Newborn Health

 

Welcome to the programmatic area on newborn health within MEASURE Evaluation’s Family Planning and Reproductive Health Indicators Database. Newborn health is one of the subareas found in the women’s health part of the sexual and reproductive health (SRH) section of the database. All indicators for this area include a definition, data requirements, data source(s), purpose, issues and—if relevant—gender implications. The goal of many programs in developing countries is to improve maternal and newborn health and survival. The World Health Organization (WHO) estimates that globally, 8.8 million children a year die before their fifth birthday; of these, more than 40 percent of deaths occur during the first month of life (WHO, 2010). The majority of these deaths are preventable and virtually all of them occur in developing countries. Although great progress was made in addressing the fourth Millennium Development Goal (reduce child mortality), there is still much work to be done. The newborn health indicators selected for this database measure both health outcomes and impacts as well as quality of care. Based primarily on the work of the Saving Newborn Lives Technical Working Group, many of the indicators measure how well the essential components of newborn care are being implemented—both at the facility and community level. Key indicators to monitor and evaluate newborn health can be found in the links at left.   Full Text The goal of many programs in developing countries is to improve maternal and newborn health and survival. WHO estimates that globally, 8.8 million children a year die before their fifth birthday; of these, more than 40 per cent occur during the first month of life (WHO, 2010). The majority of these deaths are preventable and virtually all of them occur in developing countries. Although great progress has been made in addressing the fourth Millenium Development Goal (reduce child mortality), there is still much work to be done. Most newborn deaths in developing countries can be prevented by interventions already widely used. The most common causes of mortality among neonates--prematurity and low-birth-weight, infections, asphyxia and birth trauma-- can be prevented by simple cost-effective interventions that also benefit the mother (WHO, 2009). Furthermore, providing all infants with an essential package of newborn care  including appropriate resuscitation, warmth, cleanliness and hygiene, clean cord care, and early exclusive breastfeeding also increases survival and reduces the proportion of surviving infants with disability (World Vision International, 2017). Operations research studies have identified which interventions are likely to effectively reduce newborn mortality, but how these services should be scaled up, by whom, and at what cost is still being determined.  Despite the close link between maternal and newborn health, separating maternal and newborn health indicators into two distinct parts may appear a false dichotomy when the antecedents of a poor pregnancy outcome, and the program interventions required to address these, may be the same for both mothers and babies. However, the purpose in doing so is to acknowledge growing awareness of the importance of newborn health and to highlight the fact that despite the many parallels between maternal and newborn health programs, important differences influence the way that programs are monitored and evaluated. These differences arise, not only because program interventions may vary, but because interventions that benefit both mothers and babies may differentially affect mortality.  For example, because of their greater impact on newborn survival, interventions such as immunizing pregnant mothers against tetanus and detecting and treating STIs are more likely to be monitored in newborn health programs than in safe motherhood programs. Methodological Challenges of Evaluating Newborn Health Programs Some of the challenges of evaluating newborn health programs are similar to those for safe motherhood: the need to consider two outcomes, the large number of proximate determinants, and the difficulties of attributing causality to certain interventions because services are "bundled."  Even though newborn deaths are more frequent than maternal deaths and therefore easier to count, the several measurement challenges include, but are not limited to, the following: Countries define births, deaths, and "newborn period" in different ways, making valid international comparisons difficult.  Meaningful use of any indicator is only feasible when standard definitions are used and applied. The first challenge for managers of newborn health programs is the lack of a generally agreed-upon definition of the "newborn period." In this database, the term newborn refers to the neonatal period (i.e., the first 28 completed days of life).  The Neonatal and Perinatal Mortality document defines the perinatal and neonatal periods (WHO, 2006). A second challenge is the different ways of aggregating newborn deaths according to the timing of the death. Typically, deaths are aggregated in the first month or first week of life or as fetal deaths. Many countries, however, define and record births and deaths in ways that may differ from the standard definitions of fetal, perinatal, and neonatal deaths recommended by WHO. Further difficulties may also arise because national birth and death criteria may be interpreted differently, and thus live births may be misclassified as fetal deaths and vice versa.   Ideally, all deaths (including fetal, perinatal, and neonatal) should be counted, but in practice, counting neonatal deaths is often the only feasible approach. Realistically, few programs record information on all neonatal, perinatal, and fetal deaths. In most developing countries, the majority of births and deaths occur at home (WHO, 1996b). Few countries have sufficiently well-developed vital registration systems that can provide valid and reliable information on all births and deaths in the community. Health information systems can only provide information on facility births and deaths and, in most settings, are also poorly developed. Most community-based programs, if they have the capacity to measure mortality at all, will generally only be able to collect valid data on neonatal deaths for reasons explained below. The quality of newborn mortality data is poorer than the quality of data for other ages. Evaluators require information on all births and deaths to derive valid measures of newborn health outcome. As mentioned above, few developing countries have sufficiently developed vital registration systems to provide this data and, in many settings, reporting is very incomplete due to institutional, social, and cultural barriers.  There are major biases in the way deaths are reported. Even in countries with well-developed registration systems, a bias exists towards the reporting of larger, older babies, whereas deaths of very small babies early in the neonatal period are often omitted. Fetal deaths are much less likely to be reported than deaths of live births (WHO, 1996b).  Survey estimates of newborn mortality may not be suitable for short-term monitoring. Prospective studies would provide the most reliable mortality rates but are too expensive for regular reporting purposes. In practice, the most reliable estimates of neonatal mortality are derived from large scale surveys that rely on the retrospective report of deaths in early infancy. Surveys focusing on live births provide estimates of neonatal mortality, but perinatal mortality estimates require complete pregnancy histories. Because many population-based surveys focus on obtaining demographic indicators that use live births in the denominator, there has been relatively less experience with the use of pregnancy histories (which collect information about stillbirths). The reliability of any survey estimate depends on the completeness of reporting, and underreporting is generally more pronounced for deaths in early infancy. Because of the relatively small numbers of deaths recorded in this type of survey, national neonatal mortality rates are usually presented for a period of five years before the survey, and sub-national estimates are presented for ten years before the survey. Lack of precision in the estimates may sometimes make it very difficult to assess the significance of small changes between surveys (Rutstein, 1999).  Measuring perinatal and neonatal morbidity is very difficult. Estimates of newborn morbidity are important for designing effective program interventions. As with safe motherhood, however, existing estimates of newborn morbidity are usually derived from facility data and are unlikely to reflect the true burden of morbidity in the community unless all births and deaths are institutional. Although community members can learn to diagnose  illness in a sick newborn (Bang et al., 1999), illness is often difficult to recognize because babies usually present with relatively non-specific symptoms, such as poor feeding and lethargy. Assigning a cause of death may be difficult because many different diseases may present with the same symptoms, and many babies die at home before ever reaching medical attention. Few facilities have adequate diagnostic facilities when ill babies do eventually present for care. New program indicators are required at the individual, community, and facility level.  Process indicators are required for measuring the availability, accessibility, quality, and demand for services at the facility level where the provision of newborn health services has historically been overlooked. A national survey in Kenya, for example, showed that over one third of hospitals lacked even the most basic equipment for resuscitation (MOH, NCPD, and ORC Macro, 2000). In addition to monitoring at the facility level, indicators are also required for monitoring and evaluating interventions at the individual and community level. Many infants become ill and die before ever reaching medical care.  It is particularly important to develop indicators that help programs understand community knowledge, attitudes and behaviors in response to newborn illness and to determine which interventions are the most effective. Indicator Selection The newborn health indicators selected for this database measure both health outcomes and impacts as well as quality of care.  Based primarily on the work of the Saving Newborn Lives Technical Working Group, many of the indicators measure how well the essential componenets of newborn care are being implemented -- both at the facility and community level. ____________ References: Bang, A.T., R.A. Bang, S.B. Baitule, M.H. Reddy, and M.D. Deshmukh. 1999. "Effect of Home-based Neonatal Care and Management of Sepsis on Neonatal Mortality: Field Trial in Rural India (comments)." Lancet 354, 9194: 1955-1961. World Vision International. Intervention 2: Essential Newborn Care. Accessed July 5, 2017. Available at: http://www.wvi.org/health/intervention-2-essential-newborn-care Narayanan I, Rose M, Cordero D, Faillace S, and Sanghvi T. The Components of Essential Newborn Care. Published by the Basics Support for Institutionalizing Child Survival Project (BASICS II) for USAID. Arlington, Virginia, June 2004.Rutstein, S.O. 1999. "Guidelines for the MEASURE DHS+ Main Survey Report." Demographic and Health Surveys. Baltimore, MD: Macro International Inc.   USAID.  Essential Maternal and Newborn Health.  2009.  Available at: https://www.usaid.gov/what-we-do/global-health/maternal-and-child-health/technical-areas/maternal-health   WHO and UNICEF. Countdown to 2015 decade report (2000-2010): taking stock of maternal, newborn and child survival. Geneva, 2010. WHO.  Newborns: reducing mortality.  Fact sheet No333.  August, 2009. WHO. 1996b. Essential Newborn Care: Report of a Technical Working Group, April 1994. Maternal and Newborn Health/Safe Motherhood Unit. Division of Reproductive Health (Technical Support). Geneva: WHO. WHO. Neonatal and Perinatal Mortality: Country, Regional and Global Estimates. 2006. Available at: http://apps.who.int/iris/bitstream/10665/43444/1/9241563206_eng.pdf

Percent of audience who know at least three warning/ danger signs of newborn complications

Definition:

Community knowledge and awareness of the warning/ danger signs of newborn complications

The "audience," the intended population for the pro­gram, will usually be mothers in the case of newborn babies. Husbands or other household members known to influence decisions about care seeking, as well as other health care providers (such as traditional birth attendants), may also need to know about signs of new­born illness.

