Indicator Manual MH CH FP

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Indicator Manual

MATERNAL HEALTH INDICATORS

Indicator MH 1: Antenatal care first visit coverage rate

A: ANC First VisitB:ANC First Visit in first trimesterC: ANC registered under JSY

Definition Percentage of pregnant women who used Antenatal Care(ANC) provided by skilled health personnel, for reasonsrelated to pregnancy, registered in first trimester ofpregnancyN.B - This indicator is also known as Any Antenatal carevisit

Numerator:

A: New Registered/first ANC visit of a pregnant womanB: Pregnant women registered within first trimester

C: New women registered under JSYDenominator

A:Total expected pregnanciesB,C: Total number of ANC registered

Rationale This first visit should be a "registration" visit where allinitial procedures relating to assessing/preparing awoman for pregnancy and delivery. This should includehistory, examination, initial blood tests andimmunisation.

Antenatal care coverage is an indicator of access anduse of health care during pregnancy. All women shouldhave at least three antenatal visits during a pregnancy.

ANC should start as early in pregnancy as possible. % ANC registration in first trimester shows early care

and level of awareness

% of women registered under JSY shows: number ofwomen entitled to benefits under JSY. This is include :a) all women in EAG and NE states b) only BPL & SC/STwomen in HPS states

% of pregnant women receiving any ANC is a sensitiveindicator of outreach

DataSource

Antenatal / pregnancy registers; Maternal health cards

Household surveys

Population data - an estimate of the number ofpregnant women is close to the number of childrenborn (2.2-3.2% of population)

Suggested level ofuse

National, state, district/ block and sub-centre

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OtherUsefulIndicators

Risk and continuity indicators are important in ANC

VDRL (syphilis) and HIV testing coverage shows qualityof care. This should be done in first ANC visit

Haemoglobin testing and anaemia management rates

ANC referrals shows risk detection (and transport

availability). % women getting third ANC shows continuity of care,

which is often related to perceived quality.

CommonProblems

Attendance for pregnancy test or simple registrationwithout history and examination do NOT constituteantenatal care.

Women who have started ANC elsewhere,butwho come to your facility for follow up should becounted as follow up ANC and not first ANC

ActionstoConsider

Low coverage means either the strategy for providingANC needs to be reviewed to increase access, or thecommunity should be approached to increaseawareness through ASHA,VHSC,BCC etc

Indicator MH 2: ANC third visit coverage rate

Definition Percentage of women who used antenatal care providedby skilled health personnel for reasons related topregnancy at least 3 times during pregnancy

Numerato

r

ANC third visit

Denominator

A. Expected pregnanciesB. ANC any visit

Rationale Antenatal care third coverage is an indicator ofcontinuity and use of health care during pregnancy andalso of access

Poor quality ANC could also be a reason that womencome once and then stop

DataSource

ANC Register maintained by health workers

Other

UsefulIndicators

Drop-out rate first to third ANC

Comparison of third ANC to delivery rates

%ANC with full blood tests (Hb, HIV, VDRL)


State, District, Block and sub-centre

Common When ANC has been done in different

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Problems facilities

High coverage may mean problems with your choice ofdenominator, or double counting

Actionsto

Consider

Low coverage means either the strategy for providingANC needs to be reviewed to increase access, or the

community should be approached to increaseawareness through ASHA,VHSC,BCC

Improved quality of care in earlier visits

Ensure that first ANC are not done through sporadiccamps or MMU approaches

Indicator MH 3:

% ANC TT-1 coverage rate

% ANC TT2 and TT booster coverage rate

ANC 100 IFA coverage rate

Definition Percentage of pregnant women who used antenatal careand were given TT1,TT2 or TT booster vaccine

Numerator

A Antenatal care given TT-1B. Antenatal care given TT2 or TT boosterC. Antenatal care given 100 IFA Tablets

Denominator

Total ANC registered (ANC first visit)

Rationale Antenatal care 100 IFA coverage is an indicator ofquality of ANC

Antenatal care TT-1, TT-2 / Booster coverage is anindicator of quality of ANC

It is also an indicator for availability of the basicimmunisation of ANC

All pregnant women are recommended 100 IFA Tablets

Woman in her First pregnancy needs TWO TTimmunisations; subsequent pregnancies she needs onlya booster

DataSource

Registers maintained by health workers; Householdsurveys


TT protected at birth rate measures % of newbornsprotected from tetanus by their mother being fullyimmunised for TT

Neonatal Tetanus rate measures cases of Neonataltetanus- a failure of our ANC TT immunisation program

Anaemia rateSuggested level of

State, District, Block, sub centre

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useCommonProblems

IFA tablets given may not be consumed

Actions toConsider

Addresses supply side issues

Ensure quality of ANC

Awareness generation among mothers on availingcomplete ANC services

Indicator MH 4: ANC Anaemic & Hypertension testing andmanagement rates

A. % ANC moderately anaemicB. % ANC severely anaemicC. % ANC severely anaemic treated rateD. % ANC hypertension new case detection rateE. Eclampsia cases management rate

Definition Percentage of pregnant women tested to be moderatelyanaemic (Hb level


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J.Maternal death due to excessive bleeding is more likelyin an anaemic

K. Laboratory equipment availability rateSuggested level of

use

Health sub-centre, PHC, CHC

CommonProblems

L. BP is often not taken and Hb testing is not doneM. Health sub-centres do not have BP apparatus and

Hb kitsN. Sufficient stock of IFA tablets

Actions toConsider

O. Address supply side issuesP. Ensure quality of ANCQ. Awareness generation among mothers to avail

complete and quality ANC services

Indicator MH 5: Skilled Birth Attendant (SBA) delivery rate

Definition Proportion of total deliveries assisted by a Skilled BirthAttendant (at home and at institutions)

SkilledBirthAttendantdefinition

A skilled birth attendantis an accredited healthprofessional - such as a midwife, doctor or nurse - whohas been educated and trained to proficiency in the skillsneeded to manage normal (uncomplicated) pregnancies,childbirth and the immediate postnatal period, and in theidentification, management and referral of complications

in women and newbornsNumerator

Deliveries by SBA (SBA Home + all Institutionaldeliveries)

Denominator

A. Expected numbers of deliveriesB. Total recorded deliveries

Rationale Attendance of deliveries by skilled birth attendantsis the single most important factor in reducing maternalmortality, and is a MDG indicator.

