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Health
Indicators
Guidelines for their generation,
interpretation and analysis
for global monitoring
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Contents
I About these guidelines
1 Introduction 1
2 Indicators—an overview in the context of global monitoring 4
2.1 Purpose and limitations 4
2.2 Providing an overview of reproductive health 4
2.3 Conceptual considerations 5
2.4 Contextual considerations 5
2.5 Interpretation 6
2.6 Structure of the guidelines 6
1 Introduction
At the Millennium Summit sponsored by the United Nations in September
2000, the members of the United Nations reaffirmed their commitment
to working towards a world in which sustainable development and the
elimination of poverty would have the highest priority. This initiative is
known as the Millennium Project, with its Millennium Development Goals
(MDGs) and related targets. The MDGs were guided in part by agreements
and resolutions of international conferences over the past decade, including
the International Conference for Population and Development (ICPD) in Cairo
in 1994. The goals are commonly accepted as a framework for measuring
development progress.
The MDGs focus the efforts of the world community on achieving significant
and measurable improvements in people’s lives (see Annex 1). The first seven
goals are mutually reinforcing and aim to reduce poverty in all its forms. The
eighth and last goal—global partnership for development—is about the means
to achieve the first seven. In the years between rich and poor even within
following the ICPD, international agencies countries). This calls for disaggregation
agreed on a shortlist of 17 indicators for of indicators by relevant factors such as
monitoring the reproductive health goals place of residence (urban versus rural),
(Table 1). Selection of these indicators educational or economic status and
included a comprehensive review process, age group, so that local realities are
and this document contains a brief not obscured and MDG targets can be
description of and justification for each of monitored independently of national
these 17 indicators. averages.
Universal access by 2015 to the widest possible range of safe and effective family
planning methods, including barrier methods, and to the following related reproductive
health services: essential obstetric care, prevention and management of reproductive tract
infections including sexually transmitted infections (2).
UNFPA for the years 1990, 1995 and 2000 Nations General Assembly(3) prompted
indicate that more than half a million governments, organizations and the
women die every year from complications international community to strengthen
of pregnancy and childbirth, of which national information systems to produce
more than 50% occur in Africa and 40% reliable statistics in a timely manner,
in Asia (1). Because maternal mortality is including indicators on access to sexual
difficult to measure and, in general, trend and reproductive health services. The
I n d i c a t o r s
comparisons are not reliable, efforts have 17 indicators presented here include
been made to identify appropriate process indicators of outcome, access and use and
indicators to assess reproductive health they represent an attempt to focus efforts
(Box 1). This has shifted the emphasis so that the gap in available data can be
from indicators of health to indicators of reduced.
access and use of health care systems.
In addition, the recognition that some There is relatively little experience so far
women need specialist obstetric care if in the use and interpretation of indicators
they are not to die in childbirth has led of service use or need for obstetric care.
to indicators for assessing the availability These guidelines draw on the experience
of basic and comprehensive essential gained with the indicators over the past
obstetric care. few years, and aim to provide a structured
description of generation and interpretation
Furthermore, the reduction and for each of the shortlisted indicators at
2 elimination of poverty need to be national level.
considered within the framework of
reducing inequality and enhancing equity. This document is intended for national
Goals ought to be achieved by reaching public health administrators and health
the poorest (i.e. reducing differences programme managers. It briefly reviews
theoretical and practical considerations of
indicators, followed by a discussion of the
definition, data sources, collection methods,
periodicity of collection, disaggregation,
use, limitations and common pitfalls for
each of the shortlisted indicators. It is hoped
that the document will contribute towards a
consistent global monitoring and evaluation
of reproductive health.
References
1. Maternal mortality in 2000: Estimates
developed by WHO, UNICEF and
UNFPA. World Health Organization,
Geneva, 2004.
2. United Nations. Report of the
International Conference on Population
and Development. New York,
United Nations, 1994 (document A/
CONF.171/13).
3. Report of the Ad Hoc Committee of
the Whole of the Twenty-first Special
Session of the General Assembly. New
York, United Nations, 1999 (document
A/S-21/5).
3
2. Indicators—an overview in the context of
global monitoring
2.1 Purpose and limitations
Indicators are markers of health status, service provision or resource
availability, designed to enable the monitoring of service performance or
programme goals. Monitoring is a process of comparison, across populations
or geographical areas, to highlight differentials or to detect changes over
time (to measure progress) between reality and goals. Goals or objectives are
an essential component in quantifying the aims of health-related policies,
programmes and services. At the national and international levels, an indicator
must be able to “measure progress” towards agreed goals.
