TABLE OF CONTENTS

1 INTRODUCTION...............................................................................................................7
1.1 Objectives............................................................................................................................9
1.2 Target...................................................................................................................................9
1.3 Content Overview..............................................................................................................10
1.4 Scope and Limitation.........................................................................................................10
1.5 How to Use this Manual.................................................................................................... 11
MATERNAL AND NEONATAL DEATH REPORTING................................................. 11
2 SYSTEM........................................................................................................................... 11
2.1 MNDRS Objectives........................................................................................................... 11
2.2 Limitations.........................................................................................................................12
2.3 System Architecture...........................................................................................................12
2.4 System Components..........................................................................................................14
3 ORGANIZATIONAL STRUCTURE................................................................................15
3.1 Community Health Team Members...................................................................................16
3.2 Reporting Facilities (Hospitals/Health Facilities/Birthing Homes/RHUs/HCs)...............16
3.3 Municipal Health Office/City Health Office/Health Center..............................................16
3.4 Provincial Health Office/Provincial or City Review Team...............................................16
3.5 Centers for Health Development.......................................................................................17
3.6 Family Health Office.........................................................................................................17
3.7 National Epidemiology Center..........................................................................................17
3.8 Information Management Service.....................................................................................18
4 MNDRS POLICIES AND PROCEDURAL GUIDELINES.............................................18
4.1 Statement of Policies.........................................................................................................18
4.2 MNDRS Process Flows.....................................................................................................19
4.3 Reporting Frequency.........................................................................................................27
4.4 Security and Confidentiality Mechanism..........................................................................27
4.5 MNDRS Service Requirements.........................................................................................28
4.6 System Monitoring and Evaluation...................................................................................28
5 MNDRS OPERATIONS...................................................................................................29
5.1 MNDRS System Operations..............................................................................................29
6 REFERENCES..................................................................................................................31

MNDRS Manual 1
 ACRONYMS

AOG Age of Gestation

BEmONC Basic Emergency Obstetric and Newborn Care

BHS Barangay Health Station

CCT Conditional Cash Transfer

CEmONC Comprehensive Emergency Obstetric and Newborn Care

CHD Center for Health Development

CHD IVA Center for Health Development Region IVA - CALABARZON

CHD IVB Center for Health Development Region IVB - MIMAROPA

CHD NCR Center for Health Development – National Capital Region

CHO City Health Office

CHT Community Health Team

DCN Death Certificate Number

DOA Dead on Arrival

DOH CO Department of Health Central Office

DOH HEMS Department of Health - Health Emergency Management System

DOH IMS Department of Health Information Management Service

DOH WCFHC Department of Health Women Children and Family Health Cluster

DR Delivery Room

FHSIS Field Health Service Information System

FIMR Fetal and Infant Mortality Review

FMDRF Facility Maternal Death Reporting Form

FNDRF Facility Neonatal Death Reporting Form

GP Gravidity Parity

HC Health Center

IMR Infant Mortality Rate

LCR Local Civil Registry/Registrar

MDG Millennium Development Goal

MDR Maternal Death Review

2 MNDRS Manual
 MDRF Maternal Death Reporting Form

MHO Municipal Health Officer

MMR Maternal Mortality Ratio

MNDRS Maternal and Neonatal Death Reporting System

NDHS National Demographics and Health Survey

NDRF Neonatal Death Reporting Form

NHTS National Household Targeting System

NMR Neonatal Mortality Rate

NSO National Statistics Office

OR Operating Room

PHIC Philippine Health Insurance Corporation (PhilHealth)

PHO Provincial Health Officer/ Provincial Health Office

PRT Provincial Review Team

RHU Rural Health Unit

SMS Short Message Service

SPEED Surveillance in Post Extreme Emergencies and Disasters

TBA Traditional Birth Attendant

TPAL Term, Premature, Abortion, Living children (describes the

pregnancy outcome/result)

UFMR Under Five Mortality Rate

WHT Women’s Health Team

MNDRS Manual 3
 DEFINITION OF TERMS

Abortion : Abortion is the spontaneous or induced termination of pregnancy

prior to 20 weeks’ gestation or a fetus born weighing less than 500 g.

Antecedent Cause of Death : Fetal and/or maternal conditions giving rise to the immediate cause
of death.

Example:

Hypovolemic shock related to postpartum

hemorrhage secondary to uterine atony

(The underlined word is the antecedent cause of death)

Fetal Death : The death of the fetus aged 20 weeks and above prior to the complete
expulsion from the mother; the death is indicated by the fact that
after separation, the fetus does not breath or show any evidence of
life such as beating of the heart, pulsation of the umbilical cord or
definite movement of voluntary muscles.

Full Term Neonate : Neonate born at least 37 - 42 weeks AOG.

Gravidity : Number of times a woman has been pregnant regardless of the

outcome of pregnancies.

Health Facility : Any facility that provides MNCHN services. These include hospitals,
lying-in clinics, BHS, and RHUs to name a few.

Immediate Cause of Death : Disease, injury or complication that led directly to death.

Example:

Hypovolemic shock related to postpartum

Hemorrhage secondary to uterine atony

(The underlined word is the immediate cause of death)

4 MNDRS Manual
Invalid Maternal Death Report: Reported as a maternal death case, but after validation, the report
did not pass the criteria to be considered as a maternal death case

Maternal Death : Death of a woman while pregnant or within 42 days of termination

of pregnancy, irrespective of the duration and site of the pregnancy,
from any cause related to or aggravated by the pregnancy or its
management but not from accidental or incidental causes.

Multiple Births : More than one fetus is being carried to term in a single pregnancy.
Examples of multiple births include twins, triplets etc.

Neonatal Death : Death of a liveborn infant within the first 28 days of life.

Non- Institutional Delivery : Childbirth occurring in a non-health facility (i.e. home, modes of
transportation, roads, commercial buildings, prisons etc.)