There is increasing evidence that the SBA is mosteffective when delivering in institutions, rather than athome.

DataSource

Labour records and maternity registers maintained atfacilities and by health workers; Household surveys


SBA deliveries as proportion of ANC first visit

SBA deliveries as proportion of reported deliveries

SBA deliveries at institutions and at home;

Peri-natal mortality from SBA deliveriesSuggeste District, Block

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d level ofuseCommonProblems

The definition of SBA excludes Traditional birthattendants, even if they have been trained. Evenprofessional staff that have had training, lose their

delivery skills if they do not use them. Even ANMs only have a minimal amount ofdelivery training and most of their skills are learnedthrough experience, not formal training. For the purposeof measurability, all nurses and ANMs are counted, whichleads to an overestimation of those who are skilled.

Since deliveries in private sector and underservedareas are unreported, the use of expected number ofdeliveries may lead to an underestimation of SBAdeliveries, hence the need to use reported deliveries asdenominator

ActionstoConsider

Include private sector deliveries

Indicator MH 6: Institutional delivery rate

A Institutional delivery rateB Reported Institutional Delivery RateC Institutional delivery complication attendance rateD Postnatal maternal complications attendance rateE % Institutional delivery receiving JSY benefitDefinition A) Proportion of total deliveries that took place in

any health facilityB) Institutional deliveries that took place in health

facilitiesC) Proportion of Institutional deliveries with delivery

complicationsD) Proportion of Institutional deliveries with maternal

postnatal complicationsE) Proportion of institutional deliveries where the

woman got JSY benefitsNumerator A) All institutional deliveries

B) All institutional deliveriesC) Number of complicated delivery cases attended(public + private institutions)

D) Postnatal complications attendedE) Delivery institutional women received JSY benefits

Denominator

A: Expected deliveries (2.2 To 3.2 % of population)B: Total Number of deliveries reportedC: Total Number of deliveries reported

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D: Total Number of deliveries reported E:= DeliveriesInstitutional

Rationale A) There is clear evidence that institutionaldeliveries by SBAs are the key to reducingmaternal mortality, due to improved emergency

infrastructure, access to transport and referralfacilities and a number of other factors.

B) In absence of complete estimated populationfigures in states, the institutional deliveryperformance can also be calculated by totalreported delivery figures. This can supplementthe overall understanding of the institutionaldelivery in the state

C) Postnatal complications shows the rate ofidentification of postnatal complications at PNCvisits

D) JSY benefits are given to encourage women tocome for institutional deliveries, thus reducingmaternal mortality.

DataSource

Maternity registers maintained by health workers athealth facilities; Household surveys


Institutional deliveries can be broken down by typeof institution SC, PHC, CHC, hospital etc

Institutional Perinatal mortality rate is a goodindicator of quality of care;

% deliveries by SBAs should be assessed where notall nurses at institutions are trained SBAs,

Suggestedlevel of use

National and below

CommonProblemsActions toConsider

Indicator MH 7: Home delivery rate

A Home delivery rateB Reported home delivery rate

C Home delivery by Skilled birth attendant (SBA) rateD Home delivery by Non Skilled birth attendant rateE % Home delivery receiving JSY benefit

Definition A) Percentage of total deliveries that took place athome

B) Reported home delivery rateC) Home deliveries attended by SBA

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D) Home deliveries attended by Non-SBAE) Home deliveries receiving JSY benefit

Numerator

A) Deliveries Home (SBA and non-SBA)B) Deliveries Home (SBA and non-SBA)C) Deliveries home SBA

D) Deliveries home Non-SBAE) Deliveries home women received JSY benefit

Denominator

A, C & D =Total expected deliveriesB= Total reported deliveries (home + Institution)E=total home deliveries

Rationale Home deliveries occur in all states, but are notencouraged because when complications arise , lifesaving EmOC is not available

Home deliveries by SBAs should be discouraged, as itis more effective to deliver at institutions wherefacilities are better, access to BEmOC is improved and

the SBAs are able to attend to more deliveriesDataSource

Registers maintained by health workers; word of mouthfrom TBAs ANMs


Home deliveries per reported deliveries

Perinatal mortality at home deliveries

Maternal deaths from home deliveries


State and District

CommonProblems

Home deliveries by untrained TBAs are often not reported

ActionstoConsider

Home deliveries should be actively discouraged ifmaternal mortality is to be reduced

Conditions at institutions should be made moreacceptable (culturally, socially, financially etc) toencourage institutional deliveries

Indicator MH 8: Basic Emergency Obstetric Care (BEmOC) availability

Definition Number of facilities with functioning BEmOC per 500,000populationNumerator

Facilities who have reported all three BEmOC signalfunctions within the past 3 (WHO RHI) months

