Mapedir interviewers reference manual l 19_may2008

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  • 1. 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
  • 2. TABLE OF CONTENTS 3About this manual................................................................................................................................ 41. What is MAPEDIR?.......................................................................................................................... 4 Background................................................................................................................. 42. 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. .........................................................................73. Interviewer and Supervisor Roles and Responsibilities .............................................................. 7 Overview of the interviewer’s activities and responsibilities..................................... 7 Supervisory procedures and approach.........................................................................74. Ethical Training................................................................................................................................ 7 Confidentiality.............................................................................................................8 Falsification of Data....................................................................................................85. 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...........................................................................96. 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...................................................................117. Conducting the Interview ............................................................................................................. 11 Materials you will need ............................................................................................11 General Instructions for completing the MAPEDIR format..................................... 11 Correcting mistakes...................................................................................................13 Skip patterns..............................................................................................................148. 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..........269.6 If Action 9.2 was not seeking formal health care, then ask: Did she/the family have anyproblems that kept her from seeking formal health at that time? ................................................. 279.7 Did she seek formal health care at any time during the fatal illness? .................................... 28If the first action taken for the illness (Q9.2) was not seeking formal health care, then we askhere if the woman ever sought formal care. Just as in Q9.2, if they were trying to seek formalhealth 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, goto Open History. The remainder of Sections 9 and 10 are about the details of formal healthMAPEDIR Interviewers Reference Manual May 19, 2008 2
  • 3. care. If the woman never sought formal care, then we skip this and go to the open history toask about the illness in the respondent’s own words. .................................................................. 28SKIP INSTRUCTION: STOP: If the woman died before reaching the facility, go to (F1: OpenHistory / F2 or F3: Section 10). ........................................................................................................ 30The rest of Section 9 asks about the care the woman received at the facilities she visited. Ifyou are completing matrix column 1 and she died before reaching facility 1, then go to theopen history to ask about the illness in the respondent’s own words. If she died before leavinghome, then Q9.15, Q9.16 and/or Q9.17 may not apply. For example, if the husband went to lookfor a taxi and his wife died while he was out searching, then Q9.15 and Q9.16 would not applyif he was not able to find a taxi; however, Q9.15 and Q9.16 would apply if he pre-paid for thetaxi but Q9.17 still would not apply. Mark the answers to the relevant questions and then go tothe open history. If you are completing matrix column 2 (or 3) and she died before reachingfacility 2 (or 3), then go to Section 10 to ask if a doctor or nurse told the family the cause ofdeath. 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.......................................................................................... 32The purpose of this section is to help maintain the quality of the maternal death inquiries. Thisis best accomplished by the supervisor participating in every interview that the teamconducts. At least, the supervisor should carefully check the completeness and accuracy ofeach completed interview form and discuss the findings with the team members whoconducted the death inquiry. The supervisor must decide how to resolve any identifiedproblems, including a repeat visit to the household if needed. Once the supervisor is satisfiedwith the quality of the completed format, s/he should sign and date the form to certify that it iscorrect and complete. ....................................................................................................................... 32APPENDIX A: INTERVIEWER’S CHECKLIST................................................................................... 33F. ___ Participate in team meeting (date: ______________).......................................................... 34APPENDIX B: SUPERVISOR’S CHECKLIST.................................................................................... 35APPENDIX C: CONSENT FORM........................................................................................................ 37APPENDIX D: INTERVIEWER’S ROLE PLAY GUIDE....................................................................... 38MAPEDIR Interviewers Reference Manual May 19, 2008 3
  • 4. About this manualThe purpose of this manual is to provide MAPEDIR interviewers with the information they need toconduct systematic, reliable and valid verbal autopsy interviews for maternal deaths. The manualdescribes 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 thecourse of their work as MAPEDIR interviewers. The manual also serves as a reference for trainersand 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 andrespond to the social, biological and medical events that led to a maternal or perinatal death. Inquiriesare conducted of the deaths that occur in a community over several months time, in order to identifycommon factors that can be acted upon to prevent further deaths. Ongoing inquiries over severalyears allow a community to assess the impact of its preventive actions and the need for additionalinterventions. Death inquiries are conducted in the community using a “verbal autopsy” interview withthe families of deceased persons. This is particularly helpful in areas where many deaths occuroutside 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 andchildren 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 thepast 50 plus years, 2) hospital-based perinatal death reviews encouraged by the American College ofObstetricians and Gynecologists in the United States, 3) the community and hospital inquiry into allmaternal deaths required by the Sri Lanka Ministry of Health since 1985, 4) the community verbalautopsy and hospital-based confidential inquiry of maternal deaths encouraged by the PhilippinesMinistry 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 andChild Health (RCH) Program has reviewed all maternal deaths and a sample of infant deaths since2003, the government of Kerala has reviewed all maternal deaths since 2005, and WHO supportsmaternal death reviews at Safdarjang Hospital in Delhi and Christian Medical College in Vellore.The MAPEDIR projectUNICEF is supporting the implementation of MAPEDIR in the context of RCH2, which calls forincreasing community participation in bottom-up health planning and the demand for quality healthcare. 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 withWHO to support facility-based reviews of maternal deaths. The project is initially focusing on inquiriesof maternal deaths. Perinatal death inquiries will be added in the future.MAPEDIR Interviewers Reference Manual May 19, 2008 4
