Safe Motherhood

 

Welcome to the programmatic area on safe motherhood within MEASURE Evaluation’s Family Planning and Reproductive Health Indicators Database. Safe motherhood is one of the subareas found in the women’s health part of the sexual and reproductive health (RH) 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 inauguration of the Safe Motherhood Initiative in Kenya in 1987 marked the beginning of concerted international efforts to reduce maternal mortality. Since that time, reducing maternal mortality has continued to be the aim of many international health programs. Over time, policies and strategies to achieve safe motherhood have changed as knowledge and understanding about the determinants of maternal health have become clearer. The indicators in this section are intended mainly for use at the national level or in the context of large-scale programs. Key indicators to monitor and evaluate safe motherhood can be found in the links at left.   Full Text The inauguration of the Safe Motherhood Initiative in Kenya in 1987 marked the beginning of concerted international efforts to reduce maternal mortality. Since that time, reducing maternal mortality has continued to be the aim of many international health programs. Improving maternal health was included as the fifth Millenium Development Goal (MDG), which calls for a 75 percent reduction in maternal mortality between 1990 and 2015.  And reducing maternal mortality by 30 percent accross assisted countries is one of the targets for USAID's Global Health Initiative (USAID, 2011). Although safe motherhood has remained high on the political agenda, the scope of what constitutes "safer" motherhood has changed considerably. A major factor has been the incorporation of a human rights approach into the definition of Safe Motherhood following the agenda set at the International Conference on Population and Development (ICPD). By defining maternal death as social injustice, programs for "Safer Motherhood" are able to invoke a much broader range of political, social, and economic initiatives than was previously possible (UNFPA et al., 1997). Policies and strategies to achieve safe motherhood have also changed as knowledge and understanding about the determinants of maternal health have become clearer.  In the Initiative's early years, the focus was on maternal death as a result of poor or inaccessible medical care.  But then recognition was given to the range of direct and indirect problems that contribute to poor maternal health: lack of education for girls; early marriage; lack of access to contraception; poor nutrition; and women's low social, economic, and legal status (Starrs, 2006).  Over the past two decades, many other new priorities and challenges have also emerged that need to be addressed under the safe motherhood umbrella. Foremost among these is the HIV/AIDS pandemic, which continues to have a disproportionate impact on women and girls.  Another major development is the increasing focus on newborn care. Awareness that relatively simple interventions both before and after birth may substantially reduce the estimated eight million perinatal and neonatal deaths has given rise to many more programs that target improving newborn survival.    Conceptual Model Several different models or frameworks exist to help program managers and communities understand the determinants of maternal mortality (Campbell et al., 1997; McCarthy and Maine, 1992; Thaddeus and Maine, 1994; Koblinsky et al., 2000). The "Three Delays Model" identifies the points at which delays can occur in the management of obstetric complications at the community and facility level. The first "delay" (delay in deciding to seek care) may relate to a number of factors, including the lack of knowledge about obstetric danger signs, community perception of poor quality facility care, or the lack of health services availability which increases the opportunity costs and therefore reduces the likelihood of care seeking. The second "delay" (delay in identifying and reaching a medical facility) relates to the geographical proximity and accessibility of health services, and includes factors such as the availability of transportation. The third "delay" (delay in receiving appropriate care at health facilities) is related to factors in the health facility, including the availability of staff, equipment, and resources as well as the quality and (in some cases) the cost of services.  (Click on image to enlarge.) Methodological Challenges of Evaluating Safe Motherhood Interventions In addition to the changes in the definition, policies, and strategies as well as the emergence of new public health problems that drive the need for an increasingly wide range of indicators, monitoring and evaluating safe motherhood programs pose a number of inherent methodological challenges. These include, but are not limited to, the following issues. Maternal mortality is difficult to measure, and estimates of maternal mortality should not be used for monitoring purposes. Maternal mortality estimates are valuable and particularly relevant now due to the need to evaluate MDG-5, improve maternal health.  Mortality estimates do, however, have a number of inherent methodological weaknesses that limit their use for monitoring purposes; they are costly, they do not explain the causes of maternal deaths, and they cannot detect short term change (Graham et al., 2008). Few developing countries have registration systems with sufficiently wide coverage to provide accurate national estimates of maternal mortality. Alternative approaches to deriving estimates, such as surveys and the sisterhood method, also have limitations in that the estimates are relatively imprecise and relate to periods several years before the survey. Even in countries where the maternal mortality is high, maternal deaths are rare events; therefore, surveys are very costly because of the need for large sample sizes to provide a statistically reliable estimate. The wide confidence limits on the estimate also make it very difficult, if not impossible, to assess whether change has occurred over time. For these reasons, maternal mortality estimates, if required, should be measured only infrequently (e.g., once a decade), and program-level indicators that measure the availability, use, and quality of care are recommended for monitoring purposes (AbouZahr, 1999).  Maternal morbidity is difficult to define, interpret, and measure Maternal morbidity is much more common than maternal death; thus, the prevalence of maternal morbidity provides a conceptually appealing alternative outcome to measure. Moreover, relatively little is known about the burden of reproductive morbidity; more work is needed to explore the dimensions and determinants of the problem as well as to evaluate the effectiveness of interventions. The link between morbidity and mortality is not straightforward.  Safe motherhood interventions primarily offer secondary prevention; that is, they prevent deaths from complications rather than preventing the complications themselves. Furthermore, unlike death, which has a very defined outcome, measures of morbidity are difficult to define and thus to measure. Even persons with medical training may misclassify complications; consequently, generating any meaningful comparative measures is difficult (Fortney and Smith, 1999). Safe motherhood outcomes need to be measured for two individuals: the mother and baby  Under most circumstances interventions that benefit or harm the mother similarly affect the baby and vice versa. Some exceptions are notable. For example, a cesarean section for fetal distress may be critical to ensure a good neonatal outcome but may more negatively influence the mother's health than a normal vaginal delivery will. The provision of appropriate maternity care is a complex process that requires multiple indicators to monitor Unlike most areas of public health, providing appropriate maternity care is a complex process that involves a wide range of preventive, curative, and emergency services as well as several different levels of care (from the community to the facility and beyond).  The occurrence of an emergency sets into motion a complex chain of events to ensure that a woman receives adequate care. First, the family needs to recognize the problem and be able to access the appropriate services.  Second, the equipment, supplies and medicines must be available at the facility to enable the care provider to make the correct diagnosis and to provide appropriate treatment promptly. If definitive care cannot be provided at the first level, then transport needs to be available quickly to take the woman to a higher level of care that must also deliver the appropriate services. Problems at any one of these stages may mean that the woman receives substandard care, which may be of critical importance in determining the outcome. From a program perspective, a series of indicators is required to reveal whether a problem occurs on the "demand" or "supply" side of the equation, and hence, whether the interventions need to address community mobilization, behavior change, health system performance, or a combination of these factors. Interpreting whether outcomes are attributable to program interventions is difficult, because most interventions consist of "bundled" services  Demonstrating change as a result of a safe motherhood program is difficult because programs usually provide a package of care to communities rather than providing one single intervention. Therefore, such programs do not lend themselves easily to randomized control trials or cluster randomized community-based trials. Many programs adopt "before-after" designs for evaluation purposes that can demonstrate "plausible association" but that fall short of determining causality (UNFPA et al., 1997). Indicator Selection The indicators in this section are intended mainly for use at the national level or in the context of large-scale programs. However, many can serve in a much wider monitoring and evaluation context. These indicators were selected on the basis that they:  Are widely used by international organizations and/or ministries of health; Have a relatively strong link to health or mortality outcomes; and Will likely provide valid comparisons at a national and international level.   Not all indicators included in this section are equally strong or provide the same quality of information. Certain indicators (for example, Percent of pregnant women attending antenatal clinics screened for syphilis) are included because of the potential importance of the information, even though the feasibility of collecting valid information at a national level may be low. At least one indicator is included to represent each element of the proposed safe motherhood framework, and under some headings, no "strong" indicators were available. In addition, the program-level indicators are included because they are now used rather widely, and they provide useful information about local planning and decision-making. However, several are clearly not intended for national level use. The indicators included in this section focus on a rather narrow definition of safe motherhood.  To address related issues of STIs/HIV/AIDS, Women's Nutrition, Cervical Cancer, Obsteric Fistula, etc., users are encouraged to look at those indicators in their respective sections. Priority is given to core indicators currently in use to monitor safe motherhood programs and those most closely related to maternal outcome.  However, programs need to develop their own set of indicators according to the objectives of the program and the interventions designed to achieve those objectives. ____________ References: USAID, 2011.  "The United States Government Global Health Initiative".  Available at: http://www.usaid.gov/ghi/. UNFPA, UNICEF, The World Bank, WHO, IPPF, and The Population Council.  1997.  The Safe Motherhood Action Agenda: Priorities for the Next Decade. Report on the Safe Motherhood Technical Consultation.  October 18-23. Starrs, A. 2006. "Safe motherhood initiative: 20 years and counting." The Lancet 368, 9542: 1130-1132. Graham WJ, Ahmed S, Stanton C, Abou-Zahr CL, and Campbell OMR. 2008. "Measuring maternal mortality: An overview of opportunities and options for developing countries." BMC Medicine 6:12.

Existence of a safe motherhood strategic or operational plan to promote access and/or quality of safe motherhood services

Definition:

The degree of explicit support for access to and/or quality of safe motherhood programs on the part of the government and other bodies, including service delivery organizations.

Most, but not all, developing countries now have some national family planning/reproductive health (FP/RH) law, policy, or strategy in place. Safe motherhood policies and plans may be separate from or included within the larger RH policies or strategic plans.

Data Requirements:

This qualitative indicator is based on the existence of a safe motherhood plan. Evaluators assign a "yes" value if a strategic or implementation plan exists. Sometimes safe motherhood strategies are incorporated into RH or maternal and child health implementation plans; thus, evaluators should assess these plans to determine if the objectives and corresponding strategies adequately address safe motherhood.

Evidence of an approved plan for safe motherhood with evidence for approval (or submission for approval). In addition, supporting documentation should include the plan, where and by whom it was issued or published, and how the plan promotes access and/or improves the quality of safe motherhood services.

Data Sources:

Documents from the government organization designated as responsible for coordinating safe motherhood or RH. Content analysis of the plan document should determine whether the plan: (1) defines the objectives of the country's safe motherhood program; (2) defines a clear strategy for attaining these objectives; (3) establishes an organizational structure for the program which is consistent with the strategy and which covers both public and private sectors, including women's groups; and (4) estimates and projects the resources required to implement the strategy, and specifies how these resources are to be secured.

Purpose:

This indicator measures the degree of explicit support for access to and/or quality of safe motherhood programs on the part of the government and other bodies, including service delivery organizations. It tells us if policy is translated into a strategic or implementation plan. The purpose is to measure whether the safe motherhood or pregnancy program has developed a clear view of its mission and objectives and the strategies for attaining them.

Issue(s):

Strategic implementation planning at the national level requires the participation of various government ministries or departments, including the health, finance, planning, information, education, interior ministries, as well as important private groups (NGOs and commercial establishments), women's groups, and religious and civic organizations.

Minimum package of antenatal care services defined

Definition:

There is documented evidence of a national policy and/or Ministry of Health (MOH) guidelines for a recommended minimum package of services to be provided by antenatal care (ANC) facilities. Variations exist among recommended essential and minimum care packages, and can be attributed to the types of health risks prevalent in different settings (e.g., areas of endemic malaria or generalized HIV epidemic). For women whose pregnancies are progressing normally, WHO recommends a minimum of four ANC visits, ideally at 16 weeks, 24-28 weeks, 32 weeks and 36 weeks (USAID/Population council, 2006).

Each visit should include care that is appropriate to the overall condition and stage of pregnancy and should include four main categories of care (with specific examples provided for each category):

  1. Identification of pre-existing health conditions (e.g., check for weight and nutrition status, anemia, hypertension, syphilis, HIV status)
  2. Early detection of complications arising during pregnancy (e.g., check for pre-eclampsia, gestational diabetes)
  3. Health promotion and disease prevention (e.g., tetanus vaccine, prevention and treatment of malaria, nutrition counseling, micronutrient supplements, family planning counseling)
  4. Birth preparedness and complication planning (e.g., birth and emergency plan, breastfeeding counseling, antiretrovirals for HIV positive women and reducing mother-to- child transmission [MTCT] of HIV)

For additional background on recommended components of ANC, see USAID/Population Council (2006); WHO (2002); USAID/CORE Group (2004)USAID (2009); and Mailman School of Public Health (2007).

This indicator is measured as yes/no based on whether all the minimum recommended services are included in national policy and/or MOH guidelines.

Data Requirements:

Written national policies and/or MOH documentation of   recommendations or guidelines for a minimum package of ANC are needed to provide evidence for this indicator.  The documents should reflect the range of recommended essential ANC services under the WHO four categories of care listed above and reflect specific needs for country and regional settings, such as malaria treatment in endemic areas.

Data Sources:

National policy documents and/or MOH written guidelines for ANC; interviews with key informants.