Reproductive health is a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity, in all matters relating to the reproductive system and
to its functions and processes. Reproductive health therefore implies that people are able to have
a satisfying and safe sex life and that they have the capability to reproduce and the freedom to
decide if, when and how often to do so. It also includes sexual health, the purpose of which is
the enhancement of life and personal relations.
prevention and management of sexual are often more readily available and may
violence; be more sensitive to change.
active discouragement of harmful Output indicators can, however, only act
traditional practices such as female as valid proxies for impact when there is
genital mutilation; and an established causal link with outcome.
reproductive health programmes for These links between possible programme
specific groups such as adolescents, inputs and outputs, and especially health
including information, education, impacts, vary greatly in terms both of
communication and services. the existence and strength of evidence
for a causal connection, and of ease
The aim of the shortlist is to provide a
of measuring a connection. Therefore,
set of indicators that reflect all areas of
in order to draw tenable conclusions
reproductive health. While no single
regarding improved reproductive health
indicator was able to fulfil all the selection
status based on output indicators, it is
criteria outlined (see Annex 2), many
crucial to have a clear understanding both
of the indicators in the shortlist are
of the goals themselves and the routes
complementary and, in combination, they
to achieving them, i.e. the association
encompass the measurement of outputs
between the output (e.g. service utilization)
and impacts for a range of reproductive and observed change in health status.
health programme areas. Supporting Conclusions based on these measures will,
indicators and their complementary roles however, always be open to challenge.
are outlined for many of the indicators
I n d i c a t o r s
7
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II Generation, interpretation and analysis of the
shortlisted national reproductive health indicators
ASFRs are often expressed per 1000 women. Seven ASFRs are normally
calculated, one for each five-year age group (15–19, 20–24, 25–29, 30–34, 35–
39, 40–44 and 45–49 years). Single-year rates can also be computed. Assuming
that ASFRs have been computed for each five-year age group and are expressed
per 1000 women, the total fertility rate per woman can be computed as follows:
ASFRs x 5
TFR (per woman) =
1000
Whereas ASFRs are expressed per 1000 women, the TFR is expressed per
woman. Note that the TFR is occasionally called total period fertility rate
(TPFR), because it is based on ASFRs prevailing at a particular time rather
9 than those experienced by a cohort of women as it passes from age 15 to age
Generation, interpretation and analysis...
49 years. TFR thus refers to the number Data sources and collection methods
of births a woman would have if (a) she As indicated above, TFRs are calculated
lived from age 15 to age 50 and (b) she from the ASFRs. Data for ASFRs may
experienced throughout her reproductive be derived from three main sources,
life exactly the ASFRs observed for the year namely vital registration (on births only),
in question. population censuses and population-based
surveys.
Generation of the indicator
The first step is to compute ASFRs by When counts of births are derived from
single- or five-year age groups. If they vital registration, population figures for the
are computed by five-year age groups it number of women in each reproductive
is necessary to multiply by five. If, as is age group could be obtained from, for
common, the ASFRs are expressed per example, census returns. Most developing
countries have incomplete vital
Table 2. Age-specific (ASFR) and total fertility rates registration, and underreporting of births
(TFR) for Indonesia is a major problem. In addition, different
sources of data for the numerator (births)
Age group ASFR, 1990 ASFR, 1997 DHS*
(years) census (1995–1997) and denominator (women) make the
(1986–1989) estimation of ASFRs difficult.
15–19 71 62
20–24 178 143 Population censuses provide information
25–29 172 149 on both the numerator and the
30–34 128 108
denominator. Estimates using censuses are
35–39 73 66
derived from questions on births during
a specified period preceding the census
40–44 31 24
(usually 12 months). Age misclassification
45–49 9 6
is a common problem with this method.
TFR TFR
More specifically, dates of birth are shifted
15–49 3.31 2.79
backwards in time to show a spurious
15–44 3.27 2.76
decline in fertility. It has therefore become
*Demographic and Health Survey
Source: Central Bureau of Statistics and Macro
common practice to use births in the
I n d i c a t o r s
Sampling errors
Estimates derived from surveys are prone
to large sampling errors. It is therefore
essential to provide sampling errors and
confidence intervals for the estimated
TFRs.
Limitations
The TFR is a hypothetical measure of
completed fertility. It is thus possible that
women of reproductive age at any given
point in time may have completed family
sizes that are considerably different from
12 that implied by a current TFR, should ASFR
rise or fall in the future.
