Indicator Manual

MATERNAL HEALTH INDICATORS

Indicator MH 1: Antenatal care first visit coverage rate A: ANC First Visit B: ANC First Visit in first trimester C: ANC registered under JSY Definition Percentage of pregnant women who used Antenatal Care (ANC) provided by skilled health personnel, for reasons related to pregnancy, registered in first trimester of pregnancy N.B - This indicator is also known as Any Antenatal care visit Numerato A: New Registered/first ANC visit of a pregnant woman r: B: Pregnant women registered within first trimester C: New women registered under JSY Denomin A:Total expected pregnancies ator B,C: Total number of ANC registered Rationale This first visit should be a "registration" visit where all initial procedures relating to assessing/preparing a woman for pregnancy and delivery. This should include history, examination, initial blood tests and immunisation. Antenatal care coverage is an indicator of access and use of health care during pregnancy. All women should have 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 of women entitled to benefits under JSY. This is include : a) all women in EAG and NE states b) only BPL & SC/ST women in HPS states % of pregnant women receiving any ANC is a sensitive indicator of outreach Data Source Antenatal / pregnancy registers; Maternal health cards Household surveys Population data - an estimate of the number of pregnant women is close to the number of children born (2.2-3.2% of population) National, state, district/ block and sub-centre

Suggeste d level of use

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Other Useful Indicator s

Risk and continuity indicators are important in ANC VDRL (syphilis) and HIV testing coverage shows quality of 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. Attendance for pregnancy test or simple registration without history and examination do NOT constitute antenatal care. Women who have started ANC elsewhere, but who come to your facility for follow up should be counted as follow up ANC and not first ANC Low coverage means either the strategy for providing ANC needs to be reviewed to increase access, or the community should be approached to increase awareness through ASHA,VHSC,BCC etc

Common Problems

Actions to Consider

Indicator MH 2: ANC third visit coverage rate Definition Percentage of women who used antenatal care provided by skilled health personnel for reasons related to pregnancy at least 3 times during pregnancy Numerato ANC third visit r Denomin A. Expected pregnancies ator B. ANC any visit Rationale Antenatal care third coverage is an indicator of continuity and use of health care during pregnancy and also of access Poor quality ANC could also be a reason that women come once and then stop Data ANC Register maintained by health workers Source Other Drop-out rate first to third ANC Useful Comparison of third ANC to delivery rates Indicator %ANC with full blood tests (Hb, HIV, VDRL) s Suggeste State, District, Block and sub-centre d level of use Common When ANC has been done in different 2

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Problems Actions to Consider

facilities High coverage may mean problems with your choice of denominator, or double counting Low coverage means either the strategy for providing ANC needs to be reviewed to increase access, or the community should be approached to increase awareness through ASHA,VHSC,BCC Improved quality of care in earlier visits Ensure that first ANC are not done through sporadic camps 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 care and were given TT1,TT2 or TT booster vaccine Numerato A Antenatal care given TT-1 r B. Antenatal care given TT2 or TT booster C. Antenatal care given 100 IFA Tablets Denomina Total ANC registered (ANC first visit) tor Rationale Antenatal care 100 IFA coverage is an indicator of quality of ANC Antenatal care TT-1, TT-2 / Booster coverage is an indicator of quality of ANC It is also an indicator for availability of the basic immunisation of ANC All pregnant women are recommended 100 IFA Tablets Woman in her First pregnancy needs TWO TT immunisations; subsequent pregnancies she needs only a booster Data Registers maintained by health workers; Household Source surveys Other TT protected at birth rate measures % of newborns Useful protected from tetanus by their mother being fully Indicators immunised for TT Neonatal Tetanus rate measures cases of Neonatal tetanus- a failure of our ANC TT immunisation program Anaemia rate Suggeste State, District, Block, sub centre d level of 3

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use Common Problems Actions to Consider

IFA tablets given may not be consumed Addresses supply side issues Ensure quality of ANC Awareness generation among mothers on availing complete ANC services

Indicator MH 4: ANC Anaemic & Hypertension testing and management rates A. % ANC moderately anaemic B. % ANC severely anaemic C. % ANC severely anaemic treated rate D. % ANC hypertension new case detection rate E. Eclampsia cases management rate Definition Percentage of pregnant women tested to be moderately anaemic (Hb level <11g) Percentage of severely anaemic pregnant women treated ( Hb level <7g) Percentage of pregnant women tested with hypertension/ high blood pressure (BP>140/90) Numerato A. Pregnant women tested anaemia <11g r B. Severely anaemic pregnant women treated (Hb<7g) C. Pregnant women detected BP>140/90 D. Number of eclampsia cases managed during delivery Denomina A, B & C =Total ANC registration tor D = Total deliveries (home + institution) Rationale E. Testing for anaemia and hypertension is an indicator of quality of ANC services and also detection of important risks associated with preventable mortality . F. Hb<7g and BP>140/90 is a danger sign for pregnant women and should be managed by arranging for referral transport and informing the medical officer in-charge in advance Data ANC/ Pregnancy Registers maintained by health workers Source Other G. ANC hypertension management rate Useful H. LBW rate is common consequence of anaemia & Indicators Hypertension I. Still birth rate/PNM affected by anaemia 4

