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MATERNAL HEALTH INDICATORS
Indicator MH 1: Antenatal care first visit coverage rate
A: ANC First VisitB:ANC First Visit in first trimesterC: ANC registered under JSY
Definition Percentage of pregnant women who used Antenatal Care(ANC) provided by skilled health personnel, for reasonsrelated to pregnancy, registered in first trimester ofpregnancyN.B - This indicator is also known as Any Antenatal carevisit
Numerator:
A: New Registered/first ANC visit of a pregnant womanB: Pregnant women registered within first trimester
C: New women registered under JSYDenominator
A:Total expected pregnanciesB,C: Total number of ANC registered
Rationale This first visit should be a "registration" visit where allinitial procedures relating to assessing/preparing awoman for pregnancy and delivery. This should includehistory, examination, initial blood tests andimmunisation.
Antenatal care coverage is an indicator of access anduse of health care during pregnancy. All women shouldhave 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 ofwomen entitled to benefits under JSY. This is include :a) all women in EAG and NE states b) only BPL & SC/STwomen in HPS states
% of pregnant women receiving any ANC is a sensitiveindicator of outreach
DataSource
Antenatal / pregnancy registers; Maternal health cards
Household surveys
Population data - an estimate of the number ofpregnant women is close to the number of childrenborn (2.2-3.2% of population)
Suggested level ofuse
National, state, district/ block and sub-centre
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OtherUsefulIndicators
Risk and continuity indicators are important in ANC
VDRL (syphilis) and HIV testing coverage shows qualityof 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.
CommonProblems
Attendance for pregnancy test or simple registrationwithout history and examination do NOT constituteantenatal care.
Women who have started ANC elsewhere,butwho come to your facility for follow up should becounted as follow up ANC and not first ANC
ActionstoConsider
Low coverage means either the strategy for providingANC needs to be reviewed to increase access, or thecommunity should be approached to increaseawareness through ASHA,VHSC,BCC etc
Indicator MH 2: ANC third visit coverage rate
Definition Percentage of women who used antenatal care providedby skilled health personnel for reasons related topregnancy at least 3 times during pregnancy
Numerato
r
ANC third visit
Denominator
A. Expected pregnanciesB. ANC any visit
Rationale Antenatal care third coverage is an indicator ofcontinuity and use of health care during pregnancy andalso of access
Poor quality ANC could also be a reason that womencome once and then stop
DataSource
ANC Register maintained by health workers
Other
UsefulIndicators
Drop-out rate first to third ANC
Comparison of third ANC to delivery rates
%ANC with full blood tests (Hb, HIV, VDRL)
Suggested level ofuse
State, District, Block and sub-centre
Common When ANC has been done in different
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Problems facilities
High coverage may mean problems with your choice ofdenominator, or double counting
Actionsto
Consider
Low coverage means either the strategy for providingANC needs to be reviewed to increase access, or the
community should be approached to increaseawareness through ASHA,VHSC,BCC
Improved quality of care in earlier visits
Ensure that first ANC are not done through sporadiccamps or MMU approaches
Indicator MH 3:
% ANC TT-1 coverage rate
% ANC TT2 and TT booster coverage rate
ANC 100 IFA coverage rate
Definition Percentage of pregnant women who used antenatal careand were given TT1,TT2 or TT booster vaccine
Numerator
A Antenatal care given TT-1B. Antenatal care given TT2 or TT boosterC. Antenatal care given 100 IFA Tablets
Denominator
Total ANC registered (ANC first visit)
Rationale Antenatal care 100 IFA coverage is an indicator ofquality of ANC
Antenatal care TT-1, TT-2 / Booster coverage is anindicator of quality of ANC
It is also an indicator for availability of the basicimmunisation of ANC
All pregnant women are recommended 100 IFA Tablets
Woman in her First pregnancy needs TWO TTimmunisations; subsequent pregnancies she needs onlya booster
DataSource
Registers maintained by health workers; Householdsurveys
OtherUsefulIndicators
TT protected at birth rate measures % of newbornsprotected from tetanus by their mother being fullyimmunised for TT
Neonatal Tetanus rate measures cases of Neonataltetanus- a failure of our ANC TT immunisation program
Anaemia rateSuggested level of
State, District, Block, sub centre
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useCommonProblems
IFA tablets given may not be consumed
Actions toConsider
Addresses supply side issues
Ensure quality of ANC
Awareness generation among mothers on availingcomplete ANC services
Indicator MH 4: ANC Anaemic & Hypertension testing andmanagement rates
A. % ANC moderately anaemicB. % ANC severely anaemicC. % ANC severely anaemic treated rateD. % ANC hypertension new case detection rateE. Eclampsia cases management rate
Definition Percentage of pregnant women tested to be moderatelyanaemic (Hb level
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J.Maternal death due to excessive bleeding is more likelyin an anaemic
K. Laboratory equipment availability rateSuggested level of
use
Health sub-centre, PHC, CHC
CommonProblems
L. BP is often not taken and Hb testing is not doneM. Health sub-centres do not have BP apparatus and
Hb kitsN. Sufficient stock of IFA tablets
Actions toConsider
O. Address supply side issuesP. Ensure quality of ANCQ. 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 BirthAttendant (at home and at institutions)
SkilledBirthAttendantdefinition
A skilled birth attendantis an accredited healthprofessional - such as a midwife, doctor or nurse - whohas been educated and trained to proficiency in the skillsneeded to manage normal (uncomplicated) pregnancies,childbirth and the immediate postnatal period, and in theidentification, management and referral of complications
in women and newbornsNumerator
Deliveries by SBA (SBA Home + all Institutionaldeliveries)
Denominator
A. Expected numbers of deliveriesB. Total recorded deliveries
Rationale Attendance of deliveries by skilled birth attendantsis the single most important factor in reducing maternalmortality, and is a MDG indicator.
