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Report of a Consultative Meeting on

Survey-based Indicators for Monitoring and Evaluation of

Newborn Health Programs

April 29-30, 2008

Saving Newborn Lives

Consultative Meeting Report -- Indicators for Newborn Health

Save the Children, Washington, DC

Acknowledgments

Save the Children’s Saving Newborn Lives program, the organizer of the consultative meeting, is grateful to a number of individuals, groups and organizations for their contribution to the success of the meeting:

the presenters for investing their time and energy in preparing for the meeting and willingness to share their ideas and insights;

leads and reporters of the breakout sessions for facilitating the sessions, preparing notes and sharing it with all the participants;

the participants, who represented various organizations and expertise areas, for their thoughtful consideration of the complex issues at hand;

those who could not attend the meeting yet provided helpful ideas and feedback;

Marie Thoma for carefully taking notes and preparing first draft of the report;

all the presenters, breakout-session leaders and rapporteurs and other individuals who reviewed the draft of the report and provided helpful comments and suggestions;

JoAnn Paradis for logistic and administrative coordination; and

BASICS, JHSPH, LSHTM, MACRO/PATH, MACRO DHS, UNICEF, URC, and USAID for their cooperation and participation.

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Executive Summary

In April 2008, a consultative meeting was convened at Save the Children in Washington D.C. to assess survey-based indicators for monitoring and evaluation of newborn health. In light of recent evidence from the Countdown to 2015 report, it is evident that gaps in the data for tracking newborn health exist. This meeting provided an opportunity to identify areas to expand available data and improve survey guidance to SNL program countries and others as well. The focus of the meeting was survey-based questions and indicators, particularly those measured in household surveys. Other instruments for measuring newborn health, such as health facility assessments, policy instruments, and verbal and social autopsy modules, were outside the scope of this meeting. Meeting objectives were to:

1. Review accepted questions used in large population-based surveys, such as DHS and MICS, relevant to maternal and newborn care;

2. Review existing survey modules from field studies and share experience with modules and questions;

3. Identify questions that are:a. commonly used in national and global surveys and determined to be robust;b. commonly used in sub-national surveys with face validity but which may need further

testing; and,c. questions in need of further development; and,

4. Develop action steps for testing questions and developing survey modules with broad consensus.

The meeting participants reviewed evidence from research studies, experiences from the field, and engaged in discussion and group work. Working groups met to discuss recommendations for household survey questions related to intrapartum care, postnatal care, and pregnancy and birth history modules, which were presented at the conclusion of the meeting.

Recommendations and action steps for module development were outlined by the groups and are also included in this report. For a complete overview of the meeting background and objectives please see Appendix I.

Recommendations and discussion points included:

Intrapartum Care ModuleThe intrapartum care working group defined a set of questions that they considered to be robust and widely used in population-based surveys. These questions include information related to the place of delivery, who attended the birth, delivery by C-section, length of stay in the facility, reasons for not delivering in a facility (if a home birth), baby’s weight and size, and time of first breastfeed. Questions considered to need more testing and validation included ones related to recognition of danger signs, care-seeking, thermal care, cord cutting and care, resuscitation, and skin-to-skin care.

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The working group acknowledged that more time is needed to develop questions around skin-to-skin care and determine who should be targeted (routine or LBW babies only). Other suggestions were to consider whether all 3 thermal control questions were needed or whether a simplified, combined question or a question on just one component (e.g., wrapping only) as proxy for the indicator would be more achievable.

Postnatal Care ModuleThe timing, place and provider of postnatal care has historically been measured in DHS for births taking place at home and specifically refers to a check on the mother's health. Recently this has been expanded to include all births regardless of place of delivery. Some surveys also ask about a check on the baby's health, but only for those born at home. Only one MICS (Malawi 2007) has measured postnatal care. Many countries have adapted the existing postnatal questions for their own uses, making the data difficult to compare across countries and often with confusing skip patterns. There is an immediate opportunity to improve the existing set of questions to understand more about the care provided to mothers and babies after childbirth, regardless of place of delivery.The postnatal care working group defined a set of questions that they considered to be robust and widely used in population-based surveys. These questions included information related to when and where a postnatal examination of mother and baby took place and who conducted the examination. For mothers in a facility, a question on time spent at the facility was also recommended. These questions were limited to the first postnatal care visit and asked for both mother and baby.Questions considered to need further testing included total number and content of postnatal health checks for the mother and baby, recognition of danger signs, care seeking for danger signs, giving colostrum, skin-to-skin care, and knowledge of Kangaroo Care. Further concerns of the group were the wording of questions and interpretation within different cultural contexts (e.g. check vs. examine), appropriate timing of events and mother’s interpretation, mother’s recall of the content of the first and subsequent postnatal visits, and whether the mother considers the first check to be at the time of delivery. Validation studies and qualitative research were recommended for these questions. In addition, it was noted that the questions being asked and the quality of responses will be largely influenced by the recall period (5 years vs. 1 year recall).Participants noted that, while not a perfect measure, contact is an important proxy for services that impact neonatal mortality. However, others thought that contact was vague and did not provide information regarding interventions that could impact neonatal mortality. There was a clear consensus among participants of the need for more consistency across studies, which they attributed to a lack of clear definitions and terminology. Some suggestions for definitions were made during the meeting.

Pregnancy and Birth History ModulesThe recommendation of the pregnancy and birth history module group was to include a full pregnancy history module that excluded questions probing reasons for early pregnancy loss (e.g., miscarriage vs. abortion) and an additional question on duration of pregnancy. The 2006 Nepal DHS is an example of this.

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Advantages of a full pregnancy history are that it captures stillbirths and provides a better measure and classification of neonatal deaths. Including an additional question on duration of pregnancy can also provide better information on preterm birth rates.Many participants noted the benefits of measuring stillbirths for programs and that programs may underestimate the impact of certain interventions without stillbirth data. Some of the limitations for incorporating a full pregnancy history include an increased length of interview time (dependant on the TFR of country) and cultural barriers to talking about pregnancy. The group recognized that more information is needed on the quality of data provided by pregnancy history verse birth history modules, exploration of cultural barriers, and feasibility of implementation (timing and burden to interviewers and mothers).

Technical Working Group

A group was formed, with representation from USAID, UNICEF, DHS, and SNL, to develop terms of reference for a technical working group to develop a newborn health survey module (that could be undertaken in conjunction with DHS-type national surveys or separately with the inclusion of respondent/household background section in the survey) a plan to test questions where needed, and define action steps to move forward. The technical working group will be responsible for determining a timeline and process for developing and vetting the proposed survey module.

Timeline and Next Steps

May 2008: A technical working group formed during the consultation will be sent a draft ToR for comments by a consultant engaged by SNL;The consultant will finalize the ToR.

May-July 2008:Technical working group will meet to develop a generic survey module based on existing evidence and information gathered from quantitative and qualitative data sources, field experiences, and interviews over the next few months.Technical working group will also outline a plan for testing and validating questions that are less developed.Develop a virtual workspace for sharing information and coordinate a series of meetings to reconvene working group to share information.

August 2008:The survey draft module will be submitted by the technical working group.Deadline for MICS draft module.

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September 2008: Deadline for DHS draft module.

October 2008:Meeting to assess progress of technical working group.

November 2008:

Finalize draft of a recommended MICS survey module.

December 2008: Finalize draft of the newborn survey module. Develop a forum/website where progress on new questions and indicators can alert a wider public health audience.

