This guide is designed to help understand and interpret common indicators in reproductive, maternal, newborn, child and adolescent health (RMNCAH) scorecards.
View the latest RMNCAH scorecards posted by African countries.
Categories
Countries generally organise indicators in their scorecard in 6 to 8 categories following the continuum of care (integrated service delivery for mothers and children from pre-pregnancy to delivery, the immediate postnatal period, and childhood).
Scorecard indicators are often organised into the following categories:
- Maternal health and pregnancy
- Newborn health
- Child health, immunisation and nutrition
- Adolescent health
- Reproductive health
In some RMNCAH scorecards, health information system indicators are also added, related to data completeness and timeliness.
National indicators (impact indicators)
The top section of the scorecard usually includes high-level ‘national indicators’, using one data value to represent the situation for the entire country. National level indicators are usually ‘impact indicators’.
Impact indicators refer to the health status of the target population: reduction in child mortality, reduction in child morbidity. These indicators do not show progress over relatively short periods of time. The source for these indicators is often surveys which are done every 3 to 5 years.
Common impact level indicators include:
- Maternal mortality ratio (MMR) (view indicator on WHO’s Global Health Observatory)
- Under 5 mortality rate (view indicator on WHO’s Global Health Observatory)
- Newborn (or Neonatal) mortality rate (view indicator on WHO’s Global Health Observatory)
- Infant mortality rate (view indicator on WHO’s Global Health Observatory)
- Under 5 stunting rate (view indicator on WHO’s Global Health Observatory)
For more information on impact indicators, Consult Countdown 2030’s report on Monitoring maternal, newborn and child health: understanding key progress indicators (PDF).
Subnational indicators
The lower section of scorecards consists of ‘subnational indicators’, showing the performance of the lower levels of the country, such as regions, districts, subdistricts, and even health facilities. Subnational level indicators are often coverage, output, outcome and quality of care indicators. In most cases, subnational indicators mostly come from routine data sources like the health management information system (HMIS), which often uses DHIS2 software. The following sections of this document highlight common subnational scorecard indicators.
Maternal health and pregnancy indicators
ANC4 (antenatal care visits)
Definition: Proportion of pregnant women who have made at least four antenatal care visits during pregnancy. View this indicator on WHO’s Global Health Observatory.
Associated indicators: Some countries also look at ANC1 (antenatal care visits during the first trimester)
Source: Routine data from a health management information system (DHIS2 in most countries)
Countries with scorecards published on the Scorecard Hub who track this indicator: Mali, Burundi, Ghana, Rwanda, Kenya, Zambia
Best practices on how this indicator was improved through the review of the scorecard
In Uganda’s Jinja District, the scorecard review identified low ANC4 coverage. In response, an innovative ‘group antenatal system’ was created for health facilities group mothers with ANC appointments on the same day, living in the same area. The women are then encouraged to remind and motivate each other to attend appointments. Community health education on the importance of ANC was also intensified. These interventions were associated with an increase in ANC4 from 56% to 82% within two quarters.
In Rwanda, a review of the scorecard showed ANC1 and ANC4 were red in many districts, especially in the Southern Province. This led the Ministry of Health to engage with local and religious leaders and partners to mobilise resources and introduce interventions to increase ANC uptake.
Skilled attendant at birth (SBA)
Definition: Proportion of births attended by skilled health personnel (such as a doctor, nurse, midwife). View this indicator on WHO’s Global Health Observatory.
Associated indicators: Some countries also look at institutional (health facility) delivery – the proportion of births occurring in health facilities
Source: Routine data from a health management information system (DHIS2 in most countries)
Countries with scorecards published on the Scorecard Hub who track this indicator: Mali, Burundi, Ghana, Rwanda, Kenya, Zambia
Best practices on how this indicator was improved through the review of the scorecard
In Kenya’s Bungoma county, after review of the scorecard showed low SBA, 400 traditional birth attendants were retrained to support pregnant women. Read Kenya’s best practice.
Early postnatal and postpartum care for women and babies (PNC)
Definition: Proportion of women with a recent birth and their babies who received postnatal care within two days of birth (regardless of the place of delivery). View this indicator on WHO’s Global Health Observatory.
Associated indicators: Postnatal care for mothers, postnatal care for babies, postpartum family planning (met need for family planning after birth)
Source: Routine data from a health management information system (DHIS2 in most countries), household surveys
Countries with scorecards published on the Scorecard Hub who track this indicator: Burundi, Ghana, Rwanda, Kenya, Zambia
Best practices on how this indicator was improved through the review of the scorecard
In Rwanda, the scorecard review showed that there was a low uptake of postpartum family planning services, especially for women who had delivered their babies in hospitals (40% of all deliveries). As a result, the Ministry of Health worked with district hospitals to appoint one focal point of family planning in each hospital who would oversee providing education sessions and family planning methods to women who had just given birth. This led to an increase of postpartum family planning coverage.
Read the Rwanda best practice.
