Mapedir interviewers reference manual l 19_may2008

MAPEDIR Interviewer’s Reference ManualVerbal Autopsy Questionnaire for

Women of Reproductive Age

Maternal and Perinatal Death Inquiry and Response (MAPEDIR) Project

United Nations Children’s Fund (UNICEF)Delhi, India

in association with:

Johns Hopkins Bloomberg School of Public HealthBaltimore, MD, USA

May 19, 2008

TABLE OF CONTENTS

3 About this manual ................................................................................................................................ 4 1. What is MAPEDIR? .......................................................................................................................... 4

Background ................................................................................................................. 4 2. Project Organization and Procedures ............................................................................................ 6

Block-level team with district oversight ..................................................................... 6 During your training you will review the death notification format that is used to

conduct the initial investigation of deaths of women of reproductive age, as well as the register that supervisors keep to track these deaths and assign suspected maternal deaths to the interviewers. You will also discuss the appropriate waiting period after a death before conducting the MAPEDIR interview. ......................................................................... 7

3. Interviewer and Supervisor Roles and Responsibilities .............................................................. 7 Overview of the interviewer’s activities and responsibilities ..................................... 7 Supervisory procedures and approach ......................................................................... 7

4. Ethical Training ................................................................................................................................ 7 Confidentiality ............................................................................................................. 8 Falsification of Data .................................................................................................... 8

5. Approach to the Household and Selecting the Respondent(s) ................................................... 8 Introducing yourself at the household ......................................................................... 9 How to select the best respondent ............................................................................... 9 How to handle multiple respondents ........................................................................... 9

6. Communication and Sensitivity Issues ....................................................................................... 10 How to approach the respondent ............................................................................... 10 Selecting an environment for the interview .............................................................. 10 Sit at the same level as the respondent(s) and maintain eye contact ......................... 10 Build rapport with the respondent(s) ......................................................................... 10 Language problems ................................................................................................... 10 Not wanting to answer certain questions ................................................................... 11

7. Conducting the Interview ............................................................................................................. 11 Materials you will need ............................................................................................ 11 General Instructions for completing the MAPEDIR format ..................................... 11 Correcting mistakes ................................................................................................... 13 Skip patterns .............................................................................................................. 14

8. Question-by-Question Instructions for the MAPEDIR Suspected Maternal Death Format ...... 16 SECTION 2: Information about the interview .......................................................... 16 SECTION 3: Background information from respondents ......................................... 17 SECTION 5: Pregnancy history ................................................................................ 19 SECTION 6: Circumstance of the woman’s death (and the baby’s outcome) .......... 20 SECTION 7: Illness complications ........................................................................... 23 SECTION 8: Injury ................................................................................................... 26 SECTION 9: Careseeking for obstetrical complications that led to the death .......... 26

9.6 If Action 9.2 was not seeking formal health care, then ask: Did she/the family have any problems that kept her from seeking formal health at that time? ................................................. 27 9.7 Did she seek formal health care at any time during the fatal illness? .................................... 28 If the first action taken for the illness (Q9.2) was not seeking formal health care, then we ask here if the woman ever sought formal care. Just as in Q9.2, if they were trying to seek formal health care, even if they had not yet left the house or were on route to a facility, then mark “1. Yes.” RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know. SKIP INSTRUCTION: If 2 or 8, go to Open History. The remainder of Sections 9 and 10 are about the details of formal health

MAPEDIR Interviewers Reference Manual May 19, 2008 2

care. If the woman never sought formal care, then we skip this and go to the open history to ask about the illness in the respondent’s own words. .................................................................. 28 SKIP INSTRUCTION: STOP: If the woman died before reaching the facility, go to (F1: Open History / F2 or F3: Section 10). ........................................................................................................ 30 The rest of Section 9 asks about the care the woman received at the facilities she visited. If you are completing matrix column 1 and she died before reaching facility 1, then go to the open history to ask about the illness in the respondent’s own words. If she died before leaving home, then Q9.15, Q9.16 and/or Q9.17 may not apply. For example, if the husband went to look for a taxi and his wife died while he was out searching, then Q9.15 and Q9.16 would not apply if he was not able to find a taxi; however, Q9.15 and Q9.16 would apply if he pre-paid for the taxi but Q9.17 still would not apply. Mark the answers to the relevant questions and then go to the open history. If you are completing matrix column 2 (or 3) and she died before reaching facility 2 (or 3), then go to Section 10 to ask if a doctor or nurse told the family the cause of death. Then continue with the open history. .................................................................................. 30

SECTION 10: Reported cause of death .................................................................... 31 10.1Did a doctor or nurse at the health facility tell you the cause of ________’s

death? ....................................................................................................... 31 Open history .............................................................................................................. 31 Supervisor’s certification .......................................................................................... 32

The purpose of this section is to help maintain the quality of the maternal death inquiries. This is best accomplished by the supervisor participating in every interview that the team conducts. At least, the supervisor should carefully check the completeness and accuracy of each completed interview form and discuss the findings with the team members who conducted the death inquiry. The supervisor must decide how to resolve any identified problems, including a repeat visit to the household if needed. Once the supervisor is satisfied with the quality of the completed format, s/he should sign and date the form to certify that it is correct and complete. ....................................................................................................................... 32 APPENDIX A: INTERVIEWER’S CHECKLIST ................................................................................... 33 F. ___ Participate in team meeting (date: ______________) .......................................................... 34 APPENDIX B: SUPERVISOR’S CHECKLIST .................................................................................... 35 APPENDIX C: CONSENT FORM ........................................................................................................ 37 APPENDIX D: INTERVIEWER’S ROLE PLAY GUIDE ....................................................................... 38


About this manualThe purpose of this manual is to provide MAPEDIR interviewers with the information they need to conduct systematic, reliable and valid verbal autopsy interviews for maternal deaths. The manual describes the roles and responsibilities of MAPEDIR interviewers, and provides a question-by-question guide to the verbal autopsy questionnaire for women of reproductive age.

Interviewers are to use this manual as a reference guide during their training and, as needed, in the course of their work as MAPEDIR interviewers. The manual also serves as a reference for trainers and supervisors of the interviewers and for persons who are administering the MAPEDIR project.

1. What is MAPEDIR?Background“Maternal and Perinatal Death Inquiry and Response” (MAPEDIR) means to thoroughly examine and respond to the social, biological and medical events that led to a maternal or perinatal death. Inquiries are conducted of the deaths that occur in a community over several months time, in order to identify common factors that can be acted upon to prevent further deaths. Ongoing inquiries over several years allow a community to assess the impact of its preventive actions and the need for additional interventions. Death inquiries are conducted in the community using a “verbal autopsy” interview with the families of deceased persons. This is particularly helpful in areas where many deaths occur outside of health facilities and for highlighting relevant social factors and health careseeking problems. Health facilities where many deaths occur also should review the care provided to the women and children in order to identify medical practices that need to be improved to prevent additional deaths.

Maternal and child death inquiries have been conducted in many settings. Some examples include: 1) the routine practice of maternal death review by medical practitioners in the United Kingdom over the past 50 plus years, 2) hospital-based perinatal death reviews encouraged by the American College of Obstetricians and Gynecologists in the United States, 3) the community and hospital inquiry into all maternal deaths required by the Sri Lanka Ministry of Health since 1985, 4) the community verbal autopsy and hospital-based confidential inquiry of maternal deaths encouraged by the Philippines Ministry of Health, and 5) maternal death reviews supported by the World Health Organization (WHO) in selected hospitals of Nepal, Bangladesh and Myanmar. In India, the Tamil Nadu Reproductive and Child Health (RCH) Program has reviewed all maternal deaths and a sample of infant deaths since 2003, the government of Kerala has reviewed all maternal deaths since 2005, and WHO supports maternal death reviews at Safdarjang Hospital in Delhi and Christian Medical College in Vellore.

The MAPEDIR projectUNICEF is supporting the implementation of MAPEDIR in the context of RCH2, which calls for increasing community participation in bottom-up health planning and the demand for quality health care. The goals and objectives of the MAPEDIR project are to:

1. Sensitize communities to maternal and perinatal health issues, including the need for birth preparedness, complication readiness and inquiries into maternal and perinatal deaths;

2. Identify recent maternal deaths and conduct community-based inquiries with close acquaintances of the women;

3. Share the findings of the death inquiries with communities and help them interpret the data to develop appropriate local interventions and advocate for improvements in health care; and

4. UNICEF also will use the findings of the inquiries to advocate with policy makers for needed improvements in health care.

While the MAPEDIR project focuses on community-based death inquiries, UNICEF is partnering with WHO to support facility-based reviews of maternal deaths. The project is initially focusing on inquiries of maternal deaths. Perinatal death inquiries will be added in the future.


The causes of maternal mortality and its preventionA maternal death is the death of a woman during pregnancy or within six weeks of having an abortion or giving birth. Most maternal deaths are due to complications directly related to pregnancy, including severe bleeding (hemorrhage), pregnancy-induced hypertension (eclampsia), severe infection starting in the reproductive organs (puerperal sepsis), and obstructed labor (which leads to hemorrhage or sepsis). In India many maternal deaths are due to or hastened by severe anemia, which often results from a combination of factors, including inadequate nutrition, malaria, and blood loss from menstruation and prior pregnancies. About 20% of maternal deaths may be caused by pre-existing conditions such as chronic heart disease or acute illnesses such as malaria that are made worse by the pregnancy. Deaths that occur during pregnancy but that are not related to the pregnancy itself, such as accidents, generally are not counted as maternal deaths.

While a biological complication is defined as the cause of death, in fact most maternal deaths result from a chain of events that includes many social, cultural and medical factors. Some of these can be prevented even before a woman becomes pregnant, such as by ensuring that she is well nourished and not suffering from anemia. However, since it is usually not possible to predict which women will suffer a severe pregnancy or delivery complication, the most effective way to prevent maternal deaths is to be ready to respond to complications when they occur. This often requires taking action at one or more of the links in the chain, with a focus on the “three delays” in a woman’s receiving care for a maternal complication. The following diagram shows where the three delays occur.

Delay 1

Deciding to

seek care

Delay 2

Arranging resources

and reaching the

appropriate facility

Delay 3Receiving

quality care

Onset of complication

Home

FRU Quality

Sub-center

Quality

Delay 1Delay 2

Delay 2

Delay 2

Non-FRU PHC/CHC

Quality

Dela

y 1

Social and cultural factors that may contribute to delay 1 include: 1) low education, 2) poverty, 3) women’s lack of participation in decision-making, 4) not recognizing or understanding the importance of maternal complications, and 5) using traditional home care and informal providers for maternal complications instead of formal providers who might be able to save the woman’s life. The second delay can be due to the time needed to organize funds to pay for transportation or health care, a lack of transport, poor roads, or long distances to a health facility where the woman can receive appropriate care. The third delay may be due to a lack of needed drugs, blood, medical or surgical equipment, or skilled health personnel at the facility. If a woman is referred from a FRU, where she should be able to receive comprehensive emergency obstetric care, then the third delay also includes the additional travel and waiting time before she receives adequate care at the referral facility.

During pregnancy, women and families should be sensitized to the need to prepare for the birth of their child and be ready to deal with any complications that might occur. Such “birth preparedness and complication readiness” includes planning ahead of time where the woman will give birth, who will assist with the delivery, and where and how she will seek emergency care if necessary. Having a plan will enable the woman and her family to respond rapidly should the need arise. Community


participation in planning for safe deliveries will help ensure that women and their families recognize when emergency care is needed and know where and how to seek this care. Part of the community’s sensitization to maternal health issues will include being informed about MAPEDIR and why the death inquiries are needed. During your training as a MAPEDIR interviewer, you will be told about the plans being made to sensitize your community and share the MAPEDIR findings to be used in developing effective interventions against maternal mortality.