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Context of the meeting

On April 29th and 30th 2008, a consultative meeting was convened at Save the Children in Washington D.C. to assess survey-based indicators for monitoring and evaluation of newborn health. On behalf of Save the Children/Saving Newborn Lives (SNL), Shyam Thapa opened the two-day meeting and reviewed the context, objectives, and agenda. He emphasized the increasing attention toward newborn health policies and programs, both nationally and globally. In addition, he called attention to the growing number of questions related to newborn health being asked through large population-based surveys, such as Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), and independent research projects focused on the newborn. However, in light of recent evidence from the Countdown to 2015 report, it is evident that gaps in the data for tracking newborn health exist. This meeting provided an opportunity to identify areas to expand available data and improve survey guidance to SNL program countries and others as well. Three main categories under which survey-based questions and indicators for newborn health can be broadly defined were outlined:

Category 1:Questions and indicators commonly used in national and global surveys and determined to be robust;

Category 2:Questions and indicators commonly used in sub-national surveys with face validity but which may need further testing; and,

Category 3:Questions and indicators that need further testing about which very little is known about their validity and reliability for general use.

Given these 3 categories, participants were asked to think about what to measure and why, what data is currently available from global surveys (eg. DHS and MICS), and what questions could be asked based on survey research experiences and formative research findings and insights. The focus of the meeting was survey-based questions, particularly those contained in household surveys. Other instruments for measuring newborn health indicators, such as health facility assessments, policy instruments, and verbal and social-autopsy modules, were outside the scope of this meeting.

The objectives for the meeting were to:

1. Review accepted questions available through large population-based surveys, such as DHS and MICS, relevant to maternal and newborn care;

2. Review existing survey modules from field studies and share experience with modules and questions;

3. Identify questions that are commonly used in national and global surveys and determined to be robust, questions used in sub-national surveys with face validity but which may need further testing, and questions in need of further development; and,

4. Develop action steps for developing survey modules and implementing recommendations (including testing and validating new indicators) resulting from this meeting.

The agenda and the participants list are given in Appendix 1 and Appendix 11, respectively.

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PRESENTATIONS: DAY 1 (APRIL 29TH, 2008)

Presentation #1: Tracking Newborn Health from the Saving Newborn Lives (SNL) PerspectivePresenter: Kate Kerber, Save the Children

Kate Kerber provided a detailed review of tracking newborn health from the SNL perspective. Her presentation identified sources for monitoring newborn health, the SNL framework for tracking newborn health, and how these data can be used to influence policy. She first identified multiple data sources used to monitor newborn health, such as national household surveys (DHS, MICS), sub-national surveys, health facility/service provision assessments, estimates of mortality rates/causes of newborn deaths/morbidity, national health accounts, policy reviews, and formative research. While the meeting focused on the first two sources of data, multiple sources of data are used within the SNL framework to work toward the common goal of reducing neonatal mortality. Due to the uncertainty surrounding how much a mother knows about what happens to her newborn either at home or in facility, it is important not to entirely rely on household surveys for newborn health data and more information should be gleaned from these other sources to create a full picture of newborn health status.

Most of the SNL core indicators are at the strategic objective level: use of newborn care services and health behaviors at scale. Some of the challenges of relying solely on household survey data include the time-lag (5 or more years between surveys), mother’s recall of use of services, limited tracking of postnatal care, and the absence of policy, finance and health systems information. She pointed out that immediate and early postnatal care is the focus of SNL

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because we know it is the time when the greatest number of maternal and neonatal deaths occur, but also has the least data.

There are a number of potential strategic objective indicators (population level use of services and behaviors) crucial to newborn health that are not yet a part of the “core” SNL indicators due to lack of data. The examples below are already at some stage of inclusion within some country through DHS, other large surveys, or SNL sub-national surveys. In addition, she noted it is important to track the disparities within these and all SO level indicators, e.g. looking at differences between urban/rural, wealth quintiles, education levels.

Antenatal care: • Birth preparedness• HIV VCT & PMTCT

Immediate and early postnatal care: • Cord cut with new or clean instrument• Baby dried and wrapped with clean cloth • Colostrum given• Number and timing of visits• Delayed bathing for first 24 hours• Skin-to-skin care

Extra and emergency care:• Care for babies not breathing at birth• Extra visits for the small baby• Care seeking and case management of pneumonia

During the subsequent discussion participants noted that most postnatal care tracking is currently limited to asking if the woman or newborn was seen and that assessing the quality of postnatal care visits is important, since woman may be seen but not be provided with key services. Questions related to postnatal care were contrasted with questions related to ANC in which women are asked about the content and quality of the ANC visit. However, participants also remarked that quality of care is more difficult to measure than timing and the relevancy of questions may vary depending on the cultural context. One participant noted the challenge of capturing neonatal mortality, thus questions selected to measure postnatal care need to be concerned with estimation but also improving the quality of data from these questions. This participant recommended standardization of how we record timing of events.

Presentation #2: Measurement of newborn practices via surveillance data collection & periodic surveys: Experiences from the NEWHINTS Intervention Trial, Ghana Presenter: Betty Kirkwood, London School of Hygiene and Tropical Medicine (LSHTM)

Betty Kirkwood began the presentation on the Newborn Home Intervention Study (NEWHINTS) by describing the overall aim and primary objectives of the cluster randomized trial. The overall aim of the intervention trial is to develop a feasible and sustainable community-based approach to improve newborn care practices in rural Ghana and by so doing improve neonatal survival. The primary objectives for the study are to link with the District Health Management teams to develop a feasible and sustainable intervention to improve newborn care practices through

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routine home visits in pregnancy and the first week of life; to evaluate the impact of these home visits on all cause neonatal mortality; to evaluate their impact on newborn care practices; and to

evaluate the cost-effectiveness of the intervention. Secondary objectives are to assess the coverage and quality of the service provided and the family and community response to the service; to evaluate whether the impact of the intervention on neonatal mortality differs between home- and facility-based deliveries; and to evaluate the impact of the intervention on age- and cause-specific neonatal mortality. She presented the integrated intervention package provided by NEWHINTS with the core focus of the intervention being routine home visits led by community-based surveillance volunteers (CBSVs).

The core of the presentation concentrated on information provided during the home visits. In describing the decision-making process about the type of information included at each visit, she emphasized that the study did not want to overwhelm women with too much information. Instead, they targeted key behaviors and ideal practices during 5 different visits (early pregnancy, 3rd trimester, day of birth, day 3, and day 7). She also noted that questions on cord care and hygiene were missing because they found, during formative research, that this practice was not an area of concern within this population and they did not want to dilute other important health messages by including it. The content of the visits is outlined below.

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Four-weekly surveillance of all women and infants in 49 intervention and 49 control zones is being conducted. At each home visit, data collectors identified pregnancies, births, and deaths of women and infants and administered a birth form if there was a newborn. Questions on the birth form included immediate care after birth (drying, wrapping, and breastfeeding), bathing, exclusive breastfeeding, skin to skin care (for LBW babies), and care seeking for illness, which are found below.

Behavior Question Response(s)Drying and wrapping

Was the baby dried after delivery? 1. Yes, before cord tied2. Yes, after cord tied, before placenta delivered3. Yes, after placenta delivered4. No, not dried after birth8. NK

Was the baby wrapped after delivery? 1. Yes, before cord tied2. Yes, after cord tied, before placenta delivered3. Yes, after placenta delivered4. No, not dried after birth8. NK

Bathing How soon after delivery was the baby bathed?

1. Less than 1 hours2. 1-6 hours3. After 6 hours but less than 24 hours4. After 24 hours8. NK

Was the water heated? 1. Yes2. No8. NK

How many times did you bath your baby during the day yesterday? # ___ ___ (88=NK)

Breastfeeding: Initiation

How soon after birth was the baby first put to the mother’s breast?