  • 5. The causes of maternal mortality and its preventionA maternal death is the death of a woman during pregnancy or within six weeks of having an abortionor giving birth. Most maternal deaths are due to complications directly related to pregnancy, includingsevere bleeding (hemorrhage), pregnancy-induced hypertension (eclampsia), severe infection startingin the reproductive organs (puerperal sepsis), and obstructed labor (which leads to hemorrhage orsepsis). In India many maternal deaths are due to or hastened by severe anemia, which often resultsfrom a combination of factors, including inadequate nutrition, malaria, and blood loss frommenstruation and prior pregnancies. About 20% of maternal deaths may be caused by pre-existingconditions such as chronic heart disease or acute illnesses such as malaria that are made worse bythe 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 resultfrom a chain of events that includes many social, cultural and medical factors. Some of these can beprevented even before a woman becomes pregnant, such as by ensuring that she is well nourishedand not suffering from anemia. However, since it is usually not possible to predict which women willsuffer a severe pregnancy or delivery complication, the most effective way to prevent maternal deathsis to be ready to respond to complications when they occur. This often requires taking action at one ormore of the links in the chain, with a focus on the “three delays” in a woman’s receiving care for amaternal 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 approSocial 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 importanceof maternal complications, and 5) using traditional home care and informal providers for maternalcomplications instead of formal providers who might be able to save the woman’s life. The seconddelay can be due to the time needed to organize funds to pay for transportation or health care, a lackof transport, poor roads, or long distances to a health facility where the woman can receiveappropriate care. The third delay may be due to a lack of needed drugs, blood, medical or surgicalequipment, or skilled health personnel at the facility. If a woman is referred from a FRU, where sheshould be able to receive comprehensive emergency obstetric care, then the third delay also includesthe 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 oftheir child and be ready to deal with any complications that might occur. Such “birth preparedness andcomplication readiness” includes planning ahead of time where the woman will give birth, who willassist with the delivery, and where and how she will seek emergency care if necessary. Having a planwill enable the woman and her family to respond rapidly should the need arise. CommunityMAPEDIR Interviewers Reference Manual May 19, 2008 5
  • 6. participation in planning for safe deliveries will help ensure that women and their families recognizewhen emergency care is needed and know where and how to seek this care. Part of the community’ssensitization to maternal health issues will include being informed about MAPEDIR and why the deathinquiries are needed. During your training as a MAPEDIR interviewer, you will be told about the plansbeing made to sensitize your community and share the MAPEDIR findings to be used in developingeffective interventions against maternal mortality.2. Project Organization and ProceduresBlock-level team with district oversightThe MAPEDIR project is organized at the block and district levels. In most states, a death notifierinitially investigates community reports of deaths of women of reproductive age and transmits his/herfindings to the block-level MAPEDIR team supervisor. S/he assesses each report and assigns thesuspected maternal deaths for a MAPEDIR interview. Interviewers in most states have chosen towork in teams of two, with one serving as the interviewer and the other as the data recorder. Theymay 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 projectimplementation in all the district’s blocks. Death reports and completed MAPEDIR interviews arecompiled and analyzed at the district level with technical assistance from UNICEF, and the interviewfindings are shared with the community via district and block officials and NGO partners. In somestates, NGOs play a prominent role as well in administering the project and conducting the deathinquiries. 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 directorateMAPEDIR Interviewers Reference Manual May 19, 2008 6
  • 7. During your training you will review the death notification format that is used to conduct the initial investigation of deaths of women of reproductive age, as well as the register that supervisors keep to track these deaths and assign suspected maternal deaths to the interviewers. You will also discuss the appropriate waiting period after a death before conducting the MAPEDIR interview.3. Interviewer and Supervisor Roles and ResponsibilitiesOverview of the interviewer’s activities and responsibilitiesAs a MAPEDIR interviewer, you will represent the project to households in your block. You will informbereaved families about the purpose of MAPEDIR and conduct the verbal autopsy interview with theappropriate family members. Your tasks include: Meet with your supervisor to receive your interview assignments for maternal deathsthat have occurred in your block; Locate households where a maternal death occurred and visit the families to plandates for conducting interviews; Conduct verbal autopsy interviews with family members on the appointed dates andcorrectly complete the MAPEDIR format; Return completed interview forms to your supervisor and discuss and solve anyproblems you have encountered; Strive for continuous self-improvement of your performance; and Maintain the ethical standards of the project and good relations with the community.Interviewer self-assessment and improvementOne of your responsibilities as a MAPEDIR interviewer is to continually strive to improve yourperformance. Your supervisor is also there to assist you in overcoming any problems that occur, butto make the greatest progress you should always seek to do the best job possible. Appendix Aprovides an interviewer’s self-assessment checklist to help you in this task. How to use the checklistwill be discussed during your training as a MAPEDIR interviewer.Supervisory procedures and approachYour supervisor will assign suspected maternal deaths to you for interview and provide you with blankMAPEDIR 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 othersupervisory 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 MAPEDIRinterviewers. This means assisting the interviewers whenever necessary and helping them toovercome problems that they face in completing the interviews. Supervisors will have theopportunity to practice this approach during the MAPEDIR training.4. Ethical TrainingPart of your training as a MAPEDIR interviewer or supervisor will be on ethical aspects of conductingresearch interviews, such as informed consent and confidentiality. This is to ensure that you areMAPEDIR Interviewers Reference Manual May 19, 2008 7
  • 8. aware of the importance of these issues and will maintain the highest ethical standards in your work atall times. Some important concepts to be discussed during the ethical training are described below.Informed consentAll potential respondents have the right to determine for themselves whether or not they willparticipate in the interview. All respondents must be at least 18 years old, to help ensure that they arecapable 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 projectand death inquiry before asking any questions; and that after learning all the facts they consent to beinterviewed. 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 theseand other facts are described in a “consent form,” which you must read and explain to therespondent(s) before conducting the interview. Each respondent must make their mark on the consentform, which you will then sign to testify that the person consented to be interviewed. Complete aseparate consent form for each respondent. The consent form is in Appendix C of this manual.ConfidentialityIt is critical that all information obtained from the MAPEDIR interviews remains strictly confidential.You are not permitted to discuss the findings from an interview, gossip about it, or show your recordsto anyone other than your supervisor. Make all entries on the questionnaires yourself. Do not leaveyour 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 therespondents from any repercussions that might occur as a result of the information they haveprovided. It is also necessary to maintain the trust of the community and assure that people will bewilling to talk openly to us about the maternal deaths. The project will share the interview findings withthe community but never in a way that reveals which information came from which person or family.Falsification of DataYour job as a MAPEDIR interviewer will not always be easy. There may be times when you have tovisit a household more than once to meet with the best respondent. The interview will often take onehour or longer to complete. Many of the questions seek sensitive information that may appear toreflect badly on care provided to women by their families and sometimes by the health system. Allthese conditions can lead to temptations to falsify data in order to quickly complete the interview andnot record painful facts. However, you must never falsify your work. The whole purpose of theMAPEDIR project is to collect and share information with the community that can be used to preventmaternal deaths. This will be possible only if the information collected is truthful. It is yourresponsibility to assure that you maintain this standard. You should work as a MAPEDIR intervieweronly 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 womanduring her fatal illness and death. However, when approaching a household in a rural village you arelikely to be met by a crowd of interested persons. Once inside the yard or the house several neighborsand family members who know little about the woman’s illness may want to participate in the interviewor just observe. You must manage this situation effectively and sensitively in order to ensure that youinterview the most knowledgeable person(s) and that the others are not offended. These issues willbe discussed during your training, and you will have the opportunity to role play some situations(found in Appendix D) that you might face during your work. Following are some suggestions.Manage the scene and gain the trust and cooperation of householdsConsider working with a local respected person (e.g., schoolteacher, village leader) to pre-arrange themeeting and/or to accompany the interview team to the household.MAPEDIR Interviewers Reference Manual May 19, 2008 8
