MATERNAL HEALTH INDICATORS - pbnrhm.org · MATERNAL HEALTH INDICATORS ... reasons related to pregnancy, ... Definition Percentage of women who used antenatal care

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MATERNAL HEALTH INDICATORS

Indicator MH 1: Antenatal care first visit coverage rate

A: ANC – First Visit

B: ANC First Visit in first trimester

C: ANC registered under JSY

Definition Percentage of pregnant women who used Antenatal

Care (ANC) provided by skilled health personnel, for

reasons related to pregnancy, registered in first trimester of

pregnancy

N.B - This indicator is also known as “ Any Antenatal care

visit”

Numerator: A: New Registered/first ANC visit of a pregnant woman

B: Pregnant women registered within first trimester

C: New women registered under JSY

Denominator A:Total expected pregnancies

B,C: Total number of ANC registered

Rationale • This first visit should be a "registration" visit where all initial procedures relating to assessing/preparing a woman for

pregnancy and delivery. This should include history,

examination, initial blood tests and immunisation.

• Antenatal care coverage is an indicator of access and use of health care during pregnancy. All women should

have at least three antenatal visits during a pregnancy.

• ANC should start as early in pregnancy as possible.

• % ANC registration in first trimester shows early care and

level of awareness

• % of women registered under JSY shows: number of

women entitled to benefits under JSY. This is include : a)

all women in EAG and NE states b) only BPL & SC/ST

women in HPS states

• % of pregnant women receiving any ANC is a sensitive

indicator of outreach

Data Source • Antenatal / pregnancy registers; Maternal health cards

• Household surveys • Population data - an estimate of the number of

pregnant women is close to the number of children born

(2.2-3.2% of population)

Suggested

level of use

National, state, district/ block and sub-centre

Other Useful • Risk and continuity indicators are important in ANC

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Indicators • VDRL (syphilis) and HIV testing coverage shows quality of care. This should be done in first ANC visit

• Haemoglobin testing and anaemia management rates

• ANC referrals shows risk detection (and transport

availability).

• % women getting third ANC shows continuity of care,

which is often related to perceived quality.

Common

Problems

• Attendance for pregnancy test or simple registration

without history and examination do NOT constitute

antenatal care.

• Women who have started ANC elsewhere, but who

come to your facility for follow up should be counted as

follow up ANC and not first ANC

Actions to

Consider

Low coverage means either the strategy for providing

ANC needs to be reviewed to increase access, or the

community should be approached to increase

awareness through ASHA,VHSC,BCC etc

Indicator MH 2: ANC third visit coverage rate

Definition Percentage of women who used antenatal care

provided by skilled health personnel for reasons related to

pregnancy at least 3 times during pregnancy

Numerator ANC third visit

Denominator A. Expected pregnancies B. ANC any visit

Rationale • Antenatal care third coverage is an indicator of continuity and use of health care during pregnancy

and also of access

• Poor quality ANC could also be a reason that women

come once and then stop

Data Source ANC Register maintained by health workers

Other Useful

Indicators

• Drop-out rate first to third ANC

• Comparison of third ANC to delivery rates

• %ANC with full blood tests (Hb, HIV, VDRL)

Suggested

level of use

State, District, Block and sub-centre

Common

Problems

• When ANC has been done in different facilities

• High coverage may mean problems with your choice

of denominator, or double counting

Actions to

Consider

• Low coverage means either the strategy for providing

ANC needs to be reviewed to increase access, or the

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community should be approached to increase

awareness through ASHA,VHSC,BCC

• Improved quality of care in earlier visits

• Ensure that first ANC are not done through sporadic

camps or MMU approaches

Indicator MH 3:

a. % ANC TT-1 coverage rate

b. % ANC TT2 and TT booster coverage rate

c. ANC 100 IFA coverage rate

Definition Percentage of pregnant women who used antenatal

care and were given TT1,TT2 or TT booster vaccine

Numerator A Antenatal care given TT-1

B. Antenatal care given TT2 or TT booster

C. Antenatal care given 100 IFA Tablets

Denominator Total ANC registered (ANC first visit)

Rationale • Antenatal care 100 IFA coverage is an indicator of

quality of ANC

• Antenatal care TT-1, TT-2 / Booster coverage is an

indicator of quality of ANC

• It is also an indicator for availability of the basic

immunisation of ANC

• All pregnant women are recommended 100 IFA Tablets

• Woman in her First pregnancy needs TWO TT

immunisations; subsequent pregnancies she needs only

a booster

Data Source Registers maintained by health workers; Household

surveys

Other Useful

Indicators

• TT protected at birth rate measures % of newborns

protected from tetanus by their mother being fully

immunised for TT

• Neonatal Tetanus rate measures cases of Neonatal

tetanus- a failure of our ANC TT immunisation program

• Anaemia rate

Suggested

level of use

State, District, Block, sub centre

Common

Problems

• IFA tablets given may not be consumed

Actions to

Consider

• Addresses supply side issues • Ensure quality of ANC

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• Awareness generation among mothers on availing

complete ANC services

Indicator MH 4: ANC Anaemic & Hypertension testing and management rates

A. % ANC moderately anaemic

B. % ANC severely anaemic

C. % ANC severely anaemic treated rate

D. % ANC hypertension new case detection rate

E. Eclampsia cases management rate

Definition • Percentage of pregnant women tested to be

moderately anaemic (Hb level <11g)

• Percentage of severely anaemic pregnant women

treated ( Hb level <7g)

• Percentage of pregnant women tested with

hypertension/ high blood pressure (BP>140/90)

Numerator A. Pregnant women tested anaemia <11g

B. Severely anaemic pregnant women treated

(Hb<7g)

C. Pregnant women detected BP>140/90

D. Number of eclampsia cases managed during

delivery

Denominator A, B & C =Total ANC registration

D = Total deliveries (home + institution)

Rationale E. Testing for anaemia and hypertension is an

indicator of quality of ANC services and also detection

of important risks associated with preventable mortality

.