1. Immediately2. Within an hour of birth3. After 1 hour but within first 12 hours4. Between 12 and 24 hours5. Day 26. Day 37. Day 4 or after8. NK9. NA (mother did not breastfeed baby)

(Skip if previous question response was 1, 2, or 3) Otherwise ask: Why was the baby not put to the mother’s breast in the first 12 hours after birth?

1. Mother ill/weak2. Child ill/weak3. Child died4. Nipple/breast problem5. Not enough milk6. Mother working7. Child refused8. Did not want to give colostrum9. Mother died10. Other99. NA (mother did breastfeed baby in first 12 hrs.)

Breastfeeding: First 24 hours

In the first 24 hours after birth, was the baby offered anything else: [Prompted]

1. Yes2. No

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after birth Breastmilk from another woman?

Other milk [Prompt: cow’s milk, tinned milk, infant formula, lactogen, SMA)?

Other fluids [Prompt: water, tea, traditional medicine]?

Any foods [Prompt: any solid foods, gruels, porridge, bread, rice, cerelac, nutrimix]?

8. NK

Did you give colostrum to this baby? 1. Yes2. No8. NK

Breastfeeding: Last 24 hours

How many times did you breastfed your baby during the day yesterday? # ___ ___ (88=NK)How many times did you breastfeed your baby during the night? # ___ ___ (88=NK)In the last 24 hours, was the baby offered anything else: Breastmilk from another woman?

Other milk [Prompt: cow’s milk, tinned milk, infant formula, lactogen, SMA)?

Other fluids [Prompt: water, tea, traditional medicine]?

Any foods [Prompt: any solid foods, gruels, porridge, bread, rice, cerelac, nutrimix]?

1. Yes2. No8. NK

Skin-to-skin care

Have you heard of skin-to-skin contact between the mother and her baby as a way to take care of the new baby?

1. Yes2. No8. NK

Was your baby placed in skin-to-skin contact in the first 24 hours after delivery?

1. Not at all2. A little (up to 2 hours total)3. Moderate amount (between 2 to 5 hours total)4. A lot (more than 5 but less than 12 hours)5. Most of the time (day & night, more than 12

hours)How soon after delivery was your baby placed skin-to-skin for the first time?

1. Before the cord tied2. After the cord tied, before the placenta

delivered3. After the placenta delivered, within the first

hour after birth.4. After one hour after delivery8. NK9. NA (baby was not put skin-to-skin at all)

Care-seeking: Serious Illness

Since birth, has your baby had any illness that you thought was serious or severe?

1. Yes2. No8. NK

What illness/illnesses did the baby have? Weak, abnormal crying, or no crying Unresponsive/Lethargic Too weak to feed or stopped feeding Difficulty breathing Fast breathing Very hot body Very cold body Convulsions/shocks Jaundice

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Vomits all feeds Asram Puni

Other serious illness, please specify:Care-seeking: Outside the home

Was care sought outside the home for this illness/illnesses?

1. Yes2. No8. NK

Who was consulted? 1. Traditional healer2. Druggist3. CBSV4. Doctor/Nurse at clinic5. Doctor/Nurse at hospital

Was your baby admitted to the hospital? 1. Yes2. No8. NK

Where was he/she admitted? [ENTER FACILITY CODE]

Care-seeking: referral

Did anyone advise you to take the baby to the clinic or hospital during this illness/illnesses (or for any other condition)?

1. Family member2. Traditional healer3. Druggist4. CBSV5. TBA

Intervention: CBSVs

Have you had any visits from a CBSV: During pregnancy? Since delivery?

1. Yes (1 visit)2. Yes (2 visits)3. Yes (3+ visits)4. No8. NK

She commented that the most common reason for why the baby was not put to the mother’s breast during the first 12 hours after birth was “not enough milk.” Some women thought that this was teasing the child and, therefore, did not breastfeed until there was a good flow of milk. She also noted that there was resistance to the cord being put against the mother’s body. Formative research demonstrated that showing women a photo, as opposed to a drawing, of another Ghanaian woman practicing skin-to-skin care helped with uptake of the behavior. Skin-to-skin care was only promoted for low birth weight (LBW) babies, since the researchers thought that if it were promoted to all babies it may counter efforts to assure immediate drying and wrapping and immediate breastfeeding for all infants. With regard to care-seeking for serious illnesses, ethnographic evidence from the study indicates there is little illness recognition among women. She pointed out that the birth form provides good outcome data; however, it is insufficient for process monitoring and evaluation. In addition to the birth form, 3-monthly in-depth interviews exploring practices and some quantitative data are being collected on random sub-samples from the intervention and control areas. Information on whether mothers carried out advice on special care for LBW babies and hospital referrals is also being collected on a sub-sample of women from the NEWHINTS zones to monitor and evaluate practices.

In the subsequent discussion, participants acknowledged the breadth and depth of the study and inquired about the content of the questions. One participant noted that the questions do not ask when the postnatal care visits occurred. Betty Kirkwood responded that this information could be obtained from the date of birth and date of interview records and she suggested possible tabulation of indicators by response time. She noted that the phrasing of the question “since time

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of delivery” or some major event was much easier to recall than if women tried to report on the timing of each visit. Other participants were concerned with questions related to timing (eg. within 1 hour of delivery, 6 hours, etc.) and noted that it is hard for women to identify these periods after birth and also questioned the rationale for such a precise measure. Betty agreed that the measure of timing will not be precise; however, they have found dose response relationships with timing of breastfeeding and neonatal mortality and suggested that these intervals are wide enough that it can provide some indication of timing. Several participants commented on possible validation of some of the questions adopted by the NEWHINTS study and asked whether the study had conducted a formal validation. Specifically, one participant suggested the need for validation of thermal protection questions and suggested that asking questions related to timing based on when the cord was cut could be problematic if cultural reasons exist for variation of when the cord is cut. Betty noted that most of the validation for the study was based on consistency of responses and pilot studies, but she indicated that they could do some validation as part of their process evaluation. One participant brought up the problem of oversaturation of health messages and inquired about experiences from the NEWHINTS study with regard to recognition of danger signs. Betty responded by saying that they provide information on this, but that the health workers emphasize that women should seek care if they are at all worried about their baby. She emphasized that the messages are targeted to care seeking because that is the area with the most constraints and only a small proportion of women who think their baby is ill actually seek care. One participant mentioned the possibility of using a composite measure of essential newborn care (immediate breastfeeding, clean cord care, drying/wrapping), since they have found that coverage among individual indicators may be high but as a composite measure it was quite low. Betty agreed that co-coverage of interventions is an important, but neglected, area; she also thought it was important to look at individual coverage as well as inequities across socioeconomic groups.

Presentation #3: Closing the measurement gap for intrapartum practices and postnatal care: What do we want to measure? What are we measuring now?Presenter: Joy Lawn and Kate Kerber, Save the Children

Joy Lawn and Kate Kerber identified the gaps in coverage along the continuum of care and information needed to address intrapartum and postnatal care for mothers and newborns. Measurement and programmatic issues related to tracking include having a clear definition of the denominator (facility or home based), clear definitions related to timing, comparability of questions across surveys, and non-integration of programs and services related to child health. Despite high coverage of some interventions, little information exists for intrapartum and postnatal care and the content and quality of those interventions. Routine intrapartum care packages for mother and baby and problems with measurement were presented. The percentage of live births attended by skilled health personnel (doctor, nurse, midwife, auxiliary midwife) is a scientifically robust measure of intrapartum care coverage and used in most surveys. Interventions in the routine package for the mother are measured easily at the health facility level, but they are difficult to track in household surveys. Routine health packages for the newborn can be tracked through household surveys; however, the quality of response may vary depending on how much the mother knows about what happens to her newborn either at home or in facility.