Complicated Delivery: IV Antibiotics

Complicated Delivery: IV Oxytocics

Complicated Delivery: IV Antihypertensives/ Magsulph

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Denominator

500,000 populationPlanned BEmOC centres or 24x7 facilities + FRUs

Rationale BEmOC facilities are needed 4:500,000 total population(Ref Programming for safe motherhood UNICEF 1999)Three monthly indicator from facility development form

DataSource

Labour Records / Maternity Registers at BEOC-designatedfacilities


CEOC availability

% Of DHs with functioning BEmOC

% Of CHCs with functioning BEmOC

% Of PHCs with functioning BEmOC

Complications Rate

Breakdown of BEOC signal functions to identify whichdesignated facilities are NOT providing the full rangeof BEmOC

Caesarean section rate SBA attendance rate


State and district

CommonProblems

Distinction must be made between those facilitiesactually functioning and those that have the equipmentbut are NOT performing the functionsPoor reporting of signal functions by BEmOC facilities dueto poor recordsData from private facilities is often not collected, leading

to an under-estimationActionstoConsider

Equipment, staff and skills for BEmOC

Indicator MH 9: Comprehensive Emergency Obstetric Care (CEmOC)availability

Definition Number of facilities with functioning CEmOC functions per500,000 population. This implies that the facility hasprovided BEmOC signal functions in addition to CEmOC

functions.Numerator

Facilities who have reported all BEmOC functions ANDCEmOCCaesarean sectionBlood transfusion

Denominator

A. 500,000 population (WHO guidelines)B. No of FRUs planned/ No of DHs

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Rationale CEmOC facilities are needed 1:500,000 total population(Ref Programming for safe motherhood UNICEF 1999)This is a monthly indicator from facility development form

Data

Source

Theatre Records / Maternity Registers at CEmOC-

designated facilitiesBlood transfusion records


Caesarean Section rate shows only surgicalinterventions, without other CEmOC functions. Thisshould be 5-15 %% of DHs with CEmOC functions% of CHCs with CEmOC functions

Blood transfusion rate will show blood transfusions forCEmOC and other non-obstetric emergencies

Suggeste

d level ofuse

State and district

CommonProblems

Many facilities provide caesarean sections WITHOUT thefull package of BEmOC interventions. This should beactively discouraged by a system of accreditation andlicensing.Many private institutions do not report caesareansections, and it is often these instiutions that provideC/sections without adequate indications

Actionsto

Consider

Include private facilities in reporting maternal healthindicators

Indicator MH 10: Admission duration after delivery

Definition Percentage of women who were discharged in less than48 hrs of delivery

Numerator

Institutional delivery discharged up to 48 hrs of delivery

Denominator

Deliveries Institutional

Rationale Postnatal careAll women should be kept in hospital for at least 48 hoursrisk of postnatal complications and maternal mortality ishighest during this period

DataSource

Maternity Registers maintained by the health workers andhealth facilities

OtherUsefulIndicator

Causes of PNC complications

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sSuggested level ofuse

District

Common

Problems

Many women want to go home early, but this prevents

adequate PNCActionstoConsider

Indicator MH 11: Maternal Mortality Ratio

Definition The death of a woman while pregnant or within 42 days ofdelivery or termination of pregnancy, irrespective of theduration and site of the pregnancy, from any cause

related to or aggravated by the pregnancy or itsmanagement but not from accidental causes.

Numerator

Deaths Maternal ( this month; over last 12 monthsperiod)

Denominator

No of live births recorded

No of live births estimated over a one year periodRationale Maternal mortality Ratio reflects the quality of care during

pregnancy and the puerperium.All maternal deaths should be subjected to an audit,according to national guidelines

DataSource

Line listing of maternal deaths; Labour records andregisters maintained at facilities CRS; Communityfeedbacks


A Maternal Mortality Audit should provide detaileddisaggregation by:

Cause (sepsis, malaria, PPH, PIH, Obstructed labour,unsafe abortion, anaemia)

Maternal Age, under 19 years, over 35 years

duration of pregnancy first, second, thirdtrimester, post delivery

place of delivery- home, institution etcMaternal mortality rate is collected by special surveysSuggested level ofuse

National and below

CommonProblems

Maternal deaths are relatively rare events and need largesample sizeUnder-reporting is a major problem with MMR. Most

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women who die in pregnancy , die at home and it isdifficult to collect this data.Even special surveys have problems getting accuratedata because respondents are not keen to talk aboutthese very tragic issues

ActionstoConsider

Indicator MH 12: Birth reporting rate

Definition Proportion of births reported over a given period of time.Numerator

Births reported

Denominator

Estimated births of population

Rationale This indicator assesses the proportion of births reported

by the health services in order to assess overall coverageof safe deliveries by health workers.

DataSource

Line listing of births; maternity registers and householdsurveys etc


Comparison to CRS reports


National, State, District and Block

CommonProblemsActions toConsider

Indicator MH 13: Postnatal care

Definition Percentage of women who used postnatal careprovided by skilled health personnel

Numerator

Postnatal mother/baby visits

Denomin

ator

Total Deliveries (Institutional + Home)

Rationale Postnatal care (PNC) is an essential component ofboth maternal and neonatal care, to detectcomplications so that they can be treated early.The postnatal check-up should follow nationalprotocols.

PNC coverage is an indicator of access and use ofhealth care after delivery.

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The numerator should include mothers of babiesborn at home and coming to health serviceswithin 48 hours.

Women should receive at least 2 postnatal carecheck-ups, to avoid and treat any complication.

