MPDSR Gudeline Final Aproved 6 - 11 - 2019

THE UNITED REPUBLIC OF TANZANIA
MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT,
GENDER, ELDERLY AND CHILDREN
Maternal and Perinatal Death

Surveillance and Response Guidelines
Reproductive and Child Health Section
Dodoma
October 2019
THE UNITED REPUBLIC OF TANZANIA
MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT,
GENDER, ELDERLY AND CHILDREN
Maternal and Perinatal Death

Surveillance and Response Guidelines
Reproductive and Child Health Section
Dodoma
October 2019
ii Reproductive and Child Health Section Dodoma | 2019
Maternal And Perinatal Death Surveillance And Response Guidelines
Table of Contents
Abbreviations........................................................................................................................ v
Foreword............................................................................................................................. vii
Executive Summary............................................................................................................ viii
Acknowledgements.............................................................................................................. ix
Chapter 1: Introduction......................................................................................................... 1
Chapter 2: Definitions........................................................................................................... 3
Chapter 3: Vision, Mission and Objectives........................................................................... 6
3.1 Vision............................................................................................................................... 6
3.2 Mission............................................................................................................................. 6
3.3 Objectives........................................................................................................................ 6
Chapter 4: MPDSR Overview................................................................................................ 7
4.1 The rationales for the MPDSR.......................................................................................... 7
4.2 Steps of MPDSR................................................................................................................ 8
4.3 Principles for MPDSR....................................................................................................... 9
Chapter 5: Identification and Notification.......................................................................... 10
5.1 Maternal and perinatal death notification..................................................................... 10
5.2 Notification at health facility.......................................................................................... 10
5.3 Identification and notification of maternal/perinatal deaths in the community........... 11
5.4 Immediate response after notification........................................................................... 11
5.5 Zero reporting................................................................................................................ 12
Chapter 6: MPDSR Committees.......................................................................................... 13
6.1 Types of Committees...................................................................................................... 13
6.2 Composition of Facility MPDSR Committees.................................................................. 13
6.2.1 Consultant Hospitals................................................................................................... 13
6.2.2 Regional Referral Hospital MPDSR Committee........................................................... 15
6.2.3 District Hospital MPDSR Committee........................................................................... 16
6.2.4 Health Centre and Dispensary.................................................................................... 17
6.2.5 Community MPDSR Committee.................................................................................. 19
6.3 Technical MPDSR Committees at Different Levels.......................................................... 19
Reproductive and Child Health Section Dodoma | 2019 iii

6.3.1 National MPDSR Technical Committee....................................................................... 19

6.3.2 Regional MPDSR Technical Committee....................................................................... 22
6.3.3 Council Technical MPDSR Committee......................................................................... 23
Chapter 7: Maternal and Perinatal Death Review Process................................................ 25
7.1 Facility Review................................................................................................................ 25
7.1.1 MPDSR Focal person/ Coordinator............................................................................. 25
7.1.2 The Clinical Summary.................................................................................................. 25
7.2 The Review Process........................................................................................................ 29
7.3 Community Maternal Death Review.............................................................................. 38
Chapter 8: Response............................................................................................................ 40
8.1 Immediate response after review.................................................................................. 40
8.2 Periodic response........................................................................................................... 40
8.3 Evidence based response............................................................................................... 41
8.4 Follow up of implementation of MPDSR action plans.................................................... 42
Chapter 9: Data Analysis and Dissemination of Results..................................................... 43
9.1 Framework for data analysis and flow of information................................................... 43
9.2 Dissemination................................................................................................................ 43
Chapter 10: Monitoring and Evaluation............................................................................. 45
10.1 Periodic Evaluation....................................................................................................... 45
References........................................................................................................................... 55
Annexes............................................................................................................................... 56
Annex 1: ICD 10 MM and PM.............................................................................................. 56
Annex 2: FACILITY MATERNAL DEATH NOTIFICATION FORM (MDNF).................................. 67
Annex 3: FACILITY PERINATAL DEATH NOTIFICATION FORM (PDNF).................................... 68
Annex 4: COMMUNITY IDENTIFICATION OF SUSPECTED MATERNAL DEATH...................... 69
Annex 5: COMMUNITY PERINATAL DEATH IDENTIFICATION FORM..................................... 70
Annex 6: MATERNAL DEATH REPORTING FORM.................................................................. 71
Annex 7: PERINATAL DEATH REPORTING FORM.................................................................. 76
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Abbreviations
AGOTA Association of Gynecologists and Obstetricians of Tanzania

APHFTA Association of Private Health Facilities in Tanzania
BBA Born Before Arrival
C/S Caesarean Section
CHMT Council Health Management Team
CHW Community Health Worker
CNO Chief Nursing Officer
CPD Cephalopelvic Disproportion
CRHS Commonwealth Regional Health Secretariat
CSSC Christian Social Services Commission
DMO District Medical Officer
DNO District Nursing Officer
DRCHCo District Reproductive and Child Health Coordinator
FBO’s Faith Based Organisations
HIV/AIDS Human Immunodeficiency Virus/Acquired Immune-Deficiency
HMIS Health Management Information System
IDSR Integrated Disease Surveillance and Response
IMCI Integrated Management of Childhood Illnesses
IUFD Intra-Uterine Fetal Death
KCMC Kilimanjaro Christian Medical Centre
KG Kilogram
MDGs Millennium Development Goals (MDGs)
MDR Maternal Death Review
MDSR Maternal Death Surveillance and Response
MoHCDGEC Ministry of Health, Community Development, Gender, Elderly and
Children
MPDR Maternal and Perinatal Death Review
MPDSR Maternal and Perinatal Death Surveillance and Response
MSD Medical Stores Department
MUHAS Muhimbili University of Health and Allied Sciences
Reproductive and Child Health Section Dodoma | 2019 v

NBS National Bureau of Statistics

NGO’s Non-Governmental Organisations
NIMR National Institute for Medical Research
NM Nurse Midwife
OPD Out Patient Department
PAT Paediatric Association of Tanzania
PID Pelvic Inflammatory Disease
PORALG President’s Office, Regional Administration and Local Government
PPH Post-Partum Haemorrhage
RCHC Reproductive and Child Health Clinic
RHMT Regional Health Management Team
RMO Regional Medical Officer
RNO Regional Nursing Officer
SDG Sustainable Development Goals
SMI Safe Motherhood Initiative
SVD Spontaneous Vaginal Delivery
TAMA Tanzania Midwives Association
TDHS Tanzania Demographic Health Survey
UNICEF United Nations International Children’s Emergency Fund
VEO Village Executive Officer
VHW Village Health Worker
WHO World Health Organization
WRA Women of Reproductive Age
vi Reproductive and Child Health Section Dodoma | 2019

Foreword
Complications of pregnancy, childbirth and abortion are major causes of death for women of
reproductive age in Tanzania. According to the Tanzania Demographic Health Survey 2015/16
the maternal mortality ratio (MMR) is 556 deaths per 100,000 live births with wide variations
across regions. The major direct causes of maternal deaths include haemorrhage, hypertensive
disorders of pregnancy, obstructed labour, sepsis and abortion complications. Indirect causes
such as Malaria, HIV/AIDS and anaemia also contribute to maternal deaths. Perinatal mortality is
also still high at 39 per 1,000 total births.
However, most of these deaths and serious morbidities are preventable with quality and timely
appropriate care. Improving women’s health and specifically reducing maternal and perinatal
mortality and morbidity remains core to the safe motherhood programme in the country. This
can be achieved through quality of care during pre-pregnancy, pregnancy, labour and delivery
and the postpartum period. Attending antenatal care at least once is almost universal in the
country, but only 51% of pregnant women attend required minimum of four visits.
Delivering in health facilities and postnatal care coverage are equally low, impacting negatively
on pregnancy outcomes. The main goal of the maternal and perinatal death surveillance
and response guideline is to facilitate identification, review, notification and respond to
recommendations generated from the reviews. This will in turn improve the quality of care
provided, and consequently reduce maternal and perinatal deaths in our health facilities. The
main objective of Maternal and Perinatal Death Surveillance and Response (MPDSR) is to provide
information, recommendations and actions to be taken so as to eliminate preventable maternal
and perinatal deaths at health facilities. The guideline should never be construed as a way of
apportioning blame or as a basis for litigation or management sanctions. The purpose of MPDSR
is to allow for a full understanding of the chain of events related to maternal and perinatal death,
identify the main problems in the management of the patient, from before admission to the time
of death, and then come up with the best solutions to correct the identified gaps. The MPDSR
will also help to clarify the most likely medical cause(s) of death and circumstances/factors that
might have adversely affected provision of care, such as shortage of medicines, equipment and
essential supplies, as well as factors beyond the health system such as women’s status in the
community. It is my sincere hope that all health care providers in maternal and newborn fields
will find this document helpful and will use it effectively so as to reduce maternal and perinatal
morbidity and mortality in Tanzania.
Dr. Zainab A. S. Chaula

Permanent Secretary (Health)
Reproductive and Child Health Section Dodoma | 2019 vii

Executive Summary:
The main goal of the maternal and perinatal death surveillance and response guideline is to
facilitate identification, review, notification and respond to recommendations generated from
the reviews. This will in turn improve the quality of care provided, and consequently reduce
maternal and perinatal deaths in health facilities. The main objective of Maternal and Perinatal
Death Surveillance and Response (MPDSR) is to provide information, recommendations and
actions to be taken to eliminate preventable maternal and perinatal deaths at health facilities.
The guideline emphasizes that it should never be construed as a way of apportioning blame or
as a basis for litigation or management sanctions.
The purpose of MPDSR is to allow for a full understanding of the chain of events related to
maternal and perinatal death, identify the main problems in the management of the patient,
from before admission to the time of death, and then come up with the best solutions to correct
the identified gaps. The MPDSR will also help to clarify the most likely medical cause(s) of death
and circumstances/factors that might have adversely affected provision of care, such as shortage
of medicines, equipment and essential supplies, as well as factors beyond the health system such
as women’s status in the community.
This Guideline emphasizes the importance of enhancing accountability at various levels of

Governance in implementing MPDSR. In that line, on daily basis all maternal and perinatal deaths
from the health facility and community level are notifiable event to District Medical Officer
and Regional Medical Officer. The later is responsible for preparing technical assistance team
of 1-3 experts to complementing health facility and district MPDSR committee to investigate
the maternal and perinatal deaths. The notification requires that, on daily basis maternal and
perinatal deaths will be reported to the MoHCDGEC at the Department of Preventive Services
that will be responsible for preparing a monthly report to be submitted to the Chief Medical
Officer.
This Guideline recognizes the existence of Health Facility, District, Regional and National MPDSR
Committees. Health facility MPDSR committee will convene within 7 days to discuss maternal or
perinatal death whenever is occurs. District MPDSR committee will meet every month to discuss
all district maternal and perinatal deaths, Regional MPDSR Committee will meet quarterly to
discuss reports of maternal deaths from districts and National MPDSR Committee will meet
semi-annually to discuss regional reports of maternal and perinatal deaths. All members of these
committees will be appointed by the head of institution with a letter of appointment.
It is the expectation of this guideline that every MPDSR committee shall have action plan
emanating from its meeting to implement and the progress of implementation will be the first
matter of discussion in any MPDSR meeting.
viii Reproductive and Child Health Section Dodoma | 2019

Acknowledgements
The Ministry of Health, Community Development, Gender, Elderly and Children acknowledges
the contribution of all experts who worked tirelessly during the review of this guideline. The
Ministry expresses special appreciation to UNICEF office for their financial and technical support
which facilitated the review and update of these guidelines. The Ministry recognizes individual
effort of expert who participated in the review of this document; these experts include;
Dr. Ahmad Makuwani Assistant Director, MoHCDGEC-RCHS, Dr. Phineas F. Sospeter MoHCDGEC-
RCHS, Dr. Felix Bundala of MoHCDGEC-RCHS, Ms. Leila Diwani Bungire MoHCDGEC-RCHS, Dr.
Joseph G. Kimaro Njombe Regional Referral Hospital; Ms.Ennegrace Nkya of Temeke Regional
Referral Hospital; Mary Shadrack of Dodoma Regional Hospital; Dr. Mzee M. Nassoro of Dodoma
Regional Referral Hospital. Ms. Happiness Nyanda, and Mr. Francis Mukulu of University of Dar
es Salaam, Dr. Francis Rwegoshora of Mbeya Referral Hospital, Dr.Pendo Mlay KCMC.
Prof. S.N. Massawe and Dr Ali Said of Muhimbili University of Health and Allied Sciences, Dr.
Mary B. Charles and Dr. Victor Bakengesa of Muhimbili National Hospital, Dr. Moke Magoma of
Options Tanzania Limited; Dr. Chrisostom Lipingu and Dr. Goodluck Mwakitosha of Jhpiego; Dr.
Asia Hussein and Dr. Mary Mmweteni of UNICEF, and Dr. Theopista John Kabuteni of WHO.
Prof. Muhammad Bakari Kambi

Chief Medical Officer
Reproductive and Child Health Section Dodoma | 2019 ix

Chapter 1:
Introduction
Maternal and perinatal mortality is still one of the major obstacles to women and children’s
survival, in 2015 the global maternal mortality ratio was estimated at 216 maternal deaths per
100, 000 live births, which translates to 303,000 deaths and many more women suffering from
major morbidities from pregnancy and childbirth complications (UN maternal mortality estimate
2015). Developing countries account for approximate 99% (302, 000) of the global maternal
deaths with sub-Saharan Africa accounting for 66%, equivalent to 201,000 annual maternal
deaths (UN Maternal Mortality Estimates 2015). In recent years, the world has made a significant
step in the reduction of maternal and perinatal deaths but only a few countries achieved the
Millennium Development Goals 5 (MDG 5) target of reducing maternal deaths by 75% by the
year 2015. Tanzania is one of the countries that did not achieve the MDG5 target and its current
maternal mortality ratio is 556/100,000 live births (TDHS 2015). More recently, the international
community has set up targets of reducing maternal mortality ratio to less than 70 deaths per
100,000 live births and neonatal mortality rate to as low as 12 per 1,000 live births by 2030 in the
Sustainable Development Goals 3 (SDG3) (ICSU 2015; Alkema et al. 2016).
Maternal, newborn and child health is one the thematic areas in the Tanzania Health Sector
Strategic Plan (HSSP) IV 2016-2020. The aim of HSSP IV is to reach all households with essential
health and social welfare services, meeting the expectations of the population, adhering to
quality standards, and applying evidence-informed interventions through efficient channels of
service delivery. In The National Strategic Plan to Improve Reproductive, Maternal, Newborn,
Child and Adolescent Health in Tanzania 2016 – 2020 (One Plan II), Tanzania aims to reduce
maternal mortality ratio from 556 to 292 per 100,000 live births and neonatal mortality rate
from 25 to 16 per 1,000 live births by year 2020 (One Plan II). The realization of these goals will
mean more investments in human resources, infrastructure, equipment and supplies as well as
improvements in quality of care and accountability.
Perinatal deaths contribute to a high infant mortality rate in Tanzania. Currently, the perinatal
mortality rate is estimated at 39 per 1,000 total births (TDHS 2015). Perinatal mortality rate
is a sensitive indicator for the quality of health care provided during the perinatal period. In
most developing countries, priority is usually given to interventions addressing post neonatal
and early childhood causes of deaths. As a result, causes of perinatal deaths are not given the
attention they deserve, resulting in slow progress in reducing perinatal mortality rates, and thus
contributing to high levels of infant mortality.
Tanzania was among the first countries to adopt the Safe Motherhood Initiative (SMI) programme
following its inception in 1987. The review of 10 years of safe motherhood implementation in
1997 in Colombo, Sri Lanka, highlighted that broad interventions embraced in the SMI needed
to be revised in order to have an accelerated impact. Above all, the need for measuring progress
was emphasized and hence development of process indicators. It was also realized that,
Reproductive and Child Health Section Dodoma | 2019 1

misclassification of maternal death is a common phenomenon which needed to be addressed

by developing a standardised tool for identifying, learning and classifying maternal deaths. Every
maternal and perinatal death counts and needs to be investigated, thus the need for prioritizing
MPDSR to improve maternal and perinatal survival.
The process works as a reminder to health service providers on what went wrong at the community,
patient and facility levels. It allows a more rational understanding and classification of causes of
maternal and perinatal deaths, moving beyond medical boundaries by looking at factors that
might have contributed to the development of life threatening complications, including health
care seeking behavior. The process also opens up a space for constructive dialogue among those
involved in care provision, allowing rectification of the identified problems to reduce maternal
and perinatal deaths.
Maternal and Perinatal Deaths Review (MPDR) guidelines were developed and rolled-out in
the country in 2006. The guidelines required identification, notification and review of maternal
and perinatal deaths occurring in health facilities. Specifically, reporting was to happen from
health facilities to districts and from districts to regions and to national levels. Despite evidence
that reviews occurred at health facilities and were reported to districts, notification to regions
and to the Reproductive and Child Health Section (RCHS) at the Ministry of Health, Community
Development, Gender, Elderly and Children (MoHCDGEC) was not being equally implemented.
This led to a paucity of country data to inform strategies for the reduction of maternal and
perinatal mortality. Information was also scarce on actions implemented from recommendations
related to maternal and perinatal deaths reviews across all levels of the health care system.
In 2015, Ministry of Health and Social Welfare (MoHSW) developed and rolled out the national
MPDSR guidelines to replace the MPDR guideline of 2006. Over the years of implementation,
new priorities and challenges emerged. The RCHS of MoHCDGEC has revised and standardised
the process and forms to be used for learning and reporting maternal and perinatal deaths as
well as inclusion of deaths occurring at community. The new guidelines rightfully emphasize the
surveillance and response that are critical to identify and map deaths as well as to determine the
causes and implementing actions to prevent similar deaths.
The purpose of these guidelines is to provide guidance towards the surveillance and response
mechanism in order to reinforce maternal and perinatal death reviews in the country as well
as build a platform for accountability and better quality of maternal and newborn health care.
The guidelines will also be used as a resource tool for all health care stakeholders across all
levels of the health system delivery including the community. RHMTs and CHMTs should include
maternal and perinatal death reviews in their comprehensive health plans for sustainability and
ensure that recommendations from reviews are implemented to improve maternal and perinatal
survival. The MoHCDGEC and President`s Office Regional Administration and Local Government
(PORALG) should provide guidance and oversight to ensure effective implementation of the
MPDSR guidelines at all levels including monitoring and reporting.
2 Reproductive and Child Health Section Dodoma | 2019

