID# / Full name of mother: Include all ID numbers that are standardly used by your health-care facility.
If no standard ID numbers are used, write the mother’s name here.
1.2: ID# / Full name of baby: Include all ID numbers that are standardly used by your health-care facility.
If no standard ID numbers are used, put the baby’s name. If the baby has no name, put mother’s name
+ “boy” or “girl”. If there are multiple babies for the same mother, add “boy #1” or “girl #1” as needed.
1.3: Facility name: Put the name of the facility where the maternal death took place. If it is being reviewed
at a different facility, add “reviewed at facility: ____” to clarify.
1.4: Type of care available: Circle the type of care available at the time the mother presented for care.
Type of care is defined according to the World Health Organization classification of basic emergency
obstetric and newborn care (BEmONC) and comprehensive emergency obstetric and newborn care
(CEmONC), from Monitoring emergency obstetric care: a handbook, 2009.
To classify care as “basic”, it must provide all of seven essential interventions:
1) administer parenteral antibiotics
2) administer uterotonic drugs (i.e. parenteral oxytocin)
3) administer parenteral anticonvulsants for preeclampsia and eclampsia (i.e. magnesium sulfate)
4) manually remove the placenta
5) remove retained products of conception (e.g. manual vacuum extraction, dilation and curettage)
6) perform assisted vaginal childbirth (e.g. vacuum extraction, forceps childbirth)
7) perform basic neonatal resuscitation (e.g. with bag and mask).
To classify care as “comprehensive”, it must provide the seven essential interventions listed above and
the following additional interventions:
1) perform surgery (i.e. caesarean section)
2) perform blood transfusion.
1.5: District name: Put the name of the district where the facility at which the mother delivered is located.
This may not be the district that the mother is from.
1.6: Referred: Circle “not referred” if the woman presented from home.
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If the woman was referred from another hospital, health centre or clinic, write the name of that facility
on the line for “referred in from”.
If the woman was referred out to another hospital or other facility, but the name of that hospital or other
facility on the line for “referred out to”.
Section 2: Pregnancy progress and care

2.1: Obstetric history: For “gravidity”, put the total number of pregnancies the mother had. Include the
pregnancy being discussed. Pregnancies with twins or other multiples are counted as one pregnancy.
For “parity”, put the total number of births that the woman has had of babies of gestational age of 28
weeks. Some countries consider babies of gestational age of 22 weeks, so please adopt based on your
country’s national definition. Include the pregnancy being discussed. Deliveries of twins or other multiples
are counted as one childbirth.
For “live births”, put the number of living children of the mother. If both are living, twins are counted as
two living children.
For “dead”, put the number of deceased children of the mother. Include the fetus or neonate being
discussed. If both are dead, twins are counted as two deceased children.
For “stillbirths”, put the number of deceased babies before birth, among fetuses that are, by order
of priority, of at least 1000 g birthweight, and/or at least 28 weeks gestation, and at least 35 cm long,
depending on the country’s national definition.
For “neonatal deaths”, put the number of deaths after birth and within the first 28 days of life.
For “abortions”, put the total number of terminations of pregnancy for the mother, whether elective
or spontaneous.
2.1a: Previous caesareans: Write the number of caesarean section done along with the dates if any.
2.1b: Previous pregnancy complications: write the number of pregnancy complications, the date when
they happened, and under “description”, write what happened.
2.2: Mother’s age: Put the mother’s age in completed years. For example, a woman of 23 years and 10
months of age would be entered as “23”.
2.3 Mother’s education: Specify the level of education of the mother, whether she has a primary or
secondary level of school or higher, or whether she received no education.
2.4 Marital status: Specify her marital status (single and never married, married, widowed, divorced,
separated but married, or living in union, but not married and not single)
2.5: Contraception use just prior to pregnancy: Specify if the woman was using any family planning
method, and if so, which modern contraception method the woman was using.
2.6: Type of pregnancy. Circle the type of pregnancy being discussed:
• “singleton” if a pregnancy with one fetus;
• “twin” if a pregnancy with two fetuses;
• “higher multiple” if greater than two fetuses. If greater than two fetuses, put the number of fetuses
next to the equals sign;
• “unknown” if the total number of fetuses is/was not known.
2.7: Antenatal care number of visits: Circle the total number of antenatal care visits the mother had during
this pregnancy with the fetus or neonate being discussed.
2.8: Malaria prophylaxis: Circle the number of intermittent prophylactic treatments (IPT) for malaria that
the woman received during her pregnancy with the fetus or neonate being discussed.
• Circle “not needed” if malaria prophylaxis was not medically indicated due to lack of malaria in her
residence during pregnancy.
• Circle “IPT3+” if she received at least three treatments.
• Circle “IPT2” if she received only two treatments.
• Circle “IPT1” if she received only one treatment.
• Circle “not received” if she did not receive any IPT in an area where it is indicated.
2.9: Tetanus toxoid vaccination: Circle the number of tetanus toxoid (TT) doses that the woman received
during her pregnancy or whether she was protected at birth (“PAB”) through vaccinations during
childhood or during previous pregnancies.
2.10: HIV status: Indicate the mother’s HIV status.
• Circle “HIV negative” if the woman was tested and found to be negative.
• Circle “HIV positive” if the woman was tested and found to be positive, or was known to be positive
prior to pregnancy (and proceed to 2.71 below).
• Circle “not done” if no HIV testing was performed during pregnancy.
• Circle “unknown” if the HIV status and testing status are unknown.
2.10.1: If the woman was found to be HIV positive or known to be HIV positive prior to pregnancy,
indicate what action was taken:
• Circle “HAART” if the woman received highly active antiretroviral treatment during her pregnancy.
• Next to “other”, write if:
– any additional treatment was received for HIV or its complications
– no treatment was received
– treatment was received but the type is unknown.
Do not complete line 2.10.1 for any woman who was not known to be HIV positive.
2.11: Syphilis test: Indicate the mother’s syphilis status
• Circle “negative” if the woman was tested for syphilis and found to be negative.
• Circle “syphilis-positive” if the mother was tested and found to be positive.
• Circle “not done” if no syphilis testing was performed during pregnancy.
• Circle “unknown” if the syphilis status and testing status are unknown.
Section 3: Labour and birth

3.1: Mother’s LMP: Enter the date of the mother’s last menstrual period (LMP) here. Choose LMP to
record in this order:
1) If there is an LMP in line with first trimester ultrasound, enter this LMP.
2) If there is no LMP in line with first trimester ultrasound, enter the estimated LMP according to the
mother’s recollection.
3) Do not enter LMP based on third trimester ultrasound or estimated by size at childbirth.
Annexes 99
4) If there is no LMP by ultrasound or mother’s recollection, circle “unknown”.
3.2: Date of birth: record the date and time of birth here, whether live or stillborn
3.3: Gestational age: enter gestational age in weeks and days at the time of birth (live or stillbirth), using
the LMP. If there is no gestational age calculated, circle “unknown”.
3.3.1 Circle the method by which this gestational age was calculated. This should be the same method as
was used to derive LMP. Additionally, circle “sure” or “unsure” LMP dates based on mother’s certainty.
If mother’s certainty is not stated, circle “sure”.
3.4: Place of childbirth: Circle the place of childbirth. If childbirth was at a facility, enter the facility’s name
on this line. 3.4.1 Attendant at childbirth:
• Circle “midwife” if childbirth was attended by a trained midwife.
• Circle “doctor” if childbirth was attended by a physician.
• Circle “nurse” if childbirth was attended by a trained skilled birth attendant.
• Write in “other” if childbirth was attended by someone else.
• Circle “unknown” if childbirth attendant is not known.
3.5: Onset of labour: Circle if onset was spontaneous, induced or if baby was delivered by caesarean
section before onset of labour.
3.6: Fetal heart sounds on admission: If fetal heart sounds (fetal heart tones) were auscultated on
admission and were not present, circle “no”. If fetal heart sounds (fetal heart tones) were auscultated
on admission and were present, circle “yes”. If fetal heart sounds were not auscultated on admission,
or if this information is not available, circle “unknown”.
3.7: Partograph used: Circle whether or not a partograph was used during childbirth, or “unknown” if
this information is not available. If a partograph was used during childbirth, write any relevant additional
comments next to “yes”. For example, write “incomplete” if it was used for only a portion of childbirth,
or does not include all standard information on a partograph.
3.8: Mode of childbirth: Circle the mode of childbirth of the fetus or neonate being discussed. Circle
“CVD” for cephalic vaginal childbirth, or “breech” if a breech vaginal childbirth, or “caesarean” if this
was the case, or “other” if none of these (and describe other complications, e.g. shoulder dystocia on
the line), or “unknown” if this information is not available.
3.9: Time between action decision and birth: If mode of childbirth was anything other than “CVD”, circle
the time from the decision to proceed with this form of childbirth and the childbirth itself. If childbirth
was “CVD”, circle “not applicable”.
3.10: Apgar score: Record the Apgar scores at 1 and at 5 minutes. Next to these, circle “6 or more” or “5
or less” as indicated by the score. If either of these scores is not available, circle “unknown” for that score.
3.11: Resuscitation:
• Circle “not needed” if not indicated by Apgar scores or clinical state.
• Circle “bag + mask” if performed.
• Circle “none” if resuscitation was indicated but not performed.
• Circle “other” and record if the following forms of resuscitation were performed:
– stimulation
– suction
– intubation
– CPR
– other forms of resuscitation (record).
3.12: Sex of baby: Circle “male”, “female” or “unknown” as indicated.
3.13: Birthweight: Record the total birthweight, and circle the appropriate category of birthweight. The
acronyms stand for:
• Low birthweight (LBW), < 2500 g
• Very low birthweight (VLBW), < 1500 g
• Extremely low birthweight (ELBW), < 1000 g.
Section 4: Details of death

