DRAFT
Ministry of Health
Maternal and Perinatal Death
Reviews (MPDRs) Health Workers Trainers Guide
March 2013
Acknowledgements
Aogu : Dr. Romano Byaruhanga, Dr. Jolly Beyeza, Dr. Imelda Namagembe, Dr. Dan
Murokora
UPA: Dr. Jolly Nankunda
WHO Dr. Olive Sentumbwe
UNFPA: Ms Maria Najjemba, Dr. Yvonne Mugerwa
MOH. Dr. Jesca Nsungwa, Dr. Collins Tusingwire, Dr. Miriam Sentongo, Ms Juliet, Ms Carol
Nalugya, Wilberforce Mugwanya, Sarah Nakitto, Ms Lilliane Luwaga, Rogers
Kalyesubula
Save the Children Dr Naamala Hanifah sengendo
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Acronyms
ANC
Antenatal Care
CS
Caesarean Section
DHIS2
District Health Information System 2
HC
Health Centre
HW(s)
Health Worker(s)
ICD
International Classification of Diseases
MCH
Maternal and Child Health
MDSR
Maternal Death Surveillance and Response
MPDSR
Maternal and Perinatal Death Surveillance and Response
MOH
Ministry of Health
MPDR
Maternal and Perinatal Death Review
RRH
Regional Referral Hospital
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Table of contents
Acknowledgements ........................................................................................................................................................ 1
Acronyms ........................................................................................................................................................................... 2
Table of contents............................................................................................................................................................. 3
Glossary of Terms............................................................................................................................................................ 4
Content Outline ............................................................................................................................................................... 5
Topic 1: Introduction......................................................................................... Error! Bookmark not defined.
Topic 2: Quality of care .................................................................................... Error! Bookmark not defined.
Topic 3: Preparing to conduct MPDR at the facility level ................................................................................ 4
Topic 4: Forming MPDR committee ...................................................................................................................... 18
Topic 5: Conducting MPDR ...................................................................................................................................... 19
Topic 6: Reporting ....................................................................................................................................................... 30
Topic 7: Follow – up .................................................................................................................................................... 38
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Glossary of Terms
Maternal Deaths:
Martenal Morbidity
Maternal Mortality Rate
Maternal Mortality ratio
Direct obstetric deaths
Indirect Obstetric deaths
Perinatal Deaths:
Perinatal Morbidity
Perinatal mortality rates
Perinatal Mortality Ratio
Newborn Deaths
Stillbirths
Early neonatal deaths
Near miss
Live births
Confidential Inquiry
Case fatality rate
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GENERAL INFORMATION
Trainers:
Training is provided by persons trained in medical audit and with practical
experience in Maternal Deaths Reviews and basic mentoring skills. They should
be familiar with Emergency Obstetric and Newborn Care protocols, policies and
guidelines.
There will be one trainer for every 5 participants.
Selection of participants
This course is designed:
1.
For health professionals: gynaecologist-obstetricians, anaesthetists,
intensive care practitioners, paediatricians and/or neonatologists, general
practitioners, midwives, nurses, pharmacists/dispensers, and laboratory
technicians.
2.
For representative(s) of administration or hospital director.
The objective is to form a multidisciplinary team.
The recommended maximum number of people per session is 15 to 20 people in
order to enable active participation.
Criteria for selection of participants
The main objective of this training is to improve maternal and newborn health,
therefore It is important that persons who can are involved in the day today
care of the mothers and newborns participate in the process. They should be
active in service provision at the facility (administrative or otherwise)
Planning for the training
When planning to conduct National and District trainings, the
facilitators, should do the following;



Notify the relevant authorities at least 2 weeks prior to the proposed dates
of training
Inform the District Directors and or hospital directors/Medical superintendents
about the training and request them to select and invite 3-5 participants from
hospitals and Health centres. Hospitals should have a minimum of 5
participants. Ideally the incharge of martenity, obstetrician/medical officer,
hospital administrator, pharmascist, Laboratory staff, Theatre, biostatistician.
Liase with the incharge of the martenity to organize files of maternal and
perinatal deaths to be used during the training and make them
anonymous.(Hide name of deceased and signatures of the Health worker (s)
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Become familiar with the curriculum and review objectives, content
outline and learning activities for the sessions.
Prepare/obtain the training materials for each session.
Plan for and provide simulated situations that offer the opportunity for
trainees to practice and be assessed in relevant skills and attitudes.
Training
The day before training
On arrival in the district, the team of trainers/facilitators should;
 Meet with the DHO and DHMT and Maternal Death surveillance team if it
exists.
 Request to be taken to LC5 and the RDC, Secretary for Health. Pay courtesy
call explaining why the MPDR process in the country and inform the District
leadership of their own roles and responsibilities in the MPDR activities. (The
magnitude of martenal and perinatal deaths in Uganda MPDR Policy their role
and responsibilities including establishing committees at district level. Also
explain the training and what it will entail)
 Request for a representative of the DHO, who is attached to Reproductive
Health or the DHO himself to participate in the training in the hospital.
 Check the training venue. Agree on the set timetable and arrange for how
meals of participants will be availed.
 Ensure that all the participants from within the hospital and those from other
health facilities have been invited
 Agree on the coordination for the activity
In the hospital
Trainers should introduce themselves to the Medical Director and explain the
process.
Request the participation of the following departmental heads who are also
members of the MPDR Committee (potential or ready formed)
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Hospital Director or Medical Superintendent
Principal Nursing Officer
Medical Officer/Specialist in charge of maternity unit
Sister in charge of Maternity
Chief Lab Technician
Blood Bank Representative
Pharmacy
Representative of midwives
Hospital Secretary
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
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Biostatistician
Anaesthest
Training Materials and methods
This training in MPDR focuses on competency-based learning and is intended to be as
interactive as possible. Much time will be dedicated to practical exercises. The practice will
be based on “real” maternal, perinatal and neonatal death cases (previously rendered
anonymous) that occurred in any health facility where the training takes place.
Different learning methods will be used:

Interactive presentations:

Practical exercises (individual and by group) on conducting all steps of MPDR based on
“real” but anonymized cases records. The last exercises will use patient files (near miss
case or death) from the hospital where the training takes place. Role plays are essential
activities for the participants to acquire the attitudes needed to conduct a review session
and to adopt a systematic approach to address each stage of MPDR.
The training materials include:

The MPDR guidelines

WHO guidance on maternal and perinatal death surveillance and response

Additional resources:
5-6 anonymized maternal/perinatal death files prepared by the training team
Prepared PowerPoint presentations (PP) for interactive presentations


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Emergency obstetric care protocols and treatment guidelines
Standard operating procedures for maternity.
Training Evaluation form
Duration of Training:
The course will last 3 days
How to use this Training Guide:
Trainers must read and familiarize themselves with the content of all modules
and how they relate to each other as well as the MPDR guidelines.