There is increasing evidence that the SBA is mosteffective when delivering in institutions, rather than athome.
DataSource
Labour records and maternity registers maintained atfacilities and by health workers; Household surveys
OtherUsefulIndicators
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 deliveriesSuggeste District, Block
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d level ofuseCommonProblems
The definition of SBA excludes Traditional birthattendants, even if they have been trained. Evenprofessional staff that have had training, lose their
delivery skills if they do not use them. Even ANMs only have a minimal amount ofdelivery training and most of their skills are learnedthrough experience, not formal training. For the purposeof measurability, all nurses and ANMs are counted, whichleads to an overestimation of those who are skilled.
Since deliveries in private sector and underservedareas are unreported, the use of expected number ofdeliveries may lead to an underestimation of SBAdeliveries, hence the need to use reported deliveries asdenominator
ActionstoConsider
Include private sector deliveries
Indicator MH 6: Institutional delivery rate
A Institutional delivery rateB Reported Institutional Delivery RateC Institutional delivery complication attendance rateD Postnatal maternal complications attendance rateE % Institutional delivery receiving JSY benefitDefinition A) Proportion of total deliveries that took place in
any health facilityB) Institutional deliveries that took place in health
facilitiesC) Proportion of Institutional deliveries with delivery
complicationsD) Proportion of Institutional deliveries with maternal
postnatal complicationsE) Proportion of institutional deliveries where the
woman got JSY benefitsNumerator A) All institutional deliveries
B) All institutional deliveriesC) Number of complicated delivery cases attended(public + private institutions)
D) Postnatal complications attendedE) Delivery institutional women received JSY benefits
Denominator
A: Expected deliveries (2.2 To 3.2 % of population)B: Total Number of deliveries reportedC: Total Number of deliveries reported
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D: Total Number of deliveries reported E:= DeliveriesInstitutional
Rationale A) There is clear evidence that institutionaldeliveries by SBAs are the key to reducingmaternal mortality, due to improved emergency
infrastructure, access to transport and referralfacilities and a number of other factors.
B) In absence of complete estimated populationfigures in states, the institutional deliveryperformance can also be calculated by totalreported delivery figures. This can supplementthe overall understanding of the institutionaldelivery in the state
C) Postnatal complications shows the rate ofidentification of postnatal complications at PNCvisits
D) JSY benefits are given to encourage women tocome for institutional deliveries, thus reducingmaternal mortality.
DataSource
Maternity registers maintained by health workers athealth facilities; Household surveys
OtherUsefulIndicators
Institutional deliveries can be broken down by typeof institution SC, PHC, CHC, hospital etc
Institutional Perinatal mortality rate is a goodindicator of quality of care;
% deliveries by SBAs should be assessed where notall nurses at institutions are trained SBAs,
Suggestedlevel of use
National and below
CommonProblemsActions toConsider
Indicator MH 7: Home delivery rate
A Home delivery rateB Reported home delivery rate
C Home delivery by Skilled birth attendant (SBA) rateD Home delivery by Non Skilled birth attendant rateE % Home delivery receiving JSY benefit
Definition A) Percentage of total deliveries that took place athome
B) Reported home delivery rateC) Home deliveries attended by SBA
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D) Home deliveries attended by Non-SBAE) Home deliveries receiving JSY benefit
Numerator
A) Deliveries Home (SBA and non-SBA)B) Deliveries Home (SBA and non-SBA)C) Deliveries home SBA
D) Deliveries home Non-SBAE) Deliveries home women received JSY benefit
Denominator
A, C & D =Total expected deliveriesB= Total reported deliveries (home + Institution)E=total home deliveries
Rationale Home deliveries occur in all states, but are notencouraged because when complications arise , lifesaving EmOC is not available
Home deliveries by SBAs should be discouraged, as itis more effective to deliver at institutions wherefacilities are better, access to BEmOC is improved and
the SBAs are able to attend to more deliveriesDataSource
Registers maintained by health workers; word of mouthfrom TBAs ANMs
OtherUsefulIndicators
Home deliveries per reported deliveries
Perinatal mortality at home deliveries
Maternal deaths from home deliveries
Suggested level ofuse
State and District
CommonProblems
Home deliveries by untrained TBAs are often not reported
ActionstoConsider
Home deliveries should be actively discouraged ifmaternal mortality is to be reduced
Conditions at institutions should be made moreacceptable (culturally, socially, financially etc) toencourage institutional deliveries
Indicator MH 8: Basic Emergency Obstetric Care (BEmOC) availability
Definition Number of facilities with functioning BEmOC per 500,000populationNumerator
Facilities who have reported all three BEmOC signalfunctions within the past 3 (WHO RHI) months
Complicated Delivery: IV Antibiotics
Complicated Delivery: IV Oxytocics
Complicated Delivery: IV Antihypertensives/ Magsulph