4.1 and 4.1.1: Record the date and time of death.
4.2: Type of death: Circle the type of death:
• “Neonatal death” is the death of a baby born alive, but who died within the first 28 days of life.
• “Intrapartum stillbirth” is the death of a fetus who was alive at the onset of labour, but who died
before childbirth.
– This can be determined by the presence of fetal heart sounds (fetal heart tones) on admission or
prior to childbirth, or, by the appearance of a “fresh” stillbirth (intact skin and fetus on childbirth).
Examination of fetal remains for signs of skin deterioration, skin or umbilical cord staining due to darkened
amniotic fluid, or skull softening can assist in determining whether the fetus died more than 12 hours
prior to childbirth (macerated stillbirth), or less than 12 hours (fresh).
• “Antepartum stillbirth” is the death of a fetus before the onset of labour.
– This can be determined by the “macerated” appearance of the fetus upon childbirth, in combination
with absence of fetal heart sounds on admission.
○ Absence of fetal heart sounds on admission does not necessarily indicate an antepartum
stillbirth, if the mother was admitted with labour already in progress.

○ Presence of fetal heart sounds on admission of a labouring woman does exclude the possibility
of an antepartum stillbirth.
• “Stillbirth, unknown timing” should be circled if it is not possible to tell the time of death of the fetus.
Note the potential for misclassification between antepartum and intrapartum stillbirths and the importance
of stillbirth timing on the implications for quality of care.
4.3: Main maternal condition: Enter the name of the main maternal condition found on the maternal
conditions reference page according to ICD-PM guidance. Please see the WHO application of ICD-10 to
deaths during the perinatal period: (ICD-PM) for more detail.
4.4: Cause of death: Identify the relevant cause of stillbirth or neonatal death. For infections, circle the most
appropriate response. After choosing a main cause of stillbirth or neonatal death, indicate the maternal
condition in the relevant M1–M5 category, using the numbers provided on the accompanying reference
page according to ICD-PM guidance. If the mother was healthy, enter 1 in the M5 column corresponding
to the cause of stillbirth or neonatal death.
Section 5: Critical delays and modifiable factors

5.1: Critical delays: Circle any delays in care that are recognized in review of the case.
Annexes 101
Delay 1: Delay in the decision to seek care. (For example, a woman may labour at home for too long
because she and/or her family are afraid to come for care, are concerned about the cost of care, or do
not recognize developing problems).
If a Delay 1 is present, circle “Delay 1” and describe the delay on this line. If no Delay 1 is identified, circle
“not identified”.
Delay 2: Delay in reaching care. (For example, a labouring woman may not be able to find or afford
suitable transport to a care facility).
If a Delay 2 is present, circle “Delay 2” and describe the delay on this line. If no Delay 2 is identified,
circle “not identified”.
Delay 3: Delay in receiving adequate care. (For example, a labouring woman may arrive at a hospital
without any clinicians available to provide any care to her, or transfer between lower and higher-level
facilities may take too long to provide effective care and prevent death).
If a Delay 3 is present, circle “Delay 3” and describe the delay on this line. If no Delay 3 is identified,
circle “not identified”.
5.2: Modifiable factors: This section relates to modifiable factors in terms of levels of system failure.
These may be helpful to identify interventions aimed at preventing future deaths.
Family-level related: Did the family of the pregnant woman who died not understand when to seek care?
Should families in their community be recipients of any educational campaign, or resources to get them
to care sooner?
If a family-level modifiable factor is present, circle “family related” and describe the factor(s) next to
“specify”. If no family-level modifiable factor can be identified, circle “none identified”.
Administration-level related: Was transfer between lower and higher-level facilities inhibited by
administrative barriers? Was there a stock-out of any needed drugs or equipment?
If an administration-level modifiable factor is present, circle “administration related” and describe the
factor(s) next to “specify”. If no administration-level modifiable factor can be identified, circle “none
identified”.
Provider-level related: Was a provider unable to give timely and adequate care? Is there a need for training
or additional resources for provider use?
If a provider-level modifiable factor is present, circle “provider related” and describe the factor(s) next to
“specify”. If no provider-level modifiable factor can be identified, circle “none identified”.
Comments on critical delays and avoidable factors:

This section is the least structured part of the form, but potentially the most important.
Participants in the perinatal death review should work together to highlight the critical delays and avoidable
factors that can be targeted by interventions. It is particularly helpful to ask the question: “What if we
could not say that any individual (either the mother or any provider) was at fault? What could actually be
done to prevent a critical delay or avoidable factor?”
Provide any comments that the group can generate to address these critical delays and avoidable factors,
attaching additional pages as needed.
Adding a contact name for “form completed by” with contact information can be very helpful to future
people reviewing the forms.
Add the date on which the review was completed next to “Date”.
Annex 14: Minimum perinatal data set
The minimum perinatal data set is a core set of data elements for mandatory collection on every birth and
death. There should be an agreement to collect uniform data across all sites involved in data collection
and to supply it as part of the national collection. However, this does not preclude providers from facilities
from collecting additional data to meet their own specific needs. The following data elements have been
proposed as the minimum, which all facilities should collect and report to national level:
• mother’s obstetric history (gravida, parity)
• mother’s medical history
• mother’s age
• single or multiple pregnancy
• antenatal care history (number of visits)
• HIV status
• gestational age (and method of determination)
• place of childbirth
• date and time of birth
• attendant at childbirth
• mode of childbirth
• sex of baby
• birthweight
• date and time of death (if applicable)
• type of death (antepartum stillbirth, intrapartum stillbirth, neonatal death)
• cause of death using ICD-10/11 or ICD-PM.
Annexes 103
Annex 15: MPDSR monitoring framework
Purpose of the Monitoring Framework
This Monitoring Framework provides basic guidance on how Maternal and Perinatal Deaths Surveillance
and Response (MPDSR) is being implemented, based on MPDSR principles as outlined in the Maternal
death surveillance and response technical guidance and Making every baby count.
The indicators within this monitoring framework are based on the following MPDSR principles:
• maternal and perinatal deaths as notifiable events
• timely review committee meetings
• data quality
• implementation of recommendations
The following indicators are needed to monitor an MPDSR programme:

• record each maternal and perinatal death as a notifiable event
• conduct timely MPDSR steering committee meetings to review the information on the deaths at all
levels
• ensure data quality
• identify causes of deaths and modifiable factors
• make recommendations for interventions to reduce deaths
• implement recommendations
• monitor the progress and the effect/impact of recommendation implementation and adjust where
necessary
The purpose of this Monitoring Framework is to provide a conceptual framework for monitoring MPDSR
programmes rather than prescriptive instructions.Each country has an existing data and monitoring
system and its monitoring needs will vary depending on the national context.4
There are several levels to the monitoring system including facility level, district/regional level, national
level, and global level (common/core indicators (see Table 1). For each level of the monitoring system,
there are specific indicators to measure output, outcome and impact indicators. The specific indicators
each programme uses will vary depending on the data needs, as well as local context, resources and
priorities. For the first three levels (facility, district/regional and national levels), indicators will vary
depending on programme priorities. For this reason, a catalogue of suggested indicators by level is
provided in Annex 17. At global level, we propose a standardized set of common/ core indicators to
track progress across all countries. These standardized indicators are shown in Annex 16 and represent
a small number of standardized indicators for monitoring all MPDSR programmes. We also propose a
list of indicators that require additional testing.
4
The development of this Monitoring Framework was guided by other monitoring frameworks, including the UNFPA Maternal
and Newborn Health Thematic Fund, the WHO Framework for Quality of Care for Maternal and Newborn Health, the WHO
Indicator and Monitoring Framework for the Global Strategy for Women’s, Children’s and Adolescents’ Health, and the WHO
100 core indicators. The Monitoring Framework was reviewed by the Global MPDSR Technical Working Group.
Monitoring components
This Monitoring Framework outlines five key levels:
1. Health facility indicators – to support facility leadership and coordination functions for monitoring
MPDSR activities and improving quality of care in facilities.
2. District/regional indicators – to support district/regional leadership and coordination functions for
improving and sustaining MPDSR activities at district/regional level.
3. National indicators – to support national leadership and coordination functions for improving and
sustaining MPDSR activities in the country.
4. Common/Core indicators – to provide a common set of standardized indicators for monitoring
country performance and for facilitating learning and sharing across countries implementing MPDSR.
5. Indicators that require additional testing – to provide a list of indicators that require further testing
and research.
Measurement methods and data sources

The data sources for the indicators at each level of the health system will vary depending on the available
health information and data systems. Data will be collected using routine, local measurement methods and
documentation of MPDSR activities as well as routine systems such as health management information
systems (HMIS) and others. Each measurement and data source has inherent strengths and weaknesses
that will need to be considered as countries define an optimal and feasible monitoring framework for their
national context. The data sources that may contribute to calculation of this Monitoring Framework’s
indicators include, but are not limited to:
Routine data sources:

• Patient records/facility registers. These provide detailed information on patient demographics, care
received and health outcomes.
• Data aggregated within Health Management Information Systems (HMIS) or District Health
Management Information System 2 (DHIS2). Selected data from facility registers are typically
aggregated in HMIS (and DHIS2 in some countries). To varying degrees, HMIS can provide routine
(e.g. monthly) information on service utilization, treatment of maternal and perinatal complications,
number and causes of death, and case fatality rate.
• Civil registration and vital statistics. These systems provide data on mortality and population-based
denominators used to calculate rates and proportions.
• Human resources and staff training. The placement, availability and training of health staff are often
routinely tracked at facility, district and/or national levels in human resource information systems.
• Logistics management information systems (LMIS) and supply chain management. The availability,
distribution and quantity of medicines, commodities and medical supplies are often routinely tracked
in LMIS and other supply chain management systems from central warehousing to service delivery
points, such as health facilities.
Other data collection sources:

Community surveys/verbal & social autopsies. These provide detailed information on deaths that occur
outside of health facilities, including the care received, care-seeking behaviours, and health outcomes.
Annexes 105
Documentation of MPDSR activities:
Death case summary reports. These provide a summary of causes and contributing factors for of every
notified maternal and perinatal death.
Review committee meeting records. These provide information on review committee activities, including
meeting schedules, minutes, attendance and membership, and audit reports, recommendations and
implementation of recommendations.
Quality review reports. These reports by the quality improvement team(s) provide information
on the quality of the reports at different levels of the health system, including the quality of MPDSR
implementation and MPDSR monitoring activities.
Common/core indicators
Annex 16 presents a list of standardized global indicators to facilitate learning across countries
implementing MPDSR. These indicators were selected based on the following criteria:
• relevant and useful for most MPDSR stakeholders;
• aligned to the extent possible with standardized global MNH indicators (Every Woman Every Child,
Ending Preventable Maternal Mortality (EPMM), Every Newborn Action Plan (ENAP), WHO 100 core
indicators) and with data currently being collected by partners;
• clearly provide information regarding whether (or not) health outcomes, care processes or inputs
are improving.
These common/core indicators should be collected by all programmes at all levels of implementing
MPDSR, in an effort to better track implementation across programmes for both national and
global level.
Output • % of countries with functional national MPDSR steering committee

• % of countries with functional district/regional MPDSR steering
committees
• % of countries with annual report
• % of countries with national policy/guideline on MPDSR
• % of recommendations implemented in last year, by level
Outcome • % of expected maternal/perinatal deaths notified to MPDSR system

• % of expected maternal/perinatal deaths reviewed by MPDSR steering
committee
Impact • Institutional maternal mortality ratio

• Institutional perinatal mortality rate
• Maternal mortality ratio*
• Perinatal mortality rate*
• Number of maternal deaths by cause, ICM-MM5
• Number of perinatal deaths by cause, ICD-PM6
* This indicator can only be reported if MPDSR system includes both facility and community deaths
5
WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD-Maternal Mortality (ICD-MM)
6
WHO Application of ICD-10 to perinatal deaths: ICD-Perinatal Mortality (ICD-PM)
Indicator catalogue
To help district and facility managers prioritize indicators for monitoring, the Monitoring Framework
includes a streamlined set of indicators as an indicator catalogue (summarized in Annex 17). The indicator
catalogue categorizes indicators by type (output, outcome and impact) and specifies potential data
sources for each indicator to help stakeholders design their monitoring framework. The catalogue further
describes the purpose, measurement and calculation, source of information, frequency of data collection,
and target for each indicator Generally, the data for the indicators in the catalogue will be collected by
district managers and/or health staff that work in facilities.
The selection of these indicators and frequency of data collection will vary according to countries’
policies and resources. It not intended that all these indicators should be selected. Rather, national-,
district- and facility-level managers should select indicators that are most relevant for the issues being
addressed in their programmes, on the basis of what is possible within their information systems.
Certain data collection methods, such as forms and templates, can be adapted from the MPDSR
implementation tools and appendices. Facilities, districts/regions and countries are encouraged to identify
and communicate gaps in data collection and sources, with the aim of strengthening their health data
systems through MPDSR.
• Inputs: include what needs to be in place to conduct quality MPDSR activities.
• Outputs: includes actual MPDSR activities, e.g., reviews, meetings, improvement plans
• Outcomes: include the process of arriving at the desired results and activities and their effects on the
MPDSR system.
• Impact: includes the overall impact of the MPDSR system on maternal and perinatal mortality.
Indicators that require further testing

This list of indicators includes those that are currently being tested. These are listed in Annex 17.
Evaluation of MPDSR
The purpose of this document is to provide guidance on routine monitoring of MPDSR. However, it is
also essential to evaluate the MPDSR system, especially if the routine monitoring indicators demonstrate
that: 1) one or more of the steps in the MPDSR process is not reaching expected targets; or 2) maternal
and/or perinatal mortality is not decreasing. A more detailed evaluation can also be used to assess
whether the system could function more efficiently and effectively.
There is a standard set of criteria for evaluating surveillance systems such as the MPDSR. Attributes that
are particularly important to evaluate for MPDSR include acceptability, timeliness, data quality and stability.
Criterion Definition
Acceptability Willingness of persons and organizations to participate in the MPDSR system.
Timeliness Time between any two steps in the MPDSR process. The relative importance of
timeliness of process intervals varies by MPDSR objective and health event .
Data quality Completeness and validity of data in the surveillance system.
Stability Ability to collect, manage and provide data without failure (reliability) and to be
operational when needed (availability).
Annexes 107
Annex 16: Common/Core measures for monitoring MPDSR
across countries
These indicators should be collected from all countries at health facility, district/regional, and national levels.
Output • % of countries with functional national MPDSR steering committee