Obstetric Death, Direct : Maternal deaths resulting from obstetric complications (i.e.
hemorrhage, pregnancy related hypertension, infection and difficult
labor) of the pregnant state (i.e. pregnancy, labor and puerperium).
Commonly reported causes stem from intervention errors.

Obstetric Death, Indirect : Maternal deaths resulting from either previous existing diseases
or diseases that developed during pregnancy. Both are not due to
direct obstetric causes but aggravated by the physiologic effects of
pregnancy.

Operative Delivery : Any obstetric procedure in which active measures are taken to
accomplish delivery. Examples of operative deliveries are those
vacuum deliveries, forceps deliveries and caesarian section.

Parity : Number of times a woman has given birth to a fetus with AOG > 20
weeks, regardless whether the child was born alive or dead.

Preterm Births : Premature births: > 20 weeks but < 37 weeks AOG.

Preterm Neonate : Neonate born after 20 weeks AOG but before 37 weeks AOG.

MNDRS Manual 5
Term Deliveries : Term births: > 37 weeks AOG.

Underlying Cause of Death : Disease or injury that initiated the train of events leading directly to
death.

Example:

Hypovolemic shock related to postpartum

Hemorrhage secondary to uterine atony

(The underlined word is the underlying cause of death)

Valid Maternal Death Report : Reported and validated as a maternal death case by the Provincial or
City Review Team

6 MNDRS Manual
1 INTRODUCTION

One of the difficult undertaking that is being thoroughly and systematically addressed in
the Philippines is achieving its commitment to Millennium Development Goals of lowering
maternal mortality ratio and infant mortality rate. The target is to lower maternal mortality ratio
(MMR) to 52 deaths per 100,000 live births from 162 (NSO, 2006) and neonatal mortality rate
(NMR) to 10 per 1000 live births from 16 (NSO, 2008, NDHS) by 2015. Studies show that the
leading causes of these neonatal deaths are disorders related to short gestation and low birth weight.
This is much higher among infants whose mothers had no antenatal care or medical assistance at
the time of delivery (NSO, 2006; NSO, 2008; DOH, 2008).

In 2008, the Philippine Department of Health issued the guidelines on implementing Reforms
for the Rapid Reduction of Maternal and Neonatal Mortality (DOH, 2008) through effective
population-wide provision and use of integrated Maternal, Newborn, and Child Health and
Nutrition (MNCHN) services as appropriate to any locality in the country. The strategy changed
from a risk approach that ascertain and focusing only at pregnant women at risk of complications
to a model that considers all pregnant women at risk of such complications. The overall strategy
and interventions converged on addressing four risk factors of maternal and child health, namely
(DOH, 2008): Having untimed, unwanted, unplanned and unsupported pregnancy; Not securing
adequate care during the course of the pregnancy; Delivering without the care of skilled birth
attendants and/or not having access to emergency obstetric and neonatal care; and Not securing
proper post partum and post natal care.

The strategy aims to achieve the following intermediate results (DOH, 2009):

1. Every pregnancy is wanted, planned and supported;

2. Every pregnancy is adequately managed throughout its course;

3. Every delivery is facility-based and managed by skilled birth attendants/skilled health

professionals; and

4. Every mother and newborn pair secures proper post-partum and newborn care with
smooth transitions to the women’s health care package for the mother and child survival
package for the newborn.

To ensure continuous decline in mortality and morbidity focus is on the constant

implementation of wide-ranging appropriate and integrated interventions and health care services
that address the demand side of informed decisions by mothers and their families and on the
supply side of a responsive health system (DOH, 2008). Those considered having the greatest
impact on reproductive health are:

1. Provision of family planning and other pre-pregnancy services including adolescent

health and control of sexually transmitted infections and HIV prevention services.

2. Access to comprehensive antenatal care services

3. Facility-based births attended by skilled health professionals.

4. Immediate postpartum and postnatal care by skilled health”

MNDRS Manual 7
 Women are encouraged to give birth in conveniently located health facilities that are suitably
equipped to render basic emergency obstetric and newborn care (BEmONC). Complicated
pregnancies and those needing caesarian sections and blood transfusions are referred to higher
level facilities rendering comprehensive emergency obstetric and newborn care (CEmONC). This
network of basic and comprehensive emergency obstetric and newborn care provider facilities is
deployed in such a manner as to allow women to access the services they need within a timeframe
that ensures a safe outcome.

But, even if quality services are available, a major challenge is to facilitate utilization of clients
of these services especially among mothers that are hard to reach and unprotected from financial
risk. Likewise the geographic characteristics of the country and some cultural practices contribute
to the problem. Using ICT is a facilitating tool for health services given its pervasive use in
the country. Based on 2012 statistics, there are 86 mobile cellular phone subscriptions per 100
inhabitants (DOST-ICTO, 2012) and an average Filipino user sending an average of 600 messages
per month.

The Philippines has devolved it health services in 1991 such that Local Government
Unit-governed health system delivers the integrated maternal newborn child health and nutrition
service package which should be strengthened to ensure delivery of the integrated model more
responsive to the local situation. This strategy and the archipelagic characteristics nature as well
as the presence of many geographically isolated and disadvantaged areas (GIDAs) require among
others the use of information and communication technology. All BEmONC or CEmONC facilities
are required to be equipped with radio or telephone to facilitate contact with a designated higher-
level facility in cases of referrals.

Two specific information and communication technology (ICT)-based intervention in support

to the MNCHN strategy: Watching Over Mothers and Babies (WOMB) Project, a maternal and
neonatal tracking system and the Maternal and Neonatal Death Reporting System (MNDRS).

