ORDINANCE Nº 1119, of June 5, 2008

Regulates the surveillance of maternal deaths.

THE MINISTER OF STATE FOR HEALTH, using the powers conferred upon it by subsection II, Sole paragraph of art. 87 of the Federal Constitution, and

Considering that research carried through in the Country shows that mortality maternal has high magnitude and transcendence;

Considering Objective V of the Millennium, that establishes the commitment to reduce in ¾ the mortality reason maternal, between 1990 and 2015;

Considering that the real sizing of the maternal death in Brazil is made it difficult by the sub-register of deaths and the sub-enumeration of the death maternal;

Considering that the identification of the main factors of risk associates to the death maternal makes possible the definition of strategies of prevention of new occurrences;

Considering that Law n º 6,015, of 31 of December of 1973, establishes that no burial is made without official certificate of death;

Considering that the Declaration of Death (OF) is the official document that certifies the death of an individual, and that the System of Information on Mortality (YES) is the official instrument of the Health department for the information of the one OF the one in all the domestic territory and that, from 2006, it has greater agility in the transmission of the information on the death;

Considering that the Declaration of Deaths is document of obligator fulfilling for the doctors, with attributions detailed for Resolution 1779/2005 of the Federal Advice of Medicine,

Considering that, where had been implanted the actions foreseen in the National Pact for the Reduction of Mortality Maternal and Neonatal, launched for the Presidency of the Republic in 8/3/2004 and approved in the meeting of the Commission Tripartite Inter-managers (CIT) and National Advice of Health (CNS), the results if had shown staff;

Considering made use in Ordinance n º 1.172/GM, of 15 of June of 2004, that it regulates abilities of the Union, the States, the Cities and the Federal District, in the area of monitoring in Health, between them to investigate maternal deaths;

Considering that the agility in the information and the opportune beginning of the inquiry is basic factors for the success of the action; and

Considering that the reduction of the death maternal is one of the priorities of this Ministry and to in such a way they come being implemented a series of measures,

IT DECIDES:

Art. 1° the monitoring of maternal deaths for all the confirmed events or not, independent of the occurrence place, it must be carried through by health professionals, assigned for the authorities of monitoring in health of the spheres federal, state, municipal and of the Federal District.

Art. 2° the maternal deaths and the deaths of women in fertile age, independently of the declared cause, are considered events of obligator inquiry, with the objective of raising determinative factors, its possible causes, as well as subsidizing the adoption of measures that can prevent its relapse.

§ 1º For inquiry ends, is considered maternal death the death of woman, occured during the gestation or up to one year after its ending, which had to any causes related with its development or aggravated in its course, for measures also adopted during the pregnancy, independently of its duration or the localization, excluded accidental or the incidental ones.

§ 2º For I compute of the mortality reason maternal, will be excluded the cases of deaths occurred after forty and two days of the ending of the gestation, but all must be investigated, also to certify itself of the dates of the ending of the gestation and the death.
§ 3° For inquiry ends is considered deaths of women in fertile age those occurrences in women of 10 the 49 years of age.

Art. 3° the instrument base for the trigger of the inquiry process is Declaration of Death (OF), adequately filled in all the fields, with distinction, beyond the age of the woman, for the basic cause amongst the constants of the Attached I to this Would carry.

Art. 4° the instruments that will serve as script for the inquiry, can in such a way be those standardized ones for use in the Unit of Federacy - UF how much in the “Manual of the Committees of Maternal Mortality of the Health department”, fiches B, C and D, or others that come to be recommended by the Secretariat of Monitoring in Health of the Health department.
Sole paragraph. In any in case that, the UF must obligatorily include the questions constants of Annex III to this Would carry, that it will serve of document base to feed the module of inquiry of deaths in the System of Information on Mortality - YES.