• % of countries with functional district/regional MPDSR steering committees
• % of countries with annual report
• % of recommendations implemented in last year, by level
Outcome • % of expected maternal/perinatal deaths notified to MPDSR system

• % of expected maternal/perinatal deaths reviewed by MPDSR steering committee
Impact • Institutional maternal mortality ratio

• Institutional perinatal mortality rate
• Maternal mortality ratio*
• Perinatal mortality rate*
• Number of maternal deaths by cause, ICM-MM
• Number of perinatal deaths by cause, ICD-PM
* This indicator can only be reported if MPDSR system includes both facility and community deaths
Annex 17: Indicator catalogue for monitoring MPDSR at health facility, district/regional and
national levels
It is not intended that ALL these indicators should be collected. Rather, national-, district- and facility-level managers should select indicators that are most relevant
for the issues being addressed in their programmes, on the basis of what is possible within their information systems at different levels of the health care system.
Please refer to the resources in this document for sources of information.
HEALTH FACILITY MEASURES

Frequency of
Source of data collection,
Indicator Purpose Numerator Denominator information target Reference Remarks/notes
OUTPUTS
Functional interdisciplinary review committee
Proportion of planned Measures the Number of planned Number of Minutes Quarterly, 100%
steering committee practice and steering committee steering committee of steering
meetings conducted capacity to perform meetings conducted meetings planned committee
facility-level reviews meetings,
number of
usual meeting
frequency
Proportion of timely7 Measures the Number of timely Number of Schedule Quarterly, >90% MDSR Technical
steering committee timeliness of case steering committee steering committee of steering Guide
meetings conducted reviews at facility meetings conducted meetings committee
level conducted meetings
Proportion of steering Measures the Number of steering Number of Attendance list Quarterly, 100% MDSR Technical
committee meetings practice of effective committee meetings steering committee with cadres Guide
which include health facility which include all meetings of steering
interdisciplinary teams reviews involving interdisciplinary conducted committee
(OB/GYN, nurse, all actors in facility teams meetings
midwife, pediatrician, working together
others)
Annexes
7
Timely – immediately after death or within one month of death
109
110
Frequency of
Proportion of steering Measures the Number of steering Number of Attendance list Quarterly, 100% MDSR Technical
committee meetings linkage of MPDSR committee meetings steering committee with cadres Guide
which include quality to QI and other which include QI meetings of steering
improvement (QI) programs teams conducted committee
teams meetings
Proportion of maternal/ Measures use of Number of maternal/ Number of Minutes Annually, 100% MDSR technical
perinatal reviews MPDSR data for perinatal reviews maternal/perinatal steering guide
that include SMART likely potential to that include SMART reviews conducted committee
recommendations improve quality of recommendations meetings UNFPA
care
Proportion of Measures the Number of Number of Minutes Quarterly, >80% MDSR technical
recommendations response and recommendations recommendations steering guide
implemented implementation of implemented or reported committee
recommendations show evidence of meetings, case UNFPA
implementation summary forms
OUTCOMES
Maternal and perinatal deaths notified and reviewed
Proportion of maternal Measures reporting Number of maternal Number of Minutes Quarterly, 100% ENAP
deaths notified8 of data at facility deaths notified maternal deaths at steering
through MPDSR level through MPDSR facility committee UNFPA MDSR
system meetings, Technical
case summary Guidance
forms,
notification
forms, HMIS
8
Notified to be defined after UNFPA review of their data
Frequency of
Proportion of perinatal Measures reporting Number of perinatal Number of Minutes Quarterly, 100%
deaths notified2 of data at facility deaths notified perinatal deaths at steering
through MPDSR level through MPDSR facility committee
system meetings,
case summary
forms,
notification
forms, HMIS
Proportion of maternal Measures the Number of maternal Number of Minutes Quarterly, 100% ENAP
deaths notified through performance of the deaths notified maternal deaths steering
MPDSR that are MPDSR system to through MPDSR that notified through committee QED
reviewed at steering review all maternal are reviewed MPDSR meetings, UNFPA
committee meetings deaths case summary
forms, HMIS
Proportion of perinatal Measures the Number of perinatal Number of Minutes Quarterly ENAP
deaths reviewed at performance of the deaths that are perinatal deaths steering
steering committee MPDSR system to reviewed committee QED
meetings review perinatal meetings,
deaths case summary
forms, HMIS
IMPACT
Number of maternal Measures the Number of maternal n/a Minutes Quarterly ENAP
deaths, by cause number of deaths, by cause steering
(ICD-MM) maternal deaths committee QED
and completeness meetings, WHO 100 Core
of MPDSR case summary EPMM,
forms, CRVS
Annexes
111
112
Frequency of
Number of deliveries/ Measures the Number of deliveries/ n/a Health facility Quarterly
total births number of total births records,
deliveries/total summary
births forms, CRVS,
HMIS
Number of perinatal Measures the Number of perinatal n/a Minutes Quarterly ENAP
deaths, by cause number of deaths, by cause steering
(ICD-PM) maternal deaths committee QED
and completeness meetings,
of MPDSR case summary
forms, CRVS,
HMIS
Number of stillbirths Measures results Number of stillbirths9 n/a Health facility Quarterly GS Disaggregate
and enables records, by macerated/
tracking of progress summary antepartum
forms, labour and fresh/
and delivery intrapartum as
registers, CRVS, feasible
HMIS
Number of early Measures the Number of early n/a Minutes Quarterly
neonatal deaths number of early neonatal deaths steering
(0–7 days) neonatal deaths (0–7 days) committee
meetings,
case summary
forms, CRVS
9
A stillbirth or fetal death is defined as a baby born with no signs of life after a given threshold; for international comparison, WHO defines stillbirth as birthweight of 1000 g or more, if the
birthweight is not available, a gestational age of 28 weeks or more or a length of 35 cm or more (ICD-10). However, countries may use different cut-offs for stillbirth, and the national definition
should be used if applicable.
Frequency of
Case fatality rate – Measures the Number of women Number of Case records Quarterly, <1% ENAP
maternal effects of MPDSR with named obstetric women with
program conditions admitted named obstetric QED
to health facility who conditions
died admitted to health
facility
DISTRICT/REGIONAL MEASURES
Frequency of
OUTPUTS
Trained staff
Proportion of health Measures capacity Number of health Number of health Health facility Annually MDSR Minimum number of
facilities with trained of facilities to facilities with facilities reports, Technical staff needed for each
staff in MPDSR10 carry out MPDSR adequately trained interviews Guide facility will depend
functions staff in MPDSR on the capacity and
size of each facility.
Details on “adequate”
will be defined at
country level.
Annexes
10
Trained staff “staff who have completed training in MPDSR in the last five years
113
114
Frequency of
Functional review committee
Proportion of planned Measures the Number of planned Number of Minutes At least
district/regional practice and district/regional planned district/ of steering quarterly, 100%
review steering capacity to perform review steering regional review committee
committee meetings reviews committee meetings steering committee meetings,
conducted conducted meetings scheduled
of planned
meetings
Proportion of district/ Measures the Number of steering Number of Attendance Quarterly, 100% MDSR
regional steering practice of effective committee meetings steering committee list with Technical
committee meetings health facility which include all meetings conducted cadres of Guide
which include reviews involving interdisciplinary steering
interdisciplinary all actors in facility teams committee
teams (OB/GYN, working together meetings
nurse, midwife,
pediatrician, others)
Proportion of district/ Measures the Number of steering Number of Attendance Quarterly, 100% MDSR
regional steering linkage of MPDSR committee meetings steering committee list with Technical
committee meetings to QI and other which include QI meetings conducted cadres of Guide
which include quality programs teams steering
improvement (QI) committee
teams meetings
Data forms, completeness
Proportion of Measures reporting Number of health Number of health Health facility Annually, 95% QED
health facilities with of data with detailed facilities with facilities submitting forms,
complete registers/ and accurate complete registers/ registers/forms
forms or case information to use forms, case
summaries for reviews summaries
Proportion of SMART Measures the Number of Number of Minutes Semi-annually, MDSR
recommendations response and recommendations recommendations steering >80% technical
implemented implementation of implemented at at district/regional committee guide
recommendations district/regional level level meetings
UNFPA
Frequency of
OUTCOMES
Maternal and perinatal deaths notified and reviewed
Proportion of health Measures reporting Number of health Number of health Steering Quarterly, 100%
facilities reporting of data at facility facilities reporting facilities committee
maternal deaths level maternal deaths meeting
through MPDSR through MPDSR minutes
Proportion of health Measures reporting Number of health Number of health Steering Quarterly, 100%