Chapter 2:
Definitions
2.1 Maternal death
Death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective

of the duration and the site of pregnancy from causes related to or aggravated by the
pregnancy or its management, but not from accidental or incidental causes.
2.2 Suspected maternal death
This refers to death of any woman while pregnant or within 42 days of the termination of
pregnancy. Any suspected pregnancy related death should be notified.
2.3 Probable maternal death
This refers to death among women of reproductive age not clearly due to incidental or
accidental causes.
2.4 Direct maternal death
This refers to maternal death resulting from obstetric complications of the pregnancy state
(pregnancy, labour, or pueperium); from interventions, omissions, or incorrect treatment;
or from a chain of events resulting from any of the above (e.g. obstetric haemorrhage,
hypertensive disorders of pregnancy, abortion complication etc.).
2.5 Indirect maternal death
Is a maternal death resulting from previously existing disease or disease that developed
during pregnancy and which was not due to direct obstetrics causes but was aggravated by
physiological changes during pregnancy (e.g. severe anaemia, HIV/AIDS, Malaria etc).
2.6 Unspecified maternal death
This refers to maternal death where the underlying cause is unknown or undetermined.
2.7 The underlying cause of death
This is defined as a condition or disease that initiated a chain of events that ended with a
maternal/perinatal death.
2.8 Contributing medical causes of death
Include all complications that resulted from underlying cause and preexisting disease
conditions that may have contributed to death but not related to disease or condition causing
it e.g. a severely anaemic patient dying from postpartum haemorrhage (PPH) (anaemia is a
contributing cause).

2.9 Contributing factors
Are non-medical factors/causes from outside or inside the health facility that have
contributed to maternal or perinatal death. These may include;
- Lack of knowledge on recognition of danger signs
- Unwillingness to seek professional help
- Delayed decision making at family level
- Lack of resources in the family
- Poor infrastructure
- Sub-optimal antenatal care
- Late referral from another facility
- Inadequate supplies, equipment or infrastructure at health facility
- Inadequate staff
- Inadequate skills of provider
- Delay in receiving appropriate treatment in the health facility.
2.10 Stillbirth
This refers to a baby born at or after 28 weeks of gestation with no signs of life.
2.11 Early neonatal death
Is the death of a live newborn within the first seven days of life.
2.12 Perinatal death
Is an inclusive term of both stillborns and early neonatal deaths. Death of a fetus from 28
weeks of gestation age to seven completed days of life including stillbirths. Example of
medical causes of perinatal death include: complications of prematurity, severe infection,
asphyxia, anaemia, congenital malformations, birth injuries etc.
2.13 Contributing factors for perinatal deaths include:
- Poor maternal health

- Inadequate care during pregnancy
- Inappropriate management during labour and delivery
- Poor hygiene during delivery and the first critical hours after birth
- Sub-optimal newborn care
- Baby - mother separation after birth
2.14 Maternal Death Review (MDR)
Is defined as “a qualitative, in-depth investigation of the causes of and circumstances

surrounding, a maternal death” and includes methods designed for reviewing deaths that
occur in both health facilities and communities.

2.15 Maternal/perinatal death surveillance
This is a form of continuous tracking of maternal/perinatal deaths and linking to the health
information system and quality improvement process from the local to the national levels.
2.16 Response
Is the implementation of action plans from maternal/perinatal death reviews to avoid

occurrence of similar preventable cause(s) and circumstances of death.
2.17 Maternal and Perinatal Deaths Surveillance and Response (MPDSR)
Is the routine identification, notification, quantification and determination of causes and

avoidability of all maternal and perinatal deaths, as well as the use of this information to
respond with actions that will prevent future deaths.
2.18 International Classification of Diseases and Related Health Problems (ICD)
It is an international standard for defining and reporting diseases and related health
conditions. It allows international sharing and comparing of information on causes of death
using a common language.
2.19 International Classification of Diseases Maternal Mortality (ICD MM)
It is a standard international diagnostic classification system used by health care providers to

classify and code all causes of maternal deaths to facilitate the consistent collection, analysis
and interpretation of information on maternal deaths.
2.20 International Classification Disease version -10 Perinatal Mortality (ICD PM)
It is the standardised system for classifying stillbirths and neonatal deaths which helps
countries to link stillbirth and neonatal deaths to contributing conditions in pregnant women.
2.21 Verbal Autopsy
It is the method used to ascertain the cause of death based on interview with next of kin or
other care givers to help determine probable cause of death in cases where there were no
medical records or formal medical attention.
2.22 Maternal near miss
Is defined as very ill pregnant or recently delivered woman who nearly died but survived
complication during pregnancy, child birth or within 42 days of termination of pregnancy.
2.23 Medical Certification on the Causes of Death (MCCD)
It is a tool that captures the medical causes of death.

Chapter 3:
Vision, Mission and Objectives

3.1 Vision
To eliminate all preventable maternal and perinatal deaths, using evidence-based strategies
to guide both clinical and public health actions by all stakeholders and monitor progress.
3.2 Mission
To provide information and recommendations for actions in order to eliminate preventable

maternal and perinatal deaths at health facilities and in the community.
To document maternal and perinatal deaths so as to understand and determine the actual
magnitude of the problem, and trends over time in order to assess the impact of various
maternal and perinatal mortality reduction strategies.
3.3 Objectives
3.3.1 To guide collection of reliable data on maternal and perinatal deaths through
identification, notification, reviews and analysis of maternal and perinatal deaths.
- Identification, notification, reviews and analysis of facility-based maternal

and perinatal deaths.
- Identification, notification and review of community-based maternal and

perinatal deaths.
- Document causes of facility and community maternal and perinatal deaths

as well as associated factors.
3.3.2 To guide analysis of maternal and perinatal mortality data for an in-depth
understanding of causes, trends and associated factors (groups at increased risk,
geographical mapping, socio-demographic and health system dysfunctions).
3.3.3 To guide use of maternal and perinatal mortality data for recommendation and
implementation of evidence based strategies for reducing maternal and perinatal
deaths.
3.3.4 To enhance accountability aiming at reducing maternal and perinatal mortality at all
levels (from individual families to national government).
3.3.5 To guide appropriate packaging and dissemination of maternal and perinatal

mortality findings and recommendations to targeted groups and to the wider
public, including advocacy for maternal and perinatal survival as well as allocation
and disbursement of more resources for maternal and perinatal health.

Chapter 4:
MPDSR Overview
This is a continuous action cycle that involves constant surveillance, identification, notification
and review of maternal and perinatal deaths with the aim of preventing deaths from the
information collected. It is an integrated system that also provides accurate data of maternal and
perinatal deaths from both facilities and communities.
Figure 1: The MPDSR cycle (WHO 2013); a continuous action cycle including community and
facility as well as district, regional and national levels
Respond and Identify and

monitor response notify deaths
M&E
Anayse and make Review maternal
recommendations deaths
4.1 The rationales for the MPDSR
The MPDSR has two main rationales:
4.1.1 Information in MPDSR creates awareness of maternal and perinatal mortality at

community, facility and inter-sectoral level. The increased awareness can lead to
changes in practice among health practitioners as well as reallocation of resources
to activities for decreasing maternal mortality. An enabling environment of
collaboration rather than blame is needed to conduct MPDSR and apply the
findings towards action.
4.1.2 It forms a framework for accurate assessment of the magnitude of women`s deaths
related to pregnancy. The will enable policy and decision makers to give the
problem the attention it deserves. Also evaluators will more accurately assess
the effect. Ultimately MPDSR aims to identify every maternal/perinatal death in
order to accurately monitor mortalities and the impact of intervention to reduce
them.

4.2 Steps of MPDSR
4.2.1 Identification and notification on an ongoing basis: It is an integrated system that

involves constant surveillance and identification of suspected maternal and
perinatal deaths in facilities (maternity and other wards) and communities,
followed by immediate notification (within 48 hours) to the appropriate
authorities in the district, region and national level. It should be followed up
with an immediate response from all levels to redress events that led to death.
4.2.2 Review of maternal and perinatal deaths: Examination of medical and non-
medical contributing factors that led to the death, assessment of avoidability,
development of recommendations and their implementation for preventing
future deaths. The review of death can be done in number of ways depending
on circumstances;
- Facility maternal death review: A qualitative, systematic, confidential,

in depth investigation of the causes and circumstances leading to each
maternal/perinatal death occurring at the health facility
- Community based maternal death review: Consists of interviewing
people who are knowledgeable about events leading to death that
occurred in the community such as family members, neighbours,
village government leaders and traditional birth attendants.
- Confidential inquiry to maternal deaths: A systematic multi-
disciplinary anonymous investigation of all or a representative sample
of maternal/perinatal deaths occurring in a country identifying the
numbers, causes and avoidable or remediable factors associated with
them.
- Survey of severe morbidity (“near miss”): A systematic review of
events of a woman who nearly died but survived a complication that
occurred during pregnancy, childbirth and within 42 days of termination
of pregnancy. Near misses are reviewed with the aim of improving
practice and quality of care. It is recommended to review near misses
when the facility has no maternal death to ensure constant review and
continuous improvement of quality.
- Clinical audit: Systematic critical analysis of the quality of care provided
to patients at a health facility with primary aim of improving clinical
practice.
NB. - The review process described in this guideline includes facility and or
community review of maternal and perinatal deaths.
4.2.3 Data analysis, making recommendations and dissemination of results: Information

from the reviews is analysed to make recommendations for actions. Also, there

is an aggregation and examination of trends of data at all levels of the health

system in a systematic predetermined period with the aim of providing reports
to stakeholders (both government and non-governmental) for action.
4.2.4 Respond and monitor response: This is the implementation of recommendations

from maternal/perinatal death reviews made by the MPDSR committee and
those based on aggregated data analysis. Monitoring response is a systematic
and long-term process that gathers information regarding the progress made
during the implementation of action plans.
4.3 Principles for MPDSR

Box 1: Principles of establishing an MPDSR system
Capacity building: For MPDSR to work, health care providers need to be trained on
different aspects of the cycle such as identification and notification of maternal and
perinatal deaths, collect information, analyse results, recommend solutions, implement
recommendations, then evaluate and refine.
Intensive and inclusive planning: Establish a code of conduct, legal environment and
standards for conducting MPDSR activities. Engage and orient all stakeholders, and
identify champions at all levels from the community, facility, public and private sectors
as well as professional associations.
Sustained collective learning: To promote shared responsibility and teamwork;

introduce MPDSR principles in training curricula and foster collective learning for
action at all levels.
Optimising opportunities for achieving wider benefits: To develop a culture of

accountability and quality of care centred on continuous improvement of health care
services; improve record keeping, data flow, data quality and Health Management
Information System (HMIS), strengthen the existing systems including vital registration
and population/pregnancy surveillance; and focus on improved understanding on
burden and level of maternal deaths in the population.
Adopted from MDSR Technical Guidance (WHO 2013)

Chapter 5:
Identification and Notification

Maternal and perinatal deaths often indicate weaknesses in the health-care system therefore
timely maternal and perinatal deaths reporting is essential if the MPDSR is to be successful.
Recall of events that might have contributed to a maternal or perinatal death becomes less clear
as time passes.
Maternal and perinatal deaths are thus notifiable events;

it is an offence if not notified.
Maternal and Perinatal Death Surveillance and Response always starts with the important step
of identification and notification. The two processes should be done both in the community
and health facility in order to get complete and accurate data. Identification of maternal deaths
should start with identifying deaths of all women of reproductive age both in community and
health facility. The next step is to identify all suspected maternal deaths. These are deaths of
women which occurred during pregnancy or within 42 days of termination of pregnancy or when
there is any suspect of presence of pregnancy. Likewise in perinatal death, the identification is
done both at health facilities and community.
5.1 Maternal and perinatal death notification
Notification of maternal and perinatal deaths should be completed in a timely manner in order
to facilitate review and prevention efforts. In order to do this efficiently, all suspected maternal
and perinatal deaths are notifiable events in the National Integrated Diseases Surveillance and
Response (IDSR). All perinatal deaths and suspected maternal deaths that occur in a health
facility or community should be notified within 24 and 48 hours of occurrence respectively.
When maternal or perinatal death occurs in the health facility or community, notification
should immediately be sent to District Reproductive and Child Health Coordinator (DRCHCo)
through SMS and email or by any fast means of communication including WhatsApp (and related
applications) and the notification form should be filled and sent to the same person.
5.2 Notification at health facility
The facility in-charge should identify an MPDSR focal person that conducts constant surveillance
of deaths of women of reproductive age and perinatal deaths throughout the facility. For referral
and tertiary hospitals, there should be one focal person for maternal and another for perinatal
deaths.
• A case definition of suspected maternal/perinatal death should be used to identify cases.

• All perinatal and suspected maternal deaths should be sent to the MPDSR committee for
review and confirmation of their causes.
• All perinatal and suspected maternal deaths should be notified to the district level.
• The DRCHCo should be the district focal person who actively does surveillance of health

facilities and receives information on all notified perinatal and suspected maternal deaths
in the district/council.
• Notification of deaths should be done using the Maternal/Perinatal Death Notification
Form (Annex no. 2 Facility maternal death notification form and Annex no. 3 Facility
perinatal deaths notification form).
• The facility focal person should make an effort to notify the DRCHCo and facility IDSR focal
person immediately using SMS or email for inclusion in the electronic notification database
in the IDSR system.
• The focal person should also send a filled notification form to DRCHCo. The form should be
filled in duplicate, one copy is sent to the DRCHCo and another stays in facility.
• The DRCHCo will send the copy of the form to the region and the MoHCDGEC.
5.3 Identification and notification of maternal/perinatal deaths in the community
Perinatal and suspected maternal deaths that occur in the community should be identified
through registration of all deaths that occur in the community. This should be done using the
form for community identification of perinatal and suspected maternal deaths.
Each death of a woman of reproductive age or stillbirth and death of newborn below 7 days after
birth that occurs in the community should have the form filled and determination of whether it is
suspected maternal/perinatal death done. The Village Executive Officer (VEO) or Street Executive
Officer should be responsible for constant surveillance of deaths that occur in their community
to identify perinatal and suspected maternal deaths. Perinatal and suspected maternal deaths
in the community should be notified to the nearby health facility within 24 hours by sending
the filled form (Annex 4 and 5). The health facility in-charge or any other appointed health care
provider should confirm the perinatal or suspected maternal death then notification to district
(DRCHCo) should be done within 24 hours by sending SMS or email and a copy of the filled form.
The DRCHCo should send a copy to IDSR focal person, region and MoHCDGEC. The notification
should be done immediately using SMS, WhatsApp or email and filled notification form.
5.4 Immediate response after notification
This Guideline expects that each level the focal person shall respond accordingly to the notified
maternal and perinatal death. On daily basis, all maternal and perinatal death from health
facilities and community level shall be notifiable event to the District Medical Officer and the
later shall notify the Regional Medical Officer (RMO). The RMO response on the notifiable event
shall be to form a team of 1-3 experts that will be responsible to provide technical assistance
to Health Facility or District MPDSR committee to investigate the cause of maternal or perinatal
deaths at health facility or community level, respectively. In additional, the RMO will notify the
maternal death(s) to the MoHCDGEC at the Department of Preventive Services and the later will
compile a monthly report to be submitted to the Chief Medical Officer. In this process, the District
and Regional Reproductive and Child Health Coordinators will provide a key link in notification
and review of all maternal and perinatal deaths from both health facility and community level.
The process above is summarized in figures 2 & 3 on next page.