Art. 5° the declarations of maternal death and women in fertile age, legalized in the terms of the article 3o, will have to follow constant special flow of Annex II or the adopted one for the UF, since that observed the following stated periods:

I - counted from the occurrence:
a) forty and eight hours, for the service or professional of health to inform the death, with the sending of 1ª saw of the one OF;
b) thirty days, for the State Secretariat of Health to available the register it saw YES for the Health department; e
c) one hundred and twenty days, for the team of monitoring of responsible maternal death to conclude the survey of the data that compose the inquiry, to send the material to the death committee maternal of reference and to send to the fiche-synthesis of the inquiry epidemiologist (Attached III) to the manager of YES.

II - seven days, to count of the act of receiving of the data of the fiche-synthesis of the inquiry epidemiologist (Attached III), for the manager of YES providing the feeding of the module of inquiry of maternal deaths; e

III - thirty days after the conclusion of the inquiry that it deals with interpolated proposition I, paragraph “c”, to bring up to date YES with the deriving data of the fiche the synthesis of the inquiry epidemiologist, being included alterations of the cause of the death, with adequacy of the codification and the election, when appropriate, as well as the transference of the modified register and its availability for the Health department.

Art. 6° the non-observance of the made use one in this Would carry will be able, as the case, to try the adoption of the steps foreseen in articles 21, 22 and 23 of Ordinance GM/MS nº. 1.172, of 15 of June of 2004.

Art. 7° the Hospital Nucleus of Epidemiology (NHE) e, in the lack of its implantation, directions techniques, clinics and of nursing of the care establishments or the specific structures, defined for the local manager of health, will have to carry through active search, daily, of maternal deaths and woman in fertile age, occurrences or declared in its dependences, any that is its cause, and to assure the fulfilment of the flows and the stated periods established in this It would carry.

Art. 8° the medical hospitals, doctor's offices, basic units of health or any another care service will have, in the stated period of forty and eight hours of the request of the team of monitoring of maternal deaths, to make available to it to the access to handbooks of the women deads under its cares, in the conditions and the period foreseen in § 1º of art. 2º or in fertile age, to make possible the opportune beginning of inquiry of the occurrence. Sole paragraph. The team of monitoring of maternal deaths will use the registers of the handbook to collect given, that it will transcribe for used proper instrument in the inquiry (article 4º), guaranteed the secrecy and the privacy of the patients, following the effective ethical rules.

Art. 9º the conclusion of the inquiry epidemiologist is an attribution of the team of monitoring of deaths of reference of the city of residence of the woman and will have to be supported by the team of monitoring of deaths of reference of the place where it died or it received assistance for prenatal, childbirth, abortion or puerperium.

Art. 10º the Department of Analysis of the Situation of Health of the Secretariat of Monitoring in Health - DASIS/SVS/MS will communicate, biweekly, to the Area Technique of Health of the Woman, of the Department of Action Programmatic and Strategic of the Secretariat of Attention to the Health - DAPE/SAS/MS and to the Center of Strategical Information in Monitoring in Health - CIEVS/SVS/MS, the informed cases of maternal death in YES and will available, with this regularity, a brought up to date version of its national base in the internal net of the Ministry of the Health, with the extract of maternal deaths, according to clipping defined in the death manual maternal.

Art. 11º the DASIS/SVS/MS, in set with the CIEVS/SVS/MS and the DAPE/SAS will carry through the monitoring of the national data, granting accesses with specific clippings for managers e citizens.

Art. 12º Cabe to the Secretariat of Monitoring in Health, to the Secretariat of Attention to the Health and the Department of Computer science of the Only System of Health - DATASUS the support to the operationalization of the made use one in this Would carry. Only paragraph. The module of inquiry of maternal deaths of the system of information on mortality will have to be concluded and to enter in operation in the stated period of up to sixty days, after the publication of this Would carry.

Art. 13º This Would carry enters in vigor from its publication.

Art. 14º revoked are the paragraphs 1º and 2º, of the Art. 1º and Art. 3º of Ordinance nº. 653/GM, of 28 of May of 2003, published in Federal official gazette nº. 103, of 30 of May of 2003. Section 1, p 79.

JOSÉ GOMES TEMPORÃO

ANNEX I

FULFILLING OF THE DECLARATION OF DEATH AND ITS CHARACTERIZATION AS AN INFORMATION CONCERNING A CASE OF MATERNAL DEATH

The adjusted fulfilling of the Declaration of Death is what it will make with that this is characterized as a notification of maternal death.