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Denominator
500,000 populationPlanned BEmOC centres or 24x7 facilities + FRUs
Rationale BEmOC facilities are needed 4:500,000 total population(Ref Programming for safe motherhood UNICEF 1999)Three monthly indicator from facility development form
DataSource
Labour Records / Maternity Registers at BEOC-designatedfacilities
OtherUsefulIndicators
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 whichdesignated facilities are NOT providing the full rangeof BEmOC
Caesarean section rate SBA attendance rate
Suggested level ofuse
State and district
CommonProblems
Distinction must be made between those facilitiesactually functioning and those that have the equipmentbut are NOT performing the functionsPoor reporting of signal functions by BEmOC facilities dueto poor recordsData from private facilities is often not collected, leading
to an under-estimationActionstoConsider
Equipment, staff and skills for BEmOC
Indicator MH 9: Comprehensive Emergency Obstetric Care (CEmOC)availability
Definition Number of facilities with functioning CEmOC functions per500,000 population. This implies that the facility hasprovided BEmOC signal functions in addition to CEmOC
functions.Numerator
Facilities who have reported all BEmOC functions ANDCEmOCCaesarean sectionBlood transfusion
Denominator
A. 500,000 population (WHO guidelines)B. No of FRUs planned/ No of DHs
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Rationale CEmOC facilities are needed 1:500,000 total population(Ref Programming for safe motherhood UNICEF 1999)This is a monthly indicator from facility development form
Data
Source
Theatre Records / Maternity Registers at CEmOC-
designated facilitiesBlood transfusion records
OtherUsefulIndicators
Caesarean Section rate shows only surgicalinterventions, without other CEmOC functions. Thisshould be 5-15 %% of DHs with CEmOC functions% of CHCs with CEmOC functions
Blood transfusion rate will show blood transfusions forCEmOC and other non-obstetric emergencies
Suggeste
d level ofuse
State and district
CommonProblems
Many facilities provide caesarean sections WITHOUT thefull package of BEmOC interventions. This should beactively discouraged by a system of accreditation andlicensing.Many private institutions do not report caesareansections, and it is often these instiutions that provideC/sections without adequate indications
Actionsto
Consider
Include private facilities in reporting maternal healthindicators
Indicator MH 10: Admission duration after delivery
Definition Percentage of women who were discharged in less than48 hrs of delivery
Numerator
Institutional delivery discharged up to 48 hrs of delivery
Denominator
Deliveries Institutional
Rationale Postnatal careAll women should be kept in hospital for at least 48 hoursrisk of postnatal complications and maternal mortality ishighest during this period
DataSource
Maternity Registers maintained by the health workers andhealth facilities
OtherUsefulIndicator
Causes of PNC complications
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sSuggested level ofuse
District
Common
Problems
Many women want to go home early, but this prevents
adequate PNCActionstoConsider
Indicator MH 11: Maternal Mortality Ratio
Definition The death of a woman while pregnant or within 42 days ofdelivery or termination of pregnancy, irrespective of theduration and site of the pregnancy, from any cause
related to or aggravated by the pregnancy or itsmanagement but not from accidental causes.
Numerator
Deaths Maternal ( this month; over last 12 monthsperiod)
Denominator
No of live births recorded
No of live births estimated over a one year periodRationale 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
DataSource
Line listing of maternal deaths; Labour records andregisters maintained at facilities CRS; Communityfeedbacks
OtherUsefulIndicators
A Maternal Mortality Audit should provide detaileddisaggregation by:
Cause (sepsis, malaria, PPH, PIH, Obstructed labour,unsafe abortion, anaemia)
Maternal Age, under 19 years, over 35 years
duration of pregnancy first, second, thirdtrimester, post delivery
place of delivery- home, institution etcMaternal mortality rate is collected by special surveysSuggested level ofuse
National and below
CommonProblems
Maternal deaths are relatively rare events and need largesample sizeUnder-reporting is a major problem with MMR. Most
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women who die in pregnancy , die at home and it isdifficult to collect this data.Even special surveys have problems getting accuratedata because respondents are not keen to talk aboutthese very tragic issues
ActionstoConsider
Indicator MH 12: Birth reporting rate
Definition Proportion of births reported over a given period of time.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 coverageof safe deliveries by health workers.
DataSource
Line listing of births; maternity registers and householdsurveys etc
OtherUsefulIndicators
Comparison to CRS reports
Suggested level ofuse
National, State, District and Block
CommonProblemsActions toConsider
Indicator MH 13: Postnatal care
Definition Percentage of women who used postnatal careprovided by skilled health personnel
Numerator
Postnatal mother/baby visits
Denomin
ator
Total Deliveries (Institutional + Home)
Rationale Postnatal care (PNC) is an essential component ofboth maternal and neonatal care, to detectcomplications so that they can be treated early.The postnatal check-up should follow nationalprotocols.