The MNDRS is one response to problems on flawed and uncertain reporting of maternal
and neonatal mortalities. Underreporting of deaths among women and children is common
(Garces, 2009) especially in GIDAs and with Indigenous Peoples, and death reviews are done
only quarterly. The MNDRS tries to respond to these problems. The MNDRS functional design
supports MNCHN Strategy by capturing deaths at an early stage at various levels of the health
system and thus, tries to address underreporting and late reporting. This is envisioned to provide
a fairly complete estimation, and an immediate and efficient report of both maternal and neonatal
mortalities with the limitations of the routine registration system.

Republic Act No. 10354 otherwise known as the “Responsible Parenthood and Reproductive
Health Act of 2012,” in Section 8 requires health facilities to conductregular “maternal, fetal
and infant death reviews” to ensure something is learned from each circumstance and proper
interventions are put in place.

8 MNDRS Manual
 This Manual of Operations highly takes into account the operational component of the
Maternal and Neonatal Death Reporting System to address the above situational health conditions.
It principally attempts to fill in the need for a reference guide for the employment of the system
for health workers. The document discusses the guiding principles, policies, and standards in the
adoption, implementation, management and integration of properly, completely, and adequately
reporting maternal and neonatal deaths in an MNDRS. As an overall management, it institutes
appropriate interventions on the gaps that lead to maternal and neonatal mortalities at various
levels in the health system.

The normative policies, standards and guidelines mentioned in this document are adoptions
from guidance documents from the WHO, DOH and Centers for Health Development and health
partners. The MNDRS architecture and implementation plans were developed from a series of
consultative workshops with various national and regional stakeholders, demonstration projects,
and local experiences on maternal and neonatal mortality reduction initiatives. The success of local
government units in implementing innovative strategies and achieving favorable health outcomes
provided inspiration and additional inputs in finalizing this document.

1.1 Objectives

This MNDRS Manual of Operations (MANOPS) aims to:

a. Guide health service providers in the employment and management of appropriate

technological services for MNDRS at all levels of implementation;

b. Provide advocacy support for health program managers, hospital administrators

and health and LGU officials, local authorities, professionals and other concerned
organizations to invest resources for relevant interventions; and

c. Serve as reference for national, regional, provincial and municipal program

coordinators, hospital administrators and officials, other government agencies and
non-government organizations in providing support to the implementation of the
MNDRS system.

1.2 Target

This MANOPS is principally intended for maternal and child health service providers
especially those involved in the prevention, monitoring, and management of maternal and
neonatal deaths at various levels of governance. Health service providers include those at
the primary health facilities and hospitals, both at the public and private sectors.

This information system guides service providers in the adoption, implementation,

management and integration of the MNDRS into the current local approach towards
tracking, review and eventually prevention and management of maternal and neonatal
mortalities.

MNDRS Manual 9
 1.3 Content Overview

This document is focused on the implementation of an automated system of reporting

as aligned to the current Maternal Death Reporting and Review System (MDRRS) Manual
of Operations developed by DOH in 2007 (DOH, 2007). It is divided into five sections as
follows:

Section 1: The Manual of Operations

This section introduces the objectives and target users of the manual, and gives an
overview of the contents.

Section 2: Overview of the Maternal and Neonatal Death Reporting System

This section briefly depicts the MNDRS objectives, system scope and limitations,
system architecture and components.

Section 3: Organizational Structure

This section describes the various key stakeholders involved in MNDRS, with their
corresponding duties and responsibilities in the overall system implementation, supervision,
evaluation and sustainability.

Section 4: MNDRS System Policies and Procedural Guidelines

This section describes the system policies and procedural guidelines in its rollout both
at the community and hospital level.

Section 5: MNDRS Procedural Steps

This section describes the step by step account of the four focal processes of the
MNDRS.

1.4 Scope and Limitation

This MANOPS attempts to provide the minimum standards needed for the overall
implementation of MNDRS. It also offers a comprehensive amalgam of salient and
vital information to guide health providers especially those at the local level on the
operational management of the system. This manual remains a work in progress.

10 MNDRS Manual
 1.5 How to Use this Manual

This manual is intended for health service providers at all levels of health service
delivery system. Here are suggestions on how the manual is to be used:

a. Read sections 2 and 3 to have a comprehensive overview on the MNDRS.

b. Read sections 4 and 5 for specific procedural guidelines on the systems operation
of the MNDRS.

2 MATERNAL AND NEONATAL DEATH REPORTING SYSTEM

The Maternal and Neonatal Death Reporting System (MNDRS) is a mechanism for reporting
of maternal and neonatal deaths using internet and SMS technology. It is the DOH’s response
in support to addressing the increase and incomplete and uncertain reporting of maternal and
neonatal mortalities, along with the inadequate and late maternal review.

The functional design of the system commits deeply to the MNCHN Strategy which strongly
integrates “more innovative ways to deliver cost-effective and sustainable interventions” focusing
on the major causes of maternal and newborn death in the short term period (2008-2015).

The technical design, in contrast, primarily intends to add in Short Message Service (SMS)
applications to the current health data reporting system. If properly implemented, this program can
provide the agency not only a fairly complete estimation, but also an immediate and efficient report
of both maternal and neonatal mortalities in the absence of a reliable routine registration system;
subsequently, better concerted efforts can be taken to promote timely, effective and preventive
interventions.

2.1 MNDRS Objectives

The MNDRS serves the following purposes:

a. To facilitate real time reporting of maternal and neonatal deaths

b. To serve as an ALERT SYSTEM to concerned health workers and Management for

proper action and review

c. To provide the necessary reports at all levels for proper monitoring, development of
program interventions, policies and protocols

MNDRS Manual 11
 2.2 Limitations

The MNDRS covers all data reported after the occurrence of maternal and/or neonatal
deaths. However, this initiative will not settle on comprehensive analysis of the reported
deaths, as well as on pregnancy tracking. These concerns will be addressed broadly in
separate systems.

