Service Quality

 

The quality of services collection includes results-based financing indicators that measure process of care, reaching standards of care, and patient satisfaction. Quality checklists are not included in the indicator compendium. The RBF Indicator Compendium has three other collections: structural, service use and intervention coverage, and health outcomes and impact. 

Percent of pregnant women who have a preparedness plan for birth and complications

Definition:

Percent of pregnant women who have a preparedness plan for birth and complications.

Numerator:

Number of pregnant women with a preparedness plan for birth and complications.

Denominator:

Total number of pregnant women attending at least one antenatal care visit.

Disaggregation:

Age, place of residence, socioeconomic status, type of facility.

Data Sources:

Questionnaires

Chart reviews

Purpose:

All pregnant women should have a plan for birth and for dealing with unexpected adverse events, such as complications or emergencies, that may occur during pregnancy, childbirth or the immediate postnatal at each antenatal assessment and at least one month prior to the expected date of birth. The plan will assist women and their partners and families to be adequately prepared for childbirth by making plans on how to respond if complications or unexpected adverse events occur to the woman and/or the baby at any time during pregnancy, childbirth or the early postnatal period. 

References:

World Health Organization (WHO). Consultation on Improving Measurement of the Quality of Maternal, Newborn and Child Care in Health Facilities.; 2013. http://apps.who.int/iris/bitstream/10665/128206/1/9789241507417_eng.pdf

World Health Organization (WHO). Standards for Maternal and Neonatal Care. 1.9 Birth and emergency preparedness in antenatal care. Integrated Management of pregnancy and Childbirth (IMPAC). 2006  http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/emergency_preparedness_antenatal_care.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. http://www.iom.edu/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines.aspx

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 antenatal care visits at which blood pressure was measured

Definition:

Percent of antenatal care visits at which blood pressure was measured.

Numerator:

Number of antenatal care visits at which blood pressure was measured.

Denominator:

Total number of antenatal care visits.

Disaggregation:

Age, place of residence, socioeconomic status, type of facility.

Data Requirements:

Collected by delegated staff from available records.

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

Data Sources:

Antenatal care registry or hand-held prenatal record (facility-specific)

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. 

Issue(s):

Data on whether women’s blood pressure was measured during an ANC visit, as taken from routine health records, will not include information for pregnancies occurring outside the public health sector, including home and private facility deliveries.

References:

World Health Organization (WHO). Education material for teachers of midwifery. Midwifery education modules - second edition. Managing eclampsia.; 2008. http://apps.who.int/iris/bitstream/10665/44145/5/9789241546669_5_eng.pdf

World Health Organization (WHO). Consultation on Improving Measurement of the Quality of Maternal, Newborn and Child Care in Health Facilities.; 2013. http://apps.who.int/iris/bitstream/10665/128206/1/9789241507417_eng.pdf

World Health Organization (WHO). 2015 Global Reference List of 100 Core Health Indicators.; 2015. http://apps.who.int/iris/bitstream/10665/173589/1/WHO_HIS_HSI_2015.3_eng.pdf

Percent of pregnant women who were screened for anaemia

Definition:

Percent of pregnant women who were screened for anaemia

Numerator:

Number of pregnant women screened for anaemia

Denominator:

Total number of pregnant women attending at least one antenatal care visit.

Disaggregation:

Age, place of residence, socioeconomic status, type of facility.

Data Sources:

Chart review

Purpose:

Anemia is associated with higher risk of maternal and infant mortality. Screening during pregnancy will allow for treatment of anemia in addition to standard iron supplements for pregnant women.

References:

World Health Organization (WHO). Consultation on Improving Measurement of the Quality of Maternal, Newborn and Child Care in Health Facilities.; 2013. http://apps.who.int/iris/bitstream/10665/128206/1/9789241507417_eng.pdf

World Health Organization (WHO). 2015 Global Reference List of 100 Core Health Indicators.; 2015. http://apps.who.int/iris/bitstream/10665/173589/1/WHO_HIS_HSI_2015.3_eng.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 pregnant women attending antenatal care services who were treated for syphilis

Definition:

Percent of pregnant women attending antenatal care services who were treated for syphilis. 