2. Project Organization and ProceduresBlock-level team with district oversightThe MAPEDIR project is organized at the block and district levels. In most states, a death notifier initially investigates community reports of deaths of women of reproductive age and transmits his/her findings to the block-level MAPEDIR team supervisor. S/he assesses each report and assigns the suspected maternal deaths for a MAPEDIR interview. Interviewers in most states have chosen to work in teams of two, with one serving as the interviewer and the other as the data recorder. They may switch roles for alternate interviews, so each person serves both as an interviewer and recorder. The two interviewers and their supervisor comprise the block team. Some states include an additional, alternate, interviewer and so have a four-person block team. A district official oversees project implementation in all the district’s blocks. Death reports and completed MAPEDIR interviews are compiled and analyzed at the district level with technical assistance from UNICEF, and the interview findings are shared with the community via district and block officials and NGO partners. In some states, NGOs play a prominent role as well in administering the project and conducting the death inquiries. The following diagram illustrates the process, which varies somewhat from state to state.

MAPEDIR Interviewers Reference Manual May 19, 2008

District CMHO analyzes and reports

data

6

District collector / CEO (PRI)

ANM, AWW, others identify all deaths of women of childbearing age (14-49 years)

Block-level death notifier (e.g., GP secretary) does initial investigation of all reported deaths

Block CEO (PRI)

Block MAPEDIR team supervisor (team investigates suspected

maternal deaths)

Block MO

State directorate

Share analyzed MAPEDIR data with the community (Gram

Panchayats, VHC, SHGs, etc.) with NGO partners

During your training you will review the death notification format that is used to conduct the initial investigation of deaths of women of reproductive age, as well as the register that supervisors keep to track these deaths and assign suspected maternal deaths to the interviewers. You will also discuss the appropriate waiting period after a death before conducting the MAPEDIR interview.

3. Interviewer and Supervisor Roles and ResponsibilitiesOverview of the interviewer’s activities and responsibilitiesAs a MAPEDIR interviewer, you will represent the project to households in your block. You will inform bereaved families about the purpose of MAPEDIR and conduct the verbal autopsy interview with the appropriate family members. Your tasks include:

Meet with your supervisor to receive your interview assignments for maternal deaths that have occurred in your block; Locate households where a maternal death occurred and visit the families to plan dates for conducting interviews; Conduct verbal autopsy interviews with family members on the appointed dates and correctly complete the MAPEDIR format; Return completed interview forms to your supervisor and discuss and solve any problems you have encountered; Strive for continuous self-improvement of your performance; and Maintain the ethical standards of the project and good relations with the community.

Interviewer self-assessment and improvementOne of your responsibilities as a MAPEDIR interviewer is to continually strive to improve your performance. Your supervisor is also there to assist you in overcoming any problems that occur, but to make the greatest progress you should always seek to do the best job possible. Appendix A provides an interviewer’s self-assessment checklist to help you in this task. How to use the checklist will be discussed during your training as a MAPEDIR interviewer. Supervisory procedures and approachYour supervisor will assign suspected maternal deaths to you for interview and provide you with blank MAPEDIR questionnaires. You must return all completed interviews as well as your completed self-assessment checklist to your supervisor. The supervisor’s checklist in Appendix B lists other supervisory tasks and will be discussed during the training. Some of these tasks include:

Keep a register of adult female deaths; Assign suspected maternal deaths for interview; Provide needed logistical support to locate and reach the assigned households; Observe and critique early interviews (and later interviews as possible); Check all completed interview forms for completeness and errors; and Hold periodic meetings with the interviewers to discuss and solve problems.

Supervisors should support the interviewers in achieving their full potential as MAPEDIR interviewers. This means assisting the interviewers whenever necessary and helping them to overcome problems that they face in completing the interviews. Supervisors will have the opportunity to practice this approach during the MAPEDIR training.

4. Ethical TrainingPart of your training as a MAPEDIR interviewer or supervisor will be on ethical aspects of conducting research interviews, such as informed consent and confidentiality. This is to ensure that you are


aware of the importance of these issues and will maintain the highest ethical standards in your work at all times. Some important concepts to be discussed during the ethical training are described below.

Informed consentAll potential respondents have the right to determine for themselves whether or not they will participate in the interview. All respondents must be at least 18 years old, to help ensure that they are capable of making this decision. Part of your job as an interviewer is to administer “informed consent” to all potential respondents. This means that you must fully inform them about the MAPEDIR project and death inquiry before asking any questions; and that after learning all the facts they consent to be interviewed. Respondent(s) must fully understand the purpose and expected duration of the interview, the risks and benefits of being interviewed, and their right to not answer any or all questions. All these and other facts are described in a “consent form,” which you must read and explain to the respondent(s) before conducting the interview. Each respondent must make their mark on the consent form, which you will then sign to testify that the person consented to be interviewed. Complete a separate consent form for each respondent. The consent form is in Appendix C of this manual.

ConfidentialityIt is critical that all information obtained from the MAPEDIR interviews remains strictly confidential. You are not permitted to discuss the findings from an interview, gossip about it, or show your records to anyone other than your supervisor. Make all entries on the questionnaires yourself. Do not leave your verbal autopsy forms lying around where unauthorized persons may have access to them.

Maintaining confidentiality is an ethical responsibility that we all share. It is necessary to protect the respondents from any repercussions that might occur as a result of the information they have provided. It is also necessary to maintain the trust of the community and assure that people will be willing to talk openly to us about the maternal deaths. The project will share the interview findings with the community but never in a way that reveals which information came from which person or family. Falsification of DataYour job as a MAPEDIR interviewer will not always be easy. There may be times when you have to visit a household more than once to meet with the best respondent. The interview will often take one hour or longer to complete. Many of the questions seek sensitive information that may appear to reflect badly on care provided to women by their families and sometimes by the health system. All these conditions can lead to temptations to falsify data in order to quickly complete the interview and not record painful facts. However, you must never falsify your work. The whole purpose of the MAPEDIR project is to collect and share information with the community that can be used to prevent maternal deaths. This will be possible only if the information collected is truthful. It is your responsibility to assure that you maintain this standard. You should work as a MAPEDIR interviewer only if you are certain you can accomplish this.

5. Approach to the Household and Selecting the Respondent(s)

The MAPEDIR interview is best conducted with the one or a few persons who were with the woman during her fatal illness and death. However, when approaching a household in a rural village you are likely to be met by a crowd of interested persons. Once inside the yard or the house several neighbors and family members who know little about the woman’s illness may want to participate in the interview or just observe. You must manage this situation effectively and sensitively in order to ensure that you interview the most knowledgeable person(s) and that the others are not offended. These issues will be discussed during your training, and you will have the opportunity to role play some situations (found in Appendix D) that you might face during your work. Following are some suggestions.

Manage the scene and gain the trust and cooperation of householdsConsider working with a local respected person (e.g., schoolteacher, village leader) to pre-arrange the meeting and/or to accompany the interview team to the household.


In order to have respondent’s cooperation and obtain complete and accurate data, you must first gain the trust and confidence of the household. You can do this by making a good impression and conducting yourself in a professional, but also friendly manner.

Understand the projectIf you are knowledgeable about the project and your responsibilities respondents will be more likely to trust you and participate. You should be able to answer any questions that household members may ask about the purpose of the project and how the information they share will be used.

Emphasize the confidentiality of the informationYou must assure participants that their responses will be held in strictest confidence. No information will ever be released to anyone outside the project in a way that reveals who provided the information.

If a household member or respondent hesitates to cooperate because of confidentiality concerns, you should fully explain how confidentiality will be maintained. Explain that no names will ever be revealed and that the information from all interviews will be combined in a report for district and national use.

Introducing yourself at the householdThis is a very sensitive time for the family so it is important that you be polite and sensitive when introducing yourself. Be sure to state the purpose and confidential nature of the interview—these are key elements to gaining the family’s cooperation. An example is provided below:

My name is [say your name]. I am a nurse/_____ in the _____ center, and an interviewer with the MAPEDIR Project. I have been informed that a woman in your household died. I am very sorry to hear this. Please accept my sympathy. In order to improve health care in our district, we are collecting information on recent deaths of women in this area. I would like to talk to the person in your house who took care of [say the woman’s name] during her illness before death. I assure you that any information you or your family provide will be kept confidential.

How to select the best respondentThe respondent is the main person that will provide information about the deceased. S/he should be the one who was with the woman during her illness. Usually, the woman’s husband, mother, sister or mother-in-law is the preferred respondent for a maternal death. In some cases more than one person will have taken care of the woman or been present during different stages of the illness. For example, the woman’s mother may have attended the birth at home, while the woman’s husband may have accompanied her to the hospital after the birth. All respondents must be at least 18 years of age.

What to do if the potential respondent(s) is away or lives elsewhereIf the person(s) who appear(s) to be the best respondent is not available when you first visit the household, try to make an appointment to return when they will be at home. If no one is at home when you visit the house try to ask a neighbor when you might be able to find family members at home. Then leave a message indicating that you plan to return at this time. In either case, make a note of this return date in your notebook.

Sometimes the best respondent(s) may have moved to another village. In this case, you should discuss the situation with your supervisor, who will decide if you should travel to the other village or if help needs to be sought from the MAPEDIR team in another block.

How to handle multiple respondentsAs discussed above, there may be instances when you need more than one respondent to get the full story of the woman’s illness. If you interview these persons together it should be clear as to who is the respondent for which stage of the illness. More than one person answering the same question can lead to confusion and greatly lengthen the interview.

Some persons who were not with the woman during her illness may insist on attending the interview or even on being the respondent. For example the woman’s husband or mother might not let the sister talk to you alone, even if she took care of the woman during the illness. Or, the respondent may have children to care for who distract her attention from the interview. Lastly, having a visitor at the household can attract many other unwanted people to observe the interview. In these cases it is important to stress to the respondent the importance of confidentiality and privacy. You can try:


Suggest moving to a different location Ask some of the bystanders to leave and come back once the interview is finished. Reschedule a time to come back and finish the interview

6. Communication and Sensitivity IssuesEffective communication with the respondent is of key importance in obtaining high quality information. As a MAPEDIR interviewer, you will interact with bereaved relatives of women who have recently died. In addition to mastering basic communication techniques, you need to be sensitive to the emotions of these bereaved persons and know how to handle difficult situations that might arise during the interview. You will role play some of these situations (in Appendix D) during your training.

How to approach the respondentAlways have a positive approach. Do not use phrases such as: “Are you too busy?” or “Can you spare an hour?” Such questions invite refusal before you start. Instead, begin by restating condolences for the death and say: “I would like to ask you a few questions.” or “I would like to talk with you for a few minutes.” Just as when approaching the household, state the purpose of the interview and its importance for helping the community; and stress the confidential nature of the interview.

However, if a respondent insists that s/he does not wish to talk to you, do not argue. Instead, ask her/him for another day or time when s/he would be available to participate in the interview. Answer any questions the respondent asks frankly and to the best of your knowledge.

Selecting an environment for the interviewIt is best to conduct the interview in a private location where you and the respondent(s) can be alone. However, it is to be expected that other family members may be present during the interview. In cases where complete privacy is not possible, try to limit the number of outsiders present.

Basic communication techniquesSit at the same level as the respondent(s) and maintain eye contactAlways look at the respondent when administering the interview. Remember, this is a difficult time for the respondent and they must feel comfortable with you in order to complete the interview.

Build rapport with the respondent(s)Try to build rapport with the respondent(s) before discussing the case of the deceased. For example, if culturally appropriate, you may ask the respondent what work s/he does, or ask about her/his family.

Encourage speech, listen actively, no not rush, nod your headThese are ways of showing the respondent that you are interested in what s/he is saying, and will encourage her/him to continue.

Be non-judgmental Some of the respondent’s answers may lead you to feel that s/he contributed to the woman’s death, for example, by not taking her for health care quickly enough. However, you must not transmit this message in any way because it will discourage the respondent from providing truthful answers. The success of the MAPEDIR project depends on all of us taking this non-blaming approach. The idea is for us and the community to learn what we can do together to prevent maternal deaths. This can only be accomplished by working together without blaming individuals for the deaths.

Language problemsIf you encounter any language difficulties, for example, if you anticipate that a respondent speaks a different dialect than you do, talk to your supervisor beforehand.