2.3 System Architecture

The MNDRS Architecture (Figure 1) demonstrates the relationship of the SMS

gateway and web-based technologies in the reporting and management of all maternal and
neonatal death-related data. The network utilizes an interoperability mechanism that allows
data exchange within and between systems when needed and when appropriate. However,
it is vital to note that the nature and level of the information exchange is highly dependent
on the stage of data management being employed at the time.

a. Reporting begins at the designated reporting unit – either at the community or the
healthcare facility where the deaths happen. Registered MNDRS reporters – either
a midwife in the community or a designated health service provider in a healthcare
facility - gather all pertinent data surrounding the event. They then transfer the
data into appropriate e-MNDRS forms, according to the place of occurrence of
death, and send the report either through SMS submission via the SMS gateway or
through online submission via web-based technologies.

b. The MNDRS Central Database System located at the DOH Central Office in Manila
receives the reports sent.

i. For reports sent via text messaging, only correctly formatted reports are
integrated into the online system for updating. For reports to be sent via
online, in contrast, the designated reporter can directly fill out and supply
all the required data on the online MNDRS report form. After which, these
reports are made accessible to all designated recipients, namely the Municipal
Health Officer (MHO)/City Health Officer (CHO), Provincial Health Officer
(PHO), Center for Health Development (CHD) and DOH Central Office (CO)
at all levels of health governance through the MNDRS website. However, the
viewing rights and access levels of these recipients differ, depending on their
designated responsibility, and area of jurisdiction.

ii. For the SMS and online reporting, the MNDRS likewise sends Immediate
Notification Alerts to the mobile phones of designated recipients alerting
them that a mortality report has been submitted and requires appropriate
and immediate action. Similarly, for every validation or review made on the
reports, these designated recipients are further notified via text messaging.

12 MNDRS Manual
 iii. In addition, the National Statistics Office and the Office of the Local Civil
Registrar shall also receive monthly reports for validation of congruity of
statistical reports between agencies.

c. In the MNDRS website, tables and graphs can be generated from which statistical
trends and distribution patterns of the mortalities can be analyzed. Furthermore,
tables outlining the actions – validation or review of these reports - taken by the
designated recipients on the submitted reports will also be shown; thereby, providing
the CHD and DOH CO a vantage point of the work performance of these units
within their jurisdiction.

d. Consolidated reports can be generated by the DOH CO. Findings and

recommendations from these reports will be taken into account during the planning
and development of responsive and preventive programs.

Figure 1. The MNDRS Architecture

MNDRS Manual 13
 2.4 System Components

The key feature of the MNDRS is the SMS reporting functionality, enabling a
rapid and alert reporting to all concerned health workers at various levels parallel to the
accomplishment and submission of forms, triggering immediate investigation and review,
and development of appropriate and immediate interventions, if applicable.

The MNDRS employs a three-pronged reporting approach in the overall management

of maternal and neonatal mortality, namely: alert system, incident reporting system and
decision support system (Figure 2).

a. Alert System

This is the key component of MNDRS that enables sending of advanced notification
related to or regarding the deaths as they occur, thereby allowing for fast and real time
reporting, particularly during emergency setting, and conduct of necessary investigation,
validation and development of immediate intervention, if applicable. However, this
also has its limitation given the purpose it serves: the data included in the actual reports
are short and limited, and the report submitted has yet to be confirmed and validated.

b. Incident Reporting System

This feature deals with drawing up of conclusions and recommendations on data

gathering, in addition to correction and validation of submitted reports. Variation, though,
in the timeliness of the report submission occurs, depending on the manner of completion of
form. Based from current healthcare guidelines, however, the report form must be filled out
as soon as possible following the incident, but only after the situation has been stabilized.
In this manner, the details written in the report is ascertained as accurate as possible.

c. Decision Support System

Another key characteristic of the MNDRS is the generation of reports that can be used
by the DOH Program Managers for health planning. It dwells mainly on the management
decision and interventions vis-à-vis statistical trends and distribution patterns (i.e. gender,
age, cause-specific deaths, geographical location etc.) of the mortality reports. Findings from
the reports will serve as basis for the formulation of general policies, budgeting protocols
and development of counteractive interventions to support better decision-making.

14 MNDRS Manual
 Figure 2. The MNDRS System Components

3 ORGANIZATIONAL STRUCTURE

Figure 3. The MNDRS Reporting Structure

MNDRS Manual 15
 As shown in Figure 3, the Department of Health is the principal agency in ensuring the successful
and smooth implementation of MNDRS. The Women Children and Family Health Cluster
(WCFHC) and the Information Management Service (IMS) with the National Epidemiology
Center (NEC) shall spearhead the operations of this project.

The duties and responsibilities of the various key stakeholders involved in MNDRS are as
follows:

3.1 Community Health Team Members

a. Ensures that all pregnant mothers are tracked and have accomplished birth plans

b. Report maternal/neonatal death(s) that occurred in the community thru SMS

c. Accomplish and submit the CHT Maternal/Neonatal Death Reporting Form(s) to

the MHO or to the health center physician-in-charge, nurse, or midwife supervisor
in the case of urban areas

3.2 Reporting Facilities (Hospitals/Health Facilities/Birthing Homes/RHUs/HCs)

a. Report maternal/neonatal deaths that occurred in the health facility

b. Encode validated data in the Maternal and Neonatal Death in the MNDRS website

c. Endorse Maternal/Neonatal Death Report and copy of Death Certificate to the

Technical Secretariat of the Provincial or City Review Team

3.3 Municipal Health Office/City Health Office/Health Center

a. Validate the report submitted thru SMS or verbally by the Community Health Team

b. Validate the data then encode the reported maternal/neonatal death in the MNDRS
website

c. Accomplish Death Certificate and forward to Local Civil Registrar or forward to

the City Health Office and finally to the Municipal or City Local Civil Registrar

d. Endorse Maternal/Neonatal Death Report and copy of Death Certificate to the

Technical Secretariat of the Provincial or City Review Team

e. Conduct community and facility based data collection and analysis of the deaths
within their area of jurisdiction