"Know" refers to the percentage who can spontaneously name at least three warning/danger signs of newborn complica­tions.

Danger signs that have been proposed include:

This indicator is calculated as:

(# respondents who know the warning/ danger signs of  newborn complications / Total # of respondents) x 100

Data Requirements:

Response to knowledge questions asked in surveys

Data Sources:

Population-based survey, preferably with a representa­tive sample of the audience

Purpose:

The purpose of this indicator is to assess community knowledge and awareness of the warning/danger signs of newborn complications in order to plan and monitor the impact of behavior change communication program efforts at the community level.

Because most babies are born at home or are discharged from the hospital in the first 24 hours, increasing com­munity awareness of the danger signs of newborn com­plications is of critical importance for improving new­born survival. More babies die in the first week of life than at any other time in childhood, and those who be­come ill shortly after birth may deteriorate and die very rapidly. The warning signs of newborn illness may not be recognized, because they are often much less pro­nounced than those in an older child or adult. Commu­nity members can, nevertheless, learn to recognize signs and symptoms of newborn illness (Bang et al., 1999). 

Issue(s):

The limitations of assessing community knowledge of signs and symptoms of newborn illness are similar to those outlined for obstetric complications. (See indica­tor Percent of audience who know three primary warning/danger signs of obstetric complications.)

A major limitation with newborn complications is that little consensus exists on which signs and symptoms the general public can use to improve the early diagno­sis of serious illness at the community level. Algorithms shown to be sensitive and specific in clinical settings are too complex for use by the general public (McCarthy, Lawn, and Ross, 2001). More simple measures are less specific and will lead to larger numbers of newborns receiving unnecessary treatment. However, having some healthy babies over-treated is preferable to having some sick babies being under-treated and dying as a result.  

Programs aimed at raising community awareness of neo­natal illness should carry out formative research to de­termine what signs of illness are already recognized in the community and how to adapt general recommenda­tions to a specific setting. More fundamental research is required to reach consensus on which signs and symp­toms caretakers in different settings can consistently rec­ognize.

References:

Bang, A.T., R.A. Bang, S.B. Baitule, M.H. Reddy, and M.D. Deshmukh. 1999. "Effect of Home-based Neonatal Care and Management of Sepsis on Neonatal Mortality: Field Trial in Rural India (comments)." Lancet 354, 9194: 1955-1961.

McCarthy, B., J. Lawn, and S. Rae Ross. 2001. The Healthy Newborn: A Reference Manual for Program Managers. CARE, Center for Disease Control, CCHI, and World Health Organization. (Unpublished)

Percent of newborns receiving immediate care according to MOH guidelines

Definition:

The percent of newborns delivered at a health facility receiving immediate care according to ministry of health (MOH) guidelines.

The clinical standard for the immediate care of newborns includes a physical examination consisting (at a minimum) of the following:

This indicator is calculated as:

(# of newborns delivered at a facility who receive immediate care according to MOH guidelines / total # of newborns delivered at the facility) x 100

The indicator is calculated for a specific reference period (e.g., per quarter or per year, depending of the size of the facility).

Data Requirements:

Number of newborns delivered at the facility during the reference period who receive immediate care according to MOH guidelines; the total number of newborns delivered at the facility during the reference period.

If targeting and/or linking to inequity, classify sites by location (poor/not poor) and disaggregate newborns receiving care by location.

Data Sources:

Review of medical records; direct observation of providers

Purpose:

Immediate care of the newborn helps identify whether the baby has a normal condition; has a condition or problem requiring urgent, rapid treatment; or has a condition/malformation or other problem that requires transfer to another facility or service. Providing immediate care to newborns helps reduce neonatal complications, sequelae, and deaths.

Physicians and nurses at all levels can learn to systematically perform immediate care for newborns.

The immediate care guidelines can also include specific protocols for identification and treatment of asphyxia, hypothermia, or hypoglycemia.

A low score on this indicator should trigger some intervention(s) to address skills and knowledge of pro­viders, the organization of care, or both. The district health team or facility supervisor can provide support and encouragement to facility staff to ensure compli­ance with this important standard. Quality improvement teams can also help the facility determine causes for observed difficulties in compliance with the standard, as revealed by the indicator.

Issue(s):

For the newborn record to be a reliable data source, staff must fill the record out consistently and accurately. Ideally, the recording form will specify the standards, will facilitate accurate charting, and will stimulate appropriate actions.

 

Percent of deliveries in which a perinatal clinical record was properly completed

Definition:

The attentiveness of staff to maintaining a complete record on the mother and baby during the perinatal period.  Depending on the definition, this period starts between the 20th and 28th week of gestation and ends when the baby is 28 days old.

The perinatal record is one or more forms containing information for both the mother and the neonate at each contact œ during pregnancy, delivery, and the neonatal period.

This indicator is calculated for a specific reference period as:

# of deliveries at the facility with a properly completed perinatal clinical record x 100

______________________________________________________________

# of deliveries at the facility

 

The reference period for this indicator is determined locally, but is generally from 3 to 5 months, but can be as much as 12 months.

Data Requirements:

Number of deliveries with a perinatal clinical record completed; number of deliveries at the facility during the reference period

Data Sources:

Review of medical records; direct observation of providers

Purpose:

This indicator measures the attentiveness of staff to maintaining a complete record on the mother and baby from the prenatal period through approximately the postnatal period. The importance of a complete standardized perinatal clinical record is paramount to the quality of maternal care, because it reminds health providers of the stan­dards of care. In Latin America, most ministries of health have adapted the model of a "simplified perina­tal clinical record“ developed by the Centro Latinoamericano de Perinatologia. The standard clini­cal record has sections for identification data, obstetri­cal history, pregnancy data, as well as delivery, new­born, and postpartum information. The clinical record has sections in yellow that represent some important factors that can increase perinatal risk.

The format and content of the perinatal clinical record may vary by country, or even within a country if the MOH has not introduced a standardized format. What­ever the format and content agreed upon at the facility, providers should use and know how to complete it ac­curately for each pregnancy and delivery. This indica­tor creates awareness among program administrators of the need for a standardized perinatal clinical record or for improvements to an existing one.

This indicator pri­marily measures staff compliance with record-keeping, an important function that improves continuity of care.

Issue(s):

Whereas staff have a responsibility to maintain records on all women in their clinical facilities, they cannot be held totally responsible for women who do not return to the facility for postpartum care.

Percent of deliveries in which a partogram is correctly used

Definition:

The percent of deliveries correctly monitored with a partogram (sometimes known as a partograph).

A partogram is a simple chart that clinical staff can use to monitor labor and identify when it is not progressing satisfactorily.

Correct use is defined as: (1) starting the monitoring process only after the woman begins labor and (2) measuring the essential parameters, such as cervical dilation, descent of fetal head, and uterine contractions.

The indicator is calculated for a specific reference pe­riod as:

# of deliveries correctly monitored with a partogram x 100

__________________________________________

Total # of deliveries

 

Data Requirements:

Number of facility-based deliveries monitored with a partogram; evi­dence of correct use of the partogram; number of de­liveries at the facility during the reference period (e.g., 3 months, 12 months)

Data Sources:

Review of medical records; direct observation by su­pervisor or external evaluator (regarding correct use); and review of the partogram

Purpose:

In a pictorial overview, the partogram graphically displays the dynamics of labor during the first stage of delivery. It records fetal condition, la­bor progress, and maternal condition with the aim of alerting health professionals to any problems with the mother or baby. In this way, the partogram acts as an "early warning sys­tem" that detects insufficient uterine action and/or cephalopelvic disproportion leading to obstructed la­bor (WHO, 1991a).

If properly used, the partogram helps reduce prolonged labor and its sequelae through earlier referral. Midwives, physicians, and nurses at all levels can learn to use and interpret partograms correctly, and thus can reduce cases of prolonged labor, maternal morbidity, and peri­natal mortality (Schwarcz, Díaz, and Nieto, 1990).

A low score on this indicator may reveal a need for ad­ditional interventions, such as on-the-job training or refresher tutorials for staff. 

Partogram 

partograph

Issue(s):

There is no one partogram template; different health facilities may use different versions, with varying degrees of usefulness and simplicity.  The WHO still recommends partograms as a method of diagnosing obstructed labor, with the focus being on low-resource settings.  However, a systematic Cochrane review concluded, "On the basis of the findings of this review, we cannot recommend routine use of the partogram as part of standard labour management and care. Given the fact that the partogram is currently in widespread use and generally accepted, it appears reasonable, until stronger evidence is available, that partogram use should be locally determined. Further trial evidence is required to establish the efficacy of partogram use" (Lavender et al., 2012).