Ideally 3 PNC check-ups are required, 3rd after 42days

DataSource

Registers maintained by health workers; Householdsurveys


Length of stay after delivery shows whethermothers and babies are retained long enough toreceive adequate PNC

Postnatal care at 7 and 28 days are alsomeasured , but these have minimal impact onmaternal and neonatal mortality

Perinatal mortality rate

SBA delivery rateSuggested level ofuse

National and below

CommonProblemsActionstoConsider

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CHILD AND NEONATAL HEALTH INDICATORS

Indicator CH 1: % newborns breastfed < 1 hour

Definition

Percentage of new born babies breastfed within one

hour of birthNumerator New born breastfed within one hour of birth

Denominator Total live births(as recorded)

Rationale Breastfeeding in the first hour also helps to establishbreastfeeding. The more the first feed is delayed themore difficult it is to initiate breastfeeding.Breastfeeding in the first hour also gives the neonatecolostrum, which is rich in immuno-stimulants.However many cultures do not give this.

This is a very good index of effectiveness of BCC workand of ASHAprogramme where this is part of her work. Thisindicator can beused to strengthen these programmes. Even ifbreastfeeding is done within 2 hours, or within 24hours, if colustrum is not purposefully expressed outand thrown away, colustrum feeding is considered asachieved.

DataSourceThis would figure in the birth register, in the labourroom register and in the pregnancy 1 Registersmaintained by health workers and healthfacilities. Oral reports from home based caregivers( likeASHAs andAnganwadi workers) as told to ANMs be recorded byANMs.Home visits in early neonatal period for home deliveriesis essential for this information

OtherUseful

breast feeding in first two hours. ( potentiallyavailable if line-listing in reporting of births includes

this. At present it does not). This improves earlier thanat one hour and is also reflective of ASHA/ healthworker efforts

Breastfeeding initiation in first 24 hours.( availability of data element same as above).This shows the severity of this problem

Perinatal mortality rate, neonatal mortality rate.Low birth weight rate

Indicators

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Postnatal care rate

Suggestedlevel of use District

Common

Problems Often not recorded, as there is often no space inmaternity registers torecord this dataStaff not focused on task of persuading mother /familyCollection of data from ASHAs could be a problem ifASHAprogramme is not designed to deliver this.

Actions toConsider Formative research to understand the issue and design

BCC programmes to promote immediate breastfeedingEnsure registers re modified to include immediate

breastfeedingInclude in support protocols for home based care giverslike ASHAs

Indicator CH 2: Neonatal referral rate

Definition Percentage of neonates (upto 28days old) with complicationsreferred forinstitutional care

Numerator Neonates seen in a PHC or CHC or higher facility because it is sickor low birthweight or has a complication- whether it was referred from thehome, orpresented on its own in the institution, or whether it wasdiagnosed in theinstitution.

Denominator Live births( as recorded)

Rationale This data should be collected by institutions to identify theproportion of

neonates with complications referred for specialised careDataSource Neonatal registers at institutions

OtherUseful

% of newborn referrals against estimated live births this needsno new data element- and is most useful where private sector isalso reporting.

% of low birth weights and severe low birth weight

Indicators

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Suggested

level District

of use

Common The number of families advised a referral is NOT being taken asit is difficult to estimate how seriously referral advice was takenup by

Problems family. Therefore only those referral that were received byinstitution are measured, evenif some are self-referred.

Referrals to Private hospitals will not be picked up and this mayaccount for the majority

No specific place of recordingin facility registers. Skills to detect a sick new born lacking amongst health workersand

hence both referral from below and identification in theinstitution couldbe poor.Best calculated with at least3000 births.

Actions to If rate is low find out whether it is due to lack of newborn visitsand newborn referrals or due to poor transport or due to poor

care and credibility at the facility. To Build up credibility andquality of care giving institutions

Consider Ensure private sector alsoreports

Indicator CH 3: Sex ratio at birth

DefinitionNumber of females born per 1000 males born in a give timeperiod

Numerator Live Births females x 1000

Denominator Live Births males

Rationale Declining sex ratio is an important public health concerns and sexratio at birthsis one of most precise indicators of this. Note that the usual sexratio at birth where there is no active discrimination is about 950

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females per 1000 males( this is due to a slightly greater loss ofmale fetuses). Due to a slightly greater mortality of male childrenin next five years, it becomes an equal or female preponderantratio for sex ratio in the 0 to 6 age group. However with optimumcare these slightly increased loss before and after birth may

decline. Therefore figures in this 950 range need to beinterpreted with caution. Below this figure there a genderdiscrimination factor becomes likely.

DataSource Line listing of births maintained by health workers; delivery

registers

OtherUseful

Sex ratio in 0-5 age groupIndicators

Sex ratio in population

Suggestedlevel National and below, particularly district as there is no other

source of data at district level.of use Calculate only when you have at least 3,000 births, otherwise

fluctuations willbe too high.

Common Completeness of birth reporting is an issue

Problems

Actions to Strengthen implementation of PNDT act

Consider Social mobilisation to combat son preference

Indicator CH 3A: Recorded Birth rate

Definition Live births per 1000 population

Numerator: All recorded live births in that facilitys servicearea/block/district in the last 12 months

Denominator: Population of that facilitys service area/ block/district

Rationale This is the crude indicator of fertility in that population. Alsoby comparing the recorded birth rate with the estimated birthrate or external survey based birth rates one can arrive at apicture of how many children in that area are being missed outand this is useful to keep in mind while reading andinterpreting all other child health indicators.

Data Source Birth and death registerMaternity registers of Sub-Centres, PHC and CHCs.

