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  1. 1. Introduction
    1. 1.0 Overview
    2. 1.1 What is the Purpose of the Field Guide
    3. 1.2 Who is the Field Guide intended for?
    4. 1.3 How is the Field Guide organized?
  2. 2. Background
    1. 2.0 Overview
    2. 2.1 Humanitarian Settings Across the Globe
      1. 2.1.1 Challenges to Newborn Health Service Delivery
    3. 2.2 Newborn Health: Epidemiology
      1. 2.2.1 Global burden of newborn mortality
      2. 2.2.2 Principal causes of neonatal deaths
  3. 3. Newborn Health Services
    1. 3.0 Overview
    2. 3.1 General Principles and Considerations
      1. 3.1.1 The Continuum of Care Across the Lifecourse
      2. 3.1.2 Levels of Care
    3. 3.2 Essential Newborn Care
    4. 3.3 Newborn Care at Household/Community Level
      1. 3.3.1 During the Antenatal Period
      2. 3.3.2 Intrapartum and essential newborn care
      3. 3.3.3 Postnatal care
    5. 3.4 Newborn Care at Primary Care Facilities
      1. 3.4.1 Antenatal care
      2. 3.4.2 Intrapartum and essential newborn care
      3. 3.4.3 Postnatal care
    6. 3.5 Newborn Care at Hospitals
      1. 3.5.1 Antenatal care
      2. 3.5.2 Intrapartum and essential newborn care
      3. 3.5.3 Postnatal care
    7. 3.6 Additional Considerations for Preventing and Managing Principal Causes of Neonatal Deaths
      1. 3.6.1 Prematurity/Low Birth Weight (LBW)
      2. 3.6.2 Newborn Infections
      3. 3.6.3 Intrapartum Complications
  4. 4. Strategic Considerations
    1. 4.0 Overview
    2. 4.1 Mainstreaming newborn health in humanitarian coordination
      1. 4.1.1 Incorporate questions about newborn health services within a rapid health assessment
      2. 4.1.2 Advocate for the inclusion and prioritisation of newborn health in humanitarian response plans
    3. 4.2 Conducting a situational analysis
      1. 4.2.1 Examine national policies and protocols relevant to newborn health
      2. 4.2.2 Examine existing clinical guidelines, key messages/ BCC materials, tools and training materials
      3. 4.2.3 Assess resource availability: facilities, supplies and staff
    4. 4.3 Developing an inclusive and unified response strategy
      1. 4.3.1 Prioritizing newborn interventions
      2. 4.3.2 Update and distribute clinical guidelines and protocols
      3. 4.3.3 Develop and collate needs based staff training materials
      4. 4.3.4 Procure and distribute essential medicines and supplies
      5. 4.3.5 Ensure quality improvement and respectful care
      6. 4.3.6 Develop proposals to secure additional funding
    5. 4.4 Developing and implementing a monitoring and evaluation (M&E) plan
      1. 4.4.1 Compromised data flow and routine information systems
  5. 5. Program Implementation Considerations
    1. 5.0 Overview
    2. 5.1 Developing and disseminating key messages/behavior change communication (BCC) materials
    3. 5.2 Developing a referral system
      1. 5.2.1 When referral is not feasible
    4. 5.3 Home visits for mothers and babies
    5. 5.4 Procuring newborn care supply kits
    6. 5.5 Managing newborn deaths in crisis settings
      1. 5.5.1 Support for neonatal loss
      2. 5.5.2 Documenting neonatal loss
  6. 6. Annexes
    1. 6.1 Annex 1: Newborn health services summary tables by levels of care
      1. 6.1.1 Annex 1A
      2. 6.1.2 Annex 1B
      3. 6.1.3 Annex 1C
    2. 6.2 Annex 2: Doses of Common Drugs for Neonates
    3. 6.3 Annex 3: Advanced Care for Very Sick Newborns
    4. 6.4 Annex 4: Tools to Support Neonatal Referrals
      1. 6.4.1 Annex 4A: When to Refer a Newborn to the Hospital
      2. 6.4.2 Annex 4B: Job Aid: Transporting the Sick Newborn
      3. 6.4.3 Annex 4C: Sample Referral Note
    5. 6.5 Annex 5: Newborn Kits for Humanitarian Settings
    6. 6.6 Annex 6: Indicators
      1. 6.6.1 Annex 6A: Newborn Health Indicators for Routine Data Systems
      2. 6.6.2 Annex 6B: List of Indicators and Questions to Measure Facility Capacity to Provide Key Newborn Health Services
Newborn Field Guide

6.6 Annex 6: Indicators

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6.6.1 Annex 6A: Newborn Health Indicators for Routine Data Systems

Incorporate key indicators (bold) into national reporting systems. Other indicators are suggested to provide additional information, where feasible.