  • 9. In order to have respondent’s cooperation and obtain complete and accurate data, you must first gainthe trust and confidence of the household. You can do this by making a good impression andconducting yourself in a professional, but also friendly manner.Understand the projectIf you are knowledgeable about the project and your responsibilities respondents will be more likely totrust you and participate. You should be able to answer any questions that household members mayask about the purpose of the project and how the information they share will be used.Emphasize the confidentiality of the informationYou must assure participants that their responses will be held in strictest confidence. No informationwill 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, youshould fully explain how confidentiality will be maintained. Explain that no names will ever be revealedand that the information from all interviews will be combined in a report for district and national use.Introducing yourself at the householdThis is a very sensitive time for the family so it is important that you be polite and sensitive whenintroducing yourself. Be sure to state the purpose and confidential nature of the interview—these arekey elements to gaining the family’s cooperation. An example is provided below: My name is [say your name]. I am a nurse/_____ in the _____ center, and an interviewer with the MAPEDIR Project. I have been informed that a woman in your household died. I am very sorry to hear this. Please accept my sympathy. In order to improve health care in our district, we are collecting information on recent deaths of women in this area. I would like to talk to the person in your house who took care of [say the woman’s name] during her illness before death. I assure you that any information you or your family provide will be kept confidential.How to select the best respondentThe respondent is the main person that will provide information about the deceased. S/he should bethe one who was with the woman during her illness. Usually, the woman’s husband, mother, sister ormother-in-law is the preferred respondent for a maternal death. In some cases more than one personwill 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 haveaccompanied her to the hospital after the birth. All respondents must be at least 18 years of age.What to do if the potential respondent(s) is away or lives elsewhereIf the person(s) who appear(s) to be the best respondent is not available when you first visit thehousehold, try to make an appointment to return when they will be at home. If no one is at home whenyou 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 ofthis return date in your notebook.Sometimes the best respondent(s) may have moved to another village. In this case, you shoulddiscuss the situation with your supervisor, who will decide if you should travel to the other village or ifhelp needs to be sought from the MAPEDIR team in another block.How to handle multiple respondentsAs discussed above, there may be instances when you need more than one respondent to get the fullstory of the woman’s illness. If you interview these persons together it should be clear as to who is therespondent for which stage of the illness. More than one person answering the same question canlead to confusion and greatly lengthen the interview.Some persons who were not with the woman during her illness may insist on attending the interviewor even on being the respondent. For example the woman’s husband or mother might not let the sistertalk to you alone, even if she took care of the woman during the illness. Or, the respondent may havechildren to care for who distract her attention from the interview. Lastly, having a visitor at thehousehold can attract many other unwanted people to observe the interview. In these cases it isimportant to stress to the respondent the importance of confidentiality and privacy. You can try:MAPEDIR Interviewers Reference Manual May 19, 2008 9
  • 10.  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 interview6. Communication and Sensitivity IssuesEffective communication with the respondent is of key importance in obtaining high qualityinformation. As a MAPEDIR interviewer, you will interact with bereaved relatives of women who haverecently died. In addition to mastering basic communication techniques, you need to be sensitive tothe emotions of these bereaved persons and know how to handle difficult situations that might ariseduring the interview. You will role play some of these situations (in Appendix D) during your training.How to approach the respondentAlways have a positive approach. Do not use phrases such as: “Are you too busy?” or “Can you sparean hour?” Such questions invite refusal before you start. Instead, begin by restating condolences forthe death and say: “I would like to ask you a few questions.” or “I would like to talk with you for a fewminutes.” Just as when approaching the household, state the purpose of the interview and itsimportance 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, askher/him for another day or time when s/he would be available to participate in the interview. Answerany questions the respondent asks frankly and to the best of your knowledge.Selecting an environment for the interviewIt is best to conduct the interview in a private location where you and the respondent(s) can be alone.However, it is to be expected that other family members may be present during the interview. In caseswhere complete privacy is not possible, try to limit the number of outsiders present.Basic communication techniquesSit at the same level as the respondent(s) and maintain eye contactAlways look at the respondent when administering the interview. Remember, this is a difficult time forthe respondent and they must feel comfortable with you in order to complete the interview.Build rapport with the respondent(s)Try to build rapport with the respondent(s) before discussing the case of the deceased. For example,if culturally appropriate, you may ask the respondent what work s/he does, or ask about her/his family.Encourage speech, listen actively, no not rush, nod your headThese are ways of showing the respondent that you are interested in what s/he is saying, and willencourage her/him to continue.Be non-judgmentalSome 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 thismessage in any way because it will discourage the respondent from providing truthful answers. Thesuccess of the MAPEDIR project depends on all of us taking this non-blaming approach. The idea isfor us and the community to learn what we can do together to prevent maternal deaths. This can onlybe accomplished by working together without blaming individuals for the deaths.Language problemsIf you encounter any language difficulties, for example, if you anticipate that a respondent speaks adifferent dialect than you do, talk to your supervisor beforehand.Bereaved respondents and sensitivity issuesPersons who are mourning the death of a loved might have several emotional responses that couldinterfere with the interview. These might include the following, some of which are discussed below:MAPEDIR Interviewers Reference Manual May 19, 2008 10
  • 11.  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 reasonsSadness, tearfulnessFirst, be sure to express your sympathy and condolences for the respondent’s loss before starting theinterview. It may also help respondents to know that the health program and community will use theMAPEDIR data to help improve care for other women. If a respondent begins to cry or have greatdifficulty in answering questions because s/he is overcome with emotion, you should pause and offera tissue for tears. Acknowledge how difficult it must be to answer the questions, give the respondenttime to regain their composure, and ask if s/he can continue at this time. If the respondent choosesnot to continue, attempt to reschedule the interview.AngerA respondent may be angry at the health program if s/he feels that an individual health worker or thehealth program in some way contributed to the death. The respondent might direct this anger at you ifs/he sees you as a representative of the health program. Another possibility is that a respondent mayblame a relative or neighbor for the woman’s death if, for example, s/he feels that this person did notprovide help that was needed. This anger could also come out during the interview. If this happens, letthe person express their anger. Then, again express your condolences for their loss and acknowledgethat you understand that they blame the particular person or the