2 Contraceptive prevalence
The proportion of women of reproductive age who are using (or whose partner is
using) a contraceptive method at a given point in time
Numerator: Number of women of reproductive age at risk of pregnancy who are
using (or whose partner is using) a contraceptive method at a given point in time
Denominator: Number of women of reproductive age at risk of pregnancy at the
same point in time
Most surveys use broadly similar questions It is also relevant at all levels of the
to measure contraceptive use. Women (and health system to assess the coverage of
men in some instances) are first asked what contraceptive services, which allows
methods they know of, and the interviewer the quality of service to be assessed to
then names or describes methods that some extent. Preferences for methods
were not mentioned. Respondents are and sources can be tracked and related
then asked about the use of each method to continuation and contraceptive failure
that was recognized. This procedure rates.
helps make clear to the respondent
which methods are to be counted as Issues of interpretation
contraceptives. The contraceptive methods The convention is to base this calculation
are usually listed in order of efficacy, on women who are married or in a sexual
starting with sterilization, the pill, IUD and union. Nevertheless, in countries where
condom (the supply methods) and followed sexual activity outside stable relationships
by non-supply methods such as rhythm is widespread, basing the prevalence
and withdrawal. If the respondent mentions estimate only on women in such
more than one method, the method higher relationships would ignore a considerable
on the list is marked. proportion of current users.
15
Generation, interpretation and analysis...
in the field, a major disadvantage is that the large to produce stable estimates, then
pooled estimate derived from using data it is realistic to consider annual figures.
from all respondents relates statistically to However, where population surveys are
a point around 10–12 years prior to the needed because routine systems are weak
survey. The method also relies on a number or nonexistent, then sample sizes and
of assumptions that restrict its use in thus field costs are likely to be too great to
settings with very low fertility and/or major justify producing precise estimates more
migration flows to or from the population. frequently than every 5–10 years.
The direct approach, on the other hand,
provides a more current estimate at about Disaggregation
3–4 years prior to the survey, but this comes Although it would be helpful to countries
at the cost of larger sample sizes and more to produce estimates disaggregated at a
complex questions and is thus more costly subnational level, for example into rural
and time-consuming to gather and analyse. vs urban or administrative regions, this
Without sufficiently large sample sizes to should not be encouraged unless the data
avoid overlapping confidence intervals, the are of sufficient quality and scope to yield
direct sisterhood method cannot be used a reliable picture. The same would apply
to monitor time trends. Both the indirect to other covariates, such as maternal age
and direct methods provide estimates and parity.
rather than precise figures for the maternal
mortality ratio.
Analysis and interpretation
Confidential enquiries into maternal deaths The currently available data sources and
identify the numbers, causes and avoidable collection methods described above have
factors associated with maternal deaths. very different strengths and weaknesses
Through the leassons learnt from each and yield estimates of varying reliability.
woman’s death, and through aggregating This variation needs to be remembered
the data, they provide evidence of where when using and interpreting estimates of
the main problems in overcoming maternal the maternal mortality ratio.
mortality lie and an analysis of what can
be done in practical terms, and highlight Use
the key areas requiring recommendations
I n d i c a t o r s
methods for estimating maternal mortality London School of Hygiene & Tropical
all have strengths and weaknesses, and Medicine, 1997.
in many developing countries the figures
produced should be regarded as broad
indications of level rather than precise
statistics.
Supporting indicators
Supporting indicators are “maternal
mortality rate”, “lifetime risk of maternal
death”, “antenatal care coverage”, “births
attended by skilled health personnel” and
“perinatal mortality rate”.
20
4 Antenatal care coverage
The proportion of women attended, at least once during their pregnancy, by skilled health
personnel for reasons relating to pregnancy
Numerator: Number of pregnant women attended, at least once during their pregnancy, by
skilled personnel for reasons related to pregnancy during a fixed period
the short term. Some sources recommend associated with improved perinatal survival
constructing the indicator on a yearly basis, (10), and measuring ANC coverage
but annual monitoring is feasible only when therefore has a greater role in the monitoring
the data are derived from routine data and evaluation of programmes that address
sources. For international comparisons, newborn health and survival (3).
periods of 3–5 years are recommended (6).
More frequent surveys are probably not Issues of interpretation
desirable because sampling error makes it When comparing data from multiple
difficult to assess whether small changes are sources it is important to be aware of
real or are due to chance variation. how subtle variations in the definition of
terms, in the construction of the indicator
Disaggregation and in the reliability or representativeness
Where appropriate, the ANC indicator of the data can limit the drawing of any
meaningful conclusion.
may be disaggregated by geographical and
22 administrative strata and demographic and
care characteristics. If the main purpose of Common pitfalls
the indicator is to monitor progress towards Who is included in the category of skilled
international targets, the data should be health personnel?
disaggregated by urban and rural areas. Differences in the categorization of skilled
health personnel, in particular whether give birth to a live child and exclude fetal
auxiliary staff or traditional birth attendants deaths and stillbirths, which will give a
have been included, may also account for false positive outcome in terms of ANC.
discrepancies between countries. Although
the WHO definition of skilled health This indicator is a measure of antenatal
personnel (1) is widely used, this only care use and not a measure of the
includes a qualitative measure—the need adequacy of care received. ANC is a
for training to result in proficiency. package of services whose content and
quality vary widely between settings.