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The percentage of mothers with live births who received postnatal care within 2 days of childbirth is a core indicator for Countdown 2015 and currently measured in most surveys. Interventions in the routine package and danger signs for mothers and newborns and extra care for newborns were reviewed. A very high proportion of deaths occur in the first hours and days after birth. Prevention of these early neonatal deaths will require improvements in care at the time of birth and improvements in care in the early neonatal period. Given the paradigm shift to postnatal care, the presenters described language and definitions regarding timing that need to be clarified:

o Postpartum: up to 6 weeks after childbirth (mother)o Neonatal: birth up to 28 days after birth (baby)o Postnatal: literally means after birth. No specific time period. Taken for mother and

baby from birth to 6 weekso Immediate: the first hours after birth (with the caregiver at time of birth/predischarge)o Early: the first week of life, with priority given to first 2 days

The presenters outlined what is tracked for intrapartum and postnatal care in mothers and newborns and the source for that data as presented in the table below (suggestions for questions to be asked in a standard/minimum module are in italics).

Intrapartum care for the mother

Intrapartum care for the newborn

Postnatal care for the mother

Postnatal care for the newborn

Place of delivery (DHS core)Facility• Who attended the birth

(DHS core)• Length of stay in

facility (DHS core)• Delivery by cesarean

section (DHS core)• Who accompanied

woman to facility (e.g. Uganda DHS)

• How long before service was received (e.g. India NFHS)

• Was the attendant nice / responsive / respectful (e.g. India NFHS)

• Blood transfusion (e.g. Nepal DHS)

• Cleanliness of facility (e.g. India NFHS)

• Check on health before discharge (e.g. India NFHS)

Home • Who attended the birth

(DHS core)• Reasons for not

• Time of first breastfeeding (DHS Core)

• Baby weighed (DHS Core)

• Drying before delivery of placenta (e.g. Nepal DHS – home births only)

• Wrapping before delivery of placenta (e.g. Nepal DHS – home births only)

• Immediate drying and wrapping “without being bathed” (e.g. India NFHS – home births only)

• How long after birth was first bath (e.g. Nepal DHS – home births only)

• Clean instrument used to cut umbilical cord (e.g. Nepal DHS – home births only)

• Measures taken to help baby breathe at birth (e.g. Ethiopia SNL survey)

• Visit time, place, and provider (DHS Core)

• Total number of visits

• Content and quality (danger signs)

• Discharge, abdomen checked (e.g. Uganda DHS)

• Checked for massive vaginal bleeding and very high fever (e.g. India DHS)

• Counselled on family planning (e.g. Sudan RH survey)

• Was the health provider nice / responsive / respectful (e.g. India NFHS)

• Counselled on danger sign recognition (e.g. Ethiopia SNL survey)

• Visit time, place, and provider (DHS Core)

• Total number of visits• Content and quality

o Anything placed on cord (e.g. Nepal DHS)

o Feeding other than breastmilk (DHS Core) – more detail from Ghana

o Baby abdomen, eyes checked (e.g. Uganda DHS)

o Mother counselled on baby danger signs (e.g. Ethiopia SNL survey)

o Skin-to-Skin/KMC (e.g. Ethiopia SNL survey)

o Immunization (DHS Core)• Care seeking and treatment for

illness o Diarrhoea, fever or cough

(DHS Core)o Any care-seeking for danger

signs; if yes: place of care-seeking, provider and treatment, if no: reason why not (Ethiopia SNL survey)

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delivering in facility (DHS core)

• Use of safe delivery kit (e.g. Nepal DHS)

Recognition of complications and care-seeking including time waited before seeking care (e.g. Sudan RH survey)

• Baby delivered on to mother’s chest and kept skin-to-skin with mother (e.g. Ethiopia SNL survey)

• Cord tied / clamped (e.g. Ethiopia SNL survey)

• If facility birth, check on health before discharge (e.g. DHS core) – content?

Questions and comments related to some of the postnatal care questions include whether total number of visits should be for both mother and baby, if content and quality questions should be limited to the first visit, and that questions on diarrhea and cough in the DHS may not be applicable for the neonate and, thus, not a good measure of careseeking and treatment for illness. Measurement challenges and information from an SNL validation study of home births in Bangladesh were also discussed. They found that low birth weight was over reported by mothers, immediate warming, immediate drying and immediate breastfeeding were underreported, lack of prelactal feeds was overreported, and a slight number over-reported that a clean instrument was used to cut the cord. In addition, PNC has different delivery strategies and places, which adds an additional layer of complexity for capturing care for mothers and babies. Implications of this for surveys are added cost due to added questionnaire length and complexity of the questionnaire due to skips and open-ended questions.

Comments following the presentation indicated that participants should consider whether postnatal care questions be asked separately for mothers and newborns during group work. Some participants noted that there are a number of questions that still needed validation and some things may not be achievable by August and September 2008, which are the deadlines for survey revision for the MICS and DHS. However, it was pointed out that there are some questions that have been validated or some that need some adjustments and agreement regarding numerators and denominators across surveys. Another participant suggested coming up with one or two indicators for postnatal care that could be added to the DHS module. It was also suggested that there may be two different modules-- a minimal newborn care module and a more expanded module for countries with specific newborn health objectives and programs.

Presentation #4: Experiences (strengths, limitations, lessons learned) from Sylhet, Mirzapur, CARE, and Shivgarh studies on using survey data for selected indicatorsPresenter: Saifuddin Ahmed, Johns Hopkins Bloomberg School of Public Health

Saifuddin Ahmed opened his presentation by giving an introduction to the surveys being conducted at four sites: Projahnmo-1 Trial in Sylhet District, Bangladesh; Projahnmo-2 Trial in Mirzapur, Bangladesh; Integrated Nutrition and Health Program (INHP) II Area of CARE/India; and Cluster-Randomized Trial of Essential Neonatal Care (ENC) at Shivgarh, Uttar Pradesh, India. He then reviewed the essential elements of routine maternal and newborn care and provided a matrix of questions for each of the studies by essential element categories. In addition to survey questions, a clinical algorithm from the Projahnmo studies was presented and

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discussed. The Projahnmo-1 study is a cluster-randomized controlled trial with three study arms, which include a comparison group that received the usual services of governmental facilities/providers in the area, home-based care with community health workers, and community level intervention with referral. The sequence of surveys conducted included a baseline survey, formative research, an adequacy survey, home visit surveillance, and an endline survey. The CARE study involved a quasi-experimental design and implemented a baseline and endline survey. The Shivgarh study was a cluster-randomized controlled trial with three study arms, which include a comparison group that received the usual services of governmental and non-governmental organization (NGO) providers in the area; Essential Neonatal Care (ENC), including skin-to-skin care (STSC), promoted through behavior change management, layered on existing services as the comparison arm, and ENC plus use of ThermoSpotTM.1 The presentation ended with a discussion of the challenges, in general, and as they relate to measurement and analysis.