PNC coverage is an indicator of access and use ofhealth care after delivery.
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The numerator should include mothers of babiesborn at home and coming to health serviceswithin 48 hours.
Women should receive at least 2 postnatal carecheck-ups, to avoid and treat any complication.
Ideally 3 PNC check-ups are required, 3rd after 42days
DataSource
Registers maintained by health workers; Householdsurveys
OtherUsefulIndicators
Length of stay after delivery shows whethermothers and babies are retained long enough toreceive adequate PNC
Postnatal care at 7 and 28 days are alsomeasured , but these have minimal impact onmaternal and neonatal mortality
Perinatal mortality rate
SBA delivery rateSuggested level ofuse
National and below
CommonProblemsActionstoConsider
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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 birthNumerator New born breastfed within one hour of birth
Denominator Total live births(as recorded)
Rationale Breastfeeding in the first hour also helps to establishbreastfeeding. The more the first feed is delayed themore difficult it is to initiate breastfeeding.Breastfeeding in the first hour also gives the neonatecolostrum, which is rich in immuno-stimulants.However many cultures do not give this.
This is a very good index of effectiveness of BCC workand of ASHAprogramme where this is part of her work. Thisindicator can beused to strengthen these programmes. Even ifbreastfeeding is done within 2 hours, or within 24hours, if colustrum is not purposefully expressed outand thrown away, colustrum feeding is considered asachieved.
DataSourceThis would figure in the birth register, in the labourroom register and in the pregnancy 1 Registersmaintained by health workers and healthfacilities. Oral reports from home based caregivers( likeASHAs andAnganwadi workers) as told to ANMs be recorded byANMs.Home visits in early neonatal period for home deliveriesis essential for this information
OtherUseful
breast feeding in first two hours. ( potentiallyavailable if line-listing in reporting of births includes
this. At present it does not). This improves earlier thanat one hour and is also reflective of ASHA/ healthworker 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
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Postnatal care rate
Suggestedlevel of use District
Common
Problems Often not recorded, as there is often no space inmaternity registers torecord this dataStaff not focused on task of persuading mother /familyCollection of data from ASHAs could be a problem ifASHAprogramme is not designed to deliver this.
Actions toConsider Formative research to understand the issue and design
BCC programmes to promote immediate breastfeedingEnsure registers re modified to include immediate
breastfeedingInclude in support protocols for home based care giverslike ASHAs
Indicator CH 2: Neonatal referral rate
Definition Percentage of neonates (upto 28days old) with complicationsreferred forinstitutional care
Numerator Neonates seen in a PHC or CHC or higher facility because it is sickor low birthweight or has a complication- whether it was referred from thehome, orpresented on its own in the institution, or whether it wasdiagnosed in theinstitution.
Denominator Live births( as recorded)
Rationale This data should be collected by institutions to identify theproportion of
neonates with complications referred for specialised careDataSource Neonatal registers at institutions
OtherUseful
% of newborn referrals against estimated live births this needsno new data element- and is most useful where private sector isalso reporting.
% of low birth weights and severe low birth weight
Indicators
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Suggested
level District
of use
Common The number of families advised a referral is NOT being taken asit is difficult to estimate how seriously referral advice was takenup by
Problems family. Therefore only those referral that were received byinstitution are measured, evenif some are self-referred.
Referrals to Private hospitals will not be picked up and this mayaccount for the majority
No specific place of recordingin facility registers. Skills to detect a sick new born lacking amongst health workersand
hence both referral from below and identification in theinstitution couldbe poor.Best calculated with at least3000 births.
Actions to If rate is low find out whether it is due to lack of newborn visitsand newborn referrals or due to poor transport or due to poor
care and credibility at the facility. To Build up credibility andquality of care giving institutions
Consider Ensure private sector alsoreports
Indicator CH 3: Sex ratio at birth
DefinitionNumber of females born per 1000 males born in a give timeperiod
Numerator Live Births females x 1000
Denominator Live Births males
Rationale Declining sex ratio is an important public health concerns and sexratio at birthsis one of most precise indicators of this. Note that the usual sexratio at birth where there is no active discrimination is about 950
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females per 1000 males( this is due to a slightly greater loss ofmale fetuses). Due to a slightly greater mortality of male childrenin next five years, it becomes an equal or female preponderantratio for sex ratio in the 0 to 6 age group. However with optimumcare these slightly increased loss before and after birth may
decline. Therefore figures in this 950 range need to beinterpreted with caution. Below this figure there a genderdiscrimination factor becomes likely.
DataSource Line listing of births maintained by health workers; delivery
registers
OtherUseful
Sex ratio in 0-5 age groupIndicators
Sex ratio in population
Suggestedlevel 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 willbe 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 facilitys servicearea/block/district in the last 12 months
Denominator: Population of that facilitys service area/ block/district
Rationale This is the crude indicator of fertility in that population. Alsoby comparing the recorded birth rate with the estimated birthrate or external survey based birth rates one can arrive at apicture of how many children in that area are being missed outand this is useful to keep in mind while reading andinterpreting all other child health indicators.
