MONTHLY MATERNAL, NEONATAL and INFANT DEATH REPORTING

FORM
MATERNAL DEATH REPORTING FORM
Municipality: BULA Province: CAMARINES SUR
Month: JUNE 19__ 2018_________________
Instructions: The Municipal Health Office must accomplish and submit this form to the PHO and DMO during the 1st week of the succeeding
month furnishing a copy to the DOH RO-5 Family Health Office through email at dohrov.familyhealth@gmail.com. Reporting must be according
to the place of residence of the mother and/or the child.

Sources of Data: FHSIS and Maternal Death Report and Review (MDRR) form accomplished and validated by health personnel in the catchment
area

Definition of Terms:
Maternal Death refers to the women who die from any cause related to or aggravated by pregnancy or its management (excluding accidental
or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the
pregnancy.

Three Delays
Delay 1 – Delay in decision to seek care
Delay 2 – Delay in the arrival at a health facility
Delay 3 – Delay in the provision of adequate care

Accomplished by:

__MYLENE C. MILLA, MD__________________

Name and Signature of Municipal Health Officer

Noted by:

__HON. AMELITA A. IBASCO_______________

Name and Signature of Municipal Mayor
 MONTHLY MATERNAL, NEONATAL and INFANT DEATH REPORTING
MATERNALFORM
DEATH REPORTING FORM
Case No. 1 Case No. 2 Case No. 3
Name GLAIZA BROQUEZA BRIONES
Barangay PAWILI BULA CAM.SUR
Age 33

Gravida Parity G3 P3
Number of Antenatal Check-ups
EVERY MONYH
(Indicate number of visit/s per trimester)
Birth attendant
IMELDA SOCORRO MARINAS MD
(Doctor, Nurse, Midwife, TBA)
Place of Delivery
(Home, BHS, RHU, Hospital, Others: NICC-DOCTOR HOSPITAL
Specify name of the Facility also)
Date of Death JUNE 19,2018
Place of Death
(Home, BHS, RHU, Hospital, Others: NICC-DOCTOR HOSPITAL
Specify)
During Pregnancy
(Indicate number of months)
Woman
During Childbirth DURING DELIVERY
died:
After childbirth
(Indicate number of days)
Three Delays Assessment CARDIOPULMONARY ARREST
PREGNANCY UTERUS PLACENTA
Cause of death (Medical)
PERCRETA
Intervention DISSEMINATED INTRAVASCULAR
(Medical and Non-medical) COAGULOPATHY
PhilHealth membership
PRIVATE SECTOR
(NHTS 4Ps, LGU sponsored or none)
 MONTHLY MATERNAL, NEONATAL and INFANT DEATH REPORTING
FORM
INFANT/NEONATAL DEATH REPORTING FORM
Municipality: BULA Province: CAMARINES SUR
Month: __________ ____
Instructions: The Municipal Health Office must accomplish and submit this form to the PHO and DMO during the 1st week of the succeeding
month furnishing a copy to the DOH RO-5 Family Health Office through email at dohrov.familyhealth@gmail.com. Reporting must be according
to the place of residence of the mother and/or the child.

Sources of Data: FHSIS accomplished and validated by health personnel in the catchment area

Definition of Terms:
Neonatal Death refers to the newborns dying within the first 28 days of life.
Infant Death refers to the infants dying after the first 28 days of life but before reaching the age of one year. It represents an important
component of under-five mortality rate.

Three Delays:
Delay 1 – Delay in decision to seek care
Delay 2 – Delay in the arrival at a health facility
Delay 3 – Delay in the provision of adequate care

Accomplished by:

___MYLENE C. MILLA, MD_________________

Name and Signature of Municipal Health Officer

Noted by:

____HON. AMELITA A. IBASCO_____________

Name and Signature of Municipal Mayor
 MONTHLY MATERNAL, NEONATAL and INFANT DEATH REPORTING
FORM
NEONATAL/ INFANT DEATH REPORTING FORM
Case No. 1 Case No. 2 Case No.3
Name GLAISA BROGUESA BRIONES

Barangay Z-1 PAWILI BULA CAM. SUR

Age (days/months)

Sex FEMALE

Date of Birth DECEMBER 3, 2016

Immunizations Received OPV1

Last immunization received OPV1 (2/7/17)
(Specify immunization and date.)
Exclusive Breastfeeding MIXED FEEDING

Date of Death FEBRUARY 15, 2017 (9:40 PM)

Place of Death HOSPITAL (NICC
(Home, BHS, RHU, Hospital, Others:
Specify)

Three Delays

Cause of Death (Medical)

Intervention
(Medical and Non-medical)

PhilHealth Dependent NHTS 4Ps

(NHTS 4Ps, LGU-sponsored or none)
MONTHLY MATERNAL, NEONATAL and INFANT DEATH REPORTING
FORM