Does the indicator relate to all antenatal In this indicator, the overall number
visits or only to visits for “reasons related and timing of visits, the reasons for
to pregnancy”? seeking care, the skills of the provider
Discrepancies may arise because the and the nature or quality of care are not
estimate relates either to all antenatal specifically defined. Therefore, similar
visits or only those that occur “for reasons rates of ANC coverage should not be
related to pregnancy”. This qualification interpreted to imply similar levels of care.
was added to the indicator to clarify the
definition of care and to strengthen the Limitations
causal relationship with maternal health ANC coverage for one visit should be
outcomes. In practice, information on used in combination with other indicators
women’s motives for seeking care is rarely to derive a better understanding of the
collected. situation. Disaggregation by important
differentials can provide insights into
Does the denominator relate to live disparities of service provision in countries
births or to pregnant women? where there is variation in rates of ANC
It is important to know whether the coverage. In high-coverage countries,
denominator used is all births, the most ANC coverage can be further described in
recent birth or all women. Including all terms of the number and timing of ANC
births will overrepresent women who have visits and the proportion of women with
more than one birth. These women are no ANC.
also more likely to have other risk factors
for adverse pregnancy outcome, such as Supporting indicators
high parity, lower levels of education and ANC coverage is one of four mutually
lower rates of health service use. Including supportive indicators in the minimum
all births will thus result in a lower ANC list measuring maternal health service
coverage than using a woman-based coverage. The other three indicators
analysis. This difference will be greater are “births attended by skilled health
the longer the survey period used. A personnel”, “availability of basic essential
woman-based estimate can be obtained by obstetric care” and “availability of
using ANC coverage for the most recent comprehensive essential obstetric care”.
birth. Since programmes target women, As mentioned above, ANC coverage is
using a woman-based denominator also associated with newborn health and
may be conceptually more appealing to survival, and is weakly associated with
programme managers. maternal mortality. Thus, this indicator
can also be interpreted in conjunction
Overrepresentation of positive outcomes with perinatal mortality rates, but should
A birth-based analysis is essential for be interpreted with caution in relation to
determining the impact of ANC on
23
maternal mortality rates.
pregnancy outcomes. Nevertheless,
surveys normally include women who
Generation, interpretation and analysis...
References
1. Making pregnancy safer: the critical
role of the skilled attendant. A joint
statement by WHO, ICM and FIGO.
Geneva, World Health Organization,
2004.
2. ICD-10. International statistical
classification of diseases and related
health problems: 10th revision.
Geneva, World Health Organization,
1992.
3. Graham W, Filippi V, Ronsmans C.
Demonstrating programme impact
using maternal mortality. Health
Policy and Planning, 1996, 11:16–20.
4. Monitoring reproductive health:
selecting a shortlist of national and
global indicators. Geneva, World
Health Organization, 1997 (document
WHO/RHT/HRP/97.26).
5. Demographic yearbook 1991. New
York, United Nations, 1992.
6. Indicators to monitor maternal health
goals: report of a technical working
group, Geneva, 8–12 November
1993. Geneva, World Health
Organization, 1994 (document WHO/
FHE/MSM/94.14).
7. Bloom SS, Lippeveld T, Wypij D. Does
I n d i c a t o r s
are probably not desirable because “Skilled attendant at birth” has been
sampling error makes it difficult to assess proposed as an intermediary, process or
whether small changes are real or are due proxy indicator for monitoring progress
to chance variation. towards the reduction of maternal
mortality. This indicator is highly
Disaggregation correlated with maternal mortality levels,
Disaggregation by place of delivery, type although such a correlation does not
of skilled health personnel, urban/rural provide levels of causality (6).
and socioeconomic characteristics is
recommended where appropriate. Issues of interpretation
The key steps to a meaningful
Analysis and interpretation interpretation of levels of births attended
To aid the interpretation of maternal by skilled health personnel are (a) to
health care indicators, it is useful to address the strengths and weaknesses
separate health service coverage into three of the data and (b) to identify any
elements: inconsistencies in definitions and changes
availability of services—potential in the numerator and/or denominator.
coverage
Common pitfalls
accessibility and acceptability of
services Ambiguities in the categorization of
“skilled personnel”
utilization of services—actual Ambiguities and differences in the
coverage. categorization of “skilled personnel”,
Both births attended by skilled personnel and in particular whether traditional birth
and antenatal care coverage are measures attendants have been included or not,
of health care utilization; they provide often help explain wide discrepancies
information on actual coverage (the between statistics from different sources for
effective population that receives the the same population. It is important to state
care). If analysed in conjunction with the the definition of skilled attendant used in
two indicators measuring availability of order to make valid comparisons across
obstetric care, they can provide a more time or between countries. Nevertheless,
I n d i c a t o r s
complete picture of the utilization– even where the definition is clearly stated,
provision synergy (3). levels of training and skills of health care
providers may vary between countries.
