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What is a maternal death?

A maternal death is the death of a woman (or girl)1 while pregnant or within 42 days of the end of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.

Should each maternal death be reviewed?

Yes. Every maternal death that occurs within a refugee camp or settlement (of a refugee or a national) or a refugee living outside of a settlement or at a referral health facility or en route should be systematically notified (within 24 to 48 hours2 ) and reviewed, ideally within the 1st week following the death.

What is the purpose of reviewing a maternal death?

It is estimated that half a million women die every year during pregnancy and childbirth and an additional 7+ million women who survive childbirth suffer serious health problems(WHO). A maternal death review provides an opportunity for health staff, family and communities to learn from a tragic – and often preventable - event. Maternal death reviews should be conducted as learning exercises that do not include blaming, finger-pointing or punishment. The purpose of a maternal death review is to improve the quality of safe motherhood programming to prevent future maternal and neonatal morbidity and mortality and to identify actions to prevent future shortcomings in access to quality essential maternal and neonatal health services.

Should each maternal death be reported?

Yes. The accompanying report form should be completed for each maternal death review and emailed (at minimum) to:

• The UNHCR Public Health Officer of the settlement/camp

• The UNHCR Public Health Officer/Reproductive Health Officer of the country office, and

• The UNHCR Regional Public Health Officer and Reproductive Health Officer (where present) , and

• Other relevant staff (e.g. IP Health Coordinator, other partner agencies, etc.)

• District or Provincial Health Officer

As much as possible maternal death reporting and review in refugees or other persons of concern should feed into the national reporting and review process. Where available national maternal death review forms should be used. If not available, please use the accompanying UNHCR maternal death review form.

How should this information be obtained?

In order to complete this form, please consult any relevant persons familiar with the case.

This should include at least:

• Any medical staff that was involved in the patient care

• Caretakers or staff included in the transfer of the patient

• A family member or community member that was with the woman before and or during the events prior to death (abortion, accident, labour, delivery, etc)

Any additional person with relevant knowledge on the events preceding and/or contributing to the death, should be heard and related information included

Which Maternal death audit format should be used?

Whenever available and feasible, the maternal mortality audit format of the host government should be used. UNHCR will advocate for adjustments of national documents and administrative instructions and/or propose to use the UNHCR standard when:

a. When available and not complying with minimum standard of needed information

b. When administrative instructions (e.g. can only be filled out by a medical officer of the government) delay or prevent timely establishment of audits

The following guide will clarify and define how to complete the maternal death audit form. It will include definitions and explain why the collection of specific is important.