Questionnaires for Child Death Review Under Goalpara BPHC

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Brief Information: Questionnaires for Child Death Review Under Goalpara BPHC

The objective of this exercise is to find out: At which level do you think the delay occurred?

1.       Delay at home (eg; seriousness of illness not recognized, treatment not sought, treatment sought at a late stage, family members did not allow treatment seeking)

2.       Delay in transportation (eg; transport facility not available, could not afford local transport, difficult/hilly terrain, long distance to the health facility)

3.       Delay at facility level (eg; doctor/staff not available, drugs & equipment not available, delay in initiation of treatment)

What are the areas to be assessed?

Background Information

Details of Pregnancy and Delivery: Mother’s RCH number: When was 1st ANC registration done: 1st/2nd /3rd/4th trimester How many times she received the ANC: 1/2/3/4/5 or more How many months long was the pregnancy: Mother’s age of marriage: Mother’s age of pregnancy: Mother’s Gravida and Parity: Did the mother receive 2 doses of Inj TT: Yes/No/Don’t know? Was there any complication during pregnancy (High Risk Pregnancy): Yes/No If diagnosed as high-risk pregnancy then for which condition it was diagnosed (Write specifically): Was there any delivery micro-planning for the mother (Birth Preparedness? No of antenatal checkup: 1/2/3/4/5 or more: Did the mother attend the PMSMA : Yes/No If yes then who many times: Was USG done at least for once throughout the pregnancy: Yes/ No. If Yes how many times: Where she was delivered: Home with SBA trained Staff/Home without SBA trained staff (Traditional birth attendant) /HI Mode of Delivery: C-Section/ Normal Delivery/ Assisted (Instrumental)Delivery Any complications during delivery and or thereafter: Mother’s had fit/ More than normal bleeding during delivery/Water broke 1 or more days before contractions started/Prolonged or difficult labour (12 hours or more)/ Mother had fever/Others (Tick) In case of Preterm Labour (Less than 34 weeks of gestation) did the mother 4 doses of Antenatal Corticosteroid? : Yes/No If answer to the question 17 is Yes then how many doses: Was the baby attended by labour room staff (Staff nurses/MO) at the time of birth: Yes/No Did the baby cry at birth: Yes/No Did the baby require resuscitation: Yes/No. If yes then up to what level: Initial Steps/Bag & Mask/Chest compression/ Medications. When the baby was first breastfed: Was the baby given Inj. Vitamin K/OPV/BCG/HepB at birth: Yes/No (Tick whichever are given) History of previous pregnancies and its outcomes, H/O maternal complication in previous pregnancies.

1. Name of the Child/ Baby of (In case of new born):
2. Date of Birth (if available)
3. Age: Years /Months /Days (if age less than 1 month) /Hours (if age less than one day)
4. Sex: Male Female
5. Address:
6. Name of Area PHC :
7. Name of Area Sub-center:
8. Order of Birth: 1/ 2 /3/ 4/ 5 or more
9. Belongs to: SC/ ST /OBC /General
10. Does the family have a Below Poverty Line (BPL) card/ PMJAY/ATAL AMRIT card/ Any other: Yes/No (TICK against the name of card)
11. Immunization Status (As per age): Fully /Partially / No immunization
12. Weight (if recorded in the MCP card):  …………..Kg
13. Growth Curve (fill for child less than 3 years; check MCP card):

• Green zone b. Yellow Zone c. Orange Zone d. No record

14. Any H/OIllness/Injury: Yes/No
15. What are the symptoms during the current illness which lead to death (Put duration)?

 

16. Was ASHA informed by family about the child illness: Yes/No
17. If Yes, did the ASHA came home on the 1^st day of information about the child illness: Yes/No
18. What danger sign/signs the ASHA identified in the sick child:
19. What ASHA did on the 1^st day of contact with family: Given Advices to the family by herself/ Referred to nearby HI
20. Did the family follow the ASHA’s instruction: Yes/No (Didn’t go to health facility)
21. Did the ASHA accompany the child and family to HI: Yes/No
22. Did the family take the child to local traditional healers/Quacks / Unqualified AYUSH practitioners/ Informal providers instead of taking the child to HI: Yes/No
23. If answer to the question 22 is yes, then what duration the family has given medicines prescribed by traditional healers/QuacksUnqualified AYUSH practitioners/ Informal providers:
24. Did the family take the child to nearby HI when there is no improvement after giving medicines of traditional healers/QuacksUnqualified AYUSH practitioners/ Informal providers: Yes/NO
25. If taken to HI then on which day after start of appearance of symptoms:
26. Where the child died: At home/In-transit/HI
27. What diagnosis is made by the district as a cause of death:
28. Did the ASHA/Family members call 108 services for free transportation of pregnant women for delivery/To take the sick child to the nearby HI: Yes/No
29. What was the awaiting period of arrival of 108 after the last call in this case:
30. If No, then how the family managed to bring the pregnant women/sick child to hospital: Rented car/Public Transportation/ Others
31. What is the average response time 108 takes to reach the destination in that block:
32. Did the 108 drivers take extra money from the family for transportation: Yes/No. If yes then how much:
33. Did the mother/infant get Adarani services: Yes/No
34. Who attended the sick child when child came to health institute for the 1^st time: Staff Nurse/Medical Officer.
35. What duration the sick child had to wait before examination by medical officer of that HI:
36. Did the infant/child receive treatment immediately after arriving the hospital: Yes/No
37. Did the family spend money for drugs and consumables and laboratory investigations in the HI: Yes/No. If yes then how much:
38. For how many days the child was treated at the facility:
39. Was the child referred to higher facility immediately:
40. If yes, then the reason:
41. Was the child stabilised before referral to higher HI: Yes/No
42. Is there any delay during referral to higher HI from the facility: Yes/No.
43. In case of SNCU discharged new born/ Preterm LBW infant, did the ASHA complete the community follow up: If yes write the competed schedule:
44. In case of SNCU discharged new born did the parents take the infant for facility follow up as per schedule: If yes then write the completed schedule:
45. For those infant who died before 45 days of life, did the ASHA complete the HBNC schedule: Yes/No. If yes then write the completed schedule:
46. What % of ASHA home visits under SNCU graduate follow up/ LBW follow up or HBNC are supervised by ASHA supervisors/BCM in that area:
47. Accessibility to Health Care Facilities (Good/Poor):
48. Distance from nearest Health Facility (in Kms & in Hours):
49. Distance of village from Nearest FRU (in Kms & in Hours):
50. Has village been declared as ODF village: Yes/No
51. Availability of Electricity connection: Yes/No
52. Availability of Clean drinking water: Yes/No
53. Availability of Clean source of energy for cooking: Yes/ NO (What source is used:
54. Availability of Toilet in the household:

Final Diagnosis: Level of Delay: At Home/Transportation/At Facility

Additional Remarks by MO/ANM

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