Use
The indicator helps programme Does the denominator relate to live
management at district, national and births or to pregnant women?
international levels by indicating whether The most commonly used denominator is
safe motherhood programmes are on the number of live births, which acts as a
target in the availability and utilization proxy for the number of pregnant women.
of professional assistance at delivery. This, however, underestimates the total
In addition, the proportion of births number of pregnancies by excluding those
attended by skilled personnel is a measure that end in stillbirth or spontaneous or
of the health system’s functioning and induced abortion, as well as ectopic and
26 potential to provide adequate coverage molar pregnancies. Observed differences
for deliveries. On the other hand, this in coverage may thus be due not to true
indicator does not take account of the type changes in coverage of all pregnancies but
and quality of care. to differences in the stillbirth and abortion
rates. It has been suggested that applying a Supporting indicators
raising factor of 15% to the total number of This indicator is one of four mutually
live births would provide the approximate supportive indicators in the minimum
number of pregnant women in need list measuring maternal health service
of care (7). Issues of data availability coverage. The other three indicators are:
and international comparability clearly “antenatal care coverage”, “availability
influence the choice of the denominators, of basic essential obstetric care” and
and the consequences of this choice in “availability of comprehensive essential
terms of accuracy and representativeness obstetric care”. In combination, these
of the indicator should be acknowledged. indicators measure progress towards the
goal of providing all pregnant women
Overrepresentation of women with short with antenatal care, trained attendants
birth intervals during childbirth, and referral facilities
It is important to know whether the for high-risk pregnancies and obstetric
denominator used is all births, the most emergencies.
recent birth or all women. Including all
births will give a birth-based analysis that References
overrepresents women with short birth 1. Making pregnancy safer: the critical
intervals. These women are also more role of the skilled attendant. A joint
likely to have other risk factors for adverse statement by WHO, ICM and FIGO.
pregnancy outcome, such as high parity, Geneva, World Health Organization,
lower levels of education and lower rates 2004.
of health service use. This approach will
2. ICD-10. International statistical
result in a lower than actual “skilled
classification of diseases and related
attendant at delivery” coverage. Therefore,
health problems: 10th revision.
survey studies should include only the
Geneva, World Health Organization,
most recent birth for the survey period.
1992.
Limitations 3. Graham WJ, Filippi VA, Ronsmans C.
The pitfalls discussed above are also the Demonstrating programme impact on
limitations of this indicator. For example, maternal mortality. Health Policy and
in some settings there is ambiguity over the Planning, 1996, 11:16–20.
definition of skilled health personnel, and 4. Demographic yearbook 1991. New
births attended by trained traditional birth York, United Nations, 1992.
attendants and private health providers are
included in the numerator. It is therefore 5. Indicators to monitor maternal health
essential to state which definition is goals: report of a technical working
used in each instance, since a change group, Geneva, 8–12 November
in definition may create difficulties in 1993. Geneva, World Health
comparability over time. Organization, 1994 (document WHO/
FHE/MSM/94.14).
With regard to data obtained from surveys, 6. Maternal mortality in 1995: estimates
the validity of such data depends on the developed by WHO, UNICEF,
correct identification by the women of UNFPA. Geneva, World Health
the credentials of the person attending the Organization, 2001 (document WHO/
delivery, which may not be obvious in RHR/01.9).
certain countries.
7. Sharing responsibility: women, society 27
and abortion worldwide. New York,
Alan Guttmacher Institute, 1999.
Generation, interpretation and analysis...
Two process indicators related to the availability of essential obstetric care are recommended as
assessment tools to gauge national and global progress in reduction of maternal mortality:
Causal pathway
Theoretical pathway associating the availability of EOC services with maternal mortality
Information about
Appropriate
services
Timely use of management of Reduction
Motivation to seek care life-threatening in maternal
good-quality
Money services obstetric mortality
Time conditions
Transportation
Availability of services
records or lack of full enumeration of them. that the skills of these birth attendants
If private facilities are not included, the approximate the skills required to perform
availability of EOC for the population will the six BEOC or eight CEOC functions.
be underestimated, although information
on the extent to which the national public References
health system meets women’s needs for 1. UNICEF/WHO/UNFPA. Guidelines
obstetric care will still be provided. for monitoring the availability and
use of obstetric services. New York,
Limitations United Nations Children’s Fund,
The estimation of CEOC coverage 1997.