health program. (Never state that youagree with them, just that you understand that this is their feeling.) Last, again explain that thepurpose of the MAPEDIR interviews is to learn more about the problems that lead to maternal deathsand to help the community work together to overcome these problems.Not wanting to answer certain questionsThere could be several reasons that a respondent does not want to answer certain questions. Aquestion may rekindle painful memories; it may ask about a topic that is particularly sensitive for therespondent; the respondent may feel that they personally did not do enough to help the woman andthat the answer to the question would reflect badly on them, etc. Whatever the reason, you mustnever demand or even ask a respondent to answer a question that they have told you they do notwant to answer. As stated in the informed consent statement, respondents’ participation is totallyvoluntary and they have the right to refuse to answer any or all questions. It should not be a problemfor the interview if a respondent refuses to answer only a few questions. However, many refusals willcompromise the quality of the interview. You should make a note about any reasons you think mightbe leading to the respondent’s reluctance and discuss such cases with your supervisor.7. Conducting the InterviewMaterials you will needInterviewers will be provided the materials listed below to help them perform their duties. Make surethat 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.MAPEDIR Interviewers Reference Manual May 19, 2008 11
  • 12. 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 9.41transportation 1. Walk..................... 1.  If only walk, go 1.  If only walk, go 1.  If only walk, gomethod was used 2. Rickshaw/cart...... 2.  to Q9.17 2.  to Q9.30 2.  to Q9.43to 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:MAPEDIR Interviewers Reference Manual May 19, 2008 12
  • 13. 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 mistakesIf you make a mistake when marking your answers do not erase the information. Instead, cross it outneatly with one line so the original entry can still be read, and then mark the correct answer. Writeyour initials next to the correction, so anyone who later examines the completed format will know whomade 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” withone line, recorded the correct answer and wrote her initials next to response box.1. Yes2. No 2 RS8. Don’t know 1MAPEDIR Interviewers Reference Manual May 19, 2008 13
  • 14. 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 care2. No one was available to accompany her √ RS3. She had to attend to household duties √4. Transportation not available √Skip patternsRequired skips are indicated by an “If…” statement with a possible response choice that points towhere you should go. For example, the following indicates to skip over question 4.5.1 if the answer toquestion 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 knowAlso note that the question numbers are designed to help you follow the skip pattern. In the aboveexample, 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.MAPEDIR Interviewers Reference Manual May 19, 2008 14
  • 15.  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.MAPEDIR Interviewers Reference Manual May 19, 2008 15
  • 16. 8. Question-by-Question Instructions for the MAPEDIR Suspected Maternal Death FormatSECTION 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 providesbackground information that was gathered by the death notifier, which you should use to help locatethe 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 interview2.1 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.MAPEDIR Interviewers Reference Manual May 19, 2008 16
  • 17. 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 respondentsINSTRUCTION: Introduce yourself and the purpose of your visit. Say that we are trying to improve thecare of women and children. Ask to speak to the person(s) who knows the most about thecircumstances 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 ofthe illness. If someone you need to speak with is not available, arrange a time to return when s/he willbe home. Read the consent form to the respondent(s) and ask for her/his participation. Eachrespondent 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 youmust 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 consentshould not be included in the interview. If no potential respondent(s) consent to be interviewed, thenyou 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 willdetermine whether you complete the entire interview or just the cause of death and open historysections at the end of the format. Begin by reading the following statement, which will help maintainthe 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.MAPEDIR Interviewers Reference Manual May 19, 2008 17
  • 18. 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 family4.1 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.MAPEDIR Interviewers Reference Manual May 19, 2008 18
  • 19. 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 54.12.1 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 historyRead: 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 65.2 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.MAPEDIR Interviewers Reference Manual May 19, 2008 19
  • 20. 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 Q6.56.4.1 If yes, ask: How many times did she receive antenatal care from an ANM, nurse or qualified doctor? Women should make at least three antenatal care visits during a pregnancy. RECORD THE NUMBER OF TIMES. Don’t know = 88.Read: Now, I’d like to ask you about the circumstances of __________’s death.6.5 Did she die while having an abortion or within 6 weeks after having an abortion? Any pregnancy that ends spontaneously at 5 or fewer completed months or that is induced (including MTP) at any time with the intent to kill the fetus is considered an abortion. The answer should be “No” if the pregnancy ended spontaneously at 6 or more completed months. The answer should be “Yes” if the woman died either during an abortion or within 6 weeks after an abortion. RECORD ONE ANSWER: 1. Yes, during an abortion; 2. Yes, within 6 weeks after an abortion; 3. No; 8. Don’t know. SKIP INSTRUCTION: If 1, go to Q6.6. If 3 or 8, go to Q6.9 (Antenatal). (This means that the Antenatal questions begin with question 6.9.)Abortion questions follow – Ask these questions only if she died during or after an abortionThis instruction guides you to ask the following questions only for abortion deaths.6.5.1 If she died after an abortion, ask: How many days after the abortion did she die? RECORD THE NUMBER OF COMPLETED DAYS. For example, 1 day and 4 hours = 01 day. Less than 1 day = 00; Don’t know = 88.6.6 Was the abortion spontaneous or induced, including MTP? “Spontaneous” means the abortion happened on its own. This is the same as a miscarriage. “Induced” means someone purposefully ended the pregnancy. “MTP” (medical termination ofMAPEDIR Interviewers Reference Manual May 19, 2008 20
  • 21. 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 Q6.76.6.1 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 know6.8 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 anabortionThis instruction is to help guide you through the questionnaire. It follows-up the skip instruction fromquestion 6.5, which was “If 3 or 8, go to Q6.9 (Antenatal).” It is like a stone in a creek. You jump fromQ6.5 to the stone and then from the stone to Q6.9. If the answer to Q6.5 was 1 or 2 (abortion), youwould 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 Q7.1Labor and Delivery questions follow – Ask these questions only if she did not die before laborbeganThis 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 maternalMAPEDIR Interviewers Reference Manual May 19, 2008 21
  • 22. 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 Q6.136.12.1 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.MAPEDIR Interviewers Reference Manual May 19, 2008 22
  • 23. SECTION 7: Illness complicationsRead: Now, I’d like to ask you about the problems __________ had during the last part of herpregnancy 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 threetypes of maternal death. You have already determined the type of maternal death in Section 6. Usethat 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 inSection 6 that this was an Antenatal or Labor and Delivery death. The questions are about illnesssymptoms that can occur with these deaths. The causes of maternal death associated with thesesymptoms 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 know7.2 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 know7.3 During the last part of the pregnancy or the fatal illness, did a doctor or nurse tell her that she had anemia? The answer should be “Yes” only if a doctor or nurse made this diagnosis. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know7.4 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 know7.6 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 know7.7 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 know7.8 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.MAPEDIR Interviewers Reference Manual May 19, 2008 23