Trainers should use pre- prepared newsprint/powerpoint,.
Use the trainee handout as much as possible to guide the participants
through various sessions.
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HOW THE TRAINING GUIDE IS ORGANISED
Following the introduction, the training guide is arranged in … topics. which are
in turn divided into sessions. These topics are organized in such a way that they
flow sequentially.
The information for each topic is organized as follows:
i) The topic and session Title
ii) Duration – This is the suggested time that each session should take.
Depending on the level of skills trainees already have, the sessions may
take a longer or a shorter time.
iii) Methods and training materials
iv) Objectives: These are the expected outcomes of the training activity.
They have been presented as specifically as possible for easy
understanding
v) Procedure or Learning experience indicating the training techniques
used
TRAINING GOAL
The training goal is:
To equip health workers with knowledge and skills on maternal and perinatal
death review (MPDR) in order to improve quality of Health care delivery thus
reducing maternal, perinatal and newborn mortality and morbidity.
General training Objectives:
By the end of the training trainees will be able to:
1. Acquire knowledge and skills to enable them to conduct MPDR
in their health facilities
2. Identify avoidable factors and develop recommendations for
quality improvement To improve the quality of documentation
and management of information regarding clients
3. To reflect on individual or team attitude performance for and
contribution to the improvement of quality of care.
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4. To develop plans to address avoidable factors and monitor the
progress of the implementation of the recommendations (MPDR
cycle).
5. To advocate for MPDR in their workplace
6. To compile reports for dissemination to relevant audiences.
Content Outline
Topic 1: Introduction
Session 1: Climate setting and orientation to training
Session 2: Overview of maternal and perinatal death reviews
- Magnitude of maternal and perinatal deaths
- Trends in the Reproductive Health Indicators
- Policy on Maternal/Perinatal Death Review
- Maternal and Perinatal death Review
o Introduction to the MPDR Cycle
Topic 2: Quality of care
- Definition
- Principles of quality of care
- Protocols
Topic 3: Preparing to conduct MPDR
Topic 4: Forming MPDR committees
Topic 5: Conducting the MPDR Review
Session 1: The MPDR cycle
Session 2: Filing forms and summarizing cases
Session 3: Conducting Maternal and Perinatal death review meetings
Topic 6: Reporting & feedback
Topic 7: Follow – up, monitoring and evaluation
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Orientation to the training
Description of the Topic
This topic seeks to create a conducive climate among trainers and trainees that
will enhance effective learning.
The roles of trainers and trainees will be identified and agreed on through
sharing expectations and Training objectives.
This topic will also give an overview of maternal and perinatal death reviews in
Uganda and help participants to appreciate it in the context of improving the
Quality of care.
SESSION 1.1: Climate Setting and Orientation to training
DURATION:
30 MINS
Materials
 News print/PowerPoint slides with Workshop Goal and Objectives
 Workshop schedule
PROCEDURE
Facilitator:
 Welcomes trainees.
 Introduces the trainers/facilitators and
 Asks participants to introduce themselves and mention their expectations for
the workshop
 Ask trainees to register themselves if they have not already done so
 Explains briefly the workshop goals and objectives
 Explain the workshop schedule noting the starting and ending time; breaks,
 Allow questions and make necessary clarifications
 Explain workshop logistics i.e. accommodation, meals, allowances, transport
refund, any other issues
 Ask trainees if they have any problems with the schedule and /or logistics
and make modifications if possible
 Allow and answer questions
Trainer:
 Highlight major issues covered during the session
 Wrap up and introduce the next session.
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SESSION 1.2: Overview of Maternal and
Perinatal death Review in Uganda
Duration: 1 hour
Session outline
- Magnitude of maternal and perinatal deaths
- Trends in the Reproductive Health Indicators
- Policy on Maternal/Perinatal Death Review (when & who)
- Why Maternal and Perinatal death Review (pg 12 of guidelines)
o The MPDR Cycle
SESSION OBJECTIVES
By the end of the session participants will be able to:
1. Discuss the rationale/justification for conducting MPDR
2. Explain the MPDR policy
3. outline the MPDR cycle
Methods:
Lecturette, Large group discussion
Materials:
Handouts/PowerPoint slides on the MPDR cycle, newsprints, markers, masking
tape
Preparations: Slides/flipchart
Procedure:
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Trainer:
Asks participants to mention some of the RH indicators they know
Acknowledge response
Put up newsprint/slide and discuss one by one (MMR, PMR, NMR, Still birth, CPR,
Facility deliveries, causes of MPD (obstetric causes and Contributing factors), Case
Fatality Rate)
Trainer:
Asks participants to share what they know or hear about MPDR Policy in Uganda
Acknowledge response
Explain the MPDR Policy in Uganda
Allow discussion and clarify where necessary
Emphasize that there are many factors that contribute to a maternal and or Newborn
death, so MPDR is a process to analyze and find Solutions to prevent another death but
not a blame game for the Health workers thus not a finger pointing process.
Trainer:
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Leads a discussion on why Maternal Perinatal Deaths should be reviewed (refer to the
MPDR guideline)
Allows questions and answers
Clarifies as necessary
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
Trainer:
Displays newsprint/power point slide of the MPDR Cycle
Explains the different steps of the cycle
Allows questions and clarifies as necessary
Summarizes and closes session
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Topic 2: Quality of care / quality improvement (Ms. Najjemba & Dr. Olive)
Topic Description
The major purpose of this topic is to make participants appreciate MPDR as one of the ways to
improve the Quality of care in maternal and new born care.
It will discuss the principles and steps to be followed in quality improvement.
Topic Outline
o Definition of Quality of care and Quality improvement
o Principles of Quality of care improvement
o Steps in Quality improvement.
Duration: 1 1/2 hrs
-
Session 1 Definition of Quality of care and Quality improvement
SESSION OBJECTIVES
By the end of the session participants will be able to:
1. Define the terms quality, quality of care and quality improvement
2. Discuss the principles of quality of care/improvement
3. Explain the steps in quality improvement
Methods:
Materials:
Lecturette, Brain storming, large group discussion
Handouts newsprints/PowerPoint slides, markers, masking tape
INTRODUCTION
Trainer :
Asks participants to imagine that they are clients.
Asks What they would expect of a service, What they would like to have available at the facility
and how would they would want to be treated if they went to a health facility for health care?
Acknowledges response and introduces the topic
Appreciate the relationship between death reviews and quality improvement
PROCEDURE
Trainer:
Asks participants to mention what they understand by the term quality
Acknowledges responses
Asks participants the meaning of quality of care and what they understand by the term quality
improvement
Ackonwledges responses
Displays newsprint with the meaning of quality of care and quality improvement
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Quality
Quality” has many definitions – according to context of use
•
Performance according to standards
•
Conformance to requirements/specifications
•
Doing the right thing, the right way and at the right time
Quality of care
All actions taken to ensure that standards and procedures are adhered to and that delivered
products or services meet performance requirements
Quality Improvement –
Applying appropriate methods to close the gap between current and expected level of
quality/performance as defined by standards
Trainer;
Asks participants to mention the principles ofquality of care/improvement
Acknowledges responses
Displays newsprint/gives handouts with principles of quality of care/improvement and explains
one by one
Principles of quality of care/improvement