(available and functioning, seven days
2. Measure/DHS+. Service provision
a week, 24 hours a day) may be more
assessment (SPA) tool kit. Calverton,
accurate than that of BEOC coverage in
MD, Macro International, 2000.
some countries, if private primary care
facilities are common. It is difficult to 3. Paxton A, Maine D, Hijab N. AMDD
enumerate private EOC facilities without Workbook. (Almost) everything you
special surveys or complete facility want to know about using the UN
registration, although private CEOC services process indicators of emergency
are generally provided by hospitals or large obstetric services. New York,
I n d i c a t o r s
31
Generation, interpretation and analysis...
Numerator: Number of perinatal deaths (fetal deaths and early neonatal deaths) x 1000
of death for the liveborn infant. In vital which would result in underreporting of
registration, the certificate provided by early deaths.
the health worker delivering the infant
provides this type of information. When Perinatal mortality is associated with
registration is done without the medical/ poor maternal health. It provides useful
birth certificate, however, the information insight into the quality of intrapartum and
is less precise and reliable. In surveys, immediate postnatal care and may be used
a set of questions on pregnancy history as a good proxy measure of the quality
and number and age at death of live and of those services. It has been suggested
stillborn infants is used in calculating as an alternative and more sensitive
perinatal mortality. measure of maternal health status, since
the ascertainment of perinatal death is less
difficult than that of maternal morbidity.
Periodicity of data collection
Vital registration systems, notification
Issues of interpretation
systems and hospitals provide routine
In general, perinatal mortality is a
annual reports. There is no general rule
good summary measure for comparing
about the periodicity of perinatal mortality
pregnancy and childbirth outcomes across
by population surveys. It is, however,
countries, populations or institutions and
helpful to have perinatal mortality
over time. As in many other indicators
estimated every five years.
such as maternal mortality ratio, observed
differences in the perinatal mortality rate
Disaggregation
may not, however, reflect improved health
It is useful to report perinatal mortality
status but may be due to changes in the
by geographical and administrative
reporting system. Distinguishing between
subdivision, urban/rural residence,
real and artificial changes in perinatal
mother’s socioeconomic status, place mortality requires good knowledge of
of birth, birth attendant, private/public the data and methodology. Some of the
provider, and singleton and multiple births. factors, largely related to the data sources,
Information on prepartum and intrapartum definitions and quality, are discussed
stillbirths, early neonatal deaths (deaths in below.
the first week) and birth-weight-specific
I n d i c a t o r s
correct reading technique. Digit preference not distinguish between preterm birth and
is frequently observed in birth weight data, restricted fetal growth and second, it does
especially around 500 g values. Heaping not permit assessment of the entire range of
at these values can substantially affect the gestation and fetal growth. Birth weight and
actual incidence of LBW. Digit preference its mean and standard deviation comprise
can only be improved by regularly a better summary measure of size at birth
analysing and presenting data to those who in a population. Optimal birth weight may
weigh babies. differ according to maternal size, parity, age
and number of babies born, as it is assumed
Where spring scales and especially that maternal growth constraint may limit
categorical spring scales (<1500 g, 1500– the fetal growth to protect the health of the
<2500 g, 2500 g and more) are used, mother and baby.
adequate measures should be taken to
ensure accurate reading. “Reading up and Using data to monitor trends in low birth
down” (whereby the scale is not at eye weight
level) is very common in the use of such Where most births (>90%) occur in
scales and may considerably distort the institutions such data can reflect population
actual LBW rates. trends. Where substantial numbers of
births occur at home, drawing conclusions
Reporting errors from institutional data should be avoided.
LBW is defined as a birth weight of less Furthermore, simple assessment of
than 2500 g (i.e. up to and including comparative size at birth may not be
2499 g). Rates are sometimes erroneously adequate to assess trends.
reported that include weights of 2500 g.
This can substantially affect the rate, mostly Supporting indicators
because of the digit preference at 2500 g. Prevalence of low birth weight is
complementary to the perinatal mortality
Proxy measures rate as a measure of newborn risk.
Proxy measures of LBW (e.g. chest
circumference) have been recommended References
for assessing birth weight at home, but are 1. ICD-10. International statistical
not a good substitute for growth.
I n d i c a t o r s
The percentage of pregnant women aged 15–24 years attending antenatal clinics with a
positive serology for syphilis
Numerator: Number of pregnant women aged 15–24 years attending antenatal clinics,
whose blood has been screened for syphilis, with a positive serology for syphilis during a
specified period x 100
Denominator: Total number of pregnant women aged 15–24 years attending antenatal
clinics, whose blood has been screened for syphilis during the specified period
The percentage of women of reproductive age screened for haemoglobin levels who have
levels below 110 g/l (pregnant women) and 120 g/l (non-pregnant women).
