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Making Every Baby Count

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. antepartum complications<br />

Annex 2: Births and Deaths<br />

Summary Form<br />

(and guidance for completion)<br />

Annex 2a: Births and Deaths Summary Form<br />

Annex 2A<br />

Section 1: Identification<br />

1.1 Data collected at (facility name):<br />

1.2 Data for the month of:<br />

1.3 District name:<br />

1.4 Births Total births<br />

(incl deaths)<br />

< 1000 g<br />

1000–1499 g<br />

1500–1999 g<br />

2000–2499 g<br />

2500 g+<br />

Stillbirths (SB)<br />

Neonatal deaths<br />

Antepartum SB Intrapartum SB Unknown SB Early Late<br />

1.5 Multiple pregnancies babies from pregnancies<br />

1.6 Born before arrival total<br />

1.7 Mode of delivery<br />

CVD vacuum forceps caesarean unknown<br />

1.8 Gestational age<br />

term post-term ext preterm very preterm mod preterm unknown<br />

1.9 HIV status<br />

negative positive unknown<br />

1.10 Syphilis serology<br />

negative positive unknown<br />

1.11 Maternal age<br />

20–34 y > 34 y 18–19 y < 18y unknown<br />

Section 2: Cause of death<br />

2.1a Cause of death: antepartum stillbirths M1 M2 M3 M4 M5 other unknown<br />

82 MAKING EVERY BABY COUNT: a. AUDIT congenital AND REVIEW OF STILLBIRTHS AND NEONATAL DEATHS

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