Pregnant women who receive long-lasting insecticidal nets (LLINs) during antenatal care
Definition: Proportion of pregnant women who received a long-lasting insecticidal treated mosquito net during their antenatal care appointment. View this indicator on WHO’s Global Health Observatory.
Associated indicators: Percentage of pregnant women who report having slept under an insecticide-treated bed nets (ITN) the previous night (a survey indicator)
Source: Routine data from a health management information system (DHIS2 in most countries), Surveys
Countries with scorecards published on the Scorecard Hub who track this indicator: Kenya
Several countries track this indicator in their malaria scorecards including Ghana, Rwanda, Mozambique, Zambia, Burkina Faso.
Best practices on how this indicator was improved through the review of the scorecard
In Tanzania’s Geita Region, the scorecard analysis showed a decline in long-lasting insecticidal net (LLIN) distribution through routine antenatal care appointments (ANC). Bottleneck analysis revealed that there was a delay in procurement and distribution of LLINs during the transition. The region urgently communicated with the responsible partner to ensure adequate stock of LLINs were mobilised to health facilities. ANC LLIN distribution increased from 64% in quarter 4, 2019 to 97% in quarter 1, 2020.
Read Tanzania’s best practice.
IPTp3 (intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine)
Definition: Proportion of women who received at least three doses of intermittent preventive treatment of sulfadoxine-pyrimethamine (IPTp-SP). View indicator on Measure & Evaluation’s website.
Source: Routine data from a health management information system (DHIS2 in most countries), surveys
Countries with RMNCAH scorecards published on the Scorecard Hub who track this indicator: Burundi, Ghana, Kenya
Several countries track this indicator in their malaria scorecards including Kenya, Ghana, Rwanda, Mozambique, Zambia, Burkina Faso.
Best practices on how this indicator was improved through the review of the scorecard
In Zambia, the scorecard review highlighted that the IPTp3 indicator was underperforming due to a stock out of the drug sulfadoxine-pyrimethamine (SP). The scorecard was used as an advocacy tool to urgently procure SP.
In Uganda’s Mukono district, discussions on the low uptake of IPTp3 revealed misconceptions about side effects and the low importance of more than one dose of IPTp. Subsequently, health education talks in the community and in antenatal clinics were designed to address these misconceptions and this was associated with over 20% increase in performance over three quarters.
Other maternal health and pregnancy indicators
Anaemia
Anaemia is highly prevalent globally, disproportionately affecting children and women of reproductive age. Anaemia is associated with poor cognitive and motor development, and work capacity. Among pregnant women, iron deficiency anaemia is also associated with adverse reproductive outcomes such as preterm delivery, low-birth-weight infants, and decreased iron stores for the baby, which may lead to impaired development
View this indicator on WHO’s Global Health Observatory.
HIV in pregnancy indicators
Indicators can include ‘percentage of women screened for HIV during pregnancy’ and ‘antiretrovirals for HIV-positive pregnant women to reduce the risk of mother-to-child transmission during pregnancy and delivery’.
Audit of maternal deaths
This indicator contributes to the measurement of facility management performance, such as the existence and use of administrative systems to maintain and improve health service provision. View indicator on Measure and Evaluation’s website.
Caesarean section rate
Caesarean section is a surgical procedure that can effectively prevent maternal and newborn mortality when used for medically indicated reasons. Caesarean section rates have increased steadily worldwide over the last decades. This trend has not been accompanied by significant maternal or perinatal benefits. WHO has recommended that the ideal rate for caesarean sections to be between 10 to 15%. When medically necessary, a caesarean section can effectively prevent maternal and newborn mortality. WHO recommends that when caesarean section rates rise towards 10% across a population, the number of maternal and newborn deaths decreases. When the rate goes above 10%, there is no evidence that mortality rates improve.
View this indicator on WHO’s Global Health Observatory.
Newborn health indicators
Use of uterotonics in labour and delivery
Definition: This indicator measures the use of medications given both to induce labour and to reduce postpartum haemorrhage. The three uterotonic drugs used most frequently are oxytocins, prostaglandins and ergot alkaloids.
Associated indicators: Indicators include ‘Percent of women receiving oxytocin immediately after the birth of the baby (within 1 minute of delivery), before the birth of the placenta, irrespective of mode of delivery’. View this indicator on Measure and Evaluation’s website.
Source: Routine data from a health management information system (DHIS2 in most countries)
Countries who have selected this indicator in their RMNCAH scorecard (not currently published on the Scorecard Hub): Nigeria
Neonatal resuscitation
Definition: Proportion of all live newborns born at term (37 weeks or later) at a health facility who were not breathing spontaneously but were breathing spontaneously after resuscitation
Associated indicators: Availability of a clean and functional bag and mask of newborn size in the delivery area of the maternity service.
Source: Data often compiled from household surveys such as Demographic and Health Surveys (DHS).