3.4 Provincial Health Office/Provincial or City Review Team

a. Schedule the review of submitted Maternal/Neonatal Death Report and Death
Certificate

b. Conduct the review process for decision-making, planning for interventions and
policy development

c. Encode result of review process in the MNDRS website

d. Consolidates all municipal reports and submit to CHD

16 MNDRS Manual
 3.5 Centers for Health Development
a. Learn current software operations of the MNDRS and further updates on the system

b. Conduct orientation and training on Maternal and Neonatal Death Reporting System

c. Review reports submitted by the Provincial Health Office or City Review Team and
assist the PRT/CRT in the maternal and neonatal death reviews

d. Monitor submission of data in the MNDRS

e. Manage and supervise the smooth implementation of the system

f. Resolve or troubleshoot issues, concerns, and/or problems

g. Elevate issues, concerns and/or problems to concerned personnel or office

h. Consolidate and submit all maternal and neonatal death review reports submitted
by the PRT/CRT, to FHO

i. Assess and analyze statistical trends and distribution patterns of maternal and
newborn mortalities in the region to guide in decision-making for interventions and
policy development

j. Oversee and supervise day to day operations and ensure efficient and effective
implementation of the system

3.6 Family Health Office

a. Review and analyze reports submitted by the CHDs; if necessary conducts a
national maternal and neonatal deaths review at least once a year

b. Draft operational policies, standards and protocols

c. Resolve program related issues, concerns, and/or problems

d. Provide overall direction and guidance

e. Monitor the implementation of the system together with IMS

3.7 National Epidemiology Center

a. Review and analyze reports submitted by the CHDs

b. Perform data validation

c. Generate reports and statistics for analysis and planning

3.8 Information Management Service

a. Ensure that system is updated and that all software related problems are properly
addressed

b. Maintain and enhance the software as necessary

MNDRS Manual 17
 c. Resolve issues, concerns, and/or problems gathered from the field users with regard
to software

d. Help manage and supervise the smooth implementation of the system

e. Maintain network and database operations 24 hours a day, and 7 days a week

f. Establish, maintain, and regularly update backup and restore procedures for servers,
application system, and database

g. Assist in disaster recovery planning and testing

h. Conduct growth analysis and capacity planning

i. Troubleshoot problems that may impede successful implementation or operations

of the system

j. Maintain records, prepare and submit required reports

k. Provide help desk support

l. Provide regular feedback to all end-users on the technical operations of the MNDRS

m. Oversee and supervise day to day operations and ensure efficient and effective
implementation of the system

4 MNDRS POLICIES AND PROCEDURAL GUIDELINES

4.1 Statement of Policies

a. Timely, complete, and accurate reporting of maternal and neonatal mortalities shall
be mandatory to all health facilities.

b. The WCFHC, NEC and IMS shall oversee the overall management and
implementation of MNDRS.

c. The Center for Health Development shall oversee and regularly monitor the
submission of data on maternal and neonatal death reporting or review cases.

d. The DOH CO shall develop responsive programs, protocols and guidelines

both at the preventive and interventional level, relative to the gaps, issues
and problems that comes out from the review of maternal and neonatal deaths.

18 MNDRS Manual
 4.2 MNDRS Process Flows

a. Maternal Death – Community Reporting System

The community death reporting is illustrated in Figure 4.

Figure 4. Maternal Death, Community Reporting Flow

i. Once maternal death has occurred in the community, the CHT/Midwife

promptly conducts review of pregnancy tracking case file, identifying the
levels of prenatal care received by the deceased, if any. The team will then
establish the cause of the maternal death and gather other pertinent data
surrounding the event, followed by transferring these data into the CHT MDR
form and send the report either via text or directly filling out the online form.

ii. The midwife-accomplished CHT MDR form then submits to the MHO/
CHO for validation as to the veracity and reliability of the data on
the death report. An Immediate Notification Alert will also be sent to
the MHO/CHO and other authorized health personnel, alerting them
of the submitted report requiring immediate and appropriate action.

MNDRS Manual 19
 iii. Once the report has been fully validated, the MHO/CHO encodes other
relevant data gathered from the report into the online system and mark the
report “validated.” Consequently, the MHO/CHO has to sign the CHT MDRF
and accomplishes the death certificate.

iv. Accomplished death certificate is forwarded to the LCR for registration. Once
registered, a copy of death certificate with the DCN is given to the MHO/
CHO. The DCN is affixed to the accomplished online maternal death record.

v. The signed CHT MDRF and registered death certificate is submitted to

the PRT/CRT. The PRT/CRT Secretariat conducts the initial review of the
submitted reports for accuracy, completeness and soundness of the data.
If deemed accurate and valid, reports are compiled and consolidated and
subjected to comprehensive review by the PRT/CRT. The review includes
analysis of findings surrounding the deaths, and subsequent formulation of
appropriate plans of actions relative to the gaps, issues and problems that
come out or are extracted from the review of maternal and neonatal deaths

vi. Reviewed reports from the PRT/CRT are submitted to the respective CHD
for further assessment and analysis, such as statistical trends and distribution
patterns of the maternal mortalities within the region.

vii. Consolidated maternal death reports from the PRT/CRT at the CHD level are
forwarded to DOH CO in a quarterly basis. Findings and recommendations
drawn from the reviewed reports are taken into account for the planning and
development of responsive program interventions, policies and protocols.

20 MNDRS Manual
 b. Maternal Death – Facility Reporting System

Figure 5 shows the maternal death reporting in the health facility.