Bereaved respondents and sensitivity issuesPersons who are mourning the death of a loved might have several emotional responses that could interfere with the interview. These might include the following, some of which are discussed below:


Becoming sad or upset Getting offended or angry Being wary or suspicious of the entire interview or certain questions Not wanting to answer certain questions for unstated reasons

Sadness, tearfulnessFirst, be sure to express your sympathy and condolences for the respondent’s loss before starting the interview. It may also help respondents to know that the health program and community will use the MAPEDIR data to help improve care for other women. If a respondent begins to cry or have great difficulty in answering questions because s/he is overcome with emotion, you should pause and offer a tissue for tears. Acknowledge how difficult it must be to answer the questions, give the respondent time to regain their composure, and ask if s/he can continue at this time. If the respondent chooses not to continue, attempt to reschedule the interview.

AngerA respondent may be angry at the health program if s/he feels that an individual health worker or the health program in some way contributed to the death. The respondent might direct this anger at you if s/he sees you as a representative of the health program. Another possibility is that a respondent may blame a relative or neighbor for the woman’s death if, for example, s/he feels that this person did not provide help that was needed. This anger could also come out during the interview. If this happens, let the person express their anger. Then, again express your condolences for their loss and acknowledge that you understand that they blame the particular person or the health program. (Never state that you agree with them, just that you understand that this is their feeling.) Last, again explain that the purpose of the MAPEDIR interviews is to learn more about the problems that lead to maternal deaths and to help the community work together to overcome these problems.

Not wanting to answer certain questionsThere could be several reasons that a respondent does not want to answer certain questions. A question may rekindle painful memories; it may ask about a topic that is particularly sensitive for the respondent; the respondent may feel that they personally did not do enough to help the woman and that the answer to the question would reflect badly on them, etc. Whatever the reason, you must never demand or even ask a respondent to answer a question that they have told you they do not want to answer. As stated in the informed consent statement, respondents’ participation is totally voluntary and they have the right to refuse to answer any or all questions. It should not be a problem for the interview if a respondent refuses to answer only a few questions. However, many refusals will compromise the quality of the interview. You should make a note about any reasons you think might be leading to the respondent’s reluctance and discuss such cases with your supervisor.

7. Conducting the Interview Materials you will need Interviewers will be provided the materials listed below to help them perform their duties. Make sure that you secure them in a safe place in your home when you are not working to prevent loss, damage, or any unauthorized person seeing information that is recorded on the MAPEDIR forms.

MAPEDIR interviewer identification card (be sure to wear it where it can be seen) This manual, MAPEDIR Interviewer’s Reference Manual Interviewer’s self-assessment checklist Blank MAPEDIR maternal death verbal autopsy formats Pencils or pens for writing, and erasers Bag for carrying forms and other materials.

General Instructions for completing the MAPEDIR format

1. Instructions to the interviewer always appear in italic print. Do not read the instructions to the respondent. They are for your use only.


2. Some symbols and abbreviations are used in the format that you need to understand. The symbols and abbreviations and their meanings are: Q (question), DK (don’t know), # (number), < (less than), and = (equals).

3. Many questions include a blank, like this: ________. Wherever this appears, state the name of the deceased woman.

4. Read all questions exactly as they are written so that all respondents are asked questions in the same way. Read slowly and clearly so the respondent understands. Allow the respondent to think about the question before recording their answer. Note that respondents may tend to give answers that they think will please the interviewer. Do not show any surprise, approval or disapproval of the respondent’s answer by the tone of your voice or facial expression.

5. If the respondent doesn’t know the answer to a question or looks uncomfortable with the question, you can try “probing” to get an answer. This means asking other questions similar to the subject material to try and help the respondent remember certain events. For example, if the respondent cannot remember who assisted the woman with the birth in the home, you might try “probing” by asking: “Who was in the room at the time of delivery?” Use your judgment when probing. Remember, this is a very sensitive time for the respondent and we do not want to upset them further.

6. A few questions include words within parentheses and also before or after a slash mark. For example “What did the (facility/provider) do for her problem?” Read the correct word or words for the situation. Another use of the slash mark is the expression “she/the family.” Read this as “she,” “the family” or “she or the family,” depending on which is correct for the situation.

7. Most questions allow only one response and include one large box to record the number of the response. The below provides an example where the answer to the question is “2. No.”

4.10 Does the house have electricity? 1. Yes2. No8. Don’t know

8. Questions that allow multiple answers provide a small box for each possible response. Follow the instructions and tick (√) all of the respondent’s choices. In the first example below, the interviewer is instructed only to check all answers that the respondent gives; in the second example, the interviewer is told to prompt for additional responses. Do this by asking if there was “anything else” after the respondent has given their initial response.

What transportation method was used to take her there?

Multiple answers allowed. Check all that apply.

1. Walk.....................2. Rickshaw/cart......3. Bus......................4. Taxi/auto/trecker. .5. Ambulance...........6. Other....................8. Don’t know...........9. Could not arrange

9.151. If only walk, go2. to Q9.173. 4. 5. 6. 8. 9.

9.281. If only walk, go2. to Q9.303. 4. 5. 6. 8. ------

9.411. If only walk, go2. to Q9.433. 4. 5. 6. 8. ------

4.12.1 Please tell me the benefits of the card.

Prompt: Is there anything else?

Multiple answers allowed. Check all choices that the respondent mentions.

1. Subsidized ration2. Kerosene oil3. Housing4. Health care5. Referral transport6. Other

1. □2. □3. □4. □5. □6. □

9. Responses in units of time, distance or cost are recorded in blank spaces. If the answer requires fewer spaces than are provided, put a “0” in any unfilled spaces. For example:


2

How far is it from… 9.14 …home to fac 1?

_0_ _2_ _3_ km (<1=000; DK = 888)

9.27 …facility 1 to 2?

__ __ __ km(<1=000; DK = 888)

9.40 ..facility 2 to 3?

__ __ __ km (<1=000; DK = 888)

Always record the completed number. For example, the below woman may have been in labor for 15 hours and 45 minutes, so she completed 15 hours of labor. Also note that you should record “00” for any answer that is less than 1.

7.11 How long was she in labor? _1_ _5_ Hours (<1 hour = 00; DK = 88)

10. Section 9 (and questions 7.18.1 and 7.19.1) includes time questions that can be answered with more than one unit. Again, put a “0” in any unfilled spaces, as in the example:

How long was she at this facility?

[Mark Days, Hours and/or Minutes as needed. Example: 01 day, 05 hours and 30 minutes;Example: 02 days, 03 hours and 00 minutes]

9.22_0_ _1_ Days

(DK = 88)

9.35

__ __ Days (DK = 88)

9.48

__ __ Days (DK = 88)

_0_ _5_ Hours (DK = 88)

__ __ Hours (DK = 88)

__ __ Hours (DK = 88)

_3_ _0_ Minutes (DK = 88)

__ __ Minutes (DK = 88)

__ __ Minutes (DK = 88)

11. Some questions, as in the above examples, require you to enter the digit “8” in all the response boxes or spaces if the respondent does not know (DK) the answer, like this:

7.11 How long was she in labor? _8_ _8_ Hours (<1 hour = 00; DK = 88)

12. Answers that request more specific information provide a box or space for this purpose. Write

the respondent’s answer in the box or space. For example:

7.24.1 If 1. Yes, specify:

13. Do not make any stray marks on the questionnaire. Always mark answer boxes in one of the ways shown above, entering either a number, tick mark (√) or specific response, as appropriate for the particular question. Do not mark any answer boxes with an “X” to show that this is not the answer. Just leave a box blank if the associated answer does not apply.

Correcting mistakesIf you make a mistake when marking your answers do not erase the information. Instead, cross it out neatly with one line so the original entry can still be read, and then mark the correct answer. Write your initials next to the correction, so anyone who later examines the completed format will know who made any changes in the answers. Corrections can be made only by the designated interviewer.

In the following example, the interviewer wrote “1” for “Yes” by mistake. She crossed out the “1” with one line, recorded the correct answer and wrote her initials next to response box.

MAPEDIR Interviewers Reference Manual May 19, 2008

1. Yes2. No8. Don’t know

2 RS

13

1

Here is an example of how to correct an answer for a question that allows multiple responses.

1. She was not sick enough to need health care 2. No one was available to accompany her √ RS3. She had to attend to household duties √4. Transportation not available √

Skip patternsRequired skips are indicated by an “If…” statement with a possible response choice that points to where you should go. For example, the following indicates to skip over question 4.5.1 if the answer to question 4.5 = 1, 3 or 8.

4.5 Was the main breadwinner…

[Read the choices to the respondent]

1. fully employed?2. seasonally employed?3. unemployed8. Don’t know

If 1, 3 or 8, go to Q4.6

4.5.1 If seasonally employed (2), ask:About how many months per year did s/he work? __ __ Months

(<1 = 00; DK = 88)

4.6 What is the family’s religion? 1. Hindu2. Muslim3. Christian4. Other8. Don’t know

Also note that the question numbers are designed to help you follow the skip pattern. In the above example, question numbers 4.5 and 4.5.1 start the same because they are closely related.

The major skip patterns in the questionnaire include:

Question 3.6 determines if the deceased woman was pregnant or within 6 weeks after a pregnancy ended. If not, then you skip over most of the rest of the interview to Section 10.

3.6 Was she pregnant at the time of death, or did she die within 6 weeks after a pregnancy ended?

[If the respondent is uncertain, then discuss that the pregnancy could have been ended by an abortion, stillbirth, delivery of the baby, or the woman’s death]

1. Yes, pregnant or within 6 weeks after a pregnancy ended

2. No8. Don’t know

If 2 or 8, go to

Section 10

In Section 6, you determine whether this was an abortion, antenatal or labor and delivery death. The instructions will guide you to the correct questions. For example, question 6.5 determines if this was an abortion death. If not, then you would skip the following questions, which are about the details of an abortion, and go to question 6.9 to determine whether this was an antenatal death.

6.5 Did she die while having an abortion or within 6 weeks after having an abortion?

1. Yes, during an abortion

2. Yes, within 6 weeks after an abortion

3. No8. Don’t know

If 1, go to Q6.6

If 3 or 8, go to Q6.9 (Antenatal)

If this was an abortion death, then you would continue with questions 6.6 to 6.8, where you would be told that this was an abortion death and to go to question 7.17.


6.8 If the abortion was spontaneous, ask:Who completed the abortion?

If the abortion was induced or don’t know, ask:Who performed the abortion?

[Record the highest level provider mentioned]

1. No one (completed spontaneously)

2. Herself3. Relative/friend4. Dai5. Quack6. ANM7. Nurse8. General doctor9. Obstetrician10.Other88. Don’t know

This was an abortion death.

After answering Q6.8, go to Q7.17

Similarly, the instructions for other questions will tell you if this was an antenatal or labor and delivery death and where to go to find the relevant questions.

Section 7 has blocks of questions for abortion, antenatal and labor and delivery deaths. Some blocks are for one type of death, and others are for more than one type. For example, the following instruction between questions 7.10 and 7.11 tells you to ask the next questions only if this was a labor and delivery death.

Ask Q7.11 – 7.16 for Labor and Delivery deaths.

If it was not a labor and delivery death, then you would skip to the next block of questions to determine if they are relevant for the type of death you are interviewing at that time.

In Section 9, after question 9.24 you may need to “skip” to question 9.25 on the previous page, and after question 9.37, you may need to “skip” to question 9.38 on the previous page. These questions are on the previous page due to the matrix format of Section 9. The matrix starts like this…

– MATRIX QUESTIONS – FACILITY 1 FACILITY 2 FACILITY 3

After (deciding to seek care/she was referred), how long did it take to make the arrangement to go from…

[Discuss that this includes the time needed to arrange for transportation and the money to pay for this and the woman’s health care.]

[Mark days, hours and/or minutes as needed. Example: 01 day, 05 hours and 30 minutes;Example: 00 days, 02 hours and 10 minutes]

9.12 …home to fac1?

__ __ Days (DK = 88)

9.25 …facility1 to 2?

__ __ Days (DK = 88)

9.38 …facility2 to 3?

__ __ Days (DK = 88)

__ __ Hours (DK = 88)

__ __ Hours (DK = 88)

__ __ Hours (DK = 88)

__ __ Minutes (DK = 88)

__ __ Minutes (DK = 88)

__ __ Minutes (DK = 88)

and ends like this…

If she was taken to another facility…

…go to Q9.25(start of Facility 2)

…go to Q9.38(start of Facility 3)

Also in Section 9, after questions 7, 17, 23, 30, 36 and 43, you must either continue with the next question or skip to Section 10 depending on the answer.


