Maternal Death Review GOI Guidelines_WB_2011

8/7/2019 Maternal Death Review GOI Guidelines_WB_2011

1/20

MATERNAL DEATH REVIEW

(Facility & Community Based)

Govt of India National Guidelines


2/20

National Guidelines for Maternal Death Review

(MDR)

Objectives

To establish operational mechanisms/

modalities for undertaking MDR at selectedinstitutions and in community level

To disseminate information on data collection

tools, data/information flow, analysis

To develop systems for review and remedial

follow up actions


3/20

Key Points in MDR

Implementation of MDR should be supported

by a State Govt Order

Notification of Maternal Deaths

Facility Based Maternal Death Review Community Based Maternal death Review

All health functionaries have a role in MDR

District Collector ( DM) to conduct reviewmeeting with the relatives of the deceased and

service providers

No punitive action against service providers


4/20

MDR: Committees and Key Personnel

at different level

State Task Force

State Nodal Officer

District MDR Committee District Nodal Officer

- Facility MDR Committee

- Facility Nodal Officer Block: Block Nodal Officer (BMOH)

- Block Investigation Team

Notifier of deaths


5/20

State Level Task Force

Members: Principal Secretary - Health and Family Welfare,Mission Director SHS, Senior Obstetrician/s of the Medical

College Hospital, IMA. FOGSI and any other members

nominated by Government.

STF will meet once in 6 months - to discuss the actions

taken on the minutes of the last meeting and make

recommendations to Government for policy and strategy

formulations.

Every year an annual maternal death report for the state

will be prepared and a dissemination meeting will be

organized to sensitize the various service providers and

managers.


6/20

State Nodal Officer

Identification of District Nodal officers

Organizes analysis of data collected from the

districts and feed back to the district.

Organizes state level sensitization workshops

Convene state task force meeting

Facilitate preparation of annual maternal death

report and dissemination meeting


7/20

MDR at District Level

Formation of MDR committee

Chairman: CMOH- roles and responsibilities

District Nodal Officer- roles & responsibilities

Monthly review meeting by MDR Committee

Quarterly review by DM

Quarterly review meeting with analyzed data

and process indicators Feed back

Remedial measures


8/20

FACILITY BASED MATERNAL DEATH REVIEW

Activities to Initiate FB-MDR

Identify & orient

nodal officer(s)

from selected

facilities

By State Nodalofficer

Constitution of

MDR Committee

at the facility

By Principal

/Superintendentof the facility

Identification of

facilities for MDR

By State Director/ Programme

Manager


9/20

Facility Based Maternal Death Review:

Steps-Process

Formation of facility level committee & identification of

facility nodal officer (co-nodal officer) for each facility

Notification of maternal deaths by MO on duty within

24 hours to FNO (Annex 6)

FNO to inform district and state nodal officer within 24

hours telephonically and through Annex 6.

Investigation within 24 hours using prescribed format

(Annex 1) by MO/Faculty/ ACMOH (for facilities other

than MCH) & sending to FNO.

Preparation of case summary (Annex 3) by FNO and

sending copy of filled up format, summary and case

sheet to facility MDR committee and DNO.


10/20

FBMDR: Steps-Process..

Maintain registerof maternal deaths in the facility line listing of maternal deaths (Annex-4)

Monthly review by the FBMDR committee headed

by the Hospital superintendent/MSVP and sending

minutes to DNO.

Remedial measures


11/20


12/20

COMMUNITY BASED MATERNAL DEATH REVIEW

Activities to Initiate CB-MDR

Orientation of all

ASHAs/ANMs/AWWs

on reporting of

women deaths and

MDR

Orientation/

training of block

team on MDR

programme at

district level

Identify & orient

the District Nodal

Officer for MDR

at the state level.


13/20

Community Based MDR: Steps- Process

Notification: ASHA/Health worker: Notify all deaths of women between

15-49 years within 24 hours to block PHC MO telephone

and in the primary informer format (Annex 6).

Block Medical Officer: Notify to district and state nodalofficer within 24 hours of receipt of information and send

the details in format (Annex 6).

Investigation:

All suspected maternal deaths to be investigated by a teamof 3 members (BPHN/PHN, ANM, LHV etc) with verbal

autopsy format (Annex 2) within 3 weeks

Preparation of case summary (Annex 3) by BMOH and

sending to DNO along with filled up format (Annex 2)


14/20

CB-MDR: Steps- Process ..

MOH to maintain registerof all deaths of women in the

reproductive age group (Annex 5) and line listing of all

confirmed maternal deaths (Annex 4) at block PHC.

- ASHA/ANM also maintain line listing of maternal deaths

(Annex 4)

Feedback sharing with service providers at monthlymeeting

District Level: DNO to receive both FBMDR and CBMDR

formats and case summaries, prepare combined casesummary if required and maintain line listing of all

maternal deaths (Annex 4).


15/20

COMMUNITY BASED MATERNAL DEATH REVIEW

Process Flow Chart

ASHA/Others

Telephonically informs

about the maternal death

within 24hrs to Block MO

PHC

BLOCK

DISTRICT

STATE

COMMUNITY

Line listing of maternal deaths,

submitted to Block MO PHC byASHA ( monthly)

Block MO

PHC

Telephonically informs

DNO and SNO within

24hrs of receipt of

information of maternal

deaths

Deploys investigation team (BPHN/

ANMPHN/Nurse to visit the deceased

womans house and conduct verbal

autopsy

Confirmed death recorded at Block level and

MO analyses and discusses the findings withthe team

Case summary sheet for every maternal

death and format sent to the DNO

Maternal death reports are reviewed

by Dt MDR committee chaired by Dt

CMO (monthly)

DT. Collectors/ Dt. Health Society

DT Collectors Monthly

Review Meeting

State Review

2 relatives of the

deceased attend


16/20

Maternal death review at District level

Monthly district maternal death review by MDRcommittee chaired by CMOH:

All maternal deaths reported in the month both FBMDR

and CBMDR

Quarterly district maternal death review by DM:

All the maternal death reports compiled by the district MDR

committee will be put up to the District Magistrate, who willhave the option of reviewing a sample of these deaths,

which will be representative of deaths occurring at home, at

facilities and in transit.


17/20

District maternal death review by DM

Purpose To institute measures to prevent maternal deaths due to

similar reasons in future

To sensitize service providers to improve accountability

To find out the system gaps to take appropriate corrective

measures with time-line

To allocate funds from the district health society for the

interventions

To monitor the implementation of the corrective measures

- at the community level

- at the facility level

- requiring state support


18/20

Maternal Death Review Process

F1 F2 F3Facility based

review in each of

the institutionV1 V2 V3

ASHA ASHA

BLOCK-1

ANM ANM

CMO/DNO

DM

2

3

1

1

BLOCK-2

BLOCK-3

Community

based review


19/20

Orientation Training

At different levels

National level: Sensitization and Training State level: Sensitization and Training

District level: Sensitization and Training

Facility level: Orientation Block level: Sensitization


20/20

Maternal Death Review GOI Guidelines_WB_2011

Documents

Transcript of Maternal Death Review GOI Guidelines_WB_2011