facilities reporting of data at facility facilities reporting facilities committee
perinatal deaths level perinatal deaths meeting
through MPDSR through MPDSR minutes
Number of maternal Measures reporting Number of maternal n/a Steering Quarterly, 100% ENAP
deaths notified of data at facility deaths notified committee
through MPDSR level through MPDSR meeting UNFPA
minutes
Number of perinatal Measures reporting Number of perinatal n/a Steering Quarterly, 100% ENAP
deaths notified of data at facility deaths notified committee
through MPDSR level through MPDSR meeting UNFPA
minutes
Proportion of Measures the Number of maternal Number of maternal Steering Quarterly, 100% ENAP
maternal deaths performance of the deaths notified deaths notified committee
notified through MPDSR system to through MPDSR that through MPDSR meeting QED
MPDSR that are review all maternal are reviewed minutes UNFPA
reviewed at district/ deaths
regional level
Proportion of Measures the Number of perinatal Number of perinatal Steering Quarterly ENAP
perinatal deaths performance of the deaths that are deaths notified committee
reviewed at district/ MPDSR system to reviewed through MPDSR meeting QED
regional level review perinatal minutes
deaths
Annexes
115
116
Frequency of
IMPACT
Number of maternal Measures the Number of maternal n/a Minutes Quarterly ENAP
deaths, by cause number of maternal deaths, by cause steering
(ICD-MM) deaths and committee QED (WHO
completeness of meetings, 100 Core,
MPDSR case EPMM,
summary
forms, CRVS
Number of deliveries/ Measures the Number of deliveries/ n/a Health facility Quarterly
total births number of total births records,
deliveries/total summary
births forms, CRVS
Number of perinatal Measures the Number of perinatal n/a Minutes Quarterly ENAP
deaths, by cause number of maternal deaths, by cause steering
(ICD-PM) deaths and committee QED
completeness of meetings,
MPDSR case
summary
forms, CRVS
Number of early Measures the Number of early n/a Minutes Quarterly
neonatal deaths number of early neonatal deaths steering
(0–7 days), by cause neonatal deaths and (0–7 days) committee
(ICD-PM) completeness of meetings,
MPDSR case
summary
forms, CRVS
Frequency of
Institutional stillbirth Measures results Number of stillbirths Total facility births, Health facility Quarterly Disaggregate
rate and enables tracking delivered in facility per 1,000 records, by macerated/
of progress towards summary antepartum and
global goals, and forms, labour fresh/intrapartum as
captures integration and delivery feasible
(maternal and registers,
perinatal) of CRVS
MPDSR
Institutional maternal Measures the Number of maternal Number of Health facility Annually ENAP
mortality ratio effects of MPDSR deaths in health deliveries in health records,
program facilities facilities (per summary QED (WHO
100,000 deliveries) forms, CRVS 100 Core,
EPMM,
Institutional perinatal Measures the Number of perinatal Number of total Health facility Annually ENAP
mortality rate effects of MPDSR deaths in health births in health records,
program facility facility (per 1,000 summary
total births) forms, CRVS
Annexes
117
118
NATIONAL MEASURES
Frequency
of data
Source of collection,
OUTPUTS
Policy for maternal and perinatal death notification and review
National policy Measures the national National policy or n/a National policy, Annually, MDSR
or guideline on policy on maternal guideline in place WHO Policy yes technical
maternal death a death notification for notification of all Survey guide
notifiable event11 maternal deaths
UNFPA
National policy Measures the national National policy or n/a National policy, Annually, MDSR
on reviewing all policy on maternal guideline in place for WHO Policy yes technical
maternal deaths death review review of all maternal Survey guide
deaths
National policy on Measures the national National policy or n/a National policy, Yes
reviewing perinatal policy on perinatal guideline in place for WHO Policy
deaths12 death review review of perinatal Survey
deaths
Functional national MPDSR committee
Proportion of Measures the practice Number of planned Number of Minutes At least
planned national and capacity to perform national review planned national of steering annually,
review steering reviews steering committee review steering committee 100%
committee meetings conducted committee meetings,
meetings meetings scheduled of
conducted planned meetings
11
Notification should occur within 24 hours for facility-based deaths and 48 hours for community-based deaths.
12
Policy can include review of all perinatal deaths or a proportion of perinatal deaths.
Frequency
of data
Evidence of Measures the capacity National MPDSR n/a National- Annually, MDSR
national MPDSR for leadership and coordinator level staff yes Technical
coordinator guidance in MPDSR appointments Guide
QED
Annual report developed
Completion of Measures Annual report n/a Annual report Annually, UNFPA
national annual dissemination of developed and yes
MPDSR report maternal and perinatal published including QED
mortality data and performance of the UNFPA
implementation of MPDSR programme,
recommendations description of
implementation of
recommendations,
and follow up on
recommendations
from previous year
Implementation of recommendations
Proportion of Measures the response Number of Number of Implementation Semi- MDSR
recommendations and implementation of recommendations recommendations plans and records annually, Technical
implemented at the recommendations implemented at the reported at the >80% Guide
national level national level national level
Evidence of Measures integration Recommendations n/a Annual health Annually, MDSR
integration of of recommendations at from MPDSR plans and health- yes Technical
recommendations the national level and reviews included in system packages Guide
within annual coordination of health annual health plans
health plans and systems and policies and health-system
health-system packages
packages
Annexes
119
120
Frequency
of data
Linkages with routine data systems
Proportion of Measures the practice Number of reported Number of CRVS reports Annually, QED This is defined as
maternal deaths and capacity of the maternal deaths reported maternal 100% deaths included
identified in CRVS system identified in MPDSR deaths identified in in both MPDSR
MPDSR included in incorporated into MPDSR system and CRVS
CRVS CRVS
Proportion of Measures the practice Number of reported Number of CRVS reports Annually, QED This is defined as
perinatal deaths and capacity of the perinatal deaths reported perinatal 100% deaths included
identified in CRVS system identified in MPDSR deaths identified in in both MPDSR
MPDSR included in incorporated into MPDSR system and CRVS
CRVS CRVS
Proportion of Measures the practice Number of reported Number of HMIS, routine Annually, This is defined as
maternal deaths and capacity of a maternal deaths reported maternal data systems 100% deaths included
reported in health national reporting identified in MPDSR deaths identified in in both MPDSR
management system incorporated in MPDSR system and HMIS
information system health management
information system
Proportion of Measures the practice Number of reported Number of HMIS, routine Annually, This is defined as
perinatal deaths and capacity of a perinatal deaths reported perinatal data systems 100% deaths included
reported in health national reporting identified in MPDSR deaths identified in in both MPDSR
management system incorporated in MPDSR system and HMIS
information system health management
information system
OUTCOMES
Proportion of Measures the Number of maternal Estimated number MPDSR annual Annually, UNFPA
expected maternal performance of the deaths notified to the of maternal deaths report, MMEIG 100%
deaths that are MDSR system at MoH through the for previous year estimates
notified through population level to MPDSR system in
MPDSR program in ensure that all maternal the previous year
the previous year deaths are notified
Frequency
of data
Proportion of Measures the Number of maternal Estimated number MPDSR annual Annually, CARMMA
maternal deaths performance of MDSR deaths reviewed in of maternal deaths report, MMEIG 100% scorecard
reviewed in the system at population the last year for previous year estimates
country in the level
previous year
IMPACT
Institutional Measures the effects of Number of maternal Number of Health facility Annually ENAP
maternal mortality MPDSR program deaths in health deliveries in health records,
ratio facilities facilities (per summary forms, QED (WHO
100,000 deliveries) CRVS 100 Core,
EPMM
Institutional Measures the effects of Number of perinatal Number of total Health facility Annually ENAP
perinatal mortality MPDSR program deaths in health births in health records,
rate facilities facilities (per 1000 summary forms,
total births) CRVS
Maternal mortality Measures the effects of Number of maternal Number of live Health facility Annually This indicator can
ratio MPDSR program deaths (facility births (per 100,000 records, only be reported
and community) live births) summary forms, in MPDSR system
CRVS includes facility and
community deaths
Perinatal mortality Measures the effects of Number of perinatal Number of total Health facility Annually This indicator can
rate MPDSR program deaths (facility births (per 1000 records, only be reported
and community) total births) summary forms, in MPDSR system
CRVS includes facility and
community deaths
Maternal deaths by Measures the effects of Number of maternal MPDSR annual Annually ENAP
cause (ICD-MM) MPDSR program deaths by cause report, CRVS
QED
Perinatal deaths by Measures the effects of Number of perinatal MPDSR annual Annually ENAP
Annexes
cause (ICD-PM) MPDSR program deaths by cause report, CRVS