Numerator:

Number of pregnant women screened for syphilis who tested positive and received treatment.

Denominator:

Total number of pregnant women attending at least one antenatal care visit.

Disaggregation:

Age, place of residence, socioeconomic status, type of facility, first/any visit

Also: add whose sexual contacts were traced

Data Requirements:

Collected by delegated staff from available records.

Data Sources:

Chart review(s)

Questionnaires

Purpose:

Identification of a pregnant woman’s syphilis serostatus provides an entry point for prevention, care, and treatment services.

Pregnant women with untreated syphilis (maternal or gestational syphilis) can transmit the infection to the fetus in utero or by direct contact with lesions during childbirth; the resulting congenital syphilis is the most prevalent form of neonatal infection in the world. Untreated syphilis is associated with stillbirth, spontaneous abortion, low birth weight, and serious neonatal infections, which are in turn associated with an increased risk of perinatal death.

Different kinds of diagnostic tests are available; some provide results in minutes, allowing for treatment at the same visit. The appropriate treatment for syphilis during pregnancy is at least one dose of intra-muscular (IM) penicillin G, which should be provided as close as possible to the time at which a positive result is found in the screening tests. This is a programmatic indicator reflecting treatment coverage among those identified as seropositive for syphilis.

This indicator allows countries to monitor early treatment coverage among syphilis-infected pregnant women to reduce the risk of transmission to the child and as an assessment of the women’s own health.

Issue(s):

The indicator does not measure further quality of care, for example, penicillin allergy management. Also, treated women need to be reevaluated with quantitative serologic tests every 1 to 3 months in order to assess treatment failures, reinfection, or neurosyphilis (the last of which requires a lumbar puncture).

There is a risk of double counting in cases where treatment is provided at different points in time and/or in different health facilities. Data
collection and reporting system shoul therefore be in place to minimize the potential for double counting.

References:

Pan American Health Organization (PAHO). Regional Initiative for the Elimination of Mother-to-Child Transmission of HIV and Congenital Syphilis in Latin America and the Caribbean. Washington, D.C.:; 2010. https://www.unicef.org/lac/Regional_Monitoring_Strategy.pdf

World Health Organization (WHO). Consultation on Improving Measurement of the Quality of Maternal, Newborn and Child Care in Health Facilities.; 2013. http://apps.who.int/iris/bitstream/10665/128206/1/9789241507417_eng.pdf

World Health Organization (WHO). 2015 Global Reference List of 100 Core Health Indicators.; 2015. http://apps.who.int/iris/bitstream/10665/173589/1/WHO_HIS_HSI_2015.3_eng.pdf

Percent of women in the past 3 months for whom a partograph was completed

Definition:

Percent of women in the past 3 months for whom a partograph was completed.

Numerator:

Number of women for whom a partograph was completed in the past 3 months.

Denominator:

Number of women admitted to the labour and childbirth ward in the past 3 months.

Disaggregation:

Age, place of residence, socioeconomic status, type of facility.

Data Requirements:

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

See also: Percent of deliveries in which a partogram is correctly used

Data Sources:

Generally available through birth records and/or partographs, birth unit registry, patient records, and/or chart review.

Purpose:

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

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

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

References:

World Health Organization (WHO). Consultation on Improving Measurement of the Quality of Maternal, Newborn and Child Care in Health Facilities.; 2013. http://apps.who.int/iris/bitstream/10665/128206/1/9789241507417_eng.pdf

MEASURE Evaluation. FP and Reproductive Health Indicators Database — MEASURE Evaluation. http://www.cpc.unc.edu/measure/prh/rh_indicators/ 

Percent of women with prolonged labour

Definition:

Percent of women with prolonged labour.