Particularly in a hospital setting where there are several people looking at the labor notes, a partogram is helpful for a quick, consistent review and is a useful tool for good decision making.  However, in settings where there are one or two people monitoring the labor, there are other ways to appropriately and efficiently document labor notes apart from using a partogram. Furthermore, knowledgeable and experienced health providers need not rely on a partogram to identify when a woman's labor is not progressing well. 

Therefore, use of this indicator as a proxy measure of quality of care should be interpreted with caution.

References:

Schwarcz R., A. Diaz, and F. Nieto. 1990. "Guía para la vigilancia del parto. Partograma con curvas de alerta." Montevideo, Uruguay: Centro Latinoamericano de Perinatología.

WHO. 1991a. Essential Elements of Obstetrical Care at First Referral Level. Geneva: WHO.

Lavender T, Hart A, Smyth RMD. Effect of partogram use on outcomes for women in spontaneous labour at term. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD005461. DOI: 10.1002/14651858.CD005461.pub3.  http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005461.pub4/pdf 

Percent of home births with cord cut with clean instrument

Definition:

The coverage of clean cord care at the time of delivery, either from use of a clean delivery kit, a new blade or instrument, or a boiled blade or instrument, to cut the baby's umbilical cord (KPC, 2000). This should be measured for home deliveries only.

This indicator is calculated as:

# of births with a clean delivery kit or clean blade x 100

___________________________________________

Total # of births recorded

Clean births kits typically include at least soap, a new razor blade, cord ties, gloves, and a plastic sheet.

Data Requirements:

Number of home births with a clean delivery kit or clean blade in a defined geographical place and time, based on self-reports of women with children 0-23 months and number of home births in the same place and time period

Where data on the numbers of live births for the de­nominator are unavailable, evaluators can calculate to­tal estimated live births from the total population and crude birth rate in a specified area. Total expected births = population x crude birth rate.

Data Sources:

Population-based survey (national, regional, district)

Although clean cord care is as important in facility-based deliveries as home deliveries, because women who deliver at a facility typically do not know what was used to cut the cord, the births that occurred in a facility should not be included in the survey.

Purpose:

This indicator is most appropriate in settings where fa­cility births are rare.  It measures the coverage of clean-delivery and cord-care practices at birth for deliveries that take place both outside a facility.

Tetanus and sepsis are two leading causes of maternal and neonatal morbidity in the developing world. These deaths result from contamination from an unclean en­vironment but could be prevented with improved hy­giene and cord care at the time of delivery.  Use of clean home delivery kits and a new or sterile (i.e. boiled) blade or instrument for cutting the um­bilical cord have been shown to reduce the incidence of simple cord infection, but no studies have assessed the impact on mortality or more serious infections because of the need for very large sample sizes (Tsu, 2000). Clean cord care is one of the key elements in the Essential Newborn Care Package (WHO, 1996a).

The many elements to clean cord care and a number of alternative or complementary indicators include the fol­lowing:

In addition to including beneficial practices, some pro­grams may wish to monitor the reduction in potentially harmful practices that encourage the spread of tetanus. For example:

Issue(s):

Two caveats warrant mention.  First, surveys that rely on a women‘s recall of events at the time of delivery are subject to a recall bias likely to increase with the length of the recall period. Furthermore, if a woman was attended by a traditional birth attendant, she may be unaware whether a clean delivery kit was used or how the cord was cut. A courtesy bias may affect the response if respondents are aware that programs are known to be promoting certain delivery practices.

 

References:

Koblinsky, M., K. Mc Laurin, P. Russell-Brown, and P. Gorbach (eds). 1995. Indicators for Reproductive Health Program Evaluation. Final Report of the Subcommittee on Safe Pregnancy. Chapel Hill, NC: The EVALUATION Project.

Tsu, V. 2000. Clean Home Delivery Kit: Evaluation of the Health Impact. Seattle, WA: PATH.

WHO. 1996a. Mother-Baby Package: Implementing Safe Motherhood in Countries. Maternal Health and Safe Motherhood Program, Division of Family Health. WHO/FHE/MSM/94.11. Geneva: WHO.

Percent of newborns with nothing harmful applied to cord (for home and facility deliveries)

Definition:

The percentage of most recent births during a specified time period delivered at home or in facilities where the newborn had nothing harmful applied to the umbilical cord after cutting and tying.

This indicator is calculated as:

(Number of most recent live births with nothing harmful applied to cord / Total number of most recent live births during a specified time period) x 100

Data Requirements:

Data on newborn cord care practices for most recent births from population based surveys such as Demographic Health Survey (DHS) and the UNICEF Multiple Indicators Cluster Survey (MICS) or from newborn care program surveys and reviews of facility delivery records. Generally DHS uses a recall period of five years and MICS uses a two year period. Data for calculating this indicator can also be collected through surveys of facilities and direct observation of providers in facilities. Data can be disaggregated by home versus facility deliveries, type of facility (e.g., public, private, non-governmental organization) and other factors such as district or urban/rural location.

Data Sources:

Population based surveys such as DHS and UNICEF/MICS; program surveys; direct observation in facilities, reviews of facility delivery records.

Purpose:

This indicator assesses whether newborns had nothing harmful applied to their umbilical cords after cutting and tying, which is a core component of recommended clean cord care at delivery, and can be used as a measure for the quality of and adherence to service protocols, performance of birth attendants, and adoption of newborn care messages at the community level (Gage et al., 2005). Where a national policy on cord care of newborns exists, this can be used as a standard against which to assess the practices of health care providers. Clean cord care is one of five ‘Best Practices’ for all newborns: (1) Keeping the newborn warm to prevent hypothermia; (2) cord care; (3) eye care; (4) promotion of exclusive breastfeeding within one hour; and (5) routine immunizations (WHO, 2003). Clean cord practices, including keeping the cord stump clean and dry, are essential to preventing cord infections, the occurrence of which are at highest risk in the first three days of life.  In some cultures, substances such as clarified butter, cow dung, ashes, or herbal pastes are placed on the cord and increase the risk of infection (Save the Children, 2004).

Chlorhexidine, a broad-spectrum antiseptic, has been used extensively in clinical settings to cleanse the umbilical cord and prevent infection in neonates. Evidence suggests that chlorhexidine interventions may have significant public health impact on the burden of neonatal infection and mortality in developing countries (Mullany, Darmstadt, and Tielsch, 2006).  Keeping the cord dry and avoiding the application of other substances to the cord are components of newborn clean cord care. Further details on cord care can be found in Save the children (2004); (Save the Children, 2010); and USAID/CORE Group(2004). This indicator measures one of several cord care practices that can improve infant health outcomes and is directly related to achieving Millennium Development Goal #4 to reduce infant and child mortality.

Issue(s):

Surveys rely on recall of events and this indicator is subject to recall bias, which is likely to increase with the length of the recall period. Recall bias can be minimized by keeping the reference period short. A mother may not know if anything was applied to her most recent baby’s cord after delivery and there is also the possibility that a mother would report the recommended behavior rather than actual practice (Gage et al., 2005). Direct observation is a way to avoid this bias.

References:

Gage A, Ali D, Suzuki C, 2005, A Guide for Measuring and Evaluating Child Health Programs, Chapel Hill, NC: MEASURE Evaluation. https://www.cpc.unc.edu/measure/publications/ms-05-15  

Mullany L, Darmstadt G, and Tielsch J, 2006, "Safety and Impact of Chlorhexidine Antisepsis Interventions for Improving Neonatal Health in Developing Countries". Pediatric Infecttious Disease Journal, August 25(8): 665-675. 

Save the Children, 2010, Report of a Technical Working Group Meeting on Newborn Health Indicators, Washington, DC: Save the Children.

Save the Children, 2004, Every Newborn’s Health: Recommendations for care for All Newborns, Washington, DC: Save the Children. http://www.savethechildren.org/atf/cf/%7B9def2ebe-10ae-432c-9bd0-df91d2eba74a%7D/EVERY-NEWBORNS-HEALTH.PDF

USAID/CORE Group, 2004, Maternal and Newborn Standards and Indicators Compendium, Washington, DC: USAID  http://www.coregroup.org/storage/documents/Workingpapers/safe_motherhood_checklists-1.pdf

WHO, 2015, Integrated Management of Pregnancy, Childbirth, Post Partum, and Newborn Care: A Guide for Essential Care Practice, Geneva: WHO.  http://www.who.int/maternal_child_adolescent/documents/imca-essential-practice-guide/en/

Percent of newborns dried immediately after delivery (for home and facility deliveries)

Definition:

 

The percentage of most recent births during a specified time period delivered at home or in facilities where the newborns were dried with cloth immediately after birth.  The term ‘immediately’ needs to be defined as a specific amount of time in minutes (Save the Children, 2010). Drying after delivery is a component of newborn thermal care and further details on summary indicators for thermal care can be found in Gage et al. (2005) and USAID/CORE Group(2004).

This indicator is calculated as:

(Number of newborns dried with cloth immediately after birth / Total number of most recent live births during a specified time period) x 100

Data Requirements:

Data on thermal care practices for most recent births from population based surveys such as Demographic Health Survey (DHS) and the UNICEF Multiple Indicators Cluster Survey (MICS) or from newborn care program surveys and reviews of facility delivery records. Generally DHS uses a recall period of five years and MICS uses a two year period. Data for calculating this indicator can also be collected through surveys of facilities and direct observation of providers in facilities. Data can be disaggregated by home versus facility deliveries, type of facility (e.g., public, private, non-governmental organization) and other factors such as district or urban/rural location.

