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”
Numerator:
A: New Registered/first ANC visit of a pregnant woman
B: Pregnant women registered within first trimester
C: New women registered under JSY
Denominator A:Total expected pregnancies
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
Suggested
level of use
Other Useful
• 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
• Risk and continuity indicators are important in ANC
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Indicators
• 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.
Common
Problems
• 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
Actions to
Consider
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
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
Numerator
ANC third visit
Denominator
A. Expected pregnancies
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 Source ANC Register maintained by health workers
Other Useful
Indicators
Suggested
level of use
Common
Problems
Actions to
Consider
• Drop-out rate first to third ANC
• Comparison of third ANC to delivery rates
• %ANC with full blood tests (Hb, HIV, VDRL)
State, District, Block and sub-centre
• When ANC has been done in different 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
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Indicator Manual
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:
a. % ANC TT-1 coverage rate
b. % ANC TT2 and TT booster coverage rate
c. ANC 100 IFA coverage rate
Definition
Percentage of pregnant women who used antenatal
care and were given TT1,TT2 or TT booster vaccine
Numerator
A Antenatal care given TT-1
B. Antenatal care given TT2 or TT booster
C. Antenatal care given 100 IFA Tablets
Denominator
Total ANC registered (ANC first visit)
Rationale
Data Source
Other Useful
Indicators
Suggested
level of use
Common
Problems
Actions to
Consider
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
Registers maintained by health workers; Household
surveys
• TT protected at birth rate measures % of newborns
protected from tetanus by their mother being fully
immunised for TT
• Neonatal Tetanus rate measures cases of Neonatal
tetanus- a failure of our ANC TT immunisation program
• Anaemia rate
State, District, Block, sub centre
•
• IFA tablets given may not be consumed
• Addresses supply side issues
• Ensure quality of ANC
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• Awareness generation among mothers on availing
complete ANC services
Indicator MH 4: ANC Anaemic & Hypertension testing and management rates
A.
B.
C.
D.
E.
% ANC moderately anaemic
% ANC severely anaemic
% ANC severely anaemic treated rate
% ANC hypertension new case detection rate
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)
Numerator
A.
Pregnant women tested anaemia <11g
B.
Severely anaemic pregnant women treated
(Hb<7g)
C.
Pregnant women detected BP>140/90
D.
Number of eclampsia cases managed during
delivery
Denominator A, B & C =Total ANC registration
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 incharge in advance
Data Source ANC/ Pregnancy Registers maintained by health workers
Other Useful G.
ANC hypertension management rate
Indicators
H.
LBW rate is common consequence of anaemia &
Hypertension
I. Still birth rate/PNM affected by anaemia
J.
Maternal death due to excessive bleeding is more
likely in an anaemic
K.
Laboratory equipment availability rate
Suggested
Health sub-centre, PHC, CHC
level of use
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Common
Problems
Actions to
Consider
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 Birth
A skilled birth attendant is an accredited health
Attendant
professional - such as a midwife, doctor or nurse - who
definition
has been educated and trained to proficiency in the
skills needed to manage normal (uncomplicated)
pregnancies, childbirth and the immediate postnatal
period, and in the identification, management and
referral of complications in women and newborns
Numerator
Deliveries by SBA (SBA Home + all Institutional deliveries)
Denominator
A. Expected numbers of deliveries
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 Source Labour records and maternity registers maintained at
facilities and by health workers; Household surveys
Other Useful • SBA deliveries as proportion of ANC first visit
Indicators
• SBA deliveries as proportion of reported deliveries
• SBA deliveries at institutions and at home;
• Peri-natal mortality from SBA deliveries
Suggested
District, Block
level of use
Common
• The definition of SBA excludes Traditional birth
Problems
attendants, even if they have been trained. Even
professional staff that have had training, lose their
delivery skills if they do not use them.