QED
121
122
INDICATORS THAT REQUIRE ADDITIONAL TESTING

Source of Frequency of data

Indicator Purpose Numerator Denominator information collection, target Reference Remarks/ Notes
Implementation Measures the The four components of n/a MPDSR Annually UNFPA
of four main implementation of MPDSR are implemented program reports;
components of MPDSR at national level: 1) National WHO Policy
MPDSR guidelines and tools for Survey
MPDSR; 2) National policy
to notify all maternal
deaths13; 3) costed national
MPDSR plan including
in maternal health plan;
and 4) functional national
MPDSR committee
Proportion of Measures the Number of maternal Number of MPDSR annual Annually, 100% UNFPA
maternal deaths practice and capacity deaths notified that were maternal deaths report, special
notified reviewed of reviewing death reviewed according to notified that study
according to quality reviews for quality quality standards were reviewed
standards14 assurance
Proportion Measures the Number of perinatal Number of MPDSR annual Annually, 100% UNFPA
of perinatal practice and capacity deaths that were reviewed perinatal deaths report, special
deaths reviewed of reviewing death according to quality that were study
according to quality reviews for Q standards reviewed
standards1
13
Within 24 hours for deaths in health facilities and within 48 hours for community deaths
14
Quality standards include: 1) Organized by a M(P)DR committee of 6–10 people selected from a variety of backgrounds; 2) Involving all professionals who took part in managing the case; 3) All findings recorded and
reported completely and anonymously, in accordance with the “no name, no blame” principle; 4) Including ‘clinical case summary’ with the most significant events that took place from before the woman’s admission
to the health facility until her death; 5) Including a ‘systematic case analysis’, identifying the causes of death by reviewing the medical cause of death (using ICD-MM); 6) Identifying the various factors/events that may
have contributed to the death; 7) Including recommendations and action plan to address gaps and; 8) Having an M(P) DSR session report.
Source of Frequency of data
Indicator Purpose Numerator Denominator information collection, target Reference Remarks/ Notes
Proportion of Measures the practice Number of health facilities Number of MPDSR Annually, 100% QED
health facilities with and capacity to with evidence of data health facilities summary forms,
evidence of data perform data analysis analysis and data analysis minutes from
analysis and data plan facility meetings
analysis plan15
Score on meeting Measures the degree Number of interdisciplinary Number of Based on a score:
of interdisciplinary of interdisciplinary team members present interdisciplinary
teams for MPDSR steering committee for the steering committee teams that are 1=if one team is
steering committee membership meeting part of steering present
meetings committee 2=if two teams are
present
3=if more than two
teams are present
Annexes
15
Includes comparing reported versus estimated deaths, comparing/analyzing causes of death, and monitoring whether implemented recommendations change morbidity/mortality.
123
124
Annex 18. Ten strategies for promoting a “No Name, No Blame and No Shame” culture and key
resources with more information

Strategy Markers or measures Level Key literature (* highlighted in module as example)
Ensure that policy Policy mandate: national Macro *Smith H, Ameh C, Godia P, Maua J, Bartilol K, Amoth P et al. Implementing maternal death
and planning for MPDSR policy and surveillance and response in Kenya: incremental progress and lessons learned. Glob Health Sci
MPDSR includes guidelines Pract. 2017;5(3):345–54.
national guidelines
Availability of MPDSR tools WHO Global Reproductive, Maternal, Newborn, Child and Adolescent Health Policy Survey:
and policies on how
indicates which countries have national MPDSR guidelines (https://www.who.int/data/maternal-
to conduct blame-free Legal framework for
newborn-child-adolescent-ageing/national-policies?selectedTabName=Documents, accessed
MPDSR, and legal notifying deaths
29 May 2021).
frameworks to draw and involve communities
a distinction between and other sectors E4A. 2012. Maternal death surveillance and response systems: overcoming legal challenges and
the audit process creating an enabling environment. MDSR Action Network. Presented during ‘Interactive MDSR
and appropriate Resource Room’ at XXFIGO World Congress of Gynecology and Obstetrics, Rome, Italy, 7-12
disciplinary action October 2012.
Ensure national Global and regional Macro * Melberg A, Mirkuzie AH, Sisay TA, Sisay MM, Moland KM. “Maternal deaths should simply
prioritization of commitments (e.g. SDGs) be 0”: politicization of maternal death reporting and review processes in Ethiopia. Health Policy
prevention of Plan. 2019;34(7):492–8.
Targets in national health
maternal and
plans * Tura AK, Fage SG, Ibrahim AM, Mohamed A, Ahmed R, Gure T et al. Beyond No Blame:
perinatal deaths
practical challenges of conducting maternal and perinatal death reviews in eastern Ethiopia. Glob
Health Sci Pract. 2020;8(2):150–4. doi:10.9745/GHSP-D-19–00366.
Harmonize Integrating MPDSR into Macro, * Biswas A. Shifting paradigm of maternal and perinatal death review system in Bangladesh: a
MPDSR in routine DHIS or other national meso, real-time approach to address sustainable developmental goal 3 by 2030. F1000Res. 2017;6:1120.
monitoring systems routine monitoring systems micro
* Purandare C, Bhardwaj A, Malhotra M, Bhushan H, Shah PK. Every death counts:
to standardize the
electronic tracking systems for maternal death review in India. Int J Gynaecol Obstet.
process and enable
2014;127(Suppl 1):S35–9.
accountability
Smith H, Ameh C, Godia P, Maua J, Bartilol K, Amoth P et al. Implementing maternal death
surveillance and response in Kenya: incremental progress and lessons learned. Glob Health Sci
Pract. 2017;5(3):345–54.
Create and Address human and Macro, Austin A, Langer A, Salam RA, Lassi ZS, Das JK, Bhutta ZA. Approaches to improve the
advocate for an material resource shortages meso quality of maternal and newborn health care: an overview of the evidence. Reprod Health.
overall enabling across the system 2014;11(Suppl 2):S1. doi: 10.1186/1742–4755–11-S2-S1.
environment for
Coordination mechanisms Bandali, S., Thomas, C., Hukin, E., Matthews, Z., Mathai, M., Ramachandran Dilip, T., Roos, N.,
implementation,
Lawley, R., Igado, O. & Hulton, L. 2016. Maternal Death Surveillance and Response Systems in
including an Implementing broader
driving accountability and influencing change. Int J Gynaecol Obstet, 135, 365–371.
organizational quality improvement
culture of learning, strategies * Belizan M, Bergh AM, Cilliers C, Pattinson RC, Voce A & for the Synergy Group. Stages of
accountability and change: a qualitative study on the implementation of a perinatal audit programme in South
Data quality assessments
transparency Africa. BMC Health Serv Res. 2011;11:243.
Promote MPDSR as a
Bergh AM, Pattinson R, Belizan M, Cilliers C, Jackson D, Kerber K et al. & for the Synergy Group.
learning experience
Completing the audit cycle for quality care in perinatal, newborn and child health. Pretoria:
Prioritize preventative Medical Research Council of South Africa; 2011.
measures
Biswas, A., Rahman, F., Eriksson, C., Halim, A. & Dalal, K. 2015. Facility Death Review of
Ensure anonymity – e.g. Maternal and Neonatal Deaths in Bangladesh. PLoS One, 10, e0141902.
notes and reports – to
de Kok B, Imamura M, Kanguru L, Owolabi O, Okonofua F, Hussein J. Achieving accountability
protect patients and staff
through maternal death reviews in Nigeria: a process analysis. Health Policy Plan.
involved
2017;32(8):1083–91.
* Dumont A, Tourigny C, Fournier P. Improving obstetric care in low-resource settings:
implementation of facility-based maternal death reviews in five pilot hospitals in Senegal. Hum
Resour Health. 2009;7: 61.
Lewis G. The cultural environment behind successful maternal death and morbidity reviews.
BJOG. 2014;121(Suppl 4):24–31.
Lewis G. Emerging lessons from the FIGO LOGIC initiative on maternal death and near-miss
reviews. Int J Gynaecol Obstet. 2014;127(Suppl 1):S17–20.
Manandhar, D. S. 2004. Perinatal death audit. Kathmandu Univ Med J (KUMJ), 2, 375–83.
Richard F, Ouedraogo C, Zongo V, Ouattara F, Zongo S, Gruénais ME et al. The difficulty of
questioning clinical practice: experience of facility-based case reviews in Ouagadougou, Burkina
Faso. BJOG. 2009;116(1):38–44.
Annexes
125
126