Purpose:

This indicator measures the level of national commitment provision of quality ANC services through the health system. Quality ANC is associated with a better overall pregnancy outcome for both mother and infant.  Many health problems experienced by pregnant women can be prevented, detected and treated during ANC visits with trained health workers. ANC can foster a rapport between the mother and the father and the health care provider, provide preventive care and health education, identify and treat illness, encourage skilled attendance at birth and prepare the mother, other family members, and birth attendants for possible emergencies (WHO, 2006). Good ANC can help prevent factors associated with newborn mortality such as low birth weight and complications from infectious diseases, including reducing MTCT. Male partner participation in antenatal health care can encourage male partner support and involvement in pregnancy and delivery (WHO, 2006). Overall, women’s access to quality ANC is central to achieving the Millennium Development Goals #5. improve maternal health and #4. reduce child mortality.

Issue(s):

Evaluators may have difficulty obtaining evidence that the full range of recommended minimum ANC services have been incorporated into government policy or MOH guidance. This indicator does not measure if the recommendations are being distributed throughout the ANC health system and if the minimum package guidelines are being followed or monitored at the facility level. Evaluators would need to follow-up to verify if and to what extent these recommendations are being operationalized.

References:

Mailman School of Public Health, 2007, Package of Care to be provided according to type of Health facility, New York City: Columbia University/Mailman SPH Website. http://cumc.columbia.edu/dept/icap/resources/pmtct/PMTCTpackagecare092507.pdf  

USAID/Population Council, 2006, Acceptability and Sustainability of the WHO Focused Antenatal Care package in Kenya, Washington DC: USAID.  http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.175.8488&rep=rep1&type=pdf

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

USAID, 2009, Child Survival and Health Grants Program (CSHGP), Technical Reference Materials: Maternal and Newborn Care, Washington, DC: USAID.  http://www.usaid.gov/our_work/global_health/home/Funding/cs_grants/cs_index.html

WHO, 2002, Antenatal Care Randomized Trial: Manual for the Implementation of the New Model, Geneva: WHO. http://whqlibdoc.who.int/hq/2001/WHO_RHR_01.30.pdf

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

Maternal neonatal program index (MNPI)

Definition:

This indicator is a score (ranging from 0-100) that measures the strength of the national maternal and neonatal health program of a given country based on five main areas: policy and support services, facility capacity, access to services, care received, and family planning (FP). The five main areas cover 13 components:

  1. Capacities of health centers;
  2. Capacities of district hospitals;
  3. Percent of women with access;
  4. Care at antenatal visits;
  5. Care at delivery;
  6. Care for newborns;
  7. FP at health centers;
  8. FP at district hospitals;
  9. Policies toward safe pregnancy;
  10. Resources;
  11. Information, education;
  12. Training; and
  13. Monitoring and evaluation.

Within each component, the researcher averages items to produce a component score, and converts these scores to a 0-100 scale. The index also yields a total score, which is simply the mean for the 13 components with equal weight for each component (Bulatao and Ross, 2000).

Data Requirements:

Responses to a detailed questionnaire composed of 81 items from selected key informants (experts from Ministries of Health, medical schools and universities, nongovernmental and community organizations, and donors). Besides rating current program adequacy, experts rate each item on the questionnaire as of three years prior to the survey.

Data Sources:

The MNPI questionnaire completed by 10-25 individuals per country.

Purpose:

The purpose of the MNPI is to:

More specifically, the MNPI is intended to measure the effort put into reducing the maternal/ neonatal mortality and morbidity in a given country. The index is designed to assess only the program inputs, processes, and outputs as they relate to the "supply" or program side of the conceptual framework (Ross, Campbell and Bulatao, 1999). Since the data was first collected in 1999 (then again in 2002 and 2005) it has provided a measure by which to make cross-country and regional comparisons. The MNPI is not designed to provide a single measure of the quality of maternal care; rather, it provides many measures that collectively define a broad standard programs should meet (Bulatao and Ross, 2000).

Issue(s):

The MNPI instrument relies on expert judgments, replicating an approach used in family planning and HIV/ AIDS. (See Family Planning Program Effort Index and AIDS Program Effort Index (API) under Family Planning and STIs/HIV/AIDS, respectively.) Standards, however, are ultimately subjective, resting on the knowledge and expertise of the raters, who are different in each country. Whereas the data collection protocol calls for using raters with varying backgrounds (at least ten per country), validating their ratings is difficult (Ross, Campbell and Bulatao, 1999).

Another limitation is the difficulty of correlating the index closely to a reduction in maternal mortality, largely because maternal mortality levels are hard to determine accurately (Bulatao and Ross, 2001).

Number of facilities per 500,00 providing basic and comprehensive emergency obstetric care

Definition:

The number of facilities providing basic and comprehensive obstetric services (known as signal functions) at least once in the previous three months per 500,000 population.

Basic obstetric services are defined as:

  1. Administration of parenteral antibiotics;
  2. Administration of uterotonic drugs (i.e. parenteral oxytocin);
  3. Administration of parenteral anticonvulsants for pre-eclamsia and eclampsia (i.e. magnesium sulphate);
  4. Manual removal of the placenta;
  5. Removal of retained products (e.g.,manual vacuum aspiration);
  6. Perform assisted vaginal delivery (e.g., vacuum extraction, forceps); and 

In addition to these six, a comprehensive emergency obstetric care facility will also:


Facilities are divided into those that provide "basic" emergency obstetric care (EmOC) and "comprehensive" EmOC. If a facility has performed each of the first six functions in the past three months, it qualifies as providing basic EOC. If it has provided all eight of the functions, it qualifies as a "comprehensive" EmOC facility.

Other items have been discussed as signal functions, but these nine were chosen by technical consultation because of the role they play in the treatment of the five major causes of maternal death.

Data Requirements:

Count of the facilities meeting the requirements for "basic" and "comprehensive" EmOC.  If there are at least five basic and emergency obstetric care facilities (including one comprehensive facility) for every 500,000 population, then this indicator meets the acceptable level as defined by WHO/UNICEF/UNFPA/AMDD (2009).

Data Sources:

Facility surveys that examine medical records or service statistics. Ideally, records should provide the emergency obstetric signal functions. Personal interviews with knowledgeable staff who attend obstetric patients are a second, albeit, potentially more biased source of information than written records are.

Purpose:

This indicator demonstrates the existence of life-saving obstetric care services. It distinguishes between "basic" and "comprehensive" care services to emphasize that maternal lives can be saved not only in hospitals providing all the services listed above, but also at health centers or smaller hospitals that do not.

The list is intentionally brief to facilitate assessment and monitoring; it does not constitute the complete list of services that either a basic or comprehensive EmOC facility should provide but rather focuses on the key medical interventions that are used to treat the vast majority of global maternal deaths. For a complete list of recommended procedures and drugs, refer to WHO's Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors and Managing Newborn Problems: A guide for doctors, nurses, and midwives.

This indicator is relatively easy to produce, but it should reflect how facilities are actually functioning and not how they are supposed to function. For example, providers may lack confidence in their skills and refer patients to a higher level, although they are otherwise equipped to treat these patients.

Generally, facility-based assessments cover all the facilities in a specific area. Private facilities may be more reluctant to collaborate than may public facilities. Also, samples of facilities generalizable to a national level such as the Service Provision Assessment (SPA) are possible, but may not always include all the signal functions listed above (MEASURE DHS+, 2000).

This indicator should respond to changes within a fairly short period of time (e.g., 6-12 months).

Generally, this indicator applies to a large region or country. The recommendation (as a minimum acceptable level for every 500,000 population) is one or more facilities providing comprehensive EmOC and four or more facilities providing basic EmOC.  For this reason, the indicator is often shown as two indicators:

  1. Availability of basic essential obstetric care.
  2. Availability of comprehensive essentail obstetric care.

If areas fall short of the overall minimum level, they may upgrade existing facilities and/or build new ones. If the minimum level is met, evaluators should study the geographical distribution by looking at smaller divisions of the population. National summary measures may hide important sub-national disparities. Disaggregation by geographic (urban/rural) and by administrative (public/ private) divisions is recommended (Bertrand and Tsui, 1995).

Issue(s):

The use of this indicator in a wide variety of countries has revealed at least three difficulties in its application. First, where geographical terrain is particularly challenging and transportation is precarious, the ratio of facilities to population may require adjustment for local use. Second, the reference period for assessing whether a signal function or procedure has been performed is generally three months, but when patient volume is low, one or more of the signal functions may not be performed, because an occasion did not present itself, not for lack of infrastructure or provider skills. Finally, a third situation concerns normative medical practice that fails to include one of the procedures, for example, assisted vaginal delivery. In some countries, vacuum extraction or a forceps delivery is no longer taught to medical students or midwives and only a few older providers are experienced at performing these procedures.

To solve these problems, one may consider preparing the indicator in several ways. But, to compare facilities across space and time effectively, it is recommend to maintain the original operational definitions of these ratios. Evaluators should well document alternative calculations, and should report the adjusted ratio of population to facility; the length of the new reference period, (if it is extended); the way a category of "potential" basic EmOC was created (if a procedure is generally performed, but during the study period was not); or the way country-specific criteria were established (if the criteria omits a particular signal function).

Evaluators can also calculate the "number of EmOC facilities" for smaller geographical areas to show the distribution of EOC facilities at a sub-national level.

References:

Monitoring emergency obstetric care: a handbook.  WHO, UNFPA, UNICEF, AMDD.  2009.

Much of the text for this indicator comes from Maine, McCarthy, and Ward, 1992 and UNICEF, WHO, and UNFPA, 1997.

Geographic distribution of EmOC facilities

Definition:

The assessment by map or interactive geographic information system (GIS) of the actual geographic distribution, distances, and travel time to emergency obstetric care (EmOC) facilities. Optimally, basic EmOC facilities should be located so they can be accessed within a maximum of two hours, and comprehensive EmOC facilities should be accessible within a maximum of 12 hours UNFPA (2004).

Basic EmOC service facilities are defined by the performance of the complete set of these seven signal functions (WHO et al., 2010):

  1. Administer parenteral antibiotics
  2. Administer uterotonic drugs (i.e. parenteral oxytocin)
  3. Administer parenteral anticonvulsants for preeclampsia and eclampsia
  4. Manually remove the placenta
  5. Remove retained products (e.g. manual vacuum extraction, dilation and curettage)
  6. Perform assisted vaginal delivery (e.g. vacuum extraction, forceps delivery)
  7. Perform basic neonatal resuscitation (e.g., with bag and mask)

The facility is classified as functioning at the comprehensive EmOC level when it offers the seven signal functions plus surgery (e.g. caesarean) and blood transfusion.  For additional background on this indicator and basic and comprehensive EmOC, see WHO et al, (2010); UNFPA (2004); and AMDD (2003).

This indicator is calculated as:

The number and distribution of basic EmOC service facilities, and/or estimates of the proportion of the population within two hours travel time from a facility, calculated using maps or a GIS mapping system for subnational areas, such as districts, subdistricts, and urban areas. 

Alternatively, the minimum acceptable number of comprehensive EmOC facilities for an area can be estimated by dividing the subnational area population by 500,000. The resulting number is multiplied by five to calculate the overall minimum number basic and comprehensive facilities for the area. To calculate the percentage of the recommended minimum number of facilities that is available to the district population, divide the number of functioning EmOC facilities by the recommended number and multiply by 100. To ensure equity and access, all of the district and urban areas should have the minimum acceptable numbers of EmOC facilities or at least five facilities (including at least one comprehensive facility) per 500,000 population (WHO et al., 2010).

Data Requirements:

Spatial analysis conducted with the use of GIS mapping for the distribution of facilities and for estimates of the proportion of households within two hours of a basic EmOC facility. Alternatively, estimates can be made of minimum acceptable numbers of EmOC facilities within subnational areas using lists of the numbers and locations of basic and comprehensive EmOC facilities. Data on EmOC facilities in subnational areas can be stratified by public, private, and non-governmental types of facilities.

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

Data Sources:

GIS mapping systems; maps and listings with locations of basic and comprehensive EmOC facilities

Purpose:

This indicator measures access to EmOC services based on geographic distribution and travel time to facilities. Simply having sufficient numbers of EmOC facilities is not enough; their geographic distribution must also be considered.  For example, if all comprehensive EmOC facilities are clustered in urban areas, a large number of women, especially those living in rural areas, will not be able to access services in a timely manner. Women’s access to basic and comprehensive EmOC services is vital to achieving Millennium Development Goals #5. improve maternal health #4. reduce child mortality.

In settings with rugged terrain, traveling even relatively short distances may take a very long time with the journey often made on foot, horseback or by donkey cart. Thus, a companion indicator for the proportion of households within a given travel time for a woman to reach a basic or comprehensive EmOC facility is useful. Ideally, all women should live within two hours of a basic EmOC facility. This time frame was selected as a maximum limit because hemorrhage, the most rapidly fatal complication of pregnancy, can kill a mother in two hours. Therefore, in order to save the maximum number of lives, facilities must be able to treat pregnant women within two hours. Hemorrhage can be treated at a basic EmOC facility, although some cases may need to be referred to a comprehensive facility for blood transfusions. An optimal geographic distribution of facilities would ensure that all women live within two hours of a basic EmOC facility and within twelve hours of a comprehensive one (UNFPA, 2004). The creation and dissemination of maps that show the EmOC status of facilities, the distance of communities from basic and comprehensive facilities (both in travel time and in relation to road networks), population dispersion and density and other features that show inequities in terms of access to care can be effective advocacy and planning tools.