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•
•
Actions to
Consider
•
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
Denominator A: Expected deliveries (2.2 To 3.2 % of population)
B: Total Number of deliveries reported
C: Total Number of deliveries reported
D: Total Number of deliveries reported E: Deliveries
Institutional
Rationale
A) There is clear evidence that institutional deliveries
by SBAs are the key to reducing maternal
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Data Source
Other Useful
Indicators
Suggested
level of use
Common
Problems
Actions to
Consider
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
B
C
D
E
Home delivery rate
Reported home delivery rate
Home delivery by Skilled birth attendant (SBA) rate
Home delivery by Non Skilled birth attendant rate
% Home delivery receiving JSY benefit
Definition
A) Percentage of total deliveries that took place at
B)
C)
D)
E)
home
Reported home delivery rate
Home deliveries attended by SBA
Home deliveries attended by Non-SBA
Home deliveries receiving JSY benefit
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Indicator Manual
Numerator
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
Denominator
A, C & D =Total expected deliveries
B= Total reported deliveries (home + Institution)
E=total home deliveries
Rationale
• 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
Data Source Registers maintained by health workers; word of mouth
from TBAs ANMs
Other Useful • Home deliveries per reported deliveries
Indicators
• Perinatal mortality at home deliveries
• Maternal deaths from home deliveries
Suggested
State and District
level of use
Common
Home deliveries by untrained TBAs are often not reported
Problems
Actions to
• Home deliveries should be actively discouraged if
Consider
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
Numerator
Number of facilities with functioning BEmOC per 500,000
population
Facilities who have reported all three BEmOC signal
functions within the past 3 (WHO RHI) months
• Complicated Delivery: IV Antibiotics
• Complicated Delivery: IV Oxytocics
• Complicated Delivery: IV Antihypertensives/ Magsulph
Denominator 500,000 population
Planned BEmOC centres or 24x7 facilities + FRUs
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Rationale
Data Source
Other Useful
Indicators
Suggested
level of use
Common
Problems
Actions to
Consider
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
Indicator MH 9: Comprehensive Emergency Obstetric Care (CEmOC) availability
Definition
Numerator
Denominator
Rationale
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.
Facilities who have reported all BEmOC functions AND
CEmOC
Caesarean section
Blood transfusion
A. 500,000 population (WHO guidelines)
B. No of FRUs planned/ No of DHs
CEmOC facilities are needed 1:500,000 total population
(Ref Programming for safe motherhood UNICEF 1999)
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Indicator Manual
Data Source
Other Useful
Indicators
Suggested
level of use
Common
Problems
Actions to
Consider
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
Indicator MH 10: Admission duration after delivery
Definition
Percentage of women who were discharged in less than
48 hrs of delivery
Numerator
Institutional delivery discharged up to 48 hrs of delivery
Denominator Deliveries Institutional
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 Source Maternity Registers maintained by the health workers and
health facilities
Other Useful • Causes of PNC complications
Indicators
Suggested
District
level of use
Common
Many women want to go home early, but this prevents
Problems
adequate PNC
Actions to
Consider
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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.
Numerator
Deaths Maternal ( this month; over last 12 months period)
Denominator No of live births recorded
Rationale
Data Source
Other Useful
Indicators
Suggested
level of use
Common
Problems
No of live births estimated over a one year period
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
Line listing of maternal deaths; Labour records and
registers maintained at facilities CRS; Community
feedbacks
A Maternal Mortality Audit should provide detailed
disaggregation by:
• Cause (sepsis, malaria, PPH, PIH, Obstructed labour,
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
National and below
Maternal deaths are relatively rare events and need
large sample size
Under-reporting is a major problem with MMR. Most
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 12: Birth reporting rate
Definition
Proportion of births reported over a given period of time.
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Indicator Manual
Numerator
Births reported
Denominator Estimated births of population
Rationale
This indicator assesses the proportion of births reported by
the health services in order to assess overall coverage of
safe deliveries by health workers.
Data Source Line listing of births; maternity registers and household
surveys etc
Other Useful Comparison to CRS reports
Indicators
Suggested
National, State, District and Block
level of use
Common
Problems
Actions to
Consider
Indicator MH 13: Postnatal care
Definition
Percentage of women who used postnatal care
provided by skilled health personnel
Numerator
Postnatal mother/baby visits
Denominator Total Deliveries (Institutional + Home)
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.
• 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
Data Source Registers maintained by health workers; Household
surveys
Other Useful • Length of stay after delivery shows whether
Indicators
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
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Indicator Manual
Suggested
level of use
Common
Problems
Actions to
Consider
• 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
Numerator
Denominat
or
Rationale
Data
Source
Other Useful
Indicators
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
• Postnatal care rate
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Indicator Manual
Suggested level
District
of use
Common
Often not recorded, as there is often no space in
Problems
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.
Actions to
Formative research to understand the issue and design
Consider
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
Indicator CH 2: Neonatal referral rate
Definition
Numerator
Percentage of neonates (upto 28days old) with complications
referred for
institutional care
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.