Data Source Birth and death registerMaternity registers of Sub-Centres, PHC and CHCs.
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Household surveys
Other useful Total fertility rateindicators
NormalRanges
The states birth rate is available from the SRS. The goal isto 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 homeget missed. Since much of the reporting could be based onhearsay- there is loss of accuracy. There could be doublecounting
Problems The indicator is an estimate. For many reasons thedenominator could be wrong or the birth rate could bemore or less that expected.The numerator should be for a full year. This means addingthe livebirths of the last 12 months- and then plotting thisindicator on a graph so as to see trends. Monthly use ofthis indicator has little role. Also take a unit which hasmore than 3000 births in that period ( a number of areastaken together, or a number of months taken together ) tobe able to cast a meaningful indicator.
If the indicator is low, check whether all births are beingrecorded or some areas are getting missed out/ poorquality of recording or whether it is because there hasbeen a change in the denominator or due to declining
fertility.
Actions to
If indicator is higher than expected and sustained it may bea major movement of the population in or increase offertility rates
consider
Indicator CH 4: Low birth weight rate
Definition
Percentage of live born infants with a Birth weight under
2,500 gramsNumerator: Live births with a birth weight < 2500g.
Denominator: Live births weighed
Rationale At the population level, the low birth weight (LBW) rate is anindicator
of a multifaceted public-health problem that includes long-
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termmaternal malnutrition, ill health, hard work and poor healthcare inpregnancy.
On an individual basis, low birth weight is an important
predictor ofnewborn health and survival
Live babies with weight of
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Efforts to increase percentage of children weighed- bystudying who is getting missed out and why.
Improved quality of ANC
Actions to BCC regarding nutrition, smoking and drinking duringpregnancy
consider Attention to adolescent anaemia and malnutrition Assistance to secure food entitlements during maternity
Improve institutional new born care and referralarrangement where severe low birth weight is high
Indicator CH 5: Neonatal mortality rate
DefinitionNeonatal mortality rate (NNMR) measures the number of live-born babiesdying within 28 completed days of life per 1,000 live births.
Numerato
r Deaths in first 28 daysDenominator 1000 live births
Rationale Neonatal mortality (particularly early mortality) is affected byquality of carefor the neonate. This is a significant proportion of IMRDirect Causes are asphyxia , sepsis, hypothermia and neonataltetanus. Indirectcauses are low birth weight, prematurity, birth injuries andcongenital anomalies
DataSource Line listing in the birth and death register and InstitutionalrecordsRegistrar of births and deaths- compulsory registration system,Household surveys
OtherUseful
NNMR can be divided into early (0-7 days) and late (8-28 days).This information is potentially available in the line list- butcurrently not being aggregated.
Indicators NNMR can be disaggregated by gender
Suggested
level State and district. Calculate only when you have at least 3,000births, otherwiseof 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 cumulativetotal of a a number of months or even a year.
Common Underreporting and misclassifications ( as still births )arecommon, particularly for deaths. Cultural reluctance to reportingearly neonatal deaths- which only good training and supervision
Problems
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occurring early in life (particularly first hour).
Actions to Staff training and health facility equipment for a functionalnewborn care
Considerunit
Appropriate home based neonatal health care providers to betrained
Indicator CH 6: Infant Mortality rate
Definition Infant Mortality rate (IMR) measures the number of deaths ofinfants under
one year of age per 1,000 live birthsNumerator
Deaths infants less than one year old (Neonatal death plusdeaths in 1-12 months)
Denominator 1,000 Live birthsRationale This MDG indicator is a good measure of the socio-economic,
nutritionaland environmental health status of a given population.Common causes of death after the neonatal period arediarrhoea, acute respiratory infection, malaria,malnutrition, vaccine preventablediseases, especially measlesA significant proportion of the IMR is related to neonatal careInfant deaths should be reported monthly and IMR calculatedsemi-annually. One needs to ensure thatin this period of calculation therehas been at least 3000 live birthsin that area.At a local level blockor lower- this information isactionable even without making itinto an indicator.
Data SourceRoutine: Line listing of deaths; Institutional recordsOthers: Registrar of births and deaths, Population-basedsurveys, especially Sample Registration Surveys
Other Useful IMR by gender gives insight into poor care for the femalechild and
Indicatorsfemale infanticide
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Perinatal and neonatal death rates measure quality of careat birth Disease specific death rates due to diarrhoea, malaria, ARIetc provide clues for immediate action IMR can be disaggregated by social class, residence, income
etc Underweight rate under one year measures nutritionalstatus. This acts as a risk factor, increasing the likelihood ofdeath from any of the above causes.
Suggestedlevel of
National, state and district. Belowdistrict even the data element byitself provides actionableinformation.
use
CommonProblems IMR from routine data can be inaccurate because of
unreported deathsoccurring in the home, particularly amongst poor anddisadvantagedcommunities not reached by health services. Culturalreluctance to report neonatal deaths.