  • 24. 7.10 Did she have convulsions during the fatal illness? Having convulsions could mean that the woman died from eclampsia. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know. SKIP INSTRUCTION: If this was an antenatal death, go to Q7.19. (Questions 7.11 – 7.18 are only for Labor and Delivery and Abortion deaths.)Ask Q7.11 – 7.16 for Labor and Delivery deaths.This is a ‘staying stone’ instruction that tells you to ask the following questions if you determined inSection 6 that this was a Labor and Delivery death. The questions do not start with “During labor anddelivery…” because it is clear from the questions that you are asking about this period.7.11 How long was she in labor? “Labor” begins when the woman has regular contractions no more than 10 minutes apart. Labor usually lasts less than 12 hours. RECORD THE COMPLETED NUMBER OF HOURS. Less than 1 hour = 00; Don’t know = 88.7.12 For how long did she have to make an effort? “Make an effort” is the pushing a woman does at the end of labor to deliver the baby. This effort usually lasts less than 2 hours. RECORD THE COMPLETED NUMBER OF HOURS. Less than 1 hour = 00; Don’t know = 88.7.13 Did she have labor pain that was worse than normal labor pain and that started suddenly? This is a sign of a ruptured uterus, which can result in severe bleeding. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know7.14 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 know7.15 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 know7.16 How long after the baby’s birth did the placenta come out? The placenta should come out within one hour after the baby is delivered. Retained placenta can lead to postpartum hemorrhage. RECORD THE COMPLETED NUMBER OF HOURS. If the woman died before the placenta came out, then record that it never came out. Less than 1 hour = 00; Don’t know = 88; Never = 99.Ask Q7.17 – 7.18 for Abortion and Labor and Delivery deaths.This is a ‘staying stone’ instruction that tells you to ask the following questions if you determined inSection 6 that this was an Abortion or Labor and Delivery death. The questions are about illnesssymptoms 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.MAPEDIR Interviewers Reference Manual May 19, 2008 24
  • 25. 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. Thequestions 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 Q7.207.19.1 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 May 19, 2008 25
  • 26. 7.23 During the fatal illness, did she become unconsciousness? Unconsciousness is a sign of severe illness that could be due to a pelvic infection or malaria. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know.SKIP INSTRUCTION: If not semiconscious and not unconscious, go to Q7.24.This skip instruction is placed here since it applies to both Q7.22 and 7.23. Ask Q7.23.1 and 7.23.2 ifthe woman had semiconsciousness or unconsciousness.7.23.1 How long was she semiconscious or unconscious? INSTRUCTION: If she was both semiconscious and unconscious, then record the total time. Knowing how long the reduced consciousness lasted helps us determine if the woman died from pelvic infection or malaria. RECORD THE NUMBER OF COMPLETED HOURS. Less than 1 hour = 000; Don’t know = 888.7.23.2 Was she semiconscious or unconscious until she died? “Until she died” means right up to the moment she died. This also helps us determine if she died from pelvic infection or malaria. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know.7.24 Did she have any other problem? INSTRUCTION: If “Yes,” specify. You can use this space to record another symptom not already mentioned. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know. If the answer is Yes, then record the symptom in the space provided.7.24.1 If 1. Yes, specify: This is where you can specify any other symptom that the woman had during the illness.SECTION 8: Injury8.1 Did ________ suffer an injury or accident of any kind in the days before death? RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know. SKIP INSTRUCTION: If 2 or 8, go to Section 9. (If she did not have an injury, then we don’t need to ask any more injury questions.)8.1.1 What kind of injury or accident did she suffer? INSTRUCTION: Allow the respondent to answer spontaneously. If she has difficulty identifying the injury, read all the choices slowly. RECORD ONE ANSWER: 1. Motor vehicle accident; 2. Fall; 3. Violence; 4. Suicide; 5. Other (specify other); 8. Don’t know. If the answer is “5. Other,” then write the details in the space provided.8.1.2 How long after the injury did she die? It is more likely that the injury was the cause of death if the woman died soon after it occurred. RECORD THE NUMBER OF COMPLETED DAYS: For example, if 3 days and 8 hours, then record 003 days. Less than 24 hours = 000 days; Don’t know = 888.8.1.3 Did she die from the injury? We are asking for the respondent’s opinion. This can help us understand whether or not the injury was severe. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know.SECTION 9: Careseeking for obstetrical complications that led to the death9.1 Now, please tell me, where was ________ when her fatal illness began? Knowing this can help us put together the picture of the woman’s illness. The answers to Q9.1 and Q6.13.2 will usually fit together. For example, if the illness had already begun when she started out for the health facility (Q6.13.2 = 2), then it probably began at home (Q9.1 = 1). And if she was in normal labor when she started out for the facility (Q6.13.2 = 1), then usually the illness will have begun on route to (Q9.1 = 3) or at (Q9.1 = 2) the facility where she gave birth. However, it could have begun on route home (Q9.1 = 4) or after returning home (Q9.1 = 1) from the facility. Discuss the situation with the respondent to make sure Q6.13.2 and Q9.1 make sense together before recording the answers. RECORD ONE ANSWER: 1. Home (her, relative’s, friend’s, informal provider’s); 2. Hospital /Other formal health facility; 3. On route to a formal health facility; 4. On route to home from a health facility; 5. Other; 8. Don’t knowMAPEDIR Interviewers Reference Manual May 19, 2008 26
  • 27. 9.2 And what was the first thing she or her family did for the illness? INSTRUCTION: Mark only the first action taken. If they were trying to seek formal care, even if they had not yet left the house or were on route to a facility, then mark “3. Sought formal care.” If Q9.1 = 2, then Q9.2 will usually = 4. If not, then discuss the situation with the respondent to make sure s/he understood the questions. If the answers still don’t match, then write a short explanation in the question box to help your supervisor understand the situation. A woman with a severe maternal illness requires formal health care to save her life. Formal care means care by a licensed doctor or nurse. Informal care means by an unlicensed provider such as a dai or quack. RECORD ONE ANSWER: 1. Gave home care; 2. Sought care from an informal provider (includes at her own home); 3. Sought formal health care; 4. She was at the formal provider where she went for normal labor, to have an MTP or any other reason when her illness began; 5. Other (specify other); 8. Don’t know. If “5,” specify the action in the space provided. SKIP INSTRUCTIONS: If 4, go to Q9.11. If 8, go to Q9.7.9.3 Who decided that this was the action to take? INSTRUCTION: Only one response allowed. Record the main decision maker. Women who decide for themselves usually seek formal care faster than if someone else decides for them. RECORD ONE ANSWER: 1. The woman, herself; 2. Her husband; 3. Her mother; 4. Her mother-in-law; 5. Other male; 6. Other female; 8. Don’t know.9.4 How long after the illness began did s/he decide to do this? INSTRUCTION: Mark days, hours and/or minutes as needed. (See general instruction 9 on page 14 on how to record the answer.) The definition of careseeking delay 1 is how long it took to decide to seek formal health care. If ACTION 9.2 was to seek formal care, then the response to Q9.4 defines delay 1. Don’t know = 88.9.5 Which symptom(s) did ________ have at this time? Delay 1 is partly due to not recognizing for which symptoms a pregnant woman urgently requires formal health care. RECORD ALL THE SYMPTOMS THE RESPONDENT STATES the woman had when it was decided to take ACTION 9.2.9.6 If Action 9.2 was not seeking formal health care, then ask: Did she/the family have any problems that kept her from seeking formal health at that time? If Action 9.2 was seeking formal heath care, then ask: Did she/the family have to overcome any problems in order to seek formal health care at that time? INSTRUCTION: Prompt: Was there anything else? Multiple answers allowed. Check all that apply. Check only “14” if she had no careseeking problem. (See general instruction 7 on page 13 for how to follow this instruction.) Knowing the reasons for careseeking delays 1 and 2 can help develop interventions to overcome these delays. RECORD ALL THE RESPONDENT’S ANSWERS: 1. Did not think she was sick enough to need health care; 2. No one was available to accompany her; 3. She had to attend to household duties; 4. Transportation not available; 5. Could not pay for transportation; 6. Could not pay for the care provider/facility; 7. Other cost; 8. Not satisfied with the available health care; 9. Her problem(s) require traditional care; 10. Thought she was too sick to travel; 11. Thought she would die no matter what; 12. It was late at night; 13. Other (specify); 14. No careseeking problem; 88. Don’t know. If the answer is “13. Other,” write the details in the space provided. Record only “88. Don’t know” if the respondent doesn’t know if the woman had any careseeking problem.If the first action was to seek formal care (Q9.2=3), go to Q9.11.Questions 9.7-9.10 are about the first time that formal care was sought for the illness. If the first actionwas to seek formal care, then Q9.3-9.5 asked these questions so we don’t need to ask them again.MAPEDIR Interviewers Reference Manual May 19, 2008 27
