Indicators Towards Monitoring Progress Towards Maternal and Newborn Survival Revised

8/16/2019 Indicators Towards Monitoring Progress Towards Maternal and Newborn Survival Revised

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Indicators for monitoring progress towards maternal and newborn survival

Introduction:Monitoring and evaluation is an integral component of health research projects. Yet measuring progressacross projects in different settings on the basis of monitoring and evaluation data, has been difficult. Theabsence of a common set of indicators applicable for all the projects is one reason for this difficulty. Maternal

and newborn health programmes share these problems.During the inception of MotherNewBorNet, it was discussed among the members that a common set ofindicators to monitor progress towards maternal and newborn survival is a timely need. ome or all of theseindicators could be part of member projects along with other monitoring and evaluation indicators specific tothe projects. These indicators will help to identify programmatic and progress gaps, and provide someunderstanding of the progress of maternal and newborn health projects across different regions.

Methodology:!nformation on suitable indicators was collected from projects implemented by the members ofMotherNewBorNet. "#isting recommendations, methodological guidelines for developing valid and reliableindicators, and a compendium of indicators of maternal and child health were also reviewed. The set ofindicators developed was circulated among the members including policy ma$ers, public health e#perts,program managers, and academicians. The members were re%uested to select & indicators they consider

most suitable to monitor progress of their projects. The initial list circulated among the members included '(indicators measurable at household community, and facility level )Table (*.

Table 1: Initial list of indicators to monitor progress towards maternal and child survival

(. Neonatal Mortality +ate'. !nfant Mortality +ate. Maternal mortality ratio-. ercentage of mothers who received at least ' Tetanus To#oid )TT* doses before the birth of theiryoungest child&. ercentage of mothers who received any antenatal care )/N0* visits from trained health personnelduring the last pregnancy1. ercentage of mothers whose last childbirth was attended by s$illed birth attendant2. ercentage of mothers received postnatal care from trained health personnel within 2 days of delivery

3. ercentage of mothers received postnatal care from a trained community wor$er within 2 days ofdelivery4. ercentage of mothers received care from a trained community wor$er within days of delivery(5. ercentage of babies who were dried and wrapped immediately after birth((. ercentage of babies who had delayed bathing after birth )delay to be defined*('. ercentage of babies who were breastfed within '- hours of delivery(. ercentage of babies e#clusively breastfed at ( month and 1 months of age(-. ercentage of babies received care from trained health personnel within days of delivery(&. Number of newborn infection cases treated by health provider (1. ercentage of mothers started using any modern contraceptive by 2 months after delivery(2. ercentage of mothers who practiced 6/M during the first - to 1 months after delivery(3. ercentage of mothers who $now at least ' danger signs of pregnancy, labor and postpartum period(4. ercentage of mothers who $now at least ' danger signs of newborn

'5. ercentage of project districts with referral facilities having active management of rd stage of labor'(. ercentage of project districts with referral facilities having 07 delivery '- hours a day and 2 days awee$

Results:!n an electronic discussion with members that followed, members made comments in favor or against theinclusion of specific indicators in the list, along with comments to improve the indicator. / summary ofcomments and concerns raised by the members is given below by indicators8

Indicator- 1: Neonatal Mortality Rate

This was considered as a common indicator for all the projects. !t was also recommended that there is aneed to capture stillbirths in future.

Indicator- 2: Infant Mortality Rate

This was also recommended as a common indicator for all the projects. There was a concern that, it will bedifficult to get data on this indicator, from the projects having interventions only for newborns.

Indicators to monitor progress towards maternal and newborn survival, a MotherNeworNet !ublication in "ctober 2##$


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Indicator-%: Maternal mortality ratioMaternal mortality is a very rare event in each setting, and population si9e is often too small to calculate thematernal mortality ratio. !t was recommended that projects can collect data over the years on numbers ofmaternal deaths and could carry out verbal autopsies, which might provide useful programmatic information.

Indicator-&: !ercentage of mothers who received at least 2 '' doses before the birth of their youngest child !t is difficult to interpret what numbers of TT doses mean, as some programs are mature and women have

sufficient TT injections even prior to her last pregnancy. :or e#ample, if a woman does not have ' TT shotsin her last pregnancy, she may already be protected with & or more shots. There are also differences instrategies such as providing TT to women (&;-4 vs. pregnant woman only and card verified TT doses vs.self;reported TT doses.