F. Hb<7g and BP>140/90 is a danger sign for pregnant

women and should be managed by arranging for

referral transport and informing the medical officer in-

charge in advance

Data Source ANC/ Pregnancy Registers maintained by health workers

Other Useful

Indicators

G. ANC hypertension management rate

H. LBW rate is common consequence of anaemia &

Hypertension

I. Still birth rate/PNM affected by anaemia

J. Maternal death due to excessive bleeding is more

likely in an anaemic

K. Laboratory equipment availability rate

Suggested

level of use

Health sub-centre, PHC, CHC

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Common

Problems

L. BP is often not taken and Hb testing is not done M. Health sub-centres do not have BP apparatus and

Hb kits

N. Sufficient stock of IFA tablets

Actions to

Consider

O. Address supply side issues

P. Ensure quality of ANC

Q. Awareness generation among mothers to avail

complete and quality ANC services

Indicator MH 5: Skilled Birth Attendant (SBA) delivery rate

Definition Proportion of total deliveries assisted by a Skilled Birth

Attendant (at home and at institutions)

Skilled Birth

Attendant

definition

A skilled birth attendant is an accredited health

professional - such as a midwife, doctor or nurse - who

has been educated and trained to proficiency in the

skills needed to manage normal (uncomplicated)

pregnancies, childbirth and the immediate postnatal

period, and in the identification, management and

referral of complications in women and newborns

Numerator Deliveries by SBA (SBA Home + all Institutional deliveries)

Denominator A. Expected numbers of deliveries

B. Total recorded deliveries Rationale • Attendance of deliveries by skilled birth attendants is

the single most important factor in reducing maternal

mortality, and is a MDG indicator.

• There is increasing evidence that the SBA is most

effective when delivering in institutions, rather than at

home.

Data Source Labour records and maternity registers maintained at

facilities and by health workers; Household surveys

Other Useful

Indicators

• SBA deliveries as proportion of ANC first visit

• SBA deliveries as proportion of reported deliveries

• SBA deliveries at institutions and at home;

• Peri-natal mortality from SBA deliveries

Suggested

level of use

District, Block

Common

Problems

• The definition of SBA excludes Traditional birth

attendants, even if they have been trained. Even

professional staff that have had training, lose their

delivery skills if they do not use them.

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• Even ANMs only have a minimal amount of delivery

training and most of their skills are learned through

experience, not formal training. For the purpose of

measurability, all nurses and ANMs are counted,

which leads to an overestimation of those who are

skilled.

• Since deliveries in private sector and underserved

areas are unreported, the use of expected number

of deliveries may lead to an underestimation of SBA

deliveries, hence the need to use reported deliveries

as denominator

Actions to

Consider

• Include private sector deliveries

Indicator MH 6: Institutional delivery rate

A Institutional delivery rate

B Reported Institutional Delivery Rate

C Institutional delivery complication attendance rate

D Postnatal maternal complications attendance rate

E % Institutional delivery receiving JSY benefit

Definition A) Proportion of total deliveries that took place in any

health facility

B) Institutional deliveries that took place in health

facilities

C) Proportion of Institutional deliveries with delivery

complications

D) Proportion of Institutional deliveries with maternal

postnatal complications

E) Proportion of institutional deliveries where the

woman got JSY benefits

Numerator A) All institutional deliveries B) All institutional deliveries C) Number of complicated delivery cases attended

(public + private institutions)

D) Postnatal complications attended

E) Delivery institutional women received JSY benefits

Denominator A: Expected deliveries (2.2 To 3.2 % of population)

B: Total Number of deliveries reported

C: Total Number of deliveries reported

D: Total Number of deliveries reported E: Deliveries

Institutional

Rationale A) There is clear evidence that institutional deliveries by SBAs are the key to reducing maternal

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mortality, due to improved emergency

infrastructure, access to transport and referral

facilities and a number of other factors.

B) In absence of complete estimated population

figures in states, the institutional delivery

performance can also be calculated by total

reported delivery figures. This can supplement the

overall understanding of the institutional delivery in

the state

C) Postnatal complications shows the rate of

identification of postnatal complications at PNC

visits

D) JSY benefits are given to encourage women to

come for institutional deliveries, thus reducing

maternal mortality.

Data Source Maternity registers maintained by health workers at

health facilities; Household surveys

Other Useful

Indicators

• Institutional deliveries can be broken down by type of

institution – SC, PHC, CHC, hospital etc

• Institutional Perinatal mortality rate is a good indicator

of quality of care;

• % deliveries by SBAs should be assessed where not all

nurses at institutions are trained SBAs,

Suggested

level of use

National and below

Common

Problems

Actions to

Consider

Indicator MH 7: Home delivery rate

A Home delivery rate

B Reported home delivery rate

C Home delivery by Skilled birth attendant (SBA) rate

D Home delivery by Non Skilled birth attendant rate

E % Home delivery receiving JSY benefit

Definition A) Percentage of total deliveries that took place at

home

B) Reported home delivery rate

C) Home deliveries attended by SBA

D) Home deliveries attended by Non-SBA

E) Home deliveries receiving JSY benefit

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Numerator A) Deliveries Home (SBA and non-SBA)

B) Deliveries Home (SBA and non-SBA)

C) Deliveries home SBA

D) Deliveries home Non-SBA

E) Deliveries home women received JSY benefit

Denominator A, C & D =Total expected deliveries

B= Total reported deliveries (home + Institution)