Figure 5. Maternal Death, Health Reporting Flow

i. Once maternal death has occurred in a healthcare facility, it should prompt

either the facility health team lead or the attending physician to establish the
cause of death and gather other pertinent data surrounding the event. This is
followed by transferring these data into the FMDRF and assessment of the
report for accuracy and completeness of information.

ii. If the report is deemed complete and accurate, the designated reporter sends
the report either through SMS, or by directly filling out the online form
and mark the report “validated.” Consequently, the reporter has to sign the
FMDRF, accomplish the death certificate and submit this to the MHO/CHO
for signature.

iii. Accomplished death certificate is forwarded to the LCR for registration. Once
registered, a copy of death certificate with the DCN is given to the reporting facility.
The DCN is then affixed into the accomplished online maternal death record.

MNDRS Manual 21
 iv. Signed FMDRF and registered death certificate is submitted to the PRT/CRT.
The PRT/CRT Secretariat conducts the initial review of the submitted reports
for accuracy, completeness and soundness of the data. If deemed accurate
and valid, reports are compiled and consolidated for comprehensive review
by the PRT/CRT. The review includes analysis of findings and formulation
of appropriate plans of actions relative to the gaps, issues and problems that
comes out or is extracted from the review of maternal and neonatal deaths

v. Reviewed reports from the PRT/CRT are submitted to respective CHD for
further assessment and analysis of statistical trends and distribution patterns
of the maternal mortalities within the region.

vi. Consolidated maternal death reports from the PRT/CRT are forwarded to
DOH CO in a quarterly basis. Findings and recommendations drawn from
the reviewed reports are taken into account for the planning and development
of responsive program interventions, policies and protocols relative to the
gaps, issues and problems that comes out or is extracted from the review of
maternal and neonatal deaths.

c. Maternal Death – Facility Reporting System for DOA Cases

i. If the maternal mortality occurred in transit, the referring facility health team
leader or the sending RHU physician shall be responsible to establish the
cause of death, and in gathering other pertinent data surrounding the event,
followed by transferring these data into the FMDRF, assessment of the report
for accuracy and completeness of information and signing the form.

ii. If the report is deemed complete and accurate, the designated reporter sends
the report either through SMS, or by directly filling out the online form.
Submission of accomplished FMDRF to the PRT/CRT, MHO/CHO and
FHSIS unit proceeds after. An Immediate Notification Alert is submitted to
the designated recipients, alerting them of the submitted report that requires
their appropriate action.

iii. The MHO/CHO validates the data as to its veracity and reliability and if deemed
valid, the MHO/CHO encodes other relevant data gathered from the report
into the online system and marks the report as “validated.” Consequently, he
accomplishes the death certificate.

iv. Accomplished death certificate is forwarded to the LCR for registration. Once
registered, a copy of death certificate with the DCN is given to the MHO/CHO.
The DCN is then affixed into the accomplished online maternal death record.

22 MNDRS Manual
 v. Signed FMDRF is submitted to the PRT/CRT. The PRT/CRT Secretariat
conducts the initial review of the submitted reports for accuracy, completeness
and soundness of the data. If deemed accurate and valid, reports are compiled
and consolidated to be subjected to comprehensive review by the PRT/CRT.
The review includes analysis of findings and formulation of appropriate
plans of actions relative to the gaps, issues and problems that come out or are
extracted from the review of maternal and neonatal deaths.

vi. Reviewed reports from the PRT/CRT are submitted to respective CHD for
further assessment and analysis of statistical trends and distribution patterns
of the maternal mortalities.

vii. Consolidated maternal death reports from the PRT/CRT are forwarded to
DOH CO on a quarterly basis. Findings and recommendations drawn from
the reviewed reports are taken into account for the planning and development
of responsive program interventions, policies and protocols relative to the
gaps, issues and problems that comes out or is extracted from the review of
maternal and neonatal deaths.

d. Neonatal Death – Community Reporting

Figure 6 depicts the neonatal death reporting in the community setting.

Figure 6. Neonatal Death, Community Reporting Flow

MNDRS Manual 23
 i. Once neonatal death has occurred in the community, the CHT promptly
conducts review of pregnancy tracking case file, identifying the levels of
prenatal care received by the mother of the deceased, if any. The team then
establishes the cause/s of the neonatal death and gathers other pertinent data
surrounding the event, followed by transferring these data into the CHT NDR
form and sends the report either via text messaging or by directly filling out
the online form.

ii. The midwife-accomplished CHT NDR form is submitted to the MHO for
validation of the veracity and reliability of the data on the report. An Immediate
Notification Alert is also sent to the MHO, alerting him of the submitted report
that requires his appropriate action.

iii. The MHO/CHO validates the veracity and reliability of the data on the
submitted report online. Once deemed valid and veritable, the MHO/CHO
then now encodes other relevant data gathered from the report into the online
system and marks the report “validated.” Consequently, the MHO/CHO has
to sign the CHT NDRF and accomplish the birth and death certificates.

iv. Accomplished birth and death certificate are forwarded to the LCR for
registration. Once registered, a copy of death certificate with the DCN is
given to the MHO/CHO. The DCN is then affixed into the accomplished
online neonatal death record.

v. The signed CHT NDRF and registered death certificate is submitted to the PRT/
CRT. The PRT/CRT Secretariat conducts the initial review of the submitted
reports for accuracy, completeness and soundness of the data. If deemed
accurate and valid, compilation of said reports for comprehensive review by
the PRT/CRT ensues, followed by analysis of findings and formulation of
appropriate plans of actions.

vi. Reviewed reports from the PRT/CRT are submitted to respective CHD for
further assessment and analysis of statistical trends and distribution patterns
of the neonatal mortalities.

vii. Consolidated neonatal death reports from the PRT are forwarded to DOH CO
quarterly. Findings and recommendations drawn from the reviewed reports are
taken into account for the planning and development of responsive program
interventions, policies and protocols.

24 MNDRS Manual
 e. Neonatal Death – Facility Reporting System

Figure 7 illustrates the neonatal death reporting in the health facility.

