Mapedir interviewers reference manual l 19_may2008

MAPEDIR Interviewer’s Reference Manual
Verbal 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 Health
Baltimore, 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 manual
The 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 project
UNICEF 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 prevention
A 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.

Home Sub- Quality
center

Non-FRU Quality
PHC/CHC

Onset of ay
2
complication
Del
ay Del
1
De ing t e
De eek

la
s
cid car

y1

1
lay
Delay 2

De
o

2
lay
De
Delay 3
2
Delay ources Receiving
res
ging e quality care
Arran aching th y FRU Quality
and re te facilit
pria
appro

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 Procedures
Block-level team with district oversight
The 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.

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)
Share analyzed MAPEDIR data
with the community (Gram
Panchayats, VHC, SHGs, etc.)
with NGO partners
Block MO

Block MAPEDIR team supervisor
(team investigates suspected
maternal deaths)

District CMHO
analyzes and reports
data

District collector / CEO
(PRI)

State directorate


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 Responsibilities
Overview of the interviewer’s activities and responsibilities
As 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 improvement
One 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 approach
Your 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 Training
Part 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 consent
All 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.

Confidentiality
It 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 Data
Your 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 households
Consider 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 project
If 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 information
You 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 household
This 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 respondent
The 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 elsewhere
If 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 respondents
As 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 Issues
Effective 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 respondent
Always 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 interview
It 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 techniques
Sit at the same level as the respondent(s) and maintain eye contact
Always 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 head
These 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 problems
If 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 issues
Persons 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, tearfulness
First, 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.

Anger
A 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 questions
There 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. Yes
2. No 2
8. 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 9.15 9.28 9.41
transportation 1. Walk..................... 1.  If only walk, go 1.  If only walk, go 1.  If only walk, go
method was used 2. Rickshaw/cart...... 2.  to Q9.17 2.  to Q9.30 2.  to Q9.43
to take her there? 3. Bus...................... 3.  3.  3. 
4. Taxi/auto/trecker. . 4.  4.  4. 
Multiple answers 5. Ambulance........... 5.  5.  5. 
allowed. Check all 6. Other.................... 6.  6.  6. 
that apply. 8. Don’t know........... 8.  8.  8. 
9. Could not arrange 9.  ------ ------

4.12.1 Please tell me the benefits of the card. 1. Subsidized ration 1. □
2. Kerosene oil 2. □
Prompt: Is there anything else? 3. Housing 3. □
4. Health care 4. □
Multiple answers allowed. Check all 5. Referral transport 5. □
choices that the respondent mentions. 6. Other 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:


How far is it from… 9.14 …home to fac 1? 9.27 …facility 1 to 2? 9.40 ..facility 2 to 3?

_0_ _2_ _3_ km __ __ __ km __ __ __ km
(<1=000; DK = 888) (<1=000; DK = 888) (<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? 9.22 9.35 9.48
_0_ _1_ Days __ __ Days __ __ Days
[Mark Days, Hours and/or Minutes as
(DK = 88) (DK = 88) (DK = 88)
needed.
Example: 01 day, 05 hours and 30
minutes; _0_ _5_ Hours __ __ Hours __ __ Hours
Example: 02 days, 03 hours and 00 (DK = 88) (DK = 88) (DK = 88)
minutes]
_3_ _0_ Minutes __ __ Minutes __ __ Minutes
(DK = 88) (DK = 88) (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 mistakes
If 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.

1. Yes
2. No 2 RS
8. Don’t know
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 √ RS
3. She had to attend to household duties √
4. Transportation not available √

Skip patterns
Required 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… 1. fully employed?
2. seasonally employed?
[Read the choices to the respondent] 3. unemployed
8. 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. Hindu
2. Muslim
3. Christian
4. Other
8. 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 1. Yes,
die within 6 weeks after a pregnancy ended? pregnant or within 6
weeks after a
[If the respondent is uncertain, then discuss that pregnancy ended If 2 or 8, go to
the pregnancy could have been ended by an 2. No Section 10
abortion, stillbirth, delivery of the baby, or the 8. Don’t know
woman’s death]

 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 1. Yes,
abortion or within 6 weeks after during an abortion
having an abortion?
2. Yes,
If 1, go to Q6.6
within 6 weeks after an
If 3 or 8, go to Q6.9 (Antenatal)
abortion
3. No
8. Don’t know

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: 1. No one (completed
Who completed the abortion? spontaneously)
2. Herself
If the abortion was induced or don’t 3. Relative/friend This was an abortion death.
know, ask: 4. Dai
Who performed the abortion? 5. Quack After answering Q6.8,
6. ANM go to Q7.17
[Record the highest level provider 7. Nurse
mentioned] 8. General doctor
9. Obstetrician
10.Other
88. Don’t know

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 9.12 …home to fac1? 9.25 …facility1 to 2? 9.38 …facility2 to 3?
referred), how long did it take to make
the arrangement to go from…
__ __ Days __ __ Days __ __ Days
(DK = 88) (DK = 88) (DK = 88)
[Discuss that this includes the time
needed to arrange for transportation __ __ Hours __ __ Hours __ __ Hours
and the money to pay for this and the (DK = 88) (DK = 88) (DK = 88)
woman’s health care.]

[Mark days, hours and/or minutes as
needed.
Example: 01 day, 05 hours and 30 __ __ Minutes __ __ Minutes __ __ Minutes
minutes; (DK = 88) (DK = 88) (DK = 88)
Example: 00 days, 02 hours and 10
minutes]

and ends like this…

If she was taken to another …go to Q9.25 …go to Q9.38
facility… (start of Facility 2) (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 woman
Knowing 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 residence
This 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 woman
Knowing the relationship of the head of the household to the woman will help you locate the
correct household.

1.7 Date of woman’s death
The 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 notification
This is the date that the death notifier gathered the information on the cover sheet.

1.9 Key informant’s name
This 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 designation
RECORD YOUR REGULAR WORK POSITION, SUCH AS ICDS SUPERVISOR or ANM.

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


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

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

2.6 Date of last interview
RECORD 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 abortion
This 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
abortion
This 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
began
This 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

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.
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

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.
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 After 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 After 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.


Mapedir interviewers reference manual l 19_may2008

Mapedir interviewers reference manual l 19_may2008

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Mapedir interviewers reference manual l 19_may2008