8. Question-by-Question Instructions for the MAPEDIR Suspected Maternal Death Format

SECTION 1: Available background information (to be filled out before the interview)

Section 1 should be complete when you receive the format from your supervisor. It provides background information that was gathered by the death notifier, which you should use to help locate the correct household where a suspected maternal death occurred.

1.1 Name of deceased womanKnowing the woman’s name will help you locate the correct household for the interview and to communicate about the woman with the people you meet at the household.

1.2 Address of woman’s usual residenceThis is the deceased woman’s residence address.

1.3 Where did she stay during her fatal illness?ONE ANSWER WILL BE RECORDED: 1. her own home (other than with her in-laws); 2. her in-law’s home; 3. her parents’ home; 4. formal health facility where she (aborted/labored and delivered); 5. other (specify); 8. Don’t know. This is where you must go to complete the interview since the best respondent(s) are the people who were with her during the illness.

1.4 What is the address of this place (where she stayed during her fatal illness)?This is the address of the place in Q1.3 where you must go to complete the interview. If the woman stayed at her usual residence during the illness, then the answer will be the same as in Q1.2. This is also the basis for the woman’s identification number that you must write at the top of each page of the questionnaire. If any of the pages become separated, this number will allow the proper pages to be put back together. This will also be the woman’s identification number for the computer record of the MAPEDIR interview.

1.5 Name of head of household of this place (where she stayed during her fatal illness)Knowing the name of the head of the household will help you locate the correct household.

1.6 Relationship of head of household of this place (where she stayed during her fatal illness) to the womanKnowing the relationship of the head of the household to the woman will help you locate the correct household.

1.7 Date of woman’s deathThe day, month and year should be recorded. This can also help you locate the correct household and ensure that you conduct the interview about the correct woman.

1.8 Date of death notificationThis is the date that the death notifier gathered the information on the cover sheet.

1.9 Key informant’s nameThis is the person who reported the woman’s death to the death notifier. S/he may be able to help you locate the household where the woman stayed during her illness.

SECTION 2: Information about the interview

2.1 Interviewer’s name RECORD YOUR NAME IN THIS SPACE.

2.2 Interviewer’s designationRECORD YOUR REGULAR WORK POSITION, SUCH AS ICDS SUPERVISOR or ANM.

2.3 Recorder’s nameWRITE THE RECORDER’S NAME FOR THE INTERVIEW IN THIS SPACE.


2.4 Recorder’s designationWRITE THE RECORDER’S REGULAR WORK POSITION, SUCH AS NGO SUPERVISOR.

2.5 Date of first interviewRECORD THE DATE OF THE FIRST INTERVIEW FOR THIS DEATH.

2.6 Date of last interviewRECORD THE DATE OF THE LAST INTERVIEW FOR THIS DEATH. The interview might take more than one visit if, for example, you need to return to complete the interview with one respondent or if you need to interview a second respondent to get the full story.

SECTION 3: Background information from respondents

INSTRUCTION: Introduce yourself and the purpose of your visit. Say that we are trying to improve the care of women and children. Ask to speak to the person(s) who knows the most about the circumstances of the woman’s death. This might be her sister, mother, mother-in-law or other person. In some cases you may need to speak with more than one person to learn about different stages of the illness. If someone you need to speak with is not available, arrange a time to return when s/he will be home. Read the consent form to the respondent(s) and ask for her/his participation. Each respondent must consent to be interviewed.

This instruction is a brief reminder of how to introduce yourself to the household and respondent(s). Sections 5 and 6 of this manual provide more information on this topic. This is the time when you must read the informed consent form to the potential respondent(s), invite them to make their mark, and sign the form to testify that they consented to be interviewed. Any person who does not consent should not be included in the interview. If no potential respondent(s) consent to be interviewed, then you must stop the interview at this point. 3.1-3.3 Relationship of the respondent(s) to the deceased woman, and when they were with

her during her fatal illness. Use one row (3.1-3.3) for each respondent. Record the respondent’s relationship to the woman, such as her husband or sister. Then ask each respondent when (during the pregnancy, during the (labor and delivery/abortion), when she died) they were with her. It is best for a person to be the respondent only for stage(s) of the illness when they were actually with the woman. Remember, each respondent must be at least 18 years old. RECORD ONE ANSWER: 1. Yes; 2. No for each stage for each respondent.

The rest of Section 3 is where you decide whether or not the woman died a maternal death. This will determine whether you complete the entire interview or just the cause of death and open history sections at the end of the format. Begin by reading the following statement, which will help maintain the flow of the interview.

Read: First I would like to ask you about the circumstances of ________’s death. Remember to say the woman’s name where the blank appears.

3.4 What was ________’s age at the time of death? Young girls and older women are more likely to die from a maternal cause than women in their 20’s and 30’s. Even if the respondent does not know the woman’s exact age it can help to know her approximate age. INSTRUCTION: Estimate if not known exactly. RECORD THE EXACT OR ESTIMATED AGE IN COMPLETED YEARS. Don’t know = 88.

3.5 Where did she die?If the woman died at a health facility, you will ask for the name and address of the facility in Section 9 of the interview. RECORD ONE ANSWER: 1. Home (her, relative’s, friend’s, informal provider’s); 2. Hospita/Other formal health facility; 3. On route to a formal health facility; 4. On route to home from a health facility; 5. Other; 8. Don’t know.


3.6 Was she pregnant at the time of death, or did she die within 6 weeks after a pregnancy ended?INSTRUCTION: If the respondent is uncertain, then discuss that the pregnancy could have been ended by an abortion, stillbirth, delivery of the baby, or the woman’s death. The answer should be “Yes” if the woman died at any time during pregnancy or within 6 weeks after a pregnancy ended. This includes during pregnancy, during or after labor and delivery (of a live infant or a stillbirth), and during or after a spontaneous or induced abortion, including an MTP. As instructed, discuss any situation about which the respondent is uncertain, to help ensure that the answer is correct. MARK ONE ANSWER: 1. Yes, pregnant or within 6 weeks after a pregnancy ended; 2. No; 8. Don’t know. SKIP INSTRUCTION: If 2 or 8, go to Section 10. If Section 10 or the open history indicate this was a maternal death, then return to Section 4.

SECTION 4: Information about the woman and her family

4.1 How many years of school did _________ complete?Women with fewer years of schooling generally have poorer health and their babies are less healthy than those of more educated women. RECORD THE NUMBER OF YEARS. Less than 1 year = 00; Don’t know = 88.

4.2 At the time of her death, was she…INSTRUCTION: Read the choices to the respondent. Unmarried girls and women have less access to resources and so are more likely to die if they have a pregnancy complication. Unmarried girls are also more likely to have an unsafe illegal abortion. RECORD ONE ANSWER: 1. married; 2. widowed; 3. divorced or separated; 4. single (never married); 8. Don’t know. SKIP INSTRUCTION: If 4 or 8, go to Q4.3. (The next two questions are asked only if the woman was ever married.)

4.2.1 What was _________’s age when she (first) married?INSTRUCTION: Try to determine before starting the interview if the woman was married one time or more. Read “first” if she was married more than once. Some girls may marry when they are very young but continue to live with their parents. In such cases, we consider her to be first married when the marriage is consummated. Getting married early leads to having the first pregnancy when young. This increases the risk of suffering a maternal death. RECORD THE ANSWER IN YEARS. Don’t know = 88.

4.2.2 How many years of school did her husband complete?Families where the husband had less schooling usually have fewer resources than other families. This can make it more difficult to raise the funds needed to deal with an emergency, so might increase a woman’s risk for maternal death. RECORD THE ANSWER IN YEARS. Less than 1 year = 00; Don’t know = 88.

4.3 Who was the main breadwinner in her family?RECORD ONE ANSWER: 1. Husband; 2. Herself; 3. Other.

4.4 What was main breadwinner’s occupation?“Occupation” means the breadwinner’s usual type of work, for example, tailor, laborer or farmer. Different occupations pay different amounts of money, so this can affect the family’s resources available for an emergency. RECORD THE BREADWINNER’S OCCUPATION.

4.5 Was the main breadwinner…INSTRUCTION: Read the choices to the respondent. The main breadwinner’s employment affects the resources that are available to the family for emergencies. RECORD ONE ANSWER: 1. fully employed; 2. seasonally employed; 3. unemployed; 8. Don’t know. “Seasonally employed” means the breadwinner worked less than 12 months per year. SKIP INSTRUCTION: If 1, 3 or 8, go to Q4.6.

4.5.1 If seasonally employed (2), ask: About how many months per year did s/he work?RECORD THE NUMBER OF MONTHS. Less than 1 month = 00; Don’t know = 88.


4.6 What is the family’s religion?Knowing the family’s religion helps us describe the women who died and understand if there is a particular group on which we need to focus extra attention to decrease maternal mortality. RECORD ONE ANSWER: 1. Hindu; 2. Muslim; 3. Christian; 4. Other; 8. Don’t know.

4.7 What is the family’s caste?Knowing the family’s caste helps us describe the women who died and understand if there is a particular group on which we need to focus extra attention to decrease maternal mortality. RECORD ONE ANSWER: 1. SC; 2. ST; 3. Other; 8. Don’t know.

4.8 What type of house does the family live in?The type of house affects the family’s living conditions and shows how well or poor off they are. RECORD ONE ANSWER: 1. Kutcha; 2. Kutcha-Pucca; 3. Pucca; 8. Don’t know.

4.9 Does the family have its own toilet?This information helps us gain an increased understanding of the family’s living conditions, and how well or poor off they are. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know.

4.10 Does the house have electricity?This information helps us gain an increased understanding of the family’s living conditions, and how well or poor off they are. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know.

4.11 Does the family have a BPL card?If many families with a maternal death have a BPL card, then the BPL benefits might be used as part of an intervention program. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know.

4.12 Do you know about the benefits of the BPL card?Even if a family has a BPL card, they can benefit from this only if they know what it entitles them to and how to access these benefits. RECORD ONE ANSWER: 1. Yes; 2. No. SKIP INSTRUCTION: If 2, go to Section 5

4.12.1 Please tell me the benefits of the card. INSTRUCTION: Prompt: Is there anything else? Multiple answers allowed. Check all choices that the respondent mentions. (See general instruction 7 on page 13 for how to follow this instruction.) RECORD ALL THE RESPONDENT’S ANSWERS: 1. Subsidized ration; 2. Kerosene oil; 3. Housing; 4. Health care; 5. Referral transport; 6. Other.

SECTION 5: Pregnancy history

Read: Now I would like to ask you about ________’s past pregnancies.

5.1 Not including the current pregnancy how many times was she ever pregnant, whether a child was born or not?The “current pregnancy” is the one that resulted in the woman’s death. A woman’s risk of maternal death is increased in her first pregnancy and if she has had many prior pregnancies. If need be, clarify for the respondent that you mean all past pregnancies, even those resulting in an abortion or stillbirth. RECORD THE TOTAL NUMBER OF PAST PREGNCIES. Don’t know = 88. SKIP INSTRUCTION: If 00, go to Section 6

5.2 How many of her past pregnancies ended in a birth, including stillbirths?“Past pregnancies” are all those before the current one. RECORD THE NUMBER OF PAST PREGNANICES THAT ENDED IN A BIRTH. Don’t know = 88. SKIP INSTRUCTION: If 00, go to Section 6.

5.3 Were any of her past pregnancies delivered by a C-section?A past C-section can increase the chance that a woman’s uterus will rupture and bleed during the delivery of her current pregnancy. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know.


SECTION 6: Circumstance of the woman’s death (and the baby’s outcome)

Read: Now I would like to ask you about ______’s general health and her current pregnancy.

6.1 Did _________ have any of the following problems before the pregnancy began?INSTRUCTION: Read the problems list slowly and check “Yes,” “No” or “Don’t know” for each. The woman may have had a chronic condition that was not diagnosed by a doctor or nurse, such as TB or epilepsy. These might have caused her to cough blood or have fits (convulsions). RECORD “YES,” “NO” OR “DON’T KNOW” FOR EACH CONDITION: 1. Coughing blood; 2. Fits; 3. Other. If one of the answers is “3. Other,” write the details in the space provided.