In the subsequent discussion, participants discussed the differences in information provided by postnatal care contact verse content. One participant pointed out that questions about contact are vague and do not provide information regarding interventions that could impact neonatal mortality. It was suggested that the group sessions focus on the amount of information needed to ensure we are tracking something that is effective. Questions raised include: Do we need to know whether a full assessment was conducted for the baby and mother? Given that most neonatal deaths occur in the first 2 days, what do we want to know about those visits? How much information do you include for a minimum set of questions? While community mobilization to improve care seeking for newborn illness was a component of the Sylhet study, a participant

1 ThermoSpotTM (Camborne Consultants, Dorset, England) is a liquid crystal devise that changes color to indicate when body temperature drops into the hypothermic range.

General Challenges Measurement Challenges Analytical ChallengesWho are the respondents?

o Mother vs caregiver

Lack of definitionMisclassificationProspective vs retrospective

o Recall bias o Universal coverageo Use of independent

interviewer

Major causes of neonatal mortality

o LBW – proxy?o Asphyxia o Sepsis – symptoms are

atypicalFeeding/suckling difficulty – low specificityHow to measure sucking difficulty?Hypothermia

o Morbidity – algorithmsWhen to measure?Sample size for subgroups – e.g., skin-to-skin

Quality of dataMissing responsesWho are in the denominators?

o Identifying at-risk population

Reverse causalitySurvival biasDecomposition analysis of multiple elements of an intervention programSmall area estimation – helping local health administrators

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pointed out that data from Sylhet showed that identification of sepsis through case management was accomplished through increased contact.

Participants noted that, while not a perfect measure, contact is an important proxy for services that impact neonatal mortality. Another participant suggested using contact as a question for large population-based surveys and routine supervisory systems to characterize the content of postnatal care visits without having to ask women about it in a representative sample. Other participants suggested that the context of a large population-based survey versus focused research studies be kept in mind when developing a module. The time period of reference is very different for a DHS survey in which women are asked about births over the last 5 years compared to a more focused study in which women are asked over the last year or month. The questions being asked and the quality of responses will be largely influenced by the recall period. Another participant also suggested that, as a module is developed, we consider what questions are being asked as national level indicators versus questions related to program level needs.

The group agreed that the development of the module should focus on a few core questions that are ready to be implemented. Other additional questions that need further validation should be identified.

PRESENTATIONS: DAY 2 (APRIL 30TH, 2008)

Presentation #5: MICS and newborn healthPresenter: Holly Newby, UNICEF

Holly Newby reviewed the background and development of the Multiple Indicator Cluster Survey (MICS), which is a household survey program developed by UNICEF to assist countries in filling data gaps for monitoring the situation of children and women. Three rounds of MICS have been conducted in1995 (MICS1), 2000 (MICS2), and 2005-2007 (MICS3). The survey questionnaires are modular tools that can be customized to the needs of a country. They consist of three questionnaires: a household questionnaire, a questionnaire for women aged 15-49, and a questionnaire for children under the age of 5 (addressed to the mother or primary caretaker of the child). The survey can be customized to meet country needs by including or excluding modules. UNICEF is responsible for developing the survey tools and providing technical and financial support to implementing the MICS. The survey approach is similar to DHS with regards to sampling and data processing and content is largely harmonized with DHS model instruments. Information regarding the most recent survey (MICS3) is available at www.childinfo.org. With regard to newborn health, MICS3 has newborn health modules found in the women’s and under-5 questionnaires that cover the following topics:

o Antenatal care (provider, number, content)o Skilled attendant at delivery (provider)o Institutional deliveries (provider)o Low birth weight and children weighed (yes/no)o Timely initiation of breastfeeding (births in last two years)o Tetanus toxoid protection at birth

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http://www.childinfo.org/


Some of the challenges of the MICS3 survey were the small sample sizes, lack of proper customization at country level, lack of in-country support, low budgets, and delays in completion of activities.

Planning for MICS4 is currently underway and surveys are expected to be conducted in 2009 and 2010. UNICEF is planning to provide support for MICS surveys at three year intervals and has already begun working with interagency groups. The focus of MICS4 will be on MDGs, Countdown indicators, and Medium Term Strategic Plan (MTSP) indicators. The questionnaires will be developed from scratch (ie. no module from MICS3 will be automatically incorporated into MICS4). Decisions regarding inclusion into MICS4 will take into account testing and validity of modules, comparability with MICS3, UNICEF priorities, and simplicity of modules. The deadline for the design of questionnaires is the end of August 2008 and testing of questionnaires will begin in November 2008.

Following the presentation, one participant expressed concern with potential overlap between MICS and DHS. Holly stated that the general approach agreed upon by both DHS and MICS is that if a DHS is already planned in that country, then a MICS would not be held. However, because MICS is administered at the country level, there are limits regarding what UNICEF headquarters can recommend. One participant noted that at the global level there is coordination between DHS and MICS; however, at the country level that doesn’t always work. More coordination at the country-level was recommended. Another participant queried about having a shorter MICS instrument as they move to do more frequent surveys and combining efforts with DHS to increase sample size. Other participants commented that the issue is often the capability of implementing and organizing the study regardless of cost savings due to shared resources with other organizations. In addition, streamlining surveys does not always result in savings, since most of the cost is in operational costs of putting together a survey team, sampling, training the team, etc.

Presentation #6: DHS and Delivery/Newborn Health: Strengths, Gaps, Limitations and Future PlansPresenter: Alfredo Fort, MACRO/PATH

Alfredo Fort reviewed the role of DHS and its strengths and limitations in tracking indicators for maternal and neonatal health. The strengths of the DHS include consistent and comparable indicators for programs and interventions relating to maternal and neonatal health and survival, utilization of healthcare services and nutrition. The indicators, based on the data thus collected, are then correlated with background/contextual and proximate factors. Specifically, the strengths in tracking delivery and neonatal health include identifying circumstances around birth (eg. C-section); baby’s weight and perceived size; place of and assistance at childbirth, length of stay, and reasons for not delivering in a health facility; type of assistance provided at birth; occurrence and timing of first postnatal care visit for all mothers (before and after discharge for women delivery in a health facility); occurrence, timing and assistance provided at first postnatal care for newborns (only among women delivering outside a health facility); and mortality (neonatal, post-neonatal, child mortality, and under-five mortality). Based on DHS data, he showed that over 40% of women did not receive a postnatal check in almost half of DHS countries and that

19


only 8% received postnatal care less than 24 hours after childbirth. There has also been a 24% decline in post-neonatal mortality with a smaller decline of 17% for neonatal mortality from 1996 to 2006 in a DHS analysis that included data from 38 countries.

He highlighted numerous gaps in DHS with regard to birth preparedness (no financial, transport, blood or contact arrangements), delivery complications (no information on long labor, hemorrhage, malpresentation, fever or convulsions), newborn status and care (no information on breathing, tone/movements, use of delivery kit, cord cut and care, drying/wrapping/bathing, or resuscitation), postpartum and postnatal care (limited to non-institutional births for newborns and, until recently, for mothers), and content of postnatal care (no content for mothers or newborns). He also pointed out some of the difficulties and assumptions faced by DHS, including an increasingly large survey and the assumption that women will have poor recall of what happened to them around the time of birth and given the time-lag in surveys (5 years). However, he stressed that these are all assumptions that need to be tested. In addition, definitions are needed according to content and timing of postnatal care and emphasized that questions based on the period “before the cord is tied” could produce different responses because cultural differences determine when the cord is cut and tied. He proposed some possible definitions:

Immediate Newborn Care (INC): within 1 hr (e.g., for early BF) Postnatal Care (PNC): starts “after delivery of the placenta” (ADP) Early Postnatal Care (EPNC): ADP to up to 12 hours Mediate (or Mid-term) Postnatal Care (MPNC): 12 hours ADP to 7 days Late Postnatal Care (LPNC): from 7 days ADP to 42 days

Future plans for the DHS include standardizing additions of newborn health questions, adding a few of the proven newborn health questions to the core questionnaire, and validating and testing a newborn health module. Current projects underway include a study on Neonatal Mortality and Background characteristics (including new neonatal health questions) in five Asian countries in collaboration with USAID. To assist in better ways of formulating newborn health questions, future research will conduct a qualitative study to test assumptions about mothers’ lack of knowledge/awareness of delivery, postpartum and newborn care in collaboration with SC/SNL and USAID.