Countries with scorecards published on the Scorecard Hub who track this indicator: Rwanda
Kangaroo mother care (KMC)
Definition: Kangaroo mother care is a method of caring for preterm and low birth weight newborns by direct, continuous skin-to-skin contact, in the kangaroo position, with their mother or guardian. The current evidence base indicates that KMC reduces mortality among clinically stable newborns weighing less than 2000 grams when initiated in a health facility
Associated indicators: Some indicators measure outcome indicators (such as proportion of low birth weight (LBW or babies under 2,000 grams), babies who received KMC, some also measure output (such as the number of staff trained in KMC)
Source: Routine data from a health management information system (DHIS2 in most countries), also training in KMC is captured in health facility surveys
Countries with scorecards published on the Hub who track this indicator: Mali
Countries who have selected this indicator in their RMNCAH scorecard (not currently published on the Scorecard Hub): Senegal
Early initiation of breastfeeding
Definition: Proportion of children who were put to the breast within one hour of birth. View indicator on WHO’s Global Health Observatory.
Associated indicators: Early breastfeeding can be used as a tracer indicator for essential newborn care. Associated indicators include mothers exclusively breastfeeding their infant for the child’s first six months
Source: Data often compiled from household surveys such as Demographic and Health Surveys (DHS).
Countries with scorecards published on the Hub who track this indicator: Kenya (Kenya is tracking female infants under 6 months on exclusive breastfeeding and male infants under 6 months on exclusive breastfeeding)
Countries who have selected this indicator in their RMNCAH scorecard (not currently published on the Scorecard Hub): Senegal, Madagascar
Child health indicators
Proportion of children under 1 years old fully immunised
Definition: The percentage of one-year-olds who have received one dose of the bacille Calmette-Guérin (BCG) vaccine, three doses of the polio vaccine, three doses of the combined diphtheria, tetanus toxoid and pertussis (DTP3) vaccine, and one dose of the measles vaccine. View indicator on WHO’s Global Health Observatory.
Associated indicators: Penta3 coverage, Measles-1 coverage, BCG coverage
Source: DHIS2, Surveys (Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys (MICS) and Reproductive Health Surveys (RHS)
Countries with scorecards published on the Scorecard Hub who track this indicator: Mali, Burundi, Ghana, Rwanda, Kenya
Vitamin A coverage (6 to 59 months)
Definition: Percentage of children aged 6 to 59 months who received two age-appropriate doses of vitamin A in the past 12 months.
Purpose: Vitamin A deficiency (VAD) is a major public health problem in developing countries. WHO estimates that between 100 and 140 million children are vitamin A deficient. For children, lack of vitamin A causes visual impairment, blindness, and significantly increases the risk of severe illness and death from common childhood infections such as diarrheal disease and measles. Supplementation as a vitamin A deficiency control strategy is the most immediate and direct approach to improving vitamin A status and the one most widely implemented. Read more on WHO’s website.
Source: Household surveys, routine facility data from a health management information system (DHIS2)
Countries with scorecards published on the Scorecard Hub who track this indicator: Mali, Burundi, Ghana, Kenya.
Best practices on how this indicator was improved through the review of the scorecard
In Tanzania’s Songwe region, the scorecard review identified poor performance of the vitamin A coverage indicator. The Regional Commissioner directed facilities to procure vitamin A for routine use. Following this, vitamin A coverage improved from 89% in quarter 1, 2018 to 102% in quarter 3, 2018.
Read Tanzania’s best practice.
Some countries like Tanzania and Kenya have a dedicated nutrition scorecard. View Kenya’s nutrition scorecards.
Adolescent health indicators
Read an analysis on the use of adolescent health indicators in country scorecard is available here.
Percentage of adolescents registering for ANC
Definition: Proportion of pregnant adolescent (10 to 19 years) mothers who register for antenatal care
Associated indicators: ANC coverage, % of deliveries among adolescents
Source: Routine data from a health management information system (DHIS2 in most countries)
Countries with scorecards published on the Scorecard Hub who track this indicator: Ghana, Madagascar, Malawi, Senegal
Best practices on how this indicator was improved through the review of the scorecard
In Ghana, the scorecard review showed a low percentage of adolescents (16%) were presenting for antenatal care during pregnancy. A bottleneck analysis revealed causes for this included cultural practices that were associated with early marriages, poor utilization of family planning among adolescents and data issues which led to wrong age categorization within the health information systems. Actions to address these bottlenecks included organization of community meetings on adolescent health services land formation of adolescent health clubs to sensitize communities on adolescent health, orientation of health facility staff on adolescent-friendly services and district follow up with health information managers to correct data errors.
Other adolescent health indicators in country scorecards include:
- prevalence of adolescent pregnancies
- availability to adolescent-friendly services and access to family planning
- HIV testing, antiretroviral therapy (ART) initiation among adolescents with HIV (tracked in Zambia)
- access to services for victims of domestic violence (tracked in Malawi)
- coverage of HPV (human papillomavirus) vaccination among adolescent girls (tracked in Uganda)
- percentage of youth accessing services
- adolescents receiving family planning
- maternal deaths among adolescents
- adolescents receiving counselling for mental health