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Household surveys

Other useful Total fertility rateindicators

NormalRanges

The states birth rate is available from the SRS. The goal isto reach a birth rate of less than 21 per 1000 population.Normally it should be 100%

Common

Many births that take place in private sector or at homeget missed. Since much of the reporting could be based onhearsay- there is loss of accuracy. There could be doublecounting

Problems The indicator is an estimate. For many reasons thedenominator could be wrong or the birth rate could bemore or less that expected.The numerator should be for a full year. This means addingthe livebirths of the last 12 months- and then plotting thisindicator on a graph so as to see trends. Monthly use ofthis indicator has little role. Also take a unit which hasmore than 3000 births in that period ( a number of areastaken together, or a number of months taken together ) tobe able to cast a meaningful indicator.

If the indicator is low, check whether all births are beingrecorded or some areas are getting missed out/ poorquality of recording or whether it is because there hasbeen a change in the denominator or due to declining

fertility.

Actions to

If indicator is higher than expected and sustained it may bea major movement of the population in or increase offertility rates

consider

Indicator CH 4: Low birth weight rate

Definition

Percentage of live born infants with a Birth weight under

2,500 gramsNumerator: Live births with a birth weight < 2500g.

Denominator: Live births weighed

Rationale At the population level, the low birth weight (LBW) rate is anindicator

of a multifaceted public-health problem that includes long-

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termmaternal malnutrition, ill health, hard work and poor healthcare inpregnancy.

On an individual basis, low birth weight is an important

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Efforts to increase percentage of children weighed- bystudying who is getting missed out and why.

Improved quality of ANC

Actions to BCC regarding nutrition, smoking and drinking duringpregnancy

consider Attention to adolescent anaemia and malnutrition Assistance to secure food entitlements during maternity

Improve institutional new born care and referralarrangement where severe low birth weight is high

Indicator CH 5: Neonatal mortality rate

DefinitionNeonatal mortality rate (NNMR) measures the number of live-born babiesdying within 28 completed days of life per 1,000 live births.

Numerato

r Deaths in first 28 daysDenominator 1000 live births

Rationale Neonatal mortality (particularly early mortality) is affected byquality of carefor the neonate. This is a significant proportion of IMRDirect Causes are asphyxia , sepsis, hypothermia and neonataltetanus. Indirectcauses are low birth weight, prematurity, birth injuries andcongenital anomalies

DataSource Line listing in the birth and death register and InstitutionalrecordsRegistrar of births and deaths- compulsory registration system,Household surveys

OtherUseful

NNMR can be divided into early (0-7 days) and late (8-28 days).This information is potentially available in the line list- butcurrently not being aggregated.

Indicators NNMR can be disaggregated by gender

Suggested

level State and district. Calculate only when you have at least 3,000births, otherwiseof use fluctuations will be too high.If we are plotting the monthly trend

that either it is for a large area or we are taking the cumulativetotal of a a number of months or even a year.

Common Underreporting and misclassifications ( as still births )arecommon, particularly for deaths. Cultural reluctance to reportingearly neonatal deaths- which only good training and supervision

Problems

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occurring early in life (particularly first hour).

Actions to Staff training and health facility equipment for a functionalnewborn care

Considerunit

Appropriate home based neonatal health care providers to betrained

Indicator CH 6: Infant Mortality rate

Definition Infant Mortality rate (IMR) measures the number of deaths ofinfants under

one year of age per 1,000 live birthsNumerator

Deaths infants less than one year old (Neonatal death plusdeaths in 1-12 months)

Denominator 1,000 Live birthsRationale This MDG indicator is a good measure of the socio-economic,

nutritionaland environmental health status of a given population.Common causes of death after the neonatal period arediarrhoea, acute respiratory infection, malaria,malnutrition, vaccine preventablediseases, especially measlesA significant proportion of the IMR is related to neonatal careInfant deaths should be reported monthly and IMR calculatedsemi-annually. One needs to ensure thatin this period of calculation therehas been at least 3000 live birthsin that area.At a local level blockor lower- this information isactionable even without making itinto an indicator.

Data SourceRoutine: Line listing of deaths; Institutional recordsOthers: Registrar of births and deaths, Population-basedsurveys, especially Sample Registration Surveys

Other Useful IMR by gender gives insight into poor care for the femalechild and

Indicatorsfemale infanticide

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Perinatal and neonatal death rates measure quality of careat birth Disease specific death rates due to diarrhoea, malaria, ARIetc provide clues for immediate action IMR can be disaggregated by social class, residence, income

etc Underweight rate under one year measures nutritionalstatus. This acts as a risk factor, increasing the likelihood ofdeath from any of the above causes.

Suggestedlevel of

National, state and district. Belowdistrict even the data element byitself provides actionableinformation.

use

CommonProblems IMR from routine data can be inaccurate because of

unreported deathsoccurring in the home, particularly amongst poor anddisadvantagedcommunities not reached by health services. Culturalreluctance to report neonatal deaths.

Tendency to underreport due to threat of reprimand fromaboveDeaths before the first birthday are all included in this.

Actions toConsider

Improved notification through line listing by health workers,

Community notification ofdeaths- to VHSCs, PRIs,NGOs etc - a form ofcommunity monitoring touncover unreporteddeaths.

Ensure that truthfulreporting of higher deathsthat expected is not metwith reprimands but withassistance.

Indicator CH 7: Under 5 mortality rate

DefinitionUnder-five mortality rate measures the number of childrenwho die before theirfifth birthday per 1000 children under five years

Numerator Deaths Neonatal + Deaths infant + Deaths 1-5 years

Denominator 1,000 children under five years

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RationaleUnder-five mortality rate is a general indicator of the level ofchild health,It measures more the socio-economic, environmental andnutrition status ofchildren, rather than direct health

care delivery.Data Source Line listing of deaths at Sub Centre; Institutional records

Vital registration- registrar of births and deaths; Populationcensus; Population-based surveys, such as DHS.