After the presentation, participants discussed the process by which instruments are reviewed by the DHS. The DHS review and revision process invites other organizations to suggest revisions and changes and DHS works collaboratively with other organizations implementing surveys to harmonize questions. In addition, a qualitative study has started to inform the development of the module. Another participant suggested that the DHS should interview the interviewers after a recent survey to assess how questions are working in the field and that this could provide a lot of information and be fairly easy to do. There was a clear consensus among participants of the need for more consistency across studies, which they attributed to a lack of clear definitions and terminology. Several participants suggested creating a small technical working group to provide clear definitions and language that could be used to guide qualitative efforts, conduct analyses and validation studies, and inform future modules. One participant from SNL said that they have been doing a lot of work in this area and that DHS could piggy back on these efforts. Particpants also suggested further analyses that the DHS could do to inform the development of the modules.

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During the presentation, bivariate analyses were presented that showed differences in neonatal mortality for certain indicators. It was suggested that this analysis be expanded to identify where the gaps are, and where the survey could be strengthened. Alfredo noted that the DHS plans to look at multivariate analyses and that these findings need to be interpreted within a country context. Additionally, other participants suggested that the technical working group look at each question more critically. For example, asking the mother whether the neonate was examined might not be as valid as questions that ask, for example, whether anyone observed the mother breastfeeding or examined the mother.

Presentation #7: An overview of SNL surveys, core indicators and new questionsPresenter: La Rue Seims, Save the Children

La Rue Seims reviewed the background of SNL surveys, differences in SNL questions compared to DHS questions, and identified questions needing further testing and why. In the first phase of SNL, surveys were initially conducted in six focus countries and five research countries measuring 25 core indicators with standard definitions. Questions were included on antenatal, delivery, postnatal care, and breastfeeding. Respondents were mothers with a child less than 1 year and sample sizes ranged from 300 to 4,513. Currently, surveys have been completed or are planned in 14 countries, with seven planned from May to September, 2008. Some of the major differences between SNL and DHS questions are:

SNL asks questions regarding postnatal care and timing for all babies, including those born in facilities and at home; Both SNL and DHS now ask questions about maternal postnatal care before discharge and after discharge separately for facility births. Early SNL surveys did not make a distinction between postnatal care before and after discharge for facility births and current SNL surveys do not make this distinction for postnatal care for babies; SNL has used a pregnancy or birth history for research studies, but not in all countries doing operations research.

With regard to indicators testing nationally and globally (category 1), most SNL surveys include all DHS questions on the content of ANC. Questions tested in sub-national surveys (category 2), include questions related to danger signs during pregnancy, birth and postnatal care for mother and baby; cord care; thermal protection; and number of times for PNC. These questions were tested by SNL through the CS Grant Project and specific questions are found below:

Category 2: Questions Tested in Sub-national SurveysContent Illustrative QuestionDanger signs o During any of your antenatal care visits were you told about the

danger signs of pregnancy? o What are the danger signs, or symptoms, during pregnancy

indicating the need to seek immediate health care? o Were you told where to go if you had any of these danger signs?Similar questions were asked for delivery and postnatal care.

Cord Care o What instrument was used to cut the cord?

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o Was anything put on (NAME)’s cord after it was cut? o What was put on (NAME)’s cord after it was cut.

Thermal Protection o How long after birth was (NAME) bathed? (Answers recorded in hours, days, weeks after delivery.)

Number of PNC visits o How many times did (NAME) receive care in the first week after he/she was born?

La Rue also discussed questions needing further development (category 3) but which have been included in SNL surveys. It was noted that questions on resuscitation and sick babies (infections) had small samples sizes.

Category 3: Questions needing further developmentContent Illustrative QuestionsThermal protection o Was (NAME) dried (wiped) immediately after birth before the

placenta was delivered?o Was (NAME) wrapped in a [warm] cloth or blanket immediately

after birth before the placenta was delivered?Ethiopia only:o What have you done to keep (NAME) warm following delivery?o In the first fifteen days of life, how frequently per day did you

hold (NAME) skin-to-skin against your breasts during the daytime and nighttime?

o In the first fifteen days, did you sleep with (NAME) against you at night, or do you lay him/her on the bed/cot, or elsewhere?

Postnatal Care Content o What did the health provider do during that visit to check on your health? (Malawi) (Malawi questionnaire was shared with response categories.)

o Sequence of questions asked on content of last three PNC visits (Ethiopia) (Ethiopia questionnaire was shared.)

Birth preparedness o During your last pregnancy did you make any preparations for your delivery?

o What preparations did you make for the delivery? (Many surveys)

o Who did you plan to attend the delivery? With whom did you discuss this plan? What was the decision on place of delivery? Who decides in this family on whether or not to go to a skilled birth attendant? (Indonesia)

o How did you prepare financially for the delivery? Did you or members of your family set aside any money specifically for care during the delivery? How much money did you set aside specifically for care during the delivery? Who did you plan to

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attend your delivery? During your last delivery, did you plan for a place to deliver your child? Where did you plan to deliver your child? (Ethiopia)

Small babies o Since your baby was small, did you receive extra visits or care for your baby?

o Since your baby was small, what extra care did you give to your baby? (Ethiopia)

Extensive counseling questions

The mother was asked about counseling topics discussed with her. Spontaneous responses were recorded and then each response was prompted. For each topic mentioned, a list of sub-questions were asked: o During that visit, what were the topics discussed with you? (E.g.

breastfeeding, umbilical cord care, etc.)o What advice on breastfeeding was given to you by health

personnel? o What advice on umbilical cord care was given to you by health

personnel? (Indonesia)

Resuscitation o Did your baby cry or breathe easily immediately after birth?o What was done to help the baby cry or breath at the time of

birth? o Who took these measures to help the baby cry [or breath]?

(Ethiopia)Sick babies (infections) o An additional module was conducted (Ethiopia)

After the presentation, one participant inquired about how neonatal mortality was assessed from an SNL study in Pakistan where women are interviewed if they had had a child within the previous year. This prompted discussion on the differences in administering birth or pregnancy histories. As some members of the pregnancy and birth history module working group noted, there is a great challenge in finding studies that can compare birth verse pregnancy history and the quality of data. The main benefit for administering pregnancy history is that it provides a better measure of stillbirths and reduces misclassification of early neonatal deaths. Many participants noted the benefits of measuring stillbirths for programs and that programs may underestimate the impact of certain interventions without stillbirth data. One participant noted that the effects on maternal health, stillbirths, and neonatal deaths are all related to the same set of events, thus, we may be cutting ourselves short by not tracking stillbirths. Additionally, several participants remarked that some of the cultural assumptions, such as not talking about pregnancy or stillbirths, need to be challenged. Many provided experiences from different countries where these assumptions proved incorrect; however, these assumptions may vary in different cultural contexts and they need to be tested. Another participant noted that some of the SNL questions on cord care in the DHS need further prompting for some of the response categories and that standardization of these questions is needed across surveys. For example, the question on cord care in the SNL surveys asks about what instrument was used to cut the cord, but does not follow-up with a question on whether the instrument was boiled or not, which has implications for measurement. Other participants suggested that resources be made available not only to DHS and MICS, but for other organizations with a need to have consistent, standardized

23


and tested questions. It was suggested that working group could identify sources of studies to pull questions from and that a virtual workspace be created where these questions can be posted.