Tendency to underreport due to threat of reprimand fromaboveDeaths before the first birthday are all included in this.
Actions toConsider
Improved notification through line listing by health workers,
Community notification ofdeaths- to VHSCs, PRIs,NGOs etc - a form ofcommunity monitoring touncover unreporteddeaths.
Ensure that truthfulreporting of higher deathsthat expected is not metwith reprimands but withassistance.
Indicator CH 7: Under 5 mortality rate
DefinitionUnder-five mortality rate measures the number of childrenwho die before theirfifth birthday per 1000 children under five years
Numerator Deaths Neonatal + Deaths infant + Deaths 1-5 years
Denominator 1,000 children under five years
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RationaleUnder-five mortality rate is a general indicator of the level ofchild health,It measures more the socio-economic, environmental andnutrition status ofchildren, rather than direct health
care delivery.Data Source Line listing of deaths at Sub Centre; Institutional records
Vital registration- registrar of births and deaths; Populationcensus; Population-based surveys, such as DHS.
Other Useful U5MR can be disaggregated by gender, social class,residence, income etc
Indicators See infant mortality rateindicators
Suggestedlevel of National and below. Calculate only when you have at least
3,000 births,
use otherwise fluctuations will be toohigh.
CommonProblems Poor reporting of child deaths, particularly in hard-to-reach
and poorcommunities
Actions toConsider
Improved notification through line listing by health workers, Community notification ofdeaths- improve recording of
unreported deaths and increasescommunity action to preventdeaths
Improved quality of care for children through healthworkers at home
Definition
Peri-natal deaths comprise still births (gestation over 228 weeks />1000 gramsweight) plus early neonatal deaths (infants dying within 7 days).
Numera
tor Deaths Peri-natal (still births plus early neonatal in first week)Denominat
1000 live Births.or
Rationale PNMR directly reflects maternal health, quality of prenatal, intra-
partum and
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neonatal carePeri-natal deaths comprise up to 40% of infant deaths and theirreduction is themost 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 firstweek deaths. Any pregnancy outcome other than a live birth afterthe pregnancy has achieved 28 weeks would get included in this.The criteria of weight above 1000 gms may have to be ignored ifweight of the still-birth/aborted fetus is not available.All peri-natal deaths should be audited according to nationalguidelines to identifypreventable 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 asDHS.
Still birth rate- this is what can be calculated from the current dataelements available. Still birth estimation has a reciprocal relationshipwith both abortion at one end and neonatal mortality at the other.For calculating perinatal mortality rate as defined above-one needsto be collecting neonatal deaths in the first week as distinct from anyneonatal death. However this information is potentially available inthe 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 abortionswhich at around 28 weeks could be a problem.
Other A perinatal audit can provide useful additional information onquality of care
UsefulPNMR at different type and level of Institutions, public and privateIndicato
rsPNMR by type of birth assistant (SBA, Non-SBA)PNMR by genderCompare with NNMR
Suggest
ed National and below. Calculate and make predictive trend analysisonly when youlevel of
usehave 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
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populations.Reporting of still births is also problematic
Actionsto Institutions with high PNMR need additional support to identify the
causes of theConside
r deaths, and will normally need training on neonatal caretechniques.By comparing PNMR with other rates, one can arrive at conclusionsabout whichareas of child care require prioritisation.
2 Some authorities state 22 weeks or 500 grams but in India neonates of thisage are not viable, Other authorities use 32 weeks: hence 28 weeks or startof 3rd trimester is taken as cut-off.
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IMMUNISATION INDICATORS
Indicator CH IMM 1: Vaccine Specific Immunisation coverage under
one yearA BCG
B OPV (1,2,3)C DPT (1,2,3)D MeaslesE Hep B (1,2,3) where used
DefinitionVaccine specific immunisation coverage is the percentage ofchildren under a year whohave received particular doses of a specific vaccine
Numerator Children under 12 months( which is same as saying children 0 to11 months old) given the specific vaccinesBCG,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.
RationaleVaccine specific Immunisation coverage rates are used to monitorimmunisation services,to guide disease eradication and elimination efforts,They are an indicator of health system performance.Measles immunisation coverage is a national and MDG indicatorused as a proxy for fullimmunisation coverage.
DataSource
Immunisation registers kept by health workers; Immunisationcoverage cluster surveys;other household surveys
Normalrange
National target is 100%; states and districts need to set their owntargets
OtherUseful
Full immunisation coverageIndicators
Immunisation drop-out ratesIncidence of vaccine preventable diseasesVaccine utilisation rates
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Vaccine availability ratesCold Chain function indicators
Suggestedlevel
National for Measles; State and district for others
of useCommon No vaccinations given to children over one year should be includedin this
Problems Indicator.
Actions to Low immunisation coverage needs urgent action by health servicesand
Consider communities. It may indicate poor planning, supply side problemse.g. out ofstock or need for vaccine transportImprove local planning and community involvementRates over 100% mean denominator problems or double counting
Indicator CH IMM2: Full Immunisation coverage
DefinitionFull Immunisation coverage is the percentage of one-year-oldchildren who have receivedall required vaccines.