  • 28. 9.7 Did she seek formal health care at any time during the fatal illness? If the first action taken for the illness (Q9.2) was not seeking formal health care, then we ask here if the woman ever sought formal care. Just as in Q9.2, if they were trying to seek formal health care, even if they had not yet left the house or were on route to a facility, then mark “1. Yes.” RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know. SKIP INSTRUCTION: If 2 or 8, go to Open History. The remainder of Sections 9 and 10 are about the details of formal health care. If the woman never sought formal care, then we skip this and go to the open history to ask about the illness in the respondent’s own words.9.8 Who decided that she needed to seek health care? INSTRUCTION: Only one response allowed. Record the main decision maker. Women who decide for themselves usually seek formal care faster than if someone else decides for them. RECORD ONE ANSWER: 1. The woman, herself; 2. Her husband; 3. Her mother; 4. Her mother-in-law; 5. Other male; 6. Other female; 8. Don’t know.9.9 How long after the fatal illness began did s/he decide to seek this care? INSTRUCTION: Mark days, hours and/or minutes as needed. (See general instruction 9 on page 14 on how to record the answer.) The definition of careseeking delay 1 is how long it took to decide to seek formal health care. If ACTION 9.7 was to seek formal care, then the response to Q9.9 defines delay 1. Don’t know = 88.9.10 Which symptoms did she have at this time? Delay 1 is partly due to not recognizing for which symptoms a pregnant woman urgently requires formal health care. RECORD ALL THE SYMPTOMS THE RESPONDENT STATES the woman had when it was decided to seek formal health care.9.11 How many formal facilities was she taken to (or intended to go) before she died? INSTRUCTION: Include any facility she did not reach because she died before leaving or on route. Include the facility she went to for normal labor, an MTP or any other reason if her illness began at this facility. Visiting many facilities instead of going to the correct facility first causes additional delays. We include any facilities that the woman did not reach because we want to know about all her attempts to seek care. This includes facilities that she intended to go to but died before leaving home or another facility or while on route to a facility. This can happen, for example, if it takes too long to arrange for transportation. RECORD THE NUMBER OF FORMAL HEALTH FACILITIES.9.11.1 Mark the facility where she had an abortion or delivered (if this was an abortion or L&D death and she was sick while at the facility) and where she died. Aborted here box: If she went to a formal facility to complete a spontaneous abortion, or if she had an MTP at a formal facility and her illness began while there, then mark the “Aborted here” box for the facility. Delivered here box: If she labored or delivered in a formal health facility and she was sick when she arrived there or her complications began while at the facility, then mark the “Delivered here” box for that facility. Died here box: If she died in a formal facility, mark the “Died here” box for that facility.9.11.2 Name and address of the first facility she went to: FACILITY 19.11.3 Name and address of the second facility she went to: FACILITY 29.11.4 Name and address of the third facility she went to: FACITLITY 3 RECORD THE NAME AND ADDRESS OF EACH FORMAL HEALTH FACILITY she went to for the fatal illness. Remember to include facilities the woman tried to go to but did not reach because she died before leaving home or another facility or while on route to the facility. Also include any facility where her illness began, for example, if she had an MTP there and began to bleed while at the facility.MATRIX QUESTIONSMAPEDIR Interviewers Reference Manual May 19, 2008 28
  • 29. The remainder of Section 9 is structured as a matrix, with one column for each facility visited, and withroom for up to three facilities. If the woman went to more than one facility, complete the questions forone facility (e.g., Q9.12-9.24 for facility 1) before asking the questions for the next facility.9.12 After (deciding to seek care/she was referred), how long did it take to make the9.25 arrangements to go from… home to facility 1? …facility 1 to facility 2? …facility 2 to9.38 facility 3? INSTRUCTION: Read “…home to facility 2?” or “…home to facility 3?” if she first went home before going to the next facility. Read “After deciding to seek care…” when going from home to facility 1 (or from home to facility 2 or 3). Read “After she was referred…” when going from facility 1 to 2 or from facility 2 to 3. Discuss that this includes the total time needed to arrange for transportation and the money to pay for this and the woman’s health care. Mark days, hours and/or minutes as needed. See general instruction 9 on page 14 on how to record the answer. The time it takes to make all needed arrangements to go to a health facility is part of careseeking delay 2. Don’t know = 88.9.13 How did she/the family arrange this money?9.26 INSTRUCTION: Multiple answers allowed. Check all that apply. Without adequate9.39 preparation, funding the transport and health care costs for an emergency trip to the hospital can deplete a family’s resources. RECORD ONE ANSWER: 1. Had available; 2. Borrowed; 3. Sold assets; 4. Community fund; 5. Government scheme; 6. Other; 8. Don’t know.9.14 How far is it from… home to facility 1? …facility 1 to facility 2? …facility 2 to facility 3?9.27 INSTRUCTION: Read “…home to facility 2?” or “…home to facility 3?” if she first went home9.40 before going to the next facility. Careseeking delay 2 is the time it takes for a woman to reach the facility where she can get the care she needs. The distance to the facility is one reason for this delay. RECORD THE NUMBER OF WHOLE KILOMETERS: For example, if 14 and one- half kilometers, record 014. Less than 1 kilometer = 000; Don’t know = 888.9.15 What transportation method was used to take her there?9.28 INSTRUCTION: Multiple answers allowed. Check all that apply. See general instruction 7 on9.41 page 13 for how to follow this instruction. Lack of transportation is another reason for delay 2. Response choice “9. Could not arrange,” is for cases where the family tried to seek formal care but was not able to arrange transportation and did not leave the house. This response is not relevant to Q9.28 and Q9.41 because these questions are asked only for women who left facility 1 or 2. RECORD ALL THE RESPONDENT’S ANSWERS: 1. Walk; 2. Rickshaw/cart; 3. Bus; 4. Taxi/auto/trecker; 5. Ambulance; 6. Other; 8. Don’t know; 9. Could not arrange. SKIP INSTRUCTION: If “walk” is the only response, then go to Q9.17 (Q9.30, Q9.43).9.16 How much did this cost?9.29 Even if transportation is available, it might be too costly for many people to afford. Q9.16 does9.42 not apply if the family could not find transport to facility 1. The “NA” response is not available for Q9.29 and Q9.42 because these questions are asked only for women who left facility 1 or 2. RECORD THE NUMBER OF RUPEES. Don’t know = 8888; Not applicable=9999.9.17 How long did it take to travel to… …facility 1? …facility 2? …facility 3?9.30 INSTRUCTION: Mark days, hours and/or minutes as needed. We want to know the total9.43 travel time to the facility so the question does not apply if she died on the way.Travel time to the facility is part of delay 2. See general instruction 9 on page 14 on how to record the answer. Don’t know = 88; Not applicable = 99.MAPEDIR Interviewers Reference Manual May 19, 2008 29