E=total home deliveries

Rationale • Home deliveries occur in all states, but are not

encouraged because when complications arise , life

saving EmOC is not available

• Home deliveries by SBAs should be discouraged, as it is

more effective to deliver at institutions where facilities

are better, access to BEmOC is improved and the

SBAs are able to attend to more deliveries

Data Source Registers maintained by health workers; word of mouth

from TBAs ANMs

Other Useful

Indicators

• Home deliveries per reported deliveries

• Perinatal mortality at home deliveries

• Maternal deaths from home deliveries

Suggested

level of use

State and District

Common

Problems

Home deliveries by untrained TBAs are often not reported

Actions to

Consider

• Home deliveries should be actively discouraged if

maternal mortality is to be reduced

• Conditions at institutions should be made more

acceptable (culturally, socially, financially etc) to

encourage institutional deliveries

Indicator MH 8: Basic Emergency Obstetric Care (BEmOC) availability

Definition Number of facilities with functioning BEmOC per 500,000

population

Numerator Facilities who have reported all three BEmOC signal

functions within the past 3 (WHO RHI) months

• Complicated Delivery: IV Antibiotics

• Complicated Delivery: IV Oxytocics

• Complicated Delivery: IV Antihypertensives/ Magsulph

Denominator 500,000 population

Planned BEmOC centres or 24x7 facilities + FRUs

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Rationale BEmOC facilities are needed 4:500,000 total population

(Ref Programming for safe motherhood UNICEF 1999)

Three monthly indicator from facility development form

Data Source Labour Records / Maternity Registers at BEOC-designated

facilities

Other Useful

Indicators

• CEOC availability

• % Of DHs with functioning BEmOC

• % Of CHCs with functioning BEmOC

• % Of PHCs with functioning BEmOC

• Complications Rate

• Breakdown of BEOC signal functions to identify which

designated facilities are NOT providing the full range

of BEmOC

• Caesarean section rate

• SBA attendance rate

Suggested

level of use

State and district

Common

Problems

Distinction must be made between those facilities

actually functioning and those that have the equipment

but are NOT performing the functions

Poor reporting of signal functions by BEmOC facilities due

to poor records

Data from private facilities is often not collected, leading

to an under-estimation

Actions to

Consider

Equipment, staff and skills for BEmOC

Indicator MH 9: Comprehensive Emergency Obstetric Care (CEmOC) availability

Definition Number of facilities with functioning CEmOC functions

per 500,000 population. This implies that the facility has

provided BEmOC signal functions in addition to CEmOC

functions.

Numerator Facilities who have reported all BEmOC functions AND

CEmOC

Caesarean section

Blood transfusion

Denominator A. 500,000 population (WHO guidelines)

B. No of FRUs planned/ No of DHs

Rationale CEmOC facilities are needed 1:500,000 total population

(Ref Programming for safe motherhood UNICEF 1999)

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This is a monthly indicator from facility development form

Data Source Theatre Records / Maternity Registers at CEmOC-

designated facilities

Blood transfusion records

Other Useful

Indicators

Caesarean Section rate shows only surgical interventions,

without other CEmOC functions. This should be 5-15 %

% of DHs with CEmOC functions

% of CHCs with CEmOC functions

Blood transfusion rate will show blood transfusions for

CEmOC and other non-obstetric emergencies

Suggested

level of use

State and district

Common

Problems

Many facilities provide caesarean sections WITHOUT the

full package of BEmOC interventions. This should be

actively discouraged by a system of accreditation and

licensing.

Many private institutions do not report caesarean

sections, and it is often these instiutions that provide

C/sections without adequate indications

Actions to

Consider

Include private facilities in reporting maternal health

indicators

Indicator MH 10: Admission duration after delivery

Definition Percentage of women who were discharged in less than

48 hrs of delivery

Numerator Institutional delivery discharged up to 48 hrs of delivery

Denominator Deliveries Institutional

Rationale Postnatal care

All women should be kept in hospital for at least 48 hours

risk of postnatal complications and maternal mortality is

highest during this period

Data Source Maternity Registers maintained by the health workers and

health facilities

Other Useful

Indicators

• Causes of PNC complications

Suggested

level of use

District

Common

Problems

Many women want to go home early, but this prevents

adequate PNC

Actions to

Consider

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Indicator MH 11: Maternal Mortality Ratio

Definition The death of a woman while pregnant or within 42 days

of delivery or termination of pregnancy, irrespective of

the duration and site of the pregnancy, from any cause

related to or aggravated by the pregnancy or its

management but not from accidental causes.

Numerator Deaths Maternal ( this month; over last 12 months period)

Denominator No of live births recorded

No of live births estimated over a one year period

Rationale Maternal mortality Ratio reflects the quality of care during

pregnancy and the puerperium.

All maternal deaths should be subjected to an audit,

according to national guidelines

Data Source Line listing of maternal deaths; Labour records and

registers maintained at facilities CRS; Community

feedbacks

Other Useful

Indicators

A Maternal Mortality Audit should provide detailed

disaggregation by:

• Cause (sepsis, malaria, PPH, PIH, Obstructed labour,

unsafe abortion, anaemia)

• Maternal Age, under 19 years, over 35 years

• duration of pregnancy – first, second, third

trimester, post delivery

• place of delivery- home, institution etc

Maternal mortality rate is collected by special surveys

Suggested

level of use

National and below

Common

Problems

Maternal deaths are relatively rare events and need

large sample size

Under-reporting is a major problem with MMR. Most

women who die in pregnancy , die at home and it is

difficult to collect this data.

Even special surveys have problems getting accurate

data because respondents are not keen to talk about

these very tragic issues

Actions to

Consider

Indicator MH 12: Birth reporting rate

Definition Proportion of births reported over a given period of time.

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Numerator Births reported

Denominator Estimated births of population

Rationale This indicator assesses the proportion of births reported by

the health services in order to assess overall coverage of

safe deliveries by health workers.

Data Source Line listing of births; maternity registers and household

surveys etc

Other Useful

Indicators

Comparison to CRS reports

Suggested

level of use

National, State, District and Block

Common

Problems

Actions to

Consider

Indicator MH 13: Postnatal care

Definition Percentage of women who used postnatal care

provided by skilled health personnel

Numerator Postnatal mother/baby visits

Denominator Total Deliveries (Institutional + Home)

Rationale • Postnatal care (PNC) is an essential component

of both maternal and neonatal care, to detect

complications so that they can be treated early.

The postnatal check-up should follow national

protocols.

• PNC coverage is an indicator of access and use

of health care after delivery.

• The numerator should include mothers of babies

born at home and coming to health services

within 48 hours.

• Women should receive at least 2 postnatal care

check-ups, to avoid and treat any complication.