Numerator Number of children 9 to 12 months who completed theirimmunisation schedule (BCG, OPV3 and DPT3 and measles) in thepast yearNumber of children 12 to 23 months who hadalready complete immunization or completed
their immunization schedule during the pastyear
Denominator
Expected number of 0 to 12 months children based on mid yearestimates.Actual number of 0 to 12 months children based on live birthsduring this yearExpected number of 12 to 23 months children based on mid-yearestimatesActual number of 12 to 23 months children based on householdsurvey done at year beginning.
Rationale Full Immunisation coverage is the pinnacle indicator forimmunisation coverage and
means that the child should be fully protected against the sixvaccine preventablediseases, and is a valuable way to reduceinfant mortality.
DataSource
Immunisation registers kept by healthworkers ; There needs to be a separate columnin this register where the age of child inmonths when given the last immunization
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needed for full immunization status is recordedEPI cluster surveys; Other household surveys
OtherUseful
Full immunisation coverage by gender male and female
Indicators Vaccine-specific vaccination coverage rates Full immunisation coverage rates fromcluster surveys
Vaccine preventable disease incidence rates
Vaccine utilisation and availability rates Cold chain function indicators
Suggestedlevel
National, State, District, Blockof 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 surveyssuch as DHS. Surveys usually use a 12 to 23 monthdenominator.
Actions to Children need an immunisation card to track that all doses havebeen given. The register also needs provision for child tracking.
Consider Vaccine register should show children who completedimmunisation
schedule in a separate column by comparing full and individual immunisation coverage, catchup
campaigns to be instituted to provide individual vaccines inspecific areas
Indicator CH IMM 3: Immunisation adverse reactions
DefinitionAn adverse immunisation reaction is an unwanted or harmfulreactionexperienced following administration of a vaccineIt can be described as a medical event that takes place after an
immunisationthat causes concern and is believed to be caused byimmunisation(Immunisation handbook for health workers GoI 2007)
NumeratorAdverse reactions
A) AbscessesB) Deaths
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C) Others
Denominator Total number of immunisations given
Rationale Adverse effects are a sensitive indicator of quality ofimmunisation
Adverse reactions can be grouped into reactions inherent toimmunisation(pain, swelling, redness or general reactions), due to faultytechniques,hypersensitivity, neurological involvement, provocativereactionsUnder RIMS, three kinds of reaction are identified Abscess,Deaths andOthers e.g. allergy, anaphylaxis, hypotensive /hypo responsiveepisodes, BCGlymphadenitis, etc
DataSource Immunisation registers, facility data collection forms, IDSP death
reports
OtherUseful Drop out rates show perceived quality by the mother
Suggestedlevel
State and belowof use
Common Non-reporting;
Problems Others is a large category
Death of the child upto 6 days after the immunization is tobe reported- unless it is due to accident. Many of thesedeaths may have other causes- but that is to be validatedby medical officers separately these deaths are onlypresumptively vaccine related- the point is to have a highindex of suspicion so as not to miss cases.
Delayed reactions are difficult to collect
Actions to
Investigate all adverse reactions to identify the cause andadvise peripheral workers to take appropriate action forabscesses and other complications. Check on supply .Fordeaths it needs to be reported to state and national level andseparate report filed with vaccine batch details etc.
Consider
Indicator CH IMM 4: % of planned immunisation sessions held
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Definition Percentage of total planned immunisation sessions held
Numerator Number of immunisation sessions held
Denominator Total number of immunisation sessions planned
Rationale For a given population with a known number of healthfacilities and staff and outreach points( eg anganwadicenters)the number of immunisation sessions to cover thepopulation is pre-determined. It is important to see what percentage of thisneededcoverage is achieved.Immunisation needs careful planning and this indicatormeasuresimplementation of the plan. Poor planning leads to poor
implementationof immunisationLack oftransport is a common reason for cancellation ofsessions; Non availability of the ANM due to sickness orother personal causes, lack of vaccine supplies etc are alsoother causes. Need to ensure adequate transport forvaccines and transport for the ANM where this is theconstraint.
Data SourceRegisters maintained by health workers and health facilitiesDenominator from district immunisation office
Suggestedlevel ofDistrict, Block
use
Common Reliability of reporting of immunisation sessions held islow because
Problemsworker 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 improvedConsidersupervision
Involve communities in planning of immunisations atsites and time
convenient to them and reporting sessions NOT held
Indicator CH IMM 5: Vitamin A coverage rate
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DefinitionPercentage of children who have received all required vitamin Adoses. (Onedose for a child under one and five doses for a child under threeyears)
Numerator
Children who received Vitamin AA) 1 dose under one yearB) 5 doses under three yearsC) 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 isstated to reduce
mortality by 23%, where vitamin A deficiency exists. Vitamin A supplements as part of measles case managementcan reduce the case
fatality rate by more than 50%.DataSource
Immunisation register and Reports of Vitamin A by serviceproviders
OtherUseful
Measles case fatality ratesIndicators Vaccine-specific coverage rates to compare to vitamin A
coverage rates
Suggestedlevel
State and District
of useCommon
Difficult to report multiple doses at different agesProblems
No age estimates of 3 year old children availableUnless children have a vitamin A/immunization tracking cardwhich goes upto 5 years- it would be difficult to estimate whohas achieved the 5th, dose, 9th dose etc. It is not advised to makebulky registers that list all children upto 5 years and track themall along for each dose.