Denominato
r
Live births( as recorded)
This data should be collected by institutions to identify the
Rationale
proportion of
neonates with complications referred for specialised care
Data Source Neonatal registers at institutions
Other Useful •% of newborn referrals against estimated live births – this needs no
new data element- and is most useful where private sector is also
reporting.
Indicators
• % of low birth weights and severe low birth weight
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Indicator Manual
•
% Newborn referrals successfully treated( if appropriate data
element is added)
Suggested
level
District
of use
Common
Problems
Actions to
Consider
• 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
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.
• 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
• Ensure private sector also
reports
Indicator CH 3: Sex ratio at birth
Definition
Numerator
Denominat
or
Rationale
Number of females born per 1000 males born in a give time period
Live Births females x 1000
Live Births males
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 females
per 1000 males( this is due to a slightly greater loss of male fetuses).
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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
Line listing of births maintained by health workers; delivery registers
Other Useful
• Sex ratio in 0-5 age group
Indicators
• Sex ratio in population
Suggested
level
of use
National and below, particularly district as there is no other source
of data at district level.
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
Numerator:
Denominator:
Rationale
Data Source
• Live births per 1000 population
• All recorded live births in that facility’s service
area/block/district in the last 12 months
• Population of that facility’s service area/ block/district
• This is the crude indicator of fertility in that population. Also 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
• Maternity registers of Sub-Centres, PHC and CHCs.
• Household surveys
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Other useful
indicators
Normal
Ranges
Common
Problems
Actions to
consider
• Total fertility rate
•
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%
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
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
•
•
Indicator CH 4: Low birth weight rate
Definition
Numerator:
Denominator:
Rationale
• Percentage of live born infants with a Birth weight under
2,500 grams
• Live births with a birth weight < 2500g.
• Live births weighed
• At the population level, the low birth weight (LBW) rate is an
indicator
of a multifaceted public-health problem that includes longterm
maternal malnutrition, ill health, hard work and poor health
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Indicator Manual
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
Other useful
indicators
Normal
Ranges
Common
Problems
• Maternity registers of Sub-Centres, PHC and CHCs.
• Household surveys
% children weighed- the denominator would be recorded
• 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 there is no other
• complication.
Less than 10% of all birth should be under 2,500 grams,
• though many
states have up to 30% LBW
Many children are not weighed at birth, particularly those
• delivered at
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
Efforts to increase percentage of children weighed- by
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Indicator Manual
Actions to
consider
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
Definition
Numerator
Denominat
or
Rationale
Neonatal mortality rate (NNMR) measures the number of live-born
babies
dying within 28 completed days of life per 1,000 live births.
Deaths in first 28 days
1000 live births
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 Useful • NNMR can be divided into early (0-7 days) and late (8-28 days).
This information is potentially available in the line list- but currently
not being aggregated.
Indicators
• NNMR can be disaggregated by gender
Suggested
State and district. Calculate only when you have at least 3,000
level
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
common, particularly for deaths. Cultural reluctance to reporting
Problems
early neonatal deaths- which only good training and supervision
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Indicator Manual
and community dialogue can overcomes
Actions to
occurring early in life (particularly first hour).
• 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
Numerator
Denominat
or
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.
Data Source
Other Useful
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
Indicators
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Indicator Manual
Suggested
level of
use
Common
Problems
female infanticide
• 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.
Actions to
Consider
• 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.
Indicator CH 7: Under 5 mortality rate
Definition
Under-five mortality rate measures the number of children who
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Indicator Manual
Numerator
Denominator
Rationale
Data Source
Other Useful
Indicators
Suggested
level of
use
Common
Problems
die before their
fifth birthday per 1000 children under five years
Deaths Neonatal + Deaths infant + Deaths 1-5 years
1,000 children under five years
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
Actions to
Consider
• 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
Peri-natal deaths comprise still births (gestation over 228 weeks /
Definition >1000 grams
weight) plus early neonatal deaths (infants dying within 7 days).
Numerat
or
Deaths Peri-natal (still births plus early neonatal in first week)
Denomin
1000 live Births.
at
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Indicator Manual
or
Rationale PNMR directly reflects maternal health, quality of prenatal, intrapartum and
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
Indicator PNMR at different type and level of Institutions, public and private
s
PNMR by type of birth assistant (SBA, Non-SBA)
PNMR by gender
Compare with NNMR
Suggeste
d
National and below. Calculate and make predictive trend analysis
only when you
level of
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Indicator Manual
use
have at least 3,000 births, otherwise fluctuations will be too high.