6.2 Was she ever told by a doctor or nurse that she had any of the following illnesses before her pregnancy began?INSTRUCTION: Read the problems list slowly and check “Yes,” “No” or “Don’t know” for each. Some maternal deaths are due to the pregnancy causing an existing condition to worsen. Only record conditions identified by a doctor or nurse. RECORD “YES,” “NO” OR “DON’T KNOW” FOR EACH CONDITION: 1. Anemia; 2. Heart disease; 3. Diabetes; 4. Cancer; 5. Hypertension; 6. Tuberculosis; 7. Epilepsy; 8. Other. If one of the answers is “8. Other,” specify the details in the space provided.

6.3 How many months did the current pregnancy last?This is basic information we need for every maternal death. RECORD THE NUMBER OF COMPLETED MONTHS. For example, if the respondent says 7 months and 3 weeks then record 07 months; and if the answer is 8 and one-half months then record 08 months. Don’t know = 88.

6.4 Did ________ seek any antenatal care for the pregnancy from an ANM, nurse or qualified doctor?Antenatal care is important both for a woman’s health and that of her baby. Note that we are asking about antenatal care from a formal provider. If the woman received antenatal care only from an informal provider, such as a dai or quack, then the answer is “2. No.” RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know. SKIP INSTRUCTION: If 2 or 8, go to Q6.5

6.4.1 If yes, ask: How many times did she receive antenatal care from an ANM, nurse or qualified doctor?Women should make at least three antenatal care visits during a pregnancy. RECORD THE NUMBER OF TIMES. Don’t know = 88.

Read: Now, I’d like to ask you about the circumstances of __________’s death.

6.5 Did she die while having an abortion or within 6 weeks after having an abortion? Any pregnancy that ends spontaneously at 5 or fewer completed months or that is induced (including MTP) at any time with the intent to kill the fetus is considered an abortion. The answer should be “No” if the pregnancy ended spontaneously at 6 or more completed months. The answer should be “Yes” if the woman died either during an abortion or within 6 weeks after an abortion. RECORD ONE ANSWER: 1. Yes, during an abortion; 2. Yes, within 6 weeks after an abortion; 3. No; 8. Don’t know. SKIP INSTRUCTION: If 1, go to Q6.6. If 3 or 8, go to Q6.9 (Antenatal). (This means that the Antenatal questions begin with question 6.9.)

Abortion questions follow – Ask these questions only if she died during or after an abortionThis instruction guides you to ask the following questions only for abortion deaths.

6.5.1 If she died after an abortion, ask: How many days after the abortion did she die?RECORD THE NUMBER OF COMPLETED DAYS. For example, 1 day and 4 hours = 01 day. Less than 1 day = 00; Don’t know = 88.

6.6 Was the abortion spontaneous or induced, including MTP?“Spontaneous” means the abortion happened on its own. This is the same as a miscarriage. “Induced” means someone purposefully ended the pregnancy. “MTP” (medical termination of


pregnancy) means a medical practitioner induced the abortion. RECORD ONE ANSWER: 1. Spontaneous; 2. Induced, including MTP; 8. Don’t know. SKIP INSTRUCTION: If 1or 8, go to Q6.7

6.6.1 If the abortion was induced, ask: How was it induced?This question may bring risky practices to light. Oral medicine is least risky. Anything inserted in the vagina can cause bleeding or infection. Instrumentation is most risky. INSTRUCTION: Record the highest risk method mentioned. RECORD ONE ANSWER: 1. Oral medicine; 2. Traditional vaginal herbal application; 3. Vaginal tablet; 4. Instrumentation; 8. Don’t know.

6.7 If the abortion was spontaneous, ask: Where was the abortion completed?If the abortion was induced or don’t know, ask: Where did she have the abortion?This question is asked differently depending on whether the abortion was spontaneous or induced. Often, a spontaneous abortion will need to be completed medically in order to stop the bleeding. RECORD ONE ANSWER: 1. Home (her, relative’s, friend’s, informal provider’s); 2. Sub-center; 3. PHC/BPHC; 4. Government hospital; 5. Private clinic/center; 6. Private hospital; 7. On route to formal health facility; 8. Other; 88. Don’t know

6.8 If the abortion was spontaneous, ask: Who completed the abortion?If the abortion was induced or don’t know, ask: Who performed the abortion?This question is asked differently depending on whether the abortion was spontaneous or induced. INSTRUCTION: Record the highest level provider mentioned. This information may help focus a plan to prevent abortion-related deaths. RECORD ONE ANSWER: 1. No one (completed spontaneously); 2. Herself (the woman); 3. Relative/friend; 4. Dai; 5. Quack; 6. ANM; 7. Nurse; 8. General doctor; 9. Obstetrician; 10. Other; 88. Don’t know. SKIP INSTRUCTION: This was an abortion death. After answering Q6.8, go to Q7.17. Knowing this was an abortion death will guide you through Sections 6 and 7. The next abortion questions start with Q7.17.

Antenatal questions follow – Ask these questions only if she did not die during or after an abortionThis instruction is to help guide you through the questionnaire. It follows-up the skip instruction from question 6.5, which was “If 3 or 8, go to Q6.9 (Antenatal).” It is like a stone in a creek. You jump from Q6.5 to the stone and then from the stone to Q6.9. If the answer to Q6.5 was 1 or 2 (abortion), you would have asked Q6.6-6.8 and then skipped to Q7.17.

6.9 Did she die while still pregnant, before labor began?RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know. SKIP INSTRUCTION: If 2 or 8, go to Q6.11 (L&D). (The Labor and Delivery questions begin with question 6.11. You would skip to the L&D questions because this would not be an Abortion death or an Antenatal death.)

6.10 How long was the illness that led to her death?INSTRUCTION: Convert response to days: use 1 month = 30 days. We will better understand the illness if we know how long it lasted. RECORD THE NUMBER OF COMPLETED DAYS: For example, if 6 days and 9 hours, record 006 days. Less than 1 day = 000; Don’t know = 888. SKIP INSTRUCTION: This was an antenatal death. After answering Q6.10, go to Q7.1. The next questions for Antenatal deaths begin with Q7.1

Labor and Delivery questions follow – Ask these questions only if she did not die before labor beganThis instruction is just like the above ‘skipping stone’ for Antenatal deaths. 6.11 Did she die while in labor or delivery or within 6 weeks after delivery, including a

stillbirth?RECORD ONE ANSWER: 1. Yes, during labor and delivery; 2. Yes, within 6 weeks after the delivery; 3. No; 8. Don’t know. SKIP INSTRUCTION: If 1, go to Q6.12. If 3 or 8, go to Section 10. You would skip the rest of Section 6, which is only for Labor and Delivery deaths. You would also skip Sections 7-9 because you would have just determined that this also was neither an abortion nor antenatal death. However, these findings could be mistaken since you would have arrived at Section 6 only after learning from question 3.6 that this was a maternal


death. Section 10 and the open history may help you clarify the situation, after which you can return to the correct part of Section 6 and then continue with Section 7.

6.11.1 If she died after the delivery, ask: How many days after the delivery did she die?Knowing how long after the delivery she died can help us determine the cause of her death. RECORD THE NUMBER OF COMPLETED DAYS. Less than 1 day = 00; Don’t know = 88.

6.12 Did she have a plan where to delivery the baby?Having a plan for where to deliver is an important part of “birth readiness.” RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know. SKIP INSTRUCTION: If 2 or 8, go to Q6.13

6.12.1 If she had a delivery plan, ask: Where was it planned for the baby to be delivered?This is a follow-up question to 6.12. RECORD ONE ANSWER: 1. Home (her, relative’s, friend’s, informal provider’s); 2. Sub-center; 3. PHC/BPHC; 4. Government hospital; 5. Private clinic/center; 6. Private hospital; 7. Other; 8. Don’t know.

6.13 Where did she (labor/deliver the baby)?INSTRUCTION: Read “labor” if she died before delivering. RECORD ONE ANSWER: 1. Home (her, relative’s, friend’s, informal provider’s); 2. Sub-center; 3. PHC/BPHC; 4. Government hospital; 5. Private clinic/center; 6. Private hospital; 7. On route to formal health facility; 8. Other; 88. Don’t know. SKIP INSTRUCTION: If 1, 8 or 88, go to Q6.14.

6.13.1 If at or on route to a health facility, ask: What is the name and address of the health facility? RECORD THE NAME AND ADDRESS OF THE FACILITY.

6.13.2 When she started out for the health facility, was she in normal labor or had her illness already begun?Delivery complications can occur at any time, so it is best for women to go to a health facility even if their labor is normal. Response choice 3 is for women who went for any other reason and their problem started while at the facility. RECORD ONE ANSWER: 1. Normal labor; 2. Her illness had already begun; 3. Went for any other reason (e.g., ANC); 8. Don’t know.

6.14 Who attended the (labor/delivery)?INSTRUCTIONS: Read “labor” if she died before delivering. Record the highest level provider mentioned. It is best for a skilled birth attendant to deliver the baby. RECORD ONE ANSWER: 1. Herself; 2. Relative/friend; 3. Dai; 4. Quack; 5. ANM; 6. Nurse; 7. General doctor; 8. Obstetrician; 9. Other; 88. Don’t know.

6.15 How was the (baby delivered/delivery attempted)?INSTRUCTION: Read “delivery attempted” if she died before delivering.” RECORD ONE ANSWER: 1. Spontaneous vaginal (no drugs); 2. Mechanically induced (forceful external pushing); 3. Induced with drugs; 4. Forceps; 5. C-section; 8. Don’t know.

6.16 What part of the baby came out first?If the baby’s buttocks, feet or hand came out first, then this could have been a difficult delivery. RECORD ONE ANSWER: 1. Head; 2. Buttocks/Feet; 3. Hand; 4. No part delivered. 8. Don’t know. SKIP INSTRUCTION: If 4, go to Section 7.

6.17 What was the baby’s outcome?The baby has a high risk of dying if the mother dies. RECORD ONE ANSWER: 1. Not delivered at time of mother’s death; 2. Stillbirth; 3. Born alive and died; 4. Currently alive; 8. Don’t know. SKIP INSTRUCTIONS: If 1, 2, 4 or 8, go to Section 7.

6.17.1 If born alive and died (3), ask: How many days old was the baby at death?Ask this question only if the answer to question 6.17 is “3. Born alive and died.” RECORD THE ANSWER IN DAYS. Less than 1 day = 000; Don’t know = 888.

This was a labor and delivery death. Continue with Section 7.This is another ‘skipping stone’ that tells you the type of death this was (L&D) and where to continue.


SECTION 7: Illness complications

Read: Now, I’d like to ask you about the problems __________ had during the last part of her pregnancy and the fatal illness.This statement helps make the transition from determining the type of maternal death (abortion, antenatal, labor and delivery) to identifying the woman’s illness symptoms and cause of death.

Section 7 is organized into blocks of questions about the main symptoms that occur with the three types of maternal death. You have already determined the type of maternal death in Section 6. Use that information to decide which question blocks to ask.

Ask Q7.1 – 7.10 for Antenatal and Labor and Delivery deaths.This is a ‘staying stone’ instruction that tells you to ask the following questions if you determined in Section 6 that this was an Antenatal or Labor and Delivery death. The questions are about illness symptoms that can occur with these deaths. The causes of maternal death associated with these symptoms are discussed on page 4 of this manual. 7.1 During the last part of the pregnancy, was she breathless or very weak when doing her

usual work?Being breathless or weak when doing your usual work is sign of anemia. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know

7.2 During the last part of the pregnancy or the fatal illness, were her eyes or hands more pale than usual?Pallor is also a sign of anemia. We ask about pallor (and symptoms 7.3 – 7. 7) during pregnancy or the fatal illness because women who died after delivering could have had these symptoms at one or both times. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know

7.3 During the last part of the pregnancy or the fatal illness, did a doctor or nurse tell her that she had anemia?The answer should be “Yes” only if a doctor or nurse made this diagnosis. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know

7.4 During the last part of the pregnancy or the fatal illness, did she have blurred vision? Blurred vision is a sign of severe pre-eclampsia. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know.