Note: Numerator and denominator should always be reported along with the percentages and should be for the same reporting period.

Outcomes
Indicator Numerator Denominator Disaggregation Utility and limitations of indicators

Neonatal mortality rate

Number of newborns who died during the first 28 days (day 0-27) of life in health facilities in a specified time period Total number of live births (per 1000) in a specified time period By timing of death (early neonatal death = 0 to 6 days; late neonatal death = 7 to 27 days) Reports should indicate whether deaths that occur in the community are recorded at a facility.

Pre-discharge neonatal mortality rate

Number of babies born live in a facility who die prior to discharge from the facility during the first 28 days (day 0-27) of life in a specified time period Number of babies born live in a facility in a specified time period By timing of death (early neonatal death = 0 to 6 days; late neonatal death = 7 to 27 days)

Neonatal cause of death

Number of newborn deaths due to

  • Low birth weight and prematurity

  • Complications of intrapartum events

  • Infections (including tetanus, sepsis/meningitis, pneumonia)

  • Congenital malformations or abnormalities

  • Other

  • Unspecified

Number of newborn deaths recorded at a facility By timing of death (early neonatal death = 0 to 6 days; late neonatal death = 7 to 27 days) The indicator is not meant to be interpreted as a case fatality rate but rather provides information on cause of death among known, reported deaths. Reports should indicate whether causes of deaths that occur in the community are recorded at a facility.

Stillbirth rate in health facility

Number of fetuses and infants born with no sign of life and born with birthweight of 1000g or more, or after 28 weeks gestation, or 35 or more body length in a specified time period Total number of births (per 1000) at a facility in a specified time period

By timing/type of fetal death or stillbirth (antepartum or intrapartum), where possible[1]

Reports should indicate whether stillbirths that occur in the community are recorded at the facility.
Percent of live births at a facility where the newborn had trouble breathing at birth (or was not breathing at birth) Number of live births at a facility where the newborn had trouble breathing at birth (or was not breathing at birth) Number of live births at a facility

The numerator for this indicator serves as the denominator for “Percent of newborns having trouble breathing at birth (or was not breathing at birth) where resuscitation techniques were used” (see below).

Interpret this indicator with extreme caution. If non-breathing babies are often misclassified as stillbirths, introduction of a resuscitation program and training may lead to the apparent increase in the number of babies not breathing at birth. At the same time, high numbers of non-breathing newborns can indicate poor quality of intrapartum care.

Percent of babies born with low birthweight (<2500g)

Number of live-born neonates with weight less than 2500 g at birth Total number of live births at a facility

Important especially where gestational age measurement is unreliable.

While specific birthweight should be taken and recorded for each individual baby, if reporting is weak, one category capturing babies weighing <2500g with a yes/no response can be used in registers instead.

Percent of births at a facility that are pre-term

Number of newborns born under 37 weeks gestation Total number of live births at a facility

Disaggregate by gestational age in weeks and days, where possible:

  • Moderate to late preterm (32 to <37 weeks)

  • Very preterm (28 to <32 weeks)

  • Extremely preterm (<28 weeks)

If gestational age for births outside a facility is recorded at the facility, the denominator can be changed to total number of live births (see indicator on preterm birth rate (populations based)).

Gestational age is often obtained by asking the pregnant woman for the date of last menstrual period rather than by clinical measurement, and is therefore subject to reliability issues.

Service utilization, coverage and quality of care
Indicator Numerator Denominator Disaggregation
Antenatal care (at least one visit) Number of women who were attended by skilled health personnel at least once during the pregnancy that led to their last birth Total number of women with a live birth

The numerators for these indicators can be used to calculate “Percent of antenatal clients who had a fourth ANCabbreviation visit” (numerator: number of antenatal clients with 4th ANCabbreviation visit; denominator: total number of antenatal clients with a 1st visit)

Antenatal care (at least four visits)

Number of women who received antenatal care four or more times from any provider during the pregnancy that led to their last birth Total number of women with a live birth
Antenatal client 1st visit before 12 weeks gestation Number of antenatal clients 1st visit before 12 weeks Total number of antenatal clients with a 1st visit Marker for women having contact with a provider early enough in pregnancy to permit delivery of essential pregnancy services and early identification of problems that can be addressed to improve outcomes for women and newborns.