Ideally 3 PNC check-ups are required, 3rd after 42

days

Data Source Registers maintained by health workers; Household

surveys

Other Useful

Indicators

• Length of stay after delivery shows whether

mothers and babies are retained long enough to

receive adequate PNC

• Postnatal care at 7 and 28 days are also

measured , but these have minimal impact on

maternal and neonatal mortality

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• Perinatal mortality rate

• SBA delivery rate

Suggested

level of use

National and below

Common

Problems

Actions to

Consider

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CHILD AND NEONATAL HEALTH INDICATORS

Indicator CH 1: % newborns breastfed < 1 hour

Definition

Percentage of new born babies breastfed within one

hour of birth

Numerator New born breastfed within one hour of birth

Denominat

or Total live births(as recorded)

Rationale

Breastfeeding in the first hour also helps to establish

breastfeeding. The more the first feed is delayed the

more difficult it is to initiate breastfeeding. Breastfeeding

in the first hour also gives the neonate colostrum, which is

rich in immuno-stimulants. However many cultures do

not give this.

This is a very good index of effectiveness of BCC work

and of ASHA

programme where this is part of her work. This indicator

can be

used to strengthen these programmes. Even if

breastfeeding is done within 2 hours, or within 24 hours, if

colustrum is not purposefully expressed out and thrown

away, colustrum feeding is considered as achieved.

Data

Source

This would figure in the birth register, in the labour room

register and in the pregnancy 1 Registers maintained by

health workers and health

facilities. Oral reports from home based caregivers( like

ASHAs and

Anganwadi workers) as told to ANMs be recorded by

ANMs.

Home visits in early neonatal period for home deliveries is

essential for this information

Other Useful

• breast feeding in first two hours. ( potentially available

if line-listing in reporting of births includes this. At present it

does not). This improves earlier than at one hour and is

also reflective of ASHA/ health worker efforts

• Breastfeeding initiation in first 24 hours.( availability

of data element same as above). This shows the

severity of this problem

• Perinatal mortality rate, neonatal mortality rate.

Low birth weight rate

Indicators • Postnatal care rate

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Suggested level

of use District

Common

Problems

Often not recorded, as there is often no space in

maternity registers to

record this data

Staff not focused on task of persuading mother /family

Collection of data from ASHAs could be a problem if

ASHA

programme is not designed to deliver this.

Actions to

Consider

Formative research to understand the issue and design

BCC programmes to promote immediate breastfeeding

Ensure registers re modified to include immediate

breastfeeding

Include in support protocols for home based care givers

like ASHAs

Indicator CH 2: Neonatal referral rate

Definition

Percentage of neonates (upto 28days old) with complications

referred for

institutional care

Numerator

Neonates seen in a PHC or CHC or higher facility because it is sick

or low birth

weight or has a complication- whether it was referred from the

home, or

presented on its own in the institution, or whether it was diagnosed

in the

institution.

Denominato

r Live births( as recorded)

Rationale

This data should be collected by institutions to identify the

proportion of

neonates with complications referred for specialised care

Data Source Neonatal registers at institutions

Other Useful

Indicators

•% of newborn referrals against estimated live births – this needs no

new data element- and is most useful where private sector is also

reporting.

• % of low birth weights and severe low birth weight

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• % Newborn referrals successfully treated( if appropriate data

element is added)

Suggested

level

District

of use

Common • The number of families advised a referral is NOT being taken as it

is difficult to estimate how seriously referral advice was taken up by

Problems

family. Therefore only those referral that were received by

institution are measured, even

if some are self-referred.

• Referrals to Private hospitals will not be picked up and this may

account for the majority

• No specific place of recording

in facility registers

• Skills to detect a sick new born lacking amongst health workers

and

hence both referral from below and identification in the

institution could

be poor.

Best calculated with at least

3000 births.

Actions to • If rate is low find out whether it is due to lack of newborn visits

and newborn referrals or due to poor transport or due to poor care

and credibility at the facility. To Build up credibility and quality of

care giving institutions

Consider

• Ensure private sector also

reports

Indicator CH 3: Sex ratio at birth

Definition Number of females born per 1000 males born in a give time period

Numerator Live Births females x 1000

Denominat

or Live Births males

Rationale

Declining sex ratio is an important public health concerns and sex

ratio at births

is one of most precise indicators of this. Note that the usual sex ratio

at birth where there is no active discrimination is about 950 females

per 1000 males( this is due to a slightly greater loss of male fetuses).

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Due to a slightly greater mortality of male children in next five

years, it becomes an equal or female preponderant ratio for sex

ratio in the 0 to 6 age group. However with optimum care these

slightly increased loss before and after birth may decline. Therefore

figures in this 950 range need to be interpreted with caution. Below

this figure there a gender discrimination factor becomes likely.

Data

Source

Line listing of births maintained by health workers; delivery registers

Other Useful • Sex ratio in 0-5 age group

Indicators

• Sex ratio in population

Suggested

level National and below, particularly district as there is no other source

of data at district level.

of use

Calculate only when you have at least 3,000 births, otherwise

fluctuations will

be too high.

Common • Completeness of birth reporting is an issue

Problems

Actions to • Strengthen implementation of PNDT act

Consider

• Social mobilisation to combat “son preference”

Indicator CH 3A: Recorded Birth rate

Definition • Live births per 1000 population

Numerator:

• All recorded live births in that facility’s service

area/block/district in the last 12 months

Denominator: • Population of that facility’s service area/ block/district

Rationale

• This is the crude indicator of fertility in that population. Also by

comparing the recorded birth rate with the estimated birth rate

or external survey based birth rates one can arrive at a picture

of how many children in that area are being missed out and

this is useful to keep in mind while reading and interpreting all

other child health indicators.

Data Source •

Birth and death register

Maternity registers of Sub-Centres, PHC and CHCs.

• Household surveys

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Other useful • Total fertility rate

indicators •

Normal

Ranges

•

The states birth rate is available from the SRS. The goal is to

reach a birth rate of less than 21 per 1000 population.