Presentation #8: Presentations of group work on intrapartum practice module, postnatal visit content and timing module, and pregnancy and birth history modulesPresenters: Goldy Mazia, BASICS Kate Kerber, Save the Children

Marie Thoma, JHU SPH

Presentation #8a: Intrapartum practices module

Goldy Mazia reported the results of the group work on the intrapartum care module. The groups presented a list of questions used to assess intrapartum care for the mother and baby and questions concerning the robustness of these questions for measuring maternal and newborn health. The questions and related concerns are outlined below:

Category 1: Tested globally and nationally

Place of delivery (DHS core) Facility

Who attended the birth (DHS core) o How would mother know?

Delivery by cesarean section (DHS core)Length of stay in facility after delivery (DHS core Q437)o How is this indicator being used?

Home Who attended the birth (DHS core) Reasons for not delivering in facility (DHS core) o Useful? How is data used?

AllBaby weighed and weight (DHS) Perception of baby size (DHS) Time of first breastfeeding (DHS)

Category 2: Used before, but need further testing

Did you receive a blood transfusion? (Nepal DHS Q425)o Needs to be validated

Use of safe delivery kit o Context-driven, further analysis on associations needed

AllHow long after birth was the first bath? Hours/days;o recognition of time, needs validation for facility births

Knowledge of danger signs during labor and delivery (Include during antenatal care) DHS includes a question on pregnancy danger signs (Ethiopia) o Face validity but needs some testing

Did you have complications during delivery? (Optional- relatively smaller

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sample sizes, survival bias) (Sudan)Did you seek care? (Optional-not relevant if in facility already, sequence? Filter?) (Sudan)When did you seek care? (Optional) (Sudan)Where did you go? (Optional) (Sudan)Drying before the placenta was delivered o Needs validation; perception of drying, recall, define ‘immediate’

Category 3: Need further development

Wrapping before the placenta was deliveredo Complex if you ask wrapping and skin-to-skin, sequence, recall,

perception of wrapping.Hat/ Cover the baby’s headInstrument used to cut umbilical cordo Recall, response categories (clean, boiled etc), mother’s knowledge,

home births only.What was used to tie the cord? o Validation needed, Response categories problematic

Anything placed on cord on first day (e.g. Nepal DHS)o Question for postnatal package, validation needed, recall,

responses,timingDid baby cry or breathe at birth? What measures taken to help baby cry or breathe at birth? o Validation needed, sequence

Skin-to-Skin/KMC (e.g. Ethiopia SNL survey)o Validation needed, routine or LBW, duration of STS, timing, needs a

lot of work

Participants discussed the element of timing of events and how the questions are asked. Skin-to-skin care was mentioned as being particularly problematic, since it is not a well known practice in most countries and has only been shown to be effective in low birth weight babies. The working group acknowledged that more time is needed to develop questions around skin-to-skin care and who should be targeted (routine or LBW babies). One participant mentioned the NEWHINTS study in Ghana that Betty Kirkwood presented and that they only directed attention to low birth weight babies, because they did not want to detract from the overall message of thermal management through drying, wrapping, and delayed bathing. Another participant questioned whether we need to ask about all three events (drying, wrapping, bathing) and that a more simplified, yet effective, question may be more achievable.

Presentation #8b: Postnatal visit content and timing module

Kate Kerber presented the results of the postnatal care group work, which presented the types of questions to be included within a postnatal care module and further considerations that need to be addressed. The questions and related concerns are outlined below. The group also set action steps and deadlines for moving forward. Immediate goals include the formation of a technical working group to develop a core questionnaire, develop a virtual workspace for sharing information, and coordinate a series of meetings to inform each other of new evidence by the end

25


of May 2008. Short-term goals include further analysis of existing quantitative and qualitative data and a draft newborn health module by the end of 2008.

Category 1: Tested globally and nationally

Time, person, and place of first PNC checko Ensuring PNC (mother) and PNC (baby) is asked of mothers

delivering both at facility and at homeo Needs to be accompanied by length of stay in facilityo Tweaked questions to ensure similarity between mothers and

babies, to remove leading questionsCategory 2: Used before, but need further testing

Total number of postnatal health checks: In the first week after the birth of (NAME) how many times in total did any health care provider/traditional birth attendant check on your/(NAME) health?

o Within what time frame? Within one week? o For both mother and baby

Content of postnatal health checks (mother): Were any of the following done as part of the check on your health?

o Asked/checked for fever/temperatureo Asked/checked for discharge/bleedingo Checked breastso Counselled on family planning, breast care and feeding and mother

danger signso Quality of service (e.g., India DHS)

Content of postnatal health checks (baby): Were any of the following done as part of the check on (NAME)?

o Undress and examine babyo Checked for fever/temp o Observed breastfeedingo Baby weighedo Counselled on baby danger signso Asked/checked difficult/fast breathingo Asked/checked for convulsions/spasmso Checked umbilical stump o Ointment in baby’s eyeo Counselled on immunisation

Category 2/3: Practice of care-seeking for danger signso Which ones?o Newborns failing to feed taken to health care provider

Practice of giving colostrumPractice of skin-to-skin

o breast vs chest, all babies vs LBW, timingKnowledge of mother danger signsKnowledge of baby danger signsKnowledge of Kangaroo Mother Care

Category 3: Need further development

Wording o Did any health care provider [check vs. examine] the health of the

mother/baby

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o Health provider and traditional birth attendant vs. did anyone check on your health, if so whom?

o Cord care – when is the important time for the practice vs. asking the question?

Mother’s recallo Content of the first checks/visit [details vs. big picture action]o Content of subsequent checks/visits.

Mother’s understandingo Is this first check on your health included at the time of delivery

(further data analysis, also qualitative research)

This presentation led to some discussion regarding the importance of asking about content of postnatal care after the first visit. While there was not a complete consensus, the working group suggested asking about the content and quality of the first visit and then asking about the number of postnatal care visits since the 1st visit. Another participant noted that women who deliver in an institution might not report having received postnatal care. She suggested that more testing is needed to understand when mothers consider the birth process to have ended and postnatal care to have begun. Other participants discussed the need for a reliable indicator on newborn illness and better clarification of the appropriate symptoms to measure.

Presentation #8c: Pregnancy and birth history modules

Marie Thoma presented results from the group work on pregnancy and birth history modules. The questions between birth history and pregnancy history modules were compared. The group discussed possible options for inclusion of a pregnancy or birth history module to include a standard birth history (current DHS core), a full pregnancy history, or a composite history. Other options were considered for the full pregnancy history, such as whether or not to include questions that probe for early pregnancy loss or abortion, and inclusion of an additional question on duration of pregnancy. A composite history included using a birth history plus a truncated pregnancy history or a birth history plus an additional question on whether the baby cried, moved, or breathed. Advantages of a full pregnancy history are that it captures stillbirths and provides a better measure and classification of neonatal deaths. Including an additional question on duration of pregnancy can also provide better information on preterm birth rates. Some of the limitations for incorporating a full pregnancy history include an increased length of interview time (dependant on the TFR of country) and cultural barriers to talking about pregnancy. However, there is limited evidence that pregnancy histories produce better quality data and more examination of cultural barriers is needed.