Cesarean section rate

Number of caesarean sections in a specified time period Total number of women who gave birth at a facility in a specified time period Marker of comprehensive emergency obstetric care. Large numbers can mean use of non-indicated cesarean sections. Could be disaggregated by urban/rural and/or private versus public sector to capture inequities as well as inappropriate use.

Newborn resuscitation with bag and mask

Number of newborns who were not breathing spontaneously or crying at birth and, subsequently, required resuscitation (stimulation and/or bag and mask) to be performed Total number of live births at a facility While important to monitor implementation of resuscitation programs, this indicator needs to be interpreted with extreme caution. See notes above for the indicator percent of live births at a facility where the newborn had trouble breathing at birth (or was not breathing at birth).

Early initiation of breastfeeding

Number of newborns breastfed within one (1) hour of birth in a health facility Number of total live births in a health facility It should be noted that the early initiation of breastfeeding indicator is part of essential newborn care, but cannot be used as a proxy on its own for essential newborn care

Newborns receiving essential newborn care

Number of newborns who received all four (4) elements of essential newborn care (immediate and thorough drying; immediate skin-to-skin contact; delayed cord clamping; and initiation of breastfeeding in the first hour) Total number of live births at a health facility

Chlorhexidine (CHX) cord cleansing

Number of newborns who received at least one (1) dose of chlorhexidine digluconate (7.1%) to the cord within 24 hours of birth Total number of live births

A measure of CHXabbreviation use for clean cord care, as prevention of infection. In some countries, where other antiseptics are used according to standard guidelines or as routine clinical practice, the indicator may be modified to capture the antiseptic being used.

Postnatal care (PNC) coverage – newborn

Number of newborns who received PNC with a healthcare provider within 2 days of childbirth Total number of live births The timing of expected PNC visits may be modified in accordance with the country specific definition by the MoH

Newborns on Kangaroo Mother Care (KMC)

Number of newborns initiated on KMCabbreviation at a facility (or admitted to KMCabbreviation unit if separate unit exists)

Total number of live births in the facility

Does not measure the quality of KMCabbreviation services or whether the newborn received KMCabbreviation for a sufficient length of time. The total number of preterm or eligible babies is difficult to determine, so this indicator uses a ratio of the number of KMCabbreviation admissions to the number of live births. Other information (causes of newborn death, etc) should be used in conjunction with this indicator to estimate whether most preterm/LBWabbreviation births are receiving KMCabbreviation at facilities.

Newborns treated for neonatal sepsis/infection

Number of newborns who receive treatment (at least one injection of antibiotic) for suspected serious bacterial infection in the facility. Total number of live births in facility

Measure of quality of care because newborns with PSBIabbreviation must complete treatment (based on national guidelines) to maximize chance of survival. Does not include newborn cases initiating treatment in community settings; denominator could be adapted to national treatment policy if sepsis treatment initiation at community level is included. Best used at local level to monitor and improve quality of care.

Indicators to track antenatal care interventions
Indicator Numerator Denominator Disaggregation

Percent of pregnant women attending ANC who received Tetanus toxoid 2+

Number of women receiving at least two doses of tetanus toxoid Total number of women with a live birth

Tracking the number of ANCabbreviation visits is insufficient – this indicator measures whether important components are delivered, many of which can prevent newborn deaths.

Longitudinal registers are preferred for tracking these indicators.

Percent of pregnant women attending ANC who received Syphilis screening

Number of antenatal clients screened for syphilis in a specified time period. Total number of antenatal clients with a first visit in a specified time period.

Tracking the number of ANCabbreviation visits is insufficient – this indicator measures whether important components are delivered, many of which can prevent newborn deaths.

Longitudinal registers are preferred for tracking these indicators.

Pregnant women counselled and tested for HIV

Number of women counselled and offered voluntary HIVabbreviation testing at ANCabbreviation before their most recent birth and received their test results

Total number of women with a live birth

Tracking the number of ANCabbreviation visits is insufficient – this indicator measures whether important components are delivered, many of which can prevent newborn deaths.

Longitudinal registers are preferred for tracking these indicators.

6.6.2 Annex 6B: List of Indicators and Questions to Measure Facility Capacity to Provide Key Newborn Health Services

Adapted from Newborn Indicators Working Group, Newborn Services Rapid Health Facility Assessment, June 2012.