Other Useful U5MR can be disaggregated by gender, social class,residence, income etc

Indicators See infant mortality rateindicators

Suggestedlevel of National and below. Calculate only when you have at least

3,000 births,

use otherwise fluctuations will be toohigh.

CommonProblems Poor reporting of child deaths, particularly in hard-to-reach

and poorcommunities

Actions toConsider

Improved notification through line listing by health workers, Community notification ofdeaths- improve recording of

unreported deaths and increasescommunity action to preventdeaths

Improved quality of care for children through healthworkers at home

Definition

Peri-natal deaths comprise still births (gestation over 228 weeks />1000 gramsweight) plus early neonatal deaths (infants dying within 7 days).

Numera

tor Deaths Peri-natal (still births plus early neonatal in first week)Denominat

1000 live Births.or

Rationale PNMR directly reflects maternal health, quality of prenatal, intra-

partum and

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neonatal carePeri-natal deaths comprise up to 40% of infant deaths and theirreduction is themost important way health services contribute to reducing IMR.PNMR gives an

indication of the quality of maternal and child health services.This indicator includes still births, which are as numerous as firstweek deaths. Any pregnancy outcome other than a live birth afterthe pregnancy has achieved 28 weeks would get included in this.The criteria of weight above 1000 gms may have to be ignored ifweight of the still-birth/aborted fetus is not available.All peri-natal deaths should be audited according to nationalguidelines to identifypreventable deaths and improve neonatal care.

Data Registers from Delivery and neonatal wards; Line listing by ANMs;Vital

Source registration; Population census; Population-based surveys, such asDHS.

Still birth rate- this is what can be calculated from the current dataelements available. Still birth estimation has a reciprocal relationshipwith both abortion at one end and neonatal mortality at the other.For calculating perinatal mortality rate as defined above-one needsto be collecting neonatal deaths in the first week as distinct from anyneonatal death. However this information is potentially available inthe line list.Abortion rates- this also closely correlates with the above rates.Abortion data elements have to be crossed with the pregnancy

tracking to ensure that stillbirths are not misclassified as abortionswhich at around 28 weeks could be a problem.

Other A perinatal audit can provide useful additional information onquality of care

UsefulPNMR at different type and level of Institutions, public and privateIndicato

rsPNMR by type of birth assistant (SBA, Non-SBA)PNMR by genderCompare with NNMR

Suggest

ed National and below. Calculate and make predictive trend analysisonly when youlevel of

usehave at least 3,000 births, otherwise fluctuations will be too high.

Common Comparisons between different rates may be hampered by varying

definitions,Problems registration bias, and differences in the underlying risks of the

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populations.Reporting of still births is also problematic

Actionsto Institutions with high PNMR need additional support to identify the

causes of theConside

r deaths, and will normally need training on neonatal caretechniques.By comparing PNMR with other rates, one can arrive at conclusionsabout whichareas of child care require prioritisation.

2 Some authorities state 22 weeks or 500 grams but in India neonates of thisage are not viable, Other authorities use 32 weeks: hence 28 weeks or startof 3rd trimester is taken as cut-off.

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IMMUNISATION INDICATORS

Indicator CH IMM 1: Vaccine Specific Immunisation coverage under

one yearA BCG

B OPV (1,2,3)C DPT (1,2,3)D MeaslesE Hep B (1,2,3) where used

DefinitionVaccine specific immunisation coverage is the percentage ofchildren under a year whohave received particular doses of a specific vaccine

Numerator Children under 12 months( which is same as saying children 0 to11 months old) given the specific vaccinesBCG,OPV, (1,2,3)DPT,(1,2,3)Measles,Hep B (1,2,3) where used

Denominator

a. Total recorded live births :b. Expected number of children under 12 months, based on mid

year estimates.

RationaleVaccine specific Immunisation coverage rates are used to monitorimmunisation services,to guide disease eradication and elimination efforts,They are an indicator of health system performance.Measles immunisation coverage is a national and MDG indicatorused as a proxy for fullimmunisation coverage.

DataSource

Immunisation registers kept by health workers; Immunisationcoverage cluster surveys;other household surveys

Normalrange

National target is 100%; states and districts need to set their owntargets

OtherUseful

Full immunisation coverageIndicators

Immunisation drop-out ratesIncidence of vaccine preventable diseasesVaccine utilisation rates

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Vaccine availability ratesCold Chain function indicators

Suggestedlevel

National for Measles; State and district for others

of useCommon No vaccinations given to children over one year should be includedin this

Problems Indicator.

Actions to Low immunisation coverage needs urgent action by health servicesand

Consider communities. It may indicate poor planning, supply side problemse.g. out ofstock or need for vaccine transportImprove local planning and community involvementRates over 100% mean denominator problems or double counting

Indicator CH IMM2: Full Immunisation coverage

DefinitionFull Immunisation coverage is the percentage of one-year-oldchildren who have receivedall required vaccines.

Numerator Number of children 9 to 12 months who completed theirimmunisation schedule (BCG, OPV3 and DPT3 and measles) in thepast yearNumber of children 12 to 23 months who hadalready complete immunization or completed

their immunization schedule during the pastyear

Denominator

Expected number of 0 to 12 months children based on mid yearestimates.Actual number of 0 to 12 months children based on live birthsduring this yearExpected number of 12 to 23 months children based on mid-yearestimatesActual number of 12 to 23 months children based on householdsurvey done at year beginning.

Rationale Full Immunisation coverage is the pinnacle indicator forimmunisation coverage and

means that the child should be fully protected against the sixvaccine preventablediseases, and is a valuable way to reduceinfant mortality.