  • 30. SKIP INSTRUCTION: STOP: If the woman died before reaching the facility, go to (F1: Open History / F2 or F3: Section 10).The rest of Section 9 asks about the care the woman received at the facilities she visited. If you are completing matrix column 1 and she died before reaching facility 1, then go to the open history to ask about the illness in the respondent’s own words. If she died before leaving home, then Q9.15, Q9.16 and/or Q9.17 may not apply. For example, if the husband went to look for a taxi and his wife died while he was out searching, then Q9.15 and Q9.16 would not apply if he was not able to find a taxi; however, Q9.15 and Q9.16 would apply if he pre-paid for the taxi but Q9.17 still would not apply. Mark the answers to the relevant questions and then go to the open history. If you are completing matrix column 2 (or 3) and she died before reaching facility 2 (or 3), then go to Section 10 to ask if a doctor or nurse told the family the cause of death. Then continue with the open history.9.18 Which illness symptom(s) did she have while at… ...facility 1? …facility 2? …facility 3?9.31 Knowing the woman’s symptoms can help us determine if the facility provided quality health9.44 care. RECORD ALL THE SYMPTOMS THE RESPONDENT STATES the woman had while at the facility.9.19 What did the (facility/provider) do for her problem?9.32 INSTRUCTIONS: Prompt: Was there anything else? Multiple responses allowed. Check all9.45 that apply. See general instruction 7 on page 13 for how to follow this instruction. If the respondent observed the woman’s care while at the facility, then we can assess the quality of the care that she received. Providers sometimes advise family members to go buy a medicine that is not available in the facility. This can contribute to the delay in the woman receiving appropriate care at the facility. Use choice “7” to record this finding. RECORD ALL THE RESPONDENT’S ANSWERS: 1. IV fluid other than blood; 2. Massaged abdomen to stop the bleeding; 3. Medicine to stop the bleeding; 4. Blood transfusion; 5. Completed the abortion; 6. C-section; 7. Advise to buy outside medicine; 8. Other (specify); 9. Nothing; 88. Don’t know. If “8. Other,” specify the action or treatment in the space provided. SKIP INSTRUCTION: If “9, Nothing” or “88. Don’t know,” go to Q9.21 (Q9.34, Q9.47)9.20 How much did all this care cost?9.33 This is part of the economic impact of the illness. RECORD THE NUMBER OF RUPEES.9.46 Don’t know = 88888.9.21 Did the (facility/provider) refer ________ to another health care facility?9.34 The woman should be referred as soon as possible if the facility is not equipped to handle her9.47 problem. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know. SKIP INSTRUCTION: If 2 or 8, go to Q9.22 (9.35, 9.48)9.21.1 Why was she referred?9.34.1 INSTRUCTIONS: Multiple responses allowed. See general instruction 7 on page 13 for how9.47.1 to follow this instruction. RECORD ALL THE RESPONDENT’S ANSWERS: 1. For a certain problem (specify); 2. Did not have blood; 3. For a procedure (specify); 4. Lack of a specialist (specify); 5. Other (specify). If “1. Certain problem, “ “3. Procedure,” “4. Specialist” or “5. Other,” write the details in the space provided.9.21.2 How long after this problem started was she referred?9.34.2 INSTRUCTION: Include only her time in the facility if she had the problem when she arrived.9.47.2 Discuss with the respondent whether the problem for which the woman was referred started before or after she arrived at the facility. Mark days, hours and/or minutes as needed. See general instruction 9 on page 14 on how to record the answer. Time in the first facility may be well spent in stabilizing the woman’s condition. However, if she had to go to another facility to receive appropriate health care, then any unnecessary time at facility 1 is part of delay 2. Don’t know = 88.9.22 How long was she at this facility?9.35 INSTRUCTION: Mark days, hours and/or minutes as needed. See general instruction 9 onMAPEDIR Interviewers Reference Manual May 19, 2008 30
  • 31. 9.48 page 14 on how to record the answer. This should be the total time the woman was at this facility, including the time before and after she was referred. Don’t know = 88.The rest of Section 9 is only for facilities 1 and 2. If the woman went to a fourth facility, thenafter Q9.48 ask the respondent to describe the visit to facility 4 as part of the open history.9.23 Was she taken to another health facility after leaving… …facility1 …facility 2?9.36 Unlike in Q9.11, where we include facilities she intended to go to but died before setting out, here we only want to know whether the woman actually left for another facility. If she left and either died on route to or reached the next facility, the answer should be “1. Yes.” RECORD ONE ANSWER: 1. Yes, 2. No, 8. Don’t know. SKIP INSTRUCTIONS: If 8, go to Section 10.9.24 If not taken to another facility, ask: Did she/the family have any problems that kept her9.37 from going to another facility? If taken to another facility, ask: Did she/the family have to overcome any problems in order to go to another facility? INSTRUCTIONS: Prompt: Was there anything else? Multiple answers allowed. Check all that apply. See general instruction 7 on page 13 for how to follow this instruction. RECORD ALL THE RESPONDENT’S ANSWERS: 1. No transportation; 2. Transportation or health care cost; 3. Not satisfied with available care; 4. Thought she would die no matter what; 5. She died at facility 1 or facility 2; 6. Other (specify). 7. No careseeking problem; 8. Don’t know. If “6. Other,” write the details in the space provided. Record only “7. No careseeking problem” if the woman did not have any careseeking problem. Record only “8. Don’t know” if the respondent doesn’t know if the woman had any careseeking problem. SKIP INSTRUCTION: If “5. She died at F1/F2,” go to Section 10.SKIP INSTRUCTION: If she was taken to another facility… …go to 9.25 (start of Facility 2) …goto 9.38 (start of Facility 3)This is a skipping stone that takes you to the first question for the next formal health facility where thewoman sought care. This question is at the top of the next column.SECTION 10: Reported cause of death10.1 Did a doctor or nurse at the health facility tell you the cause of ________’s death? The cause of death reported by a doctor or nurse could be useful information. RECORD ONE ANSWER: 1. Yes; 2. No; 8. Don’t know. SKIP INSTRUCTION: If 2 or 8, go to Open History.10.1.1 If 1. Yes, specify cause 1: RECORD THE FIRST CAUSE OF THE WOMAN’S DEATH THAT A DOCTOR OR NURSE TOLD TO THE RESPONDENT. If the family has a death certificate or other written medical record that shows the cause of death, then you can also record this information.10.1.2 If 1. Yes, specify cause 2: RECORD THE SECOND CAUSE OF THE WOMAN’S DEATH THAT A DOCTOR OR NURSE TOLD TO THE RESPONDENT. If the family has a death certificate or other written medical record that shows the cause of death, then you can also record this information.Open historyRead: Thank you for answering the many questions that I’ve asked. Would you like to tell meabout the illness in your own words? Also, is there anything else about her illness that I didnot ask and you would like to tell me about?INSTRUCTIONS: After the respondent(s) finishes, ask: Is there anything else?Write the respondent’s exact words. After s/he has finished, read this back and ask her to correct anyerrors in what you wrote.As the statement and instructions make clear, this is an opportunity for the respondent to tell aboutthe events of the woman’s illness in her/his own words, or to fill in any gaps left by the interview.MAPEDIR Interviewers Reference Manual May 19, 2008 31
  • 32. END OF INTERVIEW THANK RESPONDENT(S) FOR THEIR COOPERATIONSupervisor’s certificationThe 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.MAPEDIR Interviewers Reference Manual May 19, 2008 32
  • 33. APPENDIX A: INTERVIEWER’S CHECKLIST 1INTERVIEWER’S SELF-ASSESSMENT CHECKLISTInterview and informed consent forms (before the interview)A. ___ Have blank consent formsB. ___ Have a blank MAPEDIR format for referenceC. ___ Have the MAPEDIR format given by the supervisor for the respective suspected maternal death, with Section 1 filled by the supervisorLocating information and transportationA. ___ Understand address and locating information for assigned interviewB. ___ Understand transportation method to interview locationC. ___ Meeting(s) arranged with village leader/other community member(s), if needed to help locate or be introduced to a household with a deathAt the household, before the interviewA. ___ Inform household member of the reason for the interviewB. ___ Show household member my personal identificationC. ___ Ask to speak with the person(s) who know the most about the circumstances of the woman’s deathD. ___ Arrange another visit if the best respondent(s) were not home or preferred another interview timeE. ___ Read and explained (if necessary) the informed consent form to the respondent(s)F. ___ Obtain each respondent’s mark on a separate consent formCompleted interviewA. ___ Interviewer ID information (section 2 of MAPEDIR format) is completeMAPEDIR Interviewers Reference Manual May 19, 2008 33
  • 34. B. ___ Deceased woman’s ID information is complete on each page of the MAPEDIR formatC. ___ All sections of the format are complete, with all pages presentD. ___ Read all questions exactly as written on the MAPEDIR formatE. ___ No or only a few questions answered, “Don’t know” or ___ If several “DK,” list problem questions by section and number: _____________________________________________________________F. ___ Respondents answered all questions or ___ If a respondent refused to answer a question, record the number and reason: _____________________________________________________G. ___ Responses within the interview were consistent with each other or ___ Any inconsistent responses were resolved during the interviewH. ___ Answered any questions the respondents askedInteraction with supervisor and interviewer teamA. ___ Submit completed MAPEDIR format and marked consent form(s) to the supervisorB. ___ Discuss checklist and any problems with supervisorC. ___ Resolved problems: _____________________________________________________________D. ___ Unresolved problems that may require a change in procedures: _____________________________________________________________E. ___ Give any death reports received in the community to supervisorF. ___ Participate in team meeting (date: ______________)MAPEDIR Interviewers Reference Manual May 19, 2008 34