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Suggeste d level of use Common Problems Actions to Consider

J. Maternal death due to excessive bleeding is more likely in an anaemic K. Laboratory equipment availability rate Health sub-centre, PHC, CHC L. BP is often not taken and Hb testing is not done M. Health sub-centres do not have BP apparatus and Hb kits N. Sufficient stock of IFA tablets O. Address supply side issues P. Ensure quality of ANC Q. 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 Birth Attendant (at home and at institutions) Skilled A skilled birth attendant is an accredited health Birth professional - such as a midwife, doctor or nurse - who Attendan has been educated and trained to proficiency in the skills t needed to manage normal (uncomplicated) pregnancies, definition childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns Numerato Deliveries by SBA (SBA Home + all Institutional r deliveries) Denomin A. Expected numbers of deliveries ator B. Total recorded deliveries Rationale Attendance of deliveries by skilled birth attendants is the single most important factor in reducing maternal mortality, and is a MDG indicator. There is increasing evidence that the SBA is most effective when delivering in institutions, rather than at home. Data Labour records and maternity registers maintained at Source facilities and by health workers; Household surveys Other SBA deliveries as proportion of ANC first visit Useful SBA deliveries as proportion of reported deliveries Indicator SBA deliveries at institutions and at home; s Peri-natal mortality from SBA deliveries Suggeste District, Block 5

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d level of use Common Problems

Actions to Consider

The definition of SBA excludes Traditional birth attendants, even if they have been trained. Even professional staff that have had training, lose their delivery skills if they do not use them. Even ANMs only have a minimal amount of delivery training and most of their skills are learned through experience, not formal training. For the purpose of measurability, all nurses and ANMs are counted, which leads to an overestimation of those who are skilled. Since deliveries in private sector and underserved areas are unreported, the use of expected number of deliveries may lead to an underestimation of SBA deliveries, hence the need to use reported deliveries as denominator Include private sector deliveries

Indicator MH 6: Institutional delivery rate A Institutional delivery rate B Reported Institutional Delivery Rate C Institutional delivery complication attendance rate D Postnatal maternal complications attendance rate E % Institutional delivery receiving JSY benefit Definition A) Proportion of total deliveries that took place in any health facility B) Institutional deliveries that took place in health facilities C) Proportion of Institutional deliveries with delivery complications D) Proportion of Institutional deliveries with maternal postnatal complications E) Proportion of institutional deliveries where the woman got JSY benefits Numerator A) All institutional deliveries B) All institutional deliveries C) Number of complicated delivery cases attended (public + private institutions) D) Postnatal complications attended E) Delivery institutional women received JSY benefits Denominat A: Expected deliveries (2.2 To 3.2 % of population) or B: Total Number of deliveries reported C: Total Number of deliveries reported 6

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Rationale

Data Source Other Useful Indicators

Suggested level of use Common Problems Actions to Consider

D: Total Number of deliveries reported E:= Deliveries Institutional A) There is clear evidence that institutional deliveries by SBAs are the key to reducing maternal mortality, due to improved emergency infrastructure, access to transport and referral facilities and a number of other factors. B) In absence of complete estimated population figures in states, the institutional delivery performance can also be calculated by total reported delivery figures. This can supplement the overall understanding of the institutional delivery in the state C) Postnatal complications shows the rate of identification of postnatal complications at PNC visits D) JSY benefits are given to encourage women to come for institutional deliveries, thus reducing maternal mortality. Maternity registers maintained by health workers at health facilities; Household surveys Institutional deliveries can be broken down by type of institution SC, PHC, CHC, hospital etc Institutional Perinatal mortality rate is a good indicator of quality of care; % deliveries by SBAs should be assessed where not all nurses at institutions are trained SBAs, National and below

Indicator MH 7: Home delivery rate A Home delivery rate B Reported home delivery rate C Home delivery by Skilled birth attendant (SBA) rate D Home delivery by Non Skilled birth attendant rate E % Home delivery receiving JSY benefit Definition
A) Percentage of total deliveries that took place at

home
B) Reported home delivery rate C) Home deliveries attended by SBA

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D) Home deliveries attended by Non-SBA E) Home deliveries receiving JSY benefit

Numerato r

Denomin ator Rationale

Data Source Other Useful Indicator s Suggeste d level of use Common Problems Actions to Consider

A) Deliveries Home (SBA and non-SBA) B) Deliveries Home (SBA and non-SBA) C) Deliveries home SBA D) Deliveries home Non-SBA E) Deliveries home women received JSY benefit A, C & D =Total expected deliveries B= Total reported deliveries (home + Institution) E=total home deliveries Home deliveries occur in all states, but are not encouraged because when complications arise , life saving EmOC is not available Home deliveries by SBAs should be discouraged, as it is more effective to deliver at institutions where facilities are better, access to BEmOC is improved and the SBAs are able to attend to more deliveries Registers maintained by health workers; word of mouth from TBAs ANMs Home deliveries per reported deliveries Perinatal mortality at home deliveries Maternal deaths from home deliveries State and District Home deliveries by untrained TBAs are often not reported Home deliveries should be actively discouraged if maternal mortality is to be reduced Conditions at institutions should be made more acceptable (culturally, socially, financially etc) to encourage institutional deliveries