DataSource

Immunisation registers kept by healthworkers ; There needs to be a separate columnin this register where the age of child inmonths when given the last immunization

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needed for full immunization status is recordedEPI cluster surveys; Other household surveys

OtherUseful

Full immunisation coverage by gender male and female

Indicators Vaccine-specific vaccination coverage rates Full immunisation coverage rates fromcluster surveys

Vaccine preventable disease incidence rates

Vaccine utilisation and availability rates Cold chain function indicators

Suggestedlevel

National, State, District, Blockof use

Common This data is hard to keep accurately routinely with current tools

Problems Routine data should be cross-checked by EPI cluster surveys(see WHO mid level

manager cluster survey manual) and other household surveyssuch as DHS. Surveys usually use a 12 to 23 monthdenominator.

Actions to Children need an immunisation card to track that all doses havebeen given. The register also needs provision for child tracking.

Consider Vaccine register should show children who completedimmunisation

schedule in a separate column by comparing full and individual immunisation coverage, catchup

campaigns to be instituted to provide individual vaccines inspecific areas

Indicator CH IMM 3: Immunisation adverse reactions

DefinitionAn adverse immunisation reaction is an unwanted or harmfulreactionexperienced following administration of a vaccineIt can be described as a medical event that takes place after an

immunisationthat causes concern and is believed to be caused byimmunisation(Immunisation handbook for health workers GoI 2007)

NumeratorAdverse reactions

A) AbscessesB) Deaths

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C) Others

Denominator Total number of immunisations given

Rationale Adverse effects are a sensitive indicator of quality ofimmunisation

Adverse reactions can be grouped into reactions inherent toimmunisation(pain, swelling, redness or general reactions), due to faultytechniques,hypersensitivity, neurological involvement, provocativereactionsUnder RIMS, three kinds of reaction are identified Abscess,Deaths andOthers e.g. allergy, anaphylaxis, hypotensive /hypo responsiveepisodes, BCGlymphadenitis, etc

DataSource Immunisation registers, facility data collection forms, IDSP death

reports

OtherUseful Drop out rates show perceived quality by the mother

Suggestedlevel

State and belowof use

Common Non-reporting;

Problems Others is a large category

Death of the child upto 6 days after the immunization is tobe reported- unless it is due to accident. Many of thesedeaths may have other causes- but that is to be validatedby medical officers separately these deaths are onlypresumptively vaccine related- the point is to have a highindex of suspicion so as not to miss cases.

Delayed reactions are difficult to collect

Actions to

Investigate all adverse reactions to identify the cause andadvise peripheral workers to take appropriate action forabscesses and other complications. Check on supply .Fordeaths it needs to be reported to state and national level andseparate report filed with vaccine batch details etc.

Consider

Indicator CH IMM 4: % of planned immunisation sessions held

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Definition Percentage of total planned immunisation sessions held

Numerator Number of immunisation sessions held

Denominator Total number of immunisation sessions planned

Rationale For a given population with a known number of healthfacilities and staff and outreach points( eg anganwadicenters)the number of immunisation sessions to cover thepopulation is pre-determined. It is important to see what percentage of thisneededcoverage is achieved.Immunisation needs careful planning and this indicatormeasuresimplementation of the plan. Poor planning leads to poor

implementationof immunisationLack oftransport is a common reason for cancellation ofsessions; Non availability of the ANM due to sickness orother personal causes, lack of vaccine supplies etc are alsoother causes. Need to ensure adequate transport forvaccines and transport for the ANM where this is theconstraint.

Data SourceRegisters maintained by health workers and health facilitiesDenominator from district immunisation office

Suggestedlevel ofDistrict, Block

use

Common Reliability of reporting of immunisation sessions held islow because

Problemsworker is directly accountable for the failure.

Detailed micro planning exercise often not carried out.The number of sessions planned itself may be faulty.

Actions to Strengthen planning process and implementation

through improvedConsidersupervision

Involve communities in planning of immunisations atsites and time

convenient to them and reporting sessions NOT held

Indicator CH IMM 5: Vitamin A coverage rate

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DefinitionPercentage of children who have received all required vitamin Adoses. (Onedose for a child under one and five doses for a child under threeyears)

Numerator

Children who received Vitamin AA) 1 dose under one yearB) 5 doses under three yearsC) 9 doses under 5 years

Denominator Expected number of children based on mid year estimates.

Rationale Vitamin A supplements given between six and 72 months isstated to reduce

mortality by 23%, where vitamin A deficiency exists. Vitamin A supplements as part of measles case managementcan reduce the case

fatality rate by more than 50%.DataSource

Immunisation register and Reports of Vitamin A by serviceproviders

OtherUseful

Measles case fatality ratesIndicators Vaccine-specific coverage rates to compare to vitamin A

coverage rates

Suggestedlevel

State and District

of useCommon

Difficult to report multiple doses at different agesProblems

No age estimates of 3 year old children availableUnless children have a vitamin A/immunization tracking cardwhich goes upto 5 years- it would be difficult to estimate whohas achieved the 5th, dose, 9th dose etc. It is not advised to makebulky registers that list all children upto 5 years and track themall along for each dose.

Actions to Identify areas with low coverage and ensure supplies and

promotionConsider

Activity.