Issue(s):

While this indicator measures physical access, it does not address other barriers to access at EmOC facilities, such as stockouts of necessary drugs, lack of available trained staff, or inadequate equipment and supplies. This indicator is best measured by performing spatial analysis with the use of maps or GIS (which requires the appropriate software and expertise using it).  In many developing countries, the terrain is rough and communications, roads and transportation are poor, making estimates of the travel time difficult. The alternative estimation of minimum acceptable numbers of facilities per subnational area (WHO et al., 2010) does not provide information on actual distances or travel times to the closest facilities.  

References:

AMDD Program, 2003, Using the UN Process Indicators of Emergency Obstetric Services: Questions and Answers, Columbia University, New York; AMDD. http://www.amddprogram.org/v1/resources/UsingUNIndicatorsQA-EN.pdf   

UNFPA, 2004, Program Manager’s Planning Monitoring and Evaluation Toolkit, Part II: Indicators for Reducing Maternal Mortality, New York: UNFPA. http://www.unfpa.org/monitoring/toolkit/Tool6_2.pdf  

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

Percent of health facilities with skilled attendant (doctor, nurse or midwife) available 24 hours a day, 7 days a week

Definition:

The percent of health care facilities in a country or specified area with at least one skilled attendant available 24 hours per day and seven days per week.  Skilled attendants include midwives, doctors, and nurses midwifes trained in and capable of delivering the seven basic functions of emergency obstetric care (EmOC).

The seven basic EmOC service functions are (WHO et al., 2010):

  1. Administer parenteral antibiotics
  2. Administer uterotonic drugs (i.e. parenteral oxytocin)
  3. Administer parenteral anticonvulsants for preeclampsia and eclampsia
  4. Manually remove the placenta
  5. Remove retained products (e.g. manual vacuum extraction, dilation and curettage)
  6. Perform assisted vaginal delivery (e.g. vacuum extraction, forceps delivery)
  7. Perform basic neonatal resuscitation (e.g., with bag and mask)

A facility and the qualified staff are classified as functioning at the comprehensive EmOC level when they offer the seven signal functions plus surgery (e.g. caesarean) and blood transfusion. For further background on the signal functions for EmOC and guidelines on managing complications of pregnancy and childbirth, see WHO et al. (2010) and WHO (2003).

This indicator is calculated as:

(Number of facilities with at least one skilled attendant available 24 hours a day, 7 days a week / Total number of health care facilities in country or specified area ) x 100

Data Requirements:

Data from facility records and birth registers; specialized surveys; interviews with key informants. The data can be disaggregated by the type of facility (public, private, non-governmental, community based) and by other relevant factors such as districts and urban/rural location.

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

Data Sources:

Facility records; birth registers; specialized surveys; interviews

Purpose:

This indicator measures access to quality EmOC services based on the availability of a skilled birth attendant at the facility.  Most obstetric complications occur at the time of labor and delivery and skilled attendants have been trained to quickly recognize life-threatening complications and intervene in to save the mother’s life.  However, if women attend facilities where at least one skilled attendant is not available at all times, the women may not receive the life-saving care or referrals they need.  Only about 58 percent of deliveries worldwide take place in the presence of skilled attendants and, while many of these occur as home deliveries, there are facilities that do not have at least one skilled attendant on an around the clock basis. This deficiency is attributable to two main factors: 1) overall lack of skilled attendants and 2) poor distribution of skilled attendants, especially in rural areas and poor urban areas or slums. The UNFPA and international partners are addressing this problem by promoting the training of professionals and developing innovative programs to attract and retain skilled attendants in the areas of greatest need (UNFPA, 2004). Women’s access to basic and comprehensive EmOC services from skilled attendants is vital to achieving Millennium Development Goals #5. improve maternal health #4. reduce child mortality.

Issue(s):

While this indicator measures access to care as the availability of skilled attendants at facilities, it does not address other barriers to access at EmOC facilities, such as travel time to location, stockouts of necessary drugs, or inadequate equipment and supplies. In addition, the indicator does not measure the competency of the skilled attendants, for example, if they know how to deal effectively with the range of obstetric complications or will make timely referrals to comprehensive EmOC facilities for procedures, such as caesarean surgery and blood transfusions.

References:

UNFPA, 2004, Program Manager’s Planning Monitoring and Evaluation Toolkit, Part II: Indicators for Reducing Maternal Mortality, New York: UNFPA. http://www.unfpa.org/monitoring/toolkit/Tool6_2.pdf

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

WHO, 2003, Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors. Geneva: WHO. http://whqlibdoc.who.int/publications/2007/9241545879_eng.pdf

Percent of communities that have an emergency transport plan in place

Definition:

 

The percent of communities in a designated area that have made an explicit plan to provide emergency transport for pregnant women who require care at a basic or comprehensive emergency obstetric care (EmOC) facility. For further background on basic and comprehensive EmOC, see WHO et al. (2010).  

Communities can be defined as towns, villages, rural locales, and urban districts and neighborhoods that are functionally identified as communities.

Emergency transport plans should identify, at a minimum, the means of transportation, driver(s), payment scheme, and nearest EmOC.

This indicator is calculated as:

(Number of communities with an emergency transport plan / Total number of communities in a designated area ) x 100

Data Requirements:

 

Using maps or listings of communities by designated districts, the data for this indicator can be collected through specialized surveys and/or interviews with key informants from the communities and the respective destination EmOC facilities. The data can be disaggregated by the type of community (e.g., urban/ small city/ town/ rural), modes of transportation designated in plan, and types of facilities accessed by the community (e.g., basic versus comprehensive EmOC and/or public, private, non-governmental, community based).

Data Sources:

Listings of or maps identifying rural and urban communities; specialized surveys; interviews with key informants

Purpose:

 

This indicator measures access to EmOC services based on the capacity of communities to plan for providing women with timely and suitable emergency transportation. Simply having EmOC facilities within the recommended travel distance is not enough. Women in need of emergency care must have a means to get there. The details and working components of community emergency transport plans will vary greatly by the types of settings and transportation available and the distances to nearest facilities. In Northern Nigeria, select National Union of Road Transport Workers (NURTW) car drivers participated in an emergency transport scheme.  They were trained by NURTW trainers on the safe motherhood situation, the need to respond quickly to maternal emergencies, how to carry a pregnant woman, where to take them, and the need to keep a supply of gasoline within the community at all times. Families using these drivers paid a fixed amount to be transported to the health facility, and could pay in arrears if necessary. Drivers were given identification cards to ensure that they were not held up by police at road-blocks, and to facilitate their access once at the health facility (DFID, 2008).

In urban neighborhoods, women may need transportation by capably driven vehicles that can contend with congested traffic, such as emergency ambulances or vehicles with sirens. In rural communities, distances to the closest facilities may be long and vehicles are needed that can make the journey safely and efficiently. In settings with rugged terrain, traveling even relatively short distances may take a very long time if done on foot, horseback or by donkey cart, and appropriate transport is needed to help women negotiate the difficult journey.

The goal is for all women to be within two hours of a basic EmOC facility and within twelve hours of a comprehensive EmOC that can also provide surgery and blood transfusions.  The two-hour time frame was selected as a maximum limit because hemorrhage, the most rapidly fatal complication of pregnancy, can kill a mother in two hours (UNFPA, 2004).  Communities with effective plans in place to help women get to the closest facilities as quickly and safely as possible can help save the lives of women and their infants.  This indicator depicts the current status of community emergency transport plans, can show trends over time, and can be used for planning and advocacy at national, district, and community levels. This measure of women’s access to EmOC services relates to achieving Millennium Development Goals #5. improve maternal health #4. reduce child mortality.

Issue(s):

While the indicator accounts for communities having made emergency transportation plans, it does not capture the feasibility of the plans, whether the plans are being implemented, or whether the plans are successful in transporting women to EmOC facilities in a timely and safe fashion.

References:

 

UNFPA, 2004, Program Manager’s Planning Monitoring and Evaluation Toolkit, Part II: Indicators for Reducing Maternal Mortality, New York: UNFPA. http://www.unfpa.org/monitoring/toolkit/Tool6_2.pdf

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

DFID, 2008, PATHS Technical Brief: Increasing Access to Safe Motherhood Services. http://www.healthpartners-int.co.uk/our_projects/documents/NPQ_FinalVersion-SafeMotherhoodTechnicalBrief-1_000.pdf

Percent of audience that know three primary warning/danger signs of obstetric complications

Definition:

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

"Audience" is the intended population for the program (e.g., pregnant women, husbands or other members of the community who influence decisions about care seeking at the time of delivery).

"Know" refers to the percentage who can spontaneously name at least three primary warning signs of specific obstetric complications, which in a wide range of settings include:

 This indicator is calculated as:

(Number of target audience who know at least three warning/danger signs of obstetric complications / total number in the intended audience) x 100

Data Requirements:

Number of people in the target audience who can name at least three of the warning signs of obstetric complications (listed above); total population defined as the intended audience

Data Sources:

Population-based surveys

Purpose:

The purpose of this indicator is to assess community knowledge and awareness of the warning/danger signs of obstetric complications in order to plan and monitor the impact of safe motherhood initiatives at the community level.

Knowledge of the danger signs of obstetric complications is the essential first step in avoiding the first delay-- seeking appropriate and timely referral to essential obstetric and newborn care services (Perreira et al., 2001).

Improvement in knowledge of obstetric complications is usually much smaller than improvements in other health-education messages such as self care (MotherCare, 2000a and 2000b).

Issue(s):

Knowledge of the danger signs of an obstetric complication is only one aspect of obstetric-problem recognition at the community level. Knowledge about the severity of an obstetric complication (i.e., knowing when to take action) and knowledge about the appropriate lifesaving action for each complication are also important. Moreover, adequate knowledge does not guarantee that an individual will recognize a complication in practice. Certain obstetric complications that evolve from a normal to an emergency state (e.g., postpartum hemorrhage) may be particularly difficult to recognize. Care seeking is also strongly influenced by cultural beliefs about the etiology of an illness. These beliefs may more powerfully influence an individual's action than will his/her recent knowledge of the appropriate action to take (MotherCare, 2000a and 2000b).

Evaluators should combine knowledge of pregnancy danger signs with other indicators measuring related aspects of knowledge and behavior to assess the real impact of any awareness-raising program. Complementary indicators can include, for example, the percentage of the population who know the location of emergency obstetric services and the percentage of the population who intend to use these services in the event of emergency.

Indicators of knowledge of danger signs and related indicators should be complemented by good quality formative research and, where appropriate, qualitative methodologies such as illness narratives (MotherCare, 2000a and 2000b).

Gender Implications:

Most maternal deaths are due to sudden and unexpected complications. To reduce the nearly 600,000 deaths occurring each year from largely preventable causes, much effort has focused on training health workers and pregnant women to recognize danger signs so that serious complications are recognized soon enough to receive medical attention. Few efforts have been made to educate men about the risks of pregnancy, even though men often control decisions to seek medical attention and often arrange and pay for transport to a health facility. If men as well as women understood that all pregnancies carry some risk, complications would be recognized and treated.

Percent of skilled health personnel knowledgeable in obstetric warning signs

Definition:

 

The percentage of skilled health personnel who are considered knowledgeable as they can name at least three of the following warning signs of obstetric complications:

Skilled health personnel include midwives, doctors, and nurses with midwifery and lifesaving skills. Traditional birth attendants (TBAs) are typically not included in this definition. For additional background on this indicator, see USAID/MEASURE Evaluation (2007).

This indicator is calculated as:

(Number of skilled health personnel who know at least three warning signs for obstetric complications / Total number of skilled health personnel interviewed) x 100

Data Requirements:

Surveys and interviews with facility staff provide the primary data used to calculate this indicator. Questions about the warning signs for obstetric complications need to be standardized in advance and used consistently over time in order to compare trends. The data can be disaggregated by the type of skilled worker, by the type of facility (public, private, non-governmental, community based) and by other relevant factors such as districts and urban/rural location. 

Data Sources:

Health worker interviews and surveys

Purpose:

This indicator is used to assess the knowledge of skilled health personnel as the basis for their ability to make timely referrals to emergency obstetric care services (EmOC).

All pregnant women are at random risk for developing life-threatening complications and women with underlying health issues and lack of antenatal care are at increased risk. Evidence shows that about 15 percent of pregnancies result in complications  and the leading high-risk complications are hemorrhage, sepsis (infection), eclampsia, and obstructed labor (UNFPA, 2004). These four complications in conjunction with unsafe abortion account for more than two-thirds of maternal deaths. The presence of skilled health attendants knowledgeable about the warning signs for complications and able to make timely referrals to EmOC is vital to reducing maternal mortality and morbidity and directly relates to achieving Millennium Development Goals #5. improve maternal health #4. reduce child mortality.