Indicator MH 8: Basic Emergency Obstetric Care (BEmOC) availability Definition Number of facilities with functioning BEmOC per 500,000 population Numerato Facilities who have reported all three BEmOC signal r functions within the past 3 (WHO RHI) months Complicated Delivery: IV Antibiotics Complicated Delivery: IV Oxytocics Complicated Delivery: IV Antihypertensives/ Magsulph 8

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Denomin ator Rationale Data Source Other Useful Indicator s

Suggeste d level of use Common Problems

500,000 population Planned BEmOC centres or 24x7 facilities + FRUs BEmOC facilities are needed 4:500,000 total population (Ref Programming for safe motherhood UNICEF 1999) Three monthly indicator from facility development form Labour Records / Maternity Registers at BEOC-designated facilities 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 which designated facilities are NOT providing the full range of BEmOC Caesarean section rate SBA attendance rate State and district Distinction must be made between those facilities actually functioning and those that have the equipment but are NOT performing the functions Poor reporting of signal functions by BEmOC facilities due to poor records Data from private facilities is often not collected, leading to an under-estimation Equipment, staff and skills for BEmOC

Actions to Consider

Indicator MH 9: Comprehensive Emergency Obstetric Care (CEmOC) availability Definition Number of facilities with functioning CEmOC functions per 500,000 population. This implies that the facility has provided BEmOC signal functions in addition to CEmOC functions. Numerato Facilities who have reported all BEmOC functions AND r CEmOC Caesarean section Blood transfusion Denomin ator A. 500,000 population (WHO guidelines) B. No of FRUs planned/ No of DHs 9

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Rationale Data Source Other Useful Indicator s

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 Theatre Records / Maternity Registers at CEmOCdesignated facilities Blood transfusion records Caesarean Section rate shows only surgical interventions, without other CEmOC functions. This should be 5-15 % % of DHs with CEmOC functions % of CHCs with CEmOC functions Blood transfusion rate will show blood transfusions for CEmOC and other non-obstetric emergencies State and district Many facilities provide caesarean sections WITHOUT the full package of BEmOC interventions. This should be actively discouraged by a system of accreditation and licensing. Many private institutions do not report caesarean sections, and it is often these instiutions that provide C/sections without adequate indications Include private facilities in reporting maternal health indicators

Suggeste d level of use Common Problems

Actions to Consider

Indicator MH 10: Admission duration after delivery Definition Percentage of women who were discharged in less than 48 hrs of delivery Numerato Institutional delivery discharged up to 48 hrs of delivery r Denomin Deliveries Institutional ator Rationale Postnatal care All women should be kept in hospital for at least 48 hours risk of postnatal complications and maternal mortality is highest during this period Data Maternity Registers maintained by the health workers and Source health facilities Other Causes of PNC complications Useful Indicator 10

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s Suggeste d level of use Common Problems Actions to Consider

District Many women want to go home early, but this prevents adequate PNC

Indicator MH 11: Maternal Mortality Ratio Definition The death of a woman while pregnant or within 42 days of delivery or termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental causes. Numerato Deaths Maternal ( this month; over last 12 months r period) Denomin No of live births recorded ator No of live births estimated over a one year period Rationale 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 Data Line listing of maternal deaths; Labour records and Source registers maintained at facilities CRS; Community feedbacks Other A Maternal Mortality Audit should provide detailed Useful disaggregation by: Indicator Cause (sepsis, malaria, PPH, PIH, Obstructed labour, s unsafe abortion, anaemia) Maternal Age, under 19 years, over 35 years duration of pregnancy first, second, third trimester, post delivery place of delivery- home, institution etc Maternal mortality rate is collected by special surveys Suggeste National and below d level of use Common Maternal deaths are relatively rare events and need large Problems sample size Under-reporting is a major problem with MMR. Most 11

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women who die in pregnancy , die at home and it is difficult to collect this data. Even special surveys have problems getting accurate data because respondents are not keen to talk about these very tragic issues Actions to Consider Indicator MH Definition Numerato r Denomina tor Rationale Data Source Other Useful Indicators Suggeste d level of use Common Problems Actions to Consider 12: Birth reporting rate Proportion of births reported over a given period of time. Births reported Estimated births of population This indicator assesses the proportion of births reported by the health services in order to assess overall coverage of safe deliveries by health workers. Line listing of births; maternity registers and household surveys etc Comparison to CRS reports National, State, District and Block

Indicator MH 13: Postnatal care Definition Percentage of women who used postnatal care provided by skilled health personnel Numerato Postnatal mother/baby visits r Denomin Total Deliveries (Institutional + Home) ator Rationale Postnatal care (PNC) is an essential component of both maternal and neonatal care, to detect complications so that they can be treated early. The postnatal check-up should follow national protocols. PNC coverage is an indicator of access and use of health care after delivery. 12

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Data Source Other Useful Indicator s