Indicator CH IMM 6: Immunisation drop out rate

DefinitionComparison of the number of children who start receivingimmunisation andthe number who do not receive later doses for full

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immunisation

Numerator Number of children starting particular dose of antigen MINUSnumber ofchildren receiving later dose of antigen

Denominat

or Number of children starting particular dose of antigenRationale This is an indicator of quality of immunisation services and

allows a view of thetrends in coverage for specific vaccines. Useful drop out ratesareA) BCG to DPT3B) BCG to MeaslesC) DPT1 to DPT3D) DPT1 to Measles

This is a cohort sample and periodicity should be (semi) annual,rather than

monthlyDataSource

Facility routine data collection forms; Immunisation Registers;

OtherUseful

Vaccine specific and full immunisation coverage ratesIndicators Vaccine availability

Vaccine preventable disease incidence

Suggested

State and districtlevel of use

Common A high drop out rate means that mothers have no faith in theimmunisation

Problems A negative drop out rate can occur if there is a stock out ofthe earlyvaccines and good supply of the late vaccine

Actions to Ensure best possible quality of immunisation

Consider Ensure child tracking with immunisation card BCC to mothers on importance of finishing immunisationcourseEnsure constant availability of vaccine

FAMILY PLANNING INDICATORS

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Indicator FP1: Couple Year Protection Rate

Definition Percentage of eligible couples in the community protected by"modern" family planning methods for one year .

Numerator:

Number of couples protected by each family planning methodwhich is approximated by a formula:: number of cases sterilised

in particular month*10+number of pills distributed/13 + numberof IUDs inserted*5.5+ no of condom pieces distributed/100.

Denominator

Number of eligible couples (with fertile age women 15-49 years).The number of eligible couples are approximate 17% of totalpopulation. Actually recorded eligible couples is what is used asdenominator but this may be compared with estimated couplesin the population,

Rationale Each family planning method is effective for different periods -this is a calculated indicator which measures the contribution ofeach method to protection of eligible couples in the community.

Data

Source

The easiest way to calculate this is from the stock cards and

from sterilisation record. Note the total outgoing contraceptivesfor each type and divide or multiply by the appropriate factor:

Sterilisation X10 Pills / 13 IUD x 5.5 Condom pieces/ 72 X100

Actions toConsider

Low coverage means that unwanted pregnancies will occur.Increased CYPwill occur mainly through health promotion andincreases status of women, but will also be increased by:

increasing availability of contraceptives to teenagers,working women and other high risk groups;

improving the contraceptive mix to include more effectiveand longer- term contraceptives such as injectables, IUDs andsterilisations.

OtherPossibleIndicators

This indicator is best annualised - i.e. the months valuemultiplied by 12 to get a picture of what would happen if thisrate continued throughout the year.

Termination of pregnancy rate is an indicator of failedcontraception leading to unwanted pregnancies.

Method mix is the relative proportion of total CYP providedby each method. It is best visualised as a pie diagram.

Acceptor rate is number of couples reporting to be usingany method as the numerator and total eligible couples as

the denominator. a relatively low value indicator forcontraceptive effectiveness as it does not measure protectionof women, but merely attendance of women at the clinic for aparticular service. It could however be used locally to ensurethat all couples are reached and improve the programme. Thefamily planning service delivery register and tracking registerwould help track this- and the figure % of eligible couplesnot using any method but wanting to use is the most

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important category. Contraceptive prevalence rate (MDG) is the CYP

equivalent but needs a household survey to know it. Total fertility rate shows the impact of family planning .

This is got from NHFS and SRS data- but would only have

state figures. Birth rates- % of births which were third and above; % of second or

further births which had less than three years gapwith earlier birth, % of births in women less than 19years of age.( registers record the data elementsneeded- but this is not reported up currently)


National

Commonproblems

This is a complicated indicator, most easily calculated using acomputer

Actions toconsider

Indicator FP 2: Family Planning Coverage rate by method

Definition The coverage contribution of each contraceptive method tothe overall family planning program

Numerator

Total number of units of each type of contraceptive distributedA) Oral Contraceptive cyclesB) Condoms

C) IUD insertionD) Centchroman (weekly) pillsE) Emergency Contraceptive pills

Denominator

Eligible couples

Rationale The indicator provides a profile of the relative level of use ofdifferent contraceptive methods. This also suggests that thepopulation has access to a range of different contraceptivemethods

DataSource

Family Planning Registers maintained by health workers andhealth facilities; Household surveys


Method Mix


District

Common Exact number of OCPs or condoms distributed- are difficult to

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Problems estimate since these are usually given out by depot holdersand ANMs only know the stock refill they provide to thedepots. Also distribution does not mean use.

Actionsto

Consider

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Indicator FP 3: Sterilisation rateA MalesB FemalesDefinition Proportion of eligible couples sterilised

A) Males where the family size is 2 or more children and

the wife is under 49 and has not been sterilisedB) Females where the family size is 2 or more children andthe female is between 20 - 49 years and husband hasnot been sterilised

Numerator

Sterilisations performed this month plus already sterilisedeligible couples

A) MaleB) Female

Denominator

Eligible couples

Rationale Sterilisation is a permanent method that contributes

12.5years to CYP.Male Sterilisation is indicative of male participation in familyplanning and is usually held in camps

DataSource

Registers and data collection forms maintained by healthworkers and health facilities (including Camp)Eligible couple registers


Male sterilisation by type o conventional and

o NSV

Female Sterilisation by typeso Mini-laparotomy

o Conventional

o laparoscopic

Sterilisation rate by place CHC, hospital, camp, etc

Sterilisation rate by provider public/private etc.

Post-partum sterilisation rates

Total fertility rateSuggested level ofuse

National and below

Targets 20% of all sterilisations should be males

CommonProblems

Permanent sterilisation is the most commonly used method offamily planningWhen used when family size is already large, it does notaffect TFRVery few males go for vasectomy!!

ActionstoConsider

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Documents

Indicator Manual MH CH FP