Normally it should be 100%

Common

•

Many births that take place in private sector or at home get

missed. Since much of the reporting could be based on

hearsay- there is loss of accuracy. There could be double

counting

Problems

The indicator is an estimate. For many reasons the

denominator could be wrong or the birth rate could be

more or less that expected.

The numerator should be for a full year. This means adding

the livebirths of the last 12 months- and then plotting this

indicator on a graph so as to see trends. Monthly use of this

indicator has little role. Also take a unit which has more than

3000 births in that period ( a number of areas taken

together, or a number of months taken together ) to be able

to cast a meaningful indicator.

•

If the indicator is low, check whether all births are being

recorded or some areas are getting missed out/ poor quality

of recording or whether it is because there has been a

change in the denominator or due to declining fertility.

Actions to •

If indicator is higher than expected and sustained it may be

a major movement of the population in or increase of fertility

rates

consider •

•

Indicator CH 4: Low birth weight rate

Definition

• Percentage of live born infants with a Birth weight under

2,500 grams

Numerator: • Live births with a birth weight < 2500g.

Denominator: • Live births weighed

Rationale

• At the population level, the low birth weight (LBW) rate is an

indicator

of a multifaceted public-health problem that includes long-

term

maternal malnutrition, ill health, hard work and poor health

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care in

pregnancy.

• On an individual basis, low birth weight is an important

predictor of

newborn health and survival

• Live babies with weight of <2,500 grams indicate poor

nutritional

status of mothers or maternal illness, but may be influenced

by other

factors such as smoking, alcohol abuse, other illness such as

TB, HIV

or chronic lung or heart disease.

Data Source • Maternity registers of Sub-Centres, PHC and CHCs.

• Household surveys

Other useful •

% children weighed- the denominator would be recorded

live births.

indicators •

% live births with severe LBW- that is a weight below 1.8 kg

and below 1.6 kg. Below 1.6 kg hosipitalisation is mandatory

and even below 1.8 it is desirable. Children between 1.8 kg

and 2.5 kg can be managed at home if there is no other

complication.

Normal

Ranges

•

Less than 10% of all birth should be under 2,500 grams,

though many

states have up to 30% LBW

Common •

Many children are not weighed at birth, particularly those

delivered at

Problems

home. If the child is weighed after 24 hours, there is normally

some further weight loss which picks up again at about a

week and then steadily increases. Hence the insistence on

taking only the first days’ weighing as accurate.

• Many health facilities do not have accurate scales (10gm

accuracy

needed) and health staff often do not use existing scales

well, resulting

in further errors.

When percentage of births which have been weighed is

low, or live births recorded is a small part of expected live

births, this indicator has to be used with caution as it is the

most vulnerable section that tends to get left out of

coverage

Efforts to increase percentage of children weighed- by

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studying who is getting missed out and why.

• Improved quality of ANC

Actions to •

BCC regarding nutrition, smoking and drinking during

pregnancy

consider • Attention to adolescent anaemia and malnutrition

• Assistance to secure food entitlements during maternity

Improve institutional new born care and referral

arrangement where severe low birth weight is high

Indicator CH 5: Neonatal mortality rate

Definition

Neonatal mortality rate (NNMR) measures the number of live-born

babies

dying within 28 completed days of life per 1,000 live births.

Numerator Deaths in first 28 days

Denominat

or 1000 live births

Rationale

Neonatal mortality (particularly early mortality) is affected by

quality of care

for the neonate. This is a significant proportion of IMR

Direct Causes are asphyxia , sepsis, hypothermia and neonatal

tetanus. Indirect

causes are low birth weight, prematurity, birth injuries and

congenital anomalies

Data

Source

Line listing in the birth and death register and Institutional records

Registrar of births and deaths- compulsory registration system,

Household surveys

Other Useful • NNMR can be divided into early (0-7 days) and late (8-28 days).

This information is potentially available in the line list- but currently

not being aggregated.

Indicators

• NNMR can be disaggregated by gender

Suggested

level State and district. Calculate only when you have at least 3,000

births, otherwise

of use

fluctuations will be too high.If we are plotting the monthly trend

that either it is for a large area or we are taking the cumulative

total of a a number of months or even a year.

Common

Problems

• Underreporting and misclassifications ( as still births )are

common, particularly for deaths. Cultural reluctance to reporting

early neonatal deaths- which only good training and supervision

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and community dialogue can overcomes

occurring early in life (particularly first hour).

Actions to • Staff training and health facility equipment for a functional

newborn care

Consider

unit

• Appropriate home based neonatal health care providers to be

trained

Indicator CH 6: Infant Mortality rate

Definition

Infant Mortality rate (IMR) measures the number of deaths of

infants under

one year of age per 1,000 live births

Numerator

Deaths infants less than one year old (Neonatal death plus

deaths in 1-12 months)

Denominat

or 1,000 Live births

Rationale

This MDG indicator is a good measure of the socio-economic,

nutritional

and environmental health status of a given population.

Common causes of death after the neonatal period are

diarrhoea, acute respiratory infection, malaria,

malnutrition, vaccine preventable

diseases, especially measles

A significant proportion of the IMR is related to neonatal care

Infant deaths should be reported monthly and IMR calculated

semi-

annually. One needs to ensure that in this period of calculation there has been at least 3000 live births in that area.At a local level – block or lower- this information is actionable even without making it into an indicator.

Data Source

Routine: Line listing of deaths; Institutional records

Others: Registrar of births and deaths, Population-based surveys, especially Sample Registration Surveys

Other Useful

Indicators

• IMR by gender gives insight into poor care for the female child and

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22

female infanticide

• Perinatal and neonatal death rates measure quality of care

at birth

• Disease specific death rates due to diarrhoea, malaria, ARI

etc provide clues for immediate action

• IMR can be disaggregated by social class, residence,

income etc

• Underweight rate under one year measures nutritional status.

This acts as a risk factor, increasing the likelihood of death from

any of the above causes. Suggested level of

National, state and district. Below

district even the data element by

itself provides actionable

information.

use

Common

Problems

• IMR from routine data can be inaccurate because of

unreported deaths

occurring in the home, particularly amongst poor and

disadvantaged

communities not reached by health services. Cultural reluctance to report neonatal deaths.