Figure 7. Neonatal Death, Health Facility Reporting Flow

i. Once neonatal death has occurred in a healthcare facility, it should prompt

either the facility health team lead or the attending healthcare physician to
establish the direct cause of death and gather other pertinent data surrounding
the event, followed by transferring these data into the FNDRF and assessment
of the report for accuracy and completeness of information.

ii. If the report is deemed complete and accurate, the designated reporter now
sends the report either through text messaging, or directly filling out the online
form and mark the report “validated.” Consequently, the MHO/CHO has to
sign the FNDRF and accomplishes the birth and death certificate.

iii.
Accomplished birth and death certificate are forwarded to the LCR for
registration. Once registered, a copy of death certificate with the DCN is
given to the reporting facility. The DCN is then affixed into the accomplished
online neonatal death record.

MNDRS Manual 25
 iv. The signed FNDRF and registered death certificate is submitted to the PRT/
CRT. The PRT/CRT Secretariat conducts the initial review of the submitted
reports for accuracy, completeness and soundness of the data. If deemed
accurate and valid, compilation of said reports for comprehensive review by
the PRT/CRT ensues, followed by analysis of findings and formulation of
appropriate plans of actions.

v. Reviewed reports from the PRT/CRT are submitted to respective CHD for
further assessment and analysis of statistical trends and distribution patterns
of the neonatal mortalities.

vi. Consolidated neonatal death reports from the PRT are forwarded to DOH CO
quarterly. Findings and recommendations drawn from the reviewed reports are
taken into account for the planning and development of responsive program
interventions, policies and protocols.

f. Neonatal Death – Facility Reporting System for DOA Cases

i. If the neonatal mortality occurred in transit, the referring facility health team
leader or the sending RHU physician is designated to obtain birth and maternal
history and gather other pertinent data surrounding the event, followed by
transferring these data into the FNDRF, assessment of the report for accuracy
and completeness of information and signing the form.

ii. If the report is deemed complete and accurate, the designated reporter can
now send the report either through text messaging, or directly filling out the
online form. Submission of accomplished FNDRF to the PRT, MHO and
FHSIS unit proceeds after. An Immediate Notification Alert is submitted to
the designated recipients, alerting them of the submitted report that requires
their appropriate action.

iii. The MHO/CHO validates the veracity and reliability of the data on the
submitted report online. Once deemed valid and veritable, the MHO now
encodes other relevant data gathered from the report into the online system
and mark the report “validated.” Consequently, the MHO/CHO accomplishes
the birth and death certificate.

iv. Accomplished birth and death certificate are forwarded to the LCR for
registration. Once registered, a copy of death certificate with the DCN is
given to the MHO/CHO. The DCN is then affixed into the accomplished
online neonatal death record.

v. Signed FNDRF is submitted to the PRT/CRT. The PRT/CRT Secretariat

conducts the initial review of the submitted reports for accuracy, completeness
and soundness of the data. If deemed accurate and valid, compilation of said
reports for comprehensive review by the PRT ensues, followed by analysis of
findings and formulation of appropriate plans of actions.

vi. Reviewed reports from the PRT/CRT is submitted to respective CHD for
further assessment and analysis of statistical trends and distribution patterns
of the neonatal mortalities.

26 MNDRS Manual
 vii. Consolidated neonatal death reports from the PRT/CRT are forwarded to
DOH CO quarterly. Findings and recommendations drawn from the reviewed
reports are taken into account for the planning and development of responsive
program interventions, policies and protocols.

4.3 Reporting Frequency

The reporting frequency for the CHT, Facility-Based and MHO/RHU is dependent
to the frequency of death cases – as the death occurs or at a daily basis, if applicable.

For the CHD and PHO/PRT/CRT, the maternal and neonatal death tracking report
is to be accomplished quarterly.

4.4 Security and Confidentiality Mechanism

a. Security mechanisms have been incorporated within to address vulnerabilities and

ensure confidentiality of MNDR data. Such facet ascertains:

i. Accuracy and integrity of MNDRS reporting, validation and analysis

processes;

ii. Protection against known threats or hazards to the security and integrity of
such information and processes; and

iii. Protection against unauthorized access to or use of the information that could
result in substantial harms or inconvenience to any of the stakeholders.

b. The DOH CO has created respective MNDRS accounts, along with setting of
appropriate viewing rights and access levels for all designated MNDRS recipients
(i.e. RHU, MHO/CHO, PHO and CHD), contingent on their area of jurisdiction.
Moreover, each reporting facility is also designated with a unique facility code, an
indication of data ownership sent via SMS.

c. The CHD and NCDPC in collaboration with IMS shall assign the appropriate
username and password for each facility. However, the assigned password has an
expiry date to prevent inadvertent and unauthorized use, in case the user is no longer
connected with the respective health facility. The IMS sets the window period for
the password prior to expiration.

d. To rectify erroneous reports, the health facility is required to submit an incident

report, providing a plausible explanation of the request, along with the spectrum
of data for amendment to the WCFHC and CHDs assigned person, respectively.
Assigned person from WCFHC and CHDs reviews the request and if found
warranted, this is approved and the system automatically generates changes.

e. All concerned DOH staff are required to sign a non-disclosure agreement.

MNDRS Manual 27
 4.5 MNDRS Service Requirements

To ensure smooth operations of the MNDRS system, the following conditions must be met
by the concerned units:

a. At the community and facility level, any mobile phone capable of basic SMS for
sending and receiving MNDRS report.

b. At the higher management level, the following prerequisites shall be in place prior
to installation of the system:

i. With uninterrupted electricity and internet connection;

ii. All required hardware and operating system

iii. Annual budget for the following:

1) Computer supplies and miscellaneous requirements

2) Hardware maintenance

3) Local MNDRS training and workshop

4) ISP connection

iv. Full time human resource to operate or take care of the MNDRS

v. Issuances on:

1) Placement of processing and support activities

2) Delineation of duties and responsibilities among all end users

3) Confidentiality and security mechanisms

4) Monitoring and evaluation of compliance with set policies and standards

4.6 System Monitoring and Evaluation

To evaluate the progress and congruity of the system with the program objectives, a concurrent
audit and inspection of the MNDRS system both at the grassroots and top management level
shall be conducted. Specific objectives of the system audit encompass assessment of system
performance, adherence to established standards and guidelines, common issues and challenges
encountered, and software review.