5.5 Zero reporting
All facilities should have daily zero reporting of maternal/perinatal deaths from the facility and
surrounding community to the district. This will ensure continuous surveillance of occurrence
of maternal and perinatal deaths. The DRCHCo and RRCHCo are the responsible persons for the
zero reporting at council level and tertiary hospitals respectively.
Figure 2: Process of notification and response
Figure 3: Summary of maternal and perinatal deaths identification notification, and feedback
Ministry of Health Community

Development Gender Elderly and
Consultant/National Regional health management team

hospitals
Council health management team
Dispensaries, Health centers, Hospitals
Community

Chapter 6:
MPDSR Committees
Each facility (public, private or faith based) should set up a facility MPDSR committee which
will investigate or assess all perinatal and suspected maternal deaths to identify problems that
occurred and possible solutions. There are also going to be MPDSR technical committees at
council, regional and national levels. Collectively, the members of the MPDSR committee need to
have the expertise to identify both the medical and non-medical problems that contributed to the
deaths. In addition, having the right mix of expertise in the MPDSR committee is critical when it is
time to act on the death review findings and help develop and implement the recommendations.
If the review process is focused on deaths that occurred in the community, where there is
greater interest in understanding social or non-medical factors affecting maternal and perinatal
deaths, the review committee should include individuals with knowledge of the local customs
and practices, community representatives, and a social scientist. A physician and/or a midwife
should also be on the committee to review any medical information, including findings from
verbal autopsy done as part of the community-based review.
6.1 Types of Committees
There are three different types of committees involved in MPDSR:
I. Facility based MPDSR committee
II. Technical MPDSR committee at council, regional and national level
III. Community MPDSR committee
6.2 Composition of Facility MPDSR Committees
6.2.1 Consultant Hospitals
Due to the high number of patients and possibly deaths, consultant hospitals will have two
different committees as explained below:
i. Maternal deaths and stillbirths review committee and
ii. Perinatal deaths review committee
Chairperson and Coordinator
Head of Department of Obstetrics and Gynaecology or someone senior and knowledgeable on

his/her behalf.
Secretary
Nurse in-charge of Obstetrics and Gynaecology Department or someone acting in his/her

position.

Members
1. Nurses in-charge of all Gynaecology and Obstetrics wards
2. All Obstetrician Gynaecologists
3. Head of Paediatric Department or someone acting on his/her position
4. Facility MPDSR focal person (the presenter)
5. Zonal RCHCo
6. Nurse in-charge operating theatre
7. Anaesthesiologist
8. Head of Pharmacy
9. Representative RCH Clinic
10. Head of Laboratory Services
11. Provider(s) involved in management of deceased
12. Hospital Administrator/ Secretary
13. Social Welfare Officer
14. Member of facility quality improvement team
15. Facility HMIS focal person
16. Any invitee as it may be deemed necessary
ii. Perinatal Death Committee (For early neonatal deaths)
Chairperson
The Head of Neonatal Unit or someone senior and knowledgeable on his/her behalf
Secretary and Coordinator
The Nurse in-charge of Neonatal Unit or someone acting in his/her position
Members
1. Head of Paediatric Department
2. Head of Obstetrics and Gynaecology
3. All Paediatricians and Medical Officers working in the neonatal unit

5. Nurse from:
• Labour ward
• Kangaroo Mother Care (KMC) ward
• All Nursing Officers from Neonatal ward
2. Zonal RCHCo
3. Representative from operating theatre
4. Head of Laboratory Services
5. Head of Pharmacy
6. One Medical Officer from Labour Ward
7. Providers involved in the management of the deceased
8. Hospital Administrator/Secretary
10. Facility HMIS focal person
6.2.2 Regional Referral Hospital MPDSR Committee
Chairperson
Doctor in charge of Obstetrics and Gynaecology/Doctor in-charge Paediatrics Department or

Someone senior and knowledgeable on his/her behalf
Secretary
Nurse in-charge of Obstetrics and Gynaecology/Nurse in-charge Paediatrics Department
Members
1. Medical Officer in-charge of the Hospital.
2. Nursing Officer in-charge of the Hospital.
4. Representative of:
• Operating theatre
• Anaesthetist
• RCH Clinic

5. One Doctor from the Department of Paediatrics
6. One Doctor from the Department of Obstetrics and Gynaecology
7. Nurse in-charge of Labour Ward
8. Nurse in-charge Neonatal Unit
9. Hospital In-charge of Pharmacy and
10. Hospital in-charge of Laboratory Services
11. Regional RCHCo
12. Provider(s) involved in management of the deceased
13. Hospital Secretary
16. HMIS focal person
17. Zonal RCH Coordinator
6.2.3 District Hospital MPDSR Committee
Chairperson
Doctor in-charge of the hospital or someone senior and knowledgeable on his/her behalf
Secretary
Nurse in-charge of the hospital or someone acting in his/her position
Members:
1. District Reproductive and Child Health Coordinator
2. Nurse in-charge of Labour Ward
3. Nurse in-charge of Neonatal ward
4. Medical Doctor in-charge of Obstetrics and Gynaecology ward
5. Medical Doctor in charge of Paediatric Ward
7. In-charge – OPD services.

8. Representative from:
- RCH clinic
- Anaesthetist
- Operating theatre
9. Hospital in-charge of:
- Laboratory services
- Pharmacy
10. Nurse in-charge of Obstetrics and Gynaecology ward
11. MPDSR Coordinator
12. Hospital Secretary
14. Facility quality improvement chairperson
15. HMIS focal person
16. Obstetrician Gynaecologist and Paediatrician from regional level
17. Any invitee as it may be deemed necessary (e.g. Anaesthesiologist from the regional
hospital)
NOTE: The above committee composition applies for all other Hospitals in the district,
including private Hospitals. It is emphasized that whenever possible each district hospital
MPDSR committee should always have an Obstetrician and Gynaecologist, Paediatrician,
Anaesthesiologist or any other senior clinician from regional hospital or any other close facility
(e.g. faith based hospitals) during the meeting to support and provide expertise opinion,
mentoring and coaching.
6.2.4 Health Centre and Dispensary
For maternal and perinatal deaths happening at the level of the health centre and dispensary
the representatives from council MPDSR technical committee will go to the facility to work with
the facility committee to review the death. An obstetrician and gynaecologist, paediatrician, or
anaesthesiologist should also accompany the council committee representatives for the review.
Composition of members for facility based maternal and perinatal death review committee at
these levels will be as shown below:
i. Health Centre MPDSR Committee
In-charge of health centre or someone senior and knowledgeable on his/her behalf

Secretary
Nurse in-charge of Health Centre
Members
1. Medical Officers at the Health Centre
2. Assistant Medical Officers at the Health Centre
3. All Clinical officers at the Health Centre
5. All Nurse/Midwives, Registered Nurses and Enrolled Nurses at the Health Centre
6. Members of council MPDSR technical committee (DMO, DNO, DRCHCo etc)
7. Provider(s) involved in management of the deceased
8. Facility QI focal person
9. Any invitee as it may be found necessary
ii. Dispensary MPDSR Committee

In-charge of the Dispensary or someone senior and knowledgeable on his/her behalf
Secretary
Nurse in-charge of the Dispensary
Members
1. All trained health personnel at the Dispensary
2. Members of Council MPDSR Technical Committee (DMO, DNO, DRCHCo etc)
4. Any invitee as it may be found necessary
5. Provider (s) involved in management
6. Facility QI focal person
Roles and Responsibilities of Facility MPDSR Committee
• Review all notified perinatal and suspected maternal deaths in the facility
• Fill MPDSR form and submit to the council
• Provide recommendations for action at facility and higher levels
• Analyse and aggregate facility maternal and perinatal deaths data and report to the

council technical MPDSR committee

• Work with members of the CHMTs to review community maternal and perinatal deaths
6.2.5 Community MPDSR Committee
The community maternal and perinatal death committee will be composed of the some members
from Council maternal and perinatal death review committee with addition of other members
as follows:
1. DRCHCo
2. Specialist (Obstetrician or Paediatrician) from Council/Regional Hospital if available
3. Council Community Development Officer
4. Council Social Welfare member
5. Village Executive Officer (VEO)
6. Community Health Worker if available
7. Catchment area facility in-charge (Health Centre or Dispensary)
8. HMIS focal person from the facility
9. Member from Village Health Committee
10. Any other person deemed necessary
6.3 Technical MPDSR Committees at Different Levels
6.3.1 National MPDSR Technical Committee
Chairperson
Chief Medical Officer or someone senior and knowledgeable on his/her behalf
Secretary
Assistant Director RCHS
Coordinator
Safe Motherhood Coordinator and Newborn and Child Health Coordinator
Members
1. Director Preventive Services
2. Director Curative Services
3. Director Health Quality Assurance

4. Director of Policy and Planning
5. Director of Nursing Services
6. Head of Legal Unit - MoHCDGEC
7. Managing Director – MSD
8. Director Muhimbili National Hospital
9. Principal Nursing Officer Preventive Services
10. Assistant Director HMIS - MoHCDGEC
11. MPDSR focal person
12. RMO and DMO chairperson
13. Program Manager National Blood Transfusion Services
14. Members from academic and research institutions
15. MUHAS, IFAKARA, NIMR, NBS
16. Representative from professional associations:
- AGOTA
- TAMA
- PAT
- APHFTA
- CSSC
- BAKWATA
17. Head Obstetrics and Gynaecology Department from:
- Muhimbili National Hospital
- KCMC
- Bugando
- Mbeya Zonal Referral Hospital.
18. Head of Paediatrics and Child Health Department from:
- Muhimbili National Hospital

- KCMC
- Bugando
- Mbeya Zonal Referral Hospital
19. Representative from Ministry of Finance
20. Director of Health Services PORALG
21. Coordinator RMCAH Services PORALG
22. Director Community Development
23. One representative of zonal RCHCoS
24. UN agencies (WHO/UNICEF/UNFPA)
25. Two representatives from implementing partners
26. One representative from Development Partners Group - Health
27. Two experts in maternal and child health
NOTE: The committee will meet for three days twice per year to review aggregated and analysed
maternal and perinatal deaths data from the regions that occurred in the country. The RCH
section will be the secretariat of this technical committee for compiling data. The secretary to
the committee will be responsible for presenting to the committee and taking minutes of the
deliberations.
Roles and responsibilities of National Technical MPDSR Committee
• Biannual meetings should only review a few individual cases from different regions in the
country when deemed necessary to understand a particular issue
• Review aggregated and analysed maternal and perinatal deaths data from the regions
to produce a story from the data to guide improvement in quality of care. For example,
a summary of information on who died (deceased’s characteristics -age, geographical
location) and important findings during the review.
• Provide insight on causes, trends, critical missing skills, items and equipment which might
have contributed to the deaths.
• The information should enable formulation of policy and other important documents
to guide improvement of quality of services, national response and advocacy for more
resources
• Discuss monitoring and evaluation data of MPDSR implementation and provide
recommendations
• Organize biannual national MPDSR meetings
• Produce biannual and annual reports of MPDSR data and recommendations for way
forward

6.3.2 Regional MPDSR Technical Committee
Chairperson
Regional Medical Officer
Secretary
Regional Nursing Officer
Coordinator
Regional Reproductive and Child Health Coordinator
Members:
1. District Medical Officers in the region.
2. Medical Officer in-charge of all hospitals in the region (including private and FBO hospitals).
1. Matron/Patron of all hospitals in the region (including private and FBO hospitals)
2. Zonal RCH Coordinator
3. Zonal Manager National Blood Transfusion Services
4. Regional Laboratory Technologist
5. Regional Pharmacist
6. Regional HMIS focal person
7. Head Obstetrics and Gynaecology in the Regional Hospital
8. Head Paediatrics in the Regional Hospital
9. One representative from RMNCAH partners in the region.
Note: It is a 2 day session in every quarter
Roles and Responsibilities of Regional Technical MPDSR Committee
• Quarterly meetings should only review a few individual cases from different districts in the
region when deemed necessary to understand a particular issue
• Discuss aggregated and analysed MPDSR data and action plans from all councils in the
region
• Report council aggregated data and action plans to the national level (MoHCDGEC)
• Disseminate analysed and aggregated data to stakeholders/partners quarterly
• Follow up implementation of district action plans
• Provide guidance on supportive supervision/mentoring and coaching to Council MPDSR
Technical Committee

6.3.3 Council Technical MPDSR Committee
Chairperson
District Medical Officer
Secretary
District Nursing Officer
Coordinator
District Reproductive and Child Health Coordinator
Members:
1. Medical Officer in-charge of all hospitals in the district (including Private and FBO
Hospitals)
2. Matron/Patron of all hospitals in the district
3. District Pharmacist
4. District Laboratory Technologist
5. In-charge Obstetric and Gynaecology
6. In-charge Paediatrics
7. All Obstetricians available in the council including FBOs
8. All Paediatricians available in the council including FBOs
9. Focal person HMIS
10. Focal person IDSR
11. Quality improvements focal person
12. One representative from each RMNCAH implementing partner in the district.
Note: It is a 1 day session each month
Roles and responsibilities of Council Technical MPDSR Committee
• Routinely review maternal/perinatal deaths in health centres and dispensaries together

with facility committees
• Monthly meetings should only review a few individual cases from district hospitals or
other facilities when deemed necessary to understand a particular issue
• Make recommendations for actions in the district and higher level
• Solicit resources for implementation of actions in district health facilities
• Analyse and aggregate district data monthly, quarterly and annually for use at district,
regional and national level
• Provide feedback to the facilities

• Disseminate analysed and aggregated data to stakeholders/partners monthly

• Monitor implementation of action plans at the council and health facilities
• Report to the regional and national level
Capacity building of committee members
For the MPDSR process to be effective, the MPDSR focal persons/coordinators and committee
members at all levels will be trained on the MPDSR process. Trainings will be organized and
rolled out by the MOHCDGEC.

Chapter 7:
Maternal and Perinatal Death Review Process

The review of maternal and perinatal deaths is an important step in MPDSR because each death
has a story that we can learn from. The process includes facility and/or community based review
depending on where the death occurred. Often it may be necessary to use a combination of both
methods to get complete information for review.
7.1 Facility Review
How soon should maternal/perinatal death be reviewed?
Following the identification and notification of a perinatal or suspected maternal death, (see
chapter IV) a determination is made about whether it was a perinatal or a suspected maternal
death. All perinatal and suspected maternal deaths should be sent for review by MPDSR
committee. The MPDSR focal person is responsible for preparing the clinical summary for every
maternal/perinatal death. The review should be done within 7 days of occurrence for facility
deaths and at most 14 days for community deaths.
7.1.1 MPDSR Focal person/ Coordinator
Facilities at all levels (dispensary, health center, hospital – public and private) should have an
MPDSR focal person appointed by the facility in-charge to facilitate identification, notification
and the maternal and perinatal death review process. At district/council level the DRCHCo will
act as the coordinator of MPDSR in the district/council.
The MPDSR focal person/coordinator should:
- Have an in-depth understanding of data collection process, flow of data and

instruments of data collection
- Be able to relate with other staff and have authority
- Be able to review quality of data and triangulate data from multiple sites
7.1.2 The Clinical Summary
Before review of each maternal/perinatal death, the focal person will prepare a clinical summary
to be presented and used during the discussions. The MPDSR committee may solicit the clinical
case notes during the discussions if they are deemed to be necessary. The clinical summary
should have information from multiple sources such as case notes, antenatal cards, theatre
notes, delivery registers, interview of health care providers who took care of the deceased, close
relatives, ICU charts etc. The summary should have the information shown in the Tables 1 and
2. A narrative of the summary should be written as shown in the examples in Box 2 and 3 for a
maternal and perinatal death respectively.