Suggeste d level of use Common Problems Actions to Consider

The numerator should include mothers of babies born at home and coming to health services within 48 hours. Women should receive at least 2 postnatal care check-ups, to avoid and treat any complication. Ideally 3 PNC check-ups are required, 3rd after 42 days Registers maintained by health workers; Household surveys Length of stay after delivery shows whether mothers and babies are retained long enough to receive adequate PNC Postnatal care at 7 and 28 days are also measured , but these have minimal impact on maternal and neonatal mortality Perinatal mortality rate SBA delivery rate National and below

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CHILD AND NEONATAL HEALTH INDICATORS

Indicator CH 1: % newborns breastfed < 1 hour Definition Numerato r Denomina tor Rationale Percentage of new born babies breastfed within one hour of birth New born breastfed within one hour of birth Total live births(as recorded) Breastfeeding in the first hour also helps to establish breastfeeding. The more the first feed is delayed the more difficult it is to initiate breastfeeding. Breastfeeding in the first hour also gives the neonate colostrum, which is rich in immuno-stimulants. However many cultures do not give this. This is a very good index of effectiveness of BCC work and of ASHA programme where this is part of her work. This indicator can be used to strengthen these programmes. Even if breastfeeding is done within 2 hours, or within 24 hours, if colustrum is not purposefully expressed out and thrown away, colustrum feeding is considered as achieved. This would figure in the birth register, in the labour room register and in the pregnancy 1 Registers maintained by health workers and health facilities. Oral reports from home based caregivers( like ASHAs and Anganwadi workers) as told to ANMs be recorded by ANMs. Home visits in early neonatal period for home deliveries is essential for this information breast feeding in first two hours. ( potentially available if line-listing in reporting of births includes this. At present it does not). This improves earlier than at one hour and is also reflective of ASHA/ health worker 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 14

Data Source

Other Useful Indicators

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Postnatal care rate Suggested level of use Common Problems District Often not recorded, as there is often no space in maternity registers to record this data Staff not focused on task of persuading mother /family Collection of data from ASHAs could be a problem if ASHA programme is not designed to deliver this. Formative research to understand the issue and design BCC programmes to promote immediate breastfeeding Ensure registers re modified to include immediate breastfeeding Include in support protocols for home based care givers like ASHAs

Actions to Consider

Indicator CH 2: Neonatal referral rate Definition Percentage of neonates (upto 28days old) with complications referred for institutional care Numerator Neonates seen in a PHC or CHC or higher facility because it is sick or low birth weight or has a complication- whether it was referred from the home, or presented on its own in the institution, or whether it was diagnosed in the institution. Denominat or Live births( as recorded) Rationale This data should be collected by institutions to identify the proportion of neonates with complications referred for specialised care Data Source Neonatal registers at institutions Other Useful Indicators % of newborn referrals against estimated live births this needs no new data element- and is most useful where private sector is also reporting. % of low birth weights and severe low birth weight 15

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Suggested level Distric t of use Common The number of families advised a referral is NOT being taken as it is difficult to estimate how seriously referral advice was taken up by Problems family. Therefore only those referral that were received by institution are measured, even if some are self-referred. Referrals to Private hospitals will not be picked up and this may account for the majority No specific place of recording in facility registers. Skills to detect a sick new born lacking amongst health workers and hence both referral from below and identification in the institution could be poor. Best calculated with at least 3000 births. Actions to If rate is low find out whether it is due to lack of newborn visits and newborn referrals or due to poor transport or due to poor care and credibility at the facility. To Build up credibility and quality of care giving institutions Consider Ensure private sector also reports Indicator CH 3: Sex ratio at birth Number of females born per 1000 males born in a give time Definition period Numerato r Live Births females x 1000 Denomina tor Live Births males Rationale Declining sex ratio is an important public health concerns and sex ratio at births is one of most precise indicators of this. Note that the usual sex ratio at birth where there is no active discrimination is about 950 16

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females per 1000 males( this is due to a slightly greater loss of male fetuses). Due to a slightly greater mortality of male children in next five years, it becomes an equal or female preponderant ratio for sex ratio in the 0 to 6 age group. However with optimum care these slightly increased loss before and after birth may decline. Therefore figures in this 950 range need to be interpreted with caution. Below this figure there a gender discrimination factor becomes likely. Data Source Other Useful Sex ratio in 0-5 age group Indicators Sex ratio in population Suggested level 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 will be 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 All recorded live births in that facilitys service Numerator: area/block/district in the last 12 months Denominator : Population of that facilitys service area/ block/district This is the crude indicator of fertility in that population. Also Rationale by comparing the recorded birth rate with the estimated birth rate or external survey based birth rates one can arrive at a picture of how many children in that area are being missed out and this is useful to keep in mind while reading and interpreting all other child health indicators. Birth and death register Data Source Maternity registers of Sub-Centres, PHC and CHCs. 17 Line listing of births maintained by health workers; delivery registers