Strengthen Facilitation skills for Meso, * Bakker, W., van den Akker, T., Mwagomba, B., Khukulu, R., van Elteren, M. & van Roosmalen,
leadership within conducting audit meetings Micro J. 2011. Health workers’ perceptions of obstetric critical incident audit in Thyolo District, Malawi.
all participating Trop Med Int Health, 16, 1243–50.
Mentorship and supportive
professional groups
supervision Bergh AM, Pattinson R, Belizan M, Cilliers C, Jackson D, Kerber K et al. & for the Synergy Group.
at all levels, ensuring
Completing the audit cycle for quality care in perinatal, newborn and child health. Pretoria:
engagement with the Participation of senior staff
Medical Research Council of South Africa; 2011.
MPDSR focal point in the meetings and in the
on how to facilitate data analysis in order to Dumont A, Tourigny C, Fournier P. Improving obstetric care in low-resource settings:
meetings and mentor guide priorities and actions implementation of facility-based maternal death reviews in five pilot hospitals in Senegal. Hum
others Resour Health. 2009;7:61.
Kinney MV, Ajayi G, de Graft-Johnson J, Hill K, Khadka N, Om’Iniabohs A et al. “It might be a
statistic to me, but every death matters”: an assessment of facility-level maternal and perinatal
death surveillance and response systems in four sub-Saharan African countries. PloS One.
2020;15(12):e0243722.
Koblinsky M. Maternal death surveillance and response: a tall order for effectiveness in resource-
poor settings. Glob Health Sci Pract. 2017;5:333–7.
MCSP. Assessment of Maternal and Perinatal Death Surveillance and Response Implementation
in Nigeria. Washington (DC): Maternal Child Survival Program; 2017.
in Rwanda. Washington (DC): Maternal Child Survival Program; 2017.
in Zimbabwe. Washington (DC): Maternal Child Survival Program; 2017.
in Kagera and Mara Region, Tanzania. Washington (DC): Maternal Child Survival Program; 2017.
Purandare C, Bhardwaj A, Malhotra M, Bhushan H, Shah PK. Every death counts:
2014;127(Suppl 1):S35–9.
* Rhoda NR, Greenfield D, Muller M, et al. Experiences with perinatal death reviews in South
Africa – the Perinatal Problem Identification Programme: scaling up from programme to
province to country. BJOG. 2014;121(Suppl 4):160–6.
van Hamersveld KT, den Bakker E, Nyamtema AS, van den Akker T, Mfinanga EH, van Elteren
M et al. Barriers to conducting effective obstetric audit in Ifakara: a qualitative assessment in an
under-resourced setting in Tanzania. Trop Med Int Health. 2012;17(5):652–7.
Nurture team Mentorship, clinical Meso, Agaro C, Beyeza-Kashesya J, Waiswa P, Sekandi JN, Tusiime S, Anguzu R et al. The conduct of
relationships outreach and supervisory Micro maternal and perinatal death reviews in Oyam District, Uganda: a descriptive cross-sectional
among those who activities through district study. BMC Womens Health. 2016;16:38.
participate in audit engagement
* Dartey AF. The role of midwives in the implementation of maternal death review (MDR) in
through continuous
Teams: committees formed health facilities in Ashanti region, Ghana. Cape Town: University of the Western Cape; 2012.
engagement, a
and multidisciplinary
teamwork approach, Hofman JJ, Mohammed H. Experiences with facility-based maternal death reviews in northern
support from hospital Relationship between Nigeria. Int J Gynaecol Obstet. 2014;126:111–4.
management, committee members
MCSP 2017. Assessment of Maternal and Perinatal Death Surveillance and Response
deliberate efforts and Implementation in Nigeria. Washington, DC: Maternal Child Survival Program.
strategies, such as
mentorship MCSP 2017. Assessment of Maternal and Perinatal Death Surveillance and Response
Implementation in Rwanda. Washington, DC: Maternal Child Survival Program.
MCSP 2017. Assessment of Maternal and Perinatal Death Surveillance and Response
Implementation in Zimbabwe. Washington, DC: Maternal Child Survival Program.
MCSP 2018. Assessment of Maternal and Perinatal Death Surveillance and Response (MPDSR)
Implementation in Kagera and Mara Region, Tanzania. Washington, DC: Maternal Child
Survival Program.
Muffler N, Trabelssi Mel H, De Brouwere V. Scaling up clinical audits of obstetric cases in
Morocco. Trop Med Int Health. 2007;12(10):1248–57.
* Purandare C, Bhardwaj A, Malhotra M, Bhushan H, Shah PK. Every death counts:
2014;127(Suppl 1):S35–9.
Annexes
127
128