Issue(s):

The skilled attendants’ knowledge of obstetric warning signs does not indicate that they are knowledgeable about the severity of warning signs, that they know how to deal with the complications or will make timely referrals to EmOC.

References:

UNFPA, 2004, Program Manager’s Planning Monitoring and Evaluation Toolkit, Part II: Indicators for Reducing Maternal Mortality, New York: UNFPA. http://www.unfpa.org/monitoring/toolkit/Tool6_2.pdf  

USAID/MEASURE Evaluation, 2007, A Guide for Monitoring and Evaluating Population-Health-Environment Programs, Chapel Hill, NC: MEASURE Evaluation.  https://www.measureevaluation.org/resources/publications/ms-07-25

Percent of women attended, at least once during their pregnancy, by skilled health personnel for reasons relating to the pregnancy

Definition:

The percent of women attended at least once during pregnancy by skilled health personnel for reasons related to the pregnancy

This indicator is calculated as:

(Number of pregnant women attended at least once during their pregnancy, by skilled personnel, for reasons related to the pregnancy, during a fixed period / total number of live births during the same period) x 100

A skilled attendant is defined as an accredited health professional who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns.  This includes midwives, doctors and nurses but excludes traditional birth attendants (WHO, 2006).

A live birth is the birth of a fetus after 22 weeks' gestation or weighing 500 g or more that shows signs of life - breathing, cord pulsation or with audible heart beat.  This cut-off point refers to when the perinatal period begins (WHO, 2006).

Data Requirements:

Numbers of women who are seen by skilled personnel during pregnancy; all live births in a reference period.

The number of live births is a proxy for the numbers of all women who need antenatal care (ANC). Ideally, evaluators should include all births, but they usually use only live births because of the difficulty in obtaining information about non-live births (Graham and Filippi, 1994).

Where data on the numbers of live births 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.

Health facility data should not be used to estimate denominators unless utilization is very high.

Data Sources:

Routine health services data, population-based surveys. Routine health service data typically lack information on pregnancies or births that take place outside the public health sector, for example in homes or private facilities.

Purpose:

The main purpose of an indicator of antenatal care is to provide information on women's use of ANC services. ANC coverage provides a crude measure of ANC utilization (Rooney, 1992), but it does not capture the number and timing of visits, the reasons for seeking care, the skills of the provider, or the quality of care received. Therefore, evaluators should not infer that similar rates of ANC coverage mean similar levels of care.

Although epidemiological studies tend to show an association between improved maternal health outcome and ANC, most fail to control for selection biases that would positively influence the outcome (Villar and Khan-Neelofur, 2000). The association between one antenatal visit (with care provision of unknown quality) and maternal mortality is weak (WHO, 1999b). However, the finding that women who attend ANC are also more likely to use skilled health personnel for care during birth and that ANC may facilitate better use of emergency obstetric services is further support for the use of this indicator in combination with the indicator Percent of deliveries attended by skilled personnel. Therefore, women's use of ANC is more strongly associated with improved perinatal survival (McDonagh, 1996) and measures of ANC coverage may have a greater role in the monitoring and evaluation of programs addressing newborn health and survival (Graham and Filippi, 1994).

Issue(s):

One issue with collecting this data through vital registration is that the data may not be collected in a format appropriate for constructing this indicator.  Frequently the data are episode- rather than woman-based (i.e. the number of consultations performed by the provider is recorded but not the number of times a specific woman is seen). Since women may be seen several times, and may also present at different facilities, this creates the potential for double counting and therefore overestimating ANC coverage. Health service data may also be poor quality and records may be incomplete or missing.

ANC coverage is one of four mutually supportive indicators in the minimal list measuring maternal health service coverage. The other three indicators are:

In combination, these indicators measure progress towards the goal of providing antenatal care, trained attendants during childbirth, and access to essential obstetric care for all pregnant women. ANC coverage is associated with newborn health and survival and weakly associated with maternal mortality. In sum, antenatal care coverage appears to influence newborn health and survival, but its effect on maternal mortality is unclear.

Gender Implications:

Because some countries deem it culturally inappropriate for women to discuss issues related to their bodies with men, women may not be able to communicate pregnancy related problems to male providers. In addition, where women lack access to household resources or where they lack the autonomy to seek health care on their own, husbands or other family members may not be willing to invest resources in antenatal care, particularly if a given pregnancy is progressing "normally."

Percent women attended at least four times for antenatal care during pregnancy

Definition:

 

The percent of women ages 15 to 49 with a live birth within a given time period who attended antenatal care (ANC) four or more times during their most recent pregnancy. Whether at a facility or community-based, optimally the ANC should be provided by skilled personnel including doctors, midwives, or nurses with midwifery skills. The number of live births is used as proxy for the numbers of women who need ANC care.

Based on a review of the effectiveness of different ANC models, WHO has recommended a standard model of four antenatal visits (WHO 2002). WHO guidelines on the content of ANC visits include the following components: clinical examination, blood testing to detect syphilis and severe anemia (and HIV, malaria, etc. according to the epidemiological context), gestational age estimation, uterine height, blood pressure, maternal weight and height, test for sexually transmitted infections (STI)s, urine test, request blood type and Rh, tetanus toxoid, iron/Folic acid supplementation, and recommendations for emergencies (WHO, 2002). For more detail on this and related indicators, see WHO (2010); WHO (2006).

This indicator is calculated as:

(Number of women ages 15 to 49 with live births who attended ANC four or more times during most recent pregnancy / Total number of women with live births within the reference period) x 100

Data Requirements:

 

This indicator can be calculated from the survey questions in Demographic Health Survey (DHS), the Reproductive Health Survey (RHS), UNICEF Multiple Indicator Cluster Survey (MICS), and other national surveys that ask about the number of ANC visits women had with their most recent births. Specialized survey data and health facility records can also be used for more localized studies. Data can be disaggregated by the type of facility (public, private, non-governmental, community-based), by district and urban rural location, and by women’s education, wealth quintile, age, and parity. 

WHO and UNICEF compile empirical data from household surveys and produce regional and global estimates based on population-weighted averages weighted by the total number of births. These estimates are used only if available data cover at least 50 percent of total births in the regional or global groupings (WHO, 2010).

If targeting and/or linking to inequity, classify facilities by location (poor/not poor) and disaggregate ANC visits by location.

Data Sources:

Population-based surveys, such as DHS, RHS, and MICS; facility records and health services data.

Purpose:

 

This indicator provides information on women’s use of ANC services at the recommended level and can be used to track trends in utilization. Many health problems experienced by pregnant women can be prevented, detected and treated during ANC visits with trained health workers. Based on global data from 2000 to 2010, about 53 percent of pregnant women attended the recommended minimum of four ANC visits compared with only 39 percent of pregnant women in low-income countries.  Trend data on the percentage of women attending at least four ANC visits are not available for all countries, but available data show that there has been little improvement in this indicator in the past decade (WHO, 2011). The importance of ANC and the need for women’s increased access to and use of these services cannot be understated. Studies have found that women who attend ANC are more likely to use skilled health personnel during delivery, ANC may facilitate better use of emergency obstetric services, and ANC is also associated with improved perinatal survival (WHO, 2006). Overall, women’s use of ANC is central to achieving the Millennium Development Goals #5. improve maternal health and #4. reduce child mortality.

ANC utilization and coverage figures should be followed together with other related indicators, such as proportion of deliveries attended by a skilled health worker or deliveries occurring in health facilities, and disaggregated by background characteristics, to identify target populations and facilitate health system planning.

Issue(s):

 

Receiving ANC care during pregnancy does not guarantee that women received all of the recommended and necessary interventions. However, at least four ANC visits increases the likelihood of receiving the full range of interventions (WHO, 2010). Although the indicator for “at least one ANC visit” refers to visits with skilled health providers (doctor, nurse, midwife), “four or more ANC visits” usually measures visits with any provider because national-level household surveys do not collect provider data for each visit.

With population-based surveys, recall error is a potential source of bias given that the surveys ask the respondent about each live birth for a period up to five years before the interview. The respondent may or may not know or remember the number of visits, particularly as this number increases.  For data compiled at the health facility level, discrepancies are possible in recording and reporting numbers of visits and these data would differ from global figures based on survey data collected at the household level. In addition, data on women’s use of ANC from routine health records may lack information on pregnancies occurring outside the public health sector, including home and private facility deliveries. 

References:

 

WHO, 2011, Global Health Observatory (GHO), Antenatal care Situation and trends, Geneva: WHO. http://www.who.int/gho/en/

WHO, 2010, Indicator Code Book: World Health Statistics - World Health Statistics indicators, Geneva: WHO  http://www.who.int/gho/publications/world_health_statistics/WHS2010_IndicatorCompendium.pdf?ua=1

WHO, 2006, Reproductive Health Indicators: Guidelines for their generation, interpretation and analysis for global monitoring, Geneva: WHO http://whqlibdoc.who.int/publications/2006/924156315X_eng.pdf  

WHO, 2002, Antenatal Care Randomized Trial: Manual for the Implementation of the New Model, Geneva: WHO. http://whqlibdoc.who.int/hq/2001/WHO_RHR_01.30.pdf

Percent of pregnant women whose blood pressure was checked at first ANC visit

Definition:

The percent of women ages 15 to 49 with a live birth within a given time period who had their blood pressure checked at their first visit for antenatal care (ANC). WHO guidelines include blood pressure checks as a basic component of ANC (WHO, 2002).

This indicator is calculated as:

(Number of women ages 15 to 49 with a live birth whose blood pressure was checked at their first ANC visit / Total number of women ages 15 - 49 with live births within reference period) x 100

Data Requirements:

This indicator can be calculated from the Demographic Health Survey (DHS), the Reproductive Health Survey (RHS), UNICEF Multiple Indicator Cluster Survey (MICS), or other national surveys that collect detailed pregnancy histories. Specialized survey data and health facility records can also be used. Data can be disaggregated by the type of facility (public, private, non-governmental, community-based), by district and urban rural location.

Data Sources:

Population-based surveys, such as DHS, RHS, and MICS; facility records and health services data

Purpose:

This indicator measures whether ANC facilities are consistently measuring women’s blood pressure as early as possible in their pregnancies, and can serve as a proxy for the quality of ANC care. Women’s blood pressure should be monitored at each ANC visit and during delivery.  A blood pressure measure early in pregnancy (ideally in the first trimester) can help distinguish whether women have chronic high blood pressure (or hypertension), which was present before pregnancy, or a pregnancy-induced hypertension which occurs after 20 weeks gestation, during labor, or within 48 hours of delivery (WHO, 2008). Women with chronic hypertension can benefit from treatment and continued monitoring during pregnancy. For women with pregnancy-induced hypertension after 20 weeks, their condition may progress from a mild hypertension to pre-eclampsia, then to the life-threatening condition of eclampsia. If pre-eclampsia is detected and appropriately managed before the onset of convulsions and other life-threatening complications, women’s risk of developing eclampsia can be reduced. Eclampsia accounts for about 12 percent of maternal deaths (WHO, 2008). This indicator relates to achieving Millennium Development Goals #5. improve maternal health and #4. reduce child mortality. 

Issue(s):

With population-based surveys, recall error is a potential source of bias given that surveys ask the respondent about each live birth for a period up to five years before the interview. The respondent may or may not remember if her blood pressure was taken at her first ANC visit. Data on women’s blood pressure measured at their first ANC visit from routine health records will not include information for pregnancies occurring outside the public health sector, including home and private facility deliveries.

References:

WHO, 2002, Antenatal Care Randomized Trial: Manual for the Implementation of the New Model, Geneva: WHO. http://whqlibdoc.who.int/hq/2001/WHO_RHR_01.30.pdf

WHO, 2008, Managing Eclampsia: Education material for teachers of midwifery, Midwifery education modules - second edition, Geneva: WHO. http://whqlibdoc.who.int/publications/2008/9789241546669_2_eng.pdf

Percent of pregnant women who had weight checked at first ANC visit

Definition:

 

The percent of women ages 15 to 49 with a live birth within a given time period who had their weight checked at their first visit for antenatal care (ANC). WHO guidelines include weight checks as a basic component of ANC (WHO 2002).

This indicator is calculated as:

(Number of women ages 15 to 49 with a live birth whose weight was checked at their first ANC visit / Total number of women ages 15-49 with live births within the reference period) x 100

Data Requirements:

This indicator can be calculated from the Demographic Health Survey (DHS), the Reproductive Health Survey (RHS), UNICEF Multiple Indicator Cluster Survey (MICS), or other national surveys that collect detailed pregnancy histories. Specialized survey data and health facility records can also be used. Data can be disaggregated by the type of facility (public, private, non-governmental, community-based), by district and urban rural location.

Data Sources:

Population-based surveys, such as DHS, RHS, and MICS; facility records and health services data.