Table 1: Clinical summary collection guide for maternal death
Socio-demographic data Age, marital status, education, occupations, home address (district,
ward, village, sub-village/street)
Prenatal history Reproductive history (gravidity/parity/live births/stillbirths/
spontaneous abortions/induced abortions/previous Caesareans/
previous pregnancy complications); medical history; whether current
pregnancy was planned (contraceptive use and type); antenatal care
(place, gestational age at onset, number of visits, provider)
Preexisting medical Hypertension; diabetes, anaemia, hepatitis, heart conditions, HIV/
conditions AIDS, tuberculosis
Antenatal risk factors and Hypertension; proteinuria; glycosuria; anaemia; urinary tract
complications infection; HIV/AIDS; malaria; undesired pregnancy; placenta previa;
previous Caesarean section; multiple gestation; abnormal lie;
hospitalisations (date[s], place, diagnoses, test results, procedures,
treatments).
Admission, history and Admission information (time, date, condition, diagnosis, referral
physical examination information); summary history of presenting illness, general physical
examination; vital signs (heart rate, blood pressure, temperature,
respiratory rate, height, weight, any abnormalities); abdominal
exam (fundal height, presentation, abnormalities noted); pelvic
examination (stage of labour if in labour, abnormalities noted);
admission complications (PROM, abruption, preterm labour,
pyelonephritis, pre-eclampsia, eclampsia, fetal demise, sepsis,
vaginal discharge, malaria).
Labour information Onset of labour – if occurred (place/day/time); labour management
(involved health staff, use of partograph, presentation, active
management; complications (including date(s), signs and symptoms,
diagnoses (examples include: abruption, hypertension, infection),
procedures, treatments); active management of third stage of labour.
Delivery information Pregnancy outcome and condition (undelivered, delivered-live birth,
stillbirth (macerated/fresh), abortion, ectopic); method of delivery/
procedure (D&C, vaginal delivery, assisted vaginal delivery, Caesarean
section (elective or emergency) medical treatment); gestational age
at delivery; neonatal information (weight, APGAR scores).
Postnatal events Postnatal events (including date(s), signs and symptoms, diagnoses
(examples include infection, haemorrhage, pre-eclampsia,
depression).
Procedures/interventions Antenatal, intrapartum, and postnatal complications (include
date(s), signs and symptoms, diagnoses, procedures, treatments);
procedures/interventions (can include blood transfusions, antibiotics,
evacuation, hysterectomy, laparatomy, magnesium sulphate,
antibiotics).
Laboratory information Blood type and Rh, haematocrit/haemoglobin, blood chemistry;
urinalysis; VDRL, HIV/AIDS, blood sugar
Events leading to death Final complications and their sequence, intervention given
Death certification Date and time of death, documented cause of death

Table 2: Clinical summary collection guide for perinatal death
Socio-demographic data Age, marital status, ethnicity, education, occupations, home address
of the mother (district,ward/ village,sub-village/street)
Prenatal history Reproductive history (gravidity/parity/live births/stillbirths/
spontaneous abortions/induced abortions/previous Caesareans/
previous pregnancy complications); medical history; whether current
pregnancy was planned (contraceptive use and type); antenatal care
(place, gestational age at onset, number of visits, provider).
Preexisting medical Hypertension, diabetes, anaemia, hepatitis, heart conditions, HIV/
conditions AIDS, tuberculosis
Antenatal risk factors and Hypertension; proteinuria; glycosuria; anaemia; urinary tract
complications infection; HIV/AIDS; malaria; undesired pregnancy; placenta previa;
previous Caesarean section; multiple gestation; abnormal lie;
hospitalisations (date[s], place, diagnoses, test results, procedures,
treatments)
Admission, history and Admission information (time, date, condition, diagnosis, referral
physical examination information); summary history of presenting illness, general physical
examination; vital signs (heart rate, blood pressure, temperature,
respiratory rate, height, weight, any abnormalities); abdominal exam
(fundal height, presentation, abnormalities noted; pelvic examination
(stage of labour if in labour, abnormalities noted); admission
complications (PROM, abruption, preterm labour, pyelonephritis,
pre-eclampsia, eclampsia, fetal demise, sepsis, vaginal discharge,
malaria).
Labour information Onset of labour – if occurred (place/day/time); labour management
(involved health staff, use of partograph, presentation, active
management; complications (including date(s), signs and symptoms,
diagnoses (examples include: abruption, hypertension, infection),
procedures, treatments); active management of third stage of labour.
Delivery information Pregnancy outcome and condition (delivered-live birth, stillbirth
(macerated/fresh); method of delivery/procedure (vaginal delivery,
assisted vaginal delivery, Caesarean section (elective or emergency);
gestational age at delivery; neonatal information (weight, APGAR
scores).
For live newborn Status at delivery, presenting symptoms, time and date when
information symptoms stated, time reviewed by physician, physical examination,
systemic examination, congenital malformation, physical signs of
prematurity
Investigations information Blood investigations, urine, imaging studies
Diagnosis and Initial diagnosis, confirmed diagnosis, medical treatment given,
management admission to NICU, procedures done, complications of management
Events leading to death Date and time complications started, what started and follow up
events, attended by who at what time and date, management given,
complications that occurred, the last complication before death
Death information Date and time of death, documented cause of death

Box 2: Maternal Death Review: Example of maternal death narrative summary
Mrs XX a primigravida, 28 years old, was admitted at 8pm. On admission, the vital signs were; Blood
pressure of 110/70 mmHg, Pulse Rate of 110 beats per minute, Respiratory rate of 22 breaths per
minute, fully conscious with good orientation at gestation age of 37 weeks. Mrs. XX complained of
difficulty in breathing for the last 1 month and chest pain for a week. The woman started antenatal
clinic at a neighbouring health centre at a gestation age of 18 weeks and so far she had attended 3
visits. During the visits, the clinic was unable to supply SP and Fefol because each time they were out
of stock. Her only haemoglobin check was done 2 weeks prior when she was told she was severely
anaemic and referred to the district hospital for appropriate care.
After family consultation, resources were made available to enable her to come to the heath facility.
Further assessment revealed that the woman was in labour with at least 2 contractions in every
10 minutes which were graded as moderate and cervix dilation was 5 cm. Hb check in labour ward
revealed that the woman was anaemic with Hb 6 g/dl and blood for blood group and cross matching
was collected. 2 units of whole blood for transfusion were requested as the hospital did not have RBC
concentrates. However, the report from the laboratory indicated that there was no standby blood
as the refrigerator used to store blood had been out of order for the last 3 months. The labour ward
team was told to wait till the next morning for blood to be collected from the zonal blood centre.
The labour progressed but the condition of the patient continued to deteriorate. At midnight, the
patient pulse rate was 120 beats/min, BP 100/60 mmHg and RR of 28 breath per minute and the
chest was reported to have crepitation and IV Lasix 40 mg was given. The contractions were graded
as strong and cervix dilation was 8 cm. An hour later, the mother delivered a normal female baby
weighing 2.5 kg who cried immediately. However, soon after completing AMTSL the woman started
to bleed profusely, in half an hour she was reported to have lost close to 600 mls. The bleeding was
controlled with a combination of oxytocin 10 IU IM and 20 IU in 500mls of Ringers lactate drip.
However, her vital signs dropped sharply to PR 140 b/min, Blood Pressure of 80/30 and RR 34 breath
per min. Despite of giving life support with oxygen, the woman died at 4am.

Box 3: Perinatal Death Review: Example of early neonatal death narrative summary
ZN married 1 year ago and is a 17-year-old primigravida from xxxx district.

Her husband HK is a rich businessman and she is his 3rd wife. When she was 20 weeks pregnant she
noticed some foul smelling vaginal discharge, and went to the antenatal clinic at the nearby hospital.
It was her 1st antenatal care visit. At the booking visit, the midwife took her full history and filled in a
card, measured her weight and blood pressure, checked her blood group, blood haemoglobin levels
and palpated her abdomen, listened to the heart sounds of the foetus and told her everything was fine
with her and the child. She gave her a tetanus injection, prescribed her iron and folic acid tablets and
she had to take 3 antimalarial tablets at the clinic. When ZN mentioned her discharge, the midwife did
not examine her but told her that that was normal during pregnancy and that she should not worry.
She went one more time to the antenatal clinic when she was 34 weeks pregnant, got the same
treatment and went home. When she was 38 weeks she got labour pains and was taken by her mother-
in-law to the maternity ward in the hospital. On admission she had moderate contractions, the fundal
height corresponded to term, the baby was laying in longitudinal lie and cephalic presentation, the
head was 4/5 above the pelvis. The foetal heart was 130/min. On vaginal examination she was 4 cm
dilated, the membranes were intact. The midwife recorded the findings on the partograph. She was
taken to the labour ward. Four hours later her membranes ruptured spontaneously. The liquor was
slightly Meconium-stained. The head was now 3/5 above the brim of the pelvis. Cervical dilatation at
that time was 6 cm. Foetal heart rate was 120/min.
Four hours later the contractions were strong, 4 in 10 minutes, the foetal head 2/5 above the brim,
the cervix was 8 cm dilated. The foetal heart rate was 124/min. ZN was becoming tired and the
contractions were very painful. Finally, after 11 hours of labour she was fully dilated. The midwife told
her to push with each contraction. After pushing for more than 1 hour she delivered a male infant of
3.8 kg. The baby was pale and did not immediately cry after birth and was breathing irregularly. The
midwife sucked out the nose and mouth and slapped the baby on its back. There was no ambu bag
and mask in the labour room. After some time, the baby improved, but was still grunting a bit while
breathing. The APGAR score was 3 after 1 minute and 7 after 5 minutes. The midwife wiped the baby
dry and wrapped it in a cloth. Then she administered 10 U Oxytocin to the mother and delivered the
placenta by controlled cord traction. Blood loss during delivery was 300 ml. The perineum was intact.
Later that day the baby had improved and was able to suck the breast, but he was still grunting a
bit when breathing. The next day the baby got fever 38.8oC. The midwife called the doctor and he
prescribed antimalarials and ordered tepid sponging and 6 hourly monitoring of the temperature.
However, the temperature was only recorded twice a day. The next day there was still fever and
the baby was a bit greyish in colour and slightly jaundiced and had a convulsion, which lasted for 2
minutes and responded well to 1 mg diazepam rectally. The doctor ordered a complete blood count
and prescribed ampiclox syrup 8 hourly.
The next day the condition of the baby was worse. He was unable to suck, looked lethargic, had
a vacant look in his eyes and had slight twitching. The midwife inserted a nasogastric tube and
expressed breastmilk was given 3 hourly. The doctor reviewed the baby during ward round and
prescribed phenobarbitone 5mg/kg, given in 12 hourly doses. The evening of the same day the baby
suddenly stopped breathing and passed away.
7.2 The Review Process
a. Preparation
The chairperson will make sure each committee member is notified of the meeting date, time
and venue, summary and other sources of information have been prepared (by focal person),
the venue is prepared (preferably round table) and ground rules are known.

b. Ground rules/Principles of MPDSR
The chair will moderate the session and ensures participants are comfortable to express their
opinions and that confidentiality is respected.
Some of the ground rules include:
• Arrive on time to the review meeting
• The atmosphere of “NO shame NO blame NO name” should be maintained
• Respect everyone’s ideas and ways of expressing them
• Respect the confidentiality of the discussions in the group
• Participate actively to discussions
• Accept criticisms to improve clinical care
• Accept discussion and disagreement without verbal violence
• Agree not to hide useful information and to provide correct information which could
allow understanding the case
• Commitment to implement recommendations
• Try to accept that our own actions may be questioned
c. Review of the resolutions/recommendations from the previous session
This step aims at assessing whether the recommendations/resolutions reached during the
previous MPDSR session have resulted in actions and change. The following aspects should be
considered:
• The extent of implementation of planned activities and the need for further action(s)
(refer to MPDR action plan follow up form).
• The improvement of case management, which can be estimated through the observed
reduction in the previously identified dysfunctions and obstacles to good care.
d. Clinical summary presentation
The focal person will give an oral presentation of clinical summary as explained above. The
clinical summary contains all information gathered in narrative format as shown in Box 1.
e. Conducting the review
The purpose of the MPDSR session is to fully understand the chain of events related to the case,
identify the main problems in the management of the patient, from the time before admission to
the time of death and come up with solutions to correct them. In addition, the MPDSR will help

to clarify the most likely medical cause(s) of death and the circumstances/factors that might have
adversely affected care e.g. shortage of medicines, essential supplies and equipment, factors
beyond the health system such as woman’s status in the community. Strengths observed during
care should be identified and acknowledged. During the analysis process, at each step, it is useful
to systematically examine:
• The appropriateness of diagnoses and interventions (according to clinical standards)
• The quality of the monitoring of the patient’s condition (temperature, blood

pressure, pulse, bleeding, etc.)
• Reliability of information provided
To facilitate effective case review, use the provided grid analysis of clinical case management
(Table 3). The grid allows an in-depth understanding of the deceased from the time before
admission, at admission and the stages she went through while at the health facility before death
occurred.
The secretary will write down important notes during the discussions without mentioning
names. The resulting minutes should be kept confidential under lock and key together with the
case summaries.
Table 3: Maternal and Perinatal Death Review: Grid analysis of clinical case management
Date of MPDR: MPDR session NO:

In the chain of events described below, make note of points at which dysfunctions occurred and
explain why they are dysfunctions (by comparison with standards of good practice)
1. Events before admission
If this was a referred patient
• Conditions of transfer were appropriate; consider mode of transport (ambulance).
Qualified escort, first treatment (e.g. intravenous line in place) and time required to
reach the hospital. Was there a referral letter? Clear? Useful? Clinical standards of best
practice? Time taken from when the referral was ready to the start of the referral trip?
Duration from arrival at the referral facility?
If not referred but complications arose before admission

• Was a decision to seek care at health facility taken in time?
• Consider mode of transport and time to reach health facility
• Consider the contribution of the woman`s sociocultural and economic status to the
death
2. Admission
At reception:
• Was the admission carried out appropriately?
• Were resuscitative measures provided appropriately and timely in relation to the
patient’s condition?

Date of MPDR: MPDR session NO:

3. Management
If already experiencing complications at time of admission:
• Staff reaction and first assessment were appropriate in relation to the standards
• Time to diagnosis was acceptable in relation to standards
• Diagnosis at admission was appropriate on the basis of available information
• Management at admission was correct in relation to diagnosis and standards of care
If complications occurred during the stay in the health facility:

• Time to diagnosis was acceptable in relation to standards
• Management was correct in relation to patients condition and standards of care and
time in between care
In both cases:
• Investigations necessary for diagnosis were requested and carried out (all, none or some
of them) in relation to standards
• The time which passed before the investigations were made was acceptable in relation
to patient condition
• Results from investigations were acted upon
• Unnecessary investigations were not done
4. Patient monitoring
• Clear instructions on monitoring vital signs and other clinical features were given and
documented
• If applicable, instructions given were appropriate in relation to standards of care (what
to be monitored, frequency and duration)
• Monitoring of vital signs and other clinical features was documented according to the
instructions given in relation to standards of care
5. Information in patients records
All information necessary to assess adherence to standards of care was documented in the
patient`s case notes
DEATH
• On the basis of the analysis, is the medical cause of death the same as was
documented in the patient`s records?
• What are the factors/circumstances that might have adversely affected care?
• Could the death have been prevented? How?
f. Analysis of the dysfunctions
The primary objectives of the MPDSR include identifying the medical causes of death, evaluating
clinical care, and identifying non-medical and avoidable factors (WHO 2013).