Focus on the client
o Clients are a focus of any quality activity
o Services that do not meet client needs fail
o Satisfied clients comply better with advice / treatment given. And, they will
often return to the facility and / or recommend it to others
o Satisfied internal clients will work with the system better


Focus on systems and processes
o Analysis of service delivery system prevents problems before they occur. A
system is made up of inputs, processes, outputs and outcomes

Use of data
o Quality is a measure of how good something is. Measurement is important in
improving quality
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o Collect data about the activities that one want to improve – collect only the data
one needs
o Compare analysed data with standard set – reveals gap
o Analysed data is information and must be used to improve quality e.g. planning,
monitoring (correcting gaps), evaluating etc. It must be used at point of
collection
o Data may be presented as bar graphs, pie charts etc.

A teamwork/collaboration
o Team work is at the heart of methods to improve quality
o All team members are important- including the smallest member. One big tree
does not make a forest!
o In an effective team, the humble contribution of each team member should be
appreciated
o When discussed in a team, problems become opportunities
o Team members should support each other’s efforts.
Allows questions and craifies as necessary
Trainer:
Asks participants to outline the steps of qulity improvement
Acknowledges responses
Displays newsprint/gives handout with the steps of quality improvement and explains one by one
Steps of quality improvement
• Step one: Identify the problem
o Quality Improvement starts by asking questions:
o What is the problem?
o How do you know that it is a problem?
o How frequently does it occur, or how long has it existed?
o What are the effects of this problem?
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o Identify the gap - Difference between actual and desired performance
o Ways of identifying the problem - Use data from surveys, review records,
observation, feedback from clients
•
Step two: Analyze the problem
o The purpose is to measure performance of the process or system that produces the
effect.
o Techniques include flow charts, cause-effect (fish bone) diagrams, review of
existing data etc.
o Analysis involves answering the following questions; Who is involved or affected?
Why, when, where does the problem occur, What happens when the problem
occurs?
•
Step three: Develop possible solutions to the problem (improvement changes)
o Changes are possible solutions to problems identified during process of quality
improvement.
o Developed on basis of knowledge and beliefs about likely causes and solutions to
the problem
o QI teams should ask themselves the question: What changes can we make that will
lead to improvement?
o Possible solutions (proposed changes) are then developed based on the hypothesis
o Determine possible changes (interventions) we believe may yield improvement
o Organize changes according to importance and practicality
o Test changes (if possible, one change at a time )
o Improvement usually requires change but not all change is an Improvement!
•
•
Step four: Test /implement the possible solutions
o Not every proposed solution (change) leads to improvement.
o Test changes that are feasible, realistic and likely to lead to improvement.
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o Test proposed solutions on a small scale to see if they lead to expected
improvement.
o Changes tested need to be observed over some time period to see if they are
effective or not.
Allows questions and craifies as necessary
Summarizes and closes session
Topic 3: Preparing to conduct MPDR at the facility level
Learning objectives:
By the end of the session trainees will be able to:
1. Describe the seven steps of MPDR
2. Discuss the important pre-requisites for conducting successful maternal and/ or perinatal
death review
Duration:
1 hour
Methods:
Lecturette, Large group discussion
Materials:
Handouts on the seven steps, newsprints, markers, masking tape
Preparations: Slides/flipchart
Procedure:
Trainer:
 Requests trainees to list the steps they have been following to conduct MPDR in their
facility

Acknowledge responses

Display the seven steps of MPDR using slides/newsprint

Assure trainees that these steps will be explained in detail in the next sessions.
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Trainer:
 Lead discussion on important pre- requisites for successful review of maternal and or
perinatal deaths

Display newsprint/slide with good practices for having a successful death review meeting
and elaborate one by one.
Key issues to consider for successful reviews:
 Selection of cases
 MPDR committees established and sensitised
 identify and select the actors- Stakeholders sensitised on the roles and responsibilities
 make standards available, identify the cases,

