3. INFANT SURVIVAL 3.1 Infant status: Still live Died immediately Alive at 7 days Alive at 28 birth Birth after birth days 4. AVAILABILITY OF HEALTH FACILITIES, SERVICES AND TRANSPORT (4.1 & 4.2 to be filled by the investigator before the interview) 4.1 Name and location of the nearest government/private facility providing Emergency Obstetric Care Services 4.2 Distance of this facility from the residence 4.3 Number of institutions visited before death (in the order of visits) 4.4 Reasons given by providers for the No explanation Lack of referral given blood Lack of staff Others (specify) 4.5 Used 108:Y/N 5. CURRENT PREGNANCY (to be filled from the information given by the respondents) 5.1 Pregnancy Registration YES NO Antenatal Care YES NO 5.2 If yes, place of Sub Centre PHC/CHC Antenatal checkup Gov. Hosp. Pvt. Hospital VHND Govt. & Pvt. Hospital 5.3 Number of antenatal Nil 4 and above 1-3 Not Known check ups 5.4 Hb Level 5.5 High Risk 5.6 Told About Risk category: Y/N Factors: Y/N 5.7 Name & phone no. Of concerned ANM MODULE - 11 6. DEATHS DURING THE ANTENATAL PRIOD (This module to be filled for the maternal deaths that occurred during the antenatal period including deaths due to abortion. In addition to module –II, module – I should also be filled for all maternal deaths) 6.1 Did the mother had any Not known problem during antenatal NO Yes period? 6.2 If yes, was she referred YES anytime during her antenatal Don’t know period? Headache Edema Anemia
3. INFANT SURVIVAL 3.1 Infant status: Still birth live Birth Died immediately after birth Alive at 7 days Alive at 28 days 4. AVAILABILITY OF HEALTH FACILITIES, SERVICES AND TRANSPORT (4.1 & 4.2 to be filled by the investigator before the interview) 4.1 Name and location of the nearest government/private facility providing Emergency Obstetric Care Services 4.2 Distance of this facility from the residence 4.3 Number of institutions visited before death (in the order of visits) 4.4 Reasons given by providers for the referral No explanation given Lack of blood Lack of staff Others (specify) 4.5 Used 108:Y/N 5. CURRENT PREGNANCY (to be filled from the information given by the respondents) 5.1 Pregnancy Registration YES NO Antenatal Care YES NO 5.2 If yes, place of Antenatal checkup Sub Centre PHC/CHC Gov. Hosp. Pvt. Hospital VHND Govt. & Pvt. Hospital 5.3 Number of antenatal check ups Nil 4 and above 1-3 Not Known 5.4 Hb Level 5.5 High Risk category: Y/N 5.6 Told About Risk Factors: Y/N 5.7 Name & phone no. Of concerned ANM MODULE - 11 6. DEATHS DURING THE ANTENATAL PRIOD (This module to be filled for the maternal deaths that occurred during the antenatal period including deaths due to abortion. In addition to module –II, module – I should also be filled for all maternal deaths) 6.1 Did the mother had any problem during antenatal period? Not known NO Yes 6.2 If yes, was she referred anytime during her antenatal period? YES Don’t know Headache Edema Anemia