Purpose:

This indicator measures whether ANC facilities are consistently measuring women’s weight as early as possible in women’s pregnancies, and can serve as a proxy for the quality of ANC care. Recording women’s weight early in pregnancy (ideally in the first trimester) can approximate pre-pregnancy weight and allow tracking of women’s weight gain during pregnancy. Pregnancy weight gain is one of the most critical factors in determining both birth outcomes and maternal nutritional outcomes of pregnancy. Weight gain is particularly important for women who are underweight prior to pregnancy and for women who are pregnant during times of acute nutritional stress, such as famines or seasons of food scarcity.  Conversely, the prevalence of overweight has been increasing worldwide during the past two decades resulting in a “double burden” of health concerns and making excess pregnancy weight gain for overweight women a serious health problem.  Additional information on weight gain during pregnancy and implications for maternal and infant health outcomes can be found in the section on Women’s Nutrition in this database and from IOM (2009). This indicator relates to Millennium Development Goals: #5. improve maternal health and #4. reduce child mortality.

Issue(s):

 

With population-based surveys, recall error is a potential source of bias given that surveys ask the respondent about each live birth for a period up to five years before the interview. The respondent may or may not remember if she was weighed at her first ANC visit. Data on women’s weight measured at their first ANC visit from routine health records will not include information for pregnancies occurring outside the public health sector, including home and private facility deliveries.

References:

 

Institute of Medicine and National Research Council, 2009, Weight Gain during Pregnancy: Reexamining the Guidelines, Eds: Kathleen Rasmussen and Ann Yaktine, Washington, D.C.: The National Academy Press. https://www.ncbi.nlm.nih.gov/books/NBK32813/

WHO, 2002, Antenatal Care Randomized Trial: Manual for the Implementation of the New Model, Geneva: WHO. http://whqlibdoc.who.int/hq/2001/WHO_RHR_01.30.pdf

Percent of pregnant women attending antenatal clinics screened for syphilis

Definition:

The percent of pregnant women attending antenatal care (ANC) screened for syphilis.
This indicator is calculated as:

# of pregnant women attending antenatal clinics screened for syphilis x 100
_______________________________________________________
# of pregnant women attending antenatal clinics

This indicator is usually calculated for women attending for their first antenatal visit but may also be collected after delivery.

The most common screening tests for syphilis include rapid plasma reagin (RPR) and venereal disease reference laboratory (VDRL) blood tests.

Data Requirements:

The number of women attending antenatal clinics during a reference period (e.g., one year) who were screened for syphilis; the number of women attending the same antenatal clinics during the same reference period.

Data Sources:

Clinic registries (data on first visit) or individual prenatal records (individual ANC records/cards after births or immediately postpartum).

Health facility exit interviews and provider observations are useful for evaluation purposes but not for ongoing monitoring.

Purpose:

The purpose of this indicator is to measure the extent to which ANC clients are screened for syphilis. Since all women attending for ANC should be screened for syphilis at least once during pregnancy, the measure can also potentially serve as a proxy measure of the quality of antenatal care services (UNFPA, 1998a). Furthermore, when an explicit standard exists that all women should be tested at least once during pregnancy, the indicator may also be used as a benchmark to audit provider (or system) performance against compliance with local screening policy.

Syphilis infection is a major cause of maternal morbidity and perinatal morbidity and mortality in the developing world. For many African countries, reported prevalence of syphilis among pregnant women at sentinel surveillance sites ranges between 10-15 percent, with over half these pregnancies resulting in an adverse outcome, such as abortion, stillbirth, low birth weight, premature delivery, or congenital infection (WHO, 1991b).

Because adverse outcomes from syphilis are preventable, and screening and treatment in pregnancy are highly cost effective, many countries have adopted universal syphilis screening for pregnant women as a national policy (Gloyd, Chai, and Mercer, 2001). Screening programs by themselves cannot help reduce the adverse outcomes associated with syphilis and must be linked to efforts to increase ANC coverage and to improve follow up and treatment of women and their partners who test positive.

Issue(s):

Researchers may routinely collect data to calculate this indicator if antenatal clinic registries record completed syphilis screening. Most often, however, the information is collected in the context of special surveys that review the antenatal clinic cards of women who have had a recent birth. Researchers may conduct these surveys in facilities or in the community, if women keep their antenatal cards.

Health facility exit interviews and provider observations (MEASURE DHS+, 2001; WHO, 1998a) may provide a baseline measure for evaluation purposes, but are limited because they assess women who have not yet completed antenatal care and who theoretically could still be tested (MEASURE DHS+, 2001; WHO, 1998a).

The percentage of women screened for syphilis should respond quickly to changes in provider practice, particularly if the indicator is used in a local audit of facility quality of care.

This indicator is a facility-based measure and does not represent the general population, particularly when ANC coverage is low. In addition, where the indicator is obtained by record review, the validity of the findings depends on the quality and completeness of the data. Incomplete data recording may also further indicate low service quality.

Adequate syphilis screening does not equate with adequate syphilis treatment, because studies show that despite effective screening, inadequate treatment can be an important cause of preventable perinatal death. In high prevalence areas, even when syphilis testing is theoretically universal, most women are not tested (Gloyd, Chai, and Mercer, 2001).

Percent of women who received at least two doses of tetanus-toxoid vaccine in their last pregnancy

Definition:

The proportion of pregnant women receiving at least two doses of tetanus-toxoid vaccine (TT2)
This indicator is calculated as:

Total TT2 + TT3 + TT4 + TT5 x 100
_________________________
Total # of live births

Where TT2, TT3, TT4, TT5 refer to the 2nd, 3rd, 4th, or 5th dose of tetanus-toxoid vaccine administered (WHO, 1999a and c).

Data Requirements:

From service statistics:
Number of doses of TT2 + TT3 + TT4 + TT5 given to pregnant women in a reference period (usually a year)

From population-based surveys:
Number of women giving birth during a reference period (e.g., five years) who report receiving at least two doses of tetanus-toxoid during their last pregnancy and number of live births in the same reference period

The number of live births serves as a proxy for the number of pregnant women.

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

In settings where the crude birth rate is unknown, the WHO recommends using 3.5 percent of the total population as an estimate of the number of pregnant women (number of live births or pregnant women = total population x 0.035) [WHO, 1999a and c.]

Data Sources:

Service statistics; population-based surveys

Purpose:

This indicator measures the percentage of women and births protected against tetanus at the time of delivery among clients in a given program or among the general population.

Neonatal tetanus is usually fatal. A woman immunized with at least two doses of tetanus toxoid according to the WHO schedule1 develops antibodies that protect her infant against tetanus in the first two months of life. Tetanus-toxoid immunization is therefore an integral part of the ANC package offered to women in most developing countries.

Many national HIS routinely collect this indicator to provide TT2+ coverage estimates for women attending facilities for ANC. Most large population-based surveys also collect data on self reported TT2+ coverage. Note: Variations in the methods used to measure TT2+ coverage, as well as in the definition of the numerator and denominator, give rise to differences in the magnitude and reliability of the estimates obtained. For example, service statistics record the total number of doses of a vaccine in the previous 12 months, whereas surveys tend to record the total number of women who report receiving at least two vaccinations during their last pregnancy in a reference period that may be up to five years.

Promoting clean delivery and cord care practices as well as ensuring that women are adequately immunized against tetanus prior to birth can prevent transmission of neonatal tetanus. TT2+ coverage should also be reported as well as the number of neonatal tetanus cases and the proportion of live births with a skilled attendant (as a proxy for clean births).

For prevention of neonatal and maternal tetanus, WHO recommends giving women a series of five doses of tetanus- toxoid vaccine with a minimum interval between each dose. Each dose increases the level and protection against tetanus. Each dose counts as a dose towards a five-dose schedule even if given before the recommended interval. A woman who receives five doses of tetanus toxoid is fully immunized and is protected against tetanus throughout her childbearing years.

Table III.E.3 WHO Recommended Tetanus-Toxoid Series

TT Time of Dose Given Level of Protection Duration of Protection
TTI At first contact NIL None
TT2 Four weeks after TTI 80% 3 years
TT3 At least 6 months after TT2 95% 5 years
TT4 At least one year after TT3 99% 10 years
TT5 At least one year after TT4 99% 30 years

Issue(s):

Service statistics have the disadvantage that they may be incomplete or inaccurate (WHO, 1999a). They are also subject to a selection bias and are not representative of the general population, particularly when ANC coverage is low. However, they provide the only way of monitoring coverage on an annual basis and may be more reliable than self-reported data are.

Surveys provide the only means of obtaining population based coverage, but because surveys rely on selfreporting, they are subject to recall bias that is likely to increase with the length of the recall period.

Both approaches, however, underestimate the true extent of TT2+ coverage because both exclude doses of vaccine administered at times other than specified in the definition of the numerator even though the doses offer protection. For example, the doses for the childhood or mass-immunization campaign are omitted.

Percent of pregnant women who receive anthelminthic treatment during pregnancy

Definition:

In areas of moderate to high endemicity of helminths (parasitic worms), the percent of pregnant women who receive presumptive anthelminthic treatment during their pregnancy. According to the 1998 IVACG/WHO/UNICEF "Guidelines for the Use of Iron Supplements to Prevent and Treat Iron Deficiency Anemia," treatment should be done once in the second and third trimester.

In  areas  of  low  endemicity: the percent of pregnant women who received prescribed treatment during their pregnancy.

This indicator is calculated as:

# of pregnant women who receive presumptive antihelminthic treatment x 100
__________________________________________________________
Total # of pregnant women

 

Data Requirements:

Information on the number of pregnant women who receive presumptive/prescribed anthelminthic treatment and the total number of pregnant women.

Data Sources:

Program records (on number of pregnant women, number of pregnant women who receive treatment, either presumptive treatment or therapy for identified helminths, and number of pregnant women reported to be infected); population-based surveys represent an alternative source of data, but will yield different results in terms of coverage. If the source of data is a population based survey, the evaluator should calculate the indicator for the last pregnancy.

Purpose:

Helminths such as hookworm and schistosomes can cause blood and iron loss.  Where hookwork infection is endemic and anemia prevalence is high, the hookworm infection is likely to be a main cause of the anemia. In areas of low endemicity, treatment in the second trimester is recommended. In areas of moderate to high endemicity, treatment should occur in the second and third trimester. Treatment in the first trimester is not recommended.

Issue(s):

This indicator only measures whether women have received any anthelminthic therapy, without reference to adequate dosing. Because treatment of helminths depends on the availability of medication to clients in the program, this indicator may reflect inadequacies in the flow of drugs to service distribution points in the system and/or poor provider performance at the service delivery point.

An alternative indicator reflecting the adequacy of the program in meeting the needs of specific clients is the dosage (number of tablets) distributed per eligible woman.

Percent of deliveries attended by skilled health personnel

Definition:

The percent of births attended by skilled health personnel.

This indicator is calculated as:

# of births attended by skilled personnel during the reference period x 100
_____________________________________________________
Total # of live births occurring within the reference period

 

The skilled attendant is an accredited health professional who possesses the knowledge and a defined set of cognitive and practical skills that enable the individual to provide safe and effective health care during childbirth to women and their infants in the home, health center, and hospital settings. Skilled attendants include midwives, doctors, and nurses with midwifery and life-saving skills.  This definition excludes traditional birth attendants whether trained or not (WHO, 2006).

Data Requirements:

Number of births attended by skilled health personnel in a defined time period; number of live births in the same geographic area and reference period.

The number of live births is a proxy for the numbers of women who need delivery care. Evaluators should count all births but usually only use live births in calculating this indicator, because of the difficulty in obtaining information about non-live births (Graham and Filippi, 1994).

Where data on the numbers of live births 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.

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

Data Sources:

Routine health service data; population-based surveys.  Routine health service data typically lack information on pregnancies or births that take place outside the public health sector, for example in homes or private facilities.

Purpose:

The main purpose of an indicator of the skilled attendant at delivery is to provide information on women's use of delivery care services.  It helps program management at district, national and international levels by indicating whether safe motherhood programs are on target with making professional assistance at delivery available and used.  In addition, the proportion of births attended by skilled health personnel is a measure of the health system's functioning and potential to provided adequate coverage for deliveries. 

Many argue that increasing the proportion of deliveries with a skilled attendant is the single most critical intervention for reducing maternal mortality. Moreover, the proportion of births with a skilled attendant is a benchmark indicator for monitoring progress towards the Millenium Development Goals (WHO, 1999b).

The evidence that delivery with a skilled attendant reduces maternal mortality comes from a number of clinical, historical, and epidemiological sources that indicate an association but not a causal link. In general, births with a skilled attendant are associated with lower rates of maternal mortality. However, confounding factors, such as the strong correlation between skilled attendant and institutional delivery, make assessing the impact of skilled attendant alone difficult to determine.

Evaluators can disaggregate skilled attendant at delivery by place to further document the degree of care received at the time of delivery. This measure of care or "skilled attendance" will vary by setting and attendant. A skilled attendant conducting a delivery in hospital, for example, provides a higher level of "skilled attendance" than does a skilled attendant conducting a delivery at home.