Numerator:

Number of women who have not given birth or were not transferred out within 12 hours of active labour.

Denominator:

Total number of women admitted during labour and childbirth in the past 3 months.

Disaggregation:

Age, place of residence, socioeconomic status, type of facility.

Data Requirements:

Collected by delegated staff from available records. 

Data Sources:

Generally available through birth records and/or partographs, birth unit registry, patient records, and/or chart review.

Purpose:

Prolonged obstructed labour is an important cause of maternal and perinatal mortality and morbidity. This indicator looks at the proportion of women in active labour (i.e. with a cervical dilatation of ≥4 cm (documented, with clear documentation of delivery time) for more than 12 hours, since these women should have been delivered in the facility after augmentation of labour or operative delivery or should have been referred elsewhere for these interventions.

References:

World Health Organization (WHO). Consultation on Improving Measurement of the Quality of Maternal, Newborn and Child Care in Health Facilities.; 2013. http://apps.who.int/iris/bitstream/10665/128206/1/9789241507417_eng.pdf

Percent of HIV positive pregnant women who received appropriate treatment in labor, according to PMTCT recommendations

Definition:

The percentage of pregnant women who are HIV-positive and who received appropriate treatment during labor and delivery according to recommendations for preventing mother-to-child transmission (PMTCT) of HIV during the reporting period.

This indicator is calculated as:

(Number of HIV-positive pregnant women who received appropriate treatment during labor, according to PMTCT recommendations / Total number HIV-positive pregnant women who received labor and delivery care during the reporting period) x 100 

WHO et al., (2008) recommendations for PMTCT during labor and delivery include ‘Standard Precautions,’ which reduce the risk of transmission of blood-borne pathogens from the patient to the health care worker, and the following general precautions for women with HIV or unknown HIV status:

Specific interventions for PMTCT include:

For further details on this indicator and recommended practices for PMTCT during labor and delivery and emergency obstetric care, see USAID/CORE Group (2004); WHO et al. (2008) and WHO et al.(2010).

Data Requirements:

Review of labor and delivery facility records for women’s HIV status and test results and records for care received, ideally from public, private, and non-governmental facilities. Where the Baseline Assessment Tools for Preventing Mother-to-child Transmission (PMTCT) of HIV (FHI, 2003), are being used to monitor care during labor and delivery, the data can be used for these facilities and programs. Data should be collected continuously and aggregated periodically for the purposes of program management, review, and district and country-level reporting. Data can be disaggregated by type of facilities, districts, and urban/rural location.

Data Sources:

Labor and delivery facility registers; patient records; monitoring surveys, such as the FHI PMTCT assessment tool (FHI, 2003).

Purpose:

This indicator provides information on whether labor and delivery facilities are fully implementing practices for HIV infected women that meet the standard obstetric practices set forth by national or international standards. Evaluators can examine trends over time in the numbers of HIV-positive women presenting at labor and delivery facilities and the percentage of these women who are receiving the recommended quality of care. Additionally, the indicator can be used to identify areas of need and prioritize investments in resources, staffing, and PMTCT training. 

Presently, women account for nearly half of all people living with HIV and 76 percent of young people (15-24 years) living with HIV are female (UNFPA 2011). Infants of women with HIV can become infected during pregnancy, labor and delivery, and through breastfeeding. Children account for more than ten percent of all new HIV infections and most of these are through mother-to-child transmission (IATT, 2007). Many countries have programs for PMTCT and are scaling up efforts to provide comprehensive prevention, care and support for women, children and their families. For further technical guidance on interventions and indicators for PMTCT, see USAID/CORE Group (2004); UNAIDS (2010); WHO (2010).

Issue(s):

Lack of accuracy and quality control in record keeping at labor and delivery centers can impact the validity of this indicator. Missing information in records and registers may signal suboptimal care. In some settings, large numbers of pregnant women do not have access to labor and delivery services or choose not to use them. Pregnant women living with HIV may be less likely to use these services (or public rather than private services) than those who are not infected, particularly where levels of stigma associated with HIV are particularly high.  