All the fields of the declaration of deaths are important, but two integrant sets of information of Block VI of this instrument are essential for this purpose. They are:

1 - the relative fields the deaths in women:
Field 43 - the death occurred during the pregnancy, childbirth or abortion?
Field 44 - the death occurred during the puerperium?
An affirmative reply to one of the fields above it characterizes a notification of cases suspicious of maternal death, subject to inquiry for confirmation or discarding.

2 - The informed determined fields of the death certificate one with diagnostic:
A declaration that have informed in any of the lines of the death certificate one, one or more than the diagnostic below listed will have to be considered a notification of cases suspicious of maternal death, subject to the inquiry for confirmation or discarding:
2.1 - Constant diagnostic of Chapter XV of CID 10: CHAPTER XV OF CID 10 COMPLICATIONS OF THE PREGNANCY, CHILDBIRTH AND PUERPÉRIO

O00-O08 Pregnancy that finishes in abortion
O00 ectopic Pregnancy
O01 hidatiforme Spring
O02 Other abnormal products of the conception
O03 spontaneous Abortion
O04 Abortion for medical and legal reasons
O05 Other types of abortion
O06 not-specified Abortion
O07 Fail of abortion attempt
O08 consequent Complications the abortion and molar ectopic pregnancy or Hypertensive’s

O10-O16 Edema, proteinuria and upheavals in the pregnancy, the childbirth and the puerperium
O10 preexisting Hypertension complicating the pregnancy, the childbirth and the puerperium
O11 preexisting hypertentive Riot with proteinuria superece of fish Induced
O12 gestational Edema and proteinurium [for the pregnancy], without hypertension
O13 induced gestational Hypertension [for the pregnancy] without significant proteinurium
O14 induced gestational Hypertension [for the pregnancy] with significant proteinuria
O15 Eclampsia
O16 Hypertension maternal not-specified

O20-O29 Other predominantly related maternal upheavals with the pregnancy
O20 Hemorrhage of the beginning of the pregnancy
O21 extreme Vomits in the pregnancy
O22 venous Complications in the pregnancy
O23 Infections of the genitourinary treatment in the pregnancy
O24 Diabetes mellitus in the pregnancy
O25 Malnutrition in the pregnancy
O26 Assistance maternal for other on complications predominantly the pregnancy
O28 Found of the tracking [abnormal " screening"] antenatal of the mother
O29 anesthesia Complications managed during the pregnancy

O30-O48 Assistance given to the mother for on reasons to the embryo and the amniotic socket and for possible relative problems to the childbirth
O30 multiple Gestation
O31 specific Complications of multiple gestation
O32 Assistance given to the mother for reason of abnormal presentation, known or suspected, of the embryo
O33 Assistance given to the mother for a known disproportion or suspicion
O34 Assistance given to the mother for abnormality, known or suspicion, of the agencies pelvic maternal
O35 Assistance given to the mother for abnormality and injury fetal, known or suspected
O36 Assistance given to the mother for other fetal problems known or suspected
O40 Polihidrâmnio
O41 Other upheavals of the membranes and the amniotic liquid
O42 premature Rupture of membranes
O43 Upheavals of the placenta
O44 previous Placenta
O45 premature DT of the abruption placenta [placentae]
O46 Hemorrhage antepartum not-classified in another part False
O47 childbirth work
O48 drawn out Pregnancy

O60-O75 Complications of the work of childbirth and the childbirth
O60 Childbirth daily pay-term
O61 Fail in the induction of the childbirth work
O62 Abnormalitys of the uterine contraction
O63 Work of drawn out childbirth
O64 Blockage of the work of childbirth due to me - position or me - the presentation of the embryo
O65 Blockage of the work of childbirth due the pelvic abnormality of the mother
O66 Other forms of blockage of the childbirth work
O67 Work of childbirth and childbirth complicated by not classified hemorrhage intrapartum in another part
O68 Work of childbirth and childbirth complicated by fetal suffering
O69 Work of childbirth and childbirth complicated by abnormality of the umbilical lace
O70 Laceration of the perineum during the childbirth
O71 Other obstetric traumas
O72 Hemorrhage after-childbirth
O73 Retention of the placenta and the membranes, without hemorrhages
O74 anesthesia Complications during the work of childbirth and the childbirth
O75 Other complications of the work of not-classified childbirth and the childbirth in another part