The percentage of births with a skilled attendant is one of four mutually supportive indicators in the minimal list measuring maternal health services coverage. The other three indicators are:

In combination, these indicators measure progress towards the goals of providing antenatal care, trained attendants during childbirth, and access to essential obstetric care for all pregnant women.

Issue(s):

Annual monitoring is only feasible when the data are derived from routine data sources. For international comparisons, periods of three to five years are probably sufficient. Frequent surveys are generally undesirable because the survey periods may overlap, and sampling error makes it difficult to assess whether small changes are real or due to chance variation.

Evaluators should not infer that similar rates of skilled attendant deliveries between countries reflect similar levels of care; major differences are likely to exist between countries in how providers are trained, in what providers are allowed to practice and do practice, and in what resources, equipment, and supplies are at their disposal.

Differences in what definitions are used and in how skilled attendants are reported may also account for discrepancies between countries. Most surveys such as the DHS rely on women's self-report but how women interpret the question "who assisted with the delivery?" and whether they accurately identify the health staff attending is unknown.

This indicator uses a birth-based analysis (similar to the ANC indicators), and the sample will over-represent women with multiple births in the survey period. Women with more than one birth are also more likely to have other risk factors, such as high parity and lower rates of health services use. Delivery coverage may therefore be underestimated, although this underestimate is likely to be small.

Since the denominator for this calculation includes only women with live births and excludes women with fetal deaths and stillbirths, the only valid association will be with neonatal mortality and not with perinatal mortality. (See the Newborn Health section.)

This indicator does not take into account the type and quality of care from a skilled health provider.

Poverty and Equity Considerations:

(Excerpted from: Becker L, Wolf J, Levine R (2006) Measuring commitment to health. Center for Global Development.)

Little or no conclusive evidence exists on differences between the maternal mortality and morbidity
of the rich and that of the poor. There is, however, clear evidence on the difference in the use of obstetric care based on socio-economic class. In a study of 45 developing countries and transition
economies, World Bank researchers found that in every country both the wealthiest quintile and the
population as a whole was significantly more likely than the poorest quintile to have medically-trained personnel present at birth (Gwatkin, et al. 2006).  In many countries the direct correlation between wealth and use of obstetric care is consistent across all five wealth quintiles (Kunst & Houweling, 2001).

It is far more cost-effective to increase birth attendance in areas with low current rates than to  do so in areas with relatively high rates (Graham, et al. 2001).  As a result, cost-conscious policies likely will have  some measure of pro-poor focus built into them. Given this fact and the much lower rates of skilled birth attendance among the poor, it seems likely that any increased focus on increasing skilled birth attendance would have some impact on reducing the gap between the rich and poor in terms of obstetric care and, by extension, maternal mortality.

Although the academic literature does not appear to have addressed this issue, efforts to increase
the prevalence of skilled attendance at birth should also contribute to poverty reduction because of the significant burden that maternal mortality and morbidity can impose on families in developing countries. Women of child-bearing age contribute to the household financially through their labor productivity and by caring for the entire family. The loss of this resource due to death or morbidity- related disability contributes to household poverty and reduces child survival rates. Conversely, actions that prevent maternal mortality and morbidity should decrease financial risks for poor households.

References:

Becker L, Wolf J, Levine R. 2006. Measuring commitment to health. Center for Global Development.

Gwatkin D, et al. 2004. “Socio-Economic Differences in Health, Nutrition, and Population - 45 Countries”. The World Bank. March 20 2006.   https://siteresources.worldbank.org/INTPAH/Resources/IndicatorsOverview.pdf

Graham W, Bell J, and Bullough C. 2001. “Can Skilled Attendance at Delivery Reduce Maternal Mortality in Developing Countries?” Safe Motherhood Strategies: A Review of the Evidence. Eds. Vincent De Brouwere and Wim Van Lerberghe. Vol. 17. Studies in Health Services Organisation & Policy. Antwerp: ITGPress. 97-129.

Kunst A & Houweling T. 2001. “A Global Picture of Poor-Rich Differences in the Utilisation of Delivery Care.” Safe Motherhood Strategies: A Review of the Evidence. Eds. Vincent De Brouwere and Wim Van Lerberghe. Vol. 17. Studies in Health Services Organisation & Policy. Antwerp: ITGPress. 293-311.

Reproductive health indicators: guidelines for their generation, interpretation and analysis for global monitoring.  WHO, 2006.

 

Percent of births in health facilities

Definition:

The proportion of births in all health facilities in the area, or ‘institutional births’ or ‘institutional deliveries’.

This indicator is calculated as:

(Number of births registered in health facilities / Expected number of live births) x 100

The denominator is calculated by multiplying the total population of the area by the crude birth rate of the same area. Other methods for calculating the expected number of live births can also be used.

Data Requirements:

The total expected number of births in an area is based on information about the population and the crude birth rate. National statistics offices tend to base population projections on the results of their most recent census. They may also have regional crude birth rates. If not, the crude birth rate is often available from national population-based surveys, such as the DHS. When possible, estimates for the specific geographical area should be used rather than applying the national crude birth rate to all regions. Regions are often selected for interventions or programs because of special needs and therefore tend to have poorer indicators than at national level. Usually, the birth rate in poorer areas is higher than the national average, so that use of the national average would result in an underestimate of the expected number of births, and the proportion delivered in facilities would therefore be overestimated.

Data Sources:

Health facility records and national statistics for population and crude birth rate

Purpose:

To reduce maternal and infant mortality, the optimal long-term objective is that all births take place in (or very near to) health facilities in which obstetric complications can be treated when they arise. Many countries have made having 100% of deliveries in institutions their main strategy for reducing maternal mortality.  Previously, the minimum acceptable level was set at 15% of expected births. In the intervening years, many governments have committed themselves to increasing the proportion of women who give birth in health facilities, and some are aiming for 100%. Therefore, the minimum target for this indicator should be set by national or local governments.

Parallel analysis of the proportion of all births in all the facilities surveyed allows comparison of the proportion of births in emergency obstetric care facilities with the proportion of births in all facilities. This indicates the extent to which other facilities provide delivery services.  This indicator can also be analyzed by level of facility (hospital and non-hospital), by ownership or management (public and private) and by subnational area, in order to determine where women are delivering. Are women more likely to deliver in private or government facilities? Are there more institutional deliveries in certain subnational areas? Disaggregating data in this way can provide more specific information about which interventions are most needed, and where.

Issue(s):

Giving birth in a health facility does not necessarily equate with high-quality care or fewer maternal deaths. Smaller health facilities may not have adequately trained staff, or staff may not have the equipment or the authority to treat life threatening complications. Many facilities do not function well because of poor management, which should be remedied before the number of births in the facility is increased greatly.  Furthermore, deliveries in institutions are not necessarily attended by skilled birth attendants. Therefore, additional information may be needed to see which cadres of workers are involved in deliveries and their level of competence.

References:

 

Percent of all births in EmOC facilities

Definition:

The percent of all births in an area that take place in emergency obstetric care (EMoC) facilities (basic or comprehensive).

This indicator is calculated as:

(Number of women registered as having given birth in facilities classified as EMoC facilities / Estimate of all the live births in the area, regardless of where the birth takes place) x 100

Although the name of the indicator is "Percent of births in EmOC facilities", in practice the numerator is the number of women giving birth and not the number of infants born. It is recognized that the number of births will be slightly higher than the number of women giving birth, because of multiple births; however, the extra effort needed to count births rather than women giving birth might not be necessary, nor is it likely to change the conclusions drawn from the results.

EmOC services are defined as:

  1. Administration of parenteral antibiotics;
  2. Administration of uterotonic drugs (i.e. parenteral oxytocin);
  3. Administration of parenteral anticonvulsants for pre-eclamsia and eclampsia (i.e. magnesium sulphate);
  4. Manual removal of the placenta;
  5. Removal of retained products (e.g.,manual vacuum aspiration);
  6. Perform assisted vaginal delivery (e.g., vacuum extraction, forceps); and 
  7. Perform surgery (e.g., cesarean section); and
  8. Perform blood transfusion.


Facilities are divided into those that provide "basic" and "comprehensive" EmOC. If a facility has performed each of the first six functions in the past three months, it qualifies as providing "basic" EmOC. If it has provided all eight of the functions, it qualifies as a "comprehensive" EmOC facility.

Data Requirements:

Knowledge of each health facility’s EmOC status, which is made available from the results of routine monitoring or needs assessment

Data Sources:

Health facility records

Purpose:

About 15% of all pregnancies will experience life-threatening obstetric complications.  Even more concerning is that health care providers can seldom predict who will experience these complications.  That is why all women and newborns must have access to emergency care (AMDD, 2011).

This indicator was originally proposed to determine whether women are using the EmOC facilities identified by availability of EmOC services and geographical distribution of EmOC facilities, and it serves as a crude indicator of the use of obstetric services by pregnant women. Overall, this indicator shows the volume of maternity services provided by facilities. If there appears to be under-use, the reasons should be explored. To increase use, emphasis should be placed on enabling women with complications to use EmOC facilities. The first goal of programs to reduce maternal mortality should be to ensure that 100% of women with obstetric complications have access to functioning emergency facilities.

Issue(s):

Even if the use of health facilities (including EmOC facilities) is fairly high, it is worthwhile investigating which women are not using them. Certain factors strongly affect use of services in a particular area, such as distance to the facility, prevalence of ethnic or religious minority groups, level of education (often an indication of social status), the reputation of the facility and poverty. Information on some of these factors, such as residence, may already be available in health facility records, and records can be reviewed to determine whether women come from all parts of the catchment area or only from the town in which the facility is located.

References:

National Needs Assessment for Emergency Obstetric and Newborn Care.  Averting Maternal Death and Disability (AMDD).  Accessed June, 2011.  http://www.amddprogram.org/d/content/national-needs-assessments-emergency-obstetric-and-newborn-care

Percent of women who received prophylactic oxytocin for vaginal delivery before delivery of placenta

Definition:

 

The percent of women during a specified time period in both facility and community deliveries who received prophylactic oxytocin during vaginal delivery before the delivery of the placenta in order to prevent postpartum hemorrhage (PPH). The timely administration of oxytocin is one component of the active management of the third stage of delivery (AMTSL). The following activities are components of AMTSL:

For further background on this indicator, see WHO (2009).

This indicator is calculated as:

(Number of women who received prophylactic oxytocin for vaginal delivery before the delivery of the placenta / Total number of vaginal deliveries within the reference period) x 100

Data Requirements:

Data from facility records, health information systems (HIS), and specialized surveys that include community deliveries can be used to calculate this indicator. A population-based estimate can be used for the expected number of deliveries for a country, but using actual numbers of facility and community deliveries provides higher quality and usefulness at the facility and local level (WHO, 2009). The data can be disaggregated by the type of facility (public, private, non-governmental, community based) and by other relevant factors such as districts and urban/rural location.

Data Sources:

 

Facility records, country and district level HIS, surveys

Purpose:

 

This indicator measures a key component of AMTSL and, as a routine indicator for country-level HIS, helps inform the healthcare system on how to allocate resources and improve function. The occurrence of PPH is responsible for 25 to 50 percent of all maternal deaths in many low-income countries and can be prevented by the simple, low-cost interventions of AMTSL.

In addition, AMTSL helps reduce blood loss and thereby decreases the incidence and severity of anemia. It can also reduce the need for emergency obstetric care, blood transfusions, and reduce the costs associated with emergency care (WHO, 2009). The WHO recommended goal is AMTSL to be offered by skilled attendants to all women. This indicator can be used as a proxy to track the administration of AMTSL and relates to achieving Millennium Development Goals #5. improve maternal health and #4. reduce child mortality. 

Issue(s):

WHO recommends oxytocin as the uterotonic of choice, however, standards of care in many countries allow the use of several uterotonic drugs for PPH prevention and, therefore, an oxytocin only indicator may not capture the use of other uterotonics. An indicator based only on facility deliveries is easier to measure and its quality is high, however, this indicator is not appropriate for a country where a significant proportion of births occur in the community. Surveys in a number of countries have shown that AMTSL was used correctly in only up to 30 percent of cases and WHO strongly recommends reinforcing AMTSL standards of practice and scaling up for training and country PPH prevention activities (WHO, 2009).

References:

 

WHO, 2009, WHO Indicator Meeting: Prevention of Postpartum Hemorrhage/Active Management of the third Stage of Labor (AMSTL), Nov. 17, Washington, DC:WHO.

Percent of mothers examined every 30 minutes during the first two hours after delivery

Definition:

The number of newly-delivered mothers receiving standardized checks every 30 minutes after delivery for the first two hours.

"Examined" refers to a series of standardized checks: vital signs, bleeding, and uterine status.

The indicator is calculated for a given reference period as:

# of mothers examined every 30 minutes during the two hours after delivery x 100
_________________________________________________________________
# of deliveries

 

Data Requirements:

Number of newly-delivered mothers receiving standardized checks every 30 minutes after delivery for the first two hours; number of women delivering at the facility during the reference period. The checks must be timely (every 30 minutes) to be considered valid.