Common Comparisons between different rates may be hampered by varying
definitions,
Problems registration bias, and differences in the underlying risks of the
populations.
Reporting of still births is also problematic
Actions
to
Institutions with high PNMR need additional support to identify the
causes of the
Consider
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.
2
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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Indicator Manual
IMMUNISATION INDICATORS
Indicator CH IMM 1: Vaccine Specific Immunisation coverage under one year
A
B
C
D
E
BCG
OPV (1,2,3)
DPT (1,2,3)
Measles
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 :
b. Expected number of children under 12 months, based on mid
Denominator
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.
Immunisation registers kept by health workers; Immunisation
Data 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
Vaccine availability rates
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Indicator Manual
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
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
Actual number of 12 to 23 months children based on household
Denominator survey done at year beginning.
Full Immunisation coverage is the “pinnacle” indicator for
Rationale
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.
Immunisation registers kept by health workers ;
There needs to be a separate column in this
register where the age of child in months when
Data Source given the last immunization needed for full
Definition
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Indicator Manual
immunization status is recorded
EPI cluster surveys; Other household surveys
Other Useful
Indicators
• Full immunisation coverage by gender – male and female
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
Actions to
Consider
• 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
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)
Numerator
Adverse reactions –
A) Abscesses
B) Deaths
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Indicator Manual
C) Others
Denominator 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
Investigate all adverse reactions to identify the cause and
Actions to
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
Definition
Percentage of total planned immunisation sessions held
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Indicator Manual
Numerator
Denominator
Rationale
Number of immunisation sessions held
Total number of immunisation sessions planned
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
Actions to
worker is directly accountable for the failure.
• Detailed micro planning exercise often not carried out. The
number of sessions planned itself may be faulty.
• 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
Definition
Percentage of children who have received all required vitamin A
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Indicator Manual
doses. (One
dose for a child under one and five doses for a child under three
years)
Numerator
Children who received Vitamin A
A) 1 dose under one year
B) 5 doses under three years
C) 9 doses under 5 years
Denominator 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%.
Immunisation register and Reports of Vitamin A by service
Data 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
Numerator
Comparison of the number of children who start receiving
immunisation and
the number who do not receive later doses for full immunisation
Number of children starting particular dose of antigen MINUS
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Indicator Manual
number of
children receiving later dose of antigen
Denominator 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
Problems
• A high drop out rate means that mothers have no faith in the
immunisation
• 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
Indicator FP1: Couple Year Protection Rate
Definition
Numerator:
Percentage of eligible couples in the community protected by
"modern" family planning methods for one year .
Number of couples protected by each family planning method
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Indicator Manual
which is approximated by a formula:: number of cases sterilised
in particular month*10+number of pills distributed/13 + number of
IUDs inserted*5.5+ no of condom pieces distributed/100
Denominator Number of eligible couples (with fertile age women 15-49 years).
The number of eligible couples are approximate 17% of total
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.
Data Source The easiest way to calculate this is from the stock cards and from
sterilisation record. Note the total outgoing contraceptives 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
Consider
Other
Possible
Indicators
Low coverage means that unwanted pregnancies will occur.
Increased CYP will occur mainly through health promotion and
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 month’s value
multiplied by 12 to get a picture of what would happen if this
rate continued throughout the year.
• 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
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
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Deleted: .
Indicator Manual
Suggested
level of use
Common
problems
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
Actions to
consider
Indicator FP 2: Family Planning Coverage rate by method
Definition
The coverage contribution of each contraceptive method to
the overall family planning program
Numerator
Total number of units of each type of contraceptive
distributed
A) Oral Contraceptive cycles
B) Condoms
C) IUD insertion
D) Centchroman (weekly) pills
E) Emergency Contraceptive pills
Denominator Eligible couples
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 Source Family Planning Registers maintained by health workers and
health facilities; Household surveys
Other Useful Method Mix
Indicators
Suggested
District
level of use
Common
Exact number of OCPs or condoms distributed- are difficult to
Problems
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.
Actions to
Consider
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Indicator Manual
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Indicator Manual
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
Numerator
Sterilisations performed this month plus already sterilised
eligible couples
A) Male
B) Female
Denominator Eligible couples
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 Source Registers and data collection forms maintained by health
workers and health facilities (including Camp)
Eligible couple registers
Other Useful • Male sterilisation by type –
Indicators
o conventional and
o NSV
• 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
Suggested
National and below
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
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37