O80-O84 Childbirth
O80 spontaneous only Childbirth
O81 only Childbirth for fórceps or vacuum-extractor
O82 only Childbirth for caesarian
O83 Other types of attended only childbirth
O84 multiple Childbirth

O85-O92 Complications related predominantly with the puerperuim
O85 puerperal Infection
O86 Other puerperal infections
O87 venous Complications in the puerperium
O88 Embolism of obstetric origin
O89 Complications of the anesthesia managed during the puerperium
O90 not classified Complications of the puerperium in another part
O91 mammary Infections associates to the childbirth
O92 Other disorders of the breast and the lactation associates to the childbirth

O95-O99 Other not classified obstetric disorders in another part
O95 obstetric Death of not-specified cause
O96 (*) Death, for any obstetric cause, that occurs 42 days more than, but less than 1 year, after the childbirth
O97 (*) Death for sequels of direct obstetric causes
O98 infectious and parasitic Illnesses maternal you classified in another part but that they complicate the pregnancy, the childbirth and the puerperium
O99 Other illnesses of the mother, classified in another part, but that the childbirth and the puerperium complicate the pregnancy

Comments:
O08 - This code alone must be used to classify morbidity.
O30 - it does not have to be used for codification of basic cause.
O32 - it does not have to be used will have mention of
O33. If this to occur, to use O33.
O33.9 - it does not have to be used will have mention of 33.0-O 33.3. In these cases, to use the O33.0-O33.3
O64 - it does not have to be used will have mention of the 65. If this to occur to use the 65
O80 - O84 These codes do not have to be used to classify death cause, but yes for morbidity. If none another cause of death maternal will be informed, codifies as not-specified complications of work of childbirth and O75.9 childbirth
O95 - To use when it will not have plus no information and will only be written only “maternal” or obstetric.
(*) Although they do not enter in the calculation of the Reason of Maternal Death the codified deaths must be investigated as O96 and O97 (Delayed Maternal Death and Death for Sequel of Direct Obstetric Cause).

2.2 - Diagnostic are of Chapter XV of the CID-10 - some illnesses that also do not consist in Chapter XV must be taken in account. They are:

- tétano obstétrico (cód. A34, CAP. I);
- osteomalacia puerperal (cód. M83.0, CAP. XI);
- mental upheavals and Mannering associates to the puerperium (code. F53, CAP. V);
- necrosis after-childbirth of hypothesis (cod. E23.0, CAP. IV) - (**);
- malignant hidatiform spring (code. D39.2, CAP. II) - (**); e
- illnesses caused for the virus of the immunodeficiency human being (code. B20 the B24, CAP. I.) - (*).

(**) For these cases, it must be proven the relation with the puerperal state and the death must have after occurred up to 42 days the childbirth.

It is important to detach that, even so they are rare, they exist external causes (CAP. XX) that they compromise the puerperal state and they must be considered maternal deaths, since that it does not have doubt in relation to this commitment.

ANNEX II

SPECIAL FLOW FOR DECLARATION OF DEATH WITH INFORMATION CONCERNING DECLARED MATERNAL DEATHS, AS WELL AS THE DEATHS OF WOMAN IN FERTILE AGE

The declarations of death with information concerning declared maternal death, as well as the deaths of woman in fertile age will have to follow described flow and special stated periods below, or the flow existing in each Federal Unit (UF) since that obeyed the established stated periods, for the fulfillment of this It would carry:

1 - The hospital or service where it occurred or that it emitted OF the one of death directs 1ª saw, in the maximum stated period of 48 (forty and eight) hours, for the manager of the information system on responsible mortality for the processing of the occurred data of mortality in the City.