Proper documentation, filing and storage
- Complete case files for both mother and babies (all information from ANC
Cards, Exercise books and MCH handbooks are entered in the file). constitute file,
make a clinical case summary and organize a session
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Medical cause of death (completed ICD 10 Coding)
Stakeholders sensitized on the importance of proper documentation, filing and
storage
The focal person should remind members of the meeting, time and venue
Partially fill the audit forms (except for avoidable factors/recommendations)
Make preparations for the room/venue
Ensure supportive environment
Prepare minutes of previous meeting
Identify someone (secretary) to take minutes for the meeting
*Summarise/link to next session
Topic 4: Forming MPDR committee
Duration: 1hr
Learning objectives:
By the end of the session, participants will be able to:
1. Discuss the composition of MPDR committees at different levels
2. Explain the roles and responsibilities of MPDR committee members
3. Discuss the linkages between the different committees at different levels
Methods:
Lecturette, Large group discussion
Materials:
Handouts on the seven steps, newsprints, markers, masking tape
Preparations: Slides/flipchart
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Procedure:
Trainer:
 Trainer displays newsprint with categories of suitable people from which MPDR
committee may be drawn from
 Allows members to discuss and agree on the composition of the MPDR committee
 (Proposed quality improvement committees)
N.B At lower health facilities i.e. HCIII and HCII, all health workers can constitute the
MPDR committee
Trainer:
 Asks participants to brainstorm on the roles and responsibilities of MPDR committee
 Acknowledge Responses
 Display news print with roles and responsibilities/handout
 Allow questions and clarify
Trainer:
 Explains the linkages between MPDR committees at different levels (refer to WHO
guidance on MPDR)
 Allow questions and clarify
 Summarize the session
Topic 5: Conducting MPDR
Session 1: The audit/ review cycle
Duration: 45 mins
Objectives:
By the end of the session participants will be able to:
1. Discuss the audit cycle
Methods: Lecturette, brainstorming
Materials:
Hand outs
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Flip charts
Markers
Masking tape
Preparations:
Scenarios
Procedure:
Trainer:

Display the review cycle and ask one participants to read aloud the steps

Discuss the steps of the audit cycle one by one
Topic 5: Conducting MPDR
Session 2: Filling MPDR forms and summarizing cases
Session objectives
1. Identify the different sections in the maternal death notification form, maternal and
perinatal death review forms
2. Demonstrate how to fill and complete the forms including appending signatures
3. Describe how to summarise the case/s for the review meeting
DURATION:
4 HRS
METHODS:

Brainstorming

Role play

Lecturette
MATERIALS

Clinical case notes
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MPDR forms (audits) e.g. Maternal death Notification forms, Maternal Death Review
and Perinatal Deaths Review forms.


Flip charts

Masking tapes

Markers
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
Handouts

Previous MPDR meeting notes

Scenarios based on real clinical cases
PREPARATIONS:

Role play scripts

Handouts
PROCEDURE
Trainer:

Project the learning objectives on a newsprint

Read out to the trainee the learning objectives

Assess the understanding and get clarification from participants
Identifying different sections on the forms
Trainer:

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
Introduces and distributes blank maternal and perinatal review forms
asks two volunteers to identify the different sections on each of the forms.
Tells participants that they are going to learn how to fill the different sections of
each form
Filling and completing the forms including appending signatures
Trainer:
 Take participants through one form at a time explaining section by section
 Allow questions and make clarifications where necessary
 Divide participants into groups of 4-5 people
 Distribute scenarios and blank forms for each group
 Allow time for groups to complete the forms
 Lead discussions in plenary
 Ensure that forms are understood and correctly filled
 Clarify where necessary
summarising the case/s for the review meeting
Trainer:

Explain to the trainees that they will need to learn what information to summarize, when
it should be done and by whom

Ask trainees to brainstorm what information is critical in summarizing a case.

Allow a volunteer to list the response on the newsprint

Using the filled forms the trainer will point out the most critical information in each
section of the form to be summarized (for Maternal Death Review form; the Age, parity,
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Address, Gestation, condition on admission, date and time of admission and death, care
provided at any level and whether standard management protocols were followed.,
number of times mother attended ANC, core ANC interventions such as IPT, TT, HIV
testing, Syphilis testing, presence of medical conditions such as hypertension, diabetes,
HIV, malaria, etc. type of delivery, if instrumental or caesarean section what was the
indication and interval between decision making and intervention. probable cause of
death, was the postmortem done,)

For the perinatal review form, the critical information is age of mother, gestation age,
condition of the mother and the fetal heart rate on admission, number of times mother
attended ANC, core ANC interventions such as IPT, TT, HIV testing, Syphilis testing,
presence of medical conditions such as hypertension, diabetes, HIV, malaria, etc. Type of
delivery, if instrumental or caesarean section what was the indication and interval
between decision making and intervention. Whether the baby was resuscitated or not. If
baby was born alive, length of labour, APGAR score, weight at birth, sex, problems after
birth e.g. fever, convulsions, bleeding. If baby born dead, length of labour, was it fresh
still birth or macerated? Probable cause of death, underlying factors and avoidable
factors.

Practical exercise of summarizing a case

Ask Participants to go back to their groups and practice summarizing cases.
Based on the guidelines and the patients’ records, each group prepares the clinical summary of the case

Present in plenary and clarify where necessary

Summarise and close the session
Topic 5: Conducting MPDR
Session 3: Conducting MPDR meetings
LEARNING OBJECTIVES:
By the end of this session, participants will be able to:
1. Outline the procedures for conducting an MPDR meeting
2. Identify strengths and gaps in the care received
3. Describe how to generate action points for gaps identified
4. Demonstrate how to conduct a successful MPDR meeting
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DURATION:
3 HRS
METHODS:

Brainstorming

Role play

Lecturette
MATERIALS

Clinical case notes

MPDR forms (audits)

Flip charts

Masking tapes

Markers

Handouts

Previous MPDR meeting notes

Scenarios based on real clinical cases
PREPARATIONS:

Role play scripts

Handouts
PROCEDURE
Trainer:

Project the learning objectives on a newsprint

Let one of the trainees read out the learning objectives

Assess the understanding and get clarification from participants
Trainer:
 Outline the procedures for conducting maternal and perinatal death review and
emphasize that the following must be done by the chair of the committee or the
delegated person.
- Welcome remarks
- Putting people at ease (it is a quality improvement activity not for apportioning
blame)
- Decide on the number of cases to be reviewed during the meeting
- Identify a person to take notes
- Agree on length of the meeting
- Make presentations of the summarised cases to be reviewed while cross-checking
with the source documents and the MPDR Tool.
- Discuss the care given and circumstances surrounding each death and agree on what
caused the death for each of the case presented.
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Make recommendation to address the identified gaps.
Recognise and agree to strengthen good practice.
Allocate responsibilities for taking forward the necessary actions and document in
the counter-book for audit meetings.
Ensure that the MPDR form is fully filled and signed
The chair of the MPDR committee must ensure that the case notes are securely
returned to the records person.
How to identify the strengths and gaps in the care
Trainer:

Explain that identification of strengths and gaps is based on the set standards of care
and protocols.