Data Sources:

 

Population based surveys such as DHS and UNICEF/MICS; program surveys; direct observation in facilities, reviews of facility delivery records.

Purpose:

This indicator assesses the provision of a core component of recommended newborn thermal care at delivery, and can be used as a measure for the quality of and adherence to service protocols, performance of birth attendants, and adoption of newborn care messages at the community level (Gage et al., 2005). Where a national policy on thermal protection of newborns exists, this can be used as a standard against which to assess the practices of health care providers. Thermal care is one of five ‘Best Practices’ for all newborns: (1) Keeping the newborn warm to prevent hypothermia; (2) cord care; (3) eye care; (4) promotion of exclusive breastfeeding within one hour; and (5) routine immunizations (WHO, 2003). The newborn’s body temperature can drop rapidly after birth causing potentially life-threatening neonatal hypothermia, the risk of which can be reduced by drying the newborn immediately. Hypothermia can lead to low blood sugar levels, respiratory distress, abnormal clotting, and increased risk of developing infections, jaundice and pulmonary hemorrhage (Save the Children, 2004).  Drying the newborn immediately after birth, skin-to-skin contact with the mother, wrapping the infant with a dry cloth or towel, keeping the newborn’s head covered, and delayed bathing for 24 hours are essential care practices for keeping the newborn warm. Early skin-to-skin contact with the mother also promotes bonding and facilitates the initiation of breastfeeding. These strategies can be used effectively at home deliveries, as well as at facilities, and can improve newborn health and survival. Since the highest period of risk for neonatal deaths is within the first 24 hours, this indicator measures one of several thermal care practices that can improve infant health outcomes and is directly related to achieving Millennium Development Goal #4 to reduce infant and child mortality.     

Issue(s):

Surveys rely on recall of events and this indicator is subject to recall bias, which is likely to increase with the length of the recall period. Recall bias can be minimized by keeping the reference period short. A mother may not know if her most recent baby was dried immediately after birth and there is also the possibility that a mother would report the recommended behavior rather than actual practice (Gage et al., 2005). Direct observation is a way to avoid this bias.

References:

 

Gage A, Ali D, Suzuki C, 2005, A Guide for Measuring and Evaluating Child Health Programs, Chapel Hill, NC: MEASURE Evaluation.  https://www.cpc.unc.edu/measure/publications/ms-05-15  

Save the Children, 2010, Report of a Technical Working Group Meeting on Newborn Health Indicators, Washington, DC: Save the Children.

Save the Children, 2004, Every Newborn’s Health: Recommendations for care for All Newborns, Washington, DC: Save the Children.  http://www.savethechildren.org/atf/cf/%7B9def2ebe-10ae-432c-9bd0-df91d2eba74a%7D/EVERY-NEWBORNS-HEALTH.PDF  

USAID/CORE Group, 2004, Maternal and Newborn Standards and Indicators Compendium, Washington, DC: USAID  http://www.coregroup.org/storage/documents/Workingpapers/safe_motherhood_checklists-1.pdf

WHO, 2015, Integrated Management of Pregnancy, Childbirth, Post Partum, and Newborn Care: A Guide for Essential Care Practice, Geneva: WHO.  http://www.who.int/maternal_child_adolescent/documents/imca-essential-practice-guide/en/

Percent of newborns with delayed bath (for home and facility deliveries)

Definition:

The percentage of most recent births during a specified time period delivered at home or in facilities, where the newborns had their first bath delayed at least six hours after birth. Ideally the bath should be delayed until 24 hours after birth (Save the Children, 2010). Delaying baths is a component of newborn thermal care and further details on summary indicators for thermal care can be found in Gage et al. (2005) and USAID/CORE Group (2004).

This indicator is calculated as:

(Number of newborns with first bath delayed at least six hours after birth / Total

number of most recent live births during a specified time period) x 100

Data Requirements:

Data on thermal care practices for most recent births from population based surveys such as Demographic Health Survey (DHS) and the UNICEF Multiple Indicators Cluster Survey (MICS) or from newborn care program surveys and reviews of facility delivery records. Generally DHS uses a recall period of five years and MICS uses a two year period. Data for calculating this indicator can also be collected through surveys of facilities and direct observation of providers in facilities. Data can be disaggregated by home versus facility deliveries, type of facility (e.g., public, private, non-governmental organization) and other factors such as district or urban/rural location. 

Data Sources:

Population based surveys such as DHS and UNICEF/MICS; program surveys; direct observation in facilities, reviews of facility delivery records.

Purpose:

This indicator assesses delayed bathing, which is a core component of recommended newborn thermal care at delivery and can be used as a proxy for the quality of and adherence to protocols, performance of birth attendants, and adoption of newborn care messages at the community level (Gage et al., 2005). Where a national policy on thermal protection of newborns exists, this should be used as a standard against which to assess the practices of health care providers. Thermal care is one of five ‘Best Practices’ for all newborns: (1) Keeping the newborn warm to prevent hypothermia; (2) cord care; (3) eye care; (4) promotion of exclusive breastfeeding within one hour; and (5) routine immunizations (WHO, 2003).The newborn’s body temperature can drop rapidly after birth causing potentially life-threatening neonatal hypothermia. Hypothermia can lead to low blood sugar levels, respiratory distress, abnormal clotting, and increased risk of developing infections, jaundice and pulmonary hemorrhage (Save the Children, 2004).  Drying the newborn immediately after birth, skin-to-skin contact with the mother, wrapping the infant with a dry cloth or towel, keeping the newborn’s head covered, and delayed bathing, ideally for 24 hours, are essential care practices for keeping the newborn warm. Early skin-to-skin contact with the mother also promotes bonding and facilitates the initiation of breastfeeding. These strategies can be used effectively at home deliveries, as well as at facilities, and can improve newborn health and survival. Since the highest period of risk for neonatal deaths is within the first 24 hours, this indicator measures one of several thermal care practices that can improve infant health outcomes and is directly related to achieving Millennium Development Goal #4 to reduce infant and child mortality.

Issue(s):

Surveys rely on recall of events and this indicator is subject to recall bias, which is likely to increase with the length of the recall period. Recall bias can be minimized by keeping the reference period short. A mother may not know when her most recent baby was bathed after birth and there is also the possibility that a mother would report the recommended behavior rather than actual practice. In a community where the practice of bathing the newborn is prevalent and there are programs aimed at raising awareness regarding newborn care, mothers may be aware of the correct practice, but traditional norms may prevent them from adopting the behavior (Gage et al., 2005). Direct observation is a way to avoid this bias.

References:

Gage A, Ali D, Suzuki C, 2005, A Guide for Measuring and Evaluating Child Health Programs, Chapel Hill, NC: MEASURE Evaluation. https://www.cpc.unc.edu/measure/publications/ms-05-15  

Save the Children, 2010, Report of a Technical Working Group Meeting on Newborn Health Indicators, Washington, DC: Save the Children.

Save the Children, 2004, Every Newborn’s Health: Recommendations for care for All Newborns, Washington, DC: Save the Children. http://www.savethechildren.org/atf/cf/%7B9def2ebe-10ae-432c-9bd0-df91d2eba74a%7D/EVERY-NEWBORNS-HEALTH.PDF  

USAID/CORE Group, 2004, Maternal and Newborn Standards and Indicators Compendium, Washington, DC: USAID.  http://www.coregroup.org/storage/documents/Workingpapers/safe_motherhood_checklists-1.pdf

WHO, 2003, Integrated Management of Pregnancy, Childbirth, Post Partum, and Newborn Care: A Guide for Essential Care Practice, Geneva: WHO. http://www.scribd.com/doc/7524352/Pregnancy-Childbirth-and-Postpartum-and-Newborn-Care-WHO-2003

Percent of newborns receiving a postnatal care check within two days of birth

Definition:

The percent of newborns attended by a health care pro­vider during the first 48 hours following birth.

This indicator is calculated as:

# of newborns attended during by a health care provider during the first 48 hours following birth  x 100
___________________________________________________________
 Total # of live births

 

The postnatal period begins one hour after the birth of the placenta and ends 6 weeks later (WHO, 2001b). Although not officially defined, the period of interest for the purposes of this indicator is up to the late postnatal period.

Data Requirements:

Numbers of newborns who are attended during their first two days of life (the numerator should specify whether new­borns are seen for the first or subsequent visit); all live births in the same period

Data Sources:

Service statistics; population-based surveys

Routine HIS may collect data for this indicator to ob­tain estimates of early postnatal coverage. Routine health ser­vice data generally lacks information on pregnancies or births that take place outside the public sector, for ex­ample in homes or in private sector facilities, and there­fore should serve to estimate a denominator.

Where data on the numbers of live births for the de­nominator are unavailable, evaluators can calculate to­tal estimated live births using census data for the total population and crude birth rates in a specified area. To­tal expected births = population x crude birth rate

Purpose:

The main purpose of an indicator for early postnatal care is to provide information on the use of early postnatal services and to provide a measure of access to services for new­borns in this critical period.