2 - The sector that processes the data of mortality of the deaths occurred in the City it directs, in the maximum stated period of 48 (forty and eight) hours, copy of 1ª saw of the one OF the one for team of Monitoring of Maternal Death of the City department of Health (SMS), Regional or State Secretariat of Health (SES), responsible for the inquiry, as the flow defined in each place that corresponds, in the maximum, 96 (ninety and six) hours after the death.

3 - The team of Monitoring of the Maternal Death of the SMS initiates the inquiry immediately, as agreed to routines and flows together with the SES in each UF, using for this the available sources and standardized the proper instruments of inquiry for use in the UF, or the instruments standard recommended by the Manual publication „of the Committees of Maternal Mortality of the Health department ‟- fiche B to collect given in I domiciliate; fiche C to collect given hospital in general and assistentials services of health; e fiche D to collect given of findings of autopsy of the Service of Verification of Deaths (SVO) or IML, when applicable - or others that come to be recommended by the Secretariat of Monitoring in Health (SVS/MS).

4 - When the UF to opt to using instruments of collection of different data of those recommended for the Health department, these will have obligatorily to include the constant questions in the made use standardized form as in Annex III to this Would carry, and that it will serve of document base to feed the system of information of the module of inquiry of deaths of YES;

5 - Simultaneously to the guiding of the one OF to the team of monitoring of maternal deaths, the sector that it processes the data of mortality of the deaths occurred in the City carries through the codification of the causes in the declaration of deaths, and makes 1ª entered of the data in the applicatory one of YES, informing at this moment the original content of the one OF, and that the death is not investigated:

6 - The SES will agree to flow with the SMS in order to guarantee that the inserted data in YES are transferred to way SISNET (from the level that to consider more adequate, municipal, regional, or state) in the maximum stated period of 30 (thirty) days after the death, assuring as soon as these data are available in the state and federal base instantaneously at this moment.

7 - The teams of monitoring of maternal deaths will have to after conclude and to inform the result of the inquiry epidemiologist in the maximum stated period of 120 (one hundred and twenty) days the date of the death.

8 - To inform the result of the inquiry epidemiologist means:

a) to direct to the sector that processes the data of mortality of the deaths occurred in City, the Report-synthesis of the inquiry epidemiologist of maternal deaths, constant of Annex III to this Would carry, duly filled; e
b) to direct all the forms used in the process of inquiry (fiches hospital and/or outpatient and/or domiciliary and/or findings of autopsy of the SVO and/or finding of the IML) to the Committee of municipal Maternal Death or reference for the deaths of its area of coverage, as flow defined in each UF.

9 - The sector that processes the data of mortality of the deaths occurred in the City will type the summary of the inquiry of the maternal death in the module of inquiry of deaths of YES, offered for the applicatory MS in digital whose screen of entrance of data is based on the form standard (Attached III), in the maximum stated period of 7 (seven) days after the act of receiving of the Report-synthesis, being able still to available access so that the team of monitoring of maternal deaths feeds the cited module, as the decision of each place.

10 - The sector that processes the data of mortality of the deaths occurred in the City carries through 1ª update of the data in the applicatory one computerized of YES, informing at this moment that the death was investigated, (s) the source (s) of data consulted during the inquiry and the date of its conclusion.

11 - Case the inquiry epidemiologist points with respect to the necessity to modify or to complement OF, also with new causes of death, or allows to the codification of causes not gifts in the original declaration of deaths, the same ones will have to be effected and in the alteration case/update of the death causes, these must pass for a process of recoding, and new election of basic cause, that will be able to confirm or to discard the maternal death previously informed, or only classify as maternal a death originally defined as death of woman in fertile age without cause maternal.

12 - In complement, the team of monitoring of maternal deaths will have to follow the conclusion and emission to seem for the Committee of Maternal Death of reference for where they had sent the result of its inquiries epidemiologists, and to communicate its conclusions to the sector that processes the data of mortality of the deaths occurred in the City so that this can again incorporate possible alterations, including new (s) cause (s) of (s) the death (s) in YES.