Explain that facilities (hospital administrators, directors, superintendents, S/PNO)
should ensure that all the service points have the relevant management protocols
and standard operating procedures displayed on the walls and are well understood
by the users.

Present a scenario:
“A case admitted with APH and labour pains, a decision to do a caesarean section was
made but the power went off and the generator operator wasn’t around, Caesarean
section was delayed and eventually delivered a fresh still birth. She got a retained
placenta and a manual removal was done but continued to bleed profusely. Blood as
taken for grouping and cross-matching done, but there was no blood group O in the
fridge, They sent for blood from the regional blood bank. The mother died after 3 hours
of waiting due to PPH and severe anaemia.”

OR
A mother admitted with a headache for 3 days on examination was found to be obese
with pregnancy-induced hypertension (140/90mmHg), fundal height 37 treated with
Nefedipine, Panadol, iron and folic acid and asked to return if headache worsened. She
was discharged but re-admitted 7hrs later, after Complaining of s severe headache and
difficulty in breathing and collapsing suddenly. She died shortly after admission.

If time allows screen the video on “Why Mrs. X Died”
For a Maternal Death Review;
WHY MRS. X DIED
Trainer:
 Explain to the trainee that they are going to watch a video/read a script of “Why Mrs. X
died”.
 Explain that as they view/read they should identify the following:
o Possible causes, factors which may have led to her death.
Maternal and Perinatal Death Reviews
Trainers’ Guide
24




o Factors/obstacles which could have been avoided to save Mrs X.
Make sure every participant is ready and is able to see and run the video. Show video or
distribute the script and why Mrs X died.
Ask participants to list the factors as you write on the newsprint
Discuss the factors and emphasize those that could have been avoided.
Ask the participants to identify attitudinal factors, gaps in skills, and social community,
factors and facility issues e.g. lack of blood, no power/fuel for generator, no blood giving
set, no anesthetist on duty, no water, no linen, no oxygen, no spinal needles, no
caesarean section sets, no key for emergency cupboard, no airtime, no duty room, no
emergency phone, no ambulance fuel.
Factors that could have been avoided to save Mrs. X
For a Perinatal Death Review;
THE DEATH OF BABY LILIANE
Trainer:
 Explain to the trainee that they are going to read a script of “Baby Liliane”. Explain that as
they read they should identify the following:
o Possible causes, factors which may have led to her death.
o Factors/obstacles which could have been avoided to save Baby Liliane
 Make sure every participant is ready and is able to read the script
 Distribute the script of Baby Liliane
 Ask participants to list the factors as you write on the newsprint
 Discuss the factors and emphasize those that could have been avoided.
Baby Liliane was born to Nankya (a prime gravida) who had been on labour for 16 hours in
Hospital. The partograph had been filled for the first 4 hours by the midwife on call. However,
the midwife who took over for the evening duty did not continue. Baby Liliane did not breathe
spontaneously and was blue in colour. “Resuscitation” was attempted by pouring cold water on
the baby, tilting it head down and patting on the back. After 15 minutes the midwife gave up as
there was no evidence of life (no heart-rate, no breathing, cold and flabby.
Factors that could have been avoided to save Baby Liliane:
1. No consistent use of partograph the manage labour
2. Prolonged labour
3. No essential newborn care skills i.e. keeping baby warm,
breathing
4. No resuscitation skills
5.
Maternal and Perinatal Death Reviews
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Trainer:
 Check to see that all the answers in the table are given and make clarifications
 Now ask trainees to refer to the cases they summarised before
 Ask trainees to identify and brainstorm on the gaps in the care provided.
 List responses on newsprint and allow participants to discuss.
 Emphasize the avoidable factors.
Generate action points for gaps identified during death reviews
MPDR is aimed at identifying the gaps and addressing them to improve quality of care. However if
poorly conducted, the team may fail to identify the relevant gaps at various levels and make
recommendations for improvement.
How to conduct a successful MPDR Meeting
Trainer:
 Introduce the role plays using a pre-prepared script.
Role play 1. How NOT to Conduct a Maternal Audit Session with Maternity Staff

The role-play demonstrates how NOT to conduct a maternal death audit session. There are two
parts to the role-play.

Part 1: The data collector presents the case to the Maternal Deaths Review Committee
(department head and midwife).

Part 2: The department head provides his analysis, conclusions and recommendations to the
committee.

Each role-play sessions lasts for 10 minutes and is followed by a 10-minute large group
discussion.

Three people are required for this role-play: the data collector, the department head, and midwife.
The participants who perform the role-play need to be familiar with the case summary described in
and decide together how they want to perform the role-play.
Familiarize yourself with your (and each) character.
Characters in the role play
Data Collector
 During the audit session, you need to present the case from the first role-play using the Data
Collection Form for a Maternal Death. You have 10 minutes. Refer to the Data Collection Form for
a Maternal Death to relay the events prior to the death of the woman.
Department head
 You have been Head of Maternity in this hospital for 5 years. You are authoritarian. You are
worried by the number of deaths happening in your institution. You demand to be in charge of
the audit session so discussions can go the way you wish them to. You lead the audit session.
Maternal and Perinatal Death Reviews
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26
Refer to the Maternal Death Analysis Framework to aid the audit process and ensure that the
report is filled out, etc.

While audit sessions are not supposed to name names and give rise to punishment, you want to
use this case to make an example. At a certain point, you break anonymity and publicly accuse the
midwife of not having done what was needed to treat this case of postpartum hemorrhage. You
want sanctions to be taken against the midwife by writing to her professional order. You also
threaten to talk directly to the hospital’s director to have her suspended for a few weeks.
Midwife’s role
 You are the midwife who managed the woman during delivery. The woman died a few hours after
delivery.

You don’t agree with the conduct of maternal death audits in this institution. You don’t believe
this process will help reduce maternal mortality. Moreover, you’re afraid that, despite what it says,
this audit might lead to punishment against you.

Following the discussion, the department head threatened you publicly. You firmly deny the
allegations and insist that you did nothing wrong. The birthing room was very busy that night and
you were the only midwife present, with two nursing assistants. These assistants learned how to
perform deliveries by observation only, without any formal training in maternity care. There was
only one physician on call.