Service Availability
Indicator Numerator Denominator Disaggregation Utility and limitations of indicators
24/7 Skilled birth attendance Number of facilities with inpatient maternity services with a provider skilled in conducting deliveries present at the facility or on call at all times (24 hours a day, 7 days per week) and schedule observed Total number of facilities with inpatient maternity services that are assessed Type of facility (e.g, hospital versus health center)

Availability of functional emergency obstetric and newborn care facilities (EmONC) (per population)

Number of obstetric care facilities that provided EmONC signal functions in the last three months:
Basic emergency obstetric and newborn care (BEmONC):

  • Parenteral administration of antibiotics for treatment of sepsis
  • Administration of uterotonic drugs (e.g., parenteral oxytocin or misoprostol tables) for treatment of postpartum hemorrhage and intravenous tranexamic acid in addition to standard care for women with clinically diagnosed postpartum hemorrhage
  • Parenteral administration of anticonvulsants (i.e., magnesium sulfate) to manage severe pre-eclampsia and eclampsia
  • Assisted vaginal delivery (e.g., vacuum extraction)
  • Manual removal of placenta
  • Removal of retained products of conception after delivery or an incomplete abortion
  • Neonatal resuscitation (e.g., with bag and mask)
  • omprehensive emergency obstetric and newborn care (CEmONC):
  • All 7 BEmONC signal functions
  • Obstetric surgery (i.e.,. cesarean section)
Total population (per 500,000)
  • Type of facility
  • Type of service (BEmONC / CEmONC)
  • Facility caseload (e.g., facilities with <10 births per month versus facilities with ≥10)

UNabbreviation guidance on monitoring emergency obstetric care identifies at least five EmOC facilities (including at least one providing CEmONCabbreviation) for every 500,000 population. In sparsely population areas, or locations with major access constraints, more facilities may be needed to ensure services are available to meet population need

Availability of Kangaroo Mother Care (KMC)

Number of facilities in which a space is identified for KMCabbreviation and where staff have received KMCabbreviation training (< 2 years)

Total number of facilities with inpatient maternity services that are assessed Type of facility
Service Readiness
Indicator Numerator Denominator Disaggregation Utility and limitations of indicators

Percent of facilities with inpatient maternity services with no stockouts in the past 3 months of:

  • Magnesium sulfate

Number of facilities with inpatient maternity services with no stock-outs in the past 3 months of:

  • Magnesium sulfate

Total number of facilities with inpatient maternity services that are assessed

Provides information on whether commodities are available, but not if they are used as intended or if commodities are functional/unexpired.

A stock-out is defined as the complete absence of a commodity or supply at a delivery point for at least one day during the reporting
period. Data should be extracted from the national logistics management information system if the system provides details on pharmacy supply availability at the health facility level.

Key commodities may vary by country; adapt indicators based on national essential drug/ commodity lists.

Percent of facilities with inpatient maternity services with no stockouts in the past 3 months of:

  • Bag & mask (newborn size)

Number of facilities with inpatient maternity services with no stock-outs in the past 3 months of:

  • Bag & mask (size 0 and 1)
Total number of facilities with inpatient maternity services that are assessed

Percent of facilities with inpatient maternity services with no stockouts in the past 3 months of:

  • Dexamethasone (corticosteroid)

Number of facilities with inpatient maternity services with no stock-outs in the past 3 months of:

  • Dexamethasone (corticosteroid)

ACSabbreviation is expected to provided only in facilities where the following conditions can be met:

  • gestational age assessment can be accurately undertaken;
  • the preterm newborn can receive adequate care if needed (including resuscitation, thermal care, feeding support, infection treatment and safe oxygen use).
  • gestational age assessment can be accurately undertaken;
Total number of facilities with inpatient maternity services that are assessed

Percent of facilities with ANCabbreviation services with no stock-outs in the past 3 months of:

  • Iron/Folate
  • Sulfadoxine Pyrimethamine (IPTpabbreviation-SP if policy)
  • Tetanus Toxoid Vaccine

Number of facilities with ANCabbreviation services with no stock-outs in the past 3 months of:

Total number of facilities with ANCabbreviation services that are assessed

Percent of facilities with newborn care services with no stock-outs in the past 3 months of:

  • Injectable gentamicin
  • Injectable benzylpenicillin or ampicillin
  • Oral amoxicillin

Number of facilities with newborn care services with no stock-outs in the past 3 months of:

  • Injectable gentamicin
  • Injectable X-Penicillin
  • Oral amoxicillin
Total number of facilities with inpatient maternity services that are assessed
Injectable uterotonic for PPH prevention/management Number of facilities with inpatient maternity services and injectable uterotonic available (observed and at least one dose valid) Total number of facilities with inpatient maternity services that are assessed Type of facility
Equipment and Supplies
Indicator Numerator Denominator Disaggregation
Newborn bag & mask Number of facilities with inpatient maternity services with preemie and newborn bag (size o and 1) & mask available and functioning in delivery area (observed) Total number of facilities with inpatient maternity services that are assessed Type of facility
Resuscitation table Number of facilities with inpatient maternity services with resuscitation table with a heat source available and functioning in delivery area (observed) Total number of facilities with inpatient maternity services that are assessed
Infant scale Number of facilities with inpatient maternity services with infant scale available and functioning in delivery area (observed)
Soap or hand disinfectant Number of facilities with inpatient maternity services with soap or hand disinfectant in delivery area (observed)
Towel for drying Number of facilities with inpatient maternity services with towels for drying babies in delivery area (observed)
Protocols or guidelines

Number of facilities with each of the following protocols or guidelines available (observed):

  • Integrated management of pregnancy and childbirth (all facilities)
  • Referral of sick newborns (all facilities)
  • Comprehensive emergency obstetric care (facilities with inpatient maternity services)
  • Management of preterm labor (facilities with inpatient maternity services)
Documentation
Indicator Numerator Denominator Disaggregation
Up-to-date delivery register Number of facilities with inpatient maternity services with up-to-date delivery register (birth outcome for the infant and birthweight recorded for the last 10 births) (observed) Total number of facilities with inpatient maternity services that are assessed Type of facility
Monitoring postnatal care

Number of facilities with documentation of monitoring[2] of postnatal care for newborns

Total number of facilities that are assessed
Training
Indicator Numerator Denominator Disaggregation
Trained providers

Number of interviewed providers of delivery/newborn services trained in the past 12 months in each of the following areas:

  • Neonatal resuscitation using bag and mask
  • Breastfeeding (early and exclusive)
  • Newborn infection management (including injectable antibiotics)
  • Thermal care (including immediate drying and skin-to-skin care)
  • Sterile cord cutting and appropriate cord care
  • Special delivery care practices for PMTCTabbreviation of HIVabbreviation
    • Use of corticosteroids for preterm labor
Total number of interviewed providers of delivery/ newborn services Type of facility
Facilities with trained providers

Number of facilities with at least half of interviewed providers[3] trained in the past 12 months in each of the following areas:

  • Neonatal resuscitation using bag and mask
  • Breastfeeding (early and exclusive)
  • Newborn infection management (including injectable antibiotics)
  • Thermal care (including immediate drying and skin-to-skin care)
  • Sterile cord cutting and appropriate cord care)
  • KMCabbreviation for preterm and/or low birth weight babies
  • Special delivery care practices for PMTCTabbreviation of HIVabbreviation
  • Use of corticosteroids for preterm labor
Total number of facilities with interviewed providers of delivery/newborn services
Supervision
Indicator Numerator Denominator Disaggregation
Facilities with routine supervision Number of facilities with routine supervision (at least half of interviewed providers reported being personally supervised at least once during the 6 months preceding the survey). Total number of facilities with interviewed providers of delivery/newborn services Type of facility
Mortality surveillance and response
Indicator Numerator Denominator Disaggregation

Neonatal death review (audit) process in place

Number of facilities with inpatient maternity services that audit or review of newborn deaths to understand causes/circumstances of death and identify actions to mitigate future occurrences Total number of facilities visited with inpatient maternity services

Facility stillbirth review (audit) process in place

Number of facilities with inpatient maternity services that audit or review intrapartum stillbirths to understand causes/circumstances and identify actions to mitigate future occurrences Total number of facilities visited with inpatient maternity services

Percent of perinatal deaths reviewed

Number of stillbirths and newborn (perinatal) deaths that were audited Total number of stillbirths and neonatal deaths at a facility

Abbreviations

  1. An antepartum fetal death (stillbirth – macerated) refers to a fetus that has suffered an intrauterine death after the 28th week of gestation and before labour. An intrapartum fetal death (stillbirth – fresh) refers to a baby that has died after the onset of labour and before birth. Fresh stillbirths do not show any signs of maceration. ↩︎

  2. Observed register, report, wall chart/graph or other documentation of monitoring service data. ↩︎

  3. If only one provider interviewed at a facility, then criteria met if that provider was trained in each area. ↩︎