7.5 During the last part of the pregnancy or the fatal illness, did she have a severe headache?Severe headache is a sign of severe pre-eclampsia. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know

7.6 During the last part of the pregnancy or the fatal illness, did a doctor or nurse tell her that she had high blood pressure?This is also sign of pre-eclampsia. The answer should be “Yes” only if a doctor or nurse made this diagnosis. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know

7.7 During the last part of the pregnancy or the fatal illness, did she have swelling of the hands or face?This is a also sign of pre-eclampsia. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know

7.8 During the fatal illness, did she have severe swelling of the legs?This could be a sign of heart failure that may be due to severe anemia. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know.

7.9 During the fatal illness, was it very difficult for her to breathe?This could also be a sign of heart failure due to severe anemia. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know.


7.10 Did she have convulsions during the fatal illness?Having convulsions could mean that the woman died from eclampsia. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know. SKIP INSTRUCTION: If this was an antenatal death, go to Q7.19. (Questions 7.11 – 7.18 are only for Labor and Delivery and Abortion deaths.)

Ask Q7.11 – 7.16 for Labor and Delivery deaths.This is a ‘staying stone’ instruction that tells you to ask the following questions if you determined in Section 6 that this was a Labor and Delivery death. The questions do not start with “During labor and delivery…” because it is clear from the questions that you are asking about this period.

7.11 How long was she in labor?“Labor” begins when the woman has regular contractions no more than 10 minutes apart. Labor usually lasts less than 12 hours. RECORD THE COMPLETED NUMBER OF HOURS. Less than 1 hour = 00; Don’t know = 88.

7.12 For how long did she have to make an effort?“Make an effort” is the pushing a woman does at the end of labor to deliver the baby. This effort usually lasts less than 2 hours. RECORD THE COMPLETED NUMBER OF HOURS. Less than 1 hour = 00; Don’t know = 88.

7.13 Did she have labor pain that was worse than normal labor pain and that started suddenly?This is a sign of a ruptured uterus, which can result in severe bleeding. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know

7.14 Did she have labor pain that improved or stopped suddenly?This is a sign of a ruptured uterus. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know

7.15 Was her liquor (amniotic fluid) foul smelling?Foul smelling liquor is a sign of pelvic infection. You can read “amniotic fluid” if this helps the respondent understand the question. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know

7.16 How long after the baby’s birth did the placenta come out?The placenta should come out within one hour after the baby is delivered. Retained placenta can lead to postpartum hemorrhage. RECORD THE COMPLETED NUMBER OF HOURS. If the woman died before the placenta came out, then record that it never came out. Less than 1 hour = 00; Don’t know = 88; Never = 99.

Ask Q7.17 – 7.18 for Abortion and Labor and Delivery deaths.This is a ‘staying stone’ instruction that tells you to ask the following questions if you determined in Section 6 that this was an Abortion or Labor and Delivery death. The questions are about illness symptoms that can occur with Abortion and Labor and Delivery deaths.

7.17 Did she have abdominal pain that did not go away (after the abortion/between the contractions/after the delivery)?Continuous abdominal pain is a sign of pelvic infection, which can occur after an abortion, during labor or after delivery. Depending on during which of these times the woman died, read either “after the abortion,” “between the contraction” or “after the delivery.” RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know.

7.18 Did she have foul smelling vaginal discharge (after the abortion/during [or after] the delivery)?INSTRUCTION: Read “…during or after…” if she died postpartum. Foul smelling discharge is a sign of pelvic infection, which can occur after an abortion, or during labor or after delivery. Depending on during which of these times the woman died, read either “after the abortion,” “during the delivery” or “during or after the delivery.” RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know. SKIP INSTRUCTION: If 2 or 8, go to Q7.19.


7.18.1 For Abortion deaths only:How long after the abortion did the discharge start?This question is asked only for abortion deaths with discharge. INSTRUCTION: Mark days and/or hours as needed. If the discharge started before, during or less than 1 hour after the abortion, then record 00 hours. Knowing when the discharge started will help us determine if infection was the cause of death. RECORD THE NUMBER OF COMPLETED DAYS AND/OR HOURS. Less than 1 hour = 00; Don’t know = 88.

Ask Q7.19 – 7.24 for All deaths.This is a ‘staying stone’ instruction that tells you to ask the following questions for all deaths. The questions are about illness symptoms that can occur with all types of maternal deaths.

7.19 Did she have fever during the fatal illness?Fever is a sign of infection. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know. SKIP INSTRUCTION: If 2 or 8, go to Q7.20

7.19.1 For Abortion deaths only:How long after the abortion did the fever start?This question is asked only for abortion deaths with fever. INSTRUCTION: Mark days and/or hours as needed. If fever started before, during or less than 1 hour after the abortion, then record 00 hours. Knowing when the fever started will help us determine if infection was the cause of death. RECORD THE NUMBER OF COMPLETED DAYS AND/OR HOURS. Less than 1 hour = 00; Don’t know = 88.

7.20 Did she have any vaginal bleeding (during the abortion/during the last part of the pregnancy/before the delivery)?It is normal to have light bleeding with an abortion or delivery, but not during pregnancy. Read the correct words in the parentheses depending on whether she had an abortion, antenatal, or labor and delivery death. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know. SKIP INSTRUCTION: If 2 or 8, go to Q7.21.

7.20.1 Did she feel cold to touch after this bleeding started?“Cold to touch” means that she felt cold to someone else who touched her. This would usually be due to heavy bleeding. However, the woman could have internal bleeding that was hidden. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know.

7.21 During the fatal illness, did she have vaginal bleeding that was too heavy?Heavy bleeding might indicate that this was the cause of the woman’s death. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know. SKIP INSTRUCTION: If 2 or 8, go to Q7.22.

7.21.1 Did she feel cold to touch after the heavy bleeding started?“Cold to touch” means that she felt cold to someone else who touched her. This would be due to very heavy bleeding. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know.

7.21.2 For deaths Af ter Delivery only, ask: Did the heavy bleeding start…This question is asked only for deaths after delivery with heavy bleeding. INSTRUCTION: Read the choices slowly and mark one answer. RECORD ONE ANSWER: 1. before the delivery; 2. during the delivery; 3. after the delivery; 8. Don’t know.

7.21.3 For deaths Af ter Delivery only, ask:How long after the heavy bleeding started did she die?This question is asked only for deaths after delivery with heavy bleeding. If she died quickly this would indicate that the bleeding was very heavy. RECORD THE NUMBER OF COMPLETED HOURS. Less than 1 hour = 00; Don’t know = 88.

7.22 During the fatal illness, did she become semiconsciousness?Reduced consciousness is a sign of severe illness that could be due to a pelvic infection or malaria. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know.


7.23 During the fatal illness, did she become unconsciousness?Unconsciousness is a sign of severe illness that could be due to a pelvic infection or malaria. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know.

SKIP INSTRUCTION: If not semiconscious and not unconscious, go to Q7.24. This skip instruction is placed here since it applies to both Q7.22 and 7.23. Ask Q7.23.1 and 7.23.2 if the woman had semiconsciousness or unconsciousness.

7.23.1 How long was she semiconscious or unconscious?INSTRUCTION: If she was both semiconscious and unconscious, then record the total time. Knowing how long the reduced consciousness lasted helps us determine if the woman died from pelvic infection or malaria. RECORD THE NUMBER OF COMPLETED HOURS. Less than 1 hour = 000; Don’t know = 888.

7.23.2 Was she semiconscious or unconscious until she died?“Until she died” means right up to the moment she died. This also helps us determine if she died from pelvic infection or malaria. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know.

7.24 Did she have any other problem?INSTRUCTION: If “Yes,” specify. You can use this space to record another symptom not already mentioned. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know. If the answer is Yes, then record the symptom in the space provided.

7.24.1 If 1. Yes, specify:This is where you can specify any other symptom that the woman had during the illness.

SECTION 8: Injury

8.1 Did ________ suffer an injury or accident of any kind in the days before death?RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know. SKIP INSTRUCTION: If 2 or 8, go to Section 9. (If she did not have an injury, then we don’t need to ask any more injury questions.)

8.1.1 What kind of injury or accident did she suffer?INSTRUCTION: Allow the respondent to answer spontaneously. If she has difficulty identifying the injury, read all the choices slowly. RECORD ONE ANSWER: 1. Motor vehicle accident; 2. Fall; 3. Violence; 4. Suicide; 5. Other (specify other); 8. Don’t know. If the answer is “5. Other,” then write the details in the space provided.

8.1.2 How long after the injury did she die?It is more likely that the injury was the cause of death if the woman died soon after it occurred. RECORD THE NUMBER OF COMPLETED DAYS: For example, if 3 days and 8 hours, then record 003 days. Less than 24 hours = 000 days; Don’t know = 888.

8.1.3 Did she die from the injury?We are asking for the respondent’s opinion. This can help us understand whether or not the injury was severe. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know.

SECTION 9: Careseeking for obstetrical complications that led to the death

9.1 Now, please tell me, where was ________ when her fatal illness began?Knowing this can help us put together the picture of the woman’s illness. The answers to Q9.1 and Q6.13.2 will usually fit together. For example, if the illness had already begun when she started out for the health facility (Q6.13.2 = 2), then it probably began at home (Q9.1 = 1). And if she was in normal labor when she started out for the facility (Q6.13.2 = 1), then usually the illness will have begun on route to (Q9.1 = 3) or at (Q9.1 = 2) the facility where she gave birth. However, it could have begun on route home (Q9.1 = 4) or after returning home (Q9.1 = 1) from the facility. Discuss the situation with the respondent to make sure Q6.13.2 and Q9.1 make sense together before recording the answers. RECORD ONE ANSWER: 1. Home (her, relative’s, friend’s, informal provider’s); 2. Hospital /Other formal health facility; 3. On route to a formal health facility; 4. On route to home from a health facility; 5. Other; 8. Don’t know


9.2 And what was the first thing she or her family did for the illness?INSTRUCTION: Mark only the first action taken. If they were trying to seek formal care, even if they had not yet left the house or were on route to a facility, then mark “3. Sought formal care.” If Q9.1 = 2, then Q9.2 will usually = 4. If not, then discuss the situation with the respondent to make sure s/he understood the questions. If the answers still don’t match, then write a short explanation in the question box to help your supervisor understand the situation. A woman with a severe maternal illness requires formal health care to save her life. Formal care means care by a licensed doctor or nurse. Informal care means by an unlicensed provider such as a dai or quack. RECORD ONE ANSWER: 1. Gave home care; 2. Sought care from an informal provider (includes at her own home); 3. Sought formal health care; 4. She was at the formal provider where she went for normal labor, to have an MTP or any other reason when her illness began; 5. Other (specify other); 8. Don’t know. If “5,” specify the action in the space provided. SKIP INSTRUCTIONS: If 4, go to Q9.11. If 8, go to Q9.7.

9.3 Who decided that this was the action to take?INSTRUCTION: Only one response allowed. Record the main decision maker. Women who decide for themselves usually seek formal care faster than if someone else decides for them. RECORD ONE ANSWER: 1. The woman, herself; 2. Her husband; 3. Her mother; 4. Her mother-in-law; 5. Other male; 6. Other female; 8. Don’t know.

9.4 How long after the illness began did s/he decide to do this?INSTRUCTION: Mark days, hours and/or minutes as needed. (See general instruction 9 on page 14 on how to record the answer.) The definition of careseeking delay 1 is how long it took to decide to seek formal health care. If ACTION 9.2 was to seek formal care, then the response to Q9.4 defines delay 1. Don’t know = 88.

9.5 Which symptom(s) did ________ have at this time?Delay 1 is partly due to not recognizing for which symptoms a pregnant woman urgently requires formal health care. RECORD ALL THE SYMPTOMS THE RESPONDENT STATES the woman had when it was decided to take ACTION 9.2.

9.6 If Action 9.2 was not seeking formal health care, then ask: Did she/the family have any problems that kept her from seeking formal health at that time?