  • 35. APPENDIX B: SUPERVISOR’S CHECKLIST 1SUPERVISOR’S CHECKLISTDeath notification and registrationA. ___ Meet with death notifier to receive completed notification formatsB. ___ Classify notified deaths as non-maternal or suspected maternal and appropriately fill the register of adult female deathsC. ___ Classify interviewed deaths as non-maternal or confirmed maternal and appropriately fill the register of adult female deathsBefore an interviewA. ___ Fill Section 1 of the MAPEDIR format for all suspected maternal deathsB. Develop work plan with the interviewer team ___ Assign interviews (give the “Section 1-filled” MAPEDIR format to the assigned team) ___ Set a time and place for regular team meetingC. Provide logistical support (if needed) ___ Assist with transportation to the field ___ Help locate households for interviewDuring an interviewA. Observe ___ Observe interview (early in project) by interviewer number: ___ ___ Observe interview (later, if problems) by interviewer number: ___MAPEDIR Interviewers Reference Manual May 19, 2008 35
  • 36. After an interviewA. Collect and review completed MAPEDIR interview forms and marked consent forms ___ Check for frequent “Don’t know” responses ___ Check for missing data ___ Check for internal inconsistenciesB. ___ Discuss any problems found on the forms with the appropriate interviewersC. ___ Review interviewer checklists and discuss any problemsD. ___ Repeat problem interview by interviewer number: ___E. ___ Certify corrected and complete MAPEDIR formatsOther timesA. ___ Meet with community member/leader: _______________________B. Team problem solving meeting ___ Discuss left-over problem: __________________________________ ___ Discuss left-over problem: __________________________________ ___ Modify work procedure: __________________________________ ___ Modify work plan: __________________________________MAPEDIR Interviewers Reference Manual May 19, 2008 36
  • 37. APPENDIX C: CONSENT FORM Informed Consent Interview about a Maternal Death and Possible Related Perinatal DeathInstructions to Interviewer: Please ask the respondent to acknowledge her/his consent to beinterviewed by checking the response below. The interviewer should sign and date below. Ifthe respondent does not consent to the interview, thank her/him for their time and terminatethe conversation.Purpose of the interview: We are talking to people in the community to learn why some women diewhile they are pregnant or during or soon after giving birth. At the same time, we are learning aboutthe reasons that some babies die during the pregnancy or soon after the birth.What will happen during the interview: I will ask you questions about your relative/neighbor/friend whorecently died. I will ask about her background, her pregnancy history and events during her mostrecent pregnancy. I may also some questions about her baby from this pregnancy. Some questionshave a choice of possible answers and others are open-ended.Time required: Your interview will take approximately one hour.Risks: It is possible that some questions could make you feel uncomfortable by talking about badexperiences.Benefits: There are no direct benefits, however, your participation will help up improve maternal andnewborn care for women and babies.Confidentiality: All information you provide will be kept confidential. Your responses will be assigned acode number and your name will not be used in any way.Voluntary Participation: Your participation is strictly voluntary. Refusal to participate will not affectwhether or not you receive subsequent services. You may discontinue participation at any time.Contact: If you have any questions or concerns, please contact Marzio Babille at 11-469-0401.Do you agree to participate in this interview? YES NO____________________________________ ______________Interviewer____________________________________Date____________________________________Respondent’s relationship to womanMAPEDIR Interviewers Reference Manual May 19, 2008 37
  • 38. APPENDIX D: INTERVIEWER’S ROLE PLAY GUIDE INTERVIEWER’S ROLE PLAY GUIDEThis guide presents some situations you are likely to encounter as an interviewer ofmaternal deaths. You will practice handling these situations during your training. Thiswill prepare you in case one of the situations occurs during a real interview.You will play different roles, including the interviewer and the respondent, during thetraining exercise. This will help you better understand respondents’ concerns andactions and will help you learn to handle these situations. Work closely with yourfellow trainees now and later. They can help you conduct successful interviews.Situation 1—a crowd of interested observers gathers aboutYou go to a household where you were told that a woman died. Several people arestanding about in front of the house. You introduce yourself and your reason forbeing there, and ask to speak with the person or persons who know the most aboutthe circumstances of the woman’s death. The woman’s sister says she knows aboutthe illness and invites you into the house. Several people follow. The sister answerssome questions, but others in the room also answer some questions. Some of theirresponses contradict each other, and they have difficulty deciding who is correct.Situation 2—the best respondent is not available at the time of the initial visitYou go to a household where a woman died. You ask to speak to the person orpersons who know the most about the circumstances of the death. Depending on thesituation, this may be the woman’s mother, her sister, her husband or someone elsewho was with her during her illness or when she died. You are told that the bestrespondent is the woman’s mother but that she is not home.Situation 3—the family denies a death occurredYou go to a household where you were informed there was a maternal death. Youknock on the door--a man opens it. You explain why you have come to the house.The man responds that you must have the wrong house. He says that no womanfrom this household has ever died. He seems tense, and politely asks you to leave.Situation 4—a second respondent is needed to obtain complete informationYou are interviewing the sister-in-law of a woman who died in hospital. The woman’shusband was sick during her illness so the sister-in-law cared for her. She answersquestions about the woman’s symptoms without difficulty, but has trouble withquestions on the timing of some events. She explains that she did not go to thehospital with her sister-in-law. She is not sure if she went to other health facilitiesbefore going to the hospital, nor how long she was in the hospital before she died.MAPEDIR Interviewers Reference Manual May 19, 2008 38
  • 39. Situation 5—a second respondent who lives far away is neededYou introduce yourself at a household where a woman died, and ask to speak withthe person or persons who know the most about the circumstances of the woman’sdeath. The woman’s husband tells you that he took her to the hospital when shebecame very ill and you begin the interview. He easily answers several questions,but has difficulty describing the early part of his wife’s illness and tells you that shewas at her parents’ house when the illness started. The parents live in a differentvillage about one hour’s travel away.Situation 6—the respondent is actively mourning the deathYou are interviewing a man about the death of his wife. The woman died threemonths before the interview. The interview has been going well, with the husbandremembering symptoms and events with little trouble. As you ask questions aboutthe time closer to death, the husband slows in his responses and begins to cry. Hetries to control himself but starts to cry harder. Situation 7—the respondent is uncertain of many answersYou are interviewing a woman about her daughter-in-law’s death. She answersseveral questions with little hesitation, but then has trouble with a question. Sheanswers “Yes,” then changes her answer to “No,” then pauses and says “I think so.”Situation 8—the respondent does not seem to be answering the questions openlyYou go to a household where you were told that a woman died. You identify thewoman’s mother-in-law as the best respondent about the labor and her father-in-lawas the best respondent about the journey to the hospital and you begin the interview.The respondents seem to have trouble answering some of the questions and oftenglance at each other as if they are waiting for the other to answer. Also, some of theirresponses contradict each other. For example, when asked about careseeking, themother-in-law says that the first thing the family did when they noticed the womanwas ill was to call a dai to the house. But the father-in-law disagreed and said thatthe first thing they did was to seek a taxi to take the woman to the hospital.MAPEDIR Interviewers Reference Manual May 19, 2008 39