• Tendency to underreport due to threat of reprimand from

above

Deaths before the first birthday are all included in this.

Actions to

Consider

• Improved notification through line listing by health workers,

• Community notification of deaths- to VHSCs, PRIs, NGOs etc - a form of community monitoring to uncover unreported deaths.

• Ensure that truthful reporting of higher deaths that expected is not met with reprimands but with assistance.

Indicator CH 7: Under 5 mortality rate

Definition Under-five mortality rate measures the number of children who

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23

die before their

fifth birthday per 1000 children under five years

Numerator Deaths Neonatal + Deaths infant + Deaths 1-5 years

Denominator 1,000 children under five years

Rationale

Under-five mortality rate is a general indicator of the level of

child health,

It measures more the socio-economic, environmental and

nutrition status of

children, rather than direct health care delivery.

Data Source Line listing of deaths at Sub Centre; Institutional records

Vital registration- registrar of births and deaths; Population census; Population-based surveys, such as DHS.

Other Useful • U5MR can be disaggregated by gender, social class,

residence, income etc

Indicators • See infant mortality rate indicators

Suggested

level of National and below. Calculate only when you have at least

3,000 births,

use

otherwise fluctuations will be too

high.

Common

Problems

• Poor reporting of child deaths, particularly in hard-to-reach

and poor

communities

Actions to

Consider

• Improved notification through line listing by health workers,

• Community notification of

deaths- improve recording of

unreported deaths and increases

community action to prevent

deaths

•

Improved quality of care for children through health workers

at home

Definition Peri-natal deaths comprise still births (gestation over 228 weeks / >1000 grams

weight) plus early neonatal deaths (infants dying within 7 days). Numerator Deaths Peri-natal (still births plus early neonatal in first week)

Denomin

at 1000 live Births.

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or

Rationale

PNMR directly reflects maternal health, quality of prenatal, intra-

partum and

neonatal care

Peri-natal deaths comprise up to 40% of infant deaths and their

reduction is the

most important way health services contribute to reducing IMR. PNMR

gives an

indication of the quality of maternal and child health services.

This indicator includes still births, which are as numerous as first week

deaths. Any pregnancy outcome other than a live birth after the

pregnancy has achieved 28 weeks would get included in this. The

criteria of weight above 1000 gms may have to be ignored if weight

of the still-birth/aborted fetus is not available.

All peri-natal deaths should be audited according to national

guidelines to identify

preventable deaths and improve neonatal care.

Data Registers from Delivery and neonatal wards; Line listing by ANMs; Vital

Source registration; Population census; Population-based surveys, such as DHS.

Still birth rate- this is what can be calculated from the current data

elements available. Still birth estimation has a reciprocal relationship

with both abortion at one end and neonatal mortality at the other.

For calculating perinatal mortality rate as defined above-one needs

to be collecting neonatal deaths in the first week as distinct from any

neonatal death. However this information is potentially available in

the line list.

Abortion rates- this also closely correlates with the above rates.

Abortion data elements have to be crossed with the pregnancy

tracking to ensure that stillbirths are not misclassified as abortions

which at around 28 weeks could be a problem.

Other A perinatal audit can provide useful additional information on quality

of care

Useful

PNMR at different type and level of Institutions, public and private Indicator

s

PNMR by type of birth assistant (SBA, Non-SBA)

PNMR by gender

Compare with NNMR Suggested

level of National and below. Calculate and make predictive trend analysis only when you

Indicator Manual

25

use

have at least 3,000 births, otherwise fluctuations will be too high.

Common Comparisons between different rates may be hampered by varying definitions,

Problems

registration bias, and differences in the underlying risks of the

populations.

Reporting of still births is also problematic Actions to Institutions with high PNMR need additional support to identify the

causes of the

Consider

deaths, and will normally need training on neonatal care techniques.

By comparing PNMR with other rates, one can arrive at conclusions

about which

areas of child care require prioritisation. 2 Some authorities state 22 weeks or 500 grams but in India neonates of this age are not viable, Other authorities use 32 weeks: hence 28 weeks or start of 3rd

trimester is taken as cut-off.

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26

IMMUNISATION INDICATORS

Indicator CH IMM 1: Vaccine Specific Immunisation coverage under one year A BCG B OPV (1,2,3) C DPT (1,2,3) D Measles E Hep B (1,2,3) where used

Definition Vaccine specific immunisation coverage is the percentage of children under a year who

have received particular doses of a specific vaccine

Numerator

Children under 12 months( which is same as saying children 0 to 11

months old) given the specific vaccines

BCG,

OPV, (1,2,3)

DPT,(1,2,3)

Measles,

Hep B (1,2,3) where used

Denominator

a. Total recorded live births : b. Expected number of children under 12 months, based on mid

year estimates.

Rationale

Vaccine specific Immunisation coverage rates are used to monitor

immunisation services,

to guide disease eradication and elimination efforts,

They are an indicator of health system performance.

Measles immunisation coverage is a national and MDG indicator

used as a proxy for full

immunisation coverage.

Data Source

Immunisation registers kept by health workers; Immunisation

coverage cluster surveys;

other household surveys

Normal

range

National target is 100%; states and districts need to set their own

targets

Other Useful Full immunisation coverage

Indicators

Immunisation drop-out rates

Incidence of vaccine preventable diseases

Vaccine utilisation rates

Vaccine availability rates

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27

Cold Chain function indicators Suggested level

National for Measles; State and district for others

of use

Common No vaccinations given to children over one year should be included in this

Problems Indicator.

Actions to Low immunisation coverage needs urgent action by health services

and

Consider

communities. It may indicate poor planning, supply side problems

e.g. out of

stock or need for vaccine transport

Improve local planning and community involvement

Rates over 100% mean denominator problems or double counting

Indicator CH IMM2: Full Immunisation coverage

Definition

Full Immunisation coverage is the percentage of one-year-old

children who have received

all required vaccines.

