MATERNAL MORTALITY REVIEW Community Reporting Form Barangay _____________________________ Municipality_____________________________ Province _____________________________ Date _____________________________ ===================================================================== Name of the Deceased _____________________________________________ Age (at the time of death) _____________________________________________ Address _____________________________________________ Name of Contact Persons: Husband _____________________________________________ Nearest Relative _____________________________________________ Address _____________________________________________ Place of Death: Home BEmOC Facility CEmOC Facility Private Hospital Others (please specify) _____ _____ _____ _____ _____________________________________________ Woman died: ______during pregnancy ______ during childbirth ______ after childbirth; how many days? __________ (specify number of days) more than one month? __________ (please check) Cause of Death: (please check as appropriate) _______ bleeding _______ infection _______ hypertension _______ prolonged labor _______ others (please specify) ===================================================================== Submitted by: Name of Midwife Station _______________________________________ _______________________________________ Submitted to and Validated by: Name & Signature of RHU Physician Station Date of Validation Death Certificate Number _______________________________________ _______________________________________ _______________________________________ _______________________________________