Current measurement of postnatal care contacts does not provide information on the content of care provided.  The inter-agency Newborn Indicators Technical Working Group came to consensus on five signal functions for newborn postnatal care that can be performed during a postnatal check at a facility or at home by all levels of workers, including community health workers, and that mothers are likely to recall. Consensus is still needed on postnatal care signal functions for women.  These are:

  1. Checking the cord.
  2. Counseling on danger signs.
  3. Assessing temperature.
  4. Counseling on breastfeeding.
  5. Observing breastfeeding.
  6. Weighing the baby (where applicable).

Many routine HIS and population-based surveys col­lect data on postnatal care coverage. Annual statistics are only possible through HIS. Surveys of postnatal care cover­age every three to five years are sufficient. More fre­quent measurement is inappropriate because sampling errors make it difficult to assess whether small changes are real or due to chance variation.

Early postnatal care coverage should respond to program in­terventions aimed at increasing coverage in the short term.

Issue(s):

Several additional points concerning the interpretation of this indicator are worth emphasizing.

First, the lack of an agreed-upon operational definition of early postnatal care makes valid international comparisons difficult. Early postnatal care is a package of services and not one single intervention. Because the content and qual­ity of care are likely to vary between settings, similar coverage rates do not necessarily reflect similar levels of care.

Second, early postnatal coverage rates should make explicit whether care was provided principally for the mother or baby, or both mother and baby, because this detail may be difficult to determine retrospectively. The cur­rent DHS questionnaire, for example, asks about post­partum care for the mother, but not for the baby, and routine HIS may not make such distinctions.  However, in 2014 the Newborn Indicators Technical Working Group recommended including a question about postnatal care signal functions to national and sub-national surveys in countries interested in tracking newborn care.

Third, early postnatal care coverage should ideally be strati­fied by the age of the baby after birth to get a better measure of access to services in the immediate postna­tal period. Routine HIS usually collects data on postna­tal coverage without specifying when this visit took place.

Finally, surveys relying on a woman‘s recall of events are subject to a recall bias likely to increase with the length of the recall period.

References:

WHO. 1998a. Postpartum Care for the Mother and Newborn: a Practical Guide. Maternal and Newborn Health/ Safe Motherhood Unit. Division of Reproductive Health (Technical Support). Geneva: WHO/RHT/MSM/ 98.3

WHO. 1998b. WHO Recommended Standards for Surveillance of Selected Vaccine-preventable Diseases. Global Programme for Vaccines and Immunisation. Expanded Programme on Immunisation. Geneva: WHO.

WHO. 2001a. "Fifty-fourth World Health Assembly": May 14-22, 2001. Geneva: WHO.

WHO. 2001b. Essential Care Practice Guide: Pregnancy, Childbirth and Newborn Care. Integrated Management of Pregnancy and Childbirth. Geneva. (Unpublished)

Percent of low birth-weight singleton live births, by parity

Definition:

Low birth weight (LBW) is defined as weight less than 2500 g obtained within 24 hours of birth, regardless of gestational age. 

"Live birth" is the the birth of a newborn, irrespective of the duration of gestation, that exhibits any sign of life, such as respiration, heartbeat, umbilical pulsation, or movement of voluntary muscles.

"Parity" is the number of times a woman has given birth.

LBW has two main causes: preterm birth and small-for-gestational age, or intrauter­ine growth retardation (IUGR). LBW is often used as a proxy indicator to quantify the magnitude of IUGR in developing countries because valid assessment of ges­tational age is generally not available, so prematurity and IUGR are often not differentiated.

Preterm birth: The term preterm birth is used for in­fants born before 37-weeks completed gestation. Most, but not all, premature newborns in developing coun­tries weigh less than 2500g.

IUGR: a condition in which fetal growth has been impaired. In developing countries, maternal under-nutrition and maternal ill health including malaria, anemia and acute and chronic infections (e.g., STIs) are major causes.

The numerator and denominator for this indicator are defined according to parity.

For primiparous women, this indicator is calculated as:

Number of LBW singleton live births to women with first birth <2500g x 100

____________________________________________________

Total number of singleton live births to women with first birth

 

For multiparous women, this indicator is calculated as:

Number of LBW singleton live births to women with two or more births <2500g x 100

___________________________________________________________

Total number of singleton live births to women with two or more births

Data Requirements:

Number of newborns with a birth weight less than 2,500g in a defined time period (e.g., 12 months); number of live births in the same time period; parity of the mother.

If targeting and/or linking to inequity, classify sites by location (poor/not poor) and disaggregate newborns by location.

Data Sources:

Population-based surveys (i.e. malaria indicator survey, DHS)

Routine health information systems may collect data for this indicator to ob­tain estimates of LBW for facility births, but facility-based data are not representative, as they are limited to the few women who deliver in facilities. Data from health facilities or delivery records are nevertheless the main
source of data on birth weights obtained during household surveys (Blanc & Wardlaw, 2005). It is therefore critical to ensure that measurement of weight at birth in health facilities is strengthened and routinely recorded on maternity cards and registers.

Purpose:

Approximately 1 in 6 newborns, or 17 million babies, are born every year with LBW. It is the single most important predictor of new­born well-being and survival. Because maternal under-nutrition and malaria-associated maternal anemia are major determinants of LBW, high rates of LBW should be interpreted not only as an indicator of newborn under-nutrition, morbidity, and mortality, but also as an indicator of maternal well being. One of the goals of the World Summit for Children is to reduce the incidence of LBW to less than ten percent (ACC/SCN, 2000a).

In developing countries, approximately two thirds of LBW is caused by IUGR, and the remaining one third is due to preterm birth, although some preterm babies also have IUGR. By contrast, in developed countries, the majority of LBW is due to preterm birth.

LBW babies are ten times more likely to die than babies weighing over 3 kg. They are also more likely to have impaired cognitive development and to develop acute illnesses such as diarrhea and pneumo­nia in early infancy (ACC/SCN, 2000a).

As the risk for LBW has been shown to be higher among primiparous than mutiparous women, measurement of LBW must be differentiated by parity (WHO, 2007).

Issue(s):

Obtaining reliable estimates of LBW in the general population is difficult. In many developing coun­tries, the majority of births occur at home and babies are not weighed. The women surveyed may not know or recall the birth weights of all their children, or they may report them incorrectly.  Promoting childbirth in health facilities where infants are weighed at birth is likely to improve the quality of data on birth weight. 

Many household surveys collect data on birth weight, but since the weights reported are mainly from facility births, these data are also subject to selection bias. Some household surveys (such as the DHS) ask mothers to state whether their baby was smaller than average or very small; and at an aggregate level these data may be used to estimate incidence of LBW at a na­tional level. Regional estimates are also possible if the sample size is sufficiently large (Boerma et al., 1996).

This indicator measures one of the major objectives of safe pregnancy/neonatal interventions: to prevent LBW. However, since LBW is due to many complex factors, changes in LBW in­cidence occur slowly.  Estimates every five years are probably reasonable and consistent with the schedules of many large surveys (e.g., the DHS).  Evaluators must recognize that this indicator will be slow to change, even with well-executed interventions.

References:

Malaria in Pregnancy:  Guidelines for measuring key monitoring and evaluation indicators.  WHO, 2007.

Percent of infants born to HIV-infected mothers who are infected

Definition:

 

The estimated percentage of infants born to HIV-infected mothers who are also infected with HIV.  For further background and details on this indicator, see Gage et al. (2005); PEPFAR (2009) and UNAIDS (2009).

This indicator is calculated as:

(Number of infants born to HIV-infected mothers who are HIV-infected / Total estimated number of HIV-infected pregnant women) x 100

Data Requirements:

 

The indicator is calculated by taking the weighted average of the probabilities of mother-to-child transmission (MTCT) for pregnant women receiving and not receiving the various combination antiretroviral (ARV) prophylactic and treatment regimens, as well as the distribution of infant-feeding practices. Data for the numerator is drawn from national program records. Data required for the modeling can be collected through indicators for the number of women who received ARV prophylaxis to reduce MTCT (PEPFAR #P1.2.D) and for the percent of infants born to HIV-infected mothers who were tested within 12 months of birth (PEPFAR #C4.1.D). The data can be put into a computer-modeling program, such as Spectrum, commonly used for HIV projections. This will assess the impact of the programs to reduce MTCT by estimating the proportion of infants born to HIV-infected women. Other Excel-based spreadsheets, such as the “MTCT rate calculator“, (developed by the U.S. Centers for Disease Control and Prevention), also facilitate this estimation (PEPFAR, 2009). The indicator can be calculated annually, or more frequently, depending on a country’s monitoring needs.

Data Sources:

Spectrum, or other statistical modeling based on program coverage and efficacy studies and data.