Box 4: Causes and associated factors that MPDSR can help identify
• Medical causes
• Medical/clinical factors contributing to the death
- Quality of care
- Remedial clinical actions, such as need for guidelines/protocols etc.
- Health system failures/dysfunctions, such as shortage of blood or other
resources, or lack of equipment, commodities and supplies, lack of skilled
staff
• Non-medical factors contributing to the death
- Cultural attitudes and beliefs
- Specific community-based factors such as transport, communication,
geography, or financial barriers
• Whether the death was avoidable or not
Box 5: Analysis of causes of dysfunction
ANALYSIS OF CAUSES OF THE DYSFUCTIONS
For every dysfunction reported in the management of the case and/or/ in the procedures carried
out try to identify or clarify the causes. Consider the following:
• Staff
Qualifications, skills, availability, attitudes communications
• Medicines
Availability, accessibility
• Equipment
Availability, accessibility, functionality
• Standards of good practice
Existence, availability, transmission, use
• Management, care, organisation
Coordination, communication
• Patient and family
Care accessibility, knowledge, commitment, beliefs, economy
DEATH
• On the basis of the analysis, is the medical cause of death the same as was documented
in the patient`s records?
• What are the factors/circumstances that might have adversely affected care?
• Could the death have been prevented? How?
g. Classification of causes of death
The causes of death must be coded in accordance with the WHO ICD 10-Maternal Mortality
Classification (ICD-MM, WHO 2012) and ICD10 Perinatal Mortality (ICD PM, WHO 2016). This will
facilitate: the determination of the cause of death and dysfunction; compilation of comparable
national data; and data for international comparison. The guide on how to classify causes of
maternal and perinatal deaths are found in the Annex 1.

h. Medical Certificate of Cause of Death (MCCD)
If the death certificate has been completed correctly, the underlying cause of death should
normally be the single condition which the certifier has written on the lowest used line of Part 1.
Table 4: Medical Certificate of Cause of Death
Cause of death Approximate interval

(The disease or condition thought to be the underlying cause should between onset and death
appear in the lowest completed line of part I)
Part I
Disease or condition leading

directly to death
a)
Antecedent causes:
Due to or as a consequence of
b)
c)
d)
Part II Other significant
conditions
Contributing to death but not
related to the disease or condition
causing it
The woman was:

• pregnant at the time of death
• not pregnant at the time of death (but pregnant within 42 days)
• pregnant within the past year

Table 5: Example of how to fill in the MCCD
Source: The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the
puerperium: ICD-MM (WHO 2012).
i. Recommendations and action plans
Actionable recommendations are key to effective maternal and perinatal death reviews. Specific,
measurable, attainable, realistic and time bound (SMART) recommendations are mandatory.
Identification of individuals who will be responsible for implementing the suggested actions is
also important as well as specifying the timelines for those actions.
Examples of action plans for maternal and perinatal deaths (see table 6 and table 7 respectively).

Table 6: Action plan for maternal death
36
Cause of death: Direct maternal death, Obstetric haemorrhage, postpartum haemorrhage due to non-traumatic atony (ICD code O72)
Problem Reason(s)/ Action to be taken ( Responsible When ( Expected outcome Required Implementation
Identified Causes(s) for what to do) person Completion indicators resources status(Completed,
the problem date ongoing, not
identified implemented
Short Term (within one month)
Inappropriate • Lack of • Capacity • Health First week • Protocols on • None • Completed
fluid given knowledge building through facility in- of February management
and skills mentorship on charge/ – on going haemorrhagic shock in
of health management of • In-charge of place and adhered to
service haemorrhagic maternity • Training done
provider shock according ward • Patient with
to standards haemorrhagic shock
managed properly
• Oxytocics • Oxytocics • Capacity building • Health End of • Oxytocics always • None • Completed
(Oxytocin, were not on quantification facility April available
misoprostol, available and ordering/gap pharmacist/
Ergometrin) filling maternity
Reproductive and Child Health Section Dodoma | 2019

were not in-charge
given
Long Term (six months – one year)
Blood was not • Blood • Procure • Health Early July • Refrigerator for blood • RHMT/ • On going
given was not refrigerator for facility in- storage available CHMT/
available blood storage charge • Blood available HMT
• No • Liaise with zonal • Include
refrigerator blood centre to in
to store supply blood CCHP/
blood CHOP
Table 7: Action plan for perinatal death
Cause of death: Birth asphyxia
Problem Reason(s)/ Action to be Responsible When ( Expected Required Implementation

Identified Causes(s) for taken ( what to person Completion outcome resources status
the problem do) date indicators (Completed,
identified On going, Not
implemented)
Short Term (within one month)
Poor • Lack of • On-job- • Nurse in- February • Proper • None
monitoring knowledge training/ charge of the management
of fetal on proper mentorship labour ward of labour using
wellbeing monitoring on proper • Unit Head partograph
during of fetal monitoring of • Training
labour using heart rate fetal heart rate conducted
partograph
Inappropriate • Lack of • On-job- • Nurse in- March • Partograph is
use of knowledge training/ charge of the used properly
partograph on proper mentorship on labour ward
use of partograph • Unit Head
partograph • Printing
• Partograph partograph
not available using A4 paper
Long Term (six months – one year)
Infrequent • Absence • Re-allocation • DMO August • Skilled providers • PORALG
monitoring of skilled • Deployment of available • POPSM
of fetal provider skilled staff • MOHCDGEC

wellbeing
during
37
labour using
partograph
j. Completion of maternal and perinatal reviews report forms
This step involves filling the reporting forms (Annex 5 and 6) by the review team, led by the
meeting’s secretary, and should be completed at the review session. The forms should be filled
in triplicate, two copies sent to the district and another kept at the health facility. At the district,
information from the forms should be entered into the DHIS-2 data base; one form should be
kept and one form should be forwarded to the RMO who will also send the filled form to the
CMO.
k. Planning for the next session
Before closure of the review session, the date for the next meeting should be set. At the next
meeting follow up on the previous MPDSR action plan will be discussed and the persons assigned
as responsible for following up points on the action plan will report back on the implementation
of the actions.
7.3 Community Maternal Death Review
All notified community maternal/perinatal deaths should be reviewed by performing a verbal

autopsy. The cause of death, contributing causes and factors are determined by interviewing a
close relative who was present during the illness and death of the deceased. The review should
be done through following steps:
a. Identification and notification of community maternal/perinatal deaths
This is done as explained in Chapter IV.
b. Performing Verbal Autopsy (VA)
The Council Community Maternal Death Review Committee will take a lead in this process. The
committee will appoint a knowledgeable person (social worker if possible) to perform the VA
interview in the community preferably at most two weeks after the death and burial rituals. VA
will be performed in following steps:
- Identify village/sub-village/street where deceased lived

- Coordinate with Village/Street Authorities to identify the family of the
deceased
- Visit family and identify the head of the family
- Explain the purpose of the visit and ask for consent to perform VA
- Ask the head of family to identify the person(s) who were present during
illness and death
- Ask for any deceased`s medical records that are present such as antenatal
card, death certificate etc.
- Identify a quiet place to ensure secrecy and confidentiality
- Perform the VA interview using the Ministry approved VA tool
- Thank the family

c. Determination of causes of death and dysfunctions
The VA interviewer will make a summary of VA information and present it to Council community
maternal/perinatal deaths review committee. The committee will invite a representative
from the village/street (CHW or village health committee member) and nearby health facility
MPDSR focal person to take part in the discussions. The committee will meet and review the
summary and categorise medical cause, contributing causes and associated factors. They will
also determine the dysfunctions that led to death and make recommendations for action at
facility and community.
d. Feedback to the community
The facility focal person and representative from district/council (DRCHCo or representative) will
visit the village/street and meet the local government leaders and village health committee to
discuss the dysfunctions and how to implement them. They will come up with an action plan for
the community to implement.
e. Filling the report form
After the review, the Council Community Maternal and Perinatal Death Review Committee will
complete the report form for the purposes of data analysis and then share with higher levels
(region and national).

Chapter 8:
Response
This is an essential component of MPDSR and its implementation will ensure prevention of
future deaths. Each maternal/perinatal death review should have recommendations for action
at different levels to prevent another death. The responses should be both immediate responses
and periodic responses after aggregation of data. The responses also include strategies to
implement recommendations and follow implementation. Response activities should be specific
and culturally sensitive to the community and health facility. During the implementation of
recommendations, the confidentiality of the deceased, her family and health care providers
should be maintained.
8.1 Immediate response after review
Identified gaps from review of maternal/perinatal death should be addressed immediately

at health facility and community level. The committee should recommend actions to be
implemented immediately after the review at the facility. This may include issues of quality
of care improvements, skills improvements, address availability of essential equipment and
supplies, community involvement etc. For community deaths, there should be an immediate
joint action plan made by the CHMT and community members to be implemented.
Response guiding principles:
• Start with the avoidable factors/dysfunctions identified during the review process
• Use evidence-based approaches and/or standards provided by MoHCDGEC
• Prioritize (based on urgency, feasibility, costs, resources, health-system readiness, health

impact)
• Establish a timeline (immediate or short or long-term)
• Involve quality improvement team to implement and follow recommendations
• Decide how to monitor implementation
• Integrate recommendations within annual health facility plans
• Link the recommendations with the facility quality improvement plans
• Monitor to ensure that recommendations are being implemented
8.2 Periodic response
Facility, district and regions should quarterly aggregate review reports and respond according to
trends of particular problems in maternal/perinatal deaths. At national level biannual review and
aggregation of data should be done to effect policy change. All levels should have annual review
of recommendations of actions and their implementation.

• At community level, recommendations should target recognition of danger signs,

improved communication between community and facility, improving infrastructure, birth
preparedness etc.
• At facility level, recommendations should target improving quality of care, human

resources, knowledge and skills, infrastructure, equipment and supplies.
• Hospitals should review the MPDSR process to assess the implementation and whether it
is contributing to reduction of maternal/perinatal deaths.
• At council level, recommendations should be incorporated in Comprehensive Council

Health Plans (CCHPs) and aimed at strengthening the health system, training and retaining
staff, encouraging community-facility partnership, advocacy in the community and to other
stakeholders.
• At regional level, responses should focus on following up implementation of

recommendations at council levels.
• At national level, aggregated reports should provide recommendations for shaping health
plans, policies and strategies to address problems.
8.3 Evidence based response
Each recommended action for response should be based on the evidence and standards from
the MoHCDGEC and other bodies such as WHO. Where evidence for a planned recommendation
is not available, especially on issues of family, community, transport and access to care, councils
are encouraged to be innovative and work with stakeholders to come up with solutions.

Figure 4: Response to maternal and perinatal deaths
Identify suspected deaths, notify them, conduct MPDR, and analyze data
Make recommendations and action plans
Respond immediately to each death at facility and community, district,

regional and national level
Perform M&E and produce MPDSR reports at various levels ( community,

facility, district, regional and national)
Disseminate and discuss findings and recommendations with key stakeholders

(community, facility, district, regional, national, NGO’s)
Incorporate recommendations in annual plans
8.4 Follow up of implementation of MPDSR action plans
All levels from the community to national should perform follow up on the implementation of
recommended actions. The follow up schedule should coincide with the timeline agreed in the
review meeting. The facility in-charge, council coordinator, regional coordinator and national
RCH coordinator should follow up implementation of recommendations. Higher levels of the
health care system should respond to recommendations from the lower levels. The district CHMT
will be responsible for following up implementation of community recommended action plans.

Chapter 9:
Data Analysis and Dissemination of Results
All levels of the health system should analyse maternal and perinatal mortality data and produce
results specific for the level of health facility. The data should be used to guide interventions to
prevent deaths. The main aim of data analysis is to:
- Determine specific number of maternal/perinatal deaths
- Identify causes of death (using ICD MM and PM)
- Identify groups at highest risk
- Identify factors contributing to maternal/perinatal deaths
- Assess the emerging data trends
- Identify and prioritize the most important health problems to guide the public health
response
- Test efficiency and effectiveness of strategies designed to combat maternal mortality
Data analysis should utilise information from notification forms, death review report forms and
verified data reported through the national repository system or any other reporting mechanism.
Facilities should conduct monthly, quarterly and annual data aggregation and analysis. The
councils and regions should conduct quarterly and annual data analysis and report on findings
from such analysis, while the national level should analyse maternal and perinatal mortality data
and prepare reports of the findings biannually and annually.
Health facilities in particular should ensure that facility maternal and perinatal mortality data
are analysed based on facility maternal and perinatal reviews. The review committee should
be involved in reviewing the report, developing the recommendations, planning and promoting
their implementation as well as acting as advocates for change. Councils should build the capacity
of health facilities to analyse and prepare reports. Specifically, Council RCH coordinators will
produce council and facility level maternal and perinatal mortality reports from DHIS-2 database
and share this information with respective health facilities.
9.1 Framework for data analysis and flow of information
At each level maternal and perinatal deaths will be aggregated and analysed periodically and
the information used for local implementation. At council level verified reports from death
reviews will be entered into DHIS-2. Analysis and aggregation of data should follow the MPDSR
aggregation format (see the box below). At national level, the death review reports will be
aggregated and analysed to produce national reports biannually or annually. More complex
analysis can be performed depending on the need and availability of expertise.

Box 6: Format for aggregation of data

Maternal/perinatal deaths analysis should follow this guide:
1. Descriptive information (statistics) of the deceased
- Age category, marital status, level of education, gravidity/parity, delivery outcome
- Timing of death (maternal-antepartum/postpartum) (perinatal –antepartum/

intrapartum/neonatal)
- Place of death (home, on the way to facility, dispensary, health centre, hospital)
2. Contributing factors: Three delays and breakdown of factors
3. Causes of death:
- Maternal death (direct, indirect, group and specific underlying cause)
- Perinatal death (antepartum, intrapartum, neonatal, and underlying cause)
4. Avoidability:
- Could the death have been avoided with adequate efforts?
5. Trend analysis: change in number of maternal or perinatal deaths and above variables
with respect to time and specific causes of death
6. Geographical analysis: whenever possible maternal or perinatal deaths should be

analysed according to their geographical location.
7. Aggregation of agreed action plans and their implementation.
9.2 Dissemination
Dissemination of quarterly reports to relevant stakeholders/partners in the village, ward, districts

and regions will nurture better understanding of maternal and perinatal mortality (especially the
goal of eliminating preventable deaths). It will do this by including all stakeholders, including
members of the communities. It will also build a sense of responsibility/accountability for
preventing avoidable maternal and perinatal deaths. In addition, this has the potential to
attract more resources for improving maternal and perinatal health. Notably, results should be
shared in Village and Ward Committee meetings, council and regional RCH meetings, full council
meetings, regional secretariat meetings as well as national forums such as DMO/RMO/RCH
meetings. Specific dissemination materials like fact sheets and leaflets can also be produced and
disseminated as appropriate for wider public reach.
The national biannual maternal and perinatal mortality reports in particular must include a high
level dissemination event with materials for various audiences/stakeholders aiming at informing
the public on the status and common causes of maternal and perinatal mortality in the country,
achievements and challenges in MPDSR implementation and actions which are likely to make a
difference in maternal and perinatal survival, including individual level actions. A short summary
of the recommendations is more easily implemented than those in bulky documents. Policies
and strategies likely to better maternal and perinatal survival should also be highlighted. The
event should also be a platform to recognize health system and wider public entities that may
have performed exceptionally well in addressing maternal and perinatal deaths in the country.

Chapter 10:
Monitoring and Evaluation

A well-functioning monitoring and evaluation system helps to understand if all the established
steps in the MPDSR system are working and provides information on improvement options. All
steps from identification to response must be monitored to make sure they are well regulated to
achieve intended tangible results. Monitoring is recommended to be done at national level but
some indicators should also be monitored at regional and district level. Together with monitoring,
periodic evaluation is important to examine the impact of MPDSR on mortality and suggest ways
to make the system more efficient. Monitoring and evaluation requires vigorous supervision,
review meetings, regular reporting and assessment of performance at all levels of health system.
10.1 Periodic Evaluations
Periodic evaluations at different levels of the health system are important to inform the efficiency
of the system. Periodic evaluation should be done quarterly at council and regional level and
biannually at national level. The monitoring and evaluation should be done according to the
framework on the next page (Table 8) as recommended by the WHO.