Actions to Identify areas with low coverage and ensure supplies and
promotionConsider
Activity.
Indicator CH IMM 6: Immunisation drop out rate
DefinitionComparison of the number of children who start receivingimmunisation andthe number who do not receive later doses for full
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immunisation
Numerator Number of children starting particular dose of antigen MINUSnumber ofchildren receiving later dose of antigen
Denominat
or Number of children starting particular dose of antigenRationale This is an indicator of quality of immunisation services and
allows a view of thetrends in coverage for specific vaccines. Useful drop out ratesareA) BCG to DPT3B) BCG to MeaslesC) DPT1 to DPT3D) DPT1 to Measles
This is a cohort sample and periodicity should be (semi) annual,rather than
monthlyDataSource
Facility routine data collection forms; Immunisation Registers;
OtherUseful
Vaccine specific and full immunisation coverage ratesIndicators Vaccine availability
Vaccine preventable disease incidence
Suggested
State and districtlevel of use
Common A high drop out rate means that mothers have no faith in theimmunisation
Problems A negative drop out rate can occur if there is a stock out ofthe earlyvaccines 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 immunisationcourseEnsure constant availability of vaccine
FAMILY PLANNING INDICATORS
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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 methodwhich is approximated by a formula:: number of cases sterilised
in particular month*10+number of pills distributed/13 + numberof 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 totalpopulation. Actually recorded eligible couples is what is used asdenominator but this may be compared with estimated couplesin the population,
Rationale Each family planning method is effective for different periods -this is a calculated indicator which measures the contribution ofeach 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 contraceptivesfor each type and divide or multiply by the appropriate factor:
Sterilisation X10 Pills / 13 IUD x 5.5 Condom pieces/ 72 X100
Actions toConsider
Low coverage means that unwanted pregnancies will occur.Increased CYPwill occur mainly through health promotion andincreases 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 effectiveand longer- term contraceptives such as injectables, IUDs andsterilisations.
OtherPossibleIndicators
This indicator is best annualised - i.e. the months valuemultiplied by 12 to get a picture of what would happen if thisrate continued throughout the year.
Termination of pregnancy rate is an indicator of failedcontraception leading to unwanted pregnancies.
Method mix is the relative proportion of total CYP providedby each method. It is best visualised as a pie diagram.
Acceptor rate is number of couples reporting to be usingany method as the numerator and total eligible couples as
the denominator. a relatively low value indicator forcontraceptive effectiveness as it does not measure protectionof women, but merely attendance of women at the clinic for aparticular service. It could however be used locally to ensurethat all couples are reached and improve the programme. Thefamily planning service delivery register and tracking registerwould help track this- and the figure % of eligible couplesnot using any method but wanting to use is the most
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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 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 gapwith earlier birth, % of births in women less than 19years of age.( registers record the data elementsneeded- but this is not reported up currently)
Suggested level ofuse
National
Commonproblems
This is a complicated indicator, most easily calculated using acomputer
Actions toconsider
Indicator FP 2: Family Planning Coverage rate by method
Definition The coverage contribution of each contraceptive method tothe overall family planning program
Numerator
Total number of units of each type of contraceptive distributedA) Oral Contraceptive cyclesB) Condoms
C) IUD insertionD) Centchroman (weekly) pillsE) Emergency Contraceptive pills
Denominator
Eligible couples
Rationale The indicator provides a profile of the relative level of use ofdifferent contraceptive methods. This also suggests that thepopulation has access to a range of different contraceptivemethods
DataSource
Family Planning Registers maintained by health workers andhealth facilities; Household surveys
OtherUsefulIndicators
Method Mix
Suggested level ofuse
District
Common Exact number of OCPs or condoms distributed- are difficult to
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Problems estimate since these are usually given out by depot holdersand ANMs only know the stock refill they provide to thedepots. Also distribution does not mean use.
Actionsto
Consider
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Indicator FP 3: Sterilisation rateA MalesB FemalesDefinition 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 sterilisedB) Females where the family size is 2 or more children andthe female is between 20 - 49 years and husband hasnot been sterilised
Numerator
Sterilisations performed this month plus already sterilisedeligible couples
A) MaleB) Female
Denominator
Eligible couples
Rationale Sterilisation is a permanent method that contributes
12.5years to CYP.Male Sterilisation is indicative of male participation in familyplanning and is usually held in camps
DataSource
Registers and data collection forms maintained by healthworkers and health facilities (including Camp)Eligible couple registers
OtherUsefulIndicators
Male sterilisation by type o conventional and
o NSV
Female Sterilisation by typeso 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 rateSuggested level ofuse
National and below
Targets 20% of all sterilisations should be males
CommonProblems
Permanent sterilisation is the most commonly used method offamily planningWhen used when family size is already large, it does notaffect TFRVery few males go for vasectomy!!
ActionstoConsider
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