28 MNDRS Manual
5 MNDRS OPERATIONS

5.1 MNDRS System Operations

There are four focal steps in the Maternal and Neonatal Death Reporting System, namely:

a. Registration of All Designated Reporters and Validation Officers

Registration of all designated reporters and validation officer/s must commence prior
to the respective reporting and validation process.

i. The DOH CO/CHD creates respective MNDRS account, along with setting
of appropriate viewing rights and access levels of all designated MNDRS
recipients, namely: Health Facilities, Municipal Health Officer (MHO), City
Health Officer (CHO), Provincial Health Officer (PHO), Center for Health
Development and DOH Central Office depending on their area of jurisdiction.
Moreover, each reporting facility is also designated with a unique facility
code.

ii. The RHU officer/MHO/CHO registers profiles and cellular phone numbers of
all the midwives within their jurisdiction. The system automatically generates
their MNDRS account and their corresponding log in details on the website.
The MNDRS account is vital in the registration of these phone numbers to be
used for reporting.

iii. Registration of designated reporters’ phone numbers is performed either of

the two ways:

1) Upon registration of profiles of all the midwives, the Rural Health Unit
(RHU) officer/MHO/CHO registers their respective phone numbers to
be used for the reporting, and consequently informs them that the SMS
reporting can now commence from their end.

2) If the phone numbers of the designated reporters are not registered by

the RHU officer/MHO/CHO, the midwives can do the online registration
instead, as long as they are provided with their log in details of their
MNDRS account by the RHU officer/MHO/CHO.

b. Submission of Maternal and Neonatal Mortality Report

Reporting of maternal and neonatal death cases begins at the designated reporting unit
– either at the community or the healthcare facility where the deaths happen.

MNDRS Manual 29
 i. Registered MNDRS reporters gather all pertinent data surrounding the event.
They then transfer the data into appropriate MNDRS forms, according to the
place of occurrence of death – facility based death or non-institutional death.
The MNDRS Reporter must always fill out appropriate number of copies of
the paper form before submitting the report. The paper forms not only serve
as backup files for the reporting unit, but are also prerequisites for the conduct
of validation and review, respectively.

ii. The reporting unit has two options of reporting the mortalities: either through
SMS submission via the SMS gateway or through online submission via web-
based technologies.

1) For reports sent via text messaging, only correctly formatted reports are
integrated into the online system for updating.

2) For reports sent via online, in contrast, the designated reporter can directly
fill out and supply all the required data on the appropriate online MNDRS
report form.

c. Validation of Submitted Reports

i. All correctly formatted reports sent via SMS, and online reports are made
accessible to all designated recipients (i.e. MHO/CHO, PHO, and CHD) at
all levels of governance through the MNDRS website. However, the viewing
rights and access levels of these recipients differ, depending on their area of
jurisdiction.

ii. For both SMS and online reporting, the MNDRS likewise sends Immediate
Notification Alerts to the mobile phones of designated recipients (e.g. MHO,
PHO, CHD) alerting them that a mortality report has been submitted and
requires appropriate action. Similarly, for every validation or review made on
the reports, these designated recipients are further notified via text messaging.

1) First level validation is done by the system for verification of the submitted
report for any duplication.

2) Second level validation involves a two-way validation scheme: ascertaining

the accuracy, soundness and completion of data both entered online, in
addition to initial screening for duplication. The officer designated to
perform the first phase of the second level validation is either the MHO/
CHO both for mortalities occurring at the community and in transit, or
the healthcare facility team lead or attending physician of the deceased.
Validation can be done either manually or online.

3) Third level of validation involves further assessment and analyses of the

reports and conduct of maternal death review by the PRT/CRT.

4) Fourth level validation is at the CHD level, tasked not only to verify
the reports submitted by the PHOs/PRTs/CRTs, but also to draw up
conclusions and appropriate interventions at the regional level.

30 MNDRS Manual
 d. Generation of Statistical Reports

In the MNDRS website, tables, and graphs can be generated from which statistical
trends and distribution patterns of the mortalities can be analyzed. Further, tables outlining
the actions – validation or review - taken by the designated recipients on the submitted
reports will also be shown; thereby, providing the CHD and DOH CO a clear picture of the
work performance of these units within their jurisdiction.

6 REFERENCES

Department of Health (DOH) 2007. Maternal Death Reporting and Review System: A Guide for LGU
User, Manila: Women’s Health and Safe Motherhood Project 2.

DOH 2008. Administrative Order No. 2008-0029 ‘Implementing Reforms for the Rapid Reduction of
Maternal and Neonatal Mortality,’ issued on September 22, 2008, Manila.

DOH 2011. MNCHN Strategy Manual of Operations, 2nd Edition, Manila: National Center for Disease
Prevention and Control, Department of Health.

DOH, Maternal and Neonatal Deaths Reporting System Project Proposal, Project Briefs, Documentations
and Presentations, 2011-2013

Department of Science and Technology, Information and Communication Technology Office (DOST-
ICTO), 2012 Mobile cellular telephone subscriptions per 100 inhabitants by Year in Philippine ICT
Statistics Portal http://phicts.icto.dost.gov.ph/

Garces, R.G 2009. Reproductive Age Mortality Studies: Community-based Case Control Study on
Maternal Mortality Risk Factors, Manila

National Statistics Office (NSO) 2006. Family Planning Survey, 2006

NSO, Philippines, and ICF Macro 2009. National Demographic and Health Survey 2008. Calverton,
Maryland: National Statistics Office and ICF Macro

MNDRS Manual 31