Indicator-$: !ercentage of mothers who received any (N) visits from trained health personnel during thelast pregnancy There was no consensus on the cut off point for number of /N0 visits. recommended /N0 indicator is- visits although the /frica Bureau uses /N0 visits since - is too ambitious for them. /N0 with 'visits is probably too low given that the global /N0 ' visits coverage is already high )about 25?*. >therrelevant indicators were suggested on birth and newborn preparedness )e.g. percentage of deliveriesconducted by using clean delivery materials@ percentage of households with money for emergency care formothers or newborns@ percentage of households that have arranged transport for travel when emergencycare for mother or newborn is needed*. !t was felt that an operational definition of trained health personnelapplicable for all countries is needed.

Indicator-*: !ercentage of mothers whose last childbirth was attended by s+illed birth attendant This was accepted as an important indicator, but an operational definition of s$illed birth attendant was feltnecessary.

Indicator-: !ercentage of mothers received postnatal care from trained health personnel within days ofdelivery@Indicator-: !ercentage of mothers received postnatal care from a trained community wor+er within daysof delivery@Indicator-.: !ercentage of mothers received care from a trained community wor+er within % days of delivery !t was felt that 2 days is too long, and clarification was sought whether postnatal referred to mother or babyor both. !t was revealed that postpartum care within days can be feasible in some projects. !t was also

suggested to phrase the indicator as A postpartum care for mother and newborn by a trained health careprovider and include all levels of health care personnel from community health wor$er )0=


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There are potential benefits of antiseptic Abaths or sponging in poor hygienic condition. There is a paucity ofevidence about the benefits or harmful effects of just wiping the baby or actually using wet swabs orsponge. !t is not always helpful to assume that families will use cold water and therefore suggest, Ado notbathe. Babies who get wet by sponging can also get hypothermic if not properly attended. Moreover, bathinghas various connotations cold vs. warm water bathing, cleaning vs. scrubbing, sponging vs. bathing etc.

Duration of bathing delay8 /mong the programmes, the periods of delay in bathing vary from 1 hours toovernight to '- hours and even longer. !t was opined that the main issue is Amaintenance of the babyEs body

temperature in the ideal temperature range at all times. !t is necessary for health care wor$ers and mothersto reali9e that they will have to $eep babies pleasantly warm without getting chilled or overheated and verifythat the baby is maintaining his7her temperature all the time. But it is impossible to translate this wholeprocess into a simple understandable, doable term that can be readily understood and evaluated by allhealth wor$ers and family members. 0oncern was raised that use of Apercentage of babies who had delayedbathing for at least '- hours as a core indicator, will leave other relevant issues unaddressed.

:indings from formative research in a$istan showed that in rural settings a majority of deliveries areconducted at home. !mmediately after birth, the newborn is placed on cold mud floor without drying andwrapping. This is because the attending TB/ is busy delivering the placenta. !f a relative is present, the babyis handed over to her. he ta$es the baby and gives a bath considering verni# to be dirty. During the bathshe rubs s$in of the baby rather aggressively to ta$e off blood and verni#. /s a result the baby is not put tomothers breast immediately after delivery. / mi#ture of several such behaviors may lead to hypothermia. !t

was opined that programs should be encouraged to identify behaviors that may lead to hypothermia in aparticular setting. /n indicator should not focus on one particular behavior. /s far as maintaining the righttemperature according to the season is the main goal, these particular behaviors should be lin$ed withdrying the baby after delivery, warming and wrapping the baby and putting it closer to mothers breast. !ffamilies delay bathing beyond '- hours, but do not dry and wrap the newborn immediately and properlydamage is done. :rom the perspective of thermal control, immediate drying and wrapping )again beforeeven the cord is cut* should be a focus of the program.

0onsidering the fact that hypothermia may vary among different settings and cultures and the need to focuson a positive action that the birth attendant or family can practice universally, this was regarded as animportant pro#y indicator. !t was also suggested that delay needed to be defined. Two cut offs for delay wererecommended8 a. more than 1 hours and b. more than '- hours.