References:

Family Health International (FHI), 2003, Baseline Assessment Tools for Preventing Mother-to-child Transmission (PMTCT) of HIV, Arlington, VA: FHI, Institute for HIV/AIDS, http://pdf.usaid.gov/pdf_docs/pnadf776.pdf

Interagency Task Team (IATT) on Prevention of HIV Infection in Pregnant Women, Mothers and their Children, 2007, Guidance on the Global Scale-up of the Prevention of Mother-to-Child Transmission of HIV, Geneva, WHO.
http://whqlibdoc.who.int/publications/2007/9789241596015_eng.pdf

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

WHO, 2009, New WHO recommendations: Preventing Mother-to-Child Transmission, Geneva: WHO. http://www.who.int/hiv/pub/mtct/mtct_key_mess.pdf

WHO, 2010, PMTCT Strategic Vision 2010–2015: Preventing mother-to-child transmission of HIV to reach the UNGASS and Millennium Development Goals, Geneva: WHO. http://www.who.int/hiv/pub/mtct/strategic_vision/en/index.html

WHO/CDC/USHHS/GAP, 2008, Prevention of Mother-to-Child Transmission of HIV: Generic training package draft participant manual, Washington, DC: USHHS.
http://www.womenchildrenhiv.org/pdf/p03-pi/gtp-01-08/Manual_PM_1-08.pdf

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

Prevention of postpartum haemorrhage in health facilities

Definition:

Percent of women receiving oxytocin immediately after the birth of the baby (within 1 minute of delivery), before the birth of the placenta, irrespective of mode of delivery.

Numerator:

Number of women in the past 3 months who received oxytocin immediately after the birth of their infant (within 1 minute of delivery) and before birth of placenta, irrespective of mode of delivery.

Denominator:

Number of women of women giving birth in the health facility in the past 3 months.

Disaggregation:

Age, place of residence, socioeconomic status, type of facility.

Data Requirements:

Data for this indicator can be collected by delegated staff from available records or chart review.

See also: Percent of women who received prophylactic oxytocin for vaginal delivery before delivery of placenta; and Percent of mothers examined every 30 minutes during the first two hours after delivery

Data Sources:

Birth unit registry

Patient records

Admission and discharge records

Purpose:

The most important single cause of these maternal deaths is hemorrhage, most commonly in the immediate postpartum period (WHO, 1999a). Postpartum hemorrhage 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 such as the administration of oxytocin during vaginal delivery, before the delivery of the placenta.

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 prevention of postpartum hemmorhage and, therefore, an oxytocin only indicator may not capture the use of other uterotonics. 

References:

World Health Organization (WHO). Consultation on Improving Measurement of the Quality of Maternal, Newborn and Child Care in Health Facilities.; 2013. http://apps.who.int/iris/bitstream/10665/128206/1/9789241507417_eng.pdf

World Health Organization (WHO). 2015 Global Reference List of 100 Core Health Indicators.; 2015. http://apps.who.int/iris/bitstream/10665/173589/1/WHO_HIS_HSI_2015.3_eng.pdf

MEASURE Evaluation. FP and Reproductive Health Indicators Database — MEASURE Evaluation. http://www.cpc.unc.edu/measure/prh/rh_indicators/ 

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.

Severe systemic infection / sepsis in the postnatal period

Definition:

Percent of women seen in the facility with severe systemic infection or sepsis after delivery in the facility. 

Numerator:

Number of women seen in the facility with severe systemic infection or sepsis in the postnatal period, including readmissions after birth in facility.

Denominator:

Total number of women giving birth in the health facility.

Disaggregation:

Age, place of residence, socioeconomic status, type of facility.

Data Requirements:

Data for this indicators can be collected by delegated staff from available records or chart review.