Data Sources:

Review of medical records; direct observation from supervisor or external evaluator.

Purpose:

An important proportion of maternal deaths occur after delivery. The most important single cause of these maternal deaths is hemorrhage, most commonly in the immediate postpartum period (WHO, 1999a). Hence, routine checking for vital signs (especially blood pressure) and for vaginal bleeding and uterine status during the first two hours after delivery is an important standard of quality care that will help in the early detection of a potential life-threatening complication.

If a specific post-partum record is available and designed according to the standard of care, then it reminds providers to comply with the standard. If a specific form is unavailable, focusing attention on this standard may trigger the development of a specific job-aid.

Issue(s):

This indicator measures monitoring of women every 30 minutes for the first two hours following delivery as one component of quality postpartum care.  However, it does not address other aspects of quality care, such as the level of monitoring (e.g., is the facility too overcrowded for adequate monitoring), if skilled attendants are available at all times, and if there are necessary drugs, equipment, and supplies to effectively manage complications.

Percent of women discharged from facilities in less than 24 hours after childbirth

Definition:

 

The percent of women who delivered in a health care or emergency obstetric care (EmOC) facility during a specified time period, who are discharged less than 24 hours after childbirth.  Ideally, this indicator is calculated for all facilities rather than just for EmOC facilities, such as community-based facilities and district hospitals.

WHO/UNICEF/UNFPA (2010) include this indicator in its core list for evaluating recommended packages of interventions for postpartum care and ties it to the component  ‘Essential promotive and preventive care following childbirth for 24 hours to 6 weeks.’  Related indicators on health facility policies and the percent of women monitored for at least 24 hours are listed under postpartum care interventions by USAID/CORE Group (2004)

This indicator is calculated as:

(Number of women who deliver in a health facility who are discharged less than 24 hours after childbirth / Total number of women who delivered in a health facility during a specified time period) x 100

Data Requirements:

Data can be used from facility records, health information systems (HIS), and specialized surveys that include community-based facility deliveries.  The data can be disaggregated by the type of facility (public, private, non-governmental, community based) and by other relevant factors such as districts and urban/rural location.

If targeting and/or linking to inequity, classify facilities by location (poor/not poor) and disaggregate the women referenced by location.

Data Sources:

Facility records; HIS; and specialized surveys

Purpose:

This indicator reflects the percent of women who are placed at increased risk for postpartum mortality and morbidity due to early discharge after delivery, and can serve as a proxy for quality of postpartum care services.  The initial 24 hours after delivery is a high risk time frame for complications and 45 percent of maternal deaths occur within this period (WHO, 2005). At the same time, nearly half of all newborn deaths occur within 24 hours of delivery (UNICEF, 2011). The recommended best practice for health care facilities is to monitor all mothers and newborns for at least 24 hours (USAID/Core Group 2004; CARE/CDC, 2001; WHO/UNFPA/UNICEF/World Bank, 2006; WHO/UNICEF/UNFPA, 2010). This indicator relates directly to achieving Millennium Development Goals #5. improve maternal health and #4. reduce child mortality. 

Issue(s):

This indicator measures monitoring of women for 24 hours following delivery as one component of quality postpartum care.  However, it does not address other aspects of quality care, such as the level of monitoring (e.g., is the facility too overcrowded for adequate monitoring), if skilled attendants are available at all times, and if there are necessary drugs, equipment, and supplies to effectively manage complications.

References:

 

CARE/CDC, 2001, The Healthy Newborn: A reference Manual for Program Managers, Part 4, Atlanta, GA: CDC.  http://www.k4health.org/toolkits/pc-mnh/healthy-newborn-reference-manual-program-managers

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

WHO, 2005, World Health Report 2005: Facts and Figures, Geneva: WHO. http://www.who.int/whr/2005/media_centre/facts_en.pdf

WHO/UNICEF/UNFPA, 2010, Packages of Interventions for Family Planning, Safe Abortion Care, Maternal, Newborn and Child Health, Geneva: WHO.  http://www.who.int/making_pregnancy_safer/documents/fch_10_06/en/index.html

WHO/UNFPA/UNICEF/World Bank, 2006, Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice, Geneva: WHO.  http://apps.who.int/medicinedocs/en/m/abstract/Js23076en/

UNICEF, 2011.  Maternal and newborn healthhttp://www.unicef.org/health/index_maternalhealth.html   

Percent of women receiving postpartum care by a skilled health personnel within two days of childbirth

Definition:

The percent of pregnant women seen by a skilled health provider within the first 48 hours following delivery.

This indicator is calculated as:

# of women attended during the first 48 hours postpartum by skilled personnel x 100
__________________________________________________________________
Total # of live births

 

Data Requirements:

Number of women within the early postpartum period who are attended by skilled health personnel during the first 48 hours following delivery; all live births during the same time period.

The number of live births is a proxy for the numbers of all women who need postnatal care. Evaluators generally count all births, but usually use only live births to calculate this indicator because of the difficulty in obtaining information about non-live births (Graham and Filippi, 1994).

Where data on the numbers of live births 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.

Data Sources:

Routine health service data; population-based surveys.  Routine health service data typically lack information on pregnancies or births that take place outside the public health sector, for example in homes or in private sector facilities.

Purpose:

The main purpose of an indicator for postpartum care is to provide information on women's use of postpartum services in the postpartum period.

Although most maternal and newborn deaths occur around the time of delivery and in the immediate postpartum period, postpartum care (PPC) has been a relatively neglected area of maternity-services provision. Recent WHO guidelines recommend that the first postpartum visit take place within the first week, preferably within the first two to three days, with a second visit at four to six weeks. The visit should include the early detection and treatment of complications and preventive care for both mother and baby7 (WHO, 1998a; WHO, 2001b).

Because pregnancy complications occur unpredictably, the likelihood is low that one postpartum visit of unspecified content, quality, and timing may influence maternal mortality. A postnatal care visit may reduce the likelihood of severe morbidity if pregnancy complications are detected early and if effective treatment is available (Child Health Research Project, 1999). Further research in this area is required.

Some large surveys such as DHS routinely collect data on postpartum care. Routine HIS may also collect data, although historically more programs have collected data on postnatal care for the baby (for immunization coverage) than for the mother.

This indicator is responsive to change in the short term. Annual monitoring is only feasible when the data are derived from routine data sources. For international comparisons, periods of three to five years are probably sufficient. Frequent surveys are probably undesirable because sampling error makes it difficult to assess whether small changes are real or due to chance variation.

Postpartum care is a package of services instead of one single intervention. Because no widely accepted operational definition of postpartum care exists and because the content and quality of care are likely to vary between settings, similar coverage rates between countries do not reflect similar levels of care.

Furthermore, after delivery, the two individuals need very different care and attention. Postpartum care statistics should make explicit whether care was provided principally for the mother or baby or both mother and baby, because this information may be difficult to determine retrospectively. The current DHS questionnaire, for example, specifies postpartum care for the mother. WHO distinguishes between care for the mother and for the baby by using the term postpartum to refer to care exclusively for the mother and the term postnatal care for the baby.

Some surveys present only postpartum coverage for women who delivered outside a facility on the assumption that women who deliver in facilities receive some degree of postpartum care (Rutstein, 1999).

In settings where postnatal coverage is relatively high, evaluators can stratify this indicator by time of visit (e.g., within two or three days, one week or later) to better measure women's use of services.

Issue(s):

This indicator does not assess the content of the quality of the postpartum care itself, only that care was provided.

Furthermore, after delivery, the care and attention needed by mothers and babies can vary considerably. Postpartum care statistics should make explicit whether care was provided principally for the mother or baby or both mother and baby, because this information may be difficult to determine retrospectively. The current DHS questionnaire, for example, specifies postpartum care for the mother. WHO distinguishes between care for the mother and for the baby by using the term postpartum to refer to care exclusively for the mother and the term postnatal care for the baby.

Some surveys present only postpartum coverage for women who delivered outside a facility on the assumption that women who deliver in facilities receive some degree of postpartum care (Rutstein, 1999).

A related indicator would be Percent of women attended during the postpartum period by skilled personnel. Evaluators could then stratify this indicator by time of visit (e.g., within two or three days, one week or later) to better measure women's use of services.

References:

WHO Technical Consultation on Postnatal and Postpartum Care, 2006.

Percent women receiving postpartum/ postabortion family planning counseling (as a percent of women seen)

Definition:

The percent of women who received postpartum or postabortion care in a health facility or community-based program during a specified time period, who also received family planning (FP) counseling. Ideally, health facilities and programs will include all public, private, non-governmental, and community-based services in a designated area.

The postpartum period is defined as up to 6 weeks and the immediate postpartum period as the first week following delivery. The recommended topics for FP messages and counseling during the postpartum period include: exclusive breastfeeding; reproductive intentions; pregnancy risk; pregnancy spacing for women who want another child; lactational amenorrhea or other methods as reproductive intentions indicate; and importance of postnatal care for mother and newborn (USAID, 2009).

The recommended best practices for postabortion FP counseling and services are to provide these before women are discharged from the facility. In countries where abortion is legal, programs may offer FP counseling when women make an appointment for their abortion, then provide women with FP services after completion of their abortion. In countries where abortion is illegal, emergency treatment and postabortion FP counseling and services should be provided as a single service (Curtis et al., 2008). However, although this is considered a best practice and FP counseling and provision is one of the key components of postabortion care, it is frequently not provided in many settings.

This indicator is calculated as:

(Number of women who received postpartum or postabortion FP counselling / Total number of women who received postpartum or postabortion care in a health facility or community-based program during a specified time period) x 100

Data Requirements:

Data can be used from facility records, health information systems (HIS), and specialized surveys. The data can be disaggregated by whether the women were postpartum or postabortion, age, the type of facility or program (public, private, non-governmental, community-based), and by other relevant factors such as districts and urban/rural location.

If targeting and/or linking to inequity, classify outlets where counseling is taking place by location (poor/not poor) and disaggregate by area served.  Exit interviews can be conducted with clients to determine client's poverty status.

Data Sources:

Facility records; HIS; specialized surveys.

Purpose:

This indicator measures the level of postpartum and postabortion FP counseling provided by health care facilities and community-based programs, and can serve as a proxy for the integration and quality of FP with maternal health care services. Demographic and Health Surveys (DHS) show that very few women (3 to 8 percent) want another child within two years of giving birth, and 40 percent of women who intend to use FP are not doing so, thereby demonstrating a high unmet need for postpartum FP (USAID, 2009). There is strong evidence of health risks for both mothers and infants associated with short birth intervals, yet about one fourth of births in many low-income countries occur with intervals less than two years (USAID, 2008). Many women are unaware that they are at risk of pregnancy postpartum and may wait until the return of menses to seek FP. Accordingly, FP counseling in the early postpartum period is instrumental in avoiding a ‘missed opportunity’ to inform and prepare women for their return to fertility and to discuss available choices of postpartum FP methods and services. Systematically reaching women postpartum has the potential to provide FP information and services to over 90 percent of women of reproductive age in high fertility settings (USAID, 2008).

Likewise, the provision of postabortion FP counseling is a valuable opportunity to inform and provide women with effective FP. An estimated 35 million abortions occur in low-income countries each year, with 20 million of these considered unsafe, and the lives of 67,000 women lost due to complications (WHO, 2005). These abortion-related deaths represent 13 percent of all pregnancy-related mortality and, in some countries, as high as 25 percent of maternal deaths. If contraception were accessible and used consistently and correctly by women wanting to avoid pregnancy, maternal deaths could decline by an estimated 25 to 35 percent (Lule et al., 2007). Overall, FP is a cost-effective means to lower maternal mortality rates by: 1) reducing the absolute number of complications due to fewer pregnancies; 2) reducing the incidence of abortion by averting unwanted and unplanned pregnancies; and 3) averting pregnancies that occur too early, too late or too frequently during the woman’s reproductive cycle, and those that are inadequately spaced (UNFPA, 2004). Moreover, use of FP can reduce the number of cases of mother-to-child transmission of HIV. The provision of postpartum and postabortion FP counseling and services in health care facilities is directly related to achieving Millennium Development Goals #5. improve maternal health and #4. reduce child mortality.

Issue(s):

This indicator does not measure the quality of the FP counseling services, and whether the facility has methods available, makes referrals, or follows up with women on the adoption, correct use, or continuation of FP methods. Women who deliver at home and/or do not receive postpartum care will not be included in the calculation of this indicator, nor will women who do not receive postabortion care, particularly in settings where abortion is illegal or having an abortion is highly stigmatized and women do not seek care for complications.

References:

Curtis C, Huber D and Moss-Knight T., 2010, Postabortion Family Planning: Addressing the Cycle of Repeat Unintended Pregnancy and Abortion, International Perspectives on Sexual and Reproductive Health, Vol 36 (1) March. https://www.guttmacher.org/pubs/journals/3604410.html

Lule E, Singh S and Chowdhury SA, 2007, Fertility Regulation Behavior and Their Costs: Contraception and Unintended Pregnancies in Africa and Eastern Europe and Central Asia, Washington, DC: World Bank.