Indicator-12: !ercentage of babies who were breastfed within 2& hours of delivery

There was no consensus on the timing of initiation of breastfeeding. Breastfeeding within ( hour, hours,and '- hours was discussed. !t was also discussed that initiation of breastfeeding within ( hour will bedifficult for mothers who had caesarian section delivery. !t was also suggested that colostrum feeding shouldbe included along with breastfeeding within ( hour. Moreover, initiation of breastfeeding Aimmediately,especially before the delivery of placenta would be more important.

Indicator-1%a: !ercentage of babies e/clusively breastfed at 1 month!ndicator (b8 !ercentage of babies e/clusively breastfed at * month!t was revealed that Demographic and health urvey )D=* indicator is Abreastfeeding e#clusively at -months. /nalusis done by D= is normally on the basis of small sub;samples, not really big enough forsignificant results. !f this indicator is included, data on e#clusive breastfeeding for initial 1 months of ageshould be ta$en. This indicator is not suitable for countries where =!C prevalence is high. :or the purpose ofmonitoring newborn care at community level early and e#clusive breastfeeding indicators are good core as

well as tracer indicators in low =!C prevalence settings.

Indicator-1&: !ercentage of babies received care from trained health personnel within % days of delivery This was regarded as an important indicator. There was some debate on days vs. 2 days. !t wassuggested that newborn care within days might be very restrictive and hard to achieve in newbornprograms that are new. ostpartum care for newborns also needs to be further defined.

Indicator-1$: Number of newborn infection cases treated by health provider This was not regarded as a suitable indicator to be used by all maternal and newborn health projects. Thisindicator is useful only if the project aims to treat newborn infections. /lso, there are a lot of newborninfections, and indicators for each of the newborn infections are necessary for this purpose.

Indicator-1*: !ercentage of mothers started using any modern contraceptive by months after delivery This was also regarded as an important indicator. >ther related indicators suggested are8

; ercentage of /N0 or visits in which : is counseled, delivered or referred; ercentage of couples who $now ' benefits of spacing pregnancies at least two years apart; ercentage of couples who $now ' benefits of limiting births for high parity7F & years women; ercentage of women using family planning )modern methods* si# months postpartum



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; ercentage of women using contraception 1 months postpartum; ercentage of women using contraception (' months postpartum; ercentage of women using contraception 1 wee$s postpartum if not practicing 6/M; ercentage of mothers who practiced 6/M during the first - to 1 months postpartum

Indicator-1: !ercentage of mothers who practiced 0(M during the first & to * months after delivery This indicator was considered as redundant, when compared with indicator (1.

Indicator-1: !ercentage of mothers who +nows at least 2 danger signs of pregnancy, labor and postpartum period There was confusion in terms of ' in each period i.e. 1 in total or ' each ; separated into indicators. !t wassuggested that if they are all combined loo$ing at women who $new at least ' signs, usual term is$nowledge of Ematernal danger signs.E >therwise it is wise to split maternal danger signs for a. pregnancy, b.delivery and c. postpartum periods and split newborn danger signs for a. immediate and b. postnatal period.

Indicator-1.: !ercentage of mothers who +nows at least 2 danger signs of newborn!t was regarded as an important $nowledge level indicator considering the fact that some programme is yetto focus on danger signs of newborn.

Indicator-2# !ercentage of proect districts with referral facilities having active management of %rd stage oflabor

Indicator- 21: !ercentage of proect districts with referral facilities having )34 delivery 2& hours a day and

days a wee+

These indicators were considered to be inapplicable for wide use as some projects may be confined in asmall area within ( district.

Conclusion and recommendation

/fter this debate and discussion, the following list of indicators were proposed for the maternal and newbornhealth projects )Table;'*8

Table 2: Recommended Indicators for community-based maternal and newborn programs

Service Indicators:(. ercentage of pregnant mothers who received antenatal care )at least three times* by a trained =ealth 0aref/ctivityIMotherNewB ";mail8 malayJicddrb.org


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Indicators Towards Monitoring Progress Towards Maternal and Newborn Survival Revised