Purpose:

 

This indicator is used to assess progress toward eliminating MTCT of HIV primarily through increased provision of ARV medicines and is included as a core indicator in the WHO/UNAIDS/UNICEF/The Global Fund “Three Interlinked Patient Monitoring Systems” (WHO et al., 2010). Programs to prevent mother-to-child transmission (PMTCT) are consistent with achieving Millennium Development Goals #6. to combat HIV/AIDS and #4. to reduce infant and child mortality. In the absence of preventative interventions, infants born to and breastfed by HIV-infected women have about a one-in-three chance of acquiring infection, which can happen during pregnancy, during labor and delivery, or after delivery through breastfeeding. The risk of MTCT can be reduced through the complementary approaches of ARV prophylaxis for the mother, with or without prophylaxis to the infant, implementation of safe delivery practices, and use of safe alternatives to breastfeeding. ARV prophylaxis followed by exclusive breastfeeding may also reduce the risk of vertical transmission when breastfeeding is limited to the first six months. In low-income countries, significant difficulties exist in implementing these strategies due to constraints in accessing, affording and using voluntary counseling and testing services, reproductive health, and maternal and child health services with integrated PMTCT interventions (UNAIDS, 2009). However, substantial reductions in mother-to-child transmission can be achieved through approaches such as short-course ARV prophylaxis.

This indicator allows assessment of the impact of PMTCT programs by estimating the percentage of infants who are HIV-infected out of those born to HIV-infected pregnant women. Where possible, countries should try to monitor PMTCT using actual data on the HIV status and survival of infants born to HIV-infected women during follow-up health care visits with these infants. For further technical guidance on interventions and indicators for PMTCT, see UNAIDS (2010).

Issue(s):

 

If an infant becomes positive, the indicator cannot distinguish between different pathways of infection (i.e., ARV treatment failure or infection during breastfeeding). Therefore, the indicator may underestimate the rates of MTCT in countries where long periods of breastfeeding are common (Gage et al., 2005). In countries where other forms of PMTCT (e.g. caesarean section) are widely practiced, the indicator will typically overestimate MTCT (PEPFAR, 2009). Consequently, trends in this indicator may not reflect overall trends in MTCT of HIV.  It is difficult to follow-up on mother-infant pairs, particularly at the national level, due to the time lag in reporting and the number and range of health facility sites.  In countries where data are available and confirmatory tests are being conducted, an effort should be made to monitor the percentage of HIV-infected infants born to HIV-infected mothers using actual data for the numerator and denominator.

References:

 

Gage A, Ali D, Suzuki C, 2005, A Guide for Measuring and Evaluating Child Health Programs, Chapel Hill, NC: MEASURE Evaluation. https://www.cpc.unc.edu/measure/publications/ms-05-15  

PEPFAR, 2009, The President’s Emergency Plan for AIDS Relief: Next Generation Indicators Reference Guide, Washington, DC: USAID/PEPFAR.  https://www.k4health.org/toolkits/igwg-gender/president%E2%80%99s-emergency-plan-aids-relief-next-generation-indicators-reference

UNAIDS, 2009, Monitoring the Declaration of Commitment on HIV/AIDS: Guidelines on Construction of Core Indicators, Geneva: UNAIDS. http://data.unaids.org/pub/Manual/2009/JC1676_Core_Indicators_2009_en.pdf

UNAIDS, 2010, Prevention of Mother-To-Child Transmission of HIV (PMTCT): Technical Guidance Note for Global Fund HIV Proposals, Geneva: UNAIDS. http://www.who.int/hiv/pub/toolkits/PMTCT_Technical_guidance_GlobalFundR10_May2010.pdf

WHO, UNAIDS, UNICEF, The Global Fund, 2010, Three Interlinked Patient Monitoring Systems for HIV Care/ART, MCH/PMTCT and TB/HIV: Standardized Minimum Data Set and Illustrative Tools, Geneva: WHO. http://www.who.int/hiv/pub/imai/forms_booklet.pdf  

Number of neonatal tetanus cases

Definition:

The number of neonatal tetanus (NT) cases in a given year, in a defined population, including both suspected and confirmed cases

A suspected case: any neonatal death between 3-28 days of age in which the cause of death is unknown; or any neonate reported as having suffered from NT between 3-28 days of age and not investigated.

A confirmed case: any neonate with a normal ability to suck and cry during the first 2 days of life; and who between 3-28 days of age cannot suck normally and becomes stiff or has convulsions (i.e., jerking of the muscles) or both.

The basis for case classification is entirely clinical and does not depend on laboratory confirmation. NT cases reported from hospitals are considered confirmed (WHO, 1999a).

Data Requirements:

Number of NT cases or deaths

Data Sources:

Population based NT mortality surveys; neonatal teta­nus surveillance systems; and population-based surveys (TT2+ coverage, number of live births)

Purpose:

NT is a major public health problem in the developing world. Maternal and NT have been among the most common lethal consequences of unclean deliveries and umbilical cord care practices. When tetanus develops, mortality rates are extremely high, especially when appropriate medical care is unavailable.  WHO estimates that in 2008 (the latest year for which estimates are available), 59,000 newborns died from NT.

The Maternal and Neonatal Tetanus (MNT) Elimination Initiative aims to reduce the number of maternal and neonatal tetanus cases to such low levels that MNT is no longer a major public health problem. Unlike polio and smallpox, tetanus cannot be eradicated (tetanus spores are present in the environment worldwide), but through immunization of pregnant and women of reproductive age and promotion of more hygienic deliveries, MNT can be eliminated (defined as less than one case of neonatal tetanus per 1000 live births in every district).

Because the case fatality is very high in most develop­ing countries, the number of neonatal tetanus cases is often based on actual or estimated numbers of NT deaths.  In countries with tetanus toxoid immunization cover­age (TT+) of over 90 percent and a clean delivery rate over 80 percent, the number of neonatal tetanus cases is taken as the number of neonatal tetanus deaths re­ported.

In countries with lower coverage, an estimate of the number of NT cases is based on an estimate of NT deaths calculated from the number of live births, the neonatal tetanus mortality rate (NTMR), TT2+ coverage, and vac­cine efficacy.

Some countries occasionally conduct NT mortality sur­veys, although most countries with a high proportion of neonatal tetanus deaths carry out routine surveillance in "high risk" areas. Unfortunately, surveillance sys­tems function poorly, and NT continues to be seriously underreported. Community-based NT mor­tality surveys, for example, suggest that routine surveil­lance systems detect only two to eight percent of all cases (WHO, 1994b). For this reason, WHO recom­mends using the following calculation in most settings.

Live births x NTMR x # of NT deaths in 1 year=  (1-TT2+ x VE)

Where:

NTMR = the baseline Neonatal Tetanus Mortality Rate (mortality rate in unvaccinated cases); TT2+ = Tetanus-toxoid-immunization coverage; and VE = Vaccine efficacy (estimated as 0.95).

The NTMR used is the latest value reported in each country where a nationwide survey was undertaken; if no surveys were conducted, a rate of 1, 5, 10, 15 cases per 1000 live births is allocated on the basis of the NTMR reported in countries with similar risk factors. In Latin America the WHO Regional Office (AMRO) uses a correction factor for the sensitivity of the sur­veillance system to adjust for the numbers of reported neonatal tetanus deaths (WHO, 1994b).

Countries with NT surveillance systems assess their progress annually. Demographic surveys, providing neo­natal mortality at 4-14 days on a 3-5 year basis, serve to evaluate surveillance data.

Issue(s):

A number of caveats warrant mention. First, this indi­cator reflects the overall magnitude of the problem of NT deaths but does not offer a precise es­timate because of serious underreporting from surveil­lance data and because of the many assumptions inher­ent in the WHO calculation. Second, because this indi­cator is reported as a number rather than as a propor­tion, countries with lower rates of NT deaths but larger populations will rank ahead of countries with propor­tionately higher deaths rates. Third, aggregate figures at a national level may disguise pockets of high risk in certain subgroups (for example in rural populations or low-caste groups).

Surveillance systems reporting the number of NT cases should also give the percent completeness of reporting (number of NT reports received/the number of reports expected in the same time period). NT deaths should also be reported in conjunction with TT2+ coverage and the proportion of live births with a skilled attendant (as a proxy for proportion of clean deliver­ies).

In countries where NT is a recognized problem, popu­lation-based surveys may provide information on lev­els and trends of neonatal mortality. These surveys pro­vide information on neonatal mortality at 4-14 days, which is a sensitive indicator of NT mortality (Boerma et al., 1996).

References:

Maternal and neonatal tetanus elimination.  WHO, http://www.who.int/immunization_monitoring/diseases/MNTE_initiative/en/index.html.  Accessed June, 2011.

Neonatal mortality rate (NMR)

Definition:

The number of neonatal deaths per 1000 live births

A neonatal death is defined as a death during the first 28 days of life (0-27 days).

# of neonatal deaths x 1000
__________________
 Total # of live births

 

The NMR is often broken down into early and late mor­tality rates. The Early Neonatal Mortality rate (ENMR) is calculated as follows:

# of neonatal deaths 0-7 days x 1000
__________________________
Total # of live births

 

The late neonatal mortality rate (LNMR) is calculated as follows:

# of neonatal deaths 8-27 days x 1000
__________________________
 Total # of live births

 

Data Requirements:

Number of neonatal deaths in a given population and reference period and number of live births in the same population and reference period

Data Sources:

Vital registration; population-based surveys; services statistics

Where data on the numbers of live births for the denominator are unavailable, evaluators can calculate total estimated live births using census data for the total population and crude birth rates in a specified area. Total expected births = population x crude birth rate

The gold standard for NMR data collection is a well-functioning vital registration system.  Routine HIS may collect data for this indicator to ob­tain estimates of the NMR for facilities. Facility data are not recommended for estimating the NMR for the general population, because in many settings, many neo­natal deaths and live births occur outside the health sys­tem, which will cause substantial selection bias.