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Household surveys Other useful Total fertility rate indicators Normal Ranges The states birth rate is available from the SRS. The goal is to 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 home get missed. Since much of the reporting could be based on hearsay- there is loss of accuracy. There could be double counting Problems The indicator is an estimate. For many reasons the denominator could be wrong or the birth rate could be more or less that expected. The numerator should be for a full year. This means adding the livebirths of the last 12 months- and then plotting this indicator on a graph so as to see trends. Monthly use of this indicator has little role. Also take a unit which has more than 3000 births in that period ( a number of areas taken together, or a number of months taken together ) to be able to cast a meaningful indicator. If the indicator is low, check whether all births are being recorded or some areas are getting missed out/ poor quality of recording or whether it is because there has been a change in the denominator or due to declining fertility. If indicator is higher than expected and sustained it may be a major movement of the population in or increase of fertility rates

Actions to consider

Indicator CH 4: Low birth weight rate Percentage of live born infants with a Birth weight under Definition 2,500 grams Numerator: Live births with a birth weight < 2500g. Denominator : Live births weighed Rationale At the population level, the low birth weight (LBW) rate is an indicator of a multifaceted public-health problem that includes long18

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term maternal malnutrition, ill health, hard work and poor health care in pregnancy. On an individual basis, low birth weight is an important predictor of newborn health and survival Live babies with weight of <2,500 grams indicate poor nutritional status of mothers or maternal illness, but may be influenced by other factors such as smoking, alcohol abuse, other illness such as TB, HIV or chronic lung or heart disease. Data Source Maternity registers of Sub-Centres, PHC and CHCs.

Household surveys % children weighed- the denominator would be recorded Other useful live births. % live births with severe LBW- that is a weight below 1.8 kg and below 1.6 kg. Below 1.6 kg hosipitalisation is mandatory and even below 1.8 it is desirable. Children between 1.8 kg and 2.5 kg can be managed at home if indicators there is no other complication. Normal Ranges Less than 10% of all birth should be under 2,500 grams, though many states have up to 30% LBW Common Many children are not weighed at birth, particularly those delivered at Problems home. If the child is weighed after 24 hours, there is normally some further weight loss which picks up again at about a week and then steadily increases. Hence the insistence on taking only the first days weighing as accurate. Many health facilities do not have accurate scales (10gm accuracy needed) and health staff often do not use existing scales well, resulting in further errors. When percentage of births which have been weighed is low, or live births recorded is a small part of expected live births, this indicator has to be used with caution as it is the most vulnerable section that tends to get left out of coverage 19

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Actions to consider

Efforts to increase percentage of children weighed- by studying who is getting missed out and why. Improved quality of ANC BCC regarding nutrition, smoking and drinking during pregnancy Attention to adolescent anaemia and malnutrition Assistance to secure food entitlements during maternity Improve institutional new born care and referral arrangement where severe low birth weight is high

Indicator CH 5: Neonatal mortality rate Neonatal mortality rate (NNMR) measures the number of liveDefinition born babies dying within 28 completed days of life per 1,000 live births. Numerato r Deaths in first 28 days Denomina tor 1000 live births Rationale Neonatal mortality (particularly early mortality) is affected by quality of care for the neonate. This is a significant proportion of IMR Direct Causes are asphyxia , sepsis, hypothermia and neonatal tetanus. Indirect causes are low birth weight, prematurity, birth injuries and congenital anomalies Data Source Line listing in the birth and death register and Institutional records Registrar of births and deaths- compulsory registration system, Household surveys Other NNMR can be divided into early (0-7 days) and late (8-28 days). Useful This information is potentially available in the line list- but currently not being aggregated. Indicators NNMR can be disaggregated by gender Suggested level State and district. Calculate only when you have at least 3,000 births, otherwise of 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 cumulative total of a a number of months or even a year. Common Underreporting and misclassifications ( as still births )are Problems common, particularly for deaths. Cultural reluctance to reporting early neonatal deaths- which only good training and supervision 20

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occurring early in life (particularly first hour). Actions to Staff training and health facility equipment for a functional newborn care Consider unit Appropriate home based neonatal health care providers to be trained

Indicator CH 6: Infant Mortality rate Definition Numerato r Denomina tor Rationale Infant Mortality rate (IMR) measures the number of deaths of infants under one year of age per 1,000 live births Deaths infants less than one year old (Neonatal death plus deaths in 1-12 months) 1,000 Live births This MDG indicator is a good measure of the socio-economic, nutritional and environmental health status of a given population. Common causes of death after the neonatal period are diarrhoea, acute respiratory infection, malaria, malnutrition, vaccine preventable diseases, especially measles A significant proportion of the IMR is related to neonatal care Infant deaths should be reported monthly and IMR calculated semiannually. One needs to ensure that in this period of calculation there has been at least 3000 live births in that area.At a local level block or lower- this information is actionable even without making it into an indicator. Routine: Line listing of deaths; Institutional records Others: Registrar of births and deaths, Population-based surveys, especially Sample Registration Surveys IMR by gender gives insight into poor care for the female child and female infanticide 21

Data Source

Other Useful Indicators

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Suggested level of use Common Problems

Perinatal and neonatal death rates measure quality of care at birth Disease specific death rates due to diarrhoea, malaria, ARI etc provide clues for immediate action IMR can be disaggregated by social class, residence, income etc Underweight rate under one year measures nutritional status. This acts as a risk factor, increasing the likelihood of death from any of the above causes. National, state and district. Below district even the data element by itself provides actionable information. IMR from routine data can be inaccurate because of unreported deaths occurring in the home, particularly amongst poor and disadvantaged communities not reached by health services. Cultural reluctance to report neonatal deaths. Tendency to underreport due to threat of reprimand from above Deaths before the first birthday are all included in this. Improved notification through line listing by health workers, Community notification of deaths- to VHSCs, PRIs, NGOs etc - a form of community monitoring to uncover unreported deaths. Ensure that truthful reporting of higher deaths that expected is not met with reprimands but with assistance.