Numerator: Number of women of reproductive age screened for haemoglobin levels who
have levels below 110 g/l (pregnant women) and 120 g/l (non-pregnant women) during a
specified period x 100
Denominator: Total number of women of reproductive age screened for haemoglobin levels
during the specified period
scale, which compares the colour shade of Data should be provided with an
blood with defined hues of red (4,5). indication of their source (e.g. clinical
records, surveys) and the method of
Periodicity of data collection haemoglobin assessment, in order to
Rapid assessments are carried out each allow comparisons when necessary.
year, population-level surveys every five Conventionally, mean and standard error
years. should be reported.
43
Generation, interpretation and analysis...
References
1. Spontaneous and induced abortion.
Report of a WHO Scientific Group.
Geneva, World Health Organization,
1970 (WHO Technical Report Series,
No. 461).
I n d i c a t o r s
The percentage of women interviewed in a community survey who report having undergone
genital mutilation
Numerator: Number of women interviewed in a community survey who report having
undergone genital mutilation x100
Denominator: Total number of women interviewed in the survey
48
14 Prevalence of infertility in women
The percentage of women of reproductive age (15–49 years) at risk of becoming pregnant
(not pregnant, sexually active, not using contraception and not lactating) who report trying
for a pregnancy for two years or more
Numerator: Number of women of reproductive age (15–49 years) at risk of becoming
pregnant (as defined above) who report trying unsuccessfully for a pregnancy for two years
or more x100
Denominator: Total number of women of reproductive age at risk of becoming pregnant (as
24-month period or even longer. and the female partner. The cause of the
couple’s infertility could be female, male
Another measure that is sometimes used
or both. From a cultural point of view,
in surveys, for all couples/women, is “time
“infertility” is often a diagnosis, and blame
to pregnancy”, i.e. the time it has taken
may be attached to the woman. Using
or takes before a pregnancy is confirmed
this indicator, and therefore failing to
after exposure to unprotected intercourse.
address the male factor in infertility, may
This continuous variable allows one to
contribute to a further stigmatization of
analyse differences in time to pregnancy
women.
between groups of women (survival-type
data analysis), for example in measuring Reference
environmental factors affecting fertility. It
1. Programme of Action adopted at
needs to be noted that a woman’s natural
the International Conference on
fertility decreases with age, although a
50 Population & Development, Cairo,
substantial loss does not occur until after
5-13 September 1994. New York,
the age of 40 years.
United Nations Population Fund,
Regularity of sexual intercourse and timing 1996 (http://www.iisd.ca/Cairo/
of intercourse may vary considerably program/p07002.html, accessed 27
between different cohorts and groups of October 2004).
15 Reported incidence of urethritis in men
The percentage of men aged 15–49 years, interviewed in a community survey, who reported
having one or more episodes of urethritis in the previous 12 months
Numerator: Number of men aged 15–49 years who reported having one or more episodes
of urethritis in the previous 12 months x 100
Denominator: Number of men aged 15–49 years interviewed in the survey
Definitions of important terms At the first stage, survey areas are selected
Urethritis is discharge from the penis, with with probability proportional to size. At
or without a burning sensation or pain the second stage, households are selected
while passing urine. with probability inversely proportional to
the area size. All males aged 15–49 years
Discharge can be thick or thin and either are interviewed if they are usual residents
clear (like mucus) or coloured (green, of the selected household or if they have
yellow or white). Any discharge that spent the night before the interview in the
contains blood is usually not indicative of household. Regular household members
urethritis. who are temporarily away from home are
included as household members.
An episode is the occurrence of symptoms,
either for the first time ever or at least five Data collection methods will involve
days after the disappearance of previous questions that may be culturally
symptoms. sensitive and that need to be asked in
The recall period of 12 months refers to privacy. Ideally, the interviews should
the last 12 months and not the previous be conducted by male interviewers.
calendar year. Confidentiality of men’s reports needs to
be assured in order to obtain reliable data.
Generation of the indicator
Periodicity of data collection
Data sources Data should be collected at 4–5-year
The indicator requires collection of intervals.
data at a population or subpopulation
level. The most appropriate source of Disaggregation
data is a community survey, such as the
The results should be disaggregated
Demographic and Health Surveys (www.
by age, urban/rural residence and
measuredhs.com), or a study undertaken
geographical area.
for this specific purpose. Community
surveys can be conducted either at
Analysis and interpretation
national level or in specific population
groups or specific geographical areas. Use
Routine health facility records should This indicator is useful as a measure of the
not be used because of the difficulties of impact of preventive services for sexually
establishing the denominator. transmitted infections (STI). It also provides
an indication of the perceived burden
Data collection methods of STI on the adult male population, as 51
A two-stage cluster sampling survey with a it measures the reported prevalence of a
12-month recall period is recommended. major STI symptom in men.