The recommendation of the group was to include a full pregnancy history module without questions probing reasons for early pregnancy loss or abortion and with an additional question on duration of pregnancy (as has been done in the 2006 Nepal DHS). However, they recognized that more information is needed on quality of the data that pregnancy modules provide as well as exploration of cultural barriers, and feasibility of implementation. She ended the presentation with action steps to be undertaken over the next year. Immediate steps include a thorough review of the literature to identify validation studies comparing pregnancy and birth history modules and to gather information on field experiences in Nepal and elsewhere that utilize the

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pregnancy history module. Over the next few months, steps will be taken to initiate dialogue with DHS regarding new surveys, review any new experiences with survey implementation, begin any formative research, and analyze secondary data where appropriate. Additional opportunities for inclusion of a pregnancy history module and ways to improve data collection instruments will be explored over the next 12 months.

Discussion following the presentation revolved around the concerns regarding the implementation of adding a pregnancy history module. One participant commented that some view the pregnancy history to be too onerous for the mother and interviewer; however, there is increasing interest to collect, through surveys, information relating to stillbirth and this information could be very important for countries and programs. Studies are needed to assess timing and burden of administering a pregnancy history module compared to a birth history. In addition, participants discussed the paucity of data on whether pregnancy histories actually produce better quality data compared to birth histories. Participants also agreed that inclusion of a calendar history may be more complex and not improve data quality; however, this has not been validated. Another participant questioned the need for a full pregnancy history and suggested a truncated history (5-10 years) might be sufficient. She also suggested asking for history in reverse chronological order in order to capture earlier pregnancies first when the respondent is less fatigued.

Presentation #9: Next steps for finalizing modules and testing indicatorsPresenter: Joy Lawn, Save the Children

Joy Lawn concluded the meeting by reviewing the next steps set forth by the working groups and agreements reached by the participants. She pointed out the need to focus on benchmarks given the important deadlines for DHS and MICS, which provide an opportunity to change two key instruments regarding newborn health. A technical working group (TWG) was identified, with representation from USAID, UNICEF, DHS, and SNL, to develop terms of reference, to develop survey modules, a plan to test questions where needed, and define action steps to move forward. The working group will be responsible for determining a timeline and process for developing and vetting survey modules. This process will be immediate in order to meet deadlines for finalizing the MICS survey in November 2008 and for eventual inclusion of relevant information in the new DHS. The group will reconvene in six months to present its progress. Other participants recommended making this information more widely accessible to other organizations and a wider public health audience, including media and peer-reviewed journals.

The technical working group (TWG) should: o examine the recommendations presented in the group work from this meeting on

intrapartum care, postnatal care and pregnancy history;o consider the development of a generic newborn health survey module that incorporates

additional questions;o further brainstorm ideas, especially related to skin-to-skin and care seeking for illness; o identify areas (validation, recall, timing of interview) that need to be addressed through

formative research. Possible sources for these questions to be addressed are through DHS/qualitative research, SNL studies (Ethiopia and studies with repeat surveys), and NEWHINTS studies;

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o work with interviewers following the newborn health survey to determine what worked or didn’t work during survey implementation; and

o develop a forum/virtual work space where this information can alert a wider public health audience.

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Appendix I

Agenda for Consultative Meeting on Survey-based Indicators for Monitoring and Evaluation of Newborn Health

April 29-30, 2008Save the Children/Saving Newborn Lives (SNL), Washington, DC

Day One -- April 29, Tuesday, 9:30AM-4:30PM

8:45 Breakfast and meet & greet

9:30 Welcome & introductionMeeting objectives and agenda review

Leslie ElderShyam Thapa

10:00 Tracking newborn health from SNL perspective Kate Kerber

10:30

Formative and pilot experiences in Ghana in shaping the measurement of selected newborn practices via surveillance data collection and periodic surveys, especially with regard to immediate breastfeeding, skin-to-skin and home care practices (with 30-minute discussion)

Betty Kirkwood

12:00Lunch & DebriefingProgress on MDGs 4 and 5 toward the Countdown to 2015: Debriefing from the Countdown Meeting in Cape Town April 17-19

Anne Tinker, Joy Lawn &Holly Newby

1:45Closing the measurement gap for intrapartum practices and postnatal careWhat do we want to measure? What are we measuring now?Discussion

Joy Lawn & Kate Kerber

2:45 Experiences (strengths, limitations and lessons learned) from Sylhet, Mirzapur and Shivgarh studies on using survey data for selected indicators (with 30-minute discussion)

Saifuddin Ahmed, Abdullah Baqui, & Luke Mullany

3:45

Group work:

Group 1 – Intrapartum practices moduleWinnie MwebesaGoldy Mazia

Group 2 – Postnatal visit content & timing moduleSteve WallKate Kerber

Group 3 – Pregnancy & birth history modules Saifuddin AhmedMarie Thoma

4:30 Close of day one

(Cont’d)

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Appendix I (Cont’d)

Agenda for Consultative Meeting on Survey-based Indicators for Monitoring and Evaluation of Newborn Health

April 29-30, 2008Save the Children/Saving Newborn Lives (SNL), Washington, DC

Day Two -- April 30, Wednesday, 9:30AM-4:30PM

8:45 Breakfast

9:30MICS and newborn health (mortality and high impact intervention tracking: strengths, gaps and limitations; future plans)

Holly Newby & Atilla Hancioglu

10:15 DHS and newborn health (mortality and high impact intervention tracking: strengths, gaps and limitations; future plans)

Alfredo Fort

11:00 An overview of SNL surveys, core indicators and new questions La Rue Seims

12:00 Lunch

1:00

Group work -- continued

Group 1 – Intrapartum practices moduleWinnie MwebesaGoldy Mazia

Group 2 – Postnatal visit content & timing moduleSteve WallKate Kerber

Group 3 – Pregnancy & birth history modules Saifuddin AhmedMarie Thoma

3:00 Group work presentations & discussion

4:00 Next steps for finalizing modules and testing indicatorsJoy Lawn & Steve Wall

4:30 Closing of Consultative Meeting Shyam Thapa

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Appendix II

Participants for the Consultative Meeting on Newborn Health Indicators,

April 29 & 30, 2008

Name Organization Email AddressAhmed, Saifuddin JHU SPH [email protected], Alfredo Macro/PATH [email protected]

mHancioglu, Attila UNICEF/MICS [email protected], Lily USAID [email protected], Betty LSHTM [email protected], Lisa USAID [email protected], Goldy BASICS [email protected], Vinod K. Macro DHS Vinod.K.Mishra@macrointernational.

comNarayanan, Indira BASICS [email protected], Holly UNICEF [email protected], Beth Freelance

[email protected]

Rose, Mandy URC [email protected], MA ICDDR,B [email protected], P. Stan Macro DHS [email protected]

m

Alegre, Juan Carlos

SC [email protected]

Amsalu, Ribka SC [email protected], Massee SNL/SC [email protected], Leslie SNL/SC [email protected], Tanja SNL/SC [email protected], Kristina SNL/SC [email protected], Kate SNL/SC [email protected], Joy SNL/SC [email protected], David SC [email protected], Winifride

SNL/SC [email protected]

Otchere, Susan SNL/SC [email protected], La Rue SNL/SC [email protected], Steve SNL/SC [email protected]

Paradis, JoAnn Admin/Logistics Support

[email protected]

Thapa, Shyam Coordinator [email protected], Marie Note taker [email protected]

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Documents

Report of a Consultative Meeting on - Healthy Newborn Network report … · Consultative Meeting Report -- Indicators for Newborn Health Advantages of a full pregnancy history are