If Action 9.2 was seeking formal heath care, then ask: Did she/the family have to overcome any problems in order to seek formal health care at that time?INSTRUCTION: Prompt: Was there anything else? Multiple answers allowed. Check all that apply. Check only “14” if she had no careseeking problem. (See general instruction 7 on page 13 for how to follow this instruction.) Knowing the reasons for careseeking delays 1 and 2 can help develop interventions to overcome these delays. RECORD ALL THE RESPONDENT’S ANSWERS: 1. Did not think she was sick enough to need health care; 2. No one was available to accompany her; 3. She had to attend to household duties; 4. Transportation not available; 5. Could not pay for transportation; 6. Could not pay for the care provider/facility; 7. Other cost; 8. Not satisfied with the available health care; 9. Her problem(s) require traditional care; 10. Thought she was too sick to travel; 11. Thought she would die no matter what; 12. It was late at night; 13. Other (specify); 14. No careseeking problem; 88. Don’t know. If the answer is “13. Other,” write the details in the space provided. Record only “88. Don’t know” if the respondent doesn’t know if the woman had any careseeking problem.

If the first action was to seek formal care (Q9.2=3), go to Q9.11.Questions 9.7-9.10 are about the first time that formal care was sought for the illness. If the first action was to seek formal care, then Q9.3-9.5 asked these questions so we don’t need to ask them again.


9.7 Did she seek formal health care at any time during the fatal illness?If the first action taken for the illness (Q9.2) was not seeking formal health care, then we ask here if the woman ever sought formal care. Just as in Q9.2, if they were trying to seek formal health care, even if they had not yet left the house or were on route to a facility, then mark “1. Yes.” RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know. SKIP INSTRUCTION: If 2 or 8, go to Open History. The remainder of Sections 9 and 10 are about the details of formal health care. If the woman never sought formal care, then we skip this and go to the open history to ask about the illness in the respondent’s own words.

9.8 Who decided that she needed to seek health care?INSTRUCTION: Only one response allowed. Record the main decision maker. Women who decide for themselves usually seek formal care faster than if someone else decides for them. RECORD ONE ANSWER: 1. The woman, herself; 2. Her husband; 3. Her mother; 4. Her mother-in-law; 5. Other male; 6. Other female; 8. Don’t know.

9.9 How long after the fatal illness began did s/he decide to seek this care?INSTRUCTION: Mark days, hours and/or minutes as needed. (See general instruction 9 on page 14 on how to record the answer.) The definition of careseeking delay 1 is how long it took to decide to seek formal health care. If ACTION 9.7 was to seek formal care, then the response to Q9.9 defines delay 1. Don’t know = 88.

9.10 Which symptoms did she have at this time?Delay 1 is partly due to not recognizing for which symptoms a pregnant woman urgently requires formal health care. RECORD ALL THE SYMPTOMS THE RESPONDENT STATES the woman had when it was decided to seek formal health care.

9.11 How many formal facilities was she taken to (or intended to go) before she died?INSTRUCTION: Include any facility she did not reach because she died before leaving or on route. Include the facility she went to for normal labor, an MTP or any other reason if her illness began at this facility. Visiting many facilities instead of going to the correct facility first causes additional delays. We include any facilities that the woman did not reach because we want to know about all her attempts to seek care. This includes facilities that she intended to go to but died before leaving home or another facility or while on route to a facility. This can happen, for example, if it takes too long to arrange for transportation. RECORD THE NUMBER OF FORMAL HEALTH FACILITIES.

9.11.1 Mark the facility where she had an abortion or delivered (if this was an abortion or L&D death and she was sick while at the facility) and where she died.

Aborted here box: If she went to a formal facility to complete a spontaneous abortion, or if she had an MTP at a formal facility and her illness began while there, then mark the “Aborted here” box for the facility.

Delivered here box: If she labored or delivered in a formal health facility and she was sick when she arrived there or her complications began while at the facility, then mark the “Delivered here” box for that facility.

Died here box: If she died in a formal facility, mark the “Died here” box for that facility.

9.11.2 Name and address of the first facility she went to: FACILITY 19.11.3 Name and address of the second facility she went to: FACILITY 29.11.4 Name and address of the third facility she went to: FACITLITY 3

RECORD THE NAME AND ADDRESS OF EACH FORMAL HEALTH FACILITY she went to for the fatal illness. Remember to include facilities the woman tried to go to but did not reach because she died before leaving home or another facility or while on route to the facility. Also include any facility where her illness began, for example, if she had an MTP there and began to bleed while at the facility.

MATRIX QUESTIONS


The remainder of Section 9 is structured as a matrix, with one column for each facility visited, and with room for up to three facilities. If the woman went to more than one facility, complete the questions for one facility (e.g., Q9.12-9.24 for facility 1) before asking the questions for the next facility.

9.12 After (deciding to seek care/she was referred), how long did it take to make the9.25 arrangements to go from… home to facility 1? …facility 1 to facility 2? …facility 2 to9.38 facility 3?

INSTRUCTION: Read “…home to facility 2?” or “…home to facility 3?” if she first went home before going to the next facility. Read “After deciding to seek care…” when going from home to facility 1 (or from home to facility 2 or 3). Read “After she was referred…” when going from facility 1 to 2 or from facility 2 to 3. Discuss that this includes the total time needed to arrange for transportation and the money to pay for this and the woman’s health care. Mark days, hours and/or minutes as needed. See general instruction 9 on page 14 on how to record the answer. The time it takes to make all needed arrangements to go to a health facility is part of careseeking delay 2. Don’t know = 88.

9.13 How did she/the family arrange this money?9.26 INSTRUCTION: Multiple answers allowed. Check all that apply. Without adequate9.39 preparation, funding the transport and health care costs for an emergency trip to the hospital

can deplete a family’s resources. RECORD ONE ANSWER: 1. Had available; 2. Borrowed; 3. Sold assets; 4. Community fund; 5. Government scheme; 6. Other; 8. Don’t know.

9.14 How far is it from… home to facility 1? …facility 1 to facility 2? …facility 2 to facility 3?9.27 INSTRUCTION: Read “…home to facility 2?” or “…home to facility 3?” if she first went home9.40 before going to the next facility. Careseeking delay 2 is the time it takes for a woman to reach

the facility where she can get the care she needs. The distance to the facility is one reason for this delay. RECORD THE NUMBER OF WHOLE KILOMETERS: For example, if 14 and one-half kilometers, record 014. Less than 1 kilometer = 000; Don’t know = 888.

9.15 What transportation method was used to take her there?9.28 INSTRUCTION: Multiple answers allowed. Check all that apply. See general instruction 7 on9.41 page 13 for how to follow this instruction. Lack of transportation is another reason for delay 2.

Response choice “9. Could not arrange,” is for cases where the family tried to seek formal care but was not able to arrange transportation and did not leave the house. This response is not relevant to Q9.28 and Q9.41 because these questions are asked only for women who left facility 1 or 2. RECORD ALL THE RESPONDENT’S ANSWERS: 1. Walk; 2. Rickshaw/cart; 3. Bus; 4. Taxi/auto/trecker; 5. Ambulance; 6. Other; 8. Don’t know; 9. Could not arrange. SKIP INSTRUCTION: If “walk” is the only response, then go to Q9.17 (Q9.30, Q9.43).

9.16 How much did this cost?9.29 Even if transportation is available, it might be too costly for many people to afford. Q9.16 does9.42 not apply if the family could not find transport to facility 1. The “NA” response is not available

for Q9.29 and Q9.42 because these questions are asked only for women who left facility 1 or 2. RECORD THE NUMBER OF RUPEES. Don’t know = 8888; Not applicable=9999.

9.17 How long did it take to travel to… …facility 1? …facility 2? …facility 3?9.30 INSTRUCTION: Mark days, hours and/or minutes as needed. We want to know the total9.43 travel time to the facility so the question does not apply if she died on the way.Travel time to

the facility is part of delay 2. See general instruction 9 on page 14 on how to record the answer. Don’t know = 88; Not applicable = 99.


SKIP INSTRUCTION: STOP: If the woman died before reaching the facility, go to (F1: Open History / F2 or F3: Section 10).

The rest of Section 9 asks about the care the woman received at the facilities she visited. If you are completing matrix column 1 and she died before reaching facility 1, then go to the open history to ask about the illness in the respondent’s own words. If she died before leaving home, then Q9.15, Q9.16 and/or Q9.17 may not apply. For example, if the husband went to look for a taxi and his wife died while he was out searching, then Q9.15 and Q9.16 would not apply if he was not able to find a taxi; however, Q9.15 and Q9.16 would apply if he pre-paid for the taxi but Q9.17 still would not apply. Mark the answers to the relevant questions and then go to the open history. If you are completing matrix column 2 (or 3) and she died before reaching facility 2 (or 3), then go to Section 10 to ask if a doctor or nurse told the family the cause of death. Then continue with the open history.

9.18 Which illness symptom(s) did she have while at… ...facility 1? …facility 2? …facility 3?9.31 Knowing the woman’s symptoms can help us determine if the facility provided quality health9.44 care. RECORD ALL THE SYMPTOMS THE RESPONDENT STATES the woman had while

at the facility.

9.19 What did the (facility/provider) do for her problem?9.32 INSTRUCTIONS: Prompt: Was there anything else? Multiple responses allowed. Check all9.45 that apply. See general instruction 7 on page 13 for how to follow this instruction. If the

respondent observed the woman’s care while at the facility, then we can assess the quality of the care that she received. Providers sometimes advise family members to go buy a medicine that is not available in the facility. This can contribute to the delay in the woman receiving appropriate care at the facility. Use choice “7” to record this finding. RECORD ALL THE RESPONDENT’S ANSWERS: 1. IV fluid other than blood; 2. Massaged abdomen to stop the bleeding; 3. Medicine to stop the bleeding; 4. Blood transfusion; 5. Completed the abortion; 6. C-section; 7. Advise to buy outside medicine; 8. Other (specify); 9. Nothing; 88. Don’t know. If “8. Other,” specify the action or treatment in the space provided. SKIP INSTRUCTION: If “9, Nothing” or “88. Don’t know,” go to Q9.21 (Q9.34, Q9.47)

9.20 How much did all this care cost?9.33 This is part of the economic impact of the illness. RECORD THE NUMBER OF RUPEES. 9.46 Don’t know = 88888.

9.21 Did the (facility/provider) refer ________ to another health care facility?9.34 The woman should be referred as soon as possible if the facility is not equipped to handle her9.47 problem. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know. SKIP INSTRUCTION: If 2

or 8, go to Q9.22 (9.35, 9.48)

9.21.1 Why was she referred?9.34.1 INSTRUCTIONS: Multiple responses allowed. See general instruction 7 on page 13 for how9.47.1 to follow this instruction. RECORD ALL THE RESPONDENT’S ANSWERS: 1. For a certain

problem (specify); 2. Did not have blood; 3. For a procedure (specify); 4. Lack of a specialist (specify); 5. Other (specify). If “1. Certain problem, “ “3. Procedure,” “4. Specialist” or “5. Other,” write the details in the space provided.

9.21.2 How long after this problem started was she referred?9.34.2 INSTRUCTION: Include only her time in the facility if she had the problem when she arrived.9.47.2 Discuss with the respondent whether the problem for which the woman was referred started

before or after she arrived at the facility. Mark days, hours and/or minutes as needed. See general instruction 9 on page 14 on how to record the answer. Time in the first facility may be well spent in stabilizing the woman’s condition. However, if she had to go to another facility to receive appropriate health care, then any unnecessary time at facility 1 is part of delay 2. Don’t know = 88.

9.22 How long was she at this facility?9.35 INSTRUCTION: Mark days, hours and/or minutes as needed. See general instruction 9 on


9.48 page 14 on how to record the answer. This should be the total time the woman was at this facility, including the time before and after she was referred. Don’t know = 88.

The rest of Section 9 is only for facilities 1 and 2. If the woman went to a fourth facility, then after Q9.48 ask the respondent to describe the visit to facility 4 as part of the open history.