Purpose:

The NMR is a key outcome indicator for newborn care and directly reflects prenatal, intrapartum, and neona­tal care. In addition, as infant mortality rates decline, the proportion of infant deaths that occur in the neona­tal period typically increases. The NMR differs from the perinatal mortality rate in that it focuses only on deaths among live births and covers a longer period af­ter birth. Information on live births is generally thought to be easier to obtain than information on non-live births and is more widely available, because many popula­tion-based surveys such as the DHS typically only col­lect information on live births. Early neonatal deaths are more closely associated with pregnancy-related fac­tors and maternal health, whereas late neonatal deaths are associated more with factors in the newborn‘s envi­ronment.

In many countries, vital registration data are not suffi­ciently complete to allow reliable estimation of the NMR. The standard techniques for collecting data on live births and neonatal deaths in population-based sur­veys have been widely applied in programs such as the World Fertility Survey and DHS. Data quality is an important issue; com­mon problems include omission of deaths, particularly very early neonatal deaths, and heaping of the reported age at death on 7, 28, or 30 days. Heaping on these digits is particularly problematic because it will lead to the misclassification of early neonatal deaths as late neonatal death (7 days) or late neonatal deaths as post-neonatal deaths (28 and 30 days).

Evaluators typically calculate NMR at a national or in­ternational level. They may also obtain sub-national estimates if sample sizes are sufficiently large. The NMR is sometimes calculated at a facility level to moni­tor the outcome of delivery and newborn care in health facilities. Reliable estimates for individual facilities can only be obtained for very large facilities with large numbers of deliveries and neonatal admissions.

Issue(s):

The NMR may respond fairly quickly to programmatic interventions, for example, immunizing all pregnant women in areas of high tetanus prevalence. However, survey-based estimates are generally subject to relatively large sampling errors, so it is impossible to detect changes over short periods of time unless the changes are quite large.  Also, survey-based estimates are often based on a five-year period prior to the survey.  There­fore, we recommend collecting survey-based estimates of the NMR not more than every three to five years.

One limitation of note is the NMR‘s sensitivity to changes in the quality of data. For example, a rise in the NMR may indicate deterioration in newborn health outcomes, or it may indicate an improvement in the re­porting of neonatal deaths. Therefore, assessing data quality is essential to analysis.

Also, evaluators should interpret comparisons of facil­ity-based estimates of the NMR very carefully because the NMR in a facility is very sensitive to the case mix of deliveries and neonatal admissions. One should not interpret a higher NMR in one facility as suggesting that the quality of neonatal care is worse in this facility because the NMR may rise or fall in response to changes in the case-mix. Additionally, improvements in prena­tal and intrapartum care and advances in medical tech­nology may increase the NMR because babies who may otherwise have been stillbirths may survive delivery only to die in the neonatal period. For these reasons, we recommend that evaluators break down facility-based estimates of the NMR by birth weight (see Birth weight specific mortality rate) and by admission status (di­rect admission or transfer-in) as a proxy for case mix.

Perinatal mortality rate (PMR)

Definition:

The number of perinatal deaths per 1000 total births

A perinatal death is a fetal death (stillbirth) or an early neonatal death.

The perinatal mortality rate is calculated as:

(# of perinatal deaths / total # of births (still births + live births)) x 1000

A stillbirth is the death of a fetus weighing 500g or more, or of 22-weeks gestation or more if weight is unavailable (ICD 10).

An early neonatal death (END) is the death of a live newborn in the first 7 days (i.e., 0-6 days) of life.

Great variation exists both between and within countries on how the stillbirth component of perinatal mortality is recorded, particularly for early stillbirths that occur at 22- to 27-weeks gestation. For international comparisons, WHO suggests including only deaths of fetuses weighing at least 1000g, or of 28-weeks gestation or more if weight is unavailable. Presentations of the PMR should include a clear statement of the definition of perinatal mortality used. In practice, in most developing countries accurate data on birth weight or gestational age are difficult to obtain.

Data Requirements:

Number of perinatal deaths in a given population in a given reference period(i.e., 12 months) and number of births (live births + stillbirths) in the same population and reference period

Data Sources:

Population-based surveys; vital registration; service statistics

Routine HIS may collect data for this indicator to obtain estimates of the PMR for facilities. Facility data are not recommended for estimating the PMR for the general population because in many settings, many perinatal deaths and live births occur outside the health system, which will cause substantial selection bias.

Purpose:

The PMR is a key outcome indicator for newborn care and directly reflects prenatal, intrapartum, and newborn care. It has also been proposed as a proxy measure of maternal health status and mortality, but a recent study has cast doubt on its use as a proxy for maternal mortality (Akalin et al., 1997).

Because the PMR includes both fetal deaths and deaths in the first week of life, it avoids conflicting judgments as to whether a fetus exhibited signs of life and variations in administrative practice regarding whether or not a death should be counted. In many countries, however, vital registration data are not sufficiently complete to allow reliable estimation of the PMR. Techniques now exist for collecting data on stillbirths, live births, and early neonatal deaths in population-based surveys (pregnancy histories) and applied in surveys including the DHS. However, there has been relatively less experience with pregnancy histories than with birth histories because of concerns about the quality of retrospectively reported pregnancy histories. Common problems with data quality include:

Issue(s):

Prospective population-based surveys of pregnant women provide better quality data, but are expensive to undertake.

Evaluators typically calculate the PMR obtained from large population-based surveys at a national level and may aggregate data across countries to obtain a global or UN subregion statistic. Evaluators may also obtain sub-national estimates if sample sizes are sufficiently large.

The early neonatal component of the PMR may respond relatively quickly to programmatic interventions, for example, following the introduction of elements of the WHO Essential Newborn Care Package. The stillbirth component may decline more slowly because it depends more on interventions that influence primarily maternal health and on the availability of technologies such as cesarian section. Survey-based estimates are generally subject to relatively large sampling errors, so detecting changes over short periods of time is impossible unless the changes are quite large. Also, retrospective survey-based estimates are often based on a five-year period prior to the survey. Therefore, evaluators should collect survey-based estimates of the PMR not more than every three to five years.

The following caveats bear mention. The PMR is sensitive to changes in the quality of data. For example, a rise in the PMR may indicate deterioration in perinatal outcomes, or it may indicate an improvement in the reporting of perinatal deaths. Therefore, an assessment of data quality is an essential component of analysis. In this context, evaluators often find it useful to separate the PMR into its two components: stillbirths and early neonatal mortality. Data quality is generally more problematic for stillbirths than for early neonatal deaths, because the problems of obtaining gestational age and ambiguity over the definition of stillbirths and fetal deaths are much less likely to be reported than deaths of live births (WHO, 1996b).

Evaluators should interpret facility-based estimates of the PMR with caution. The PMR in a facility is very sensitive to the types of deliveries occurring in the facility. Consequently, it may rise or fall in response to changes in the complexity of deliveries in the facility. In small facilities, the PMR will be very unstable because of the small number of deliveries and perinatal deaths; thus, the PMR is ineffective for monitoring change over time within the facility.

Birth weight specific mortality rate (BWSMR)

Definition:

The Birth Weight Specific Mortality Rate (BWSMR) is a stratification of a newborn mortality rate by birth weight grouping. (See indicator Neonatal mortality rate (NMR.)) For example, the Birth Weight Specific Neonatal Mortality Rate for births over 2,500g is calculated as:

(Number of neonatal deaths weighing over 2,500 g at birth / Total number of live births weighing over 2,500 g at birth) x 100

And for births under 2,500g is calculated as:

(Number of neonatal deaths weighing under 2,500g at birth / Total number of live births weighing under 2,500g at birth) x 100

Evaluators can calculate BWSMR for perinatal deaths and stillbirths on the same basis.

Data Requirements:

Number of deaths in a particular birth weight grouping and total number of births in the same weight grouping

Data Sources:

Service statistics

HIS may collect data for this indicator in highly developed systems.

Purpose:

As discussed in the preceding sections, birth weight is one of the most sensitive predictors of infant survival and is also a good predictor of maternal health and well-being. The mortality rate for low birth weight babies is much higher than for those with a normal birth weight. Stratifying newborn deaths by birth weight helps to determine the cause of death and therefore to identify where interventions are needed. For example, deaths of very small babies are more likely related to maternal causes predisposing to intrauterine growth retardation and preterm birth, whereas deaths of normal birth weight babies are more likely to be related to intrapartum asphyxia and poor obstetric care. In the first case, interventions should focus on the mother (improving nutrition and reducing antenatal infection) and, in the second case, should focus on improving the quality of delivery care. Evaluators can obtain additional information by stratifying birth weight by time of death.