You maintain that you called the physician when you diagnosed the retained placenta, but that
the physician didn’t come. You then proceeded to reassess the uterus, after which you judged the
woman’s condition to be acceptable when she was transferred to the postpartum section. You
weren’t able to keep an eye on the woman as you would have wished because the birthing room
was full of other women in labor.
Be familiar with how the role-play will unfold.
 PART 1 of the role-play: The data collector presents the case from the interviews that were
conducted earlier to the Audit Committee. The data collector presents the information objectively
with appropriate behaviour. The department head and midwife who attended the delivery
participate in the audit session. Time provided: 10 minutes

BREAK: After this presentation of the case, the instructor then asks the group to comment on the
case presentation. Time provided: 10 minutes

PART 2 of the role-play: The department head leads the discussion. During this time, the
department head accuses the midwife of incompetence, does not respect confidentiality, and
states that she will punished. The midwife becomes very scared and no longer participates in the
audit session. The data collector tries to mediate the session by attempting to calm down the two
of them, reminding them of the ultimate objective of the audit session. Time provided: 10
minutes.

FINISH: The instructor asks the whole group to comment on the positive and negative aspects of
the session. The instructor concludes the role-play by bringing out the positive and negative
elements to an audit session.
Maternal and Perinatal Death Reviews
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27
Role play on how to identify gaps.
Trainer:
 Request volunteers to participate in two role plays
 Explain to trainees that they will do a role play to practice what they have learnt
 For each of the role play, nominate one volunteer to chair and 3-4 to participate as
members of the committee

Distribute scripts for role plays to the different groups of volunteers. Allow time for the
groups to practice the role plays.

One group presents at a time

Ask the rest of the trainees to observe and make notes on what went well and what
needs improvement for each of the role plays.
How to conduct a good MPDR and identify possible interventions for quality of care
improvement
Role play 2
The MPDR committee gathers in the hospital boardroom at 2.30p.m. on Wednesday as per
the Memo of MPDR focal person that was circulated 2 days earlier. The chairperson
welcomes everybody to the meeting. He requests one of the members to take notes. The
chairperson reminds members about recommendations from the previous MPDR meeting
and asks responsible persons to inform the meeting what has been done so far. He invites
the person who summarised the case notes of the deceased persons to present the
summaries and make clarifications as found necessary. He allows questions, answers,
clarifications and discussions. He reminds them that the purpose of this meeting is to
improve quality of care and no one should blame the other. He guides the members to
identify what was done well and what did not go well in the management of the deceased.
He/she requests the meeting to make recommendations to address the identified gaps and
identify persons responsible to take action. The Chairperson guides the meeting to focus
more on the recommendations that would help the facility to improve their performance e.g.
 address availability of blood and medicines,

partograph use,

poor surgical notes,

inadequate skills,

not handing-over duties,

poor documentation (clinical notes without date and time, signature and some
Maternal and Perinatal Death Reviews
Trainers’ Guide
28
interventions not recorded),

lack of duty room,

inter-staff communication,

standard operating procedures, etc.
The chairperson advises the meeting to focus more on interventions they can
work on themselves. He/she reminds the person taking notes to record in the
MPDR report book following the format below.
Date Summary –
of
underlying
audit cause death
Gap
intervention By
who?
When?
How?
Indicator
He/she thanks the committee members and gives them the next date of the
meeting.
Maternal and Perinatal Death Reviews
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29
Trainer:
 Emphasize the importance of following:
- Ask some of the volunteers for the role plays how they feel about the exercise
- Then ask the observers to give their views about how the two meetings were held.
- Allow a few minutes for discussion on what went well and what did not go so well.

Summarize by emphasizing the key points about conducting a
successful MPDR meeting

Close and link to the next session.
Maternal and Perinatal Death Reviews
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30
Topic 6: Reporting and feed back
Session Objectives:
By the end of the session, participants will be able to:
1. Describe the reporting mechanisms for MPDR at different levels
2. Discuss the reporting formats for the different levels
3. Demonstrate filling of different reports
DURATION:
2 HRS
METHODS: Brainstorming, Lecturette, Large group discussion, demonstration
MATERIALS: Report formats, Newsprints, handouts, markers, slides, Masking tapes,
PREPARATIONS: Slides, Flipcharts
Procedure
Trainer:

Tells participants the following story:
“KK regional referral hospital conducts MPDR meetings once a month.
In the last meeting they noted that MM district hospital sent them 5
mothers due to lack of blood. Two of them died within 30 minutes of
arrival. Two of the mothers had incomplete records i.e. the attending
doctor could not establish what intervention had been done before the
mothers were referred. They also noted that these mothers were sent
without any established IV lines.”

Asks participants what they think should be done
with this information in order to improve the quality of care in both
KK and MM hospitals.