Table 8: Monitoring and Evaluation Matrix
46
MONITORING AND EVALUATION MATRIX
LEVEL INDICATOR TARGET DATA SOURCES INDICATOR DEFINITION TIMELINE FOR

REPORTING
HEALTH SYSTEM
Community 1. Maternal and perinatal death are Yes 1.DHIS2 Weekly

notifiable events
Facility 1. Maternal and perinatal death are Yes 1.DHIS2 Weekly
notifiable events 2.IDSR
2. Facility has functional MPDSR Yes 3.RMNCAH-ISS
committee reports
3. Facility has MPDSR focal person Yes
Council 1. % of facilities with functional MPDSR 100% 1.Council MPDSR Numerator: number of facilities Monthly
committee monthly reports with functional MPDSR committees
2. % councils with community MPDSR in the council
committee 100% Denominator: number of all
3. Council has MPDSR focal person facilities in the council
Yes

Region 1. % of councils with functional MPDSR 100% 1.Regional MPDSR Numerator: number of councils Quarterly
technical committee quarterly reports with MPDSR technical committee in
2. Region has MPDSR focal person the region
Yes Denominator: number of all
councils in the region
National 1. National technical committee present Yes 1.National annual Biannually
2. National MPDSR focal person present reports
Yes

REPORTING
NOTIFICATION
Community 1. Proportion of identified and notified 100% are notified 1. Village Numerator: number of notified Monthly
suspected community maternal deaths register community maternal/perinatal
2. Community deaths
2. Proportion of identified and notified maternal/ Denominator: number of all
suspected community perinatal death 100% within 48 perinatal death community maternal/perinatal
within 48 hours hours notification deaths
forms
3. DHIS2
Facility 1. Proportion of identified and notified 100% are notified 1. Facility Numerator: number of notified Monthly
suspected facility maternal deaths maternal/ facility maternal/perinatal deaths
perinatal death Denominator: number of all facility
notification maternal/perinatal deaths
2. Proportion of identified and notified forms
facility perinatal death within 24 hours 100% within 24 2. Facility Death Numerator: number of notified
hours registry maternal/perinatal deaths within
3. DHIS2 24 hrs
Denominator: number of all
notified facility maternal/perinatal
deaths
Council 1. Proportion of expected maternal 100% are notified 1. Completed Numerator: number of notified Quarterly
deaths that are notified MPDSR council maternal/perinatal deaths
notification Denominator: number of all
2. Proportion of expected perinatal forms from all expected council maternal/perinatal

deaths that are notified Health facilities deaths
within the
47
council
2. DHIS2
48
REPORTING
NOTIFICATION
Region 1. Proportion of expected maternal 100% are notified 1. Completed Numerator: number of notified Quarterly
deaths that are notified MPDSR regional maternal/perinatal deaths
notifications Denominator: number of all
2. Proportion of expected perinatal forms from the expected regional maternal/
deaths that are notified council level perinatal deaths
2. DHIS2
National 1. Proportion of expected maternal 100% are notified 1. Completed Numerator: number of notified Biannually
deaths that are notified MPDSR national maternal/perinatal deaths
notification Denominator: number of all
2. Proportion of expected perinatal forms from expected national maternal/
deaths that are notified regions perinatal deaths
2. DHIS2
REVIEW
Community 1. Proportion of notified community 100% reviewed 1. Completed Numerator: number of reviewed Quarterly

maternal deaths that are reviewed maternal and community maternal/perinatal
perinatal death deaths

2. Proportion of notified community review form Denominator: number of notified
perinatal deaths that are reviewed 2. Completed community maternal/perinatal
community deaths
maternal
and perinatal
notification
forms
3. DHIS2

REPORTING
REVIEW
Facility 1. Proportion of notified facility maternal 100% reviewed 1. Completed Numerator: number of reviewed Monthly
deaths that are reviewed MPDSR review facility maternal/perinatal deaths
forms Denominator: number of notified
2. Proportion of notified facility perinatal 2. Death review facility maternal/perinatal deaths
deaths that are reviewed summaries
3. DHIS2
Council 1. Proportion of notified council 100% reviewed 1. Completed Numerator: number of reviewed Quarterly
(community and facility) maternal deaths MPDSR review council maternal/perinatal deaths
that are reviewed Forms from all Denominator: number of notified
Health facilities council maternal/perinatal deaths
2. Proportion of notified council and community
(community and facility) perinatal deaths within the
that are reviewed council
2. DHIS2
Regional 1. Proportion of notified regional 100% reviewed 1. Completed Numerator: number of reviewed Quarterly
maternal deaths that are reviewed MPDSR review regional maternal/perinatal deaths
Forms from Denominator: number of notified
2. Proportion of notified regional councils within regional maternal/perinatal deaths
perinatal deaths that are reviewed the region
2. DHIS2
National 1. Proportion of notified national 100% reviewed 1. Completed Numerator: number of reviewed Biannually
maternal deaths that are reviewed MPDSR national maternal/perinatal deaths
review Forms Denominator: number of notified

2. Proportion of notified national from regions national maternal/perinatal deaths
perinatal deaths that are reviewed countrywide
49
2. DHIS2
50
REPORTING
INFORMATION QUALITY
Community 1. Proportion of WRA deaths checked to 100% of deaths in 1. Village Numerator: number of community Daily
verify they are not suspected maternal WRA dying in the Register WRA death that are checked for
death community suspected maternal death
Denominator: number of all deaths
of WRA in the community
Facility 1. Proportion of WRA deaths checked to 100% of deaths in 1. Death registry Numerator: number of WRA deaths Weekly
verify they are not suspected maternal WRA in facility in the facility that are checked for
death 2. MPDSR suspected maternal death
review forms Denominator: number of all deaths
3. MCCD book of WRA in the facility
Numerator: number of maternal/

2. Proportion of maternal and perinatal 25% of maternal/ perinatal deaths checked for same
death checked for same ICD 10 code in perinatal deaths ICD 10 code in MPDSR review form
MPDSR review form and MCCD Denominator: number of all

maternal deaths reviewed

REPORTING
INFORMATION QUALITY
Council 1. Proportion of health facilities with 100% of all death 1. MPDSR Numerator: number of community Monthly
crosschecked data from facility and notification death crosschecked between
community for same maternal/perinatal Forms community and facility
death 2. MPDSR Denominator: number of all deaths
review forms in the council
3. Death Registry
4. Zero reporting
registry?? Numerator: number of health
2. Proportion of facilities with zero 100% of facilities facilities with zero reporting of
reporting with zero reporting maternal/perinatal deaths
facilities with zero maternal deaths
in the council
Regional 1. Proportion of councils with zero 100% of council 1. Zero reporting Numerator: number of councils Monthly
reporting with zero reporting registry with zero reporting of maternal/
2. Notification perinatal deaths
forms Denominator: number of all
councils with zero maternal/
perinatal deaths in the region

51
52
REPORTING
RESPONSE
Community 1. Proportion of community >80% of 1.Village Numerator: number of Monthly

recommendations that are implemented recommendations implementation implemented community
implemented report recommendations
community recommendations
Facility 1. Proportion of facility MPDSR >80% of 1. Health facility Numerator: number of Monthly
committee recommendations that are recommendations action plan implemented facility committee
implemented implemented forms recommendations
Denominator: number of all facility
recommendations
Council 1. Proportion of Council MPDSR >80% of 1. Council action Numerator: number of Monthly
committee recommendations that are recommendations plan forms implemented council
implemented implemented recommendations
Denominator: number of all council
recommendations

Region 1. Proportion of Regional MPDSR >80% of 2. Regional Numerator: number of Quarterly
committee recommendations that are recommendations action plan implemented regional

Denominator: all regional
recommendations
National 1. Proportion of National MPDSR >80% of 1. National Numerator: number of Biannually
committee recommendations that are recommendations action plan implemented national
national recommendations

REPORTING
REPORTS
Facility 1. Facility MPDSR committee produces Yes 1. MPDSR Quarterly

annual reports committee
annual reports
Council 1. Council produces annual reports Yes 1. MPDSR Quarterly
technical
committee
annual reports
Region 1.Regions produced annual report yes 1. MPDSR Quarterly
technical
committee
annual reports
National 1. National technical committee Yes 1. National Biannually
produces annual reports technical
committee
MPDSR reports
IMPACT
Facility 1. Proportional reduction of pre- 10% annual 1. Annual Numerator: difference of pre- Annual
discharge perinatal deaths decrease MPDSR report discharge perinatal deaths between
previous year and this year
Denominator: number of pre-
discharge perinatal deaths

53
54
REPORTING
IMPACT
Council 1. Maternal/perinatal cause specific 10% annual 1. Annual Numerator: cause specific number Annual
fatality rate decrease MPDSR report of maternal/perinatal deaths
Denominator: total number of
cases with same diagnosis on
specific period
MMR
2. Maternal/perinatal mortality decrease 10% annual PMR
decrease
Region 1. Maternal/perinatal mortality decrease 10% annual 1. Annual MMR Annual
decrease MPDSR report PMR
National 1. Maternal/perinatal mortality decrease 10% annual 1. Annual MMR Annual

decrease MPDSR report PMR

References
Alkema et al. (2016). “Global, regional, and national levels and trends in maternal mortality
between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the
UN Maternal Mortality Estimation Inter-Agency Group.” Lancet: 387:462.
ICSU, I. (2015). Review of the Sustainable Development Goals: The Science Perspective. Paris,
International Council for Science (ICSU).
MoHCDGEC (2016). The National Roadmap Strategic Plan to Improve Reproductive, Maternal,
Newborn, Child & Adolescent Health in Tanzania 2016 - 2020. Ministry of Health, Community
Development, Gender, Elderly and Children.
MoHCDGEC, M., NBS, OCGS, and ICF (2015). Demographic and Health Survey and Malaria
Indicator Survey 2015-2016. Dar es Salaam and Maryland USA.
UN (2015). The Millennium Development Goals Report 2015. United Nationa,New York.
WHO (2012). The WHO application of ICD-10 to deaths during pregnancy, childbirth and
puerperium: ICD-MM. Geneva; World Health Organization.
WHO (2013). Maternal death surveillance and response. Technical guidance. Information for
action to prevent maternal death. Geneva; World Health Organization.
WHO (2016). The WHO application of ICD-10 to deaths during the perinatal period: ICD-PM.
Geneva; World Health Organization.

Annexes
Annex 1: ICD 10 MM and PM
Classification of correct cause of maternal and perinatal deaths can be challenging and
inconsistent. Improper classification usually leads to challenges in interpreting information
for planning strategies and resources to prevent future deaths. It also leads to inconsistencies
in comparing data across geographical locations, misclassification, underestimation or
overestimation of maternal and perinatal deaths. Due to these problems the WHO introduced
the 10th revision of International Classification of Diseases Maternal Mortality and perinatal
Mortality (ICD MM and ICD PM) tools to bring proper and consistent code and assigning cause of
deaths to maternal and perinatal deaths (WHO 2012). These are meant to be practical, easier to
use and are derived from the codes of the ICD 10.
Classification of maternal deaths using ICD MM
ICD MM recommends classification of the underlying cause of death and identification of all
contributing causes. During coding for cause of death, the provider should apply the rules of
ICD 10 to code a single underlying cause of death. The WHO ICD MM can be used when death
is investigated through medical records, verbal autopsy, surveys or confidential enquiries(WHO
2012). The causes of maternal deaths are classified according to type, group and specific
underlying cause of death. Type of death can be either direct, Indirect or Unspecified cause.
Groups of maternal deaths causes are classified into 9 mutually exclusive groups as shown in
table below. The specific underlying cause of death should be complication that initiated the
chain of event that led to death.

Annex Table 1.1: ICD MM grouping of causes of maternal deaths
Type Group number and title Common ICD 10 Codes

Direct 1. Pregnancy with
abortive outcome O08 Abortion complication
Abortion complications
000-Ectopic pregnancy
2. Hypertensive 014.1-severe pre eclampsia
disorders in 015-eclampsia
pregnancy,
childbirth, and the
pueperium
3. Obstetric O44.1 Placenta praevia
haemorrhage O45.0 Abruptio placentae
O71 PPH – Trauma
O72 PPH – Non traumatic
4. Pregnancy related O85 puerperal sepsis

infection
5. Other obstetric O64 Obstructed labour

complications Malposition/
Malpresentation
Obstructed labour-
O65 Maternal pelvic
abnormality
6. Unanticipated O74 Anesthetic complication
complications of
management
Indirect 7. Non‐obstetric O99.0 Anaemia
complication O98.6 Malaria
O98.7 HIV/AIDS
Maternal death: 8. Unknown/ O95 Unspecified or unknown of

Unspecified undetermined death
causes of death
Death during pregnancy, 9. Coincidental

childbirth and the causes
pueperium (but not
maternal death)
NB: Others causes of death refer to ICD 10 MM codes
Unanticipated complications of management are deaths resulting from interventions,

omissions, incorrect treatment or from a chain of events resulting from any of the above during

pregnancy, childbirth or the pueperium (up to 42 days). This is a new group that has been added
in the classification.
Contributing causes of death include all complications that resulted from underlying cause and
pre-existing cause that may have contributed to the events leading to death. These should be
documented as they may help in strategizing preventive measures.
Special considerations in ICD 10 MM
Some conditions in ICD MM have been given special considerations and explanations.
Obstructed labour by itself is not sufficient to be indicated as an underlying cause of death due
to its association with other complications such as haemorrhage and sepsis. Circumstances it
can be categorised as contributing cause but when there insufficient information about the
complication followed obstructed labour then it can be an underlying cause. Other conditions
such as anaemia, malnutrition, female genital mutilation and previous cesarean section are
contributing causes. Suicide is now considered as a direct cause of maternal death even without
diagnosis of depression/psychosis. Tetanus will be categorised as direct maternal death either
as “pregnancy related infection” or other direct causes such as abortion depending of the
circumstances. Another important aspect to consider is HIV/AID as there is evidence that most
deaths of pregnant HIV patients are directly attributed to HIV/AIDS. It is important to remember
HIV/AIDS patients can die from other direct maternal deaths causes such as haemorrhage or
hypertension. When pregnancy aggravates the HIV/AIDS condition leading to death then it is an
indirect maternal death. It is also important that pregnancy can be an incidental condition in a
patient
Classification of causes of perinatal deaths using ICD PM
There are three main features of classification with ICD PM; it classifies according to time of
perinatal death (Antepartum, intrapartum or neonatal), a single main cause of perinatal death
is identified and links the contributing maternal condition. This classification makes sure there is
unification of strategies to prevent both maternal and perinatal deaths.
Classification of the main cause of death should be done with the timing of death. The timing
is denoted by letters “A” for Antepartum, “I” for Intrapartum and “N” for Neonatal deaths.
There are 6 groups of Antepartum causes, seven group of Intrapartum causes and 11 groups of
Neonatal causes as shown in figure below:
Maternal conditions contributing to perinatal deaths are arranged into five groups as follows M1-
the complications of placenta, cord and membranes; M2-maternal complications of pregnancy;
M3-complications related to labour and delivery; and M4-the medical and surgical conditions
which may or may not be related to the present pregnancy (e.g. pre-eclampsia or preexisting
hypertension). M5“no maternal condition”- when no maternal condition that might have been
on the causal pathway for the perinatal death was identified at the time of presentation of the
perinatal death.