Actions to Consider

Indicator CH 7: Under 5 mortality rate Under-five mortality rate measures the number of children Definition who die before their fifth birthday per 1000 children under five years Numerator Deaths Neonatal + Deaths infant + Deaths 1-5 years Denominator 1,000 children under five years 22

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Rationale

Data Source Other Useful Indicators Suggested level of use Common Problems Actions to Consider

Under-five mortality rate is a general indicator of the level of child health, It measures more the socio-economic, environmental and nutrition status of children, rather than direct health care delivery. Line listing of deaths at Sub Centre; Institutional records Vital registration- registrar of births and deaths; Population census; Population-based surveys, such as DHS. U5MR can be disaggregated by gender, social class, residence, income etc See infant mortality rate indicators National and below. Calculate only when you have at least 3,000 births, otherwise fluctuations will be too high. Poor reporting of child deaths, particularly in hard-to-reach and poor communities Improved notification through line listing by health workers, Community notification of deaths- improve recording of unreported deaths and increases community action to prevent deaths Improved quality of care for children through health workers at home

Definiti Peri-natal deaths comprise still births (gestation over 228 weeks / on >1000 grams weight) plus early neonatal deaths (infants dying within 7 days). Numera tor Deaths Peri-natal (still births plus early neonatal in first week) Denomi nat 1000 live Births. or Rational e PNMR directly reflects maternal health, quality of prenatal, intrapartum and 23

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neonatal care Peri-natal deaths comprise up to 40% of infant deaths and their reduction is the most 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 first week deaths. Any pregnancy outcome other than a live birth after the pregnancy has achieved 28 weeks would get included in this. The criteria of weight above 1000 gms may have to be ignored if weight of the still-birth/aborted fetus is not available. All peri-natal deaths should be audited according to national guidelines to identify preventable deaths and improve neonatal care. Data Registers from Delivery and neonatal wards; Line listing by ANMs; Vital registration; Population census; Population-based surveys, such as Source DHS. Still birth rate- this is what can be calculated from the current data elements available. Still birth estimation has a reciprocal relationship with both abortion at one end and neonatal mortality at the other. For calculating perinatal mortality rate as defined above-one needs to be collecting neonatal deaths in the first week as distinct from any neonatal death. However this information is potentially available in the 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 abortions which at around 28 weeks could be a problem. Other A perinatal audit can provide useful additional information on quality of care Useful Indicato PNMR at different type and level of Institutions, public and private rs PNMR by type of birth assistant (SBA, Non-SBA) PNMR by gender Compare with NNMR Suggest ed National and below. Calculate and make predictive trend analysis level of only when you use have at least 3,000 births, otherwise fluctuations will be too high. Commo n Comparisons between different rates may be hampered by varying Problem definitions, s registration bias, and differences in the underlying risks of the 24

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populations. Reporting of still births is also problematic Actions to Institutions with high PNMR need additional support to identify the Conside causes of the r deaths, and will normally need training on neonatal care techniques. By comparing PNMR with other rates, one can arrive at conclusions about which areas of child care require prioritisation.

Some authorities state 22 weeks or 500 grams but in India neonates of this age are not viable, Other authorities use 32 weeks: hence 28 weeks or start of 3rd trimester is taken as cut-off.
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IMMUNISATION INDICATORS
Indicator CH IMM 1: Vaccine Specific Immunisation coverage under one year A BCG B OPV (1,2,3) C DPT (1,2,3) D Measles E Hep B (1,2,3) where used Vaccine specific immunisation coverage is the percentage of children under a year who have received particular doses of a specific vaccine Numerator Children under 12 months( which is same as saying children 0 to 11 months old) given the specific vaccines BCG, OPV, (1,2,3) DPT,(1,2,3) Measles, Hep B (1,2,3) where used a. Total recorded live births : Denominat b. Expected number of children under 12 months, based on mid or year estimates. Vaccine specific Immunisation coverage rates are used to monitor Rationale immunisation services, to guide disease eradication and elimination efforts, They are an indicator of health system performance. Measles immunisation coverage is a national and MDG indicator used as a proxy for full immunisation coverage. Data Immunisation registers kept by health workers; Immunisation Source coverage cluster surveys; other household surveys Normal National target is 100%; states and districts need to set their own range targets Definition Other Useful Full immunisation coverage Indicators Immunisation drop-out rates Incidence of vaccine preventable diseases Vaccine utilisation rates 26