Potential Causes of Death for Specific Age and Birth Weight Categories

WeightFetal DeathIntrapartum Death

Early Neonatal Death

Late Neonatal Death
Less than 2500g

Maternal infection (e.g. malaria, syphilis, other STIs)

Medical complications

Antepartum hemorrage

Hypertensive disease

Complications of preterm labor/IUGR

Asphyxia

Complications of preterm labor/IUGR

Infections

Infections (ARI)

Late complications of prematurity

Tetanus

2500g and above 

Maternal infection (e.g. malaria, syphilis, other STIs)

Medical complications

Antepartum hemorrage

Hypertensive disease

Asphyxia and birth trauma

Maternal infection

Asphyxia and birth trauma

Infection

Infections (ARI)

Tetanus

Issue(s):

Evaluators can collect this type of indicator only in settings where all babies are weighed. It is therefore most appropriate for use in health facilities but has served in some community settings as part of a maternal and perinatal health care surveillance system (McCarthy, Lawn, and Ross, 2001).

One useful application of this type of disaggregation is to examine the number of intrapartum deaths in normal birth weight babies. If the quality of obstetric care is good (and women are not presenting very late in labor), then very few intrapartum deaths should occur because deliveries are expedited rapidly. The proportion of stillbirths in babies of normal birth weight may serve as a proxy indicator for intrapartum asphyxia and quality of delivery care.

Percent of women with a live birth who reported seeking care from a skilled provider for a sick newborn

Definition:

 

The percentage of women with live birth during a specified time period who report having sought care from a skilled provider for their sick newborn. A sick newborn is defined as having a reported newborn illness in the first 28 days after birth. Skilled providers can include private doctors, nurses, physician assistants, midwives and trained birth attendants, and pharmacists. 

This indicator is calculated as:

(Number of women with live birth who report seeking care from a skilled provider for a sick newborn / Total number of women with live birth during specified time period) x 100

 

Data Requirements:

Data can be used to calculate this indicator from surveys with detailed information on mothers’ newborn health care behaviors or from independent and prospective studies on mothers’ health care seeking behaviors. At present, large-scale, population-based surveys, such as the Demographic Health Survey (DHS) and the UNICEF Multiple Indicator Cluster Survey (MICS) do not have the level of detail to calculate this indicator for newborns. The data can be disaggregated by the type of skilled provider and/or type of facility visited (i.e., public, private, non-governmental, community-based), and other factors such as district or urban/rural location.

Data Sources:

Specialized surveys with detailed information on mothers’ health care behaviors for their newborns; independent studies on mothers’ newborn health care seeking behaviors.

Purpose:

 

This indicator measures women’s healthcare seeking behaviors for their newborns when the infants show signs of sickness. The indicator relates directly to the achievement of Millennium Development Goal #4 to reduce infant and child mortality.  Many newborn infants are born at home or returned home shortly after delivery, and they can become ill and die before ever reaching medical care. Until recently, newborn health was not a priority in both the international child health and safe motherhood movements, largely due to the general lack of awareness of the sheer numbers of early infant deaths. WHO estimates that each year nearly 3.3 million babies are stillborn, and more than 4 million others die within 28 days of being born. Newborn deaths contribute to about 40% of all deaths in children under five years of age globally, and more than half of infant mortality (WHO, 2005). Nearly all of these deaths occur in developing countries, and although post-neonatal mortality has declined substantially, neonatal deaths have declined only slightly (Gage, et al., 2005). 

This indicator can be used with specialized surveys and independent research studies. The Save Newborn Lives/ Save the Children expert working group (Save the Children, 2010) has recommended that this and related newborn health indicators,  including recognition of danger signs, care-seeking, and best practices for newborn care, be more widely used in population based surveys, such as DHS and MICS.  It is important to develop indicators that help programs understand community knowledge, attitudes, and behaviors in response to newborn illness and to determine which interventions are the most effective (Gage, et al., 2005).

Issue(s):

 

 

Newborn illness is often difficult to recognize because infants often present with relatively non-specific symptoms, such as poor feeding and lethargy. In many settings, few facilities or skilled providers may be accessible and affordable and, even where mothers can access skilled providers, adequate diagnostic and/or treatment resources may not be available. Given these barriers to accessing adequate newborn care, mothers may choose to not seek skilled providers. Mothers may also report the recommended behavior rather than actual practice, particularly in areas where communication programs have been promoting healthcare-seeking behaviors for mothers and their newborns (Gage et al., 2005). Surveys rely on recall of events and this indicator is subject to recall bias, which is likely to increase with the length of the recall period. Recall bias can be minimized by keeping the reference period short.  Another issue is small sample sizes – even in large surveys, few women may report that their newborn suffered from sickness, thus reducing the denominator for this indicator.  Results should therefore be interpreted with caution, especially in surveys with small sample sizes.

References:

 

Gage A, Ali D, Suzuki C, 2005, A Guide for Measuring and Evaluating Child Health Programs, Chapel Hill, NC: MEASURE Evaluation. https://www.cpc.unc.edu/measure/publications/ms-05-15  

Save the Children, 2010, Report of a Technical Working Group Meeting on Newborn Health Indicators, Washington, DC: Save the Children.

WHO, 2005, The World Health Report 2005: Make every mother and child count, Geneva: WHO.  http://www.who.int/whr/2005/media_centre/facts_en.pdf

Intrapartum and very early neonatal death rate

Definition:

 

The proportion of births weighing ≥ 2.5 kg during a specified time period that result in an intrapartum death (fresh stillbirth) or very early neonatal death within the first 24 hours during a specified time period (WHO et al., 2010).

Intrapartum or fresh stillbirths include infants born dead after 28 weeks of gestation without skin deterioration or maceration. The death is assumed to have occurred less than 12 hours before delivery and excludes infants with severe, lethal congenital abnormalities.  Early neonatal deaths include neonates born at term who could not be resuscitated, for whom resuscitation was not available, or who had a specific birth trauma, where death occurred within 24 hours of delivery. Given the fact that low birthweight infants have high fatality rates, it is recommended that newborns with weights under the international standard of 2.5 kg be excluded from the numerator and denominator whenever the data allow.  However, some countries prefer to use 2.0 kg as their threshold. For further details on this indicator, see WHO et al. (2010).

This indicator is calculated as:

(Number of births weighing ≥ 2.5 kg resulting in intrapartum deaths and very early neonatal deaths within first 24 hours / Total number of women giving birth to infants weighing ≥ 2.5 kg during specified time frame) x 100

The Research Triangle Institute in collaboration with international health partners is developing a prospective intrapartum stillbirth and early neonatal death indicator, designed to monitor improvements in the quality of obstetric and newborn care provided at birth by skilled attendants in health facilities (EngenderHealth, 2011).

Data Requirements:

Reviews of records and registers from all facilities providing labor and delivery care can be used to calculate the indicator. Alternative types of information include prospective data from facilities and retrospective data from surveys with detailed pregnancy histories. Data may be disaggregated by type of facility (e.g., by basic versus emergency obstetric care, and/or by public, private, non-governmental organization) in addition to other factors such as urban/rural location and districts.

Data Sources:

Facility records; birth and death registers; prospective studies; surveys with detailed pregnancy histories.

Purpose:

This indicator reflects the quality of intrapartum care for fetuses and newborns delivered at facilities. Worldwide, nearly two million infants die each year around the time of delivery. A major cause of intrapartum or early very neonatal death is asphyxia which can result from poorly managed obstetric complications and from the absence of neonatal resuscitation. Good quality intrapartum care is crucial for both mothers and their infants, and where appropriate and timely care is provided, most maternal and neonatal deaths can be prevented (WHO et al., 2010).  Quality intrapartum care is directly related to Millennium Development Goals #4. reduce child mortality and #5. improve maternal health.  This indicator focuses on the intrapartum and very early neonatal deaths that could have been averted by the health system’s ability to provide quality obstetric care and neonatal resuscitation.  Trends over time can be followed in the aggregate, as well as, disaggregated by facility types, locations, and individual facilities. A maximum acceptable level for the indicator can be explored and set where appropriate. In facilities with high rates for this indicator, it may be useful to conduct perinatal death audits to gain information for improving the quality of care.

Issue(s):

Few countries have sufficiently developed vital registration systems that can provide valid and reliable information on all births and deaths in the community. Health information systems can only provide information on births and deaths in facilities and, in most settings, are not well developed. Most community-based programs do not have the capacity to measure infant and child mortality. For newborn health, prospective studies would provide the most reliable mortality rates, but are costly for regular reporting purposes. Large-scale surveys that rely on the retrospective reporting of deaths in early infancy can provide estimates of neonatal mortality, but estimates of perinatal mortality (which includes intrapartum and very early neonatal deaths) require very detailed pregnancy histories (Gage at al., 2005). In addition, retrospective data are subject to recall error, which is likely to increase with the length of the recall period.

References:

 

Engenderhealth, July 2011, Maternal Health Task Force Updates, New York: The Maternal Health Task Force at EngenderHealth. https://www.engenderhealth.org/media/2010/2010-07-22-maternal-health-task-force.php 

Gage A, Ali D, Suzuki C, 2005, A Guide for Measuring and Evaluating Child Health Programs, Chapel Hill, NC: MEASURE Evaluation. https://www.cpc.unc.edu/measure/publications/ms-05-15

WHO, UNFPA, UNICEF, AMDD, 2010, Monitoring Emergency Obstetric Care: A handbook, Geneva: WHO. http://whqlibdoc.who.int/publications/2009/9789241547734_eng.pdf