Numerator

Number of children 9 to 12 months who completed their

immunisation schedule (BCG, OPV3 and DPT3 and measles) in the

past year

Number of children 12 to 23 months who had already complete immunization or completed their immunization schedule during the past year

Denominator

Expected number of 0 to 12 months children based on mid year estimates. Actual number of 0 to 12 months children based on live births during this year Expected number of 12 to 23 months children based on mid-year estimates Actual number of 12 to 23 months children based on household survey done at year beginning.

Rationale

Full Immunisation coverage is the “pinnacle” indicator for

immunisation coverage and

means that the child should be fully protected against the six

vaccine preventable

diseases, and is a valuable way to reduce

infant mortality.

Data Source

Immunisation registers kept by health workers ;

There needs to be a separate column in this

register where the age of child in months when

given the last immunization needed for full

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immunization status is recorded

EPI cluster surveys; Other household surveys

Other Useful • Full immunisation coverage by gender – male and female

Indicators

•

Vaccine-specific vaccination coverage

rates

• Full immunisation coverage rates from cluster

surveys

• Vaccine preventable disease incidence rates

• Vaccine utilisation and availability rates

• Cold chain function indicators Suggested level

National, State, District, Block

of use

Common • This data is hard to keep accurately routinely with current tools

Problems

• Routine data should be cross-checked by EPI cluster surveys (see

WHO mid level

manager cluster survey manual) and other household surveys such as DHS. Surveys usually use a 12 to 23 month denominator.

Actions to • Children need an immunisation card to track that all doses have been given. The register also needs provision for child tracking.

Consider

• Vaccine register should show children who completed

immunisation

schedule in a separate column

• by comparing full and individual immunisation coverage, catch

up

campaigns to be instituted to provide individual vaccines in specific areas

Indicator CH IMM 3: Immunisation adverse reactions

Definition

An adverse immunisation reaction is an unwanted or harmful

reaction

experienced following administration of a vaccine

It can be described as a medical event that takes place after an

immunisation

that causes concern and is believed to be caused by

immunisation

(Immunisation handbook for health workers GoI 2007)

Numerator

Adverse reactions –

A) Abscesses

B) Deaths

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29

C) Others

Denominator Total number of immunisations given

Rationale

Adverse effects are a sensitive indicator of quality of immunisation

Adverse reactions can be grouped into reactions inherent to

immunisation

(pain, swelling, redness or general reactions), due to faulty

techniques,

hypersensitivity, neurological involvement, provocative reactions

Under RIMS, three kinds of reaction are identified – Abscess,

Deaths and

Others e.g. allergy, anaphylaxis, hypotensive /hypo responsive

episodes, BCG

lymphadenitis, etc

Data Source

Immunisation registers, facility data collection forms, IDSP death

reports

Other Useful • Drop out rates show perceived quality by the mother Suggested level

State and below

of use

Common • Non-reporting;

Problems

• “Others” is a large category

• Death of the child upto 6 days after the immunization is to

be reported- unless it is due to accident. Many of these

deaths may have other causes- but that is to be validated

by medical officers separately – these deaths are only

presumptively vaccine related- the point is to have a high

index of suspicion so as not to miss cases.

• Delayed reactions are difficult to collect

Actions to

•

Investigate all adverse reactions to identify the cause and

advise peripheral workers to take appropriate action for

abscesses and other complications. Check on supply .For

deaths it needs to be reported to state and national level and

separate report filed with vaccine batch details etc.

Consider

Indicator CH IMM 4: % of planned immunisation sessions held

Definition Percentage of total planned immunisation sessions held

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30

Numerator Number of immunisation sessions held

Denominator Total number of immunisation sessions planned

Rationale

For a given population with a known number of health

facilities and staff and outreach points( eg anganwadi

centers)

the number of immunisation sessions to cover the population

is pre-

determined. It is important to see what percentage of this

needed

coverage is achieved.

Immunisation needs careful planning and this indicator

measures

implementation of the plan. Poor planning leads to poor

implementation

of immunisation

Lack of transport is a common reason for cancellation of

sessions; Non availability of the ANM due to sickness or other personal causes, lack of vaccine supplies etc are also other causes. Need to ensure adequate transport for vaccines and transport for the ANM where this is the constraint.

Data Source

Registers maintained by health workers and health facilities

Denominator from district immunisation office Suggested level of

District, Block

use

Common • Reliability of reporting of immunisation sessions held is low because

Problems

worker is directly accountable for the failure.

• Detailed micro planning exercise often not carried out. The

number of sessions planned itself may be faulty.

Actions to • Strengthen planning process and implementation through improved

Consider

supervision

• Involve communities in planning of immunisations at sites

and time

convenient to them and reporting sessions NOT held Indicator CH IMM 5: Vitamin A coverage rate Definition Percentage of children who have received all required vitamin A

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31

doses. (One

dose for a child under one and five doses for a child under three years)

Numerator

Children who received Vitamin A

A) 1 dose under one year

B) 5 doses under three years

C) 9 doses under 5 years

Denominator Expected number of children based on mid year estimates.

Rationale

• Vitamin A supplements given between six and 72 months is

stated to reduce

mortality by 23%, where vitamin A deficiency exists.

• Vitamin A supplements as part of measles case management

can reduce the case

fatality rate by more than 50%.

Data Source

Immunisation register and Reports of Vitamin A by service

providers

Other Useful • Measles case fatality rates

Indicators

• Vaccine-specific coverage rates to compare to vitamin A

coverage rates Suggested level

State and District

of use

Common • Difficult to report multiple doses at different ages

Problems

No age estimates of 3 year old children available

Unless children have a vitamin A/immunization tracking card which goes upto 5 years- it would be difficult to estimate who has achieved the 5th, dose, 9th dose etc. It is not advised to make bulky registers that list all children upto 5 years and track them all along for each dose.