Ensure that audit Meeting frequency Meso * Dartey AF. The role of midwives in the implementation of maternal death review (MDR) in
meetings take place health facilities in Ashanti region, Ghana. Cape Town: University of the Western Cape; 2012.
Incentivize attendance – e.g.
regularly and staff
staff receive professional Kinney MV, Ajayi G, de Graft-Johnson J, Hill K, Khadka N, Om’Iniabohs A et al. “It might be a
regularly attend.
credit points for statistic to me, but every death matters”: an assessment of facility-level maternal and perinatal
The literature shows
participation or attending death surveillance and response systems in four sub-Saharan African countries. PloS One.
that the more
meetings is part of work 2020;15(12):e0243722.
people attend, the
expectations
more practice they Lewis G. Emerging lessons from the FIGO LOGIC initiative on maternal death and near-miss
have and the more reviews. Int J Gynaecol Obstet. 2014;127(Suppl 1):S17–20.
embedded the * MCSP 2017. Assessment of Maternal and Perinatal Death Surveillance and Response
process becomes Implementation in Zimbabwe. Washington, DC: Maternal Child Survival Program.
* Tayebwa E, Sayinzoga F, Umunyana J, et al. Assessing Implementation of Maternal and
Perinatal Death Surveillance and Response in Rwanda. International journal of environmental
research and public health 2020; 17(12).
Put in place a code Staff involved in MPDSR Meso * Congo B, Sanon D, Millogo T, Ouedraogo CM, Yaméogo WME, Meda ZC et al. Inadequate
of conduct or “audit commit to never sharing the programming, insufficient communication and non-compliance with the basic principles of
charter” with clear information maternal death audits in health districts in Burkina Faso: a qualitative study. Reprod Health.
rules about the 2017;14(1):121.
Review committee members
purpose of meetings,
sign or verbally consent Kinney MV, Ajayi G, de Graft-Johnson J, Hill K, Khadka N, Om’Iniabohs A et al. “It might be a
expected behaviour
to a non-disclosure statistic to me, but every death matters”: an assessment of facility-level maternal and perinatal
during meetings and
confidentiality agreement death surveillance and response systems in four sub-Saharan African countries. PloS One.
the confidentiality of
2020;15(12):e0243722.
meetings Publication of proceedings
are anonymous Lewis G. Emerging lessons from the FIGO LOGIC initiative on maternal death and near-miss
reviews. Int J Gynaecol Obstet. 2014;127(Suppl 1):S17–20.
* Richard F, Ouedraogo C, Zongo V, Ouattara F, Zongo S, Gruénais ME et al. The difficulty of
Faso. BJOG. 2009;116(1):38–44.
Promote individual Competencies of managers, Micro * Armstrong CE, Lange IL, Magoma M, Ferla C, Filippi V, Ronsmans C. Strengths and
awareness of roles supervisors, providers to weaknesses in the implementation of maternal and perinatal death reviews in Tanzania:
and responsibilities, analysis and interpret data perceptions, processes and practice. Trop Med Int Health. 2014;19:1087–95.
and competence and information
* Belizan M, Bergh AM, Cilliers C, Pattinson RC, Voce A & for the Synergy Group. Stages of
to complete
Confidence of and capability change: a qualitative study on the implementation of a perinatal audit programme in South
tasks through
of health workers to Africa. BMC Health Serv Res. 2011;11:243.
on-the-job capacity-
complete and analyse
development linked Bergh AM, Pattinson R, Belizan M, Cilliers C, Jackson D, Kerber K et al. & for the Synergy Group.
deaths
to implementation Completing the audit cycle for quality care in perinatal, newborn and child health. Pretoria:
of a non-blaming Strategy for staff orientation Medical Research Council of South Africa; 2011.
approach to MPDSR
* Muffler, N., Trabelssi Mel, H. & De Brouwere, V. 2007. Scaling up clinical audits of obstetric
cases in Morocco. Trop Med Int Health, 12, 1248–57.
Richard F, Ouedraogo C, Zongo V, Ouattara F, Zongo S, Gruénais ME et al. The difficulty of
Faso. BJOG. 2009;116(1):38–44.
Annexes
129
130

Engage communities Building community Micro Biswas A, Ferdoush J, Abdullah ASM, Halim A. Social autopsy for maternal and perinatal deaths
in awareness awareness and community in Bangladesh: a tool for community dialog and decision making. Public Health Rev. 2018;39(1).
about reporting sensitization.
Biswas A. Shifting paradigm of maternal and perinatal death review system in Bangladesh: a real-
and participation in
Create an enabling time approach to address sustainable developmental goal 3 by 2030. F1000Res. 2017;6:1120.
MPDSR verbal and
environment for community
social autopsies * Biswas A, Halim MA, Dalal K, Rahman F. Exploration of social factors associated to maternal
MPDSR
deaths due to haemorrhage and convulsions: analysis of 28 social autopsies in rural Bangladesh.
Informed consent to ensure BMC Health Serv Res. 2016;16(1):659.
freedom of community to
Biswas A, Rahman F, Eriksson C, Halim A, Dalal K. Social autopsy of maternal, neonatal
speak and ethics
deaths and stillbirths in rural Bangladesh: qualitative exploration of its effect and community
Confidentiality, acceptance. BMJ Open. 2016;6(8):e010490.
engagement and Biswas A, Rahman F, Halim A, Eriksson C, Dalal K. Experiences of community verbal autopsy in
relationship between maternal and newborn health of Bangladesh. HealthMED. 2015;9(8):329–38.
health-care providers and
* Biswas A, Rahman F, Eriksson C, Halim A, Dalal K. Facility death review of maternal and
the community.
neonatal deaths in Bangladesh. PLoS One. 2015;10(11):e0141902.
Prioritize role of MPDSR
Biswas A, Rahman F, Eriksson C, Dalal K. Community notification of maternal, neonatal
focal person to facilitate
deaths and still births in Maternal and Neonatal Death Review (MNDR) system: experiences in
community MPDSR
Bangladesh. Health. 2014;6(6):2218–26.
Social autopsy serves as a
Biswas A, Rahman F, Halim A, Eriksson C, Dalal K. Maternal and Neonatal Death Review
health promotion tool for
(MNDR): a useful approach to Identifying appropriate and effective maternal and neonatal
the community to address
health initiatives in Bangladesh. 2014;6:1669–79.
maternal and perinatal
death Biswas A. Social autopsy as an intervention tool in the community to prevent maternal and
neonatal deaths: experiences from Bangladesh. MDSR Action Network. June 2016.
Biswas A. Maternal and Perinatal Death Review (MPDR): experiences in Bangladesh. Geneva:
World Health Organization; 2015 (http://www.who.int/maternal_child_adolescent/epidemiology/
maternal-death-surveillance/case-studies/bangladesh-study/en/, accessed 29 May 2021).
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maternal deaths; a cross-sectional study using verbal autopsy in four districts in Bangladesh.
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promotion tool for preventing maternal mortality in low-income countries. WHO South-East Asia
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Contact address:
Department of Maternal, Newborn, Child and Adolescent Health and Ageing
World Health Organization
20 avenue Appia
1211 Geneva 27, Switzerland
E-mail: [email protected]
https://www.who.int/health-topics/maternal-health

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Design and layout by Inis Communication

Module 3: Identifying cases  15

THE MPDSR CYCLE

QoC MMR & PMR

Who is this guide meant for?

How are maternal and perinatal death review linked?

MODULE TITLE TRAINING TRAINING CASE SAMPLE OTHER

2. Getting started at the

10. Overcoming the

Pregnancy-related death: definition

Maternal death: definition

Neonatal death: definition

Perinatal mortality: definition

Perinatal Perinatal mortality: presentation of data

Health Management Information System (HMIS)

District Health Information System (DHIS2)

Relevant tools, forms and guidance

Step 2: Set up a steering committee

Module 2: Getting started at the facility level 11

Step 3: Determine operating procedures and tasks

Relevant tools, forms and additional resources

Module 2: Getting started at the facility level 13

Module 3: Identifying cases 15

Fig.2. Community networking for capturing community deaths

Relevant tools, forms and additional resources

Module 3: Identifying cases 17

What is the purpose?

Module 4: Collecting information 19

Selecting cases for review

Community verbal autopsy

Module 4: Collecting information 21

Relevant tools, forms and additional resources

Step 1: Plan and prepare for review meetings

Module 5: Conducting joint maternal and perinatal death reviews 25

Step 3: Finalize forms and flow of information

Step 4: Prepare meeting reports

Reviews of ‘near-miss’ maternal and perinatal deaths

What is the outcome?

Module 5: Conducting joint maternal and perinatal death reviews 27

Ideas for expanding maternal and perinatal mortality audit

Community Participation in Review of Facility-Based Deaths

Module 5: Conducting joint maternal and perinatal death reviews 29

Module 6: Analysing and presenting information 31

Relevant tools, forms and additional resources

Module 7: Recommending actions and implementing change 35

Subnational level (province/district)

QoC working group/

Facility level (province/district)

Example of a maternal death review, recommendations, and actions that led to

Module 7: Recommending actions and implementing change 37

Module 7: Recommending actions and implementing change 39

Community Participation in monitoring MPDSR Responses

What is the outcome?

Relevant tools, forms and additional resources

Monitoring the MPDSR system

Module 3: Identifying cases 15

Signed: _______________________ Date:

Signed: _______________________ Date:

Signed: _______________________ Date:

Signed: _______________________ Date:

Signed: _______________________ Date:

Signed: _______________________ Date:

1.5 Multiple pregnancies babies from pregnancies

Form completed by: Date: _________________