ANNEX III

FORM STANDARD WITH THE SUMMARY OF THE INQUIRY OF DEATH MATERNAL

Form standard with the summary of the inquiry of maternal death to be adopted obligatorily as instrument of collection to feed the module of inquiry of deaths of YES, to inform the synthesis of each inquiry.

Report-synthesis of the inquiry epidemiologist of maternal deaths - Confidential: Data of identification of the inquiry:

A) Number of the one OF:
B) City/UF of residence of the dead:
C) City/UF of occurrence of the death:
D) Date of the conclusion of the inquiry:

1. Sources of data consulted during the inquiry (to mark an option more than will be necessary): ( ) Domiciliary Interview, ( ) outpatient Registers, ( ) hospital Handbooks, ( ) SVO, ( ) IML, ( ) Interviews with health professionals

1.1 The death occurred: ( ) During the gestation ( ) During abortion ( ) After abortion ( ) In the childbirth or up to 1 hour after childbirth ( ) In the puerperium (up to 42 days of the ending of the gestation) ( ) Between the 43 day and up to 1 year after ending of the gestation ( ) the inquiry did not obtain to identify the moment of death ( ) one More than year after the childbirth (discarded the case and locked up the inquiry) ( ) the death did not occur in none of the circumstances mentioned above (discarded the case and locked up the inquiry)

2. Number of times been pregnant (excluding current) ________
3.Result of previous pregnancies:
3.1 No. of vaginal deliveries: (_______)
3.2 N of cesarean deliveries: (_______)
3.3 Number of abortions / fetal (_______)
4. Date of last menstruation:
5. No. of pre-natal:
6. Date of 1st outpatient prenatal care:
7. Month of pregnancy when she realized the 1st outpatient prenatal
8. Date of last visit prenatal
9. Gestational age at last visit for prenatal care (weeks):
10. Gestational Age at death (weeks)
11. In case of death during or after abortion (in the previous question), abortion was:
( ) Spontaneous ( ) Legally Induced ( ) Triggered ( ) Do not Know

12. In case of death during childbirth, or postpartum, which was the type of delivery?
( ) Vaginal birth ( ) cesarean ( ) does not know

13. Establishment (s) where did the health prenatal care:
Name: _______________________________________________Code CNES: ___________________
Name: _______________________________________________Code CNES: ___________________
Name: _______________________________________________Code CNES: ___________________

14. Health facility where the birth occurred or abortion
Name: _______________________________________________Code CNES: ___________________

15. The investigation allowed the rescue of any cause of death, non-informed, or correction of any.
prior informed?

() No added or corrected information,
() Yes allowed the rescue of new information
() Yes allowed to correct some of the causes reported originally

16. Causes of death raised / confirmed the investigation to review the original death certificate:
Description of the diagnoses and ICD optional (if necessary, you can choose more than one diagnosis per line)

Tradução do português para inglês
PART I:
1.16 Line A) _____________________________________________________________________
2.16 Line B): _____________________________________________________________________
3.16 Line C): _____________________________________________________________________
04.16 Line D): _____________________________________________________________________
PART II
16.5 Description and CID: ________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

17. The investigation led to the amendment of some other variable declaration of deaths beyond cause and items 43 and 44:
( ) NO ( ) YES
If so, Which fields and change?
______ _________ Research field was changed to _________________
______ _________ Research field was changed to _________________
______ _________ Research field was changed to _________________
______ _________ Research field was changed to _________________
______ _________ Research field was changed to _________________
______ _________ Research field was changed to _________________

18. The case was referred to the Committee on Maternal Mortality?
( ) YES ( ) NO

19. Date of submission to the committee (if so)
( ) YES ( ) NO

20. The committee gave the opinion of maternal death?
( ) YES ( ) NO

21. If yes to question 20, the causes of death corrected above, express the opinion of
committee of maternal death?

( ) YES ( ) NO ( ) Does not apply, the committee has not issued an opinion yet ( ) Not applicable, surveillance
had no access to advice issued by the committee.