Notes responses on newsprint
 Asks participants to mention what they would consider as important
to include in the MPDR report from the hospital to the DHO.
 Acknowledge responses
Maternal and Perinatal Death Reviews
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 Displays newsprint/slide with reporting format to the DHO
 Allows discussion and clarifies as necessary
 Asks participants to mention what they would consider as important
to include in the MPDR feedback report from KK referral hospital to
the DHO of the neighbouring district and referring hospital.
 Acknowledge responses
 Displays newsprint/slide with reporting format of the feedback to the
DHO of the neighbouring district
 Allows discussion and clarifies as necessary
Trainer:
 Asks participants how often they think this feedback should be
 Allow some time for discussion
 Acknowledges responses
 Inform participants that the written feedback should be done monthly
to the neighbouring district and/or facilities. However on an annual
basis the referring unit and receiving unit should hold discussions
during the regional meeting on how to address the challenges they
have in the delivery of maternal and newborn health services.
 In addition the regional referral hospital has a responsibility of
mentoring, monitoring and supervising facilities in the catchment
area.
Trainer
 Leads a guided practical session on filling of the MPDR report formats
mentioned above.
 Allow questions and clarifies
 Summarizes the session
Maternal and Perinatal Death Reviews
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32
Hand out: REPORTING
Flow Chart on Reporting linkages
TYPES OF REPORTS AND CONTENT
 The HMIS health unit monthly summary report (HMIS Form 105) will indicate Number of
deaths
 Hospital Maternity report-……………….(No. of deliveries, no. of deaths, causes of death)
 Notification – gives a bit of details of the deceased mother (name of the person, age,
residence, and possible cause of death)
 Audit/review form – is a more detailed structured form capturing the chronological events
that led to the death of the mother or baby. Other details include circumstances that led to
the death, avoidable factors and recommended actions to address gaps identified. There is a
detailed handout (no…) on the contents of this form. Copies of the maternal death review
forms are currently being forwarded to Resource centre of the Ministry of Health. The
Ministry of Health proposes that under District Health Information System 2 (DHIS2), web
based version can be developed and analysis done at the Regional level
 MPDR Summary report captures deliveries, lives births, maternal and perinatal deaths that
are reviewed and a summary of avoidable factors, recommendations and action points that
have been implemented.
Regional referral hospitals serve more than one district. It is important that RRH document and
review all deaths that occur within the hospital and give a feedback to a health facility/DHO
Maternal and Perinatal Death Reviews
Trainers’ Guide
33
where the mother originated. What actions and recommendations were made and what needs
to be undertaken by the facility and district of origin on the maternal death/s.
Maternal Death Surveillance and Response (MDSR)
The MDSR system is a continuous-action cycle designed to provide real-time, actionable data on
maternal mortality levels, causes of death, and contributing factors, with a focus on using the
findings to plan appropriate and effective preventive actions. While building on established
approaches such as Integrated Disease Surveillance and Response and Maternal Death Reviews,
it aims to identify, notify, and review all maternal deaths in communities and facilities, thus
providing information to develop effective, data-driven interventions that will reduce maternal
mortality and permit the measurement of their impact.
District Level
Since we are moving to MDSR all maternal deaths must be reported to the DHO who has the
various officers linked to this work e.g. DHE, District MPDR Focal Person, District Health
Inspector, District Surveillance Focal Person, Maternal Health Focal Person, DHO, Biostatistician,
Records Officer and Village Health Teams.
At the DHO’s office you need to notify them that a death has occurred. The DHO should follow
up on all the deaths that have occurred to ensure that a review is done within 7 days.
Summary reports about MPDR shall be submitted to the district to elicit response from the
DHO’s office. After receiving the reports from the various health facilities, the DHO shall
compile a summary report and prepare to disseminate to the District Maternal Death Committee
and District Council on a quarterly basis.
In order for the national level to compile an annual MPDR report, copies of the summary report
will be submitted to the national level. For the time being copies will continue to be submitted
to the national level until such a time that DHIS2 is well implemented nationwide.
Regional Level:
At the regional level there should be a bi-annual MPDR meeting to discuss and follow up on all
the MPDR reports accruing in the region so that a regional response can be generated.
Health workers should review selected perinatal deaths, make recommendations and actions
and report to the DHO’s office
The Health unit should ensure that they keep all their reports in a secured file with the In charge
of the Health Facility under lock and key.
Ideally reports should only be released on written request from the Regional and national team,
Ministry of Health, independent assessors and or as required by the law. Review forms shall only
be destroyed after data have been synthesized and the report disseminated.
National level
Maternal and Perinatal Death Reviews
Trainers’ Guide
34
Aggregate both reports (summary reports and audit forms) from district health office and
regional referral hospitals, analyze and make a national report annually. Publish and disseminate
the report to relevant stakeholders.
At all levels, timely feedback should be provided and appropriate action taken
Maternal and Perinatal Death Reviews
Trainers’ Guide
35
REPORTING FORMAT
Monthly Report
Maternal and Perinatal Death Reviews
Name of Health Facility
…………………………….......................................... ...................................
Report for Period of
.................................................................................................................
Total no. of deliveries
...............................................................................................................
Total no. of live births
.................................................................................................................
Total no. of maternal deaths …………….. ..............................................................................................
Total No. of perinatal deaths
............................................................................................. …………….
No. of maternal deaths reviewed ............................................................................................ ……………
No. of Perinatal deaths reviewed ............................................................................................ …………..
Date of
audit
B.
Summary of
case (Primary
underlying
cause of death)
Avoidable
factors /
Missed
opportunities
Key
recommendations
Person to take
action & contact
information
Action points that
have been
implemented
Comments
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
..............................................................................................................................................................................
Maternal and Perinatal Death Reviews
Trainers’ Guide
36
REGIONAL LEVEL FEEDBACK ON MATERNAL AND PERINATAL DEATH
Name of
Deceased
Residence
Health unit
referring
Maternal and Perinatal Death Reviews
Cause of death
Avoidable
factors
Comments to
referring unit and
DHO
Trainers’ Guide
37
Topic 7: Follow – up, monitoring and evaluation
Session Objectives:
By the end of the session, participants will be able to:
1. Describe the importance of monitoring and evaluation
2. Discuss the indicators monitored under MPDR
DURATION:
1 HR
METHODS:
MATERIALS
PREPARATIONS:
PROCEDURE
Trainer:

Tells participants that sharing information with other
stakeholders will make them more willing to implement
recommendations from maternal and perinatal review meetings.
asks participants to mention what they think should

be monitored to ensure that there is continuous improvement
through maternal and perinatal death reviews

Acknowledge responses

Use handouts to discuss the key issues in monitoring
and evaluating MPDR at the different levels and indicators for
monitoring

Thank participants and close the session
Maternal and Perinatal Death Reviews
Trainers’ Guide
38
Handout: Monitoring and evaluation
Monitoring and evaluation of MPDR is about ensuring that major steps in
the system are functioning adequately and improving with time and that
the process of conducting MPDR is improving with time.
The ultimate goal is that every health facility will be conducting MPDR
whenever a maternal/perinatal death occurs.
The health system includes health workers as individuals providing care to
the mothers and newborns. Therefore correctly responding to some of the
recommendations will involve enhancing their own skills. The responsibility
of improving individual skills lies with the individual health worker, the
health facility in which he/she works and the mentors and supervisors in the
region and at the national level.
The responsibility of the regional referral hospital is to mentor, monitor and
supervise the lower health facilities so as to improve skills of health workers
in regard to maternal and newborn health care. And if possible, discuss
logistics management and how to improve it. The regional hospitals are
also responsible for conducting confidential inquiries periodically. The aim
of the independent confidential inquiries by the independent assessors is to
ensure that the health facilities are correctly carrying out the MPDR process.
They will also lead discussions in regional meetings on MPDR.
The national level will ensure the following:
 That all deaths are being notified according to policy.
 Maternal Death Review Committees exist at National, District and Health
facilities (up to HCIV), function and meet regularly.
 Verbal autopsies are coordinated at hospitals and HCIVs.
 National and District MPDR reports are published and disseminated.
 Ensure that districts have someone responsible for MPDR
 Gaps in health are being addressed by the responsible departments,
units and the community
Maternal and Perinatal Death Reviews
Trainers’ Guide
39
Recommendations are implemented to complete the audit/review cycle
Districts are conducting monitoring and evaluation
A system exists for correctly identifying all maternal deaths
Districts and regional hospitals are producing relevant reports
There is a system in place that continuously monitors maternal and
perinatal mortality trends
 Quality of care is continuously improving