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Vaccine availability rates Cold Chain function indicators Suggested level National for Measles; State and district for others of use Common Problems Actions to Consider No vaccinations given to children over one year should be included in this Indicator. Low immunisation coverage needs urgent action by health services and communities. It may indicate poor planning, supply side problems e.g. out of stock or need for vaccine transport Improve local planning and community involvement Rates over 100% mean denominator problems or double counting

Indicator CH IMM2: Full Immunisation coverage Full Immunisation coverage is the percentage of one-year-old Definition children who have received all required vaccines. Numerator Number of children 9 to 12 months who completed their immunisation schedule (BCG, OPV3 and DPT3 and measles) in the past year Number of children 12 to 23 months who had already complete immunization or completed their immunization schedule during the past year Expected number of 0 to 12 months children based on mid year estimates. Actual number of 0 to 12 months children based on live births during this year Expected number of 12 to 23 months children based on mid-year estimates Denominat Actual number of 12 to 23 months children based on household or survey done at year beginning. Rationale Full Immunisation coverage is the pinnacle indicator for immunisation coverage and means that the child should be fully protected against the six vaccine preventable diseases, and is a valuable way to reduce infant mortality. Data Immunisation registers kept by health Source workers ; There needs to be a separate column in this register where the age of child in months when given the last immunization 27

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needed for full immunization status is recorded EPI cluster surveys; Other household surveys Other Useful Full immunisation coverage by gender male and female Indicators Vaccine-specific vaccination coverage rates Full immunisation coverage rates from cluster surveys Vaccine preventable disease incidence rates Vaccine utilisation and availability rates Cold chain function indicators Suggested level National, State, District, Block of use Common Problems This data is hard to keep accurately routinely with current tools Routine data should be cross-checked by EPI cluster surveys (see WHO mid level manager cluster survey manual) and other household surveys such as DHS. Surveys usually use a 12 to 23 month denominator. Children need an immunisation card to track that all doses have been given. The register also needs provision for child tracking. Vaccine register should show children who completed immunisation schedule in a separate column by comparing full and individual immunisation coverage, catch up campaigns to be instituted to provide individual vaccines in specific areas

Actions to Consider

Indicator CH IMM 3: Immunisation adverse reactions Definition An adverse immunisation reaction is an unwanted or harmful reaction experienced following administration of a vaccine It can be described as a medical event that takes place after an immunisation that causes concern and is believed to be caused by immunisation (Immunisation handbook for health workers GoI 2007) Adverse reactions A) Abscesses B) Deaths 28

Numerator

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C) Others Denominat or Total number of immunisations given Rationale Adverse effects are a sensitive indicator of quality of immunisation Adverse reactions can be grouped into reactions inherent to immunisation (pain, swelling, redness or general reactions), due to faulty techniques, hypersensitivity, neurological involvement, provocative reactions Under RIMS, three kinds of reaction are identified Abscess, Deaths and Others e.g. allergy, anaphylaxis, hypotensive /hypo responsive episodes, BCG lymphadenitis, etc Data Source Immunisation registers, facility data collection forms, IDSP death reports Other Useful Drop out rates show perceived quality by the mother Suggested level State and below of use Common Non-reporting; Problems Others is a large category Death of the child upto 6 days after the immunization is to be reported- unless it is due to accident. Many of these deaths may have other causes- but that is to be validated by medical officers separately these deaths are only presumptively vaccine related- the point is to have a high index of suspicion so as not to miss cases. Delayed reactions are difficult to collect Actions to Investigate all adverse reactions to identify the cause and advise peripheral workers to take appropriate action for abscesses and other complications. Check on supply .For deaths it needs to be reported to state and national level and separate report filed with vaccine batch details etc. Consider

Indicator CH IMM 4: % of planned immunisation sessions held 29

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Definition

Percentage of total planned immunisation sessions held

Numerator Number of immunisation sessions held Denominato r Total number of immunisation sessions planned Rationale For a given population with a known number of health facilities and staff and outreach points( eg anganwadi centers) the number of immunisation sessions to cover the population is predetermined. It is important to see what percentage of this needed coverage is achieved. Immunisation needs careful planning and this indicator measures implementation of the plan. Poor planning leads to poor implementation of immunisation Lack of transport is a common reason for cancellation of sessions; Non availability of the ANM due to sickness or other personal causes, lack of vaccine supplies etc are also other causes. Need to ensure adequate transport for vaccines and transport for the ANM where this is the constraint. Data Source Registers maintained by health workers and health facilities Denominator from district immunisation office Suggested level of District, Block use Common Reliability of reporting of immunisation sessions held is low because Problems worker 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 improved Consider supervision Involve communities in planning of immunisations at sites and time convenient to them and reporting sessions NOT held Indicator CH IMM 5: Vitamin A coverage rate 30

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Definition Numerator

Percentage of children who have received all required vitamin A doses. (One dose for a child under one and five doses for a child under three years) Children who received Vitamin A A) 1 dose under one year B) 5 doses under three years C) 9 doses under 5 years