Annex Table 1.2: Grouping of Causes of Perinatal Death According to Timing of death and
Maternal Condition

Annex Table 1.3: Maternal Condition Groups
ICD-PM maternal
condition group Main maternal conditions included in group
M1: Placenta praevia , other forms of placental separation and haemorrhage,
Complications of placental dysfunction, infarction, insufficiency, fetal-placental transfusion
placenta, cord syndromes, prolapsed cord, other compression of umbilical cord ,
and membranes chorioamnionitis , other complications of membranes
M2: Maternal Incompetent cervix, preterm rupture of membranes, oligohydramnios/
complications of polyhydramnios, ectopic pregnancy, multiple pregnancy, maternal death,
pregnancy malpresentation before labour, other complications of pregnancy
M3: Other Breech delivery and extraction, other malpresentation, malposition and
complications disproportion during labour and delivery, forceps delivery/vacuum extraction,
of labour and caesarean delivery, precipitate delivery, preterm labour and delivery, other
delivery complications of labour and delivery, including termination of pregnancy
M4: Maternal Pre-eclampsia, eclampsia, gestational hypertension, other hypertensive

medical disorders, renal and urinary tract diseases, infectious and parasitic disease,
and surgical circulatory and respiratory disease, nutritional disorders, injury, surgical
conditions procedure, other medical procedures, maternal diabetes, including
gestational diabetes, maternal anaesthesia and analgesia, maternal
medication, tobacco/alcohol/drugs of addiction, nutritional chemical
substances, environmental chemical substances, unspecified maternal
condition
M5: No maternal No maternal condition identified (healthy mother)
condition

Annex Table 1.4: Code for classification of causes of perinatal death
ICD PM COMMON CODES

Maternal conditions M1 M2 M3 M4 M5 Other Total (%)
Perinatal Causes of death

Antepartum death (A)- Common Conditions
A1: Congenital Malformations
Q01: Encephalocele
Q02: Microcephaly
Q03: congenital hydrocephalus
Q05: Spinal bifida
Q21: Congenital malformations of cardiac septa
Q25: Congenital malformations of great arteries
Q32: Congenital malformations of trachea and
bronchus
Q41: Congenital absence, atresia and stenosis of
small intestine
Q44: Congenital malformations of gallbladder,
bile ducts and liver
A2: Infection
P39.9 Infection specific to the perinatal period,
unspecified
A3: Antepartum hypoxia
P20.0: Intrauterine hypoxia first noted before
onset of labour
P20.1 Intrauterine hypoxia first noted during
labour and delivery
A4: Other Specified Antepartum Disorders
P50.2: Fetal blood loss from placenta
P52.2: Intraventricular (nontraumatic)
haemorrhage, grade 3 and grade 4, of fetus and
newborn
P55.0: Rhesus isoimmunization of fetus and
newborn
P56.0: Hydropsfetalis due to isoimmunization
P61.3 Congenital anaemia from fetal blood loss
A5 Disorders related to length of gestation and
fetal growth
P05.1 Small for gestational age

A6 Foetal death of unspecified cause

P95 Fetal death of unspecified cause including
Stillbirth
Intrapartum death (P)- Common Conditions
11: Congenital Anomalies
Q01: Encephalocele
Q02: Microcephaly
Q05: Spinal bifida
bronchus
small intestine
12: Birth Trauma
P10.0 Subdural haemorrhage due to birth injury
P10.2 Intraventricularhaemorrhage due to birth
injury
P10.3 Subarachnoid haemorrhage due to birth
injury
N4 Complications of Acute intrapartum event
P21.0: Severe birth asphyxia
P39.9: Infection specific to the perinatal period,
unspecified
Other Specified Intrapartum Disorders
P50.2: Fetal blood loss from placenta
P52.2: Intraventricular (nontraumatic)
haemorrhage, grade 3 and grade 4, of fetus and
newborn
P55.0: Rhesus isoimmunization of fetus and
newborn
P56.0: Hydropsfetalis due to isoimmunization
P61.3 Congenital anaemia from fetal blood loss
Disorders related to fetal growth

Disorders related to short gestation and low

birth weight, not elsewhere classified
P07.0: Extremely low birth weight (Birth weight
999 g or less)
P07.1: Other low birth weight (Birth weight
1000–2499 g)
P07.2: Extreme immaturity (Less than 28
completed weeks (less than 196 completed days)
of gestation)
P07.3: Other preterm infants (28 completed
weeks or more but less than 37 completed
weeks)
Intrapartum death of unspecified cause
P95 Fetal death of unspecified cause including
stillbirth
Neonatal (N)
N1 Congenital anomalies
Q01: Encephalocele
Q02: Microcephaly
Q05: Spinal bifida
bronchus
small intestine
N2 Disorders related to fetal growth
999 g or less)
1000–2499 g)
of gestation)


weeks)
N3 Birth trauma
P10.0 Subdural haemorrhage due to birth injury
P10.2 Intraventricularhaemorrhage due to birth
injury
P10.3 Subarachnoid haemorrhage due to birth
injury
N4 Complications of intrapartum events
P20.0: Intrauterine hypoxia first noted before
onset of labour
P20.1: Intrauterine hypoxia first noted during
labour and delivery
P21.0: Severe birth asphyxia
N5Convulsions and disorders of cerebral status
P90 Convulsions of newborn
P91 Other disturbances of cerebral status of
newborn
P91.5 Neonatal coma
P91.6 Hypoxic ischaemic encephalopathy of
newborn
N6 Infection
A33 Tetanus neonatorum
G00 Bacterial meningitis, not elsewhere
classified
G00.1 Pneumococcal meningitis
G00.2 Streptococcal meningitis
G00.3 Staphylococcal meningitis
G00.8 Other bacterial meningitis
G04 Encephalitis, myelitis and
encephalomyelitis
G04.0 Acute disseminated encephalitis
G04.8 Other encephalitis, myelitis and
encephalomyelitis
G04.9 Encephalitis, myelitis and
encephalomyelitis, unspecified
P36 Bacterial sepsis of newborn
P36.0 Sepsis of newborn due to streptococcus,
group B

P36.2 Sepsis of newborn due to Staphylococcus

aureus
P36.5 Sepsis of newborn due to anaerobes
P36.8 Other bacterial sepsis of newborn
P36.9 Bacterial sepsis of newborn, unspecified
N7 Respiratory and cardiovascular disorders
P22.0 Respiratory distress syndrome of newborn
P24 Neonatal aspiration syndromes
P24.0 Neonatal aspiration of meconium
P24.3 Neonatal aspiration of milk and
regurgitated food
P25 Interstitial emphysema and related
conditions originating in the perinatal period
P25.0 Interstitial emphysema originating in the
perinatal period
P25.1 Pneumothorax originating in the perinatal
period
P29 Cardiovascular disorders originating in the
perinatal period
P29.0 Neonatal cardiac failure
P29.2 Neonatal hypertension
P29.3 Persistent fetal circulation
N8 Other neonatal conditions
P51 Umbilical haemorrhage of newborn
P51.0 Massive umbilical haemorrhage of
newborn
P52 Intracranial nontraumatichaemorrhage of
fetus and newborn
P52.2 Intraventricular (nontraumatic)
haemorrhage, grade 3, and grade 4 of fetus and
newborn
P52.5 Subarachnoid (nontraumatic)
haemorrhage of fetus and newborn
P53 Haemorrhagic disease of fetus and newborn
P55 Haemolytic disease of fetus and newborn
P55.0 Rhesus isoimmunization of fetus and
newborn
P56 Hydropsfetalis due to hemolytic disease
P56.0 Hydropsfetalis due to isoimmunization

N9 Low birth weight and prematurity

P07 Disorders related to short gestation and low
birth weight, not elsewhereclassified
999 g or less)
1000–2499 g)
of gestation)
weeks)
N11 Neonatal death of unspecified cause
P96 Other conditions originating in the perinatal
period
P96.1 Neonatal withdrawal symptoms from
maternal use of drugs of addiction
Drug withdrawal syndrome in infant of
dependent mother

Annex 2: FACILITY MATERNAL DEATH NOTIFICATION FORM (MDNF)

Instructions on filling the form
i. To be filled by health care provider on duty during time of death
ii. To be filled immediately after the death is certified/occurred
iii. Should be handed over to the in-charge of section or department
SECTION I
Maternal Death Information

Name of Deceased; ………………………………………. ….. Age: ……….. (Years)
Gravidity: …………….. Parity: ………… Living children: …………
Residence: Street/Village ………………. District……………………
Region…………………
Contacts details of next of kin: Name………………………………….
Relationship with deceased: ………………………… ………
Residence: Street/Village…………… …. District…………………….
Phone number: …………………………………………
Death information
Date of death: ……………………..Time of death: ……………
Place of death: Health facility. Outside health facility
Name of facility last managed: ……………………………. File Reg. number: …………………..
Status of pregnancy at death: Still pregnant Delivered/abortion Gestation age: ……..

weeks
Suspected death Confirmed death
SECTION 2
Name of notifying person……………………… …………… Cadre: ……………………
Date of notification………………… Signature: ………………… mobile No.: …………….
Form received by (name): ……………………………… Rank (e.g. HoD);…………………….
Date of receiving: ………………... Signature: …………………mobile No.: ……………….

Annex 3: FACILITY PERINATAL DEATH NOTIFICATION FORM (PDNF)

i. To be filled by health care provider on duty during time of death
ii. To be filled immediately after the death is certified/occurred
iii. Should be handed over to the in-charge of section or department
SECTION I
Perinatal Death Information
Name of Deceased; ………………………………………. ….. Age: ………..

Date of death: ……………………..Time of death:…………………weight………..Gestation

age…………….
Place of death: Health facility. Outside health facility

File Reg. number: …………………..
Type of case: Stillbirth……………… Macerated………….. Fresh…………….

Early neonatal death…………………….
SECTION 2
Name of notifying person…………………………………… Cadre: …………………
Date of notification………………… Signature: ………………… mobile No.: …………….
Form received by (name): ……………………………… Rank ( e.g HoD);…………………….
Date of receiving: ………………... Signature: …………………mobile No.: ……………….

Annex 4: COMMUNITY IDENTIFICATION OF SUSPECTED MATERNAL DEATH

i. To be filled by village/street health committee member or CHW
ii. To be filled as soon as the death has occurred in the community
iii. If you answer YES to any of questions 3, 4 or 5 in Section 2, then suspect maternal death
and send form to nearest health facility
Woman`s Information
Name of Deceased; ………………………………………. ….. Age: ……….. (Years)
Contacts details of next of kin: Name………………………………….
Phone number: …………………………………………
Death information
1 Date of death(day/month/years) …../……/……….
2 Where did she die Home …….. Others(mention)
Outside home
At TBA…….
3 Was (NAME) pregnant when she died? Yes
No
I don’t know
4 Did she die during childbirth Yes
No
5 Did she die within 2 to 3 months after the end Yes
of a pregnancy or childbirth
No
6 When did the pregnancy end? (Month and Year) ……/……/………
7 Where did the pregnancy end? Home
Outside home
At TBA
At health facility
Name of notifying person……………………… …………… Rank: ………………………

Date of notification………………… Signature: ………………… Mobile No.: …………….
At health facility
Form received by (name): ……………………………… Cadre ( e.g nurse):..………………….
Date of receiving: ………………... Signature: …………… Mobile No.: ……………….

Annex 5: COMMUNITY PERINATAL DEATH IDENTIFICATION FORM

i. To be filled by village/street health committee member or CHW
ii. To be filled as soon as the death has occurred in the community
iii. If you answer YES to any of questions 2 or 3 in Section 2, then it is perinatal death and
send form to nearest health facility
Baby`s Information
Name of Deceased/Baby of; ……………………………………… Age: ……….. (Years)
Contacts details of next of kin: Name…………………………………........................
Phone number: …………………………………………
Death information
1 Date of death(day/month/year) …../……/……….
2 Was pregnant mother at the 7 Others(mention)
months or term when delivered a Yes ……
dead fetus?
No ......
3 If the baby was born alive after

7months of pregnancy or term Yes
pregnancy, did the baby die within
seven days? No
Name of notifying person………………………… Rank: ……………………
Date of notification………………… Signature: ………………… Mobile No.: …………….
At health facility
Form received by (name): …………………… Cadre (eg, nurse):…………………
Date of receiving: ………………...
Signature: ………………… Mobile No.: ……………….

Annex 6: MATERNAL DEATH REPORTING FORM
Reporting Facility Information

1. Type of death 3. Address of the deceased
a. Facility deaths Village/street ___________
b. Community death (go to
Qn 3) Ward _________________
2. Name of Reporting Health Division ________________

Facility __________________
District ________________
Facility unique ID number (YYYY/
Number) __________ Region ________________
Deceased Information
4. Date of Death DD/MM/YYYY 5. Age at death: ___ Years *6. Gravidity ________
____/____/_____
*7. Parity __________ 8. Marital status(circle what applies. Only one response allowed)
1. Married 4. Cohabiting
2. Single 5. Separated
3. Widowed 6. Divorced
*9. Level of education (circle what 1. None 4. Higher education (above secondary)
applies) 2. Primary 5. Unknown
3. Secondary
10. Occupation 11. Admission at the health facility
_________________________ Date DD/MM/YY ___________ Time ______________
Antenatal Care (ANC)
*12. Attended ANC? 1. Yes 2. No 3. Unknown
13. Where was the ANC done? 1. Dispensary 4. Other (specify) _________
2. Health centre 5. Had not attended yet
3. Hospital
14. Number of ANC visits ___________ Not applicable (If not attended yet)
15. Basic package of services Syphilis screening 1. Yes 2. No 3. Unknown
provided on ANC (Circlewhat
applies) Hgb 1. Yes 2. No 3. Unknown
Blood group 1. Yes 2. No 3. Unknown
HIV status 1. Yes 2. No 3. Unknown
BP measurement during the follow 1. Yes 2. No 3. Unknown

up period
Urinalysis 1. Yes 2. No 3. Unknown
Fe/FoL supplementation 1. Yes 2. No 3. Unknown
TT immunization 1. Yes 2. No 3. Unknown

16. Diagnosis on admission 1. Normal labour 11. Previous C/S scar

(circle what is appropriate)Not 2. Eclampsia 12. Violence
applicable for community death 3. Hypertensive disorders without 13. Obstructed labour
eclampsia 14. Severe malaria
4. Nursing mother 15. Ruptured uterus
5. HIV/AIDS 16. Anaemia
6. Antepartum haemorrhage 17. IUFD
7. Postpartum haemorrhage 18. Others
8. Incomplete abortion (specify)_____________
9. Sepsis
10. Ectopic pregnancy
17. Name and Place of Delivery/ 1. Hospital _______________ 2. 5. Delivery before arrival
abortion (circle what applies) Health centre ____________ 6. Home
3. Dispensary ______________ 4. 7. Not applicable (in case
Maternity home ___________ undelivered
18. Date of death DD/MM/YYY 18 b. Place of Death (circle what applies)
1. At home 4. at Hospital
______________________ 2. At dispensary 5. on transit to facility
3. At health center 6. Other specify ____________
*19. Duration from onset of *20. When did death occur?(not

complication to time of death _______(hours/days) applicable for community death)
1. Before intervention
2. During intervention
21. Timing in relation to pregnancy 1= Antepartum 2= Intrapartum 3= Postpartum
Delivery and related information
*22. Mode of delivery
1. Spontaneous vertex delivery 6. Laparatomy
2. Emergency C/S 7. Hysterotomy
3. Elective C/S 8. Other ________________
4. Vacuum extraction 9. Not applicable (had
5. Breech delivery notdelivered)
23. Delivery attendant 1. Nurse/midwife 6. Assistant Clinical officer
2. Medical Officer 7. Traditional birth attendant
3. Obstetrician 8. Other _____________________
4. AMO 9. Not applicable (had not
5. Clinical officer delivered)
24. In case of cesarean section/ 1. Indication of surgery ________________________________
laparotomy/Hysterotomy (fill in or
2. Duration of surgery: a. one hour or less b. More than one hr
circle what applies)
3. Type of anaesthesia used: a. General b. Spinal c. Not recorded
4. Time from decision to performing surgery____hrs _____mins

*25 Pregnancy outcome (circle 1. Live baby 2. Fresh still birth 3. Macerated stillbirth
what applies) 4. Ectopic 5. Abortion

*26. Was a post mortem done? 1= Yes 2= No

What was the diagnosis?
__________________________
Cause of death (Using ICD MM)

Type Group Underlying cause with
ICD 10 code
For more codes refer ICD
MM
27. Direct cause (circle what 1. Pregnancy with abortive outcome ● 00 Ectopic pregnancy
applies. Only one choice for 2. Hypertensive disorders in pregnancy, ● O14.1 Severe pre
group and one choice for childbirth, and the pueperium eclampsia
underlying cause allowed ) 3. Obstetric haemorrhage ● O15 Eclampsia
4. Pregnancy related infection ● O85 Puerperal sepsis
5. Other obstetric complications ● O64 Obstructed
6. Unanticipated complications of labour – Malposition/
management Malpresentation
● O65 Obstructed
labour-
● Maternal pelvic
abnormality
● O66 Obstructed labour
– Other causes
● O44.1 Placenta praevia
● O45.0 Abruptio
placentae
● O71 PPH – Trauma
● O72 PPH – Non
traumatic
● O08 Abortion
● O74 Anesthetic
complication
● O88 Embolism
● Others specify_______
28. Indirect cause 7. Non‐obstetric complication ● O99.0 Anaemia
● O98.6 Malaria
● O98.7 HIV and AIDS
● O90.3 Cardiomyopathy
● T65 Herbal intoxication
● O24 Diabetes Mellitus
● O98.0 TB
● Others specify ______
___________________
29. Unspecified 8.Unknown/undetermined causes of ● 095 Unspecified or
death unknown cause of
death
30. Medical contributing ________________________________________________________
cause(s)) ________________________________________________________
*31. Associated factors and non-medical causes of death (Tick all that apply)