Generation, interpretation and analysis...
Supporting indicators
I n d i c a t o r s
References
1. Klouman E et al. Asymptomatic
gonorrhoea and chlamydial infection
52
16 Prevalence of HIV infection in pregnant women
The percentage of blood samples taken from women aged 15–24 years that test positive for
HIV during routine sentinel surveillance at selected antenatal clinics
Numerator: Number of HIV-positive blood samples taken from pregnant women aged
15–24 years* at selected antenatal clinics (sentinel surveillance sites) x 100
Denominator: Total number of blood samples taken from pregnant women aged 15–24
years from selected antenatal clinics that were tested for HIV
*In the immediate post-pubertal age group (i.e. the age group just beginning sexual activity virtually all
prevalent infections could be used as proxy for incident (new) infections.
large health centres and hospitals) and in young women are expected to be
to allow for representation of important higher—sometimes much higher—than
populations based on age and urban/
those in young men. It is therefore
rural residence. The focus of monitoring
inadvisable to extend interpretation of
efforts should be on estimating changes in
ANC-based prevalence estimates to the
prevalence within the major surveillance
general “both sexes” population.
strata.
References
1. Reproductive health indicators for
global monitoring. Report of the
Second Interagency Meeting, Geneva,
17–19 July 2000. Geneva, World
Health Organization, 2001 (document
WHO/RHR/01.19).
2. Zaba B, Gregson S. Measuring the
impact of HIV on fertility in Africa.
AIDS, 1998, 12(Suppl. 1):S41–S50.
Further reading
1. Second-generation surveillance for
HIV: the next decade. Geneva, World
Health Organization, 2000 (document
WHO/CDS/CSR/EDC/2000.5).
I n d i c a t o r s
56
17 Knowledge of HIV-related preventive practices
The percentage of survey respondents who correctly identify all three major ways of
preventing sexual transmission of HIV, and who also reject all three major misconceptions
about HIV transmission or prevention
Numerator: Number of survey respondents (women and men) who correctly identify all
three major ways of preventing sexual transmission of HIV, and who also reject all three
major misconceptions about HIV transmission or prevention x100
Denominator: Total number of respondents included in the survey
Representativeness
The indicator estimate will be
representative of the target population
of women and men to the extent that
(a) probability sampling methods are
correctly used in the survey design and
implementation and (b) sample weights are
calculated and used where necessary.
Supporting indicators
Knowledge of the means of preventing HIV
transmission is considered a precondition
to constructive behavioural change. Trends
in knowledge should thus be evaluated
alongside trends in indicators of behaviour
that are associated with increased risk of
HIV transmission, namely:
Goal Target
1 Eradicate extreme poverty 1 Halve, between 1990 and 2015, the proportion of people whose
and hunger income is less than $1 a day
2 Halve, between 1990 and 2015, the proportion of people who suffer
from hunger
2 Achieve universal primary 3 Ensure that, by 2015, children everywhere, boys and girls alike, will
education be able to complete a full course of primary schooling
3 Promote gender equality 4 Eliminate gender disparity in primary and secondary education,
and empower women preferably by 2005, and at all levels of education no later than 2015
4 Reduce child mortality 5 Reduce by two thirds, between 1990 and 2015, the under-five
mortality rate
5 Improve maternal health 6 Reduce by three quarters, between 1990 and 2015, the maternal
mortality ratio
6 Combat HIV/AIDS, malaria 7 Have halted by 2015 and begun to reverse the spread of HIV/AIDS
and other diseases
8 Have halted by 2015 and begun to reverse the incidence of malaria
and other major diseases
7 Ensure environmental 9 Integrate the principles of sustainable development into country
sustainability policies and programmes and reverse the loss of environmental
resources
61
Annex 1 Millennium Development Goals...
Goal Target
8 Develop a global 16 In cooperation with developing countries, develop and implement
partnership for development strategies for decent and productive work for youth
62
Annex 2 The selection criteria for the shortlist of indicators
Criterion Explanation
Scientifically robust An indicator must be a valid, specific, sensitive and reliable reflection of
that which it purports to measure.
Valid An indicator must actually measure the issue or factor it is supposed to
measure.
Reliable An indicator must give the same value if its measurement were repeated in
the same way on the same population and at almost the same time.
Ethical An indicator must be seen to comply with basic human rights and must
require only data that are consistent with the morals, beliefs or values of the
local population.
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