Actions to • Identify areas with low coverage and ensure supplies and promotion

Consider

Activity. Indicator CH IMM 6: Immunisation drop out rate

Definition

Comparison of the number of children who start receiving

immunisation and

the number who do not receive later doses for full immunisation

Numerator Number of children starting particular dose of antigen MINUS

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32

number of

children receiving later dose of antigen

Denominator Number of children starting particular dose of antigen

Rationale

This is an indicator of quality of immunisation services and allows

a view of the

trends in coverage for specific vaccines. Useful drop out rates

are

A) BCG to DPT3

B) BCG to Measles

C) DPT1 to DPT3

D) DPT1 to Measles

This is a cohort sample and periodicity should be (semi) annual,

rather than

monthly

Data Source

Facility routine data collection forms; Immunisation Registers;

Other Useful • Vaccine specific and full immunisation coverage rates

Indicators •Vaccine availability

• Vaccine preventable disease incidence

Suggested State and district

level of use

Common • A high drop out rate means that mothers have no faith in the immunisation

Problems

• A negative drop out rate can occur if there is a stock out of

the “early”

vaccines and good supply of the late vaccine

Actions to • Ensure best possible quality of immunisation

Consider

• Ensure child tracking with immunisation card

• BCC to mothers on importance of finishing immunisation

course

•Ensure constant availability of vaccine

FAMILY PLANNING INDICATORS

Indicator FP1: Couple Year Protection Rate

Definition Percentage of eligible couples in the community protected by

"modern" family planning methods for one year .

Numerator: Number of couples protected by each family planning method

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33

which is approximated by a formula:: number of cases sterilised in particular month*10+number of pills distributed/13 + number of IUDs inserted*5.5+ no of condom pieces distributed/100

Denominator Number of eligible couples (with fertile age women 15-49 years). The number of eligible couples are approximate 17% of total population. Actually recorded eligible couples is what is used as denominator but this may be compared with estimated couples in the population,

Rationale Each family planning method is effective for different periods - this

is a calculated indicator which measures the contribution of each

method to protection of eligible couples in the community.

Data Source The easiest way to calculate this is from the stock cards and from sterilisation record. Note the total outgoing contraceptives for each type and divide or multiply by the appropriate factor:

• Sterilisation X10 • Pills / 13 • IUD x 5.5 • Condom pieces/ 72 X100

Actions to

Consider

Low coverage means that unwanted pregnancies will occur. Increased CYP will occur mainly through health promotion and increases status of women, but will also be increased by:

• increasing availability of contraceptives to teenagers, working women and other high risk groups;

• improving the contraceptive mix to include more effective and longer- term contraceptives such as injectables, IUDs and sterilisations.

Other

Possible

Indicators

• This indicator is best annualised - i.e. the month’s value multiplied by 12 to get a picture of what would happen if this rate continued throughout the year.

• Termination of pregnancy rate is an indicator of failed contraception leading to unwanted pregnancies.

• Method mix is the relative proportion of total CYP provided by each method. It is best visualised as a pie diagram.

• Acceptor rate is number of couples reporting to be using any method as the numerator and total eligible couples as the denominator. a relatively low value indicator for contraceptive effectiveness as it does not measure protection of women, but merely attendance of women at the clinic for a particular service. It could however be used locally to ensure that all couples are reached and improve the programme. The family planning service delivery register and tracking register would help track this- and the figure “% of eligible couples not using any method but wanting to use” is the most important category.

• Contraceptive prevalence rate (MDG) is the CYP equivalent but needs a household survey to know it.

• Total fertility rate shows the impact of family planning . This is

Deleted: .

Indicator Manual

34

got from NHFS and SRS data- but would only have state figures.

• Birth rates- • % of births which were third and above; % of second or further

births which had less than three years gap with earlier birth, % of births in women less than 19 years of age.( registers record the data elements needed- but this is not reported up currently)

Suggested

level of use

National

Common

problems

This is a complicated indicator, most easily calculated using a

computer

Actions to

consider

Indicator FP 2: Family Planning Coverage rate by method

Definition The coverage contribution of each contraceptive method to

the overall family planning program

Numerator Total number of units of each type of contraceptive

distributed

A) Oral Contraceptive cycles

B) Condoms

C) IUD insertion D) Centchroman (weekly) pills

E) Emergency Contraceptive pills

Denominator Eligible couples

Rationale The indicator provides a profile of the relative level of use of

different contraceptive methods. This also suggests that the

population has access to a range of different contraceptive

methods

Data Source Family Planning Registers maintained by health workers and

health facilities; Household surveys

Other Useful

Indicators

Method Mix

Suggested

level of use

District

Common

Problems

Exact number of OCPs or condoms distributed- are difficult to

estimate since these are usually given out by depot holders

and ANMs only know the stock refill they provide to the

depots. Also distribution does not mean use.

Actions to

Consider

Indicator Manual

35

Indicator Manual

36

Indicator FP 3: Sterilisation rate

A Males

B Females

Definition Proportion of eligible couples sterilised

A) Males where the family size is 2 or more children and

the wife is under 49 and has not been sterilised

B) Females where the family size is 2 or more children and

the female is between 20 - 49 years and husband has

not been sterilised

Numerator Sterilisations performed this month plus already sterilised

eligible couples

A) Male

B) Female

Denominator Eligible couples

Rationale Sterilisation is a permanent method that contributes 12.5years

to CYP.

Male Sterilisation is indicative of male participation in family

planning and is usually held in camps

Data Source Registers and data collection forms maintained by health

workers and health facilities (including Camp)

Eligible couple registers

Other Useful

Indicators

• Male sterilisation by type –

o conventional and

o NSV

• Female Sterilisation by types

o Mini-laparotomy

o Conventional

o laparoscopic

• Sterilisation rate by place – CHC, hospital, camp, etc

• Sterilisation rate by provider – public/private etc.

• Post-partum sterilisation rates

• Total fertility rate

Suggested

level of use

National and below

Targets 20% of all sterilisations should be males

Common

Problems

Permanent sterilisation is the most commonly used method of

family planning

When used when family size is already large, it does not

affect TFR

Very few males go for vasectomy!!

Actions to

Consider

Indicator Manual

37