Denominat or Expected number of children based on mid year estimates. Vitamin A supplements given between six and 72 months is Rationale stated to reduce mortality by 23%, where vitamin A deficiency exists. Vitamin A supplements as part of measles case management can reduce the case fatality rate by more than 50%. Data Immunisation register and Reports of Vitamin A by service Source providers Other Useful Measles case fatality rates Indicators Vaccine-specific coverage rates to compare to vitamin A coverage rates Suggested level State and District of use Common Difficult to report multiple doses at different ages Problems No age estimates of 3 year old children available Unless children have a vitamin A/immunization tracking card which goes upto 5 years- it would be difficult to estimate who has achieved the 5th, dose, 9th dose etc. It is not advised to make bulky registers that list all children upto 5 years and track them all along for each dose. Actions to Identify areas with low coverage and ensure supplies and promotion Consider Activity. Indicator CH IMM 6: Immunisation drop out rate Definition Comparison of the number of children who start receiving immunisation and the number who do not receive later doses for full 31

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immunisation Numerator Number of children starting particular dose of antigen MINUS number of children receiving later dose of antigen Denominat or Number of children starting particular dose of antigen Rationale This is an indicator of quality of immunisation services and allows a view of the trends in coverage for specific vaccines. Useful drop out rates are A) BCG to DPT3 B) BCG to Measles C) DPT1 to DPT3 D) DPT1 to Measles This is a cohort sample and periodicity should be (semi) annual, rather than monthly Data Source Facility routine data collection forms; Immunisation Registers; Other Useful Vaccine specific and full immunisation coverage rates Indicators Vaccine availability Vaccine preventable disease incidence Suggested State and district level of use Common A high drop out rate means that mothers have no faith in the immunisation Problems A negative drop out rate can occur if there is a stock out of the early vaccines 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 immunisation course Ensure 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 . Numerato Number of couples protected by each family planning method which is approximated by a formula:: number of cases sterilised r: in particular month*10+number of pills distributed/13 + number of IUDs inserted*5.5+ no of condom pieces distributed/100. Denomina Number of eligible couples (with fertile age women 15-49 years). The number of eligible couples are approximate 17% of total tor population. Actually recorded eligible couples is what is used as denominator but this may be compared with estimated couples in the population, Rationale Each family planning method is effective for different periods this is a calculated indicator which measures the contribution of each method to protection of eligible couples in the community. The easiest way to calculate this is from the stock cards and Data from sterilisation record. Note the total outgoing contraceptives Source for each type and divide or multiply by the appropriate factor: Sterilisation X10 Pills / 13 IUD x 5.5 Condom pieces/ 72 X100 Actions to Low coverage means that unwanted pregnancies will occur. Increased CYP will occur mainly through health promotion and Consider increases 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 effective and longer- term contraceptives such as injectables, IUDs and sterilisations. This indicator is best annualised - i.e. the months value Other multiplied by 12 to get a picture of what would happen if this Possible rate continued throughout the year. Indicators Termination of pregnancy rate is an indicator of failed contraception leading to unwanted pregnancies. Method mix is the relative proportion of total CYP provided by each method. It is best visualised as a pie diagram. Acceptor rate is number of couples reporting to be using any method as the numerator and total eligible couples as the denominator. a relatively low value indicator for contraceptive effectiveness as it does not measure protection of women, but merely attendance of women at the clinic for a particular service. It could however be used locally to ensure that all couples are reached and improve the programme. The family planning service delivery register and tracking register would help track this- and the figure % of eligible couples not using any method but wanting to use is the most 33

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Suggeste d level of use Common problems Actions to consider

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 gap with earlier birth, % of births in women less than 19 years of age.( registers record the data elements needed- but this is not reported up currently) National This is a complicated indicator, most easily calculated using a computer

Indicator FP 2: Family Planning Coverage rate by method Definition The coverage contribution of each contraceptive method to the overall family planning program Numerato Total number of units of each type of contraceptive distributed r A) Oral Contraceptive cycles B) Condoms C) IUD insertion D) Centchroman (weekly) pills E) Emergency Contraceptive pills Denomin Eligible couples ator Rationale The indicator provides a profile of the relative level of use of different contraceptive methods. This also suggests that the population has access to a range of different contraceptive methods Data Family Planning Registers maintained by health workers and Source health facilities; Household surveys Other Method Mix Useful Indicator s Suggeste District d level of use Common Exact number of OCPs or condoms distributed- are difficult to 34

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Problems Actions to Consider

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

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Indicator FP 3: Sterilisation rate A Males B Females Definition 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 sterilised B) Females where the family size is 2 or more children and the female is between 20 - 49 years and husband has not been sterilised Numerato Sterilisations performed this month plus already sterilised r eligible couples A) Male B) Female Denomin Eligible couples ator Rationale Sterilisation is a permanent method that contributes 12.5years to CYP. Male Sterilisation is indicative of male participation in family planning and is usually held in camps Data Registers and data collection forms maintained by health Source workers and health facilities (including Camp) Eligible couple registers Other Male sterilisation by type Useful o conventional and Indicator o NSV s Female Sterilisation by types o 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 rate Suggeste National and below d level of use Targets 20% of all sterilisations should be males Common Permanent sterilisation is the most commonly used method of Problems family planning When used when family size is already large, it does not affect TFR Very few males go for vasectomy!! Actions to Consider 36

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