Maternal and Perinatal Death Reviews
Trainers’ Guide
40
Example of MPDSR monitoring indicators and targets
Indicator
Overall system indicators
Maternal death is a notifiable event
National maternal and perinatal death review committee exists
- that meets regularly
National maternal mortality report published annually
% of districts with maternal death review committees
% of districts with someone responsible for MPDSR
Identification and notification
Health facility:
All maternal deaths are notified
- % within 24 hours
Community:
% of communities with ‘zero reporting’ monthly
% of community maternal deaths notified within 48 hours
District
% of expected maternal deaths that are notified
Review
Health facility
% of hospitals with a review committee
% of health facility maternal deaths reviewed
% of health facility perinatal deaths reviewed (neonatal and fresh still
births)
% of reviews that include recommendations
Community
% of verbal autopsies conducted for suspected maternal deaths
% of notified maternal deaths that are reviewed by district
District
District maternal mortality review committee exists
- and meets regularly to review facility and community deaths
- % of reviews that included community participation and feedback
Data Quality Indicators
Cross-check of data from facility and community on same maternal
death
Sample of WRA deaths checked to ensure they are correctly identified as not
maternal
Response
Facility
% of committee recommendations that are implemented
- quality of care recommendations
- other recommendations
District
% of committee recommendations that are implemented
Reports
National committee produces annual report
District committee produces annual report
- and discusses with key stakeholders including communities
Impact
Quality of care (requires specific indicators)
District maternal mortality ratio
Hospital maternal mortality ratio/lethality rates
Maternal and Perinatal Death Reviews
Example Target
Yes
Yes
At least quarterly
Yes
100%
100%
Yes
>90%
100%
>80%
>90%
100%
100%
50%
100%
>90%
>90%
Yes
At least quarterly
100%
5% of deaths cross-checked
1% of WRA rechecked
>80%
>80%
>80%
>80%
Yes
Yes
Yes
Reduced by 10% annually
Reduced by 10% annually
Trainers’ Guide
41
Timing of sessions
Topic 1: Introduction
Session 1: Climate setting and orientation to training- 1 hr
Session 2: Overview of maternal and perinatal death reviews -1 hr
Topic 2: Quality of care 1hr 30mins
Topic 3: Preparing to conduct MPDR - 1 hr
Topic 4: Forming MPDR committees -1 hr
Topic 5: Conducting the MPDR Review
Session 1: The MPDR cycle -45 mins
Session 2: Filing forms and summarizing cases - 4hrs
Session 3: Conducting MPDR meetings -4 hrs
Topic 6: Reporting & feedback - 2hrs
Topic 7: Follow – up, monitoring and evaluation – 1 hr
Total time required 16 hrs 45 mins
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Program schedule of training
Day 1 :
Time
08.30 –
09.30
09.30 –
10.30
10.30 –
11.00
11.00 –
13. 00
Topic
Welcome participants
Introduction
Training objectives, program and
methods
Overview of Maternal and
Perinatal death review in uganda
Responsible
Length Material
Trainers
1 hr
Trainers
1hr
PP
Trainers
1 hr 30
mins
PP 1.4
Trainers
1 hr
Trainers
1 hr
Coffee break
Quality of Care improvement
13. 00 –
Lunch break
14. 00
14.00 –
15.00
Preparing to conduct MPDR at
the facility level
15. 00 –
Forming MPDR committees
16. 00
Maternal and Perinatal Death Reviews
PP 2.1
PP 2.2
Trainers’ Guide
43
16.00 –
16.30
Coffee break
Before leaving the place, distribute MPDR tools and anonymized case notes for
deceased mother and / or baby. Ask participants to familiarize themselves with
the contents in the notification forms and perinatal and maternal death audit
tools as well as the case notes
Maternal and Perinatal Death Reviews
Trainers’ Guide
44
DAY 2 :
Time
Topic
Responsibl
Length Material
e
08.3009.00
Recap
Trainers
45
mins
09.00 –
The Audit cycle
09.45
Trainers
45
mins
09.45 – Filling Perinatal death review form
11.00
& summarizing case
Participants
and trainers
11.00 –
11.30
11.30 –
13.30
13.3014.30
Participants
PP 2.5
MPDR tools
Coffee break
Filling maternal death review form
& summarizing cases
Lunch break
Group work
14.30 –
Practice filling the review forms &
16.00
summarizing cases
16.00 –
Tea break
16.15
16.15 – Large Group discussion 17.15
Filling review forms
Maternal and Perinatal Death Reviews
Participants
Trainers &
Participants
Trainers’ Guide
45
DAY 3 :
Time
Topic
08.00 –
11.00
Conducting MPDR meeting
Responsibl
e
Length
Material
Trainers &
Participants
3 hrs
Tools for
MDRs
11.00 –
11.30
Coffee break
30 mins
11.30 –
13.30
Reporting & feedback
2 hrs
13.30–
14.00
Lunch break
60'
14.00 –
15.00
Follow up, monitoring and
Evaluation
15.00 –
16.00
Trainers
Establish MDR Committee:
number, names of members,
Plan the calendar of future
MPDR sessions
16.0016.30
Coffee break
16.30–
17.00
Evaluation of the training by
participants
Official closing and distribution
of certificates of attendance
Maternal and Perinatal Death Reviews
1 hr 30
min
1 hr
15'
Officials
30’
Certificates
Trainers’ Guide
46