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

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

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# 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.


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


Review of medical records; direct observation of providers


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.


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.


newborn (NB), quality
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