Count every newborn; a measurement improvement roadmap for coverage data

Abstract

Background: The Every Newborn Action Plan (ENAP), launched in 2014, aims to end preventable newborn deaths and stillbirths, with national targets of ≤12 neonatal deaths per 1000 live births and ≤12 stillbirths per 1000 total births by 2030. This requires ambitious improvement of the data on care at birth and of small and sick newborns, particularly to track coverage, quality and equity.

Methods: In a multistage process, a matrix of 70 indicators were assessed by the Every Newborn steering group. Indicators were graded based on their availability and importance to ENAP, resulting in 10 core and 10 additional indicators. A consultation process was undertaken to assess the status of each ENAP core indicator definition, data availability and measurement feasibility. Coverage indicators for the specific ENAP treatment interventions were assigned task teams and given priority as they were identified as requiring the most technical work. Consultations were held throughout.

Results: ENAP published 10 core indicators plus 10 additional indicators. Three core impact indicators (neonatal mortality rate, maternal mortality ratio, stillbirth rate) are well defined, with future efforts needed to focus on improving data quantity and quality. Three core indicators on coverage of care for all mothers and newborns (intrapartum/skilled birth attendance, early postnatal care, essential newborn care) have defined contact points, but gaps exist in measuring content and quality of the interventions. Four core (antenatal corticosteroids, neonatal resuscitation, treatment of serious neonatal infections, kangaroo mother care) and one additional coverage indicator for newborns at risk or with complications (chlorhexidine cord cleansing) lack indicator definitions or data, especially for denominators (population in need). To address these gaps, feasible coverage indicator definitions are presented for validity testing. Measurable process indicators to help monitor health service readiness are also presented. A major measurement gap exists to monitor care of small and sick babies, yet signal functions could be tracked similarly to emergency obstetric care.

Conclusions: The ENAP Measurement Improvement Roadmap (2015-2020) outlines tools to be developed (e.g., improved birth and death registration, audit, and minimum perinatal dataset) and actions to test, validate and institutionalise proposed coverage indicators. The roadmap presents a unique opportunity to strengthen routine health information systems, crosslinking these data with civil registration and vital statistics and population-based surveys. Real measurement change requires intentional transfer of leadership to countries with the greatest disease burden and will be achieved by working with centres of excellence and existing networks.

Figure 1

Every Newborn Action Plan (ENAP) Measurement Improvement Roadmap: the arc of change. In support of Health Measurement and Accountability post-2015: A Common Roadmap WHO (2015) [6]. ENAP: Every Newborn Action Plan; WHO: World Health Organization.

Figure 2

Every Newborn Action Plan (ENAP) core and additional indicators. Shaded= Not currently routinely tracked at global level. Bold red= Indicator requiring additional testing to inform consistent measurement. Indicators to be disaggregated by equity such as urban/rural, income and education. Adapted from WHO and UNICEF, Every Newborn Action Plan. WHO, 2014. http://www.everynewborn.org/ and Mason et al: Lancet 2014.

Figure 3

Every Newborn Action Plan (ENAP) core indicators regarding impact, with definitions and data sources. Shaded= Not currently routinely tracked at global level. Bold= indicator requiring additional evaluation for consistent measurement. *The time period will normally be calculated per year. **ICD assumes weight and gestational age are equivalent, which they are not (see Stillbirth series Lawn et al: 2011). ICD: International Classification of Disease; UNFPA: United Nations Population Fund; UNICEF: United Nations International Children's Emergency Fund; WHO: World Health Organization.

Figure 4

Every Newborn Action Plan (ENAP) core indicators regarding coverage of care for all mothers and newborns, with definitions and data sources. DHS: Demographic and Health Survey; MICS: Multiple Indicator Cluster Survey.

Figure 5

Every Newborn Action Plan (ENAP) core indicators regarding coverage of care for newborns at risk or with complications, with definitions and data sources. Blue coloured cells= not currently tracked and collated by United Nations. Bold italics= indicator needing further work to ensure availability of consistent data in routine information systems. All coverage indicators to be tracked in such a way that they can be broken down to assess equity- e.g. urban or rural, regional, wealth quintile. ACS: antenatal corticosteroids; GA: gestational age; HMIS: Health Management Information System; KMC: kangaroo mother care; QoC: quality of care; SARA: Service Availability and Readiness Assessments; SPA: Service Provision Assessments; WHO: World Health Organization.

Figure 6

Every Newborn Action Plan (ENAP) core indicators regarding coverage of complications and extra care (specific treatment indicators), with definitions and data sources. Blue coloured cells= not currently tracked and collated by United Nations. Bold italics= indicator needing further work to ensure availability of consistent data in routine information systems. Red= service delivery package for which norms and standards will be defined and tracked. All coverage indicators to be tracked in such a way that they can be broken down to assess equity- e.g. urban or rural, regional, wealth quintile. CHX: chlorhexidine; DHS: Demographic and Health survey; EmOC: emergency Obstetric Care; HMIS: Health Management Information System; MICS: Multiple Indicator Cluster Survey; UN: United Nations.

Figure 7

Measurement improvement roadmap for coverage indicators (including care of small and sick newborns). DHS: Demographic and Health Survey, HFA: Health Facility Assessment, HMIS: Health Management Information System, MICS: Multiple Indicator Cluster Survey, PPV: positive predictive value, WHO: World Health Organization.

Figure 8

Every Newborn Action Plan (ENAP) Measurement Improvement Roadmap. ENAP: Every Newborn Action Plan; HMIS: Health Management Information System; WHO: World Health Organization.

Figure 9

Large scale data collection platforms for coverage and process indicators. ✓ Already collected. * Feasible to collect. X=Not likely to be feasible to collect (due to recall of numerator, denominator identification challenges, sample size issues). DHS: Demographic and Health Surveys, MICS: Multiple Indicator Cluster Surveys, HMIS: health management information systems, SPA: Service performance assessments, SARA: Service Availability and Readiness Assessments, EmOC: Emergency Obstetric Care.

Figure 10

Key messages and action points. ENAP: Every Newborn Action Plan; HMIS: health management information systems.