Data Sources:

Chart review

Patient records

Admission and discharge records

Purpose:

Puerperal sepsis is another important cause of maternal death and is often linked to the quality of care during labour and childbirth. As women who give birth in facilities are often discharged home before clinical signs of severe sepsis appear. This indicator includes readmissions for sepsis, in an effort to capture the occurrence of systemic infection in the postnatal period (i.e. the first 42 days after birth).

References:

World Health Organization (WHO). Consultation on Improving Measurement of the Quality of Maternal, Newborn and Child Care in Health Facilities.; 2013. http://apps.who.int/iris/bitstream/10665/128206/1/9789241507417_eng.pdf

World Health Organization (WHO). 2015 Global Reference List of 100 Core Health Indicators.; 2015. http://apps.who.int/iris/bitstream/10665/173589/1/WHO_HIS_HSI_2015.3_eng.pdf

Newborns receiving essential newborn care

Definition:

Percent of newborns who received all four elements of essential newborn care: 

Numerator:

Number of newborns who received all four elements of essential newborn care.

Denominator:

Total number of live births in the health facility.

Data Requirements:

Data can be obtained via case observation, direct observation, chart reviews and/or exit interviews of mothers.

See also: Percent of newborns receiving immediate care according to MOH guidelinesPercent of newborns dried immediately after delivery (for home and facility deliveries); and Percent of newborns with delayed bath (for home and facility deliveries)

Data Sources:

Perinatal information system

Charts

Purpose:

This indicator assesses the provision of a core component of recommended newborn thermal care at delivery, and can be used as a measure for the quality of and adherence to service protocols (Gage et al., 2005). Drying the newborn immediately after birth, skin-to-skin contact with the mother, wrapping the infant with a dry cloth or towel, keeping the newborn’s head covered, and delayed bathing, ideally for 24 hours, are essential care practices for keeping the newborn warm. Early skin-to-skin contact with the mother also promotes bonding and facilitates the initiation of breastfeeding. These strategies can be used effectively at home deliveries, as well as at facilities, and can improve newborn health and survival. Since the highest period of risk for neonatal deaths is within the first 24 hours, this indicator measures the delivery of several key thermal care practices that can improve infant health outcomes.

Issue(s):

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

References:

World Health Organization (WHO). Consultation on Improving Measurement of the Quality of Maternal, Newborn and Child Care in Health Facilities.; 2013. http://apps.who.int/iris/bitstream/10665/128206/1/9789241507417_eng.pdf

World Health Organization (WHO). 2015 Global Reference List of 100 Core Health Indicators.; 2015. http://apps.who.int/iris/bitstream/10665/173589/1/WHO_HIS_HSI_2015.3_eng.pdf

MEASURE Evaluation. FP and Reproductive Health Indicators Database — MEASURE Evaluation. http://www.cpc.unc.edu/measure/prh/rh_indicators/ 

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

Definition:

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

This indicator is calculated as:

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

Data Requirements:

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

Data Sources:

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

Purpose:

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

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

Issue(s):

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

References:

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

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

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

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

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

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

Percent of children with severe acute malnutrition who are correctly prescribed therapeutic feeding

Definition:

Percent of children with severe acute malnutrition who are correctly prescribed therapeutic feeding.

Numerator:

Number of children with severe acute malnutrition who are correctly prescribed therapeutic feeding.

Denominator:

Total number of children with severe acute malnutrition.

Disaggregation:

Age (<1 year, 1-5 years), sex, facility, geographic location

Data Requirements:

Direct observation (Not collected routinely or in existing surveys).

Data Sources:

Patient records

Registers

Referral cards 

Purpose:

Severe acute malnutrition is a difficult and complex indicator to measure. However, this indicator is relevant at the level of both primary facilities and hospitals level and could easily be collected from patient records or registers.

References:

World Health Organization (WHO). Consultation on Improving Measurement of the Quality of Maternal, Newborn and Child Care in Health Facilities.; 2013. http://apps.who.int/iris/bitstream/10665/128206/1/9789241507417_eng.pdf