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h To establish operational mechanisms/
modalities for undertaking MDR at selected
institutions and in community level
h To disseminate information on data collection
tools, data/information flow, analysis

h To develop systems for review and remedial

follow up actions
 ÿ



h „mplementation of MDR should be supported

by a State Govt Order
h Notification of Maternal Deaths
h ÷ 
 


 




h 
 


 




h ‘ll health functionaries have a role in MDR
h District Collector ( DM) to conduct review
meeting with the relatives of the deceased and
service providers
h No punitive action against service providers


  ÿ




 





[ State Task Force
[ State Nodal Officer
[ 



[ District Nodal Officer

- ÷ 


- Facility Nodal Officer

[ lock: lock Nodal Officer ( MOH)
- lock „nvestigation Team
[ Notifier of deaths
 -




! "÷ 

[ Members: Principal Secretary - Health and Family Welfare,
Mission Director SHS, Senior Obstetrician/s of the Medical
College Hospital, „M‘
FOGS„ and any other members
nominated by Government

[ STF will 


 # 
 $ to discuss the actions
taken on the minutes of the last meeting and make
recommendations to Government for policy and strategy
formulations

[ very year an   

 


%
for the state
will be prepared and a dissemination meeting will be
organized to sensitize the various service providers and
managers

 -


| 

[ „dentification 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
 






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 Facility ased Maternal Death Review:
Steps-Process
h ÷ 
 of facility level committee & identification of
facility nodal officer (co-nodal officer) for each facility
h |

 of maternal deaths by MO on duty within
24 hours to FNO ( 
.#)
FNO to inform district and state nodal officer within 24
hours telephonically and through ‘nnex 6

h +

(
 within 24 hours using prescribed format
( 
./) by MO/Faculty/ ‘CMOH (for facilities other
than MCH) & sending to FNO

h 
%
 
  ( 
.0) by FNO and
sending copy of filled up format, summary and case
sheet to facility MDR committee and DNO

 F MDR: Steps-Process«

h  

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of maternal deaths in the facility
± line listing of maternal deaths ( 
.$1)
h 


 by the F MDR committee headed
by the Hospital superintendent/MSVP and sending
minutes to DNO

h Remedial measures
  
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 Notify all deaths of women between
15-49 years within 24 hours to block PHC MO ± telephone
and in the primary informer format ( 
.#)

m "
 
 Notify to district and state nodal
officer within 24 hours of receipt of information and send
the details in format ( 
.#)

+

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m ‘ll suspected maternal deaths to be investigated by a team
of 3 members ( PHN/PHN, ‘NM, LHV etc) with µverbal
autopsy¶ format ( 
.4) within 3 weeks
m 
%
 
 ( 
.0) by MOH and
sending to DNO along with filled up format ( 
.4)
 $-

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[ MOH to  

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of all deaths of women in the
reproductive age group ( 
.6) and line listing of all
confirmed maternal deaths ( 
.1) at block PHC

- ‘SH‘/‘NM also maintain line listing of maternal deaths
(‘nnex 4)
[ Feedback sharing with service providers at monthly
meeting

[ 



 DNO to



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(of all
maternal deaths  
.1)

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-& -

 submitted to lock MO PHC by
‘SH‘ ( monthly)
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&
Deploys investigation team ( PHN/
" ‘NMPHN/Nurse to visit the deceased
& woman¶s house and conduct verbal
!

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 ÿ |  -|

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  Case summary sheet for every maternal


 death and format sent to the DNO

2 relatives of the  






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‘ll maternal deaths reported in the month ± both F MDR
and C MDR

m)

 



 




‘ll the maternal death reports compiled by the district MDR
committee will be put up to the District Magistrate, who will
have the option of reviewing a sample of these deaths,
which will be representative of deaths occurring at home, at
facilities and in transit

 



 





 %
5
[ 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
 Maternal Death Review Process
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 Orientation Training

 






[ National level: Sensitization and Training

[ State level: Sensitization and Training
[ District level: Sensitization and Training
[ Facility level: Orientation
[ lock level: Sensitization