UNFPA, 2004, Program Manager’s Planning Monitoring and Evaluation Toolkit, Part II: Indicators for Reducing Maternal Mortality, New York: UNFPA. http://www.unfpa.org/monitoring/toolkit/Tool6_2.pdf

USAID, 2009, Family Planning for Postpartum Women: Seizing a missed opportunity, Washington, DC: USAID  https://www.k4health.org/sites/default/files/FP%20for%20PP_eng.pdf 

USAID/ACCESS-FP, 2008, ACCESS Programmatic Framework for Postpartum Family Planning in an Integrated Context, Washington, DC: USAID. http://www.accesstohealth.org/toolres/pdfs/ACCESSFP_pgmframework.pdf

USAID, 2008, ‘Community Based Family Planning,’ Technical Update, No. 5, FP during the First Year Postpartum, Washington DC: USAID.  https://www.k4health.org/sites/default/files/community%20based%20family%20planning%20tech%20update%205.pdf

WHO, UNFPA, 2008, National-level monitoring of the achievement of universal access to reproductive health: conceptual and practical considerations and related indicators, Geneva: WHO. http://whqlibdoc.who.int/publications/2008/9789241596831_eng.pdf

WHO, 2007, Maternal Mortality in 2005; Estimates Developed by WHO, UNICEF, UNFPA and the World Bank, Geneva:WHO. http://www.who.int/whosis/mme_2005.pdf  

WHO, 2009, WHO Recommended Interventions for Improving Maternal and Newborn Health2009, Geneva: WHO. http://whqlibdoc.who.int/hq/2007/WHO_MPS_07.05_eng.pdf

Percent of maternal deaths due to indirect causes at EmOC facilities

Definition:

The percent of maternal deaths in emergency obstetric care (EmOC) facilities during a specific time period that resulted from indirect causes. Indirect causes of death are defined as those resulting from a previous existing disease or disease that developed during pregnancy, which was not due to direct obstetric causes, but which was aggravated by the physiologic effects of pregnancy.  Indirect causes include infections (e.g., malaria and hepatitis), cardiovascular disease, psychiatric illnesses (e.g., suicide and violence), tuberculosis, epilepsy, and diabetes (WHO et al., 2010).

Other categories of maternal death, for instance accidental or incidental deaths, generally are not included in the calculation of maternal death rates or ratios, and they are excluded from the numerator for this indicator. For further details on this indicator and on classification of direct and indirect causes of maternal deaths, see WHO et al. (2010).

The direct obstetric case fatality rate also can be calculated for all facilities other than just for EmOC facilities, such as district hospitals.

This indicator is calculated as:

(Number of maternal deaths due to indirect causes in EmOC facilities / Total number of maternal deaths in the same facilities during the same period) x 100

Data Requirements:

The reporting of maternal deaths and their causes varies widely and is associated with a country’s level of statistical development, although all countries tend to follow some version of the International Classification of Diseases (WHO, 1992). In countries with well-developed health and statistical reporting systems, the source of this information is the vital registration system. Separate cause-specific rates can be calculated for each of the major indirect causes of maternal death. The number of maternal deaths in a given facility or aggregate of facilities may be too small (e.g., fewer than 20) to calculate a stable rate for each complication. Therefore, in most facilities, only an aggregate indirect obstetric case fatality rate should be calculated. The data can be disaggregated by the type of types of facilities (e.g., basic versus comprehensive EmOC and/or public, private, non-governmental, community based) and by other relevant factors, such as district and urban/rural location.

Data Sources:

National health information system; death records/certificates in the vital registration system; health facility records.

Purpose:

A substantial proportion of maternal deaths in most countries are due to indirect causes, particularly where HIV and other endemic infections, such as malaria and hepatitis are prevalent. Where infectious and communicable disease rates are high, often the number of maternal deaths due to direct causes is also high. With the rising prevalence of overweight among girls and women of reproductive age in many regions of the world, related chronic conditions, such as cardiovascular disease and diabetes, are increasingly contributing to indirect maternal deaths. This indicator does not lend itself easily to a recommended maximum level. Rather it highlights the larger social and medical context of a country or region and has implications for intervention strategies beyond EmOC where indirect causes kill many women of reproductive age. Research is needed in the area of indirect maternal deaths, including on the mechanisms by which indirect conditions cause maternal death and what programs could reduce them. This relatively new indicator of maternal mortality can be a proxy for the coverage and quality of programs for preventing or treating conditions associated with indirect maternal deaths (WHO et al., 2010) and relates to achieving Millennium Development Goals #5. improve maternal health #4. reduce child mortality.

Issue(s):

The indirect maternal fatality rates do not take into account deaths outside the EmOC health system and are not generalizable to the wider population. In settings where many women give birth at home or outside facilities, this indicator may be subject to bias because a disproportionate number of maternal deaths in a facility result from women who come for treatment of complications. In addition, the numbers of deaths and indirect obstetric case fatality rates may increase when efforts are made to improve hospital services and more women come for treatment. On the other hand, the absence of maternal deaths might indicate that women with serious complications are not brought to facilities or are referred on. The absence of reported deaths can also suggest that deaths are not being reported.

The causes of maternal deaths are often misclassified, for example, the death of an HIV-positive woman might be classified as due to AIDS even if it was due to a direct cause such as hemorrhage or sepsis. On the other hand, due to lack of testing and reporting, as well as the associated stigma, HIV infection might be an underreported cause of maternal death. Misclassification of cause of death can lead to serious under-recording and problems of attribution of cause (WHO et al., 2010). Death certificates may never be filled out, may fail to indicate whether pregnancy was a recent occurrence, or may list multiple causes of death but an underlying cause is not registered. Similar to the recording of obstetric complications, training staff to comply with national standards of death certificate completion can result in more accurate and complete recording. Conducting reviews of all deaths of women of reproductive age in facilities, especially those who do not die on the maternity ward, could lead to more complete recording. Data collection for this new indicator may be difficult, however, the WHO technical consultation considered that it would be useful for governments and international agencies. In a few years, the indicator will be reviewed to see if it is useful and whether it should be modified (WHO et al., 2010).

References:

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

WHO, 1992, International Statistical Classification of Diseases and Related Health Problems. Tenth Revision (ICD-10). Geneva: WHO. http://apps.who.int/classifications/apps/icd/icd10online/

Percent of facilities that conduct case review/audits into maternal death/near miss

Definition:

The number of facilities that conduct case review/audits into maternal death/near miss.

This indicator is calculated as:

# of facilities conducting case review/ audits into maternal death/near miss x 100
___________________________________________________________
# of facilities at the appropriate level*

* Certain facilities will be too small to conduct their own audits, but may participate in established procedures.

Case review refers to a detailed review of the management of a particular patient or clinical case.

An audit is the systematic and critical analysis of the quality of care. Audit differs from case review because it looks at the whole process of care and at conformity with specified standards of care as part of an iterative cycle of quality improvement (Graham et al., 2000). The different types are as follows:

Data Requirements:

Number of facilities conducting or participating in audits of maternal death and near-miss cases; number of facilities in a specific geographic area.

Data Sources:

Health-facility surveys; district health-management team records.

Purpose:

An audit is one of many established mechanisms for improving provider performance in developed countries, and studies have shown that it also applies to developing countries.  Case reviews or audits, which entail collecting and analyzing data, can be critical to improving the quality of obstetric care and thus reduce maternal morbidity and mortality.  An example of this is in Rwanda, where just six months after the government introduced the maternal death audit system in late 2009, the method revealed the major causes of maternal mortality (allAfrica, accessed May 2011). 

Issue(s):

This indicator may be collected as part of a facility survey (MEASURE DHS+, 2001), although most programs will need to set up their own monitoring system for assessing the coverage and quality of effective audit practices.

This indicator measures only the proportion of facilities conducting audit or case reviews and does not measure the quality or the impact of the review process. Although case reviews are a routine part of many facility activities, effective audit is not. Firstly, data may be missing due to poor documentation of case notes.  Secondly, data regarding community factors leading to the woman's death in the facility may be difficult to obtain.  And thirdly, facility-based maternal death reviews are sometimes not conducted in a blame-free manner (Kongnyuy and van den Broek, 2008).  For these reasons, programs may want to collect complementary information on the quality and effectiveness of the process.

In most cases, smaller facilities will find it impractical to conduct their own audit or case reviews. Staff representatives from these facilities, however, should participate in the audit cycles of larger facilities or districts.

References:

"Maternal Death Audit System Key to Curbing Mortality", May 20, 2010.Accessed in May, 2011 at allAfrica.  Available at: http://allafrica.com/stories/201005200005.html 

Kongnyuy E. and van den Broek N. The difficulties of conducting maternal death reviews in Malawi.   BMC Pregnancy and Childbirth 2008, 8:42.

WHO, 2011.  Evaluating the quality of care for severe pregnancy complications: The WHO near-miss approach for maternal health. http://whqlibdoc.who.int/publications/2011/9789241502221_eng.pdf 

Percent of pregnant women with obstetrical complications treated within two hours at a health facility

Definition:

The percent of women with obstetric complications who are treated within two hours of admittance to a health facility measured during a given reference period.

Obstetric complications include:

Treatment for obstetric complications depends on the complication and local protocols for treatment.

This indicator is calculated as:

# of women with obstetric complications treated within 2 hours of admittance to a health facility x 100
___________________________________________________________________________
# of women admitted at a health facility with obstetric complications

Data Requirements:

Numerator: date and time of admission; date and time of treatment/delivery; total number of women admitted with complications and their diagnosis at the time of admission; and information on the time and nature of treatment given.

Denominator: number of women admitted to the health facility with obstetric complications.

Data Sources:

All registers that record where women are admitted to a facility (e.g., labor ward register, antenatal, emergency room or postnatal ward register); registers that record where definitive treatment is administered (e.g., operating theatre register, specific complications registers); case records

Purpose:

The purpose of this indicator is to provide a measure of the quality of maternity care, because maternal mortality is directly related to the effectiveness and timelines of treatment for emergency complications (Koblinsky, et al., 1995).

Issue(s):

This indicator is most appropriate at a facility level for those facilities interested in auditing their own care practice. It is less suitable for comparison purposes across facilities because of variation in the services provided and in case mix at different facilities as well as variations in the definitions of the indicator.

Information required to construct the indicator should be available directly from facility registers and case notes. The lack of certain information may signal suboptimal care/management. The feasibility of the indicator also critically depends on standard definitions of admission-to-treatment-time-interval (ATTI) for each obstetric complication. For example, does admission time mean time of first arrival at the hospital, time seen by the admissions clerk, or something else? What is the treatment time for an obstetric hemorrhage? Is it when an intravenous drip is inserted, when a blood transfusion starts, when an oxytoxic is given, or when the hemorrhage stops?

This indicator should respond rapidly to changes in staff or facility administration practice. Early rapid response may simply be due to a Hawthorne effect (i.e., apparent improvement simply because of an observation taking place), but this type of improvement will not be sustained. To maintain improvement, programs should regularly audit ATTI. Better still, ATTI could be incorporated into routine management practice (e.g., discussed routinely in all case reviews). (See indicator, Percent of Facilities that Conduct Case Reviews/ Audits into Maternal Death/Near Miss).

This type of indicator has several ambiguities and deficiencies, as follows:

Because of these limitations, evaluators can best measure ATTI in combination with other indicators or approaches that measure complementary aspects of the quality of care, for example in the context of care reviews or near-miss audits.

Cesarean sections as a percent of all births

Definition:

The percent of pregnant women who have a cesarean section (C-section) in a specific geographical area and reference period.

This indicator is calculated as:

# of C-sections performed x 100
____________________________
# of live births

 

Data Requirements:

The number of C-sections performed in a defined population during a reference period; total number of live births in the same reference period.

Data Sources:

Numerator: clinical registries for data in a given geographical area on the number of C-sections performed; estimates of the number of births in that area; and population- based surveys for self-reported C-sections only.

Denominator: all live births during the reference period. Where data on the numbers of live births are absent, 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.

Household demographic surveys often produce national and disaggregated estimates of the self-reported C-section rate.

Purpose:

This indicator demonstrates the extent to which a particular life-saving obstetric service is being performed in emergency obstetric care facilities. It reflects the accessibility and utilization of services as well as the functioning of the health service system. The appropriate use of a C-section leads to a decrease in maternal mortality and morbidity, as well as a decrease in perinatal morbidity and mortality. While cesarean sections may be performed solely for the health of the fetus or newborn, in developing countries the vast majority relate to maternal indications.

Many of the major pre- and intrapartum causes of maternal mortality and morbidity require the use of this procedure to save the woman's life or to prevent serious morbidity.

Of all the procedures used to treat the major obstetric complications, C-sections may be the easiest to study because record-keeping for C-sections is more reliable than that for other procedures or obstetric complications (MotherCare, 2000b; UNICEF, WHO, UNFPA, 1997). However, it is critical that evaluators include information for all facilities performing C-sections in the area under study in the numerator.

Changes in the ability of the health care system to provide C-sections can have an impact within six to nine months.

U