☐Traditional practices ☐ Lack of decision to go to health facility

☐Failure to recognize danger signs ☐ Unwillingness to seek medical help
☐Delay in starting antenatal care ☐ Delayed referral from home
Delay 1 ☐Unavailability of someone to take care ☐Fear of ill- treatment at facility
of children and house ☐Lack of support from family/community
members
☐lack of accompaniment to health facility
☐Delayed arrival to referred facility ☐Lack of transportation
Delay 2 ☐Lack of roads ☐No facility within reasonable distance
☐Lack of money for transport ☐Distance from home to health facility
☐Sub optimal antenatal care

Delay 3 ☐Delayed arrival to next facility from another facility on referral
☐Delayed or lacking supplies and equipment (specify) _______________________
☐Delayed management after admission
☐Human error or mismanagement (specify) ____________________________
☐Inadequate skills of provider (specify) _______________________________
☐Lack of health care provider at health facility
☐Gender insensitivity of health care provider
Others (specify) __________________________________________________________________
_________________________________________________________________________
32. Could this death have been avoided? ☐Yes ☐ No
Comment ______________________________
_______________________________________
_______________________________________
33. List the avoidable factors, missed opportunities or
substandard care – why did this happen?
NB: Attach facility and council action plans

How to complete maternal death review form
Following a review session, forms should be filled according to instructions. For questions with
star (*) further clarifications can be obtained as indicated in this guideline.
Q6. Gravidity: For those who died undelivered
Q7. Parity: Should indicate number of deliveries after 28 weeks of gestation including the index
pregnancy if the mother died after delivery. Note: “+” indicates number of abortions or ectopic
(e.g. para 2 + 1 means this woman had delivered twice, and had abortion or ectopic once).
Q9. Duration from onset of complication(s) to death: This refers to duration from the onset of
complication which has led to death. It can be minutes, hours or days.
Q12 Unknown: No ANC card and no information
Q19. Duration from onset of complication(s) to death: This refers to duration from the onset of
complication which has led to death. It can be minutes, hours or days.
Q20. Death occurred: Before intervention means the actual treatment of the condition has not
been started e.g. in case of ectopic pregnancy laparotomy has not been done although specimen
for blood grouping and cross-match has been taken. During intervention means despite an
appropriate treatment death occurred e.g. in case of ectopic pregnancy the patient died after
laparotomy.
Q22. Mode of delivery: This question can have more than one response in case of multiple
pregnancy delivered by different routes e.g. Twin delivery delivered by SVD and breech, or SVD
and caesarean section.
Q25. Outcome of pregnancy: can have more than one response in case of multiple pregnancy
Q26. Post mortem done: Post mortem is indicated to all maternal death whose diagnosis is not
certain.
Q31. Associated factors: This question can have more than one response. Some responses in this
question need elaboration
● Poor infrastructure implies problems in transportation and communication
● Inadequate skills – means lack of skills to institute appropriate treatment despite

availability of equipment and supplies.
● Delay in decision-making refers to delay at family or community level in deciding to seek

medical attention.

Annex 7: PERINATAL DEATH REPORTING FORM
Reporting Facility Information

1. Name of Reporting Health Facility 2. Facility unique ID 3. Address of the health
___________________________ number (YYYY/Number) facility
_________________ District: ___________
Region: ___________
4. Category of health facility (circle what applies) 5. Date of reporting
i. Consultant Hospital iv. Health Centre
DD/MM/YYYY
ii. Regional Hospital v. Dispensary ____/____/_____
iii. District/Any other Hospital vi. Maternity home
Deceased Information
6. Date of death DD/MM/YYYY
____/____/_____
7. Place of Death (circle what 1. Dispensary 2 Health centre.
applies) 3. Hospital 4. On the way to facility
5. Other specify ____________
8. Date of delivery DD/MM/YYYY Condition at delivery (circle 1. Alive
____/____/_____ what applies) 2. Stillbirth (2.1 Fresh stillbirth,
2.2 Macerated Stillbirth)
9. Place of Delivery (circle what 1. Dispensary 2 Health centre.
applies) 3. Hospital 4. On the way to facility
5.Home 6. Other specify ____________
10. Admission at the health facility DD/MM/YYYY

____/____/_____ 11. Duration from admission to
Time _______ ☐ time of death hrs
12. Address of the mother Ward: ______________ Division: ______________
District: ____________ Region: ______________
13. Marital status of mother Circle what applies. Only one response allowed
1. Married 4. Cohabiting
2. Single 5. Separated
3. Widowed 6. Divorced
14. Level of Education of 1. None 4. Above secondary
mother 2. Primary 5. Unknown
3. Secondary
15. Mother’s occupation ______________________ Unknown
*16. Parity of mother including this delivery _____________

17. Level of education of the 1. None 4. Above secondary
father 2. Primary 5. Unknown
3. Secondary
18. Occupation of the father ______________________________ Unknown
Antenatal Care (ANC)
*19. Mother attended ANC? 1. Yes 2. No 3. Unknown

20. Where was ANC done? 1. Dispensary 4. Other (specify) _________

2. Health centre 5. Mother had not attended yet
3. Hospital
21. Number of ANC visits ___________Not applicable
22. Basic package of services provided Syphilis screening 1. Yes 2. No 3. Unknown

on ANC (Circle what applies) Hgb, 1. Yes 2. No 3. Unknown
Blood group 1. Yes 2. No 3. Unknown
HIV status 1. Yes 2. No 3. Unknown
BP measurement during the
follow up 1. Yes 2. No 3. Unknown
Urinalysis 1. Yes 2. No 3. Unknown
Fe/FoL supplementation
1. Yes 2. No 3. Unknown
TT immunization 1. Yes 2. No 3. Unknown
*23. Relevant antenatal problems Di Diabetes mellitus 1. Yes 2. No 3. Unknown
detected during ANC (circle what Mp Multiple pregnancy
applies) 1. Yes 2. No 3. Unknown
A Antepartum
Haemorrhage 1. Yes 2. No 3. Unknown
M Malaria 1. Yes 2. No 3. Unknown
A Anaemia 1. Yes 2. No 3. Unknown
Po Polyhydramnios 1. Yes 2. No 3. Unknown
H Heart disease 1. Yes 2. No 3. Unknown
U Untreated syphilis 1. Yes 2. No 3. Unknown
Hypertensive disorders 1. Yes 2. No 3. Unknown
HIV and AIDS……… 1. Yes 2. No 3. Unknown
Or Others (Specify) ……………
None
Unknown
Not applicable (did not
attend ANC)
24. Mode of delivery 1. Spontaneous vertex delivery 2. Emergency C/S
3. Elective C/S 4. Vacuum extraction
5. Breech delivery 6.Laparotomy/Hysterectomy
7. Other __________
25. Duration of labour 1st stage _________ hours ☐not recorded ☐ Not known
2nd stage _________minutes ☐not recorded ☐ Not known
☐ elective c/section

26. Delivery attendant 1. Nurse/midwife 2. Medical Officer 3. Obstetrician

4. AMO 5. Clinical officer /Assistant Clinical officer
6. Medical attendant 7. Traditional birth attendant
8. Family member 9. Unassisted
27. In case of caesarean section/ 1. Indication of surgery ………………………………

laparatomy/Hysterotomy (fill in or circle
what applies) 2. Duration of surgery a. One hour or less
b. More than one hour
3. Type of anaesthesia a. General b. Spinal
used: c. Not recorded
4. Time from decision to …….hours ……...minutes

performing surgery
5. Not applicable
(delivery not by C-section/
laparatomy)
*28. Weight at birth ________ grams Sex of the baby

☐not recorded ☐ unknown
☐ unknown
*29. Gestational age at birth _______ weeks APGAR score at 5 minutes
☐ not recorded ☐M ☐F
☐ unknown
*30. Duration of life after birth _________(hours/days) Is the mother alive?
☐ Stillbirth☐ unknown ☐ Yes ☐ No
31. Was a post mortem done? ☐ Yes ☐ No

What was the diagnosis?
_____________________________________
32.Timing and underlying cause of death (inserting the specific ICD 10 code in the box)
membrane and cord
M1: Complications of placenta,
pregnancy
M2: Maternal complications of
labour and delivery

M3: Other complications of
surgical conditions
M4: Maternal medical and
identified
M5: No maternal condition
Others
Maternal conditions
Antepartum death
A1: Congenital malformations,
deformations and
chromosomal abnormalities
A2: Infection

A3: Antepartum hypoxia

A4: Other specified Antepartum disorder
A5: Disorders related to fetal growth
A6: Fetal death of unspecified cause
Intrapartum death
I1: Congenital malformations,
deformations and
I2: Birth trauma
I3: Acute intrapartum event
I4: Infection
I5: Other specified intrapartum disorder
I6: Disorders related to fetal growth
I7: Intrapartum death of unspecified
cause
Neonatal deaths (within 7 days of life)
N1: Congenital malformations,
deformations and
N2: Disorders related to fetal growth
N3: Birth trauma
N4: Complications of intrapartum events
N5: Convulsions and disorders of
cerebral status
N6: Infection
N7: Respiratory and cardiovascular P24.0
disorders
N8: Other neonatal conditions
N9: Low birth weight and prematurity
N10: Miscellaneous
N11: Neonatal death of unspecified
cause
33. Underlying maternal medical conditions that could have _______________________________
contributed to the death
_______________________________
_______________________________
34. From the available information and the assessment carried ☐Yes ☐ No
out, could this death have been avoided? Comment… ________________
__________________________
__________________________
__________________________

*35. Briefly explain factors that contributed to this perinatal death Health facility
at following levels
Antenatal
Foetal/Newborn
Maternal
36. List the avoidable factors, missed opportunities or substandard

care – why did this happen?
*37. Associated factors and non-medical causes of death (Tick all that apply)
☐Traditional practices ☐ Lack of decision to go to

☐Failure to recognize danger signs health facility
☐Delay in starting antenatal care ☐ Unwillingness to seek
☐Unavailability of someone to take care of medical help
children and house ☐ Delayed referral from home
Delay 1 ☐ Fear of ill- treatment at
facility
☐ Lack of support from family/
community members
☐ lack of accompaniment to
health facility
☐Delayed arrival to referred facility ☐ Lack of transportation
Delay 2 ☐Lack of roads ☐ No facility within reasonable
☐Lack of money for transport distance
☐ Distance from home to
health facility
☐Sub optimal antenatal care
Delay 3 ☐Delayed arrival to next facility from another facility on referral
☐Delayed or lacking supplies and equipment (specify)
_______________________
☐Delayed management after admission
☐Human error or mismanagement (specify)
____________________________
☐Inadequate skills of provider (specify)
_______________________________
☐Lack of health care provider at health facility
☐Gender insensitivity of health care provider
Others (specify) ______________________________________________________
______________________________________________________________

How to fill perinatal death review form
In this form questions with a star (*) which need further clarification include the following:
Q16. Parity: Should indicate number of deliveries after 28 weeks of gestation including the index
pregnancy if the mother died after delivery. Note: “+” indicates number of abortions or ectopic
(e.g.Para 2 + 1 means this woman had delivered twice, and had abortion or ectopic once).
Q19 Unknown: No ANC card and no information
Q23: Relevant antenatal problem detected: This question may have more than one response
(a) HIV/AIDS and syphilis must be confirmed by positive laboratory test
(b) If the response is “others” the following apply
● Age below 18 years
● History of previous IUFD
● History of early neonatal death
● Pelvic deformity
● History of previous Vacuum Extraction
● Gestation age above 42 weeks
● Fundus not corresponding to gestation age.
Q 24: Intrapartum complications: This question may have more than one response.
If the response is “others” the following apply:
● Malposition.
● Stuck after coming head in case of breech.
● Shoulder dystocia.
● Severe hypertension without eclampsia.
Q28: Weight at birth: All babies whether alive, or stillbirth must be weighed and recorded.
Q29: Gestational age at birth:
● Calculate gestation age from the last normal menstrual period OR.
● Estimate from the date of quickening if dates are unknown and the woman
booked late.

Where available, ultrasonography estimation may be used.
Note: Fundal height is not necessarily equivalent to gestation age and should not be taken as the
substitute to unknown gestation.
Q30: Duration of life after birth: Record the duration of life in full days only when the child
survived more than 24 hours.
Q32: Insert the specific ICD 10 for the underlying cause from the list of codes in the table provided.
The specific code should be inserted in the box that shows timing of deaths in rows and
maternal condition in column.
Q35: Briefly explain:
Factors at the health facility:
Indicate here what could have been done at the facility to reduce the chances of death but
were not done e.g. availability of equipment and supplies like ambu bag, suction bulb/
machines oxygen etc. presence of skilled providers.
Antenatal factors:
Indicate here what could been done at the antenatal clinic to reduce chances of perinatal
death but were not done e.g. screening facilities for anaemia, isoimmunization, syphilis
and HIV, proteinuria and hypertensive disorders. Secondly, if screening was done but
appropriate action(s) were not taken.
Maternal factors:
List all intrapartum complications which could have led to a perinatal death e.g. abruptio
placenta, prolonged second stage, eclampsia etc.
Foetal/newborn factors:
List factors which the foetus or newborn could have which increases the chances of death
e.g. congenital malformations, cord prolapse etc.

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THE UNITED REPUBLIC OF TANZANIA

MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT,

GENDER, ELDERLY AND CHILDREN

Maternal and Perinatal Death

Reproductive and Child Health Section

MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT,

GENDER, ELDERLY AND CHILDREN

Maternal and Perinatal Death

Reproductive and Child Health Section

Reproductive and Child Health Section Dodoma | 2019 iii

6.3.1 National MPDSR Technical Committee....................................................................... 19

iv Reproductive and Child Health Section Dodoma | 2019

AGOTA Association of Gynecologists and Obstetricians of Tanzania

Reproductive and Child Health Section Dodoma | 2019 v

NBS National Bureau of Statistics

vi Reproductive and Child Health Section Dodoma | 2019

Dr. Zainab A. S. Chaula

Reproductive and Child Health Section Dodoma | 2019 vii

This Guideline emphasizes the importance of enhancing accountability at various levels of

viii Reproductive and Child Health Section Dodoma | 2019

Prof. Muhammad Bakari Kambi

Reproductive and Child Health Section Dodoma | 2019 ix

Reproductive and Child Health Section Dodoma | 2019 1

misclassification of maternal death is a common phenomenon which needed to be addressed

2 Reproductive and Child Health Section Dodoma | 2019

Death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective

2.2 Suspected maternal death

2.3 Probable maternal death

2.4 Direct maternal death

2.5 Indirect maternal death

2.6 Unspecified maternal death

2.7 The underlying cause of death

2.8 Contributing medical causes of death

Reproductive and Child Health Section Dodoma | 2019 3

2.9 Contributing factors

2.11 Early neonatal death

2.12 Perinatal death

2.13 Contributing factors for perinatal deaths include:

- Poor maternal health

2.14 Maternal Death Review (MDR)

Is defined as “a qualitative, in-depth investigation of the causes of and circumstances

4 Reproductive and Child Health Section Dodoma | 2019

2.15 Maternal/perinatal death surveillance

Is the implementation of action plans from maternal/perinatal death reviews to avoid

2.17 Maternal and Perinatal Deaths Surveillance and Response (MPDSR)

Is the routine identification, notification, quantification and determination of causes and

2.18 International Classification of Diseases and Related Health Problems (ICD)

2.19 International Classification of Diseases Maternal Mortality (ICD MM)

It is a standard international diagnostic classification system used by health care providers to

2.21 Verbal Autopsy

2.22 Maternal near miss

2.23 Medical Certification on the Causes of Death (MCCD)

It is a tool that captures the medical causes of death.

Reproductive and Child Health Section Dodoma | 2019 5

Vision, Mission and Objectives

To provide information and recommendations for actions in order to eliminate preventable

- Identification, notification, reviews and analysis of facility-based maternal

- Identification, notification and review of community-based maternal and