9.23 Was she taken to another health facility after leaving… …facility1 …facility 2?9.36 Unlike in Q9.11, where we include facilities she intended to go to but died before setting out,

here we only want to know whether the woman actually left for another facility. If she left and either died on route to or reached the next facility, the answer should be “1. Yes.” RECORD ONE ANSWER: 1. Yes, 2. No, 8. Don’t know. SKIP INSTRUCTIONS: If 8, go to Section 10.

9.24 If not taken to another facility, ask: Did she/the family have any problems that kept her9.37 from going to another facility?

If taken to another facility, ask: Did she/the family have to overcome any problems in order to go to another facility?INSTRUCTIONS: Prompt: Was there anything else? Multiple answers allowed. Check all that apply. See general instruction 7 on page 13 for how to follow this instruction. RECORD ALL THE RESPONDENT’S ANSWERS: 1. No transportation; 2. Transportation or health care cost; 3. Not satisfied with available care; 4. Thought she would die no matter what; 5. She died at facility 1 or facility 2; 6. Other (specify). 7. No careseeking problem; 8. Don’t know. If “6. Other,” write the details in the space provided. Record only “7. No careseeking problem” if the woman did not have any careseeking problem. Record only “8. Don’t know” if the respondent doesn’t know if the woman had any careseeking problem. SKIP INSTRUCTION: If “5. She died at F1/F2,” go to Section 10.

SKIP INSTRUCTION: If she was taken to another facility… …go to 9.25 (start of Facility 2) …go to 9.38 (start of Facility 3)This is a skipping stone that takes you to the first question for the next formal health facility where the woman sought care. This question is at the top of the next column.

SECTION 10: Reported cause of death

10.1 Did a doctor or nurse at the health facility tell you the cause of ________’s death?The cause of death reported by a doctor or nurse could be useful information. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know. SKIP INSTRUCTION: If 2 or 8, go to Open History.

10.1.1 If 1. Yes, specify cause 1:RECORD THE FIRST CAUSE OF THE WOMAN’S DEATH THAT A DOCTOR OR NURSE TOLD TO THE RESPONDENT. If the family has a death certificate or other written medical record that shows the cause of death, then you can also record this information.

10.1.2 If 1. Yes, specify cause 2:RECORD THE SECOND CAUSE OF THE WOMAN’S DEATH THAT A DOCTOR OR NURSE TOLD TO THE RESPONDENT. If the family has a death certificate or other written medical record that shows the cause of death, then you can also record this information.

Open history

Read: Thank you for answering the many questions that I’ve asked. Would you like to tell me about the illness in your own words? Also, is there anything else about her illness that I did not ask and you would like to tell me about?

INSTRUCTIONS: After the respondent(s) finishes, ask: Is there anything else?

Write the respondent’s exact words. After s/he has finished, read this back and ask her to correct any errors in what you wrote.

As the statement and instructions make clear, this is an opportunity for the respondent to tell about the events of the woman’s illness in her/his own words, or to fill in any gaps left by the interview.


END OF INTERVIEWTHANK RESPONDENT(S) FOR THEIR COOPERATION

Supervisor’s certification

The purpose of this section is to help maintain the quality of the maternal death inquiries. This is best accomplished by the supervisor participating in every interview that the team conducts. At least, the supervisor should carefully check the completeness and accuracy of each completed interview form and discuss the findings with the team members who conducted the death inquiry. The supervisor must decide how to resolve any identified problems, including a repeat visit to the household if needed. Once the supervisor is satisfied with the quality of the completed format, s/he should sign and date the form to certify that it is correct and complete.


APPENDIX A: INTERVIEWER’S CHECKLIST

1INTERVIEWER’S SELF-ASSESSMENT CHECKLIST

Interview and informed consent forms (before the interview)

A. ___ Have blank consent forms

B. ___ Have a blank MAPEDIR format for reference

C. ___ Have the MAPEDIR format given by the supervisor for the respective

suspected maternal death, with Section 1 filled by the supervisor

Locating information and transportation

A. ___ Understand address and locating information for assigned interview

B. ___ Understand transportation method to interview location

C. ___ Meeting(s) arranged with village leader/other community member(s), if

needed to help locate or be introduced to a household with a death

At the household, before the interview

A. ___ Inform household member of the reason for the interview

B. ___ Show household member my personal identification

C. ___ Ask to speak with the person(s) who know the most about the

circumstances of the woman’s death

D. ___ Arrange another visit if the best respondent(s) were not home or

preferred another interview time

E. ___ Read and explained (if necessary) the informed consent form to the

respondent(s)

F. ___ Obtain each respondent’s mark on a separate consent form

Completed interview

A. ___ Interviewer ID information (section 2 of MAPEDIR format) is complete


B. ___ Deceased woman’s ID information is complete on each page of the

MAPEDIR format

C. ___ All sections of the format are complete, with all pages present

D. ___ Read all questions exactly as written on the MAPEDIR format

E. ___ No or only a few questions answered, “Don’t know”

or

___ If several “DK,” list problem questions by section and number:

_____________________________________________________________

F. ___ Respondents answered all questions

or

___ If a respondent refused to answer a question, record the number and

reason: _____________________________________________________

G. ___ Responses within the interview were consistent with each other

or

___ Any inconsistent responses were resolved during the interview

H. ___ Answered any questions the respondents asked

Interaction with supervisor and interviewer team

A. ___ Submit completed MAPEDIR format and marked consent form(s) to the

supervisor

B. ___ Discuss checklist and any problems with supervisor

C. ___ Resolved problems:

_____________________________________________________________

D. ___ Unresolved problems that may require a change in procedures:

_____________________________________________________________

E. ___ Give any death reports received in the community to supervisor

F. ___ Participate in team meeting (date: ______________)


APPENDIX B: SUPERVISOR’S CHECKLIST

1SUPERVISOR’S CHECKLIST

Death notification and registration

A. ___ Meet with death notifier to receive completed notification formats

B. ___ Classify notified deaths as non-maternal or suspected maternal and

appropriately fill the register of adult female deaths

C. ___ Classify interviewed deaths as non-maternal or confirmed maternal

and appropriately fill the register of adult female deaths

Before an interview

A. ___ Fill Section 1 of the MAPEDIR format for all suspected maternal deaths

B. Develop work plan with the interviewer team

___ Assign interviews (give the “Section 1-filled” MAPEDIR format to the

assigned team)

___ Set a time and place for regular team meeting

C. Provide logistical support (if needed)

___ Assist with transportation to the field

___ Help locate households for interview

During an interview

A. Observe

___ Observe interview (early in project) by interviewer number: ___

___ Observe interview (later, if problems) by interviewer number: ___


After an interview

A. Collect and review completed MAPEDIR interview forms and marked consent

forms

___ Check for frequent “Don’t know” responses

___ Check for missing data

___ Check for internal inconsistencies

B. ___ Discuss any problems found on the forms with the appropriate

interviewers

C. ___ Review interviewer checklists and discuss any problems

D. ___ Repeat problem interview by interviewer number: ___

E. ___ Certify corrected and complete MAPEDIR formats

Other times

A. ___ Meet with community member/leader: _______________________

B. Team problem solving meeting

___ Discuss left-over problem: __________________________________

___ Discuss left-over problem: __________________________________

___ Modify work procedure: __________________________________

___ Modify work plan: __________________________________


APPENDIX C: CONSENT FORM

Informed ConsentInterview about a Maternal Death and Possible Related Perinatal Death

Instructions to Interviewer: Please ask the respondent to acknowledge her/his consent to be interviewed by checking the response below. The interviewer should sign and date below. If the respondent does not consent to the interview, thank her/him for their time and terminate the conversation.

Purpose of the interview: We are talking to people in the community to learn why some women die while they are pregnant or during or soon after giving birth. At the same time, we are learning about the reasons that some babies die during the pregnancy or soon after the birth.

What will happen during the interview: I will ask you questions about your relative/neighbor/friend who recently died. I will ask about her background, her pregnancy history and events during her most recent pregnancy. I may also some questions about her baby from this pregnancy. Some questions have a choice of possible answers and others are open-ended.

Time required: Your interview will take approximately one hour.

Risks: It is possible that some questions could make you feel uncomfortable by talking about bad experiences.

Benefits: There are no direct benefits, however, your participation will help up improve maternal and newborn care for women and babies.

Confidentiality: All information you provide will be kept confidential. Your responses will be assigned a code number and your name will not be used in any way.

Voluntary Participation: Your participation is strictly voluntary. Refusal to participate will not affect whether or not you receive subsequent services. You may discontinue participation at any time.

Contact: If you have any questions or concerns, please contact Marzio Babille at 11-469-0401.

Do you agree to participate in this interview? YES NO

____________________________________ ______________Interviewer

____________________________________Date

____________________________________Respondent’s relationship to woman


APPENDIX D: INTERVIEWER’S ROLE PLAY GUIDE

INTERVIEWER’S ROLE PLAY GUIDE

This guide presents some situations you are likely to encounter as an interviewer of maternal deaths. You will practice handling these situations during your training. This will prepare you in case one of the situations occurs during a real interview.

You will play different roles, including the interviewer and the respondent, during the training exercise. This will help you better understand respondents’ concerns and actions and will help you learn to handle these situations. Work closely with your fellow trainees now and later. They can help you conduct successful interviews.

Situation 1—a crowd of interested observers gathers aboutYou go to a household where you were told that a woman died. Several people are standing about in front of the house. You introduce yourself and your reason for being there, and ask to speak with the person or persons who know the most about the circumstances of the woman’s death. The woman’s sister says she knows about the illness and invites you into the house. Several people follow. The sister answers some questions, but others in the room also answer some questions. Some of their responses contradict each other, and they have difficulty deciding who is correct.

Situation 2—the best respondent is not available at the time of the initial visitYou go to a household where a woman died. You ask to speak to the person or persons who know the most about the circumstances of the death. Depending on the situation, this may be the woman’s mother, her sister, her husband or someone else who was with her during her illness or when she died. You are told that the best respondent is the woman’s mother but that she is not home.

Situation 3—the family denies a death occurredYou go to a household where you were informed there was a maternal death. You knock on the door--a man opens it. You explain why you have come to the house. The man responds that you must have the wrong house. He says that no woman from this household has ever died. He seems tense, and politely asks you to leave.

Situation 4—a second respondent is needed to obtain complete informationYou are interviewing the sister-in-law of a woman who died in hospital. The woman’s husband was sick during her illness so the sister-in-law cared for her. She answers questions about the woman’s symptoms without difficulty, but has trouble with questions on the timing of some events. She explains that she did not go to the hospital with her sister-in-law. She is not sure if she went to other health facilities before going to the hospital, nor how long she was in the hospital before she died.


Situation 5—a second respondent who lives far away is neededYou introduce yourself at a household where a woman died, and ask to speak with the person or persons who know the most about the circumstances of the woman’s death. The woman’s husband tells you that he took her to the hospital when she became very ill and you begin the interview. He easily answers several questions, but has difficulty describing the early part of his wife’s illness and tells you that she was at her parents’ house when the illness started. The parents live in a different village about one hour’s travel away.

Situation 6—the respondent is actively mourning the deathYou are interviewing a man about the death of his wife. The woman died three months before the interview. The interview has been going well, with the husband remembering symptoms and events with little trouble. As you ask questions about the time closer to death, the husband slows in his responses and begins to cry. He tries to control himself but starts to cry harder.

Situation 7—the respondent is uncertain of many answersYou are interviewing a woman about her daughter-in-law’s death. She answers several questions with little hesitation, but then has trouble with a question. She answers “Yes,” then changes her answer to “No,” then pauses and says “I think so.”

Situation 8—the respondent does not seem to be answering the questions openlyYou go to a household where you were told that a woman died. You identify the woman’s mother-in-law as the best respondent about the labor and her father-in-law as the best respondent about the journey to the hospital and you begin the interview. The respondents seem to have trouble answering some of the questions and often glance at each other as if they are waiting for the other to answer. Also, some of their responses contradict each other. For example, when asked about careseeking, the mother-in-law says that the first thing the family did when they noticed the woman was ill was to call a dai to the house. But the father-in-law disagreed and said that the first thing they did was to seek a taxi to take the woman to the hospital.


Health & Medicine

Mapedir interviewers reference manual l 19_may2008